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\A

 
 
 
a.
ON DISEASES OF THE SKIN. 
                        PLATES
                               TO
WILSON  ON DISEASES  OF  THE  SKIN."
                       FOR SALE SEPARATE,

       A SERIES OF  PLATES, ILLUSTRATING THE  PRESENT WORK,

                           CONSISTING of

    TWENTY BEAUTIFULLY  EXECUTED PLATES,
                             OF WHICH

             THIRTEEN ARE EXQUISITELY COLORED,
PRESENTING THE NORMAL ANATOMY AND PATHOLOGY OF THE SKIN, AND EMBRACING
    ACCURATE COLORED REPRESElfTATIONS OF NEARLY ONE HUNDRED VARIE-
            TIES OF DISEASE, MOST OF THEM THE SIZE OF NATURE.

                       Price  in  cloth, $4.50.
  To the series of plates prepared by Mr. Wilson to accompany his work on
" Diseases of the Skin," and which  are referred to throughout its pages, the
publishers have added those prepared by him for his volume on "Syphilis and
Syphilitic Eruptions."  The diseases represented in these, latter are  treated at
some length, while they form no part of the original plates.   It is therefore
hoped that, in rendering the series  of  illustrations  more  complete, the value
of the whole has been correspondingly  increased.
  For  beauty of drawing, and accuracy and finish  of coloring, these plates
are confidently presented as superior to anything of the kind as yet issued in
this country.
  The "Diseases of the Skin," by Mr.  Erasmus
Wilson, may now be regarded as the standard work
in that department  of medical literature.  The
plates by which this edition is accompanied leave
nothing to be desired, so far as excellence of deli-
neation and perfect accuracy of illustration arc
concerned.—Medico-Chirurgical Review.
  Of these plates it is impossible to speak too
highly. The representations of the various forms
of cutaneous disease are singularly accurate, and
the coloring exceeds almost anything we have met
with in point of delicacy and finish.—British and
Foreign Medical Review. 
ON
DISEASES OF THE SKIN.
BY
ERASMUS WILSON, F.R.S.
    FIFTH AMERICAN
      FROM TriE
FIFTH AND REVISED LONDON EDITION.
WITH ILLUSTRATIONS ON WOOD,
OHy j

    PHILADELPHIA:
BLANCHARD AND LEA.
        1863. 
MX .
i
                  W7*f7P^
                  \<U3
I-', \ir»-\  no* Wofol   1-V«.^  \
    PHILADELPHIA:

COLLINS, PRINTER, 705 JAYNE STREET. 
PREFACE.
   Cutaneous Medicine is an important branch of General Medi-
cine ;  it embraces every form of pathological change which takes
place in the external surface-tissues of the body.  It demands, for its
thorough, comprehension, all  that appertains to the philosophy of
General Medicine, as well as the particular knowledge which belongs
to the dermal textures.   It  presents itself to our notice in the double
sense of  a disturbance of the general organism of the body, and as a
disturbance of the special organism of the skin.   In the former  cha-
racter  it calls upon  us to  consider the  phenomena,  as well of the
organic.as of the animal  constitution; in the latter  it directs our
inquiry into the organism of the  skin, both  in its normal and in its
pathological condition.   In its constitutional character, it includes all
that concerns the health  of the individual; in its special or local  cha-
racter, it comprehends, in an  equal  degree, all that  belongs to the
organism of the  part: its vessels with their blood; its nerves  with
their governing principle; its glandular apparatus with their secernent
functions;  and its various component tissues.
   Just as in General Medicine there exist disorders of the organic
system, disorders of the  blood, disorders of the nervous system, and
disorders which are not directly traceable to either of these  heads;
so, in Cutaneous Medicine, there are disorders with which the glandu-
lar system  is chiefly  concerned; others in which the main cause of
evil is the  blood; others which are chiefly referable  to the nerves;
and others which do not exclusively  appertain to any  one of these
sources.  And, for the same reason, that, to be clearly understood,
the morbid phenomena of General Medicine require to be classified
according to some recognized principle;  so, also, do the morbid mani-
festations included by Cutaneous  Medicine.
   Classification would seem  to have been coeval in its origin with the
earliest observation of diseases of the skin.   Hippocrates laid the
foundation  of an Etiological Classification, and the  basis of a 
VI
preface.
sound practice, as true at the present day as it was in his own times,
when he divided cutaneous diseases into local and constitutional.  Local
affections  he believed  to depend  upon some pathological  change
present in the part, and independent of the general constitution ;  and
constitutional affections he regarded as an effort on the part of nature,
to throw out or eliminate a cause of disease by the cutaneous tissues.
Lorry adopted the classification of Hippocrates and gave it additional
expansion; and  the work of Baumus, entitled, "Nouvelle Dermato-
logie," is founded on a similar hypothesis.
  Galen, following the medical theory of his day, became the founder
of a Topographical Classification,  when  he  divided cutaneous
diseases into such as affect the head;  and such  as affect the remainder
of the  body.  And this classification has been followed by Jerome
Mercurialis, a  physician of Italy, who flourished  in the sixteenth
century; by Daniel Turner, in England, in 1714 ; and by Alibert,
in his first classification, in France.
  Riolanus, a French physician, who was at the height of his repu-
tation during the latter  half of the sixteenth century, tells us  that
some physicians include  all diseases of  the skin under three genera,
namely, alterations of smoothness, of color, and of magnitude ; but that,
as this arrangement affords no place for  disorders of the  hair, others
prefer to distinguish them under the three heads of Pustules, Deformi-
ties, and Tubercles:  Pustules  comprehending  all eruptions attended
with roughness of the skin, whether  pimples, vesicles, true pustules,
or scales; Deformities, marks of  all  kyids, morbid coloration,  and
diseases of the hair; and, Tubercles, warts and condylomata.  Plenck,
in 1776, amplified this simple grouping into fourteen classes;  namely,
Maculae, Pustuloe, Yesiculae, Bullrc, Papulae, Crustae, Squama?, Callosi-
tates, Excrescentiae, Ulcera,  Vulnera, Insecta,  Morbi unguium,  and
Morbi pilorum;  and these fourteen  classes he subdivided into one
hundred and fifteen genera.
  This classification, which treats the visible phenomena of cutaneous
disease as  Linnaeus treated the plants and efflorescence of the vegeta-
ble world, is essentially artificial, and, like the  botanical arrangement
of Linnaeus, may be styled the Artificial Classification—in other
words, the classification of signs or appearances. Pruned of some of
its  members, the classification of  Plenck was  adopted by Willan,
and became the  basis of  the classification published  by him  in 1778.
The orders of cutaneous diseases of  Willan, eight in number,  are as
follows: Papulae, Squama-, Exanthemata, Bullae, Yesiculae, Pustuloe,
Tubercula, Maculae.
  Alibert, in framing his first classification, adopted the  topographs 
preface.
vii
cal basis founded by Galen ;  but, subsequently, proposed a scheme of
arrangement which he designated the "Natural System."  This system
embraced  the whole of diseases  of the skin under the general title of
" Dermatoses."   The dermatoses were divided into twelve groups, the
twelve limbs of  the  " Arbre  des  Dermatoses;" and  the twelve limbs
gave off numerous  branches which  represented the  genera  of his
classification. • Alibert's natural system was arranged as follows :—

   Dermatoses Eczemateuses.—Erythema;  erysipelas; pemphix; zoster;
       phlyzacia ; cnidosis ;* epinyctide ;2 olophlyctide ;3 ophlyctide ;4
       pyrophlyctide ;s anthrax; furunculus.
   Dermatoses  Exanthemateuses.—Yariola ; vaccinia; clavelee ;6 vari-
       cella; nirle;7 roseola; rubeola; scarlatina;  miliaria.
   Dermatoses Teigneuses.—Achor;8 porrigo; favus; trichoma.9
   Dermatoses  Dartreuses. — Herpes;10 varus*;*1  melitagra;12  esthio-
       me'ne.13
   Dermatoses  Cancereuses.—Carcinoma;  keloide.
   Dermatoses Lepreuses.—Leuce ,*  spiloplaxie ;15 elephantiasis; rade-
       sige.10
   Dermatoses Veroleuses.—Syphilis ;  mycosis.17
   Dermatoses Strumeuses.—Scrofula ; farcinoma.
   Dermatoses Scabieuses.—Scabies ;  prurigo.
   Dermatoses Hemateuses.—Peliosis ;18  petechiae.
   Dermatoses DyschrorAateuses.—Pannus ;19  achrome.20
   Dermatoses Heteromorphes.—Ichthyosis ; tylosis ; verruca ;  onygos;21
        dermatolysie ;22 naevus.

   Twenty years ago,  when the first  edition of this work  was  pub-
 lished,23 I constructed  a  classification founded  on the anatomy  and

    1 Urticaria.
    2 A nocturnal eruption, disappearing by day, described only by Alibert.
    3 Herpes.                  i Aphthae.          6 Malignant pustule.
    6 A varioloid of sheep transmissible to man.       7 A varioloid.
    8 Crusta Lactea.                             9 Plica polonica.
   10 The  squamous diseases, Lepra, including Psoriasis and Pityriasis.
   11 Acne and Sycosis.         12 Impetigo.         13 Lupus.
   14 The  Jewish leprosy.                         I5 Malum mortuum.
   16 The name given to an elephantiasis (?) of northern countries, in Norway.
   17 This genus includes Frambcesia and Molluscum.     18 Purpura.
   19 This genus includes Lentigo, Ephelis, Pityriasis versicolor and Pityriasis nigra.
   *" Vitiligo; Albinismus.
   21 Onychia.                 22 Abnormal extensibility of the skin.
   21 The dates of  the several editions of this work are: 1842; 1847; 1851 ; 1657
 1863. 
vni
preface.
 physiology of the skin, a Physiological Classification ; and I took
 as the heads of my arrangement the natural division of the skin into—
 1. Derma proper; 2. Sudoriparous system;  3. Sebiparous system;
 4. Hair and hair-follicles.  The first of these heads I subdivided into
 five secondary  groups, as follows:  Inflammation; Hypertrophy of
 papillae; Disorders of the vascular tissue; Disorders of sensibility ;
 and  Disorders of chromatogenous function.  And  the first of  the
 secondary groups, namely,  inflammation,  I  further  divided  into:
 Congestive inflammation ;  Effusive inflammation;  Suppurative in-
 flammation ; Depositive inflammation ; Squamous inflammation; and
 inflammation from  the presence of Acari.
   Time, however, brought with it the  conviction, that however well
 adapted such a  classification  as the Pysiological Classification might
 be for the student, or for the mere scientific inquirer, it  was not
 equally suitable to the practitioner; and, that, as the primary object
 of the study of medicine should be to cure disease ; a classification
 must be sought for that would carry with  it the idea and principle
 upon which our curative operations ought to  be  conducted.  These
 were the views with which I advanced the classification adopted in the
 fourth edition of this work; a classification founded upon the sup-
 posed cause  of  Cutaneous disease; and which I then distinguished
 as an Etiological Classification.  Further experience has con-
 firmed my approval of the etiological classification ; so that, although
 I  foresee  a probability of improving it at some future period, that
 time has not yet arrived; and I am content for the  present to follow
 it without alteration.
   As the cause of  disease  is  naturally obscure, our appreciation of
 the  nature of a  cause must be greatly influenced by the theory of
 medicine, which  has been impressed upon  us in our early  education,
 or by the prevalent theory  of the  day.  One theory that has  been
 handed down  to  us from a  very  early age, is that of the humors;
 which assumes that the  majority of diseases originate in  a morbid
 condition of the humors  of  the body,  and  especially of the blood.
 This is the foundation of the Humoral Pathology, and the disciples of
 this  doctrine are  the  Humoralists.  Ilumoralism was early  adopted
 as an explanation of cutaneous disease; and the practice which has
 been founded upon  that theory has been most successful in the treat-
 ment of these diseases.   Theory assumes a morbid  alteration of the
 blood ; practice exerts all its powers to remove the offending con-
 stituents of the blood,  to improve the condition of the blood ; in fact,
to  purify the blood.
  But humoralism does not explain all the known phenomena  of 
PREFACE.
IX
cutaneous disease; and for  the simple  reason that Humoralism ad-
dresses itself only to the fluids of  the body;  and although it must be
admitted that there can be no healthy solids without healthy fluids, yet,
on the other hand, the nervous system  plays so important a part in
the health of the body, and in the health of the blood itself, that we
are bound to recognize certain phenomena manifested  by diseases of
the skin as originating in  the nervous system;  as being, in fact,
neuropathic phenomena.  In the treatment of diseases of the skin, we
must therefore chasten our humoral views,  with views drawn from a
neurotic source, with dynamic views; and while we bestow our chief
attention on the purification of the blood, we must at  the same time
comprehend the importance  and secure the integrity of that governing
influence, the nervous power.
   Reviewing the long list  of cutaneous diseases, we might select a
group which originate in the presence of 2l poison in the blood, which,
in a pathological point of view, may be regarded as an effort of nature
to eliminate a poison which has  been accidentally admitted into the
blood, and which is  in its nature foreign to the blood.  Such is the
group of exanthematic fevers, " diseases arising from animal poisons of
unknown origin, and giving rise to eruptive fevers;"  and "diseases arising
from the syphilitic poison."  But  even in these diseases  we have to
regard  not merely the action of the poison on the  blood, but also its
influence on the nervous  system. Irrespective of the  neuropathic
symptoms which accompany these disorders, and follow in their train
as  sequelae, the occasional paralysis partial or complete, we not un-
frequently hear of cases of "nervous smallpox,"  and we recognize
the intense neuralgia of syphilis.  We  have, therefore, in the  treat-
ment of these diseases, to balance our humoral views with a remem-
brance  of the  necessity of keeping up the tone  and power  of the
system, we must act the part of dynamo-humoralists.
   In another and very important, because  the most common  of the
diseases of the skin, namely, the  eczematous group, we have also an
impure state of the blood, but an impurity different from that  of the
preceding, not a poison foreign to the blood, but an impurity depending
on malassimilation, crude and morbidly altered organic elements and
effete material, which has failed to be eliminated by  the proper
emunctory  organs.    This  accumulation not  unfrequently results
from a  preceding deficiency of  power of the  nervous system; or
acting upon individual nerves, may give rise to a morbid alteration
in the tissues which  those nerves supply, constituting an apparently
local eczema.  Here,  again, we  see the necessity of combining  the
neuropathist  and the humoropathist  in administering  to the  one 
X
PREFACE.
harmonious whole, which nature had in view in the construction of
the animal frame.   Weak nerves may be the  occasion of morbid
blood, morbid blood may react  on the weakened nerves, or  if the
morbid  blood precede the weak nerves, then the neuropathic phe-
nomena will be  secondary.   As in the  preceding group of  dis-
eases, the  principle of treatment must be  humoralist,  so far  as the
correction of the impurity of the blood, dynamic, to support the tone
of and invigorate the nervous system.
   In another group of cutaneous diseases, the affection of the nerve
obviously  precedes the cutaneous disorder ; and there exists no ground
for suspecting a  faulty  constitution  of the blood;—for  example,
Herpes; a draught of cold air chills a cutaneous nerve; the  tissues
to which the filaments of that nerve  are distributed are lowered in
tone; circulation is  disturbed, retarded, congestion  and vesication
follow.  In Herpes Zoster, we see  the  curious  and  striking  pheno-
menon of  the affection of the  cutaneous branches of a single inter-
costal nerve.  Here  the  healthy blood must be assumed to  be the
irritant, acting on tissues depressed  in their vitality  by the previous
injury done to the nerve  by the simple operation of cold.  Commonly
the nerves which govern the  circulation  and nutrition  of the  part
chiefly suffer; but sometimes the sensitive filaments are also effected,
and then  we  may  have  neuralgia  in every  degree, from  simple
tingling, smarting, and pricking, to intense  and deep seated  pains,
which  are obviously referable to the  trunk of  the nerve.  In cases
such as these, we cease to be  humoralists,  unless we can find some
error of digestion or assimilatkm also present;  we  are for the time
being Dynamists.  But the respective attributes of  humoralisin and
solidism are too precious to permit us to part willingly with  either;
we will be "big  of heart " and  hold both.
   In the influence of Cold and Heat upon the skin we have striking
examples of the Neuropathic Theory.   Let us take  the every-day
example of a common chilblain.  A healthy child  is exposed  to the
cold ; the cold  seizes  chiefly  on the peripheral parts of  the body,
because in them the nervous  filaments  are the  least protected; the
part is benumbed, the tissues are lowered in their tone, their vitality  is
reduced;  circulation returns,  the vessels, having lost their contract-
ility, no longer carry the blood as actively as usual through  the
weakened tissues; the blood  accumulates,  this is congestion;  inflam-
mation follows,  and with inflammation its  consequences.    This  is
clearly an example of pure   blood  acting as an  irritant  upon  the
tissues of the skin,  in consequence of their deprivation of nervous
power. 
PREFACE.
xi
     It  would be  easy  to  accumulate examples  in  which the nerves,
   governing the circulation, the nutrition, the tone and the sensation of
   the skin, are weakened and injured by disease;  but I will satisfy my-
4  self with one further example, namely, alopecia areata.  On a circular
   plot of skin of the scalp, probably in close relation with a  branch of
   a cranial nerve, the hair has fallen off, the part is bare, it is thin, it is
   pale,  it is lowered in sensibility.  There can be no  doubt  as to the
   pathological condition of this  portion  of skin.  We can  see it,  we
   can touch it;  we can bring our best organs of sense and judgment to
   bear upon it.  Its nutritive  power is exhausted, for it is thin, and it
   is no longer capable of performing its normal function  of  producing
   hair ; its circulation  is diminished, for  it is pale and  anaemic;  its
   sensitive nerves must be more or less paralyzed,, for its sensibility is
   to a considerable extent lost.  Here, again, is  a  case in  which our
   dynamic influence must be brought to bear  upon our  patient.  We
   must improve nutrition, we must improve innervation, both generally
   and locally.
      That same great mind that taught us the importance of recognizing
   the constitutional origin of local disease,  also impressed upon us the
   delicate handling of  the local  disorder,  whether proceeding from a
   constitutional or from a local cause.  That  certain diseases obviously
   proceed from a  local  cause, and are in their essence local diseases, and
   independent of constitutional influence, is the natural inference  to be
   drawn from" the foregoing prolegomena.  This truth  has been strongly
   impressed upon us by the celebrated dermatologist of Yienna, Hebra.
    Many cutaneous diseases which in this country, and with our humoral
    tendencies, we should be led to treat by constitutional as  well as  by
   local means, Professor Hebra would treat by local  means alone, and
   the great success of his  treatment leads us  to  inquire at what  point
    between  the two extremes  the  truth lies concealed.  I believe that
    our lesson  will be best learned  by devoting more attention than here-
    tofore to local treatment; and not  less, to constitutional treatment.
    The  great excellence of the treatmept of disease in England depends
    upon the proper appreciation  of its. almost universal constitutional
    origin.  During his late stay in London,  Professor Hebra honored me
    with his presence  in  my  consulting-room  on several occasions, and
    has left on  my mind an ineffaceable impression of his rapid and sound
    diagnosis, and his extraordinary tact in the  local management of cuta-
    neous diseases.   He is too sound a physician  to reject constitutional
    means; but he  declares that they are much less needful than is  be-
   lieved by us, and  that  a  very considerable number of diseases  are
    local in their nature, and may be perfectly cured by local remedies. 
xii
PREFACE.
          The name of Hebra  leads me to another topic.  Those who have
        honored me by perusing my writings and following my inquiries,
        may have noted the difficulty which I have experienced in dealing
        with the word " psoriasis."  By my immediate predecessors, and espe-  >
        cially by the French, I found the words psoriasis and lepra used synony-
        mously, both being applied to one and the same disease.  Again, it
        was not unfrequent, as in the writings of Bateman, to see the term  •
        psoriasis, besides being  used synonymously with lepra, also applied to
        eczema in its  most chronic period, when it is  accompanied with con-
        siderable thickening and extensive desquamation of the diseased patch.
        Hence, to  clear away the confusion occasioned  by the misuse of this
        term,  I  recommended its abolition, or, at the least, its application
        solely to the chronic eczema above noted.   But it may very properly
        be asked, Why call eczema by any other name  than its own ?  I can
        only answer, that I have done so heretofore in deference to authority,
        and to a widely-spread custom.  Perhaps the moment has come, and
        I hope it has, when a better, and possibly the proper  use of the term,
        may be recognized.
          To  return to Hebra.   The term Lepra—der Aussatz in German—
        signifies the eruption,  the great eruption.  It is synonymous with
        Leprosy, the leprosy, the ancient leprosy, that which has since been
        called elephantiasis.  Therefore, let us bestow the term lepra where it
^        rightfully belongs, or reject it altogether.   The trivial affection which
        we at present call lepra has no single point of comparison with leprosy.
        We cannot but admit the truth of this argument, and we cannot, also
        but recognize in an instant the monstrous absurdity of calling a com-
        paratively  insignificant disease by so portentous a name.  Let us sup-
        pose a patient addressing his medical adviser:  "What is the name of
        my complaint, Doctor?"  And now I will ask any medical man to
        whom this question has ever been addressed, to reflect on the pang which
        has gone through his entire frame before he has brought himself to
        give the only  possible  answer—"Lepra."  "What!" exclaims  the
        startled patient; " Leprosy?" And then the apologetic response—"2so,
        not leprosy; lepra."  And the medical man can only hope that the
        patient will not go at once to his dictionary, and find out that either
        the dictionary is wrong  or the Doctor.
          Now, Hebra cuts the Gordian knot. Eczema he calls eczema; lepra,
        lepra;  and that very common affection which we at present term lepra,
        he calls psoriasis. The change is simple, the reasons for it important.
        We cannot do better than adopt it.  Moreover, it suits the spirit of
       the British  bull-dog to call things by their proper names, and we are 
PREFACE.
xiii
too noble in our nature not to recognize and value the intellect of our
foreign  brethren.  The great  International Exhibition of 1862 will
not have existed in vain, if it have accomplished no more than  to
enable us to give the proper name to a very common and troublesome
disease.
  In the present edition  the reader will find numerous emendations
and additions, both in  pictorial and  typographic illustration.

    London, November 1862. 
 
CONTENTS.
                          CHAPTER I.

Axatomy and Physiology of the Skin
    Pigment of the skin
    Sudoriparous system
    Sebiparous system
    Hairs   .....
    Nails    .....
    Physiology of the skin  .

                         CHAPTER  II.

Classification of Diseases of the Skin  . ■
    Tables of classification .

                         CHAPTER III

General Pathology of the Skin .

                         CHAPTER IV

General Therapeutics of the Skin

                          CHAPTER V.

Erythematous  or Exanthematous Eruptions
    Erythema       ....
    Erysipelas      ....
    Roseola  .      .     .
    Urticaria .      .     ...
Lichenous or Papulous
    Lichen
    Strophulus
    Prurigo  .
   CHAPTER VI.

Eruptions 
XVI
contents.
CHAPTER VII.
Eczematous or Vesicular Eruptions
    Eczema  ....
    Sudamina.
PAGE
 182
 184
 208
CHAPTER VIII
Impetiginous or Pustular Eruptions
    Impetigo ....
    Ecthyma ....
210
212
220
CHAPTER IX.
Herpetic and Bullous Eruptions
    Herpes
    Pemphigus
223
224
235
FURUNCULAR ERUPTIONS
    Furunculus
    Hordeolum
    Anthrax  .
CHAPTER X.
243
245
247
247
Scorbutic Eruption
    Purpura  .
CHAPTER XI
254
255
CHAPTER  XII.
Diseases arising from Special External Causes	262
Scabies ........	263
Malis .......	274
Ambustio ......	285
Gelatio .......	295
CHAPTER XIII.	
Diseases arising from Special Internal Causes	298
Lepra .......	300
Lupus .......	315
Scrofuloderma ......	322
Kelis...... .	324
Elephantiasis ......	333
 
CONTENTS.
XV11
CHAPTER XIV.
	PAGE
Diseases arising from the Syphilitic Poison	3b2
Table of Syphilodermata ....	.-. 385
Syphilodermata primitiva ....	386
{First period)	
Syphiloderma erythematosum	386
Syphiloderma papillosum ....	388
Syphiloderma tuberculosum	390
Syphiloderma pustulosum ....	399
Syphiloderma pilare ....	403
Syphiloderma ungueale ....	403
{Second period) .....	404
Syphiloderma erythematosum	405
Syphiloderma tuberculosum	407
Syphiloderma ulcerans . . .	.410
Syphilodermata hereditaria ....	411
{First period)	
Syphiloderma erythematosum	412
{Second period)	
Syphiloderma tuberculosum . •	413
{Third period)	
Syphiloderma; lepra ....	417
                          CHAPTER  XV.

Diseases arising from Animal  Poisons of unknown Origin, and giving
rise to Eruptive Fevers	428
Rubeola ......	432
Scarlatina .....	441
Variola ......	459
Varicella ......	478
Vaccinia ......	464
                         CHAPTER XVI.

          Diseases affecting the Special Structure of the Skin.

Diseases of the Vascular Structure    ....
    Hypertrophia venarum  ......
    Noevi vasculosi  .......

                         CHAPTER  XVII.

          Diseases affecting the Special Structcrk of the Skin.
Diseases of the Xervous Structure     ....
    Hyperesthesia   .......
    Anaesthesia     .......
    Pruritus  ..-••••
        2
508
508
510
513
513
513
514 
xvm
CONTENTS.
                        CHAPTER  XVIII.

          Diseases affecting the Special Structure op the
Diseases of the Papillary  Structure
    A^erruca  .
    Clavus, Tylosis  .
    Pachulosis

                         CHAPTER XIX.
          Diseases affecting the Special Structure of the
Diseases of the Pigmentary Structure
    Melanopathia
    Spilus vel Nevus Pigmentosus
    Lcucopathia
    Alphosis .
    Ephelis
    Lentigo
    Chloasma
    Melasma .
    Decoloratio argentea
Skin.
Diseases affectin
CHAPTER  XX
g the Special Stf.ui
Diseases of the Sudoriparous  Organs
    Idrosis
    Anidrosis .
    Osmidrosis
    Chromidrosis
    Ilemidrosis
PAGE


 517
 518
 521
 525
	.J-.J
	52*3
	534
	535
	535
	537
	533
	53^
	540
	541
ture of the >kix.	
	542
•	542
	543
	548
	550
	551
CHAPTER  XXI.
         Diseases affectin
Diseases of the Sebh'arous
    Stearrhcca simplex
    Xeroderma
    Steanhcea flavescens
    Steanhcea nigricans
    Ichthyosis sebacea
    Comedones
    Accumulations scbacc;
    Cornua humana .
    Tubercula miliaria
    Tumores sero.-i  .
    Tuinores sebacei .
    Acne
    Tuberculum malignum
a the Sphcial Structure of the
 Organs
553
	555
	556
	561
	561
	563
	571
	573
	534
	590
	591
	591
	593
	597
 
CONTENTS.
XIX
               CHAPTER XXII.
Diseases affecting the Special Structure of the Skin.
Disease of the Hairs and Hair-Follicles				599
Hirsuties ......				600
Nevi pilosi				601
Defluvium capillorum				604
Alopecia .				605
Calvities .				60.7
Trichiasis ciliorum				611
Trichiasis coacta				611
Trichosis decolor				611
Trichosis cana				613
Trichosis furfuracea				617
Trichosis plica				628
Erythema folliculorum				630
Stearrhoea folliculorum .				632
Inflammatio folliculorum, suppur	ans			633
Sycosis				634
Favus				637
                       CHAPTER  XXIII.
         Diseases affecting the Special Structure of the Skin.
Diseases of the Nail-Follicles and  Nails
    Degeneratio unguium   .      .      .     .    ,  .
    Onychia  .      .      .       .      .      .
653
655
656
                        CHAPTER  XXIV.
History and Description of the Itch-animalcule, acarus scabiei   .     659
History and Description of the Steatozoon folliculorum   .      .     673
CHAfTER  XXV
Selected Formulae
Index .
681
685 
 
DISEASES   OF   THE  SKIN.
                      CHAPTER  I.

          ANATOMY AND PHYSIOLOGY OF THE SKIN.

  The skin is the exterior investment 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 epidermis.
  The derma, cutis, or true skin (Plate II.), is chiefly composed of
areolo-fibrous  tissue; besides which it has entering into its structure
elastic tissue and smooth muscular fibre, together with bloodvessels,
lymphatic 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 superficial  stra-
tum is fine in texture, reddish in color, soft, raised into minute papillae,
and endowed with an abundant supply of vessels and nerves.   This
peculiarity of structure of the derma has given rise to its considera-
tion as consisting of two layers, the superficial or papillary layer, and
the deep stratum or corium.
  The epidermis, cuticle, scarfskin, or scurfskin (Plate I.) is a product
of  the derma,  which it serves  to envelop and defend.  That surface
of  the epidermis which is exposed to the influence of the atmosphere
and exterior sources of injury, is hard and  horny in texture; while
that which lies in contact with the sensitive papillary layer of the
derma is  soft,  and  composed  of newly-formed  cells.   Hence  this
membrane, like the  derma, offers two  strata for our observation, the
outermost stratum,  commonly  spoken of as the  epidermis,  and the
innermost stratum, or rete mucosum.   The latter was considered and
described  by  Malpighi  as a  distinct  membrane,  and  is frequently
referred to under the name of rete Malpighianum.
  Besides the derma and epidermis, the skin includes certain import-
ant secreting organs, and certain appendages, which call for separate
notice.  The secreting organs are  the sudoriparous and sebi parous
glands;  and the appendages, the hairs  and the nails.
  The derma presents considerable variety in degree of thickness in
      3 
34
ANATOMY OF THE SKIN.
different parts of the body.  Upon the more exposed regions, as the
back, the outer sides  of the  limbs, and the  palms1 and soles,  it is
remarkable for its  thickness; while on protected  parts, as  the inner
sides of the limbs, and the  ventral surface of the trunk, it is compara-
tively  thin.  On the eyelids, the penis, and the scrotum, again, it is
peculiarly delicate.  The papillary layer also  presents differences in
extent of development; on the palms of the hands, the pulps of the
fingers, and the soles of the feet, this layer is thick, and the  papillae
numerous and of great length, while in most other situations it is thin,
and the papillae  are little apparent.   Some  contrariety is observed,
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 the pulps of the fingers, where the
latter is strikingly manifest, the corium is thin.
  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 dis-
tribution.  In the superficial strata of the corium, the white fibres are
collected  into small fasciculi, and  form  an intricate interlacement,
which supports the  papillae, and constitutes a  nidus for the capillary
rete of vessels and terminal plexus of nerves.   In  the middle strata,
the fascicula are larger and flattened, and the areolar network coarse;
while in the deep layer (pars reticularis—Plate II., fig. 3) the fasciculi
are broad—namely, about a line in diameter, and  the areolar  spaces
two lines  in width.   These latter are occupied by small  masses of
adipose tissue, while the fasciculi are continuous with the subcuta-
neous cellular membrane.  The yellow elastic fibres  are solitary in
their arrangement;  they are abundant in the superficial layers of the
corium, but rare and scantily 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 branches of  vessels and nerves find
a safe passage to the papillary layer, wherein, and in the  superficial
strata of the corium, they are principally distributed.
  The  smooth or unstriped muscular fibre of the derma is distributed
most abundantly in the deep stratum of the corium, within the spaces
which give passage  to the hair follicles, and, especially, in the areola
of the nipple and in the dartos of the scrotum.  These fibres are simple
homogeneous filaments, smaller than those of muscular fibre of animal
life; they are flat and smooth, possess no transverse stria?, and have a
reddish hue.   They are fusiform in shape, of variable  length, and are
composed of a thin  external membrane, blended with and inclosing a
soft and finely  granular contained substance.  The shorter fibres
have a central nucleus; the longer ones a  succession of nuclei which
give to the fibre a knotted  appearance;  and the nuclei are sometimes
oval and  sometimes elongated or columnar.   The fibres are  united
into fasciculi by an adhesive interstitial substance; and the fasciculi,

 1 In the palm of the hand the derma measured three-fourths  of a line in thickness. 
STRUCTURE OF  THE DERMA.               35
which are sometimes round and sometimes flat, are  intermingled in
greater or less proportion with the fasciculi of the areolo-fibrous tissue.
Kolliker found small bundles of smooth muscular tissue  measuring
Tiij to 7X5 of an inch in connection with the hair follicles; these small
bundles, which have been termed by Eylandt arrectores pilorum, take
their  origin by two or three penicillar digitations (Henle) from the
upper stratum of  the corium  nearest the  limitary  membrane,  and
descend obliquely to the follicle of the hair,  to become blended with
the outermost layer of the follicle immediately below the  sebiparous
gland.   Kolliker describes  two of these  muscles as  appertaining
to each  hair-follicle, but Dr. Lister1 finds only one, and this on the
sloping side of the follicle,  a position "exactly that which is  best
adapted for erecting, as well as protruding, the hairs."  These muscles
are the agents of erection of the hairs,  and also of that erection of the
pores of the skin called cutis anserina, or goose-skin; it is not unlikely,
moreover, that the excretion of the sebiparous glands may  be assisted
by the same  agency.   It may also be  noted that these  little muscles
not only lift  up the follicle and give a prominence to the pore,  but,
as they take their  origin at a short distance from the pore, they at
the same time depress the surface of the intermediate skin;  the term
spasmus periphericus, has been, not inaptly,  therefore, applied to  this
state  of  the  derma.  In the areola of the  mamma, the bundles of
smooth  muscular  tissue  have a  circular arrangement;  Dr. Lister
describes them in the deepest part of the corium of the areola mammae
as a  " delicate, pale, reddish yellow fasciculus, circularly  arranged.'1
Henle thought that he had seen similar muscular tissue  in connection
with the sudoriparous glands of the  palm of  the hand and sole of the
foot, but this observation has not yet been  verified, and is otherwise
doubtful.
   The PAPILLARY layer of the derma (Plate II., figs. 1, 2) is raised
into small prominences or prolongations, which are termed  papillae;
the general form of these papillae is  cylindrical and conical, but some
are club-shaped and slightly  flattened,  and others spring from a short
trunk in a tuft of two, to four or five, and  are  termed "compound,"
the former being "simple" papillae.  Upon the general  surface of the
body  the papillae are  short, and exceedingly minute,  but  in other
situations, as on the palmar  surface  of the hands and fingers, and on
the plantar surface of the feet and toes, they are long, of comparatively
large  size, and very numerous; they are  also found in  great abund-
ance on the prolabium of the lips, on the nipples, on the glans penis,
the glans clitoridis, and nyrnphae.   Weber  estimates the number of
papillae in a square line of the surface  of the  palm of the hand at  150
to 200 simple and  81  compound papillae.  They also differ in their
arrangement in the situations above cited;  thus, on the general  sur-
face, they are distributed at unequal distances, singly and in groups,
whereas, on  the  palms and  soles, and on the corresponding surface
of the fingers and  toes, they are  collected into  little square clumps,
containing from ten to twenty papilla?,  and these little clumps are

         1 Microscopical Journal and Transactions, vol. i. 1853, p.  2G2. 
36
ANATOMY OF THE SKIN.
disposed in parallel rows.  It is this arrangement, in rows, that gives
rise to  the characteristic parallel ridges and furrows which  are met
with on the hands and on the feet.  The papillae, in these little square
clumps, are for the most part uniform 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
free border of the nail; they occupy the dermal follicle of the nail,
and are long  and filiform.  In structure the papilla is composed of
homogeneous nucleated and fibrillated  areolar tissue, bounded by a
structureless limitary  membrane,  and containing either a capillary
loop {vascular papilla) or a nerve fibre {nervous papilla).  Modern re-
searches1 have shown that the papillae of the skin are properly divisi-
ble into vascular and nervous; that in the vascular papilla a nerve is
rarely found ;2 while in the nervous papilla a capillary loop  is equally
absent; and that those exceptional papillae which contain both a vessel
and nerve may be regarded as a result of the fusion of two papillae of
different kinds.  The nuclei or endoplasts of the homogeneous areolar
tissue are  oval  in shape, and  lie with their long axis sometimes
parallel with the boundary of the papilla and sometimes  horizontally;
and from these nuclei are thrown off rudimentary elastic fibres which
give a fibrillated character to the tissue.  In the nervous papillae,
Wagner has described an oval or  pine-shaped  mass which occupies •
the centre of the papilla, and has been named, from its relation to the
nerve fibre, corpusculum  tactus; and  by Kolliker, from  its situation,
axile corpuscle.  The  axile corpuscle is found  only in  the nervous
papillae, and is composed of the same homogeneous nucleated areolar
tissue as the  rest of the papilla, but somewhat more  dense  in its
nature, and having its nuclei and  elastic fibres disposed transversely
to the axis of the corpuscle.   The axile corpuscle has been  compared
to the Pacinian corpuscles of the cutaneous nerves of the hand, and,
like the Pacinian corpuscle,  has  been  shown  by Huxley3 to be  a
development of  the neurilemma of the nerve fibre:  to be, in fact, the
"continuation and termination1' of  the neurilemma of the nerve; not
surrounding the cylinder of the nerve-fibre equally as in the Pacinian
body, but swelling out more  on one side than on the other, and ex*
tending for a greater or lesser distance beyond the end  of the nerve.
From the  relative position of the  nerve-fibre, and the mass  of the
corpuscle, the fibre, after breaking  up into its ultimate threads, has
the appearance of ramifying upon the axile body, and its ultimate
fibrils are gradually  lost in the tissue of the corpuscle, at a greater or
less distance from its extremity.   Nervous papillae, provided with an
axile corpuscle, have been principally found in the hand and fingers,
on  the red edges of the lips, and at the point of the tongue.
  The arteries of the derma, which enter its structure through the
areolae of the under surface of the corium, speedily divide into iunu-

  1  Wagner; Meissner; Kolliker ; Huxley.
  2  Kolliker finds nerves in tbe vascular papillae of the lip.
' 3  On the Structure and Relation of the  Corpuscula Tactus (Tactile Corpuscles or
Axile Corpuscles), and of the Pacinian Bodies.   By Thomas H.  Huxley, F. R. S.  in
the  " Quarterly Journal of Microscopical Science," vol. ii.  1854. 
NERVES OF THE DERMA.
37
merable  intermediate vessels, which form a  rich capillary plexus in
the texture of the superficial stratum 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 surface.  To see the capillary plexus of the papillae,
it consequently becomes necessary to  examine the  injected  skin by
means of a vertical  section; but if the  horizontal rete is to be ob-
served, no section is needed.   In  the papillae of some  parts of the
derma, the capillary vessels form simple loops, but in other papillae,
they are convoluted to a greater or  less  extent, in  proportion to the
size and  importance of the papillae.  (Plate II., figs. 3, 5.)  The capil-
lary rete of  the  horizontal stratum 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 ducts and hairs make
their way to  the surface.  After a certain extent of  course, the inter-
mediate  vessels unite to form the veins by which the blood circulated
in the skin returns to the system.
   The lymphatic vessels probably form in the superficial stratum
of the derma,  a  plexus, the meshes  of which are  interwoven 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 office in that situation.   I once suc-
ceeded  in  injecting a  minute lymphatic plexus  in the derma of a
foetal lamb.
   The nerves of the  derma, after entering the areolae of the deeper
part of the corium, divide into minute  fasciculi, which form a terminal
plexus in its  upper stratum.  This terminal  plexus  corresponds with
the vascular rete, and from  it are given off the primitive nerve-fibres,
which enter the papillae, and terminate in the axile  corpuscles.  The
belief has long prevailed, that the distribution of the nerve-fibres in
the papillae  takes  place  by means of loops,  but more careful re-
search throws doubt over this  mode  of termination.  Mr. Huxley,1
who has seen such loops in  the cutaneous papillae of fishes, observes:
" I have never been able to  convince myself of their  presence (in
man);  and frequently when I believed I had such cases  before my
eyes, the use of a higher power, or the causing the papillae to turn  a
little, would  undeceive me.  On  the  other hand, it is by no means
difficult  to obtain the clearest  possible evidence of the occurrence of
the so-called  free ends."  According to the same observer, the termi-
nation of the nerves takes place "by one or two pointed extremities,
which appear to be continuous with the tissue of the corpuscle."  As
already  stated, nerve-fibres are chiefly found in the non-vascular ner-
vous papillae, and are constantly associated with the axile corpuscle,
the corpusculum tactus.
   The nerves of the derma, previously to reaching the base of the
corium,  and while yet  imbedded in the  subcutaneous areolar tissue,
1 Loc. citat. 
33
ANATOMY OF THE SKIN.
 are remarkable  for the presence, on their smaller twigs, of minute,
 oval-shaped, glistening bodies, first described by Pacini, and thence
 named  Pacinian corpuscles.  The Pacinian  corpuscles have  been
 chiefly found in the most sensitive parts of the skin, as the  palm of
 the hand and sole of the foot, and especially on the pulps of the fin-
 gers ; and  it has been  calculated, that in the  palm of the hand and
 palmar surface of the fingers there exist about six hundred  of these
 bodies.   They vary in size from half a line to three lines in  length ;
 and, clustered around the small twigs of the nerves, have very much
 the  appearance  of buds upon the branch  of a tree.   The Pacinian
 bodies are commonly described as composed of from twenty to sixty
 concentric layers or capsules of areolar tissue, having  betweem them
 as many spaces, which contain a  serous fluid, and in  the  centre an
 oval-shaped cavity, also containing fluid and the axis cylinder of a
 nerve-fibre denuded of its medulla and sheath, and  terminating  by a
 small round tubercle, or by a bifid or trifid extremity.  Mr. Huxley,
 however, who confirms the anology subsisting between the axile cor-
 puscles and the Pacinian bodies, observes: That there are no spaces
 filled with fluid between the capsules;  that the so-called capsules or
 layers are united by a transparent, granular, or fibrillated substance;
 that there is no central cavity, but a central solid homogeneous  sub-
 stance, which envelops the nerve-fibre, and in which the nerve-fibre
 ends; that the appearance of concentric capsules is produced  by the
 parallel arrangement of  the  nuclei   of  the  connective  tissue  and
 their elastic fibres; that, in a word, the Pacinian  bodies are  nothing
 more than  thickened processes of the  neurilemma of  the nerve,  and
 differ from  the tactile corpuscles only in the degree of thickening and
 manner of disposition of the neurilemma.
  Recognizing, therefore, the analogy of the Pacinian  corpuscle  with
 the axile corpuscle of the papilla, and observing that both exist in the
 most sensitive parts of the  skin, and notably in parts where a special
 tact  is resident,  we are led to the conclusion, that they perform an
 important part in connection with  the sense of touch; and this conclu-
 sion  is borne out  by  tracing the progressive  development of similar
 cutaneous organs in  other  animals.  For example, the corpuscles de-
scribed by Savi, in the skin of the torpedo, consist of a pedunculated
capsule of homogeneous connective tissue, containing a clear  gelatin-
ous substance, and at  the junction of the peduncle a small prominence,
in which are found a vessel and the termination  of a  nerve.  Now,
the analogy of this organ with a Pacinian body is clear enough;  but
if, as Mr. Huxley remarks,  a hair  be produced on this vascular and
 nervous prominence,  and this hair issue from the opposite pole of the
capsule, the hair would be a sensitive vibrissa,  the most fully de-
veloped form of this series of cutaneous organs.  While, if the Savian
corpuscle be supposed to be magnified in size, it  would represent an
eyeball, one of the highest  organs of sense, of which the capsule is the
sclerotic coat, the gelatinous substance the vitreous humor, and  the
prominence of the peduncle the point of penetration of the optic nerve
and the vessels of the retina.   A similar analogy may be traced with 
STRUCTURE  OF  THE  EPIDERMIS.
39
the organ of hearing; and all the organs of sense may thus be shown
to be developed according to one simple and primitive plan.
  The epidermis (Plate I.) is a membrane of defence spread out upon
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 surface being
dense and horny, the inner  or  attached surface  being  soft and com-
posed of cells.  Moreover, the epidermis is laminated in its structure,
and the laminae present a progressively increasing density, as they
advance from  the  inner to the outer surface.  This difference  in
density is dependent on the  mode of growth of the epidermis;  for, as
the external surface is constantly subjected 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 epidermis, I have
made the subject of careful 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
make no apology for quoting entire the paper1 in which these obser-
vations are detailed:—
   " It  is the commonly received doctrine at the present day that the
cells of the  epidermis, and  of epithelium in general, originate 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 surface, the ' basement
membrane'  of Bowman.  Having reached  the exterior plane  of the
latter,  the changes commence which  result  in  the  development  of
granules in  the previously fluid  liquor sanguinis, or rather, perhaps,
in the  aggregation  of the molecules of the 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  coagulation,  and where  inorganic matter  is con-
cerned, 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 crystallization.
Indeed, coagulation, though occurring out of the body, and sometimes
after 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  previously charged  in abundance.
  " As regards the tissue under consideration, there is every ground
for belief that  the organizable material  or blastema of the liquor san-
guinis  is appropriated by the epidermis 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 sanguinis, being taken up
by  the  newly-formed cells to be transmitted in succession to  more
1 This paper was read before the Royal Society, June 19,1845. 
40
ANATOMY OF THE SKIN.
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 the absence of any fluid stratum between the
epidermis and the derma, and by the close connection known to sub-
sist between those two membranes.  It is well known that to separate
the epidermis from the derma until the former  is so  thoroughly satu-
rated with fluid by maceration as to  have acquired a considerable
addition to its dimensions in all directions, or until decomposition has
commenced, is next to impossible; and in the living state of the body,
separation never takes place until tire  mutual connection between the
layers has been destroyed by the effusion of fluid.  The microscope
gives additional weight to  this evidence; I have observed that the
cells of the  deep  surface of the epidermis are in immediate contact
with  the  boundary  limit  of  the derma, and  that, moreover, it is
frequently difficult to determine the exact line between  them.  I have
also made the following experiment: I cut very thin vertical slices of
the skin at daily periods from the moment of death  until decomposi-
tion 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 proportion 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 epidermis 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 epidermis
with the higher powers of the microscope, and failing in all my attempts
to effect this object by taking the entire thickness of the epidermis or
by  scraping, I awaited the first indication  of its separation1 from the
derma, and then removing it carefully, made a thin slice parallel with
the surface which I wished to examine. This plan succeeded beyond
my expectations; for not  only  did I obtain parts so  diaphanous as to
enable me to see the surface  distinctly, but the septa  between the
depressions  for the papillae of the derma  afforded natural laminae of
such transparency as permitted their structure to be well examined.
  "When the under surface of the epidermis was exposed to view, I
found it to be composed of four kinds of elements, arranged in such a
manner as to  constitute an irregular mosaic plane.  These elements
are—1. Granules, measuring about ^1^-$ of an inch in diameter; 2.
Aggregated granules, measuring about t^*;  3.  Xucleated granules,
measuring sv\v to ,^T; and 4.  Cells, measuring jfa to ^^ of an
inch.  (Plate I., fig. 8.)
   " The granules, which I may distinguish by the name of primitive
granules, are globular in form, homogeneous, solid, brightly illumined

  1  It may be  necessary to inform those who are unskilled in the manipulations re-
quired in pursuing investigations in  minute anatdmy, that no decomposition had
occurred in this case ; both epidermis and derma were perfectly fresh, and the separa-
tion resulted chiefly from the inbibition of water by the epidermis. 
DEVELOPMENT OF THE EPIDERMIS.
41
by transmitted light when the centre is under the focus of the micro-
scope, but  dark when viewed upon the surface, the darkness being
increased whenever they are congregated in clusters.  These granules
I conceive  to be the first organic shape of the blastema of the liquor
sanguinis.
  "The aggregated granules,  measuring about T7JfT of an inch in
diameter, are minute masses, composed of four, five, or six of the pre-
ceding, or  as many as can be  aggregated without leaving an unoccu-
pied space  in the centre of the mass.  With an imperfect focus, these
granules have the appearance of possessing a transparent globular
nucleus; but this appearance ceases when the focus is perfect, and then
the component granules are quite obvious, and the centre becomes a
dark point—namely, the shadow caused by the meeting of the primi-
tive granules.
  " The nucleated  granules, measuring between g^Vo" and 7oVo" °f 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 ' aggre-
gated granule' has now become  a  nucleus, and at the same  time has
undergone other changes, which indicate  its longer existence.  For
example, the primitive granules composing it are  denser than they
were originally, and they are separated from each other  by a very
distinct interstitial space, filled  with a transparent and homogeneous
matter.   Sometimes this interstitial  substance  presses the granules
equally on all sides, constituting  a circular nucleus; but more fre-
quently 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
with the secondary 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 peripheral tier of
granules are 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 this latter
circumstance  that gives the  facility  of determining their  mode of
construction.
  " The cells of the deep stratum of the  epidermis, measuring -^s
to 35V<r  0I> an in°h iQ 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 structure, 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 tessellated position, they are con-
stituted by the addition of a transparent border to the last described
nucleated   granule.  The periphery  of this transparent border is
bounded by a dark interstitial  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
difficulty of isolating these cells, and their  roughness of outline when 
42
ANATOMY OF THE SKIN.
separated, seem  to  prove that if a membrane  be really present, it
must be exceedingly thin and easily torn.  Assuming, therefore, from
analogy rather than from demonstrative evidence, that there exists a
boundary membrane to  the  bodies I am now describing,  I have
termed  them 'cells;' the  cavity of the cell I apprehend to be  'the
transparent border ;' the ' nucleated granule' is the nucleus of the cell;
the 'aggregated granule' of the latter the nucleolus; and the entire
body a 'nucleolo-nucleated cell.'
   "Before quitting the structure of the 'nucleolo-nucleated cell,' or
primitive cell of the epidermis, 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 surrounding the  former, and the
cell-chamber a tier  of aggregated granules inclosing the whole.
   "To  return to the  mosaic-like  plane of the under-surface of the
epidermis:  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 intercellular spaces  are occupied by
the  'nucleated  granules,'' aggregated  granules,'and ' primitive gra-
nules,' irregularly set in a homogeneous interstitial  substance, which
fills  up all vacuities.  The granules and interstitial substance modify
the light transmitted through them variously at different foci of the
microscope; sometimes the granules look dark, while the interstitial
substance is light, and sometimes the reverse is  the case.
   "Such is the structure of the mosaic-like plane of the under surface
of the  epidermis;  and so  far, my observations, having  reference to
             facts,  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 ap-
             pearances.   In the first place, then, I must acknowledge
             myself wholly divided between a belief in the possibility
             of formation of the 'aggregated  granule' by the aggre-
face or'the'Lal*  9a^on of primitive granules, the idea which prompted me
•kin, showing the  to give it that name; and  the  formation of the aggre-
mcaic-iike ap-  gated  granule' by the cleavage of a primitive granule.  If
new".8  form!*  this <luestion  related  merely to  the formation of the
surface.        ' primary aggregated  granule' it would  be unimportant,
             but it has  a  more extended  application.   The  utter-
most layer of  the nucleus  is composed, as I have  shown, of ag-
gregated granules,  and so also is  that layer which  alone forms the
chamber in the nucleolo-nucleated cell.  To these the  hypothecs  of
cleavage of a single 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
 
GROWTH  OF THE  EPIDERMIS.
43
 considerable doubt.  The process of development  appears to consist
 in the successive production of granules, one layer of granules  suc-
 ceeding another, so that, if the organizable principle  exists in each
 separate granule, the organizable force may be supposed to be more
 and more weakened in successive formations until the moment  ar-
 rives when it ceases entirely.   Is that which  I have  described as a
 'nucleolo-nucleated cell' really a eell or still a nucleus?  The only so-
 lution of the question that occurs to  me is, determining the presence
 of a cell-membrane, in which I have not satisfactorily succeeded.
   "Admitting the nucleolo-nucleated bodies now described to be cells
 in  their earliest state of formation, their size is -g^Vo to 35V0- OI" aQ
 inch in the long diameter, and that of their nucleus from g^0TT to 7 J^
 of  an inch.  In the  stratum  immediately above the deepest layer I
 find cells  measuring  ^'^ of an inch with nuclei of ^gVu-  Above
 these,  cells  measuring  TBV^, with nuclei varying from 7oVo- to 3<roo-i
 and above the  latter, cells measuring T5Vtf» with nuclei of 5gVo--   la
 following the layers of epidermis upwards to the surface, cells may be
 observed possessing  every intermediate  degree of size between the
 last-named cell, namely, j^Vtt ar>d zhj>i which is the measurement of
 the scales which constitute  the  uppermost stratum of the epidermis.
 It must not be supposed, however, that the growth of the epidermal
 cells reaches its maximum only at the surface ;  I have found cells of
 that magnitude in the deeper  strata, and there  is every indication of
 the growth of these cells being completed in the stratum immediately
 above  the mosaic-like  layer.
   "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 separation 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  o^Vo- and TBVo"  °f 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;  inhibi-
 tion and assimilation of organizable  material must necessarily 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 o^ou of an iuch and
 less, the entire nucleus is rendered transparent and less discernible than
 before; but when cells of a somewhat larger  size,  and consequently
 longer growth, are submitted to the same process, the nucleus is ren-
 dered much more distinct than it was previously.  But the body which
 is made so  conspicuous in this latter experiment  is not the entire
 nucleus, but simply the central and older granules of the nucleus;  the
younger grauules 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 appear- 
44
ANATOMY OF  THE SKIN.
ance 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 the demonstration of the mere fact which it is made to illus-
trate.
  " 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 ' aggregated granules' exter-
nally 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  of this process; the growth of the cell-mem-
brane being consentaneous with  the development and growth of aggre-
gated granules within it.  In cells of T5Vo-t0 tsVo- or" an inch, the
aggregated granules of the periphery are not easily discernible, but in
cells measuring 1T?w, and 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 full 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.   (Plate I., fig. 8, H.)
  "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
epidermis and  epithelium in  a tissue manifestly subjected to consider-
able pressure.   I sought in  vain  for  the  watch-glass cells, elliptical
cells, and globular cells  in  the epidermis, and my  search has been
rewarded by the discovery of the above described beautiful process of
formation and  growth.  It will  be seen that, according to this view of
the growth of  epidermal cells, they never possess anything approach-
ing to a globular form ;  that 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 growth, again, is made mani-
fest by the observation of a vertical section of the epidermis.   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 thickness, all the same average length, an  appearance easily
explained, when we regard them as parent cells, containing secondary
and tertiary  cells of the same average size as the cells of earlier forma-
tion.   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
epidermis, could not  be expected to produce Ttny difference of charac-
ter in the  middle  and superficial strata;  but this is not mentioned, as
far as I know, by Schwann.
  " The process of growth here described explains also the fact of the
disappearance of the nucleus  in the scales of the epidermis.  The outer-
most 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 growth
to secondary cells.  The original  nucleus, therefore, is not lost, but
merely robbed of some of its component granules, which may be dis- 
GROWTH  OF  THE  EPIDERMIS.
45
covered in many parts of the epidermal scale, instead of being concen-
trated in a single mass.   In these scales, and particularly in epithelial
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 epider-
mal scale, measuring g^ff of an inch  in long-diameter, I found several
secondary cells measuring T5Voa others measuring 57Vo> and  in the
interstices, primitive granules, aggregated granules, and nucleated
cells.
  " My observations, it will be seen,  have been chiefly directed to the
epidermis, and I am prevented at present from 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 epidermis.
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 ^\^ and 7£F of an inch,
presented a very remarkable  appearance; they had  a rounded tabu-
lated 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.
  "Another illustration of the structure now described, I  found in
the cells of  melanosis, and in  the pigment cells of the choroid  mem-
brane of the eyeball, and I am induced to believe that the same struc-
ture will be discovered more  extensively than at present can be an-
ticipated.  The corpuscles of melanosis, according to my observation,
are parent cells having an  average  measurement of T^n>^ 0I< an inch,
containing secondary cells and nucleated and aggregated granules, as
well as  separate primitive  granules.  The aggregated granules mea-
sured from  TTo-oo-  t°  Wo"o- °f an inch, and the  primitive granules
about 3Tro-7TT.
  " 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 assimilative powers of the
primitive granules, by which  the latter are altered in their  color; in
short,  are converted  into  'pigment granules.'   Pigment  granules
appear to differ in no respect  from the primitive  granules, excepting
in  tint  of color  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 epidermis of  the negro  appears to  consist wholly of pigment
granules; while, in the European, there is a greater or less admixture
of colored and uncolored granules.  The central granules are gene-
rally lighter in  tint than the  rest, and give the idea of a  colorless
nucleolus,  while those around  the circumference are more deeply
colored.   Besides  a difference in the depth of color 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 
46
ANATOMY OF THE SKIN.
 cells.  For example, intermingled 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 colored granules in the midst of colorless cells.
   " When pigment granules are examined separately, they offer very
 little indication of the depth of  color  which is produced  by  their
 accumulation.  I have observed some to have the hue of amber, while
 others scarcely exceeded the most delicate fawn.   The depth of color
 of the deep stratum of the epidermis in the negro is evidently due to
 the composition  of that layer,  of these  granules  chiefly, while the
 grayness of the superficial layers of the same tissue results not merely
 from the desiccation of these granules, but also from the fact of those
 subsequently produced being less  strongly colored,  and also from the
 addition of a considerable mass  of colorless cell  membrane.  The
 epidermal  scale of the negro has a mottled appearance, from  the
 numerous  secondary  nuclei,  and their  attendant colored granules,
 which are  scattered through its texture."
   It follows, from a review of the structure of the epidermis, that this
 membrane is  accurately modelled on the papillary layer, that  each
 papilla finds its  appropriate sheath in the newly-formed epidermis or
 rete mucosum, and that each irregularity  of surface of the former has
 its representative  in the soft  tissue  of the  deep layers of the latter.
 (Plate I., figs. 2, 5.)  It is  not, however, the  same with the  external
 surface of the epidermis; this is modified by attrition and exposure to
 chemical and physical influence; the minute elevations, corresponding
 with 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 situations, in consequence of the large  size of the papillae, and
 their peculiar arrangement in rows, ridges corresponding with  the
 papillae are strongly marked on the  superficial surface of the epider-
 mis.  (Plate I., fig. 1.)   Moreover, upon  the borders of the fingers,
 where the  linear-disposed and magnified papillae of the palmar surface
 gradually  pass into the irregular and minute papillae of the  dorsal
 surface, a transition state of the epidermis may usually be observed.
   Besides the form bestowed upon the epidermis 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 palms1 of the hands, where
 the papillae are large, the  epidermis  is thick; while on the backs of
 those organs, or  on the scalp, where the papillae  are small, it is ex-
 ceedingly thin.
   Another character presented by the epidermis is  also  to be consi-
 dered as the consequence of its connection with and dependence on the

  ' In an individual not exposed to much manual labor, I found the epidermis in the
palm of the hand to measure one-fourth of a line in thickness. The horny covering
 of the foot of the dog  is formed by papillae of unusually large  size, and hitrhlv vas° 
STRUCTURE  OF THE  EPIDERMIS.
47
derma—namely, the network of linear furrows, which everywhere
intersect each other,  and trace  out  the surface into  small polygonal
and lozenge-shaped areas.   These lines correspond with the folds of
the derma produced  by its movements, and are most numerous where
                        ■
                              Fig. B.
those movements are greatest, as in  the flexures, and on the convex-
ities of joints.  Some difference is perceived in the form of the areae,
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 areae are large, and more nearly quadrangular.
The furrows of the epidermis 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 the sole of the foot.  The latter or
smaller occupy the interspaces of the former, and those parts of the
surface  where the furrows  of articular motion  have no existence.
Their plan of arrangement is as follows: from each of the hair-pores
(a, a) there pass off on all sides, like rays from a centre, from six to
ten lines,  which meet by their extremities lines proceeding from other
pores.  These lines mark  out the surface into small triangular spaces
(6, b), or areae, within which are other and more minute pores, proba-
bly 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 areae (c, c), arid giving to the entire net-
work the appearance of a number of nicely-adjusted angular wheels.
On the shoulder of a child of about five years of age, I counted sixty
of the hair-pores with the wheel-like rays within the limit of a square
inch; while between these larger pores were six  hundred  smaller
pores, constituting so many secondary centres and secondary wheels,
and forming an elegant mosaic pattern.  On the scalp, the furrows run
between the hair-pores, and the included areae are more open  than on
the general surface of the skin.
   The deeper tint of color of the skin observable among the natious
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 epidermis. 
48
ANATOMY OF  THE SKIN.
The pigment-bearing cells are most abundant in the furrows  of the
derma, and in the hollows between  the papillae.   The production  of
pigment granules is not, however, limited to the horizontal stratum of
the derma: they  are also met with in the various inflexions of the
epidermis, constituting the lining of the sudoriparous and sebiparous
glands, and hair-follicles. It is in consequence of the presence of these
granules in tl\e cells composing  these inflections 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 the perspiratory
and sebaceous secretions.
   The chemical  composition of the pigment of  the  skin may  be
inferred from the analysis of the pigmentum nigrum oculi made by
Scherer.1  The principal elementary  substances composing this pig-
ment, and also composing the epidermis, were found in the following
proportions:—
                            Pigment.  Epidermis.
Carbon.....58.27     50.34
Hydrogen  ....
Nitrogen   ....
Oxygen    . ,  .
 5.97      6.61
13.76     17.22
21.98     25.63
  The proximate composition of the epidermis, according to an analy-
sis by John, is as follows:—
               Hardened albumen   .   .   93.0 to 95.0
               Gelatinous 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 lime; and sulphate  and phosphate of ammonia;  the
oxides, those of manganese and iron.
  The identity of structure of the external tegument or skin, with 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 directs our notice8 to this fact, and adduces  an-
other  point of similitude between these membranes.  He finds beneath
the epithelium 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, colorless, and of extreme  tenuity;" 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 boundary layer  of all vascular mem-
branes,  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 thickness does not exceed 34(i5 of an inch; in
the seminiparous tubuli, it is  ttj^tj °f an in°h in thickness; in the
lungs, it forms almost the entire thickness of the air-cells; and in no
situation has it been found to  exceed gxnro-  of an inch.  Reasoning
from'analogy, he infers the existence of a corresponding membrane on

      1 Liebig, Organic Chemistry.
      2 Cyclopedia of Anatomy and Physiology ; Article, Mucous Membrane.
l> 
SUDORIPAROUS  SYSTEM.                  49
the surface of the derma—an inference that will be unreservedly ac-
corded him;  but he finds it difficult to demonstrate this membrane in
the latter situation, in consequence of its close adherence to the vascu-
lar rete, and deeper seated stratum.  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 connection be-
tween the basement membrane and the vascular rete is so slight,  that
they separate on the gentlest pressure.  In like manner he finds no
difficulty in distinguishing this membrane in the tubuli  of the sudori-
parous and sebiparous glands; and he remarks, that it is it which gives
firmness and  form to the minute tubuli of secreting glands.
Fig. c
                      SUDORIPAROUS SYSTEM.

   The sudoriparous  glands (Plate  II.,  fig.  3)  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 epidermis, and also
 in the subcutaneous cellular tissue.   They are small round or oblong
 bodies, of a reddish-yellow color, and composed of the convolutions
 of a minute tube, which commences by a coecal extremity, and after
 quitting the gland mounts to the surface of the epidermis and becomes
 its efferent  duct.  The efferent duct ascends through the structure of
 the derma and epidermis, to terminate by a  funnel-shaped and oblique
 aperture  or pore upon  the surface of the  latter.  The sudoriparous
 glands are found in every part of the body with the exception of  the
 inside of the concha and  the meatus auditorius,
 and they present considerable differences of size
 in different regions.  They are smallest on the
 eyelids, the nose, the pinna of  the ear, the penis,
 and the scrotum, where  they average T^ of an
 inch  in  diameter; and  largest in the areola of
 the mamma, at the base of the scrotum and penis,
 and in the  axilla—in the latter situation reach-
 ing  a size  of half a line to a  line .and a half.
 The common average of bulk of these glands in
 their general distribution is go  of an inch;  and
 in the palm  of the hand  I found them range
 between  ^fo and  y^o  °f an inch.  The entire
 length of each tubulus, comprising that which
 constitutes  the  gland, as well as the excretory
tduct,  is  about one  quarter of an  inch.  The
 efferent duct presents some variety  in its course
 upwards  to the surface.   Below  the derma it is
 curved and serpentine;  and having pierced the
 derma, if the epidermis be thin, it proceeds more
 or less directly to the excreting pore.  Sometimes
 it is spirally curved beneath the  derma, and having passed the latter,
 is regularly and beautifully spiral in its passage through the epidermis,
 —the last turn forming an oblique and valvular opening on the surface.
       4
\
V
 A perspiratory gland with
its tubule.
 a. The pore. 6. That por-
tion of the tube which is
situated in the- scarf-skin ;
the spiral is close,  c. The
tube within the sensitive
skin;  the spiral is more
open than the- preceding.
d. The gland. 
50                 ANATOMY OF THE SKIN.
The  spiral course  of  the duct is especially remarkable in  the thick
epidermis of the palm of the hand and  the sole of the foot.  In those
parts  of the body where  the papillae 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  surface
of the hands and  feet, the pores  are situated  at  regular distances
along the ridges, at points corresponding with the intervals of the
small square-shaped clumps of papillae.  (Plate I, fig. 1; Plate II.,
fig. 1.)  Indeed,  the apertures of the pores seen upon the surface of
the epidermal ridges give rise to the appearance of small  transverse
furrows, which intersect the ridges from point to point.   On the palm
of the hand and  palmar surface of  the fingers the sudoriferous 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 ridges.
  Krause estimates the total number  of sudoriparous glands of the
entire body, exclusive of those of the axilla, which are so numerous as
to form  almost a continuous  layer beneath the  corium, at 2,381,248.
On the  cheeks, the back of the trunk, and thighs, he estimates the
number in a square inch of surface at  400  to 600; on the rest of the
trunk of the body, the forehead, neck, forearm, leg, and  back of the
hand  and foot, at 924 to 1090; in the palm of the hand, at 2736;  and
in the sole of the foot,  at 2685.  This estimate is probably somewhat
too high, but may be accepted as a general idea; the aggregate bulk
of these organs, including those of the axilla, he states at 39,653 cubic
inches.
  The efferent duct and glandular tubulus of  the sudoriparous gland
are lined by an  inflection of the epidermis.   This inflection is thick
and infundibuliform in the upper stratum of the derma, but soon be-
comes uniform and soft.  The infundibuliform projection is drawn out
from  the duct when the epidermis is removed, and may be perceived
on the under surface of the latter as a nipple-shaped cone (Plate I., fig.
2).  A good view of the sudoriferous ducts is obtained by gently sepa-
rating the epidermis of a portion of decomposing skin;  or they may
be better seen by scalding a piece of skin, and then withdrawing the
epidermis from the derma.  In both these cases it is the lining sheath
of epidermis which 'is  drawn out from  the duct (Plate III., fig. 17).
The average diameter of the tubular epidermal  lining of a sudorifer-
ous duct examined in the palm of  the hand was ?£o 0I> au 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 com-
posed of two or three layers of cells, of which the most external, namely,
those which corresponded with the corium, measured -j^Vo of an inch
in diameter.
  The tubule of the sudoriparous gland and that of the efferent duct
into which it is prolonged are uniform in diameter, and composed of
two, and, in some instances, of three coats ; the two coats are an outer
fibrous coat, which is continuous above with the basement membrane
of the surface of the derma, and an epithelial lining identical in struc- 
SUDORIPAROUS  SYSTEM.
51
ture with the deep layer of the rete mucosum.  In certain of the glands,
especially those of larger size, there is an intermediate coat of smooth
muscle, and a similar coat is found in the efferent ducts of the glands
in the axillary region.   In these latter, moreover, the efferent duct is
sometimes seen  to bifurcate, and sometimes its branches have been
observed to divide dichotomously in forming the convolutions of the
gland.  The cavity of the tubule presents two  important differences:
in one it is open for the greater  part or the whole of its  extent, in
which case the epithelial lining is distinct;  in the other, the tubule is
filled with epithelial contents to a greater or less degree,  and there is
no cavity present excepting in the efferent duct.  The contents of the
tubules of the smaller glands are commonly clear and aqueous, while
those of the larger glands*are opaque and grumous, and  composed of
an admixture of cells, entire and broken  up, cell-nuclei, and granules,
suggesting  a resemblance with sebaceous substance, and the more so
as there is also present protein and fat.1   When, therefore, the tubules
contain fluid only, the epithelial lining is complete;  but when the con-
tents are of the mixed character already described, the epithelial lining
is more or less deficient or entirely absent.  Hence the  perspiration
participates in the double mode of secretion common amongst glands,
namely, transudation and cell elaboration.
   The sudoriparous gland is inclosed in a network of capillary ves-
sels, which in an injected preparation have a very beautiful appear-
ance ;  but nothing is known  as to the arrangement of its  nerves.
   Taken  separately, the little  perspiratory tube, with its appended
gland, is calculated to awaken in  the mind very little idea of the im-
•portance of the  system to which it belongs; but when the vast num-
ber of similar organs  composing this system are  considered—for it
includes the sebiparous glands, 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 the individual.  I use the words
" imperfect notion," advisedly,  for the reality surpasses  imagination
and almost belief.  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 little 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 the 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  in 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
1 Kolliker. 
52                 ANATOMY  OF THE SKIN.
surface in a man of ordinary height and bulk  is 2500 ;J  the number
of pores,  therefore, 7,000,000, and the  number  of inches  of perspira-
tory tube 1,750,000, that is, 145,833 feet, or 48,600 yards, or nearly
twenty-eight miles.
  The development of the sudoriparous apparatus  has been observed
and described by Kolliker.  He discovered small masses  of nucleated
cells resembling buds, growing from the rete mucosum into the derma,
in the foot of the foetus at the fifth month; by the sixth month, the
buds, assuming the form of elongated  processes with coecal ends, had
reached the mid thickness of the  corium; by  the end of the seventh
month they had traversed the entire thickness of the corium, and were
bent at the extremity, beginning to assume  the  convoluted  arrange-
ment they were afterwards to possess.  Subsequently they pursued
their progress  with  rapidity; continued cell-multiplication enabled
them to  reach their  full length; the convolutions increased  until
the  gland was perfected; and the central cells yielding  to  the  pro-
cess of softening and liquefaction common to the formation  of tubu-
lar glands,  their cavity was established.  So  that, at the time of birth,
the  sudoriparous system is complete throughout the entire skin.


                       SEBIPAROUS SYSTEM.

  The sebiparous glands  (Plate III.) are  the  special producing or-
gans of the sebaceous substance or fatty secretion of the skin; they are
associated with the hairs, being connected with the upper part of the
hair-sacs, and, like the hairs, are  distributed almost universally  over
the  surface of the body.  They are situated in the upper part of the*
corium, and are either simple  follicular sacs,  or more or less subdi-
vided into  branches or lobules, so as to constitute simple racemose and
compound  racemose glands.  Opening into the hair-sacs  of the scalp
there exist commonly a  pair of these glands  to each hair, while in the
beard and axilla there are more;  and  in the mons veneris, labia ma-
jora, and scrotum, often as many as seven or  eight,  which surround
the neck of the hair-sac and  have a radiated  or rosette-like appear-
ance.  They are whitish in color, and  vary in size from the five or six
hundredth of an inch, to a line in diameter.  The largest of the  sebi-
parous glands of  the  body are those  of  the eyelids, the meibomian
glands.
  The purpose of the sebiparous organs being to supply the surface
of the skin with an oily secretion, they are found most abundantly in
situations where  such a secretion is chiefly required,  as among the
hair, to which they lend their  aid in preserving its smooth and glossy
appearance; on the face, and particularly its more exposed parts, as
the nose; in the hollow of  the folds of the body, as the axilla and
pudendum; and  around the apertures of junction with the mucous
membrane, as along the eyelids, and at the anus. The so-called  ceru-
minous glands of the ear-tubes have been shown by Kolliker to belong

  1  Haller's estimate of the extent of surface of the body is fifteen square feet, that is,
2160 square inches. 
SEBIPAROUS SYSTEM.
53
rather to the sudoriparous than to the sebiparous system, and are not
the producers of the cerumen or ear wax, which is a sebaceous matter
secreted  by sebiparous glands, which are as
abundant in the meatus auditorius as else-
where.
  In  structure, a sebiparous gland  is com-
posed of membrana propria, or proper invest-
ing coat, consisting of areolar  or connective
tissue, and  an  internal epithelial lining of
nucleated Cells, Which is COntinUOUS through   Meibomian glands; natural size;
its excretory duct With the OUter rOOt-sheath  imbedded in the cartilage of the
of the hair-sac.  The excretory or sebiferous  uPPer eyelid-
duct  is  the  medium of communication be-         _  •
tween the gland and the hair-sac, and  its epithelial lining consists of
several layers; but in the subdivisions of the  gland these layers are
reduced in number, until in the glandular vesicles of the periphery
there remains only a single layer.  Within the cavity of the gland is
found a grumous pulp, more or less fluid, consisting of cells.containing
a yellowish and transparent homogeneous substance, others containing
small globules  of oil, and others again filled with oil;  this, with some
free oil and watery fluid, is the sebaceous secretion.  It is not a fluid
secretion, but a cellular secretion.  In chemical composition the seba-
ceous substance, according to Esenbeck, consists of fat, albumen with
casein, extractive matter, and phosphate of lime, in nearly equal pro-
portions.
   The sebiparous glands have no special supply of capillary vessels,
as have the sudoriparous glands; and  nothing is known as to  their
nerves.
   Development of the sebiparous glands takes place from the hair-sacs
between the fourth and fifth month  of foetal existence, and follows the
order of formation of the hairs.   The first trace of the future gland is
a bud-like prominence  of  the neck  of the  hair-sac, derived from and
consisting of nucleated cells identical with those of the outer root
sheath;  the bud elongates, and either  remains single or divides, and
by the same process of budding its division continues until the entire
gland is completed.  This completion  does not always take place at
once, but the process may cease  for a time and subsequently be
resumed; hence, it is continued after birth  and during the growth of
the body, or may be set up in after life as  a pathological action.   At
about the sixth month a difference of character is  observed between
the cells of the periphery of the newly formed gland and those of the
centre;  the latter become  darker colored,  and are found to contain
globules of oil; this is the sebaceous secretion.  The process of sepa-
ration of the  cells  commences at the distal part of the gland,  and
gradually moves onward to the excretory duct, until it reaches the
hair-sac; and  its secretion-cells are poured out into the hair-sac to be
distributed on the surface  of the skin.  The growth of the glands, as
well  as the formation of the secretion, is a process  of cell multiplica-
tion,  the production of a succession of new  cells out of the elements of
the older or parent cells.
 
54
ANATOMY OF THE SKIN.
                             HAIRS.

  Hairs (Plate IY.) are horny filaments, appertaining to the structure
of the skin, and distributed more or less extensively  and abundantly
over the surface of the body.  Every part of the cutaneous surface is
organized for the production of hair,  with the exception of  the palms
of the hands, the soles of the feet; the dorsum of the ungual phalanges
both of the hands and feet, and the upper eyelids.   They are abundant
on the head, on the face, in the axillae, on the pubes,  and less numer-
ously  dispersed  over the  trunk of  the body  and limbs,  and they
present certain  special characters, such as  shape, size,  length, color,
quantity and structure, which call for separate consideration.   We
have also  to pass in review their mode of growth, their development,
and their physiological dependence on the rest of  the organism.
  A hair admits of a natural division into a middle  portion or shaft
(scapus), and two extremities; a  peripheral  extremity, the point; and
a central extremity inclosed within the skin, the root.  The root is
somewhat thicker  than  the shaft, and cylindrical  in  figure, while its
extremity is expanded  into a spherical or  oval mass twice or  three
times the  thickness of the  shaft, the bulb.
  The shaft of  the hair is rarely perfectly  cylindrical; it is more or
less compressed or flattened, and oval or  fabiform in section.  Leeu-
wenhoeck observes with regard to the shape of the hair, " quot crines,
tot figurae."  This, however, is not strictly true, for the  typical figure
of the  shaft of the hair  is cylindrical;  and the aberrations from that
type are more or less flattening in  consequence of desiccation by  the
air of that part of the shaft which is emitted from the follicle in which
its  root is contained.  Flattening  of the shaft gives rise to waving
and curling hair; and in hair which is much curled  the flattening is
more or less spiral in direction.
  Hairs are divisible into two primary  groups, long and short;  but
each of these groups admits of division into two sub-groups, namely,
1. Long and soft hairs, of which the hairs  of the head are the  type;
2. Long and stiff hairs, which include the hair of the beard, whiskers,
pubes, and axilla; 3. Short and stiff hairs, such  as those of the eye-
brows, the eyelashes, the  vibrissae nasi, and the hairs  of the meatus
auditorius;  and, 4. Short and fine hairs, including  the downy hairs
(lanugo,) and those of the  caruncula lachrymalis.
  The hairs of the head offer  much variety in  point of  size.  For
example: in 2000 hairs,  taken from 38  persons, the  finest ranged
between TJ^a and j}iJf of  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
chestnut hair.  The coarsest hairs  in the same heads ranged between
40it and T{„of an inch, the former being the  flaxen hair of a female
child,  and the latter, a brown hair from 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  (TT>V<r of an  inch), next in
the man (5^), and lastly  in the  woman (4^).  The  coarsest hairs of 
FORM  AND SIZE OF HAIRS.                5o
the same individuals were 3^ of an inch in the man and woman, and
3}^ in the child.   The color 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 7^, and the  coarsest ^ 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 measured  ri\ <j, and the  coarsest ?i^ of an inch.  For conve-
nience of reference-1 have arranged these  measurements in a tabular
form, as follows:—
                          Number of hairs     Fi  t          Coarsest.
                            examined.
      British    ....  20001  ...   T^T to jfo  ...  ,fotoTiff
      South American Indians  .   155   ...   T^ to ¥£5  ...  ^ to 2 j5
      Now Zealander    .    .    50   ...     j£ff     ...    ?£ff
      Scrofulous child    .    .    97   ...     jVjj     • • •    slo
   The  average thickness of the 2000  hairs above examined ranged
between 5^ of an inch, the flaxen hair of a female child, and 3^ of
an inch, the brown hair of an adult woman.  The average thickness
of the hairs of the three South  American  Indians was 4^ of an inch
in the child, 3^  in the woman, and 3^0  *n the man.  The average
measurement of the hair of the New Zealand chief was 3^,  and that
of the scrofulous child, B£T of an inch.   In  a tabular  form, these
measurements would stand  as follows:—
      British..........?h io ?h
      South American Indian  .        .....sio"to 3o"o"
      New Zealander........sio"
      Scrofulous child........so"o"
   The average dimension  in thickness of human hair, according to
the above  table, is ^ of an inch.   Leeuwenhoeck and Roseumiiller
state it to be  g^T of a Paris inch,2 which  is certainly too little; while
Weber approaches more nearly to  the measurements given above, as
may  be seen by the following table :—
      His own hair  .   .   .   .   '.    .    •  ihto vfa Paris inch.
      Mulatto      .   .   .    •    •    •    •  4I0" to *ta
      Zenegambian negro, woolly .    .    ..   .  7J4 to 5i^
      Nubian negroes   .   .   .    •    •    •  sis to 5^4

   Rosenmiiller's table is as follows:—
      Adult........soar to ¥ta Paris inch.
      Child........goo-tOfoo
      Lanugo from body of foetus ....  j^

   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  ascertaining the medium
 range, and deducing the average from  that range.
   With respect to the influence of age  and sex upon the thickness of
 the hair, my observations are in favor of the coarsest hair being found

   1 The measurements were in all cases  made as close  to the head as possible, to
 avoid the influence of stretching and wear.
   2 A Paris inch is j1, longer than an  English inch. 
56
ANATOMY OF THE SKIN.
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.
     Child   ....  6    ...    269
     Man    .    .    •    -18    ...    1016
     Woman  .    .    .    .18    ...    940
Range of thickness.

  TSU to T£u
  sks to 3^ff
  sin tO ^5
  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 have been expected to conduce to its greater strength.
Indeed, in one of the cases  examined, the head had been  repeatedly
shaven with a view to render the growth of the hair strong, but  the
hair did not exceed the medium average of size.
  The variety in the thickness of the hairs of the same head is very
considerable, as  may be perceived in the following instances, taken
without selection from a number of observations:—
Number of hairs.	Finest.	Coarsest
67	Wan	YSa
81	"TsVff	3o"o"
79	tbW	?io"
97	7^0"	sio"
57	jln	IT5
64	J$T>	zio"
Medium range.	Average.
riff ^0 sh	iio"
yia t° 5oo"	*fo"
vh t° ih	4 <0"
sin to g^	4 0"0"
sirs to 7|o"	?io"
30"0" t0 i 0"0"	i u ')
  The " medium range" in  this table includes the  measurements
within which the greatest number of hairs are found, and from it the
average is deduced.
  Variety in thickness is not, however, confined to the different hairs
of a single head; it is met with even in ah individual hair.  Thus, a
hair six inches  long, and apparently of uniform dimensions, ranged
between -g^^ and  -3-3^ of an inch  at  various  points of its length;
another ranged between ^\-^ and T^;  while a  white hair, which  was
obviously  enlarged at short distances, presented a range of 1\v to 3^,
the diameter of its point measuring  goVu of an inch.  The short hairs
of the body not unfrequently exhibit  an  appearance which may be
termed  varicose.   In the instance  of  the long hairs of the head a
small share  of the difference of diameter may  be  referred to over-
stretching 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  returned to within  one-seventeenth of its
original length.
  With respect to color as  a condition associated  with diversity in
thickness, my observations tend to show that flaxen is the finest,  and
black the  coarsest hair.   Gray hairs commonly represent in thickness
the color 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 pigmentary is compensated by excess of albuminous principle. 
DIMENSIONS  OF  HAIRS.
57
  The most extensive range in thickness is  enjoyed by light brown
hair.   The average measurements of hairs of different colors are as
follow:—
      Flaxen........jl^ to T^5 of an inch.
      Chestnut    .    .".....jhto?h
      £e<*........J** to ,ta
      Dark brown.......sin *° sin
      Light brown.......^in to ^
      White........j^tosfo
      Black........ifoto,^
  These observations accord with those of  Whithof.
  The hairs of different regions of the body of the same individual
necessarily present some degree of variety of diameter; but the amount
of variation is less than might have been anticipated, as  may be seen
by the following 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.
		M	an, chestnut.	Man, black.	Man, brown.	Woman, brown.
Head . . . • ?h ••				sio"	?o"o"	sin
Beard			• ?o"o"	?in		
Eyebrow			• jin		sin	—
Pubes			sin	?sn		7^0"
Breast .				sin	tin	tin
Whiskers			sin	sin		
Eyelashes				sJo"	—	—
Axilla .			sin	sin	—	sin
Thigh .			—	iin	—	
Leg			sin	zin	—	—
Vibrissa? auris			Tzsn		—	—
  Upon the greater part of the body the hairs are very minute (downy
hairs, lanugo), and in many situations are not apparent above tlje level
of the skin ; in others, as upon the outer sides of the limbs, they attain
a certain length; and, upon the head, face,  pubes, perinaaum, axillae,
and around the nipple, their length is considerable.   When left to its
full growth, as it is in the  female, the  hair of the head attains a length
of from twenty inches to a yard, the latter being regarded as unusually
long; but  in an instance that lately came under my notice, the hair
measured six feet.   The hair is known, besides, to constitute a sexual
charaqter, appearing for the first time on certain parts of the body at
the period  of  puberty, and occurring on regions of the body of the
male where it is generally imperceptible in the female, as upon the
sides of the face, the chin,  the breast, the shoulders, and the abdomen.
  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 surface,  the point appears obtuse,
on account of its little  difference in  diameter from that of the shaft
(Plate III.  fig. 18).  In  the short hairs of the 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 desicca-
tion.  The  pointed character of a hair is very perceptible in the eye-
brows and  eyelashes, as also in the vibrissas of the nose and meatus
auditorius.   When the hair has been cut, its pointed character is neces-
sarily lost.   Sometimes, however, there is an appearance of pointing, 
58                 ANATOMY  OF THE  SKIN.

the combined result of attrition and desiocation.   But the more usual
character, when the hair has been long neglected, is a splitting of the
end into two or three filaments.
  The root  of a hair, or that part which is included within the skin,
inclosed in  the hair-sac or  follicle, is somewhat  greater in diameter
than the rest of the shaft, in consequence  of being nearer the source
of the nutritive fluids,  and  protected  from evaporation:  and for the
same  reasons it is cylindrical in  form, while at its lower part the root
expands into an oval-shaped mass, the bulb, which occupies the whole
breadth of the follicle,  and is implanted on a small elongated papilla,
derived from the fundus of the follicle, the  papilla  of the hair.  When
a hair is cast, no trace of the bulb is perceptible, because the soft cells
of which it is composed are dried up, and only those cells remain which
have undergone transformation into the horny fibres of the hair.   In
this state the root of the hair is pointed, and resembles an  old paint-
brush worn  to a conical stump (Plate III., fig. 18).   But when it is torn
out by force, it presents a variety of  appearances, depending  on the
removal with it of more or less of the  epidermal lining o£ the follicle,
the root-sheath.  Sometimes this  follicular root-sheath is collected in
a mass at the extremity of  the hair, and the latter appears, in conse-
quence, 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.
  In  structure, a hair is composed of  three different modifications of
tissue  (Plate IV. fig. 3), namely, a loose cellulated tissue, which occu-
pies its centre, and-constitutes the medulla or pith; a fibrous tissue,
which incloses the preceding, and forms the chief bulk of human hair;
and  a  thin  layer,  the  so-called  cuticle, which envelops the  fibrous
structure, and forms the smooth  external surface of the hair.
  The medulla is absent in the minute or  downy hairs, and is not un-
frequently absent or small in quantity in fine hairs, from whatever
region they  are selected. In the coarser hairs of the head and body,
on the  other hand, it is always present, and is especially remarkable
in white-hair.   It varies in breadth from a mere  line to a cylindrical
body of one-third the diameter of the hair (fig. E), and is composed of
          large nucleated cells, of a globular or oval figure, filled with
  Fig. E.   granules, and packed together,  apparently without 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'
       I  with the microscope.   Varieties in structure of the hair are
       |  unusual; I have, however, once observed the presence of
       v  two medulke.  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.
  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 
STRUCTURE  OF  HAIRS.
59
epidermis, 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 dis-
cover the cells, but  their component granules are always obvious, and
from the plan of disposition of the cells, and their oblong shape, the
granules have a linear arrangement, and assume the character of fibres.
The hair-fibres offer some variety of appearance, according 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 appear 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 com-
posed 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.
  The color of hair appears to reside partly in the granules and partly
in an intergranular pigmentary substance which  occupies  the inter-
stices of the  granules and of the fibres.  The most deeply-colored
granules are those which constitute the nuclei of the cells, and in the
lighter  hairs these  alone give color to the fibrous structure.   In the
darker hairs  more or less of the peripheral granules are also colored,
and pigment  may be observed in greater  or less abundance in the
interfibrous spaces.  With respect to the granules, the pigment ap-
pears to occupy their periphery, sometimes  surrounding them com-
pletely,  and sometimes occupying a portion only of their surface.  In
the peripheral granules  of the cells, the outer segment is the more
frequent seat of the pigment, while many are entirely destitute of that
element.  This total absence of color, in many of the granules com-
posing  even the blackest  hair, gives to the fibrous structure, when
examined with the microscope, an interruptedly streaked appearance
(Plate IV., fig. 2); and the irregular intermixture of pigment granules
with colorless granules, bestows upon the tissue between the streaks
a dotted character.  In red hair the  granules have a delicate golden
yellow tint,  while the pigmentary matter  is  amber colored.   In the
white hair of Albinoes and of the aged, the pigment is wanting.
  The external layer  or cuticle of the hair  is a thin and transparent
envelope, measuring in the hairs of the head about 5oW °?
an inch in thickness.  It is transparent and homogeneous,    Fig- F-
but is marked externally by  undulating and jagged lines,
which represent the edges of quadrangular non-nucleated
scales or plates, which 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  (Fig. F).  The  prominence of the edges  of the
superficial scales of a hair is the cause of the sensation of roughness 
60                 ANATOMY  OF THE SKIN.
which we experience in drawing a hair between  the fingers from 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 axillas the external layer is gene-
rally more or less split up into fibres,  which give it  a shaggy appear-
ance.  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 con-
spicuous around the entire shaft.  It  forms a  remarkable distinctive
character of the hairs of this region, and is due, as I  believe, not  to
original formation, but to their saturation with the perspiratory fluid
and the breaking up of the scales of the cuticle by softening and con-
stant attrition.  In the neighborhood of the bulb, the two  portions of
the cuticle of the hair, now described, namely, the outer scale-formed
layer and the inner transparent  layer, are distinguishable from each
other as separate structures, and  are peculiarly interesting, from illus-
trating the homology of hairs and teeth; the transparent  part of the
cuticle of the hair  being, according to Huxley, homologous with the
enamel of a tooth;  and the squamous layer, which is essentially the
basement membrane of the papilla of the hair, with the corresponding
membrane of the pulp of a tooth, and described by Nasmyth  under
the name of " persistent capsule."
  The hairs are implanted at a variable depth within the skin, and are
maintained in their position by means of their  follicles.  The depth
of implantation of the hairs of the head is between j>v and  5V or"  an
inch, their bulbs being  situated in the deep stratum of the corium,
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-depth.  The depth of implantation of the hair of the pubes is
the same as that of the hairs of the head.
  The follicle of the hair, or hair-sac, is a tubular canal excavated in
the substance of the derma and  lined by a thick layer of epidermis.
It consequently presents  the same structures that enter into the com-
position of the skin, namely, an epidermal lining or sheath, commonly
called the root-sheath from its intimate  relation  with the  root of the
hair; the basement membrane of the corium, known as the structure-
less  membrane of the hair-sac;  and two fibrous layers, one consist-
ing  of fibres with transversely arranged columnar  nuclei (Kolliker's
layer):  and an  exterior  membrane, consisting of longitudinal fibres
and  nuclei,  into which  the muscles  of the hair-sacs, the arrectores
pilorum, are inserted.  This latter layer  also contains a plexus  of
bloodvessels, together with the  filaments of nerves, and supplies the
means of nutrition  to the root-sheath  and its contained  hair.  The
epidermal layer or  root-sheath is composed of several strata of cells,
which, having each a different arrangement, are regarded as distinct
membranes;  the most external of these, corresponding with the rete
mucosum of the epidermis, presents a  stratum of cells of which the
long axis is transverse;  this is the outer root-sheath ;  next follows a
stratum, of which the cells have a longitudinal arrangement and have 
STRUCTURE OF  THE HAIR-FOLLICLE.
61
no nuclei, this  is the inner root-sheath of Henle; while, lining the
latter, is a third layer, composed of cells with nuclei also  arranged
longitudinally (Huxley's  layer).1  The epidermal  layer is nearly as
thick as and often thicker than the hair which it  incloses, and lies in
close contact with the latter to the fundus of the sac and base of the
papilla pili.
   The hair-follicle or hair-sac terminates inferiorly in a slightly dilated
ccecal pouch,  and from the  centre of the fundus  of this pouch there
projects into its cavity a  dermal papilla of an ovate form, the broad
end of the papilla being free, and the smaller end continuous with the
substance of the derma external to the sac.  This is the papilla of the
hair, the hair-pulp, or hair-germ, or  blastema  pili; it is identical in
.structure with an ordinary dermal  papilla, only differing in size, in
form, in position, and in  the absence of capillary vessels.  The  hair-
papilla measures between £ and ?V of a line in length, by r\ to 5V of
a line in breadth;2 and is surrounded by the elements  of the future
hair, which are  round nucleated cells, more or  less charged with pig-
ment, and about 7oVo- or  stfVo" of an inch in diameter.   As these cells
are traced higher into the root of the hair, they become elongated and
gradually metamorphosed into the  permanent  structures of the  hair,
the fibrous cortex and  the  still cellular medulla.   The  researches of
Mr. Huxley have tended  to establish an identity of nature and design,
in other words,  an homology between the hair and a tooth; and to
prove that as a  tooth is a product of the corium of the mucous mem-
brane, so also is a hair the  product  of  the  corium  of the skin; and
that  as the pulp of  the  tooth  is metamorphosed into  ivory, so the
papilla or pulp  of the hair bulb is  metamorphosed into  the fibrous
cortex of the hair—the cuticle of the hair representing the enamel of
the tooth, and the medulla of the hair the cavitas pulpse.3
   Growth of the hair is  accomplished  by the successive formation of
new cells in the superficial  portion of the papilla of the hair, and these
cells are gradually  moved  onwards and converted into the fibrous
tissue of the hair, while new cells are produced to supply their place.
As this metamorphosis takes place, the cells in course of conversion
into the fibres of the hair become elongated, while their lateral diame-
ter is correspondingly reduced, and the newly-formed root of the hair
is consequently smaller  than the bulb.  Probably the fluids of the
metamorphosed cells are  transmitted onwards into the shaft of the
hair, and so tend to its nutrition and health.  The energy of growth
of the  hair offers considerable  diversity; it is more  active in youth
than in age, in  summer than in winter, in hair which is cut than in
that which is left to its natural growth, and in hair that is frequently
cut than in that which is  cut but seldom.  In a young person of feeble
constitution recently shaved, I  found, the hair of the head  to  have
grown four lines in three weeks, showing that the amount of growth
is probably more ^han a line  in the  course of the week.  Berthold4

   1 Kolliker's Manual of Human Histology, vol. ii.                 2 Kolliker.
   3 On the Development  of the Teeth and on  the Nature and Import of Nasmyth's
Persistent Capsule.  Microscopical Journal, vol. i., Ib53, p. 149.
   4 Muller's Archiv.  1850. 
62
ANATOMY OF THE SKIN.
ascertained that in  young females between the age of sixteen and
twenty-four, the growth was seven  lines  in  the  month.   He  also
showed by his observations that the hair grew  the quicker for being
frequently cut; that the beard shaved every twelve hours grew at the
rate of five inches and a half to  one foot in the course of a year; that
when shaved every  twenty-four hours, it grew at the rate of five to
seven inches and a half; and  that shaved every thirty-six hours, it
grew only four  to six inches and a-half during the same space of time.
He also found that  the  hair grows one-sixteenth faster by day than
by night, and  more quickly in the summer  than the winter  time.
Whithof calculated  that the hair of the beard grows at the rate of one
line and a half in the week; equivalent to six inches and a half in the
course of  a year, or twenty-seven feet in a  life-time of eighty years. ■
And Eble informs us that in the Princes' court at Eidam, there is a
full length painting of a carpenter whose beard was nine feet long.
   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 epidermis, such  a  follicle 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.
   In  a  healthy state  of the skin  the space  between the  epidermal
lining  of the follicles and the hair is very trifling.  Indeed, it is
merely sufficient 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 surface) within the derma, how-
ever, the  space  enlarges,  in consequence of the junction with  the
follicle of one,  two, or  more excretory ducts  of sebiparous glands,
and the consequent stream of  sebaceous substance which  is poured
into it.  It is in this  part that the entozoa of the hair follicles  are
chiefly found.
   Mandl entertains  some peculiar views with  regard to the structure
and mode of growth  of hair.  He describes a hair as consisting of
a cortical  portion, which is cellular, and  a  medullary  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 some-
times  commences at the point.. The  latter fact he explains by  the
transmission of colorless fluids  to the end of the hair.  Besides this
mode of increase, he admits that another takes place at the root by
apposition.  I have convinced  myself that Mandl  is in  error with
regard to this hypothesis.  Growth never takes place at the  point of
the hair, and, consequently, the  hair cannot  grow white at the point.
It may exhibit indications of bleaching in that situation, from external 
DIRECTION OF THE HAIR.
63
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 cuticle of the
hair, the scales being smaller and less jagged in that situation than on
the shaft of the hair.
  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 toward  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 func-
tions.   Thus, on, the head, the  hair  radiates from a single point, the
crown,1 to  every part  of the circumference, making  a gentle sweep
behind, towards the left, 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 habitually  turned. On the forehead the downy
hairs proceed from the middle vertical line, with a gentle curve to the
right and left, sweeping downwards to the situation  of the whisker,
and forming, by their lower  border, the upper  half of the  eyebrow.
Occasionally, the line  of divergence of the forehead  is oblique in its
direction, running  from  the 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 the
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 proceeding from the opposite centre, and those, also,
which are diverging from the vertical cental line of the forehead ; so
that here a lozenge is formed, which is the point of approximation of
hairs from four 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 an-
other  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 the eye curve along the upper lid, forming, by their upper
margin, the 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, together with
those from the vertical line at the side of the nose, mouth, and chin,

  1  Sometimes  there are two crowns, as in a  little girl now before me, in whom the
sweep from the left crown is to the left, and the right to the right, so that the hairs
from the \md crowns converge and meet in a crest along the middle line of the head. 
64                 ANATOMY OF THE SKIN.
 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, after
 passing beneath the ear, in the middle line  of the back of the neck,
 and the lowest  rays in the angle or bend of the jaw, in which latter
 situation they come into opposition 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 musta-
 chio ; 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  line.   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 back-
 wards beneath  the ear, with the current from the  face, to the middle
 liue of the nape; while those which pass down behind the ear con-
 verge with those from the back of the head also to the middle line of
 the nape.
  On the trunk of the body  there is a centre of radiation from each
 armpit,  and two lines*©f divergence, one of the latter proceeding hori-
 zontally 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 the
 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  outer-
 most part of the current passing over the shoulder to the  middle line
 of the back.  From the lower side of the horizontal line, and from the
 front of the upper half of the vertical line of the trunk, the set of the
 current  is downwards  and inwards, with a  gentle undulation to the
 middle line, and from  the lower half of the vertical line of the trunk,
 the direction  is upwards 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, also with
 an easy undulation, to the middle line of the back.   The inner ex-
 tremity  of  the horizontal line of the chest is the seat of a lozenge of
 divergence, and that of the line of the bend  of the lower jaw, at the
 front of the neck, of a second.
  From the axillary centre just described there proceeds another line
 of divergence, which encircles the arm like  a bracelet,  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.  Another 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 
DEVELOPMENT OF  HAIR.
65
sets, at first, with a sweep forwards, and then with 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; while on the
back of the hand and fingers the sweep outwards, with a curve having
the concavity upwards, is quite obvious.
   On the lower limb there are two  vertical  lines of-divergence; 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 con-
tinuing down the outer side of the leg,  reaching the front of the ankle,
and  terminating on the foot at the cleft between the 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 the 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 there is but one line, the diverging currents sweep
around the limb, and  meet upon the shin, while on the  foot  they
diverge with a sweep as upon the back of the hand.
   Quantity .of hair has reference to the proximity of the follicles, and
also  to the number of follicles which  open  by one common aperture
on the skin.  Whithof counted the number of hairs on a square  inch
of skin, and found of black, 588; chestnut, 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  "
          Chin  .   .    .    .    .   . •   .   .   .  52  "
          Pubes.........45 "
          Forearm   .        ......31  "
          Outer border of hand .    .   .   .   .   .  20 "
          Front of thigh.......21 "
  In four  years after  this calculation was made, the man having
married in the mean time, the 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 on the latter five.
   In my own observations directed to this point, I ascertained thai;
the number of hair-pores in  the scalp  of a man twenty-five years of
age,  having black hair, amounted in the square inch to  744.  Now,
supposing each pore to give passage to  a single hair only, this number
would represent the amount of hairs growing on a superficial  square
inch of the skin of the head ; and, as the extent of surface of the scalp
is about one hundred and twenty superficial square inches, the number
of hairs  on  the  entire  head would  amount to 89,280, or  in round
numbers  to 90,000.  This calculation,  however, has reference only to
a thin head of hair, for many of the pores give passage to two hairs;
and,  supposing this to be the case with one-half, we should then have
as the number of hairs in a superficial square inch, 1116; and upon
      5 
66                 ANATOMY OF THE SKIN.
the entire head 133,920.   Or,  supposing,  as would probably be the
case, in  a thick head of  hair,  that every pore gave forth two hairs,
the number in an inch would then be increased to 1488, and the total
number for the whole head to 178,560 : nearly two hundred thousand.
As an average, therefore, of the number of the hairs of the head, I
think we may fairly take the number in a superficial square inch at
1000, which would give us the number on the entire head 120,000.
  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 is increased 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 at page 56.
A  single hair of a boy  eight years 7of age, says Eobinson,  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
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 horsehair,  seven times thicker, 7970
grains.  The  strength of the hair is due to its  fibrous portion, for
hairs deficient in this structure, like those  of the  fallow deer, are
remarkable for their brittleness.
   The development of hair has been made the subject of research by
Heusinger, Simon,1 and  other physiologists.   The  earliest trace of
the hair rudiments is perceptible at the twelfth week of embryonic
life, and of the hair itself at the eighteenth'week.  These early traces
are found  in the eyebrow, and are followed  successively  by  similar
appearances on the head, back, chest, and  extremities, so that by the
end of the sixth month hair may be met with on  the whole body,
with the  exception of the hands and  parts of  the forearm and leg.
Development of the hair commences by the formation  of small globular
masses, resembling buds, on the  under surface of the rete mucosum.
These buds grow inwards into the corium, and after a time have the
appearance of flasks, composed of nucleated cells, identical in struc-
ture with those of the rete mucosum.   Subsequently the central cells
become elongated in form, darker colored  than the peripheral cells,
and  separate from the latter; and at a still later period,  the  central
cells.are metamorphosed into  a hair and inner  root-sheath, while the
external cells become transverse in their  position, and are converted
into the outer root-sheath, around  which are developed  the three
membranes of the hair-sac.  It  follows,  therefore, that the primitive
hair does not grow, as in its subsequent  existence, but is  developed,
in all its completeness,  with a point, a shaft, and a bulb, and that at
 the same time with the growth inwards of the flask-shaped process of
 the rete mucosum, a papilla is developed  from  the corium, and grows
 outwards to  penetrate its fundus, and  develop the first trace of the
 future  hair.   Two movements of growth are therefore  established—a
 growth inwards of the hair rudiment, and a growth outwards of the

   1 Zur  Ehtwickelungsgeschiclite der Haare.  Von Dr. Gustav Simon.  Muller's
 Archiv., 1841. 
        SHEDDING  AND REPRODUCTION  OF THE  HAIR.      67

papilla and hair.  The point of the hair is in this way brought to the
surface of the epidermis, and bursting  through the cone of the inner
root-sheath, is developed  as  a free hair. Simon  has described the
young hair as being bent upon itself, so  that the point and the bulb
are approximated, and  the young hair as making  its way through
the aperture of the follicle in  the form of a loop.
  In the human embryo, the  lanugo infantium begins, therefore, to
be  apparent  during  the first half of the  fifth month of intra-uterine
existence, upon the eyebrows, upper lip, and around the mouth ;  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  ear,
and the nose.  At the sixth month Eble found the hairs of the head
to measure three lines, those of the eyebrows two lines, and the eye-
lashes half a line.  At birth  the foetus is covered  with a  thick down,
the minute hairs being pale, and without color, and in their structure
consisting only of cortical substance and cuticle.   It is at this  period
that we  have the best opportunity  of observing the direction of the
hairs; for  during the first year the greater  part of these temporary
hairs have been shed, and they are succeeded by a more permanent
kind, which  appear  upon the surface only in certain situations.  At
the period  of adolescence the hairs  acquire a new impulse of growth
in  co-relation with the more active development of  the frame;  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 process of shedding and renewal of the hair has been observed
by Kolliker in the eyelashes of a child a year old, and has since been
seen in  operation in  other regions of the body.  It is simply a repe-
tition of the phenomena of development of the hair already described,
but taking place from the fundus of  a hair-sac instead  of from the
surface.  The cells of the root-sheath protrude, and form a bud, and
the bud gradually elongates in the deeper layers of the corium, carry-
ing with it the hair-sac, and having inclosed in its mass a hair papilla.
On attaining a certain length, the central and peripheral  cells assume
a difference of character—the former acquiring pigment and a longi-
tudinal prolongation;  the latter remaining clear, and becoming trans-
verse;  the former undergoing metamorphosis into hair and. inner
root-sheath, the latter into outer  root-sheath.  Subsequently, growth
outwards begins  to be active; the old  hair is moved  onwards to the
surface, and  ejected  through the aperture of the  follicle;  while the
new hair bursts its enveloping sheath, and takes the place of its pre-
decessor.  By this  mode the downy hair  of the  infant, the lanugo
infantium,  is replaced by the permanent hair  by which it is succeeded;
but it is doubtful whether this process of renewal is continued after
the period  of infancy.  It is  obvious that it  may occur,  and  may be
one mode of reproduction of the  hair; while, on the other hand, it is
known  that the common mode of reproduction  of the hair, when a
hair has fallen or been removed by violence, is the  regeneration of
the original papilla,  or the restoration of its normal functions.
   In chemical composition hair is found to differ from epidermis and 
68
ANATOMY OF THE SKIN.
 horn, and also from albumen and fibrin.   Its chief constituents are an
 animal substance, a modification of protein, apparently a compound of
 protein and sulphur,  a certain  quantity of fat, some pigment, and
 certain mineral and earthy salts, among which are iron, manganese, and
 silica—the quantity of ash varying between one and two per  cent.
   According to the analysis of Vauquelin, the chemical constituents
 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 manganese;  iron; sulphur, and
 silex.   Eed 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 magnesia.   The white hair of old persons contains
 a  maximum proportion of phosphate of lime.
   The ultimate  analysis of hair, according to  Scherer,1 exhibits the
 principal elementary constituents in the following proportions:—
          Carbon.........50.652
          Hydrogen........6.769
          Nitrogen........17.936
          2X?g™  I........24.643
          Sulphur J
   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.

                     , .       NAILS.

   The nails are horny appendages of the skin, identical in formation
 with the epidermis, but peculiar in their  mode of growth.  A nail is
 convex on  its external surface, concave within,  and implanted  by
 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.
 The surface of the corium, on which the nail rests, is termed its matrix
 or bed, and the prominence which surrounds it and overlaps it on its
 two sides and at  its root  is  the wall of the nail.  The surface of the
 matrix is marked by  longitudinal ridges,  which increase  in depth
 from the root towards  the extremity, and in  the fundus of the fold are
 several rows of transverse ridges; the ridges are studded with minute
 papillae, which are the active agents in the  growth of the nail.  The
 papillae of the fundus  of the follicle produce the margin of the root,
fand by the successive lormation of cells push the nail onwards in its
 growth. The concave surface of the nail is in contact with the derma,
 and the latter is covered with laminae, which perform the double office
 of retaining the nail in its place, and giving it increased thickness, 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-operat-
Liebig, Organic Chemistry. 
STRUCTURE  OF  THE  NAILS.
69
ing with the continual reproduction taking place along the margin of
the root, which insures the growth of the nail in the proper direction.
For it is clear that if the adhesion of the concave surface of the nail
with the derma  were not perfectly soft and yielding, the addition of
successive layers of cells to the follicular margin would be wanting in
the force necessary to push it forward in the direction of its growth.
   The nail  derives a peculiarity of  appearance from the disposition
and form of the laminae upon the 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 ridges^which  are more minute,
and consequently less vascular, than  the laminae somewhat further on.
This patch  of ridges is bounded by a semilunar line, of  which the
concavity is turned towards the root, and in consequence of appearing
lighter in color than the rest of the  nail, has been termed the lunula.
Beyond  the lunula  the laminae  are raised  into longitudinal plaits
(Plate II., figs. 4, 5), which are exceedingly vascular, and give a deeper
tint of redness to the nail.  These plait-like laminas 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  examined,
these longitudinal laminae, corresponding with the longitudinal plaits
of the ungual  portion of the derma, are distinctly apparent; and if the
nail be forcibly detached, the laminas may be seen in the act of part-
ing from the grooves of the plaits. This laminated structure upon the
internal surface of a nail is seen in a magnified form in animals; for
instance, in  the perpendicular wall of the hoof of the horse.  More-
over, it is this structure that gives rise to the ribbed appearance of
the nail,  both  in animals and man.   The surface of the derma which
produces the  nail, the matrix of the nail,  is continuous around the
circumference of  the attached part of  that  organ with the derma of
the surrounding skin, and the horny  structure of  the nail is conse-
quently continuous with that of the epidermis.
   That nothing may be wanting to complete the analogy between the
structure of the nails and that of the epidermis, pigment granules are
found entering into their composition.  The  grayness of hue which
the nails of  some persons exhibit is  due to the presence of this ele-
ment, and upon a microscopic examination of a section  of the  nail,
the granules may be observed in greater or less number disseminated
in streaks amongst the horizontal strata of which the nail is composed.
Pigment is also found in the deeper cells of the nail of the negro.  The
only difference in structure that has been noted between the epidermis
and the nail, is the persistence of the nucleus of the cells of the latter.
While in other respects, the  cells of  nails undergo  a more complete
condensation  and  solidification  as  a  consequence  of their mode of
growth, and probably of a more active nutrition.   When kept pared,
nails have a constant and active  growth, but when left to themselves
they attain a certain  length and then cease to grow; as we see in bed-
ridden persons, and amongst those nations of the East, as amongst the 
70
ANATOMY OF THE SKIN.
Chinese, who permit  the  growth of the nail  to  its full extent.  A
French  physician, Dr. Beau,1 has found that the nails of the feet were
four times slower in their growth than those of the hands.   The latter
increased in length one millimetre, that is, two-fifths of a line, in one
week;  while the nails of the foot required four weeks  for the same
amount of increase.   According  to this  observer, the length of the
thumb-nail, including the  root, which is hidden  from  sight, is eight
lines, that is, twenty millimetres; consequently, the  period occupied
in the growth of that nail would be  twenty weeks or five month's.  In
like manner, the nail of the great toe, measuring  in length nine lines
and a half, or twenty-four  millimetres, and requiring four  times the
period  of the thumb-nail^Jivould consume ninety-six weeks, that is,
nearly two years, in its growth.
  Dr. Beau has further remarked, that during  the continuance of
every constitutional disorder the nails suffer to a  greater or  less ex-
tent.  According to him, the law  of growth of the nails is precisely
the same both in health and disease (an assumption which, although
not strictly true, approaches sufficiently  near the truth to be admitted
as a general proposition);  but in  the  latter  state, the materials of
growth  are  supplied  by the blood in diminished quantity.  Hence,  '
the portion  of  nail formed during the existence of disease will be
perceptibly thinner than that  produced during  health, and  may be
distinguished on  the  surface as a transverse groove.  If the disease
have been sudden, the outer boundary of  the  groove will be abrupt,
and vice versa.   And if the disease be one in which the nutritive func-
tions are seriously affected, the depth of the groove will maintain a
relative correspondence.  Admitting these data, Dr. Beau suggests, as
a practical application of  his  observations, the  possibility of deter-
mining  the perjod of occurrence and also the period of  duration of a
disease,  provided the time do not  exceed that required for  the entire
growth  of the nail.   For example: a groove, or rather ledge, situated
at the distance of eight millimetres  from the edge of the root of the
thumb-nail, or five from the free margin of the skin, is indicative of
an attack of disease which  commenced eight weeks previously; while
the breadth of the groove being two  millimetres would  prove the
disease  to have contiuued for  the  space  of two weeks.  After  five
months  the thumb-nail ceases to be  a tell-tale, on  account of its entire
growth  in length being accomplished, and  the vestige of disease con-
sequently obliterated.   The great  toe-nail, however,   may  now be
appealed to.  At five months the  groove indicative of .the  above dis-
ease has advanced  only five millimetres  from the root, and is only
just becoming apparent beyond the free margin  of the skin, the breadth
of the groove being only half a millimetre. In making these obser-
vations, M. Beau selects the thumb-nail and corresponding nail in the
foot, because in them only he finds the appearances regularly present.
  To put Dr. Beau's observations to the test of experiment, I noted an
illness which took place in myself, commencing on the 14th  of Decem-
ber, and lasting for a fortnight.  On the 1st of May following, I found,
Archives Gengrales de M6decme, vol. xi. p. 447. 
GROWTH OF  THE NAILS.
71
Fig. G.
 A  thumb-nail bearing
the mark of a foregone ill-
ness,  a. Is the edge of
scarf-skin which overlaps
the nail at its root.  b. The
lunula, c. The groove oc-
casioned by deficient for-
mation during the period of
the illness,  d. The free
extremity of the nail.
across each thumb-nail, a groove measuring one line in breadth.  Now,
a line is  equal to two and  a half millimetres,  and as the rate  of
growth, according to Dr. Beau, is one millimetre  a  week, my illness
should have lasted two weeks and a half  instead
of two weeks.  I therefore came to the conclusion
that,  either my  own  feelings of convalescence
preceded  trie  perfect restoration of the functions
of nail-formation,  or that  the rate of growth of
the nail was more rapid in me than in other per-
sons.   I next measured the distance between the
distal margin of the groove  and the epidermal
margin at the root of the nail, and adding to that
quantity three millimetres for the depth  of nail
concealed by the follicle, obtained as a result seven-
teen millimetres;  in  other words, a space repre-
senting seventeen weeks, whereas the  real time
was nineteen  weeks  and a half.   This was  ex-
actly the reverse of my first observation, and went
to prove that, in me at least, the growth of the nail
was less rapid than is  represented  by Dr. Beau.
Nevertheless,  the  experiment  came sufficiently
near the truth to render Dr. Beau's observations  interesting and de-
serving of attention.
   The development of the nail commences during the third month of
embryonic life, by the prominence of the corium around the boundary
of the future matrix of the nail;  this prominence is the wall of the
nail, which marks out a quadrangular area: and up to the end of the
third month, the matrix  is covered by ordinary epidermis.  During
the fourth month a harder layer is formed under the epidermis, and
becomes gradually thicker and larger, until, in the seventh month, it
protrudes its free edge.  The nail is, therefore, developed  originally
under the epidermis, and at a later  period only, assumes its external
position.   At birth, in  consequence of the growth of the fingers, the
nail is narrower at the free edge than elsewhere, and is commonly
broken offj but the whole of the original nail is not worn away until
the infant is six or seven months old.
   In a chemical analysis of the horny  tissue of nail, Scherer1 found
the elementary constituents in the following proportions :—
           Carbon........51.089
           Hydrogen .   .   .    .    ...   .    .    6.324
           Nitrogen......           16.901
           °Yg>?n........}  25.186
           Sulphur   .   .   .    .    .   .   .    . )
   The chief nitrogenous element is protein  with sulphamide;  the
amount of ash is the same as  for  epidermis, about one per cent., but
there was more sulphur and carbon; and, according to Lauth, more
phosphate of lime, giving additional hardness to the nail.
Liebig, Organic Chemistry. 
72                PHYSIOLOGY OF THE SKIN.
                    PHYSIOLOGY OF THE SKIN.

  In a physiological point of view, the skin is an organ of sensation,
absorption, and secretion ; in the former capacity it supplies us with
knowledge, affords us gratification, and warns us of the presence of
injurious or destructive  agents;  by  means of the second, it is enabled
to appropriate the fluids contained  in the surrounding medium, and
perform the office of a respiratory organ; and by means of the third,
it provides for its own softness and pliancy, regulates the influence of
temperature, both external  and internal, and acts as an important
depurating organ of the blood.
  As an organ of sensation, it endows us with the function of touch,
of determining the qualities of objects by their properties of resistance,
of extent, and of variety of surface.  It enables us to distinguish be-
tween hard and soft, smooth or  rough, hot or  cold.   And the educa-
tion of this sense, effected by concentration of attention, and increased
powers of appreciation and adaptation, enables the blind to read with
the aid of their fingers, to trace the most minute variations of form or
surface, and even to detect the mysterious tactile differences of colors.
  The sensibility of the skin varies  normally in different parts of the
body;  thus, it is greatest on the  pulps of the fingers, and leas^ 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 per-
ception of a double impression.  Thus, upon the pulp of the middle
finger, the two points were felt when only separated from each  other
to  the extent of one-third of a line; on the palmar surface 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, as, transversely on  the face and front of
the neck, longitudinally on  the fingers, &C.1  The same author has
pointed out  some remarkable instances of differences in the percep-
tion of temperature; thus, he has shown that if the two hands be im-
mersed in'Water of the same temperature, that in which the left is placed
will feel the warmest, while  the  right rs the  most sensitive of touch;
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 the entire
of the other hand; the single finger will suffer no inconvenience from
the heat, while to the hand  it may be insupportable.   For the same
reason, the hand  is better adapted than  the finger to test the  tempera-
ture of a bath before the immersion of the body;  and even then it
may be found that  a heat which is pleasant to the hand may  be in-
tolerable to the  entire  skin.  In pursuing the  investigation of the

     1 I have repeated these experiments, and the results are truly surprising. 
             ABSORBENT FUNCTION OF THE SKIN.           73

diseases of the skin, we find hourly instances in corroboration of these
facts.
  The sensibility of the skin is subject to considerable modification
under the influence of disease;  the natural sensibility may be height-
ened, or it may be diminished, or, again,  it may be altered.   These
changes obviously depend on some modification of the nervous system,
the nature of which is, for the present 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,
tickling, burning, scalding, &c.; and it is to be remarked that these
sensations are more acute  in certain situations than in others, and that
they are simple modifications of common sensation, and have no con-
nection with the special tactile function of the skin ; for example, the
armpits, the sides of the body, and the soles of the feet, are the most
sensitive to tickling, while the  nipple is  comparatively insensible to
the pressure and  friction of clothing, but is highly appreciative of
touch.
  By means of its absorbing  power the skin is enabled to act as a
respiratory 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 epidermis most nearly in con-
tact 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 atmosphere in which he moves.
,  The absorbing  power of the skin,  in  common  with that of the
mucous lining of the  respiratory passages, is actively brought into
play whenever the body has been  exhausted  of its fluids, and becomes
a means of restoring their equilibrium.  A gentleman, who was pur-
suing the practice of the Turkish Bath with great zeal, made at my
request the  following  observations on himself, and  repeated  them
many times  with  precisely similar results—and  I  may observe that
identical results have attended the same experiment when performed
by  others.   On entering the bath he  was carefully weighed,  and at
the conclusion of the bath he was weighed again after having  passed
an hour in a dry atmosphere, heated to 180° degrees; he had lost a
pound in weight.  He then dressed  and returned  leisurely  to his
home, and after the lapse  of two  hours was  again  weighed.  He had
recovered the pound which he  had lost in the bath; he had absorbed
it from the atmosphere, for he had  neither  eaten nor drunk during
the interval.  The fact  is somewhat  startling, and teaches us the
power of opposition which nature creates  to recover an equilibrium
which we too frequently set ourselves wilfully  to disturb.   It is a
powerful  argument against the excessive sweating which the pro-
moters of the dry-air bath have so heedlessly encouraged.  The real
Turkish Bath is a bath of low temperature, about 120°, of which the
atmosphere abounds inmoisture, having rills of water streaming over
its heated floor, and which therefore restores as quickly as it with-
draws  the watery fluids  from  the body—establishing, in fact, a cir- 
74                PHYSIOLOGY OF THE SKIN.
culation in the aqueous fluids of the system, and changing its nature
without altering its quantity.
  When the body is immersed in water of a certain temperature, say
82° of Fahrenheit,1 and a few degrees below, and allowed to remain in
it some time, it increases in weight by absorption of the fluid.  The
fact is proved  by  the experiments  of several  physiologists.  West-
rumb 2 detected ferrocyanate 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  bathed in the Vichy waters.
Other experimentalists have succeeded in discovering coloring matters,
such as rhubarb, in the urinary secretion after  bathing in water con-
taining such substances; and Fourcault observed that birds kept under
water all  but  their heads, until they died, threw up a  watery  fluid
from their stomach.  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 absorp-
tion 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.
  The absorbent property of the  skin is sometimes taken  advantage
of for the purpose of  introducing nutritive matters into the s}Tstem,
and at others for the exhibition of medicinal  substances.  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 additional aid of friction, and, more-
over,  we  select those parts of the skin  in which the epidermis is
thinnest.  The substances  to be  absorbed must be presented to the
skin in a state of solution, or suspension in water or oil; but at the
same  time it may be granted that the quantity taken into the system
is very small.  The exhibition of medicinal substances by friction on
the skin, termed the Iatraleptic method,  is only  adapted for the more
powerful medicines,  and is rarely  employed at the present day, ex-
cepting in the instances of mercury, croton oil, strychnine, <$cc.   The
epidermis acts as  an  impediment to  absorption, and as  such, is an
important safeguard against the admission of injurious and poisonous
substances into  the blood.  Thus we find that it is only after  long
soaking, or by long-continued friction, that we are enabled  to over-
come this natural defence,  and then only to a very  partial extent.
But when  the epidermis  is removed,  the case is altogether 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 introduced 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  medicinal agents, it is necessary to raise a blister in the

                  1 Berthold, in Muller's Arohiv. for 1838.
                  2 Journal Hebdomadaire, No. 7. 
           PERSPIRATORY FUNCTION OF THE SKIN.         75

most expeditious and least painful 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  only  such
medicines can be administered in this manner as produce their effects
in very small  doses, such  as  strychnine, morphine, digitalis,  bella-
donna, lead, mercury, &c.   The absorbent power of the skin is some-
times painfully evinced in the inflammation of the kidneys whic^
follows the application of a blister, in the constitutional effects result-
ing from the absorption of lead,  or in those which succeed the use of
arsenic to ulcerated surfaces.
  An observation made  by Mf. Ceeley1 would  seem to explain the
accidental  absorption  of poisonous substances by the skin, without
abrasion of the epidermis, and to prove that the confinement of its
exhalation is an  important auxiliary.   Thus, he remarks, " I  have
often succeeded in procuring  vaccine vesicles 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 trick-
ling 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
consideration in respect to the prolonged contact of poisonous sub-
stances with  the skin.
  The softness and pliancy of the skin are, in great measure, depend-
ent on the  secretion of the sebaceous substance  which is poured out
on every part of its surface.  This secretion is most abundant in situa-
tions 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  arm-pits,  and in the perineum.   The sebaceous secretion
is an oleaginous fluid, containing water, stearine, oil globules, pig-
ment granules, and salts, together with epidermal cells thrown off by
the parietes of the glands and ducts.  The secretion is modified  in its
qualities in different parts of the body; in  some, by the presence of
an odorant principle;  in others, by a peculiarity in taste or color.  Of
the former is the butyric acid of the perineal region; of the latter,
the yellowish brown and  bitter product of  the sebiparous glands of
the meatus auditorius, the cerumen or ear-wax.   In chemical compo-
sition sebaceous substance consists, according to Esenbeck,2 of
           Fat..........24.2
           Osmazome, with traces of oil .....  12.6
           Watery extractive (salivary matter)    .   .   .  11.6
           Albumen and casein   ......  24.2
           Carbonate of lime  .    .    .     .    .   .   .2.1
           Phosphate of lime.......20.0
           Carbonate of magnesia  ......  1.6
           Acetate and muriate of soda and loss   .    .   .3.7

                                                    100.0

  1 Observations on the Variola Vaccina, in the Transactions of the Provincial Medi-
cal and Surgical Association, vol. viii.
  2 Gerber's General Anatomy, edited by Gulliver. 
76
PHYSIOLOGY OF THE SKIN.
  " The ear-wax is an emulsive compound which contains a soft 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."1
  The function of the  skin as a  regulator of the temperature of the
body, and as a purifier of the blood, is effected by means of  a peculiar
secretion, the perspiration.  When this secretion is eliminated in the
form of an imperceptible vapor, it  is termed  insensible,  and when
condensed or poured out in a fluid  state, sensible perspiration.   The
insensible perspiration is partly derived from  the sudoriparous and
sebiparous  glands, and partly from the natural evaporation taking
place from  the epidermis.  The sebiparous system has not been here-
tofore pointed out as a source of the perspiratory fluid, but frequent
observation has convinced me that 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—making  a  total of fifty-
four ounces for  both, or somewhat more  than  three pounds; while
they set down the maximum at eighty ounces,  and the minimum at
twenty-one ounces.   The experiments of Dr. Dalton furnished  him
with different results, since he attributes  to the lungs an amount of
exhalation five times greater than that of the skin.
  In some experiments made by Dr. South wood Smith2 on the stokers
of the Phoenix Gas Works, it was ascertained that the maximum  loss
of weight in men who had been at work in a high temperature for a
period varying between three-quarters of an hour and an hour and a
quarter, ranged  between 2  lbs.  15 oz. and 5 lbs. 2 oz.—the lesser
degree of loss occurring  on a cold and foggy day—the greater on a
warm, clear, and somewhat windy day; and  that of two of the  men
placed in a bath of 95°, one recovered half a pound in weight in  half
an hour,  and the other lost half a pound in the same space of time.
The general results of Dr. Southwood  Smith's  experiments tend to
show  that  the amount  of perspiration—in other words, of loss of
weight by  perspiration—presents  considerable  variety in  different
men ; that it presents considerable variety in the same individual at
different  times;  that the  subsequent absorption or  recovery of the
lost fluid  presents equal variety ; and  that the amount  of loss is
greater on a warm and clear day than on a cold and foggy day.
  The quantity  of perspiration  is altered by  a variety of circum-
stances which affect the body physically, or  through the agency of the
nervous system.  Of the former kind  are  the  temperature, "current,
and hygrometric condition of the atmosphere, and stimulation of the
skin ; of the latter, excited or depressed nervous powers.   When the
temperature of the atmosphere 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

           1 Simon, Animal Chemistry, translated bv Dr. Day.
          2 The Philosophy of Health, &c. 1S37. "Vol. ii. p. 391. 
SECRETION OF PERSPIRATION.
77
atmosphere pass over the surface in a current, the quantity of perspira-
tion is still further increased, and  the cooling influence is more  felt.
But  if, with the same temperature, the atmosphere be loaded with
moisture, perspiration is prevented, and the heat of the body becomes
intense.  The influence of stimulation in the promotion of perspira-
tion is shown in the effects of exercise, 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 posesses its
highest amount of  activity during digestion, while immediately after
taking food-it is at its minimum.
   The secretion  of perspiration is  also modified  by the greater or less
activity of the other secretions, particularly of the lungs and kidneys,
the functions  of these  organs  being frequently vicarious with the
skin, and vice versa.  Thus, during the summer, and in warm climates,
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 is the case.  On quitting a warm apartment,
especially after  indulging  in  stimulants,  for  the  cold  air, a sudden
check is given to the cutaneous function, while that of the kidneys is
suddenly and actively called into exercise.  The same fact is observed
in certain diseases; thus, the excessive  sweats of phthisis may be re-
garded as  vicarious  of the diminished exhalation  from  the lungs,
while diabetes is accompanied by a remarkably  dry state of the skin.
The  arrest of perspiration again,  from cutaneous disease, is  often
attended with serious congestions of the mucous membranes.
  Of some experiments made by Dr. Lining in South Carolina, on the
relative quantities  of  perspiration  and urine  during the warmer and
colder months of the year,  the results are as follows -}—
                                     Perspiration.       Urine.
          July......86.41    ...    43.77
          May......68.11    ...    56.15
          October.....40.78    ...   46.67
          February.....3*45    ...    77.86
   The influence of the perspiration in regulating the heat of the  body
is strikingly  evinced in the numerous recorded instances of exposure
of the person to elevated  temperatures.  Sir Charles  Blagden sup-
ported a temperature of 260° for nearly ten minutes.  The furnace in
which Sir Francis Chantrey dried his moulds, and which was frequently
entered by his workmen, is said to have been kept heated to a tempe-
rature of 350° ;  and the oven used by Chabert, during his exhibitions
in London, was heated to between  400° and 600°.   The thermometer
placed in the 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 animals when  the heat has  been raised  to  a degree sufficient to
cause death,  has never  exceeded in elevation from nine to fourteen
degrees above the natural standard.2

  1 Dr. Robley Dunglison on Human Health.
  2 It is interesting  to  note, that  in animals made the subjects of these experiments, 
78
PHYSIOLOGY  OF  THE  SKIN.
  The effort which is being made to introduce amongst us a bath
similar to that used in the East, and in some measure resembling the
ancient  bath of the  Eomans,  has afforded  new  illustrations of the
effects of heat upon  the animal  economy,  and of the powers  with
which we are endowed of  resisting its influence.   A temperature of
160°-180° of dry air to the naked skin is inexpressibly agreeable, if
the amount of evaporation from the surface be nicely adjusted to the
degree of  temperature—that is,  if the quantity  of  perspiration be
sufficient, or  somewhat  more than sufficient, to carry off by evapo-
ration every particle of heat which might act unpleasantly  upon the
sensations.  But if the heat be greater in proportion than the quantity
of perspired fluid—that  is, if there be a less degree of moisture of the
skin than  is equivalent to the  carrying off of the excess of heat—
then a slight feeling of chill, as of a breath  of  cold air playing  over
the surface, is experienced, and the skin becomes red, dry, and parched.
Persons who are unacquainted with the cause of this change are apt
to express  their wonder, that while they perspired freely in a lower
temperature, they had ceased to perspire in one that is considerably
higher; whereas, in reality, they do perspire more abundantly in the
higher temperature, but evaporation is  rendered more active by the
increase of heat.
  In a temperature of 250° of dry air, I experienced no inconvenience
for  the first few minutes, whilst evaporation and temperature  were
nicely balanced.   Soon, however, I felt faint and  uncomfortable, in
consequence of the excessive demand  so suddenly made upon the
watery fluids of the body ;  then, also, a chilly feeling seemed to travel
over the surface of the skin, accompanied  here and  there with a dry
parching sensation; the skin  became  dry,  red, and congested; the
heat had evaporated the moisture  of my mouth  and fauces, my throat
felt dry ; there was a dazzled sensation in my eyeballs, as though  from
congestion of its.vessels; then followed a buzzing sound in the  ears,
apparently from the same cause, and at  the end of  ten minutes I was
glad to put an end to  the experiment.
  In  a damp atmosphere the  cooling influence of the perspiration is
necessarily lost;   and the  effects  upon  the system of a prolonged
exposure  to a moist  atmosphere  at a  high temperature have  been
recorded by a gentleman who recently visited the baths of Xero, near
Pozzuoli,  the ancient Posidianaa.   To reach the bath he had to pass
along a narrow, winding passage of about 120 yards in length, and 7
feet high, by about three in  breadth.   A little within the  mouth of
the passage the temperature was 104°  in  the upper strata of the
atmosphere, and 91°  near the ground;  farther on, the air was  filled

the  blood was found in the opposite, position to that which it would have occtlpied
after death from cold.  Instead of being collected about the heart and internal organs,
as in death  ensuing from  the latter cause, the heart was empty, and the vital "fluid
dispersed towards the  periphery of the body, in some instances being actually  forced
out of its vessels into the surrounding tissues.  The blood seeniedto have bee'n killed
by the heat, for it had lost its power of coagulating, and its deep black hue was not
altered by exposure to the atmosphere—a change 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. 
                SECRETION  OF 'PERSPIRATION.              79

with dense  vapor, of a temperature of 118° above, and 1110 below ;
and over  the bath is 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 farther, 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 sensations 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 required
all his remaining power to enable him to hurry back to the open air.
On reaching, the mouth  of the passage  he staggered, and nearly
fainted,  and was very uncomfortable until  relieved  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  repose.  The same  gentleman bore a
temperature of 176° in dry air without inconvenience.1
  The recent experiments of M. Fourcault2 throw considerable light
on the importance to health of the  secreting function of the skin.
These  experiments were  instituted for the purpose of illustrating a
theory of the author, that suppression of cutaneous transpiration is a
potent cause of chronic disease, and especially of scrofula and pulmo-
nary consumption—diseases which he traces to  the conjoint effect of
a cold and damp atmosphere, and the absence of sufficient  exercise to
promote healthy perspiration.  M. Fourcault endeavored to suppress
the action of the skin in animals by means  of an impermeable varnish ;
and, as a consequence of this operation, he caused vicarious congestion
of the  mucous  membranes, and also of the serous membranes and
nervous system.  A horse had intense congestion of the mucous mem-
brane  of the nasal passages and a profuse discharge; sheep equally
suffered with  congestion of the Schneiderian membrane and coryza;
while  dogs were seized with inflammation of the bowels, and enlarge-
ment with congestion of the liver.   The respiration became oppressed
and laborious, and the animal died in a short space of time of asphyxia,
often accompanied  with convulsions. In an animal in whom  only
one side of  the body was varnished, the cutaneous capillaries of that
side were found gorged with dark-colored  blood, while on the opposite
side the blood was of a scarlet hue, and  small in quantity. Jn the
majority of the animals examined after death the veins near the heart
were found distended with black soft coagula, and  in some there  were
ecchymoses in the lungs.   Fourcault found that animals deprived of
their skin survived  longer than  those covered with  varnish; and
reminds us of the poor child, intended to  represent the golden age at
the election of Pope Leo the Tenth,  who,  being covered with gilding,
soon after died from the effects of the process. Becquerel and Breschet

  1  Gazette Medicale, April 27, 1844.         2 Examinateur Medicale, Oct. 1841. 
80                PHYSIOLOGY OF  THE SKIN.
repeating the experiments of Fourcault in reference to animal tempera-
ture, conceived that if they could  prevent transpiration by the skin,
they would induce internal fever; the contrary, however, was the fact.
After the application of a thick layer of varnish upon  the skin of a
rabbit,  and adjusting their thermo-electric needles, they found the
temperature of  the deep  muscles, in the course of half an  hour,
reduced from  100° to 89° ; in another half-hour to 76° ; and in a third
half-hour it stood  at only 3° above the temperature of the atmosphere,
63°; so that, in the course of  an  hour and a half the temperature of
the animal had fallen  34°, and the  creature  died.  Fourcault also
produced albuminuria in dogs by a similar expedient; the first change
perceptible in the  urine  was a diminution of its acid reaction ;  then
albumen became apparent, and at the same time the urine was alka-
line.  He conceives that the  detention of the lactic acid salts in the
blood destroys the equilibrium of  organic affinities, and leads to the
elimination of the albuminous element of the blood.
  The  chemical  constituents of  perspiration are, water, nitrogen,
animal  extract, fat; carbonic  acid with its  salts, carbonates  of soda
and lime;  lactic acid with its  compound, lactate of ammonia; acetic
acid, acetate of soda, butyric  acid,  chloride of sodium, hydrochloxate
of ammonia, phosphate  of soda  and  lime, sulphate  of soda, salts of
potash,  and peroxide of iron.   Anselmino gives the following analysis '
of the dried residue of the perspiratory secretion :—
     Matters insoluble in water and alcohol, chiefly calcareous salts,  .  2
     Animal matter  soluble in water, insoluble in alcohol, regarded by
       Anselmino as salivary matter (?), and sulphates,   .    .   .21
     Matters soluble in dilute alcohol; chloride of sodium and osmazome, 43
     Matter soluble in alcohol, osmazome, and lactates,  .   .    .   .23

                                                          100
  Simon collected the perspiratory fluid from  the arms  and face, and
found it to be a  turbid, dirty-looking  fluid,  which  deposited gray
floccules on standing.  By the microscope these floccules were ascer-
tained to be epidermal cells.   The  specific gravity of the fluid was in
one instance 1003, and in another 1004.  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 vapor of ammonia.  The  results of the investigations of Simon
establish the existence in the normal perspiratory secretion of—
  "Substances soluble  in  ether:  traces  of fat, sometimes including
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: watery extract, phosphate  of lime,
and occasionally an alkaline sulphate.
  "Substances insoluble in water;  desquamated epithelium and (after
the removal of the free lactic acid by alcohol) phosphate of lime, with
a little peroxide of iron." 2

  1 Muller's Physiology, Translation, page 579.
  2 Animal Chemistry with reference to the Physiology  and Pathology of Man. By 
ANALYSIS  OF  PERSPIRATION.
81
  Dr. Landerer  found  urea in healthy perspiration  in  addition  to
phosphates, sulphates,  acetates, lactates,  chloride  of sodium, and
osmazome.1
  Dr. P. A. Favre sums up his researches on the chemical composition
of the perspiration as follows: Its solid components, with the excep-
tion of a trace, are soluble in water; its predominant salt is chloride
of sodium; alkaline sulphates exist in it in very small quantity; alka-
line and earthy  phosphates are barely discoverable; lactic acid is
presented in the form of lactates;  it possesses a peculiar  nitrogenous
acid, sudoric acid, resembling uric acid in its chemical  nature;  the
new acid is combined with alkalies, but uric acid never occurs  ; urea
is present;  there is but little oily or albuminous matter; the latter is
in combination with the alkalies; the  potash is chiefly combined with
the organic acids, the soda with the mineral acids; the composition of
the perspiration obtained under similar circumstances, but at different
periods, is  generally similar;  the  organic salts exceed  the  mineral
salts at the beginning of perspiration, and vice  versd; the proportion
of water to the solid constituents remains the same during the entire
continuance of forced perspiration.2
  Our information with regard to morbid perspiration is  very limited
and unsatisfactory.  Simon made  the analysis of this secretion, ob-
tained from a man who had been the subject of psoriasis vulgaris for
seventeen years; but his results are inconclusive, from the fluid being
in a state of decomposition.  Its specific gravity was 1008;  it smelt
strongly of hydro^sulphate of  ammonia, and gave off,  when evapo-
rated, a penetrating odor of sulphuretted hydrogen, which ultimately
merged  into a nauseous animal smell.  "It yielded 9.9 of solid con-
stituents, 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 little phosphate  of lime, and  a fair  amount of
sulphuric acid."   The  perspiration of "persons with  the itch is said
to have a mouldy odor."   And " according to Stark, the quantity of
free lactic  acid is increased" in certain cutaneous affections.
  The gases of the perspiratory secretion—namely, carbonic acid and
nitrogen—are exhaled  in largest quantity after meals or violent ex-
ertion,  the former  being most abundant  where the food has been
vegetable, and the latter where  the  food has been animal.3   The
quantity of water excreted by the skin bears  reference to the circum-
stances above detailed—namely, the comparative activity of the ex-
haling 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 with
the saliva, or absorbed from the exterior by means of the skin.   Dur-
ing digestion, the oxygen of the atmospheric  air enters into combina-

Dr.  J. Franz Simon.   Translated and edited by Dr. George E. Day, for the Sydenham
Society, vol. ii. p. 103.
  1  Heller's Archiv.,vol. iv. p. 196.
  1  Archives Generates de Medecine, vol. ii. 1853.
  •  Collard de Martigny, in Magendie's Journal, vol. x. p. 162.
       6 
82       CLASSIFICATION  OF  DISEASES OF THE SKIN.

tion 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 skin.  It follows, therefore,
that  the  quantity  of  nitrogen set free in the stomach, and, conse-
quently, 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 carnivora.  The same circumstance must  take place
when any cause exists  which retards digestion.   The quantity of car-
bon 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, irre-
spective 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  odor
of the  perspiratory fluid, while its acid reaction is  determined by the
latter.
                      CHAPTER  II.

         CLASSIFICATION OF DISEASES OF THE SKIX.'

  A GOOD classification of diseases of the skin is one of the first wants
of the student of dermatology, as it is amongst the  first labors which
have engaged the attention of the professors of this branch of medicine
from the earliest to the present times.   The classification which has
heretofore served as the framework of the present treatise, and to which,
fifteen years back, I gave the title of " natural  system," was founded
on the physiology and pathology of the skin, and took as its leading
characters the phenomena  of inflammation of the derma—namely,
congestion, effusion, suppuration,  desquamation, &c.  This classifica-
tion accords in all essential particulars with the arrangement of Willan,
which is the one  pretty universally  adopted  throughout the world at
the present day.  The claims of the Willanean system to general favor
are its simplicity and  convenience; but like the artificial system of
classification of Linnaeus, as applied  to the animal and vegetable king-
doms, to which the same merit is due, it is open to many and  serious
objections;  it conveys no idea of the  nature and cause of the various
forms of disease, and,  consequently,  affords no aid to the comprehen-
sion of their treatment.
   The artificial system of classification of diseases of the skin, or, as
it may be termed, the Teutonic-English system, from its origin with 
         CLASSIFICATION  OF  DISEASES  OF THE  SKIN.       83

Plenck1  and subsequent  amplification and improvement by Willan,
is attractive to the student and superficial  observer, from  its easy
applicability to the discovery of the name of a given disease;  but this
discovery only too frequently results in the  " vox et  preterea nihil."
The tongue that glibly utters the name has no words to tell the cause
or suggest the treatment;  and  the  practical physician is naturally
offended with a system which is all for the  eye and  nothing for the
judgment, which embarrasses rather than helps him to the comprehen-
sion of a correct " methodus medendi."  In the consulting-room or by
the bedside of the patient, he yearns for that fuller knowledge of the
disease, which will enable him to satisfy both his conscience and his
self-respect, by guiding him to a correct  and successful principle of
treatment.  This object is clearly not to be  attained by the  artificial
system;  and  therefore, with many others who have  similarly felt, I
have long turned  my mind  to the construction of a classification of a
more  practical and, I may  add, more philosophical kind,  embracing
the conveniences of the artificial system, with the medical fitness of a
more practical system.
   An etiological system of classification was initiated by Hippocrates,
when he divided diseases of the skin into local and constitutional; and
Hippocrates has been  followed  in his  endeavors by Lorry, Derien,
Joseph Franck, Plumbe,  and more recently by Baumes.2
   Without venturing to comment on the theories which  have served
as the basis of the classifications proposed by these authors, I will pro-
ceed to develop the etiological system which has resulted from  my own
researches into the nature of these diseases, and which, I trust, may, as
an ultimate result, render the treatment of diseases; of the  skin  more
simple and rational, and  remove them from  the  special and isolated
position which they at present occupy into the general category of dis-
eases of the human frame.  Physicians,  no doubt, may still be found,
who, from taste or superior ability, will pursue, and become  eminent
iu, the treatment of these diseases, as a special department; but there
will no longer be a reason for the neglect of their study in the general
education of the physician,  nor need their very existence be  so  com-
pletely ignored, as is at present the case in our general hospitals and
medical schools.
   The great family of diseases of the skin  admits of division into two
primary  groups;  namely—
        I. Diseases affecting the  general structure; and
       II. Diseases affecting the special structure of the skin.
   The diseases affecting the general structure of the skin, or derma
proper, are such as implicate at  once  all the  tissues which enter into
its composition.
  The diseases affecting  the special structure of the  skin are those

  1 Doctrina de morbis cutaneis.  Vienna.  1776.
  2 Nouvelle  Dermatologie ou precis theorique  et  pratique sur les maladies de la
peau, fonde sur une nouvelle classification medicale, &c, par P. Baumes, Chirurgeon
en chef de l'hospice de l'Antiquaille de Lyon, &c, 1842. 
84       CLASSIFICATION OF DISEASES  OF THE  SKIN.
which select its  separate  components, such  as  the vessels,  nerves,
papillas, and pigment; or its special organs—namely, the sudoriparous
glands, sebiparous glands, hair-follicles and hairs, and nail-follicles and
nails.                                                        .
  The diseases affecting the general structure of the skin are divisible
into five groups as follows : namely—
        I. Diseases affecting the General Structure.
           1. Diseases arising from general causes.
           2. Diseases arising from special external causes.
           3. Diseases arising from special internal causes.
           4. Diseases arising from the syphilitic poison.
           5. Diseases arising from animal poisons of unknown origin,
               and giving rise to eruptive fevers.
  The diseases affecting the special structure of the skin are divisible
into eight groups, as follows:  namely—

        II. Diseases affecting the Special Structure.
           1. Diseases of the vascular structure.
           2.         "      nervous structure.
           3.         "      papillary structure.
           4.         "      pigmentary structure.
           5.         "      sudoriparous organs.
           6.         "      sebiparous organs.
           7.         "      hair follicles and hair.
           8.         "      nail-follicles and nails.

  I.  DISEASES AFFECTING  THE  GENERAL  STRUCTURE  OF
                           THE SKIN.

  Returning now  to the  first  of  the primary divisions—namely,
" Diseases affecting the general structure of  the skin"—and taking its
first group, " Diseases arising  from general causes," I  have grouped
under this head seven typical forms of  disease, five of which corres-
pond with as  many  orders of the Willanean  classification—namely,
Exanthemata, Papulae, Vesiculas, Pustula?, and Bullae.
  The term general, as applied to the causes giving rise to the diseases
assembled together in this group,  is  simply intended to convey  a
signification the opposite of special, and to suggest the idea of a cause
originating in the mal-performance of the ordinary functions of animal
life, rather than to include a variety of causes.  Indeed, in my opinion,
the whole of the diseases grouped under  this head proceed from  one
primary and essential cause, namely, mal-assimilation ; in other words,
from an irritant poison generated in the organism of the individual as
a consequence of mal-assimilation, the morbid action in the cutaneous
tissues  being a vital process having for its object the elimination of
that poison by the  skin.1   Arising, then,  from one and the same pri-

  1  It is interesting to glance at the theory of cutaneous disease held by the renowned
physician Riolanus, who flourished three centuries back: Sed cur cutis, tot adeoque; 
CLASSIFICATION  OF  DISEASES  OF  THE SKIN.        85
mary cause, the variety which is presented in the form and condition
of the apparent disease,  is simply the result  of certain phenomena
which are known to modify and alter the character of disease when
it attacks other organs of the body—the result,  in  fact, of  predis-
posing causes, either congenital or acquired.  The divisions belonging
to this group are as follows:—

           1. Diseases arising from General Causes.
a. Erythema,   (exanthemata.)   c. Eczema,            (vesiculae.)
     Pityriasis.                        Psoriasis.
     Erysipelas.                       Sudamina.
     Roseola.                      d. Impetigo,            (pustulae.)
     Urticaria.                      Ecthyma.
                                  e. Herpes,                (bullae.)
b. Lichen,            (papulae.)     Pemphigus.
     Rosacea.                      /. Furunculus,        (tubercula.)
     Strophulus.                    Anthrax.
     Prurigo.                      g. Purpura.
   In the reading of this table Erythema is taken as the type of a
group of diseases, of which erysipelas, roseola, urticaria, and pityriasis
are modified forms—pityriasis being,  in  fact,  simply a chronic ery-
thema.   In like manner, rosacea, strophulus,  and prurigo are varieties
of the type Lichen ;  and psoriasis and sudamina of the type Eczema.
I shall  explain  fully in  its proper place my reasons for  regarding
psoriasis as a form of eczema, in fact as a chronic eczema, and taking
it from a position  which it certainly has  no right  to occupy—by the
side of Lepra.   In an etiological classification, as  compared with the
dermatographic classification or classification  of forms, at present in
use, this change becomes necessary, and will,  I believe, be attended
with no inconvenience.

       2. Diseases arising from Special External Causes.
   The external causes  which tend to irritate the skin  and give rise to
disease are few in number,  being limited  to  the presence of parasitic
animals on, in, or under the skin ; and to the destructive agency of
heat and cold.   Of the class of " diseases affecting the general structure
of the skin," it is in this group  alone  that we meet with affections of
the cutaneous tissue  independent of constitutional origin—in other
words,  pure diseases of  the skin; those  of  the other groups being
essentially blood-diseases, and-depending for their existence on a mor-
bid condition of the vital fluid.   The  representatives  of the present
division are—
Scabies,
Mai is,
Ambustio,
Gelatio.
differentes affectus patitur tarn saepe ut vix ulla audiatur tarn frequens querimonia ?
quia est emissarium commune et sub ea colligitur tertiae coctionis superfluitas omnis :
nisi fuligniosa excrementa per cutis spiracula libere expurgentur, si stegnosis conni-
ventia, densitas, astrictio vel obstructio pororum cutis difflationem impediat quae sub
cute subsistent excrementa, occasionem dabunt morbis cutaneis "  (Johannis Riolani
Ahibiani medici Parisiensis viri clarisimi opera omnia, 1610, p. 548.) 
86       classification of diseases of the skin.
     3. Diseases arising from  Special Internal Causes.
  This is an important group, heretofore intermingled with the general
diseases of the skin, from  which,  in truth, they are totally distinct.
In the  Willanean classification, they are associated with other diseases
of the  general type in the two orders Squamce and Tubercula; by
which means their natural affinities are destroyed, and the'opportunity
is lost of considering their relations to each other, and comparing their
mutual characters.  The diseases constituting this group are,—
                 Lepra,        (squamae,  Willan).
                 Lupus,        (tubercula, AVillan).
                 Scrofuloderma,     "        "
                 Kelis,
                 Elephantiasis.      "        "

       4. Diseases arising from the  Syphilitic Poison.
  In the preceding group the cause is unknown  or merely hypo-
thetical ; in this, on the contrary,  the cause—namely, the syphilitic
poison—is well known and universally recognized.  The laws and
phenomena of the syphilitic poison have been made the subject of
careful investigation, and the  facts established by the observation of
this poison become a guide to the comprehension  of the action of
poisons less known or only suspected, such as in all probability  are
the hidden cause of the diseases assembled in the  foregoing  group.
The forms in which syphilis appears in the skin (syphilo-dermata) may
be classed as follows:—
     a. Erythema,                   c. Tubercula.
        Roseola.                       Tubercula ulcerantia.
                                    d. Rupia.
     b. Lichen,                      e. Alopecia.
        Lichen pustulosus.          /. Onychia.

   5. Diseases  arising from Animal  Poisons* of unknown
        Origin, and giving rise to Eruptive Fevers.
  The  eruptive fevers originating  in special animal poisons—poisons
of which the phenomena  and laws are known, but  whose source is
hidden from our knowledge—naturally form a group by themselves.
These poisons are three in  number, rubeolous, scarlatinous, and vari-
olous, and the diseases proceeding  from them as follows :—
               Rubeola,              -  Variola,
               Scarlatina,               Varicella,
                                        Vaccinia.

  II. DISEASES AFFECTING THE SPECIAL STRUCTURE OF
                          THE  SKIN.

  The  special structure of the skin being  its vessels and nerves, the
sources of its nutrition and innervation ;  its papilla?, which  determine
the character of its surface;  the  pigmentary principle,  which gives
color to the investing cuticle; together with its  glands,  hair,  and 
         classification of diseases  of the skin.       87

nails;—these become so many heads, under which the morbid  affec-
tions of its particular organs may be considered.  Many of the affec-
tions of these special organs are  simply local—in fact, pure diseases
of the  skin, and  removed from  the influence  of the constitutional
powers, and  from the more  important category of blood-diseases,
which  compose the first great division of cutaneous affections; but
some among them take their source  in constitutional disturbance.
The number of the latter, however, is not sufficient to  render the
application of the etiological method of classification to this division
a matter of advantage.  I have therefore adhered, as respects them,
to the physiological system previously in use.
  In the instance of the vascular structure, the  only derangements
which  call for separate consideration are those resulting from simple
enlargement  of the cutaneous  vessels,  especially  the  veins; and,
abnormal increase  of the  capillary vessels, giving  rise to  vascular
naevi.  In the nervous structure the deviations from the standard  of
health  are three in  number, as indicated by excess of sensibility,  or
hyperaesthesia; diminished sensibility,  or  anaesthesia;  and altered
sensibility, or pruritus.   These two groups admit of arrangement  as
follows:—

  1. Diseases affecting the Vascular Structure of the Skin.
         Hypertrophia venarum,           Naevi vasculosi.

  2. Diseases affecting the Nervous Structure of the Skin.
         Hypersesthesia,      Anaesthesia,       Pruritus.

  3. Diseases affecting the Papillary Structure of the Skin.
   The diseases in which the papillae of  the skin are chiefly concerned
are such as result from the enlarged growth, or hypertrophy of those
organs;  they are  represented  by the wart, the corn, and by callosity
and thickening of the cuticle;  and may be grouped as follows:—
               Verruca,                   Tylosis,
               Clavus,                     Pachulosis.

       4. Diseases affecting the Pigmentary Structure.
   Disorded conditions of the  pigment of the skin resolve themselves
into two degrees of development of the pigment as respects quantity,
and one  in which the quality of the pigment is altered.   To these I
have added  that change of color of the skin which  is occasioned by
the internal use of the salts of silver, not from any title it may be
supposed to possess to consideration in this place,  but simply for con-
venience.  It thus forms a fourth head under the  name of "Chemical
Coloration of the skin."
                    a. Augmentation of pigment.
                          Melanopathia,
                          Spilus,
                          Naevi pigmentosi, 
88       classification  of diseases of  the skin.
                    b. Diminution of pigment.
                          Alphosis,
                          Leucopathia,
                    c. Alteration of pigment.
                 Ephelis,             Chloasma,
                 Lentigo,             Melasma.
                    d. Chemical coloration.
                    Decoloratio argentea.

       5. Diseases affecting the Sudoriparous Organs.
  The disorders of perspiration are,  like those of the pigmentary pro-
duct,  reducible to three, namely, excess,  defect, and  altered quality;
as follows:—
                    a. Augmentation of secretion.
                          Idrosis.
                    b. Diminution of secretion.
                          Anidrosis.
                    c. Alteration of secretion.
                          Osmidrosis,
                          Cbromidrosis,
                          Haemidrosis.

            6.  Diseases of the  Sebiparous  Organs.
  The disorders of the sebiparous  organs are somewhat  more com-
plicated and numerous than-those of the sudoriparous glands, as may
be inferred from their greater size and more extensive function.   They
are not alone referable to the three states of excess, defect, and alter-
ation  of secretion; but also involve the phenomena of impeded ex-
cretion and inflammation  of  the gland  extending  to  surrounding
tissues.  They  may be grouped as follows:—
                    a. Augumentation  of secretion.
                        Stearrhcea simplex.
                    b. Diminution of secretion.
                        Xeroderma.
                    c. Alteration of  secretion.
                        Stearrhoea flavescens,
                        Stearrhcea nigricans,
                        Ichthyosis sebacea.
                    d. Retention of secretion.
          (Duct open.)                       (Duct closed.)
          Comedones,                    Tubercula miliaria,
          Accumulationes sebaceae,        Tumores serosi,
          Cornua.                        Tumores sebacei.
          e. Inflammation of the gland and adjacent textures.
                             Acne.

          7. Diseases of the Hair and Hair-Follicles.
  The abnormal and morbid conditions of the  hairs and hair-follicles
are numerous, being partly referable to modifications in quantity, di-
rection, and color of the hair, and partly to disease involving chiefly 
CLASSIFICATION  OF  DISEASES OF THE SKIN.       89
the hairs themselves or the follicles in which they are produced.  The
following arrangement will embrace the whole of these aberrations:—
a.  Augmented formation.
    Hirsuties,
    Naevi pilosi.
b.  Diminished formation.
    Defluvium capillorum,
    Alopecia,
    Calvities.
c.  Abnormal direction.
    Trichiasis ciliorum,
    Trichiasis coacta.
d. Alteration of color.
     Trichosis decolor,
     Trichosis cana.
e. Diseases of Hairs.
     Trichosis furfuracea,
     Trichosis plica.
/. Diseases of Hair-Follicles.
     Stearrhcea folliculorum,
     Erythema folliculorum,
     Inflammatio folliculorum,
     Sycosis,
     Favus.
        8.  Diseases of the Nails.and Nail-Follicles.
  The disorders of the nails and nail-follicles  are referable to altera-
tions in  the growth and  texture of the nails, both of which states may
be included under the term " degeneration;" and inflammation followed
by suppuration of the matrix of the nail or onychia; thus,
                     Degeneratio unguium,
                     Onychia.
  In a tabular form, this classification will stand as follows: —
I. Diseases affecting the General Structure of the
1.   Diseases  arising
from General Causes.
a.  Erythema, (Exanthemata,
   Erysipelas,
Skin.
Willan)
	Roseola,	
	LTrticaria.	
	b. Lichen,	(Papulae, Willan)
	Strophulus,	
	Prurigo.	
	c. Eczema,	(Vesiculae, Willan)
	Sudamina.	
	d. Impetigo,	(Pustuke, Willan)
	Ecthyma.	
	e. Herpes,	(Bullae, Willan)
	Pemphigus.	
	/. Furunculus,	(Tubercula, Willan)
	Anthrax.	
	g. Purpura.	
2. Diseases arising	Scabies,	
from Special External	Malis,	
Causes.	Ambustio, Gelatio.	
3. Diseases arising	Lepra,	(Squamae, Willan)
from Special Internal	Lupus,	(Tubercula, Willan)
Causes.	Scrofuloderma, Kelis,	
	Elephantiasis.	-
 
90      CLASSIFICATION  of diseases  of the skin.
  4.   Diseases arising
from  the  Syphilitic
Poison.
  5.   Diseases arising
from Animal Poisons
of unknown origin, and
giving rise to eruptive
Fevers.

II. Diseases affecting the
1. Vascular structure.

2. Nervous structure.
3.  Papillary structure.

4.  Pigmentary structure.
5.  Sudoriparous organs.
6. Sebiparous organs.
      a. Erythema,
         Roseola.
      b. Lichen,
         Lichen pustulosus.
      c. Tubercula,
         Tubercula ulcerantia.
      d. Rupia.
      e. Alopecia.
      /. Onychia.
      Rubeola,
      Scarlatina,
      Variola,
      Varicella,
      Vaccinia.

the Special Structure of the Skin.
      Hypertrophia venarum,
      Naevi vasculosi.
      Hyperaesthesia,
      Anaesthesia,
      Pruritus.
      Verruca; Clavus;
      Tylosis;  Pachulosis.
      a. Melanopathia,
         Spilus,
         Naevi pigmentosi.
      b. Alphosis,
         Leucopathia.
      c. Ephelis; Lentigo;
         Chloasma; Melasma.
      d. Decoloratio argentea.
      Idrosis;  Auidrosis ;
      Osmidrosis;  Chromidrosis;
      Haemidrosis.
      a. Stearrhcea simplex.
      b. Xeroderma.
      c. Stearrhcea flaveseens,
         Stearrhoea nigricans,
         Ichthyosis sebacea.
      d. Comedones,
         Accumulationes sebaceae,
         Cornua,
         Tubercula miliaria,
         Tumores serosi,
         Tumores sebacei.
      e. Acne. 
GENERAL PATHOLOGY  OF THE  SKIN.           91
7.  Hair-follicles and Hair.      a. Hirsuties; Naevi pilosi.
                              b. Defluvium capillorum,
                                 Alopecia; Calvities.
                              c. Trichiasis ciliorum,
                                 Trichiasis coacta.
                              d. Trichosis decolor,
                                 Trichosis cana.
                              e. Trichosis furfuracea,,
                                 Trichosis plica.
                              /. Stearrhcea folliculorum,
                                 Erythema folliculorum,
                                 Inflammatio folliculorum,
                                 Sycosis;  Favus.
8.  Nail-follicles and Nails.      Degeneratio unguium; Onyshia.
                      CHAPTER  III.

              GENERAL PATHOLOGY OF THE SKIN.

  Regarding the skin with the view of understanding and arranging
its pathological phenomena, we find it to present, in the first place, a
general superficies; secondly, a glandular apparatus; thirdly, a cover-
ing of hairs;  fourthly, an epidermal  investment, including  the nails,
and  a pigmentary structure; and fifthly,  vessels and nerves.   The
superficies is the most extensive of these parts, and that especially in
which the first great division of cutaneous diseases, namely, diseases
affecting the general structure of the skin, is developed ; it will therefore
be necessary to define exactly what should be comprehended under
this  term.
  By general  superficies is to be understood  not only the apparent
surface of the skin, but also  that portion of the surface which forms
the vascular walls of the follicles and excretory ducts of glands.  The
depth to which this latter portion extends is variable, but  may be
supposed to cease before reaching the actual structure of the glands."
Thus, although appertaining anatomically to the glandular apparatus
of the skin, the superficial portion of the follicles and of the glands,
together with their outlets the pores, belongs, in a pathological point
of view, to the superficies.
  In considering the pathological phenomena of inflammation of the
superficies, we find erythema, or simple vascular congestion; lichen,
or congestion  of the pores and superficial portion of the follicles,  pro-
ducing a tumid state of those parts, and constituting pimples ; eczema,
a vascular  congestion, accompanied  by effusion of liquor sanguinis,
lyinph, or  serum, and giving  rise  to  vesicles;  impetigo, a  similar
pathological condition, resulting in the production of  pus and pustules ;
and furunculus, vascular congestion, with loss of vitality  of a part 
92           GENERAL PATHOLOGY  OF THE  SKIN.
of the structure of the skin.  The first four of these pathological states
are, as we have  already seen, the basis of the dermatographic, or
Teutonic-English  classification.   They are the exanthemata, papulae,
vesiculae, and pustuloe  of  Plenck and  Willan; and  the congestive,
depositive, effusive,  and suppurative  inflammation  of my own early
classification.
  Now, as simple inflammation is capable of,  and is the active agent
in, producing these several morbid conditions  of the skin, we are not'
surprised  at  finding that they  are mutually convertible;  that  an
erythema, for example, may become a lichen  by the  development of
pimples, an eczema by the evolution of vesicles, or an  impetigo  by
the production of pustules.  In the  same manner,  the pimples of
lichen having subsided, the lymph or ichor of eczema being dried up,
and the pus of  impetigo exfoliated in crusts, there may remain behind
a chronic erythema, to which  another  term,  namely, psoriasis,  has
been applied.
  Therefore, in essential  nature, erythema, lichen,  eczema,  impetigo,
and psoriasis, are simply modified manifestations of inflammation of
the skin, corresponding with recognized stages of common inflamma-
tion ;  the  modifications resulting from intensity, cause, and idiosyn-
crasy, in  other words, from accidental  conditions.   Let me  illustrate
this position by reference to a common and well-known inflammation
of the skin, scabies, occasioned  by a known  cause, namely, a local
irritant, the acarus scabiei.  If we imagine an entire family affected
with this  complaint, what shall  we find in its  various members ?   In
the father, with a sturdy constitution and firm skin, hardened  by
labor, we  shall probably  find erythema and  lichen;  in the mother,
with a woman's idiosyncrasy, we have erythema, lichen, and eczema;
in her little  girl, a delicate child,  erythema, lichen, eczema, and
impetigo,  and so  on for  the rest.  I have verified this  observation
many  times over.  It  is  one  beyond  dispute or  doubt, and must
necessarily lead  to  the  conclusion,  that  although,  in  their fully
developed state, erythema, lichen, eczema, impetigo,- and  psoriasis,
are strikingly dissimilar, yet in their pathological nature they may
be and are essentially the same.
  Let  me take another line of argument.  A medical man is called
to a case of  inflammation  of the skin; he recognizes an erythema;
he visits his patient the next day, it  has become  an eczema; he at
once regards the erythema of the day before in its true light, namely,
as a stage of  inflammation.  Instead of an eczema the second day, he
might have found a lichen or an impetigo.  But supposing, as is often
the case,  that the pimples of lichen have subsided, probably been  lost
in the general thickening of the inflamed portion of skin, that all trace
of vesicles and pustules is gone, but  that a chronic  state of inflam-
mation, accompanied by  its usual signs, redness, thickening, exfoli-
ation  of cuticle, perhaps chapping, continues—what is the case now ?
obviously chronic erythema, or  psoriasis. Therefore,  I repeat, an
erythema may be, according to the period at which it is viewed, or in
obedience to accidental  circumstances,  an erythema, a lichen,  an
eczema, an impetigo, or a psoriasis. 
GENERAL  PATHOLOGY OF THE SKIN.
93
  In endeavoring to show the analogy subsisting between the morbid
affections of the skin and the common source of  those I have already
enumerated, it must not be  supposed  that I undervalue the distinc-
tions  which at present exist between them.  I should  be  as little
inclined to dispute the propriety of the terms, helix, antihelix, tragus,
antitragus, &c, applied to parts of the external ear; but I can only
regard them in the same light, namely, as serving to facilitate descrip-
tion, to enable us to fix with certainty the point of discussion, to assist
diagnosis and prognosis, and in an equal degree to determine a prin-
ciple of treatment.   But it would be difficult, with the above expla-
nation before  us, to consider them  as essentially different  diseases,
and more so as separate orders, or genera, or even  species of disease;
the utmost rank they can aspire to, is that of varieties of manifestation.
  The light in which I have hitherto placed the typical  forms of
inflammation of the superficies of the skin, is the one most favorable
to their consideration as  separate diseases.   I have now to remark,
that they are seldom found perfectly  distinct;  for  example, erythema
is generally present in combination with the others ; and furthermore,
the united presence of lichen  and eczema, of lichen and  impetigo, of
eczema and impetigo, is among the commonest phenomena  of cutaneous
disease.  Indeed, so frequent are these unions,  that they have been
thought worthy of celebration by special names ; for example, eczema
impetiginodes, impetigo eczematosa, &c.; so that,  not only are  the
forms of erythema,  lichen, eczema, impetigo, and psoriasis convertible
into each  oth.er, but they  are also Yery frequently found in conjunc-
tion.   How, then, any longer can we admit them to be separate orders
or genera of disease ?
  But this is not all the illustration of which the subject  admits.   In
the same attack of eruption, the form of disease is different in different
regions of the body, a difference resulting from the particular organi-
zation of  the part.   For example, on the scalp true papulae are never
seen, and vesicles  very rarely.   On the  hands, and  especially  the
fingers, vesicles  and pustules are frequent;  but  on the rest of the
surface of the body lichen is the common type.  So that,  in a general
eruption  occurring upon the entire body, the diagnosis would  be
erythema in one part, lichen in another, eczema in a  third,  possibly
impetigo in a fourth, and  psoriasis in a fifth.  Now, if we conceive a
disciple of the schools brought in presence of a patient so affected, he
would  gravely  inform us  that  he  saw  five different  and distinct
complaints belonging to five different orders of disease, and possibly,
to complete the absurdity, he might think it necessary  to  prescribe
five different modes of treatment: whereas, in a practical  point of
view, there is but one disease, an inflammatory eruption, exhibiting
on various parts of  the body the five usual modes  of manifestation of
cutaneous inflammation, and all  amenable to the same treatment.
  The  term Erythema (t^vdrma, rubor)  is  well  chosen to express
inflammatory redness of the skin without pimples,  vesicles, or pus-
tules.  The  redness is more or less uniform, and is  produced by simple
congestion of the cutaneous vessels.  The inflamed part is but slightly
swollen, excepting  where  effusion of serum into the tissues of the skin 
94           GENERAL  PATHOLOGY  OF THE SKIN.

has taken place,  constituting  oedema.   It  may be  acute  or  chronic.
The former terminates by subsidence of the  redness and exfoliation
of the cuticle; the latter,  from long  continuance, produces deeper
changes—the skin becomes thickened  and hard, cracks in the direc-
tion of the lines of  motion,  constituting chaps  or rhagades,  and
throws off a copious furfuraceous desquamation.   It is  to the latter
state  of chronic  erythema  that  the  term psoriasis  is  properly
applied.
  The term Lichen (uwyv, summae cutis asperitas) is applied to that
form of roughness of  the skin which results from the development of
pimples (papulae).  The pimples of lichen, in their pathological nature,
are a state of congestion and thickening of  the walls of the excretory
ducts  of the skin;  both the congestion and thickening tending to
raise the pores above the level of the general surface, and constitute
pimples.  In its simplest form, where there is not much congestion of
vessels, lichen is not to be distinguished  from the cutis anserina, pro-
duced by muscular contraction of the skin, and desertion of the capil-
laries  by its' blood.   In its more congested form, the papules are
redder and larger than those of cutis anserina.  The papules of lichen
are never found upon the scalp, the palms  of the  hands, or  soles of
the feet;  in the former situation, probably because the pores are large,
more firmly retained in place from their relation to the hairs, and the
skin between the pores more susceptible of the congestive action.  In
the latter, they  do not occur, in consequence of the thickness of the
cuticle.  The papules of lichen vary in size in different regions of the
body and at different periods of life; they are small and hard on the
trunk and limbs, in the adult;  large and soft on the face; and also
large and soft in infants, in whom they are  termed strophulus.  When
a lichenous  papule is  examined with a lens, its summit is found to be
whitish and transparent—an appearance which results from the cone
of transparent cuticle  which occupies the mouth of the dermal follicle.
This appearance has been mistaken for fluid, and the summits of such
pimples have been described as vesicles containing  serum.   The true
vesicle requires no such nice observation; it  is a fair blister, of small
size it is  true, but never so small as to require the aid of a lens for its
discernment.
  Lichen terminates, like erythema, in subsidence and cuticular exfo-
liation ; the latter action being kept up for a considerable time when
the eruption is chronic.
  Such are the  characters of simple lichen; but a  more severe form
exists,  to which the term lichen agrius (<*y$ios,  fierce) has been given.
In lichen simplex, the papules are isolated,  and unattended with much
erythema ;  but  in lichen  agrius, the papules are congregated so as to
form a cluster  of greater or less  extent; the heat and itching are
intense;  the erythema excessive; and there is, moreover, an oozing
of an ichorous fluid from the surface,  the ichorous secretion being
abundant when the  inflamed  surface is rubbed  or scratched.   In
almost every smart attack of lichen,  patches  of lichen agrius occur;
or they may be found separately, and independent of a general erup-
tion of lichen.  Here, then, we have imported into  lichen, essentially 
             GENERAL  PATHOLOGY OF THE SKIN.           95

an eruption of dry pimples, a new element, namely, an ichorous exu-
dation;  in  other words, the eczematous element; and lichen agrius,
with a more definite nomenclature, becomes  lichen ichorosus, or lichen
eczernatosus.  Sometimes the ichorous secretion becomes purulent, and
small pustules are developed around the  inflamed patch;  in which
case the term lichen impetiginodes might not be inaptly applied. Then,
after a time, the inflammation subsides, the ichorous exudation is no
longer produced, but the affected skin remains thickened, is uneven,
from the presence of numerous cracks and  fissures, and coated with
thin cuticular scales, which are constantly thrown  off by exfoliation,
to give place to a new succession  of  similar scales.  The case is now
one of psoriasis; the papules have long since subsided and  ceased to
be apparent,  and the pathological  aspect is  that of a circumscribed
erythema with thickening of the skin, more or  less fissured  with
cracks and chaps, and coated with  little flakes or scales of  dried cuticle,
—a chronic erythema, in fact, which in cutaneous pathology is known
by the name  of psoriasis.
  Eczema (}x&<-> ; exferveo, to boil out, or  seethe) is the  term applied
to the development of small vesicles on the skin, in combination with
more or less of erythema.  The term does not mean simply to  com-
pare the small vesicles with the bubbles of a  seething or boiling fluid,
but also to take  into consideration the heat  accompanying  that pro-
cess; "Eas ix&pata, ab ebulliente fervore, Graeci vulgo appellant," says
JEtius.   Now, in essential nature, eczema  is  the same as  lichen,
accompanied  like lichen with more or less  of erythema,  the vascular
congestion, as in lichen, being most intense in the walls of the excre-
tory ducts  of the skin, and the vesicles being formed chiefly at  their
outlets or pores.   The  difference  between eczema  and lichen is not
one  of cause, but of manifestation—the difference of manifestation
being chiefly  due to difference  of  temperament and sex.  Eczema is
more common in females than in males, in the sanguine and lymphatic
than in the choleric and nervous temperaments.  Eczema,  moreover,
is never present without lichen, and only becomes eczema  when the
vesicles are in excess  over the papules.  Eczema  may also have a
mingling of the pustules of impetigo, or the ichorous contents of its
vesicles may become purulent; in either  case it ceases  to be simple
eczema, and is then eczema impetiginodes.
  The phenomena which I have pointed  out as  subsisting in lichen,
and  determining the transition of lichen  simplex into lichen agrius,
are also  demonstrable  in  eczema.  Eczema may exist as isolated
vesicles,  or vesicles  few  in number, without inflammation—-eczema
simplex.  Eczema may  be accompanied  by much  inflammation—
eczema rubrum.   The  ichorous secretion of eczema  may become
purulent, and pustules  be developed  in the midst of the  vesicles—
eczema impetiginodes; and eczema may pass  into  a  chronic stage,
marked  by dull  redness, a thickened and  chapped state of the skin,
and the production of cuticular scales—into  that state, in fact, which
is denominated psoriasis.
  In the consideration of lichen, I remarked that the summits of the
papules have  a certain transparency, occasioned by  an accumulation 
96           GENERAL  PATHOLOGY OF THE SKIN.

of epidermis, a mere anatomical character; and that this transparency
has suggested the idea of their containing fluid, and has led to their
being punctured with a fine  instrument, to  determine whether such
were the case.  Now,  the  true vesicle is not a doubtful appearance ;
it requires no rigid  examination, no exploration  by the needle or  the
lens ;  it is a little bladder, perfectly appreciable by the eye.  It is true
that it varies in form, being conical  when  it occurs singly on  the
summit of a papule,  as in  scabies, and semispheroidal  where  the
effusive action is more general.  At first  it involves the periphery of
a pore;  by degrees vesicles  are formed  on the derma between  the
pores, and  it is no uncommon thing to  see the cuticle raised  up to
some  extent, as, for example, completely  around a finger, or for  the
space  of an inch or more of the surface of the skin.  The vesicle is no
longer uni-locular;  it has become multi-locular.   If the inflammation
subside, the effused fluid may become absorbed or evaporated, and the
raised, and consequently  dead cuticle, thrown off' by desquamation.
Should the inflammation be kept up, and the quantity of effused fluid
increase, the  softened  cuticle will burst, and come  away  in  flakes,
leaving behind  it the inflamed and uncovered derma, moistened by a
colorless lymph or ichor, which is poured  out in considerable quantity.
In this latter state the separate vesicles are lost, as are the  papules in
lichen agrius, and the  diagnosis must rest on the excoriation of surface
and the abundant effusion of  ichorous fluid—in  fact, upon characters
which equally belong to lichen agrius.
  Impetigo, derived, according to Pliny, ab impetu, a bursting forth
with violence, conveys nothing in its name of the signification which
we are in the habit of attaching to it, namely, a pustular eruption.   It
is an inflammation  of  the skin, attacking primarily, like  lichen and
eczema, the mouths of the follicles, and giving  rise  to an effusion of
pus, in  place of the ichor or lymph of eczema.   The pustules  are
small, sometimes not  bigger  than the vesicles of eczema; at  other
times, and especially on the  scalp, larger, and sometimes, by conflu-
ence, spreading over a considerable surface.
  Impetigo is a rarer  affection than eczema, and in its pathological
nature differs from eczema rather  in  the pyogenic  tendency of  the
constitution than in any  more essential character.   It is, in fact, a
pustular eczema, just as eczema is an ichorous lichen, and the latter a
papulous erythema.  Impetigo presents, also, another character, which
is common to it with  lichen  and  eczema; it has its "fierce" form, in
which there is  great  redness, some tumefaction of the skin, but es-
pecially the secretion of an  abundance of colorless lymph, which is
often  poured forth  in such quantities as to saturate all the coverings
applied  to it.  In this state, and taking  the ichorous secretion as  the
essential character of  eczema, this form  of the disease, this impetigo
ichorosus, has been called impetigo eczernatosus, just as the term eczema
impetiginodes was  suggested  by  the occurrence of eczema  in a pyo-
genic  habit of constitution.
  Furunculus (furere, to rage) is a term intended to express a higher
degree of inflammation of the skin than the " boiling" of eczema, or
the " impetuous bursting forth " of impetigo, and carries us back to a 
            GENERAL THERAPEUTICS OF  THE SKIN.          97

period when  mode of development, appearance, or  immediate effects,
formed the basis of nomenclature.  In its pathological nature, furun-
culus, or boil, is an  inflammation of a small portion of the skin, slow
in progress, but intense in operation, and resulting in the gangrene or
mortification of a portion of the cutaneous tissue.   The  part of the
skin especially attacked, and the primary seat of congestion, is the
vertical portion of the superficies, that-, in fact, which constitutes the
wall of the excretory duct; and  to this  circumstance may probably
be attributed the mortification of the part primarily inflamed.   Con-
gestion is necessarily accompanied by swelling, and swelling producing
pressure  of the  follicle, impedes  circulation  through its vessels, and
determines the mortification which  follows.  The gangrene of furun-
culus, therefore, is not a  consequence of specific inflammation, but
simply of the anatomical structure of the part inflamed.   The morti-
fied part is the core (coeur) of the boil; it is separated from the living
tissue like any other mortified part, and is eventually thrown off".
   The size of the boil is determined, firstly, by the nature of the cause ;
and  secondly, by the  extent of the surface inflamed; it may  be a
single excretory duct;  it may be several excretory ducts  lying  adja-
cent to each other; or it may be the excretory apparatus of an exten-
sive surface, giving rise to an anthrax, or carbuncle.   Anthrax (a.vBpo.%,
a burning coal), or carbuncle, is, therefore, an aggregation of furunculi,
a furunculus agrius, and its  severity has reference  to the consequent
multiplication of morbid action; it bears to  furunculus  the same re-
lation that lichen agrius bears to simple  lichen, or  eczema impetigi-
nodes to simple eczema.
                      CHAPTEK  IV.

            GENERAL THERAPEUTICS OF THE SKIN.

  Diseases of the skin present  themselves to our notice  in the two
states, acute and chronic; at the three periods of life, infancy, manhood,
and old age; in different temperaments,  normal and abnormal; in
persons of different idiosyncrasy and diathesis; and in different con-
ditions of vigor or debility of the constitution.  These diversities in
the degree of the disease and in the power of the individual constitute
so many grounds of modification both of the material and strength of
the treatment which should be applied;  while other sources of modi-
fication are met with in  the  season of  the year, the locality of the*
disease, as upon the scalp, the palms of the hands, the face, &c.r and
other special conditions appertaining to this class of diseases.
  The treatment of cutaneous diseases  divides itself naturally into
constitutional and local, and in all the degrees  of acute or chronic, we
shall have to consider these two parts of our treatment.  These  two
divisions of the subject are the medical  and surgical  practice of the
       7 
98          GENERAL  THERAPEUTICS OF THE  SKIN.

therapeutic art, the physician and surgeon of the medical  profession;
so that, in the treatment of diseases of the  skin, the physician and the
surgeon must be blended.  The two great branches of medical art are
so nicely balanced in the management of these diseases, that it becomes
difficult to say which is the more important; the constitutional treat-
ment is greatly  assisted by local attention;  and the local treatment
would be almost useless without constitutional aid.  If I were required
to discard either, I  would retain the constitutional power, and carry
cutaueous diseases into the realm of the physician—in defiance of the
ancient rule that gives to surgery all that can be reached by the eye
and by the hand, and to medicine that which is internal and occult.1
The etiological principle of classification naturally  develops this view
of the mutual importance of  the two branches of  the  therapeutic
management of cutaneous diseases; it regards these affections as issu-
ing from  an unhealthy  condition of the  blood, as being  essentially
blood DISEASES, and not local or skin diseases.  The skin disease is the
mere symptom, the tell-tale of the disorder of the  blood; and to the
experienced eye, it not only tells of the existence of disturbance, but
it likewise tells the cause of the disorder and how that disorder may
be removed.  The local  disease in this sense becomes so powerful an
aid to the  interpretation of the general state of the constitution, that
I believe it quite possible by the mere visual examination of the erup
tion, the rest of the patient being concealed by a screen, to declare
the diathesis of the individual, and to  give a general but  accurate
detail of his entire  medical history.  Cuvier*determined the natural
characteristics, the form, the history of an animal, from a bone; the
experienced dermatologist may do as much in regard of the constitu-
tion of  his patient, by the inspection of an eruption.
   Cutaneous disease, however acute, rarely calls for depletion by Iofs
of blood, either  by  the lancet or by leeches;  however, there  can be
no objection to the removal  of blood, if the general  fever run high,
and the severity of the constitutional  disturbance seem, in the judg-
ment of the  medical man, to warrant the measure.  Diseases of mal-
assimilation are  generally diseases in which the powers of the consti-
tution are weakly,  and moderate purging, with effervescent  salines,
which combine with their refrigerant power a diaphoretic and diuretic
action, are usually all that is needed to subdue the fever of the blood.
   The best  remedies of this class are the mildest, namely, the  salts of
magnesia, soda, and  potash, either separately or in combination; the
compound extract of colocynth, with blue  pill, ipecacuhan, squills, or
guaiacum; and as effervescent salines, the liquor  ammoniae acetatis,
sesquicarbonate  of  ammonia,  citrate  or tartrate of potash, spiritus
aetheris nitrici, and antimony.
   When the acute stage has passed, we must  have recourse  to tonics,
bitters with the  mineral acids, bitters with alkalies, with  or without
the ferruginous salts, as the haemic or anaemic condition of the patient
may  determine.    Every physician  has his favorite  remedies; as  a

  ' Riolanus observes:  "Cutanei enim morbi non minus ad  medicum quam ad
ihirurgum pertinent, im6 frequentius de illis consulitur medicus quam chirurgus." 
GENERAL  THERAPEUTICS OF THE SKIN.         99
workman has his favorite tools, and an artist his favorite bfHshes and
tints, so I may be permitted to declare in favor of particular remedies;
of these are gentian, in combination with nitro-muriatic acid ; sulphate
of quinine with  sulphuric acid;  sulphate of quinine with compound
infusion of roses and sulphuric acid, with or  without the addition of
sulphate of magnesia; infusion of quassia with sulphate of magnesia
and sulphuric acid; gentian or calumba with bicarbonate of potash or
soda; citrate of quinine and  iron ; citrate of iron in effervescence;
tincture of the hydrochlorate  of iron with gentian and the  mineral
acids or with phosphoric acid; tincture of the acetate of iron with the
mineral acids; liquor cinchonae with sulphuric acid; the trisnitrate of
bismuth with  soda or potash, &c.
  In chronic affections of the  skin the presence and  effects of mal-
assimilation are more or less obvious ; the complexion of the patient .✓
is muddy, yellowish, and discolored; the eye  is dull;  the  vessels of
the conjunctiva being  sometimes turgid  and sometimes anaemic; the
tongue is broad, pale, flabby, and indented by the teeth; the mucous
membrane of  the  mouth  and fauces is relaxed; the muscles of the
whole  body are soft;  the heart is  weak,  easily excited to palpitation ;
there is more or less dyspepsia, as indicated by acidity of stomach, flatu-
lence, sinking before  taking food,  and pain or distension afterwards;
often there is  weight and uneasiness in  the right  flank from torpid
colon; the bowels  are sometimes relaxed,  sometimes confined; the
urine is sometimes loaded, but mostly pale and  abundant; there is a
general feeling of languor and lassitude, inaptitude for exertion, men-
tal or physical, and depression of spirits.  And yet, with these symp-
toms, or at least with some of these symptoms present in a greater or
less degree, the patient will declare himself perfectly well in health—
a declaration which simply amounts to " I eat, drink, and sleep;" he
forgets to add, But I do all imperfectly, and I  have no  real enjoyment
of life ; as  a steam-engine I act when the fire is lighted and the steam
up ; but  I am  in want of new sockets, new bolts, and an abundance of
oil to rub off the rust,  and ease my movements.
  In these symptoms we see the operation of  a mal-assimilation, of a
cacochymia, which must, before long, lead to  the destruction  of the
patient unless presently arrested.  In a few  words, there is mal-diges-
tion, mal-conversion,  and mal-appropriation  of the food taken  to
sustain life; and the blood recruited from this disturbed and unhealthy
source becomes loaded with  morbid products, in the shape  of salts,
coloring principle, and fluids.  If we follow  this impure, this contami-
nated  blood through  its course,  we shall find the organs which  it >
supplies injured in their physical state and weakened in their function.
The muscular system  becomes soft and feeble, the heart participates,
and the foundation is laid for disease of that  organ, with all its painful
train of  consequences.  The brain and nervous system suffer in an
equal  degree; the brain, irrigated with  mudded blood, can  develop
none but muddy ideas ; the intellectuality of the man is deranged, his
mind depressed, and a state bordering on insanity, in fact, the prompt-
ings to suicide are at hand.   Dyspepsia may be a trifling affection in
itself, mal assimilation may be but a  small matter when considered 
 100        GENERAL  THERAPEUTICS OF THE SKIN.

 apart;  b#t when these conditions, the authors, so to speak, of cutane-
 ous disease, are viewed in relation to their consequences, they may be
 ranked among the most serious of the bodily infirmities of man.
   It may be argued, that the occurrence of these changes in the blood
 has been  wisely provided for in the structure of man, by the creation
 of certain organs whose function it is  to purify the blood, to eliminate
 from the  blood its noxious  components, to act the  part of  emuncto-
 ries. This is  quite true; the lungs, the liver, the kidneys, the bowels,
 the  skin,  are  all emunctories, and all-sufficient for the purposes  of
 health,  but insufficient, as is well known, for the necessities of disease.
 Indeed, even for the offices  of health, it is an  essential condition that
 these organs  should themselves be healthy;  but  as  they, like  the
 muscular  system and  brain, are  irrigated  with  impure blood, they
 also, like  those organ=, lose  their vigor  and  their power of perform-
 ance of their proper functions, and finally fall into a state of disease.
 Hence,  when need is greatest relief is  weakest; the  source of help is
 enfeebled, and possibly may fail completely.  It does not follow that
 all the emunctory organs should give  way at the same moment; they
 become exhausted by degrees, and yield up their powers in succession.
 For a while the liver performs its office actively, and keeps off  the
 pressure from  the other emunctories;  perchance the kidneys, in addi-
 tion to their own, do part of the work of the rest; or may be,  the
 mucous membrane of the small intestine takes on the duty of a safety-
 valve, and by  an inordinate  secretion  from its surface, constituting a
 permanent diarrhoea, maintains the equilibrium, not of health, certainly,
 but of  a state  of existence which often passes for  such—a spurious
 currency.
   Now, let us consider  the  state of the human system thus loaded
 with morbid humors, thus impoverished in its power of eliminating
 them from the blood.  A " casus belli," in the  shape of a disturbing
 cause, takes place; it may be mental emotion, muscular exertion more
 than common, a cold wind, a shower of rain, wet feet, some error of
 diet.  The organism, in a state of health, has the power of  resisting a
 disturbing cause of considerable intensity; but now, in the condition
 before us,  enfeebled by the poisonous  state of its own blood, it yields
 before one of an apparently trivial  kind.  The  immediate effect of the
 disturbing cause is to depress the nervous energies ; elimination, before
 retarded,  becomes  suspended, accumulation of morbid humors  to
 excess  follows, and the organism  is for the moment  overwhelmed.
 For an instant Nature staggers  under the sudden load, but quickly
 afterwards reaction ensues; the "vis vitas" collects all its strength  for
 one great  effort to expel from the blood its morbid burden; the morbid
 matter is driven to the surface, causing congestion, and forced elimina-
 tion commences.  We may ask what determines the seat of the con-
 gestion?  to which the  answer  is plain—temperature, season, age,
 idiosyncrasy, previous  debility or disease, the predisposing or the
 exciting cause. In  the cold  seasons of the year, the morbid humors,
 driven  for elimination upon  the mucous membrane of the lungs, may
 occasion bronchitis; in warmer weather they may be precipitated  on
the mucous membrane of the alimentary canal, causing  diarrhoea; 
GENERAL  THERAPEUTICS OF THE SKIN,        101
under the influence of moral excitement, the result may be apoplexy;
or, in other states of the system, gout, rheumatism, or neuralgia;  or,
in the absence of, or even in association with any of these, the seat of
elimination may be the skin, and the result an eruption of erythema,
lichen, or eczema.
  In the treatment of acute  disease of the skin, the principle is, as
we  have seen, to subdue the feverish  excitement, to neutralize and
eliminate the morbid salts.   In chronic disease, and in  the  chronic
stage of acute disease, all this must be done, and at the same time  the
powers of the system must be kept up; in other words, we must con-
join with an antiphlogistic,  neutralizing,  and eliminating plan,  an
invigorating or tonic treatment.   Sometimes  we meet with instances
of depression of the animal powers from simple  accumulation  of
morbid humors, in which case simple elimination by purgative medi-
cines strengthens the entire frame, and that which might be presumed
to lower, actually heightens the power of the patient.  At other times,
and more frequently, we are early made aware that the disease is one
which, in popular language, is ascribed to " poverty of  blood," and
our tonic system must begin from the commencement of treatment.
  Let us suppose a patient suffering from  chronic cutaneous disease
sitting before us; and  pen in hand, we proceed  to draw  up the pre-
scribed course of treatment;  what are the indications to be fulfilled ?
They are firstly, to eliminate; secondly, to restore power; thirdly, to
alleviate the local distress. To eliminate, we  must secure the proper
action  of the bowels, liver, kidneys, and skin.  To restore power,  we
appeal to tonics, which we usually conjoin with eliminants. To allevi-
ate the local distress, we resort to local means.  We will consider  these
indications, with our means to fulfil them, in detail.
  To eliminate, our remedies are purgatives;  but in the use of these
agents, we must endeavor to  imitate the operations of  nature, who
works always by gentle means.   Our purgatives must be efficient, but
mild; the colocynth pill, for example,  with  blue pill, to secure the
discharge of the bilary secretion;  henbane, to prevent pain from the
action  of the pill;  and soap, to secure its solution.  Sometimes, to
effect a more decided excretion from the mucous membrane, we may
add to the compound colocynth pill, ipecacuhan, or squill; or some-
times, simply soap.   In certain constitutions, a pill composed of the
watery  extract  of  aloes, with a bitter extract, such as  gentian  or
chamomile, acts better than the  colocynth  pill; sometimes the  com-
pound rhubarb pill, and sometimes a scruple of guaiacum,  with ten or
fifteen grains of the bicarbonate of potash,  or a drachm of the bitar-
trate.  The best time for the exhibition of the aloetic and rhubarb
pill is immediately before dinner, and for #ie colocynth  pill and
guaiacum, at bed-time.  They should be continued through the cure,
unless contra-indicated by any unpleasant effect produced upon the
patient;  and  they  should be taken  daily or  less frequently,  as may
seem  most desirable.   It must, however, always be  borne  in mind,
that the safety of the patient demands, before  the local  excretion is
checked, that a  drain  in a  more  natural direction, and of  a more
natural  kind, should  be established  to supply its  place.  For this 
102        GENERAL THERAPEUTICS  OF THE  SKIN.
reason, I make elimination the first and most prominent of the indica-
tions to be fulfilled in the treatment of cutaneous diseases.
   To restore power is an indication which  must be attempted concur-
rently with  elimination.   While  the  latter  carries off  the morbid
humors the former is intended to give tone to the assimilative organs,
and secure a supply of better and more wholesome nutritive fluid.  The
old material of the  organism is to be swept  away, while new and
sounder  material is added in  its  place.  Under this head  we have to
consider tonic  mediciues and a  proper system of diet.  We exhibit
tonics on the one hand, while on  the other, we keep up an active move-
ment of the excretions by means  of laxatives and purgatives.  We may
select nervo-tonics, such as quinine or quinine and iron;  tonic-elimi-
nants, such as gentian combined with potash; or tonic-alterants,  such
as gentian with  the  nitro-muriatic acid.   These remedies  may  be
administered twice or three times in the day;  the simple tonics, nervo-
tonics, and the gentian and nitro-muriatic acid, an hour before meals;
the tonic alkalies three hours after meals.  If the rheumatic, the gouty,
or the lithic  acid  diathesis be present, a preference  may be given  to
the tonic alkalines; but as alkalies, long continued, weaken the crasis
of the blood, and lower the tone of the system,  their effects should be
watched, and as soon  as any  lowering  action is discovered, they  must
be suspended, and their place supplied by invigorating tonics.   The
nitro-muriatic  acid will often eliminate the  morbid fluids,  without
being open to  the objection of lowering the tone of the  system, and
hence may be  substituted advantageously for the alkalies, even  from
the outset of the treatment, and before the lithic acid diathesis has been
, corrected by other means.
   The diet most suitable for cutaneous diseases, and especially those of
a chronic kind, is a nutritive animal  diet, moderate in quantity, but
sufficient for comfort as well as mere necessity.   A judicious blending
of animal and vegetable food for  breakfast; namelv, meat,  ham, bacon,
eggs, butter and  bread, with tea, or cocoa made  from the nibs, not
exceeding a single breakfast cup, aud abstinence from sugar.  Coffee
is more heating than tea, and a check to the active operations of nutri-
tion,  and therefore not so good;  but if taken, it should be so without
sugar, or with as little sugar as possible.  For the mid-day meal (lunch
or dinner, as the case may be), meat, vegetables, and a moderate amount
of sherry with water, soda-water, or seltzer-water, or any simple  spirit
in  place of wine, such as  brandy or whisky.  Malt  liquor is objec-
tionable, from the large quantity of sugar which it contains;  but  other
vinous drinks which coutain  no sugar, or a minimum of sugar, may
be taken,  if preferred, such as Bordeaux, Rhenish wines, and dry
Champagne.  Pudding* and tarts are prohibited, with the exception
of plain suet pudding; the whole family of light puddings are indiges-
tible  and detestable.   For the third  meal of the day (dinner, tea, or
supper), the  second  meal may be repeated, the fluid taken with  the
 meal being like that of the previous meal,  or simply tea without sugar,
or with the minimum of sugar, as already mentioned.  Sometimes  the
third meal of the day is a simple cup of tea, or two small cups, and to
this, provided  sugar be avoided, no objection  can  be made.  When 
            GENERAL  THERAPEUTICS OF THE SKIN.        103

this is the case, a fourth meal succeeds (dinner or supper), the compo-
nents of which have be,en already considered.  There are certain arti-
cles of diet against which  an unfounded objection prevails, and others,
with as  little reason, which  are popularly received with favor.   Ham,
salted meats, and vinegar fall into the  first category; water-cress into
the last.  Ham and salted meats, at the present day, are so little injured
as articles of diet by the process of preserving, that I cannot conceive
any objection to their occasional use; certainly more good would result
from  their being taken, if the appetite  urged in their favor, than harm
from  their supposed toughness  and indigestibility, or from the qi an-
tity of salt which they might be thought to contain.  The salted meats
of the present day are not the salt junk  or salted  pork of the time of
Anson's great voyage round the world, when his men were exhausted
with  scurvy, from their exclusive dependence on those articles of food.
Vinegar is  antiseptic,  and an aid to digestion: in some constitutions,
it produces flushiugs of the face, and nettle-rash ; but this is an excep-
tion  to  the  rule, and, as an article of diet, vinegar may  be pronounced
to be perfectly wholesome.   I oannot speak  so favorably of pickles,
which came under the designation of crude vegetable matter, which is
certainly indigestible and difficult of assimilation.  Salads are of this
class, and especially that singularly-favored and supposed antiscorbutic,
the water-cress.   The only redeemable quality of the water-cress is its
pungency, which  gives warmth to the  stomach;  the mustard and cress,
on the  same principle, give their medicine to the salad, but the  salad
is only rendered  less  innocuous by large quantity of aperient  oil of
olives which it should contain.  Potatoes  may  be ranked with objec-
tionable articles of vegetable diet, and  should be taken only in extreme
 moderation.
   We  now come to  local  remedies, which  may be divided into two
classes—those which simply defend the  eruption from  external irrita-
 tion, and those which stimulate and  produce  an alterative action in
 the skin.   Of the former kind are water-dressing, fomentations, certain
 lotions, and certain ointments; of the  latter kind are other lotions
 and  ointments.   The  water-dressing, acting as a poultice, facilitates
 the relief of the congested vessels of the skin by  promoting secretion,
 and  is  suitable to the early stages of the disease.  But water dressing,
 too long continued, destroys the tone of the skin, and retards the cure;
 and  the moment must be watched when this remedy  has performed
 all the good of which it is capable, to change it for  another, which
 will  continue the good that has been already commenced.  Fomenta-
 tions, either of plain water or decoction of poppy-heads, may be used
 separately  or in  conjunction with water-dressing; they relieve heat
 and  pain, and facilitate excretion by the skin.  The lotions of a cool-
 in°-  and  soothing kind are—the spirit lotion, lead lotion, emulsion of
 bitter almonds with hydrocyanic acid, &c.  But against all lotions an
 exception  may be entered  from the first;  for a time, and during ap-
 plication, they are agreeable and  useful;  but when the surface dries
 up, the stiffness, uneasiness, and distress return, and are even greater
 than before.   For this reason I rarely make use of lotions as soothing
 or protective remedies.   In the next degree to lotions comes a lini- 
104         GENERAL THERAPEUTICS  OF  THE SKIN.
rnent of oil and lime-water, such as is kept for scalds and burns, which
may  be used either alone or in  combination with  liquor  plumbi or
tincture of opium.  Among ointments of the soothing class are, simple
cerate with liquor plumbi, simple  cerate with camphor, the calamine
ointment, and the oxide of zinc ointment.
   When  first I commenced  the  treatment  of diseases of  the  skin,
water-dressing  had just  been  introduced, and suddenly became  the
surgical fashion of the day, while a general  outcry was raised  against
ointments—" greasy applications," as they were contemptuously called.
Finding that in practice it was impossible to contrive any substitute
for ointments, in the treatment of these diseases, and being  unable to
discover any cause for the objections raised  against  them by my con-
temporaries, I set myself to inquire into the possible reasons of their
disrepute.   This was soon ascertained;  they were  ill-prepared, long
kept, and,  in  many  instances,  so rancid  as  to act as irritants and  ag-
gravators of the disease.   On  the other hand, when properly prepared
and perfectly fresh,  ointments are all that can be desired as local appli-
cations.  Again, it is to be remembered that a cutaneous eruption, by
virtue of the inflammatory congestion which exists, is an  actively
oxidizing surface, and ointments perfectly fresh when applied, are apt,
by absorption of oxygen, to  pass  quickly  into  a state of rancidity.
Hence we have not only  to regard the purity of the  ointment in  itself,
but also its tendency, when applied to the  inflamed skin, to deVelop
those acids of decomposition which constitute the rancid state.   Thus
the same ointment, according to its state of freshness  or  otherwise,
may be a soother, or an irritant of the most mischievous kind,  when
applied to  the skin.  The power of gum benjamin  in preventing de-
composition in ointments is an important discovery, and is now pretty
generally adopted  by our London chemists.   This  gum, in a state of
powder, added to the melted lard in the proportion of ten grains to the
ounce, the ointment being  subsequently filtered through paper, not
only serves to preserve the ointment for a  much longer time than it
would otherwise  remain fresh, but also  gives it an agreeable odor, a
condition of some importance where an  application is required  to be
kept on the skin during the period required for cure.*

  * Mr. Julius Schweitzer, in a paper published in the " Chemical News" for August,
1860, on the Unguentum Zinci, details the history of  the parent of the oxide of zinc
ointment, the ceratum de lapide caliminari of Daniel Turner, the Turner's  Cerate of
the present time.  The lapis caliminaris is, as  he explains, a native carbonate of zinc  ;
but, being often made of impure materials, and  adulterated to please the eye and
seem like the original, the cerate fell into disrepute, and oxide of zinc was substituted
in place of calamine.  The next difficulty was  the procuration of a pure oxide of zinc  ;
the old process afforded a very imperfect article, mingled with carbonate of zinc, and
even with sulphate : " The Pharmacopoeia of 1836 published a process which produces
a pure anhydrous oxide, differing  from a,ll  the former compounds by its greater
density, slight  buff color, and far greater purity."   Again, the eye test  and public
prejudice did their best to deteriorate this  substance ; and, but for the efforts of Mr.
Redwood, might have succeeded.  The buff color was thought to indicate impurity,
which is not the  case ; but  happily an experienced manufacturer, Mr. Hubbuck,
stepped in and supplied an equally pure white oxide ; so that we have now two oxides
of equal purity, and only differing,  to all appearance, in their tint of color.  I have
always given a preference to the ointment made with the buff oxide, without knowing
why; but Mr. Schweitzer, in his remarks, helps us  to an explanation.  " Fats and 
GENERAL THERAPEUTICS OF  THE  SKIN.         105
   The  benzoated oxide  of zinc ointment, properly prepared, is  the
 most  perfect  local application  for  all  chronic  inflammations of  the
 skin that  is  known.   It is cleanly and agreeable, of a cream  white
 color, not diffluent and oily like other ointments; and it has a tendency
 to concrete upon the  skin, and constitute  an artificial  cuticle to an
 irritated  and  denuded surface.   It is rendered further  acceptable to
 an  inflamed and  heated  skin by the  addition  of spirits  of wine, in
 the proportion  of a drachm to the  ounce; or, if  preferred, spirits  of
 camphor.   The  mode of application of this and other ointments is a
 matter  for attention ;  it should be gently  smeared upon the eruption
 with the finger, or, if  the diseased skin be too  tender, with a camel's
 hair brush, smeared  so as to distribute it in a moderately  thick layer
 over the whole  of the affected part, to  introduce it into all the cracks
 and hollows that may be present, and to insinuate it as much as possible
 under  any  crusts  that  may have formed  on  the disease.   Once
 properly  applied, it will loosen  the  crusts and prevent further crusts


 oils," he says, " when in contact or mixed  with metallic  oxides, soon  turn rancid, a
 circumstance which gave dispensing chemists a great deal of trouble with seemingly
 quite simple and  unimportant  articles of their stock, namely, a few ointments,
 amongst which  the unguentum zinci, the most  delicate and  nicest looking, may well
 be said  to be the principal one.   All animal substances  will only keep good for a
 limited space of time, and such preparations as pomatums and ointments may fairly
 be said  to be subject to  certain deterioration by age ; nevertheless it  was a well ob-
 served fact, that  some of the French pomatums retained their original sweetness for
 an almost unlimited space of  time, the cause of which  was long a mystery desirable
 to be ascertained.  At last it became known that this property was due  to an addition
 of gum benzoin, or  benzoic  acid, a proceeding which in  one instance we had already
 adopted.  In  the preparation  of  those singular looking  little  bottles of pomatum
 known under the name of ' Pomade divine,' amongst a  host of other ingredients, we
 are directed to digest gum benzoin with the fat at a gentle heat  for about forty-eight
 hours.  But it was left to the late Mr.  Bell to draw our attention particularly to the
 preservative property of the gum benjamin, of which he proposed to avail himself in
 the  preparation  of an unguentum zinci benzoatum.  This  proposition was eagerly
 accepted, and medical men and chemists will still remember Mr. Bell by this, one of
 his last improvements in pharmaceutical chemistry—the unguentum zinci benzoatum.
  " This  ointment is made by selecting the  best and most fragrant gum benzoin, the
 so-called benzoin in tears ; this, when comminuted, is added to good fresh lard, in the
 proportion of ten grains to the ounce, and  the whole digested in a water bath for
 about forty-eight hours ; this, subsequently strained, is used for the  preparation of
 the benzoated zinc ointment.
  " In making this  ointment with two oxides of zinc, a difference of reaction will be
 observed between the oxide made by  combustion and  that made  according to  the
 Pharmacopoeia, which, slight  as  it may be, deserves  nevertheless  some attention.
 The  buff-colored oxide of the Pharmacopoeia seems ready and speedily to amalgamate
 with the benzoated lard, so much so as sometimes to impart to the whole still warm
 fluid a certain consistency, which in far greater degree becomes more observable when
 the ointment is  cold.  Subsequent experiments showed that the  seemingly lighter
 oxide of  combustion resists with greater effect  the influence of weaker acids, while
 the dense oxide of the Pharmacopoeia is readily  dissolved by them.
  " This chemical difference is in all probability the cause of the different behavior
 of these two oxides when used for the unguentum zinci  benzoatum.  Benzoic acid is
 readily dissolved by fats and oils ; and in digesting the gum for some  time with  the
 lard, this acid, as well as the aromatic principles, impregnates the  fat, and sub-
sequently acts on the sine.  How far this greater susceptibility to weak acids may be
by itself a beneficial application to a wound is a surgical question ; but it is a well-
known fact that many of  the most skilful and  eminent surgeons always prefer the
buff-colored zinc ointment to the perfectly white  one made with the new oxide of zinc
of combustion." 
106 •       GENERAL THERAPEUTICS  OF THE  SKIN.
 from collecting, while  it serves the several purposes of a new cuticle
 to the  abraded skin, a water-dressing, and a barrier  to  the rapidly
 oxidizing action always present in  inflammation.  If secretions are
 poured out, the eruption may be wiped, but not washed, and a fresh
 application  of  the ointment may be made morning and night, or  as
 often as the  previous layer of ointment has been disturbed or displaced.
   If we look upon an ointment  when applied in this  way to the skin
 in its true light, we shall  see that  it presents  conditions and advan-
 tages which no other local  application  possesses;  and we cannot but
 arrive at the conclusion that it is a most valuable remedy, and one for
 which  no equally  efficient  substitute can  be found.   It  is  light,
 produces no pressure,  is thin as a  film of varnish, and  yet  excludes
 the air from the inflamed part, thus preventing desiccation and  oxid-
 ization, and it  retains the ordinary  moisture of the skin, acting, as I
 before remarked, as a water-dressing, or natural poultice.  Moreover,
 it in no way interferes with  the use, at the same time, of other local
 applications which may be thought necessary, such as the evaporating
 lotion,  fomentations  or poultice. I  make it a  prominent part of my
 directions, that the morbid part should not be  washed after the  appli-
 cation of the ointment:  it may  be wiped with a soft  napkin as much
 as may seem  necessary;  but when  the  ointment is  once applied, it
 should not  be  removed by washing without good reason.
   The stimulant and alterative local remedies  are lotions containing the
 bichloride of mercury, lotions of bicarbonate of ammonia, acetate of
 ammonia, vinegar, creasote, sulphuret of potash, kc, and ointments of
 the  salts of mercury, tar, creasote, sulphur,  &c.  The  intention  of
 these  applications is expressed  in  their title; they  are intended to
 stimulate in various  degrees, to set up  a new action, to restore the
 tone of exhausted  nerves,  and establish an  alteration of function;
 hence the terms stimulant  and alterative.  The lotion of bichloride of
 mercury in emulsion of bitter almonds, in the proportion of from one
 to three grains to the ounce, is an  admirable  stimulant in cases  of
 torpid  skin, such as impacted  sebaceous follicles of the face, excess
 of oily secretion, and acne, and is also useful in pruritus.  The lotions
 of acetate of ammonia, vinegar,  creasote,  and sulphuret of potash, are
 also excellent  remedies for relieving  pruritus.   As a stimulant appli-
 cation  for  chronic erythema and eczematous or  lichenous  psoriasis,
 there is  no better remedy than the unguentum  hydrargyri nitratis,
 diluted more or less according to the amount of stimulation required
 to be effected; it is also  admirable  in that chronic affection  of the
 eyelids, psoriasis palpebrarum.   For chronic  erythema  or  pityriasis
 of the scalp,  T prefer the unguentum hydrargyri  nitrico-oxydi as
 being a more  cleanly  application ;  and for a similar  reason, i" some-
 times give a  preference  to the unguentum  hydrargyri  ammonio-
 chloridi.  The questions,  to soothe, or not  to  soothe, to  stimulate, or
 not to stimulate, often press themselves on the  attention of the medical
 man, and he must be ready to decide these questions when they arise.
 Not unfrequently, the credit of the physician turns upon his decision
■ in these simple matters—simple, it  is  true, only in the abstract;  for
 they may be  of vital importance to the patient.  I have seen cases 
GENERAL  THERAPEUTICS OF THE SKIN.         107
wherein the mere omission of a too stimulating or an irritating appli-
cation has been followed by a rapid cure; and the medical man  who
ordered such a remedy has consequently fallen  in the estimation of
his patient.  On the other hand, I have seen cases in which a stimulant
boldly used has brought about an immediate cure.   The tact of the
practitioner lies in the being able to determine which of the two is
the proper course.  In chronic  affections of the skin, it often occurs
to us to see medical men, thwarted by some obstinate disease, have
recourse to a method which cannot be too strongly condemned, namely,
that of trying  a succession of  remedies;  and if  they be  new and
unknown, perhaps foreign, they seem to have an additional charm.
The word try implies doubt, uncertainty, experiment;  and the question
arises, what right have we to make experiments of unknown  remedies
upon our patient ? and  which of our  patients shall we select for the
purpose ?  These are serious questions, and questions that appeal to
the religio medio'.  To try a succession of soothing remedies where we
have determined that the indicator points to soothing, is legitimate ;
to try graduated stimulants when the soothers have  failed, is  also
correct; and to try a succession of stimulants, equally so.  But to try
like a man in  despair, catching at this or that,  whichever may come
first into hismind, without a settled principle of action, is unscientific
to medicine and dishonest to our patient.  It is this which  gives rise
to the frequent instances we meet with, of a succession of changes of
treatment  without plan, without order, and even without  the  time
necessary to determine  the  effects of the varied means;  whereas,
were the selection of a remedy judicious,  and the principle of its
selection sound, the practitioner  would but have to carry it  out  with
patience and discretion, to insure an ultimate success.
   Next in order to  mercury,  I must place sulphur as a cutaneous
remedy of the class of stimulants;  the simple sulphur ointment of the
pharmacopoeia, either alone  or with the addition of camphor—the
unguentum sulphuris hypochloridi  compositum — an  old remedy,
revived and much used  by  myself, and  the iodide of sulphur  oint-
ment.   The use  of  sulphur in  scabies, as  a destroyer of the acarus
scabiei, is generally  recognized, and the  simple ointment is  perfectly
adapted to this use.  The compound sulphur ointment is an unneces-
sarily violent remedy for that purpose, and  I have never had occasion
to use it.   It must always be borne in mind that sulphur is a stimu-
lant, and if continued too long, or used too largely, will become an
irritant also, giving rise to erythema,  lichen, and even to an eruption
of pustules.  Hence the apparent perpetuation of scabies in the  eyes
of those who see in that disease only an eruption of papules, vesicles,
and  pustules.  But because sulphur is the remedy for  scabies, it would
be absurd to fall into the error of supposing that all eruptions suscep-
tible of cure by the use of sulphur are therefore scabies.  I note this
error because I have seen it committed, and therefore  caution the
practitioner against it.  Where, as  in a chronic  inflammation of the
skin of long duration, such  as  chronic erythema, pityriasis, or psori-
asis, the obvious indication is a stimulant or discutient, then the sul-
phur ointment  is a good and effective remedy, and  in this capacity 
108        GENERAL THERAPEUTICS OF THE SKIN.
may be placed by the side of the mercurial ointments. Hence, sulphur
may be found to cure many varied infirmities of the skin, when the
stimulating element is the one required.  In scabies it is specific; in
other affections it is simply an individual member of the class of stimu-
lants.  The same remarks apply to sulphur in other forms, and nota-
bly to the sulphur vapor bath. I  have seen sulphur ointment applied
to the inflamed skin in a case of eczema  rubrum, and worse than that,
in a case of eczema impetiginodes; a stimulant to an organ in a state
of acute inflammation,  as if the general  principles  of medicine and
common sense were to be wholly abandoned, because the case was one
of skin disease.   Such errors, it is to be hoped, will not be repeated.
Again, in  a case which especially calls for a stimulant application—
namely, acne—both the  indurated and the rosaceous kind, the ungu-
entum  sulphuris hypochloridi compositum is an excellent remedy.1
  It is not sufficient in medicine to possess  a good remedy,  it is also
necessary  that  we should  know  how to employ it.   To know the
remedy is a qualification that  belongs to the science of medicine; to
know how to use it is an attribute of the art of medicine; and in prac-
tice the former  avails little without the  latter.  A bad remedy, judi-
ciously used, is often more  advantageous than a good  remedy abused
in its application; and the experience of daily medical life shows that
much of this want of  practical knowledge  subsists among us.  The
skilful workman may effect his purpose  with bad tools;  but the un-
skilful one  will  fail even  with  the  best.  Indeed, the success of a
medical man, his reputation as a healer or a theorist, a learned theo-
rist maybe, turns upon this talent of application of science to the pur-
poses of art;  to know it and to do  it are not synonymous; and in
exerting myself to create a new school of cutaneous medicine, I am
anxious to make doers in preference to mere knowers.  And this, as
an introduction to the use of the  hypochloride  of sulphur ointment.
In the application of a soothing  ointment, such as that of the benzo-
ated oxide of zinc, the contact with the inflamed part should be gentle,
yet sufficient to reach all the vacuities and interstices of the surface;
but  in the case of a  stimulant,  the combination with the remedy of
another form of stimulation, namely, friction, is not undesirable. This
remark applies equally to all stimulant  topical remedies which may
be increased in their stimulant properties to almost  any degree by the
addition of friction.  Thus, in a case of chronic indurated  acne, I
recommend the affected skin to  be rubbed  with  a  towel before the
application of the hypochloride of sulphur  ointment, and the latter
to be afterwards rubbed into the skin  with a certain amount of fric-
tion.   This  is to be done  at  bed-time,  the ointment left in contact
with the skin during the night, and  well washed off" with soap and
water in the morning.   The iodide of sulphur, as  an ointment, con-
taining from ten to twenty grains of the salt to the ounce, is a cuta-
neous stimulant applicable to several chronic affections, and especially
to sycosis.

  1 The formula for this ointment and other special formulae, referred to in the course
of the work, will be found in the " selected formulas" at the end of the volume. 
GENERAL  THERAPEUTICS OF THE SKIN.        109
   Tar has long enjoyed a reputation in cutaneous diseases, both as
a specific internal remedy and as a local application.   In the former
capacity  we may defer its consideration for the present, and  only
regard it as a local remedy.  The forms in which it is chiefly known
to us are—tar-water, the unguentum  picis liquidae  et nigrae of the
London Pharmacopoeia; the Barbadoes tar, or naphtha; the juniper
tar, or oil of cade; and creasote.   The tar  ointments  of the  pharma-
copoeia are stimulant and antiseptic; and  are mostly  used in chronic
affections of the scalp, and for a class of patients where nicety and.
refinement are  matters of secondary moment.  The tar-water, Barba-
does  tar, and  creasote, are also stimulant and antipruritic; but the
most  elegant of  these remedies is  the juniper tar, for which, in the
shape of ointment,  a formula will  be found  among the  " selected
formulae" at the end of the volume.  The juniper tar is  also made appli-
cable to pruritus of the skin, in the form of an ointment.  In that  most
distressing of all the forms of pruritus, namely, pruritus pudendi, the
juniper tar ointment has proved mo-re successful than any other remedy
with  which I am acquainted.
   Having said thus much on the general remedies applicable to dis-
eases  of the skin, let us now proceed to the consideration of one which
enjoys  a reputation of a specific kind—namely, arsenic.  Arsenic is
known  to us as a tonic, as a corrector of mal-assimilation, as a stimu-
lant of  the nervous system, and as a stimulant also of the surface of
the body, both  cutaneous and  mucous; in other words, an  alterant-
cutaneous tonic.  Educated on the banks of the Thames, where  ague
is endemic, I have been in the habit of administering arsenic from my
boyhood, when quinine was a  luxury too  costly for the agricultural
laborer and parish pensioner.  Arsenic at that time  enjoyed a  high
reputation as a  tonic and anti-periodic, and properly administered, was
as safe a remedy as bark or quinine; my further experience of arsenic,
spreading over many years, is equally in its favor; and administered
with caution, in proper cases and at the proper time, I believe it to
surpass every  other  remedy known.   It is a power as simple, as
manageable,  and  almost as certain, as the steam-engine, and  to my
thinking is one of the most valuable of the  therapeutical possessions
of medicine,  ranking, in this respect, with  opium and  quinine.
   While vindicating  thus warmly the claims to respect of an excel-
lent medicine,  I would  equally strongly  declaim against its abuse.
It is known to be useful in cutaneous disease, and therefore it has  been
used in all cutaneous affections;  it is admirable in certain stages of
some, and tlje only known remedy in one particular disease; and yet it
has been administered indiscriminately in all stages of these diseases,
and almost without any principle to determine its preference.   This
is a melancholy abuse, disgraceful  to our colleges, and disgraceful to
the profession of medicine, and ought to have a speedy end.
  Arsenic is  rarely administered at the present day in its crude form;
the Asiatic pill1  is  the only preparation  of the arsenious acid  that
occurs to me.   When sulphur first obtained its reputation for the  cure
1 Vide"Selected Prescriptions." 
110        GENERAL THERAPEUTICS  OF THE  SKIN.

of diseases of the skin, it was wont to be taken in its raw state, wherein
it is found to contain a certain amount of arsenic.   But since sulphur
has been submitted to the refiner, and the arsenic is withdrawn, its
virtues as a cutaneous medicine have ceased, and  it is scarcely used
now but as a popular remedy.  The preparations of arsenic at present
in use,  are—the arsenite of potash;  arseniate of soda;  arseniate of
ammonia; arseniate of quinine; Fowler's solution, namely, solution
of the arsenite of potash;  De Valangin's solution, namely, the liquor
acidi arseniosi hydrochlorici, vel liquor solventis mineralis; the  potas-
sio-tartrate of arsenic; iodide of arsenic; and Donovan's solution, or
the liquor hydriodatis hydrargyri et arsenici.  These different  forms
have each their different conveniences to the prescriber ;  the combina-
tions of arsenic with the alkalies and hydrochloric acid are well adapted
for administration with meals;  the arseniate of soda may be given in
powder or pill;  the arseniate of quinine and iodide of arsenic are also
suited to administration by pills; and Donovan's solution is an  useful
combination of iodine and mercury with arsenic.   Formulae for these
preparations will be found at the end of the  book.  Those which I
principally employ are, Fowler's solution, De Valangin's solution, the
arseniate of soda, and  Donovan's solution.
  The standard  dose of arsenic in skin  affections is five  minims of
Fowler's solution, equivalent  to ^th of a grain of solid  arsenic or
arsenious acid, and the frequency of  its administration is three times
a-day, making the daily dose  amount to  |th of a grain, about one
grain a-week, or four  grains a-month.  In this dose, which is as large
as is ever required for cutaneous  disease,  the remedy may be taken.
without inconvenience for months, and even for years.   In mention-
ing its medicinal properties, I have said that it is a stimulant  to the
mucous membrane, a stimulant to the nervous system, and a general
tonic; and to these effects I may  add, that it  is a local irritant when
brought in contact with the mucous membrane: exciting  in this latter
capacity, pain, spasmodic  griping, and  nausea.   The  art of  using
arsenic  with advantage is to escape  its  inconvenient effects, and en-
courage such as are favorable to our purposes.  To avoid nausea, we
administer the remedy in its  most simple form,  and with  as little
offence to the stomach as possible; thus  we distil our five drops into
the fluid which our patient takes with his meal, or, better  still, we drop
them on a piece of bread, and require that the bread should be eaten
with the meal; and to  render them still less objectionable, I am in the
habit of prescribing a liquor potassae arsenitis, in which the tiucture of
lavender is omitted; the flavor of the latter being inconsistent with
our intention of soliciting the favor of the stomach.  Again, to  insure
exactitude of dose, I prefer to combine with the arsenical solution some
simple fluid, such as the tincture of ginger, in the proportion of three
parts to one, so that the dose becomes magnified to twenty drops, and
the chances of error of dose diminished in equal proportion.   Some-
times the convenience of the patient is met, by combining the arsenic
in a pill, in which case the arseniate of soda is the preparation to be
selected.
  Another precaution in the use of arsenic, and one which is intended 
GENERAL  THERAPEUTICS OF THE SKIN.        Ill
to prevent irritation of the mucous membrane of the stomach, and its
consequences, uneasiness, pain, griping, and nausea, is, its administra-
tion with a meal, during or instantly after a meal.  By this means,  we
secure the  admixture of the five drops with the whole  mass of the
meal,  its distribution over an extensive surface, its dilution, in fact,
and we avoid as far as we are able, the contact of the arsenic with the
mucous membrane.  We gain another end, also, by this mode of ad-
ministration  of the medicine: we  secure  its thorough  incorporation
with the chyme, and its immediate transmission into the blood with the
chyle and other absorbed fluids.  This is a reason why we are enabled
to effect a cure with so small a dose;  the  whole, or nearly the whole
of the arsenic, it  is  to be presumed, is taken into the blood,  and is
thus conveyed into the most favorable position for exerting its medi-
cinal  effects.
   While following a course of arsenic, we prohibit our patient crude
vegetable matter, indigestible articles of food, and excess of acids; and
we may be strict or otherwise in this prohibition, according  to  the
effects of the medicine.   In some persons, the  mucous membrane is
tender and easily irritated;  in others, the  arsenic produces  no incon-
venient effect, even in the midst of dietetic irregularities.  Sometimes
it may be found  desirable to administer the remedy twice instead of
three times a day, and sometimes to reduce the dose to four or three
minims.  In  these cases, we may watch the moment for restoring the
dose to the ordinary standard of five drops.  As the standard dose of
arsenic is extremely moderate, it calls for little  variation with differ-
ence of age;  an  infant at the  breast  will take  two  minims without
inconvenience; from two to seven years, the dose may be three minims;
from seven to fourteen, four minims;  and  after  fourteen,  the standard
dose of five minims.
   I have alluded to one disease in which arsenic is specific and  the
only remedy—I mean lepra; in this disease we have most experience
of its use and of  its effects.   It presents remarkable variety as to the
time required for producing its constitutional action;  and in this  re-
spect differs essentially from mercury.  We can hardly look for any
indication of its operation on the skin in a less  period than from three
to six weeks, and often this period is protracted  to  a much longer
interval.  It  would seem to be cumulative in its effects, and to reach
its point of  saturation, in  other words,  to evince its  constitutional
action, suddenly, and often unexpectedly.   The completion of satura-
tion is sometimes announced by congestion of the conjunctiva, and
sometimes by a  rapid disappearance  of the eruption from  the skin.
It is a curious  phenomenon, to observe with what extraordinary  ra-
pidity a lepra of many years' standing will get quite well, every spot
vanishing completely, when the happy point of saturation  is reached
by the arsenic.   I have repeatedly seen cases wherein no effects were
visible after  months of regular use of this medicine; and in three
weeks afterwards, every trace of the disease had disappeared.
   As arsenic, besides acting on the skin as a cutaneous alterative, is
also a stimulant of the nervous system and of the mucous membrane,
and as its action upon these latter must take place during the adminis- 
112
GENERAL  THERAPEUTICS OF  THE  SKIN.
tration of the remedy, sometimes concurrently with its action on the
skin, and  sometimes independently  of that action, we have now to
consider the nature of these phenomena, that we may stop the use of
the remedy  the instant any symptoms arise which may be deemed
injurious; in other words, the instant the poisonous effects of arsenic
begin to be evinced.  I  have already said, that when acting unfavor-
abfy, arsenic will produce uneasy feelings of weight or sinking at the
epigastrium, and nausea; it will also produce  vomiting, griping, diar-
rhoea, sometimes  constipation and suppression of urine, dry. cough,
stiffness in the throat, soreness of  gums, sometimes ptyaljsm, rigidity
and weight of the  eyeballs, and  congestion of the conjunctiva;  all
these symptoms being referable to congestion of the mucous membrane.
The symptoms referable to the nervous system are, extreme restless-
ness, sleeplessness, sensation of faintness, numbness and tingling in the
hands and feet, and  headache.  Sometimes when the remedy acts with
more violence on the skin than on  other organs  of the body,  there
may happen an arsenical erythema.
  Now upon the occurrence of the slighter of these symptoms, as soon
as they reach the point of real inconvenience or distress, the patient
is instructed to suspend the remedy, until  the feelings of discomfort
have subsided; and then to resume it.  A suspension of a few days,
or at most for a week, will, in general, be sufficient for the dispersion
of the threatening symptoms ; and as  soon as this happens, there can
be no objection to beginning  and  continuing  the medicine as before.
By taking this  simple precaution, I rarely meet with cases  wherein
the arsenic may  not be continued for a period  necessary for cure,
unless in persons of peculiar idiosyncrasy, who are unable to take the
remedy even in the smallest doses.
  And now it may  be asked, What are the cases in which the use of
arsenic is indicated? Arsenic  is applicable  to cases of determined
maf-assimilation when the eruption is chronic from .the  commence-
ment, or has passed its acute stage, and the chronic condition is per-
fectly established;  it is applicable also to those chronic forms of
eruption which from long continuance are deemed inveterate, such as
psoriasis; and it is  also applicable, but this time as a specific remedy,
to lepra.  With the exception of  lepra, arsenic is  not to be employed
until the general symptoms have been combated by general remedies,
and until the general disorder of the digestive and circulating systems
has been removed—not even until  ordinary tonics have been  given
without effect, and the tonic alterative powers of  arsenic remain as  a
last resource.  This is my practice in  cutaneous disease, not from any
fear of the effects of arsenic, but  simply because a large majority of
these cases  may be cured  by general  means judiciously applied and
steadily pursued ; and when all have failed, then comes the time  for
this admirable medicine.   The same remarks apply also to lepra when
complicated with erythema or eczema, as we sometimes find it to
exist;  in  this  case, the complications should be first subdued by
appropriate general treatment, and then the specific  employed; on
the other hand, when the lepra is simple and uncomplicated, and  the 
             GENERAL THERAPEUTICS OF THE  SKIN.         113

general condition  and tone of the patient moderately healthy,  the
arsenical treatment may be commenced  from the outset.
   I have once more to draw attention to the  fact of the existence of
two modes of action of arsenic—namely, its primary or tonic action,
by virtue of which it corrects  and regulates  assimilation; and  its
secondary or stimulant action, which it  exercises on  the skin.  It is
in the first of these capacities that it becomes the efficient and curative
tonic  at the close of  febrile eruptions, and  produces  its effects  as
quickly as an ordinary tonic.   In its secondary or stimulant capacity,
it requires time to  enter the blood, to diffuse itself through the system,
to reach and operate  upon the tissues of the skin, and probably  be
eliminated by the skin, and to excite in  the skin that discutient power
by means  of which the eruption is finally removed.  In  the latter
mode of operation it gives rise to congestion of  the conjunctiva, con-
gestion of  the  skin, commonly denominated arsenical erythema, and
an erythematous excitement of the patches of lepra which  commonly
precedes their departure.  This erythematous condition of the patches
of lepra, which is the frequent precursor of  their dispersion, is  one of
the signs of the constitutional action of the remedy which  the derma-
tologist looks for with interest;  as is the occasional appearance of a
fresh outbreak of  the eruption after the remedy has  been continued
for a sufficient length of time.
   I have remarked upon  the curious fact, that arsenic is well  borne
by infants  and young children:  in them it  evidently exerts its tonic
influence on the assimilative powers, and evinces its good effects with
marvellous rapidity.   I know of  nothing more striking in the practice
of medicine than the celerity with which one of the most unpromising
eczemata will get well under the influence of arsenic when judiciously
administered.   I have seen such a case cured in a week, or, at most, in
two or three weeks, a perfect triumph of medicine.   It is clear that in
these cases the.medicine has not  time to produce its secondary action
on the skin, and that  the cure  must result from its primary tonic
action on the assimilative organs.1

  1 I had recently a conversation with a manufacturer of the salts of  arsenic, who
assured me that the men employed in the works experienced no inconvenience from
the constant inhalation of that substance, nor was their longevity influenced by the
nature of their occupation.  Mr. Arthur Church,in a  note published in  the "Chemi-
cal News" for August, 1860, on the arsenical water of Whitbeck in Cumberland, after
stating that the water contains a very perceptible amount of arsenic, namely j a frac-
tion of a grain to each gallon, "probably derived from the  veins  of arsenical cobalt
ore through which it percolates," observes: "The arsenical water is habitually used'
for every purpose by the inhabitants of the little village of Whitbeck, and, as far as I
can learn, with beneficial rather than injurious  results.  But it is remarkable that
Whitbeck, though in every respect suitable for trout, is the only stream in the neigh-
borhood from which that fish is absent; eels, however, have  been found in it.  Ducks
will not live if confined to this arsenical water. When the railway was being carried;
past Whitbeck, the first use of the water quickly produced  the usual marked effect
on the throats both of the men and horses employed on the works.  The soreness of
mouth from which they at first suffered soon however  disappeared, and in the horses
gave place to that sleekness of  coat assigned as  one  of the effects produced by the
administration of arsenic.  It is a question how  far  the rosy looks of the Whitbeck
children, and the old age which a large portion of the inhabitants of the village attain,.
are to be attributed to the arsenic present in the  water they drink."
       6 
114         GENERAL THERAPEUTICS OF  THE SKIN.

  Tar and pitch, used as internal  remedies, probably act upon the
skin as eliminant stimulants, and  require to  be taken  for  a  long
period to produce their effects.   They may be employed where there
is great intolerance of arsenic, and in similar cases, but I do not attach
any value to them as a medicine.  Pitch is administered  in the form
of pills, of which a large number have to be taken daily;  but a more
efficient remedy is the Barbadoes tar, which  is inclosed in capsules,
and requires the exhibition of a less quantity.   The cases to which
tar is particularly suited, are chronic erythemata, including pityriasis
and psoriasis, and lepra.  I have not  had much  experience of their
effects, believing that I had other, more active, more convenient, and,
I may add, more certain remedies within reach; and it has only been
as a variation to the  arsenical course, or in persons who were unable
to take arsenic for  a sufficient time to be  useful, that  I have had
recourse to them.
  Cod-liver oil has  been spoken  of in connection with cutaneous
diseases, and cod-liver oil has consequently been  made the subject of
trial; sometimes with benefit, and sometimes the reverse; the usual
fate of good remedies tried without any principle to guide or deter-
mine their use.  I have said that  I  regard  mal-assimilation as the
essence of cutaneous  disease;  with mal-assimilation there is necessarily
more or less  of mal-nutrition, and with  the latter emaciation.   Now,
these are the cases for  cod-liver oil, and in them cod-liver oil, is an
excellent remedy.  Cod-liver oil improves  nutrition ; with improved
nutrition there is an advance of general power; and with general
power, a better assimilation  returns.  The medicinal virtues of cod-
liver oil are therefore such as result from its easy adaptation to nutri-
tion ;  in this sense  it becomes  an admirable  tonic, like beef and
mutton, but one which may be employed when the appetite is opposed
to the latter.   Some  time back, it occurred to  me to make trial  of cod-
liver oil in a dietetic form, and with the willing aid  of an ingenious
chocolate manufacturer  [Mr. Lebaigue, of No. 9 Langbam Street, St.
Marylebone,  by whom this chocolate is now manufactured under a
patent right,  to secure its purity; its price is four shillings  the  pound,
each pound containing  four ounces of cod-liver oil, or one part in
four;  the pound is  grooved into thirty-two tablets, each of  which,
therefore, contains one drachm of oil and three of chocolate, and may
be taken as a dose] I soon had at my disposal  an ample supply  of cod-
liver oil chocolate, and believed that with a dietetic  substance  of this
kind, I should be able to overcome the repugnance which some per-
sons, children in particular, have to swallowing oil; that I  should pre-
sent the oil to the stomach  in a state more favorable for  the  assimi-
lating  process;  that  I should escape the nausea resulting from the
presence of  undigested oil in the stomach, and that a small quantity
of oil would be more effective than a larger  dose administered in its
crude state.   My anticipations in all these particulars were  fully borne
out by the  result, and  I found myself in possession  of  a valuable
dietetic medicine.  To be quite certain of its powers, I confided it to
my brother to use among my poorer patients; and  he reports to me
that he found it most serviceable with children; that in many instances 
GENERAL  THERAPEUTICS OF THE SKIN.        115
he used no medicine but a simple  aperient to regulate the bowels,
and  that the improvement  in  the  condition  and disease  of these
children, in the course of a week, was really marvellous.  He observes,
moreover, that  the cases which he selects for the use of the chocolate
are such as evince a distinctly mal-assimilative or cachectic diathesis,
a lymphatic or  pyogenic tendency, and more or  less of emaciation;
these being the subjects in which eczema impetiginodes and impetigo
eczematosum mostly prevail.
  As cod-liver  oil has  been  tried internally, so cod-liver oil has been
tried externally, by way of inunction through the skin;  and cod-liver
oil has been reported to be  an excellent remedy, externally applied
in cutaneous disease.   There can  be no doubt that, used by way of
inunction,  some portion of the oil is  absorbed into  the blood, and
applied to the  purpose of nutrition, becoming, in fact, an  internal
remedy.  But as far as its  real external powers  are  concerned, cod-
liver oil possesses  no virtues greater than any other oil, or even lard,
which  brings us back to the use of ointments; the true value of which
we shall perceive at once, if we compare the dry, parched, exfoliating,
cracked, oozing skin of cutaneous disease, with the moist, pliant, soft
integument saturated with oil or lard.
  Besides the more apparent properties of oily  matters applied to the
skin, their  deoxidizing powers are  to be borne in mind; and as oxygen
is the great stimulant of chemical action generally, and of the chemical
processes taking place  in the blood of  an inflamed part, the value of
this  power of fencing off the oxygen cannot be estimated too highly.
This power I claim for ointments,  as applications to eruptions of the
skin.  The plan of inunction  by  the  skin  in  measles, scarlet fever,
and  smallpox, has been successfully pursued in  Germany ,and I have
adopted it in my  own practice with  great advantage.  It not only
diminishes the  heat and pruritus of the surface, but, by checking the
formation of the poison in the capillaries of  the skin,  reduces materi-
ally  the general fever.   Upon  the same  principle, carbonic  acid  gas
becomes a  valuable remedy in  states of inflammatory congestion of
the skin, in irritable eruptions  and ulcers, and is probably the bene-
ficial agent in that excellent topical application, the  yeast poultice.
In  selecting  an oleaginous substance for  inunction  by the skin,  I
should prefer fresh lard or fresh neat's-foot oil to the cod-liver oil.
   Glycerine, during the last few  years, has been largely used as an
application for  the skin, and was first introduced to the notice of the
profession  by Mr. Startin.  Struck by the peculiar and paradoxical
properties  of this singular  fluid,  which up to that  time had been
regarded as a useless product, and was allowed  to flow away into  the
sewers of the Thames, this curious substance, sweet as syrup,  without
containing a particle of sugar or fermentable matter, and mixing with
water with the  utmost  ease, although extracted directly from  oil, was
preserved by Mr. Warrington of the Apothecaries' Hall, under  the
hope that some day a use mijxht be found for it, whenever it  came to
be more generally  known.   Mr. Warrington's  expectation was soon
realized; he mentioned it to Mr.  Startin, and afterwards to me, and
it became suddenly called for by the profession, to a greater extent 
116      DISEASES ARISING  FROM GENERAL CAUSES.

than could be supplied.  It was necessary,  therefore, to manufacture
glycerine;  and  that substance  which a few months before  had been
wasted as an effete and useless product, was now manufactured at the
sacrifice of the materials out of which it was formed.  As it originally
existed in the carboys preserved by Mr. Warrington, glycerine was
perfectly free from odor; it had been produced by the decomposition
of the oil which takes place in the manufacture of lead plaster.   Now,
having become a valuable and costly medicine, new sources  of supply
were opened, and among others, that of the soap-boiler;  and the gly-
cerine derived from this source  was  so offensive in smell, that for a
time I discarded its use, and glycerine fell  into the danger of being
dismissed altogether  from our Pharmacopoeia;  subsequently, Mr.
George Wilson, one of the managing directors of Price's Patent Candle
Company, discovered  a method of separating glycerine by distillation
from the materials used in their manufactures,  and has succeeded in
producing it perfectly free from smell, of a purer quality than that
heretofore in use, and in a quantity  which  renders its exhaustion at
any future period very improbable.
  Glycerine is an exceedingly useful therapeutical preparation  in all
cases where dryness, scaliness, or scurfiness of the cuticle is the pre-
dominating feature; for example, in that general dryness of the surface
which I  have called  xeroderma, in  pityriasis,  and notably in the
extreme dryness of the palms of the hands which accompanies psori-
asis palmaris.  It may be employed  either  in  its pure state, or more
or less diluted in the form of a lotion.  I have  not found  it a good
remedy in irritable  erythemata  nor  in eczema, and I confine its use
exclusively to the cases mentioned.
                      CHAPTER  V.

          DISEASES ARISING FROM  GENERAL CAUSES

          ERYTHEMATOUS OR EXANTHEMATOUS ERUPTIONS.

  The eruptions belonging to this group, of which erythema, inflam-
matory blush, is taken as the type, are four in number; namely,
               Erythema,                Eoseola,
               Erysipelas,               Urticaria.
  These eruptions correspond with  the exanthemata of Willan;  but
Willan included besides, under the same head, scarlatina, rubeola, and
purpura, while he omitted  erysipelas, considering  that in his order
Bullae.  I have thought it more consistent with the  present state of
knowledge to  treat of scarlatina and rubeola among the eruptive
fevers, as being diseases originating in an animal poison of unknown
origin.  Purpura I have placed apart, as belonging to a group re- 
ERYTHEMATOUS  OR  EXANTHEMATOUS  ERUPTIONS.  117
markable for dyscrasis of the blood and tissues, while the bullae of
erysipelas may be considered as almost an accidental character, being
frequently altogether absent.
  I have committed violence to Willan's system, in respect of another
affection, which I have taken  from his order Squamae, and  placed in
this  group, as  a variety, or rather as a form  of chronic erythema,
namely pityriasis.  Pityriasis  is evidently an erythema, attended with
exfoliation of the epidermis, the exfoliation  being furfuraceous, and
probably more copious than in the simply congestive forms of this
affection.   But the latter character cannot be considered sufficient to
transfer it to a different order, and to associate with it a specific affec-
tion so entirely distinct as lepra.   All the natural affinities of Pity-
riasis sufficiently point it out as erythema.

                          ERYTHEMA.

  Syn. Inflammatory blush.  Efflorescence cutanee, Fran.—Hautrbthe,
                Germ.—Dartre erythemdide, Alibert.

  Erythema1 (Plate I., G.—K.) is a superficial inflammation of the skin,
characterized by a diffused or  circumscribed redness occurring in one
or several patches of irregular form, and varying from a  few lines to
several inches in extent.   It is non-contagious, occasionally produced
by local irritation, but  generally symptomatic of constitutional or
visceral disturbance.  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 dispersion of the red-
ness, the skin retains for some  days a purplish and bluish tint, and the
epidermis exfoliates in  the form of  a  furfuraceous and laminated
desquamation.
  There are two  degrees of  erythema—acute and  chronic;  acute
erythema presenting eight principal varieties—namely,
     Erythema fugax,                 Erythema intertrigo,
         "    circinatum,                "     papulatum,
         "    marginatum,               "     tuberculatum,
         "    laeve,                      "     nodosum.
  These varieties admit of arrangement into three groups—sympto-
matic,  local, and general or idiopathic.  The symptomatic kinds are
erythema  fugax, erythema circinatum, and  erythema  marginatum.
The  local group comprehends erythema laeve, a disease depending on
the local condition of the limb, and very appropriately designated by
Good, erythema cedematosum; and erythema  intertrigo,  the  conse-
quence of local irritation.   The general or idiopathic varieties are ery-
thema  papulatum, tuberculatum, and  nodosum, which are  preceded
and accompanied by general febrile symptoms, and are closely allied
with each other.
1 Der. IgvQeilvtiv, to Tedden. 
118      DISEASES ARISING  FROM GENERAL  CAUSES.

                        ERYTHEMA FUGAX.

  Erythema fugax appears in the form of diffused patches of redness,
which are variable  in  depth of color and extent, and occur for the
most  part on 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 evanescent and fleeting disposition,
one while vanishing suddenly, to  reappear  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 with considerable heat and dryness of surface,
and sometimes by swelling.  At its decline, the epidermis is left rough
and furfuraceous, from  the disturbance to which  the formative func-
tion of the derma had been subjected.
  Erythema  fugax  is  chiefly  important as a symptom  of visceral
derangement, and in some instances it may be regarded as an indica-
tion  of the  long continuance  and danger of such disorder.   It  is
particularly noticed in  connection with irritation of the mucous tis-
sues of the body, as  of the alimentary mucous membrane, the respira-
tory 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, inflammation of the kidneys, &c.  It  is
also  seen in some nervous affections and fevers;  and Willan records
«, fatal case of puerperal fever  in which erythema fugax was a con-
spicuous symptom.   This inflammation  is most frequently observed
in the female sex.
  I had lately under my care a striking instance of this affection in
the person of a  young military  officer, who was not aware of  any
disturbance  of his  general  health.  The efflorescence was attended
with swelling, would come on in the course of an  hour, and after the
continuance of a few hours subside  as rapidly as it had appeared.
His attention was generally drawn to the seat of the disease by some
degree of itching, and on examining the part, the redness and swelling
were  perceived.  Trifling as the disorder appeared, it was a source of
serious  annoyance;  it  sometimes  made  its appearance while he  was
engaged on  military duty, or dressing for a  dinner-party, fixing, for
example, upon the  cheek, aud closing his eye by tumefaction  of the
lids.
                     ERYTHEMA CIRCINATUM.

  Erythema  circinatum (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 disap-
pears.  In  this manner, a number of rings with  broad margins are
produced, which run over the surface of the affected region, and, as
they  increase, communicate by their borders,  and give rise to a num-
ber of irregular and broken bands resembling segments of circles of
various magnitude.   The central  portion of the rings, and the surface 
      ERYTHEMATOUS  OR EXANTHEMATOUS  ERUPTIONS.. 119

which has been left by the erythema, has a yellowish tint, and throws
off a furfuraceous desquamation.   The duration of erythema circina-
tum is greatly dependent on the nature of the disease with which it is
associated; it  may be stated generally at from a  few days to two or
three weeks.
  I have before me the notes of a case of this  form of  erythema,
associated with acute rheumatism, which occurred  in the hospital prac-
tice 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 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 de-
veloped in connection with augmented perspiration.

                     ERYTHEMA  MARGINATUM.

  Erythema  marginatum is an aggravated form of erythSma circina-
tum, occurring, for the most part, in association with chronic visceral
disorder, and  in elderly persons.   In this variety there is a greater
degree of congestion of the skin  than  in the preceding;  ther§ is  a
deeper but variable tint of  redness, which frequently 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
circinatum,  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 definition
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 from the  healthy skin, raised, promi-
nent, and slightly  papular;" while Willan and Bateman,  taking the
latter stages as their type, describe the marginal ridge as existing only
on one side of the patch, the redness diffusing itself gradually in the
rest of its circumference.  The eruption may occur upon  all parts of
the body, but is most frequently seen on 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 ex-
tends to several weeks.

                        ERYTHEMA L^EVE.
                        Erythema  oedematosum.
  Erythema  laeve  is an inflammation of the skin  associated  with
oedema, and  appearing for  the most part in  the lower  extremities.
When, however, the vital powers of the system  are reduced, it mav 
120      DISEASES  ARISING FROM GENERAL CAUSES.

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  color;  it is
more or less swollen from distension of  the subcutaneous cellular
tissue with serous fluid, and is attended with itching, and by a painful
sensation of tension.   When  left to itself,  ©edematous erythema  may
continue without change for several weeks, and may terminate event-
ually in ulceration or mortification.  When it  issues in  resolution,
the swelling 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 appear-
ance.   Moreover, the epidermis desquamates in thin lamellae.
  There is a form of erythema laeve which is very common in persons
beyond middle life, and  which  affects the legs,  extending from the
instep  and ankle  to the hollow  below the  knee.   The legs are more
or less swollen, they pit on pressure, the oedema being greatest around
their lower'part;  they are hot, painful,  itchy,  particularly  in  the
evening and in bed, and they  are more or  less reddened by a patchy
and irregular redness.  In this particular, also, there is a good deal of
variety; sometimes the redness is general  and  vivid, and at other
time?  hardly  discernible.   In  either case, if the skin  be  closely
examined, it will be found to have the appearance of being cracked
all,over, which is really  the fact.   From the distension  which has
taken place, the cuticle has given way, and the derma, corresponding
with the lines of rupture, looks red and angry, and forms a network
of rough, more or less raised lines over the affected skin.   The small
islets  of unbroken skin  between the  lines are more or less smooth,
but sometimes roughened by exfoliation of the  cuticle  from  their
surface.  Their edges, corresponding with the line of ruptured cuticle,
are also rough, and in some instances their  appearance is such as to
suggest a comparison  with the scaly integument of a serpent.
  Not  unfrequently,  the're is  an oozing of an ichorous fluid from the
inflamed lines; in which case  the secretion dries, and forms a  thin
crust,  and the eruption  might  be mistaken for eczema.   At other
times the  inflamed lines have a papular character, and the  case might
be considered to be  one of lichen.   This form of erythema la?ve  is
often troublesome and tedious,  equally annoying  to the patient  and
to his physician.
  In young persons, erythema laeve is an occasional result of sedentary
habits,  or of fatiguing exertiou in  close  apartments. Those of the
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 persous of advanced
life the affection is by no means uncommon, and  occurs.as a conse-
quence of over-exertion in standing or walking.  It is also a frequent
complication of  the  oedema which  accompanies varicose  veins  and
anasarca.   The local affection is usually accompanied by slight febrile
symptoms, and by some degree  of constitutional  disorder. 
      ERYTHEMATOUS  OR  EXANTHEMATOUS ERUPTIONS.  121

  Besides the erythema cedematosum now described, which  results
from a pre-existing oedema, and is  found in a dependent  part of the
body, an  ©edematous erythema is  sometimes met with around the
eyes.   This form  of eruption  commonly occurs in persons beyond
the mid-period of  life, and more frequently in women than in men :
the oedema is not,  as in the former case, the predisposing cause of the
inflammatory congestion, but a consequence of that action operating
on a tissue prone  to serous infiltration.  Not  unfrequently it is met
with in association with eczema existing in other parts of the body,
or  it occurs in persons who have previously suffered from eczema,
and may itself be regarded as a stage of the latter disease.  Moreover,
it is apt to be' taken for erysipelas, and, as far as external appearances
are concerned, it closely resembles that affection, differing from it only
in the lesser degree of constitutional disturbance.  Under these cir-
cumstances, erythema cedematosum is often considered and treated as
an  erysipelas, and  is constantly spoken of by those who have suffered
from  its attack as being that disease.

                     ERYTHEMA INTERTRIGO.

  Erythema intertrigo1  is that  form of cutaneous inflammation which
is induced by chafing the skin, either by the  friction 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-disten-
sion of the skin, eruptive affections, &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  contact of secretions, the abraded derma pours out a sero-purulent
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,  as in bed-sores, 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, particu-
larly  if the parts be moistened by secretions, or unprotected by clean-
liness ; in the- folds of  the skin of fat  persons, especially in warm
weather;  upon the face, from the  overflow of tears, the saliva, or the
secretion  of the nose ; upon the vulva, the prepuce, and  the scrotum,
around the anus, and between  the toes.  When the disease occurs
around the anus, it gives rise to pain during the action of the bowels,
and frequently to spasm of the sphincter.  In a case for which I was
lately consulted, where the disease affected the prepuce, the aperture
of  this  part was so much contracted and hardened by the cicatrices
following  upon  chaps, that not only had phymosis resulted, but the
urethra was also obstructed.
1 Intertrigo, a chafe-gall, a fret. 
122      DISEASES  ARISING  FROM GENERAL CAUSES.

                     ERYTHEMA PAPULATUM.

  Erythema papulatum (Plate I., G.) is characterized by the develop-
ment of numerous small red spots, of which the largest scarcely exceed
the disk of a split  pea.  They are accompanied by considerable itch-
ing 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  color,
and slightly raised above the surface of the surrounding skin.   The
swelling, however, subsides in  the  course of a few days, but the red-
ness continues for  one or two  weeks, becoming  purplish  in its tint,
and yellowish as it fades away.   In distribution  the  spots are irregu-
lar, 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, chest,  arms,
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, and is  usually associated with irritation of the gastro-pul-
monary mucous membrane, and sometimes with  rheumatism.

                      ERYTHEMA TUBEROSUM.

  Erythema  tuberosum (Plate I., H.)  consists of an  eruption  of
patches of a circular form, and of a size varying between a four-penny
piece  and a shilling.  They  are frequently  interspersed  among the
smaller 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 pre-
ceded 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 green-
ish 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 dis-
turbance.  This form  of erythema is frequently met with in female
servants, particularly in those   who have  been  recently transferred
from the fresh air  of the country to the confinement of London  kitch-
ens.  It is seen also in  persons of debilitated constitution, and, accord-
ing to Dr. Corfe, is  generally associated  with disordered  menstrual
function.
                       ERYTHEMA NODOSUM.

  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 position, and two  patches, one before and one
behind, meeting by their extremities, have surrounded the leg as with
a bracelet.   The oval patches are slightly raised above the surround-
ing surface, the elevation increasing gradually  towards the centre; 
      ERYTHEMATOUS  OR EXANTHEMATOUS  ERUPTIONS.   123

they are hot, painful, and tender; of a bright red color at their erup-
tion, but change in the course  of a few days to  a purplish and livid
tint, which becomes subsequently  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
painful; they then become softer to the touch, and by the eighth or
tenth day have nearly subsided; terminating by a transient discolor-
ation of the skin, and  desquamation of  the  epidermis.- 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 diminishing on the appearance of the eruption. It
has  also been observed  in connection with  rheumatism; it  attacks
chiefly young persons and females, and those of a debilitated habit of
body.
   Erythema papulatum, tuberosum, and nodosum, are so closely allied
to each other, that they might with advantage be  included 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 CHRONICUM.

   The term chronic has reference to two  states  of erythema, namely,
that in which the erythematous blush is from the beginning slow in its
progress, subsequently stationary, and does not  affect the integrity of
the skin;  and that which represents the advanced stage of an acute
erythema, wherein the erythema, instead of terminating by resolution,
becomes, as it were, permanently established in the skin, assumes  new
characters, and persists for an  indefinite length of time.
   Of the former kind, namely,  slow in progress, and subsequently station-
ary, are the red patches called fiery spots, that are frequently seen upon
the face; which vary in brightness with the health of the  patient, and
are especially vivid after meals.
   Of the latter kind, namely, those which represent a, persistent stage of
erythema, are patches of erythema commonly found among the folds of
the skin, in the flexures of joints, behind the ears, upon and around the
lips, around the nipples, in the perinseum, in the groins, around the vari-
ous apertures of the body, and upon the scalp. In this form of erythema,
there  is besides the redness of the skin, more or less thickening of the
derma, more or less exfoliation of the epidermis, and sometimes cracks
and chaps of the skin.  This form of erythema is  very commonly met
with as a sequal of chronic lichen and chronic eczema; a chronic lichen,
in fact, wherein the papulae have subsided, or a chronic eczema in which
the ichorous secretion has ceased to be formed, the redness, the thick-
ening  of the skin, and more  or less of exfoliation of the epidermis
remaining;  in a word, the pathological state of the skin to which the
term psoriasis has been  applied, and  to which it should  be  strictly
limited.
   Psoriasis, therefore, is nothing more than a chronic erythema;  and 
124      DISEASES ARISING FROM  GENERAL  CAUSES.

as this form of erythema is more  frequently a sequela of lichen and
eczema, most commonly of the latter, than of common erythema, I
have made its description follow that of chronic eczema.
  Another form of chronic eczema, sometimes appertaining to the
first, and sometimes to the  second  class, but more properly belonging
to the former, remains, however, to be described.  It is characterized
by an erythematous blush of the skin, circumscribed, of a more or less
circular figure, and covered by a furfuraceous, or more frequently by
a mealy desquamation of the  epidermis.  This is the eruption which
has been denominated pityriasis.  In the dermatographic classification
of cutaneous diseases, pityriasis is  associated with  psoriasis, and both
are described  in companionship with lepra, simply  from the circum-
stance  of  presenting a surface coated with minute scales.   Psoriasis,
moreover, is confounded with  lepra; but these diseases have nothing
in common with lepra, further than some slight similarity  of appear-
ance.
                      ERYTHEMA PITYRIASIS.

Syn. Lepidosis pityriasis ; Mason Good.  Dartre furfuracee;  Alibert.—
            Schuppen, Germ.   Dandruff.   Branny tetter.

  Erythema  pityriasis1 (Plate XII., 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 or pinkish color, but some-
times so light as scarcely to be distinguishable from  the surrounding
skin.   They are developed on any part of the body,  frequently in suc-
cession, and are attended with heat, and some degree of pruritus and
tingling.  The scales are thrown oft* as soon as formed, and are repro-
duced with great rapidity;  they are for the most part small and mica-
ceous ;  in certain  situations, however, where the integument is thick,
they are larger and furfuraceous, and in those parts  where  the integu-
ment is thin, as in the flexures of joints, are  pulverulent  and mealy.
Pityriasis, from its chronic nature,  is a disease of long continuance,
but is not contagious.
   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, pityriasis rubra, pityriasis
versicolor, and pityriasis nigra; the first of these alone deserves to be
considered as an erythema ; the other two are chiefly remarkable for
their alteration of color, and are  consequently referable to the  chro-
matogenous disorders.   The  local  variety indicated by  Willan is
pityriasis capitis;  to which Haver has added pityriasis  palpebrarum,
labiorum, palmaris et plantaris, praeputialis, pudendalis, and pityriasia
oris.   The whole of these so-called varieties of pityriasis are clearly
nothing more than chronic erythema, verging more or less on psoriasis.

  1 Der irirvpn, furfur, bran, from the bran-like desquamation by which it is attended. 
      ERYTHEMATOUS OR EXANTHEMATOUS ERUPTIONS.   125


                       PITYRIASIS VULGARIS.
                     Syn. Pityriasis  rubra, Willan.
  Pityriasis vulgaris (Plate XIL, F.) occurs indiscriminately upon any
part 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, neck, and  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  affection  is very  com-
monly met with in children and persons  possessing a delicate skin
and fair complexion, upon the sides of the chin, around the mouth,
and  on  the  forehead.  When of  considerable extent, pityriasis  is
attended with itching 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
surface, 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 cellular tissue sometimes becomes thick-
ened and infiltrated ;  and if the surface be abraded by scratching, an
ichorous fluid is poured  out (eczema), which desiccates into thin
scabs, and complicates the diagnosis of the disease.  After the decline
of pityriasis, the skin presents for some time a yellowish stain.  When
the disease is general, or a  large surface of the body is implicated,
the eruption is accompanied with  languor and slight  constitutional
disturbance.

                        PITYRIASIS CAPITIS.
                           Syn. Dandruff.
  Pityriasis capitis appears upon  the head chiefly in children and old
persons, commencing usually upon the  temples, and around  the fore-
head,  and thence extending to the rest of the scalp.  It is a trouble-
some 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, but is per-
fectly amenable to treatment.

  Diagnosis.—The diagnostic characters  of erythema  are,  redness
and heat of skin with but trifling swelling,  the redness passing by
degrees into a purple and livid tint, as  the inflammatory excitement
subsides.  The absence of tumefaction, and distension  of the subcu-
taneous cellular tissue, at once distinguish  erythema from erysipelas.1
  Erythema fugax (E. volaticum  genarum) is distinguished from the
other  varieties principally by negative  characters,  namely,  by the

  • Plenck's definition of erythema is as follows: " Macula rubra, solitaria, apyreta,
et topica." 
126      DISEASES  ARISING  FROM GENERAL CAUSES.

absence of those  peculiarities which mark the rest.  The redness is
diffused, there is little swelling, the surface is dry and hot, and  the
inflammation evanescent.
  Erythema circinatum  is remarkable  for the annular  form of its
patches;  it is distinguished from herpes circinatus by the absence of
vesicles, and from lepra in progress of cure by its general appearance,
and by the previous history of the affection.
  Erythema marginatum is recognized at an early stage by the annu-
lar form of the patches, and, at  a later period, by its abrupt and papu-
lated border.
  Erythema laeve is  characterized by its association with oedema of
the subcutaneous cellular tissue.
  Erythema intertrigo is distinguished  from eczema by  the  absence
of vesicles.   The cause of intertrigo, again,  is immediately  obvious
(E. ab applicatis acribus; E.  a  decubitu; E. ab  attritu ;  rubedo clu-
nium in equitantibus).
  Erythema papulatum may  be confounded with some forms  of rose-
ola, from which it differs but  little, and particularly with  urticaria ;
but the latter is more irregular and unsteady in its progress,  and  the
itching is more pungent.
  f1 rythema tuberculatum is  distinguished by the circular red patches
developed on the skin, and by the constitutional symptoms.
  Erythema nodosum is so clearly characterized, as to offer little room
for  confounding it with any  other eruption.   Eoseola 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 may  be known by its general characters;  the
furfuraceous and mealy desquamation  determining the forms which
belong to pityriasis,  and the  remains of papulae, or some degree of
ichorous discharge, the sequelae of chronic lichen or chronic eczema.
  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 disorder of the digestive
organs, from the use of improper food, or from taking irritating mat-
ters into the stomach, as copaiba.  The peculiarities of color observed
in the disease under consideration  are explained by reference to  the
general principles of inflammation.  During the period of excitement
the blood is of a bright red color; it courses rapidly through the part,
and the vessels become dilated.  After  the subsidence of the excita-
tion, 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 circula-
tion through the  limb, and interference with the vascular distribution
in the skin  by  cedematous  distension of the subcutaneous  cellular
tissue, while its predisposing cause is very  commonly, gout. 
      ERYTHEMATOUS OR  EXANTHEMATOUS ERUPTIONS.   127

  Prognosis.—Erythema is for the most  part a slight affection, and
derives its chief importance from the disease with 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 erythema speedily yields when the exciting cause is removed,
and erythema laeve, the most serious of the erythematous inflamma-
tions when  it occurs in old persons, is easily controlled by judicious
treatment.
  Treatment.—The principles  of treatment of erythema  resolve
themselves into three indications:  1.  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 symptomatic varieties of erythema require to be treated through
the disease upon which  they are dependent.  The  method of treat-
ment must consequently vary in relation to circumstances.  In some
instances, the antiphlogistic  plan may be required, in others, the irri-
tation 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 a  useful
remedy,  particularly in females.
  When the system  is reduced, and the powers  are  enfeebled, tonic
remedies are indicated ; bitters combined with acids are of great ser-
vice, together with an appropriate  regimen and  the judicious use  of
exercise; after a course of these remedies, Fowler's  solution may be
commenced, in doses of three or four minims three times a day, either
directly after or with meals.   In chronic erythema arsenic is especially
indicated.
  Sponging the entire surface of the body with tepid water and soap
every day, or every other day, with  occasional tepid baths, and drying
the skin  thoroughly  with a 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,1 combined with one ounce of spirit  of
rosemary and three of rose-water; or two drachms of liquor ammoniae
fortior to aqua calcis and oleum olivae optatum, two ounces each.
  The local treatment should, according  to circumstances, consist  in
evaporating  lotions, water-dressing, or  warm fomentations.  In  the
erythema fugax of the  face and neck, the benzoated zinc ointment
with spirits of wine 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, with at-
tention to diet.  Where gout is suspected  to be  the cause of the dis-
ease, a warm antacid purgative, such as Gregory's powder, or a powder
composed of rhubarb, soda, and calumba, with or without colchicum

  1 The tincture of croton, a most valuable cutaneous stimulant, is made by adding
four ounces of spirit of wine to one ounce of the bruised seeds of croton. It is ready
for use at the end of a week. 
128      DISEASES ARISING  FROM GENERAL  CAUSES.

or iodide of potassium, should  be  given  twice or three times a-day,
and the juice of two or  three lemons as a cooling drink.   The local
treatment demands rest, such a position of the limb as will assist the
venous circulation as much as possible ; evaporating lotions or warm
fomentations in the acute stage, succeeded, as  soon  as the inflamma-
tion has somewhat subsided, by inunction with the  ceratum plumbi,
or the oxide of zinc ointment, either alone or in combination with the
liquor plumbi diacetatis, or spirits of wine, and by  the application  of
a well-adjusted cotton  bandage.  Gentle frictions 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, or anointed  with the oxide of zinc
ointment.   Erythema paratrimma is best treated by the oxide of zinc
ointment,  or by soap plaster spread upon wash-leather.  In erythema
a decubitu, or bed-sore, the  inflamed skin  should be painted with a
liniment of white  of egg and spirit of wine, and afterwards covered
with soap plaster spread  on amadou.
  Erythema papulatum, tuberosum, and nodosum, require antiphlo-
gistic regimen, a brisk  purgative of calomel and colocynth  at the com-
mencement, then tonics and  the mineral acids.
  Chronic  erythemata  are to be managed according to the  general
principles of treatment above detailed; the excitement of the  affected
part is to  be reduced in  the first  instance by soothing applications,
and then astringents and gentle stimulants are  to be used.   The chap-
ping 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 off, so as
to remove any stickiness that may remain. Glycerine may be applied
in the same way,  or an ointment of oxide  of zinc may be found
useful for the same purpose.
  Erythema or pityriasis capitis, invariably yields  to an  application
composed of one part of the red precipitate ointment to three of lard;
or to the white precipitate ointment diluted in the same  proportion.
  Erythema of the nipples (chapped nipples) is best relieved by the
application  of the oxide  of zinc ointment made into a cream with
spirits of wine or spirits  of camphor, 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.   Other useful applications for chapped  nipples are
—a powder consisting of equal parts of borax and powder of acacia,
which should be dusted  frequently upon the  cracks and excoriated
surface; and mucilage of gum acacia.  The latter should be pencilled
on the tender part immediately after suckling, and the nipple protected
with a leaden shield or limpet shell. I have also  seen great  bene-
fit result from the  use  of collodion,  which, judiciously  applied, and 
      ERYTHEMATOUS  OR EXANTHEMATOUS ERUPTIONS.   129

assisted by other means, will be found a valuable remedy.  Collodion
is  a good defensive agent for  protecting the tender skin from the
effects of pressure and moisture.
   It is judicious, in most cases, to wean the infant  when the nipples
are tender and chapped;  but when weaning is objected to or inconve-
nient, a shield and teat should be applied, without interfering with
the zinc or nitrate of silver ointment.
   For erythema of the vulva and anus, the most soothing applica-
tions are, the superacetate  of  lead ointment, or the oxide of  zinc
ointment with liquor plumbi diacetatis.   Over these an evaporating
lotion may be used, if requisite;  and when the acute stage is passed,
the milder ointments may be replaced by the  nitrate of mercury oint-
ment, more or 'less diluted, as the feelings of  the patient may permit.
The nitrate of silver ointment and juniper tar ointment are also found
to be of service income instances.

                    Cases Illustrative of Erythema.

   Erythema papulatum.—A married lady, habitually dyspeptic, became
overheated on the  16th of December, 1845; she was afterwards chilled
by exposure to cold in an open  carriage for some hours.  At night
she was feverish and restless.
   Dec. 17. Next day she felt unwell, with general malaise and lassi-
tude, was exposed to cold as before.  In the afternoon had nausea and
chills.  At dinner she partook  of boiled beef, at all times an unpala-
table dish to her, and suffered  in the evening from nausea and head-
ache.   In the night she was awakened 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.
   22d.   Seventh 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 color, 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 in diameter 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 eruption was very tender to  the touch.
   28d.  Eighth day.  The symptoms of nausea and feverishness, which
were slightly diminished  on the appearance of  the eruption, were
now  greatly relieved.  The eruption was on the decline;  the tender-
ness subsided; the redness diminished; and  each little  papula, as it
        9 
130      DISEASES  ARISING FROM GENERAL  CAUSES.

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.
  Erythema papulatum et nodosum.—A widow, forty-five years of age,
regular, had been suffering four  months with bronchitis.   On the 1st
of°April, 1846,  she  had an eruption on  the face, and then  on the
hands, of papulae of a bright red color, and accompanied by  severe
itching and tingling.   These symptoms  were  increased  on   taking
fluids of any  kind, particularly  such as were warm, and  they were
greatly augmented by the  warmth  of bed.   The papulae  were very
tender to the touch, particularly  around the finger nails.  A few days
after the disappearance of the eruption on  the face, the large, oval-
shaped swelling (delineated in  Plate VII.)  made its appearance,  at-
tained its  height on the  second day, and  declined on the fourth,
leaving behind it a purplish and yellow stain, like that of a  bruise.
The constitutional symptoms preceding and  accompanying this erup-
tion were nausea, feverishness, and extreme  lassitude.  The languor,
with great depression of spirits, continued  until the termination of
the disease.
  Erythema tuberosum.—A  young woman, aged twenty-two, enjoyed
good health until nine months ago, when she obtained service in Lon-
don as housemaid.  Since that period she has suffered constant illness;
sometimes  her bowels were constipated, sdmetimes she  had nausea, at
other times cough;  menstruation was disturbed, becoming scanty and
light-colored ;  she had leucorrhoea, and copious deposits in her urine,
with difficulty 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 appetite, and
indisposition to make any  exertion.  While in this  state she was
seized (January 1846) with a  dry, hard cough, accompanied with
headache and the usual train of febrile  symptoms;  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 distributed  regularly over the skin, and
were very  tender to  the  touch.   On  their first appearance they
were vividly red, but soon became purplish 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.   Water-dressing was used to the eruption.
   Erythema Iceve 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 cedematous, particularly around the ankle.  In the latter situation
there was a broad and extensive 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 saliues, had the leg supported on an inclined plane, the
inflamed parts wetted with a layer  ol lint dipped in a saturnine and 
      ERYTHEMATOUS  OR EXANTHEMATOUS ERUPTIONS.   131

alcoholic lotion, and the whole of the lower leg enveloped in  oiled
silk.  By the next morning the redness had diminished very consider-
ably, and the oedema was much reduced.  I then moistened the limb
with camphorated spirit, aud  bandaged it firmly, from  the  foot up-
wards, to the lower part of the thigh, readjusting the bandage  night
and morning.  From the first day of the  application of the bandage
she was  enabled to walk, but  in  consequence of again over-exerting
herself, and misapplying the bandage, which, after the first few  days,
I intrusted  to herself,  it was found necessary to confine her again  to
bed, where in a short time  she recovered.  .
  Severe erythema Iceve of  both legs.—In the autumn  of  1841 I was
called, with my friend, Mr. Coulson, to see a lady of advanced age,
affected  with this disease.   She  was corpulent, of sedentary habits,
had long suffered from oedema, and her present attack had lasted for
several weeks,  resisting  the various  modes of treatment which had
been  pursued.   The  skin  of the entire  surface of  both legs was
of a red tiut, highly congested,  and covered with  a  rough  and ex-
foliating epidermis.  Her tongue was foul,  and her general health very
much disturbed, 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 fol-
lowed by fomentation and  bandaging.  To this, however, she 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.
   Erythema laeve, issuing in mortification and death.—An aged woman
complained of great pain  and uneasiness in the left foot and ankle.
There was a diffused patch of redness, with slight  oedema, 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 neighboring medical friend.
In a few days the part became discolored, and sphacelus commenced,
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.

                          ERYSIPELAS.
Syn.  Erythema Erysipelatosum; Mason Good. Rosa. Ignis Sacer.  Ignis
         Sancti Anthonii.   Erysipele, Fran.  Rothlauf, Germ,
   Erysipelas1 is a diffused  inflammation of the skin and subcutaneous
cellular  tissue, affecting a part of the surface of the body, and accom-
panied by fever.  The local inflammation has a special disposition to
spread;  it  is attended with swelling, a pungent, burning, and tingling
 heat, and  by a redness which disappears  under  pressure  with the
Der. IfEu'S:?, rubor. 
132      DISEASES ARISING FROM  GENERAL CAUSES.
finger, to return so soon as the pressure is remitted.  It is often accom-
panied by vesications containing a limpid amber-colored serum, which
quickly burst, and form thin, dark-colored crusts.  Erysipelas termi-
nates generally in resolution with desquamation of the epidermis, some-
times in delitescence, or suppuration, and more rarely in mortification.
  Erysipelas admits of division  into two principal varieties, erysipelas
simplex, and erysipelas phlegmonodes.  The former of these possesses
several  subwarieties, and some local  forms deserving 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 phlegmonodes offers but one sub-variety of
importance.  The  varieties and  sub-varieties of erysipelas may be
thus arranged :—
                       ERYSIPELAS SIMPLEX.
         Sub-varieties.                    Local sub-varieties.
     Erysipelas erraticum,             Erysipelas faciei,
         "     metastaticum,               "      capitis,
         "     miliare,                    "      mammae,
         "     phlyctenodes,               "      umbilicale.
         *'     cedematodes.

                   ERYSIPELAS PHLEGMONODES.
                           Sub-variety.
                     Erysipelas gangrenosum.

                       ERYSIPELAS SIMPLEX.
               Syn. Febris Erysipelatosa ; Sydenham.
  The inflammation  of erysipelas always extends more  or less deeply
into the tegumentary textures.   That which affects the  skin the most
superficially, is the form at present under consideration, which would
seem to be  limited to the derma and  its immediately  contiguous
cellular tissue.  Simple erysipelas occurs  most frequently upon the
face and head, next  in frequency upon the limbs, and most rarely on
the trunk 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—chilliness
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; thirst, loss of appetite, white  and coated tongue,
bitterness of mouth, nausea, vomiting, pain at the epigastrium, and
constipation.  These, or some of these symptoms, and in  greater or
less degree, precede the local disorder for 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, mut-
tering delirium,  with subsultus  tendinum, an exceedingly rapid pulse,
and a brown and dry tongue.  At the close  of the fever there is 
ERYTHEMATOUS OR EXANTHEMATOUS  ERUPTIONS.  133
commonly a critical relaxation of the bowels, a sediment in the urine,
and occasionally a slight hemorrhage 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," Schonlein remarks,
" loaded  with bile-pigment, and is of a reddish-brown or  red color.
At the urinary crisis, fawn-colored precipitates 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
face and  a good deal  of fever, his pulse being 112.  The urine of the
first analysis was of a deep  yellowish red  color, and clear ; its specific
gravity was  1.021.  That of  the second  was so  deeply colored  as to
appear almost black; it threw down a reddish 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 day of the fever.  The
analyses are  as follows: Becquerel's  analysis of healthy urine being
placed for comparison in a third column :—
                                    Anal. 1.    Anal. 2.    Health.
       Ounces of urine in 24 hours, .    .    27.0  ...   30.8  —  45.0

       Water,......965.5  ...   961.9  — 972.0
       Solid constituents,.    .    .    .    34.5  ...   38.1  —  28.0

          Urea,.....12.5  ...   12.7  —  12.1
          Uric acid,    .    .    .    .1.2  ...    1.3  —   0.4
          Fixed salts.....—   ...    8.2  —   6.9
          Extractive matter, ...    —   ...   15.9  —   8.6
       Specific gravity,   ....  1021.0  — 1023.1  —1017.0

   "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 color, strongly acid, threw down a  yellow sediment  sponta-
neously,  and had a specific gravity of 1023.1.  It contained—
          Water   ..'....•..  961.7
          Solid constituents ....... 38.3

              Urea........11.7
              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 threw down a  reddish sediment, and in two a
little  albumen was occasionally present."1
   The heal affection  makes its appearance on the second or third day
from  the commencement of the febrile symptoms, and is frequently
accompanied by soreness of throat and congestion of the fauces.  On
the skin  it appears as a somewhat swollen and irregularly circum-
scribed  yellowish  red patch, which  is  accompanied by a  painful
sensation of  tension,  and by a sharp, burning, and tingling, or prick-
1 Simon's Animal Chemistry, vol. ii. p. 278. 
134      DISEASES  ARISING  FROM GENERAL CAUSES.

ling 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 epidermis is
thrown into wrinkles, is dry and friable, and speedily desquamates in
thin, transparent scales.   The  resolution of erysipelas is the most
favorable termination of the disease.

                           Sub-varieties.

  Erysipelas erraticum.—Erysipelas is  remarkably and characteristi-
cally disposed to wander from the spot where it was first developed,
to extend  itself more diffusely, and to fix upon new situations.  Some-
times we find it simply spreading, and  thus increasing in extent the
inflamed surface; at other times it subsides entirely on the parts first
affected, as it  proceeds in  its erratic course, or it suddenly quits its
original situation to appear as suddenly on one more  distant.  This
erratic or  ambulant disposition of erysipelas  is often  seen  upon the
face and head, where it is exceedingly intractable.
  Erysipelas metastaticum.—This designation indicates a variety of
erysipelas in which the  efflorescence suddenly disappears on the sur-
face  of the body, and some internal organ becomes 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 erysipelas of the head and face.  The organs
most liable to suffer from the metastatic action in  erysipelas are the
brain or its membranes, and the gastro-pulmonary mucous membrane.
Metastasis 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  supervention of
delirium and coma, while the external  inflammation continues, is of
common occurrence."
   ErysijJelas miliare.—It occasionally happens that a crop of small
vesicles  (Erythema vesiculare,  Mason Good),  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-colored scabs.
   Erysipelasphlyctenodes is a common form of the  disease; it is  that
in which vesicles (Bullte, Erysipelas bidlosum) of considerable size, and
irregular  in their form, appear upon the inflamed skin.  They usually
arise on the fourth or filth 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
bullae contain a limpid  serum, at first colorless,  but changing by
degrees to a pale straw or amber tint.  Occasionally the fluid becomes
opaque,  and  sometimes assumes a purplish  hue;  the latter is an
 unfavorable sign.
   Erysipelas cedemaiodes.—In persons of a  lymphatic temperament, 
      ERYTHEMATOUS  OR  EXANTHEMATOUS ERUPTIONS.  135

and in constitutions debilitated by  previous  disease or excess, there
exists a disposition to the effusion of a serous fluid  into the tissue of
the derma and into the sub-dermal textures, constituting oedema.  In
this -form of erysipelas  (Erythema cedematosum, Mason  Good)  the
inflamed surface is less brightly red than  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. Erysipelas cedema-
todes occurs most frequently in the lower extremities and external
organs  of  generation, and terminates  like  the simple form  of  the
disease, the effused fluid being removed  by subsequent absorption.

                        Local sub-varieties.

  Erysipelas of the face.—The face is the most frequent seat of erysi-
pelas.   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  recognizable.  The cheeks  are enlarged,  the  eyelids
turgid and infiltrated, and the lips tumid.   The  constitutional symp-
toms accompanying the local disorder are exceedingly  severe; there is
violent  headache,  sleeplessness,  frightful dreams, and  commonly
delirium.  The disease reaches its height  on the fourth or fifth day,
and terminates on the seventh or eighth.  It is frequently 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 hemorrhage from the  pituitary
membrane.  Erysipelas  of the face is always serious, from the great
liability to the occurrence of metastasis or extension to the brain, and
it  is frequently  succeeded by subcutaneous  abscesses and diffused
suppuration; the latter sequela is most commonly met with in the neck.
  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 apncea, from infiltration of  the submucous tissue of
the glottis; and a  third, asthenia, or a  total  prostration of the vital
powers.1
  Erysipelas of  the scalp  is usually  the  consequence of a wound  or
injury of the head, and occurs in about a  week or ten days from the
reception of the violence.  The  affected  integument is  ©edematous,
smooth, 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 cellular  and fibrous tissue
of the scalp.  It  often terminates by metastasis, or rather by extension
to the brain.
  Erysipelas of the mammce.—From  the  quantity of cellular substance
surrounding the mammary gland, erysipelas in this  region is disposed
to take on the phlegmonous character, and to terminate in extensive
suppuration, and gangrene of the  fibrous substance.  The redness
accompanying the exanthem is by no meaas vivid.
1 Dr. Watson—Lectures. 
136      DISEASES ARISING  FROM GENERAL CAUSES.

  Erysipelas of the umbilical region occurs in infants (erysipelas neon-
atorum), particularly in public  institutions, and is referable to irrita-
tion produced by mismanagement of the umbilical cord, or, with more
likelihood, to some endemic cause.  From the umbilicus, the erysipelas
extends to the integument of the abdomen, and  frequently to the or-
gans of generation.  It sometimes gives rise to sphacelus  of  the
integument and subcutaneous cellular tissue, and terminates  fatally.

                   ERYSIPELAS PHLEGMONODES.

  Phlegmonous erysipelas is much more severe in its nature than the
simple varieties, and affects the deeper-seated textures, the subcutane-
ous cellular tissue, the superficial and deep fasciae, and the intermuscu-
lar cellular tissue, as well as the integument.  It may occur on any
part of the body, but is most frequently observed in the extremities.
This form of erysipelas terminates rarely in resolution, commonly in
extensive suppuration,  and gangrene of the cellular tissue and fasciae.
  The constitutional symptoms are identical with  those which  accom-
pany 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 local symptoms, when the inflammation is comparatively super-
ficial, are, vivid redness, which disappears on  pressure,  and  returns
slowly on its remission ; tumefaction; a smooth,  shining surface; 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  fasciae in all  directions, unless released by in-
cision  or ulceration.  If  an incision be made, it gives exit to healthy
pus, mingled with small portions of dead cellular tissue.   When the
inflammation is disposed to terminate in resolution, the redness, pain,
and swelling diminish on the fifth or sixth day, the epidermis becomes
dry and scaly, and the effused fluids are gradually removed.
  If phlegmonous  erysipelas attack more deeply-seated textures, or
an entire member, the inflammation appears suddenly, the  pain is
more severe  and distressing than in the preceding form, and the sur-
face is vividly red, tense, shining, and exquisitely sensitive.   On the
fifth or sixth day, and sometimes earlier, suppuration  takes place,
accompanied by throbbing, and preceded by occasional chills and
rigors. The redness and pain diminish on the occurrence of suppura-
tion, and an  obscure fluctuation  and boggy sensation  are felt on the
application of the hand.  If the parts.be opened at this period by a
free incision, a large quantity of pus will  escape, mingled with con-
siderable flakes of cellular tissue in a state of gangrene.  Should the
incision be  neglected, the pus spreads  around  the  limb, burrowing
beneath the  fasciae, between the muscles, and  separating the  integu- 
      ERYTHEMATOUS  OR  EXANTHEMATOUS ERUPTIONS.   137

ment from  the  parts  beneath.   Eventually, the matter discharges
itself by means of ulceration; but the constitutional irritation is ex-
cessive ;  hectic fever is  induced,  accompanied  by colliquative  diar-
rhoea ; aud the scene quickly closes in death.
  When the pus is bound down by aponeurosis, or fasciae, the consti-
tutional  effects  are  still more intense than those above described.
The integument, in a few days, becomes livid and dark-colored,  large
vesicles or phlyctenae, containing a purplish serum, rise upon the sur-
face, gangrene ensues, attended with entire prostration of the physical
powers, and death speedily follows.   In  some  cases,  however,  when
the strength of  constitution of the patient enables him to  resist the
effects of sphacelus,  sloughs  are formed, which are thrown off, and a
granulating surface is slowly established.   The issue of phlegmonous
erysipelas in mortification, constitutes  the  sub-variety, termed  gan-
grenous erysipelas [Erythema gangrcenosum, Mason Good].

  Diagnosis.—The  principal diagnostic characters of erysipelas are,
inflammation of the  skin, extending more or less deeply into the sub-
cutaneous cellular tissue; tumefaction of the inflamed parts ; a special
disposition to spread ;  and  symptoms of a dangerous fever, pursuing
a regular and definite course.  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 laeve may, at first sight, appear
to be a contradiction to these characters, but  the oedema in  this  affec-
tion is the cause, and not the effect, as in  erysipelas; and  erythema
cedematosum may be regarded as a transition link between  erythema
and erysipelas.
  The uniform redness of  the inflamed surface, and  its partial seat,
sufficiently  distinguish erysipelas from other exanthematous fevers.
A few instances are on record wherein erysipelas is stated to have been
universal, but such cases must be extremely rare.
  Simple erysipelas is distinguished from erysipelas  phlegmonodes,
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 on the part first attacked,
without spreading to distant  regions.
  Causes.—Erysipelas appears to originate sometimes in infection or
contagion, and is now and then seen prevailing epidemically, or run-
ning through the wards of  an  hospital.   Puerperal fever  has  been
shown to be one of the sources of the contagion of erysipelas, and the
evidence  on this head  seems  to place  beyond  question the fact,
that these two diseases are reciprocally transmissible.1  The predis-
posing causes of erysipelas are, some inherent peculiarity of the con-
stitution, as in cases where  it occurs hereditarily; or some morbid
state of the system.  It not  unfrequently appears in  those whose

  1 See an excellent paper on this subject in Dr. Ranking's " Abstract of the Medical
Sciences" (vol. iv. 1846), from the pen of the editor. 
138      DISEASES  ARISING  FROM GENERAL CAUSES.

nervous 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 with a pin, a leech-bite, a blister, seton, or
issue, &c.   In like manner, a wound, either accidental, or occasioned
by a surgical operation, may be the exciting cause of erysipelas. Per-
sons with a thin and irritable skin, and members of the female sex,
are especially liable to erysipelas.   It makes its attack most frequently
in the summer season,  and is sometimes dependent on functional
derangement, such as amenorrhcea, the critical period, &c.  In delicate
females it occasionally takes place periodically.
  Prognosis.—The prognosis of erysipelas depends upon the various
circumstances enumerated amongst  its causes.  When the  fever is
moderate, the constitution sound, and the  local inflammation not  ex-
tensive, the disease may be regarded  as of little consequence.   When,
however, the constitution is debilitated, the invasion  of erysipelas is
to be apprehended, not only from the deficient  power of the system,
but also from the liability which exists to inflammation of the super-
ficial veins and lymphatics, and purulent deposits in the viscera.  The
prognosis is also unfavorable 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 dangerous, from
the possibility of some vital organ being secondarily attacked.  Ery-
sipelas 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.
  Treatment.—The  management of erysipelas presents two indica-
tions : firstly, to  subdue the fever; and secondly, the local inflamma-
tion.
  The first of these indications is to be effected by means of rest, an
invalid diet, neither too low nor too  stimulating, a brisk purge, aided
by an active  dose of  sulphate of magnesia and senna, rhubarb and
magnesia,  or rhubarb and sulphate of soda, to clear out the digestive
canal;  subsequently saline diaphoretics; and if there be much irritabi-
lity and restlessness, opium; and when the violence of the febrile symp-
toms has abated, or the vital powers flag, diffusive  stimulants, wine
and tonics.   Few constitutions will bear the abstraction of blood; and
it must be remembered that erysipelas rapidly exhausts the powers of
life, is  asthenic  in its character, and speedily  makes a  demand  for
stimulant  remedies.   An active purgative at the  outset of  the com-
plaint,  once or twice repeated, will, besides performing the necessary
office of emptying  the alimentary canal and biliary ducts, reduce  the
vascular system  as much as the constitution will bear.  We may then
follow  it up with the liquor ammonia acetatis and sesquicarbonate of
ammonia; or the latter in effervescence with lemon-juice; or, better
still, the sesquicarbonate of ammonia should  be given in simple solu-
tion  in water, in doses of three to six grains every two to four hours,
as recommended by  Drs. Peart and Wilkinson  for scarlatina  and
measles ; and once or twice in the day a dose of Dover's powder.  As 
      ERYTHEMATOUS or exanthematous  ERUPTIONS.   139

soon as the first  violence of the febrile symptoms is abated, the diet
may be improved.   Wine may be added, and tonics of bark or quinine
with the mineral acids exhibited.
  The tincture of the sesquichloride of iron is regarded by Dr. George
W. Balfour1 as a specific.  "Erysipelas," he observes,  "is one of the
few diseases for which I now believe we have a certain and  unfailing
remedy, and this, whether it be infantile or adult, idiopathic or trauma-
tic."  He first of all clears the bowels with a smart purge, such as ten
grains of calomel with a drachm of jalap, or two drachms of sulphate
of potash;  and then administers twenty drops of the tincture of the
sesquichloride of iron in  simple water every two  hours until the dis-
ease is subdued.   He found it to remove pain, lessen the heart's action,
clean the tongue, and to  act as  a  diuretic on the kidneys;  while its
special influence is exerted on the capillary vessels of the  skin.   It
should be  administered  regularly, so as to saturate the system as
quickly as possible ; for it is not until the point of saturation is attained
that it effects its curative action.  It may be given in any stage of the
fever, even in high delirium ; it never  produced headache ;  it arrests
suppuration even  in  phlegmonous erysipelas;  and it brings about a
cure in less than a week.   In infants of four months old he prescribes
two minims as a dose, and  increases the dose in proportion to the  age
of the patient.  One of his cases brings the remedy in contrast with
the sesquicarbonate of ammonia; a patient affected with scarlatina was
at the same time suffering  under erysipelas; the ammonia  which he
was taking for the scarlatina made no impression on the erysipelas;
but when the  sesquichloride of iron was given the erysipelas got well.
   Dr. Robert Williams remarks with regard to the treatment of erysi-
pelas:  " The mode, then, in which I am in the habit of treating idio-
pathic erysipelas, whatever may be the part affected,  or with what-
ever 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 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 becomes 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 miti-
gated, 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 successful."2
   This author records several remarkable instances of the advantages
of his 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," continues the  author, " not less  instructive, were
recently treated in St. Thomas's.  The patients were both stout, healthy

         1  Monthly Journal of Medical Science, vol. xvi. 1853, p. 426.
         2  Page 284.- 
140      DISEASES  ARISING FROM GENERAL  CAUSES.

young women, and nearly of the same age; the seat of the disease also
was the same, on the head and face, and they suffered equally from
delirium, so that the difference between them, if any, was scarcely dis-
tinguishable.  For the one, four ounces 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 instance, 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 necessary to raise it to
eight  ounces, and the patient now rapidly recovered."
  Mr. Grantham of Crayford,  in Kent, a successful practitioner and
original thinker, suggests  the propriety of making early observation
of the state of the urine in erysipelas.   " I begin," he observes, " with
large  doses  of  carbonate of ammonia, spirits of ammonia, and cam-
phor  mixture, as an alkaline mode  of treatment,  which  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 full doses of the acidum sulphuri-
cum aromaticum.  The diet should be liquid and nutritive, 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 healthful neighborhood,
remote from the causes of depression which  exist  in towns and cities.
In the latter sedatives appear to form as essential  a part of the treat-
ment  as stimulants.  The dose of sesquicarbonate of ammonia may be
as much as five or six grains every three or four hours.
  By some practitioners an emetic has been strongly recommended in
the 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 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 cuta-
neous transpiration, and for this  purpose  should  be administered in
half-grain doses every four hours.  Mr. Liston remarks, 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 blis-
ters applied to the calves of the legs. 
      ERYTHEMATOUS  OR EXANTHEMATOUS ERUPTIONS.   141

  The second indication, namely, that which relates to local treatment,
is to be fulfilled, in milder cases, by rest, position, evaporating lotions,
sedative  lotions, poppy fomentations, or water-dressings, the tempera-
ture of the applications being determined by the feelings of the patient.
A lotion  which I have found of much service in allaying the uneasiness
of feeling attendant on erysipelas,  is one composed of a drachm of ses-
qui carbonate of ammonia, the same quantity of diacetate of lead, and
half an ounce of laudanum to a pint of water.  But inunction with
lard is in every way superior  to  all fluid applications.  My friend,
Mr. Grantham,  to whom I am indebted for the  first suggestion of lard,
remarks  with regard to its use: " 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."   If there be soreness of throat from congestion of the fauces, it
should be touched with nitrate of silver.
  On the head  and face, fomentations and fluid applications are gene-
rally inconvenient, and their place may  be usefully supplied by  in-
unction with lard, or  by flour dusted cbpiously on the surface  from
the dredging-box.  In more severe cases  the congestion 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  pursued by Sir Richard Dobson for many years,
and  always  with the  most  favorable results.  He  observes that the
punctures heal in the  course of a few  hours, that he makes them on
every part of the body, and that  he never saw 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 demand.  Mr. Liston advocates the same plan.  For
some time I have adopted this method in the local treatment of erysipe-
las, and always with  good effect.   It is remarkable how quickly the
tension and  pain are diminished, and the  tumefaction reduced.
  The relief afforded to the  inflamed surface by inunction and punc-
ture, must be referred to two principles altogether different from each
other;  the one  being,  so to speak, endosmotic, the other  exosmotic.
But a substance which has been recently employed as an application
to the skin,  namely, collodion, is known to possess both these proper-
ties in conjunction, and, among the numerous experiments which have
been made of its virtues, has been found to be a valuable topical agent
in erysipelas, compressing the surface,  and so relieving tension and
pain,  constituting an impermeable varnish, and  so preventing cuta-
neous oxygenization of the blood, and the development  of caloric,
which results from that chemical combination.  As the purpose of the
collodion is to form an impermeable covering, it should be applied with
a brush over the entire of the inflamed surface, and repeated as fre-
quently as may be necessary.
  Great benefit is sometimes derived from the  application of a strong
solution of nitrate of silver to the  inflamed surface.  Mr. Higginbot-
tom, of Nottingham, by whom this mode of treatment-is recommended, 
142      DISEASES ARISING  FROM GENERAL CAUSES.

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  inflamed  and  surrounding
skin is next to be  moistened, and a long stick of the nitrate of  silver
is to be passed over the moistened surface, taking care that not only
every part  of the inflamed skin should be touched,  but the surround-
ing 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-
mation ; 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 appli-
cation  of the solution according 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 diffusion over the  surface.  "The
success 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 the
remedy.  Instead of covering the whole inflamed surface and the sur-
rounding Wealthy 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  proceeding which  has  seldom the  power of even
preventing the spreading  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 consider the
application of the nitrate  of silver as  perfectly safe.  I have seen no
case of metastasis or any other bad effects from the use of it during
upwards of twenty years." *  Mr.  Higginbottom further  recommends
that where erysipelas extends to the scalp, the head should be shaved,
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."
   M. Jobert8 has used, with great success, an ointment  composed of
nitrate of silver and lard,  in the proportion of two to four  drachms
of the salt  to  an  ounce.   This is applied night and morning  to  the
inflamed skin, and for a small space beyond it, and a thin layer is  left
on the surface.
   The nitrate of silver is an  excellent means of  limiting the extension
of the disease, by encircling  the inflamed  part with a line drawn with
a  wetted stick of the caustic.  When an extremity is attacked,  the
defensive cordon  must extend completely around the limb, above  the
affected  part;  and if this simple manoeuvre be properly  performed,
the  inflammation will, in many  cases, be limited to the part first
1 Lancet, vol. ii., 1843, p. 515.
* Gazette de? Hopitaux, May 11, 1848. 
       ERYTHEMATOUS OR  EXANTHEMATOUS ERUPTIONS.   143

 attacked.   Nitrate of silver appears to act by exciting an effusion of
 lymph and adhesive inflammation in the line of its application, which
 opposes an obstacle to the propagation  of the exanthema; upon the
 same principle, a narrow or linear blister has been  used  to form the
 circle,  but whether it possesses  any superiority over the nitrate of
 silver is very doubtful. 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 con-
 tained fluid gently pressed out and  absorbed by a soft sponge.  The
 epidermis of the phlyctenae should be preserved as entire as possible,
 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.  Edematous
 erysipelas  is especially benefited by  the punctures  above  recom-
 mended, followed, as soon  as the inflammation is  subdued,  by com-
 pression with a bandage.  Erysipelas of the scalp, when it affects the
 deep-seated textures, as in wounds and bruises 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 pro-
 portion of an ounce to the  pint of water, as a local  application in
 erysipelas.  This solution, he  remarks, produces a sudden improve-
 ment 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 constitutional  morbific influence
 is expended.   In situations  where a lotion  would  be inconvenient,
 this  surgeon employs an ointment, containing a drachm of the salt to
 an ounce of lard.
    Dr. Fahnestock, of Pittsburg, speaks in great praise of pure creasote
 as a local application in erysipelas.  It  should  be sufficiently strong
 to render the cuticle white immediately it  is  applied,  and should be
 pencilled over the whole of the inflamed surface, and for a small space
 beyond it.  In phlegmonous erysipelas the application should  be made
 more frequently than in the idiopathic kind, and a cold bread poultice
 or compress, moistened with a  solution  of creasote,  kept on the part.
 When the mucous membrane of the mouth  or fauces is affected,  he
 uses a solution of nitrate of silver, of the strength of half a drachm or
 a drachm to the ounce.
    Dr. James Arnott advocates  congelation as a local remedy for ery-
 sipelas, and adduces numerous  cases as examples of its success.
    Phlegmonous erysipelas  requires great activity  of management.
• At the outset of the inflammatory attack the patient should be freely
 purged.  The affected part should be placed in position  to facilitate the
 circulation through the limb as much as possible.  Leeches should be
 applied, and followed  by  fomentations  and 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 affected tissues, so as to divide freely the superficial 
144      DISEASES ARISING  FROM GENERAL CAUSES.

and deep fascia, and offer a clear  passage to any pus that  may have
been formed.  To effect the object completely, the incisions should be
two or three inches in length, and sufficiently deep.   The advantages
of this mode of treatment are obvious;  the  congested vessels of the
inflamed part are relieved, and the tendency to morbid action conse-
quently diminished. The tension, pain, and tumefaction are reduced,
even where  no matter is already formed;  and when suppuration is
established, a free outlet is given  to the pus, and flakes of gangrenous
cellular 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 bandage applied,  to facilitate ab-
sorption of the fluids effused 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 sub-
sided, tonics must be employed  and aided by a more  generous diet.

                          ROSEOLA.

Syn.  Exanthesis  roseola; Mason Good.  False measles.   Rose-rash.
                  Cutaneous blush. Roseole, Fran.

  Under the name of roseola, Willan has described  certain forms of
cutaneous inflammation, some of which seem to occupy a middle posi-
tion between erythema, urticaria,  and rubeola, without being strictly
referable to  either;  while others ought more properly to be considered
under one or other of the before-mentioned  heads.   The title of this
affection is, perhaps, the most objectionable  in the entire nomenclature
of diseases of the skin, since color can only be an accidental character,
depending for its existence upon a greater or  less congestion or dis-
tension of the vascular rete of the derma, and, therefore, liable to con-
stant change from trivial causes.  The true characters of the disorder
must evidently be sought in the morbid  conditions which collectively
constitute the disease; in other  words, in those symptoms which  ap-
pear to be characteristic of the affection.
  Roseola (Plate VII.) is a non-infectious and  non-contagious inflam-
mation of the skin; characterized by  febrile symptoms which assume
the sub-acute type,  by patches of redness, of small size and irregular
form,  distributed over more or less of the surface of the body, and by
more or less redness of  the  fauces.  The exanthema is  transient, is
accompanied by more  or less prickling or tingling of the  skin, is
brightly red or crimson  at first, subsides gradually into a dull roseate
tint, and disappears by  degrees, often leaving behind it petechial or
ecchymosed spots and the discoloration which follows a bruise.
  Willan has described seven varieties of roseola, to  which five other
varieties may be added;  three of these, namely, roseola rheumatica,
arthritica, and cholerica, resting  on the authority  of Bateman and 
ERYTHEMATOUS OR EXANTHEMATOUS ERUPTIONS.   145
Rayer; one, roseola punctata, described by myself; and one, roseola
febris continuae, embracing the roseolous eruption common to typhus
and typhoid fever.  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 are—
            Idiopathic.                       Symptomatic.
         Roseola  infantilis,            Roseola variolosa,
             "     aestiva,                  "    vaccina,
             "     autumnalis,             "    miliaris,
             "     annulata,               "    rheumatica,
             "     punctata.               "    arthritica,
                                         "    cholerica,
                                         "    febris continuae.

                       ROSEOLA INFANTILIS.
                            False Measles.
   In  roseola infantilis the  patches of redness  are of small size, and'
closely grouped  together, and resemble, in general  appearance, the
eruption of rubeola.  They are subject to much variety in relation to
extent, duration, and the local inconvenience 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 troublesome itching and  tingling.  The constitutional symp-
toms, like the other characters of the affection, are marked by uncer-
tainty in respect of degree ; in some  subjects  the febrile indications
are severe and active, while in others they are transient, and speedily
decline.
                         ROSEOLA ESTIVA.
                            False Measles.
   Roseola aestiva  (Plate VII., 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 attacks persons of a weakly
and irritable state of  system^ particularly of  the female sex.   The
disorder  usually commences with the ordinary  series of febrile symp-
toms of the slighter kind,  namely, 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,

  1 " Portraits of Diseases of the Skin:" the eruption of Roseola is well shown in
Plate XXIV., P., which represetns a case of Roseola Syphilitica.
       10 
146      DISEASES ARISING FROM  GENERAL  CAUSES.

on closer examination, is found  to consist of patches of larger size
and more irregular form, and, at a later period, the difference is still
more striking, in consequence of the change  of tint to a dark roseate
hue.  The  fauces are also  affected by the disease, presenting a deep
red tint, with some degree  of swelling 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 with tingling and itching.  On  the fourth day the rash
begins to fade, and  on the fifth disappears, together with  the  con-
stitutional symptoms.
  The eruption  is sometimes local in its attack, being confined to the
face and neck, which become  tumefied, and  exceedingly painful. It
is liable also to delitescence, in which case the constitutional symptoms
are aggravated, and relieved only by the reappearance of the rash.

                      ROSEOLA AUTUMNALIS.

  Roseola autumnalis 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, with congestion of the fauces.  The eruption
appears in roundish circumscribed 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
most frequently on 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 furfuraceous des-
quamation.

                       ROSEOLA ANNULATA.

   This form of  roseola1 is characterized by the figure of the eruption,
appearing, in the first instance, as rose-red circular spots, and increas-
ing in a short space of time into rings of variable size, having a central
area of natural  skin.  This eruption possesses all the general charac-
ters  of roseola,  as described  in  roseola  aestiva.  It  appears after a
slight  attack of constitutional symptoms, which are  relieved by the
outbreak of the eruption, and  aggravated  if  it  should chance to
recede; it occasions considerable  tingling and smarting of the skin,
which are increased during the night, so as frequently to destroy rest;
and it affects,  more or less  extensively, the mucous membrane of the
fauces.  When the disorder sets in with severe symptoms, the eruption
reaches its height on the fourth day, and terminates, like roseola aestiva,
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 intervals.
Willan relates the case of  a  lady who suffered  from this disease for
several months  together for three successive  years.  On its decline, it
leaves behind it stains on  the skin like  those produced by a bruise;

  1 " Portraits of Diseases of the Skin," Plate II., AK, exhibits a good example of
Roseola Annulata. 
      ERYTHEMATOUS  OR  EXANTHEMATOUS  ERUPTIONS.  147

and not unfrequently a deep-seated tenderness, as if the bruise ex-
tended into the substance of the limb.

                       ROSEOLA PUNCTATA.

   Roseola punctata is a rare  affection, of which I have seen only a
few examples.   Its characters are as follow:—
   Febrile symptoms of a sub-acute type, accompanied with redness of
the eyes, slight coryza,  redness of  the fauces, and swelling of the
mucous membrane of the  mouth,  ushering in an exanthema at the
end of three days; the exanthema appearing on the mucous mem-
brane and skin; on the latter, in the form of  small red spots occupy-
ing the mouths of the follicles, then becoming diffused so as to cover
the greater part of the body,  reaching its height on the third day ;  at
first of a bright raspberry-red color,  afterwards acquiring a dull rose-
ate hue, the dulness increasing with the progress of decline; the
primary red spots resembling dull red stains as  decline advances, and
fading by degrees after the disappearance  of the rash; the  entire
attack lasting ten days, of  which three belong to the febrile period,
three to  the exanthema, and  four to its decline, the  dark stains being
perceptible for some days afterwards, the  rash  assuming a difference
of form on different parts of the surface, such differences being all
referable to  roseola.   The following is an  example of this form of
exanthema.  For  the opportunity of observing  it I  am indebted to
Mr. Marson, the .resident-surgeon of the Smallpox  Hospital, who,
during a connection of twelve years with  that hospital, has seen
about ten cases:—
   A young man, aged twenty-four, Of good  constitution, engaged  as
light porter in a draper's house in Oxford Street, exposed himself to
cold by riding on the outside of an omnibus during the prevalence of
cold  winds.  At the end  of his journey  he  felt chilled, and, in  the
course of the same evening, experienced headache, pain in his limbs,
and sensations of general illness.
   Sept. 8th.—On the  following morning, after a restless night,  he arose
fatigued; his headache had increased, his appetite  was gone, and he
performed his duties painfully and wearily.  He was chilly during the
day, and in the evening feverish; had a dry mouth, and retired early
to bed.
   9th.—He had still greater difficulty in getting through his work to-
day than yesterday.  His symptoms were  the same, but increased in
'severity.   At night, after getting to  bed he smoked a cigar and took
a basin of gruel, and  being well covered  up, broke out in a profuse
perspiration.
   10th.—This day he scarcely felt able to  rise from his bed ; but suc-
ceeded  in getting  down  stairs and  cleaning some knives.   While
engaged in that occupation  he observed an eruption of  small red
spots on his arms, and soon afterwards returned to  his bed.  On taking
off his clothes he found his whole body covered with spots, the upper
parts being most, and the lower least affected.  He remarked, also, that 
 14S      DISEASES ARISING FROM GENERAL  CAUSES.

 his eyes looked red, that his  lips were swollen, and that there were
 red spots likewise inside his mouth.
   11th.—Having  been seen this day by a medical man, he was sent
 to the Smallpox Hospital, under the impression that the eruption was
 incipient smallpox.  At this time the eruption  consisted of small red
 spots,  the centre of each spot being very slightly raised, and corres-
 ponding with the aperture of a cutaneous follicle.
   12th.—The redness of the eyes, accompanied  with coryza in a slight
 degree, the swelling of the lips, and  the spotted  state of the mucous
 membrane of the  mouth, were  at their height to-day, and >to these
 symptoms was superadded a  cough,  making the  general  symptoms
 very similar to those of rubeola.  The red spots had now become con-
 fluent, and assumed the character of patches, which  covered the greater
 part of the body.   The congested skin  was slightly raised  above the
 level of  the unaffected  parts, and  the.color presented the  raspberry
 hue of measles.
   13th.—The patient's eyes  were still somewhat  congested, his lips
 swollen  and  dry,  the  mucous membrane of  the mouth was thickly
 covered with red spots, the fauces were red, his tongue was coated with
 a white, moist deposit, which was beginning  to  separate  in flakes,
 leaving the surface beneath quite smooth, and he uttered occasionally
 a short, mucous cough.
  The efflorescence had a decidedly rubeolous hue, but offered some
 variety of appearance on different parts of the body.  On his face,
 which was somewhat swollen, the patches of redness were irregular in
 form, and diffused.
  On  the trunk of the body, and particularly on the abdomen,  the
 efflorescence presented  the ordinary rubeolous appearance of common
 roseola.
  On the arms and legs the  red patches had  run together, so as to
 cover the greater part of the skin, and form a dull,  red ground, which
 was studded all over with spots of a dark red color.  These spots,
 which I  have assumed  as the specific character of  the eruption, were
 the original red points  by which the  efflorescence commenced.  They
 presented a deeper red than the rest of the surface, were about two
 lines and a-half in diameter, and were dark and slightly raised in the
 centre.   The redness was partly the effect of congestion,  and partly of
 the transudation of the coloring principle of the blood;  and in some
 lew situations, as around the ankles, and upon the back of the should-
 ers, where the  weight of the  body rested, there was a decided ecchy-
 mosis  from  the latter  cause.  It was obvious  that these red points
 represented the follicles of the skin, in which  the  inflammation com-
 menced,  and the elevated centre was the pore raised above its natural
 level, as  a joint effect of the congestion of the  capillary vessels, and
effusion into the meshes of the vascular network.
  On the neck the efflorescence appeared in the form of patches dis-
 tinctly circumscribed, slightly elevated, more or  less circular in figure,
and of an average size of half an inch in diameter.   On careful exami-
nation, these  patches were seen to be formed by the confluence of a
number of small circular congested spots, each taking its rise around 
      ERYTHEMATOUS OR  EXANTHEMATOUS ERUPTIONS.   149

the aperture of a follicle, and many of these separate spots, of about a
line in diameter, were sprinkled in the interspaces of the patches.  In
several of the larger patches there were one or more yellowish spots,
which, at first sight, gave the idea  of the elevations of urticaria, but
which the changes succeeding on the following day proved to be faded
points indicating the decline of congestion.  The  increase  of these
pale spots  gradually converted  the patches into rings, and the latter
finally disappeared.  I  must remark,  that the spots above referred to
were quite distinct from the deeper colored and star-like spots on the
arms, which  suggested  the specific name, "punctata," which I  have
given to the disease.
   14th.—The eruption is now on the  decline.  The  efflorescence is of
a duller hue;  the spots  have  more the character of stains than yester-
day, and the  patches on the neck are converted into rings; on the
abdomen, chest, and thighs, the efflorescence is fading away, like ordi-
nary roseola.  The thin skin of the  penis has a remarkable appear-
ance,  from being covered with deep rose-red stains.
   On Friday,  and  the two following days, the general symptoms im-
proved, while the efflorescence continued  to fade, and  on Monday he
was sufficiently well to be re-vaccinated, and  to leave the hospital.

                       ROSEOLA VARIOLOSA.

   Variolous  roseola is  an erythematous inflammation of  the skin,
which not unfrequently attends  the eruptive fever of inoculated small-
pox, appearing on the second day from the commencement of the con-
stitutional  symptoms, and  the ninth  or  tenth  after inoculation.  It
shows itself, in the first instance, 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 vividness, and on the fourth subsides altogether.   The proportion
in which roseola occurs  in inoculated smallpox  is one in every fifteen
cases.  In natural smallpox it is more rare.
   Variolous roseola has  been regarded as favorable  to the  prognosis
of smallpox, and indicative of a mild  eruption.   When, however, the
color of the rash is deep and  dusky in its tint, and the eruptive fever
severe, the most dangerous form of smallpox may  be apprehended.
In some instances of inoculation, the roseola has been known to super-
sede the eruption of the smallpox, and  the patient is said to be equally
protected  against variolous 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 the 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
inconvenient results.
                        ROSEOLA VACCINA.

  Roseola  vaccina is an efflorescence similar to that  which accom-
panies variola; it  follows  the development  of the vaccine vesicle, 
150      DISEASES ARISING  FROM GENERAL CAUSES.

appearing on the ninth or tenth day, but much more rarely than after
inoculation.  It  occurs in the  form of  small erythematous patches,
which seem to be  propagated from the inflamed 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 MILIARIS.

  Under the name of roseola miliaris, Bateman  describes an erythe-
matous inflammation of  the  skin, accompanied by the development
of small vesicles, which he observed on the ninth day and towards the
close of continued fever.   This eruption consisted of oval-shaped and
slightly-raised patches, which appeared upon the arms and breast, and
were followed by a decided  remission of the febrile symptoms.  The
patches increased in size for the space of three days ; they were of a
bright rose  color  at first,  diminishing  gradually in  redness, and
assuming a bluish  tint, and at the end of this period they disappeared
altogether.
  Miliary vesicles,  or sudamina, are not unfrequently met with during
the second  week of typhus, typhoid, and relapsing fever;  they  are
most commonly developed on the sides of the neck, on the chest, and
in the axillae, and  are usually associated with  the roseola of those
fevers;  they generally  accompany the  perspiration  which  occur
towards the end of the second week of typhus and typhoid fever, and
the critical sweat of relapsing fever.  Appearing under these circum-
stances, their consideration belongs to continued fever rather than to
roseolous eruption.

              ROSEOLA  RHEUMATICA ET ARTHRITICA.

  Rheumatic and  arthritic roseola  is an  erythematous inflammation
of the skin, appearing in  spots and patches, of various size and form,
and  upon different parts of  the body, in persons affected  with rheu-
matism or gout.  In some  instances the efflorescence 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, apd 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 on the legs,  and thence extend to the rest
of the body.  They present the deep rosy  color, subsequently becom-
ing purplish and livid, which is characteristic of roseola.

                      ROSEOLA CHOLERICA.

   This form of roseola rests on 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 occurred  in  some patients, 
      ERYTHEMATOUS OR  EXANTHEMATOUS ERUPTIONS.  151

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 characterized by  patches, for the most part of an  irregularly
circular shape, of a bright red color, elevated above the surface, and
but slightly itchy.  Very numerous on  the hands, arms, and chest,
they were less so on various other parts;  in some places they were
crowded together, tended to confluence, and had an appearance very
analogous to the efflorescence of slight scarlet fever ; in other 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 with an inflammatory
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 color.   About the sixth or seventh day the epidermis  cracked,
and was thrown off in  large flakes on almost all the places where the
eruption had existed.

                   ROSEOLA FEBRIS  CONTINUE.

   Roseola is not unfrequently present in continued fever, in typhus,
in typhoid fever, and in the relapsing fever; and may be regarded as
the cutaneous manifestation of the  elimination of the special poison of
continued fever from the blood.  In these fevers the skin is more  or
less muddy and discolored, and at the beginning  of the second week a
roseolous eruption  is developed  more or  less extensively over the
surface, the characters of the eruption being influenced by the nature
of the fever; having a bright rose color in  typhoid fever, and a mul-
berry color in typhus.   The  exanthem may be  distributed  more  or
less profusely over  the  trunk of the body and  limbs, or it  may be
limited to the extremities, and sometimes to the back of the hands; it
rarely occurs on the face.   The eruption is successive, a  fresh crop
taking place each day, and running- a  course of three  days;  so  that
after a few days it may be seen in all its stages, crescent,  mature, and
fading.
   The roseola of typhus is distinguished by its mulberry color and by
its petechial character.   It is persistent under pressure with the finger,
and persistent after  death.
   The roseola of typhoid fever  is of a bright rose tint, often  papular,
scantily distributed  over the surface, and disappears under  pressure
with the finger and  after death.
  The roseola  of  relapsing fever  passes quickly into the state  of
petechias, and is more  frequently accompanied with miliary vesicles
than the preceding forms.

  Diagnosis.—Roseola is distinguished from other exanthemata by
negative rather than by positive characters.. The diseases with which 
 152      DISEASES  ARISING  FROM GENERAL CAUSES.

 it is most likely to be confounded are rubeola, scarlatina, erythema,
 urticaria, and purpura.
   The  varieties of roseola the most nearly allied in  appearance to
 rubeola are, roseola infantilis and roseola aestiva;  but particularly the
 former,  which  is probably frequently mistaken for measles, and,
 indeed, is known by the trivial name of " false measles."  The diag-
 nostic characters by which it  is  distinguished from rubeola are, the
 absence or extreme mildness of the catarrhal symptoms, the inferior
 degree of febrile affection, the larger size, more irregular form, and
 deeper color of the patches, their progress from the extremities to the
 trunk of the body, and above all, the uniformity of the redness as
 contrasted with the punctiform character of that of  rubeola.  More-
 over, the latter is contagious^ and generally of epidemic origin, which
 is not the case with roseola.  These remarks  apply also to  the diag-
 nosis between  roseola and scarlatina, substituting for the  catarrhal
 symptoms of rubeola the angina of scarlatina.
   The degree of congestion affecting the skin in roseola \s  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,
 and of a venous character.  The form originating in local  irritation
 it would be more correct to consider as an erythema.
   From urticaria, the distinction of roseola lies in the light-colored
 and raised spots and wheals of the former, as contrasted with  the more
 uniform redness of the patches of the latter.  Sometimes, as in rose-
 ola annulata, the red spots have pale centres even at the beginning,
 but there is no elevation  as in urticaria.   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.
   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  teething, intestinal irri-
 tation, or objectionable diet.  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 overload  of fruit, indigestible sub-
 stances, copaiba, &c.   Other causes are, gastric and intestinal irrita-
 tion, and disordered menstruation.   The forms called into action by
 local irritation are obvious in their causes, while  those which  accom-
 pany rheumatism, gout, cholera, or continued fever, are occasioned by
 an effort of evolution of the gouty or other morbid salts or poison by
 the skin.
   Prognosis.—Roseola is  a slight affection, and one of favorable ter-
 mination.  When it occurs critically in connection with constitutional
disease, it is of good omen, as implying a derivative action, and should
be encouraged.
   Treatment.—In the treatment of roseola, the cause, when  obvious,
should be removed; in the case of children suffering  from dentition, 
      ERYTHEMATOUS OR EXANTHEMATOUS ERUPTIONS.   153

this is best  effected by scarifying  the  gums, and exhibiting a dose of
castor-oil;  and where intestinal irritation is  in fault, by one grain  ol
calomel well triturated with one of sugar,  by the hydrargyrum  cum
creta  combined with rhubarb, by soda with rhubarb, or by fluid mag-
nesia, to regulate  the secretions,  these measures being assisted by  a
light  and moderate diet. • In adults;  laxatives, diluents, and salines,
followed, in weakly persons, by tonics combined with mineral acids,
are the appropriate remedies; a mixture consisting of infusion of roses,
with  one drachm of  sulphate of magnesia, and one grain of sulphate
of quinine the dose, will often conduct a patient to  a favorable issue
without any other assistance.   The varieties  accompanying particular
diseases  call for the treatment applicable to those  diseases; as, for
instance, alkalies  in the case  of rheumatism,  &c.   When  disorded
menstrual  function  is the  exciting cause, recourse  must be had  to
steel  medicines, aloetic aperients, &c.  Local  remedies  are  rarely
necessary, and are only called for when the  itching and  tingling are
troublesome.  In  this case, a lotion of sesquicarbonate of ammonia,
a drachm to the half pint of rose water; a lotion of liquor ammoniae
acetatis  with  mistura camphorae,  equal  parts, and.used tepid, or an
emulsion of bitter almonds with hydrocyanic acid,  a drachm  to the
half pint, and also used tepid, might  be of  service.   Sponging  with
tepid »water containing a little vinegar frequently answers every pur-
pose.   These remedies would only be required  if the pruritus were
severe, seeing that it would  be undesirable to run the risk  of chilling
the surface and repelling the eruption.  There is less chance of  such
an occurrence when an unguent is employed; therefore, where a local
application  seems indispensable, the oxide of zinc ointment, rubbed
down with camphorated spirit or spirit of wine (3j ad Ij) would be
found to be the most efficacious ;  or, simply,  warm lard.

                         URTICARIA.

Syn.  Enanthesis urticaria; Mason Good.   Uredo.  Nettlerash.   Filvre
    ortiee porcelaine.  Essera, Ital.  Urticaire, Fran.  Brennesselauss-
    chlag,  Germ.   Cnidosis, Alibert.

  Urticaria, or nettlerash (Plate VII.), is a transient  and non-conta-
gious inflammation of the skin ; it is characterized by the  eruption of
small elevations, having a round, oval, or wheel-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
accompanied by febrile symptoms, and is associated with more or less
irritation of the gastro-pulmonary mucous  membrane.  The eruption
is attended with  itching, and a burning and tingling sensation  like
that produced by the sting of a nettle, and is  occasionally followed by
slight desquamation of the  epidermis.
  The varieties of urticaria,  distinguished by Willan, are six in .num-
ber, of which  two are referable to the acute, and four to the chronic
form of inflammation.   The six varieties are, 
154      DISEASES  ARISING  FROM GENERAL CAUSES.
                                            Chronic.
                                        Urticaria evanida,
                                            "    perstans,
                                            "    subcutanea,
                                            "    tuberosa.
                      URTICARIA  FEBRILIS.

  Febrile nettlerash is especially characterized  by the presence of
severe constitutional disorder.  It commences  with a sense of  weight
and sickness at the stomach, white furred tongue, quick feverish pulse,
pain in the head, anxiety,  lassitude, faintness, and drowsiness.  On
the second day from the invasion of these symptoms, the patient is
seized with rigors, which are followed by the eruption  upon the skin
of irregular patches, of a  vivid red color, slightly raised  above the
level of the surrounding surface, 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 unexpectedly,
and without order, and may be produced instantly on parts apparently
unaffected, by simply rubbing or scratching the skin.   They are irre-
gular in size and form, pale and little  developed during the day, but
brightly red towards the evening and during the night, at which time
the febrile symptoms exacerbate, 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 tem-
porary 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 desquamation of the epidermis, and sometimes oedema
of the subcutaneous cellular tissue.
   Although febrile urticaria may be regarded as a mild form of cuta-
neous exanthema, yet  it is  always troublesome and distressing to the
patient, from the irritation with which it is accompanied.   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 constitu-
tion by hard labor 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 dif-
fused over the  body, with much heat and  itching of the skin.  While
the rash continued vivid  his  internal complaints abated,  but  on its
sudden  disappearance,  about the fifth day, 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 delirious;  he remained in the same state  during the
following day, and died in the evening."  The same author also relates
      Acute.
Urticaria febrilis,
      "   conferta. 
       ERYTHEMATOUS OR EXANTHEMATOUS ERUPTIONS.   155

 a  very distressing case of this  malady which occurred in a gentle-
 woman, twenty-seven years of age, and returned at intervals of a week
 for a considerable length of time.
   Febrile  urticaria frequently attacks  children, particularly during
 teething, and in them is remarkable for its  unexpected development.
 Dr. Underwood observes that it " occurs in children more generally
 under two years of age, and is exceedingly  troublesome to the infant,
 as well as  matter  of surprise to  parents, from the suddenness of its
 appearance.  Children going to bed prefectly well, wake very uneasy,
 and frequently continue screaming  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."  This description  corresponds with that of  an erup-
 tion, afterwards to be described, lichen urticatus, which is peculiar to
 children.
   Urticaria ab ingestis.—The symptoms produced by noxious alimen-
 tary 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 suffers from weight and  an uneasy feeling in the stomach,
 accompanied with nausea and giddiness, and  sometimes by vomiting
 and diarrhoea, a prickling sensation in the throat, and constriction of
 the fauces, which produces a short,  troublesome cough, and occasion-
 ally threatens suffocation; the tongue is swollen, and the voice altered
 from the extension of the swelling of the mucous membrane into the
 larynx.  The face  shortly begins to swell,  while  the ears, nose, and
 lips are burning hot, and  itch  violently.   By degrees the eruption
 spreads to  the  trunk  of the  body, and  from the latter to  the limbs,
 affecting the joints particularly.   When the rash reaches the extremi-
 ties the disagreeable symptoms pass off, and the patient recovers. This
 kind of attack generally terminates at the end of two days,  and some-
 times  after a few hours, leaving behind it little  or  no trace  of  its
 existence.

                      URTICARIA CONFERTA.

   Urticaria conferta (Plate VII., b) is merely a severe degree of the
 local affection of urticaria.  The elevation of the circular prominences
 and wheals is not so great as in the preceding variety, but they are
 more numerous, frequently coalesce, and are attended with  considera-
 ble inflammation of the surrounding skin.   The itching and tingling
 are exceedingly severe, particularly at night,  and  the  integument is
 tumid  and  swollen.  This form of the affection is apt to continue for
 several weeks.

                       URTICARIA EVANIDA.

   Urticaria evanida (Plate VII., A A) is a chronic variety of nettlerash,
appearing and disappearing upon the skin in the form of white round-
ish prominences and wheals, without febrile symptoms, and with trifling 
156      DISEASES ARISING FROM  GENERAL  CAUSES.

redness.  The eruption is not the less attended with troublesome itch-
ing and tingling, particularly on the removal of the dress at bedtime,
and on the return of warmth, induced by the bed-clothes.   It is chiefly
remarkable for its  duration, lasting  sometimes for months, and even
for years.
                      URTICARIA PERSTANS.

  Urticaria perstans1 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 not so frequently on the  trunk of the body.
The gastric disorder, with the itching and tingling  under the influence
of heat,  which are typical of urticaria, are also present  in the per-
sistent variety.

                     URTICARIA SUBCUTANEA.

  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 con-
tinues only a few days at each  return, but the patient is harassed dur-
ing the  intervals,  as well as during  the eruptions, with a  violent and
almost constant tingling in the skin, and with other distressing symp-
toms.  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 afterwards felt  more  and  more  extensively along the limbs,  or
perhaps over nearly the whole surface of the body.  Sudden changes
of the temperature of the air, and agitation of mind, occasion increased
uneasiness in the skin, so that pains are sometimes  felt as from a sharp
instrument puncturing in different directions; at other times, as from
needles piercing or pushing the skin upwards.   There  is usually a
stiffness  and  slight torpor in  the muscles of the parts most affected;
an appearance of wheals takes place on  the arms,  chest, or lower ex-
tremities, from* time to time, especially during the summer.   In most
of the cases  that  I have seen or known the complaint was partial,
affecting only the loins and thighs, or sometimes the arms."  In illus-
tration of  this disease,  Willan  records  the  case  of a lady, which
appears  rather to resemble a chronic affection of the  spinal cord,
attended occasionally with the eruption of urticaria.  Stinging and
pricking in the integument is a common symptom in diseases of the
nervous system,,but this surely affords no grounds for the  designation
subcutanea,  as applied  to this variety.

                      URTICARIA TUBEROSA.

  Urticaria tuberosa appears chiefly in debilitated constitutions, and
is a rare  form  of cutaneous disease.  It  has  received its  name  from
being characterized by the  production of elevations  of considerable
size, and extending deeply into  the  subcutaneous  cellular tissue.
1 Portraits of Diseases of the Skin, Plate I., L. 
ERYTHEMATOUS OR EXANTHEMATOUS  ERUPTIONS.  157
These  tumors 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, and sore, as
if  he had been bruised,  or had  undergone  much fatigue."   The
disease  "often proves  tedious and obstinate;  I have known it con-
tinue," 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, observes:
" The urine, in a case of urticaria tuberculosa, has been analyzed by
Scherer.  The patient was a  young man, who likewise suffered from
rheumatism.  The urine was discharged in very' small  quantity,  often
not  more than five or six ounces in  forty-eight hours.   It was clear,
of a brownish-red color, very acid, and its specific gravity was  1028.
It  contained in 1000 parts—
           Water     .            .....931.58
           Solid residue.......68.42

              Urea........30.46
              Uric acid.......0.74
              Alcohol extract, with much lactic acid  .    .  21.24
             ' Water extract    . '.....4.92
              Alkaline salts......8.03
              Earthy phosphates    .....    2.02
The most remarkable points in the constitution of the urine are the
large amount of earthy phosphates, and  the excess of free acid."
   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 urine.   Dr. Maclagan ventured, therefore, to propose, as the patho-
logical view of the case, that the defect  here was merely a deficiency
of the urea and  uric acid; in short, a want of  what modern chemists
call  the  products of transformation of the tissues, and  that the reten-
tion in this way in the system of matters which ought to be eliminated
from it  might be the cause  of  this cutaneous irritation, especially
occurring, as it did, after meals."1
  AVith the view of modifying the imperfect transformation of tissues
here referred to, the patient was treated with colchicum, upon which
1 Edinburgh Monthly Journal. 
158      DISEASES ARISING FROM GENERAL CAUSES.

the specific gravity of  the urine was found  to have risen  to  1029.9,
and its composition to  be as follows:—
          Urea.........20.36
          Uric acid........0.50
          Inorganic salts.......12 72
          Organic matter and water.....966.42
  The conclusions deduced from this observation are:—
  1.  '•'That urticaria is intimately connected wth 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 deficient
salts, and thus curing the disease.
  3.  " Rheumatism and urticaria, and purpura and urticaria, are fre-
quently 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."1
  Diagnosis.—The diagnostic characters of urticaria are, firstly, the
appearance  of the  eruption, which  resembles the  whitish  elevated
spots and wheals  produced by nettles; secondly, the  itching, tingling,
and pricking, which accompany the eruption;  thirdly, the evanescent
and fleetingr habits of  the eruption;  and fourthly, its association with
symptoms $f  gastric irritation.   These  characters, well appreciated,
sufficiently distinguish it from every other cutaneous eruption.
  The only affections to which urticaria  bears so close a resemblance
as to deserve  remark,  are, lichen urticatus,  and erythema papulatum,
tuberosum, and nodosum.  The pimples  of lichen urticatus  are, how-
ever, smaller and more persistent than the  wheals of urticaria; they
appear  in  successive  crops, and become   surmounted  by  a small
dark-colored scab.  Erythema papulatum resembles  urticaria, both in
general and local symptoms, but differs in its course and persistency.
The spots of erythema  tuberosum are quite  superficial and persistent,
as are  those  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 with rubeola, variola, and prurigo.
  Causes.—The proximate cause of urticaria is an irritation of the
nerves of the skin, giving  rise to the peculiar prickling and tingling
sensation,  and exciting  spasm  of  the  muscular structure  of the
corium; hence the white buttons and wheals emptied of their blood
by muscular contraction, and developed on a  surface reddened by
vascular congestion;  hence,  also, the  gradual subsidence of the
wheals, the  recovery of the natural  tint of the  skin, and  their  sud-
den  reproduction  on  the recurrence of  slight irritation.  In the
instance of the rash occasioned by the sting of a nettle,  the poisonous
juices of the plant act directly on the  nerves of the skin.  In the
1 Lancet, vol. ii. 1846, p. 160. 
      ERYTHEMATOUS  OR  EXANTHEMATOUS ERUPTIONS.   159

case of urticaria excited by  poisonous food, the action is  an excito-
sensory reflex operation,  the  seat  of  primary irritation  being the
nerves of  the  stomach; while  in  other examples of the disease the
primary irritation  may exist  in any organ  supplied with sympathetic
nerves; in  a  word, urticaria  is a  neuropathic affection,  as distin-
guished from erythema and roseola,  which are haemopathic disorders.
This view of the pathology of urticaria explains its association with
other eruptions of haemopathic origin; indeed, it is matter for sur-
prise, that a spasmodic state of the muscular structure of the skin so
rarely accompanies its inflammation in other diseases.
  The exciting causes of  urticaria  are  referable to irritation of the
gastro-pulmonary  and genito-urinary mucous membranes.  Thus it is
induced by  dentition, by gastric irritation,  by intestinal irritation, by
uterine, and, more rarely,  by pulmonary  irritation.   Mental excite-
ment or anxiety,  fatigue, exposure  to cold or  heat, also  contribute
towards its  development, 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
watched the red wheals appear and creep along the skin  and  disap-
pear, while  I  purposely engaged  her in conversation on  indifferent
subjects.  A  word, a  look,  the slightest excitement, would  imme-
diately 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 frequent in children, particu-
larly during the period of dentition.
   The alimentary substances which are  capable of exciting urticaria,
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  referable to  the  natural susceptibility of the indi-
vidual ; while in others, the  probable cause is a poison generated by
putrefactive decomposition.   The  substances which have been  ob-
served to give rise to  these effects in  different persons  are very
numerous;  they are—some  kinds of fish, as  mussels, lobsters, crabs,
prawns, shrimps, oysters,  dried fish,  &c.;  certain meats, such as pork,
goose, &c.; certain fruits and vegetables, as rice, almonds, strawberries,
raspberries, cucumbers, mushrooms, &c.   Rayer mentions oatmeal
gruel, as occasionally producing this effect; and certain  medicines, as
valerian,  copaiba, &c.  A member of my own family suffers, con-
stantly, 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  has  been stated  by  some  authors to have
occurred  epidemically. 
160      DISEASES ARISING FROM GENERAL CAUSES.

   Persons of great cutaneous susceptibility have the power of exciting
the eruption at any time, by merely scratching the skin.

   Prognosis.—Urticaria is not, in itself, a dangerous disease.  The
acute form  is  easily removed  by  appropriate  treatment.  Chronic
urticaria is frequently symptomatic of nervous debility, mucous irri-
tation, or visceral disorder, and may consequently prove  obstinate,
resisting all therapeutic measures  until the disease of which  it is a
dependence is relieved.   Retrocession of  this eruption has sometimes
been followed by a serious aggravation of internal disease.
   Treatment.—The treatment  of febrile urticaria should be strictly
antiphlogistic;  in some cases it may be advisable to deplete by gene-
ral bleeding; in others, abstraction of blood  from the neighborhood
of the organs especially affected, by means of leeches, may suffice.  The
rest of the treatment should consist in the administration of aperients,
salines, maintaining an  abstemious and cooling  diet,  using the tepid
bath and foot-bath occasionally, and if the seat of the visceral disorder
be  apparent, applying  a blister  over  the organ  affected.   During
convalescence,  if the powers  of the system have been reduced, tonic
medicines, combined with alkalies or acids, according to the stage of
the affection, should be  prescribed.
   When difficult dentition is the cause of eruption, the gums must be
laid freely open with the lancet;  the little 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 ejec-
tion of the offending matters.   For this purpose the sulphate of
zinc or sulphate of copper is 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 liability to operate too violently,  and give rise to faintings.  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 ether, to be given every half hour.
  Chronic urticaria calls for  the  use of  aperients, counter-irritants,
tonics, warm and cold baths, particularly the sponge bath and shower
bath, careful attention to regimen, and the avoidance  of all indigest-
ible substances.  I have derived  the greatest amount of success in
the treatment of chronic urticaria from the use of warm aloetic purga-
tives, combined with the citrate of  iron  or nitro-muriatic acid in a
bitter infusion or tincture,  and afterwards followed by arsenic.  The
influence  of dietetic substances was  shown  in  the fact that, in one
patient sugar was excommunicated with  advantage, and in the same
case great benefit was derived from  the citrate of iron, at  first com-
bined with the hydriodate of potash,  and  subsequently with quinine.
In another case, the infusion of serpentaria with carbonate of magnesia
and carbonate of ammonia was  completely successful.  In  a third, a
course of  sulphate of magnesia in drachm-doses, combined with car-
bonate of  magnesia and iodide of potassium,  cured  the patient after 
            LICHENOUS  OR PAPULOUS ERUPTIONS.        161

other means had failed ; and in a fourth, five minims of the tincture
of colchicum were usefully substituted  for the iodide.   I have also
derived advantage from bismuth  and from the oxide of silver;  the
latter in one-grain doses a quarter of an  hour before meals.  Urticaria
tuberosa is often so severe as to require depletion by venesection, and
active antiphlogistic measures.  Whenever urticaria assumes an inter-
mittent 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.  Locally the lini-
mentum saponis, with chloroform and laudanum, two drachms of each
to the four ounces, is a valuable  application.  Acetous  and alcoholic
lotions, and lemon-juice, are sometimes  useful for a similar purpose;
and a lotion composed of carbonate of ammonia 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 quelling the pruritus of this and other eruptions; but that
upon which I chiefly rely  is one composed of bichloride of mercury,
from five to ten grains, spirit of rosemary and spirit of  wine of each
an ounce, and six ounces of the emulsion of bitter almonds.
  If the eruption show a disposition to  recede, or if it  have already
receded, blisters should be applied to the skin; or  the surface well
rubbed with some stimulating liniment,  such as that of croton-oil, in
order to. restore the  eruption, or set up an equivalent  action  in the
skin.
                     CHAPTER VI.

         DISEASES  ARISING FROM GENERAL  CAUSES.

              LICHENOUS OR PAPULOUS ERUPTIONS.

  In the present group of cutaneous affections, Lichen is taken as the
typical form, just as Erythema is made to constitute the type of the
] (receding group.   This  group corresponds with the order  Papulae of
Willan, and the genus Exormia of Mason Good.   It  includes three
affections, namely,
         Lichen.           Strophulus.           Prurigo.
  Rayer and Gibert remark that the above number might very pro-
perly be reduced to two; for that strophulus is nothing more than the
lichen of young children  and infants, while Alibert considers the whole
under the single genus Prurigo.
  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, with an inflamed base,
very seldom containing a fluid, or suppurating, and commonly termi-
      H   \ 
 162      DISEASES ARISING FROM GENERAL  CAUSES.

 nating in scurf."   Papulae terminate by resolution, generally with fur-
 furaceous desquamation of the epidermis.  The papulae of strophulus
 have usually  a greater elevation than those  of lichen aud  prurigo.
 Some differences  are perceived also in relation to color; thus,  the pim-
 ples of strophulus may be either red or pale, those of lichen are always
 more or less red  and inflamed, while the papulae of prurigo scarcely
 differ in tint from the surrounding skin.
   The seat of morbid action in the lichenous eruption is the  vascular
 boundary of the  various excretory tubules of the skin; for example,
 the sudoriferous and sebiferous ducts, and hair-follicles.  In this fact
 we have an explanation of various of the phenomena which accompany
 the eruption;  for example, the frequent perforation of the pimples by
 a hair, the formation of a thin scale upon the summit of the papule,
 the occasional appearance of a minute aperture in this situation, and
 the oozing of a transparent and  colorless fluid from the same point.
"We can  also better understand the  provoking  itching which  is a
 symptom of the  eruption,  the obstruction which  is offered to the
 escape of secretions, and  the  obstinacy of these disorders.   The pa-
 pulae of prurigo are perfectly identical with the 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  diseases;  an  unevenness of surface, pro-
 duced by numberless slight but broad elevations, separated a^va each
 other by the linear markings of the  skin.  These are the elevations
 which have been  described by all dermatologists under the name of
 the  broad and flat papulae of prurigo.   "Soft and smooth  papulae,
 somewhat larger  and less acuminated than those of lichen, and seldom
 appearing red or inflamed, except from  violent friction.  Hence an
 inattentive observer may overlook the papulae altogether."1  Rayer
 speaks of them as being "soft to the touch, and broader than those of
 lichen, from which they also differ in  preserving the natural color of
 the skin."   "They occasionally project in so slight a degree that they
 appear  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 fact, which must have involved  many in perplexity
 with regard to the real  meaning of  the  authors.   Papulae, precisely
 defined, broad, soft, smooth, and large, and yet not distinguishable in
 color 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 endeavor  to explain the difficulty.
   As a consequence of the altered nutrition and  innervation of the
 skin which  accompany prurigo, the dermal tissues become changed
 in structure, namely, condensed  and  thickened.   The  most  careless
 examination is sufficient  to establish 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
 color is changed; it looks yellowish  and dirty.   But  it is  smooth;
1 Bateman, Synopsis, third edition, p. 15. 
LICHENOUS OR  PAPULOUS  ERUPTIONS.
163
there are no such projections as we should call pimples, or if there be,
they are few and scattered.   Arrived at this point, there remains but
one conclusion for the student.  There are no papulae, therefore the
disorder cannot be prurigo.  And yet the disease  is so  characteris-
tically prurigo, that, setting aside the symptom of pruritus, the derma-
tologist 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
skin,  and  the  consequences of this  condition.  Upon close exami-
nation, the angular areae included by the  linear markings of the skin
are seen  to be  raised 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 pores,  namely, in the furrows which
constitute  the  linear marking, and  at the point  of divergence  of
several of these.  The elevations, therefore,  are simply the effect of a
swollen state of the derma, the  areae being magnified by hypertrophy,
and the linear markings being  magnified  in depth by the  same cause.
These swollen areas are the so-called  papulae, the broad, and flat, and
smooth papulae.  It is not, then, to be wondered  at,  that they should
be with difficulty discerned, that theyshould be " overlooked," seeing,
as I have shown, that they are not papulae at  all.
   But we do meet with  papulae in prurigo, although not a  necessary
feature of that disease.   These papulae  are not the areae of  the linear
marking^ 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 abra-*
sion of their tips  from scratching, and then become  surmounted by a
small, dark-colored scab.

                            LICHEN.

        Syn.  Exormia lichen, Mason Good.   Lichenous rash.

   Lichen (Plate XL) is an eruption of  minute conical papulae  distri-
buted upon a single  region, or over the  entire surface of  the body.
The pimples are comparable in  size to millet seeds;  they  are reddish
in color, or scarcely different from the natural  hue of the skin, and are
attended with  itching,  tingling, and  smarting.  They are usually
developed  in clusters, and appear  in single or  successive eruptions.
They are non-contagious, and terminate  in resolution and furfuraceous
desquamation, sometimes in superficial  ulceration.
   The appearance, situation, form, and  severity  of  the disease, have
given rise to its division into nine described varieties, which may with
advantage be reduced to six, the other  three, namely,  lichen, lividus,
lichen pilaris, and lichen gyratus, being mere modifications of varieties.
The six which remain are:—
           Lichen simplex.                  Lichen urticatus.
             "    annulatus.                  "    tropicus.
             "    circumscriptus.              "    agrius. 
164      DISEASES ARISING  FROM GENERAL CAUSES.
                         LICHEN SIMPLEX.

   In the simple  form of lichen (Plate XL, a), the  pimples are dis-
 tributed irregularly over the surface affected, forming little patches
 from point to point, in which the papulae are more numerously assem-
 bled than in  neighboring parts.  Simple  lichen is usually a chronic
 disorder, but occasionally  presents  itself  in an acute  form.  The
 acute variety is  preceded  and  accompanied  by febrile  symptoms,
 which are referable  to  the disordered state of the  system, and are
 relieved by the outbreak of the eruption.'
   In the acute  form of lichen,1 the eruption is  ushered  in  by some
 degree of smarting and  pruritus, which are increased towards night;
 the papulae  are  red  and inflamed, and continue 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 desquamation  of the epidermis.
   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 especially  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, papulae  are large  and rounded in form; on the neck,
 trunk, and limbs, they are small, more vivid in color, and  acuminated,
 and on the hands they are somewhat paler than in other situations.
   The ordinary seat of the  acute variety of lichen simplex is the face
 and trunk 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 simplex has received the name of lichen lividus, when,
 from its occurrence in persons of weakly and debilitated constitution,
 or in those who are ill-fed, badly clothed, and live in unhealthy and
 confined situations, the pimples  have a bluish and livid  appearance.
 It  is commonly met with  among the squalid  inmates of our work-
 houses  at the  period  of  admission,  and  is  unaccompanied  with
 constitutional disturbance.   The papulae of lichen lividus are soft
 and somewhat flattened, they have a purplish red or  livid hue, are  of
 longer continuance than fnose of simple lichen, and are developed on
 the arms and legs, but chiefly on the latter.  Not  unfrequently they
 are  intermingled with  petechiae,  and small  purple blotches and
 ecchymoses.  The eruption is  frequently  prolonged  by successive
 eruptions for several months.

  1 Portraits of Diseases of the Skin, Plate IX., Q.  This case is curious from being
 so exactly limited in extent by a woollen vest which the patient wore.  The clustered
 or corymbose distribution of the pimples on the arms is also interesting. 
LICHENOUS OR PAPULOUS ERUPTIONS.         165
  Lichen pilaris (Plate XL, b) is a term which is applied to lichen
simplex, when the pimples are developed around  the mouths of  the
pores by which the  hairs issue from  the skin.   They are red and
inflamed, extend  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 furfuraceous
desquamation of  the  epidermis, but are sometimes  prolonged by suc-
cessive  eruptions  to  several  months or years.   This form of lichen
occurs  in  persons of  unsound  and irritable constitution, and  is
frequently  coincident with disorder of the  stomach and bowels, and
the abuse of spirituous drinks.

                       LICHEN ANNULATUS.

Syn.   Lichen annulatus solitarius.   Lichen  annulatus serpigiriosus.
     Erythema  marginatum, Bateman.   Lichen marginatus.   Lichen
     gyratus, Biett.
  There is a variety of lichen, in  which the disease commences as a   .
mere spot, and  increases rapidly in size until it forms a distinct ring.
There  is generally but one such ring on  the  whole body; and the
eruption may  therefore be   properly  designated   lichen  annulatus
solitarius}  The existence  on the  same person of more than two  or
three of these rings, is an exceptional occurrence.   It is an  eruption
more frequently met  with  in  women and children  than among men,
and  the ring, after  attaining a certain size, remains stationary, for
two, three,  or four weeks, and then  disappears.  The boundary ring
in lichen annulatus presents some variety in  point of elevation and
degree  of  papulation.   Sometimes  the elevation  is so  trifling   as
scarcely to  be  perceptible, at other times it  is strongly marked;
usually the ring is  formed   by a  line of well-developed  papules,
sometimes  a double row, while  often it is an  almost uniform ridge.
The want of clear definition  of the  papules, and  the appearance of
the area of the  ring, which is  yellowish and mealy, have caused it  to
be described under  tl^ name of erythema (Plate  VII.,  l), but  its
proper place is the present  group.
  The ring in  lichen annulatus is of a lightish red  color, with here
and there a more vivid tint, from the presence of a papule of a brighter
hue than the rest.  The area presents a yellowish tint, and is covered
with a mealy scurf; it is for the  most part uniform, but occasionally
has a few papules sprinkled on its surface, and sometimes includes a
series of two or three  concentric  papular rings.   (Plate  VII.,  M.)
Lichen annulatus solitarius is  frequently associated  with trichosis fur-
furacea, or  common  ringworm, and is, in  fact, the  ringworm  of the
hairless skin.   But it is also  found where no ringworm of the scalp
is present.
  Lichen annulatus serpiginosus2 is another form of the  annulate

  1 Portraits of Diseases of the Skin, Plate XL, AI.  In this plate several varieties of
eruption  are  shown.  This eruption is not unfrequently associated with common
ringworm, and is, in fact, the so called " ringworm of the body."
  2 Portraits of Diseases of the Skin, Plate X., AD. 
166      DISEASES  ARISING FROM GENERAL  CAUSES.

variety of lichen;  its special characters  being, the development  of
rings in considerable  numbers, generally upon the breast or back;
and  the rapid spreading of the rings, so that they run together, and
form one broad and extensive patch, upon and around which the more
or less complete or interrupted markings of its component circles may
be traced.  This eruption is attended with very considerable itching,
is chronic in its nature, and is succeeded by a mealy exfoliation of the
epidermis.
  The eruption  commences by lichenous pimples, which, subsiding at
the summit and spreading  at the base, are speedily converted into
small, flat, erythematous disks, bounded by  a sharp and distinct mar-
gin.   These disks, about half an inch in diameter, throw up at their
edges, at one, two, or three points, several  bright red pimples, and,
increasing in size to the diameter of  one or two inches, are converted
into  rings.  When the centrifugal  growth is equally active  on all
sides, the ring remains  circular, and the margin  is.formed by a row
of pimples more or less complete; sometimes the row of  pimples  is
broken at several points, sometimes they are ranged only on one side
of the circle, and at other times they  are entirely absent, and the mar-
gin is formed by a simple ridge, along the summit of which the cu-
ticle has become fissured (erythema marginatum).  Bateman observes,
that  "the  erythema marginatum occurs in patches, which are bounded
on one side by a hard, elevated, tortuous red border,  in some places
obscurely papulated ; but the redness has no regular boundary on the
open side."  When  the pimples are developed only  on one side  of
the circle, so as  to form a crescentic rim, the ring is  apt  to increase
chiefly by this side, and becomes more or less oblong; and when the
pimples constitute several broken rows, the ring is still more irregular.
Increasing in this way,  and by a portion only of the periphery of the
ring, the rest of the ring is apt to be  lost, and then only a portion  of
the margin remaining, the title of lichen marginatus is not inapplicable.
Or, whea  portions of  several circles are  more or less  connected with
each other, so as to form an uneven  line of some extent, we find an
explanation of the term lichen gyratus, assigned by Biett to a narrow,
tortuous band composed of lichenous papules.
   The area of the rings has a yellowish tint of color,  and  the cuticle
covering it is slightly corrugated and dry, and sometimes  the seat  of
a  mealy exfoliation.   In other respects, the area is uniform  and
smooth, and rarely presents any trace of pimples.  Along the line  of
the margin, on both sides of the base of the papular ridge, the cuticle
is commonly broken, and presents a thin, free edge.

                     LICHEN CIRCUMSCRIPTA.

                         Clustering  lichen.
  Lichen circumscriptus (Plate XL,  e f) differs from  lichen simplex
only in the mode of aggregation of the pimples.  They are collected
into one or several patches, of a circular  or  oval  form, and bounded
by a well-defined margin, consisting generally of the largest and most
inflamed papulae.  The patches in the first  instance appear as small 
            LICHENOUS OR PAPULOUS  ERUPTIONS.         167

aggregated  clusters, which progressively increase  by their  circum-
ference, while they exhibit a  tendency to fade in the centre, and form
rings of variable size.  In the latter case,  the  boundary of the ring
maintains a certain breadth, and forms a kind of ribbon or belt around
the included area, in which a greater or less number of pimples con-
tinue to be developed.
   When the ribbon or belt is broken in its circle, or parts of several
circles  are irregularly connected together, we  have  the variety de-
scribed by Biett under the name of lichen  gyratus, which  consists in
the aggregation of the papulae 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 ribbon, which,
commencing on the front of  the chest, curved  downwards along the
inner border of the arm, and continued onwards, precisely in the di-
rection 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.

                   Lichen urticosus, Mason Good.
   In lichen urticatus  (Plate XL, 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 generally  show themselves suddenly,
and disappear, unless irritated by scratching, in the course of a day.
More frequently,  however, from the burning heat and pungent itching
which attend  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 healthful 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 frequently in clusters, particularly on  the face,
neck, and shoulders.  The pimples  are excited by warmth; for ex-
ample, by warmth of  bed, so  that she is sometimes  awakened in the
night by the itching.  They are also excited by mental emotion; thus,
if she be scolded,  the itching begins; and, to use her mother's expres-
sion, 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 the 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 
163      DISEASES ARISING FROM  GENERAL CAUSES.

appearing,  the eruption has now been prolonged without amendment
for three months.
   Such was the state of the case when I first saw her.  I  prescribed
for her citrate of iron, with  hydriodate of potash, and a lotion of
bichloride of mercury in an emulsion of bitter almonds, five grains to
the half pint.   The lotion relieved  the itching, but the Eruption con-
tinued  unchanged, 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.

            Syn. Essera, Eshera, Arabic.   Summer rash.
   Lichen tropicus, or prickly heat, is the usual form of this eruption
when it occurs in warm climates.  Willan gives an excellent descrip-
tion  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 papulae, about  the size of a
small pin's  head, and elevated so  as to  produce a considerable rough-
ness of the skin.  The papulae are of a  vivid  red color, and often
exhibit an  irregular form, two or three of them being in many places
united together, but no redness  or  inflammation 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 face, excepting on the  upper 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 papulas 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 humor are often  inter-
mingled with the prickly heat,  more especially on the breast and
about the wrists ; but they terminate in scales, having  no  disposition
to ulcerate, 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 stationary,
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 papuke.  They  sometimes disappear  on  a sudden, and
return again as suddenly, without any  obvious  cause;  but whenever 
LICHENOUS OR  PAPULOUS  ERUPTIONS.
169
 the  eruption  continues for  a length of time, the papulae throw off
 minute scales, and are succeeded by a fresh crop, no vestiges being left
 in the 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, how-
 ever, be easily  effected;  it  is certainly  not produced  by  bathing,
 which has been hitherto thought  highly  prejudicial.  A vivid  erup-
 tion of the prickly heat is  a proof that the person affected with it is in
 a good state of health, although its absence does not always indicate
 the contrary.  The sudden disappearance of it which frequently hap-
 pens, 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 tempo-
 rary stimulus, applied to the stomach, as by spirits, tea, or other warm
 liquids, has the  power of restoring the eruption.   Its appearance on
 the skin  of persons in a  state of convalescence from fevers, &c, is
 always a favorable sign, indicating the return of health and of vigor."
   " Various means have been employed to alleviate the  itching and
 tingling of the  prickly heat; the favorite remedy  at Sierra  Leone is
 the juice of limes rubbed  on the skin, which, however, has  no  con-
 siderable 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:  "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
 the 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 temporary relief
 only,  and what was worse, a more violent paroxysm frequently suc-
 ceeded."
   " The sensations arising from prickly heat are perfectly indescrib-
 able,  being compounded   of  pricking, itching, tingling, and many
 other feelings for which I have no appropriate appellation."
  " It is usually, but not invariably, accompanied  by an  eruption of
 vivid  red  pimples, not larger in  general than  a  pin's head, 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 in repelling this eruption, Dr.
Johnson continues, " Indeed, I never saw it even repelled by  the cold
bath;  and in my own case, as well  as in many others, it seemed rather
to aggravate the eruption and disagreeable sensations, especially during 
170      DISEASES ARISING FROM  GENERAL CAUSES.

the glow which succeeded immersion. 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 unmoved  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."
  The author very truly observes, that an  affection similar to  lichen
tropicus is  sometimes seen during the summer season in this country.
I have myself suffered from its annoying  attack on one or two occa-
sions, and can add my testimony to that of Dr. Johnson.

                         LICHEN AGRIUS.

         Syn. Lichen eczernatosus, vel ichorosus.  Lichen ferns.
                         Agria, Graecorum.
  Lichen Agrius (Plate XL, g h) is the most intense, and when  exten-
sive, a very  severe form  of lichenous disease;  the papulae  are acu-
minated and prominent, of a vivid red color,  and numerous;  they are
aggregated into clusters of irregular form and size, are attended with
much heat, smarting, and itching, by  a painful sensation of tension,
and are surrounded by considerable inflammation.
  These symptoms continue to increase for  several days, when the less
inflamed papulae diminish in redness, and become covered with a  fur-
furaceous desquamation.  The more inflamed papulae, however,  and
especially those  which are collected into clusters,  have their  points
torn  off by friction or scratching, arid form  small superficial abrasions,
which pour forth an ichorous or sero-purulent fluid,  and this secretion
desiccates into thin yellowish crusts.  The  skin  around the papulae is
at the same time thickened by the continuance of  the inflammation,
and fissured by  deep cracks, from which a copious watery secretion
exudes.  In  milder cases the  disease subsides  before reaching  this
extreme, the redness and painfol symptoms  diminish, and the eruption
dies away in two or three weeks.
  In the severe form, as soon as the crust  falls off  and desquamation
occurs, new papulae are developed, which pursue the same course as
their prede'cessors, and the disease is prolonged to several  weeks, or
months; at other  times, the eruption  appears and  disappears several
times in succession before a cure is accomplished.
  More commonly, the eruption is of chronic  origin;  it begins as a
small patch of irritable pimples, say on the back of the  hand; these
pimples  are  very irritable, they are rubbed or scratched,  and next
day more pimples are developed.  This process may go on for several 
               LICHENOUS  OR  PAPULOUS  ERUPTIONS.         171

   weeks, the pimples sometimes  glowing and sometimes fading;  until,
   without  any apparent cause, the patch suddenly becomes as large as
   a half-crown piece, and establishes itself as a permanent eruption.
     Lichen agrius is generally partial in its eruption, being confined to
   one or more regions.  It is most frequently seen upon the arms, the
   hands, the shoulders, the loins, the  legs, as also upon  the  chest and
   face.   On  the  backs of the hands  it constitutes the  bricklayer's,
   grocer's, baker's, and washerwoman's itch of Willan  and Bateman.1
   The itching and smarting are sometimes intolerable, generally periodic,
   and much aggravated towards  the evening, or by the warmth of bed,3
   exercise, stimulating food, and drink, &c.   Occasionally the papulae
   are intermingled with small vesicles or pustules, which speedily burst,
   and terminate by desquamation.
     The eruption very commonly takes place without any constitutional
   symptoms;  or, if such be present, they have, no special reference  to
   the invasion of the disorder.   Generally they  are only of a  kind
   indicating dyspepsia, such  as acidity and flatulence, with a sense  of
   heaviness and debility; sometimes accompanied with neuralgic, rheu-
   matic, or gouty pains.  At other times the constitutional symptoms
   are more severe: for example,  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 for
   several days previously to  the  appearance of the cutaneous affection,
   and are, for the most part, relieved by its eruption.  When the disease
   has been suddenly checked, some visceral derangement has generally
   taken  its place.

    Diagnosis.—The diagnostic  characters of lichen are, its solid and
   prominent pimples, the coloration of these pimples, and their attendant
   itching, which is of the tingling kind.  The diseases  with which it
   may 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
   surmount 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 remarked, 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
   the regions  furnished with the thinnest skin  are those affected by
   scabies.  Eczema, it will be recollected, is a vesicular or ichorous
   eruption, and therefore distinct from the  solid, dry  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.

    1 Portraits of Diseases of the Skin ; Plate XII., G., represents a case of Lichen agrius
  dorsi manus.
    2 Plumbe remarks, that the parts smart for an hour or more, as if they "had  been
  severely scalded." 
172      DISEASES ARISING FROM  GENERAL CAUSES.

   Lichen circumscriptus bears some resemblance in the form of the
patch  to erythema  circinatum, erythema marginatum, and  herpes
circinatus, but from these the  diagnosis is by no means  difficult:   In
erythema circinatum, the surface is smooth; in erythema marginatum,
although raised and papulated, there are no scattered papulae in the
neighborhood 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 the comparative absence of pruritus.
   Lichen agrius is especially  characterized by the  close aggregation
and highly inflamed state of the pimples,  by the severe smarting and
tingling, by scaly crusts, the superficial excoriations, the fissures and
chaps which so frequently form, and by the thickening and conden-
sation  of the integument.
   Causes.—Lichen  occurs in persons of every temperament, and at
all periods of life.   It is most  frequently observed in the spring and
summer season, and  especially in  the latter.   Increased temperature
appears to have a  certain influence in  producing the disease, as we
see evinced  in lichen tropicus, or  prickly  heat;  for the same reason
the eruption is met with on the arms and face of persons employed
near the fire, as of cooks and smiths.  Local irritation  is not  un-
frequently an exciting cause, in persons of irritable skin, from the use
of flannel or woollen raiment, or  coarse body  linen.   Other exciting
causes are, depressing moral or physical conditions, excessive fatigue,
irregularities 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 persons,
females, and young persons of sanguine or nervous temperament.  It
is usually referable to fatigue, anxiety, or dyspepsia, and is a frequent
accompaniment of the rheumatic and gouty diathesis.   But the most
troublesome cases  of lichen agrius with which I have had to contend, -
have occurred upon  the legs of men who had passed  the  mid-period
of life.  These cases were all accompanied with oedema, and sometimes
with varicose veins.
   Prognosis.—Lichen  is not dangerous to life, but is often exceed-
ingly troublesome.  That which  originates from  the  more simple
causes in young persons, and pursues an acute course, generally termi-
nates in two or three weeks, but the chronic kinds may last  for years.
Lichen of the face  is especially obstinate.
   Treatment.—Simple lichen  requires  a treatment directed upon
ordinary antiphlogistic   principles;  with, locally, a  tepid  bath, or
lotions containing liquor plumbi diacetatis, distilled vinegar, or lemon-
juice, to subdue the local irritation.
   In more chronic forms of the eruption a purgative is always indi-
cated,  while attention should  be  bestowed on the secretions of the
liver, kidneys, and skin, and the bowels regulated.
   LicheM agrius is essentially  a disease of the assimilative functions; 
LICHENOUS OR  PAPULOUS  ERUPTIONS.         173
  and its frequent association with  the rheumatic and gouty diathesis
  must be  borne  in mind.  Antacid  purgatives,  with diuretics  and
  diaphoretics;  warm purges of rhubarb and aloes, combined with diu-
  retics ;  or, if the indication be obvious, with colchicum; with lemon-
  ade for drink—are the class of means to be employed.  Sometimes a
  specific course of diuretics is attended  with  successful results.   But
  the practitioner is often put upon his mettle by this disease, and must
  use considerable ingenuity to  foil the adversary.   In females I  have
  found  the mistura ferri composita, with decoctum aloes compositum,
  and liquor  potassae, an admirable remedy.  As  soon as it appears
  judicious to stop the purgative plan, alteratives and tonics come  into
  play; and, in a very chronic state of the disease, the special cutaneous
  alteratives, Donovan's, Fowler's, and De Valangin's solutions.
    The activity of treatment in lichen agrius must, of course, be regu-
  lated by the severity and extent of the eruption.
    Lichen lividus is to be managed by an alterative and tonic plan of
  treatment, after a preliminary clearance of the alimentary canal.
    The local treatment of  lichen agrius consists in the judicious selec-
  tion and application of lotions and ointments; in the first instance, to
  calm the surface while the general remedies act upon the blood; and
  secondly, to modify the local  disease  when it merges  into a chronic
  form.   The best lotions  for the former  purpose are, the saturnine
  spirit lotion, with camphor or  vinegar; a lotion containing the sesqui-
  carbonate of ammonia and liquor plumbi; if the itching be severe, a
  lotion of hydrocyanic acid; or if there  be ichorous discharge, a weak
  spirit lotion containing one or two drachms of the oxide of zinc to the
  half-pint.  The best ointments  for  the same purpose are—ceratum
  cetacei, with a drachm of liquor plumbi to the ounce;  the oxide of zinc
  ointment, either alone or in combination with liquor plumbi or spiritus
  camphorae ; calamine ointment; or oleaginous compounds of almond
  oil, lime-water,  and liquor plumbi, oxide of zinc,  or trisnitrate of
  bismuth.
    There has been a  fashion  of late—and fashions  in medicine are
, always false and dangerous—to abuse ointments; "greasy" applica-
  tions,  as they are universally called.  They are,  nevertheless,  most
  essential in the  treatment of cutaneous complaints; and when they
  irritate or inflame the skin, the fault is  not in the  pure ointment, but
  in  the rancidity or otherwise decomposed  quality of the substance
  employed.  Ointments are valuable as  agents preventing the hyper-
  oxygenization  of the blood which occurs in all cutaneous inflamma-
  tions, and which has of late rendered lard so conspicuous as a remedy
  for exanthemata, smallpox, and erysipelas.    Lotions, on the contrary,
  unless they be kept constantly applied,  are followed  by desiccation of
  the skin, and a consequent increase of irritation of the eruption. There
  is one substance, however, which may be combined with any form of
  lotion, and is an exception to this law, namely, glycerine.  Glycerine
  maintains a permanent  state of moisture of the surface; and where
  ointments, in peculiar idiosyncrasies, or under particular circumstances,
  cannot be borne, glycerine will be found to be an efficient and useful
  substitute.  It may be applied either in its concentrated form  or  in a 
174      DISEASES  ARISING  FROM GENERAL CAUSES.

state of dilution; and, if there be no abrasion of the skin, is unirritant,
and a mild and soothing remedy.
  When the purpose of local treatment is to modify the morbid action
taking place in the skin, the lotions and ointments best suited to the
case are, a lotion of bichloride of mercury in almond emulsion, or in
simple solution with  the hydrochlorate of ammonia; a lotion contain-
ing creasote; or pencilling with the tincture of croton, or compound
tincture of iodine.   The ointments are, unguentum  hydrargyri  am-
monio-chloridi; the nitrate of mercury ointment, pure or diluted; the
nitric oxide of mercury ointment, pure or diluted; calomel ointment;
the ointment of the deutioduret of  mercury, ten grains to the ounce;
the ioduret of sulphur  ointment, also ten grains to the ounce;  or the
unguentum hydrargyri; the force of these remedies being augmented,
if requisite, by the addition of  friction.
  I cannot say that I have seen any advantage result from the use of
collodion in this complaint.


                        STROPHULUS.

Syn. Exormia strophulus, Mason Good.  Tooth-rash.  Red gown. Red
                      Gum rash.  Gum rash.

  Strophulus  (Plate XI.) is a disease of early infancy, consisting in
the eruption of small pimples upon part, or upon the whole surface of
the body.   The pimples are usually red, but sometimes paler than the
surrounding skin; they are attended with  itching, which is increased
by warmth ; but they give rise to little constitutional disturbance, and
terminate by resolution and epidermal desquamation.
  The appearance, distribution, and color of the pimples of strophulus
have given rise to its division into  five varieties, namely,
          Strophulus intertinctus,     Strophulus albidus,
               "     confertus,           "      candidus.
              "     volaticus,

                    STROPHULUS INTERTINCTUS.

  Strophulus intertinctus (Plate XL, i) the red gum-rash, or red gown
of popular language, is an eruption of prominent pimples of a vivid
red color, upon one  or several regions of  the body, or generally dis-
persed 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 desquamation  of the epidermis. Occasionally the
strophulus appears at successive periods, being alternated  by intervals
of freedom from eruption.   It is observed by Willan, that the pimples
are developed principally on the cheeks, the backs of the hands, and
the fore-arms; they are unaccompanied by  symptoms of constitutional
disturbance, and as frequently affect the strongest and healthiest as
weakly children.  Strophulus is usually coincident  with acidity of 
            LICHENOUS OR PAPULOUS  ERUPTIONS.         175

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.

  Strophulus confertus, or tooth-rash (Plate XL, i), is a more severe
variety than the  preceding.  The pimples are more numerous, and
smaller in  size; they are aggregated into considerable patches, and
are often confluent.   Sometimes they are  distributed  generally over
the surface of the body, but more frequently  are confined to a single
spot, or to  several regions, as the face, the  breast, or the arms.   The
redness of the pimples is less vivid but more lasting than that of stro-
phulus intertinctus;  the  eruption usually attains its  height in twelve
or fourteen days, and  then subsides, leaving a copious furfuraceous
desquamation of the epidermis.  Strophulus confertus, according to
Willan, occurs at about the fourth or fifth month; and frequently on
its decline  a fresh eruption succeeds.
  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 downwards, along the arm. 'The patches,
as well as the intermediate skin, are of a deep red color, and are suc-
ceeded by an extensive epidermal exfoliation;  the skin  remains, for
some time after, dry and harsh, and of a dull red color.
  This form of strophulus sometimes occurs upon the legs,  and assumes
a painful and obstinate shape.  The eruption extends upwards along
the thighs to the loins  and abdomen, and produces a redness which is
nearly continuous.  The epidermis becomes dry, and cracks and sepa-
rates in  large  flakes, leaving the integument beneath inflamed and
rough.  These symptoms, with considerable heat, pruritus, and irrita-
tion, 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 pre-
ceding variety, are very  slight, but the local pruritus is troublesome,
and often severe.   The disease is referable for its cause to the  irrita-
tion of teething, as is implied in its popular designation of tooth-rash.

                     STROPHULUS  VOLATICUS.

  Syn. Exormia volaticus.  Erythema volaticum, Sauvages.  sEstus
               volaticus.  Feu volage.  Wild-fire rash.
  This variety (Plate XL, k) is characterized by the eruption of papulae
of a vivid red color, 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 itching.  In a few days the
inflammatory condition subsides, the  pimples assume a brownish tint,
and the eruption terminates by epidermal  desquamation.  More fre- 
176      DISEASES ARISING FROM  GENERAL CAUSES.

quently, however, new patches appear as the older ones decline, and
the disease  may be  prolonged for  several weeks.  The patches of
strophulus volaticus are particularly observed on the cheeks and arms.
  Strophulus  volaticus is accompanied with general uneasiness and
fretfulness, quick pulse, white tongue, and disordered bowels.

                      STROPHULUS ALBIDUS.

                         White gum-rash.
  In  strophulus  albidus (Plate XL, 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 inter-
mingled with the red papulae of the preceding varieties.

                      STROPHULUS CANDIDUS.

                         Pallid gum-rash.
  In  this variety (Plate XL, 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, shoulders, and loins.   They subside at the end of the
week, and then gradually disappear.   This eruption occurs most com-
monly in the later periods of dentition, and is sometimes observed
during convalescence from  inflammatory disorders.

  Diagnosis.—Strophulus is distinguished from other  papular affec-
tions  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.
  Causes.—Strophulus  is generally  due  to  gastric  and  intestinal
irritation,  and  is frequently associated with the constitutional disturb-
ance 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.   As  far as its
prognosis  is concerned,  it is  unattended  with  danger, and rarely
presents any features of severity.
  Treatment.— When the eruption  obviously originates in local
irritation,  the acting cause should be removed, and frequent ablutions
adopted.  The t^pid  bath  should be  used frequently, 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  the sesquicar-
bonate of ammonia, acetic acid, lemon-juice, salt and water, or almond
emulsion.   When  the  eruption  is  dry and chapped, or  when an
ichorous secretion is poured  out, the best application  will be found 
LICHENOUS OR  PAPULOUS  ERUPTIONS.         177
to be an ointment  containing  the liquor  plumbi diacetatis,' half a
drachm to the ounce; or the oxide of zinc ointment diluted  with
spintus^ camphorae, a  drachm to the ounce;  or, again, an ointment
containing hydrocyanic acid or creasote, apportioning the strength
according to the necessities of the case.  If the disease be associated
with gastro-intestinal irritation,  it is desirable  to avoid the possibility
of repelling the cutaneous congestion by cold applications ; and where
this has unfortunately been done, recourse  must be immediately had
to the warm  bath,  either simple,  or medicated with a handful of
mustard.
   When difficult dentition is the exciting cause, relief may  be obtained
by incising the gums.   And if gastro-intestinal irritation be present,
antacid and  laxative remedies should be administered.  Mercury with
chalk and rhubarb, are valuable medicines in this state of the alimen-
tary canal.

                           PRURIGO.

          Syn. Exormia prurigo, Mason Good.   Pruritus.

   Prurigo (Plate XL) is a chronic and non-contagious  affection of
the skin,  characterized by  a thickened  and discolored state  of that
membrane, and by an excessive and burning pruritus.   Moreover,
this state of skin is generally accompanied with an eruption of isolated
and scattered  papulae,  not differing in color from that of  the general
surface.  The thickening of the  skin gives it a coarseness of character,
and on close examination it is found raised into small flat elevations,
caused by the swelling of the little angular compartments between
the linear markings.   It is also  more or less streaked with scratches
made by the finger nails, and the torn papulae are  each surmounted
by a small, thin, and black scab.  The color of the skin is yellowish
and dirty.  The disease is unaccompanied by constitutional symptoms.
   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,
                            "   senilis.

                         PRURIGO MITIS.

  In the milder form of prurigo (Plate XL, 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 de-
grees thickened, indurated, and coarse ; the pimples, few in number at
first,  become numerous, many have  their points torn offjand are sur-
mounted  by a small  black crust; there are scratches here and there
upon the skin ; it becomes yellowish and dirty;  and the epidermis is
      12 
178       DISEASES  ARISING FROM  GENERAL CAUSES.

thrown" off as a furfuraceous  and pulverulent desquamation.   Occa-  ,
sionally the extreme  irritation produced by this eruption gives rise to
the development of ecthymatous pustules.
  Prurigo mitis makes its appearance  in  the spring  and summer
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 three weeks;
at other times the affection  is prolonged for several months.

                        PRURIGO FORMICANS.

  Prurigo formicans (Plate XL,  n  n) is a  severe degree of prurigo
mitis, differing from  the Tatter 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 sen-
sation, compared, by  the sufferers, to having their flesh  devoured by
thousands of ants, or to the piercing the skin with red-hot needles.
Rayer observes, that  patients describing their sufferings speak of heat
of the blood, burning fires, maddening itchiness, &C.1  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 forgetful-
ness, or after a night of disturbed sleep are awaked with the first dawn
by  their  unsparing tormentor.   The  violence of the scratching to
which the sufferers so afflicted yield themselves, produces redness of
the skin, and by removing  the heads of the papulae, 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 frequently the only indication
of the disease.   Prurigo formicans is very tedious in duration, extend-
ing to several  months, and sometimes, with intermissions, to  years.
At the termination of the disorder  the skin remains dry  and  thick-
ened, and the epidermis exfoliates by a furfuraceous and mealy des-
quamation.
  Prurigo formicans  is frequently associated with some visceral affec-
tion, 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 disease  occurs both in
children and adults, and at all seasons of the year.

  1 The Abbe Morellet was afflicted with this distressing  disease at the advanced age
of eighty years.  It obliged him to rise several times in the course of the night, to
sponge his body with vinegar and water containing the acetate of lead.  Writing to
Alibert, he  expressed himself as writhing  on the "gril de St. Laurent."  A soldier,
affected with the same disease, compared his sufferings to being pierced all over with
halberds.  Alibert records several distinguished men among those who have been
afflicted with tltfs persecuting malady, as Plato, Charles V., and Charles IX. 
LICHENOUS OR  PAPULOUS  ERUPTIONS.         179
                         PRURIGO SENILIS.

   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 obstinate, and frequently
endures for years.
   "In severe cases," write Cazenave and Schedel, "the skin becomes
swollen and inflamed; eruptions of vesicles, pustules, and boils, appear;
and sometimes abscesses are formed.  Under such circumstances there
are frequently symptoms of fever, restlessness, and sleeplessness, and
sometimes indications of  gastro-intestinal 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 the skin, and  he
remarks upon the frequent association of the pediculus vestimentorum
with  the  eruption; of course, he means among  the  lowest classes of
persons.
                         LOCAL VARIETIES.

   The principal local varieties of prurigo are three  in number; they
are characterized by intense  itching, and by the alteration of the
dermal tissues above  described as constituting the general affection.
Willan describes, under  this designation, several other  forms of dis-
tressing itching, which are unaccompanied by papulae, and are ascrib-
able to an altered sensibility of the cutaneous nerves.   I have there-
fore thought it advisable  to arrange the latter affections under the head
of pruritus,  and  treat of  them  separately in  a distinct section of the
work. The local varieties of prurigo are—
                      Prurigo podicis,
                         "      scroti,
                         "      pudendalis.
   Prurigo  podicis consists in an alteration of the skin, similar to that
already described, around the anus, and upon the  neighboring regions
of the perineum and thighs.  The itching is severe and distressing,
and  increases at night,  commencing shortly 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
several months.   After it has continued for some  time the integument
becomes much thickened.
  This form of eruption might be  advantageously considered as a
chronic lichen or chronic eczema, in short, a psoriasis.

  Prurigo  scroti  is frequently an extension of  the  preceding affec-
tion;  the papulae are developed on the scrotum and root of the penis,
and give  rise to  unappeasable itching.  The patient, in making at-
tempts to  relieve the pruritus,  often produces painful  excoriations,
which increase his misery. 
180      DISEASES ARISING  FROM GENERAL CAUSES.

  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 vulva,  but sometimes
extends upwards along the vagina.   The  pruritus is  generally con-
stant, 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.

  Diagnosis.—Prurigo is distinguished from other papular eruptions
by the morbid alteration of  the skin, and by the burning  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 recollected
that the signs of the latter are a ragged and  undermined  state of the
epidermis, the presence of vesicles, and, above all, of the acarus scabiei.
The pruritus of the two diseases is  also different;  in prurigo  it is
burning and tingling, and occurs in paroxysms, while in scabies it is
constant, and  more supportable;  situation  forms another ground of
diagnosis.
  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  mitis  is chiefly seen during the
spring and summer months.   The causes of prurigo are want of clean-
liness, insufficient clothing, residence in  unhealthy situations, amenor-
rhcea, dysmenorrhcea, uterine irritation associated with-pregnancy, &c.
Prurigo formicans is occasionally induced by the presence of visceral
disease and  mental affections of long continuance, improper and over-
stimulating diet, stimulating drinks,  deficient and ira'proper food, &c.
Prurigo senilis appears to depend upon  debility of the system, a  state
which is popularly expressed by the term,  impoverished blood.
   Prognosis.—Prurigo is often exceedingly obstinate,  and  resists
every kind  of  treatment, and in old persons, by the continuance of
irritating and unappeasable pruritus, may  be destructive  of life. In
young and adult  persons it is not attended  with danger.
   Treatment.—The first point, and one of the most important in the
treatment of prurigo, is the  employment of baths, which should be
used daily.  The temperature of the baths  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 sul-
phur bath is found to irritate the skin, it should be alternated with the
simple soap bath.   The cold  water bath and sea-bathing may  also be
found useful in restoring the tone of the nervous system and skin, and
promoting recovery.
   With  a view of exciting a  new action  in the diseased  skin, and
modifying its morbid condition, stimulating applications, such as the 
lichenous or papulous  eruptions.         181
tincture of croton, either pure (page 127) or diluted with an equal part
of spirit of rosemary, may be prescribed.  Previously to the use of the
crotod, 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 frictions with oatmeal
should be continued.  After  a few applications of the croton in this
way, the bichloride of mercury in almond emulsion, in the  proportion
of fifteen or twenty grains  to the  half-pint, will often complete the
cure.   I  have seen considerable benefit result from the use of the tinc-
ture of iodine painted on the  morbid surface.   Another local remedy
frequently of service in allaying the itching of prurigo senilis, is gly-
cerine, applied by means of a  sponge.
  The applications best suited for the temporary relief of pruritus are,
vinegar,  lemon-juice, weak solution of bichloride of mercury, tincture
and watery solution of opium, creasote  ointment and lotion, tar oint-
ment, and especially that of the juniper tar, ointment of opium with
camphor, the diluted nitrate of mercury ointment, ointment of lime,
lotion of hydrocyanic acid, acetate of ammonia, muriate of ammonia,
sulphuret  of potash, chlorate of soda, &c.  It is always necessary, as
well as desirable, 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 perfectly effect-
ual for this purpose in one case may be utterly useless in the next;
I therefore subjoin several formulae recommended by French dermato-
logists, and quoted by M. Gibert.  One  of these  is an ointment con-
sisting of hydrate of lime, 3\j;  subcarbonate of soda, laudanum, aa 3ss;
and lard, 3j.  An anti-pruriginous ointment recommended by Alibert
is as follows : Laudanum, sublimed sulphur, aa 3ss; oxide of zinc, 3j;
oil  of almonds, 3j; lard, 3iij.  Biett employed successfully, for  an
obstinate prurigo of the hands: Cinnabar, laudanum, aa 3ij ; sublimed
sulphur,  |ss; lard, I v.  And for local  prurigo, the  following was
found of service:  Muriate of ammonia, 3j; powder of white hellebore,
3ss; lard, 3iij.
  The general treatment of prurigo must consist  in  the  avoidance
of stimulating  food and  drinks, and the use of laxative  medicines,
diuretics, diaphoretics, alkalies combined with bitter  infusions, acid
tonics, &c.  Sulphur with cream of tartar, in  moderate doses night
and morning, for two or  three weeks, is sometimes found  useful, par-
ticularly 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 requisite, especially in cases  of prurigo- formicans.
Indeed, I have seen bleeding in such cases act like a charm in allaying
the unappeasable torture from which the  patient was suffering.   In
prurigo senilis, a  generous and nutritious  diet is indicated, with oc-
casional laxative  and tonic medicines.   When the disease resists the
influence of other means, Donovan's solution, or the liquor arsenicalis,
may be exhibited without hesitation;  of the former,  ten   to twenty
minims three times a-day; of  the latter, three to five; with  meals.  It
is necessary, in directing  the use of these solutions, to advise the com-
mon precaution  of  avoiding  acids, fruits, and vegetables, and  the 
182      DISEASES ARISING FROM  GENERAL CAUSES.

omission of the drops whenever any pain, giddiness, or uneasy sen-
sations in the head, nausea, sickness, or pinchings of the stomach, are
experienced.  They may be resumed after a rest of  a day  or two, or
as soon as the symptoms 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 cases constitutional treatment is re-
quired.  The local means  for relieving the  pruritus  are especially
needed in prurigo podicis and prurigo scroti; and, in the former, ab-
straction of blood from the verge of the anus, by means of leeches,
might  possibly be useful.   Additional  local applications are, cold
poultices or compresses, ice, cold hip-baths, opium suppositories, cold
cream, poultices saturated with liquor plumbi, 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 will
be found useful, and their use must be aided  by general means, and
by depletion, by leeches, from the vulva.  The juniper tar ointment
is particularly useful in prurigo of the pudendal region.
                     CHAPTER VII.

          DISEASES ARISING FROM  GENERAL CAUSES.

              ECZEMATOUS OR VESICULAR ERUPTIONS.

  The  special character of the eruptions considered under this head,
is the effusion on the surface of the derma, and beneath the epidermis,
of a colorless and limpid or ichorous fluid which raises the epidermis
into small vesicles.  In the eruption  called sudamina no other cha-
racters are present; but in eczema, which is the typical form of the
affection, there is more or less vascular congestion of the skin, namely,
erythema; more  or less oedematous swelling; and more  or  less of a
lichenous eruption resulting from congestion of the vascular parietes
of the cutaneous follicles.  In those  regions of the body where the
epidermis is thin,  it is easily lifted from its bed by the effusion beneath
it, and  the  vesicles are distinct and well defined; but where the
epidermis is  thick,  as on the fingers and hands, as also  on the feet,
the effused ichor being resisted in its vertical pressure, the vesicles
are not so distinct, and the fluid spreading horizontally, the epidermis
becomes separated from the derma, to a greater or less extent; and on
the decline of the eruption is thrown off in large flakes.
  Willan's definition oiveskula is, "a small orbicular elevation of the
cuticle, containing lymph, which is sometimes clear and colorless, but
often opaque, and whitish or pearl colored.   It is sucoeeded either by
scurf or by a laminated scab."   Vesicles are rarely seen in the precise 
           ECZEMATOUS OR VESICULAR ERUPTIONS.        183

and definite form here described, excepting in situations favorable for
their development, as on the back of the hand, and at the commence-
ment of the eruption.  At this early period they may be seen like trans-
parent granules on the skin, some discreet, and others confluent; later
in the progress of the complaint the epidermis may have been rubbed
off, and then the ichorous secretion becomes the prominent feature of
the disease.  At the first moment of effusion the ichor or lymph is
always transparent, and mostly colorless, or slightly tinged with the
coloring  principle of the  bile; very  soon it becomes  whitish and
opaque, and  the vesicles have the appearance of minute pearls.   The
exact seat of the vesicles is the same as that of the papules of lichen,
namely, the apertures of the follicles of the skin, where they may be
developed completely round the opening, or merely on its lip.
   In his Order Vesiculae, Willan assembled seven genera of eruptions,
namely, varicella, vaccinia, herpes, rupia, miliaria, eczema, and aphtha.
Of these seven I have retained only two, namely, eczema, as the type
of the eruption, and miliaria.   Of the remaining five, varicella and
vaccinia are forms of variola, and are classed with the disease.  Herpes
I  have taken  as  the  type of a  group  of large  vesicles gradually
expanding into the bullae of pemphigus.  Rupia I  have transferred to
its proper place among the syphilitic eruptions; and  aphtha, although
a simple vesicular eruption, is an affection of the mucous  membrane,
and not of the skin.
   In the present group of  cutaneous affections, the eczematous group
I have thought it right to restore to its proper place, that term derived
from  the  Hebrew, tsorat,  namely, psoriasis,  which,  as Mason Good
observes, "having lost its primitive and restricted signification, seems to
have wandered in search of a meaning, and had at different times, and by
different persons, various meanings attributed to it;  being sometimes
used to express scaly eruptions generally, sometimes the scales of .
leprosy;  but at last, and with a pretty common  consent,  the  far
slighter efflorescence of scaly tetters or  scalls, denominated in the
Levitical code  saphat; and by the Latins scabies, or  impetigo sicca.;;i
Psoriasis, in  its proper acceptation, signifies a scaliness of the  skin,
resulting from chronic erythema,  attended with  thickening of the
tissues of the derma, and more or less chapping of the inflamed part;
in a word, chronic eczema, when eczema, has produced a thickened and
chapped  state of the skin, and ceasing to pour out an ichorous secre-
tion, throws off  from the inflamed surface a successive crop of scales;
or chronic lichen agrius,  when lichen has left a similar condition of the
skin,  the papules  of the original eruption being  obliterated in the
general thickening of the chronically inflamed part.  In brief, psoriasis
is  to eczema  and lichen agrius what pityriasis is to erythema.
   It  will be  seen by these observations that I might have introduced

  1 Riolanus terms Eczema scabies humida; and defines the other division of scabies,
namely, scabies  sicca, as being rough and pimply like goose-skin, in which definition
we recognize our present lichen. And scabies sicca, according as it produces small
and furfuraceous scales, or larger ones like fish scales, he denominates psora porrigo
and psora lepra. Psora porrigo, therefore, corresponds with the pityriasis of modern
nomenclature, and psora lepra with lepra vulgaris. 
184      DISEASES ARISING  FROM GENERAL CAUSES.

psoriasis into the  group  of  lichenous  eruptions  following  lichen
agrius;  but I have preferred to attach it to eczema, and the more so,
because lichen agrius may be regarded as holding a transition-place
between lichen and eczema, as being in fact*a lichen  passing into the
stage of eczema, or assuming the  characters of eczema, of  being
indeed a lichen eczernatosus.
  Under the head of Lepra will be shown the differences between that
disease and psoriasis, two affections commonly grouped together at the
present day, from  the  existence of scales in  both; but essentially
distinct in the nature of their respective scales, and equally distinct
in their origin and phenomena.

                           ECZEMA.

  Syn. Ecphlysis eczema, Mason Good.   Humid tetter, or scall.   Dartre
             squameuse humide, Alibert.  Heat eruption.
  Eczema1 (Plate IX.) 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 on
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 rupture  and moist  excoriations
succeeded by thin  crusts, and by furfuraceous desquamation.  The
eruption is generally successive, and variable in duration;  it  some-
times extends to the mucous membrane, and is often developed on the
scalp, and hair-bearing parts of the body.
  The varieties  of eczema are  divisible into two  groups, acute and
chronic.   In the  former  are arranged four principal  varieties, and in
the latter, one only.  Besides these, several local forms of the disease,
either from severity, or  from certain  peculiarities which they present,
deserve separate consideration, and  may  be assembled  in  a third
group, the members of  that group being susceptible of assuming, as
circumstances may determine, either the acute  or  the chronic type.
The varieties of  eczema, therefore, are,—
                             1. Acute.
        Eczema simplex,              Eczema impetiginodes,
           "    rubrum,                 "    infantile.
                           2.  Chronic.
                 Eczema chronicum, vel psoriasis.
                          3.  Local forms.
     Eczema capitis,             Eczema pudendi,
       "     faciei,                  "     articulorum,
       "     aurium,                "     manuum et pedum.
       "     mammillarura,
1 Der. ixfe'y, effervere, to boil out. 
ECZEMATOUS OR VESICULAR  ERUPTIONS.       185
                        ECZEMA SIMPLEX.

            Syn.  Humid tetter.  Eczema solare. Willan.
  In  this,  the most  simple form  of eczema,1 (Plate IX., I i)  the
vesicles,  about the size of the head of a  small  pin, exceedingly
numerous, and clustered into confluent patches of various  extent, are
accompanied by only a slight degree of redness and inflammation of
the skin.
  The eruption makes its appearance suddenly, without premonitory
symptoms, and the vesicles are  distended  with a transparant lymph,
which gradually becomes opaline, and afterwards milky.   The fluid
is then by degrees  absorbed, and the epidermis shrivels into a a thin
pellicle, which is thrown off by desquamation.  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  affection 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
sometimes considerable and troublesome, but presents no constitutional
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.
  Eczema is sometimes general, but more frequently local, and  may
occur on any part of the body.   Rayer alludes to a variety of eczema
simplex  described  by Dr. Levain.   This variety,  which is  purely
accidental,  and appertains rather  to  eczema rubrum than eczema
simplex, 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 skin,
which only appears red in the places affected.  On  the red patches,
covered  with  vesicles,  the  cuticle may  sometimes  be  raised  and
removed in  a single piece."

                        ECZEMA RUBRUM.

Syn.  Humid tetter.  Running scall.   Dartre  vive.   Dartre squameuse
  humide, Alibert.   Dartre erysipelateuse.  Herpes  squamosus madi-
  dans.
  Eczema rubrum, or inflammatory eczema  (Plate IX.,  K k), is dis-
tinguished  from the  preceding  variety by the development of the
vesicles upon  a  surface which  is tense, swollen, and  of a vivid  red
color.  The  eruption appears, in the first instance, in the form of mi-
nute white points, dispersed in great numbers over  the inflamed sur-
face.  These speedily  increase in size,  and become small, transparent
vesicles, filled  with a vicious, colorless lymph, and surrounded by  an

 1 "Portraits of Diseases of the Skin," Plate III., X represents eczema simplex and
eczema rubrum on the arm and hand. 
186      DISEASES ARISING  FROM GENERAL CAUSES.
areola  of deeper  redness.  At  other times,  the  skin  being red and
swollen, the pores are elevated  into pimples  like those of hwen. I he
slightest friction, or the removal of a dressing which has adhered to
the pimples, brings off' the loosened cuticle  which covers them; and
then in lieu of pimples, we have small circular excoriations, about
one line in diameter, and more vividly  red than  the rest of the skin.
These  little circular excoriations are dispersed irregularly over  the
inflamed surface, some being isolated, others confluent, while here and
there they constitute a patch of larger size; they are  moist with an
ichorous discharge which they pour out, often in large quantity, and
resemble so many little springs  issuing on the inflamed surface. When
the disease terminates favorably, the redness subsides at the end ot  a
few days or a week, the fluid contained within the vesicles is absorbed,
and their epidermal parietes shrivel and dry up, forming thin scales,
which are thrown off by desquamation, leaving a redness of the skin,
which continues for a considerable  time.
   When the affection is more severe, the inflammation augments, and
the vesicles become confluent.   Their contents, at first transparent,
become turbid and milky; they burst  almost as soon as formed, and
leave behind them inflamed and excoriated  surfaces, which pour out
an abundant secretion.   The ichor  from the inflamed surfaces is pro-
fuse and irritating, and serves to increase the exteut of the  excoria-
tions.1  The exposed derma is of a bright crimson color, and is covered
here and there with flakes of a whitish membranous  film.  Some of
these crimson excoriations are bordered by an abrupt margin of thick
and softened epidermis.   When the discharge diminishes m quantity,
it concretes into the form of  softish  lamellae, which  harden by ex-
posure.to the atmosphere, and  constitute  scabs  of various  extent and
thickness.   The  more severe degrees  of  eczema rubrum endure for
several weeks, and are apt to assume the chronic form.
   Eczema mercuriale — A form of  eczema rubrum,  only  differing
 from that  now described in its  supposed exciting cause, has been dis-
 tinguished by the name of eczema mercuriale, and has received the
 various synonyms of Hydrargyria ; Erythema mercuriale; Erythema
 vesiculare; Erythema ichorosum, Marcet; and Mercurial lepra, Moriarty.
 Dr. Alley describes three varieties, or rather degrees, of this rare affec-
 tion—namely,  hydrargyria mitis, febrilis, and maligna.
   Eczema mercuriale is characterized  by a  red efflorescence occurring
 in patches of  variable size, and surmounted  by minute transparent
 vesicles.   In the mild form of  the affection the vesicles are very small,
 but in the more severe degrees they are larger, and their transparent
 contents opaque and purulent. In some instances, where febrile symp-
 toms are present, the efflorescence  occupies a large extent of surface,
 sometimes the entire body, and assumes the appearance of roseola; at
 a later period  the blotches coalesce, and form  patches  of  larger size.
 The usual seat of the  eruption  is the trunk, or the thin skin of the
 pudendal  regiou ; sometimes it appears first on the backs of the hands,

   ' A patient from the west of England, who consulted me lately, in reference to this
 ichorous secretion, made use of the very expressive term "anguish water." 
            ECZEMATOUS OR VESICULAR  ERUPTIONS.        187

 and more rarely on the face.   The  eruption  is preceded by heat and
 smarting of the skin, and its progress is marked by excessive  heat,
 smarting and pruritus.  When the vesicles are minute, they dry up
 without giving rise to secondary inconvenience ; but when they occur
 in folds of the skin, or are larger in size, they are usually broken, and
 the abraded derma pours out an acrid and offensive1 ichor in consider-
 able quantity.  When the eruption  declines, as usually happens about
 the tenth or twelfth day in the mild form of the disease,  and at a varia-
 ble period later in the severe forms, the epidermis  is  thrown off by
 repeated desquamation, leaving the  skin of a deeply red color.  Some-
 times at the close of the eruption the disease concentrates itself on a
 particular spot, and remains obstinately fixed for weeks or months.
   Mercurial  eczema, in its mildest form, may appear without consti-
 tutional symptoms, or with trifling gastro-intestinal disturbance  and
 feverishness.  But in a more severe degree—that, for instance, named
 febrilis by Dr. Alley—the attack is marked by rigors, nausea, pains in
 the head, diminished secretions, and other symptoms of constitutional
 disturbance.   The fauces are more or less  inflamed, and the congestion
 of the mucous membrane often extends  to the  bronchial tubes.   In
 the most violent form of the  affection, namely, in that produced by a
 continuance in the use of mercury after the eruption  has appeared,
 the hydrargyria maligna of Dr. Alley, the face is enormously swollen,
 the eyelids closed, the throat tumefied and  painful, the color of the
 efflorescence of a deep purple color, and all the symptoms aggravated.
 The epidermal exfoliation continues for a  greater length of time, it is
 thrown off in large flakes, and the nails are  sometimes cast with  the
 epidermis.   Persons who have  once suffered  from eczema mercuriale
 are subject to subsequent attacks.
   The mercurial  eruption is sometimes  the  consequence of a long-'
 continued use of mercury, but occasionally would seem to depend on
 a peculiar idiosyncrasy of the individual, unless  we  suppose the eyes
 of the observers to have become so obscured by a favorite 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 suggested when we read of eczema
 mercuriale  following the exhibition of a  single  blue pill;  but I  am
 bound to admit, that in certain  constitutions the influence of mercury
 is poisonous even in the smallest quantity.   I once saw a man salivated
 by the metallic alloy used for stopping his tooth; and I have at  pre-
 sent under my care,a lady who has several times had a very troublesome
 attack of lichenous erythema following the administration of a small
 dose of mercury.  She is so sensitive of this  metal that she has more
 than once detected it in  her medicine when it had been  inadvertently
 prescribed; and on a late occasion, having received on her hands and
 arras the gastric fluids  of her  child, who had taken a  dose of gray
 powder, in a few hours afterwards she felt a return  of the old  irrita-
 tion of the skin.   More  commonly,  mercurial inunction, or a mercu-
rial atmosphere, has preceded the eczematous eruption.   Dr.  Alley
1 Spens compares it to putrid fish. 
188      DISEASES ARISING  FROM GENERAL CAUSES.

conceives that in his case the  effect of the mercurial ointment may
have been heightened by its admixture with camphor,  the  formula
consisting of two scruples of the latter to  an ounce of the unguent.
Dr. Moriarty1 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,2 the eruption  was reproduced by one  grain of
opium.   Cold, also, has had the effect of re-exciting it.
  The treatment of eczema mercuriale consists in the removal of the
cause, and the pursuance of the  general plan laid down for the manage-
ment of eczema rubrum.  Dr. Crawford  found a liniment of oil and
lime-water the best local application.  Internally he gave tonics.  Dr.
Marcet's3 case, which followed  an attack of gonorrhoea, was treated
with the  warm  bath, poultices moistened with liquor plumbi, and dia-
phoretic laxatives.4
                     ECZEMA  IMPETIGINODES.

  Eczema impetiginodes (Plate IX., l l)  may either be a severe degree
of eczema rubrum—that is, an  eczema rubrum aggravated by irritat-
ing causes to the production of small psydracious pustules of impetigo,
or a copious semipurulent secretion; or it may be an  eczema rubrum
developed in a  person possessing the pyogenic diathesis, as commonly
happens in weakly lymphatic children and women.  Devergie remarks,
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,
and the vesicles, in many places aggregated into confluent  clusters,
often  communicate wifch each other, and  form a continuous vesicle of
some extent.  The contents of the vesicles, at first limpid, soon become
turbid and puriform, and are effused on the surface  by the rupture of
the epidermis,  and the purulent secretion  concretes  into yellowish,
lamellated crusts, often of considerable extent.  When the crusts are
rubbed off, or removed, the  exposed surface  of the derma presents a
vivid crimson color, partly concealed here and there by films of whitish
lymph, and  secreting an abundant ichorous fluid,  having a reddish
tinge.  This secretion hardens, if the inflamed surface be exposed to
the influence of the atmosphere, into a thin, dark-colored 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 the
disease, is successive ; fresh crops of pustular vesicles  are produced as
the first decline, and the disease is  prolonged for two, three, or more
weeks, often lapsing into the chronic form of eczema..
  Eczema impetiginodes is for  the most  part local in  its attack, con-
fining itself to a single region of the body,  and that of limited extent.
The forearms and hands are the frequent seat of the disease, and the

  1 Edinburgh Medical and Surgical Journal, vol  xvi. p. 37.          8  Idem.
  3 Medico-Chirurgical Transactions, vol. ii.
  4 The Edinburgh Medical and Surgical Journal  contains other cases by Dr. Spens,
vol. i.; Dr. MacMullen, vol. ii. ; Dr. Rutter, vol. v.; and Dr. Ramsey, vol. vii. 
ECZEMATOUS OR VESICULAR  ERUPTIONS.        189
face is not uncommonly affected.  In these cases there  are no special
constitutional symptoms.  But when the eruption is general, or when
children are the subjects of the partial affection  in any degree  of
severity, the ordinary constitutional symptoms accompanying inflam-
mation are developed, viz., quick circulation, excited nervous system,
disordered  digestive system, and diminished  secretions.  The local
symptoms are burning and  distressing heat, and excessive smarting
and throbbing,  augmented by the warmth of bed,  and  destructive of
sleep.

                       ECZEMA INFANTILE.

Syn.  Crusta lactea.   Tinea  lactea.  Porrigo larvalis.   Tinea mucosa;
   Tinea granulata ; Alibert.  Milchgrind, Milchschorf;  Germ.  Psori-
   asis infantilis.
   Infants at the breast and young children are  peculiarly subject to
eczema, and in them it is apt to assume the severest form presented
by cutaneous disease.  In young infants it  commences at the end of
the first month or six  weeks, and, unless submitted to proper treat-
ment, may continue for months and years ;  in fact, lay the foundation
of a cutaneous disease which may be  prolonged  in a chronic form
until manhood, or may hang about the patient for the remainder of
his days.
   Eczema infantile, like eczema adultorum, originates  in mal-assimi-
lation,  and, with good reason,  is  commonly  ascribed to  a faulty
secretion of milk on the  part of the mother:  but when once estab-
lished, is not remedied, as might be expected, by  the  withdrawal of
the  cause and  the substitution  of  a  different  and less faulty food.
Unsuccessful attempts to  cure the disease, probably, carry the child
on to the  period of cutting the teeth; then the  continuance of the
disease  is  attributed to dentition, this time without so good  reason,
and hopes  are raised that when the milk teeth are perfected the
disease  will subside.  The milk teeth are all cut, but still the eczema
lingers, and then a new  light  of  prophecy  beams upon the little
patient; when  puberty arrives, then certainly the disease will go ; but
puberty possesses as little of the physician's art as change of food, or
completed primary dentition; and so the malady becomes perpetuated.
I have  seen this  picture in life so frequently that  I could not refrain
from sketching it.
   It is  remarkable how trivial an exciting cause may become the
origin of this distressing malady.  A lady, six weeks after her confine-
ment, travelled by the railroad from London to the sea-coast, carrying
with her her infant.  She was chilled  by the journey, was feverish
during  the night; her infant was  feverish the following day,  and
threw out an eruption of eczema, which brought the child to me some
months afterwards.  This  day a neighbor brought  me her infant
covered with eczema from head to foot; the child was a few months
old;  in her confinement  the mother lost her husband under  painful
circumstances; the distress caused by this  affliction was transmitted
to the offspring as an eczema rubrum.  How small the cause of  mal- 
I
190      DISEASES ARISING  FROM GENERAL CAUSES.

assimilation in these cases, which may be taken as the type of the
whole  family; how  easily is  the assimilative function of infants
disturbed ; how difficult often to restore !
  When cutaneous  eruption attacks an infant  under these  circum-
stances, it revels in all the typical and  modified forms of cutaneous
disease.  At the same moment, and on the same child, may be seen
ervthema, lichen, strophulus, eczema, impetigo,  pityriasis, and psori-
asis, and an observant nurse seems to take a special delight in pointing
out the  various diseases  which pervade the flesh of  the poor little
sufferer.  In certain parts of the body erythema is apt to prevail; but
a broken or cracked state  of the skin, with however small a degree of
ichorous oozing, must determine the  case to be an eczema.   On the
back lichen is apt to predominate; on  the head, in the bends of the
joints,  and on the pudendum, eczema; on the cheeks and ears, eczema
impetiginodes; all  on the same  skin and in gross defiance of  the
orders, genera, and species of the Plenckio-Willanean method of
classification.
  The predominance of one or other of the typical forms of cutaneous
eruption is determined by the condition  and  temperament  of  the
infant.  The child may present every shade of variation of appearance
from a state difficult to distinguish from complete  health to one in
which  the little thing is attenuated and  shrivelled up, and looks like
a little old man.  In the former extreme, however ruddy and full the
child may seem, there is evidence of an existing weakness in the soft-
ness of its muscles; but, with that exception, no trace of disorder of
constitutional health can be discovered.   Next to softness of  muscles
comes  pallor in a slight degree, then an increasing  whiteness of the
eye, attributable to progressing anaemia; then follows emaciation; the
skin shows  signs of wrinkles, becomes  dry and discolored, and ulti-
mately  sordid.   With  these, the outward signs of the disease, of
mal-assimilation in fact, there is rarely any disturbance, or but little,
of the  digestive  organs;  the »child  takes  its food  well, and is  not
particularly restless or fretful.  Sometimes the motions are green ;
sometimes  mingled  with  an excess of  mucus, and  sometimes  white
from suspended biliary secretion ; but  there is  nothing beyond  the
commonest gastro-intestinal derangement, and that in a very insigni-
ficant degree.
  The eruption usually commences as a patch  or blotch of  slightly
raised pimples; the patch is itchy, is rubbed, increases in size, becomes
more  inflamed, the  cuticle is raised in more  or  less defined  vesicles,
which  are usually broken  by friction, the surface becomes excoriated,
somewhat swollen, and pours out an ichorous secretion, varying from
a mere oozing to an excess that wets through everything that is applied
to it.   With the  increase of irritation, consequent  on  the excessive
secretion and the congestion which gives rise to it, the  patch spreads;
where  the eruption  commenced by several blotches, they probably
run into one;  the ichorous discharge also increases-the local  disease,
by irritating the parts over which it flows.   The case up to this time
is one of inflammatory eczema, or eczema rubrum.  The state of eczema
simplex has  hardly existed, and is only to be seen occasionally;  but 
            ECZEMATOUS OR VESICULAR ERUPTIONS.        191

 the disease  still runs on, its violence increases, and the morbid secre-
 tion,  from  being  a transparent  and colorless  ichor, like  water  in
 appearance, becomes slightly opaque  (tinea  mucosa),  milky, then
 yellowish and semipurulent, and the case is transformed into eczema
 impetiginodes; or the discharge may take on a still more  decidedly
 purulent character, while small pustules are developed on the  red and
 tumefied skin around the patch, and then the case is one of impetigo.
 Thus the plus or minus of these  pathological  conditions, irrespective
 of the cause or essential nature of the disease; in other words, the
 disease being the same, it  may, according to  the temperament or
 constitution of the child, be  an  erythema verging upon eczema; an
 eczema rubrum; an eczema verging on impetigo or eczema  impeti-
 ginodes; or, the pustular element being in  excess, it  may be an
 impetigo.  Again, as I have before said, whatever the predominating
 character may be, whether  erythema,  lichen, eczema, or  impetigo,
 there will always be present in a greater or less degree some, or the
 whole of the other forms sprinkled over the body; a simple  erythema
 here, an erythema with  strophulus or lichen there, a few scattered
 vesicles of eczema in a third  place; or a few congregated psydracious
 pustules of impetigo in a fourth.
  In  this description of the general characters of eczema infantile, I
 suppose the eruption to be  comparatively undisturbed; but that is
 rarely the case, the great heat, the prickling, the tingling, the  intense
 itching which accompany the disease, render abstinence from rubbing
 and scratching impossible; hence these have to be added to the causes
 of aggravation of the local disorder.  Again, the burning heat of the
 skin on the  one hand, and exposure to  the atmosphere on the other,
 tend to desiccate the surface very rapidly, the contents of the vesicles
 in the simplest form of the affection dry up into a thin, transparent,
 amber-colored crust; in eczema  rubrum, with  a  more  copious dis-
 charge, the crust is less transparent  and  thicker; and in eczema impe-
 tiginodes it  is still further increased in thickness, is lighter both in
 color and texture, and uneven in  surface;  while in impetigo, from the
 desiccated matter being pus, it is thickest of all, and has  the appear-
 ance of dried  honey; this circumstance  has given the name of meli-
 tagra to the latter disease.   As may be supposed, the crust presents
 considerable variety of  appearance, according to the prevalence of
 accidental circumstances in a greater or  less degree, such as accumula-
 tion of secretion, amount of desiccation, &c.  Not unfrequently, as a
 consequence of pressure  or  friction, blood is  mingled with the dis-
 charges, and the crusts become colored of various hues from  a lightish
 brown to positive  black.   Again, a variety of color results  from  the
 age of the crust, that which  has  been longest  formed being usually
 lighter than  the rest; and another difference occurs when the original
 crust is broken, and a new discharge issues from between the several
 fragments.
  Sometimes this terrible disease  attacks the whole body of the child
 and the little thing has  scarcely a patch of sound  skin on its entire
surface, being covered from  head to foot with erythema, excoriations,
and scabs of every variety of size  and dimensions, and giving out an 
192      DISEASES ARISING FROM  GENERAL  CAUSES.

offensive valerianic odor which has been  compared  to  the urine of
cats;  but more frequently it is limited  to one or more regions of  the
body, the commonest seats of the eruption being the head and face,
the front of  the  chest, the  umbilicus, the  pudendal  region, and  the
flexures of the joints.   On the head the eruption is  complicated by  the
presence of hair, which entangles the discharges, and the crusts  are
apt to form, in consequence, of considerable  thickness, sometimes in-
cluding the entire scalp in a thick, rugged, yellowish, and discolored
cap.   At other" times, when the discharge is less abundant, it dries  up
into a friable crust, which, broken into small  fragments by scratching
and  rubbing, has been compared  to  particles of mortar dispersed
among the hair, and has received the name of tinea granulata.  Many
of these particles of crust being pierced by  the hairs, have the appear-
ance of a string of rude beads.  Later in the history  of the eruption,
and when it  has become decidedly chronic, when erythema of the
scalp  with copious furfuraceous desquamation are  the leading charac-
ters of the disease, it has been termed tinea furfuracea ; and later still,
when, with a slighter degree of erythema, the epidermal exfoliation is
mealy, the case is one of pityriasis capitis.
   When the ears are attacked they become  much swollen, and give
forth  an excessive quantity of ichorous secretion,  which  may be seen
distilling from the pores of the skin, and standing  in drops on the  in-
flamed and excoriated surface.  When the disease  fixes on the face it
is  also attended with swelling, and often gives the child a bloated and
frightful appearance, every feature being distorted;  and the deformity
is  increased by the production of a thick discolored scab,  which forms
a  mask sometimes  to the  entire face. This huge, unnatural mask
covering the  child's face, suggested  the term larvalis, given to one of
his species of porrigo by Willan; only that, instead of porrigo larvalis,
it  should have been eczema larvale, or impetigo larvalis.  Again, from
occurring at the milk period of life, this extraordinary crust, whether
arising from the desiccated secretions of eczema rubrum, eczema impe-
tiginodes, or impetigo proper, has received  the name of milk-crust,  or
crusta lactea.
   The inflammation of the scalp and face is apt to  produce, as one  of
its secondary effects, enlargement, and  sometimes suppuration of the
lymphatic glands.   Thus we find the gland situated  behind the ear,
the occipital, the submental, and  cervical lymphatic  glands swollen
and painful;  and not  unfrequently,  in a pyogenic diathesis, there are
superficial abscesses in the neighborhood of these glauds.
   The pudendal region, both in the'male and female infant, is not un-
commonly the seat of the eruption, being  determined to this region
partly by the heat and moisture, resulting  from its function, and
partly by the thinness and delicacy  of the skin.
   For the latter reason it is commonly met with in the flexures of the
elbows and knees, and  sometimes  in the axillae.  In the flexures  of
the joints the inflamed skin is apt to crack into fissures  of consider-
able length and depth, and often to bleed; the blood  mingling with
the excessive ichorous secretion poured out by the denuded skin.
   The general character of eczema infantile is to form patches of con- 
              ECZEMATOUS OR VESICULAR ERUPTIONS.        193

   SJderablei size, several inches square, and to attack, as I have alreadv
   explained, a whole region at once, such as the  head, face, &c; but in
   addition to this, and  sometimes without these  extensive patches, the
   eruption appears in rounded blotches from half an inch to two inches
   in diameter, sprinkled  upon the -skin in various parts,  as  upon the
   trunk, neck, arms and legs.  These patches are identical with tbe cir-
   cumscribed patches which are seen upon the skin in lichen agrius,
   and the eruption has more of the character of the  latter disease than
   of eczema rubrum.  The blotches are raised, thickened, papulated,
   excessively irritable, discharging but  a  small quantity of ichorous
   fluid, and  covered, when desiccated, with  thin, squamous, laminated
   crusts.
      Eczema  infantile, when left to itself, has no natural tendency to reso-
   lution or spontaneous cure;  on the contrary, it merges progressively
   into  a chronic form, and undergoes that kind  of modification which
   is common to cutaneous disease when passing from an acute to a
   chronic stage.   By degrees  the  ichorous  discharge diminishes, and
   the eruption retires to certain situations, where it continues  to linger,
   sometimes  subsiding into a state of calm, and sometimes breaking out
   afresh like a slumbering volcano.  The situations  on which it  most
   commonly retreats, are the scalp, the eyelids, the ears, particularly the
   backs of the ears; the integument around the mouth, the arm-pits, the
   groins, and the bends of the elbows,  wrists, knees  and ankles.  The
   parts of the skin over which  it has passed are arid and parched; and
   the fountains  of moisture, the natural  secretions from the  skin, the
   perspiratory and  sebaceous secretions, are dried up.  On the scalp the
   dried and parched skin, continually throwing off a furfuraceous des-
'  quamation, presents the common characters of pityriasis capitis.   And
   not only is the skin left in a state of parched exhaustion,  but the hair
   also is dried up, is scanty in quantity, and its growth is arrested.
      The dry, parched, hot, fevered state of the skin, which is  the com-
   mon  sequel of eczema infantile, is a sign of the disorganization and
   extreme disturbance of function which the skin  has undergone. Even
   where there was no  eruption, the  cuticle is rugged and constantly
   thrown off'as a mealy exfoliation; but where the eruption existed, as
   around the eyelids, upon the ears, around the mouth, and in the bends
   of the joints, the skin is more or less red, thickened, uneven, cracked,
   and chapped, and the ichorous secretion having ceased, it throws oft'
   perpetually scales of dried cuticle of various size, some being mealy,
   others furfuraceous, and others as large as the finger-nail.   This, then,
   is a case of genuine psoriasis; eczema infantile  has therefore become,
   by the mere result of continuance, chronic eczema infantile; or,  in
   other words, psoriasis infantilis.
     This process of constant exfoliation  is  necessarily attended with
   pruritus, which is often very considerable;  the  inflamed part is then
   rubbed and scratched, and from time to time the ichorous secretion is
   reproduced.
     I have noted that, in the early outbreak  of the eruption,  the only
   trace of  deteriorated condition that may be present in the child is a
   feeling of  softness of  the  muscles, and a slight degree of paleness  of 
194:      DISEASES  ARISING FROM GENERAL CAUSES.

the skin and  of the conjunctiva; in fact, the  discernment of these
trivial but nevertheless significant signs is a matter of observation and
tact.  Later, however, in the progress of the disease, these signs be-
come sufficiently obvious to attract the attention of the unobservant;
and later still, the poor little child is strangely altered from its normal
state; mal-assimilation, cacochyrnia, are traced in conspicuous lines on
every part of the surface, in every feature.  The limbs are thin, show-
ing out  the prominence of the joints;  the muscles are soft and flabby;
the skin is soft and pasty, or discolored and  shrivelled; there is an
expression of  care, anxiety, of thought,  upon.the little face; from the
general  emaciation of the body, the  head looks larger than natural;
as I before observed, one is struck with the senile look of  the child;
the  mucous membrane of the conjunctiva and mouth  is  pale; and,
above all, is the strangely white anaemic eye, sometimes dull and list-
less, and sometimes bright and clear.  The eye tells an eloquent tale
of defective nutrition.
   I have remarked above that the symptoms of internal  disorder are
but trifling at the commencement of the disorder; and far from being
severe through its course;  they attract little of the attention either
of the mother of the child or of the medical  man.  The great, the
urgent  symptom  of the whole is the  teasing, the intense, the violent
itching; sometimes the itching  is constant, with frequent  exacerba-
tions ; sometimes there  are intervals  of repose, which are  apt to be
disturbed by any change of temperature, and then a violent attack of
pruritus recommences;  but the crowning  suffering of all occurs at
night; the child is often frantic with itching;  it scratches with all its
force, digging its little nails into the  flesh,  while the blood and ichor
run down in streams.  At  last, worn out with suffering and exhaus-
tion, the child sleeps, probably to be awaked  again several times in
the night by a repetition of the same agony.   This constant suffering
naturally wears out the child's powers, and added  to the mal-assimi-
lation, brings  about that state of atrophy  which I have previously
described.  But it is nevertheless remarkable how  little  the strength
and spirits of  the child  are affected by  these  separate paroxysms of
suffering; in the morning, after a night  of  distress, the little thing is
fresh and lively, eager for its food, and ready for the battle of the day;
while the nurse or mother  is languid and powerless, from watching
and anxiety.
   Not  unfrequently, in eczema infantile,  the  mucous membrane of
the mouth and nose, of the air-tubes and lungs, and of the alimentary
canal, participates in the disease, and  is  either affected simultaneously
with the skin, or takes a vicarious part.  The affection of the alimen-
tary canal gives rise  to diarrhoea  and the production  of mucus in
large quantities, and sometimes  of coagulated  lymph. The affection
of the mucous membrane of the mouth  and nose is shown by redness,.
sometimes aphthae and augmented secretion; and the eczematous con-
gestion  of the mucous  membrane of the air-tubes produces bronchitis
in various degrees, accompanied with hoarseness, from thickening of
the  mucous lining of the larynx, and an  excessive accumulation of
phlegm throughout the lungs.   This  latter symptom is one which is 
ECZEMATOUS  OR VESICULAR  ERUPTIONS.       195
 calculated to give us some anxiety, and requires  dexterous  manage-
 ment ; but it is less severe than  common  bronchitis, and is  often  as
 sudden in getting well as in its attack.  When the mucous membrane
 of the mouth and air-passages is affected, hoarseness is a conspicuous
 and striking feature of  the complaint; the hoarse cry is unmistakable,
 and is  sometimes the first and  only  sign of  the congestion of the
 mucous membrane.   It  is a sign as diagnostic of congestion of the
 respiratory mucous membrane, as  is whiteness of the eye of general
 anaemia.
   In the treatment of eczema infantile, the three great principles
 which I have already laid down as the law of treatment of cutaneous
 disease,  namely, elimination, restoration of power, and alleviation  of
 heal distress, are to be put in force, but with a  change in their order.
 Elimination must always go  first; but in eczema infantile  I would
 place alleviation of local distress  second; and restoration of power
 third.  Thus the principles of treatment, the indications for treatment,
 being settled, let us consider the means.
   For elimination, the remedy is calomel or gray powder : I prefer the
 former;  one grain of calomel rubbed down with  one  grain  of  white
 sugar, or sugar of milk, is the  dose  for  the youngest infant; for a
 child a year old, a grain and a-half;  for  a child  two years old, two
 grains.   Of course  this dose is modified according to the  apparent
 strength of the child in the first instance, and in accordance  with the
 action of the medicine in the second; the object to be attained  being
 such a dose as will produce an  efficient relief to the alimentary canal;
 and moreover, such an amount of relief as shall act as a diversion to
 the morbid secreting action taking place in the skin ;  in other word^s,
 to divert the morbid secretions  of the skin into  their  more natural
 and proper channel, the alimentary canal.  For this purpose  calomel
 excels every other medicine; from its small bulk it is convenient for
 exhibition, merely requiring to be dropped into the child's mouth ; it
 stimulates the liver to an increased flow  of bile; and in children  it
 always acts most kindly on the alimentary canal.  Again, a free action
 of the alimentary canal being secured, all probability  of repulsion of
 the eruption by the remedies required for the  second indication is at
^ an  end; and the mother's and nurse's alarms lest the  disease should
 be  driven in are set at  rest.  A free clearance  of the stomach and
 bowels is therefore a primary, a necessary step at the very commence-
 ment of the treatment.   After the first dose, the  calomel may be  re-
 peated according to circumstances; once a week,  twice a week, every
 other night for a few times;  even every night  for two or three nights,
 if absolutely necessary.  In my own practice, I  usually find once a
 week sufficient, and I am guided to the repetition of the dose by the
 state of  the little patient. If there be any feverishness, fractiousness,
 irritability of temper, any increase of pruritus, inaction of the bowels,
 morbid  secretion  of the bowels,  or  threatened   congestion of  the
 mucous membrane of the air-tubes, then the calomel  powder is to  be
 administered  at once,  without hesitation, and without delay.   The
 mother or nurse soon learns the moment  for a powder, and  whatever
 prejudices they may have to the  name  of calomel, they are always 
1.96      DISEASES ARISING FROM GENERAL  CAUSES.

ready to resort to it after they have once seen its action in this disease.
As I have already said, I have no objection to the mercury with chalk
beyond the fact of its being more bulky and less agreeable to swallow,
while it certainly possesses  no recommendation which  can render it
superior to calomel.   Sometimes I find one or two  grains  of nitrate
of potash a useful addition to the calomel and sugar.
   Having disposed  of the first indication, and cleared out of  the
system  any  acrid  matters  that  might  be rebellious and capable of
exciting irritation or feverishness: having, moreover,  unloaded  the
blood-vessels of some  of their watery and solvent elements by  the
same remedy;  we may .now have recourse to our means of alleviating
the heal distress, in other words, of soothing and healing the eruption,
subduing the pruritus, and arresting the morbid discharge.  We can
do all this by the benzoated ointment of oxide of zinc, rubbed down
with spirits of wine in the proportion of a drachm of the latter  to
an ounce of the former. This ointment should be applied  abundantly,
and gently distributed upon the surface until every part of the eruption
has a complete coating; the ointment should be applied morning and
night, and if accidentally rubbed off', or used  upon  parts exposed  to
the air and friction, it may be repeated more frequently.  When once
applied,  the ointment should be considered as a permanent dressing
to the inflamed skin, and  never removed  until the skin  is healed,
unless special conditions arise which render such a  process necessary.
To secure undisturbed  possession to  the ointment, a piece of linen
rag, a sheet of  cotton wool, or a piece of tissue paper, should be laid
over it and maintained in position  by any convenient method.   Thus,
when the eruption covers more or less of the entire body, I  have a
little shirt made of old linen, with sleeves for the arms and legs, and
means of-being fastened  closely around the legs, and, if necessary,
closed  over  the  hands and feet.   This  little dress is to.be worn
constantly, night and day, and for .a week together, if necessary; it
is intended   as a mere envelope .or dressing to  the  inflamed and
irritated skin,  and its  saturation with ointment,  which necessarily
ensues, only contributes to its greater utility in that capacity.  Where
the eruption is chiefly confined to the arms or legs, linen sleeves, with
or without cotton wool, will be sufficient for the  purpose.   On the
face no other covering than the ointment is necessary,  but  the latter
should,  therefore, be used the more largely;  and sometimes  in this
situation, small pieces  of thin  tissue paper, of convenient size and
form, laid on the ointment, are very serviceable.
   When the oxide of  zinc ointment is employed in the manner now
described, the formation of crusts  on the. eruption  is prevented, in
in consequence of the exclusion of the atmosphere, and the consequent
absence  of desiccation.  And when  crusts are already formed, the
object  to be  attained  is,  to soften  the crusts by saturating them
thoroughly with the ointment, and then, by  gentle friction, to displace
them, and substitute a  thin stratum of the ointment in  their place.
When the eruption passes  from the acute into the  chronic  state, and
the process  of exfoliation of the cuticle is active, gentle friction  of
the skin with  the ointment  is even more desirable  than in  the Sicute 
           ECZEMATOUS  OR VESICULAR ERUPTIONS.        197

stage  of the  disease, and is, at  the  same  time, very grateful to the
little patient.   On the scalp the ointment should be applied in the
direction of the hair, to avoid matting, and as soon as  the oozing of
ichorous discharge has somewhat subsided, the hair should be gently
brushed.  I am rigorous  in enforcing  the  non-disturbance  of the
ointment, but sometimes  my aides carry their instructions beyond the
proper point, and accumulate the ointment too thickly over a given
part, retaining  thereby .the secretions, and  interfering with the cure;
in this case, if  the finger be pressed  upon such an accumulated  plate
of the  ointment, the morbid fluids will be seen to ooze up  between
its  chinks  or around  its edges, and the source of evil  is detected;
When such  an occurrence takes place, the  whole of the ointment
should be carefully  washed off the  part with the yelk of egg, and
after drying the skin,  fresh ointment should  be  applied.   This
excessive accumulation of  the  ointment takes place the most fre-
quently on the scalp, encouraged by  the matting of the  hair,  a reason
for keeping the hair brushed whenever the nature of the eruption
permits.
  Another of my instructions is to a\joid washing the inflamed skin ;
it may  be  wiped  with a soft  napkin, to  remove exudations  or
secretions, but  washing is  unnecessary, indeed  injurious, as tending
to irritate the skin and increase the  pruritus  and inflammation after-
wards.   While the  washing lasts, and the irritated  skin  is softened
by  the  water, the part is  relieved  and comforted; but  the drying
which  follows  after more than avenges the temporary solace of the
ablution.  On the same principle, I never order or recommend lotions
in this eruption.
  In cases of chronic eczema infantih, that is, in pityriasis capitis and
psoriasis partium aliarum, the stimulant properties of the nitric oxide,
and nitrate of mercury ointments may be brought into  operation;
the former is specific for pityriasis  capitis, in the proportion of one
part to three of lard; and the latter, variously diluted from one part
in  eight to equal  parts,  may  be used  for the chronic eczema  or
psoriasis of other parts, particularly  of the eyelids.  But even in the
chronic state of the disease, the benzoated  zinc ointment  will be
found to be an  invaluable and indispensable remedy.  In the parched
state of skin left  by the chronic  disease, glycerine may be found of
use as an emollieut, but  when  any  inflammation exists, it generally
proves irritant,  as compared with the zinc ointment.
  We now come to the remaining indication in the treatment of eczema
infantile, namely, restoration of power; in other words, to correct mal-
assimilation, and restore the blood to  its normal and healthy condition.
For this  purpose, the great remedy is that admirable alterative-tonic,
arsenic.  It  is  remarkable  how  well infants of the earliest age bear
this medicine, and how rapidly  in them  it exerts its tonic and bon-
assimilative  effects.   As  an effective, harmless tonic, arsenic stands
alone, and without its peer in this vexatious disease; indeed, in eczema
infantile, it is specific; it cures rapidly, perfectly, unfailingly; it would
be difficult to say as much for any other medicine in relation to any
other disease;  and I pronounce this  eulogium on arsenic after a large 
198      DISEASES ARISING FROM GENERAL CAUSES.

experience.   The  preparation  of arsenic which I select, is Fowler's
solution, the dose two  minims to an infant  from a month to a year
old, repeated three times in the day, with or directly after meals;  and
as mal-assimilation is  always attended with anaemia, in a greater or
less degree,  I conjoin with the two minims of Fowler's solution, fifteen
of vinum ferri, my formula being as follows:—
                 R.—Vini ferri,
                     Syrupi tolutani, aa §ss.
                     Liquoris potassse arsenitis, Tl\xxxij.
                 M.  Aquae anethi, §j.
  The dose  of this mixture is one drachm, with or directly after meals,
three times  a day.
  With these three remedies, namely, the calomel powder, the benzo-
ated ointment of oxide of zinc, and  the ferro-arsenical mixture, repre-
senting, as they do, the three indications for treatment of eczema in-
fantile, I regard the cure as certain and rapid,  and failure impossible;
and if success were  not complete, I should  seek for the cause, not in
the remedies, but  in the  mode of administering them.  So confident
am I of success, that I have often  undertaken the treatment of  this
disease without seeing the patient,  and at hundreds of miles distance,
being satisfied, for my only aid, with the vigilance of an intelligent
mother or  nurse.   I have never known any evil  effects, present or
future, result from this treatment, but I never fail to give strict in-
junctions, that if the medicine appear to disagree with the child, it should
be given  less frequently, say twice, instead of three times a day, or sus-
pended instantly, if the child appear ill; moreover, that in the event of
such an occurrence, the calomel powder should be immediately resorted
to.  The period of continuance of  the remedies  must be left to the
judgment of the medical man;  the treatment sometimes occupies three
weeks, and sometimes more. And  if a recurrence of the eruption take
place, the treatment must be recommenced, and conducted on the same
principle, and with the like precautions.
   The diet  of the child while under this treatment  must be carefully
inquired into; it should be good, wholesome, and nutritious; the lead-
ing  constitutional  indication  is to nourish properly;  and this idea
should be carried out in the food as well as in the medicine.   I  find
the juice of meat of great value in these cases, and it may be given
either alone, as beef or mutton tea, or mixed with the other food.
   The consideration of diet and food  brings me to an  important die-
tetic medicine which is of great value in this disease, when the latter
is attended  with emaciation, and in the chronic stage;  in acute cases,
it is less applicable: I  mean the cod-liver oil.  The child will often take
the oil greedily in its natural state, and  its good effects on nutrition
are  speedily made  apparent; it  may be given with  safety to the
youngest infant.  In  children somewhat older,  and particularly in
chronic cases, the cod-liver oil chocolate becomes a useful  ingredient
of diet;  and it is  in these latter, more particularly, that the chocolate
was found so successful in the hands of my brother among my poor
patients, as already mentioned.  When  I have wished to avail myself
of the excellent properties of the  cod-liver oil  in  conjunction with 
ECZEMATOUS  OR VESICULAR ERUPTIONS.        199
arsenic, I have often found the following formula a convenient vehicle
for its use:—
               R.—Olei jecoris aselti, gij.
                    Vitelli ovi, j.
                    Liquoris potassae arsenitis, n\,lxiv.
                    Syrupi simplicis, 5ij-
               M.  Aquae fontanae, q.s. ad §iv.
A drachm a  dose, three  times a day, with or directly after meals.
When eczema infantile is complicated with diarrhoea or congestion of
the mucous membrane of the air-tubes or lungs, the arsenical remedy
should be instantly suspended, the calomel powder immediately ad-
ministered, and  ordinary  antiphlogistic remedies  adopted;  magnesia
and aromatic confection for diarrhoea; and ipecacuanha for the bron-
chitic or pulmonary congestion.  Where the air-tubes are loaded with
phlegm, an emetic is sometimes useful; and a poultice to the chest and
abdomen will  be found to be a valuable adjuvant.
   In  concluding my observations on eczema  infantile and its treat-
ment, I must  repeat, that I know of no cases  in the whole catalogue
of the diseases of the human frame, in which the disease itself is more
unpromising in  appearance and distressing in its effects, and at the
same  time more  amenable and tractable under the treatment now laid
down, than this disease.

               ECZEMA CHRONICUM—VEL PSORIASIS.

   Whenever,  from the continuance of any of the preceding forms of
eczema for a lengthened period, either  as a result of the severity of
the original disease, or of mismanagement  in its treatment, the sur-
rounding  skin is irritated by the ichorous discharge 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  cellular  tissue becomes  dense and  infiltrated,  new
excoriations, with deep and extensive chaps and fissures, are produced,
and more or  less  ichorous secretion is poured out by the diseased
structure.  The  chronic form of eczema is  most frequently met with
in the flexures of joints,  more rarely-it extends over a considerable
surface, and occasionally involves an  entire limb.   It is obstinate and
troublesome under treatment, and frequently endures for months or
even years.
   Sometimes  the  secretion diminishes in quantity, ancl  concretes 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  gradually progressing towards cure,  when suddenly the
redness and tumefaction return,  and a fresh  discharge is produced.
In  this manner, fresh and fresh outbreaks occurring at intervals, the
morbid action is kept up for months, and often for years.
   In another variety of psoriasis the eruption forms a  circumscribed
patch, which is callous and dense, sometimes thin and dry like parch-
ment, sometimes thick like buckskin, and sometimes horny and warty
in character from hypertrophy of the papillae of the  skin, and the 
 200      DISEASES  ARISING FROM GENERAL CAUSES.

 consequent production of the cuticle in sheaths, which are vertical to
 the  surface.  All discharge has long since ceased on these patches,
 and in their pathological  nature  they have degenerated  into dry,
 thickened, callous erythematous patches, generally smooth  on their
 surface, or only roughened with epidermic exfoliations, but susceptible
 at any time of becoming inflamed,  and chapped, and pouring out an
 ichorous  exudation.   It is the patches that realize the true idea of
 psoriasis  more fuily than any other form of eruption.
   Chronic  eczema is attended with  severe itching, which  is only
 relieved when a free  ichorous discharge is emitted, and which com-
 monly follows the act of rubbing and scratching, or when the scratch-
 ing is succeeded by  the escape of a little blood.  Sometimes the
 scratching exasperates the irritation, and the whole nervous system is
 thrown into a state  of great excitement.  Moreover, in certain situa-
 tions, the pruritus is sometimes unbearable, and almost maddening,
 exciting  the  wildest paroxysms;  as, for instance,  when it  occurs in
 the vulva, upon  the scrotum, or around the anus.
   Occasionally the irritation of chronic eczema takes on the character
 of cutaneous neuralgia, and then the sufferings of the patient are very
 severe.   I  once  saw a distressing  case of this kind, where  the chief
 seat of the eczematous disorder, and of the neuralgia, was the axillae.
 As  may  be inferred, the constitution of the patient in  these  cases  is
 highly nervous; the abnormal nervous susceptibility sometimes result-
. ing from  idiosyncrasy, and sometimes from the exhaustion occasioned
 by previous or long continued illness.

                      LOCAL VARIETIES.

                         ECZEMA  CAPITIS.

 Syn.  Vesicular  scall; Running scall;  Erythema  ichorosum;  Dartre
   squameuse humide; Porrigo  asbestina.   Tinea  amiantacea;  Tinea
   furfuracea ; Alibert.  Tinea granulata.
   Eczema  capitis1 presents the general characters of eczema rubrum,
 with excessive ichorus  discharge;  and sometimes, in  an aggravated
 form running into eczema impetiginodes, complicated  by its special
 seat of development on the hairy scalp, from which it is apt to extend
 to the forehead and temples, the  ears, and nape  of the neck.  The
 scalp is  red and swollen, and the  cuticle cracked  in every direction,
 and more or less raised from the inflamed surface beneath by ichorous
 secretion.  The quantity of ichorous fluid is excessive, filling the hair
 with moisture, and  distilftng in little rills from beneath it;  at first it
 is transparent and colorless, but viscous and tenacious; by degrees it
 becomes  opaline and milky (tinea mucosa), and later in the progress of
 the disease, semipurulent, with the addition, here and  there, of an
 admixture of blood.   The hair soon becomes matted and agglutinated
 by  the morbid secretions, and the latter dry up into thick, greenish,
 and yellow crusts, blackened here and there by the presence of blood.
1 Portraits of Diseases of the Skin, Plate IV., AX. 
           ECZEMATOUS  OR VESICULAR ERUPTIONS.        201

Wherever  the crust breaks, new discharges' issue from the openings,
and still further augment and consolidate the mass, reeking and fetid
with the accumulated secretions.  The odor of the head when in this
state is valerianic and peculiarly offensive, and nothing can be effected
in the treatment of the disease until the filthy mass is  removed.
  When the hair is  sufficiently short from the first  to prevent the
excessive accumulation here described, a curious phenomenon occa-
sionally presents itself.  The crust having become desiccated over the
surface  of  the scalp, necessarily contracts, and the contraction  results
in the  fracture of the crust into polyhedral fragments or divisions,
which  resemble so many small islands, covering the  head; each of
these little  islands has it own proper portion of hairs, and these hairs,
by the further  contraction of the fragment, are drawn together, and
form a conical pencil.  All the hairs of the head may in this manner
be collected into conical bundles, and present a very singular appear-
ance.  The next thing that happens is equally curious.  The ichorous
secretion flows down these cones, and drips from their extremity;  and
when the secretion subsequently dries, each cone is seen to be inclosed
in a  thin, transparent, glistening sheath, the hairs included within the
sheath  having the appearance of asbestos.  Rayer compares them very
aptly to  the  " pellicles that envelop the sprouting feathers of young
birds."   This is the origin of the terms teigne amiantacee and porrigo
asbestina, bestowed  by Alibert  on  eczema capitis, and  is  another
instance of the  extreme absurdity of dermatographical  nomenclature.
  At a later period of the complaint,  when  the morbid  secretions
have diminished in quantity, the crust which is produced is of a dull
gray color, and more friable  than the  crust  previously  described.
This grayish crust, broken  into fragments, or rather into granules, and
dispersed among the hair, has been compared  to particles of mortar,
and suggested the term tinea granulata.  Sometimes these little masses
or granules, being pierced by the hairs, have the appearance of being
threaded on them like beads upon a string.
  Eczema capitis is apt to become chronic, and, having ceased to pour
out an  ichorous secretion, produces a desquamation of furfuraceous
scales  in large quantity;  this  is tinea furfuracea.  Later still,  the
erythema and parched state of skin remaining, the desquamation is
mealy instead of being furfuraceous or branny, and the disease  has
become pityriasis capitis.
  Not  uncommonly the  persistent inflammation  of the. skin, which
accompanies chronic eczema, causes destruction of the hair, and pro-
duces partial alopecia.   Sometimes, but rarely,  the  vitality of the
scalp is so  much injured that the growth or the hair is permanently
arrested.  At all stages  of the disease the lymphatic  glands  of the
occipital, auricular, cervical, and sub-mental regions are apt to enlarge
and become painful; sometimes to suppurate.
  Eczema  faciei.—Eczema, when  it attacks  the face, is most  fre-
quently met with on the  forehead, the chin, the eyelids and  cheeks,
and around the mouth.   It presents no  special features calling for
attention, and is apt, when  it attacks the  eyelids and mouth, to pass
into the chronic form. 
202      DISEASES  ARISING FROM GENERAL  CAUSES.

  Eczema aurium.—Eczema makes its attack upon the ears at all
periods of life, and in both sexes, and is not uufrequently met with in
children during dentition.  The  ears affected by this disease are red,
swollen, and  tender,  and are covered with excoriations and chaps,
which  pour out a profusion of ichorous fluid.   The discharge spread-
ing upon the inflamed surface desiccates into a yellowish and brownish
lamellated crust, which is constantly augmented  by fresh  secretion.
From the pinna the inflammation often extends into  the  meatus, and
gives rise to great pain.   Small  subcutaneous abscesses form in the
integument around the ears, and the neighboring lymphatic glands
enlarge.
  When the  eczema aurium assumes the chronic form, the quantity
of  secretion  becomes  less,  the  incrustations are thinner  and less
abundant ; the tissues of the  ear are  swollen and thickened; the
meatus is constricted; the skin fissured by painful chaps; and the
disease is extremely  obstinate; often resisting every  method of  treat-
ment, and enduring for years.
  Eczema mammillarum.—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, suc-
ceeded by chaps, both the one and  the other exuding a considerable
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 difficult of cure. When
it occurs during lactation it is desirable that the  infant should be
weaned.
  Eczema pudendi.—In this  affection  the  eczematous eruption  is
developed upon the scrotum in the first instance, and thence extends
to the  neighboring parts of the thighs and  to the  anus;  or it may
commence in the latter situation, and spread to  the scrotum.   The
disease, whatever its mode of origin, is exceedingly distressing,  being
accompanied  by a most unbearable pruritus, which is increased rather
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 secretion is poured out, fissures and  exco-
riations are produced, and great suffering is the consequence. Eczema
in this region generally a&umes the chronic form, and continues, with
temporary remission in the severity of the symptoms, for months and
years.   It is  generally met with in persons of the middle period of life.
  In the female,  eczema pudendi  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 discharge of morbid  secre-
tions from the vagina.   All  the functions of the region  are rendered
painful, the smarting is excessive, and the pruritus unbearable. Adults 
eczematous or vesicular eruptions.       203
are most frequently attacked with this disease, and children rarely. I
have, however, seen one instance in a little girl eight years of age.
  Eczema articulorum.—As before remarked, eczema of the flexures
of the joints is a common complication  of general eczema; so that
where the latter is present, the thin skin of the bends of the joints is
sure to  be affected to a greater or less degree.  In chronic eczema,
again, the eruption  lingers about the joints  after it has disappeared
from other parts of the body.  And  sometimes the eruption is, from
the first, limited to the joints. When the latter is the case, the disease
may present itself in the form of eczema simplex or eczema rubrum ;
and  at a later period it may become a confirmed  eczema chronicum
or psoriasis.   As eczema  chronicum or psoriasis, the integument is
thickened, red, dry, hot, and contracted, cracked into fissures  which
bleed whenever the joint  is stretched, and roughened by a more or
less copious laminated or furfuraceous desquamation.   When eczema
rubrum has got well, the skin remains congested for some time after-
wards, it looks tender and wrinkled, and  is covered by a thin, trans-
parent and polished cuticle.
   Eczema manuum et pedum.—Eczema of the hands and feet is
similar in its characters; but, from exposure  to the atmosphere, the
disease is  more common in the former than in the latter.  The com-
mon seat of the eruption is the back of the hand, where it resembles
lichen  agrius, and in its chronic  state becomes psoriasis dorsi mantis.
Eczema appears on the back of the hands in its simple vesicular form,
as when excited by the sun's rays, eczema solare; but it is more com-
monly met with as eczema rubrum, with  the characters  common to
that stage of the  affection, namely, slight tumefaction, cracked, exco-
riated, and softened cuticle, and a profusion of transparent, ichorous,
and viscous discharge, which may be seen distilling from the exposed
and congested derma, and oozing from numerous smaller points, where
the cuticle has been removed by friction or scratching.   Later in the
course of  the  disease the eczema becomes chronic, the  ichorous  dis-
charge diminishes in quantity, or ceases  altogether, and  the surface
becomes coated over with thin  crusts and scales.
   Not  unfrequently the disease is met with on the hands  under the
form of eczema digitorum, appearing towards  the  end and  upon the
tips of the fingers, and  attended  with muph  suffering from itching,
tingling, smarting, burning,  and extreme  tenderness.  It commonly
happens that  no trace of eczema or  eruption exists upon any other
part of the body, and the small extent of the disease becomes remark-
able. Sometimes a single finger only is attacked, sometimes the same
finger on both hands; and although  trifling in itself, it is a source of
great annoyance to the patient,  not only from the pain which it excites,
but  from  its unsightly  appearance and obstinate persistence.   This
troublesome eruption commences with a feeling of itching in the part;
when scratched or rubbed  there is a sensation  of hard granules under
the skin;  and, upon close inspection, the  cuticle will be  seen to be
studded with dark, transparent, circular spots, evidently drops of
effused lymph, which, from the thickness of the epidermis, are unable 
204      DISEASES ARISING FROM  GENERAL  CAUSES.

to raise it into vesicles.   On the backs of the fingers and  around the
nails, true  vesicles  are formed, which  are sometimes numerous, and
sometimes, by communication with each other, raise up  the cuticle to
a considerable extent, and finally cause its exfoliation.  In mild forms
of the complaint, the fluid of  the vesicles is absorbed, and the cuticle
desiccates into a thick, yellowish, and horny  layer; sometimes the
disease passes into the chronic form,  the skin becomes thickened, dry,
and cracked, the  cuticle exfoliates repeatedly, and the  morbid action
is perpetuated as a chronic  eczema digitorum.   When  the  disease
fixes on the thin  skin at the ends of  the fingers, the nail is sometimes
destroyed.
   Eczema  rubrnm  dorsi maniis disputes  with lichen agrius  dorsi
maniis, the popular titles of grocers' itch and  bricklayers^ itch; and it is
often a point of nice distinction to determine whether to call a given
eruption, eczema or lichen  agrius, lichen  eczernatosus, as it might
with great propriety be called.

   Diagnosis.—The different  varieties of eczema  present differences
of character which  are peculiar to themselves,  and must  be borne in
mind in our endeavors to establish the diagnostic signs of the disease.
Thus, in eczema  simplex we find clusters of minute vesicles in great
numbers, and without accompanying 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 vesicles contain a purulent fluid, others are ichorous, and others,
again,  are supplanted by excoriated  patches; in the latter  stages of
all the above varieties, we find lamellated  scabs and incrustations of
variable thickness; and in eczema chronicum, or psoriasis, we  have
chaps and fissures pouring out an ichorous fluid, and, at a later  period,
copious desquamation.   Moreover, eczema is  frequently seen  as a
complication of scabies, and is itself complicated with 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 likely
to occur. In both, there are vesicles;  in both, the eruption is developed
without redness ;  both are situated in the flexures of joints, between
the fingers, &c; and both are  accompanied with pruritus.   But,  upon
careful examination, considerable differences will be detected betweeQ
the two diseases.
   Simple  eczema is likely  to be confounded  with sudamina,  with
which its vesicles  bear considerable analogy.  The characters by which
it may be distinguished are, that, in the latter, the vesicles are of larger
size than those of eczema, being equal in bulk  to a millet seed, while
those of eczema rarely surpass the head of a small pin.  The vesicles
of sudamina are scattered aud discrete ; those of eczema, confluent and
aggregated.   The former are associated with  profuse perspiration,
which  is not the case with eczema.  Moreover,  sudamina  occur  with-
out preceding irritation of the skin, and their  presence gives rise to
no abnormal sensations.
   Eczema impetiginodes is liable to be mistaken for scabies and impetigo. 
           eczematous or vesicular  eruptions.        205

Scabies complicated with pustules, as it sometimes occurs, presents
several points of resemblance with eczema impetiginodes, 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 lymph;  they
are larger than the eczematous lymph-pustules, unmixed with vesicles,
and confined to a small extent of surface.  Again, the hardened cover-
ings of the  excoriations of eczema  are thin scabs, while those  of
impetigo 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,  the ichorous secretion
from the  excoriated surfaces,  and the copious exfoliation  of scales.
Indeed it is only by means of the previous history of the eruption that
their diagnosis can  be determined.  The result of the diagnosis  is,
however, of little consequence, as both, at this stage, come  under the
designation of psoriasis.
  Eczema capitis  is  sufficiently distinguished  from  other diseases  of
the scalp by the characters which have been already indicated.
  Eczema aurium is distinguished from erythema intertrigo by the
absence of all trace of vesicles in the latter, and by its sole appearance
in the cleft behind the ears.  It is attended with chapping, and by the
effusion of ichorous discharge.   The same characters serve to establish
the diagnosis between eczema mammillarum, pudendi, and articulo-
rum, and erythema of those  regions.
  Causes.—Eczema is apt to occur either symptomatically, as a con-
sequence 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, par-
ticularly 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,  a^;
amenorrhcea, 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 been
denominated eczema  solare.  It not unfrequently attends the  inflam-
mation produced upon the skin by the irritation of a blister, or by the
application of the compound sulphur  ointment, or of a 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
powdered or stimulating substances.   In the same category must be
enumerated the transmission of eczema, by contact, from one person
to another, the discharge from the vesicles  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 
206      DISEASES ARISING  FROM  GENERAL CAUSES.

observation which must be referred for its explanation to the greater
cutaneous susceptibility of the former than of the latter sex.  Again,
different parts of the body exhibit a greater or less disposition  to 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  occur-
rence of the disorder in the parent.
  Prognosis.—Eczema acts  very 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 the  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 symptomatic of constitutional dis-
turbance, or visceral disease,  which must  be removed before the local
affection can be conquered; indeed, it usually happens that the cure of
the constitutional disorder is followed by a spontaneous disappearance
of the eczema.
  Treatment.—Eczema must be treated in accordance with the prin-
ciples laid down in the chapter on general therapeutics, and the three
indications therein announced must  be observed.   Elimination must
be effected by means of aperients, the compound colocynth pill, with
soap or henbane, and if thought necessary, calomel or blue pill;  sul-
phate and  carbonate of magnesia, with nitrate of potash and mint
water, or any more convenient form.  If there be  fever, effervescent
salines are the proper remedy;  if there be an excess of acid salts in
the system, with symptoms of rheumatism,  neuralgia,  or gout, then
alkalies with bitters should be  given, and a grain of the acetous ex-
tract of colchicum conjoined with the aperient pill.
  Restoration of  power, the  second  indication, is to be  attained by
means of tonic  remedies, one while conjoined with alkalies, if the acid
diathesis prevail; and  then with the mineral  acids, nitromuriatic and
sulphuric.   If there be debility,  with  languor, lassitude,  and depres-
sion of spirits,  the plan of bitters with acids is the correct one to
pursue.  Later in the course of the disease, when it has proved rebel-
lious  to treatment  by general  remedies, or has  passed  into the
chronic stage, and  is established as a chronic disease, we may have
recourse to the specific powers of arsenic. Three  to  five minims of
Fowler's solution, or six  to ten of the acid  solution of  de Valangin,
may be given three times a  day, with meals;  and in very chronic
cases, when the  conjunction of mercury and  iodine with arsenic is
thought desirable,  ten minims of Donovan's  solution may be taken
with meals, also three times a-day.  When chronic eczema resists every
other mode of treatment, it  may be assailed  by the tincture of cau
tharides exhibited in combination with compound tincture of camphor 
           ECZEMATOUS OR VESICULAR  ERUPTIONS.        207

and bark.  In these very obstinate cases the bichloride of mercury in
tincture of bark has sometimes been found of great service.
  In the exhibition  of arsenic, the known irritative  effects of that
medicine when  taken  for too long a time, in excess,  or by persons
intolerant of the remedy, must be borne in mind and carefully watched,
and  the  instant any of these symptoms occur, the remedy must  be
suspended.  The same remarks apply to  the administration of can-
tharides.  The rule that I lay down for the  guidance  of my patient
while taking arsenic is simply this: If you feel ill from any cause what-
ever, think you  have  taken  cold, or have any pains in  your  stomach,
immediately -stop the medicine until  those symptoms have subsided; and
then resume it as before.  By  obeying these  instructions the patient will
avoid all danger from harm, while taking  an excellent medicine.
  The third indication, the alleviation of heal distress, in other words,
the local treatment, brings us to operate with those topical applications
which are known to  soothe  a part  in the state of inflammation;  the
first of them is water-dressing, the  second a soothing unirritating
ointment, such  as the benzoated ointment of oxide of zinc, rubbed
down with spirits of wine, a drachm of spirit to the ounce, and perfectly
fresh.  When the water-dressing is used,  the intention should be  to
reduce the local congestion  and suffering, and encourage  discharge.
 As soon as that end is attained, we  must endeavor to arrest discharge,
 and heal the excoriated skin ; then is the time  for the oxide of zinc
 ointment, and then it is unfailing, if properly applied.
   In eczema simplex, the lotio plumbi may be found useful,  and if
 there  be  much pruritus,  a  lotion of sesquicarbonate  of ammonia, a
 drachm  to the half-pint;  an emulsion of bitter almonds with hydro-
 cyanic acid;  a lotion of the liquor ammonias acetatis with camphor
 mixture; a liniment of olive oil and  lime-water with liquor plumbi;
 simple cerate with camphor ; the oxide of zinc ointment, with spirits
 of wine or camphor, or the  unguentum plumbi compositum.
   In eczema rubrum and  eczema impetiginodes, after the heat  and
 inflammation of the  skin have been sufficiently  reduced by water-
 dressing, the benzoated ointment of oxide of zinc should  be applied
 somewhat thickly over the  whole  surface, so that  every hollow  and
 recess may receive its share, then a piece of linen  rag thinly spread
 with the same ointment, or  a sheet of cotton wool, should be laid over
.the part.  This kind  of dressing  should be  repeated once or twice
 a-day, and to uncovered parts as often as the ointment may be acci-
 dentally disturbed or rubbed off.   At first, and when the skin is in a
 state of inflammation, the ointment cannot be applied too lightly ; later
 in the course of the disease a little friction  may be used;  and later
 still, when crusts have formed on the eruption, a gentle effort may be
 made, while applying  the  ointment, to displace the crusts  with  the
 finger during  the act of friction.  Throughout the whole period of
 treatment of the eruption  by ointment no water should be used, and
 consequently no washing.  Occasionally, when the crusts and ointment
 have accumulated unduly,  the part may be sponged with warm water,
 and immediately after anointed  afresh, but  generally,  washing is
 mischievous rather than beneficial. 
208      DISEASES ARISING  FROM  GENERAL CAUSES.

  If heat and inflammation occur during the treatment of the part by
inunction, there is nothing to prevent the application of strips of rag
wetted with evaporating lotion externally to the covering which keeps
the ointment in its place;  and other means of relief, such as position
or fomentation, may also  be adopted.   Sometimes  when  the tone of
the skin has been much lowered by the continuance of the disease, or
the prolonged  use of water-dressing, and particularly when the lower
extremities are the seat of the  eruption, a bandage, to make a firm
and  equable pressure on  the surface of the limb, may be used with
advantage.
  In chronic eczema other topical remedies are required, one while to
relieve pruritus, and another while to exert a discutient action on the
affected part.  The juniper tar-ointment, considerably diluted, is an
excellent anti-pruritic remedy, while, stronger, or of its full strength,
it is powerfully discutient.   Among the best of the discutient remedies
are the ointments of the nitric  and  hydrochloric salts of  mercury,
variously  diluted  ; for example, the nitric oxide of  mercury, unguen-
tum hydrargyri nitratis, and unguentum hydrargyri  ammonio-chloridi.
In some forms, of chronic  eczema one  or other of these  ointments is
specific; for example, the unguentum hydrargyri nitrico-oxydi diluted
to the extent of one part in four, in pityriasis capitis; the unguentum
hydrargyri nitratis, one part in eight, in'-psoriasis palpebrarum, &c.
  Sometimes eczema rubrum and eczema impetiginodes, when of long
continuance, or when the water-dressing or poultice has been unduly
prolonged, become excessively tender, so tender, in fact, as to be irri-
tated by the mildest application.  I have such a case in remembrance,
wherein the disease of the skin was rendered most  distressing by its
association with cutaneous neuralgia;  and  I have since  seen several
cases of a similar kind.  In this  morbidly  sensitive state of the skyi
and of the eruption, I have found no remedy act so well as a solution
of nitrate  of silver in spiritus aetheris nitrici, in the  proportion of one
grain to the ounce.

                          SUDAMINA.
Syn. Miliary vesicles.   Miliaria.   Miliary eruption.  Hydroa. Herpes
       ■miliaris.  Die Friselblattern ; die Schweisblattern, Germ.
  Sudamina are  small prominent vesicles, of a rounded form, and
about equal in size to millet seeds.  They are transparent at first, and
have a pinkish hue (miliaria rubra), but at the end of twelve or twen-
ty-four hours, 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; their most
frequent seat being the trunk, where they usually occupy a district of
considerable extent; and select by preference the sides of the thorax,
the axillae, and the adjacent part of the inside  of the arm;  being no
doubt encouraged by the heat of this region.  They are always discrete, 
ECZEMATOUS OR VESICULAR ERUPTIONS.        209
though  sometimes 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 associated
with excessive  heat of the skin, and often with  profuse  perspiration.
Hence they are occasionally met ,with in eruptive fevers, namely, in
rubeola, scarlatina, and variola.  They also accompany simple, remit-
tent, and typhoid fevers,  and  most imflammatory affections accom-
panied  with  profuse  perspirations, as acute  rheumatism.  From the
size which they  usually  present, namely, that of  a millet seed, they
have been termed miliary  vesichs,  hence  the specific  designation
attached to certain diseases, as erythema miliare,  implies a complica-
tion by these vesicles.  Sudamina are most frequently observed in
persons possessing a thin and  irritable skin, and during the summer
season.
   Since the  days of Sydenham, who advocated  sp powerfully 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  connection  with fever, were regarded as a
specific disorder,  preceded and accompanied by severe and dangerous
fever.  This  fever was  termed miliaria, and for many  years was
regarded as a dangerous and fatal disease, spreading like an epidemic,
and destroying multitudes 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  erup-
tion 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 stimu-
lating regimen in a confined  atmosphere. The almost total annihila-
tion of the disease, of late years, since the general adoption of a better
practice,*is of  itself unequivocal  evidence  of its origin."  "Hippo-
 crates, 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, Sydenham  witnessed  no
 such fever;  but-  mentions the occasional appearance only of miliary
 vesicles, which he ascribes to their proper cause."1
   " 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 puerperal women.  This is suf-
 ficiently accounted for by the treatment 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 im-
 mediately 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

                 1 Synopsis, edited by Dr. Thompson, p. 348.
        14 
210      DISEASES  ARISING FROM GENERAL CAUSES.

a fire, all access of air was denied, even through a keyhole.  From
these causes fever was almost necessarily induced, with the most pro-
fuse  sweats, oppression, anxiety, and fainting; and these  again, were
aggravated by spicy caudles, spirits, opiates, and ammonical medicines.
That numbers should perish under such management,  with every
symptom of malignity, and that many who survived it should escape
with broken constitutions, will surprise  no  person who is acquainted
with the baneful influence of  over-excitement in febrile complaints."1

  Diagnosis.—The diagnosis of miliary vesicles is not difficult; their
being discrete, though  numerous; their form  and size; their occur-
rence chiefly on the trunk of the body; the absence of inflammatory
redness of the skin; and their association with constitutional disease,
and  generally with a clinical state of the patient, sufficiently distin-
guishing them from the smaller, itching  and tingling, clustered vesi-
cles  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 pre-
ceding  description, and the prognosis  must depend upon  the disease
with which they are associated, and of which they are simply symp-
tomatic.
  The treatment, again, applies to the fever which they accompany.
The  vesicles are too insignificant to call for the use of therapeutic
measures.
                     CHAPTER  VIII.

          DISEASES ARISING FROM GENERAL CAUSES.

              IMPETIGINOUS OR PUSTULAR ERUPTIONS.

 • 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 eczematous group of diseases, the  inflamed derma gives
rise  to  the formation of pus; the pus occupying the surface of the
derma, and producing an  elevation of the epidermis to a limited ex-
tent.  This irregularity of the surface of the skin, namely, an eleva-
tion of the epidermis consequent on  the presence of pus, is termed a
pustule, and this is the only accurate sense in which that  term can be
employed.  There is a wide distinction between a vesicle and-a pus-
tule, when these two pathological forms present their typical charac-
ters ; but it not unfrequently happens, that, in consequence of a repa-
rative action set  up in the vesicle, pus is produced upon its dermal
1 Synopsis, edited by Dr. Thompson, p. 350. 
IMPETIGINOUS  OR  PUSTULAR  ERUPTIONS.        211
base, and, mingling with the lymph, constitutes a semi-purulent, and
subsequently a purulent  or pustular vesicle.  In  such  a case it is
necessary to remember that a true pustule contains pus from the first
moment of its formation, and, by this circumstance, is essentially dis-
tinguished from a vesicle.
   It is requisite, at the outset  of our study of cutaneous diseases, to
be precise in our  definitions, and to draw as broad a line as possible
between  the various jtithological forms which we are desirous of cha-
racterizing.   Scarcely any word in medical  nomenclature  has been
used more loosely than  the term pustule.  At one time it was em-
ployed to signify a papula, at another a vesicle.1   Willan employed
it, with the characters above stated, as the type of his fifth order, pus-
tular; and in this  sense it has  been  subsequently adopted by succes-
sive dermatologists.
   The diseases which  I propose to  consider  under  the  definition
above given, are two in number, namely,
                 Impetigo,                  Ecthyma.
   The order Pustulae of Willan  embraces five diseases, two  of  which,
had he lived at the present time, would, I am convinced, have been
excluded by himself, namely porrigo and scabies.   The genus Porrigo
of Willan contains diseases of the most opposite kind, and has been
the source of much confusion, so much, indeed, that it would be well
that .the term should, for the future, become  obsolete  and forgotten.2
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 pustulae,  is forcibly torn
from  all its natural affinities,  and  for this reason I have thought
 it correct to transfer it to the group of eruptive fevers.   Rayer admits
 no less than ten genera of pustular inflammations,  for four  of which
 he  is indebted to variola, namely, variola, varicella, vaccinia,  and

   1 Riolanus informs us that in his time (the sixteenth century), cutaneous diseases
 were grouped into three genera, according to their prominent characters in reference
 to smoothness, color, and magnitude ; but as this arrangement excluded diseases of
 the  hair, others preferred dividing them into pustules, deformities, and tubercles.
 The genus pustulae comprehending all eruptions attended with roughness of  the
 skin, whether pimples, vesicles, proper pustules, or scales.
   2 The diseases. marked by roughness of the skin (asperitas cutis), the group of
 pustulae, present as a secondary group, scabies, an eruption attended with much itch-
 ing, and exciting  the " desiderium scabendi," hence its name.  Scabies, again, has
 two species, humida et sicca ; scabies humida is the representative of eczema ;  and
 scabies sicca, which, besides being dry, is rough and pimply like gooseskin, seems to
 correspond with- lichen.  But scabies sicca has two sub-genera which are scaly,  and
 are therefore named psora, the parent of the psoriasis of the present time ; and psora
 is subdivided in reference to the bulk of its scales into psora porrigo, and psora lepra
 —the scales of the former being furfuraceous, and of the latter as large and thick as
 fish-scales. We are thus enabled to trace the proper signification of  porrigo ; it is a
 dry furfuraceous eruption attended with itching ;  its furfuraceous quality being indi-
 cated  by the first two syllables of the word; "aporro, quia ut porrum in tunicas
 involucra, ita  cutis velut in squamas  resolvitur;" and its pruritic character by the
 terminal syllable, " quasi  prurigo."  Porrigo, therefore, corresponds  with pityriasis ;
 while porrigo capitas is further named tinea, because the skin seems eroded  like gar-
 ments attacked with the moth. 
 212      DISEASES ARISING FROM  GENERAL  CAUSES.

 vaccinella.   There could have been no objection to thus establishing
 a distinct group of  variolous affections, indeed, some benefit  might
 have flowed from such an  arrangement, but the possible advantages
 are immediately destroyed by the companionship  with which he has
 leagued them.  Thus, from the highly inflammatory and contagious
 fever of variola, we pass on immediately to three  forms of disease of
 the face, two of which are affections of the sebiparous glands and hair
 follicles, namely,  rosacea,  acne,  and sycosis ; next in order follows
 impetigo; then favus,  a peculiar  disease of the  hair follicles ; and
 lastly, ecthyma.
   The genera impetigo and ecthyma constitute the two essential forms
 of pustules indicated by Willan, namely, psydracia and phlyzaci'a, the
 former being a psydracious (tyxe.* ih^axia, frigidae guttulae)  pustule,
 that is, "a small pustule, often irregularly circumscribed, producing
 but a slight  elevation of the cuticle, and  terminating in a  laminated
 scab.   Many of the  psydracia usually appear together, and  become
 confluent; and after the discharge of pus, they pour out a thin, watery
 humor, which frequently forms an irregular incrustation."   The latter,
 a  phlyzacious (y\v£ttv, to be hot) pustule ;  that is, one, " commonly  of
 a  large size,  raised on a hard, circular base, of a vivid red  color, and
 succeeded by a thick, hard, dark-colored scab."   The achor and the
 favus of Willan are pustules developed around the  mouths of the hair
 follicles on the scalp.

                           IMPETIGO.

 Syn. Psydracia.  Ecpyesis impetigo, Mason  Good.   Crusted tetter,  or
   scall.   Dartre cruslacee,  Fran.  Kleienaussatz,  Germ.    Melitagra,
   Alibert.
   Impetigo1  (Plate X., a-f) is a  non-contagious  inflammation of the
 skin, assuming  usually a subacute type,' and characterized  by the
 eruption of small, hemispheroidal, or flattened 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
 surface; at other times they are distributed  more or less  generally
 over the surface of  the body.  Each pustule attains its full develop-
 ment and bursts, in the course of two or three days, terminating in a
 rough,   yellowish, and transparent crust,  of considerable  thickness.
The disease  occurs frequently in successive  crops, is attended with
 trifling  or no constitutional symptoms, and endures  from three to four
 weeks to as many months, and even years.
   The  mode  of distribution  of the pustules has given rise to the divi-
 sion of the disease iuto 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 desirable to
' Impetigo, ab impetu, according to Pliny.  Impetu agens. 
           IMPETIGINOUS  OR  PUSTULAR ERUPTIONS.       213

 consider as sub-varieties under the above heads; one of these, impetigo
 rodens, I omit altogether from consideration, since the disease described
 by Bateman under this name is evidently a syphilitic ulceration of the
 skin, and not an impetigo.   The remaining varieties are—
                       Impetigo scabida,
                          "     erythematica,
                          "     capitis.

                        IMPETIGO FIGURATA.

             . Syn.  Dartre crustacieflavescente, Alibert.
   This variety (Plate X., 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 disease  commences with the appear-
 ance of one or several small  patches of redness, which remain distinct
 throughout the  progress of the eruption, or subsequently unite with
 each  other, and constitute a single  patch; or it may appear at  once
 as an inflamed patch of considerable size.  Upon  this inflamed  patch
 a crop of small yellow pustules are developed, which rise  but slightly
 above the  surface 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 effused  fluid
 desiccates into thick, brittle, greenish-yellow colored crusts, resembling
 a patch of dried honey.  Beneath the crust the surface is red, inflamed,
 and excoriated, and  pours out  an abundant semi-purulent  viscous
 ichor,1  which contributes  still more  to  the thickness of the crust.
 Unless prolonged by successive eruptions, the  crust falls off in from
 two to four weeks, leaving the surface beneath of a vivid red color,
 somewhat  swollen, exceedingly tender, and covered with a  thin and
 shining epidermis.  The surface is occasionally fissured by the move-
 ments of the part, and a secretion is poured out, which hardens into
 a thin secondary crust, and is followed by successive laminae, 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 semi-purulent ichorous secretion
 diminishes by  degrees,  and ultimately  ceases;  the crusts  are  no
 longer augmented in  thickness; the  secondary crusts, which  have
 become 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 color and pliancy.
  Constitutional symptoms are either  yery 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 feeling of tension  and

  1 .Mason Good has given the terms " running scall and humid scall" to impetigo;
both, however, more properly belong to eczema. 
214      DISEASES ARISING  FROM  GENERAL CAUSES.

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 fresh irritation.
  Impetigo figurata presents various  modifications in  relation to the
extent of surface affected, 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  first instance, while the  disease
spreads by  its circumference (impetiginous ringworm), so .as eventually
to cover a large surface, whereof the centre presents the crusted stage
of the affection, and  the  periphery its  erythematous and pustular
stages.  The crusts again occasionally offer  a peculiarity of appear-
ance,  being  conical in their shape,  and compared  by  Alibert  to
stalactites.   This variety he terms dartre crustacee stalactiforme; it is
most  frequently seen  upon  the  eyelids, borders of  the eyebrows,
nose, &c.;  in brief, in  any situation where the effused secretion  has
an inclination  favorable  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 successive
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  condensation  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 face, and more
particularly the cheeks, but it may also occur upon  the trunk of the
body  and extremities.  The fore-arms I have remarked to  be a not
unusual position of the eruption.  It commoi^y appears on  several
regions at  the  same  time, and there  exists sonie. little difference in
regard  to  the form of the patch, according  as it may be developed
on  the  upper   or the  lower extremities;  thus, on  the former, it
approaches nearer the circular,  ou the latter, the oval shape.
   Impetigo figurata sometimes  assumes a chronic form; fresh crops of
pustules are no longer produced, but the integument takes on a morbid
action, it becomes thickened and infiltrated, and the excoriated surfaces
pour out a viscous, semi-purulent secretion, which desiccates  into fresh
incrustations, the  incrustations being reproduced as often as they are
rubbed or thrown off.  Occasionally the incrustations, 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 this
kind, has  been compared, very aptly, to the trunk of a tree covered
with a rough and cracked bark. 
           IMPETIGINOUS  OR  PUSTULAR ERUPTIONS.       215

                        IMPETIGO  SPARSA.

                Syn.  Scattered crusted scall, or tetter.
  Impetigo sparsa (Plate X., c) differs from impetigo figurata 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
sprinkkd form, distributed over  a considerable surface; for instance,
over an entire^imb, 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, being freshly developed  in
the midst of fully formed crusts.   Impetigo sparsa* usually appears on
the limbs, especially on the  lower  extremities and about the ankles,
and is frequently seen in the neighborhood of joints.   On the legs it
is not unfrequently associated with oedema, and is exceedingly trouble-
some.
  Impetigo sparsa is more  apt  to degenerate into the chronic form
than the preceding variety.  The surface beneath the crusts often pre-
sents superficial  ulcerations, the  integument becomes thickened  and
infiltrated, and the large collections of crusts constituting impetigo
scabida, are more frequently produced.

                        IMPETIGO SCABIDA.

  Impetigo scabida (Plate X., f) is merely that state of the two pre-
ceding varieties  in which the surface is covered by a thick incrusta-
tion resembling  the rough bark of a tree.  This crust  is broken and
fissured from point to point  by  the  movements  of  the  part,  and
through the apertures  a quantity of semi-purulent secretion oozes to
the surface, and  desiccates  on 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 super-
ficial ulcerations, and Tresh incrustations are speedily formed.  Impe-
tigo scabida is for the most part  met with in old persons, and in those
of debilitated 'constitution, and  is not  unfrequently associated with
oedema.
                    IMPETIGO ERYTHEMATICA.
             Impetigo  erysipelatodes.  Erythematic scall.   '
  The  ordinary  forms  of impetigo  are  characterized by the absence
of constitutional  symptoms, and  by the  moderate degree of inflamma-
tion  which accompanies  the local disease.  Sometimes, however, the
eruption  is preceded by  burning heat  of surface, tension, great  red-
ness, tumefaction; in short, by the usual  signs of acute erythema.   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 symptoms that Willan has bestowed the designa- 
216
DISEASES  ARISING  FROM GENERAL CAUSES.
tion of impetigo erysipelatodes, which I have ventured  to correct by
changing the name to impetigo erythematica.

                        IMPETIGO CAPITIS.

  Impetigo capitis may present itself to our observation, either in its
aggregated or its  scattered form;  and it may be developed at once
upon the entire head, or  make its appearance separated on the scalp,
the face, or the ears.  The aggregated form of the dilease, impetigo
figurata, may be looked upon as an advanced stage of eczema impeti-
ginodes, or an eczema rubrum bursting into existence with a crop of
pustules instead of .vesicles; as, in fact, an eczema occurring in a pyo-
genic constitution.  Hence, when impetigo capitis is severe, the local
state and symptoms  so closely resemble eczema impetiginodes, as to
force upon the mind  the  impression of their being the same disease;
and, as far astheir management is concerned, their treatment must be
precisely the same.
  Impetigo figurata being an eruption of pustules, and the discharges
which are poured out in  the course of the disease being  as abundant
as those of eczema, with  the addition of their purulent character, the
crusts are remarkable for their  thickness.  They are of a yellowish
and brownish-yellow color, and  have been compared to dried honey,
the disease itself, in consequence of this similitude, being termed meli-
tagra.  Another point of resemblance between impetigo figurata capitis
and eczema impetiginodes is the strong odor of valerianic acid exhaled
by the purulent and  semi-purulent secretion.
  Impetigo figurata is usually met with in young persons and children,
particularly infants at the breast, hence  the term  impetigo hctantium.
Then, when the thick crust forms upon the head, the term tinea lactea
is applied to this affection, as well as to  its congener, eczema impeti-
ginodes.   On the face, for the same reason, it constitutes a crusta lactea
and porrigo larvalis ;  and it would be difficult for the most experienced
dermatologist  to  determine, in an established  case of crusta lactea,
whether  the  disease  had commenced  as a crop of pustules  or of
vesicles.  Subsequently,  the discharges are exactly  the same, the  dif-
ferences,  if any,  being simply a  plus, or minus in the proportion of
pus globules entering into the composition of the morbid  secretion.
This admixture of the pus of impetigo with the ichorous and viscous
secretion of eczema,  gives a milky opacity to the fluid, suggestive of
a mucous, or rather  of a muco-purulent,  secretion ; hence .the term
employed by Alibert to designate this character, namely, tinea mucosa.
In like manner, tinta granulata, another term originating with Alibert,
has been applied to impetigo, as well as to eczema; deriving its origin
from the broken crusts which are scattered among the hair in impetigo
capitis, and more particularly in impetigo sparsa capitis.
   When impetigo figurata capitis attacks the hairy scalp, it gives rise,
by its secretions and  crusts, and by the disorder and matting  of the
hair which ensue, to  all  the distress  and  suffering which have been
described in association  with  eczema  impetiginodes of  the  same
region ; so, in impetigo faciei, the symptoms are the same as in crusta 
IMPETIGINOUS OR PUSTULAR ERUPTIONS.       217
lactea  from  eczema.  In a  case  of  this  disease,  delineated in my
Portraits of Diseases of the Skin,1 the crust  upon the face was so thick
as to retain the features in a fixed position, and the surface so tender,
that the slightest touch produced pain.  The disease, having extended
to the ears and back of the neck, prevented  the patient  from lying
down in bed; and  an  accidental pressure  of any  kind,  even the
motion  necessary  to open the mouth, occasioned a cracking of the
skin, and an  oozing  of blood from the cracks; to which was added
a constant pricking and itching pain, and a feeling of excessive heat.
   Impetigo sparsa is not unfrequently met with on the scalp (Plate
X., D e), where it occurs as single pustules  or in small groups.  These
individually run through the course already described as appertaining
to impetigo  figurata, forming crusts  of  various size and various
degrees of thickness.   They  are attended with  heat, itching,  and
sometimes  pain;  are  often very  tender,  and, when  the  crusts are
removed, are found to be excoriated and moist, from the oozing of a
semi-purulent secretion.   At the decline of the disease the crusts are
broken up, and the fragments, mingled among the hair, or strung like
beads on separate hairs, present the characters which have  been dis-
tinguished  as tinea granulata.
   Impetigo rarely does any injury to the roots of the  hair, and it  is
only in very  severe or neglected cases that  partial alopecia can occur.

   Diagnosis.—The  pathognomonic characters of impetigo are, the
small size and little elevation of its psydracious pustules ; the subse-
quent abundant viscous  and yellowish secretion which  the exposed
surfaces pour  out; and the thick, yellowish-green, or  brownish and *
grayish semi-transparent crusts.
   When impetigo affects the chin  only, it may be mistaken for
sycosis, unless we recollect that in  the latter eruption the pustules are
larger, more  prominent, discreet, less yellow in color, and  succeeded
by less secretion.  Moreover the crusts of sycosis are darker in color,
less moistened by secretion, not  renewed when  they fall off,  and
accompanied  by tubercles and indurations.
   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.
   The disease is referable to constitutional causes, and is commonly
found associated with the general disturbance produced by dentition,
amenorrhcea,  or the cessation of the menstrual period.  Its appearance
seems influenced,  also,  by the mental  excitement, excess in  diet or
stimulating drinks, violent exercise, &c.   It is commonly met with in
workhouses, where a number of children  of unhealthy constitution,
poorly fed, and  insufficiently  clothed, are assembled  together;  and
particularly where care is not bestowed upon the three great hygienic
principles, ventilation, cleanliness, and exercise.
  Local irritation of the skin is an occasional exciting cause, as  in
•Plate VIII., AR. 
  218      DISEASES ARISING FROM GENERAL  CAUSES.

  that produced by lichen, the application of stimulating substances to
  the cutaneous surface,  and the heat of the sun.
    The  impetigo capitis  et  faciei  of infants,  the crusta lactea,  is
  referable to the same causes as eczema  infantile, with  which it is
  closely allied.
    Prognosis.—Impetigo is a troublesome and offensive  disease, but
  by no means dangerous to  life.  It is frequently tedious, 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.
    Treatment.—In impetigo, during its inflammatory  stage, emollient
  and sedative fomentations and water-dressing are the best local appli-
  cations.  When the inflammation  is somewhat abated, the eruption
  should be coated with the benzoated  ointment of oxide of zinc rubbed
  down  with spirits of wine (3j ad 3j). The ointment  is best  applied
  with the finger, and in infants, with a small brush; and  care should
  be taken to fill all the hollows of the surface, and the  crevices of the
  crusts, where they have been allowed to form.  This ointment should
  be applied thickly, and repeated morning and night, and as frequently
  during the day as the surface may be disturbed, or the previous layer
  of ointment rubbed off.  If discharges are formed, they may be wiped
  off with a soft napkin, and in the same way loosened  crusts may be
  removed.   No  attempt  should  be  made to wash the  eruption, as
  washing is always followed by desiccation of the surface and an imme-
  diate increase of local inflammation and suffering.  On the same prin-
  ciple lotions of all kinds are mischievous, unless applied over a coating
»  of the oxide of zinc ointment. This latter step may be taken at any
  time, as the ointment in no way interferes with the evaporating action
  of cooling lotions applied to the skin, or the  soothing and softening
  effect of water-dressing and fomentations.  In general this is all the
  local treatment required, but where the surface is too sensitive to bear
  the zinc ointment, and remains so after the use of water-dressing and
  emollient or sedative fomentations, it may be  pencilled  with a weak
  solution of nitrate of silver in distilled water (gr. ij—vj ad oj).   An-
  other useful local remedy of the  soothing class, is a liniment of olive
  oil and lime-water, either alone, or  with the addition of liquor plumbi
  diacetatis, or the sedative solution of opium, covering the  surface after
  its application with a sheet of cotton wool.
    In the chronic state of the local disease the nitrate of mercury oint-
  ment, more or less diluted, is a valuable remedy;  or the  nitric oxide
  of mercury ointment, or the ammonio-chloride.   Another useful oint-
  ment for allaying pruritus as well as restoring the skin to its normal
  state by  gentle stimulation,  is the juniper tar  ointment, diluted or
  strong.   With these ointments may  be conjoined a moderate amount
  of friction.  In  extremely  obstinate chronic impetigo,  the  sulphur
  ointment may be found serviceable.
    The constitutional treatment of impetigo requires in the first instance
  attention to the functions  of digestion, the removal of all irritant
  matter from the alimentary canal, the suppression of fever or feverish
  symptoms, if they  exist, by antiphlogistic means; and subsequently 
           impetiginous or pustular eruptions.       219

the restoration of the general tone of the  system.  With this view,
gently purgative medicines, with salines, or alkalies with bitter infu-
sions or tinctures, should be exhibited, and these should be followed
by the class of tonics, gentian, quinine, bark, calumba, chirayta, cha-
momile, quassia, or taraxacum, according to  the  custom or views of
the practitioner.   With the tonics, alkalies may be continued, if the
lithic diathesis still remain, or if there  be evidence of the rheumatic
or gouty diathesis.  But if the powers of the system be lowered, then
the mineral acids may be combined with the bitter remedies, either
the  hydrochloric, the  nitric, the   nitromuriatic, or  the  sulphuric.
Again, if  anaemia be present, the citrate  of quinine and iron, simple
tincture of the bydrochlorate of iron, or the  acetate of iron with  nitro-
muriatic acid, may be administered,  according to the judgment of the
practitioner.
  In  the chronic stage of impetigo, the alterative tonic  properties of
arsenic may be required, and then, as in psoriasis following erythema,
lichen, or  eczema, any of the arsenical preparations commonly in use
may  be adopted; Fowler's or De Valangin's solution';  the arseniate
of soda, ammonia, or quinine; the  iodide of arsenic, or in very stub-
born  cases, where the  alterative action of  mercury and iodine may
seem  to be desirable, in addition to  that of arsenic, the liquor hydrio-
datis  hydrargyri et arsenici or Donovan's solution.
  In  crusta lactea my treatment is as follows: a calomel purge of one
or two grains, according to the age of the child,  and  repeated once  or
twice in the week, or as often  as the child  may evince feverishness,
great irritation,  restlessness, heaviness, or peevishness;  from two  to
three minims of Fowler's  solution   given with  meals  twice  or  three
times a-day; and the constant and efficient application of the benzoated
ointment of oxide of zinc with spirits of wine.  These means properly
used,  I have never known  to fail, and I  believe never can  fail.  As
there is always some anaemia in children  affected with this disease, I
usually  combine  the  Fowler's solution with  a  few  drops of vinum
ferri; sometimes I prefer the  solution of De Yalangin, in which case
the tincture of the hydrochlorate of iron  is  the  best associate for the
arsenic; and  sometimes I give the preference to  the arseniate of soda,
on account of its great convenience as a medicine for  infants.   It  is,
moreover,  necessary, in this disease  of mal-assimilation and mal-nutri-
tion, to secure to the child  a  wholesome  diet, and to add to its ordi-
nary food  beef-tea or mutton-tea.   It is, perhaps, hardly necessary to
remark, that the arsenic, which usually agrees remarkably well with
infants, and with them is an invaluable remedy, should be watched,
lest it disagree;  and immediately it does so, omitted, and a calomel
powder given.
  In impetigo of the scalp, it may be  necessary  to shorten and  thin the
hair;  but  where attention has been  bestowed to cleanliness,  and the
head  kept well brushed and anointed, I have rarely found  it neces-
sary to shave or even crop  the hair. 
220      DISEASES ARISING  FROM  GENERAL  CAUSES.
                           ECTHYMA.

Syn.  Ecpyesis ecthyma,  Mason Good.  Phlyzacia.   Papulous  scall.
  Ecthyma1 (Plate  X., 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 surface of  the body.
The pustules are discrete and scattered, they are developed on a hard
and inflamed base, and terminate in dark-colored crusts, which  leave
a deeply congested  surface, and often a brown stain, at 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 ge-
neral ;  in the former case it may endure for one or two weeks, in the
latter for several months.   It is not contagious.
  Ecthyma is  endowed by  Willan  with four varieties, having relation
to the constitution and age of the patient; these are, ecthyma vulgare,
ecthyma infantile,  ecthyma  luridum,  and ecthyma cachecticum.  I
prefer, however, with Rayer, to consider the disease as presenting an
acute and a chronic type; the former of these divisions corresponding
with the ecthyma vulgare,  and  the latter embracing the three remain-
ing varieties.   In a tabular form, the varieties of ecthyma are,
               Ecthyma acutum, seu vulgare.
                                   ( E. infantile,
               Ecthyma chronicum, 1 E. luridum,
                                   ( E. cachecticum.

                 ECTHYMA ACUTUM, SEU VULGARE.

  This  eruption (Plate X., 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 appearance of small, red, and cir-
cumscribed spots, which gradually rise above  the 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 epidermis, and the matter continues to be
augmented  by additional  secretion,  until a pustule is formed.   The
size of  the pustule is various;  usually 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 re-
sembles  a bulla distended with  pus.   The development and  growth of
the pustule are accompanied  by  severe and often  lancinating pain.
In the course of three or four days after the completion of the pustule,
the contained  fluid  dries up into a dark-colored scab of various thick-
ness, which falls off in eight or ten days, leaving  behind a  congested
circular spot of a deep red  color.  Sometimes the purulent fluid is re-
moved by  absorption, and the  surface of the  skin is restored to its
natural  state, after  repeated desquamation.  At other times a super-

  1 Der. IxSuiiv, to burst forth. " Apertum est ab ixflJsi*, quod est l£of/uaV, id est, erum-
pere, derivatum esse ; UQv/xag-i, id est, papulis, nomeu in iis  quae sponte extuberant in
cute."—Hippocrates, lib. iii. sec. 51. 
           IMPETIGINOUS OR PUSTULAR ERUPTIONS.       221

ficial ulcer is formed, particularly on the lower extremities, and ter-
minates with a slight cicatrix.  When the eruption of pustules has
been numerous, the congested spots left by the fall of the crusts pre-
sent 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," writes this author,1 1. " That in their first stage (red
elevations) there is merely sanguineous injection, with conical tume-
faction 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 mat-
ter  deposited in the centre of the elevation, which is now evidently
perforated; 4. That after the voidance of this matter, and the removal
of the cuticle, the pustule appears under  the form  of  a cup-shaped
cavity, surrounded by a hard, thick, puffed  edge; 5. Lastly, that on
the following days, this thickened margin subsides, at the same time
that a slight cicatrix is formed under the crust, the centre of which is
fixed within the point where the perforation had been observed."

                      ECTHYMA  CHRONICUM.

  Chronic  ecthyma (Plate X., h—q) is a more common form of dis-
ease than the acute variety;  it  occurs  in  successive eruptions, ge-
nerally 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 constitutes that variety
which has been designated  by Willan, ecthyma infantile.  This erup-
tion 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, surrounded by an areola more or  less inflamed, and terminate
by absorption of the purulent fluid and epidermal desquamation, or
by ulceration.  The ulcers  in this disease are unhealthy,  and difficult
of cure.
  In  old persons,  and  in those  whose constitution is injured by
excess, the congested areolae often present a purplish-red and livid
color; the pustules are of large size,  and filled with a sanguinolent,
puriform fluid, and they are  remarkable for the tardiness of their
course.  This character of the eruption constitutes the ecthyma luridum
(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 frequently 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 epidermis
is raised by the effusion of a small quantity of dark sanguinolent pus,
1 Translation by Willis, second edition, p. 530. 
222      DISEASES ARISING  FROM  GENERAL CAUSES.

which  forms, by its increase, an  unhealthy and discolored pustule.
When the pustule is fully developed, the epidermis bursts, and the
denuded surface becomes covered by a thick, dark-colored crust, which
remains adherent for several weeks.  If the crust be removed by acci-
dent or design, an ill-favored ulcer, with inflamed  edges, is exposed,
which  is tedious and difficult of cure.
  The pustules of ecthyma  are not unfrequently associated with sca-
bies, lichen, prurigo, and some other chronic affections of the skin.
  Diagnosis.—The large size and prominence of the  pustules, their
inflamed bases, and the mode of their development, serve  to  distin-
guish 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  eruption,  the
limited extent of the  areola, its coppery hue, the blackness and con-
centric marking of the crust,  and chiefly by the  presence of other
signs of constitutional syphilis.
  Causes.—Ecthyma may 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 is essentially
a disease of debility and cachexia.
  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  bricklayers  of the second.   The  manipulation  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 follow-
ing  the  irritation of  tartarized  antimony are ecthymatous; they are
umbilicated, contain  in their  interior a false  membrane,  are very
numerous, and are succeeded by dark-colored crusts.
  Ecthyma is often symptomatic of a  disordered state of the system,
as of some chronic affections of the viscera, or irritation 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  localities, want
of cleanliness, debilitating causes of various kinds, excesses,  and expo-
sure to vicissitudes.
  Prognosis.—The  prognosis  of ecthyma 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.
  Treatment.—In the acute variety of ecthyma, after the removal of
the cause, some gentle laxative and alterative medicine, with diluents
and  abstemious regimen, is all that will be required.   The best local
application  is the superacetate of lead,  or oxide of zinc ointment, or if 
HERPETIC AND BULLOUS ERUPTIONS.         223
the inflammatian be severe, sedative and emollient fomentations, and
water-dressing.  <
  The chronic forms  of the disease call for the use of tonics and
alteratives, of which the best is the nitro-muriatic acid with gentian.
Sometimes quinine with sulphuric acid appears to be indicated, or the
citrate of iron and quinine; the choice of the form of tonic being a
matter for the judgment of the medical man.  Where there is ema-
ciation, particularly in young persons and children,  the cod-liver oil
is an excellent and useful remedy.  Arsenic is never called  for in
ecthyma as a specific medicine,  but  as a general  tonic,  if thought
desirable, there can be no objection to its use.
                     CHAPTER  IX.

         DISEASES ARISING FROM GENERAL CAUSES.

              HERPETIC AND BULLOUS ERUPTIONS.

  In the four chapters which precede, erythema, lichen, eczema, and
impetigo follow each other in succession, and are closely allied, not
only in their general but  also in their particular cause.  I  have
endeavored to show that they may be regarded as one disease, modi-
fied by secondary conditions  appertaining to the constitution of the
individual, and that they less frequently  occur in a distinct form than
in combination  the one with the other. That erythema is the first
and the last stage of all; that lichen is an erythema affecting  more
particularly the follicular structure of the skin; that eczema differs
from erythema  and lichen only in its pathological effects, being, in
fact, an  erythema or lichen, or both together, with the superaddition
of an effusion of a colorless ichor or lymph; and that impetigo is the
simple  substitution of pus  for lymph, the natural consequence of a
pyogenic diathesis. I now, however, come  to two diseases, herpes
and pemphigus, grouped together by an artificial character (namely,
a large vesicle or bulla),  which have nothing in common with the four
preceding forms of cutaneous disease,  excepting  their origin in a
general cause, or one generated in the constitution of the individual;
and nothing in common  with  each other, excepting that same general
cause, and the special pathological phenomenon of the development
of a vesicle of a more considerable size and more distinct outline than
the vesicle of eczema, a  vesicle which ranges  in magnitude from the
size of a millet-seed to  that of a large  orange, and  has received in
consequence the technical name of bulla.
  Viewing herpes and  pemphigus side  by side, there will be found
more  difference  between  them  than in the  corresponding groups
assembled under the heads  of erythema, lichen, eczema, or impetigo.
These  groups  include  diseases which  have a certain and  mutual 
224      DISEASES ARISING  FROM GENERAL CAUSES.

affinity  with each  other, but  that cannot  be said to be  the case
between herpes and pemphigus; they differ in their proximate cause,
and  in  every feature of their  development and progress, excepting
the one  accidental similitude  of both  being attended with an effusion
of lymph, to an  amount sufficient to lift up the  epidermis into  a
vesicle  or bleb of  considerable size.  But, even in  this particular,
there is a marked  distinction  between them; the  vesicle of herpes
never exceeds a  certain moderate  bulk, namely, that of the hemis-
phere of a small pea; but the vesicle or bulla of pemphigus has no
definite  size, being of  all dimensions on the  same as well as on
separate individuals.  Then the character of the inflammation which
accompanies  them is wholly different: one is specific  and severe, the
other general and slight; one  is  remarkable for the pain with which
it is  accompanied, the other is  painless; one runs quickly into sup-
puration as  a part of its nature,  and  is apt to give rise to ulceration
of the skin; the  other  rarely produces pus, and is quite superficial.
With a perception  of these  contrasts before  me,  it is not without
compunction that I group together herpes and pemphigus, and I do
so simply with the view of limiting  the number of divisions which
would otherwise  exist, and by so much  complicate a department of
medicine which it is  my wish  to render plain.  Nevertheless, in my
own  mind, an herpetic eruption and a bullous eruption  suggest very
different ideas.
  Heretofore, founding my notions of classification upon the nature of
the product of the morbid skin, I had, with other authors, grouped
herpes  with  eczema, but I can no longer retain it in that position.
Herpes  is a  disease apart from all  others, and must stand alone; all
that  I can do for it is, to place it, as I have, by the-side of an affec-
tion, distinguished like itself insome degree, by the large size of its
vesicles. Rupia I have transferred to  a more proper location, namely,
among syphilitic eruptions.

                            HERPES.

          Syn. Tetter.   Olophlyctis,  Alibert.   Dartre, Fran.
  Herpes1 (Plate IX.)  is a  non-contagious  affection  of the skin,
characterized by  the eruption  of clusters of  globular vesicles upon
inflamed patches of an irregular or rounded form, and of small extent.
The  eruption rarely presents any  remarkable degree of severity; it is
not usually accompanied with symptoms of constitutional disturbance;
and  it  lasts  for a brief  period  only;  rarely longer than two or three
weeks.  Each vesicle runs a course of about ten days, and terminates
either by absorption of  its contents, by desiccation without  rupture,
or by rupture  and the formation  of a  thin brownish  scab, which
speedily falls.
  The varieties of herpes derive their  designation either from the form
and arrangement  of the  clusters,  or from the locality of the affection.
In reference to their general characters,  these varieties  admit of  a
1 Der. £{««», to creep. 
HERPETIC AND BULLOUS  ERUPTIONS.         225
 natural division into two groups, a phlyctenoid group, and a circinate
 group.   The phlyctenoid group is characterized by the irregularity of
 form and distribution of the clusters;  it is typified by the variety
 herpes phlyctenodes, and embraces all the local forms.   The circinate
 group, 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 circinatus  is characterized by the disposition of individual
 vesicles  in the form of a circle;  and herpes  iris presents the same
 peculiarity in the  form of concentric circles.  In a tabular plan, the
 varieties may be thus arranged:—
       1. Phlyctenoid group.                2.  Circinate group.
           Herpes phlyctenodes,                Herpes zoster,
              "     labialis,                        "    circinatus.
              "     nasalis,                          "    iris.
              "     palpebrals,
              "     auricularis,
              "     praeputialis,
             "     pudendalis.

                     HEREES  PHLYCTENODES.

     Syn. Herpes miliaris.  Nirhs.  Olophlyctis miliaris,  Alibert.
  The phlyctenoid variety  of herpes (Plate  IX., b)  presents no regu-
 larity of form or of appearance ; it may show itself upon any part of the
 cutaneous surface, or upon several regions at the same time, but is most
 commonly developed on the upper parts of the body, as the face, neck,
 and arms, and less frequently on the lower extremities.1  The vesicles
 are globular; they .vary in  size from a mere point to the  bulk of a
 pea, and are produced in a cluster 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 erup-
 tions to two, and  even to three weeks; the yellowish  spot which it
 leaves behind continuing perceptible  for as many months.
  The eruption is preceded by  a  sense of heat, tingling, and smart-
 ing, and  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
 lymph, are developed.  During the third day the contents of the vesi-
 cles become  turbid and lactescent, with here and  there one which is
 sanguinolent; and on the fourth day some few have a semi-purulent
 appearance.   On the third  and fourth days, the vesicles^)egin to shrink,
 and on the succeeding days to form, with their contained secretion
 thin, brownish scabs; these are thrown off by desquamation on the
 tenth or twelfth day, leaving a redness and livor of surface, which dis-

  1 In one instance the eruption occurred on the temple; and one vesicle was devel-
oped on the conjunctiva, and gave rise to much redness and inflammation.
      15 
226     DISEASES ARISING FROM  GENERAL CAUSES.

appears only by degrees.  The purulent vesicles are not unfrequently
followed by small superficial ulcerations.
   The local symptoms accompanying the eruption are, itching, prick-
ing, smarting, and an intense burning  heat, with frequently a deep-
seated pain, all of which symptoms continue for a short time in a miti-
gated degree after the  subsidence of  the eruption.   Constitutional
symptoms  are rarely present, and, should  they exist, are limited to
some degree of languor, thirst, loss of appetite, and diminished secretions.
   The following is an illustration of the common cause and progress
of herpes.  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
clusters were perceived  here and there  upon the red patches.  These
vesicles soon became distended with a transparent and colorless 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, pos-
sessed a rich grape-yellow tint.  On Tuesday all the vesicles were on
the decline, with the exception  of a few tardy clusters, which were
now attaining maturity.  On Wednesday the fourth day of the  erup-
tion, the greater part of the vesicles had dried up  into reddish-yellow
wrinkled scabs.   On succeeding  days  the  scabs became gradually
darker and harder, and were closely  imbedded in the skin.   By
Saturday a few  only of these scabs  remained; and on Sunday, the
completion of the week, traces only of the existence of the  eruption
remained.

                        HERPES  LABIALIS.

   Syn. Exanthema labiale.  Hydroa febrile, J. Franck.  Ohphlyctis
                         labialis, Alibert.
   Herpes labialis  resembles  herpes  phlyctenodes in every respect,
with the exception of situation and extent.  This eruption is preceded
by itching, redness, swelling, heat, and painful  tension of the lip,
sometimes  affecting the  mucous membrane of the prolabium 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 red-
ness, and sometimes earlier,  several crops of small round vesicles, five
or six in number, are developed on 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 lymph of the
vesicles becomes turbid and  lactescent, and subsequently semipuru-
lent.  On the fifth or sixth day a brownish crust is formed by the
desiccation of the vesicles and their contents;  and on the eighth or
tenth the crust falls.   The  formation of a crust  may frequently  be
prevented,  by carefully opening the vesicles as soon as formed, and  by 
HERPETIC AND  BULLOUS ERUPTIONS.         227
the application of a weak solution of sulphate of zinq in  rose water.
When the crust  is interfered with during its formation and removed,
a hardened  scab is produced, which remains  adherent  for  a  much
longer period  than the natural  crust.  Herpes labialis is  sometimes
associated with aphthae of the mouth.

         HERPES PALPEBRALIS, NASALIS, ET AURICULARIS.

   An  eruption  of globular vesicles  identical  with those of herpes
labialis is sometimes developed on 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 membrane of the  eye,  nares,
and external ear.  The progress of the eruption  is similar to that of
the preceding  affection.

                      HERPES PRAEPUTIALIS.

   Like herpes labialis, the present variety may affect either the mucous
or cutaneous surface alone, or both  conjointly.   The 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.  On the cutaneous surface the vesicles
pass mildly through  their course, the  fluid is frequently absorbed,
either in its serous or semi-purulent 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 semi-purulent, and. terminate in thin
brownish scabs.   These are not unfrequently rubbed off previously to
their natural desquamation, and leave behind them small  excoriated
surfaces, which might, by inattention, be mistaken for chancre.
   The symptoms accompanying both  these forms of eruption, are,
 heat, itching, and often a pricking sensation. The disease is dependent
for its cause on  friction  with  the  dress in persons of great suscepti-
 bility of skin; contact with discharges from the  vagina;  neglect of
 habits of cleanliness;  and irritation of the genito-urinary mucous
 membrane.  Herpes praeputialis sometimes becomes chronic, and is
 then difficult of  cure.
   In its excoriated state, as I have before remarked, this eruption offers
 some risk of being mistaken for chancre.   But the superficial ulcera-
 tion of herpes, the occurrence usually of several  small ulcerations in
 a cluster, and  the uniform level  of the exposed 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 false membrane.

                      HERPES  PUDENDALIS.

   This affection presents all the characters of the preceding varieties; •
 the vesicles appearing on the  integument and mucous membrane of
 the labia majora, or upon the internal surface of the vulva.  In these 
 228      DISEASES ARISING FROM GENERAL CAUSES.

 situations, the eruption is often rendered obstinate by the continuance
 of irritation kept up by morbid secretions from the vagina.

                           HERPES ZOSTER.

 Syn.  Zona.  Zoster.   Cingulum.  Ignis sacer.  Zona ignea.  Shingles.
               Der Gurtelausschlag, Feuergurtel, Germ.
   Herpes zoster,  or shingles1 (Plate IX., a—f),  is especially charac-
 terized by the arrangement of the inflamed patches with their clustered
 vesicles, in the form of a half-zone,2 which extends around some part
 of the trunk of the body, from the middle line in front to the middle
 line behind.  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, herpes proserpens.   In rare instances, the eruption
 is met with forming a half collar to the  neck, or a demi-zone around
 the face or head;  it has also been  observed upon one  side of  the
 scrotum or penis.  Herpes zoster occurs indiscriminately on either
 side of the body; by some authors, it instated that the eruption appears
 for the most part upon the right  side, while  others  contend that the
 left is most frequently affected; my own experience corresponds with
 the latter statement.  It is an acute disease, lasting from one to three
 or four weeks.
   Herpes zoster, in the manner and course of its eruption, is identical
 with the typical  form, herpes  phlyctenodes, but  more severe in its
 symptoms.  The putches by which it appears are of a vivid red color,
 commencing  usually  at both  extremities of the  demi-zone,  and
 proceeding outwards  by successive  eruptions, until they constitute,
 by their approximation, an irregular line.  The first formed patches
 are  larger  than  those which succeed.  They are perfectly distinct
 from each  other, being  separated, to a greater  or  less  extent,  by
 interstices of sound integument.  Shortly after  the  appearance of
 each patch, a  number of  small white and glistening prominences are
 seen upon  it, which speedily assume the form  of vesicles, and the
 latter go on increasing  in size, until, at the end of three or four days,
 they attain the magnitude of  small peas.   The vesicles are developed
 in groups, consisting of considerable numbers on each patch;  and in
 some situations they become confluent, and resemble small bulla?.
 At their first eruption they are filled  with transparent lymph, which
 becomes turbid on the second and third day,  and subsequently semi-
 purulent, or purulent in some, and of a  purplish or blackish tint in
 others.   On the fourth or fifth day, the vesicles begin to collapse and
 fade; they  look  wrinkled, and, during the two following days, dry

  1 See " Portraits of Diseases of the Skin," Plate V., AY. In this figure, besides the
 zona around the trunk of the body,  a large patch of herpes  phlyctenodes is seen oil
 the flank, just above the  hip.
  * An unfounded notion was prevalent jRmong the older physicians, that if the zone
encircled the entire body, the case would  terminate fatally.  Pliny, amongst others,
 refers to this presumption. 
HERPETIC AND  BULLOUS ERUPTIONS.          229
up, with  their contents,  into  small  scabs, of a  dark brown color,
which fall on the tenth or twelfth day, leaving behind them a redness
of the  skin, which slowly disappears.   The  vesicles are not unfre-
quently intermingled with true pustules.
  This disease is greatly modified, as regards  its termination, by the
state of health  and vigor of  the patient.  In  young and  healthy
persons the contents of  many of the  vesicles are absorbed 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 ulcerations, which are often long in
healing.   These  unpleasant consequences 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.  Some-
times, also, in old persons, the disease terminates in gangrene of the
integument.
   The symptoms  accompanying herpes zoster,  are, a pungent and
burning  heat  (ignis sacer, zona ignea) at the commencement of the
vesicular  eruption, and  a continuapce of  the  burning  pain,  to  a
greater  or less  extent, throughout  the course  of the disease.  Its'
invasion is not unfrequently indicated by acute pains,  which seem to
shoot through the chest  and epigastrium, and  by  palpitations and
tumultuous action of  the heart.  The close of the affection is some-
times marked by  severe, and  often intense  neuralgic pains, which
continue  for several  weeks,  or even  months.   The constitutional
symptoms are for  the most  part slight, consisting of feverishness,
quickened pulse, 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 subject
of chemical examination  by Heller.1   In one case, that of a boy eight
years of age, the urine was abundant,  faintly alkaline, pale yellow,
rather turbid, rapidly became putrid, and deposited crystals of ammo-
niaco-magnesian phosphate.   Its specific 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 suppressed,  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 analysis of these three cases are,
that this 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 of fat; 4. A  diminu-
tion  in the amount of uric acid;" an increase only occurring  when
the disease is accompanied with fever.   The  presence of oxalate of
lime may  always be suspected in these cases.
1 Dr. Day, in Simon's Animal Chemistry. 
230      DISEASES  ARISING  FROM. GENERAL CAUSES.


                       HERPES CIRCINATUS.

              Syn. Zona herpetica.   Vesicular ringworm.
   Herpes circinatus (Plate IX., g) is an eruption of vesicles of small
size and globular  shape,  upon  patches  of inflamed  skin, which
assume the form of a circular ring.  The circles are of various size
and breadth, rarely exceeding in diameter the palm of the hand, and
inclose an area of unaffected skin.   They are of a vivid red color, and
the vesicles  numerous and  sometimes  confluent.  The patches run
through  their  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, neck, breast, and upper extremities.
   Herpes circinatus commences in the form of small circular or oval
patches of vivid redness, which become pale 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
run through'the usual course of herpetic vesicles, becoming, at first,
turbid and milky, and then desiccating into small thin scabs, which
fall off in eight or ten days, the denuded surface of the skin retaining
a red  color, which gradually subsides.   The symptoms accompanying
the eruption are, a slight pricking and smarting sensation, with  some
degree of itching.
    When the attack is slight, the vesicles are small, and their contents
 are disposed of by absorption, the  eruption terminating by desquama-
tion.   In  other cases, the central area is not wholly free from the
influence of the inflammatory action, but desquamates with the circum-
ferential ring.

                            HERPES IRIS.

       Syn. Rainbow ringworm.   Erythema iris.   Pemphigus iris.
    Herpes iris1 is a very remarkable and comparatively rare  variety
 of cutaneous affection.  It is characterized by the eruption of a vesicle
 on a small circular erythematous blotch; the blotch increases in size
 by its periphery, throwing out an erythematous ring upon which the
 cuticle is raised  into an  annular  vesicle  more or  less  complete.
 Sometimes the process ceases at this stage, at  other times  new  rings
 are produced, either with or without fresh elevations of the  cuticle,
 and the blotches attain a considerable size.   The rings being succes-
 sive, exhibit various tints of color, hence the term iris, and the eleva-
 tions  of the cuticle being also successive,  either remain as puckered
 rings more or less complete,  sometimes as separate vesicles, or they
 are taken into the original vesicle and constitute a bulla  of consider-
 able size (pemphigus iris).  On the decline of the eruption the contents
 of the vesicles are absorbed, or dry up, and together with the cuticle

   1 Portraits of Diseases of the Skin, Plate VI., AZ, exhibits a well-marked case of this
 curious form of eruption. 
HERPETIC AND BULLOUS  ERUPTIONS.         231
form a  thin laminated  scab, which  after a time  is thrown off: the
erythematous rings also desquamate, and the site of the blotch remains
for some days,  marked  by circular traces of concentric rings, which
fade by degrees.
   As I have  remarked,  the eruption  may stop  at any stage of its
progress, and on different parts of the body, or in different degrees of
severity of the disease,  the patches are  more or less considerable, and
their characters more or less complete.   Thus, if it stop at the erythe-
matous stage, without throwing up a vesicle, but  produces a series of
rings,  the  case is  one of erythema iris; if it  develop  a vesicle  of
moderate size, either surrounded by erythematous rings, or by vesicu-
lar as well as erythematous rings, the case is herpes iris ;  and  if, by a
more active effusion, the  vesicle  should creep ou with the erythema-
tous rings, taking them into its area as  it proceeds, a bulla of greater
or less magnitude is formed, and the case is pemphigus iris.   When
the eruption is general, the whole of these forms may frequently be
seen at the same moment, and  the  gradations  of  development are
made evident.1
   In elderly persons this eruption is occasionally  met  with  occurring
on the hands and feet, and  remaining at the erythematous  stage ;  in
adults,  the herpetic form prevails; in children,  and also  in adults
where the system is relaxed and the constitution cachectic, the bullous
or pemphigoid form is  most frequently met with. In the erythema-
tous form, as it is commonly seen on the hands, the eruption presents
three shades of color, which are more  or less distinct; the centre is
red, then follows a  ring of a whitish or yellowish tint, and externally
to this is a narrow  areola of light crimson.  On other parts of the
body, the number of tints of color and the number of rings may  be
increased to five or six, or even double  that number.  I have observed
that a new ring is  generally produced  in the course  of twenty-four
hours;  so that by counting the rings it  would be possible to determine
the number of days it  had taken to arrive at its existent  state.   In
one patch I counted seven white rings,  representing seven  days, and
seven circles of fading  red between them,  the outermost white  ring
being bounded by a narrow areola of pale crimson;  and in  another
patch, only half an inch in diameter, I  counted nine different tints of
color, which from the centre to the circumference were as follows: red,
brown, white, deep red, lighter red, deep red, pale red, deep red, yel-
lowish  white,  and crimson blush.
   Herpes iris is essentially chronic, and a disease of cachexia, and in
both these particulars it is allied rather with pemphigus than with
herpes.  Herpes runs a definite course, and although  its  patches may
appear in succession, each individual patch has its specific and  uniform
career.   Not so with regard to herpes iris;  in the erythematous form
it is always slow, remaining without change for several days, while in
the bullous form, it has all the rapidity of pemphigus; and in neither

   1 Dr. Marshall Hall has given an excellent description of this disease in the " Edin-
burgh Medical and Surgical Journal."  He remarks that some  of the patches attain
the diameter of an inch, and that the central vesicle  sometimes becomes developed to
the size of a bulla, and obscures the concentric rings. 
232      DISEASES ARISING FROM  GENERAL  CAUSES.

has it the exact periods of herpes.  The same  remarks apply to the
constitutional  symptoms: in the erythematous form,  the  symptoms
are referable to chronic mal-assimilation; while in the bullous form, the
leading character of the disorder is cachexia.  In one  patient, a little
boy, there was a perpetual state of feverish nes's, with emaciation, and
a dry and parched state of  the skin ; while, in another, an adult, the
mucous membrane was severely affected; there were  aphthae in the
mouth,  fauces and nares,  the bowels  were sometimes  teased  with
diarrhoea, sometimes  with  dysentery, and  the discharges  from the
bowels contained a quantity of mucus tinged with  blood.  The whole
condition of this patient was one of cachexia, and when the eruption
broke out, the constitutional symptoms  were relieved.

  Diagnosis.—The globular form of  the  vesicles, their  size,  their
number,  their  pearl-like lustre, their clustered  arrangement, 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, more  prominent,  and better defined
than the vesicles of eczema.
  Herpes phlyctenodes and zoster are distinguished only by the arrange-
ment 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, and  are also more violent in  their
effects.
  Herpes circinatus, from  the  peculiarity  of its form, is liable to be
confounded with erythema circinatum, or with lepra in its 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 elevated
border, the absence of similar patches on other  parts of the body, the
presence of, at least, one or two herpetic vesicles, and the speedy decline
of the redness, serve to establish a difference.
  Herpes iris, in its erythematous  stage, bears some  resemblance to a
variety of roseola with concentric  rings.
  Causes.—Herpes must be regarded as a neurotic affection, as origi-
nating in some cause which weakens the tone and  vigor of a nerve or
its cutaneous branches, and  renders the  part of  the skin which it sup-
plies more sensitive to the influence of an irritant, as of a cold wind.
This seems to be especially the case in herpes zoster, in which the
neurotic  affection, as indicated by  neuralgia, precedes the eruption of
the skin, and  in which  also the neurotic  affection not unfrequently
continues after the eruption is healed.  Herpes occurs, for the  most
part, in  young  persons 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
digestive functions,  or upon irritation of the respiratory mucous mem-
brane,  and may  frequently be regarded as an effort of the  system to
eliminate some disposition to visceral disease.  The ordinary exciting 
HERPETIC AND  BULLOUS ERUPTIONS.          233
causes of the affection are,  irregularities  in  diet, exposure to cold
while the body is heated, coldness and dampness of the  atmosphere,
a cold east or north-east  wind,  contact  of local irritants, fatigue,
moral emotions of a depressing kind, &c.
  Herpes labialis  not unfrequently results from the influence of cold,
as in the transition from a warm atmosphere to a cold sharp wind.   It
is also associated with gastro-pulmonary  irritation,  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 favorable to its  appearance  are  the spring and
autumn.  Sometimes the affection would appear to' be hereditary, and
in certain seasons it has attacked so many persons  as to have  the
character of an epidemic.   In rare instances it has been observed as
a critical eruption.   I regard cold as its special cause.
  Herpes circinatus is sometimes seen to attack  several  members 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.
  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 may be concomitant, and of which it is frequently symp-
tomatic; in old persons, however, it is more  serious, from a disposition
to gangrene of the inflamed skin, and especially to neuralgia.
  Treatment.—The treatment of herpes should be mildly antiphlo-
gistic, and should  consist of gentle laxatives, diaphoretics, and diluents,
unless some visceral  disorder be suspected,  and call for especial atten-
tion.  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 should be  dusted with starch powder.
  The severe  pains which  often accompany herpes zoster, sometimes
preceding and  sometimes following it, and evidently neuralgic, should
he treated with colchicum and iodide of potassium, followed by qui-
nine; and the  local suffering at the same time combated by sedatives.
In three cases  of this kind  I found tincture of opium with tincture of
aconite, rubbed into the painful part, procure relief; but in other cases
the  remedy has failed.  Nothing can  be conceived more dreadful than
the  pangs accompanying herpes sometimes become: a gentleman whom
I once asked to give  me an idea in words of the nature of his suffer-
ing, replied: "You must fancy the marrow taken out  of the bones of
my  arm, and a rough towel threaded through them;  you must then
imagine two devils at work with all their strength at  each end of  the
towel, sawing it backwards  and forwards; that is what it is like."  In 
234      DISEASES ARISING  FROM GENERAL CAUSES.

the region of the scapula, around the thorax and around the abdomen,
the pain is  sometimes dreadfully severe.  Dr. Ranking,  in  his "Ab-
stract," records the opinions of two gentlemen,  Dr. Palmer and Mr.
Humpage, on  the local treatment of this painful affection; the former
recommends the application of the tincture of arnica, and the internal
use of the oxide of silver; the  latter proposes a blister followed by a
belladonna  plaster.  Dr. Ranking  himself suggests the endermic use
of morphine or electro-magnetism.
   Herpes labialis is too slight to require remedial treatment; if, how-
ever, the heat, tension, and itching, are productive of much uneasiness,
they  may be relieved by a weak lotion of acetate of lead, or sulphate
of zinc; by an ointment containing  a drachm of the liquor plumbi
diacetatis to an ounce of elder-flower ointment; or by the benzoated
ointment of oxide of zinc.
   The course of the vesicles,  at  an  early  stage, may frequently be
arrested by the  above  lotions;  when,  however, the vesicles have
formed, they may still be checked by puncturing them with a needle,
and inserting  into the puncture, for an instant, a fine  point of nitrate
of silver.
   The other local forms of herpes, including herpes praeputialis, 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 ruptured, and  troublesome
ulcerations  or gangrenous sores ensue.
   When the vesicles are succeeded by excoriations or ulcerations, the
ointments recommended for herpes labialis, spread upon lint, will be
found useful.   If the excoriations exhibit a  teudency  to grangrene, 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 accom-
panied with 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 smarting and itching attendant upon this disorder,
while engaged in Beechey's expedition, had recourse  to a moist cloth,
which he found of great service  in quieting those symptoms when
tliev had become  unbearable  from the  warmth of bed.  Lotions of
sulphate of zinc, of super-sulphate of alumina, and borate of soda, are
recommended by Bateman for the same purpose.
   The ectrotic treatment by caustic is applicable to herpes  zoster, as
well  as to  herpes  labialis, and  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 the cure brought more speedily about than  by leaving the erup-
tion to its course.
   If any tardiness be apparent in the development of  the eruption,
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 appear, or  immediately ad- 
             HERPETIC AND BULLOUS  ERUPTIONS.          235

joining those which are already produced.  This has not only the effect
of checking the extension of the disease, "but of producing a shrivel-
ling of the vesicles already formed, and cutting short its progress alto-
gether; avoiding at once its tediousness and all the pain attending it."
Care must be taken  not to apply the blister over the vesicles, lest  it
occasion  sloughing  of the  derma.  Moreover, Mr. Plumbe  has re-
marked, that blisters do not rise upon  the inflamed patch of herpes.
   Herpes circinatus and iris require no  especial remedies; they should
be treated upon the  general principles above  indicated, and Vy tonic
medicines and regimen.  When the circinate variety becomes chronic,
Gibert recommends an ointment composed of one drachm of sulphuret
of lime, fifteen grains of camphor, in powder, and one ounce of lard.
If this ointment should fail, a blister will  often succeed  in putting a
stop to the eruption.

                          PEMPHIGUS.

Syn.   Pompholyx. Pemphix.  Figure bulleuse, Fran.  Blasenausschlag;
              Wassenblasen, Germ.  Pemphix.  Alibert.
   Pemphigus1 (Plate YIII.) is an eruption of bullae of considerable
size, appearing upon circular or  oval erythematous patches corres-
ponding in diameter with, or  a very little larger than, the bases of
the bullae.   The bullae arise in the course of a few hours;  they vary
in bulk from that of a split  pea  to that  of one valve of a walnut-
shell, and occasionally they increase to the size of  a fowl's egg.  On
their first appearance they contain a transparent,  limpid, or yellowish
serum, which, in a short space of time, becomes pinkish, sanguineous,
or turbid, and is eventually discharged by the rupture of the bulla,
or desiccates into a thin, dark-colored crust.   When the bulla bursts,
which it  generally does in one or two days, an  excoriation corres-
ponding with its  base remains behind.  The disease  occurs usually
in successive crops;  in rare instances, only, simultaneously upon all
parts of the body.   It may be partial or general, and may be  pro-
longed in duration from a few days to several months, and even years.
   The numerous  varietiess  of  pemphigus indicated by different
authors may all be embraced  under the three heads of acute, chronic,
and  gangrenous. ' The first includes the  pemphigus vulgaris, pom-
pholyx benignus,  and pompholyx solitarius of Willan;  the second
corresponds with the pompholyx diutinus  of that author; whihs the
third is the pemphigus infantilis  of Willan, the pemphigus gangre-
nosus of  Stokes.   The pemphigus contagiosus of Willan  appears to
be based upon insufficient data.

                       PEMPHIGUS ACUTUS.
     Syn.  Pompholyx.  Pemphigus vulgaris ; confluens; confertus.
   Pemphigus acutus3 (Plate YIII.) is a rare form of cutaneous disease,

  2 Pemphigus  congenitus ; p. infantilis; p. simultaneus ;  p. successivus; p. soli-
tarius ; p. confluens ;  p. acutus ; p.  chronicus ; p. pyreticus ; p. apyreticus.
  1 Der. 7ri/i«pi£, a bubble ; wo^Kpo'xi^, a water-bubble.
  1 Portraits of Diseases of the Skin, Plate VII., AG. 
236      DISEASES ARISING  FROM  GENERAL CAUSES.

attacking children and young persons chiefly, attended with a trifling
or moderate degree of constitutional disturbance, and lasting for  a
longer or shorter period.1  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 complication of  the constitutional symptoms.
  The milder series of the above  detailed symptoms belong to the
pompholyx benignus of Willan;  the same  mild constitutional affection,
with sickness and languor, accompanies his pompholyx solitarius.
  The local  symptoms consist in the appearance, on the  second or
third day, or at a later period from the commencement of the  consti-
tutional disorder, of small red  spots, accompanied by itching and  a
dry burning sensation.  The spots speedily increase in size, and  con-
stitute circular erythematous patches, which vary in  their  degree of
redness from a pale to a vivid tint.   In the course of a few hours  a
vesicle rises in the middle of each patch, becomes rapidly  distended
with a limpid  serum, and increases to the size of a hazel-nut, or large
walnut.  The bulla is of a circular or oval form, and frequently some-
what flattened at its summit.  It usually corresponds in diameter  with
the breadth of the erythematous  patch, which  it then completely
conceals; at other 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 surface, 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 color.  When the rupture
of the bullae  does not take place,  the limpid and transparent  fluid
which they contain assumes a yellowish and amber tint; it then be-
comes turbid and opaque,  diminishes in quantity by  absorption and
evaporation, and at the end of about a week, dries up, forming a thin
dark-colored  scab.  Occasionally the contents  of the bullae  become
pink^ph 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 bullae is dependent in great measure upon situation,
and  upon the greater thickness or thinness  of the epidermis.  The
bullae present some variety in point of distribution ;  they are some-
times isolated ; sometimes aggregated into clusters or confluent; and
sometimes are disposed in  circles around  the circumference of a given

  1 Rayer  relates a remarkable and interesting case of this affection, which was ad-
mitted into hospital on the 21st of August, and discharged cured  on the 3d of Sep-
tember. 
HERPETIC  AND  BULLOUS ERUPTIONS.  •       237
patch of eryth6ma.  The duration of the disease is regulated by the
manner of its irruption;  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 prolonged in a
similar  ratio, and may extend to three weeks or a month.   In the
progress  of  the cutaneous  eruption vesicles  are not  unfrequently
observed upon the mucous membrane of the mouth.
  The fluid  of pemphigus  has been  made the subject of chemical
analysis  by  Scherer.1  It had a  yellowish tint, an acid reaction, a
specific gravity of 1018, and  deposited a sediment composed of corpus-
cles, which Scherer states to  have resembled mucus or pus-corpuscles,
but which were probably newly-formed epidermal cells.   On evapora-
tion it gave forth an odor 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 constituents    ........60.0

           Fat containing  cholesterin......2.6
           Albumen, with earthy phosphates    ....   48.0
           Alcohol extract, with lactate of soda, and chlorides of
            sodium 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 contained, the fluid contents, exa-
mined by Girardin, gave the following 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
  The urine analyzed by Heller, in a case of severe pemphigus, which
proved fatal, the patient being a woman forty years of age, was acid,
and its specific gravity  1017.5. It deposited a light cloudy sediment
of mucus with fat-globules, urate of ammonia, and epithelium  scales.
His analysis is as follows:—
      Water,..........955.80
      Solid constituents,........44.20

           Urea,     .........24.6:;'
          Uric acid,  ......•••    0.58
          Extractive matters,  .        .....11.79
          Fixed salts,     .    .    .   .    t   .    .    •    7.20
  " Of the fixed salts the earthy phosphates were normal, the sulphates
much increased, and the chloride of sodium proportionally diminished.
The urea is considerably above the normal average."2
1 Dr. Day, in Simon's Animal Chemistry.
Ibid. 
238       DISEASES ARISING FROM GENERAL  CAUSES.

  In the case of a little boy, affected  with acute  pemphigus, my
brother, Dr. Marris Wilson, found the quantity of urine passed in the
twenty-four  hours much  below  the average, namely, about twelve
ounces; its  specific  gravity high, namely,  1033;  and its reaction
powerfully acid.   It was of a light color, deposited on standing a light
flocculent cloud containing minute crystals of oxalate of lime, and was
loaded with urea.   In a thousand parts the quantity of solid constitu-
ents was 76.89.1
  In the  exceedingly rare variety of pemphigus named by  Willan
pompholyx solitarius, the bulla attains the size of an orange, enlarging
very rapidly, and containing several ounces of serous fluid.   It is pre-
ceded 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 as the
preceding.  In this way five or six bullae may follow each other suc-
cessively, 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 affect women.  I have
seen three cases of it: in one, the left arm was affected; in the other
two the breasts.  The excoriations occasioned pain and irritation, with
partial  hardness in the substance of the breasts."  Biett met with a
chronic variety of this disease.

                      PEMPHIGUS CHRONICUS.

                    Pompholyx diutinus, Willan.
  The chronic form of pemphigus is identical with the pompholyx
diutinus of Willan.   It is  of more frequent occurrence than the acute
variety, is tedious and painful in its course, always successive in  its
appearance, and takes  place in  persons of debilitated  constitution of
both sexes,  and in aged  individuals.   In its eruption it is either
general or partial, and occasionally it makes its attacks at a particular
season,  for several consecutive  years, appearing, for instance, in the
autumn or winter, and declining  in  the spring.  Sometimes  it lasts
continuously for years.2
  The  constitutional  symptoms are slight as compared with  pem-
phigus acutus.  There is usually some degree of sickness of stomach,
headache, and lassitude, which precede  for several days the  appear-
ance of the eruption.   And if the latter be severe, the  constitutional
symptoms are considerably  augmented.  The cutaneous  disease is
sometimes associated with aphthae, with considerable gastro-intestinal
irritation, with dysuria and  haematuria, and  in  old persons it not
unfrequently  terminates  fatally in consequence of its  complication
with pulmonary disease, or with effusion into the serous  cavities.

  1 For the details of this case see Portraits of Diseases of the  Skin ; pemphigus
acutus, Plate VII., A G.
  2 Dr. Duchesne-Duparc relates that he saw, in St. Louis, a girl", eighteen years of
age, of weakly  constitution, who had never menstruated, and who had been affected
with chronic pemphigus since the age of five years. 
HERPETIC AND BULLOUS ERUPTIONS.          239
  The local symptoms are ushered in with pricking and smarting of
the skin, and by the eruption of a  number of small  reddish spots,
upon which bullae speedily appear.   The bullae increase in the course
of a few hours to the size of a pea  or walnut, and sometimes attain
the magnitude of a .fowl's  egg.  At the end of three or four days
some of the bullae 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-colored scab,  covered with  the
shrivelled epidermis.  As one crop disappears another is produced, so
that the disease maybe 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 face.
   Chronic  pemphigus is sometimes complicated with prurigo, particu-
larly in old persons; this complication excites  the  most distressing
irritation, and frequently causes a fatal termination.

                    PEMPHIGUS  GANGR^NOSUS.

        Syn. Pemphigus infantilis, Willan.  Rupia escharotica.
   This disease  consists in the formation of bullae upon somewhat
prominent  and purpfish 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 sanguinolent serous fluid,  which
becomes turbid  and dark-colored, or almost black.  At this period,
the bullae are surrounded by a purplish areola, formed by  the circum-
ference of  the livid  spot  upon  which  they are  developed.  At  a
variable period  after their distension 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  fetid  pus, their
borders are thin and inflamed, 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
irritation.   This disease occurs chiefly on the lower extremities, on
the trunk of the body, more particularly its anterior surface, on  the
neck, and on the scrotum or labia pudendi.   It  is accompanied with
fever, sleeplessness, restlessness, and  general disturbance of the nutri-
tive functions.
   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 pem-
phigus gangraenosus.   It is known  in different counties  in  Ireland
under  the  names of white blisters, eating hive, and burnt holes.   Some-
times the eruption is preceded by a livid suffusion of the  skin; more
frequently, jn a state of  perfect health, one or more vesicles somewhat
larger than a smallpox pustule appear, increase for two or three days,
burst, and  discharge a thin fluid having a disagreeable smell, limpid 
240      DISEASES ARISING  FROM GENERAL CAUSES.

in most cases, sometimes whitish and sometimes yellowish.  The sore
left by the breaking of the vesicles is painful,discharges a thin, fetid,
ichorous fluid, ulcerates and spreads quickly, the edges of the ulcer
being livid.   The unfavorable signs of the disease are the rapidity of
extension of the sores, their abundant and highly fetid 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
connection 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  disease
seems  principally the effect of irritation.   When the vesicles burst,
the child begins to  grow peevish  and fretful, pale, loses its appetite,
and  the flesh becomes  remarkably flabby.  The periods of the dis-
order are not very regular; but  it often  happens  about the eighth
day that the pulse sinks, the lividity spreads over the whole sore, the
fetor and discharge  increase greatly."   " Death takes place about the
tenth or twelfth day, often preceded by convulsions, sometimes by
extreme lividity."

  Pemphigus contagiosus.—Willan founds a contagious variety of
pemphigus upon the description of an endemic  disease, accompanied
with bulla?, 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 far from being
satisfactorily established.

  Diagnosis.—Acute pemphigus, with its  bulla? 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 extensively inflamed, the tumefied and  painful surfaces pre-
sented by erysipelas.  The duration of  the disease, with the  exceed-
ing mildness of the  constitutional symptoms, are the principal charac-
teristics of the chronic form of pemphigus.
  Causes.—Acute  pemphigus attacks  children and young  persons
chiefly; occasionally it appears as a congenital affection, and is some-
times of hereditary  origin.   The season during  which it is most pre-
valent is the summer.  Its  occasional causes are teething, gastric and
intestinal irritation, excess in diet, deficient innervation, irritability
of system,  mental  affections, amenorrhcea and  dysmenorrhcea.  It
sometimes results  from  the  constitutional irritation  caused by the
introduction  of the vaccine virus into system.   It has also  been
observed as a complication of intermittent fever,  and several instances
are recorded of  its  occurrence as an epidemic  effection.'  A variety
named pemphigus indicus is described by Sauvages as a symptom of
dysentery. 
HERPETIC AND  BULL0U3 ERUPTIONS.
241
  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 those of a depressing
kind, such as fatigue, anxiety, intemperate habits, bad food, chronic
irritation  of the  gastro-pulmonary or genito-urinary mucous mem-
brane, amenorrhcea,  residence in damp and unhealthy  situations,
exposure  to cold, and starvation.   I once saw the disease as a sequela
of scarlatina.  In those most liable to this affection there is an habitual
dryness of skin and deficiency of cutaneous secretion.  Biett remarks
that he has frequently found a fatty liver in persons who have died of
chronic pemphigus.
  Dr.  Whitley Stokes  remarks that the causes of pemphigus gan-
graenosus  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 par-
ticularly subject to it than others.  The disease is more prevalent in
summer than in winter,  and appears to  be infectious, though  ob-
scurely so.
  Two cases that have recently come under my notice led me to believe
that pemphigus may sometimes result from the inoculation of the sys-
tem by some poisonous principle.   One of these cases was  that of  a
surgeon who, eighteen months  previously, punctured his  right hand
with a lancet which had just been used for opening a thecal abscess.
The arm became swollen as high as  the axilla, and was three weeks
before it got well.  Between three and four weeks after  the cure of
the arm a crop of pemphigus made  its appearance on his left thigh
and leg, and has continued to show itself from time to time up to the
present period.  The development of the bullae is always preceded by a
febrile attack; there is a scalding sensation in the skin, and the next
morning a crop of full-grown bulla? are seen.
  The second case was that of a girl, aged twenty-two, who " poisoned"
her right  hand seven years ago, in cleaning brass with a red paste.
Three or four days after the injury a number of ecchymosed spots and
bladders made their  appearance on her wrist and forearm, and have
continued  to trouble  her until the present time.
  Prognosis.—Pemphigus is dangerous in proportion to its compli-
cations, and to the constitutional disturbance of the system.   The acute
variety is of little importance, but the chronic affection is always obsti-
nate, and sometimes  fatal, particularly in old persons.  The disease
would appear to exert sometimes a beneficial effect upon the system;
thus Rayer narrates that he " once saw a man who, after having had
several attacks of haemoptysis, became subject to chronic  pemphigus
of the legs, and from this period the bleeding from the lungs did not
recur.  The cure of pemphigus has, in some  cases, been observed to
be followed by various ill consequences."
  Treatment.—When the febrile symptoms are acute, they must be
met with purgatives, salines, and antiphlogistic regimen.  The natural
tendency of the disease is, however, towards debility, and it will gene-
rally be found needful to have early recourse to tonics.  '
       16 
242      DISEASES  ARISING FROM GENERAL CAUSES.

  In the chronic forms of the disease tonics must be employed at once,
the best of them being acids and bark, the latter either in the form of
infusion or quinine.  A valuable remedy in pemphigus is the hydrio-
date of potass.   In those cases in which the symptoms present obvi-
ous indications of diseased action in any of the organs or viscera, such
disorder should be made the  especial 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, counter-irritants 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 admi-
nistered.  Restlessness and  pain will be quieted by opiates.  In an
obstinate  case of pemphigus, Rayer had recourse to arseniate of soda
in small doses; in similar cases I have found Fowler's solution a use-
ful remedy.
   The inflamed skin should then be thickly anointed with  the ben-
zoated zinc ointment;  sometimes the old Turner's cerate or calamine
ointment  forms a convenient change, and sometimes the unguentum
eetacei with liquor plumbi; the unguentum plumbi compositum,  the
unguentum creta? compositum, the unguentum mellis, the unguentum
eetacei with Peruvian balsam  (3j ad 3j),  the diluted juniper tar oint-
ment, or an ointment of the nitrate of silver (gr. ij—vj ad  Ij) may
be preferred.   When  moisture  exudes from the bullae, or  from  the
excoriated skin, the  surface may be dusted with the oxide of zinc or
starch powder;  and if the  excoriations  be very irritable and tender,
a weak solution of the nitrate of  silver  in distilled water (gr. j—iij
ad 3j)  will diminish the  morbid  sensitiveness.  Fomentations  are
rarely of  any advantage, and where the surface affected is large there
would be difficulty in applying them.
   In the  epidemic pemphigus gangraenosus; Dr. Stokes recommends
an ointment of scrophularia nodosa, containing as much green vege-
table matter  as  possrble.   He remarks that  this is a traditional
remedy, but he found it more  successful than any other plan of treat-
ment.  The ointment  should  be  warmed  until it  possesses  the
consistence of honey, and th^n laid on with a brush, and dressed with
the same spread upon  lint.   The utmost gentleness should be used,
and the dressing renewed every six hours.   Where there is swelling
of the surrounding  parts,  or  when  any  powder has been previously
used, he applies, in the first instance, a poultice of porter and oatmeal,
or a carrot poultice in a state  of fermentation.
   The  diet in  pemphigus, as  soon as  the  febrile  symptoms have
subsided, should be  nutritive  and generous. 
FURUNCULAR ERUPTIONS.
243
                      CHAPTER  X.

         DISEASES ARISING FROM GENERAL CAUSES.

                    FURUNCULAR ERUPTIONS.

  Under the  head of furuncular eruptions, I  propose to  consider
that  common  and well-known  affliction of  the skin, the boil, or
furunculus, and that greater boil, the carbuncle, or anthrax, with
whatever modifications they may chance to present.   The general
character of the furuncular eruption is  an  inflammation, extending
deeply into the skin, forming more or less prominence on the surface,
and resulting  in the loss  of vitality of a portion of the substance of
the derma.   The portion of the substance of the skin so destroyed is
the heart of the  boil,  the core (cceur), and the suppuration  which
follows  has for its object  the separation and expulsion of the core.
The  degree of prominence of the boil  would seem  to depend on  the
depth of the portion of the skin attacked; when the latter is  super-
ficial, involving parts which are looser  in  texture, and susceptible
of distension, the  prominence is greatest, but when the inflammation
sinks deeply, the  prominence  is less, although the mischief may be
considerably greater,  and the case in every way more  serious, being
attended both with a greater amount of pain, and being much slower
in its progress.   This, and  the extent of the  skin  attacked, are the
prime distinctions between the furunculus and the  carbuncle; in
furunculus  there  is but one core, and  the core  is less deep; in car-
buncle there is more than one core, and these cores  extend deeply
into  the derma.  Thus mere size is only a secondary feature in the
diagnosis between furuncle and carbuncle; a large boil  may be larger
than a small carbuncle; although the carbuncle, being  an aggregated
boil, is  generally much more extensive  than  the furunculus, some-
times reaching to  a diameter of six or more inches.
  The cutaneous  diseases which  have  formed the subjects of the
previous chapters, have all been superficial  in  comparison with  the
furuncular  eruption, and  have  resulted, as we have  seen, in  mere
exfoliation  of the  cuticle, in effusion  of lymph, and  formation of pus,
with no injury to  the vitality of the skin: but now we have before us
a disease  in which  the  mortification of the  part attacked  is the
principal and leading character;  there is a concentration of inflamma-
tion ;  that inflammation is of a destructive kind, and the death of the
part affected is the immediate consequence.  In a pathological point
of view, I  am of  opinion  that  the  purpose of the inflammation is
elimination; that  the-blood hurried on by the inflammatory impetus
centres in a follicle, or several  adjacent  follicles, the representatives
of the glandular  function of the skin; that partly  from the violence 
 244      DISEASES  ARISING FROM GENERAL  CAUSES.

 of the inflammatory impetus, and partly from the dense nature of the
 structure of that portion  of the skin surrounding the follicle, the
 blood is arrested in its current, it becomes stagnant, and the part
 which it has ceased to supply dies, while the stagnant elements of the
 blood are by a reparative process converted into  pus, and constitute
 the subsequent suppuration.
   The characters of distinction between furunculus and anthrax relate
 to their  prominence, depth, breadth, color, number of cores, and degree
 of pain.   Furunculus is more prominent than anthrax, but the latter
 extends most deeply  into the skin, and involves a greater breadth of
 the structure of the derma.  The color of furunculus is a deep red,
 becoming, as the disease advances, more or less dull and bluish; that
 of anthrax presents the same  tints  in a heightened degree, the deep
 red is still deeper and darker, often approaching a mahogany hue, and
 the bluish tint of furunculus becomes a deep purple and livid tint in
 anthrax.  The core, which is single in furunculus, may be multiplied
 to twenty or thirty in anthrax, until  the  numerous openings formed
 on its surface for the exit of the cores give it the appearance of a sieve
 or cullender.  Lastly, the pain, severe in  furunculus, is more intense
 and more burning in  anthrax.
   Furunculus and anthrax, together with hordeolum, or sty, which
 is a small boil occurring upon the edge of the eyelids, in connection
 with one of the Meibomian glands, are grouped by Willan under the
 genus phyma ; the latter term $i>p.a derived from <pv«, produco, signi-
 fying' a tuber, tubercle, or small swelling;  and applied by Hippocrates
 and the  older writers to a suppurating tumor; hence the designations
 phyma furunculus, phyma  hordeolum, and phyma anthrax.  Phyma
 is the first genus of the Order Tubercula of Willan; Plenck makes it
 the first genus  of his Class Bullae, under the popular term "Eiter-
 blsLsen,"  pus-bladder; while he. places  Terminthus, with  the popular
 signification " Erbsenblattern," pea-bladders, among Pustulae.   The
 term furunculus is derived- from furere, to rage, and is expressive  of
 the severity of the pain which often accompanies this eruption; while
 the term anthrax, av6e,a%,  carbo,  in  quo  wed,  id est,  floret ignis; a
 burning coal; indicates a greater degree  of severity, and an intense
 burning pain.  To a boil which is more painful at night than during
 the day, the term epinyctis (trfn-rxrij, otiwxtCc, lysn-eo, quoniam noctu
 oritur) has been applied.  Anthrax presents  two varieties, not recog-
 nized at  the present day, namely, prima and terminthus.  Pruna, from
'its resemblance to a small plum, a term applied by Avicenna, is a car-
 buncle  surmounted by a black eschar; while  terminthus, or tere-
 binthus,  is a variety of carbuncle  of which the core or slough has been
 likened in shape and color  to the  ripe cone of the pinus abies, or tur-
 pentine tree.
   The diseases  included in the  present chapter, as constituting the
 family of furuncular phymata, are, therefore, three in number, namely,
 furunculus, hordeolum, and anthrax. 
FURUNCULAR ERUPTIONS.               245
                          FURUNCULUS.

                 Syn.  Phyma furunculus.   Boil.
  Furunculus, or boil, is a small tumor, more or less prominent and
conical, of a vivid or deep red color, hard to the touch, excessively
tender and painful, slow in reaching maturity, suppurating imperfectly,
and containing a central core or slough of mortified cutaneous tissue.
After the ejection and separation of a grayish and pulpy slough, the
sore heals slowly, the affected skin remains for some  time congested
and discolored, and a permanent cicatrix is left behind.
  Boils may occur on any and all parts of the body; they rarely
appear as a general eruption, but are successive in their invasion ; and
are usually more  abundant upon some one region of the body than
upon the rest, although  by no  means confined to  a  single  region.
Their common  locality is the back of the neck, the shoulders, the
armpits, the wrists and hands, the buttock,  the  perineum,  the labia
pudendi, the thighs, and the legs; and they are more commonly met
with in the thick skin of the back  of the trunk and  outer side of the
limbs than upon the front of the trunk and inside of the limbs.  This
remark does not, however, apply to the eruption when it attacks the
armpits, the labia pudendi, the meatus auris, and the inside of the but-
tock, all common localities.  Among other situations, I have seen boils
on  the eyelids,  on the nose and ears, on the integument around the
mouth, on the cheeks, and on the scalp.
  The boil begins as a small red point in the  skin, frequently painful
from its origin, and tender to the touch; passing  the finger over it, it
is felt to be harder, and deeper than a common papule, and the tissue
around it is evidently condensed ; it is gradually and slowly expanding
itself in the skin, and threatening the mischief  which never fails  to
follow.  Slow and certain in its progress, the integument is gradually
raised into a prominence of a more or less conical figure, the  surface
is at first red, then vividly red, then  purplish red, sometimes a deep
dull red, and sometimes purple, and even livid. After some days (four
to six) a point is seen in the centre of the cone, showing that pus has
commenced to form, or a blister is raised, the  skin gives way, the pus
escapes, the core  or  slough  is brought  into  view, and, after a time,
several (four to six), often many days, the slough is sufficiently loosened
by the formation of pus between  it  and the SQund tissue, to be thrown
off;  granulations  are  then formed  on the surface of the cavity, the
cavity contracts, the granulations shoot up and reach the surface, and
cicatrization takes place;  the process of reparation  being extremely
active (two to four days) when compared with that of  the separation
of the slough.
  The process  now described is attended with  pain, intense pain,
crede experto;  the  tumor is excessively tender, "as sore as a bile,"
and the pain is  curiously increased at night,  reminding us of one  of
the synonyms of the  disease, namely, epinyctis.   The  great pain  at
night very probably results from the inactivity of  the  muscular
system and the  relaxation of the mind from its daily office, aided, no 
246      DISEASES ARISING  FROM GENERAL CAUSES.

doubt, by the horizontal position of the body, the warmth of bed, the
stillness of the time, and the necessity for a state of calm and insensi-
bility.  The pain  attendant  on a  single boil  is prolonged  for two,
three, and sometimes four days; and when the eruption is successive,
the pain of one  is  only  obliterated by  that of  another, until the
patient is  worn out with suffering.  Some persons  are so  happily
constituted as to their nervous system, that they suffer but little, while
others endure the most dreadful agony.   Certain differences naturally
result from the seat of a boil; a small boil in the meatus of the ear
pressing upon tissues incapable of resistance from their inclosure by
bone  and confinement by  strong ligamentous bands, almost  crushing
the numerous and  sensitive  nerves of that region, nerves which are
in intimate communication  with  all the most important   nervous
trunks  of  the body, is  painful  to  agony, to  frenzy; while, by the
same  patient, a large boil  in another situation, where  from the nature
of the tissues every facility of expansion  exists, would  be  regarded
as a mere inconvenience.   A boil is painful in relation to the density
or confinement of the  tissues in  which it occurs, in  relation to the
neighborhood of sensitive nerves.   A  boil  in a  part  of the  skin
supplied by  the trifacial  nerve, and involving a filament of that
nerve, is intensely  painful; so  is a  boil in the  skin of the nose, tied
down to the cartilages  by an unyielding fibrous tissue; or in the lip,
where every beat of the coronary artery vibrates through the system:
in the perineum, where the skiu is also fixed by strong fibrous tissue;
in the labium pudendi, where the part is apt to swell to almost bursting:
in the armpit, where many filaments of nerves are distributed, or on
the fingers, where the nerves are also abundant and sensitive.
   In  an attack of boils, it is not all that run the course described in  a
preceding  paragraph; some stop at different periods of their progress;
some  do not survive the  stage of pimples; others  acquire a certain
size,  but meither suppurate nor slough; these  are the so-called  blind
boils:  they gradually and  slowly subside; their contents, if  any, are
absorbed; they entitle themselves  to the distinction of indolent boils;
while a certain number only reach  perfection.   It sometimes happens
that  the  local   inflammation  is not confined  to the boil  itself;  it
spreads  to the surrounding tissue; the whole  region is  swollen and
painful, and occasionally  develops subcutaneous abscesses;  and some-
times the absorbent  vessels  become  inflamed, and the  inflamma-
tion is propagated  to the lymphatic glands, producing swelling, and
sometimes suppuration of those organs.  Enlarged lymphatic glands
in the groin from boils on the buttock or  pudendum are not uncom-
mon, and  enlarged  axillary  glands, from boils on the hand  or wrist.
or in the armpit itself, are comparatively frequent.
   Furunculus is commonly accompanied with constitutional symptoms
of a  very slight description; but sometimes,  when  the  pain is very
intense and prolonged, the feverish symptoms run sufficiently high  to
call   for antiphlogistic treatment.   The  pulse may  be quickened,
there may be  pain and  tightness  of the head, thirst, dryness of the
tongue, languor, and restlessness, and the secretion may be  deficient
in quantity or arrested;  added to which, when the pain  is excessive, 
                   FURUNCULAR ERUPTIONS.                247

or when the boil is  developed in the meatus  auris, there may be
delirium.
                           HORDEOLUM.

     Syn. Phyma hordeolum.   Sligh; stithe; stihan ;l stian ; sty.
  Hordeolum, or sty, is a small boil occurring upon the edge of the
eyelid, and  involving  a Meibomian  gland.  In  its progress  it  is
indolent, coming slowly to maturity, and presenting at  its  summit a
single  purulent point, and  sometimes two or three.  It is attended
with much pain, causes swelling, and  sometimes oedema of the  eye-
lids, and  diminishes  but slowly in size  as  it subsides,  sometimes
leaving behind it a chronic  redness, which may  last for  several
months.   Commonly, hordeolum is single; sometimes  two are met
with on the same lid ; sometimes one or more exist on both lids; and
sometimes both eyes are affected at the same time.

                            ANTHRAX.

         Syn.  Phyma anthrax.   CarbuncU.  Ignis  Persicus.
  Anthrax-,  or  carbuncle,  is a hard, circumscribed, flattened tumor,
very little raised above the level  of the skin, but  extending deeply
(an inch or more) into  the cutaneous tissue.  It is red in color, the
redness being  more or  less vivid or dark  at first, often  presenting a
mahogany tint; then becoming more or less  purple, then livid ; and
after the separation of the sloughs and  the healing of the skin, leaving
behind it a  chronic redness and deep brown stain, which lasts for a
considerable time.  The pain of carbuncle is very  severe, and of the
throbbing and  burning kind ; the latter  character having gained for
it its twofold appellation of carbuncle and anthrax ; carbuncle signi-
fying a little coal, and anthrax that same  coal efflorescent, with fire.
When it has attained its full size, and the surface  is purple or livid,
the cuticle becomes raised into one or more blisters, numerous suppu-
rating points appear in the skin, and these  suppurating  poiuts are
succeeded by perforations, through which the  core issues from the
stratum beneath in the form of sloughs, the sloughs being the fibrous
tissue of the derma, converted into a grayish  and whitish pulp, more
or less soft and viscous, and mingled with  an  ichorous, purulent, and
sanious discharge.  Perforated  all over its surface in  this way, the
face of the carbuncle  has  the appearance of  a cullender or  sieve.
Sometimes, instead of numerous perforations,  a portion of the skin of
considerable size loses its vitality, and becomes converted into a black
eschar, and the slough which follows is homogeneous and  extensive.
This is the pruna, or eschar carbuncle.  At other  times, and also as
a consequence of the loss  of  vitality of  a considerable  portion  of
the centre of the  carbuncle, the  brownish or reddish-brown  slough,
isolated by suppuration from the surrounding living parts, broader at
its base than its summit, and foliated on the sides by successive exten-

  1 Stihan, a Saxon word signifying arising, springing up, or ascent.  "To sty," as
used by Spenser, means " to  soar, to ascend," as in the following couplet:—
                   " To climb aloft and others  to excel,
                     That was ambition and desire to sty." 
248      DISEASES ARISING FROM GENERAL  CAUSES.

sion of the sphacelus, has somewhat of the appearance of the ripened
cone or fruit of a fir-tree.  This idea  in the poetical mind of our fore-
fathers gave  origin to  the name terminthus applied to this variety of
carbuncle; terminthus being a mode  of writing terebinthus,  and
referring to the turpentine tree, the pinus abies.
   Carbuncle, unlike boil, is generally single, and attains a considerable
size;  sometimes, when  small, there may be several  dispersed on
various- parts of the body, as not unfrequently occurs in the furuncular
epidemic at present existing.1  Commonly, the carbuncle varies from
two to six or eight inches in diameter, and one inch to one and a half
in  depth;  it is hard and dense to the  touch, and  feels  as  though it
were imbedded in the skin.  It is usually met with on the back of the
neck, close to the occiput, or upon the back of the trunk.  I have
seen it frequently on the shoulder,  the side of the trunk, or the loins;
and less frequently on the limbs.
   A large carbuncle is at all times  a dangerous complaint, on account
of the great  pain which it occasions, the long continuance  of  that
pain, the exhausting  process requisite  to separate  the  slough,  and
the irritative fever with which it is attended;  added to all, is the fact
of its very existence being due to enfeebled powers  of  constitution;
but the danger of carbuncle is vastly increased by its occurrence on
the nape of the neck, in which situation it is apt to excite erysipelas
of a serious kind, and  often give rise to congestion of the  brain, an
event which  is usually fatal.
   Carbuncle  is accompanied  with  more  or less irritative  fever and
general disturbance of the nutritive,  vascular, and nervous systems.
It occasions loss of appetite and loss of sleep;  and when the pain  is
severe the patient is not  unfrequently delirious.

   Diagnosis.—The distinguishing characters  of the furuncular erup-
tions are, their hardness, redness, depth  in the substance of the skin,
pain, and, at  a later period, the deeper tint of color which  they acquire,
their perforation  at the summit, the escape of so small and insigni-
ficant a quantity of pus, and the subsequent appearance of the core or
slough.  Hordeolum, moreover, is known by its seat of development.
The special characters which distinguish  furunculus and anthrax, at
the first appearance of the latter, are the conical shape of furunculus,
and the flatness of surface and greater depth of base of carbuncle; at
a later period,  bulk, number of cores, tendency to suppurate imper-
fectly in furunculus and slough in carbuncle, are superadded as further
distinguishing  features.  The mutual relations and  resemblances of
the two diseases are further exhibited in the  name  which  has been
given to the smaller carbuncles, when only three or four cores exist,
namely, furunculus anthracoides.
  Cause.—In  referring  to the books of our fathers of a few years
back, we  might be led to infer that boils were a proof of exuberant
health, that they  were  indicative only of the most exalted powers of
constitution, and that the plague of boils was one of the most desirable

  This furuncular epidemic commenced in l$o2 or 1853, and in 1856  is still active. 
FURUNCULAR ERUPTIONS.
249
events that could happen to youth and manhood.  " The boil," says
Mason Good, " is found in persons of an entonic or phlogotic habit, with
a peculiar susceptibility  of  irritation;" therefore, he continues, this
tumor is " chiefly found in persons of high health and in the vigor of
youth."  At the present day, however, this is certainly not the fact,
for we  see  boils associated with  debility in every degree; we are,
therefore, driven to the conclusion, that either the human constitution
must have undergone a change since the time of our ancestors, or that
altered atmospheric  conditions have induced an  alteration  in  the
diseases of man.  Probably both of  these propositions are true; for,
with regard to the first, we know that the free use of the lancet which
was made by our predecessors could not be  tolerated  at the present
time; and  with regard  to the  latter, we are aware that diseases of
dyscrasia have increased  of late years, and go on increasing; and that
the general tendency of disease is to assume a low and debilitated form.
   During the last four years, namely, from  1852 to 1856, there has
existed amongst us$ and still continues to exist, an epidemic of boils;
they afflict persons of both sexes,  at all ages, and  at all seasons of the
year, but I have never seen them occur in any one possessing genuine
good health ; there is always mal-assimilation, often cachexia, and fre-
quently the boils are associated with other forms of cutaneous disease,
such as eczema or acne. In  this so-called furuncular epidemic the
boils are for the most part small, and they have  a frequent  tendency
to put on that form which is termed  furunculus anthracoides, many of
them  having the character of small carbuncles rather than  boils.
They are also  not unfrequently  associated  with the push, a small
cutaneous phlegmon  terminating  in abscess;  and sometimes large
collections of pus are formed in the neighborhood of the boils, as when
they occur in the axilla or in the labium pudendi.
   The anthrax  or carbuncle is a disease of the  latter half of life, and
of a debilitated  constitution, being always  associated with cachexia,
and frequently  with the gouty diathesis.  This has always  appeared
to me to be the active cause of that monster carbuncle which is apt
to form upon the back of the neck; and the cerebral congestion which
frequently follows in its train is a gouty congestion, allied to the gouty
apoplexy which was so common in the winter of 1855-56, as  almost
to appear in the light ©f an epidemic.   John  Hunter remarks that
carbuncle is a disease of a full habit and good living, and almost exclu-
sively confined  to the richer classes, and that he never saw but one
case in hospital.  This was, no doubt, true at the  time that he wrote ;
it may have been true also in reference  to the  selection of cases for
treatment in hospitals, but it is directly opposed  to my own experi-
ence;  I have repeatedly seen carbuncle in the parish-workhouse, and,
among the better class, in persons who were strictly abstemious and
moderate in their habits,  whose only excess was  in mental  pursuits,
which  indeed is a  great source of deterioration  and debility  of the
physical powers.
  Prognosis.—Furunculus, however abundant, is not dangerous, and
with  the restoration  of  the  general  powers  is sure  to  get well.
Anthrax is only dangerous when  it  occurs  in a debilitated and 
250      DISEASES ARISING FROM  GENERAL CAUSES.

exhausted constitution;  when itis developed on the occiput and back
of the neck;  and when any excess of gouty salts is allowed  to take
possession of the blood during the progress of the disease or its treat-
ment.
  Treatment.—" Bleed, purge,"  say  our  ancestors; "Don't  bleed,
don't purge," is the  voice of the present day.  Empty the bowels with
mild aperients, restore the secretions as they may appear to require,
but have the tonics close at hand for ready use as soon as these indi-
cations are fulfilled ; carefully avoid depressing the system farther than
it  is  already depressed.  I return to  the enunciation of my law of
treatment of cutaneous disease, to which  the  furuncular eruptions
form  no exception.   Eliminate, for elimination is necessary; restore
tone, for tone is wanting, and the prime cause of the defect of assimi-
lation ; alleviate the local distress as best you may.
   We all know the improvement of  power which results from the
action of a simple aperient, when the system is weighted down, is
under a cloud of its own morbid humors ; relieve this.  When there
has been feverishness, as is generally the case where much pain exists,
particularly in carbuncle, I have followed up aperients, or combined
with  them antiphlogistic  and effervescent  salines; I have secured
healthy secretions,  and  then I have attacked the disease with tonics;
with  the nitro-muriatic  acid and gentian, or calumba; with cinchona
and sulphuric acid  ; with quinine and sulphuric acid,;  with~the citrate
of iron and  quinine and citric acid, &c.  It is astonishing, in these
surgical cases, how little is left for the surgeons to do, if the physician
play  his part well.
   In anthrax the  gouty salts are rarely absent;  therefore we must
combine  with our  aperients, bitters  and alkalies, gentian, calumba,
quassia, chamomile, hop, taraxacum, with bicarbonate of potash (not
soda), liquor potassa?, iodide  of potash, nitrate of potash,  sulphate of
potash, tartrate of potash, lemon-juice, &c.; but we must bear in  mind,
at the same time, that all alkalies are lowering, and debilitating, and
can only be  used  for a time,  to be quickly followed by the mineral
acids and bitters.   Sedatives may be necessary both in  furunculus
and anthrax, and  can be used with safety after the bowels are tho-
roughly relieved  and the  secretions  regulated; and, with the same
 precaution, recourse may be had, if thought desirable,  to colchicum.
   So troublesome  and painful a disorder as furunculus has naturally
suggested a variety of empirical remedies, which have obtained, from
time to time, more or less credit, partly from the vehemence with which
their merits  have been extolled, and partly  from some intrinsic value
really existing in them.  In some instances the principle of action of
empirical remedies is obvious, and they are found to derive their repu-
tation from their accidental use at the right moment, while at any other
 moment they would be mischievous and often dangerous;  in others  it
 is hypothetical, probably producing some chemical alteration  in the
 composition of the blood, or affording an element necessary for assimi-    ,
 lation.  Of this latter class is yeast; yeast taken in doses of an ounce,
 three times a day,  is said to cure the furuncular diathesis.   I  have no
 experience of the remedy, and should have no objection to make trial 
FURUNCULAR ERUPTIONS.
251
of it, after I had prepared the system  by the proper eliminants, and
when the necessity for tonics was not a more pressing indication.  I
feel disinclined to speculate upon  the "modus operandi" of  yeast,
until the  fact  of its usefulness  is more fully established.   As  an
external  remedy, yeast, in certain  cases,  is  amongst  our best local
applications.
  The  diet in furunculus, hordeolum, and anthrax, should be  gener-
ous and nutritious, with a fair proportion of stimulus; sugar, potatoes,
and beer, should be avoided, but meat and wine taken in moderation,
and regulated according to  the previous habits of the patient.  Of
wines,  sherry, claret, dry champagne,  and the Rhenish wines, are the
best; port, or rather the composition  which goes by  that name, the
worst.
  And now as to local treatment, the  last and least.  Boils  and car-
buncles may be checked  in their  progress, and at least  prevented
reaching their full extent of size, by cold applications, by the  liquor
plumbi lotion, by the liquor plumbi  diacetatis  used pure, and pen-
cilled on the coming tumor, and by an opium plaster spread  on wash
leather;  other  remedies which I do not hold in the same repute, are
pencilling  with a solution  of nitrate of silver in  nitric  aether (ten
grains  to the ounce); compound tincture of iodine, &c.
   When  the boil  or carbuncle advances  in  spite of these means,
it should be  co,vered with .water-dressing, with  Alison's prepared
corium,  or  a linseed poultice; and when  it breaks, yeast  may be
added  to the linseed poultice.  The question often arises in the course
of the treatment of  boils, should they be punctured with the lancet?
and when?  Opinion is divided  upon this  question.   I  am against
interfering with them unless the pain be very severe, or the boils
threaten  to assume a large size;  then, undoubtedly, advantage may
be gained by free incision;  such an incision as will  arrest the inflam-
 matory action by depletion, and'relieve the tension, which is  the chief
cause of pain.  Again, if the indication point to incision, the sooner
 it be performed the  better;  after suppuration is established it is com-
paratively useless.
   Taking the  relief of tension and  consequent pain, and the local
abstraction of blood as the leading indications to determine the ques-
 tion of incision, we  need never be at a loss  to  decide  when it should
 be performed ;  and this question being set at rest, another arises as to
 how the  incision should be practised.  It should be free and deep, it
 should completely bisect the tumor, and  if the tumor be large,  the
 incision must be crucial;  a small  incision does not effect the objects
 we have in view, it  neither  relieves the tension, nor does it unload the
 vessels completely,  but, on the contrary, becomes an irritant,  and adds
 to the  evil which  we are attempting  to  remedy.   Incision  must be
 thorough or none, there can be no intermediate course; and neglect
of this aphorism has brought incision  into popular discredit.   I must
not, however, be supposed to recommend the  indiscriminate use of
 the lancet or knife;  all I wish to urge is, that  if it be right to do, it
should be done completely or not at all.
   In practising an incision  in the case of boils and carbuncles, there 
 252      DISEASES  ARISING FROM GENERAL CAUSES.

 may  be present to  our  mind  the possibility  of  an unseemly scar
 following the operation,  ami the pain which we are about to inflict
 on our patient.  The first of these considerations applies chiefly  to
 cases where the boil is in sight,  as  upon the face and neck, and may
 be met by regulating the extent and direction of the incision, which
 latter should always correspond with the  natural  folds of the skin.
 The other consideration, namely, that of the pain of the operation,
 may happily be controlled by chloroform, or by the congelation of the
 part with ice, according to the plan of Dr. James Arnott.
   Incision may, therefore,  be practised on boils for the purpose  of
 cutting short their progress, and  as an ectrotic method of treatment:
 or they may be treated according to the plan previously indicated, by
 cold applications at first,  and then  by fomentation and poultices; the
 multiple boil, or furunculus anthracoides, will more  frequently require
 incision than the simple furuncle; and in  anthrax the incision can
 hardly be dispensed  with.   If the carbuncle be treated for awhile by
 cooling applications,  fomentations,  and poultices, and  if, in  spite  of
•these remedies,  it continue to increase in size, to give much pain, and
 excite considerable  irritative fever,  it must be incised at once, and
 without delay;  for unless this be done, exhaustion will soon follow,
 with  delirium, and sloughing of the tumor to a greater or less extent.
   When  a carbuncle is  freely  incised, the surface of the  section  is
 seen to be studdedtall over  with the yellow and gray spots of the pus
 and sloughs; and the substance of  the hypertrophied  derma looks
 spongy and worm eaten;  sometimes  large sloughs are brought into
 view, and a free exit is established for the stagnated blood and pent-up
 collections of pus and dead fibrous tissue.   In debilitated and  worn
 out constitutions  the loss  of blood  which  follows  the section  of a
 carbuncle  may be supposed to increase the exhaustion of the patient,
 but that is really not the case unless the  hemorrhage be excessive.
 It is surprising how much blood may be lost without  inconvenience
 to the patient, the loss being completely  compensated  by the  relief
 from  pain and suffering which immediately succeeds the operation.
   Added  to the other advantages which result from the treatment  of
 carbuncle  by incision is the saving of the skin from destruction by
 sloughing, a matter of importance  in connection with the healing  of
 the ulcer; for,  where much integument is lost, the cure of the ulcer
 is stow and protracted, and the cicatrix imperfect and unsightly. To
 obviate the pain of incision and the loss of blood attendant upon the
 operation,  it has been proposed to open the carbuncle by means of the
 caustic potash ;  but this mode of  proceeding offers a more than
 counterbalancing amount of objections; the vessels are not relieved
 of  their surcharge  of  blood, as in  the plan  by incision, and the
 destruction of integument by the  caustic  induces  all the worst local
 consequences of carbuncle in respect of the healing of the ulcer and
 the production  of  an ugly cicatrix.
   During the suppurating and sloughing stage the carbuncle should
 be kept diligently  poulticed with the linseed-poultice, the carrot-
 poultice, or the  linseed poultice with  yeast; or, when the weight and
 bulk  of a poultice are objectionable, it may be kept covered with that 
FURUNCULAR ERUPTIONS.
253
 excellent application, the invention of Dr. Scott Alispn, the prepared
 corium  or lambskin.  The prepared  corium,  when saturated  with
 water, is extremely soft, pulpy, adhesive and light, and possesses most
 of the advantages of a poultice without its objectionable qualities.
    Daniel  Turner gives  the  following admirable  account  of his
 treatment of a furuncle, the "largest bile" he had ever seen:  "When
 it was arrived to a cone, and I perceived the matter made, I passed
 in a lancet, and discharged a considerable  quantity of well-concocted
 pus, under which, after two or three days' time, I found a large core
 or slough, extending, under the lips, the whole compass of the tumor;
 to come at which I was under  necessity to dilate both upwards and
 downwards; then, filling up the ulcer with praecipitatum  rubrum,
 and a pledgit  spread with basilicon over all, I  dressed him  up, and
 left this  dressing on for two days; after removing  which there came
 out therewith  about one-half of the said  slough.  I continued this
 way of dressing till the ulcer was mundified, and being incarned with a
 mixture of the same basilicon and precipitate, cicatrized with dry lint and
 my ceratum de lapide calaminare ;  more examples  I  think needless."'
   The local treatment of furuncular eruptions  may  be summed in a
 few words:  First, allay the rising inflammation; secondly, when the
 inflammation has reached  its  height,  favor  the  formation of pus by
 means of  the  linseed-poultice; and thirdly, when  the  tumor  has
 burst or been  opened, and  the process of separation of the slough
 moves tardily,  assist that process by gentle stimulation.  For the  first
 of these  three indications  cooling  and soothing applications are
 needed;  for the second, warmth and moisture;  for the third, stimu-
 lating remedies, such as the red precipitate  and basilicon mentioned
 by Turner.  _ The right remedy in the right place and at the right time,
 is an aphorism as  applicable  to  medicine  as  to politics.   In  the
 employment of stimulants we must avoid irritation ;  and  a stimulant
 without  irritation, and admitting of being graduated to  any extent,
 we have  in pressure, pressure by means of adhesive plaster, either the
 simple emplastrum plumbi on linen, calico,  or  wash-leather, or the
 emplastrum galbani et opii.  In carbuncle,  pressure applied in this
 way is  invaluable for aiding  the separation and expulsion of the
 sloughs.  The coating of plaster has the further good effect of main-
 taining a proper degree of moisture  and warmth  of the part.
   Viewed according to this standard,  we can  understand the value
 and proper time  for  application of various popular and  domestic
 remedies which have a  reputation  in  the  treatment of boils;  for
 example, the split fig, the honey  poultice,  and the cobblers'-wax
 plaster.   The honey poultice consists of half an ounce of honey  and
 the same quantity of melted lard, with the yolk of an egg, well mixed
 together,  and inspissated to the proper degree by  the addition of flour.
 The cobblers'-wax plaster  is to be regarded as a digestive remedy of
 a somewhat active kind, suited only to the  coarse skins and coarser
 podices of the rural population  by whom  it is  employed.   Turner

  1 De Morbis Cutaneis.  A treatise of diseases incident to the skin.  Fourth Edition
1731, page 117. 
254      DISEASES ARISING FROM  GENERAL CAUSES.

observes that "the common  people apply shoemaker's wax,  a  very
uneasy application upon so tender a part; and he continues, " melilot
emplaster,  or basilicon, used by others, are much preferable, which
both suppurate and often heal." Among the remedies in use in his time
were a poultice made by boiling figs in milk, the lily root boiled in
milk, and linseed boiled in milk; these applications were frequently
mixed together,  and used in combination.
  The treatment of hordeolum should be the same as that of furun-
culus : cooling lotions to subdue heat and inflammations during the
first stage; warm fomentations and poultices to encourage suppuration
as soon as the first period is passed; stimulants, such as the unguen-
tum hydrargyri  nitratis diluted, to disperse any swelling or induration
that  may be  left after the matter is evacuated, and restore the part to
its normal state.  Constitutional treatment should not be neglected,
the principle of  treatment being the same as that for boils.
                     CHAPTER  XI.

         DISEASES  ARISING  FROM  GENERAL  CAUSES.

                      SCORBUTIC ERUPTION.

  Under the designation of scorbutic eruption I propose to describe
a peculiar disease, which  is  characterized by  the extravasation  or
effusion of blood into the tissue  of the skin, the blood  so effused
giving rise to the production of purple and livid spots.   The color of
the spots has gained for the disease the name of purpura ; while the
spots, presenting considerable  variety  of form  and size, have been
termed  stigmata, petechice,  vibices,  and  ecchymoses, or ecchymomata.
Stigma is the smallest kind of  spot,  a mere point or speck; petechia?
are small round spots, of about the size and bearing a close resem-
blance to flea-bites (hence their name), but without the central  point
which marks the puncture made by the lancets of the insect; vibices
are larger than  petechia?, and irregular in form, frequently resulting
from  the aggregation of several of  the latter;'while ecchymoses, or
ecchymomata, are distinct and  palpable extravasations  of blood,
presenting every variety of figure and  dimension.
   Willan in his classification  places  purpura  in the order Exan-
themata, defining it as " an efflorescence, consisting of small, distinct,
purple  specks and patches, attended with general debility,  but not
always  with fever."   In  the  same group  are  assembled  rubeola,
scarlatina, urticaria,   roseola, and erythema; purpura  occupying a
position  between the two  latter.  With rubeola and scarlatina, pur-
pura  has no relation whatever, proceeding from a different nature of
cause, and being totally unlike in its phenomena;  with urticaria it
has a slight tie,  as  presenting  a variety in which a rounded, button-
like elevation,  very  similar to urticaria, occurs, the variety  being 
SCORBUTIC ERUPTION.
255
distinguished by the  appellation of purpura urticans.  To roseola it
also  bears a resemblance, in the bruise-like vibices, ecchymoses, and
stains which follow some varieties of that eruption ;  and to erythema
it is distinctly allied, in its mode of manifestation on the skin. Never-
theless,  with  all  the foregoing  points of similarity, purpura has
appeared to  me  to be sufficiently distinct from the whole of these
affections to merit the position in which I have placed it, namely, at
the end of the seven  forms  of cutaneous  eruption which  originate in
general causes.
  With the exception of the vibices and  bruise-like stains which fol-
low some of the varieties of roseola, purpura is sufficiently distinct to
incur no risk of being mistaken for any other eruption of the skin.
The  deep red, blood-like, purple  and  livid spots occasioned  by the
blood particles escaped from their vessels, are totally different in color
from the redness which  is the result of congestion of  the  capillaries;
in the latter case, pressure by the finger empties the cutaneous vessels,
and the congested  spots, however vivid, immediately  disappear; but
in purpura they are permanent under pressure, the effused blood may
be compressed, but cannot be displaced from its position, and the spots,
consequently, remain unchanged.  Their ultimate removal from the
skin is the result of absorption.
   In essential nature, purpura is an escape of blood from the capillary
vessels, in  other  words,  an  extravasation  of blood, in which morbid
phenomenon both  blood and bloodvessels participate.    The  blood
itself is altered in quality, and deficient in fibrinous elements;  while
the capillaries are no doubt softened in texture, and yield before the
pressure of the circulation or any accidental pressure applied to the
skin; in a  word,  there exists a state of general cacochymia and dys-
crasia, of which the morbid constitution of the blood and the general
want of tone of all  the tissues of  the body, are  but a part.
   Let us now  proceed  to examine the particular symptoms of this
disease and its varieties.

                            PURPURA.
Syn. Purpurata apyreta.   Purpura chronica.  Porphyra, Mason Good.
   Hcemorrhoea  petechialis, Adair.  Phcenigmus petechialis, Sauvages.
   Petechice sine febre.   Petechice mendaces.  Morbus pulicaris sine febre,
   Amatus  Lusitanus.  Morbus  maculosus.  Macular nigroe sine febre.
   Ecchymoses spontanea.   Land scurvy.
   In the long series of synonyms appertaining to purpura, the terms
apyreta, chronica, sine febre, and., spontanea, are all  intended to point
to a distinction between this form of eruption  and that which accom-
panies typhus and some other fevers.  This is a purpura dependent on
causes not  inconsistent with a  moderate amount of  well-doing, as re-
spects health, on the part of the individual; that is due to the destruc-
tive  alteration of the blood concomitant  with a fever  in which the
vitality of the blood and  of the tissues is seriously compromised.
Both are symptomatic of exhausted power and  debility, but in a very
different degree, and to an extent calling for a  considerable difference
of management. 
256      DISEASES  ARISING FROM GENERAL CAUSES.

  The varieties of purpura, distinguished by Willan, are five in num-
ber, of which four are generally admitted at the present day; the fifth,
purpura contagiosa, being the  purpura above alluded to, as appearing
in connection with typhus and typhoid fevers.  The other four varie-
ties are as follows:—
                      Purpura simplex,
                         "    haemorrhagica,
                         "    urticans,
                         "    senilis.
Purpura simplex denotes the most simple form of petechial  scurvy;
slighter in its characters and degree than purpura haemorrhagica, and
unaccompanied,  like the latter,  with hemorrhage  from the  mucous
membranes.  Purpura urticans, as I have already remarked, is accom-
panied with button-like elevations resembling  urticaria; and purpura
senilis is an affection of the skin of a trivial nature, met with in elderly
persons.
                        PURPURA SIMPLEX.

          Porphyra simplex, Mason Good.  Petechial scurvy.
   Purpura simplex is an efflorescence of purple and livid spots on the
skin, presenting the forms of  stigmata, petechia?, and vibices;  appear-
ing in succession, and displaying at the same  moment every grade of
development, from the brighter  hues of recent extravasation, to the
purple and livid hue of a more advanced  stage, and  the yellow and
brown stains of the fading eruption.   It is commonly met with pretty
equally distributed over  the  body: but on the trunk, the Tspots are
most abundant on the breast  and abdomen, and on the limbs, in the
thinner skin of the insides of those members.  The eruption is accom-
panied with tingling, and with a moderate degree of soreness and ten-
derness of the  affected parts of the  skin.   At its  decline the spots
gradually fade and disappear, without exfoliation of the epidermis.
  The purple spots are sometimes seen  in the mucous membrane of
the mouth, nose, and fauces, and  sometimes on the conjunctiva. But
they are less frequently met with on  the mucous membrane  in pur-
pura simplex, than in purpura haemorrhagica.
  The constitutional symptoms accompanying purpura simplex, are,
^omc degree of  languor and lassitude, a feeling of debility, a soreness
of the muscles of the limbs;  a'pale,  broad, indented, and sometimes
coated tongue;  a yellowish  and  murky discoloration of the  skin;
bowels sometimes relaxed, and sometimes confined; urine, sometimes
scanty and sometimes abundant, sometimes deficient in uric acid salts,
sometimes containing them in excess: and more or less cedematous
swelling of the legs;  in a word, the ordinary symptoms of mal-assimi-
lation and cacochymia.   I have a case of this  kind before me at the
present moment; in the first week of  May a gentleman consulted me
for erythema attended with pruritus, and complained at the same time
of a slight degree of  sciatica, and some wandering rheumatic pains in
his shoulders and arms.   He  had  also a  few blotches  about the face,
and exhibited symptoms of cachexia, induced by anxious and long- 
SCORBUTIC ERUPTION.                 257
continued application to his duties.   In other respects, he was a man
of atonic diathesis, somewhat over temperate, and in the habit of fast-
ing too long.  I saw him  twice, at intervals of a week, and was dis-
appointed with the slow progress of improvement which he exhibited;
and on his .third visit at the end of a  month, he presented a fine speci-
men of purpura simplex,  with a yellow cachectic countenance, and
oedematous lower limbs.  The purple  spots were numerous and dis-
crete, and chiefly confined to the lower half of the body.
   In another case, occurring at about the same time as the preceding,
the details were as follow: A merchant, aged forty-two, a single man,
of temperate and abstemious habits, had applied himself too closely to
the duties of the counting-house for some time, and  had suffered in
health as a consequence.   He was  pale, of fair complexion, far from
robust or strong, and experienced frequent attacks of  dyspepsia, con-
stipation, and rheumatism.
   Towards the end of the  year 1855, and after two or three weeks of
dyspepsia, this gentleman  was suddenly seized with rheumatic pains.
which came on during the night.  The pains were most severe in the
axilla? and across the  chest and  back;  and he had pains, also, in one
of his hips.   This attack was accompanied with rigors; the  bowels
were  constipated, urine  scanty and high  colored, with red sediment,
but the appetite was not affected. After ten  days of suffering, he had
administered  to him a blue pill, and immediately following the action
of the pill, and caused by the pill as he imagined, a crop of petechial
spots made their appearance on his legs and arms.
   At the time of the appearance of the petechial spots, he suffered from
great prostration  of  strength and  depression of spirits, his muscles
were sore, and he was unable to walk. •  After four days, during which
fresh petechia? continued to appear, a crop of vibices suddenly broke
out upon the lower limbs ;  the vibices became the seat of bulla?, which
were filled with a purplish fluid; the  integument was oedematous;  he
was unable to stir his legs and there were scattered over them as many
as twenty bulla? at a time.   These symptoms continued  for six or
seven weeks, when the petechia? and vibices gradually  faded, the skin
got well,  and  he seemed to be recovering.
  Six weeks  after this another  attack of rheumatism  suddenly took
place; he was seized as before with severe pains in the axilla?, extend-
ing across his chest and back ; the muscles of the back felt as if they
had been bruised, and the rheumatic pains seemed to descend from
his chest into  the joints of  his  limbs.   While  in this state,  he had
administered to him five grains of blue pill on two consecutive nights.
and immediately afterwards  the  purpura  returned as before;  firstly.
as petechia?,  and  then as  vibices on the legs, covered  with  bullae.
With the petechia? and vibices the legs became  swollen and hot, the
muscles were  sore, and he was unable to move them.   At the end of
a month the sj^mptoms began to subside, and he was sufficiently well
to come to London from a distant county  to seek my advice.
  On the occasion of his'visit to me in  July, 1856, I found him com-
plaining of languor and lassitude ; his tongue was pale, there were no
petechia? in the mouth, no sponginess of gums, or bleeding from any
      17
* 
258      DISEASES ARISING  FROM GENERAL CAUSES.

internal organ;  his appetite was moderately good;  and his bowels,
usually costive, were regular.  He made an average quantity of water,
which  deposited  a red sediment; his pulse was weak, unequal, 126 in
the minute, and he complained of occasional palpitations of the heart.
His joints were  still tender and  somewhat  swollen, and there were,
scattered over his arms and legs a plentiful sprinkling of petechia?; on
the legs  there were vibices as well  as  petechia, but the bulla? were
dried up, and the cuticle was in a state of exfoliation.   He remarked
that he could always foretell an eruption of petechia? by an increase
of pain in his joints; and, at these times, the slightest pressure on the
skin would produce a bruise.  The eruption itself gave rise to a little
tingling, amounting, when the vibices were numerous, to some degree
of pain, but not sufficient to cause anything more than a trifling incon-
venience.
  This case is interesting, as showing the alliance between rheuma-
tism with the lithic diathesis, and purpura, and this association points
at once to the indications which we  should  follow in our treatment.
I prescribed for  him the tincture of gentian, with nitro-muriatic acid
as a tonic;  and the  guaiacum powder with bicarbonate of potash as an
aperient;  with a generous but moderate diet.
  One of my friends, of gouty diathesis, and  subject  to occasional
attacks of lichen and eczema of the legs, has  not unfrequently, in com-
bination with this eruption, a pretty extensive development of purpura
both of the simple and urticating  kind.  The deep-seated soreness and
bruised feeling of the limbs, extending deeply into the muscles, is very
remarkable ;; as is also the stinging and prickling sensation in the skin,
wherever the buttons of urticaria are developed.  The neurotic nature
of the disease is evinced by these symptoms;  and to an exhausted con-
dition  of nervous tone, may also  in  all probability be attributed the
altered plasma of the blood, and the non-retentive power of the capil-
laries and small bloodvessels.

                    PURPURA  HEMORRHAGICA.

   Porphyra hemorrhagica ;  Porphyra nautica, Mason Good.  Land
                          and sea-scurvy.
   Purpura haemorrhagica is an  aggravated form of purpura simplex,
aggravated both in  local and constitutional symptoms.   The petechias
and vibices are more numerous, and the ecchymoses more frequent
and extensive; sometimes there  are, besides, large  vesicles or bulla?
containing blood.   The mucous membranes are affected in a similar
way with the skin; the gums are spongy, and bleed; and petechial
extravasations have been met with in every tissue of the body, even
on the brain and beneath the  inner coat of the arteries and veins.
The susceptibility to extravasation of blood  is so great, that pressure,
however slight,  produces ecchymosis, and the  folds of the skin are
marked by an appearance of purple and livid stripes.  In the mucous
membrane, hemorrhages to a  greater or less extent are not uncom-
mon ;  and  it is this character which  has given the  specific name  to
the present form of purpura. 
SCORBUTIC ERUPTION.
259
  The constitutional  symptoms  of  purpura  haemorrhagica are  a
repetition of those of  purpura simplex, but in a more severe degree;
there is  more languor, lassitude, prostration, and muscular  debility.
The pulse is feeble and quick; there is more or less depression of the
moral powers, and fever of the hectic kind.   The frequent recurrence
of internal hemorrhages increases the debility and hectic feverishness;
there is  great  faintness;  the  limbs become  oedematous;  and the
patient sinks from exhaustion, sometimes dying suddenly during the
continuance of a  hemorrhage, or from the effusion taking place  in a
vital part.
  The stigmata, petechia?, vibices, and ecchymomata, present all the
varieties and phenomena which have been noted in connection with
purpura  simplex, but in a heightened degree.  They commence on
the lower  extremities, and extend by degrees to the  trunk of the
body, the hands and face being usually free.    /
  The duration of this disease, like its predecessor, is uncertain;  it
sometimes lasts for months, and has been known to continue for years.
  It is this disease which at one time was so  common in our navy,
and  was described under the  name of scorbutus (purpura nautica),
and  which is found  to prevail from  time to time among masses  of
people congregated in unhealthy localities, and subjected to vicissi-
tudes of temperature, particularly a cold and damp atmosphere, with
bad  and insufficient food, imperfect ventilation,  exhausting fatigue,
or deficient exercise,  or a too prolonged use of salt provisions, and
which is so  effectually remedied and prevented  by the reverse  of
these conditions;  namely, a dry atmosphere, good ventilation, good,
fresh, and sufficient food, and proper exercise and cleanliness.   The
general symptoms of sea-scurvy are exactly similar to those described
under the head of land-scurvy and purpura  haemorrhagica, but often
assume an  exaggerated character.  There is more physical  prostra-
 tion, the skin is pale and discolored, the vibices are  larger, the gums
 more spongy and bleeding, the breath very offensive, the excretions
 both from the bladder and bowels  fetid, the pulse weak and feeble,
 syncope frequent, hemorrhages more copious and  general, and death
 a more  common  finale of the "disorder.   On  the  other  hand, it has
 been observed in sea-scurvy that the physical depression is greater
 than that of the  mind, that the latter is  bright and vigorous to the
 last, and that the  body dies suddenly from efforts made in obedience
 to the command of the will.

                       PURPURA URTICANS.

   This  form  of  purpura  commences with round  elevations  of  a
 whitish or pale color, sometimes reddish, which resemble the rounded
 wheals   of nettle-rash; but  there is generally  less irritation  and
 pruritus, and  the wheals are  less evanescent.  When of a reddish
 hue, they have seemed to me to belong rather to erythema tuberosum
 than to urticaria; they are somewhat elevated, generally  well-defined,
 arid soon become purple and livid, after which they subside slowly,
 leaving behind them  brownish  yellow stains;  as they are successive 
260      DISEASES ARISING  FROM GENERAL CAUSES.

in eruption, they may be seen in all their stages at the same moment.
They occur, for  the mo3t part, on the lower limbs, and are commonly
attended with some degree of oedema.  I have seen purpura urticans
most  frequently in  female servants, in whom it has been associated
with uterine  disturbance; in similar cases, in fact, to those  in which
erythema tuberosum is apt to be found; and I have also seen it asso-
ciated with lichen and eczema.

                        PURPURA SENILIS.

  The form of purpura described under this name by Bateman is not
very infrequent  in  elderly women, particularly in  those whose arms
have been much exposed to local  irritants of different kinds, such as
the sun's rays, water, &c, and is always to be met with in our work-
houses.   It  is associated with  a  preternatural  degree of thinness of
the integument, which is embrowned, yellowish, and mottled, being
sometimes  smooth  and  sometimes  rigid  and  wrinkled.    Bateman
describes it so well that  I quote his words: " It appears  principally
along the outside of the forearm  in successive dark  purple blotches
of an irregular form and various magnitude.  Each of these continues
from a week to ten  or twelve days, when  the extravasated  blood is
absorbed.  A constant series of these ecchymoses  had appeared in
one case during ten years, and in  others for  a shorter period, but in
all, the skin  of the arm was  left of  a  brown  color."   The general
health is in no wise affected in these cases, and the patient suffers no
inconvenience beyond that of the unsightly appearance of the blotches.

  Diagnosis.—The purple and livid color of the spots; the blood
being not in the vessels, but extravasated in the tissue of the skin ;
the persistence of the spots under pressure with the finger; these are
the distinguishing  signs of purpura.   The  purple and  discolored
stains which follow  some forms of roseola, and the purple  pimples of
lichen  lividus, are distinguished  by their connection with  a distinct
roseolous eruption on the one hand, and a papulous eruption on the
other.
  Cause.—The  cause of purpura  is cachexia  resulting  from mal-
assimilation :  the  mal-assimilation  being  one  while  the  effect  of
generally depressing causes,  whether physical  or mental: another
while, the effect of improper or insufficient food, malarious atmosphere,
excessive fatigue, defective ventilation, neglect of exercise  and habits
of cleanliness; or, again, it may be the consequence of some organic
disease, of local weakening of the tissues, as in anasarca, or of general
and local weakening, as in old age.  The severity or violence of the
cause may  be very different  in  different constitutions;   in  some,
purpura is easily induced, and the affection is unimportant;  in others,
the system of the individual only  yields when overpowered, and the
disease is therefore grave.   In  the  first of the cases which 1  have
detailed under the head of purpura simplex,  the mal-assimilation was
induced by fatigue,  abstinence, and  some degree of mental  anxiety,
perhaps aided by some unknown  miasma, proceeding either from the 
SCORBUTIC ERUPTION.
261
neighborhood  of the residence of  the patient, or from  imperfect
drainage in his own house.  The mal-assimilation first evinced itself
as a  neuralgia;  then  as an  erythematous  eruption;  then  boils
appeared ; and lastly, purpura with  oedema of the  lower limbs;  the
skin of the face during the whole progress of the morbid phenomena
being yellow  and discolored.  In  the second  case  the  cause w;as
somewhat similar.
  Prognosis.—Purpura may be trifling or serious, according to  the
nature of  the cause, the  constitution of the  individual,  and  the
violence of the disease.   Purpura simplex is very unimportant; but
purpura haemorrhagica is always serious, in  consequence of its com-
plication with  the internal  hemorrhage, which  may take place in  a
vital organ, as in the lungs, and prove, suddenly  fatal.
  Treatment.—The treatment  of  purpura  offers no  indication
different  from  those for the treatment of cutaneous eruptions  in
general.  We  must  eliminate, we  must restore power, and  we must
remove  the patient  if possible out of the reach of the predisposing
cause.  For elimination,  our remedies are saline  aperients and effer-
vescent salines;  sometimes we may think it desirable to begin with a
dose of calomel or blue pill, to remove any irritant matters or secretions
that may be present in  the  alimentary canal or in the ducts of  the
liver,"or to induce a more healthy action of the liver and kidneys, or
we  may prefer rhubarb  or guaiacum ; sometimes we may conjoin  a
tonic with an aperient, as in  the  infusion of roses  with  sulphate  of
magnesia and quinine ; or, having done as much by way of elimina-
tion as  we  think desirable, we must endeavor to  restore power,
assimilative and vital, through  the  agency of our bitters  and acids,
bark and sulphuric acid; gentian  or calumba, or hop, with the nitro-
muriatic acid, &c.  Sometimes in the presence of a lithic acid  or gouty
diathesis, the bitters,  with mild  aperient alkalies, such as the  sulphate
or phosphate of soda, or sulphate of  potash, together with  the iodide
of potash, will do good  service.  We shall  also derive benefit,  in
some cases, from the combination of the  salts of iron with our other
tonics, such as the hydrochlorate, the acetate, and the citrate of iron,
with quinine.
  To  the  physical medicine must be added moral medicine;  a rest
from those exertions  which have acted as a predisposing cause of the
disease, change of air and scene, and  particularly a sojourn for a time
by the sea, together with tranquillity of mind.
  The diet should be moderate in quantity, but generous;  and less
abundant and stimulating during the febrile period than subsequently.
Meat is one of the most  wholesome as it is the most easy of digestion
of all our articles of  food ;  it will afford the  best materials of supply
while the old and morbid elements are being removed by the elimina-
tive process, and it will invigorate the blood and the entire organism.
To  meat mav  be  added wine, or in  some  instances beer, as the
physician shall see fit.
  Local  treatment is  rarely necessary, but if there existed any uneasi-
ness of surface, which it might be desirable  to  relieve,  the  lotion of
liquor ammonia? acetatis, diluted with oue half  of rose-water, or  an 
262      DISEASES  FROM SPECIAL EXTERNAL CAUSES.

emulsion of bitter almonds, will be found the most suitable for the
purpose.
  In  the sea-scurvy, lemon-juice and  potatoes have obtained a de-
served reputation, together with fresh meat and water, malt and spruce
beer, and wholesome hygienic conditions.
                     CHAPTER  XII.

  DISEASES ARISING FROM SPECIAL EXTERNAL CAUSES.

  The special external causes capable of affecting the skin, and giving
rise  to  irritation and inflammation, are three  in  number, namely,
parasitic animals living  in, upon, or under  the skin; heat;  and  cold.
Of the parasitic animals, the chief are, the acarus, the pediculus, the
pulex, the cimex, and the filaria medinensis.  The acarus scabiei lives
within the skin, burrowing and depositing its ova  in  the  epidermis,
and  drawing its sustenance  from  the juices of the true  skin. • The
acarus autumnalis, or harvest bug, only makes a temporary sojourn
on the skin, for  the purpose of supplving  its wants, and  is merely a
temporary infliction ;  the pediculus also resides upon the skin, cling-
ing  to its  surface, pediculus corporis; or to the hairs, close to  their
exit from the follicles,  pediculus capitis, and pediculus  pubis.  The
pulex and cimex, the flea and the bed-bug,  belong rather to the cover-
ing of man, than to his  proper  self, attacking  his skin only for the
purposes of food.  The filaria medinensis is a slender worm, of great
length, a native  of tropical countries, which forms for itself an abiding
place in the subcutaneous cellular tissue, and sometimes gives rise to
considerable pain and  inflammation  of the part infested.  As it is
occasionally brought to this country, it calls for our attention with the
present group.  Lastly, the effects of heat and  cold, the one causing
burns and scalds;  the other gelatio or frostbite  and  chilblains, require
no further illustration than that which they obtain under their respect-
ive heads.
   The diseases originating from these causes, and to be treated  of in
the  present chapter are, therefore, scabies,  the  inflammation of the
skin caused by  the acarxis scabiei;  malls, the evil or disease caused by
the presence of  parasitic animals on the skin ; ambustio, or burn; and
gelatio, or  frostbite, the effect of cold acting  destructively on the
skin ; the latter head also includes that common cause of suffering in
the  winter season, namely, pernio, or chilblain. 
scabies, or itch.
263
                           SCABIES.
  Syn.  Itch. Scabies papuliformis ; papularis; vesicuhsa; vesicularis ;
lymphatica; pustulans ; -pustuhsa ; purulenla; uherans;  vermicuhris;
cacheclica;  Willan.   Ecpyesis scabies, Mason  Good.  Gale,  Fran.
Kraetze, Germ.
  Scabies' is an affection of the skin  characterized by scaliness of the
epidermis, by vesicles,  and in some cases by pustules; to which may
be added, excoriations, accidental abrasions, and  scratches produced
by the nails.2  It is accompanied with  excessive  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 animal-
cule, the acarus  scabiei, which  burrows within  the  epidermis, and
excites irritation in the  papillary surface of the derma.  The burrowing
of this little creature gives rise to the scaliness  (scabrities) and under-
mined state of  the epidermis.'   The  vesicles, which  are few and
scattered, bearing no proportion to the  number of the acari, and little
relation to  their seat, present some differences in form and  character,
resulting from their position.   Thus,  in  the  thin  epidermis of the
lateral surfaces of the fingers they are  distinctly  conical and  acumi-
nated ; on the 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 con-
tained 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, for  example,  in children;  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 first
entrance within the epidermis, and from this spot or streak  a  whitish
fluted line may be traced either in a straight or a curved direction, into
the neighboring epidermis.  The whitish line is the cuniculus, 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 elevation of the  epidermis, the little inhabitant lies concealed.
The acarus may  be easily distinguished by the experienced eye, as a
small dark crescent,  or as a minute white glistening orb, with  a dark
crescentic edge, at the end of the cuniculus, and if a thin  capsule of
epidermis be raised in  this situation, with the point of a needle, the
little creature is brought into  view.
  The spot or streak which is here described is not met with on  all

  1 Quasi scabrities.
  8 Portraits of Diseases of the Skin; Plate XVII., AA.;  in which a good example of
icabies is shown. 
264      DISEASES  FROM  SPECIAL EXTERNAL CAUSES.

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 habita-
tion, 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 neighborhood of the little grubber that acts
as the cause of formation of the vesicle;  the vesicle is consequently
a provision of nature to protect the derma from the near approach of
the cause of irritation.  The acarus scabiei, therefore, is never situated
within the  vesicle or within  the pustule, and there is no communication
between the vesicle and the  cuniculus.
 • At a  later period it is no  uncommon thing to find at one extremity
of the cuniculus the marginal outline of the base of the  vesicle, while
at the other end  is the little dome under which the acarus is imbedded.
                      The accompanying sketch is intended to illus-
        Fig- H«         trate this appearance, the  cuniculi (a) being
                      about twice the natural size.  The vesicular
                      end of the cuniculus is a mere outline bounded
                      by the broken edge of cuticle which  formed
                      the  base of the vesicle, the rest of the vesicle
                      having been removed  by attrition and desic-
                      cation.  The  next portion of the cuniculus,
                      for about half its length, was an open groove
                      with a ragged border, while the  remainder of
                      the  cuniculus was an arched canal or tubulus,
                      somewhat expauded from point to point, where
                      the animal made its temporary rest in its mole-
                      like  progress  onwards.   In  the magnified
                      figure (B) the acarus is seen at the end of the
                      cuniculus ; it  resembles a white and pearl like
                      glistening globule  capped  on  its  anterior
                      border, or that which is nearest the end of the
cuniculus,  with a reddish brown  crescent;  the colored crescent being
the chytinous investment of the head and anterior legs.  Figure C
represents the acarus  removed from the cuniculus, and its appearance
when seen  with the naked eye through the thin convex plate of cuti-
cle which covers it as with a watch-glass.
  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, axillae, inner sides  of the thighs, and abdomen.
In weakly  constitutions it may be limited to the hands for a consider-
able period without extending further, while in severe cases and san-
guine constitutions it  may speedily spread over the entire body, with
the exception of the face, which is very rarely affected.1  The excessive
itching  causes persons suffering from this annoyance to scratch, with
violence, the seat of the eruption ; but the scratching only diffuses the

  1 The only  case on record with which I am acquainted, of scabies affecting the face,
is one mentioned by Alibert.  The subject was an infant, and was supposed to have
received the disease from the mammae of its nurse.
/
 
SCABIES, OR ITCH.                    265
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 the little black scales, like those of-prurigo.
When, in  consequence of superadded irritation from susceptibility of
the skin from scratching, from  injudicious remedies, or from a ple-
thoric state of the system, the vesicles take on the characters of pus-
tules, the disease assumes the appearance which-has been described by
Willan under the name of pustular itch (scabies purulenta)..
  The  seat of the eruption of scabies is occasionally found to be modi-
fied by circumstances.   For instance, while, in the generality of cases,
the disease is observed between the  fingers and on the wrists, in those
who, from hard labor or the  manipulation of hard substances, have
the epidermis 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, Eayer re-
marks, 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 with the vigor of the system.  When the person is of sanguine
temperament, and robust, the scabies spreads rapidly, and gives rise
to insupportable pruritus; when, however, the 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 regarded
as a mild and unimportant affection  as respects the health, producing
but little local disease, and no constitutional symptoms, yet in warmer
climates, as  observed by Dr. Adams1 in  Madeira, it is  accompanied
with pyrexia, and the local effects are often very severe.  The itch-
animalcule is very common in the island of Madeira, where it is called
oucou or oucam.   The following case, illustrative of these remarks, I
quote from Dr. Adams's account of these animalcules:2—
  "A patient (a European) applied to me on account of a spreading
inflammation, attended with large vesications, collections of serum, in
some places of pus,  with intolerable itching, sometimes intense pain
and  smart fever.  All these symptoms were much exasperated at a
certain period of the day.  I treated 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 mean time, the female
servant, who assisted with the poultices, pronounced the disease oucoes,
and to convince him of the truth of  her assertion, extracted two from
the edges of the sore, which he saw crawling on his nail.  This appear-
ance of the disease,  so entirely local, and  the part affected with such
violence, was so different from anything I had met with before, that
1 On Morbid Poisons.
2 Page 298. 
266      DISEASES  FROM SPECIAL EXTERNAL CAUSES.

no evidence less than the above would  have satisfied me.   The pain
indeed was  less surprising when we consider the disease was imme-
diately 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."

  Diagnosis.—One of  the most important features in the history of
scabies is the distinction of the disease from other cutaneous 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 improper in other diseases; while, on
the other hand, the means appropriate for the cure of other diseases
would leave the  itch in full possession of its mischievous activity.
The chief diagnostic features of scabies axe, firstly, a peculiar scaliness
and undermined  state of the epidermis, which are not  met with in
other cutaneous  affections;  secondly, its conical  vesicles, with acu-
minated and transparent points; and thirdly, and  principally, the pre-
sence of  the acarus,  which may be extracted from its retreat beneath
the loosened epidermis with the point of any sharp instrument.  The
diseases with which  this disease is apt to be confounded are, eczema,
prurigo, lichen, impetigo, and ecthyma.
  Eczema is a vesicular disease, and therefore bears some resemblance
tq one of the characters of scabies, but  the vesicles are globular, and
scarcely raised above the surface; they are always collected in clusters,
and give rise to a sensation of pricking  rather than of itching; more-
ovef, eczema is not communicable by contact.
  Prurigo  is a disease  attended with  thickening and  considerable
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 color, a few only being
black, when the  scratching is carried  to the extent of making the
vesicles bleed.  The pruritus of the  two diseases, again, is different;
in prurigo it is burning, pricking, and  painful, which is not the case
in scabies, and, moreover, the disease is not communicable.  Prurigo
is occasionally 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 inter-
spaces of the fingers; the pruritus accompanying lichen is different
from 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, the limitation of the pustules
to the hauds or flexures of the joints, and the presence of the scaly
epidermis and conical vesicles of itch, will  be sufficient to determine
the diagnosis. 
SCABIES, OR ITCH.
267
  Another complication of scabies frequently results from the irrita-
tion of substances employed  in the treament 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  continued 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.
  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 opportunity of communica-
tion  consequently greater.  When the disease makes its invasion in
respectable families, its source may generally be traced to laundresses,
servants,  and their connections.
  Until very recently scabies was  hardly known in  London,  nor
probably in England; it had  disappeared even from our work-houses,
and  was rarely  met with among nurses and  children in  private
families.   But since the  return of the army from the Crimea  the
disorder  is revived; it has spread  very extensively, and  has found*
its way into a higher class of society than that in which it previously
moved.  Immediately  upon  the close of the  war, scarcely a  day
passed without bringing me a case of scabies, chiefly in the person of
a military or naval officer; and at present I see several such cases in
the course  of a  week, not however  so  much  among the  orig'inal
introducers of the disorder, as in those to whom it has extended.
  The disease is always communicated by contact, either immediately,
or through the medium of articles of clothing  which have  been in
the possession of the infected  individual.  But there are many circum-
stances predisposing to its influence, such as luxuriant health and vigor,
sanguine or lymphatic temperament, the spring or  summer season of
the year, warm climates, youth, confined atmosphere, want of  cleanli-
ness, &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, require a  still
longer time for the  development of the vesicles, particularly in  the
winter season.
  The proximate cause  of scabies is the acarus  scabiei,1 which is
transferred by the infected to those who are sound,  by actual contact.

  1 The history of this animalcule will be found recorded in a separate chapter at the
conclusion of the volume. 
268      DISEASES  FROM SPECIAL EXTERNAL CAUSES.

In some  instances it may be conveyed to the sound  person in the
adult state; while in others,  ova, or embryos suspended in the  fluid
of the vesicles, may be the mode of transmission.  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 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,1 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  cuni-
culi having become obliterated, had disappeared."
„ Exp. 2.—"On the first of September I placed seven living acari on
my fore-arm, and covered them with a  fold of linen, and piece of
diachylon plaster. Four days after we found four or five well-marked
cuniculi.   On the sixth of September two of the acari being extracted
from their cuniculi, were found active; they were then replaced.  On
the twelfth another  animalcule was removed and  examined; it was
quite lively.  On the fourteenth there  was considerable itching, with
the development of a vesicle  ; the cuniculi were two lines long.  On
the sixteenth there were several new vesichs near  the cuniculi, but not on
their line.   On the seventeenth the vesicles of the  previous  day had
been rubbed off by the linen, but two or  three new ones were visible.
On the following day I  put  an  end to  the experiment,  by rubbing
some sulphuro-alkaline ointment into the  part.  During the course of
the experiment I suffered pruritus from time to  time."
  Exp. 3.—"On the ninth of the month I imprisoned six  acari on my
ring finger, by  means of  the  finger of  a glove.  Next day there were
two cuniculi half a line long.   The acarus of one of these burrows was
apparent for ten days, the other for three weeks, but alter 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  pruritus, and  next day perceived four  cuniculi.   Several
days after, some vesicles  showed themselves on my fore-arm."

  1 The dark brown crescentic speck produoed by the color of the head and anterior
legs, is certainly more striking as a diagnostic character than the white body  of the
animal here referred to ;  both, however, should be taken in conjunction. 
SCABIES, OR ITCH.
269
  Exp. 5.—" Having  placed two acari in the flexure of the elbow of
two persons, who expressed their willingness to submit to my experi-
ments; on one, three or four vesicles  were apparent on the fifth day,
and were accompanied by severe  itching.  On the other  there were
two cuniculi, with pruritus, but no vehicles."
  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, I 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 physio-
logical experiment.
  Prognosis.—Scabies is a mild  disease,  and little affective of the
strength  of the system.  Some few cases have been recorded in which
the eruption has subsided  during an acute disease, to reappear as  soon
as that disease had become somewhat  mitigated. Instances have also
been advanced, with a view to prove that certain serious visceral dis-
orders have occasionally  been developed, upon the sudden retroces-
sion of scabies.  These statements  are not borne out by observation,
and refer to a period  when scabies was the generic epithet for every
disease of the skin attended with itching; but there is good reason for
belief that a brisk attack  of itch would  rather  be useful than other-
wise, as a counter-irritant.                           ^«
  Treatmknt.—The treatment of scabies is purely local, and nume-
rous therapeutic remedies have been employed from time to time for
its cure;  moreover, as the object to be attained is simply the extermi-
nation of the acarus, many have been successful.   Several of these
medicines act by means of their  stimulating powers, and at the same
time that they destroy the parasite, 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 treatment, 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 be regarded as spe-
cific in  the  treatment of scabies.   To effect the cure  the sulphur is
rubbed into  the skin, and  is conveyed by imbibition into the texture
of the epidermis.   Here  it probably  combines with  hydrogen, and
sulphuretted hydrogen gas is evolved, which acts as a deadly poison
on the acarus, and destroys its ova.   In some  instances the  sulphu-
retted 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 sulphur, probably on  account of the gradual and constant genera-
tion of the gas in the tissue of the  epidermis, in the latter case.   The
sulphuretted hydrogen lotion gives rise to less irritation than the sul-
phur  ointment, and is therefore a preferable  mode of treatment in
children, and persons  with a delicate skin.  Before either of these or
any other remedies  are employed, however, it is desirable  to  prepare
the skin  for  their reception by a thorough ablution with a warm solu-
tion of subcarbonate of potash, containing about half a pound of alka-
line salt  to a gallon of water. 
270      DISEASES  FROM SPECIAL EXTERNAL CAUSES.

  To effect the cure of scabies in the shortest  possible time, the best
preparation of sulphur is the simple sulphur  ointment, of which, in
the adult, four ounces should be well rubbed into the entire skin, and
particularly into the  affected  portions, morning and evening, for two
days.  It is desirable also, that  the  patient should  wear a  flannel
shirt, and retain the  same during the whole treatment.   When this
covering is not sufficiently large to envelop the entire body, 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 effected.
Much,  however, depends upon  the manner  in  which the alkaline
ablution  and the friction of  the  affected  parts shall have been  per-
formed.  In some cases it may be desirable, as a matter of precaution,
to continue the inunction for a third day, or to use the  white preci-
pitate ointment1 to the affected  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 offers the advantage of a rapid cure,
is liable  to the inconvenience of producing accidental eruptions.  I
am in the habit of combining with  this plan the internal  administra-
tion of sulphur, in doses of a scruple or  half a drachm, with a scruple
of bitartrate of potash three times a day.   And this I should  recom-
mend to be done, when the cure of inunction of lard or chamomile
ointment is preferred.
   Reflecting on the rationale of the treatment of scabies  by sulphur,
we are led  to the conclusion  that  the object to be attained is the
thorough impregnation of the skin with the vapor of sulphur; and
then the question arises, whether this  end is to be attained  in any
other way than that  above described ?  In  hospital practice, and  in
the case  of children,  it may be easy enough to saturate the skin  with
the sulphur ointment, and keep the patient within blankets to concen-
trate the sulphureous vapor on the skin ; but  this plan is  highly
inconvenient, and often impossible, to persons engaged in  occupations
which  require daily  attention, l^t alone  the annoyance that a man  in
perfect health  must  feel  at being buried  in blankets for a couple  of
days.  Appreciating this difficulty, I have, for some years past, had
recourse to a very simple method  which I have found to answer the
purpose  completely, and which has  the advantage of demanding no
confinement,  and  none of the heroic rubbings in above described.
My plan is to require the patient to rub into his hands,  and particu-
larly into the wrists and between the fingers a little sulphur ointment.
This he repeats several times a day ; for example, every time he washes
his hands,  and again at bedtime; the  latter  rubbing being a more
thorough one than the rest.  Moreover, at  bedtime he  further rubs
the ointment into any other part of the body where the eruption may

              1 R.—Ung. hydrarg. ammonio-chloridi, 3J.
                   Moschi, gr. ij.
                   Olei lavandulse, n\,ij.
                   Olei amygdalarum, 3j-—M. 
SCABIES, OR ITCH.
271
exist.  Then, besides the outward application, he takes from ten to
thirty grains of the sulphur sublimatum twice or three times a day.
In this way we secure  a  perpetual  atmosphere of sulphur, and a
thorough  saturation  of the skin, both from  within  and without, an
amount of  saturation, in  fact,  which  no acarua can resist.   The
quantity of sulphur  ointment required is small, and such as  may
be allowed  to remain  on the  skin and  between the fingers without
detection  by an indifferent person,  and yet sufficient  to answer all
the purpose.  This method of treatment destroys the acarus in the
clothes  as well as in  the  skin of the  patient; and with the slight
exception of giving him the smell of a brimstone match, a smell which
he may cover  with  any kind of perfume, it  is unattended  with the
least inconvenience.   A  week of this treatment, followed by a second
or third week  of a modified plan,  for example, merely using  dry
sulphur-powder to the hands, instead of the ointment, and continuing
the sulphur  internally, will effectually cure the disease ; and during
its progress  the patient may take  a  tepid or warm soap-bath every
third day.   To protect the clothes not in use, shutting  them up in a
drawer, with some sulphur-powder sprinkled  between them, will be
found  sufficient, and I also  recommend the sprinkling of  sulphur
within the bed.
  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 solu-
tions in half a pint of tepid water, many times in the  course of the
day:—
     R.—Sulphureti potassse, §ij.             R.—Acidi muriatici,§j.
        Aquae, Oj.                            Aquae, Oj.
       M. ft.  solutio.                        M. ft. solutio.
  The former of these methods is well  adapted for  young children,
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 non-sulphureous,
and each possessing, according to their advocates, peculiar advantages,
have been recommended  by different  authors.  Among the  more
deserving of these remedies are the following:—

                     Saponaceous Compounds.
  $.— Potassae subcarbonatis, 3ij.              R.—Sulphuris sublimati,
     Aquae, §j.                               Saponis alb., aa ibss.—M.
     Olei olivarum, ^ss.
     Camphorae gummi, 3ij»
     Sulphuris sublimati, %v.—M.
  The saponaceous compounds possess  the advantage of not soiling
the habiliments of the patient, but they require a longer use than the
sulphur remedies, namely,  two or three  weeks.
  Pyhorel recommends the friction of half a drachm of sulphuret of
lime with sweet oil into the palms of the hands, without-any applica-
tion  to the  surface of the body, the treatment being  continued for 
272      DISEASES  FROM SPECIAL EXTERNAL CAUSES.

fifteen or twenty days.   Fantonettf advocated  the use of chloride of
lime; and  Delpech the employment of frictions of sweet oil alone.
This  last remedy would, doubtless, act most destructively upon the
acarus, could  the oil reach  the  animalcule-   In my own practice I
have  found sweet  oil, containing a  little camphor, very successful
in infants whose skin was too tender  to bear sulphur ointment.  And,
carrying out the idea of the oily matter bearing a considerable share
in the curative agency of the sulphur remedies, I have  also employed
inunction with lard alone with a satisfactory result.  The lard requires
to be well  rubbed in to all parts of the body, particularly into those
chiefly affected,  night and  morning, and  by the  end of a week the
cure is complete.  A warm soap-bath should then be taken to purify
the skin.  Mr. Stiff, in a communication made to the Medical Times, in
1845, is an advocate for this plan; and M. Bazin, in some trials lately
made at St. Louis, states that six frictions with oil or lard are all that
are requisite for the cure of  scabies.
   M.  Bazin, however, prefers an ointment  of chamomile to the simple
lard, and he states, as its advantages, that  it cures in three "frictions;
that it relieves  the  itching  instantly; and  that it gives  rise to no
secondary  eruptions,  as  is the case  with the sulphur and  sulpho-
alkaline  treatment.   His formula  for  making the ointment  is to
mingle equal parts of fresh chamomile flowers, olive-oil, and lard, and
heat them  together on a sand-bath.  It appears to me that the same
purpose would be gained by adding the essential oil of chamomile to
lard.
   Among  the simples recommended from time to time by different
physicians, or employed  popularly, are solution of tobacco, used by
Boerhaave,  but  liable  to  many objections: stavesacre, hellebore,
seabious, sweet-scented rush, elecampane, and onions.
   The use  of stavesacre  and hellebore have lately been revived, and,
according to their respective suggestors, with flattering success.  M.
Bourguignon  recommends that the patients should begin their treat-
ment  as usual, by taking a soap-bath; that, after the bath, the staves-
acre ointment should be well rubbed into the whole body, particularly
into  the parts  chiefly affected; and that the  inunction  should be
repeated  four times a-day.   On the fourth day the cure is complete,
and another soap-bath  should be  taken.  M. Bourguignon's formula
for the ointment is twelve ounces of  powder of  the seeds of stavesacre
to be stirred into twenty ounces of  boiling lard, and macerated in a
sand-bath for twenty-four hours.   It may then  be strained, and some
essences added to give it a pleasant odor.
   The formula  proposed for the hellebore is,  to mix  together eight
ounces of  powder of white hellebore with four ounces of soft soap,
and sufficient hot water  to bring it to a consistence fitted for friction
on the skin.  It should be used once a-day until all itching ceases, and
then washed away in a warm bath.    After a few frictions it produced
a feeling of heat in the skin.
   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 
SCABIES, OR ITCH.                    273
disinfected  by exposure to sulphureous acid gas.  This is a measure
of great importance, since the acari and their ova remain  attached to
all articles of apparel, and are easily communicated by them.  Indeed,
whenever practicable, 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 enriched by the observations of
M. Albin Gras, in the work before alluded to.  He observes:—
   "I was enabled to obtain living acari from a patient who had taken
two  or three sulphur baths, containing four ounces of sulphuret of
potass to the bath.  On the contrary, I have frequently  found them
all 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 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-oil, 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 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  creasote, and in concentrated acids
 and alkalies, its death was immediate. Placed over night on powdered
 sulphur, the animalcule  was found dead the next day; and  it required
 to be exposed to the vapor of burning sulphur for sixteen minutes
 before it died."
   One of the most remarkable of the phenomena of  scabies,  is the
 localization of the acarus to the hands ; while the eruption excited by
 it may be spread more or less extensively over the entire  body.   The
 animal is the excitant, and the excitation of the sensory nerves of the
 skin of the hands is communicated to the whole of the nervous appa-
 ratus of  the skin, hence the itching and eruption on  parts of  the skin
 which the acarus never reaches.   Hence, also, the principle of cure, to
 remove the local irritation,  and thereby to subdue the  excito-sensory
 phenomena which  take their  rise  in the local irritation.  But the
 morbid sensibility of the skin induced by the acarus,  is often  aggra-
 vated by the occurrence of the disorder  in a person  of eczematous
 diathesis; in which case the eczema, in some one of its forms, becomes
 established  and  permanent, and requires the treatment  of eczema for
 its removal. In such a constitution the acarus merely takes the place
 of a more  common cause of the complaint, and the  disease  which
 ensues is not to be  regarded as scabies, but in  its true character as
 eczema or lichen, as the case may  be.  The treatment also must be
 that which  is suitable  for eczema, without reference  to  the scabies,
 which must be treated locally by the usual  means;  or, as the eczema
       18 
274      DISEASES  FROM SPECIAL EXTERNAL CAUSES.

is secondary in its development, the scabies may be cured first, and
then the eczema may be attacked.   After the first week of treatment
specifically directed to the removal of scabies, the case must no longer
be confounded with  scabies;  the medical  man must not yield to the
belief that he has to do with  an instance  of  unmanageable scabies;
and the patient must not be permitted to carry away the  impression
that his medical adviser is unable to cure the scabies.  But to effect
the cure the removal of the primary cause is essential.  No treatment,
however well directed, will  benefit the eczema until the acarus is
destroyed; and when the acarus is effectually destroyed,  as may be
ascertained by the disappearance of all irritation about the hands and
wrists,  the treatment  should be continued as  for an ordinary and
uncomplicated example of eczematous eruption.
  From these experiments we may  infer, that sponging with vinegar
would be a good practice, and one sufficiently harmless to  be adopted
in the case of the youngest children.


                             MALIS.

                    Die Insektengeschwulstesucht.
  The term malis, the paus and p-auaapbi of the Greeks, is used as a
generic  term to signify the presence of parasitic  animals on, in, and
under the  skin, and may be  made  to include the bites and stings of
insects.   The  animals  which are  commonly found to  draw their
nourishment  from the human skin  are the acarus scabiei,  acarus
autumnalis, pediculis, pulex, cimex  lectuarius, and filaria medinensis.
The effects of the acarus scabiei, constituting the disease scabies, have
been already examined; there remain, therefore, to be considered, the
nature of the suffering occasioned by the acarus  autumnalis, and the
remaining parasites.  This  will be discussed under the five following
heads, namely, malis acari, malis pediculi, malis pulicis, malis cimicis,
and malis filaria?.
                          MALIS ACARI.

                      Cri'vones.   Die Mitesser.
  The  acarus,  or mite,  is very abundantly  dispersed  throughout
nature, existing apparently  wherever nourishment is to be found, and
representing among^errestrial and air-breathing animals, the infusoria
of the aqueous  world.   Acari are  well known  to inhabit vegetable
substances, such as meal, dried fruits, sugar, &c, and to be the cause
of their decay and destruction; in like manner, it is found among
animal  substances, as cheese, dried meats, and fish, &c, gradually
converting the nutritious parts to its own purpose, and leaving behind
only that  which is innutritious or resists its powers of disintegration.
The  surface of other animals, again,  is a region  in  which animal
matters of various kinds are to be met with,  either in the form of
excretions from the skin, or the juices of the skiu itself; hence it is,
that in this region we find the acarus revelling in abundance, sheltered
among the lower animals by their hairy coverings, and provided with 
            MALIS, OR CUTANEOUS VERMINATION.         275

means of fixing upon and burrowing into the smooth and uncovered
skin of man.
  To the observers of nature, the large acarus which  takes up its
quarters on the under side of the common dung-beetle is  well known.
This creature probably takes advantage of the habits of the beetle to
enjoy with him the feast which he laboriously buries in  the ground.
The acarus casei, or cheese-mite, is also familiar to all;  but  besides these
common examples of the acarus, I have discovered  it on the skin of
the pheasant, in the mouse, and in the  horse; in the latter constituting
the cutaneous disease termed the mange}  From these observations it
may be inferred that every animal has its acarus;  and, judging from
the great variety  of form which  the few examples I have had the
opportunity of observing have presented, I should be ready to conclude
that each genus or  even  species of animal had  its peculiar acarus,
modified in its configuration and structure to suit the special circum-
stances by which it may happen to be surrounded.  Thus the meal-
mite and the  cheese-mite, imbedded in their food, require  no special
prehensile organs, and are chiefly remarkable for the bush of hairs
which spring from their bodies to keep off the particles of their food
and protect them from pressure and suffocation.   The acarus scabiei
is especially  constructed for burrowing in  the substance  of  the
epidermis;  he is furnished with a coat of plate and  four strong arms
in front, spines set backwards on his body, and four  small  weak legs
behind.   The acarus equi, much larger than the acarus scabiei, is also
organized for  burrowing:  as in him, the legs are set forwards  and
backwards, the former being strong, the latter weak; and he is addi-
tionally provided with a pair of strong  perforating organs, constitut-
ing a haustellum, the sides  of the haustellum being furnished  with
recurved lateral hooks.  Both the acarus scabiei and  acarus equi have
suckers attached to their feet; but  the acarus autumnalis, being only
an occasional parasite, and not organized for habitation in or on the
skin, is only supplied with hooks to grapple with the surface while he
is taking in his supply of food.
  The acarus scabiei and acarus autumnalis  are the only two acari at
present known  which attack the human skin, at least in this country;
but it is not impossible that in other countries  and climates other
parasites of the genus acarus may be met with. In illustration of this
suggestion, I may mention that some  sjecimens of acari were sent me,
a few years since, from the United States of America, by Dr. Hanbury
Smith, with an  account of the circumstances  under which  they were
obtained.  They were found  on a lady residing in Stockholm.   She
was  for a long time teased  with  them, and they gave  rise to much
inconvenience  and vexation.   The Stockholm acarus is of  large size,
j'gth of an inch in length, by ^th of an inch in breadth ; consequently
somewhat more than three times the  size of  the  acarus scabiei  and
acarus autumnalis.   It is oval in form, and furnished with  eight legs,

  1 The acarus equi will be found described by me in the Transactions of the Veteri-
nary Medical Association for 1843-4, page 399. Some figures drawn with the camera
lucida accompany the description of the animal. 
276
DISEASES FROM  SPECIAL EXTERNAL CAUSES.
two of which are set forward and six laterally;  therefore the creature
is not organized for burrowing.   The legs are long, seven-jointed, and
Fig. I.
Fig. L.
Fig. K.
     ''A t/pfci*
   A'-'-'C/.a'' v  -7
i "lia^ Ay*l
/A ^Cf ?-a^.S^
Fig. N.
 Fig". I.—The itch animalcule, acarus scabiei, viewed upon the back; showing its figure and the arrange-
ment of its spines and filaments.
 Fig. K.—The itch animalcule viewed upon the under surface, showing its legs and lobnlated feet.
 Fig. L.—The foot and last joints of the leg of the itch animalcule.
 Fig. M.—Ova of the itch animalcule.

armed with a double  tarsal hook, which  would enable the animal to
adhere firmly to the skin;  its head is supplied with maxilla? and palpi,
                               or rather chela?, which are five-jointed ;
                               and from between the chela? is projected
                               along, lancet-shaped haustellum. Judg-
                               ing from the organization of this acarus,
                               I should conclude  that  its presence  on
                               the skin of man was the result of  acci-
                               dent, that  it drew its subsistence habit-
                               ually from some other source, but that
                               it  was  quite  capable of piercing the
                               cuticle,  and  obtaining  its food from
                               the juices  of  the human body, and in
                               this  way  giving rise  to considerable
                             ^irritation.  Probably it is to this species
                               of acarus  that  Rayer refers when  he
                               observes that "symptoms similar  to
                               those produced  by  pediculi,  may  be
occasioned  by acarides, an  insect very closely allied  to the ixodes, but
capable,  according  to Bory  St. Vincent, of forming a new  class,
characterized  by  a  small sucker,  accompanied with  two  feelers
consisting of four joints.   M. Bory St. Vincent  has observed these
insects upon a woman of about forty years of age,  who, after having
experienced violent itchiness  over the whole body, was very much
astonished  to  see thousands of acarides  on all  the parts which she
had scratched."
 The Stockholm acarus, viewed on its un-
tcr surface, and magnified :l$ diameters. 
MALIS, OR CUTANEOUS VERMINATION.         277
                       ACARUS AUTUMNALIS.

        Harvest-bug.   Mower's Mite.   Wheal-worm.  Rouget.
  The acarus autumnalis is scarcely larger than the  acarus scabiei,
measuring, in average  numbers, about T^oth of an inch in length, by
the -r^th of an inch in breadth ; the average size of the acarus scabiei
being T^th of an inch in length, by j^th of
an inch in breadth; consequently the acarus
autumnalis is narrower than the acarus sca-
biei, and flattened  instead of being globular.
It is of a reddish color,  and provided with six
legs and  two chela?.    The chela?  are  four-
jointed,. scarcely reach beyond the level of
the maxilla?,  and are  furnished at the  extre-
mity with strong nippers.  The six legs spring
from the thorax, are long, seven-jointed, and
terminated by a short  tarsus, with  a pair of   Theacarus autumnalis, viewed
     .         tit     mi   i     ii     .on its under surface, and magni-
ample  recurved hooks.  The haustellum  is  fied 70 diameters.
concealed.
  The acarus autumnalis is most troublesome in the autumn season,
and commonly during harvest, and  is met with most abundantly on a
chalky soil.  It makes its attack chiefly on the legs of those who ven-
ture into the  fields during the harvest  season, and from the legs finds
its  way to every part of the body, causing  more or less irritation
according to  the susceptibility of the individual.  Its bite is followed
by  redness and some degree of swelling, the amount of both depend-
ing more  upon the cutaneous sensibility of the person  than upon the
real injury done to the  skin ;  sometimes the bite is followed by a small,
glossy, red blotch, white, and raised in the centre, like a wheal of urti-
caria, hence  one of the  names of the little animal, wheal-worm; at
other times the  inflammatory congestion is as large as a crown piece;
or,  when the  bites have been numerous, a broad expanse of erythema
may be the consequence.  If the inflamed spot be examined with care,
a small red point will be observed  in the centre, this  is the acarus;
and it requires some dexterity on account of its adhesiveness to remove
it from the skin.  The irritation caused by this little creature, always
troublesome,  is, in some persons, so severe, as to amount for the time
to a kind  of torture.
  The  best remedies for the bite  of the harvest-bug, to destroy the
animal and subdue the irritation are, spirits of winera lotion of ammo-
nia, containing a drachm of the sesquicarbonate to eight ounces of elder-
flower water; a lotion of equal parts of sal-volatile and distilled water,
the  liquor ammonia? acetatis, distilled vinegar, the elder-flower oint-
meut, or an ointmeut consisting of simple cerate with camphor.

                         MALIS PEDICULI.

          Morbus pedicularis.   Phthiriasis.  Die Laussucht.
  Three kinds of pediculi infest the human body, the pediculus capitis,
pediculus  corporis,  and pediculus  pubis.   The  pediculus  capitis  is 
278      DISEASES  FROM  SPECIAL EXTERNAL CAUSES.

found chiefly in children, but is not absent in the adult; the pediculus
corporis is met with principally in the adult and elderly persons; and
the pediculus pubis is more common in the adult  than in the young.
   The pediculus capitis is  protected from injury by the hair, and
deposits its ova, commonly called nits, on the stems of the hairs; and
the itching which it  creates is said to be referable  more to the move-
ments of the animal  on the skin than to the  sting with which it is
supposed to be armed ;  they are named pediculi, says Isidore,  " quod
magis pedum motu kedant, quam morsu."  They are remarkable for
the rapidity with which  they  multiply, and some of the phenomena
to which their presence gives rise may be attributed to this circum-
stance.   Leuwenhoeck  put  their power of procreation to the test of
experiment; he " took two females and placed  them  in a black silk
stocking which he wore day and night, that they might have the full
benefit of feeding upon him.  He found that in six days each laid fifty
eggs without exhausting its store, and that in twenty four days the
young were capable of laying eggs themselves; and carrying  on the
calculation, he estimates that  the two females  conjointly might pro-
duce eighteen thousand in two months."
   The pediculus corporis is larger than the pediculus capitis, it is
also whiter and flatter, and its ova  are  agglomerated and deposited
among the body-clothes of the person.  Just as the pediculus capitis
never deserts the head, the pediculus corporis  is rarely found among
the hair, preferring the smooth parts of the body, to which it adheres
closely.  It is commonly met with in prisons and workhouses, and in
those abodes of the poor where cleanliness and  nastiness meet; less
frequently in hovels,  where  the mingled odors of cooking, smoking,
and match-making are  diffused through the  atmosphere.  Pediculi
have delicate noses, and are easily affronted by unseemly smells.
   Pediculi, like all other animals, are strongly influenced by the con-
ditions  among  which they  are placed;  when  those conditions are
favorable to  their existence, they multiply to  an enormous  extent,
and cover the body completely.  This  is the state to which the terms
morbus pedicularis and  phthiriasis (<J>0«e, pediculus) are particularly
applicable.  The  irritation of these  creatures on  the skin, and the
scratching  of the surface which naturally accompanies the itching,
give rise to more or less erythema and lichen, and sometimes to pus-
tules, and then the skin  presents the characters of a true disease.  It
is difficult to understand the extraordinary increase of these creatures
on the skin in certain cases, even among persons of cleanly habits, and
we cannot but come to the conclusion, that certain states of the fluids
of the body are peculiarly favorable to their nourishment.  Thus, they
are sometimes found  to be produced during an  illness, and in  some
families have been known to  invade the body shortly before  death,
and so become an admonition of the approach of death.  I have seen
them teeming on the bodies of persons laboring under malignant dis-
ease, in whom the powers of life  were scarcely sufficient to preserve
the body from decomposition; and probably to this circumstance, to
the exhalation of effluvia agreeable to their instincts, their presence in
such excessive numbers might  be attributed.   Stories are on  record 
             MALIS,  OR  CUTANEOUS VERMINATION.         279
                                                             %
relative to this disease that read rather like fable than truth, and yet
may have had some truth for their basis.   "It is recorded by authors,
both ancient and modern," writes Daniel Turner, " that diverse persons
have come to their ends, being devoured by lice, among whom the
poet Alcmanes and Pherecydes Syrus,  mentioned by Aristotle, are
accounted."  Riolanus says:—"Felicitatem Sylla? phtyriasis termina-
vit;  eodem morbo Pherecides, Pythagora? preceptor, et Alcman  peri-
erunt."   Of these last, Q. Serenus has these verses:—
              " Sed quis non paveat Pherecydis fata tragoedi,
               Qui nimio sudore fiuens, animalia tetra
               Eduxit, turpi miserum quae morte tulerunt?
               Sylla quoque infelix tali languore peresus
               Corruit, et fcedo se vidit ab agmine vinci."

Turner suggests another  idea with regard  to them  in the following
passage, they  "are reckoned to prognosticate death or speedy  mor-
tality to those they abandon, or  when they shift their quarters unpro-
voked by medicine or external  application."
   Some notion has been entertained of the development and existence
of pediculi under the skin, and  it has been reported by authors that
tumors have  been opened which were found full of lice.  There is
certainly no reaspn against the creeping of pediculi into  the  sacs of
follicular tumors of the skin, feeding on their contents, and afterwards
being found to be the  sole  possessors of these sacs, but in this case they
have originally proceeded from the  exterior, and crept  through an
opening which must have been overlooked by the observers  in whom
the reports originated.  It is clear from  their organization, that pedi-
culi  are air-breathing animals, and that they cannot exist under or in
the tissue of the skin where they would be deprived of that element.
   The pediculus  pubis is very different in form from  the preceding;
it is rather square-shaped  than long;  it is flat, has enormous legs, en-
larging towards their extremities like the claw of a lobster or crab,
and the body is covered with tubercles, from which proceed tufts of
hair.  Its resemblance to  a crab has gained for  it the appellation of
crab-louse; while other of its names are plactulce, petalce, and pessolatoi
(probably from its flatness), and morpiones.  Although termed pedi-
culus pubis, it is also found on other parts of the trunk of the body
where there is hair, in the axilla?, eyebrows, and  at the roots of the
eyelashes; but however abundant on the rest of the body it is not met
with on the head.
  The pediculus pubis gives rise to great  itching, hence it  has been
named pediculus ferox;  and by means of its strong feet, armed with a
long recurved hook,'which closes between the two sharp spines, it is
enabled to retain its hold upon the shafts  of the hair with great tena-
city, so much so, in fact, as to render its removal difficult, and scarcely
to be effected without the loss of one or  two legs.  The difficulty is
increased by the flatness of the  animal, and by the smoothness of its
back, over which the finger might pass without detecting its presence.
To the eye it  is more obvious,  and  is easily distinguished;  and the
eye is further  attracted  to its haunts by the quantity of reddish fecal 
280      DISEASES FROM SPECIAL EXTERNAL  CAUSES.

matter which it  leaves upon the skin, entangled among the roots of
the hair.
  The skin  infested by the pediculus pubis is always  more  or  less
torn by the nails; and  sometimes  it sets  up a degree of  irritation
which  pervades  the skin  more or less extensively, giving rise to an
eruption of  lichen.  On the borders of the eyelids it is apt to create
some degree of inflammation.
  Like the pediculus capitis, the pediculus pubis fixes its ova on the
hairs, by means  of the secretion which forms the horny capsule of the
ovum.   This substance,  soft when  excreted, soon becomes hard by
desiccation,  and  establishes an inseparable adhesion between the ovum
and the hair.
  The   remedies  most suitable for the treatment of the pediculus,
whether infesting the head or the body, are the white precipitate oint-
ment, scented with some pungent odor, such as lavender or camphor;
the red precipitate ointment;1 calomel ointment;"sulphur ointment or
fumigation;  a  lotion  of the bichloride of mercury,  and calomel in
powder.  Several  simples have also retained a reputation in this com-
plaint,  namely,  the seeds of  the stavesacre in infusion; the lesser
centaurea in decoction ; the powdered seeds of the  parsley; the worm-
wood seeds; seeds of veratrum, lycopodium, rue, kc.

                          MALIS  pUlicis.

  Two species  of the pulex  or flea are  commonly  recognized,  the
pulex irritans, the common flea of  this country, as  well as of the  rest
of the world ; and the pulex penetrans, the chigoe or chiggre, a  flea
met with  in the West Indies and  South America.   The former is
merely a cause of  irritation and annoyance; the latter is capable of
giving rise to a  state of real disease.
  The pulex inflicts a deep wound in the skin, by means of a pair of
very fine  and sharp lancets attached to its  head, and the sheath of the
lancets probably acts the  part of a haustellum in drawing the fluids
from the wound.  Its bite is recognized  by a small  circular spot or
petechia,  which it is  sometimes  important to distinguish  from  the
petechia of purpura.  In the petechia produced by the flea, a red point
in  the  centre indicates  the perforation  made by the  little animal,
and this point  is  perceptible under pressure of  the skin, while the
pinkish disk, in the centre of which it  is placed, disappears.  In  the
petechia of  purpura, on the other hand, there is no central  puncture,
and the whole spot remains under pressure of the finger.  Occasion-
ally, I have seen  the petechiae of flea-bites  purplish  in color,  and

  1 The  Scottish bard Burns  seems to have been acquainted with the destructive
properties of the " mercurial rozet" fortius purpose, as well as of "fell red smeddum,"
which I take to mean  red lead ; he suggests their use in the following verse:—
              '' My sooth 1 right bauld ye set your nose out,
                As plump and gray as ony grozet;
                Oh ! for some rank mercurial rozet,
                      Or fell red smeddum ;
                I'd gie ye sio a hearty dose o't,
                      Wad dress your droddum." 
            MALIS, OR CUTANEOUS VERMINATION.         281

resembling small bruises ;  in which case the distinction between them
and the spots of purpura is not so obvious.   As another ground of
diagnosis, it may be observed that the petechiae of purpura are more
general than those produced by fleas.
  Fleas,  like pediculi,  have a great repugnance to  powerful and
fragrant odors ; and these  may be employed as a means of protection
against their attacks, at least when they are not impelled by too fierce
a hunger.  Lavender, musk, thyme, are all inimical to the instincts of
the flea,  and Linnaeus commends very strongly the seeds  of the sea
wormwood, absinthium maritimum, as a pulicifuge.
  The pulex  penetrans, or  chiggre, burrows beneath  the skin,
commonly of the  feet, and  by the  side of the nails, or on  the heels,
and there deposits ova.  This operation is attended with some degree
of itching, and often  the  flea may be seen through the  skin as a
dusky spot.   After awhile  a small tumor, as large  as a lentil, rises
upon  its place of concealment, and when the tUmor bursts it is found
to contain a small quantity of sanious pus,  with an  abundance of
small, white, oblong bodies, which are the ova of the  creature. The
tumor is  succeeded by a troublesome ulcer,-which the hatching ova
continue  to irritate ; new tumors are formed, followed by other ulcers,
until  the whole foot is in a state of inflammation.  The attack of the
chiggre is generally confined to the toes, and to the sole of the foot,
but sometimes it invades the dorsum of the foot; and the ulcerations
to which it gives rise  have been known  to  occasion deep  ulcers,
with necrosis of the bones; and  in some few instances mortification
and death.
  The treatment of the chiggre is to remove the sac  containing the
ova without disturbing the latter, for  if any of the ova are allowed
to escape, the young pulices will prevent the healing  of the sore, and
all  the  inconveniences of  the  original disease will recur.  The
negroes and natives of the  countries where  the chiggre is found are
peculiarly dexterous at this operation, which they perform with a pin
or needle, and  by great care succeed  in dislodging the  sac  (entire.
After the removal of the sac they dress the wound with the juice of
tobacco.
                          MALIS CIMICIS.

  The cimex lectuarius is a well-known scourge of large towns and
cities; the creature lies hidden by day, but  issues from its retreat at
night,  and feasts   upon its victim, destroying  sleep  and rest, and
covering  the skin  more or less extensively with inflamed and irritable
bumps.   The cimex has received  its  specific  name  of lectuarius, or
lectularius, bed-bug, from being found  commonly in the joints and
crevices of the wood, of which the bed is constructed;  here it propa-
gates largely, and  is conveniently located for its nocturnal excursions.
But it is not confined to the frames of beds alone ; it also takes up its
abode in  the crevices of the walls  and  of the floor, in the seams and
under the folds of clothes ; indeed in any situation where it can obtai'n
concealment from  the light; The creature is round, flat, and of a red
color,  is provided  with a powerful haustellum, which  it buries in the 
282      DISEASES  FROM  SPECIAL EXTERNAL CAUSES.

skin to reach the nutrient fluids of the body, and has a powerful and
offensive cinnamon-like smell.
  The bumps occasioned by the cimex lectuarius  are more or less
raised and inflamed,  according  to  the constitution of the  sufferer.
They are for the most part white and elevated in the centre, where the
puncture is perceptible, and more or less deeply red  in  the circum-
ference.  They admit of being mistaken for erythema papulosum or
tuberosum; sometimes they  are accompanied with an extent  of swell-
ing amounting to oedema, particularly where they occur  on  or wear
the eyelids,  and  have suggested the idea  of an incipient attack of
erysipelas.  In doubtful cases the diagnosis may be made clear by a
knowledge of the cause and  by the presence of less swollen bumps of
a similar kind on other parts of the body.
  The best application for the relief of the irritation of these inflamed
bumps is, vinegar, Goulard's lotion,  spirits of wine and water, or
miudererus spirit, the liquor ammonia? acetatis.

                         MALIS FILARI-E.

                  Helmintiasis.  Die Hautwurm.
  The filaria  medinensis1  is a worm  found under the skin  in the
southern countries of the world, and particularly in India.  The worm
is of about  the  thickness of a crow's  quill, grows to  the length of
several feet,  is white in color, and commonly single.   There may be
several  worms in different  parts of the body, but only" one in the
particular nest which the worm makes for itself in  the  subcutaneous
tissues.   It gives  rise to  redness of the affected spot, more or less
swelling, and pain, all of which symptoms are subject to considerable
variety;  the redness may  be more or less extensive, the swelling
oedematous,  and the  pain very severe.  In  Hindostan  it attacks both
natives and Europeans, and  has  been known to give  rise to so much
inflammation and  irritative  fever as to have rendered necessary the
amputation of a limb.
  The filaria  medinensis is rarely seen in this country, but it has
been occasionally met with  in persons returning from  a residence in
India.   I have seen two such  cases in young military officers; both
were out of  health, and in one of the two I succeeded in performing
the feat in which  the  natives of India are so expert, namely, of ex-
tracting the  worm.  In this case the filaria measured more than  a
yard in  length.
  One of the most striking phenomena in connection with these cases
is the length of time  during which the worm is  latent, and. develops
no symptoms by which its presence  may be surmised.  Upwards of
twelve months had transpired since one of these gentlemen left  India,

  1 Medinensis, from the prevalence of the worm in the country of Medina  in  Arabia.
Irk medini of Avicenna;  vermis medinensis; nervus medinensis ; vena medinensis ;
vena civilis ; tyaKovria. of the Greeks ; dracunculus ; Guinea worm.  Some of the older
physicians, as Galen aud Soranus,  were of opinion that the filaria was not a worm, but
a " nervous concretion," hence the name nervus  medinensis.   " Pollux  calls the
dracunculus a piece of corrupted nerve." 
MALIS, OR  CUTANEOUS  VERMINATION.        283
before he became aware of anything being wrong with his foot.  He
then had what appeared to be a small flat abscess on  the instep; the
abscess burst, allowing a small quantity of sanious pus to escape, and
with the matter a thin white cord, like a  piece  of bobbin, protruded
from the opening.  He drew out this protruding bobbin to  the extent
of a few inches, and in a short time the wound healed.   Some weeks
later he came to me with a small phlegmon  on  the  side of the foot,
and complained of its excessive painfulness.  I  recommended him to
apply a poultice.   A day or two later I perceived a fluctuating point,
which I punctured, and a small white  loop  about an inch long was
projected from  the puncture, with a very  small quantity  of sanious
pus.  I secured the loop, and drawing upon  it gently, one end became
released from the opening.  The portion  which remained measured
four inches in length, and  this I wound upon a  narrow slip of card;
I then placed his foot under a stream of cold water, and winding as I
proceeded, gradually and slowly drew out  about six inches more.   I
repeated this operation daily for five or six days, and by that time
had  extracted  the whole of the worm—that is, the whole  of that
portion  of which the  broken end had first appeared at the opening
made by the lancet, this fragment measuring nearly a yard in length.
  On the occasion of  his  first visit to  me, there was a good  deal of
pain extending up the  limb; he was unable to walk, and during the
progress of the case this pain increased; the skin was oedematous and
shining, the ankle  swollen and erythematous, and the pain extended
in the caurse of the nerves of the limb, as high as the groin.  Once I
was  obliged to desist  from  any further  traction on the  worm for
several  days, on account of the severity of these symptoms, which
excited  some irritative  fever, and  completely destroyed his rest  at
night, while the foot was so tender that he could not bear upon it the
pressure of the bed-clothes.  My attention  was attracted from the
first, before I had discovered the cause of his suffering, to the extra-
ordinary disproportion  between the  apparent local disease and the
amount of pain of which  he complained; and  there was nothing in
the slightly-flushed and somewhat swollen blotch on  the side  of the
foot to explain so  much suffering.  On looking at'the smooth and
shining  skin covering the worm, I perceived a tortuous and slightly-
elevated ridge, which no doubt corresponded with the burrow of the
animal beneath, and which led me to  give  credence  to the patient's
suggestion,  that the cause might be the guinea-worm; and having
never seen a similar case, I watched  it with attention; the result I
have already stated.
  After each daily operation, a linseed  poultice  was wrapped around
the foot  and kept on until the following day.  When the traction was
commenced, from two to four inches of the worm came out easily;
then a little more force was required; this force became relaxed under
the paralyzing shock of the stream of cold water; but, after a little
while, no  amount of  force,  consistent with  the integrity  of the
animal, could succeed in producing a.particle more.  When it came
out easily the patient experienced no  pain;  but when  it came with
difficulty, or resisted further traction, the  pain was  excessive, and 
 284     DISEASES FROM  SPECIAL EXTERNAL CAUSES.

 finally, when  no more of the animal could be obtained, contributed
 to  the  necessity of putting a stop to the operation.  The piece of
 card  was then  secured  near  the  aperture of the opening until the
 next day.
   It appeared to me that the inflammatory process, and the suppura-
 tion which ensued, weakened  the vitality of the animal;  and that, to
 secure  its  existence, it was necessary that it  should  be enabled to
 burrow in  the tissues and feed upon them, without occasioning that'
 amount of excitement  which  results in  inflammation.  This idea is
 borne out  by the  fact of no symptoms of the  presence of the  worm
 being experienced  until  the animal  has attained the prodigious
 length  of several  feet: that then, for the first time, and as though
 from  the accident of its coming too near the  sensitive tissue of the
 skin, inflammation is  set up,  and  the inflammation is  followed  by a
 scanty  suppuration.  Bathed in the  heated  fluid  of the  inflamed
 tissues, the worm  becomes debilitated and exhausted; and when the
 abscess bursts, or is opened, a torpid  loop of the creature is ejected
 through the opening.  This  loop may be handled without exciting
 contraction or motion; it looks soft and swollen, and sometimes is so
 much softened that it breaks easily;  it is also of a  different color to
 the more vigorous part of the worm; the latter  is somewhat  trans-
 parent; its  internal structure may be seen through its tegumentary
 coat,  it is firm and even  rigid; the extruded loop, on the other  hand,
 is of  an opaque white color,  and  soft.   These differences, moreover,
 are perceptible in  the daily operations on the worm; the first portion,
•weakened  in  vitality by exposure at  the  aperture by its unnatural
 confinement around the slip of card, and by its contact with purulent
 fluid, is soft,  swollen, and  opaquely white; it yields easily to the
 effort of traction, to the extent of two, three, or  four inches; it then
 becomes thinner, more transparent, and firmer,  and soon resists every
 amount of force that can be used  for its extraction; appearing,  from
 the pain which it occasions,  to clasp with its coils the  wall of the
 tortuous burrow in which it is concealed, perhaps clutching fiercely
 on the  thread of a nervous filament.  The cold water, falling  upon
 its bed from a height,  paralyzes its muscular structure  for a moment,
 and an inch more  of the creature Is wound upon  the card, until, in a
 few minutes, it  seems to become  part of the  flesh itself, and  to be
 immovable.  Alter days of careful  and  laborious winding of this
 creature, I was agreeably surprised, on the last day, to find it  come
 out without difficulty, even to the  end, perseverance and gradual
 encroachment had finally exhausted  its vitality and powers of muscu-
 lar resistance.
   After the extraction of the  worm  all pain ceased immediately, and
 the sinuous ulcer in which  the creature had  lain  imbedded speedily
 healed.  In the second  case  that came  under my notice, there was
 more pain and  inflammation of the foot  than in the first, and the
 worm was so soft as to preclude the  use of any force in the attempts
 made  to extract it.  At last, after  about eighteen inches had  been
 removed, it suddenly broke,  and the end became retracted within
 the skin.  As we could not hope  to recover the worm, after this 
               AMBUSTIO.  BURNS AND  SCALDS.            285

accident, for a week or more, I counselled my patient to go into the
country to recruit his  health, and to return to London as soon as he
perceived any reappearance of the worm.  He paid me a visit after
a few weeks, but it was only to say that he had seen nothing more of
his enemy, and that his foot was quite well.  I am not surprised at
this report, for it appeared to me that the creature had been destroyed
by the  inflammation and  suppuration,  and that the  inflammatory
action  had occasioned a spontaneous cure.   Whether  this  result
would have followed in the native country of the animal, it is difficult
to say;  probably  it would not.
  Another remarkable phenomenon in the history of malis filaria? is
the curious fact of the isolation of the animal; and this is the more
extraordinary, as  the sanious pus which exudes from the sore  teems
with hundreds of young filaria?, all minute and all  of the same size.
Why these young filaria? do not grow to the size of the parent and
propagate in the tissues of the skin  is most difficult to decide;  but
all our records of the history of the animal tend to show that  such
is not  the case.   And the question suggests itself,  are these minute
worms  the young of the Filaria,  or  do thef  belong to a different
species ?

                          AMBUSTIO.

                        Burns and Scalds.
   Under the head of  ambustio, or burn, we  have to consider those
morbid conditions of the  skin and subjacent parts which are produced .
by caloric in a concentrated form, whether the immediate agent of
injury be irradiated heat, as that  from the sun and  bodies in a high
state of temperature, or whether it proceed from the direct contact of
flame, boiling  fluids, or heated solids.  Proceeding  from sources so
different, heat will vary in its degree of intensity, and it will also vary
in its effects upon the skin according to its duration or continuance.
The  rays of the sun, however  powerful in themselves, are not to be
compared with the sudden contact of flame, and the latter is inferior
in power to the more prolonged  contact of boiling fluids or heated .
metal.   Thus,  in degree,  heat may be feeble but prolonged; or it may
be strong and  instantaneous; strong, and continued for a brief period;
or strong, and continued for a long period.
   These differences in degree of heat, and duration of its action on the
skin, necessarily give rise to differences in effects, such differences con-
stituting the degrees of burn, noted from the earliest period of their his-
tory, and recognized universally at the present day.  Daniel Turner
divides burns—
   1.  " Into such as are superficial, where the skin is lightly scorched,
and the cuticle  raised into blisters.
   2.  " Such as go  farther, not only blistering the scarf-skin, but alter-
ing the texture of the skin itself, which comes away in a light slough.
   o\  "Into those which  penetrate still deeper, burning not only the
skin, but flesh  and other parts subjacent, into a coal or crust." 
286     DISEASES FROM  SPECIAL EXTERNAL CAUSES.

   Dupuytren has enlarged and improved on this division of burns;
he makes six degrees of severity,  which he classifies as follows:—
   1. " Erythma,  or superficial  inflammation  of the skin without
vesicles.
   2. "Inflammation of the  skin,  with  separation of the cuticle, and
the production of vesicles filled with serum.
   3. " Destruction of the papillary layer of the skin.
   4. " Disorganization of the entire thickness of the skin, down to the
subcutaneous cellular tissue.
   5. " Destruction of all the superficial structures, together with the
muscles, to a variable degree of depth short of the bones.
   6. " Carbonization of the  entire thickness of the burned part."
   For our present purpose,  and with especial reference to the skin, it
maybe convenient  to classify burns into three groups, namely:  1.
Erythematous burn; 2. Vesicated burn ; 3. Gangrenous burn ; leaving
the two degrees of destruction of the true skin, and the two degrees of
destruction of parts beyond  the skin, as sub-varieties of the latter.

   Erythematous burn (ambustio  erythematosa) is characterized by
a vivid and diffused redness of the skin, some degree of swelling, and
a  pungent smarting pain.  The  pain  continues for some hours; the
redness subsides in a variable period of time, several  hours or days,
according to the severity of the burn, and is followed by desquamation
of the epidermis, and gradual restoration of the skin to  its natural
state.
   Erythematous burn may be occasioned  by exposure to the heat of
the sun's rays in hot weather or hot climates, and particularly if the
part exposed be one usually covered by the clothes; or it may result
from the momentary action of hot water or  steam, or  from long sub-
jection to the heat of a fire.  The  erythematous burn produced by
insolation or the heat of the sun's rays  is" commonly called  ephelis
solans (irti 97X105, the sun); it  occurs chiefly in the summer season, and
generally in women and  children, or persons not habitually exposed
to the  sun's influence.  After the first effects of the erythema have
subsided, the epidermis becomes thickened, and  desquamates repeat-
edly ; the color of the skin changes to a reddish brown, which is more
or less permanent; and  the skin loses a part of its  sensitiveness to
outward impressions.
   Erythematous burn occasioned by the prolonged action of the heat
of fire on the skin, is illustrated in  an affection more common in France
than in this country, the ephelis  ignealis.   This  form of  ephelis is
known by a mottled or marbled appearance of the skin, occurring, for
the most part, on  the legs and thighs of women, and immediately re-
sulting from the heat of the charcoal brazier, or chauffrette, which they
use for warming themselves in the  winter season.  The mottled patches
are of a reddish brown color, partly owing to dilatation and congestion
of the capillaries of the skin, and  partly to increase of cutaneous pig-
ment ; and by  long continuance of the  habit, the mottling assumes a
deep brown tint.
  The constitutional symptoms of erythematous burn are insignificant 
AMBUSTIO.  BURNS AND  SCALDS.
287
or absent altogether, if the burn be slight, of small extent, or the indi-
vidual insusceptible; but, under the influence of opposite conditions,
particularly if the burn be extensive, the action of the heart may be
accelerated, and  there may be  more or  less  of irritative fever, with
gastric or intestinal disturbance.   When the head is the seat of  the
burn there may be sleeplessness and delirium, followed by coma and
death.   "Cases are related," says Dupuytren, "where  persons in  hot
countries, having gone to sleep  in the open air, have been so scorched
by the rays of the  sun that a violent inflammation of the skin  has
resulted, the inflammation has  been followed by gangrene, and they
have died on the fourth or fifth day."
   Vesicated burn (ambustio vesicularis), the second degree of burn
of Dupuytren, is indicated by  the development of vesicles (ambusta,
uritis) on  the inflamed  and erythematous skin.  The vesicles some-
times appear immediately, but more frequently after the lapse of a few
hours;  they  vary  in size, and  are filled with a transparent serum ;
occasionally a part of the epidemic is removed at the time of the burn,
and  then the local action is  more  severe, and results in suppuration.
The inflamed skin is  pervaded  with an intense  burning and smarting
pain ; and  as it becomes swollen, the pain is increased by a sense of
tension.  When the vesicles are broken  or rubbed off^ the excoriated
derma is acutely sensitive, and becomes quickly covered with a gelati-
nous and whitish film of coagulated lymph, which serves to protect it.
Sometimes, after the first symptoms are  past, the pain, swelling, and
redness subside, and  the skin,  after exfoliation of the  epidermis, re-
turns to its natural  state, without leaving any trace  behind; at other
times, and especially when the epidermis  has been removed at the time
of the burn, suppuration and sometimes superficial ulceration are  set
up, and the burn rarely gets well without leaving a cicatrix.
   The constitutional symptoms accompanying vesicated burn are more
severe than those of the erythematous kind ;  the shock to the nervous
system  being greater, and the chances of internal congestion more
probable ; moreover, the danger is increased as the subject of the acci-
dent is more  excitable and  delicate.  I once met with the case of a
young child who, standing before the fire warming its  hands, was
struck on the chest with a jet of boiling water from the spout of a tea-
kettle.  The inflamed spot  was little larger than a crown-piece ;  the
epidermis was raised into blisters.   Eleven hours afterwards the child
was seized  with convulsions  from  cerebro-spinal  irritation, and in
nineteen hours was dead.
   Gangrenous burn (ambustio gangrenosa) comprises the  third and
fourth degrees of burns of Dupuytren;  the third degree being that
in which  the papillary layer of the  derma  is alone destroyed;  the
fourth degree being  the destruction  of  the  entire thickness of  the
skin.
   The third degree of burn is distinguished by the presence of one or
more patches of a grayish white, yellowish, or brownish color, repre-
senting the dead portions of  the  papillary  layer of the skin;  the
vesicles covering these patches are filled  with a brownish, lactescent, 
288      DISEASES  FROM  SPECIAL EXTERNAL CAUSES.

or sanguineous serum, while those  on the erythematous  part of the
burn are transparent.  If the discolored patches be lightly touched,
they are found to be insensible, but if they  be pressed with any force
so as to act upon the parts below, the pain is considerable.  The pain
attending this form of burn is  always more severe than that of any
other kind, in consequence of the seat of  mischief being the most
sensitive  part of that organ of acute sensation, the skin;  and it lasts
for one or two days.  In three or four days after the  burn, the pain,
which  had ceased, is suddenly renewed, suppuration becomes active,
and  the process of separation, by which the dead is to be removed from
the living tissues,  is established.  When the ulceration  finally heals,
it leaves behind it a  cicatrix, which is white from the loss of the vascu-
lar layer of the skin, and more or less fibrous and  areolated, accord-
ing to  the depth in the corium, to which the burn had extended.
  In the fourth degree of burn the heat is prolonged, until the whole
thickness of the skin is burnt through; at first, the surface is dried by
the contact of the burning body, and the process of drying is continued
until the  skin itself becomes inflammable, and burns in the heat which
is applied to it.  The pain is excessive while the burning lasts, but as
soon as it is over, there is a  cessation of pain, on account of the entire
destruction of vitality of the injured part.  The eschar is dark gray,
or blackish and  yellowish  in color,  hard,  dry, and  insensible; and
being shrunk by the heat, draws the skin around it into puckers and
folds, the  latter  presenting  the erythematous and  vesicated forms of
burn.   In scald the  eschar is soft, pulpy, and gray.
  At the  end of three or four days the process of separation of the
slough commences, being ushered  in  by severe and acute pains, and
by the appearance of a broad erythematous band  around the eschar.
The eschar is loosened by an abundant suppuration, and at the end of
from fifteen to twenty days  is thrown oft", leaving a deep ulcer, which
heals up  quickly  by granulation.  The cicatrix  which follows the
healing of the ulcer  is indelible, and often a cause of considerable de-
formity, on account  of the contraction which ensues and the adhesion
of parts accidentally drawn  together.   It is well remarked by Dupuy-
tren, that this contraction rarely takes place on  the dorsal side of the
trunk  of  the body  and limbs, in  consequence of the  constant and
powerful  action of the flexor muscles.  In the neck, arms, hands, and
feet  it  is less uncommon.                         ,
  The fifth and sixth degrees of burn are simply more complete than
the  preceding, involving a  greater depth  of tissues in destruction.
They result either from a longer continuance or from a higher degree
of heat.  In the latter case the effects may be so rapid as hardly  to
occasion pain.  Roche, Sanson, and Begin, report the case of a young
man \m1io, having placed his foot in a gutter through which molten
metal was about to flow, was overtaken by the stream of liquid fire,
and on withdrawing his limb, found his foot and the lower part of the
leg gone,  without  having experienced any sensation of pain.
  The constitutional symptoms of gangrenous burn differ from  those
accompanying the erythematous and vesicated  burn, chiefly by the
faddition of certain secondary phenomena, which accompany the sepa- 
AMBUSTIO.  BURNS AND SCALDS.            289
ration and elimination of the dead portions of the skin.  Thus, in a
burn, we have to consider two  groups of symptoms,  primary and
secondary, the primary symptoms being those which result from the
shock done to the constitution; the secondary symptoms those which
are concerned in the reparation of the injury.
  The primary  symptoms are, cerebral and spinal  irritation,  conges-
tion of  the cerebral, thoracic,  and abdominal organs,  and internal
hemorrhagic effusions.
  The immediate agent in the excitation of the brain and spinal cord
is pain,  and the pain is sometimes so great as to destroy life at once,
particularly in children and persons of sensitive temperament.  Du-
puytren  was of opinion that the  pain might exhaust the nervous
system of  its vital spirits,  just as the heart and vascular system are
exhausted by excessive hemorrhage, and he distinguished these cases
as instances of mort par excls de douleur.   At other times, the pain, by
exciting  violently the brain and nervous S3'stem, may cause an imme-
diate and instantaneous  congestion of the  whole  of  the internal
organs of the body, the brain, the lungs and heart, the  alimentary
canal, with its cavities and  glands.  This  state, in fact, is met with
in  persons who have  been rescued dead  from  a conflagration,  or,
although living  at the moment,  have died immediately afterwards;
the brain,  heart, lungs,  and  mucous  membrane  have been found
gorged with  blood, extravasation has occurred in many places,  par-
ticularly in the  mucous  membrane, and  blood has  been effused by
exhalation into the cavities of the mucous and serous membranes.
This state of congestion is termed primary, from its occurrence at the
time of the injury, and to distinguish it  from those phenomena which
are the consequence of reaction,  secondary phenomena.  The effect
of  violent  congestion  of the heart is to  arrest the function  of  that
organ, and cause immediate death.
   In every case of burn, therefore, of  any extent,  we have to  deal
 with the shock to the nervous system, which may, as we have seen,
 exhaust life at once ; or by  excitement and violent stimulation of the
 nervous system, cause a rapid and serious congestion  of all the organs
of  the body.  In the  one  case we may find extreme prostration  of
 muscular power,  mental stupor,  cold skin and  extremities; small
quick pulse,  and slow respiration.  In  the other case we may have
excessive agitation,  mental excitement,  restlessness,   sleeplessness,
convulsions, and a high degree of fever.   In both, congestion of inter-
 nal organs may  occur, and  both  may be  speedily  fatal, or may give
way to more favorable symptoms; in the one reaction, in the other
calm and sleep.                            .
   The secondary symptoms  of burn, or those which belong  to the
reparative period, are such  as accompany  the development of inflam-
mation and suppuration for the removal of the injured parts,  and the
exhaustion which necessarily follows the suppurative process.  Ac-
cording to Dupuytren, there are four epochs  of danger in the course
of  a burn: firstly, the period of irritation ; secondly, that of  inflam-
mation ;  thirdly, that of suppuration; and fourthly, that of exhaustion.
The inflammatory reaction may be so severe as to give rise to a state-
       19 
 290     Diseases from  special external causes.

 of  general fever; th*e patient has a frequent and full pulse, the skin
 is hot and parched, the tongue red and dry ; there is thirst,  nausea,
 and vomiting, and every  indication of gastro-intestinal irritation,
 frequently complicated with cerebral and pulmonary congestion.  The
 limits of this  period are from  the  third to the ninth day.  After
 suppuration  is established,  serious internal  lesions may result from
 the absorption of pus; and during this period the internal congestions
 which have already taken place may undergo further morbid changes,
 and result in ulcerations, perforation of the duodenum, destruction
 of  tissues, and other dangerous consequences;  while the  period  of
 exhaustion, from a long-continued drain on the powers of the consti-
 tution,  is also a stage of considerable danger and anxiety.   Besides
 all these unfavorable conditions, the patient may be the subject  of
 erysipelas, or phlegmonous erysipelas, at any period of the progress of
 the injury.
   My friend, Mr. Grantham of Crayford, in Kent, has published a
 remarkable case of burn, in which several of the points of difficulty
 and danger here  laid  down are illustrated.1   The patient was  a boy,
 about seventeen years of age, who was burned by fireworks exploding
 in  his pockets; the burn  occupied nearly the whole of the trunk  of
 the body, destroying  the entire thickness of the skin, and offered an
 extent  of six  hundred superficial inches, equal  to four feet  twenty-
 four inches of  surface; and was a quarter of an  inch in depth. The
.jieriod of depression lasted forty-eight hours, being marked by coma,
 a rapid fluttering  pulse,  and coldness of surface; and reaction  was
 accompanied  by an  excitable state of the brain,  a pulse ranging
 between 150 and 200 beats in the minute, and an  irritable stomach,
 that  refused to retain fluids of  an}- kind.  This state continued for
 a period of  four days, and was succeeded for twenty-five days by a
 low typhoid form of  fever.   The fever then abated, and he gradually
 improved until the seventh  month, when he was attacked with bron-
 chitis, accompanied with sanguineous expectoration.   At the  end  of
 eighteen months he was able to walk a short distance, and then had a
 violent attack  of erysipelas, and was not finally cured until  nearly
 five years after the accident.
   The treatment pursued during the period of depression, was  opium,
 brandy, beef-tea with  arrowroot, artificial heat by  means of hot bottles
 to  restore the warmth of  the body, and  the  application of spirits  of
 turpentine to the edges of the burn.  During  the period of reaction,
 while the stomach was so irritable as to reject all flj.als, beef-tea was
 exhibited in the  form of enema; and shortly afterwards, bicarbonate
 of soda and compound spirits of ammonia were given in drachm doses
 by the  mouth, as the stomach would bear  them. During the con-
 tinuance of the typhoid fever he  was nourished with beef-tea, mutton
 broth, and port wine; and as the typhoid symptoms abated, was plen-
 tifully  supplied  with milk,  taking  on an average six  pints  within
 twenty-fours hours.

   1 Facts and Observations in Medicine and Surgery :  the gleanings of ten years of
 active general practice, &c.  Churchill.  1844. 
AMBUSTIO.
BURNS  AND SCALDS.
291
   The localtreatment consisted of linseed poultices with yeast; dusting
the separating  parts with powdered bark  and chalk; and when the
typhoid fever had abated, dressing the ulcers with spermaceti spread
on lint, covering the lint, with cotton wool, and then applying a roller.
   The attack of erysipelas, which occurred at the eighteenth month,
had the effect of enlarging the dimensions of the ulcer from forty-five
to one hundred and fifty inches; recourse was again had to opium in
small doses, and nitric acid; and after the subsidence of the erysipelas,
the healing progressed with rapidity.   By the end of the second  year
the ulcer was reduced in size to twelve inches ;  and by the end of the
third year  to one inch ; it now remains "  in a  passive state  for the
space of a year and a  half" before it finally healed.
   During the whole  process, Mr. Grantham remarks that there was
a greater or less  " tendency to congestion of the brain," which was
"relieved by  small bleedings, occasional saline aperients, and a strict
attention to diet, especially in reference to the use of stimulants, which
never appeared to be indicated."
   Of the cause and diagnosis of burn nothing need be said more  than
has been already related. The prognosis of the burn  is a question,
into the answer to which a number of considerations enter—namely,
its extent, both in breadth and  depth; its seat, .whether upon the
trunk of the body, the face, neck, or limbs; the age of the patient, his
constitution and  temperament; and the nature of the agent causing
the burn, whether fluid or solid, whether limpid or dense;  whether of
a moderate or excessive degree of temperature;  whether in the form
of steam or flame; whether combined with mephitic vapors;  and
whether instantaneous in its application to the skin, such as the explo-
sion of gas or gunpowder, or prolonged.   Again,  the question of prog-
nosis not only involves the consideration of the primary and secondary
dangers attendant on  burn, but also,  if the prognosis be favorable,
the nature of the cure; burns of the first, second, and  third degree
produce no deformity, but burns of the fourth degree are often followed
by considerable deformity, from  the contraction of the surrounding
skin, which ensues during healing, and the  adhesion  of parts (during
the granulating period) that ought to be kept separate. Thus, in burns
of the neck, the chin is liable to be drawn towards the chest, or to one
or other shoulder ; and in burns of the hands and feet, the fingers and
toes may be drawn out of their proper axes, and  the joints dislocated.
All things considered, therefore, the prognosis of burns is uncertain.
  Treatment.—The management  of burns and scalds presents two
indications  for immediate attention; firstly, to relieve pain, calm the
nervous system, and restore the circulation to  its normal standard;
secondly, by local applications, to supply a covering of defence, which
shall be soothing and agreeable to the injured part.
  The first of these  indications is  to be accomplished by means of
opium conjoined with  warm brandy-and-water, the dose to be  propor-
tioned  to the severity  of the suffering, and its repetition regulated by
the continuance of the symptoms.   The opiate to be preferred is the
liquor opii  sedativus, of which the dose may be fifteen minims; or in
the absence of the sedative solution of opium, the tinctura camphora? 
292     DISEASES  FROM  SPECIAL EXTERNAL CAUSES.

composita, two drachms;  or tinctura opii, half a drachm.   The seda-
tive may be repeated at the end of two or three hours, if necessary;
and the brandy-and-water as often  as  may be  requisite;  bearing in
mind that the  stage of depression will, if the patient survive, be fol-
lowed by a stage of  reaction, when an opposite method of treatment
will be  required.
   The best local application, where the cuticle  is  unbroken, is flour,
which possesses the additional advantage of being always at hand; it
should be thickly dusted over the burnt  or scalded part by means of
the dredger; a layer of wadding or cotton wool  should be placed next,
and then a bandage, lightly but firmly applied to prevent friction.
The purpose of the local application is threefold: namely, to cool the
heated skin;  to exclude the atmospheric air, which is always an irri-
tant to an inflamed surface; and to preserve the part in a state of repose
and defend it from pressure.   Hence  all meddling  is objectionable,
and the part once secured should not be disturbed, even although the
pain increase after the dressing has been applied.
   When blisters are formed they may  be pricked with the point of a
needle,  to prevent them from bursting  and causing excoriations; and
where excoriations exist, they may be covered  with a liniment of
olive oil and white of eggs  (pars 1 ad 2), or with the benzoated oint-
ment of oxide of zinc.  It  sometimes  happens, that  when the flour
has been on for some time, and particularly where  there has been any
■serous effusion from the vesicles, that it cakes, and becomes  hard and
uncomfortable to the skin.  In this case, the surface, and particularly
the crevices of the dried crust, should be moistened with the liniment
mentioned above; or with a liniment of lime-water and olive oil; or
lime-water and linseed oil (equal parts), and the whole covered with
lint, spread with the benzoated ointment of oxide  of  zinc, and after-
wards some cotton wool, and a light  bandage.
   In the third  and fourth degrees  of  burn, where a portion  of the
skin has been killed by the  heat, and  the  cuticle  is excoriated to a
greater  or less extent, while in the circumference, the injured part
presents the  erythematous and  vesicated degrees, the denuded part
may be pencilled with either of the  liniments already mentioned,
while the circumference  is  dredged  with  flour.  Then the  denuded
part should be covered with lint spread with zinc ointment.  Some-
times, with the idea of bringing back the vitality of the part killed by
the heat, or of preventing parts  which were  merely weakened from
adlijiy- into the state of gangrene, the stimulant properties of turpentine
are added to the remedy.  This may be effected by rubbing down a
little common turpentine with either of the above liniments ; or the
part may be dressed with the unguentum elemi compositum, after the
application of the simple liniment to  the skin.   It was upon  this
principle that Mr Grantham, iu the case  above narrated, bathed the
edges of the injured part with spirits of turpentine.
   \\ henever a burn or scald has been received  on  a  covered part of
the body, the clothes should be removed, and with extreme care, lest
the  cuticle be  rubbed oft",  and the part  excoriated;  and the part
being completely exposed to view, the flour dredger should be imme- 
AMBUSTIO.  BURNS  AND SCALDS.
293
diately brought into play.   It has  been recommended  immediately
a burn occurs, that the part should be plunged in cold water, and kept
there until the burning pain has subsided; this, however, can only be
done where a part of a limb is concerned; and there can be no objection
to it as a preparation for the flour application.   In burns or scalds of-
small extent, a poultice of the pulp of raw potatoes, or a poultice of
soap, are favorite popular remedies, and  perfectly innocent; but are
neither so pleasant nor so convenient as  the flour  dredging.  Again,
when the shock to the  system has produced  a chilled  state to the
surface, the moist  and cold applications would be objectionable, as
tending to aggravate that state.   Fabricius  and Sennertus used the
pulp of raw onions, in  combination with oil, soap, and salt; or oil,
white of egg, and salt, when the skin was unbroken, but omitted the
onion and salt where the surface was vesicated.   A liniment composed
of the whites of two eggs, two ounces of olive  oil, and  one of rose-
water, was esteemed a great secret in the time of Ferrarius, by whom
it was applied by means of  a piece of linen  rag; the  rag being kept
on  the skin, and saturated twice or thrice  a-day with  more of the
liniment.  The green  parts of the elder  were also much used, made
into an ointment with fresh butter.
   In illustration of the principle of securing an impermeable covering
to the  burn, and leaving it undistfrbed, a principle which I have
already advocated  in the treatment of eczema, I  may  mention the
remark of a house-surgeon  of a London  hospital,  emulous of distin-
guishing himself during his week  of service.  I met him one day at    *
the corner of a street, when he said: " I never left the hospital for an
entire week, and got nothing but a cut  finger and  six burns.  The
burns all died, with the exception of one, and  he  was the  worst;  he
had tumbled into  a vat of boiling soap.   When  he  came to the
hospital he was covered with the  soap, which had congealed on the
skin, and we could not remove it without bringing off the skin  at the
same time.   We could do nothing for him, so we left him alone; and
he  lived."  This brief commentary on  a  week's idleness contains
volumes for reflection and thought.  The poor man who fell into the
soap-maker's vat found  the wound and the antidote  at the  same
moment, he came out surgically dressed ;  the injury was  immediately
sealed up by the hardening soap, the air was instantaneously excluded ;
and although badly scalded, and  having  one of the  most  dangerous
of burns, that of a large surface, the whole surface of  his body in
fact, he lived.   Accident has given us  here  a lesson,  an  example, for
imitation.                                                  v-
  In burns of the third and fourth degree, where we look for inflam-
matory  reaction and subsequent suppuration for  the removal of an
eschar or slough, inflammation may sometimes run too high; and we
may find it necessary to subdue the inflammatory action  by means of
evaporating lotions, which may be applied externally to the immediate
dressing.  On the other hand, it happens most frequently that gentle
stimulation is necessary, to  quicken the flagging powers, of the skin,
and hasten suppuration, and the separation of the  dead parts.  In the
latter case we find a useful auxiliary in lotions of the chloride of lime
(3j ad 3viij);  in the compound ointment of elemi, or in the yellow 
 294     DISEASES FROM  SPECIAL EXTERNAL CAUSES.

 basilicon, the unguentum resina?.  Daniel Turner remarks, in reference
 to the manipulation of burns, that, " at this, if at any time, the lady's
 hand is required ;"  and, in reference to the class of burns now  under
 consideration, he observes,  " I seldom  found occasion to use other
 than my unguentum de lapide calaminari from  first  to last, which is
 anodyne, digests,  incarns, and  cicatriseth  to admiration ;" and he
 further lauds the uses  of the oxide of zinc,  under the magnificent
 name of Diapompholigos.
   After the period of depression, which may last for twenty-four or
 forty-eight hours, is past, and reaction is established, we may have to
 treat  constitutionally those  conditions  of  the  general system which
 accompany inflammation and congestion  of  internal organs.   We
 must have  recourse  to mild aperients, effervescent salines, and an
 antiphlogistic regimen ;  we may be required to abstract blood generally
 and locally, and contend with the various congestions as they show
 themselves.  In Mr. Grantham's  case, it will  be seen that he had to
 combat in succession  typhus fever, bronchitis  with  sanguineous ex-
 pectoration, erj'sipelas, and symptoms of congestion of the brain.  In
 the suppurative stage of the injury, where the powers of the consti-
 tution  are exhausted by a  long continued drain, it will  be found
 necessary to have recourse to a generous diet and tonics.
   Professor nebra, of Vienna, ias recently suggested for  the treat-
 ment of burns  and  scalds, as also for certain eruptions of the skin, a
 perpetual warm bath; and he has deposited at the International Exhi-
 bition of 1862  his apparatus for that purpose.   He mentions the case
 of a washerwoman, aged thirty-eight, "extensively burnt all over the
 body,  dermatitis ambustionis escharolica," who  was kept  in  the bath
 "during twenty-one  days, or 504 hours, without interruption, and
 left it perfectly healed of her sores."   And another, of a man twenty
 years old, who  had  received  a severe burn of his lower  limbs from
 falling into a lime-pit; he was placed in the bath apparatus, and  left
 there for twenty-eight days, or 672 hours, until the sores were perfectly m
 healed; the burn in this case had destroyed the vitality of  the skin'
 completely, and it fell away  from the parts beneath in charred masses.
 He also gives the case of a  boy  suffering under chronic pemphigus,
 who " was  kept for  100  days, or  2400 hours, in the warm bath appa-
 ratus,  and left  it only  when all symptoms of the  disease  had dis-
 appeared."  On a relapse taking place  some months afterwards,  the
 boy was again  placed in the bath at his own repeatedly expressed
 desi re.
   Professor nebra's bath apparatus  is a box, 6 feet  long by 3 wide,
 made of wood,  and  lined with copper or zinc.  Inside the box is an
 iron frame or stretcher, and upon the  stretcher is  placed  the bed,
 covered with a blanket, and furnished with a horse-hair bolster; while
 at two feet distance from the head of the bed is a back support, moving
 on a hinge, and admitting of being fixed by means of a simple piece
 of rack-work, at any angle that  may be agreeable  to the  patient;
 moreover, at each  extremity, the bed  is suspended by  two bands,
which  work upon rollers attached to the margin  of the box, and
enable the attendant to raise or depress the bed, and so alter the posi- 
GELATIO—FROSTBITE.
295
tion of  the  patient without  otherwise  moving him.  The supply of
water to the bath is obtained from  a copper boiler placed above the
level of the bed, and near its  head; the water flowing into the bath
enters at the bottom, and the escape pipe leaves it at the water level;
" the stream is kept constantly running, and  thus all impurities  are
rapidly washed away from the surface."  If it be desired to keep the
face continually wet, special  small tubes, with different roses affixed
to the boiler,  are provided for the purpose.
   The water of the boiler is intended  merely to secure a current in
the bath ; the bath is filled daily independently of the boiler with water
of the required heat, ranging from'90°  to 100° of Fahrenheit.  When
the patient  is properly placed  and the bath filled, the apparatus is
closed with a  wooden cover, and over this a woollen blanket is spread  ;
and if it be required to cover the head as well as the  body, a  small
frame constructed of hoops answers the purpose.
   Of the practical results of the process, as well as its theory, " the
application is too novel at present to permit of conclusive judgment."
The apparatus "requires  continual  attendance," to keep the tempera-
ture uniform and to secure the safety of the patient, "although there
exists not the slightest danger  that  the patient, in  sleeping, may run
the risk of being drowned."   During the  experiments  heretofore
 tried, nothing has  occurred  to suggest the apprehension of such a
 danger.
                             GELATIO.

                Frostbite.   Pernio.   Chilblain. Kibe.
   Cold in great severity, or applied for a long time  to the surface of
 the body, or  acting  upon  a  sensitive  constitution, produces local
 insensibility,  and may proceed to the extent of actual freezing of the
 part affected.   The first action of cold  is therefore upon the nerves of
 the body, and it attacks primarily those parts  which are  the  most
. distant from  the centres of  innervation  and circulation, namely, the
 feet, the hands, the ears, nose, chin, cheeks, and the surface of the
 body, extending from the surface inwardly to the more central organs.
 With the insensibility or numbness of the chilled part there is dimi-
 nished  or arrested  circulation, producing paleness and contraction or
 diminution of size, and there is.also loss of motion,  or stiffness.   The
 arrest of circulation and loss of power of  motion  are, however, con-
 secutive to and governed by the loss of sensation.
   Gelatio naturally presents every degree of severity, from the  mere
 chilling of a  very limited extent of the  surface of the  skin, consti-
 tuting chilblain, to  positive freezing and death of a part of the body.
 In the  one case there is a mere  suspension of vitality, in  the other a
 state ofi complete death.  So long as the state of chill is  progressive
 or persistent at the same point, the signs of gelatio are those already
 indicated, namely,  numbness or insensibility, paleness,  reduced size,
 and immobility; but when  the temperature  undergoes  a  degree of
 elevation, however slight, such as that which causes a thaw, then a
 new series of phenomena  are presented by  the congelated  part,
 phenomena which  are comprehended by  the term reaction.   Sensation 
296      DISEASES  FROM  SPECIAL EXTERNAL CAUSES.

returns, but the  sensation is of a  painful kind; a teasing itching,
where the chill is superficial, and  a burning tingling, or severe and
acute pains, where the chill has reached the deeper uerves.  Circula-
tion  also returns; the part becomes red, swollen, and hot, in the first
stage of reaction, blue and livid at a later period ;  in  other words, a
stao-e of inflammation  of t^he skin, or erythema, takes the place of the
previously pale and benumbed  condition of the part.
  But where the cold has been so  severe or so long continued  as to
destroy the life of the part, that  part  retains  the insensibility, the
coldness,  and the paleness of death;  while  the living parts  alone
take on the characters just mentioned—namely, the redness, the heat,
the swelling, and the  pain.  The redness of the skin terminates by
an abrupt  line, and  at this  line it  is, the line of demarcation, as  it  is
termed  in surgical  language,  that the  actions  which  result in the
separation of the living part from the  dead  take place.  The dead
part remains contracted  and  shrivelled, it  becomes dry and dark
colored, finally black;  and ultimately is thrown off, if it be superficial,
or drops off', if it be a part of a  limb.
  These being the general effects of cold upon the living body, we ,
may now turn  our attention  to  those  slighter degrees  of chill so
common and so troublesome amongst children and adults of weakly
powers of innervation and circulation, during the  winter season;
those minor troubles  which  go  by the  names of  perniones, chil-
blains, and kibes.
   Chilblains, like burns,  admit of division into three groups, which
represent so many degrees of severity of the affection:  they are, the
erythematous chilblain ; vesicated chilblain ; and gangrenous chilblain.
   The  erythematous chilblain (erythema a gelu), originating in
the lowest degree of cold applied to the skin, is not discoverable until
the stage of reaction is commenced.  A child may have  been exposed
to the cold during the day, and  in the evening returns  to a  warm
room, and a seat near the fire.  Then  for the first time  the chilblain.
declares its  presence, generally on the feet, on  the heels or on the
toes, or  on the  hands, by itching and  tingling; and if the part be
examined, it is found to be red and swollen.   The itching is incessant
and tormenting, and continues  until sleep overtakes the little victim.
In the  morning, or after  a few days, the chilblain has  a bluish and
livid appearance, resulting from  the establishment  of  a permanent
congestion of the part, dilatation of the capillaries, and retardation of
the  circulation ; the retarded circulation allowing time for the change
in  the  blood from its arterial to  its venous character.   In this way
 and under this form  the chilblain may be perpetuated during the
 continuance of the cold weather, fresh chilblains appearing from time
 to  time, giving  rise to swelling  and  tenderness  of  the feet, which
 prevent the  little sufferer from walking without  pain, and exciting
 fresh  attacks of itching  every time  an  alternation  of temperature
 from cold to warm occurs.  As already observed, the chilblains may
 seize upon the lobes of the ears, upon  the ears themselves, and upon
 the nose, or the prominent parts of the  face.
   The vesicated chilblain, or broken chilblain, is either an aggrava- 
GELATIO—FROSTBITE.
297
tion of the preceding, or the result of a greater degree of cold.  During
the continuance of the cold, it may be accompanied with a greater or
less  degree  of numbness;  and on  the change to a  more elevated
temperature, the pruritus, the swelling, and the  congestion are more
considerable.   The vesicated chilblain, moreover, has a purplish, livid
tint,  and the cuticle  gradually separates by effusion  beneath it, and
forms a  vesicle  or bulla of variable extent.   The contents of the
vesicle are a sanguinolent serum, and the surface  which  is exposed
on its bursting is either livid or variously mottled with red, blue, or
gray, the gray portion indicating the commencement of a slough.
Besides heat, tingling, and itching, the vesicated  chilblain is attended
with considerable pain, it  ulcerates to a greater or less  extent, and
prevents the child from walking.  Although not  dangerous, broken
chilblains are very painful and troublesome, often  lasting the greater
part of the cold weather.
  The gangrenous chilblain is rather a frostbite than a mere chill
of the surface of the  skin, like the  true chilblain.  The vitality of
the affected  part is destroyed by the cold, and  a  state of gangrene,
followed by the  separation  of a  slough, ensues.  The two  former
degrees of chill are unaccompanied by constitutional symptoms; but
the frostbite or gangrenous  chilblain is often associated with symp-
toms of general prostration and  congestion  of the  vital  organs,
particularly of the brain, and sometimes terminates fatally.
  Treatment.—The  treatment of gelatio and  chilbain is to restore
the innervation and circulation of the  part, and  to effect this resto-
ration gradually.  If reaction occur rapidly, and an active circulation
be set up in  the tissues  lowered in their vitality by the effects of the
cold, inflammation and probably death of the chilled structures will
ensue; the object of treatment is, therefore, to bring about a return of
sensibility and circulation  in the slowest manner possible.  To this
end the patient should be placed in a cold room, and  frictions made
on the part with the hand.   If the part be frozen, snow or cold water
may be rubbed upon it, to  thaw the frozen  tissues by degrees; then
the hand alone may be used, with a little starch powder, to prevent
attrition, and guard against the too great heat of the hand ; then some
mildly stimulating liniment may be used; and, finally, the part may
be enveloped in cotton-wool or flannel.
  With a common erythematous chilblain, all these precautions  are
unnecessary, but the general principle of management should be -the
same.  Frictions  with starch  powder, frictions with mild liniments,
then the use of stronger stimulants; and all with the view of bringing
back the normal circulation of the part, and restoring its tone, avoiding
always, and  as much  as possible, approach  to the fire.  One of the
most useful remedies for the above purpose is a liniment composed of
the white and yelk of two eggs, two  ounces  of spirits of turpentine,
and two ounces of distilled vinegar, well shaken together.  This lini-
ment may be lowered in strength, if thought desirable, by more vinegar;
or it may be increased in power and made more anodyne by the addi-
tion  of  laudanum, camphor, or chloroform; or  it may be rendered
more stimulating by the addition of ammonia.   If turpentine be  ob- 
298      DISEASES  FROM SPECIAL  INTERNAL CAUSES.

jected to, a liniment of camphor, ammonia, and laudanum (two parts
of camphor liniment to one of liquor ammonia? and one of laudanum)
may be preferred.  Sir Henry Harford was wont to prescribe soap
liniment with tinctura ly tta?, six parts of the former to one of the lat-
ter.  Dr. Turnbull recommended a tincture of cayenne1 to be rubbed
on the chilblain by means of a sponge, until tingling and  a feeling of
electricity were occasioned in the part.  Rayer suggests  a strong so-
lution (3j ad 3xvj) of alum; and Dr. Balfour, of  the Royal  Military
Asylum at Chelsea, uses, amongst the numerous boys under his care,
a mixture of equal parts of compound tincture of iodine and liquor
ammonia?, which  he causes to be painted on  the chilblains twice in
the day.
   The vesicated  and ulcerated chilblain are to be treated, according
to their state of activity or indolence, with the water-dressing applied
by means of Alison's impermeable lamb-skin; the  benzoated ointment
of oxide of zinc; the calamine ointment;  or some more  stimulating
remedy, such as an ointment of Peruvian balsam (5j ad 3j), the un-
guentum elemi, or ceratum" resina?.   In the broken state of chilblains,
Dr. Balfour prescribes, with great success, an ointment composed of
equal parts of ceratum resina? and spirits of turpentine.
   The gangrenous chilblain and frostbite are to be treated, after the
restoration of circulation in the sound parts, in the same manner as
sloughing and gangrene resulting from burns.
                     CHAPTER  XIII.

    DISEASES ARISING FROM SPECIAL  INTERNAL  CAUSES.

  The diseases assembled under this head, arising from specific causes,
those causes being internal and obscure, and presenting characters in
common with  each other,  namely, prominence  and permanence, are
five in number, namely,—
               Lepra,                Scrofuloderma,
              ^ Lupus,                Kelis,
                       Elephantiasis.
  Of these diseases, the least  degree of prominence  is met with ia
Lepra, which is  especially characterized  by the development  on its
surface  of  a scaly  covering;  hence, lepra is the type  of the order
squamae of Willan.  The other four, on account of their prominence,
belong to the order tubercula of Willan.  The whole of these dis-
eases are remarkable for their  chronic character and obstinate  resist-
ance of treatment.
  In previous editions of this book lepra was associated with two other

  1 R-—Cnpsici contusi ^j ; spiritus  vini rectificati §iij; macerate for a week, and
strain. 
         DISEASES  FROM SPECIAL INTERNAL CAUSES.      299

affections, namely, psoriasis and pityriasis, under the general head of
" squamous inflammation of the derma;" but longer experience and more
careful investigation have convinced me that lepra should stand alone,
the term psoriasis, which has been used indiscriminately for varieties
of lepra, and for  that kind of chronic thickening of the  skin which
often succeeds to  eczema and  lichen, should  be applied to the latter
only; and that pityriasis, which bears no relation to lepra whatever,
but is a mere  chronic erythema of the skin, accompanied with furfu-
raceous desquamation of the epidermis, should be carried back to the
erythematous  group. In fact, lepra  or not lepra? will in future be
the question to be determined  by diagnosis, and a vast quantity of
confusion will be  spared to the student of dermatology;  we may then
hear of the cure of psoriasis, a comparatively easily curable complaint,
without feeling the doubts which rise .to the mind when a lepra is
believed to be the disease in question; and by means which, in truth,
are not in the least calculated to make an  impression on lepra.
   A glance at the derivation  of the term psoriasis, supplies an addi-
tional reason for discarding it from  its connection with lepra.   Psora
is derived from the Hebrew word  tsorat, signifying venom or malig-
nity, and is a  generic term for  the worst forms of the leprosy of the
Jews.  The Greeks, in their translation of the Hebrew writings, gave
to the disease which tsorat represented, a  word  of their own, namely,
un^a, and dispensed with the term tsorat altogether, or so entirely mis-
appropriated it, that it lost  its original  signification, and " wandered
in search of a meaning."  It has since " had at different times, and by
different persons,  various meanings attributed to it; being sometimes
used to express  scaly eruptions generally, sometimes the  scales of
leprosy," l then the scaly state of the skin which accompanies scabies
(psora), and lastly, the scaly stage of chronic eczema.   With the latter
meaning, the word psora, with its altered termination, making it pso-
riasis, is used by Willan, Bateman, and  Mason Good.  Tsorat  and
psora are also the origin of our own popular expression, sore.
   The cause of the present group of diseases is obscure; it is, probably,
some poison present in the blood, engendered by conditions either ex-
ternal to the body, or within the economy itself.  Numerous observa-
tions have led me to the conclusion  that lepra originates in the syphi-
litic poison, the poison being  modified  by transmission through one
or more generations. Lupus, in some instances, is clearly referable
to the poison of syphilis; in others it seems to appertain to an affection
equally mysterious, namely, scrofula; and scrofula, I believe  to derive
one of its sources  from syphilis. Kelis  is allied with scrofuloderma,
often making its appearance on the cicatrices of scrofulous sores, or in
children suffering  under scrofulous affections.  The cause of Elephan-
tiasis is as much  a mystery, as deeply plunged in  obscurity at the
present day as it was before the commencement of the Christian  era,
when it made its first outbreak among the inhabitants of the  banks of
the Nile.  From Egypt it travelled through  Syria to Greece; from
Greece  it pursued a westerly direction  through Europe.   After ex-
1 Mason Good. 
300      DISEASES FROM SPECIAL INTERNAL CAUSES.

hausting itself in England, it  moved northward  into Scotland, from
Scotland to the islands of Orkney and Shetland; and at the present
moment rages with severity in Iceland, and on the coasts of Norway
and Sweden.

                            LEPRA.

  Syn.— Common dry tetter.  Circular dry tetter.   Diffused dry  tetter.
European Leprosy.   Alphos.  Lepidosis lepriasis.   Dartre  squammeuse.
Dartre furfuracee arrondie.  Herpes furfuraceus circinatus.   Herpes
squamosus.  Aussalz, Schuj^penflechte.
  Lepra (Plate XII.) is a non-contagious and chronic inflammation 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 epidermis.   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
replaced by successive formations.   The  local disorder is unaccom-
panied  by constitutional  symptoms; it  is most  strongly marked in
the neighborhood of the  knee and elbow  joints, where it frequently
forms  continuous  patches of  large size^Plate XII., G.) and endures
for a considerable  length  of time, sometimes recurring at  particular
periods  for several years,  and  lasting  for  several months at each
recurrence.
   The patches of lepra begin by small flat tubercles, of a brick-dust
red color, and very slightly raised above the  level of the surrounding
skin.   Like  the pimples of lichen, they  are developed around the
pores of the skin, and at their first appearance are only twice the size
of the  erected pores of cutis  anserina;  the diameter  of  the  latter,
when round,  being half  a line;  and when elliptical,  as  they com-
monly  are, half a line  in  breadth,  and three-quarters of a  line in
length.  Starting with a size of one line in diameter, the tubercles of
lepra soon attain their mature development, and measure two lines in
breadth.  The pathological element  of lepra is,  then, a small flat
tubercle, very little larger than  the papule of lichen, and occupying,
like the latter, the  mouth of a perspiratory tube or cutaneous follicle.
   Having reached its full  stage of completion, the leprous tubercle
may remain stationary, and become capped with its little white scale
of morbid cuticle,  bestowing  all its  power  on  the  production and
reproduction  of this  scale.   More  frequently,  however, it  excites
around  itself a little erythema,  and  more or less puckering and dis-
tension of the immediately adjacent epidermis.  It is now converted
into a small patch of from three to four lines in  diameter, consisting
of a central tubercle, and the slight  halo  of erythema and puckered
cuticle just described.   The eruption sometimes becomes arrested at
this stage, and constitutes the  form of lepra termed lepra guttata; the
small  slightly-raised patches, with  their little  white caps,  having
about the diameter and  somewhat the appearance of drops of  water 
LEPRA.
301
scattered over the  skin.  Sometimes the erythema extends a little
farther into the surrounding  derma, and attains a diameter of five or
six lines.  When this occurs, the included pores rise like the first into
tubercles, and the patch is found to be composed of two, three, four,
or five tubercles, the integument between the tubercles being erythe-
matous, and raised above the level of the surrounding skin, although
not so elevated as the tubercles themselves.  A similar result follows
when two, three, four, or five tubercles  occupy adjacent pores at the
same time; the patch is composed of a cluster of tubercles, but rarely
exceeds the diameter of half an inch.
  From this description, it will be seen that lepra guttata is lepra in
its most elementary form; the tubercles are dispersed  and isolated,
the presence  of a cluster of two, three, or more tubercles being the
exception and not the rule.  In a case of lepra guttata now before  me,
there are about eighty tubercles and patches, scattered over a surface
as large as  my hand ;  of this number, about one-third are isolated
tubercles,  from  one to  two lines  in  diameter; one-half are small
patches, three lines in diameter; while  the remainder  are clustered
patches, varying  in size from  four lines to  six  and seven.  The
function of the tubercles and patches is, as it were, consumed in the
production and  reproduction of thickened and morbid  epidermis,
which is cast  from time  to time in the form of scales ;  in other words,
their action is vertical and not peripheral.
  We have  next to  consider the same pathological elements, con-
joined with a  greater energy of growth, and a disposition  to peripheral
as well as to  vertical increase.  These are the characters which mark
lepra vulgaris, or, as I propose to name it, from  the rounduess of figure
of its patches, and to distinguish it from other forms of lepra, lepra
circinata.  Lepra  vulgaris consists  of  patches  of a circular  form,
varying in diameter from half  an inch  to  an inch  and a half or  two
inches, the common size being an inch, and composed of a cluster of
flattened tubercles, having separately a diameter of two lines.   The
patches of lepra vulgaris make their first appearance in a cluster, the
tubercles attacking adjacent  pores, and quickly becoming more or  less
blended with each  other.  As they enlarge the patch becomes more
or less uniform, but a certain unevenness of surface always indicates
their original composition of separate tubercles.  The patch of lepra
vulgaris enlarges  by its circumference, gradually  creeping into  the
sound  skin, and exciting as it goes  the  production of new tubercles,
and the fusion of these new tubercles into a rounded border of greater
or less elevation and uniformity.  As this peripheral growth proceeds,
the tubercles  in  the  centre  of the  patch slowly subside, and after a
time the skin assumes its normal characters.   The  patch  is now con-
verted into a ring, of  which  the dimensions of the area gradually
increase, while the  growth  of the  border continues, invading, as  it
proceeds, a greater extent of skin, but rarely exceeding the  dimen-
sions of an inch and a half or two inches.
  The arrest of growth of the periphery of the patch of lepra vulgaris,
and  the increasing dimensions of its  area, constitute  the stage of
dispersion  of  the eruption; the border becomes more and more  nar- 
302      DISEASES  FROM SPECIAL INTERNAL  CAUSES.

rowed as the area enlarges, and before long the ring itself gives way,
sometimes  at one  point, sometimes at several, the tubercles having
subsided, and the skin having resumed its normal appearance.  When
the eruption is seen at this period, that which a few days back was a.
ring is now changed to the figure of the letter C,  or, having yielded
in two  places, it represents two  crescents, or may be, having faded
further, only a single crescent or  a part of  a crescent.   Then, if two
patches have so increased that when  they  are converted into rings,
the two rings come into contact, we have the figure 8, or if both rings
have o-iven way, one on the one side, the other on  the other, the
figure Ts that of an S.  Again, if, instead of two rings, three, four, or
five,  variously  grouped, have become  connected by  progressive
growth, and have lost part or parts of their circles by dispersion, it
is clear  that a variety of curious and grotesque  figures may result,
one while,  resembling a chain, at another, astrological and necromantic
signs.  These appearances, the mere phenomena of dispersion of the
eruption, have,  to the confusion of dermatographic  science, received
the name of lepra gyrata.  The lepra vulgaris of last  month is a  new
species to-day, parading the distinction of a separate appellation.
   There are certain regions  of  the body that  belong especially to
lepra, where lepra frequently begins, where it exists  solely in some
instances,  and where  it lingers  to the last, when it has  dispersed
everywhere else; these  regions are the elbows  and knees.   If there
be any doubt  as to the  diagnosis of ah eruption,  look to the elbows
and  the knees; if it  db not exist there, and has not  visited those
regions, it is not lepra.  If a patient in Australia write to  his physi-
cian  in London, as has occurred to myself,  that he is troubled with a
dry,  scaly  eruption, dispersed over his body, and particularly trouble-
some on his elbows and knees, the diagnosis is  unmistakable;  pre-
scribe for  lepra; the rule is as certain and as free from exceptions as
any other  general rule depending on natural laws.  But the eruption
on the elbows  and the  knees presents a peculiarity, which is, that it
 obeys a regional or local law, with regard to increase, and not the
 specific  law  which governs the eruption  in  other  situations.  It
 invades the whole region, constituting a  patch  of large  size  and
 irregular  figure, in place of the  moderate size and  circular patch of
 other parts of the body.  This peculiarity is more conspicuous at the
 elbow than at the knee.
   Now, if we look into the structure of this broad patch, we shall find
 that, in consequence of  its size,  it has lost some of the characters of
 the smaller, rounder, and more  isolated patches.  It is, in  fact, an
 extensive cluster of tubercles of uniform size, less closely aggregated
 than in the circular patches, without the rounded  border which forms
 the circumference  of  the latter,  consequently without the  depressed
 centre;  and when  it disperses,  subsiding irregularly, the tubercles
 disappearing here  and there, without order,  and leaving islets of
 normal skin, and frequently yielding last of all at the point of the
 elbow;  although the law of  peripheral growth is  strong in  these
 larger  patches as it  is also in  the smaller, and the margin is not
 uncommonly the  last part to disappear. 
LEPRA.                          303
   Sometimes lepra assumes this diffused character as its general out-
 break, and entitles itself to the appellation of lepra diffusa.   The body
 is covered more or less extensively with patches of large size and
 irregular form, consisting obviously  of a large  irregular cluster of
 'tubercles of uniform size, scattered over the area of the  patch, and
 assembled with  greater or less order along its  margin.  There  is no
 sinking  towards the centre, because the central  tubercles persist  as
 long as those of the periphery, and the cure  of the patch takes place
 by the subsidence of certain of the tubercles here and there, and the
 clearance, as it were, of small spaces of normal skin.  It is true, that
 were we  to go further into the inquiry, we should find this apparently
 accidental subsidence of the tubercles in the midst of these patches,
 governed by  a peripheral law, each group of tubercles  obeying the
 same power as that which governs the entire patch;  but this is unne-
 cessary.   Now, the form of lepra which I am here describing is that
 to which the term psoriasis has been improperly assigned,  and from
 which  I shall endeavor to remove it.  I have already explained the
 derivation of psoriasis, and shown that its sole " locus standi" is that
 state of chronic thickening of the skin which sometimes follows ery-
 thema, but more frequently lichen agrius and eczema, in which  there
 is redness, thickening of derma, and  exfoliation of epidermis in scales
 of greater or  less magnitude.  But this state  of  skin, which is not
 unfrequently combined with the exudation  of an ichorous fluid,  is
 totally and entirely distinct from the clusters  of  tubercles of lepra;
 tubercles which never give forth discharge of any kind, and whose
 function  is the production of scales of a white, porous, morbid epider-
 mis, and not, as  in psoriasis, the  separation  and  exfoliation of an
 otherwise healthy  cuticle.  Again, by viewing lepra and psoriasis in
 their true light, we  are enabled to  understand how eczema may, by
 long continuance, merge  into  psoriasis, a most natural declension;
 but we  are not able  to  comprehend  this  natural phenomenon,  if
 psoriasis  is to be considered as  synonymous with lepra.
   The lepra diffusa is sometimes very extensive, involving, for example,
 an entire limb, and  with  its great extent it presents so obstinate a
 character, as to have gained for itself the appellation inveterata.  It is
 commonly termed psoriasis inveterata, but for reasons already given I
 think it more correct to name it lepra inveterata;  the thickening of the
 skin in this severe form of the eruption is often so great as  almost to
 obliterate the appearance of tubercles; and the formation of scales  is
 often excessive.
  The  tubercles  of lepra are an hypertrophy of the structure of the
 derma,  and with this general hypertrophy it is not uncommon to find
 the papilla? very considerably enlarged.  With hypertrophy of  struc-
 ture there is also an augmentation of function, hence the large accu-
 mulations of  morbid epidermis which occur in this disease.  If we
examine the scales of lepra with  attention, we  find  the epidermis of
which they are composed  to be whiter than natural, dry, porous, and
friable,  particularly at the circumference, while in the centre of the
patches they are frequently dense and horny.  If a scale  be raised
with care it will  be found closely  adherent to the  skin at its central 
304r      DISEASES  FROM  SPECIAL  INTERNAL  CAUSES.

part, and as this central  portion is lifted up, it  is found to be pitted
into numerous foveola? for the reception of the enlarged papillae of the
derma.  The  whiteness  of  leprosy  is, therefore, due  to  an  altered
epidermis, and the degree of whiteness is  referable to the greater or
less degree of thickness of that structure;  sometimes the whiteness is
dull, at other times metallic and silvery, and always very remarkable.
This character of lepra has gained for it the Greek appellation Alphos;
and for the guttated  variety the specific designation alphoides.  Lepra
is the Boak of the Hebrew writers, the dull-white leprosy ; so called to
distinguish it from  the  Tsorat or Berat Ubena, the Beras bejas of the
Arabians, the Lepra  leuce of the Greeks, the bright-white leprosy, or true
leprosy.  It is of lepra that we read in the thirteenth chapter of Levi-
ticus, that " if the leprosy have covered  all  his flesh, he (the priest)
shall  pronounce  him clean  that  hath the plague: it is all turned
white^
  The varieties of lepra are four principal, namely, guttata, circinata,
diffusa, and inveterata; and four secondary, two of which are general,
namely, nigricans and syphilitica,  and two local, namely, lepra capitis
and lepra unguium.  In  a tabular form they may be arranged as fol-
lows :—
     Lepra guttata vel alphoides,        Lepra nigricans,
 %     "    circinata  vel vulgaris,         "   syphilitica,
       "    diffusa,                       "   capitis,
       "    inveterata,         t          "   unguium.

                          LEPRA GUTTATA.

Syn.  Lepra alphoides.   Psoriasis  guttata.   Psoriasis discreta.  Dartre
        furfuracee arrondie, Alibert.   Weisse Aussatz, Germ.
  Lepra  guttata1 (Plate XII., c) occurs in  the form of small convex
and flattened scaly tubercles and  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 sprinkled upon the skin.   They are distributed  over
all parts of the body, particularly on the dorsal aspect of the limbs
and trunk, and upon the scalp and face.  The eruption commences by
small, red,  papular elevations or  tubercles, upon the summit of each
of which a small white scale  is developed.   The papula? 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 reddish and yellowish stain
for one or two weeks.  Sometimes the larger patches fade gradually
from the centre towards  the circumference, and assume  the annular
form presented by lepra  vulgaris during its progress towards cure.
  The eruption of lepra alphoides is  rarely  preceded  by symptoms
indicating constitutional disorder; if such  symptoms occur, they are
relieved by the outbreak of the eruption.  The local symptoms, as in

  1 Portraits of Diseases  of the Skin, Plate XV., AM, exhibits a good example of lepra
guttata, under its old and improper name of psoriasis guttata. 
LEPRA.
305
lepra vulgaris, are a trifling degree of pruritus when the skin is heated,
and at night.

                   LEPRA CIRCINATA VULGARIS.
Syn. Lepra vulgaris.  Dartre furfur acee arrondie.  Herpes furfuraceus
                        circinatus, Alibert.
 , Lepra circinata1 (Plate XII., a b) commences by small, smooth, and
prominent spots of a dull red  color, usually in the neighborhood 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 appearance, the*epots are covered with thin, whitish scales.  In
three  or four, days they have increased  in size, by the extension of
th#ir circumference, 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 thickness.  After
increasing gradually  in this manner to a size varying from that of a
four-penny piece to a half-crown,  the  eruption usually  becomes sta-
tionary, 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  grayish white  and silvery hue,  being* sometimes almost
metallic in appearance.   They are composed of thin  lamella?, which
gradually increase in size from the centre to the circumference,  so as
to project beyond each other in an  imbricated manner, a disposition
 which is marked on the surface  of the scale by a series of concentric
 hues.  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 color and  smooth,  in recent  cases;  and  rough,  papillated, and
 furrowed when the disease has existed for some time.   After their fall,
 the thin crusts are speedily  reproduced.
   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 on exposure Of
 the body to  changes of temperature.  When the patches are so exten-
 sive as almost or completely to surround a  joint, they are productive
 of some degree of stiffness.   The disease is slow in  its march, and
 usually continues for years,  sometimes for life,  rarely getting  well
 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.   Extending from the knee, the
patches appear in various points  upon the leg, as far as the ankle.
Willan  has  remarked, as a peculiarity of lepra, that it occurs in the
situation of a superficial bone,  as in  the course of the tibia, of the
crests of the iliac  bones, &c., and  less frequently on the muscular

  1 A good example of lepra circinata, under the name of lepra vulgaris, will be found
among my Portraits of Diseases of the Skin, Plate XIII., T.
       20 
306      DISEASES  FROM  SPECIAL INTERNAL CAUSES.

parts, as upon the calves of the legs.   The patches also proceed up-
wards  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 affects the scalp, it confines itself to the limits of the
hair, extending for a short distance only upon the neighboring skin.
In this situation  the disease is highly inconvenient, exciting much
pruritus, and producing an irritation which is  increased by scratching,
and followed by bleeding and crusts.  Nearly  the same inconveniences
attend  the affection when it invades the pubic region, where, in the
female, it is frequently  accompanied  with pruritus  pudendi.   When
the ends of the fingers are the seat of lepra, the formation of the nails
is disturbed; they are dry,  thickened, irregular and brittle; more«or
less separated from  the matrix, and have a yellowish curdy  matter
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 become 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 neighboring skin.   (Plate XII., D E F.)

                         LEPRA DIFFUSA.
   Syn. Psoriasis vulgaris.   Psoriasis confluens, Rayer.  Diffused
                            dry tetter.
  In lepra diffusa1 (Plate XII., h i) the patches are of large  size, very
irregular in their  form, and  of variable extent.  The  surface of the
patch is of a dull  red color, rough, and elevated above the surround-
ing skin, intersected by deep furrows, which correspond with those  of
the epidermis, and generally fissured by several chaps of considerable
depth.  The patches are surmounted by numerous thin scales of dried
epidermis, which are continually exfoliating,  and giving place to new
and successive layers.   The chaps  are dry, and covered by thin epider-
mal  scales;  they  frequently bleeu,  but very rarely pour forth any
secretion.  The patches are developed either by a number of small
tubercles, which  run together  and  form one continuously-affected
surface; or by several small patches, which speedily increase  in  size,
and coalesce.   In  either case the patches are two or three weeks before
they attain their complete growth ; and it frequently happens that the
eruption assumes  the character of small patches over the greater part
of the body, and of large ones around the joints.
   The eruption presents several  degrees of intensity  and extent;  it
may occur as a single patch of small or large  size, or there  may be
several; it 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.  The duration of lepra
diffusa is always tedious; in milder cases it continues for several weeks

  1 Portraits of Diseases  of the  Skin, Plate XIV., V.  Lepra Diffusa is represented
under the name of psoriasis vulgaris. 
LEPRA.
307
or months; while, in severer examples, it may be intractable for a
much longer period.

                       LEPRA INVETERATA.
  Lepra inveterata1 (Plate XII., i) is the most severe and obstinate of
all the forms of scaly tetter, and may be regarded as an intense degree
of lepra  diffusa.   It extends  over  a considerable  surface, usually
occupying the entire of the limbs, but sometimes spreading over the
whole body, with the exception of the palms of the hands, the soles
of the feet, and  the  face.  The  skin in this variety is  thickened,
congested,  and hot,  and there is more or  less pruritus, which  is
increased  and troublesome  during the night.  It is, moreover, dry,
harsh, stiff, deeply fissured by cracks and chaps, and covered with
epidermal scales, which are  produced  and thrown off in  abundance.
The harshness and  thickening of the  integument are sometimes so
great as to interfere with the action of the muscles and  movements
of  the joints.  When the surface is  abraded  by pressure, by the
violent use of the nails, or by any other  cause, some bleeding takes
place,  which discolors the scaly surface.
   In lepra inveterata of the scalp, the  scales collect in great number ;
and when  the nails  are  affected, they become yellow,  thick,  and
irregular; they are subsequently thrown off'  and replaced by shape-
less crusts.   The  duration  of lepra  inveterata is indeterminate ;  it
usually lasts for several years, and in old persons for life.

                        LEPRA NIGRICANS.
                  Syn. Schwarze  Aussatz, Germ.
   Lepra  nigricans  is a  form  sometimes assumed by lepra when  it
occurs in persons  of a  languid  and  debilitated constitution.  The
figure 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 brick-dust color, 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 an 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 nigri-
cans sometimes affects the scalp.
   Willan observes, that " the lepra nigricans affects soldiers, sailors,
scullermen, stage-coachmen, butchers,  brewers,  laborers,  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 labor are also
liable to this  disease.
   Lepra syphilitica.—Lepra syphilitica will be treated  of in the
chapter on syphilitic eruptions.

  1 Portraits  of Diseases of the Skin, Plate XVI., AO.  Lepra inveterata is repre-
sented under the psoriasis inveterata. 
308      diseases  from special internal  causes.

  Lepra capitis.—Among the special regions which lepra is apt to
attack, is the scalp, where it creates much irritation and considerable
inconvenience, from  the accumulation of scales which is apt to ensue.
It commonly extends  over the entire  scalp, and  to a short distance
beyond the margin of the hair, advancing  sometimes a little  way on
the forehead, but it rarely proceeds far, and never invades the whole
extent of the forehead  or the  face.  The  skin is thickened and red,
often torn by the nails, and the scales are thinner, and smaller, and
more furfuraceous in their character than on other parts of the body.
Lepra capitis is usually accompanied with patches of eruption on
other parts, and notably on the elbows and knees.
  Lepra unguium.—When lepra is general in its eruption, the nails
are very apt to become the seat of the disease, and undergo,  in con-
sequence, a  morbid  alteration.   At first there is an appearance of a
white deposit beneath thern ; this deposit increases, and then they are
separated from  their matrix to a  greater or less  extent, and  become
thick and rugged. Their color also is  changed;  they  are  yellowish
and tawny, are  apt to curve down over the ends of  the fingers, or
become brittle,  and are not unfrequently ragged and broken.   Some-
times they are separated entirely  from the matrix,  and  are cast off, to
be replaced by others equally deformed and unsound.

  Diagnosis.—The  pathognomonic characters  of lepra are,  the
circular  or circumscribed  form of  the patches, their elevated border
and  depressed  centre,  and their  covering of  well-defined   scales.
Their circularity of form  is traceable by means of  two or three
broken  arcs  of  circles, even when a number of disks have run toge-
ther and formed one  continuous patch of large size.
  Lichen circumscriptus, with its circular clusters of pimples fading
towards  the centre, may sometimes be mistaken for lepra in  process
of cure, but the identity of lichen is  established by the presence of
a few marginal  papula?;  whereas in lepra, the  inflamed surface,
denuded of its scales, is perfectly  smooth.
  Occasionally  we meet with cases of  chronic eczema and  chronic
lichen agrius, in circumscribed patches, in which it becomes very diffi-
cult to determine whether or not they belong to the leprous eruption.
These are, in  fact, the cases to which the designation psoriasis properly
belongs; and careful examination  generally determines  their  real
nature, particularly if there be several such patches; but  sometimes
the disease occurs in  the  form of  a solitary patch.  If there be no
eruption on the elbows and knees, a primct facie case is made  out against
lepra; and this is confirmed if there be any moisture or discharge about
the eruption.  The crust may resemble exactly that of irregular lepra,
lepra diffusa.  The  difficulty  is  increased when the lepra presents
itself in  an  irregular  form,  and when  it has become the  seat of
eczematous congestion, and pours out the peculiar ichorous secretion
of the latter disease.  The case is then one of lepra complicated with
eczema.
  Causes.—The cause of lepra is a special poison, the nature of which
is obscure.  I have stated  my belief, and I see no reason  to  change 
X
                             LEPRA.                         309

that opinion, that the  leprous  poison is  in  its essence  and origin
syphilitic; that  lepra is, in fact, a  manifestation  of  the syphilitic
poison, after transmission through at least one, and probably through
several  generations.   In examples of constitutional syphilis, we not
unfrequently meet with cases in which the resemblance between the
eruption and that of lepra is so exact, that we feel bound to accept
the term which  has been handed down  to us  by our predecessors,
namely,  lepra  syphilitica; but  lepra  syphilitica  differs  from lepra
vulgaris in this, that the former yields to the iodide of potassium and
mercury; but the latter is unaffected by those remedies.  Again, I
have published one example, and seen several, of a real lepra vulgaris
in the children of a man who was under my care for the remote effects
of syphilis, and who appeared, besides, to have had congenital syphilis.
These facts are worthy of observation, and will, at least, afford a clue
to the probable discovery of  the mysterious cause of this most mys-
terious and curious disease.
   Lepra is hereditary ; but, in some instances,  it may be very difficult
to determine its succession ; and sometimes it appears to be idiopathic.
When undoubtedly  hereditary,  it presents the curious phenomenon
of attacking only one out  <£ a  large  family, and  this without any
explanation being admissible;  it is  neither  the  strongest  nor the
weakest, the  youngest or  the  eldest child  that is afflicted.  In few
instances, comparatively,  two children become the subjects of the
disease where one of the parents suffers; and  in a case now before
me, I have a mother and  two children  all under treatment at the
same  time for  the same eruption.   Lepra is not  common  in child-
hood ; but I have seen it between  the fourth  and fifth year; it is
more frequent after puberty, but may be developed at any period  of
life, being rather a disease of mid-age than of either extreme.
   The eruption often makes  its appearance slowly and insidiously;
beginning by a  single^mall spot, which gradually enlarges, then other
spots appear; very sox»n it is found  on the elbows, and then a sym-
metrical  arrangement is observable.   Nerves from  the same centre
proceeding to opposite halves of the body, develop the same morbid
action in the parts  to  which they are distributed.  Sometimes the
eruption makes its first appearance  after an exciting  cause, such  as
mental agitation,  bodily fatigue, exposure to  wet  or cold;  a severe
illness, such as  scarlet fever;  or excess of any kind.  The exciting
cause is  simply  the spark which  fires the  pile,  already long prepared,
and only awaiting the power which is to give it life and activity.
  Prognosis.—Lepra will often get  well; sometimes spontaneously,
sometimes under  the influence of medicine; but lepra is  more com-
monly  a life-long disease.  Generally it is  periodical, making its
outbreak in the autumn and winter, and getting well in the summer,
when the skin is more active in its  functions.   At  other  times it  is
permanent, the  only change being some variation under the influence
of the seasons,  or of the  state  of health of the person.   I have  a
patient, a lady, the sister of an eminent physician, who comes to me
once or twice a-year for a little help for her troubles.   She has had this
vexatious complaint nearly fifty years.  It began in her girlhood, and 
310      DISEASES  from special internal  causes.

then she was consoled by being told that it would cease at woman-
hood; when womanhood came, and the disease was still there, she
was to look forward  to change of life as her period of cure; now she
requires no telling that the shroud alone will cure her complaint.  I
could multiply  examples, if such were  necessary.  Lepra is  not  a
disease on which to build a medical reputation.
  Treatment.—Unlike diseases originating in general causes, lepra
has no constitutional symptoms of its own, and its existence is per-
fectly consistent with a complete  state of health of the individual.
But as the leprous patient  may suffer from other diseases, these are
apt to constitute so many complications of  lepra, and may require to
be relieved before the special treatment is commenced, or at any rate
consentaneously with it.  One of the most common  complications is
that form  of  mal-assimilation which  gives rise  to  the  gouty and
rheumatic  diathesis,  and  this  is apt  to occasion  an inflamed and
painful  state of the eruption, and must be removed  before the real
treatment of lepra is begun.  It would be a mistake, however, to fail
to distinguish  between that  which is an accidental superaddition to
lepra and  the disease itself.  Not unfrequently, in the presence of
the gouty diathesis, the leprous eruptk a is  attacked  with a violent
erythema, and not uncommonly it throws out the ichorous exudation
of eczema.
  The treatment of  lepra, therefore, presents two  indications: firstly,
the removal of complications, together with the regulation of the as-
similative organs; secondly, the adoption of a course of specific  reme-
dies.
   The  complications of lepra  call for the same treatment that they
would receive independently of their connection with lepra; the treat-
ment, in fact,  which  is laid  down in the chapter  on  General Thera-
peutics and in that on Eczema; consisting of gentle aperients, salines,
bitters with alkalies, bitters  with  the  mineral jicids, colchicum,  &c.
Occasionally the effects of this treatment are very remarkable.   With
the improvement in  the general health, the lepra is always improved,
and sometimes will get entirely well without specific remedies.   The
practitioner must  not, however, in  this event, rush to the conclusion
that the remedies have cured the lepra, and will therefore cure it again.
If he endeavor to put such an idea to the test of experiment, he will
inevitably fail. The lepra, in his fortunate case, had reached its turning
point; it was no longer kept up by its own special cause, and was only
prevented  from healing spontaneously, as it  not  uncommonly does,
by the  constitutional disturbance then existing.  The medical man
allays the constitutional disturbance, and the lepra gets well, not by
the virtues of his medicine, but spontaneously.  It is the failure to
see this fact in its true  light that  imports  so many suggestions and
remedies into the treatment of lepra, remedies which flourish for a
week in the periodical in which they first appear, then probably lan-
guish for a year in some annual abstract  of delusive cures, and then
are forgotten  forever, and deservedly so;  not even leaving behind
them the appreciation of that small, thin streak of truth upon  which
they were founded.  A case of this kind happened to myself, which, 
LEPRA.
311
as it is illustrative of the treatment of lepra, I will narrate.   A gen-
tleman, the surgeon of a London hospital—of that great metropolis
that has hospitals for every disease, real or presumed, but not a ward
in all its magnificent hospitals for the instruction of students of medi-
cine in cutaneous diseases—called me to see  him during an attack  of
lepra, complicated with  excessive debility and mal-assimilation.  He
had been humoring the fancy of a young medical friend, and had been
bled somewhat largely, without any benefit, or other effect than that
of contributing considerably to his weakness.  He had suffered from
lepra for many years; but latterly, in consequence of the gouty com-
plications to which I have referred, his  attacks had been more violent
than usual.   Finding him so prostrate, that  he  had  already taken
aperient medicine, and that his urine was moderately'free from lithic
acid, while his tongue was large, pale and indented, I prescribed the
nitro-muriatic acid with gentian, and, as a local remedy to relieve the
excessive  irritation of surface, the oxide of zinc ointment.  At my
next visit, I found my friend better;  so much better,  in fact, from his
improved state of assimilation, that I did not think it necessary to see
him again.   At my first visit I impressed upon him the importance
of having an ointment prepared of perfectly pure  oxide of zinc; and,
to insure perfection in this respect, he had, he informed me, had some
sent to him from the hospital: I was curious to see what went by the
name of oxide of zinc ointment in  a  London hospital, and found stuff
only fit for the stuffing-boxes of  railway carriages.  It is thus that
ointments fall into disrepute, and an  opportunity is given to some
thoughtless  scion of "young physic" to exclaim, "Down with oint-
ments!"  " Down with all greasy applications!" But to return to my
narrative.   A few weeks afterwards  I was asked  by several medical
friends to communicate  to them a  discovery I had made in the cure
of lepra, a remedy that was attended  with unbounded success; neither
alkali nor arsenic.  I was a little  confounded- at first by this sudden
appeal, but, after a few questions, discovered the source of the rumor,
and remembered my always good friend, the  nitro-muriatic acid and
gentian.
  As a specific in lepra  there is  but one reliable remedy, and that
remedy is arsenic.  In  the chapter on General Therapeutics, I have
already expatiated on the merits of arsenic, which, in judicious hands,
is one of the best and safest remedies which we have in the pharmaco-
poeia.  Arsenic will cure lepra with certainty;  but neither arsenic nor
any other known medicine will prevent it from returning again; some-
times, after a thorough dispersion by arsenic, the  eruption never re
appears, but more frequently it recurs the following year, or after the
lapse of several years.
  The  pharmacopoeia is rich in arsenical  preparations, but  none ex-
ceeds in practical utility the liquor potassa? arsenitis, the solution  of
Fowler.  The dose of this preparation is five minims, to be taken with
meals three times a-day.   I frequently combine with it five minims
of antimonial wine, and  ten of tincture of ginger,  making the dose  of
the  mixture  twenty drops.   There is  some advantage, in unsteady
hands, in a mixture, of which a larger number than five drops is the 
312      DISEASES FROM SPECIAL  INTERNAL CAUSES.

dose; and probably if the dose were increased to  thirty drops, a still
greater accuracy would  be secured.  When the dose is limited to a
few drops, I order these to be  instilled on a fragment of bread, the
piece of medicated bread to be  eaten in the course of the meal.  By
this means I secure the  perfect  mixture of the arsenical solution with
the ingesta, and from  the comparative tastelessness of the remedy, it
is frequently preferred in this manner to any other; and to prevent
still further any  inconvenience from flavor, I  sometimes order the
omission of the tincture of lavender from the liquor arsenicalis.  If
preferred, the dose may be  taken  in  a little water, or in any fluid
drunk during meals,  but I endeavor to impress  on my patients the
necessity of taking the medicine in the middle or towards the end of
the meal.  To take it on an  empty stomach, or before a meal, would
be to invite its bad effects; on a full stomach it rarely disagrees.
  In certain exceptional cases there is a great intolerance of arsenic,
even in smaller doses than five minims,  and when those  cases come
before us,  we  must adapt our remedy to the idiosyncrasy  of  our
patient.  If five  minims be  too  much, we  must reduce the  dose to
four, three, or two.  Sometimes I find it convenient to exhibit the
medicine only twice a day, instead of three times; in  a word, coax it
in every possible way.  And  then, I never fail  to give the patient
instructions, that  if the medicine disagree in any manner whatever,
it is to be suspended  for a day or more, and afterwards resumed as
before.  I add  also to my instructions, that if the patient be out of
health from any other cause than the medicine, such as common cold,
&c, that then also  the medicine should be omitted, lest  the  morbid
symptoms  in question should be aggravated by  the  arsenic, or lest
indeed they may, unsuspectedly, have been promoted by it.
  In the chapter  on General  Therapeutics I  have  already enumerated
the various preparations of  arsenic known  to  us, and the symptoms
which are occasioned  by the  use of the medicine  in excess, or in too
large doses.  I may, however, in this  place, distinguish two or three
from the number, which may be employed in relief of Fowlers solu-
tion,  when this latter does not seem  to  agree with the  stomach, or
when for any reason a change of remedy is called for.  Next to the
arsenite of potash, I give a preference to the arseniate of soda, which
may  be administered  in powder or pill.  The dose of the arseniate of
soda is the eighth of a grain  three times a day, in combination with
guaiacum, or  with guaiacum  and the  oxysulphuret of antimony.1
After the arseniate of soda I  prefer the solution  of arsenic in hydro-
chloric acid, the solutio solventis mineralis de Valaugin, of which the
dose is from  five  to ten minims.   This solution is convenient for
giving  with  meals, as it harmonizes with the gastric juice, and has
appeared to me, in  some instances, to agree with the stomach better
than the alkaline solutions.
   In very chronic cases of  lepra, it may be found advantageous to
combine  mercury, and sometimes  mercury and  iodine with the
arsenic; and to meet  a  case of  this kind, we have the iodide  of mer-
1 See " Selection of Formulae" in the last chapter. 
LEPRA.                           313
cury, and  the triple  solution  of Donovan, the  liquor  hydriodatis
hydrargyri et arsenici.  The dose of Donovan's solution is from  ten
to twenty minims  three times a day with meals.   The  following is
Donovan's formula  for this preparation.1  Triturate of finely levigated
metallic  arsenic, 6.08  grains; mercury, 15.38 grains; and of iodine,
50 grains, with  one drachm of alcohol, until the mass be dry, and
changed  in its color from a deep brown to a pale red.   Next, triturate
the mass for'a few moments  with eight ounces  of  distilled  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
color, and each drachm*contains
          Water.........5j.
          Protoxide  of arsenic......gr. |.
          Protoxide  of mercury......gr. J.
          Iodine, converted into hydriodic acid   .    .    .  gr. |.
   Of the iodide of arsenic,2 the dose is  the tenth of a grain, and in no
instance has it admitted 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 pra?-
cordia, with  pain at the  epigastrium,  or griping.   If, besides  these,
there is tension, with an uneasy  sensation of stiffness 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 the  medicine
should be suspended for some  days.   If nausea,  cough, vertigo, or
salivation,  supervene,  it  should be left off altogether.  The employ-
ment 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."3
   Liquor potassa? and dilute nitric  acid  are among the remedies  for
lepra.  The former may be taken in doses of from one  to two drachms,
two or three hours  after a meal, three times a-day,  in  any convenient
vehicle, such as milk or beer, or in some medicinal infusion ; and is
not incompatible with  the arsenical treatment. The dilute nitric acid
is incompatible with the arsenical treatment, and may be adopted in
those cases  wherein the stomach evinces a great repugnance to arsenic.
The dose is, one or two  drachms  in  barley-water, sweetened with
sugar, to  be taken an hour before meals, twice or three times  a-day.
I have usually combined with this treatment a Plummer's pill at bed-
time.
  Other  remedies  for  lepra  recommended  from  time  to  time  by

  1 Dublin  Journal of Medical Science,  November, 1839, September, 1840.
  2 Dr. Anthony Todd Thomson's formula for the preparation of the iodide of arsenic
is, to take "seventy-five grains and a half of metallio arsenic, and six hundred and
thirty-one grains and a half of pure dry iodine ; rub them well together in a  mortar,
and sublime.  The salt is thus obtained, in the form of brick-red shining scales."
  s Commentaries on Diseases of the Skin, &c. 
314      DISEASES  FROM SPECIAL INTERNAL  CAUSES.

different authors are, tar, tincture of cantharides, iodide of potassium,
bichloride of mercury, and certain vegetable infusions or decoctions.
In the presence of so excellent and certain a remedy as arsenic, it is
difficult to find an opportunity for making trial of these medicines,
and it is only where arsenic is found to disagree with the stomach, or
as a change of  remedy, that I should be induced to adopt  them.   I
have  prescribed the Barbadoes  tar in capsules in some few cases, but
have  certainly not been impressed with its value;  and many patients
have  come to me uncured after a long use of tar, who have had the
eruption speedily removed by means of arsenic.   The cantharides may
be combined with Fowler's solution, where it may  be thought desira-
ble to employ it, as in those cases in which the kidneys appear to  be
torpid in their function ; but the tendency of this medicine to produce
inflammation of the kidneys must at the same time be borne in mind.
The  iodide of potassium and  bichloride of mercury, can only  be
regarded and employed as supplementary remedies or adjuvantia.
  The vegetable infusions and  decoctions which have  gained a repu-
tation in lepra  are  simply  to be regarded  in the light  of alterative
diluents, diaphoretics, aperients, and diuretics; they are mild  reme-
dies, and require to be  taken in considerable doses.  As assistants to
a more active treatment, and especially to the arsenical treatment, they
may be found of value; but alone, I should attach very little import-
ance to  their use.  The chief remedies of this kind are, the decoction
of dulcamara;  decoction of the woods,  namely, guaiacum,  sassafras,
and  mezereum; decoction of the arctium  lappa or lesser burdock;
decoction of elm bark; infusion of the urtica dioica, or common nettle;
and  infusion of the  galium aparine or  goose-grass.  The decoctum
bardana? or decoction of the lesser burdock, is made by macerating an
ounce of the root in twelve ounces of water, and then boiling it with
a slow heat down to eight ounces.   This quantity to be the daily dose.
  Local treatment for the cure of lepra is useless; but various indi-
cations present themselves which render  local treatment for  the relief
of irritation of the skin advantageous and necessary.  An erythema-
tous or  eczematous  state of the eruption, or a cracked and  fissured
state of the skin, will call for the use of the oxide of zinc ointment,
with  spirits of wine  or  glycerine.   Where the scales cover a large
extent of the surface of the body, a tepid soap bath or vapor bath is
indicated, and is  a source of much  comfort.  Various remedies are
found to give relief by occasioning exfoliation of the scales, such as a
lotion of bichloride of mercury; an ointment of  carbonate of potash,
of iodide of potassium, the white  precipitate ointment, the concrete
naphthaline ointment (3j ad 3J), or tar ointment.  For a dry and
parched state of the eruption the best application is a lotion of equal
parts  of distilled glycerine and rose-water.
  For the accumulation of sordes and scales which takes place in lepra
capitis, the best application is the  unguentum hydrargyri ammonio-
chloridi; and for the dry, horny, rugged, and loosened nails of lepra
unguium, steeping them in glycerine.
  But I must repeat, the local treatment of lepra is not to be regarded
as curative,  it is simply palliative; the cure must  come from within, 
LUPUS.
315
from that improved and altered state of the blood which results from
the proper administration of arsenic.


                             LUPUS.

  The term  lupus, or wolf, applied to a disease, is suggestive  of
destructiveness, and  doubtless took its origin in a form of cutaneous
affection  which is remarkable for its destructive nature, namely, lupus
exedens, called also, and for the same reason, lupus vorax.  Destruction,
then,  we may  take  as the leading character of lupus.   A further
inquiry into  the nature of lupus served, however, to show that this
destructive disease was  preceded by a circumscribed  thickeniug and
prominence of the skin, commonly termed a tubercle, hence, lupus is
considered as a tuberculous affection of the skin, and is placed in the
order tubercula of  Willan.  Now, the  destructive action  implied  by
the term  lupus, was,  in the first instance, intended to be restricted  to
that form of tubercle which commonly issues in destructive ulceration ;
but as cutaneous diseases  came to be more carefully observed, it was
perceived that  there  existed a kind of tubercle which did  not of a
necessity ulcerate, which  was chronic  and lasting in its nature, and
which, when  it disappeared, under treatment or spontaneously, left
behind it a  deep  pit or  a strongly marked cicatrix; this  tubercle
resembling the tubercle of the ulcerating lupus in many of its features,
and being unlike all  other forms of cutaneous disease, came therefore
to be  grouped under the head of  lupus, being distinguished from the
preceding by the  specific appellation  of lupus  non  exedens, or non-
ulcerating lupus. ' Destruction by ulceration and destruction without
ulceration are, therefore, the established characters of lupus.  Now,
experience  has  made us acquainted with a third form of disease,  in
which there is also destruction or atrophy of  the superficial structure
of the skin, but no ulceration and no  tuberculous  thickening; the
only other outward sign of the disease besides the atrophy being ery-
thema.  This form of cutaneous dise^pe has also been taken  into the
group of which lupus  is the head, and has  been distinguished  by
Cazenave under the name of lupus erythematosus.   I myself have noted
this latter affection, independently of the researches of Cazenave, and
finding it arise in some instances from syphilis, have described  it
under the name of syphiloderma  erythematosum  haereditarium.1  In
other  cases the syphilitic origin of the disease is not so clear, and in a
few examples I have been led to  regard it as a remnant of elephanti-
asis ;  hence, for the present at least, I  prefer to  leave the question of
cause-unsettled, and the affection  itself in the present group.
  The varieties  of lupus are, therefore, three  in number,  namely,
lupus  erythematosus, lupus  non exedens, and lupus  exedens.

  1 On Syphilis, constitutional  and hereditary, and on Syphilitic Eruptions, 1852. 
 316      DISEASES FROM SPECIAL  INTERNAL CAUSES.


                      LUPUS ERYTHEMATOSUS.

 Syn. Syphiloderma erythematosum hcereditarium faciei et capitis, Wilson.
                    Erythema centrifugum, Biett.
   Lupus erythematosus occurs upon  the face and head, principally
 on the nose and cheeks, in women, and sometimes in  men.  It makes
 its appearance in patches of  irregular  form and small size,  generally
 single, but often two or three in number; the patches are marked by
 erythema, the redness being greater near  the  circumference than
 within the  area  of the patch;  sometimes at the extreme edge the
 redness subsides by degrees into the tint of the surrounding skin ; at
 other  times  the  patch is bounded by  a slightly-raised,  wheal-like
 border.   In  recent  cases the wheal may have a delicate  purple-red
 hue, the qentral  area  being whitish and  opaque; in older  cases the
 redness  of the area is more confirmed.  The  area  of the  patch is
 always depressed,  apparently  from  exhausted  nutrition; the skin
 looks  dry and shrunken, as if its vitality were affected ; the cuticle is
 yellow and  horny; the  sebiferous pores  are  distended with  dry
 epithelial exuviae, the  sebiparous glands appear to  be in a state of
 atrophy; and the  term atrophied seems applicable  to the whole of
 the affected  skin;  it looks as if a fire had passed  over it, parched
 and seared.
   The patches of skin  affected with this disease are manifestly thinner
 than natural  from  interstitial absorption; if they occur among the
 hair, the hair follicles  are obliterated, and the hair  is permanently
 lost; if  they occur upon the nose, the  bones and cartilages become
 unnaturally prominent, and after a time the  skin has the appearance
 of  a cicatrix. When  the disease gets  well a  permanent  cicatrix
 is frequentlyxleft behind; at other times, when treatment has been
 adopted   early, the skin  may  regain  its  normal   thickness and
 appearance.
   The disease often  begins in a  very insidious manner, as in a young
 lady now before me, aged seventeen ; a small pale spot, the size of a
 split pea, made its appearance on the centre of the cheek four months
 back;  it attracted her  attention  suddenly, it gave her no pain, caused
 no irritation  whatever, but was obvious to the eye as a pale, flat, dry
 spot, perfectly smooth, and surrounded with a delicate purplish halo,
 abrupt towards the spot,  fading  into  the  surrounding  skin, and
 perceptible rather by its contrast with the pale spot,  than from any
 distinction between it and the general tint of the cheek.  Now, it has
 increased to the size of a shilling, by the formation around it of other
 spots  of  similar  character to  the first;  and the collective  patch
 presents  a  scalloped  edge,  marking  the  outer boundary of  six
 primary spots; while  at  the upper part, a  seventh  spot has formed
just outside the boundary of the existing patch.   How slight a matter
 it looks!  and yet this apparently trifling thing will  defy treatment,
 and possibly  may increase so as to be unsightly; or other patches of
 a similar  kind may form.  At  present it hardly seems a thing for
 medical  attention  or treatment,  and possibly would  not attract the 
LUPUS.
317
notice of any but the immediate members of the young lady's family,
or a medical  man who had directed  his  attention  especially to such
affections.  For what is it? a  small  pale spot with a scalloped edge,
a narrow halo of a delicate purple, like a blush of breaking day ;
and then the unchanged tint of the virgin cheek.  How ridiculous it
seems to look ominously at such a trifle, and to wish  that it were
something else of an infinitely worse appearance, in place of what
experience tells us that it is.
  Lupus erythematosus of the face is frequently accompanied with a
similar affection of the fingers, particularly in  young women.  The
erythematous spots or blotches are usually of a circular  figure, of a
purplish red  color, and  slightly raised  above the level of the sur-
rounding skin.  They vary in  size from two or  three lines to an inch
in diameter,  and gradually become depressed in  the  centre;  the
cuticle in the centre assumes a whitish,  opaque appearance;  gradu-
ally dries up into a thin, yellowish and horny layer, and desquamates
from  time  to time.  A  common  situation  of  these  blotches is  the
joints, and  they  are generally mistaken for  chilblains, until their
obstinate persistence  and their occurrence  in  the  summer as well as
the winter season render this diagnosis doubtful. They are generally
associated with coldness of the fingers and hands, which gives a color
to the suspicion of their being chilblains.  Like the similar affection
of the skin of the face, the special character of the disease is  atrophy ;
and in  a young girl  now  under my treatment, the atrophy  has
extended to the whole of one finger,  which  is conical towards the end
from loss of substance and contraction of the skin, and bloodless from
the tight clasp of the skin upon the phalanges.

                      LUPUS  NON EXEDENS.

                     Syn.   Vitiligo.  Leuce.
  Lupus non exedens1 (Plate XIII.)  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  diameter.  The  tubercles
are of a dull red hue, or salmon-colored, and  semi-transparent; and
not unfrequently 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 the finger is removed, they are blanched and flattened.
The epidermis covering the tubercles is, at the  beginning  of  the
disease,  smooth, but later, it cracks and  peels  off, and its white and
broken margins are apparent around the  circumference of the eleva-
tions.   When more than one tubercle  exists, they are usually found
clustered together, and 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 lobe of the ear, and on the arm and leg.
  The tubercles  of  lupus give  rise to  little  or  no inconvenience
1 Portraits of diseases of the Skin, Plate XLV., AC. 
318      DISEASES  FROM SPECIAL INTERNAL CAUSES.

beyond their appearance, and may exist  for months without under-
going 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 pre-
ceding, and being the cause of a repetition of  the  act 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 disappear-
ance of the tubercles is effected seems to be one of absorption.  There
is no ulceration, and yet the tubercles leave 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, salmon-colored,  and semi-transparent, the epidermis being
smooth, thin, and glossy.  Occasionally fresh tubercles  spring up on
this surface, and the disease  is  perpetuated. Sometimes I have seen
the patches covered by thick crusts  from the 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  there  are  no cicatrices.  The  epidermis 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 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 surface, they creep
along in one direction, as for example, across the face, or along the
limbs, checkering the whole superficies with a veal-skin  appearance.''
The veal-skin appearance relates to the  inside of the  skin of the
animal, an explanation without  which the text is hardly intelligible.
To the above comparison Bateman  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 the  skin, " a smooth shining surface, as if
polished, being left, and  a morbid whiteness remaining  through life.
The eruption never goes on to ulceration."  Now, all this corresponds
perlectly with the appearance of the area  of a circular patch of lupus
non exedens, or with the skin on which  its devastations have been
committed. 
LUPUS.
319
LUPUS EXEDENS.
Syn.  Herpes  exedens; Herpes  eslhiomenes; Noli  me tangere;  Dartre
            rougeante;  Esthiomene serpigineuse, Alibert.
  Lupus exedens1 commences, like the preceding, by a tubercle of a
dull red  color,-but harder and denser in structure than those above
described, and not transparent.   The more  frequent seat of the tuber-
c e is the nose, either the ala or tip, and sometimes the border of the
ala or the 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 desiccation 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 becomes concealed  by another and a larger scab, resulting from
the drying up of the ichorous and purulent secretion which is poured
out  on its surface.
  The ulcer, like the original tubercle, offers much difference in re-
spect of rapidity  of progress, being one while very slow, and another
while very speedy, in its devastating course.  When the latter ten-
dency exists, the entire nose has been destroyed in less than a month •
a character which is distinguished by the name of lupus vorax.   The
surface of the  ulcer of lupus exedens  is uneven, sometimes studded
with unhealthy granulations, but more frequently covered with white
patches of lymph.  Its edges are thickened and red, and  it frequently
pours forth a  considerable quantity of  a fetid, ichorous, and semi-
purulent fluid.
  When the ulcer of lupus exedens heals, the cicatrix is remarkable
for the white and corrugated bands, and the unhealthy-looking skin
described in connection with the previous disease;  and the recurrence
of the morbid  action  on  tlrese cicatrized spots is far from beincr un-'
common.
   The deformity which  results from this disease is sometimes quite
. distressing.  I have now before me a lady about thirty years of age,
 in whom the eruption has crept from each cheek across the face, de-
 stroying the nose completely, and producing so great an amount of
 contraction, as to draw the lower eyelids down upon the cheeks; and
 shorten the upper lip, so as to denude  permanently the gums of the
 upper jaw. ^ The lower segment of the eyeballs is completely exposed,
 and the conjunctiva congested from the irritation of the atmosphere;
 the situation of the nostrils is marked by two round apertures of small
 size;  the gums of the upper jaw are coated with sordes, and have re-
 treated from the teeth, leaving them unnaturally elongated.  On the
 cheeks and extending from the temples downwards to near the border
 of the lower jaw, the superficial ulceration continues, and over this
 has formed a very thick yellowish and blackish crust, which is broken
 into angular fragments of irregular form and size.
  Lupus exedens sometimes attacks the interior of the nose  and a
1 Portraits of Diseases of the Skin, Plates XLVI. XLVII., E, F. 
320      DISEASES  FROM  SPECIAL INTERNAL CAUSES.

fetid discharge precedes the extension of the disease outwardly; it
occasions much swelling.  The disease  also makes its appearance at
the angle of the mouth, or upon the upper lip, and sometimes on  the
cheek; and in these situations causes considerable tumefac'tion, with
redness of the surrounding skin.
  Lupus exedens is occasionally met with as a superficial phagedenic
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 ap-
pears in the annular form, leaving a circular island of unaffected skin.
When its tendency is to proceed inwards to the deeper tissues, the de-
vastation  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 remark-
able for deficiency of sensibility.

  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-look-
ing or deeply-pitted cicatrix, are pathognomonic characters.  To these
may be added, its seat; the nose, lips, eyelids and neck, being its more
common  situations.  Rayer observes, that " the solitary tubercles of
lupus exedens of  the cheeks have  frequently been mistaken during
their stationary period  for  small sanguineous  tumors  or na?vi."  I
have seen the tubercles of lupus non exedens  present  precisely this
character.
  Causes.—Lupus seems  to depend  upon a scrofulous taint of con-
stitution;  I believe hereditary syphilitic taint would be the more cor-
rect expression.  It  is  more common in women than  in men, and in
the lower than in the middle and higher classes of society.
  Prognosis.—Uncertain  and unsatisfactory; the disease is always
tedious, lasting for  years  or  for  life, and resisting  often  the  best
planned  treatment.  The indolent  form is  more  favorable than the
active kind.
  Treatment.—The treatment of lupus, whatever form it may assume,
presents  two indications; firstly, to remove the local disease;  and
secondly, by alterative tonic remedies, to improve the  general state of
health, and, if possible, act specifically upon the  skin.
  For the lupus erythematosus I have found the liquor plumbi diacetatis,
pencilled  on the part night and  morning, a good  remedy, as also  an
iodide of lead ointment containing two parts of the salt to  one of lard.
Other local remedies applicable to this case are the oxide of zinc oint-
ment, alone or in combination with glycerine, and the ointments of
nitric oxide, and nitrate of mercury.  As a constitutional remedy after
regulating the system by general means, I give the preference to the
liquor hydriodatis hydrargyri et arsenici, in doses of ten or fifteen
drops with meals  three  times  a  day, and accompanied with the  cod-
liver oil, in doses varying from one drachm to an  ounce, taken directly 
LUPUS.
321
after meals, twice or three times a day.  Cazenave recommends sudo-
rifics internally, particularly guaiacum ; and, locally, tar ointment, or
the iodide  of mercury combined with olive-oil, in the  proportion of
half a drachm to the ounce;  to be pencilled on the eruption daily or
every other day.
  For lupus non exedens the same constitutional treatment may be pur-
sued as for  the preceding; varying Donovan's  solution with Fowler's
or De  Valangin's solution,  and  with the  protioduret of  mercury.
Locally the tubercles may be destroyed by the chloride  of zinc, nitric
acid, or potassa fusa ; taking a few tubercles at a time, and  prosecut-
ing their destruction until all are removed.  In cases where the tubercle
is single or  occupies a small extent of surface, removal by these means
is generally successful.
  In lupus  exedens the -constitutional remedies and mode of treatment
are the same as for lupus non, adding the bichloride of mercury, which
is sometimes of great service.  The local treatment must consist of
caustics, which destroy the surface of the ulcer, and excite a new and
more healthy action.  The caustics the best suited for this purpose
are, the strong  nitric acid, the potassa fusa, or the chloride of zinc.
The nitric acid is to be made into a moist paste with the sulphur pre-
fsipitatum of the  pharmacopoeia,  and applied by  means of a small
wooden spatula.   The  potassa  fusa may either be  used to touch the
surface of the  ulcer, or made into a paste with  quicklime; and  the
chloride of  zinc may be made into a paste, with the addition of two
or three parts of flour to one of  zinc.  The Vienna paste,  which is
sometimes  employed for  this purpose, is composed of equal parts of
potassa cum calce and quicklime,  mixed to a proper consistence with
spirits of wine.  An arsenical  paste, consisting of equal parts of arsenic
and animal charcoal, has also been recommended; and an  arsenical
powder, bearing the name of Dupuytren, composed of one part of
arsenic mixed with two hundred  parts of calomel.  The chloride of
gold and acid nitrate of mercury have also been mentioned as suitable
caustic applications.  The nitric acid paste may be left to dry  on  the
part; the Vienna paste takes from ten to twenty minutes to produce
its  proper  degree  of effect, and frequently requires to be guarded
from contact with  surrounding parts by means of  a piece of plaster;
and the chloride of zinc paste may be allowed to remain undisturbed
for from four to eight hours.   The  arsenical caustics are dangerous
from liability to absorption of the mineral poison.
  After the caustic has been on for some hours, or when  removed, the
ulceration may be  treated with water  dressing, either with  oiled silk
or with Alison's prepared lambskin, or with a dressing of the benzoated
ointment of oxide  of zinc, or liquor plumbi, or calamine ointment.
  M. Lemery, of  St. Louis' Hospital, finding the ordinary  remedies
for lupus so little successful, had recourse to cod-liver oil, of which he
speaks in the most encouraging terms.   He begins with the dose of
an ounce three times a day, increasing the quantity for fifteen d#ys,
by which time he reaches six ounces a dose.  If the disease exhibit no
indication of submission, he goes on till he arrives at two pints in  the
day. Should the  stomach revolt, a glass or two  of seltzer water is
      21 
322      DISEASES  FROM SPECIAL INTERNAL  CAUSES.

given ; and if any symptoms of derangement of the alimentary canal
or fever supervene, the oil is suspended, but commenced again at the
minimum dose as soon as the symptoms disappear.1
   M.Devergie, M.Lemery, colleague in St. Louis, states thatM. Lemery
has over-estimated the benefits of cod-liver oil; but that in the ser-
piginous form of the disease, before ulceration has commenced, he has
undoubtedly found it of service.   He mentions the iodide of iron with
favor; and, as an application to the ulceration, the oil of juniper applied
every fourth day.  The tubercles he treats with caustic.2


                      SCROFULODERMA.

   Cutaneous scrofula presents itself to our notice in two forms, namely,
that of tubercles, and that of ulcers.
   Scrofulous tubercles are of small size, indolent, of a purplish or
livid color;  they soften internally, open and give exit to an imperfect
pus, often remain open or fistulous for a considerable time ; and when
at last they finally disappear, frequently leave behind them a hard knot
in the skin.  They are most commonly met with on the neck and face,
and in the neighborhood of ulcers or the remains  of  ulcers resulting
from inflammation of the  lymphatic glands.  These tubercles increase
so slowly in size, that they are often several months before they attain
maturity, and, if of  any bulk, are apt to open at several points, the
result of softening of separate parts of their structure; and when these
openings take place successively, the tubercles continue in  a fistulous
state for  many  months longer.   When  the  softened contents  of the
tubercle have been  partially discharged, that which ''remains forms a
crust over the aperture, and when the crust is from time to time dis-
turbed or displaced, a fresh exit of ill-formed pus or ichorous fluid
takes place, and the opening continues for an indefinite time, without
showing any disposition to heal.   When the healing is at last accom-
plished,  an ugly scar or cicatrix is  often left behind.
   Scrofulous  ulcers  may be the result  of cutaneous  or subcu-
taneous abscesses, and may vary  considerably in their depth ; like the
tubercles already described, they are extremely  indolent, their edges
are  purplish and livid;  they throw up no granulations, or, if any
appear, they are of a flabby and  unhealthy character; they  emit an
ichorous, almost colorless discharge; are  often fistulous, and either
resist  healing  altogether, or  heal  slowly and imperfectly,  leaving
behind them a livid or purplish scar of irregular form and puckered
and rugged surface.  Scrofulous ulcers are most commonly met with
in the neck, near enlarged lymphatic glands, and in  the neighbor-
hood of joints.
   In scrofulous subjects,  particularly in  young persons, it  is not un-
 common to find an inflammation of the matrix of the nail, scrofu-
 loderma ungueale.   The disease begins by  inflammation and  swelling
of #he skin immediately around the edges of the  nail, the extremity
of the finger swells considerably, and becomes vividly red ;  and the

   1 Revue Medioo-Chirurgicale, vol. iv.         2 Bulletin Therapeutique, 1848. 
scrofuloderma.
323
scrofulous hypertrophy frequently extends to the whole of the tissues
of the part, even to the bone, producing a clubbed finger.  The nail,
after a time,  becomes separated, and  leaves an  angry-looking  raw
surface, upon which a rugged, ill-formed, and imperfect nail is from
time to time produced.  The denuded  derma, covered with  fungous
granulations, secretes more or less of an unhealthy  pus, and the disease
is kept up for a considerable length of time, often for many months.
  With these manifestations of scrofula in the skin, it is common to
meet with other indications of the existence of constitutional scrofula
in other parts of the system, such as enlarged glands, enlargement of
joints, swelling of the upper lip, accompanied with  a  chapped  and
fissured state of the skin, and indolent abscesses.
  Scrofulous tubercles commonly occur singly,  sometimes a group of
three or four  appear in close proximity, and sometimes the 'morbid
action spreads in an annular form upon the surrounding integument,
leaving an area of thin, shining skin, or a livid or purplish color.  I
have met with rings of this kind, chiefly on the  back  of the hands
and feet, where they are peculiarly intractable.  The  tubercles are
disposed in an irregular manner around the circumference of the ring,
and often only along a segment of the circle; they  become  more or
less blended together, and they present in a mass the characters which
have been described as belonging to  individual  tubercles.  They  are
covered  more  or  less   completely  with yellowish or dark.-colore 1
adherent crusts; and when these crusts are removed, the surface looks
worm-eaten and papillated, and the small ulcerated hollows are filled
with an unhealthy looking pus.
   The treatment of scrofulous tubercles and scrofulous ulcers  calls
for judicious constitutional  management, as well as local remedies.
The four great hygienic principles, air, exercise, temperature, and diet,
all require regulation.   The  diet of  scrofulous  persons should be
generous, embracing as much meat as possible, and a fair proportion
of stimulus;  while appetite and digestion should  be promoted by air,
 exercise, and a genial atmosphere.   The medicinal remedies are, the
 whole family of tonics, including iron, iodine, and cod-liver oil; and
the local remedies, mild stimulants.  The tubercles may be destroyed
by nitric acid or chloride of zinc, and  afterwards dressed with some
mild digestive ointment, such as the unguentum elemi or unguentum
balsami peruviani; or with  a soothing and healing ointment, such as
that of the benzoated oxide of zinc.  Scrofulous  ulcers also require
a digestive and moderately stimulant treatment, and are generally
greatly benefited by pressure, as by  a dressing  of adhesive straps,
and, where the part will admit it, by the  application of a  bandage.
For the scrofuloderma ungueale, nothing answers so well as  the  ben-
zoated ointment of oxide of zinc, either alone or  in combination with
 Peruvian balsam.
   At the recommendation  of Mr. Peter Price, I  have employed the
 iodide of ammonium  with advantage, using it  at the same  time
internally and externally.   For internal exhibition  the dose is two or
three grains,  twice or three  times a-day, in any suitable vehicle,  such
as the compound fluid extract of sarsaparilla, or syrup of orange peel. 
324      DISEASES  FROM  SPECIAL INTERNAL CAUSES.

And for external use a convenient formula is one drachm of the salt
dissolved in  an ounce of glycerine, and  applied with a camel's  hair
brush to the enlarged glands night and morning.

                             KELIS.
  Kelis, like  lepra and  lupus,  probably originates in a  specific
poison existing in the blood, the nature of the poison being obscure
and unknown.   The disease makes its appearance in the form of an
elevated thickening of the skin or tubercle, increases in  dimensions,
and when two or three tubercles occur, they are apt to become blended
and form an  elevated and flattened  mass, often of considerable size.
Sometimes the tubercle or tumor  is isolated  and single;  more fre-
quently there are  several, and sometimes they are  sprinkled nume-
rously over the skin.  When their  development  is  complete, they
remain stationary for years, and sometimes subside and disappear; they
may attack either the deep or the superficial stratum of the derma,
and appear to select  for their pathological seat  the fibrous element of
the skin.  When the deep portion of the corium is the seat of the hy-
pertrophous growth, the surface of the skin is little affected ; but when
the disease invades the superficial stratum of the derma, the papillary
layer  of the skin is  absorbed, the  blood of the capillaries  is driven
back upon the  larger branches of arteries and veins, and the white
fibrous structure of the  corium is seen through the soft, velvety,  and
semi-transparent layer which  constitutes the surface.  The tubercles
of kelis have  no tendency  to ulceration, and rarely terminate by
absorption.
  Kelis admits  of  a  division into two kinds, according to its  seat of
origin, in the sound skin, or in a cicatrix left by some previous injury
to the skin, such  as a burn or ulcer.   In the former situation it is
termed the true kelis, kelis vera; in the latter, kelis spuria.

                           KELIS VERA.
Syn.  Kelois.  Chelois. Cancrois. Kehides.  Kelis vera ; genuina ; ovalis;
  radiciformis;  cylindracea; clavata.   Dartre de la graisse.  Der Knol-
  lenkrebs, Germ.
  The disease of the skin termed kelis, was first particularly described
by Alibert, who distinguished it by the name of "cancroide;" assigning
as his reason  for selecting that term the judicious practice of early
observers, of designating diseases by the  names of the things which
they most nearly  resembled.  The  word "cancroide"  is therefore
intended to  draw  the attention to a  supposed resemblanee in form
between this  disease and a crab, and is synonymous with " cheloide,''
derived from xn^n, forceps cancrorum, the term used by Rayer and
Gibert,  by reason, remarks  the latter, of the likeness which the pro-
longations of the  tumor bear to the feet of the crab.   Another name
given to this affection,  and one which I regard as most correct, and
have therefore  adopted, is kelis, derived from  Xrp\i.s, macula, vel pro-
brum; this term having reference to the singularly cicatrix-like appear-
ance which the disease so frequently presents. 
KELIS.                          325
  Besides the preceding, Alibert had  another reason  for employing
the term "cancroide"—namely, that of associating this disease with
cancer.   The cancroids,  he observes,  maintain a relation  both with
tetters and cancers; like  the latter, they often  give rise to acute, pun-
gent, and lancinating  pains;  and he asks, "Will they form an inter-
mediate genus ?"   This is a more important question than that of the
etymology of the disease.
  It is quite  true that in many of their features  the keloids have a
remarkable resemblance to cancer,  for example, in  their hardness,
whiteness, the meandering of small veins on their surface, the total
disorganization of the  skin, their extension into the deeper parts of
the skin by root-like prolongations, and, above all, in the acute, burn-
ing, smarting, and lancinating pain with which  they are frequently
attended.  On the other  hand, it must be admitted, that they'rarely,
if ever,  pass spontaneously into a state of ulceration; they have none
of the large  and tortuous veins which surround a cancerous tumor,
the adjacent skin is wholly unaffected,  the  lymphatic  glands are not
implicated, the tumors are extremely slow in  their progress,  often
stationary for years, and  sometimes they disappear entirely.
  Cazenave and Schedel remark, that the kelis  should be " carefully
distinguished from cancerous affections, with which, in  truth, it has
very little analogy."  Rayer says, that " keloid formations do not seem
to have  any deleterious influence on the general health."   Dr.  Warren
calls it  a "troublesome and dangerous disease."  Troublesome it is
certainly, but I do not consider it dangerous; and I am of opinion
that the case upon which Dr. Warren founds his inference of the dan-
ger of kelis was not an instance of.this disease, but one of cancer.  He
states that it affected the ala of the nose; that, after several extirpations,
" a considerable  tumor appeared on  the face, and  another under the
jaw,"  while, a fortnight after,  " a tumor is seen  extending from the
right eye and side of the nose to the cheek, where there is a frightful
enlargement, including all the textures of the face and gums."
  According to the admission of all writers on the subject, the disease
is rare;  so much so, that  the total number of cases which I have suc-
ceeded in finding recorded, amounts  only to twenty-four;  whereof
twelve are reported by Alibert, five by Rayer, three by Biett, two by
Gibert, one by Dr. Warren,1 and one by Dr. Peace.  To this number
I may add seven that have occurred in my own practice.2
  Of  the twelve  cases reported by Alibert, eight occured in women.
From  this circumstance  he was led to deduce the inference, that the
disease was more  common in females than in males.  Five out of my
seven  cases, on the contrary, were males;  while four out of the five
mentioned by Rayer were also males.   Of the entire twenty-seven, the
sex is unmentioned in three;  and of  the  remainder,  fourteen  were
females and ten males.
  The cause of  kelis must evidently be sought for among those con-

  1 The second case reported by Dr. "Warren appears to me to be an instance of car-
cinomatous disease rather than of Kelis.
  2 Subsequent experience enables me to estimate the proportion of cases  of kelis to
other cutaneous affections at about one in two hundred. 
326      DISEASES  FROM SPECIAL INTERNAL CAUSES.

ditions of the constitution, whatever they may be, which give rise to
lupus and cancer.  In five of my seven cases there existed no known
cause,  and the same may be said  of the  majority  of the  examples
reported by other authors.  In four only of the twenty-seven cases is
anything like a remote cause established, and  that  of so  trivial a
nature as to be obviously inadequate to the production of so grave a
disease.  In one of Rayer's cases, the tumor sprang from the cicatrix
of a burn received in childhood; in another, it arose from the cica-
trices  of smallpox;  and in a third,  from the  cicatrix  of a small
punctured wound; while, in  one of Alibert's  cases the remote cause
was a slight scratch.  Of the two instances in which I was enabled to
trace the growth to a cause, I found one to result from the application
of irritating substances to the skin; and the other to originate on the
seat of application of a blister.  From this circumstance I felt inclined
to classify these two  cases with others which are seen more frequently,
and  which are termed " false kelis."  These  latter  may  always  be
traced to some local  alteration of the skin, such as a cicatrix.
   With  the exception  of one of Alibert's cases, I find no reference
made to any hereditary disposition to carcinomatous disease;  in the
instance in question, a sister of the patient died of cancer uteri.  The
mother  of one  of  my patients  died,  he  informs  me, of a similar
disease, but I can trace  nothing of the kind in the families of the
other patients.
   The similarity of position of the morbid growth in  the greater
number  of the recorded examples of this disease is very remarkable.
In three of my cases the tumor occupied  the centre of the sternum ;
while, of twenty-two cases (of the •before-mentioned twenty-four) in
which the seat of the disease is stated, thirteen were situated on the
same spot.
   A matter of the first importance in a practical point of view, is the
degree of annoyance which these tumors are calculated to give to our
patients.  Alibert observes that  they are  the torment of  existence,
that they are usually attended with increased heat, that they are often
accompanied with itching and pricking to an extent that is insupport-
able, that the pain  is acute, pungent, and lancinating, and like the
piercing of the skin  with burning needles.   That often the pain
extends to surrounding  parts, and occasionally there is as it were
a dragging from  within.  On the  other  hand, they are sometimes
indolent, and  merely give rise to stiffness of the skin.  The cases seen
by Rayer appear to  have been of the milder kind referred to  by
Alibert; he remarks,  that,  at their commencement, they are mere
points, and these points are affected with "pruritus of a pretty severe
description."  When  they increase to the size of a "small hazel-nut
or the barrel of a quill," they are generally indolent, " unaffected with
morbid  heat or pain," and very seldom, indeed, the seat of "anything
like painful shooting sensations."  Further, he says, that the incon-
venience they occasion is, in  general, so  trifling, that  he has known
patients " refuse to submit to the curative means proposed for their
relief."  Cazenave and Schedel state, that the little tumors arise and
grow  without pain; in  other  respects,  these authors follow  the 
KELIS.
327
description of symptoms given by Alibert.  Dr. Warren mentions a
case which was  accompanied with a "stinging,  burning pain."  In
Dr. Peace's case the tumor originated without pain, but, after eighteen
months' growth, was so painful as to prevent the  patient from lying
on the affected side.
  In  a  good example  of kelis  illustrated in my  " Portraits,"1 the
patient was a robust man, forty-eight years of age.  The disease first
attracted his attention about seven years before his application to me.
He then perceived upon the middle of the breast four slightly-raised
tubercles, which coalesced, and gradually increased in size, until they
formed a broad-spreading, irregularly-shaped excrescence.  In figure
this excrescence bore some resemblance to  a bird, the head of the bird
pointing towards the right breast, the wings spreading out above and
below, and the body and broad tail crossing  the  sternum to  the left
breast.   The length of the  kelis, from the head-like process to the
opposite extremity, was three inches and three-quarters,  while, across
the wings, at its broadest part, it measured  three inches.   Its eleva-
tion from the surface of the skin varied between two and three lines,
the most elevated part being at its border.
   On a  first inspection, the  morbid  excrescence had the appearance
of  the cicatrix of a burn,  and,  upon  closer examination,  the only
character at variance  with that  idea was its elevation from  the sur-
rounding skin, particularly at its  borders.  Its color was  pink, lighter
in  the  centre than  at the  circumference, and it was marked on the
surface  by a coarse network of prominent white lines or ridges.  The
general  direction of these white lines corresponded with that of the
long  diameter of the  keljs, but, upon the four  processes of the
excrescence they had a transverse or semicircular  direction.   From
these processes a number of red and white lines were given  off, which
resembled roots shooting into the substance of the unaffected skin.
   It  was  also evident, from an examination of the kelis,  that its
growth  proceeded by an extension of the margins of the four processes
only, while the intermediate portions of its border, namely, those
forming the angles  between  the  processes, were drawn onwards over
the sound skin, without participating  in the deeper growth.  The
borders in these situations were rounded and free, about two lines in
thickness, and a probe might be  passed beneath them to a distance of
half an inch, and, in one or  two  places, to a greater depth.  Indeed,
these hollow ways were a source  of some inconvenience to the patient,
by serving to collect dirt and flue from his dress, and he  was obliged,
from  time to time, to have recourse to means for clearing them out.
   Besides the pink hue of the excrescence, its cicatrix-like lines and
ridges, the depressions between the latter, and its elevated borders, the
surface  of the kelis presented a  smooth polish, like that of  the new
skin of  the cicatrix of a burn, and a sort of semi-transparency.   There
were also visible, here and there, particularly about its circumference,
si-veral   small meandering  bloodvessels,  apparently veins, collecting
the returning blood from minute tributaries.
1 Portraits of Diseases of the Skin, Plate XLIV., R. 
 328      DISEASES  FROM  SPECIAL  INTERNAL CAUSES.

   To the touch, the kelis  gave an idea of a hard, resisting structure
 like fibro-cartilage,  invested  by a soft, velvety-seeming skin.  The
 central portion was harder  and more dense than the circumference,
 and the white lines had all the rigidity of bands of fibrous tissue.
   The patient's application to me had reference to the  propriety of
 removing the excrescence, in  consequence of the  pain  and annoyance
 to which it  had  given rise during the  last three years,  and more
 particularly as the pain was evidently on the increase.  At times he
 suffered much from excessive itching; at other  times the  pain was
 darting, burning, shooting;  and occasionally he experienced a darting
 sensation, which he compared  to an electric shock.  The pain did not
 endure  long, but  it recurred frequently, and was excited by any
 movement which produced pressure on the growth, such as bringing
 his shoulders together,  or lying on his side in bed. He was  not aware
 of any increase of pain depending on  change of season  or weather,
 and the  excrescence underwent no alteration of color or bulk from
 mental or bodily excitement, exercise, or  elevation  of  temperature.
   Besides the kelis on the breast the patient had a second on the outer
 side of the left leg, over the head  and upper part of  the shaft of the
 fibula.   This excrescence is of the cylindrical kind (keloide cylindracee
 Alibert), and,  like the preceding, is accompanied  by its satellite, a
 small round tubercle, situated  near its  lower end, on  the calf of the
 leg.   The'cylindrical kelis measured three inches  in length, and was
 broader  in  the extremities than  in the  middle;  measuring  at  its
 narrowest point one-quarter  of an inch ; at its upper end three-eighths
 of an inch;  and at the  lower end five-eighths of an inch.   Its eleva-
 tion was about one line.1
   The patient is not  aware of  any cause for  this  disease, either local
 or general; no scratch,  no  abrasion or undue friction of the  skin, as a
 starting-point.  He was in good health at its first appearance, and has
 remained so since.  None of his family have suffered  from  auything
 similar.  His mother died of cancer of the womb at the age of seventy-
 one, having been first attacked by that disease  within  twelve months
 of her death.
   A  London physician,  forty-one  years of age, had two  of these
 tumors of  the cylindrical kind;  one being situated on the right
 shoulder, over the spine of the scapula, the  other on  the buttock of
 the same side.
   They first attracted his attention about five or six  years ago  (1845),

  1 Since the completion of the above details I have again seen  the patient.  The
 kelis on the breast is more painful than it has ever been, and is slowly on the increase.
 The pain is confined to the edges of the excrescence, and is greatest where  the growth
 is most active, the central part being comparatively insensible.  On requiring him to
 take off his clothes, I observed four tubercles of keloid formation on the left arm ; they
 were situated on the cicatrices of as many boils, which had resulted from an accident
 he had met with six years before.  He had  been thrown  out of a chaise,  and falling
 on his left side, had sprained his wrist.  The arm became swollen and  inflamed, and
 when the inflammation subsided, the  boils made their appearance.   He had not men-
 tioned these enlargements to  me, because he considered them as merely the  remains
 of  the boils.  They had always maintained the same  size, were  never painful, but
were occasionally affected with pruritus.  He informs me that he had never suffered
pain from the kelis on the leg, but has sometimes been troubled  with pruritus. 
KELIS.
329
 when the tumor on the shoulder was not larger than a horse-bean.
 At present it measures an inch in length,  by one-third of an inch in
 greatest breadth, and  has an elevation of about one line.  This tumor
 presents obvious indications of having originally consisted of three
 hemispherical tubercles, subsequently united by a connecting ridge.
 The tubercles having been of different dimensions, the kelis is larger
 ot one end than at  the  other, and the connecting ri,dge is nodulated
 near the  larger end, from the  presence  of the  third and  smallest
 tubercle.
   The kelis on the  buttock consists, in  like manner, of two tubercles
 of unequal size joined together by a narrow ridge.  The length of this
 formation is one inch and  a  half, and its greatest breadth somewhat
 less than three-quarters of an inch.
   The color of the growths is a dull pinkish red; they are smooth
 and even on the surface, are covered by a very thin  epidermis, and
 have none  of the  white  lines of the previous case.   They are soft
 superficially, but hard, dense, and  resisting, like fibrous tissue, in
 their deeper structure, and they are strictly limited to the skin.
   Their  most characteristic  symptom is an occasional stinging, hot
 pain, compared by the sufferer to piercing the skin with a fine needle
 made red hot, and a tingling, itching sensation, after being touched or
 rubbed, or under an  increased degree of cutaneous circulation, such
 as occurs in hot weather.   A vehement desire to scratch is awakened
 by the itching, but, on the  whole,  they give rise to  little  pain or
 annoyance.  In the summer they are more troublesome  than in the
 winter season.
   During the  last  two summers, and particularly the last, the kelis
 on the buttock was excessively tender, so tender, in fact, as to cause
 pain on  the  slightest friction, as in that occasioned by  the  clothes
 in walking.
  A gentleman forty-four years of age, of ordinary stature, stout, and
 of full habit, by profession an actuary in a Metropolitan Assurance
 Society, had his attention  drawn about eight years since, in conse-
 quence of suffering  a violent  itching of the skin, to a small tumor
 situated on the middle of the breast.   The little tumor was oval-shaped,
 smooth, of a reddish color, and about the size of  a split  horse-bean.
 From this time the itching in the tumor and immediately surrounding
 skin frequently recurred, more especially after any kind of mental or
 physical excitement, after taking wine, after walking, or upon getting
 warm.  Occasionally  there were, superadded to the pruritus, sensa-
 tions of smarting, stinging, burning, and  pricking, particularly  on
 the occurrence of atmospheric changes.   In speaking of these sensa-
 tions, he compares them to the sudden piercing of the skin  with a
 number of needles.
  The tumor continued  to enlarge gradually for  the first two years;
 it then remained stationary, only changing with  his state of  health,
 for the next five years; and, during the last twelve or fifteen months,
 has been  slowly diminishing  in size.  At  present it is very  slightly
convex, or nearly flat on the surface, and lies  across  the  middle  of
the  sternum, resembling in its general form a sheaf of wheat, being 
330      DISEASES FROM SPECIAL  INTERNAL CAUSES.

narrow  at the middle, and broad at either end.   Its greatest length
is one inch and three-quarters; its breadth, at the middle, one-third
of an inch ;  and, at the expanded extremities, nearly one inch.  It is
thickest at the narrow mid-portion, where it has an elevation of one
line, and from this point gradually  subsides  to the level  of the
surrounding skin.
  Its color is pink, with a whitish line  running longitudinally through
its  middle, and dividing,  at its  expanded  portion, into four or five
indistinct radiating streaks.   It is, and  always  has  been, perfectly
smooth and polished; and, upon close inspection, a great  number  of
minute venules may be seen  meandering from its central  part to the
circumference.  In consequence  of the tension of the skin, the promi-
nences of the pores of the  follicles are  obliterated, and it might easily
be  mistaken for  the projecting cicatrix of a  deep burn.  When
examined with the finger, the  skin  is  found to  possess a velvety
softness, beneath which  may be felt a  hard cord running through the
middle of the tumor, and  dividing, in the expanded portion on each
side, into four or five smaller cords, which extend like roots into, and
appear to be lost in, the deeper structure of the  corium.   This hard
cord and its  terminal branches  correspond with the whitish  longi-
tudinal line and its radiated streaks above described.
  The principal change which the kelis has undergone in the progress
of growth, is  a  greater amount of general elevation  of  the  whole
tumor, and  a special prominence of  the central cord and its radii.
The patient  informs  me  that, at the acme of its growth, it had an
-elevation of three-quarters of  an inch at its central  part.  He  also
states, that it  underwent frequent  changes  of dimensions having
reference to his state of health, being  one while swollen, and another
while contracted in size.  It has never been wrinkled, nor has  there
been any cuticular exfoliation from the surface.
  In his youth, this gentleman  suffered  very much from  headaches,
which were  followed by  partial loss  of  hearing, and were probably
occasioned by some morbid  change  in the bones at the  base of the
cranium.   The pains have long since  ceased, but the deafness remains.
There is one other circumstance  in his medical history which deserves
to  be mentioned.   At the age of nineteen, he was  troubled by the
growth of an indurated  tumor from the  conjunctiva of the upper
eyelid.   The tumor enlarged,  during  twelve months, to the size of a
cherry, which it resembled in  appearance, and projecting  downwards
over the eyeball, completely obstructed his vision.   Some medical
friends,  among whom  was   the late Mr. Walker  of St. George's
Hospital, agreed, in consultation, that the tumor should be removed,
but, as the patient was  a little out of health, and the growth of the
disease slow, it was arranged  that  the operation should  be deferred
for  three  weeks,  during  which time the  patient should take some
gentle  aperient medicine daily.  At the end of the three weeks,
however, the tumor was so much reduced  in size, that the operation
was postponed, and in two months it  had disappeared entirely.
   I am  induced to dwell on  the speedy and complete absorption of
the conjunctival  tumor, from the parallel  which it meets  with in the 
KELIS.
331
history of the kelis.  When the latter was at the height of its growth,
the patient, at the request of a relative, consulted the  late Mr. King,
of Maddox Street, with a view to an operation, not, the patient dis-
tinctly avers,  from the inconvenience or annoyance  of  the disease,
but merely from the apprehension of its growing larger, and some
day becoming troublesome.  Mr. King, finding the disease limited to
the skin, suggested his leaving it to itself, remarking, that if it ever
extended  to the deeper  tissues, it would then be time  to  effect its
removal.  No remedies of  any kind have been used, and yet, as we
have seen, after attaining a certain amount of growth, a  spontaneous
absorption has set in, which  has resulted in the very considerable
reduction of its size, and the total cessation of the uneasy symptoms
which once existed.
   I may add, that  my observation of the above disease originated in
an accidental  exploration of the chest with the stethoscope,  in  order
to determine the state of the heart and its valves.
   Since  the date  of  my special inquiry into the nature  of  kelis,
namely, in 1851, I have seen  many cases of kelis vera.   One, occu-
pying a large extent  of surface on the left breast,  occurred in an
American gentleman.  When the tumor first appeared,  it had been
removed by operation, and the result of the operation  was a great
increase of the disease.  In another case, the  patient is a lady, whose
chest is covered with a crop of small tubercles, twenty  or  thirty  in
number,  and  varying in diameter from  three  to six lines.  Another
case is also that of a lady, who has a large, flat, dumb-bell tumor on
the right shoulder, and a smaller one of the same nature over the left
scapula.   In the two latter cases the seat of the hypertrophous growth
is the deep stratum of the derma.

                          KELIS SPURIA.

   Kelis spuria is  that tubercular prominence of the tissues of the
skin which not unfrequently takes place in the cicatrix of a burn, of
a  scrofulous ulcer,  of a surgical operation, or in  that caused by  the
destruction of the  cutaneous  tissues in confluent smallpox.   This
kind of  kelis  appears to be composed  of white fibrous tissue, and
presents  the character of an elevated and elongated ridge to which
several  bands and  cords from the surrounding altered  structure of
the cicatrix converge.  The false  kelis appears to be the  joint result
of hypertrophy, condensation, and  concentration of the white fibrous
tissue of the skin, and by a special power of contraction, would seem
to draw the rest of the cicatrix to itself, and  produce a puckering of
the adjacent surface.

'   Treatment.—Judging from the preceding sketch of the symptoms
of kelis, it will be concluded that the disease may occasionally become
excessively annoying, from the degree  of pain  which it occasions,
from its inconvenient situation in  respect of  dress or the position of
the patient, or from the apprehension of  ultimate results, to  which it
may give rise, in  the mind of the patient, or, indeed, of the  practi-
tioner.  On the other hand, it is consoling to reflect that the tumor 
332      DISEASES  FROM SPECIAL INTERNAL  CAUSES.

has scarcely ever been known to take on an ulcerative or destructive
action, or to attain a dangerous bulk.  Nevertheless, the patient may
be so anxious for relief as to  desire an operation, and then, the ques-
tion arises, as to the propriety of using the knife.  Alibert and Rayer'
have both mentioned the possibility of the spontaneous disappearance
of the disease, and one of my cases is an apt  illustration of the fact.
On the other hand,  although excision may have  been successful in
one  or two  instances, yet, in the  majority, the operation has  been
followed by a reappearance of the disease in the cicatrix, and, conse-
quently, in a position more  unfavorable than that of the  original
affection.  The  secondary kelis has also been  generally found to be
more active in growth and more painful than its predecessor.  In Dr.
Warren's case the  diseased  structure was twice excised ;  and  after
the second  operation, he  thus describes its appearance: The tumor
was " about two inches long,  and half an inch wide,  of a slightly red
color, raised from the surrounding  skin like the scar of a burn, and a
small red projection extending from its edge.   A burning and shoot-
ing  was felt in  the  parts. At each of the points where the needle
was passed through, there was a little rising similar to the first, and
about the size of a  pea, and  quite red, so that, instead of one tumor,
there were seven."   In a case reported by Alibert, in which the kelis
was removed, the wound  was many months before it healed, and the
disease returned with more intensity than before.
   The conclusion which naturally  results from these observations is
unfavorable  to  operative  procedure, and in  no case, as it appears to
me, is an operation warrantable until every chance of relief by  other
means has failed.
   The treatment heretofore  pursued has  been chiefly local.  Alibert
remarks, in  his octavo work, that  he had been successful in curing
two cases  by cautery with  nitric  acid;  but, as, in  a  repriut of the
same work, he omits this observation altogether, and speaks unfavor-
ably of all kinds of treatment, I am inclined to think that the disease
must have  reappeared in those cases.  Rayer inclines to  the  use of
pressure, and, in an  instance  that came under his  care, considers that
some benefit resulted from this plan ; he also alludes to the failure of
excision and cauterization.  Biett thinks that  frictions with hydrio-
date  of potash might be found  advantageous;  and Cazenave and
Schedel are of opinion that the sulphur vapor douche has  been bene-
ficial in softening the tumors.
   For my own part, I prefer, after  regulating the general functions of
the system, the  maintenance  of a steady course of Donovan's  solution,
in doses of ten  drops, three times a day; or of the  protioduret of
mercury in  combination with guaiacum and  the  oxysulphuret  of
antimony.  The false kelis I have succeeded  in  removing by means
of three-grain doses of the iodide of potassium three times a day, and
a Plummer's  pill at  bedtime.
   Locally, the best applications are, collodion, to produce  mechanical
pressure; liquor plumbi diacetatis, as a  sedative  to be pencilled on
the tumor;   the preparations of  iodine, either  the tincture, or the
solution of the iodide of ammonium, as recommended for  scrofulo- 
ELEPHANTIASIS.
333
 derma ;  or an ointment of iodide of lead, in  the proportion of two
 parts of lead to one of lard.   The latter remedy relieves immediately
 the  prickling  and uneasy sensation that often accompanies  kelis.
 Great comfort is frequently given by the galbanum and opium plaster
 spread on wash-leather;  or, if there  be no irritation, soap plaster or
•diachylon on wash-leather.

                        ELEPHANTIASIS.

    Elephantiasis, the Leprosy of  the  Jews;  the  Leprosy of the
 Middle  Ages;  the Leprosy  of  the Crusades;  the  Leprosy  of the
 Arabians;  and the Elephantiasis of the  Greeks, Elephantiasis Gra?-
 corum, is a disease of much interest,  on account of its early existence
 and almost universal diffusion throughout  the world,  its  intense
 severity, its spontaneous disappearance  in  countries  where it had
 raged with great violence, and its continuance in others, with all its
 original and historical characters, up to the present time.   We read
 of it in the  Bible,  as  prevailing  amongst  the  Jews during  their
 residence in Egypt, and  after their exodus  into Judea;  and in the
 New Testament, as still  afflicting them  in the time  of Christ.   We
 trace it from Syria into Persia and Hindostan, Turkey, Greece, Italy,
 France, Spain, Britain, Germany, Russia, Scandinavia and America.
 besides'being so widely distributed, we find it rising and declining at
 different periods  in different parts  of the world, moving gradually
 from the East to the  West, and  from the South towards the North.
 Probably limited in the early periods of the world  to Egypt1 and
 Syria, and  confined  to  that  region at  the  commencement  of the
 Christian era, the disease spread with rapidity through  Greece and
  the South of Europe  during  the  period ranging  from the second to
 the seventh century, reaching its culminating point during the Cru-
 sades of the eleventh and twelfth centuries, and began to deeline from
 the fifteenth to the seventeenth century.
    The earliest records of the leprosy in  Great Britain are  those of
 the Welsh  king, Hoel Dha, in the year 950 ;  and from that date until
 the beginning of the  sixteenth  century, the  disease was common in
 England.   At the  latter period, namely, during the reign of Edward
 the Sixth, 1547 to  1553, it is reported by a commission for suppressing
 colleges,  hospitals, &c,  that  most of the Lazar-houses in England
 were empty.  In Scotland, leprosy appeared one or two centuries later,
 the earliest Lazar-houses dating back to  about 1150, and  the disease
 was still  traceable  during the seventeenth century ; in 1604, a leprous
 woman was ordered into  the  Lazar-house  at  Aberdeen, and a notice
 of the same date exists of  the presence of patients in the hospital at
 Kingscase,  near Ayr.   Symptoms of decline of the disorder  in  Scot-
 land  are perceived in an order for dismantling  the  Lazar-house at
 Ureenside, Edinburgh, in  1652;  but  in the  islands to the north of

            1 " High  up the Nile, 'mid Egypt's central plains,
              Springs the dread Leprosy, and there alone."
                      Lucretius  De Naturd Rerum.  Poetical  version by
                              John Mason Good, M.D. 
334      DISEASES FROM SPECIAL INTERNAL CAUSES.

Scotland, the  Orkneys, Shetland, and Faroe Islands, the disease was
in full  activity.   Towards the  middle of  the eighteenth century,
namely, in 1742, leprosy was supposed to  have disappeared  in  the
Shetland Islands, and a public thanksgiving was ordered to commemo-
rate that event; but instances still presented themselves occasionally,
as is shown in the account of  the parish of Northmaven, given by*
Mr. Jack, in 1798, and by the more homely instance of a man  named
John Berns, who,  in 1798, was a patient in the Edinburgh Infirmary.
This man was a  native  of Shetland, and a direct descendant from
leprous ancestors.1
   But while leprosy has thus seemingly been disappearing altogether
from Great Britain, there are yet many  spots amongst its  old  haunts
where it still lingers;  as on the shores  of the Mediterranean, both in
France and Italy,-as well as in  Greece; on  the  shores of the Black
Sea, where it goes by  the name of Mo I de la  Cr-'mee ; on the shores of
the Caspian  Sea; in  the islands of the Indian Ocean; in the West
Indies;  in Madeira;  and  notably in Iceland  and on the coast of
Norway.   In  Norway, the prevalence of leprosy has been so great
and so fatal that a royal commission was appointed  a few years back,
to examine into the nature of the disease, and determine the course to
be taken  to  limit its progress, and if possible, effect its cure.  The
report of this commission, by Dr. Danielssen and Dr. Boeck, was
printed by the Norwegian Government in 1848 ; it is accompanied by
a  fasciculus of excellent  plates, and is by far the best  treatise on
elephantiasis in existence.2
   The name elephanta or elephantiasis was given to this disease  by the
early Greek and Roman  wrriters; the term occurs under a  poetic
synonym in Lucretius, who says, "There is the disease called elephas,
which has its rise on the river  Nile, in  the middle  of  Egypt,  and in
no other country."3   Aretaeus, who knew the disease well, and has left
a good description of  it, explains that it received its name from the
resemblance of the diseased skin to that of the elephant, and particu-
larly from its vastness and terrible nature.  A similar idea gave origin
to the  terms  morbus  herculeus and  morbus  heracleus.   Other  names,
such  as Leontia,  Leontiasis; Satyria, used by  Aristotle;  Satyriasis,
Satyriasmos, had reference to the deformity  of countenance produced
by the thickening, rugosity, and discoloration of the skin  of the face.
The heavy, lion-like  brow is very  remarkable;  and it seems more
than probable that the original idea of Satyrs was suggested  to the
poets by  the appearance and habits of the  lepers, who, driven from
society,  lived  in holes and  caves in the woods, and subsisted  by
robbery and  violence.  The latter  circumstance caused them to be

   1 Dr. Simp«nn, of Edinburgh, has given an excellent  and interesting account of
the Leprosy in Great Britain, in a series of papers entitled, " Antiquarian Notices of
Leprosy and Leper Hospitals in Scotland and England," published in the " Edinburgh
Medical and Surgical Journal," for October 1S-11 ; and January and April, 184:2.
  2 Traite de la  Spedalskhed, ou elephantiasis des Grecs ; par D. C. Danielssen,
Mfrlecin en chef  des Hopitaux de Spedalsques  a Bergen ; et  Wilhelm Boeck,
Prot'esseur de la Faculk de Medecine a Christiana.  Paris, 1848.
   s De Natura Rerum; translated by the Rev.  John Selby Watson.  Lucretius was
born ninety-five years before Christ. 
ELEPHANTIASIS.                     335
distinguished  in  Italy by the names of malandriosi, or brigands;
riobman, or robbers; and latrones and  ladres, thieves; thus ignoring
the cause of their original  expulsion from society, and confusing their
actions with their sufferings.  The Arabians styled the disease judam,
juzam, alzuzam, dsjuddam,  madsjuddam,  jeddem, muzdjeddem, didyam,
damadyand, dschiddam, sghiddam, judas, &c,  probably on account  of
its early victims being the  Jews.  It has, besides, received local names
in different countries; on  the shores of the Black Sea, it is called
maladie de la  Crimee,  lepre de la Chersonese, lepra Taurica ; and  in
Persia, from its supposed origin in the Crimea, krimskaia.  In India,
it is named fisanikhun, or khora, kushta  (leprosy),  mahakushta (great
leprosy), soubharry, zndjugaru; in Africa, kohan, koban, and  kokobe ;
in Greece, it is popularly known as  the  lova; in Italy, it is called il
male di san Lazaro, male  di commachio, il  male di fegato, lebbra;  in
Spain, mal rojo ; and in France, ladrerie.   The term mal rojo,  used  in
Spain, calls the attention to the dark red or reddish brown hue of the
diseased skin; while in other countries it has been named mal noir,
also from the dusky hue of the skin, and to distinguish  it from the
common white leprosy, lepra.  In Britain,  the  old Saxon terms seo
mycle adl (the myckle  ail, or great disease),  hreofi and licprower have
been given to it, together with the modern appellation, the black leprosy;
the first of these terms applies to the severity of the  complaint; the
terms hreof and licprower signify knotty or tubercular, the latter found
in the Northumberland dialect, evidently corresponds with the Nor-
 wegian word  likpra.1  Dr Simpson  remarks that the old  Scottish
name for leprosy  was Liper.   The victims of the disease were called
 Lipper Folke, and a celebrated spa and place of resort for them, two
 miles from Edinburgh, was thence named Liberton, a corruption  of
 Liper Town.  The Scandinavian designation of the disease is  spedal-
skhed, and in Sweden, spetalskhan ; in Norway it is  also called arvesy-
 yen, or hereditary disease, and likpra, that is, knotty or tubercular;  in
 Denmark, besides spedalskhed, likwoerthing and likwoerthingsof;  and  in
 Iceland,  holdsveiki, hinafalls-syki, likthrd and malaottosott.  In some
 parts of South America it has received as an appellation, the term boasi.
   We must now turn  for an instant to an episode  in the history  of
 the nomenclature of elephantiasis, which has been  and is a source  of
 much confusion.  Elephantiasis was, as we have seen, the leprosy of the
 Jews,  of the  middle  ages, of the crusades; it was a disease  which,
 rising on  the banks  of the  Nile, spread throughout the  whole  of
 Europe, from  the South towards the North, from the East  to the
 West.   It was a disease of great fatality and  frightful severity,
 and its characters are well known amongst all nations.  It  was not
 confined to a  single  member or to a part of the body, but occu-
 pied, more or less the  whole ; and was attended with symptoms which
 proved the entire  mass of  the blood to be impregnated with the
poison that gave it  origin.   Under  these circumstances, it is some-
 what remarkable that a comparatively local affection, the Barbadoes
 leg,  Bucnomia  tropica  (Mason Good), should have been mistaken for
1 Drs. Danielssen and Boeck, loc. cit. 
336      DISEASES  from SPECIAL INTERNAL  CAUSES.

elephantiasis, and handed down to us in the records of medicine as
the Elephantiasis Arabum.  The Barbadoes leg, which has no affinity
whatever with elephantiasis, was from the enormous size to which the
limb affected with this disease grows, the discoloration and rough-
ness of the skin, compared by the Arabian physicians to  the foot of
the elephant, and  called  da oolfeel  or dalfil,  the  elephant disease.
The Greeks and Romans, having no knowledge  of this disease, in
translating the works of the Arabian authors, mistook  it for the dis-
ease familiar to themselves, and called it Elephantiasis; so that, to the
present day, we are obliged to warn  the student of the error, and dis-
tinguish impressively Elephantiasis Grcecorum, the true and  only
elephantiasis, from Elephantiasis  Arabum, the Barbadoes leg.  But
this was not the only mistake: the Arabian physicians, who  knew
elephantiasis well, called  it, as has  been already  mentioned, judam,
juzam; &c.; these terms the Greeks translated by the word lepra.  So
that the judam or elephantiasis had now to be distinguished as the
lepra Arabum, in contradistinction to the lepra already known to the
Greeks, the hpra Grcecorum, corresponding with the common lepra of
the present  day.   These  three diseases, then, perfectly distinct from
each other, are almost inextricably confounded, namely, elephantiasis,
bucnomia,  and lepra;  elephantiasis having for its synonyms, lepra
Arabum, lepra Judaeorum, and lepra medii  sevi;  bucnomia, or  Bar-
badoes leg, having for its synonym, elephantiasis Arabum ; and lepra,
for its  synonym, lepra Groecorum.  The only  way at present left to set
right the difficulty, is to abandon  both the Arabs and the Greeks, and
retain  only the more simple designations of the three diseases, elephan-
tiasis, bucnomia, and lepra.
   Elephantiasis is a blood disease, probably originating in an animal
poison, and  manifesting its existence either by the deposition  of a
peculiar albuminous  substance in the skin,  mucous membrane, and
other surface tissues of the body,  or by affecting chiefly the nervous
centres and the nerves.   This double mode of manifestation of the dis-
ease has caused its division into two kiuds, tubercular and ancesthetic;
the former being that which is characterized by deposition in the sur-
face membranes of the body, particularly the skin; the  latter, that
which  is occasioned by deposition in and  around the nervous centres
and nerves.  Both forms are chronic  in their course, commencing
insidiously, progressing slowly, and lasting for years; sometimes ter-
minating in spontaneous cure, and sometimes in death.

                  ELEPHANTIASIS TUBERCULOSA.

Syn. Elephantiasis orientalis; legitima; leonina.  Lepra elephantia.; leon-
                lina; medii cevi;  tuberculosa; nodosa.
   Elephantiasis  tuberculosa  may be known by the development on
the skin of erythematous patches,  patches of discoloration or maculae,
and tubercles; similar patches  and tubercles being also met with on
the mucous membrane of the mouth, fauces, nares, and e}res.   The
''rythematous patches are of a dull red or purplish hue, more or less
vivid,  and vary in size from half an inch to two inches or more in 
ELEPHANTIASIS.
4
337
diameter.   They are commonly rounded in form, most deeply colored
in the centre, and  fade towards  the  circumference; after a time, the
redness of the centre subsides or gives place to a brownish stain, while
the circumference  spreads for a short distance, and forms a ring with
a well-defined border; later still the  redness disappears entirely, and
leaves behind it a brownish or bronzed  stain (morphcea  nigra), which
is more or less permanent.  Sometimes the central portion of the patch
becomes  bleached,  and  perfectly white and  smooth (morphoea alba,
Itucos, leuce), and is either  bordered  by an  erythematous rim or by
the abrupt line of the sound skin somewhat deeper  tinted than the
rest.  To the touch, the centre of the erythematous patches is harder
than the surrounding skin; the epidermis frequently desquamates
over this part;  the tissues  of the skin become more  and more con-
densed, sometimes, remaining perfectly flat, and sometimes  attaining.
by continued thickening, the elevation of a tubercle.   The tubercle,
when newly formed, presents the dull red and purplish hue of the
erythematous  patch, but sooner or later assumes either the bronzed
tint of the discolored skin, or is whitish in hue, from the whitish albu-
minous substance deposited in its tissue.  After a duration of several
weeks or mouths, the tubercles subside, leaving behind  them a mark
resembling a cicatrix thinner than the surrounding skin,  and either
bronzed  or white.   The tubercles vary in size from that of a pea  to
that of a pigeon's egg; sometimes they remain  unchanged for years;
at other times  they become inflamed, soften, and  ulcerate, and givt
forth a whitish, granular, albuminous substance, and a yellowish-white
ichorous secretion.  Sometimes this secretion concretes over  the sur-
face of the ulcer, and forms a dark crust of considerable thickness, likt
that of rupia; at other times, the ulcer  remains open, becomes deep
and  excavated, is bordered  by irregular, callous, and prominent edges,
 the  circumference being uneven, hard,  livid, and often painful, and
secretes an abundant, yellowish-white fluid.  After  a  time,  during
which the morbid disposition in the skin is eliminated, the ulcer closes
and  heals, leaving behind it  a hard, white, irregular,  and prominent
cicatrix.   As one ulcer  heals others form, and go through the same
 process, and the disease is thereby prolonged for an indefinite period,
in some instances terminating in spontaneous cure, but more frequently
resulting  fatally from constitutional irritation, kept up by a similar
 morbid state of the mucous and serous membranes.
   The mucous membrane  evinces a similar succession  of morbid phe-
nomena to those already  described as occurring in the skin \ the con-
junctiva is congested, thickened by infiltration, so as to form an ele-
vated ring around the cornea, the cornea becomes opaque, deposition
of the peculiar whitish matter of the disease ensues, forming a tubercle,
the tubercle softens and ulcerates, and the eye is destroyed. The Schnei-
derian membrane undergoes  corresponding changes; the nasal passages
are obstructed by the thickening and swelling of the lining membrane,
and broken up by the softening and ulceration which follow; the latter
causes perforation of the septum, denudation of the bones, and the nose
becomes Battened and distorted.  The mucous membrane of the mouth,
fauces, pharynx, aud larynx, exhibits the same train of appearances, con
      22 
338
DISEASES  FJXOM  SPECIAL INTERNAL CAUSES.
gested patches, tubercles, and  ulcerations.  The voice is hoarse  from
thickening of the lining membrane of the larynx, tubercles form  upon
the glottis and epiglottis, and both are destroyed when softening, fol-
lowed by ulceration, ensues.  Post-mortem observation shows that the
same morbid action extends throughout the mucous membrane of the
trachea and  bronchial tubes, deposits and tubercles are found also in
the pleurae and lymphatic glands of the lungs, but the tissue of the lungs
escapes altogether.   So also the morbid action may be traced through-
out the alimentary canal to the mesenteric glands, and to the peritoneum
and its sub-serous tissue.  In the  closed membranes of the body, how-
ever, although deposition is considerable, and the formation of tuber-
cles abundant, the latter proceeding to softening, there is no ulcera-
tion.   In the liver tubercles are formed, both on the surface and in the
substance of the organ, and, when softened, are converted into a thick,
yellowish matter.  The spleen, kidneys, bladder, uterus, Fallopian  tubes,
ovaries, also  suffer in  a similar way, but the  pancreas  escapes.  The
kidneys,  from their depurating function,  are always found  diseased,
even when the other internal organs  are healthy.  The lymphatic glands
are enlarged by the same morbid deposition, when the parts of the
body which  they represent are iu a  state of disease.  The invasion of
the internal organs by the morbid process only occurs in an advanced
stage of the affection of the skin;  and, when the abnormal organs have
become involved, and are seriously disorganized, the semilunar ganglia
are sometimes found softened and destroyed.  The coats of the blood-
vessels also  suffer from  deposition  and thickening,  as do the sheaths
of the nerves, the latter more particularly in the anaesthetic form of
the disease;  but the  muscular system, the  deep cellular tissue, and
the bones, are never attacked.
   Although  the  erythematous  patches and macule are  the result of a
constitutional febrile action, an eruptive fever, in fact,  which may be
so slight and ephemeral as altogether to escape observation, but which
must necessarily determine to the entire surface  of the  skin,  the  parts
of the  body  on which the disease  first appears are those most exposed
to the  action of the atmosphere, namely, the lace and the hands.  The
erythema is sometimes so slight and transient, that a discolored spot
is the  first trace of  the disease to  be perceived.  These erythematous
patches, and brownish or bronzed stains, first appear in the superciliary
region; they are succeeded by thickening of the skin, and then by
the development of the skin in the form of  tubercles, which form a
heavy mass along  the eyebrows.   A  similar change  pervades the
whole face, the skin is bronzed, uneven, the  pores more evident than
natural, the  skin  between the pores  turgid, like the rind of an orange,
the natural  folds of the skin  are thickened, and the wrinkles  more
deeply furrowed.  These changes are most remarkable where the skin
is naturally thin and white, as upon the eyelids; but it is nowhere
so striking as along the brow,  whereon it hangs like a lowering frown,
and gives a lion-like sternness to the countenance—elephantiasis leonina;
leontiasis. Concurrently with  the development of tubercles along the
superciliary ridge, the hair of  the  eyebrows falls, and  this forms one
of  the strong characteristics  of  elephantiasis,  elephantiasis  alopecia. 
ELEPHANTIASIS.
339
The ears also, early in the affection, become the seat of thickening and
tubercles, the helix sometimes presenting the appearance of a circular
tubercular border;  and sometimes the lobule of the ear is elongated
considerably.   Let us, then, array before  the mind's eye the features
here described : the discolored and  wrinkled forehead, the prominent,
tuberculated, bald eyebrows, the erythematous and bronzed skin, the
congested eyes, thickened eyelids and lips, and the enlarged, red, and
lengthened  ears, and we shall  at once perceive those characters  of
countenance which the  poet and the painter bestow on  the satyr, and
which have gained for this disease, amongst others of its  synonyms,
the names satyria, satyriasis, satyriasmos.   The suspicion of inordinate
venery does not seem established, and admits of explanation in other
ways; neither does  the  statement that  persons  afflicted  with this
disease are incapable of procreation.  The hands afford another charac-
teristic of  the  disease; erythematous  and  brown  patches are early
developed  on the backs of these organs  and on the fingers.   The
latter are remarkable for their thin and taper form, as well as for their
brown color, and for a bluish  whiteness of the nails.  The skin of the
 fingers is thinner and paler than natural, and there exists in them a
 greater or less  degree of numbness  and insensibility.
   Defective  sensation,  indicative  of the participation of  the nerves  in
 the general <fcsease, is  therefore a  feature of the  tubercular  form of
 elephantiasis, although considerably less marked than in  the anaesthetic
 form.  The development of the erythematous patches is attended with
 some little increase of sensation, but the brownish  and bronzed stains
 (morphcea  nigra) are  benumbed, and, more decidedly, the white spots
 (rnorphcea alba), particularly when attended with induration of the skin,
 from deposition of the white albuminous substance of elephantiasis.
   The constitutional symptoms which precede and accompany the de-
 velopment of elephantiasis tuberculosa are such as might be inferred
 to belong to a disease dependent upon the  generation and accumula-
 tion  of a poison in  the blood;  and the  degree  of violence  of the
 symptoms may be supposed to have reference to the quantity of poison
 present, and the susceptibility of the individual.  Sometimes the local
 disease, always slow and gradual in its progress, is unaccompanied by
 any perceptible constitutional disturbance; at other times, a pretty
 smart fever indicates the  accumulation of the poison to the point of
 excess, and Nature's  effort to expel it from  the body;  the direction
 taken by  the  poison  being, as in the case  of most  other animal
 poisons, the skin and mucous membrane.   The precursory symptoms
,are, a general  feeling of languor, lassitude, dulness, weight of limbs,
 indisposition for motion, depression of spirits,  and somnolency, with
 nausea and occasional chills.  After a longer or shorter period, the
 eruption appears, and the constitutional symptoms gradually subside.
 The erythema  and maculae, in their turn,  have a duration of several
 weeks, and sometimes months, when they also decline, leaving behind
 them  little trace  of their existence.   At  an uncertain period, the
 constitutional symptoms return, and are followed by another burst of
 erythematous  blotches, with  a like amount of relief to the  general
 system.  These 'periodical attacks are repeated from time to time, the 
340     DISEASES FROM SPECIAL  INTERNAL CAUSES.

constitutional symptoms being sometimes milder and sometimes more
severe, but  the effects on  the skin now become permanent; the
bronzed blotches  no longer disappear, and the erythematous conges-
tions  are perpetuated  in  the form of tubercles, which,  at  a  more
advanced period of the disease, pass into the ulcerative stage.   The
eruptive, depositive, and ulcerative stages always relieve the constitu-
tional symptoms,  and  when  the discharge from the  ulcers is most
profuse, the general health is at its best;  any check to the discharge,
from the healing of ulcers or any other cause,  being  accompanied by
fever,  and by a more rapid progress in the deposition  of the  morbid
product of the disease  in other  parts of the skin or mucous mem-
brane.  When the disease attacks the mucous membrane or internal
organs, other symptoms occur which  indicate its special seat:  thus,
the  affection of the conjunctiva and ej'eballs  causes  loss  of vision;
that of the mucous membrane of the nose, loss of smell; that of the
.mouth and tongue, loss of taste; and that  of the larynx and air-tubes,
hoarseness,  loss of voice, dyspnoea,  and  bronchitis.   When the
lymphatic  glands are affected,  there is more or  less oedema of the
cellular tissue; when  the  kidneys are attacked, albuminous urine;
and when the mesenteric glands and mucous membrane of the intes-
tinal  canal   are  implicated,   marasmus  and  colliquative  diarrhoea.
Under these  secondary affections the patient gradually sftiks, and dies
from exhaustion.
   Drs. Danielssen and Boeck remark, that  elephantiasis tuberculosa
sometimes, but very rarely, occurs in an acute form, in which  case the
eruptive fever is violent, accompanied with delirium, and lasts  from
twelve to fifteen days; the eruption rapidly passes into the tubercular
stage, the patches  of erythematous skin  becoming oedematous; the
tubercles  soften, and in a few weeks  the  disease accomplishes the
progress of years.  The disease may now  subside into the chronic
form, or, failing that, the patient  may be carried  off  by pneumonia,
pleuritis, or meningitis, in  the course of a few days.
   The average duration  of  elephantiasis tuberculosa, according to the
same authors, is nine years and a half.   Thus, of eighty-eight patients
who died of  this complaint in the Hospital  of  St. George,  at Bergen,
during the years 1840—47, one, between  forty and fifty years of age,     i
lived  two years; while another, between twenty and thirty, dragged
on a miserable existence for  twenty-two  years; and fifty-four out of
the  eighty-eight, nearly two-thirds, died between  the periods of six
and eleven years, both  inclusive.

                   ELEPHANTIASIS AN.ESTHETICA.
Syn.  Elephantiasis alopecia;  lepra  alopecia  medii sevi;  lepra  articnla-
   tionum;  lepra  mortificans;  lepra Arabum anaisthetos; lepra phleg-
   matica; lepra rheumatica;  leuce vulgaris ;  vitiligo alba, Celsus.  Spi-
   loplaxia indica, Alibert.
   Elephantiasis  anaesthetica  is  characterized  by symptoms which
indicate the primary seat of the disease to  be the nervous system; and
the morbid appearances in the skin are such as naturally result from
defective innervation.   The progress of  the disease  is slow and 
ELEPHANTIASIS.
341
insidious, and the constitutional phenomena, although  essentially the
same  as in the  tubercular form, are milder and less distinct.  There
is languor, lassitude, dulness, depression of spirits, and disposition for
solitude; the skin  is pale and shrunken, the countenance anxious,
and the muscles soft and reduced in size; in a word, insensibility and
atrophy are the distinguishing features of  the  anaesthetic  form of
elephantiasis.
  The effort of  evolution  by the skin, instead of producing- erythe-
matous patches followed by brownish or bronzed maculae, results in
the formation  of  white patches (morphoea  alba)  and bulke.  The
bullce  are solitary or few in number, and of large size, varying  from
one to three inches in diameter; they are  developed suddenly and
without pain, and burst in the course of a few hours, discharging a
semi-transparent, viscous,  greenish-yellow,  and  sometimes milky
fluid.   The  bullae  leave behind  them an  inflamed  and ulcerated
surface, sometimes  painful; the secretion from the denuded  surface
forms  a thin,  brownish crust, which,  after a  time, falls off", and is
followed  by a  second,  which, in its turn,  is  succeeded by others.
When the  ulcer heals,  its  place is occupied by  a cicatrix, of which
the skin is white, smooth, depressed, less sensitive than the surround-
ing skin, and destitute of hair; resembling,  in fact, the white  patches
of  morphoea alba  already described.  If  hair  return  upon these
patches, it is always white and fine, and the restored skin is deprived
of its glandular  structure.  For several years fresh and fresh  crops of
bullae continue to be formed and succeeded by white patches, without
any further change.
  As the disease advances,  larger surfaces of the skin become the seat
of an erythematous blush,  the redness  being very slight, and  having
a  lilac or purplish tint; these surfaces  also evince an  increase of
sensation,  and are  accompanied by a pricking  pain, sometimes of
considerable severity, like  that occasioned  by pressure  on a nerve.
The erythema is only of short duration, but the pricking, sensitive
condition of the skin  may  last for months or even years;  and when
it at last subsides, the skin  is left pale and insensible, deprived of  all
secretion, from  atrophy of the  glandular  organs, and like parch-
ment,  sordid and  discolored.  When  the face  is the seat  of these
changes, the countenance is emaciated  and cadaverous,  the  features
lose all expression, the skin hangs in folds, or  is drawn  tightly over
the bones;  the lower eyelid droops, producing ectropium, and leaving
the conjunctiva  dull and dry; the eyelashes  fall  out;  the tears flow
over the cheeks;  the nose is pinched; the lower lip hangs down,
leaving the teeth and  gums  exposed; the  latter recede from  the
teeth;  and  the saliva trickles from the mouth.   In  the limbs, the
paralysis of the  nerves gives  rise to thinness and insensibility of the
skin and atrophy of  the muscles.  The fingers  are  remarkable for
their  slender and  taper form; and  the wasting of  the interossei
muscles of  the  metacarpal  spaces, particularly  of the  first, is patho-
gnomonic.   As  the muscles  waste, their  balance of power  is  lost;
the extensors  draw the first  phalanges backward on the dorsum of
the hand, while the second and third  phalanges are bent inwards by 
342      DISEASES  FROM  SPECIAL INTERNAL CAUSES.

the flexors;  the  fingers first, and then the entire  limb is distorted,
and  the joints  are  rendered  conspicuous by their prominence—
elephantiasis nodosa; joint evil.  Similar changes take place in the feet.
  Later in the progress of the disease, a purplish, painful spot becomes
developed in  the  foot or hand,  generally first in the sole of the foot;
it opens, discharges a viscous, ichorous fluid; the loose skin covering
it sloughs, and an ulcer is produced.  The ulcer is atonic and insen-
sible, has thick, callous edges, deeply excavated, extending into the
substance of  the  muscles, sometimes denuding the bones, and pours
forth a  copious ichorous  secretion.  The ulcer continues for months,
or even years;  and if it heal, as is sometimes the  case, another  is
quickly formed to take its place.   Indeed, the comfort and well-being
of the patient are dependent on the quantity and continuance of this
secretion ;  for, if the quantity diminish, febrile symptoms immediately
ensue, and if it  cease, the constitutional symptoms are so severe as
greatly  to increase the degree of paralysis,  and often to threaten life.
  In a more advanced stage  of  the disease, when insensibility has
increased to so great a degree, that a lighted taper may be held to the
skin without giving pain, a new and pathognomonic symptom arises.
One of  the fingers or toes is seized with  a severe lancinating pain,
which seems  to  have its seat in the bone; the part  swells, becomes
purple or livid, points,  and  gives  exit to  a  viscous, ichorous fluid.
The pain  ceases by degrees;  the bone  is exposed, loosens, and  is
expelled through the ulcerous opening.  The ulcer then closes and
heals, and the finger or toe is left shortened and distorted.  After a
brief interval, a similar process is repeated in another finger or toe,
and in this way the  greater number of these organs may be destroyed.
Sometimes the morbid action occurs at a joint, which  is laid open, and
the cartilage exposed; the bones  of the metacarpus, metatarsus, and
even those of the tarsus, may be  thrown off in this  way, as may the
entire foot, and, more rarely, the hand.  After the  expulsion of the
bone the  ulcer  heals, and, in  the case of  the denudation of a joint,
the cartilage adheres firmly to  the integument.
   The mucous membrane, in the  ana?sthetic form of elephantiasis, is,
like the skin, pale, and, in an  advanced stage of the disease, insensi-
ble;  the conjunctiva becomes  dry, from retrocession and eversion  of
the  lower eyelid, and  frequently becomes coated with  a brownish
crust;  the mucous  membrane of the nares is also  dry and  crusted,
and the septum frequently perforated by ulceration, but the ulceration
never proceeds to the extent witnessed  in the tubercular form of the
disease, and  the  nose never becomes flattened from destruction of the
bones.   The mucous membrane of the mouth and fauces is also pale,
insensible, and dry ; the gums  recede from the teeth,  and taste, as well
 as sight and  smell, is lost.
   The morbid element in the anaesthetic form of elephantiasis differs
 from that of the tubercular  form, in being transparent and colorless,
 instead of opaque and  whitish.  In the ulcers of the skin, it is repre-
 sented by the transparent,  viscous secretion  which  is poured out in
 such quantity.   In the internal  organs  it is  found  deposited in the
 subserous tissue, as  in that of the lungs, liver, spleen, and kidneys; but
V 
ELEPHANTIASIS.
343
its most abundant and pathognomonic seat is in and upon the brain,
spinal cord, and  nerves, including the nervous ganglia of  the sympa-
thetic system within the abdomen.   The  abdominal viscera are also
found diseased in their substance ; the liver is hypertrophic, and often
fatty; the spleen is enlarged;  the mesenteric glands swollen ;  and the
kidneys always  more or less seriously diseased.  During the local
disturbance which occurs in the extremities, and which gives rise to an
ulcer or a slough, or when  the secretion from an ulcer is temporarily
checked or suspended, the  lymphatic glands of the groin and axilla
become swollen, and the  subcutaneous cellular tissue is rendered
oedematous, from effusion of the same morbid albuminous element.
  The constitutional symptoms resemble those of the tubercular form
of the disease, but are less severe,  and of longer duration.  In the
first instance, they  are limited to a general  feeling  of heaviness and
languor,  with occasional chills, and  a fixed  paleness  and anxious
expression of countenance.  Then the digestive organs begin to suffer;
there is loss of appetite,  sense of weight and oppression at the cardia,
dryness of the mouth and throat, thirst,,disturbed sleep, and increased
chilliness  of surface.  These symptoms are most marked and undergo
exacerbation,  whenever an increase  of deposition  in  the  nervous
centres, or internal organs,  or an augmentation  of the local disease is
imminent, or  whenever  a suppression of secretion  occurs; and they
subside as soon as the vessels have relieved themselves of their burden
of morbid fluids.  In the course of years  the powers, both of mind
aud body, are exhausted, and the patient sinks  gradually into death;
sometimes the last change is ushered in by colliquative diarrhoea and
cramps; at others, where the kidneys have become disorganized, and
the urine  albuminous, it is preceded by coma.   When the eyeball  is
destroyed  by the  disease there are often severe pains at the back of
the orbit, and necrosis of a bone is also accompanied by deep seated
and often violent  pains.   At the same time the insensibility of the
more superficial  parts may  be such, that the eye may be divided by
the knife  without the knowledge  of the  patient.   The coldness of
surface which accompanies the insensibility  is also a characteristic
symptom ; the temperature  of  the hands was  rarely higher than 90°,
and frequently  as low as 68°; while  in  the armpits and groins,  it
varied from 97° to 104°.
  The  average duration of the anaesthetic  form of the  disease, as
deduced from  the observation of cases in  the hospital at Bergen,
during the years  1840-47,  was eighteen years and  a half;  and of
twenty-four deaths that occurred during  that  period, two patients,
between forty and sixty years of age, had suffered  from the  disease
for five and six  years;  and one, who had  it  from infancy, for thirty-
one years.  In twelve  of the  twenty-four cases the duration of the
disease was twenty years and  upwards.

                 PATHOLOGY OF ELEPHANTIASIS.

  The material morbid element in elephantiasis is a viscous  albumi-
nous fluid, chemically composed of  an excess  of albumen, a small 
344      DISEASES  FROM SPECIAL INTERNAL  CAUSES.

quantity of fibrin, some fat, and salts; this fluid concretes  into  a
whitish,  semi-opaque mass, in  the tubercular form of disease, and
retains  its transparency in the  anaesthetic form.  Deposited  in  the
tissue of the affected organs, it  tends to their disorganization, firstly,
by the interruption of circulation and innervation; and secondly, by
the process of softening or dissolution.  Thus, when the patches of
erythematous skin in the tubercular form of elephantiasis were divided
with the knife, the corium was  found  to be swollen and thickened,
from the distension of its meshes by a sanguinolent fluid.  When  the
tubercles were divided the thickening of the  corium was found to be
more  complete; there was less  fluid in the interstices of the fibrous
structure, and the color of the section presented a brownish tint.
While in a third  stage, the stage of softening, the  structure of  the
corium  was gone, its place being  supplied by  a yellowish-white
granular mass, which, on being squeezed out, resembled gruel.  These
morbid phenomena serve, moreover, to explain the subsequent changes
which ensue, namely, the  thinness, absence of color, deficient sensa-
tion, want of secretion and hair  formation, in fact,  the atrophy of  the
skin  where the tubercles  subside spontaneously, and  the similar
appearances which follow the healing of an ulcer, and also the copious
ichorous discharge which is poured out when an ulcer is formed.
  In the  skin, the seat of deposition is the  fibrous structure of  the
corium, and the same in the mucous membrane.  The  subcutaneous
cellular tissue is not unfrequently oedematous, and sometimes thick-
ened from infiltration of a gelatinous or lardaceous deposit; but  the
latter never assumes the  opaque character  of  the deposition in  the
skin.   In the viscera, the deposition  takes  place in  the subserous
cellular tissue, and gives rise to  tumors, for the  most part  small, but
sometimes of considerable  size.   Tumors of  a similar  kind are occa-
sionally found in  the substance of  the liver, and the eyeballs  are
sometimes destroyed by  depositions  which  commence  within  the
interior of their cavity.  The ovaries and the lymphatic glands, par-
ticularly those  of the mesentery, participate in the morbid change.
Another common  seat of the morbid deposit is  the outer coat of  the
cutaneous arteries and veins, particularly  the latter, and the neuri-
lemma  of the nerves, the lardaceous  deposition  occupying all  the
space between and amongst the fibrils  of  the nerves.  These  latter
observations explain the arrest of nutrition and atrophy of the affected
part of  the skin, and also  the defective sensation.  In some instances
Drs. Danielssen  and Boeck found the semilunar ganglia of  the sym-
pathetic system  in a state of softening, and the vessels of the abdomen
were  not unfrequently in  the same  morbid  state  with those of  the
skin.   The  organs  and tissues which  were  found to  escape  the
influence of the disease, were the deep cellular tissue, the muscles,
bones, parenchyma of the lungs, pancreas, salivary glands, and brain
and  spinal cord.  The blood contained an  excess  of  albumen and
fibrin,  and, when taken from  the  patient  during the febrile stage
preceding the eruption, presented a small proportion of serum, which
was  green and  viscous, and a large  solid clot with thin, huffy coat,
and frequently on the surface of the  latter a stratum of albumen. 
ELEPHANTIASIS.
345
  In  the  Anaesthetic Elephantiasis, the prime seat  of the  morbid
deposit is the spinal cord, and the ganglia and sheaths of the nerves.
In the autopsies performed by Drs. Danielssen and Boeck, the veins
of the spinal cord were found congested, particularly  at its posterior
part;  a dense, albuminous layer,  several lines in thickness, was found
between the arachnoid and pia mater; there was general  infiltration
of the membranes of the cord  by albuminous fluid ; and the  cord
itself   was tough,  almost as  hard  as  cartilage, and  in  some cases
reduced to the calibre of a  quill.   The gray substance of the  cord
was of a  pale, dirty yellow color, and  all trace of bloodvessels,
excepting in the  middle, was lost.  With such  a state of morbid
alteration of the nervous centre, the characteristic  phenomena of the
disease, the anaemia, emaciation,  atrophy of  the  muscles and skin,
mortification of the skin, and necrosis of the bones of  the extremities,
are easily explained.  In cases where the face, nares, and mouth were
extensively reduced in sensibility and nutrition, the eyes being  in  a
state of atrophy, the Casserian ganglion was  found to be distended
with albuminous exudation.  The same albuminous deposit has been
found within the  sheaths  of  the  nerves in  other  parts of the body,
giving them  a  swollen   appearance,  and  explaining  at once  the
destroyed innervation of the  surface and  extremities, and the deep-
seated pains so common in this disease, and  particularly in its later
stages.  The same transparent albuminous exudation has been found
in the subserous tissues of the lungs and liver, and in the substance
of the lymphatic glands.  The mucous membrane is pale, aud  less
apt to ulcerate than in the tubercular form of disease; the eyeballs
become opaque  and atrophied ;   there may be a small ulcer in  the
septum nasi, but the nose never falls in ; the spleen is usually hyper-
trophied;  the liver sometimes fatty, and the kidneys always seriously
diseased;  the pancreas  and  salivary glands  commonly  escape;  the
blood in the anaesthetic form differs very little from that in tubercular
elephantiasis.
  In selecting well-marked examples of the two forms of elephantiasis,
the distinction between  them is very evident; but in slighter cases,
there  is often  a blending  of the symptoms belonging  to the two.  In
one out of six  cases, according  to  Drs. Danielssen and Boeck,  the
disease commences with anaesthesia of the hands or feet, and then passes
into the tubercular form ;  in one  case in twenty, the anaesthetic form
takes the place of the tubercular; or aborted tubercles are developed
in the course of the anaesthetic form.  In a word,  though  frequently
quite distinct, and  pursuing an independent course, the symptoms of
the  two forms may be present in  the same individual,  or the one  may
pass into the  other; moreover, parents afflicted with one form  may
have children in whom the other form is developed.   The tubercular
is more common than the anaesthetic form.

                    CASES OF ELEPHANTIASIS.

  The opportunities of observing elephantiasis in England are neces-
sarily  and fortunately very restricted at the present day, although the 
346      DISEASES FROM SPECIAL INTERNAL  CAUSES.

disease was once a native of Great Britain.  Willan remarks that he
had only seen two instances, and my own  experience does not extend
far beyond his; but although the cases which have come before me
are few in number, they have happily embraced the leading  features
of both forms, and have enabled  me to comprehend the disease, and
carry my experience into a wider field  of inquiry, namely, into that
of the existence amongst us, even now, of traces of the disease, in a
comparatively insignificant, but  nevertheless  unmistakable  shape.
The  cases  which have been  presented  to me are  of two kinds,
imported and indigenous ; the imported cases occurring in Europeans
who  have been born or passed a number of  years in  countries where
the disease  is endemical—namely, the East and West  Indies and the
Mauritius;  the indigenous cases being those who had never left this
country.
  On referring  to my notes, I find the  cases of two young persons,
both presenting the early stage of elephantiasis, but having the char-
acteristic signs of the disease well marked.  They were born of Euro-
pean  parents, the one, a young  lady, in the island of Mauritius; the
other, a young man, in Jamaica; the former was nine, the latter,
twenty-one years of age; they evinced  a dulness both of mental and
physical power, and had a peculiarly sombre and melancholy expres-
sion  of countenance.
  Case 1.—The young lady had no other  symptoms of general dis-
turbance of health than listlessness, inactivity, and coldness of hands
and feet; but the coldness was not appreciable to herself.   Her hands
were thin, the fingers long and taper, and bluish towards the ends, and
there was a bluish or purplish hue on her lips and cheeks; the con-
junctiva and mucous membrane of the mouth and fauces were pale,
and the skin of her limbs was less sensitive  than natural.  This state
had  come on imperceptibly, and the first  symptom that alarmed her
parents, and induced them to send her  to this country for change of
air and medical aid, was an eruption of erythematous blotches, which
made their appearance on the limbs after a slight  intermittent fever-
ishness of  some days' duration.  The  feverish symptoms subsided
after the development of the eruption, but the latter had continued for
several  months, and seemed to  be  permanent;  for, although the
erythematous spots gradually faded, and sometimes went away com-
pletely, yet other spots and  patches appeared from time to time, and
kept up the complaint.  On her  visit to  me, she had as many as twenty
or thirty of these spots dispersed over her limbs, presenting successive
stages of development. The spots were  rounded  in form, not raised
above the level of the surrounding skin, and from half an inch to two
inches in diameter.   At their first appearance  they presented a light
crimson blush, deeper  in  the centre than at the circumference; in a
few days they had a purplish tint, then a brownish-yellow tint, and
then by degrees they faded away, without leaving any trace of their
existence.  After some  months' duration of the disease, the patches
faded more slowly, and, instead of disappearing completely, the patch
became gradually transformed  into a  yellowish-brown  or  blackish
stain, morphoea nigra.   My patient had  several  of these  stains on her 
ELEPHANTIASIS.                    347
limbs;  some were  a little rough from desquamation of the cuticle,
but the  greater number were smooth and glossy, smoother than the
surrounding surface, in consequence of  obliteration of the lines of
motion of the skin, and possessed of a polish  of metallic brilliancy,
from stretching and tiiinning of the cuticle.  To  the touch, the centre
of the spots was denser than the normal skin;  they were dry,  from
arrest of function of the sudoriparous glands, and were insensible to
a pinch  or to the prick of a needle.  I was unable to follow this young
lady's case further, but at a later period  I have no doubt that the
bronzed spots will  become gradually bleached, from absorption of the
coloring pigment; the insensibility will increase, and the skin become
white, and pass into a state of atrophy, morphoea alba, leuce>
  After watching this patient for two years, she grew tired of coming
to see me, and I lost sight of her.  Six years later, however, she was
brought to me  sadly changed;  the face was covered with tubercles,
her complexion was yellowish-brown, the frowning eyebrows had lost
their hair, the conjunctivae were anaemic  and glassy, the eyelids were
drawn widely open, the hair of  her head was scanty, the lobes of the
ears enlarged, her limbs thin and shrunken, and her hands and fingers
wasted.   A lady of title, her relative, besought me, as a boon to her
family, that I would take charge of her, that I would take her into
hospital, that I would find an asylum for  her—in short, that I would
take her and do as I pleased with her, and relieve her family of any
further  anxiety, or even thought of her.  The  poor girl was to be
banished, might be buried, anything, provided that her family heard
nothing of her more, except that the tomb had in reality closed over
her.  Such was my commission ; it awakened historic recollections of
the ancient leprosy, and I was enabled to comprehend the barbarities
with which the leper was pursued in the olden  time.
  To obtain for  her a home was a labor of much difficulty; all who
saw her shuddered at the idea of coming in  contact with her; and I
esteemed it a piece of good  fortune, when a sister of mercy of these
modern  times,  a disciple  of Florence Nightingale,  took  my  poor
patient in charge.   A feeling of religious duty  supported  this lady in
her task;  and  without  such support she must have succumbed to the
vexations that were heaped upon her in  the course of her duty; the
inmates of her house protested, the inhabitants of the square in which
she lived made painful  remarks; she herself failed in health, and her
exhausted nervous system was haunted in the  night with the. fancied
presence and touch of  her repulsive ward; but she bore up through
all.  More than once I felt it my duty to say  to her: Tell  me when
you can bear it no longer, and you shall be relieved ; I will find  some
other asylum for her.  But religion supported her to the end;  and
she never once failed to surround with  all the  comforts in her power
the declining days  of the poor leper.
  My patient died  two  years after this,  at the age of seventeen ; she
suffered no pain, and seemed to have no idea of her repulsive state.
During the later months of her life her vision was weakened ; she had
ulceration of the larynx; ulceration of the integument of  the  arms
robbed her of nearly the whole of the skin from  the shoulders to the 
348      DISEASES FROM SPECIAL  INTERNAL CAUSES.

hands; the legs were oedematous; the  feet ulcerated; thick gouttes of
matter oozed from large openings in her  face;  and she succumbed at
last to exhaustion, precijpitated by diarrhoea, probably from ulceration
of the mucous  lining ofthe intestines.
  Case 2.—My patient, from Jamaica, was an example of a more
advanced stage of the disease than the  preceding.  He was brought to
me in the summer time, and complained of being never warm, while
in the winter he scarcely felt the cold. The disease had  first shown
itself in the form of erythematous blotches,  five years ago,  after a
winter spent in England, during which he had suffered severely from
the   cold.   The  blotches appeared first on the  calf of the leg,  and
gradually faded  away.  During the  following year the erythema
attacked the lower part of the  face, and spread upwards  by degrees.
A year after, patches were developed on  the trunk, while the  skin of
the   face, and  particularly  of  the forehead and brow, began to be
discolored and thickened. On presenting himself before me, the lower
part of the  forehead was thick and prominent, and marked by  several
rounded elevations or incipient tubercles,  which threw the brow  into
wrinkles, and gave a frowning expression  to the countenance.  There
was  a similar tubercular condition of the ears, and  a  commencing
rugosity of the  lips and chin.   The  texture of the skin was coarse
and granular, its color dusky brown or tawny, and its surface greasy
from effusion of an  excess of sebaceous substance.  This latter is one
ofthe occasional symptoms of elephantiasis; and Drs. Danielssen  and
Boeck have remarked, that when it occurs, there is an hypertrophous
condition of the  sebiparous glands.   The prominent, frowning eye-
brows of my patient were almost denuded of  hair,  and,  although
twenty-one years of age, there was no appearance of whisker or beard.
The conjunctiva and mucous membrane of the mouth and fauces were
pale, and the voice husky.  The trunk of the  body and limbs were
covered with  tawny patches,  varying in size  from a mere point to
the  breadth of the palm of the hand,  of  an irregular figure, but, for
the  most part,  rounded in form, and dry,  from deficient perspiratory
secretion.  The  small points were seated  in and around the pores of
the  skin, as if  the discoloration had commenced within the follicles;
and the larger patches were studded over with these smaller spots, of
a deeper tint than the surrounding discoloration.  There was no  itching
or irritation in the blotches, nor any hardening  in the centre, as in
the  previous case;  but  they were evidently less sensitive  than the
unaffected skin.   The hands were thin, the fingers long, slender,  and
of a leaden hue, and the skin covering them attenuated and bronzed.
He  observed that his face was more sensitive  to the action of the air
than it used to  be, and that it was  apt to become inflamed when
exposed to the rays of  the sun.  His general health was undisturbed,
but he complained of listlessness and  indisposition to apply his mind
to any mental  pursuits.
  It has been observed, that the loss of hair which accompanies tuber-
cular elephantiasis is restricted to the parts  of the  body  directly
affected by the disease,  for example,  the eyebrows, eyelids, and the
white patches of morphoea alba; in these instances, owing its fall to 
ELEPHANTIASIS.
349
the destruction or imperfect nutrition of the hair-follicles ;  but it has
been also noticed, that where  elephantiasis  occurs in a young person,
development is retarded, puberty deferred, and there is frequently a
defect in the production of hair, as in the present case. I have already
remarked that the young lady was more childlike  than beseemed her
age;  and there was also a deficiency of sexual instinct in the male.
  The previous cases are examples of elephantiasis in its  incipient
state, and developed in young persons born of European parents, but
in a country where the disease is  endemic.  I will next  proceed to
the narration of two cases of Europeans attacked by the disease after
a long residence in  India.
  Case 3.—Captain B----, aged forty-three, had resided in  India for
seventeen  years.   Between seven and  eight years  back,  while in
Scinde, he observed discolored spots  upon  his limbs, and a  dark dis-
coloration of the skin of  the face and neck.  He was otherwise quite
well in health, and  prosecuted his  military duties as usual.   Within
the last three or four years he had  been the subject  of frequent attacks
of intermittent fever, and about two years since, these aguish attacks
had become so frequent that he was under  the necessity of coming to
Europe for relief.    He states that he was in a constant state of  fever,
with exacerbation and rigors every other day.   For the relief of this
fever he resorted to Kissingen, and put himself  under a course of the
waters of that place, which brought on a crisis attended with  deter-
mination of blood to the head.  During this illness a number of fresh
erythematous patches appeared on  his limbs;  his face, and particularly
the forehead, was  congested, and a  crop of prominent elevations or
tubercles was developed along the eyebrows. The fever then  subsided,
and ceased somewhat suddenly, and he has had  no  return  of the
feverish symptoms. About  eighteen  months  after  this attack he
appeared before me for relief from the discolored patches on his limbs
and body, and from the tubercular condition of his forehead.   He made
no complaint of his general health  otherwise than that his hands were
always cold, even in the hottest weather, and this he attributed to " want
of circulation." His hands were thin, the fingers of a leaden hue, and
the skin smooth and polished, shining with a metallic  lustre.  There
were numerous dark-brown patches on his limbs, some of which were
quite smooth, while others were raised, as though oedematous or infil-
trated with a yellowish jelly, and apparently translucent.  They were
dry, from absence of cutaneous secretion, and some of the prominent
patches, in  which the  gelatinous transudation  appeared to have been
absorbed,  were collapsed  and wrinkled.  Along  and immediately
above the  eyebrows were twelve  or fourteen  prominences on each
side, of about the size and elevation of  split peas;  in the lower part
of the skin of the  forehead, and  towards  the inner end of the eye-
brows, the tubercles were isolated; along its  outer half they  were
clustered and confluent.   Upon close examination the tubercles were
whitish and semi-transparent, and marked by  the ramifications of
several large venules, the cuticle covering them being of a  dark color,
like that of the surrounding  skin.  The  hair of  the  eyebrows  was
thin, and absent on the tubercles themselves.  The dusky hue  of the 
350      DISEASES  FROM SPECIAL INTERNAL  CAUSES.

skin of the forehead, and the  heavy frown of the hairless and rugous
eyebrows, gave a strongly marked leontine character to  the  counte-
nance.
   Case 4.—Dr.----. one of  the chiefs of the Medical Establishment
of Bengal, had resided in India for forty years, and, with the exception
of several  years of suffering  from hepatic disease, enjoyed unusually
good health.  He is now seventy, and  the first symptoms of  his
present disease made their appearance in 1849, at the age of sixty-
seven.  He reports,  that in the  summer of 1850, while in Malta, he
became aware of an occasional weakness in walking, and a benumbed
sensation on the outer side of the right foot.   Later in  the year an
erythematous blotch showed  itself at the seat of the numbness, and
was  attended with a  prickling sensation and a feeling of tightness, as
of a wire fastened around the part when moving the foot.  In 1851
similar phenomena occurred  in  the left  foot, and  several new spots
appeared on the  right leg.   The  spots were of a dusky red color,
rough, and dry on the surface, tender to the touch, and accompanied
by a feeling of  tightness.  A few  months later the feet were very
tender, the prickling sensation was more general, and the  tightness on
walking had extended  higher up the leg.  While these changes were
in progress he began to experience a sensation of numbness on the
side  of the metacarpophalangeal joint of the middle finger, and ob-
served a patch of redness on the next joint. In the month of January
of the following year there was an evident numbness of the little and
ring-finger of the right hand.
   Up to this time he had not been troubled  with any constitutional
disorder, but, about the middle of January, 1852, he was  seized with
sickness of stomach, and a fortnight later  with a smart attack of fever,
accompanied with excessive sweating, the  latter symptom sometimes
coming on without being preceded by the usual hot stage.  He was
treated with quinine, and the fever speedily  gave way.   At the end
of eight days he was well;  but on the  third day of the fever, and
during the  hot stage, two large, livid, cedematous-looking blotches,
which he spoke of as resembling  blebs, suddenly made their appear-
ance on the outer border of the  left wrist.  After the subsidence of
this  febrile  attack the sensibility of his  fingers  gradually returned.
In June he had  a second  attack of fever, which  lasted eleven days,
being preceded by sickness; on the ninth day of the fever the numb-
ness  returned, but disappeared on the eleventh day.  In July there
was a third febrile attack of the same kind, accompanied with a burn-
ing sensation, pain,  aud soreness of the outer  border  of the feet,
increased numbness ofthe ring and little  finger of  the left hand, red-
ness  of the knuckles, pain on exposure to the slightest cold, and the
development of a hard and inflamed swelling just above the inner
condyle of each upper arm, in the situation of the supra-condyloidean
lymphatic gland.  During the month of August the disease continued
steadily progressing; tubercles were thrown out on the face ; erythe-
matous spots and patches appeared  on the abdomen and limbs, being
preceded by itching and smarting when fully developed.   In Septem-
ber there was a still further increase of the disease, the whole forehead 
. ELEPHANTIASIS.
351
was studded over with tubercles;  there were erythematous patches
within the  mouth, and hard tumors developed in the subcutaneous
cellular  tissue of the forearms and  back of the wrists.   The three
following months of  the year saw  only a progressive advance of the
disease in every way, with increased  insensibility and lividity of the
fingers and feet.
  In January, 1853,  numerous large  patches  made their  appearance
on the back of the thighs, and several of those already in existence
threw out a broad areola around their circumference, which gave them
an annulated appearance, dark, and  almost livid in  the  centre, and
bounded by a crimson band.  In April, after a hot bath of the tempera-
ture of 104°, the  face became flushed and spotted over with erythe-
matous patches of a vivid red color, the redness of the spots on other
parts of the skin was increased, and they became prominent  from
oedematous infiltration, while those  which were already  prominent
became  enlarged.  The symptoms now assumed a progressive cha-
racter; in the beginning of May, there was inflammation of the left
hand and oedema of the right ankle, with a sensation of extreme cold,
although the part was hot to the touch.  The face remained congested
and swollen, the features were  enlarged, and  the natural  wrinkles of
the skin deepened ; the alae of the  nose  were remarkably distended,
and hard knots, like tubercles, could be perceived as well as felt under
the skin, at the outer angle of the eye, upon the temple, and upon the
ears.  Inflammation now appeared  on the right hand, and the fingers
became  swollen  and  painful, like  those of the left.   The  deranged
sensations of cold  and pain continued in the legs and feet, spots showed
themselves on the palms  of the hands, and  the  oedema, which  had
increased in the patches, was now apparent in the lower eyelids.
  The preceding  narrative of the  case is drawn from a journal kept
by the patient himself, and at  the  conclusion of this  period, namely,
on the 25th  of May, 1853, he first came under my  observation, his
state being much aggravated, and  the disease accelerated, as  he
believed, by the treatment which had been pursued, and which con-
sisted of arsenic, in  large doses,  for  seven  weeks;  then  iodide of
potassium, at first alone, and subsequently with  arsenic, for another
term of seven weeks;  then iodide of potassium, arsenic, and bichloride
of mercury, all combined, for three weeks, until the gums became
tender;  next,  the bichloride of mercury with sarsaparilla, for seven
weeks;  and lastly, two grains of blue pill night and morning, to keep
up tenderness of gums, in addition to the bichloride  of mercury and
sarsaparilla.  It was  after this severe course of treatment, extending
in time  from August 13th, 1852,  to April 20th, 1853, that he first
consulted  me; and  I could not but agree with him in thinking that
the treatment had tended to hasten rather than check the progress of
the complaint.  I was glad, however, to  have  the  opportunity of
seeing the  results of this  active plan of treatment,  conducted, as it
had  been, by a most  able  physician; and  I  felt that little hope of
benefit could be looked for from such a course, although consisting of
remedies which, a priori, and without the experiment, I should  have
looked upon as best calculated to bring about a cure. 
352      DISEASES FROM SPECIAL INTERNAL CAUSES.

  The history of the patient, while under my care, was a progressive
advance of the disease, both in eruption and diminution of sensation,
until  the month of August, when a  state of extreme  dulness, heavi-
ness, and lethargy came on, accompanied with  febrile symptoms, and
continued for several weeks.  From this attack he gradually recovered,
and two months  later had regained strength, appetite, and a power of
applying his mind to reading.  The  oedematous tubercles on various
parts  of his body were becoming smaller; many ofthe brown-colored
spots  were fading ;  and there was a slight increase of power over the
muscles  of his  hands  and lower  limbs.  He could walk  across the
room  with the aid of a servant, and had some  feeling in his feet;  but
his hands were  still very sensitive to the  influence of cold, and he
was obliged to continue the use of warm gloves to protect  them.
  My treatment during this interval was, in  the first place, nitro-
muriatic acid with gentian; then a course of decoction of  the woods
with  Donovan's solution; then  a return to the  nitro-muriatic  acid
and gentian, with the addition  of iron; during  the febrile  attack,
ordinary  antiphlogistic  remedies, and after  its cessation, ordinary
tonics.  I had so little  faith in specific remedies, that I felt no inclina-
tion to resume them, and I cannot say that any advantage appeared
to result from the decoction of the woods.
   The nephew of this  gentleman, himself a physician, reporting the
patient's state of health in March,  1855, observes:  "By using the
warm salt-water bath, and residing some months on the sea-coast, he
so far regained  the strength of his  limbs that he was able to walk a
mile aloue, and no appearance of spots was visible, with the exception
of a few upon the abdomen."
   Case  5.—Another  case, which I believe  to  have  been one of
anajsthetic elephantiasis, occurring in a person who had never  been
out of this country, came under  my notice in 1849.   Dr. Nathaniel
JarvisHighmore, of Bradford, Wiltshire, in a letter to me, introducing
the patient,  says: " Mrs. L----, married at the  age  of twenty,  her
health previously, and  for twelve months  after, being good.  About
May,  1842,  she  became,  from family circumstances, the  subject of
great mental anxiety, weak, poorly, and complained of severe pain in
the left  side, immediately below the heart; the  skin in a few  days
became dark, discolored in patches, and swollen, especially the hands
and feet.  After a short time the skin about the  throat and chest
apparently contracted, giving the sensation of a person tightly grasp-
ing it."  Some  mouths later, Dr. Highmore   describes  her state as
being one of "depression bordering on mania; she was sleepless, and
refused either to speak or eat."   Both hands  and  feet  were  at  this
time much swollen, but she retained perfect command over them ; later,
however, they became stiffened.   Vapor baths were administered to
her  with decided  injury, and  equally injurious  was  a course of
mercurial medicine.   Dr.  Highmore first  saw her in 1846, at which
time  she was still under the influence of mental anxiety.  She became
depressed from  the slightest cause; her hands and feet were always
cold,  and if  she were  excited, they,  as well as her nose, presented a
purple tinge.  The skin of the arms, face, throat, chest, and  ueck
was hard and contracted, and of a dark olive  color. 
ELEPHANTIASIS.                    353
  When this  patient appeared before me,  she was extremely ema-
ciated, and her skin so  much contracted as to appear too small for
her body ; her lower eyelids were drawn down, exposing more of the
eye than usual; her features were  lengthened, and the lower lip had
fallen  away from the mouth, showing  the teeth and gums.   Her
fingers were bent and  contracted, and there were several sore places
upon them, occasioned by ulceration; the sensibility of the  skin was
deadened, and her movements were effected  with difficulty.
  This patient died the year following of acute bronchitis, " no change
having taken place in the appearance or functions of the skin."
  Etiology.—The cause of elephantiasis is an animal poison gene-
rated  in, or received  into the  blood, accumulated therein, probably
by a process analogous  to fermentation, to the point of  saturation,
then acting as a morbid stimulant or irritant, and giving rise  to
certain phenomena which have for their object the elimination ofthe
poison, either by the  natural  emunctories,  or  by deposition in  the
tissues of the body, the  surface  tissues in the  tubercular form,  the
nervous  centres  in  the anaesthetic form, or by the  discharges from
ulcers.  The nature and origin of the  poison  are wholly  unknown ;
certain conditions of the human body, and of the elements around it,
must have co-operated at its first production, and those conditions no
doubt continued  for a time, and may still be in action  more strongly
in some countries*than in others, for the  maintenance of the poison,
and for the perpetuation of the disease.   This  constitutes the sponta-
neous or endemic origin of elephantiasis; and in this  point of view
we may regard, as springing from such a source, the two instances of
Europeans, cases 3 and 4, previously narrated.
  Those gentlemen resided for some years in a country in  which this
disease  prevails, and were  afflicted with it  in  consequence; and a
similar consequence  may be entailed  on any  one similarly placed.
Fortunately, elephantiasis is not very common  in India, and, there-
fore, we may suppose that the causes giving  rise to it are weak ;  but
in the Mauritius, and  particularly  in  Norway, they  are still strong,
and new  residents in  those parts are in danger of being attacked  by
the disease.  Several of  the European settlers  in the Mauritius are
now suffering severely from  elephantiasis, chiefly of the  tubercular
kind; and Drs. Danielssen  and  Boeck mention the case of a naval
officer who had lived for a short time in Norway, and was afterwards
afflicted with the disease.
  The doctrine of infection and contagion, as applied to elephantiasis,
has long been abandoned;  several of the older  medical  authors
expressed their doubts as to its communicability by  this means, and
modern authors are all agreed in denying it; and not only is this the
prevailing opinion, so far as ordinary social intercourse is concerned,
but it is also denied that a husband can communicate the disease to
his wife, or a wife to her husband, or  that  a  nurse can convey the
disease to an infant by suckling.  Thus the revulsion of opinion  is
complete, and admits  of no origin for the  disease but that already
stated, and  hereditary transmission.  An European  gentleman from
the Mauritius, who lately consulted me, stated that he had resided in
      23 
354      DISEASES FROM  SPECIAL INTERNAL CAUSES.

the island for twenty-nine years;  he had married a native lady, who,
with her five children, was perfectly free from any trace of disease;
but that, within the last twelve months, symptoms of an undoubted
character had appeared in himself.  I did not hesitate to say, that I
believed marriage had no share in producing his present symptoms,
and that the disease  originated in endemic causes alone.  His case
was interesting, as presenting the earliest phase of the complaint;  he
was feeling strong,  and well, and  perfectly free from  pain or incon-
venience of any kind ; but there  was numbness of  his feet and  legs,
and part of  his arms, and he  had scalded himself accidentally with
the steam of a boiling teakettle, without being aware of any sensation.
   With regard to the second and more frequent mode of propagation
of the disease, namely, hereditary transmission, the same variation of
results  is met with  as  is  found in all  other  natural  phenomena.
Leprous parents may have all  their children affected, or one or two
out of an entire family;  or the children may escape entirely.  The
same  may take  place where the mother or father only is diseased;
but it would  seem that transmission  through the mother is more
constant than on  the side of the father.   Again, the disease may pass
over several successive generations, and show itself unexpectedly when
the remembrance of such an inheritance is forgotten.
   Elephantiasis  may occur at any period of life, but  is less frequent
in infants than in children beyond the  age  of seven,  and most com-
monly does not  show itself until  after the period  of puberty.  It
is also  more  common in the  male than in  the female sex.  When
it occurs  before  puberty it is apt to  cause a suspension of sexual
development.
   Amongst other conditions favoring the occurrence of elephantiasis,
is a damp and humid atmosphere.  The disease took its origin, as we
have  seen, on the  marshy  banks  of  the  Nile, and  its  habitat still
continues to be the banks of rivers ;  islands, as Mauritius, Madagascar,
Madeira, the Greek Islands, the  Crimea, Iceland ;  and sea-coasts, as
those of the Black  Sea, Mediterranean,  and, in particular, the coast of
Norway.   Temperature  is obviously an  uuinfluential condition, for
the disease at the present time evinces its greatest  activity in India,
the islands of the Indian Sea, and on the coast of Norway.
   We  may pass over those speculations of human ignorance which
attributed the origin of elephantiasis, one while, to divine wrath as a
punishment for sin, and  another while, to  divine  favor, securing to
the sufferers religious honors.
   The  known animal poisons are comparatively few, and the  laws
which govern them beiug the  same, or nearly the same, we are not
surprised to find that elephantiasis  has been attributed to the poison
of syphilis, or rather, that elephantiasis, being the  earlier of the two,
was supposed to pass into syphilis; and it is a curious fact, that syphilis
first began to attract  attention  in Europe when elephantiasis was on
the decline.   The  points of resemblance between elephantiasis and
syphilis are very striking and very remarkable, but hardly more so, per-
haps, than between  syphilis and other diseases originating in an animal
poison; and therefore it  would be unphilosophical to infer that there 
ELEPHANTIASIS.
355
was originally but one animal poison  from which both diseases have
Bprung.   It would be as correct, and equally probable, to assume that
two animal poisons existed at the same time, the one being the poison
of elephantiasis, the other, that of syphilis;  and that, existing together,
for a time at least, their symptoms were confounded by the early his-
torians and early  medical writers.  At the  present day, even, I meet
with diseases of the skin which  I am at a loss to classify under one or
the other poison, although to one of the two they undoubtedly belong.
  Diagnosis.—Elephantiasis may be confounded with constitutional
syphilis, chloasma, melanopathia, leucopathia, anaesthesia and paralysis
from ordinary causes.  The muddy skin, suffused eyeball, dull-red or
copper-colored patches,  congested  fauces, even  the tubercles and
enlarged venules  on  the surface of the skin, all  belong equally to
syphilis and  elephantiasis,  at a certain stage of  its course;  but the
pathognomonic signs of  elephantiasis are, the defective  sensibility of
the skin, the thinning and numbness of the fingers and hands,  and the
history and duration  of the  complaint.  In the first of the cases before
narrated, the dull, purplish-red patches, even with the skin, and leaving
behind them  smooth, brownish, or bronzed stains, more  or less insen-
sible to the action of irritants, although  pointing to the suspicion of a
morbid poison, were  totally unlike hereditary syphilis, and could not,
from the age of the patient, as well as from the absence of other symp-
toms, belong to the secondary period of acquired syphilis.  The doubt-
ful aspect ofthe eruption would lead the mind to elephantiasis as the
only other known disease which could  produce similar appearances.
In the second case, the body was covered with patches exactly resem-
bling chloasma, and, but for other symptoms, of elephantiasis, might
have been taken for  that affection.  In chloasma, however, the skin is
generally dry, and roughened by a furfuraceous desquamation, besides
being more or less irritable; but these patches were smooth, moistened
by sebaceous secretion, unaffected by itching, and clearly less sensitive
than the surrounding skin.   Still, the distinction between them was
such as could only  be appreciated by  the experienced eye, and the
diagnosis might have remained uncertain but for the appearance of
the fingers and hands, the tuberculated and thickened skin of the face,
and the frowning and alopeciated brows.  The third case was remarka-
ble for a settled chronic character, which does not belong to the more
transient syphilis; the tubercles on the  eyebrows were hard and per-
manent, the patches  on the limbs were darker, more leaden, and more
polished than the copper-colored stains  of syphilis.   By the same
characters, also, they were unlike chloasma.  Then there  was the
deficient sensibility,  the  chilled surface, the  cold extremities, which
pointed specially to  the  real disease.  In the fourth case, I recollect
having the impression given me, on the first  glance at my patient, of
syphilis;  the dusky-reddish stains, sprinkled thickly over the  face, the
slightly-raised tubercles  on the forehead and temples, the muddy-skin,
and diffused eye,  all  denoted syphilis.  But when I saw the attenuated
fingers, and broad bronzed  patches on the  arms, some oedematous, and
others shinino- with  metallic lustre, and  detected the coldness  and
numbness of the  hands, I discovered my mistake.  My first questions 
356      DISEASES FROM  SPECIAL  INTERNAL  CAUSES.

were suggested by the coup de ceil thrown on my patient at first sight;
but I soon changed my attitude of interrogator for that of listener, and
was glad to be taught the curious phenomena and progressive history
of the complaint.  In a word, anaesthesia is the diagnostic character as
well of tubercular as of anaesthetic elephantiasis, the difference being
one of degree only.   In tubercular elephantiasis, the morbid disposi-
tion seems to take  place in the  peripheral nerves alone, while in the
anaesthetic form, it occurs in the nervous  centres; in the former, the
numbness, insensibility, defective nutrition, and atrophy, are slight,
in the latter they are extreme and fatal.
   In comparing elephantiasis and syphilis, it is not uninteresting  to
observe the close resemblance in pathological phenomena which exists
between the two diseases.  The tubercles of both are accompanied by
enlargement of the cutaneous venules, or rather by a development  of
venules where they normally do not exist;  in both, the tubercles result
from the transudation of an albuminous fluid of jelly-like appearance;
both occasion a disorganization, apparently by solution, of structure
of the  skin ; and both, as a  consequence,  leave behind them an atro-
phied state of that membrane when they disappear, as they are wont  to
do, by  interstital absorption.  Also, when they  pass  into a state  of
ulceration, both give rise to ill-conditioned, corroding ulcers, which
tend to eliminate the poison from the blood.
   The distinguishing character  between  morphoea alba and leuco-
pathia, on the one  hand,  and morphoea nigra and melanopathia, or
chloasma, on the other, may be taken to be  the presence or absence
of sensation as well as of color, and the state of nutrition of the affected
skin.   In morphoea, the companion and  sometimes the sole repre-
sentative of elephantiasis, there is always,  in association with altered
color of the skin, defective sensibility, suspended nutrition, and more
or less  disorganization of structure.   In morphoea nigra  there is  a
temporary increase  of secretion, which, however, soon fails; and in
morphoea alba there is arrest of secretion and hair formation.
   Prognosis.—In  endeavoring to form an opinion as to the issue of
elephantiasis, a question of much consequence,  as affecting the hopes
of the patient and the exertions of the physician, we derive very little
aid from the writings of the ancients, since by them so many cutane-
ous affections were  included under the general head Leprosy, that it  is
impossible to determine when the real elephantiasis is under considera-
tion, and  when  some other and more  curable  affection.  Thus, the
sacred  writings, usually  exact and accurate in their  description of
events, are so confused on the subject of elephantiasis as to require to
be put out of  the pale of reference  when treating on this subject, and
the pages of the Greek and Arab authors are equally uncertain.  The
prevailing opinion of the ancient writers, as well as of many of the
moderns,  is, that elephantiasis  is incurable, or, to a certain and very
limited extent, susceptible of cure.   While, on the other  hand, we  have
before us the fact  that the  disease has ceased, in other words, has
become cured, in countries  that it once ravaged,  that the cure has
been progressive and complete,  and  that it has followed  the course
taken by the malady in its progressive march.   That the cause may 
elephantiasis.                     357
have lost its power in the countries once afflicted is  quite  true, but
that it has ceased  entirely is not so, for examples of the disease still
continue to be  met with in^its old haunts, and there is no reason why
at some later day  it may not regain all its old  power, and become a
second time one ofthe epidemic pestilences which are permitted from
time to time to affect mankind.  Therefore, while, on the one  hand,
we have the opinion of the incurability of elephantiasis, we have, on
the other hand, the proof of its curability in a race, however little such
reasoning may be applicable to the individual.
  Amongst other conditions which may influence the  prognosis of
elephantiasis, are  its hereditary or accidental origin, and its acute or
chronic  invasion.   When the disease  is  accidental in its  origin, it
offers a better chance of cure than when hereditary, and may be pro-
nounced to be susceptible of cure; and when the disease is acute, it
may be expected to yield more readily to treatment than when insidi-
ous  in its  attack and chronic  in  its progress.   Moreover, the new
light and  new vigor thrown into the  subject by Drs. Danielssen and
Boeck lead us to hope  that much more may be done in the cure of
this affection than has been heretofore supposed; and that elephanti-
asis may be moved from the category of incurable into that of curable
complaints.
  Treatment.—The treatment practised  by the early  physicians in
this  disease appears to  have been founded  on  the principles of a
rational medicine, and to the present day we have made little progress
beyond that point, having simply glided  from a rational expectant to
a rational empirical system.  In adopting this latter system, we have
perhaps attained  all that, for. the  present  at least, we  may hope to
accomplish, and our energies will be better employed in being devoted
to the perfection of this plan than in seeking farther into the obscurity
of experimental medicine.  Aretaeus, who has  left so excellent  an
account of elephantiasis in his writings, lays down as the proper plan
of treatment, the practice of venesection, followed by the use of purga-
tives, diluents, baths, and  inunction with fat, assisted by a plain, nutri-
tious, and  wholesome diet, accompanying the latter, if the powers of
the constitution be reduced, with wine.  The purgative most  preferred
is colocynth; the  diluent, milk, attenuated  with  water;  and  amongst
other medicinal substances employed, are, decoctions of simples, par-
ticularly the plantain;  and the flesh of serpents, which was held in
high repute by the ancients, and, when  properly prepared, seems to
have made a very  agreeable article of diet, corresponding  with the
turtle soup of the  present day.  Other remedies  recommended  by
Aretaeus, are, the  plant called side'ritis (ironwort), the  trefoil, sorrel,
and iris; alum, sulphur, and carbonate and phosphate of lime,  under
the form of elephant's teeth.   The fats used for inunction were those
of the panther, lion, and bear.
  iEtius follows the general plan of treatment described by  Aretaeus,
adding, that amongst the  Indians it was customary  to  exhibit as a
medicine  the  urine of  the ass, probably  on account of its diuretic
effects, and prescribe as an article of diet the flesh of the crocodile.
Serpents and  reptiles seem to  have acquired their  reputation  in  this 
358      DISEASES  FROM  SPECIAL INTERNAL CAUSES.

and other diseases in which  the skin is affected, from their periodical
exuviation of the cuticle, and the magistral inference that their flesh,
partaken by man, would enable him to throw off, by a similar process
of exuviation, the sordid covering  of morbid secretions and  scales
which is apt to form in these diseases.
  Paulus ^Egineta, pursuing the same course  of  treatment, recom-
mends its  adoption  three or four  times  a-year.  To the purgatives
already in  use  he adds aloes and white  hellebore, and  suggests the
administration of an emetic, if needful.  He also mentions, in his list
of remedies, squills, cummin, calamint, hartshorn,  theriac of salmis,
and theriac of vipers.  As a part of the hygienic plan of regimen, he
prescribes  gestation, vociferation, friction, and  gymnastic exercises,
particularly leaping.  The body is then to be anointed with the fat of
some animal, as of the boar, wolf, goat, or bird, or with butter.  After
inunction the patient should betake himself to the  bath, and be well
rubbed with  some stimulating juice or spirit, such as faenugreek, or
gum ammoniac dissolved in vinegar ;  and, after the bath, he is to  be
anointed with a solution of  gum ammoniac and  alum in white wine,
or with some gently-stimulating and  aromatic oil, such as that of
myrtle.
  Rhazes,  the  Arabian physician,  commences  his treatment with
emetics, and reserves venesection  for cases  of severity or of long
standing; he combines turbith (convolvulus  terpethum) with colo-
cynth for a purgative, and favors excitation of  the  skin  by means of
friction and hot baths, and further by the help of a liniment composed
of onions and  fennel, or of a lotion of strong acetic acid, in  which
madder-root has been for some  time digested.   If  the powers  of the
constitution be reduced by  the treatment, he recommends the  use of
good white wine.
  Amongst modern authors, Schilling, who had  considerable oppor-
tunities of experience in the treatment of elephantiasis, advocates a
modified  method  applicable to the different periods of the disease.
He commences by  enjoining a moderate  and  unstimulating diet,
consisting of bread, broth and vegetables, and abstinence from milk.
He prescribes  laxatives, carefully avoiding mercurials; and if there
be signs of plethora, he administers purgatives, and takes blood from
the arm.  Exercise he considers important, as a means of promoting
perspiration, and  rousing the patient from the  state of apathy into
which he  is  liable  to  fall; and he further acts upon the  skin  by
means of diluents and hot baths, recommending the latter to be used
carefully in advanced stages of the complaint, as being apt to  occasion
palpitations and faintings.   The diluent remedies with which he pro-
poses to dilute the humors are emollient and  demulcent drinks, as
barley-water, gruel, decoctions of mallow and pellitory; with infusions
or decoctions of  gently  stimulating or  alterative herbs,  such  as
agrimony, ground ivy, fumitory, southernwood,  veronica; and mild
aperients, as  senna and rhubarb warmed with  aniseed.  He recom-
mends these drinks to be taken in quantities of eight  pints in the
day, and  continued for six weeks  at a  time, and he  states,  as the
effect of the treatment, that the  secretions of the bowels and  kidneys 
ELEPHANTIASIS.
359
aw regulated and brought into a healthy condition.  After the above
preparatory course of six weeks, he recommends the employment of
stronger  alteratives  and sudorifics, such as decoction of saponaria.
sarsaparilla, squinanthus, contrayerva, serpentary, pimpernel, rapun-
tium, zedoary,  sassafras, juniper, scolopendrium, holy  thistle, pareira
brava, and drinks of verjuice.  He  maintains  a strict diet, and if
nausea supervene, he diminishes the dose of the remedy, or suspends
it for a while.   This, like the former course, he continues for a period
of six weeks, and, as the state of the patient or of the disease indi-
cates,  he  bleeds, purges, or  adds  tonic extracts to the preceding
decoctions, such as fumitory, holy thistle,  smaller centaury, pimpernel,
arum, and wormwood.   During the sudorific course  he cautions  the
patient to avoid cold, lest it  check  a critical perspiration and induce
diarrhoea, and  he also  suggests a cautious  administration of purga-
tives, adding to those already mentioned, namely, senna and rhubarb,
—aloes, scammony, and the aperient salts of potash and  soda.   He
prohibits acids and spirits during the treatment, as calculated to excite
febrile action, but allows a more nutritive diet, and a little good wine,
if the constitution exhibit signs of exhaustion or debility.
  The treatment should be  pursued  for some time after the patients
have recovered, and be discontinued by degrees.   The skin should be
restored to its proper state of tone by spirituous washes and aromatic
fumigation, and, after his cure, the patient should carefully follow  the
prescribed rules of diet and exercise.
  In a case treated  successfully by Baume's, there were taken three
hundred  baths in the  course of  a year;  the  chief remedies were
demulcent, diluent, and  sudorific drinks, including asses' milk,  and
the regimen was nutritious and unstimulating.
  Specific remedies, as  opposed  to  the rational  expectant system of
treatment above laid down, have  gained few supporters  and little
credit.   The mineral specifics that  have been tried from time to time
are, mercury, antimony, arsenic, iodine, zinc, and gold.  Drs. Daniels-
sen and Boeck  have had little experience in these  remedies, their
attention having been chiefly given to the physiology  and pathology
of the disease.   Mercury, they say, has largely divided  the opinions
of physicians,  because their  diagnosis was inaccurate;  and,  according
to those who are known to have had  experience of the disease, both
that mineral and its compounds have been found to be not merely
useless, but also injurious.   The chloride and bichloride of mercury
have generally given rise to  vomiting and diarrhoea difficult to check,
or, failing this, have produced dyscrasis of the  blood,-a spongy and
bleeding  state  of  the  gums, and  a scorbutic  state of the surface
membranes.  Antimony, the primum mobile of Paracelsus, had great
weight with the older physicians, in the fourfold capacity of purgative,
sudorific, diuretic, and alterative;  but it is of little if any  value, in
elephantiasis.  The preparations of iodine Drs. Danielssen and Boeck
found to  produce a burning sensation, with pain and  swelling of  the
skin, in tubercular elephantiasis, when given in ordinary doses;  but
no such  inconvenience, when the  iodide of potassium, in doses of a
grain or a grain and a  half, was administered.  In the latter case, a 
 360      DISEASES  FROM SPECIAL INTERNAL CAUSES.

 slight decrease of the tumors was  observed after  a long period of
 continuance of  the remedy, but the improvement  did  not last.   In
 the anaesthetic form, the iodide of potassium relieved the pains in the
 bones which accompany this form of the disease; and the same effect
 resulted from the use of the bromide of potassium.  Of the prepara-
 tions of gold, these gentlemen had no experience; they made trial of
 the chloride  of zinc without benefit, and Donovan's  solution was
 administered  to seven patients, in  increasing doses, and for  a long
 period, without utility.   Four  of these  patients  suffered  under  the
 tubercular, and three under the anaesthetic, form of the disease.   Of
 arsenic, they speak in terms of equal discouragement, and in a manner
 to  suggest the doubt as  to whether  it could have been  properly and
 carefully  used,  to  produce the effects which they  mention.  One
 preparation which they  enumerate,  the arseniate  of copper, seems to
 have given rise to a succession of painful symptoms  affecting  the
 abdominal viscera.
   The vegetable specifics which have  gained a reputation from  time  to
 time are, black hellebore,  lauded by Aretaeus;  pennyroyal, praised
 by Pliny ; the plantain,  esteemed by Celsus; the  anabasis  aphylla. a
 plant which grows on the shores of the Caspian Sea, commended by
 Gmelin and Pallas, but not valued by Martius; the asclepias gigantea
 of  India, hydrocotyle asiatica, dulcamara, mezereon, aconite, conium,
 ledum palustre, &c.
   The animal kingdom has contributed specific remedies from the class
 of  reptiles, saurian, ophidian, and  chelonian;  and from  the class  of
 insects, cantharides.  The latter remedy has acquired a  false  credit,
 probably from error of diagnosis, some form of common lepra having
 been mistaken for this disease.  Drs. Danielssen and Boeck make the
 same remark  with regard to tar, which has also, and with  little pre-
 tence, been admitted among the remedies for elephantiasis.
   Reverting for a moment to the treatment of this disease, pursued
 during the middle ages,  we find it, as at the present day, displayed to
 us  under the three  aspects which  constitute a  rational  expectant
 medicine, namely, hygienic, dietetic, and  medicinal.  In its hygienic
 aspect, fresh air, sufficient exercise,  physical and  moral,  baths  for
 cleanliness and to invigorate the skin, are as necessary  now as they
 were then. In a dietetic  point of view, a nutritive, unstimulating diet
 is one of the  first recommendations at present, as  well as in the past;
 and medicinally, diluents, laxatives,  and alteratives, are almost merged
 in  the general consideration of diet. Then there  remain only special
 emergencies,  which must be met by special remedies, and  the appli-
 cation of those new aids which  the  light of science has made obvious
 to  us, and those truths which she has taught  us  in later times.  In
 respect of air, an inland residence lying high  and dry, is more desir-
 able than that of a river, lake, or the sea;  for it is in the latter  situa-
• tions  that elephantiasis  is chiefly found.  The plough and the new-
 turned earth would probably supply the double requisite of the best
 air and good exercise.   In respect of baths, we have no need at the
 present  day  to  inquire the nature of the  fluid  of which it should
 consist.   The plain water-bath is as good as that  of milk, and better
* 
ELEPHANTIASIS.
361
far than the bath of blood in which the monarch of Egypt was  wont
to seethe  his leprous limbs.   As diet,  a judicious blending of the
animal and the vegetable seems that which is  best fitted to man, in
disease as  in health ;  it is that which his  tastes select; it is that which
the naturalist predicates, from the structure of his  teeth, and  confor-
mation of his stomach, he was born to.  We may,  therefore, afford a
smile of pity at the contrariety of opinions  that  exist with regard to
the nature of the diet employed, a contrariety as great as the varied
tastes of man;  one while, the diet should be wholly vegetable;  now,
to consist  alone of  antiscorbutic plants, to the exclusion of the cerealia
and farinacea ;  then, to be chiefly of the latter class ;  another while,
it should be milk;  then, no  milk ; now, no fat, although the cod-liver
oil is a remedy of acknowledged excellence ; then, asses'  flesh, and
so on, until the mind is bewildered.  But, from this very contrariety,
we are warranted in drawing the conclusion, that a simple,  moderate,
and unstimulating  diet is not only judicious, but necessary.
   Amongst the specific  remedies advocated  in  the  treatment of
elephantiasis, is one that I would fain have  omitted all reference to,.
aud I only mention now to  condemn, namely, castration.  Under the
impression that the stimulus given to the  blood by the generative
system was an  excitant of the  disease, patients  have relieved them-
selves of these glandular organs, but without any benefit whatever;
and the combined  opinion of all modern authors is opposed to the
barbarous  practice.
   To resume the practical consideration of the remedial history of
this disease, I may  now mention, that in 1844, Drs. Danielssen and
Boeck projected a plan of  treatment which was found more successful
than any which had been pursued up to that time.  They thus describe
their plan:—
   Considering elephantiasis to be a disease depending on dyscrasis of
the blood,  we were of opinion that the treatment should be directed
against the abnormal  composition of that fluid; with which  object,
we prescribed a regular diet, together with cod-liver oil, the iodides of
potash, iron, and mercury,  the bromide of potash, and sulphur baths.
As for arsenic, fearing it might give rise to indurations of  the abdo-
minal viscera, we have used it sparingly, and in very small doses. Thus
far, the treatment is the same for both forms of the disease.   Turning
now to the  tubercular kind,  we  endeavor  to follow the  method
pursued by Nature in the  removal of the tubercles; and perceiving
that her process consisted in  softening and subsequent absorption, we
had recourse to means adapted to bring about the same result.  We
sought to subdue the morbid state of the skin, and reduce its  con-
gestions, partly by  frequent bleedings, and partly by stimulating the
mucous membrane  of the alimentary canal.   For the latter purpose
we had recourse to  sulphate  of magnesia, arsenic, or the tincture of
cantharides.  As a  local treatment of the tubercles,  we employed the
acid nitrate of mercury (hydrargyri nitratis, one drachm ; acidi  nitrici,
two drachms) for their destruction.  Where  they were less in  size,
and situated on the face, we pencilled them daily, or every other  day,
with a caustic solution of  potash (potassae  fusae, one drachm; aquae 
362      DISEASES  FROM  SPECIAL INTERNAL CAUSES.

destillatae, two drachms) ;  and where  they were scattered generally
over the body, we had recourse to caustic and sulphuretted  baths,
the caustic bath being composed of six or eight ounces of carbonate
of potash, and an equal quantity  of  quicklime,  mingled  with  the
water; the sulphuretted bath, of five or six ounces  of sulphuret of
potash.   The patients were kept in  the bath for a period varying from
one to three quarters of an hour; the head was  perfectly dipped, and
after  each  dip was  deluged with  cold  water; and the bath was re-
peated daily, or every other day.  Sometimes the caustic bath gave
rise to superficial  ulceration of the tubercles;  when the  ulceration
was slight,  the baths were continued, but when it became greater, they
were suspended for awhile.  We also found caustic potash  of service
in those cases of tubercular deposition within the larynx which some-
times give rise to asphyxia; we  combined the potash with honey, and
applied it  by  means of a  brush  to the epiglottis, and even  to the
isthmus of the larynx.  A paroxysm of cough succeeded  the  appli-
cation, but each time the respiration became easier, and, after a  while,
the symptoms of suffocation subsided.
   In  the anaesthetic form of the disease,  we directed our attention
chiefly to the  nervous centres, and sought to neutralize or  interrupt
the existing morbid action by means of cupping in the region  of the
vertebral column, and counter-irritation by means of tartarized anti-
mony ointment rubbed into the incisions, or an ointment of iodide or
bromide of potash, or by moxa.   In a number of cases treated in this
way, we were enabled to determine that  the several remedies already
mentioned had a decidedly favorable influence on the disease, although,
from the incompleteness of our experiments, none were perfectly cured.
   In illustration of this method of  treatment,  Dr. Danielssen adduces
the two following cases :—
   A tailor, in whom the disease was hereditary, suffered from elephan-
tiasis in its compound form, tubercular and  anaesthetic.   He was
treated by  Dr. Danielssen,  and got well.  Twelve  months  after, he
suffered a relapse, from cold,  and the disease assumed the pure anaes-
thetic form.   There  was insensibility of the skin of  the extremities,
particularly the hands, and an increased and  painful sensitiveness of
the deeper parts, especially of the fingers, to such an extent that the
latter were bent, and he was unable to hold a spoon.   He was treated
for this attack with a three months'  course of iodine  and  bromide of
potassium, and with  decided benefit; the excessive sensitiveness ofthe
fingers  had subsided, and  given  place  to  insensibility, and he was
unable to feel his needle.   He was  thin and emaciated, his cheeks were
pale and flabby, and his skin dry and inelastic.  Dr.  Danielssen now
saw him.  He continued the iodide and bromide of potassium, ordered
cupping along the vertebral column, and subsequently, the application
of the moxa.  The patient improved  rapidly, his  fingers became
straight  and  recovered their flexibility, the sensibility of  the skin
returned, his face acquired the aspect of health, and in four months he
was enabled to resume  his occupation.
   The second case was that of a man, aged twenty-four, whose body
was covered with scattered tubercles from head to foot, some of which 
ELEPHANTIASIS.                     363
occupied the deeper  part of the skin,  others  were prominent, some
were in a state of softening, and  a few were  ulcerated and  covered
with crusts.  His face  was swollen and livid; the tubercles on  its
surface were  hard and bluish, the eyebrows were in great part gone,
and whitish tubercles were apparent  in the nasal  fossae.  There were,
besides, oedema of the legs  and feet, and a swollen state of the inguinal
glands.  The disease had commenced three or four years previously,
by an eruption  of reddish  spots,  which  first broke out  on the  arm,
and subsequently on other  parts of the body ;  the red spots becoming,
at a later period, the present  tubercles.  He  knew no cause for the
attack, excepting that  he  had been  frequently exposed to cold and
rain, and had often  slept  in  his  wet  clothes.  His progenitors  and
family were entirely  free from the disease, and, saving the above, he
had had no other symptoms than  occasional pains in the legs.
  In the month of April he was bled to twelve ounces;  five minims
of Fowler's solution  of arsenic were given twice  a-day, half an ounce
of cod-liver oil  three times a-day, and a sea bath four times a-week.
In May the bleeding was repeated to ten ounces ;  he was  cupped with
eight glasses on the legs, and  the  Fowler's solution was  increased to
eleven drops, then thirteen, then  fifteen.  In  June he was  bled to
twelve ounces ;  cupped with six glasses on the legs ;  the arsenic was
stopped early in the  month, having given rise to pains in the abdomen
and cough ; and a little more than a grain of iodide of potassium was
administered every two hours, for pains in the legs and soles of the
feet, which came on chiefly at night.   In July he was twice cupped in
the vertebral region, each  time with six glasses ; and the cod-liver oil
was discontinued, having excited disgust. In August the proto-ioduret
of mercury was given for eighteen days;  at first, half a grain, subse-
quently, one grain twice a-day, for the  purpose, apparently, of hasten-
ing the healing of the ulcers, and removing a  thickening which had
been left in the cicatrices, together with the thickening and infiltration
of the integument  of  the legs.  These objects were,  in  a great
measure, gained, the  thickening of the  cicatrices and infiltration of the
skin of the legs were removed, but the  ulcers took to bleeding, period-
ical pains  occurred  in the legs, and pains  in  the teeth.  After the
cessation of the mercury, the  ulcers progressed rapidly. In September
the iodide  of potassium was given   up, cupping  on the back  was
repeated several times, with the  view of restoring  the sensibility of
the hands and feet, and, for the same object, baths, containing sulphuret
of potash, and the caustic bath of carbonate of potash  and quicklime
were ordered;  at first,  the sulphuretted bath daily, then in alternation
with the  caustic bath,  and later  still,  the caustic bath  increased in
strength  (eight ounces of lime  and  eight  ounces of  potash).   In
October he reported  himself as feeling better  than for years before;
he had a desire for work, and, with |kbe exception of a bluish tint of
complexion, looked fresh and animated.  The baths were given up;
but, as a little dulness of feeling still  remained in the fingers  and
toes, a moxa of the size of a crown piece was  placed near the spine,
between the sixth and tenth vertebrae.   In November  the moxa  was
kept open  by means  of from sixteen to twenty peas,  the  sensibility 
 364      DISEASES FROM SPECIAL  INTERNAL CAUSES.

 was almost completely restored, but he had still a difficulty in picking
 up small objects such as needles. In December sensibility was perfect;
 he had no pains of any sort, he  was active, and returned to his  home,
 although  against  the  wishes of his physician, who still wished to
 observe his progress, and anticipate any chance of relapse.
   Early in the treatment, as early as May, the  tubercles had com-
 menced to diminish in size, and their  diminution was progressive to
 the end of the treatment, when they had disappeared entirely, leaving
 behind them, however, a bluish and apparently deep-seated discolo-
 ration ; the skin of the part being thinner than natural.  They were
 at first painted with the strong caustic solution, and subsequently with
 the acid nitrate of mercury, which caused  absorption of some and
 ulceration of others.  The ulcers within the nose were painted  with a
 liniment of laudanum and oil, one part of the former and two  of the
 latter.  In June the ulcers were in progress of healing, and their pro-
 gress was continued steadilja  In July the  tubercles on the  face had
 disappeared, but their remains might be detected under the skin, as a
 slight thickening of the tissues.   To remove these remains, the  iodide
 of mercury was successfully given in August;  and,  although the pri-
 mary effect of this remedy on  the ulcers was not satisfactory, it no
 doubt contributed to their rapid  healing, which took place immediately
 afterwards.  The thickening and infiltration of the legs was attacked
 in May by cupping, the cupping being repeated in June, and  received
 its coup de grace in August, from the  eighteen  days' course of  iodide
 of mercury.  The nocturnal  pains in  the legs and soles of  the feet,
 disturbing sleep, complained of  in June, yielded to the iodide  of potas-
 sium, in doses of four, seven, to ten grains daily, assisted, firstly, by
 a general bleeding, and subsequently by the cupping practised  for the
 swelling and infiltration of the integument of the legs.  The iodide of
 potash was given  in a peculiar manner, in one grain doses every two
 hours.  I have no experience of this mode of administering the remedy,
 and should have preferred five grains  three times a-day.  This, how-
 ever, is a matter to be determined by experience alone.   The arsenic
 seems to have played a very unimportant part in the treatment;  it was
 taken  in July for seven weeks,  and  increased  too rapidly  in dose,
 rising during that short period  from five to fifteen drops  of Fowler's
. solution.   It had, therefore, every opportunity of developing its bad
 effects, without having time to work the benefit which arsenic is capa-
 ble of producing when given in moderate and long-continued  doses.
 Early in June it was found necessary to  stop it, from the occurrence
 of abdominal  pains and cough.   The insensibility of the  feet and
 hands, which  followed the pains in those  parts, no doubt  received
 benefit from  the  iodide of mercury, and also from the  stimulating
 baths ; but the remedy especially and most successfully directed against
 that symptom was bleeding andi?counter-irritation ; the  patient was
 repeatedly cupped in  the region of  the spine, during the month of
 September, and had a large moxa applied in October; the ulcer made
 by the moxa  was  still open in December.
   The local treatment of the ulcers of elephantiasis is to be conducted
 according to the common principles of surgery, to allay inflammation, 
ELEPHANTIASIS.                     365
control decomposition, assist the separation of dead parts, and promote
the healing process.   The enumeration of these indications suggests
the means and remedies which should be employed.  Schilling recom-
mends the tinctures  of aloes, myrrh, and amber, useful stimulants,
which, in modern surgery, have been transferred to the stable, and
given place to better  means.   He  cautions us against  the use of oils
and fats, and strongly against mercurial ointments, which,  he says,
the skin cannot bear,  so  long as the morbid  miasm retains its place
within the body.
  It may be gathered from the views of treatment now put forth, that
we must  rely  upon ourselves, and  not  upon  any fortuitous gifts of
Providence, to cure elephantiasis; and on  a due appreciation of this
truth will, in great measure, depend our  success, and the  safety of
our patient.  We  must use,  and learn to  use effectively, the  means
we have; and in doing this, we shall acquire a more  powerful specific
than any that can be presented ready prepared to our hand.   If, after
this essay, the  specific should arrive, we shall be the better able to use
it judiciously; if it should not be  forthcoming, we  have discovered
the means of doing without it.  It is probable that elephantiasis would
never have been the scourge to the world it has, if this truth had been
felt and acted upon earlier;  if physicians  had set themselves to dis-
cover the cause of  the disease, and followed up their search by work-
ing methodically to remove that cause, rather than puzzle .themselves
and their  successors by vain theories and  equally vain  experiments
with the long  list of simples  which  have been proved to be at least
innocuous to man.   Drs. Danielssen  and Boeck, discarding  all these
empirical means, have determined the cause of the disease, be it miasm
or poison, to be present in the blood.  They have observed the altera-
tions of the vital fluid occasioned by its presence; they  have traced
the morbid effects of  that cause in its action on the  nervous system,
and on the various tissues of the body; they  have pointed  out that
the morbid products are projected to the surface of the affected organs,
and to the surface of the body; and they have established a principle
of treatment which  shall change the composition of the blood, alter
and improve nutrition, and eliminate the poisonous  elements of the
disease.  In  pursuing this principle  they have the means to a favor-
able  issue in their  hands, and I doubt not will successfully combat
the disease which is now ravaging the shores of their country, and at
the same time give a useful practical lesson to  the world.
  The  treatment of elephantiasis, therefore, whether it present the
tubercular or anaesthetic form, should be conducted on the same prin-
ciple.  Portions of  the  blood of the patients should be taken from
time to time,  the quantity and frequency to  be regulated  by  his
strength ; and the blood so taken should be replaced  by the nutritive
matter derived from  a  welh^elected diet.   Thus, the  morbid blood
will give place to a  sounder and more healthy fluid.  Alteratives
should be  given, to alter  and improve the chemistry  of nutrition,
than  which none are better than arsenic, judiciously employed, and
cod-liver oil.   Thus,  sanguification  will be directly benefited, and
with sanguification, as a matter of course, innervation.   Elimination 
366      DISEASES FROM SPECIAL INTERNAL  CAUSES.

is to be rendered more energetic, to facilitate the requisite changes in
nutrition.  With this  view, the alimentary  canal, the liver, the kid-
neys, the skin, are all to be brought  into more  active play; to which
end, saline aperients and diluents are  the  appropriate  remedies.
Elimination, stimulation, and  counter-irritation  of that  most potent
emunctory, the skin, are all set in operation  by baths, the hot air and
vapor  bath, sea-bath,  sulphuretted bath,  and  caustic bath, already
mentioned; and, for a local purpose, the skin  may be further stimu-
lated by counter-irritants, and by the use of the moxa.   Local symp-
toms, such as  infiltration and thickening of  the skin, require simply
a local application of the same general principle, such as cupping or
leeches ; and the loss of sensibility of parts of the  body,  cupping and
moxa to the corresponding parts of the spine.
  Having now discussed the general principles of treatment, as founded
on  the observations and researches of Drs. Danielssen and Boeck, it
will be well to pass in review certain specific remedies at present in
use in  those countries where tubercular leprosy still prevails.  The
most important of these  remedies are, the  Asclepias gigantea, of Hin-
dostan, and the Hydrocotyle Asiatica.
  The Asclepias  gigantea, or Rumex gigantea, in the native language
of  Hindostan called  Mudar, Muddar, or  Mudarrh, has gained much
reputation  in  the treatment of tubercular leprosy.  Robinson, in his
Essay  on " Elephantiasis, as it appears in  Hindostan,"1 remarks, that
in the  treatment of  this disease, bleeding,  mercury, and  antimony,
used singly, are  of no use; but that the last two, combined with the
root of the mudar, have been found successful, when  aided by the
application of topical stimulants.  The  formula he proposes is com-
posed of half  a  grain of calomel, three grains of antimonial  powder,
and from six to  ten grains of the powder of the  root bark of the ascle-
pias, to be  administered  three times a day ; and the local stimulant, a
weak acid solution (four grains to the pint, with ten minims of hydro-
chloric acid) of the bichloride of mercury,  applied with friction to the
local affection.
  The Asclepias gigantea  was discovered by Playfair, who called it
vegetabh mercury, and   regarded  it  as  specific in the cure  of lues
venerea, elephantiasis, and cutaneous eruptions.   It  is,  he remarks,
the most powerful alterative hitherto known, and  an  excellent deob-
struent.  In the jugaru, or leprosy of the joints,  he  never found it
fail  iu healing the ulcers, and often  succeeded  in  effecting a perfect
cure of the disease.  Robinson agrees with  Playfair as to the utility
of the asclepias  in elephantiasis, and bears  witness to its "powerful
effects as a deobstruent and sudorific, in almost all cutaneous erup-
tions arising  from  obstructed  perspiration and  an apathy of the
extreme vessels.   Its action is quick and  decided, causing  a sense of
heat in  the  stomach,  which rapidlmpervades  every  part  of the
system, and produces a titillating feel on  the skin, from  the  renewed
circulation through the minute vessels.   It does  not  appear to be
useful, or, indeed, admissible,  where  the affection  is inflammatory or

              1 " Medico-Chirurgical Transactions," vol. x. 1819.
« 
ELEPHANTIASIS.
367
the eruption pustular.   The great and rapid determination  it causes
to the  skin  has an  obvious tendency to  increase such  diseases.   I
have tried it  freely in  lues venerea, but cannot  venture to recom-
mend it as a substitute  for mercury.   It  will  enable  you to  heal  a
chancre, but does not eradicate the poison.  In the secondary symp-
toms, however, it is an admirable ally,  superseding, by its certain
efficacy, the exhibition of mezereon, sarsaparilla, and other vegetables
of doubtful  utility.  Where mercury has been used, but cannot be
pushed safely any further, the mudar rapidly recruits the constitution,
heals the ulcers, removes the blotches from the skin, and  perfects the
cure.  The only part of the plant useful in medicine is  the bark of
the roots.  It should be gathered in the months of March, April, and
May.  The bark stripped from the root, being well dried, is readily
beaten  into  a fine  powder, of which  the dose is from  three  to  ten
grains, thrice a-day, for  an adult;  six grains is enough  to commence
with.  As the plant  grows wild  everywhere  throughout Hindostan,
it may  be applied advantageously externally.  I  have often used  a
poultice made of equal  parts of this  powder and linseed dust, with
decided benefit, in  bad  ulcers, from  whatever cause; and even in
gangrene it acts as a detergent in  cleansing the sore, and powerfully
stimulates the healthy  granulations.   Decoctions  may often be em-
ployed, where the stomach would reject  it in substance.  When  it
causes  pain in the stomach, a  few grains of magnesia  or prepared
kali  added to each dose  will prevent that effect. That this medicine
is really the principal in the cure, I have  no  doubt; for I scarcely
ever succeeded by any means in curing or even checking the disease
before  I employed it, and  have  scarcely ever failed of doing both
since."
  The  asclepias has been employed  in combination with arsenic, as
in the celebrated "Asiatic pills," the formula of which is as follows:—
               Arsenici protoxydi, gr. lv.
               Piperis nigri, gix.
               Asclepiadis giganteae, radicis corticis, §iv.  9iv.
The  arsenic  and black  pepper  are  to  be well   rubbed  together, at
intervals of time, for four days;  the mudar and water are then added,
to form a mass, and the latter is to be divided into  eight  hundred
pills.  The dose of  these pills is one twice a-day, each pill containing
one-fourteenth of a grain of arsenic.
  The  mudar powder is also used in  Hindostan  in  the form of an
ointment,  in combination with lard or spermaceti cerate.
  The  other vegetable remedy which has attained so high and appa-
rently so deserved a reputation in the East, the Hydrocotyh Asiatica,
is a  plant resembling  in appearance  and  ordinary characters the
common hydrocotyle  of the  stagnant ponds of  this country.  The
hydrocotyle asiatica is  reputed to be specific in  many diseases, par-
ticularly those of the skin, and  useful in all  cases of leprosy.   Mr.
Hunter, in his report to the Board of Health of Madras, in February,
1854, o'n fifty cases of disease of various kinds, of which thirty were
cured and the rest greatly  benefited, remarks,  that  "the affections
in which this medicine  has  been peculiarly efficacious are, ulceration, 
368      DISEASES  FROM  SPECIAL INTERNAL CAUSES.

syphilis, and scrofula.  Almost all cases of ulceration are cured with
this  remedy.  Amongst the  cures  were  several  cases  which  had
resisted other modes of treatment.  This  medicine  may  be recom-
mended  as  an excellent stomachic and tonic.  It appears to have a
peculiar action on the capillaries of the mucous surfaces, and on the
skin; it causes at first a sensation of heat  in the stomach, and at the
same time a prickling in the extremities  and then  over  the  whole
skin of the body, soon followed by an  augmentation of appetite  and
transpiration, and a general improvement in the health."
   Mr. Boileau,  a physician of Mauritius, published  an  account of
this  plant, as a remedy for tubercular leprosy, in 1852; and  M. Jules
Lepine, of Pondicherry, in  the Journal de  Pharmacie et de  Chimie for
1855, has given  a further  description of the plant, with a chemical
analysis, pharmacology, and list of the formulae used in the  Govern-
ment dispensary  at that  place.  The properties of the plant seem to
be due to a peculiar vegetable  principle  which he  names vellarine,
from vellarai, a native name of the hydrocotyle.   Vellarine is a thick,
pale yellow oil, having a bitter and penetrating taste which abides for
some time on the tongue, and is most abundant in  the roots, wherein
it exists  in  the  proportion of  somewhat  more  than one per cent.
Besides the  vellarine there  is a  yellow oil, brown resin, green resin.
saccharine extract,  non-saccharine extract, and bitter extract;  the
latter, in the proportion  of  ten and a half  per cent., is found only in
the' root.  The fresh plant is slightly bitter and aromatic in taste.
   The pharmaceutical preparations of the  hydrocotyle are, a powder
of the entire plant, of which the dose ranges from one to six  grains
daily; a syrup, prepared from the juice, useful for children, the dose
ranging from two drachms  to two  ounces daily; a tincture, the daily
dose ranging from ten to forty drops ;  an infusion ; an ointment of the
green plant; and baths, containing four pounds of the plant, either
green or dried.   Similar preparations are made from the root, and
are much more  active than those of the  entire plant, the root con-
taining,  as  already  mentioned, the largest proportion of vellarine.
Vellarine cannot, however, be  employed  separately, from its great
hygrometric qualities and active tendency to decompose.  Vellarine
has also the property of volatilization at 212°, and the virtues  of the
plant are consequently  destroyed by exposure to  heat.  For this
reason decoction and extract are inadmissible forms.
   Dr. Marshall, of Bombay, found nitric acid a valuable and successful
remedy,  exhibited in  the  dose  of one drachm daily, diluted  with a
pint or a  pint and a half of water.  Of  two hundred  patients treated
on this plan, more than one-third were  cured, and the greater propor-
tion of the remainder much benefited.

                EXISTING FORMS OF ELEPHANTIASIS.

   Taking a mental survey of that grand, that elephant  disease, the
leprosy of the middle ages, which forms so prominent a feature in
the  history of  Europe, and especially of Great Britain, of which
examples have not very  long vanished  from  our land, the question 
ELEPHANTIASIS.                     369
naturally arises to the mind, And is it  gone ?   And if it be gone,
has it left no remains behind ?  Are there no traces of the leprosy ?
Is there nothing at the present hour which belongs to, is a part of,
is  a  living record  of that immense  disease?   Can our medical
antiquaries discover no impression of its  gigantic footsteps?  Has it
passed away like a shadow, or like the wind totally, and never to be
seen  again ?  To which we  answer,  It  would  be  contrary  to  all
analogy to suppose that it had so  totally passed away as not to leave
a trace; and yet no sign exists in the records of medicine to tell us
that such is not the case.  But though the sign may be absent in the
records of medicine, the infallible sign remains  imprinted on  man.
Leprosy exists amongst us still, but only as a faint trace of a worn-
out disease, or as an ember of the burnt-out fire.   God forbid that the
spark should be rekindled !  I repeat,  that elephantiasis still  exists
amongst us in this country as & faint trace of its former self, and the
observation of that trace, however faint, becomes a  matter of inter-
esting  research.   Although a mere shadow in comparison with the
parent  disease, it  is nevertheless  sufficient to occasion considerable
annoyance to the sufferer, and to bring him not unfrequently under
the inspection of the medical man.  Nor, when once pointed out, can
the medical man doubt for an instant the  nature of the disease  which
he has  before him:  there is  the insensibility, the  deposition, the
blanching, the exhaustion of function, and  the atrophy of the parent
malady, with  all their original  distinctness, indeed, one complete
symptom of the pure elephantiasis, preserved unchanged, as it existed
amongst the  Jews, and as it is  to be found at this moment on the
shores-of Norway, the symptom  which was called  by the  ancients
morphoea.  This symptom, or rather sign, has been  handed down to
us by our forefathers, and  it is  this which I shall now  proceed to
describe, preserving  the name by which it  was originally known.
namely,
                           MORPHOEA.
  Morphea, derived  from  the Greek word p^oe^, forma, signifying a
risible  appearance, and in application to its seat, a visible appearance
or  spot upon the skin, is, as its name implies, a spot upon or in the
skin, of irregular form, and either white morphea alba, or of dark-
brownish or blackish hue, morphea nigra.   Moreover, morphoea alba
admits  of a secondary division, from presenting  two  varieties, one in
which there is induration of the skin, from deposition in its tissue of
a lard-like substance, morphea alba lardacea, vel tuberosa; the other
being distinguished by atrophy of the skin, and  by a greater degree
of  insensibility, morphea alba atrophica, vel anesthetica.

                   MORPH03A ALBA LARDACEA.

  Morphcea alba lardacea, vel tuberosa, presents in  the form of one
or several circumscribed patches, varying in size  from a crown-piece
to several inches in extent, and may occur on any part of the skin.
The surface of the patch is uniform with the cutaneous integument,
being neither elevated nor depressed, but remarkable for its marble-
      24 
370      DISEASES  FROM SPECIAL INTERNAL CAUSES.

like whiteness, smoothness, and polish.  It is more or less dense and
hard, and frequently roughened on the surface by a slight desquama-
tion of dried-up cuticle.  Its hardness and density serve to isolate  it
from the surrounding skin as completely as its  color, and when  it
occurs in small patches, it has the appearance of being  inlaid in the
skin.   When recent,  the  edge of  normal  skin  immediately sur-
rounding it presents a delicate lilac  blush; l>ut in cases  of long
standing no such border exists.
  The smoothness, whiteness, and polish ofthe morbid  skin, all proceed
from the same cause, namely, infiltration into the tissue of the skin, or
deposition within its cells, of a white, semiopaque substance, very much
resembling lard.  The skin looks as if it were injected with lard, and
so distended as  to obliterate the  usual  markings of the cuticle; the
wrinkles of the surface, if any exist, being produced by  the folding of
the skin during the motions of the body.  Another cause of the white-
ness of the  skin, is the absence of the capillary plexus, and the almost
total absence  of bloodvessels.  Sometimes, if the patch  be  large,  a
small vein may be seen gathering its tributary venules here and there,
and sinking into the deeper structure, but the smaller patches look as
if the skin were dead.  Indeed, the deadness is not confined to appear-
ance alone; the patches are more or less deficient in, and sometimes
entirely devoid of, sensation,  showing that  not  only the bloodvessels
have  become  obliterated, but the nerves  themselves are destroyed.
In addition to these characters the patches have a peculiar baldness of
appearance; they are either  devoid of the usual downy  hair of the
skin, or the hairs are bleached and imperceptible, and with  the absence
of hair-formation, there is also an absence of the secreting function of
the skin.
   The white patch of morphoea  is often in the state now described,
when  first observed by the patient, but it always begins as an erythe-
matous spot.  When seen from the beginning, the spot is of small size,
not larger than a fleabite, but in a few days it increases  to the dimen-
sions of a crown-piece or the  palm of the hand.  The redness is alto-
gether unlike that of common erythema; it is never vivid, and scarcely
exceeds a delicate lilac blush. The redness continues for some days
or weeks, and then,  without  any other perceptible change, the skin
corresponding with the lilac blush becomes blanched,  and constitutes
the kind of patch just described.   The blanching process begins in the
centre of the patch, and the  redness then forms an areola around it,
the areola being  gradually narrowed until  it becomes a mere border
or rim, generally slightly raised, and at last fades away  altogether.
The  development of the erythematous spot is usually accompained
with a feeling of tingling, like that occasioned by pressure on a nerve.
Sometimes this  sensation is sufficiently powerful  to attract the atten-
tion of the patient, aud give him annoyance; at other times it is scarcely
appreciable.
   The size and number ofthe patches is very various.  I have seen a
number clustered together about the neck, each no larger than a lentil.
A common and  usual size is  that of a crowu-piece or  the palm of the
hand;  and  I have seen one patch occupy the greater part of the thigh. 
ELEPHANTIASIS.
371
The limb had the appearance of a piece of beautiful marble sculpture,
highly polished.   One felt tempted to touch it, it looked so white and
smooth, to be convinced thatit was not marble; and one was astonished
to find that though so lifeless in appearance, or resembling only living
marble, it gave the sensation of warmth.  I recollect  expressing my
astonishment in looking upon that limb; and, upon asking some ques-
tion, the gentleman smiled, and said that it gave him no inconveni-
ence, and if  it were not  for the appearance, he  should not know that
it was there.  The patches  rarely exceed three or four in number;
they are more  frequent in women than in  men; and their common
seat is the superclavicular region ofthe neck, the chest just below the
mammae, the front of the abdomen, and the thighs.  I have a patient
under treatment who had a patch on the forehead  and nose, in which
the morbid skin became shrunk and atrophied, and resembled a  piece
of dried white leather, perforated with small holes as if worm-eaten,
and equally insensible.
  My friend Mr. Samuel Wood, of Shrewsbury, writing to me lately,
says: "I have under my care,  in the Infirmary, a woman aged thirty,
suffering under a peculiar cutaneous disease.  Under each mamma, the
skin has deposited in it a sort of wax-looking secretion.  The part  bears
a strong resemblance to a recently blistered surface on a dead body, only
the cuticle remains, and there are  minute bloodvessels ramifying over
several parts.  The edge is slightly raised, and beyond this there is a
slight blush. The size of patch on the left side is four inches long by
three broad.  It has been slowly progressing for about twelve months.
There is little pain, but  an occasional burning heat."
  Mr. C. Wilson Steel, of Lewisham, writing to me  about the'same
time as Mr. Samuel Wood, says: "My patient is about thirty-five
years of age, and has three children, the youngest being eight  years
old.  She is of spare habit, active, has a soft, cool, but dry skin, rarely
perspires, and enjoys  good health.  About seven  years ago she per-
ceived, for the first time, a white spot on  the back of the hand; subse-
quently, other spots appeared on different parts of the body, as on the
abdomen, thighs, arms, &c;  indeed, they are dispersed more or less
abundantly  over  the entire surface.  The face is free, with the excep-
 tion of a stripe along and underneath the lower lip.   The whiteness
is more apparent in contrast with the color of the rest of the skin in
summer  than in winter; and  a  new spot is preceded by a feeling of
numbness and heaviness, which gives the patient warning of its occur-
rence.  The spots do not attain any magnitude; and the spread ofthe dis-
ease takes place by new spots, which, when once formed, are permanent.
They are distinguished from the surrounding skin, not by any raised
 margin, by  any chap, ulceration, scurfiness, or other morbid condition
visible to the eye; but simply by a dead,pearl like whiteness, bordered by
an abrupt line,  and exhibiting no transition, either on the side of  the
 morbid or healthy skin.  The spots are of various shape and size, and
 unaccompanied by sensation or pain, other than the premonitory numb-
ness and  heaviness already mentioned.  In the winter the distinction
between the white patches and the surrounding skin  is not strikingly
appreciable ; but in the summer it is very evident."
♦ 
372     DISEASES FROM SPECIAL  INTERNAL  CAUSES.

   In this  country, at the present time,  the disease,  perhaps, never
advances beyond the state of skin now described ; it may become more
extensive, harder, and more'callous ; but my experience does not enable
me to say whether any other symptoms of elephantiasis follow upon
this first step.  I have observed several cases of morphoea alba lardacea
for periods varying between  two and ten  years, and have seen no
other symptoms arise.  But in countries where elephantiasis still exists,
particularly in hot climates, this form of morphoea is often the imme-
diate forerunner of that serious disease.

                    MORPHCEA ALBA ATROPHICA.

   Morphoea  alba  atrophica,  vel  anassthetica, differs from  morphoea
lardacea not so much in  degree of insensibility of the skin, as in the
total  atrophy by which  it is attended.  The patches are of the same
figure and  size, the skin  as white, the lilac erythematous blush and the
tingling sensation which precede, and the lilac border which surrounds
them, the same; but there is  no deposition of morbid matter in the
texture of the derma, and consequently no marble-like smoothness,
polish, and hardness; the  lardaceous  deposit is absent.  In fact, the
two forms  of morphoea alba bear the same relation to each other as do
the two forms of elephantiasis;  morphoea  lardacea belonging to the
tuberculated, and  morphoea atrophica  to the anaesthetic form.   From
the absence of deposition in the tissue of the derma, and, as a conse-
quence  of defective nutrition, resulting from deficient innervation and
circulation, the  skin is thinner than natural, sometimes remarkably
attenuated, and sunk below the level of the surrounding integument.
Its glandular apparatus participates in  the  atrophy; there is  neither
sebaceous nor perspiratory secretion, and the part becomes bald from
loss of hair.  With this exception, the surface of the skin is unchanged;
the linear markings are perfectly regular, but smaller than natural,
and before the tint of color reaches the dead white of complete insen-
sibility  and atrophy, the patch has merely the appearance of being
delicately fair and soft, like that of an infant, contrasting strangely
with the often brown and olive skin which surrounds it.
   Just as elephantiasis anaesthetica and elephantiasis tuberculati, being
merely  varieties of the  same disease, may co-exist, so  morphoea alba
atrophica may be present with morphoea alba lardacea,  and sometimes
the anaesthetic form precedes the deposition  which subsequently takes
place, and becomes a stage of the lardaceous  variety.  This is the case
in a lady now under my care,  who has six or eight patches of mor-
phoea alba on the front of the body.  Three of these, of longer standing
than the rest, are distinctly lardaceous; one is dense  and hard only
in the centre of the white patch, the skin around it being natural in
texture, and simply blanched;  while several of the more recent patches
are thin, soft, and white, and delicately fair in comparison with  the
tawny skin in which they are, as it were, inlaid.
   Morphoea alba atrophica occurs for the most part on the front of
the trunk of  the body, particularly wherever the integument is thin,
as beneath  the mammae, at  the root of the  neck, in the  groins, and on 
ELEPHANTIASIS.
373
the inner side of the arms and legs.  Three or four times I have seen
it  on  the  forehead, where it resulted  obviously from paralysis of a
branch of the supra-orbital nerve.   It existed as a groove, about half
an inch in width, in the direction of that nerve; the  skin was white,
shrunken, and  insensible, the borders of the affected track being
slightly raised, and of a lilac tint.  In an advanced stage of the dis-
ease, the skin sometimes becomes shrivelled and dried up, like parch-
ment; this is more particularly the case over a hard surface, as upon
the head.
   The following is an example of morphoea alba of the forehead occur-
ring over the supra-orbital nerve, presenting itself in the first instance
in the  simple anaesthetic  form, and  subsequently taking on, in part,
the lardaceous  character.  The patient first came before  me in the
winter of 1851, being then nineteen years of age, and stated that the
disease had existed for two years.  He first  observed it after a fit of
excitement, when the whole  face was  flushed, and contrasting with
this flush there was a streak of white on the forehead, like the wheal
of nettlerash or that produced by a whip, only that it was not raised.
The streak began at the  inner end of the left eyebrow, and ran up-
wards to  the margin of the hair.  After a short time he perceived that
the white streak had become  permanent; and still later, that a small
circular bald spot of area (alopecia areata) had formed on the summit
of the head, to the left of the middle line, and at some distance from
the end of the streak.
   In March, 1855, he consulted me for  the second  time;  the white
streak  had now become a nearly straight white band, about three-
quarters of an inch in breadth, extending from the inner end of the
eyebrow to the summit of the head, and there joining with the original
spot of area, now considerably increased in size.  On the forehead the
central part of the band  was raised  to the level of the adjacent skin,
by the deposition in its structure of the peculiar lardaceous substance
of tubercular elephantiasis.  This deposit rendered the surface smooth
and polished, obliterating the linear markings of the skin, and destroy-
ing its natural texture.  And in place of the normal mottled redness
produced by the capillary vessels, there was a coarse plexus of minute
venules, the trunks of which dipped from point to point into the small
spaces between the lobules of the morbid deposit.   This venous plexus
was not evenly distributed over the whole of the raised portion of the
diseased skin, but was chiefly conspicuous in the central part, where
it existed in small patches, and gave a reddish  tint to the centre of
the white.  On  either side of the elevated  portion of the  band, the
morbid skin  subsided  below  the level of the adjoining integument,
and presented the characters of the atrophic form of the disease, pale,
thin, and atrophied ; no  vessels whatever  being perceptible in .its
structure.  Beyond this groove, the surface gradually rose, and merged
into the healthy integument, and the border of  the sound skin pre-
sented the pale lilac elephantiasis blush which constitutes the ordinary
limit of the patches of morphoea alba.  We have thus brought under
our eyes,  as far as is possible in the living body, the actual process of
the conversion of morphoea atrophica into morphoea tuberosa. Reach- 
374      DISEASES  FROM  SPECIAL INTERNAL CAUSES.

ing the summit of the forehead, the broad  white band meandered
through the hairy scalp to the top of the head, following the course
of the supra-orbital nerve, and, where that nerve ends, terminated *in
a round patch of alopecia areata (morphoea alopeciata).   The gently
undulating course of this broad band suggested to the mind the idea
of a river as represented on a map, flowing to the sea, or the flexuous
progression of  a serpent: hence, probably, the origin  of  the term
ophiasis, or tyria, applied by the  ancients to this  form  of alopecia.
The whole extent of the disease on  the  scalp presented  the form of
morphoea atrophica; the integument along the centre of the band and
on the patch of area was so thin, that the finger seemed  to touch the
bone, and was perfectly bald, from the anaemic and atrophic condition
ofthe skin.  Along the sides of the band the integument rose to the
level  of the rest of the scalp, and was furnished with a few stinted,
bent,  and  twisted hairs.   The atrophic  part of the morbid  skin was
deficient  of sensation, but  the  tuberous portion was less  so, and,
compared with my observations four years before, had*recovered some
of its sensibility.
   Besides the progress made by the chief patch of the disease upon
the forehead and  head, the  patient called  my  attention, at his last
visit,  to a white, depressed spot, a few lines in  diameter, which had
appeared  on the left side of  the nose, a  little below the  inner angle
of the eyelids;  and further, to a similar  appearance on the ala of the
nose,  which looked like a cicatrix, and had occasioned atrophy of the
part.   This latter had  given rise to some  little deformity, and had
excited in his mind a not unnatural  alarm for the safety of his nose.
   I have  mentioned that the disease appeared originally without any
symptoms to denote its invasion; and during the whole  period of  its
existence  it has been the unsightliness of the patch,  and not any
suffering occasioned by it, which caused him anxiety.   Except when
excited by business, or his digestive  functions are disturbed, he is not
aware of  any sensation in the part; but when any  disturbance of
circulation takes place from  the  causes  referred to, he experiences a
"heavy dead pain" around the edges of the patch on the forehead, and
a prickling pain around those of the scalp.
   On his  visit to me iu 1851 I prescribed for him iodide of potash in
infusion of quassia, and the local application of the compound tincture
of iodine.  In 1852 he saw another surgeon, who called it "gangrene
of the skin," and prescribed a gentle mercurial course, with the local
application of a solution  of the  bichloride of mercury.   In 1853  he
was  seen by Sir Benjamin  Brodie, who advised him full doses of
sarsaparilla, and local frictions with the  strong citrine ointmeOt.  He
does not appear to have given any of these means such a trial as could
influence  a disease so deeply rooted, nor  to have given  his adviser the
opportunity of regulating  or modifying the treatment from time to
time.  In April, 1855, he returned  to me,  when I ordered  him the
cod-liver oil, half an  ounce twice a-day,  and five minims of Fowler's
solution of arsenic, with the  same number of antimony wine three
times a-day, and local friction with tincture  of aconite in combination 
                       ELEPHANTIASIS.                     375

with soap-liniment.  As I have not seem him  since, I am unable to
report the success of this plan.

                        MORPHC3A NIGRA.

  Morphoea nigra resembles in origin and general symptoms the two
preceding .forms,  but differs from  both in the conservation of the
pigment-forming function of the skin,  which is increased instead of
being suspended, as in morphoea alba. The persistence of this function
indicates a less degree of disorganization of the integument than in the
two previous states; there is no condensation and hardening of the
skin; and if  there be  thinning, it is present in a considerably less
degree than  in morphoea atrophica.  The degree of insensibility is
about the same or somewhat less than in the other kinds; the patches
are rarely sunk below the level of the integument, but sometimes are
rendered prominent  by oedema.   Patches of morphoea  nigra  were
present  in all the cases of elephantiasis which  have come under my
observation, but  I have not seen it independently of that disease;
sometimes the patches are round, and not larger than a crown-piece;
at other times they may be as large as the palm of the hand ; in one
instance the body was spotted all over with them.
   The tint of color  in morphoea  nigra  presents some variety;  it is
sometimes a  brownish-yellow, sometimes  brown, and sometimes so
dark as to approach to a blackish hue.  The pigment does not seem
to be confined  to the surface of  the  derma, but extends into  it for
some  depth, not only in  the walls of the  glandular apparatus of the
skin, where it might be expected, but also in the interglandular por-
tion.  When any erythema  is mingled  with the  discoloration, the
patches have a purplish hue; the cuticle is for the most part smooth
and shining, and sometimes acquires an almost metallic brilliancy; at
other times it is roughened by desquamation.  In early stages of the
disease  there is often an excess of sebaceous secretion united with
the discoloration, which gives to the skin a greasy appearance, but
later in the attack the patches are dry and devoid of secretion.

                     MORPH03A ALOPECIATA.

   Elephantiasis  produces, as we have seen, a total disorganization
and complete atrophy of the skin, and necessarily destroys the secret-
ing functions of  that  organ; the perspiratory, sebiparous,  chroma-
togenic, and  trichogenetic  functions  are  suspended  or  arrested,
and  the glandular and formative apparatus of those functions  is
atrophied, and ultimately obliterated.   On the general surface of the
body  the  patches of morphoea are smooth and bald, or the  hair
covering them is colorless or white; and  when, as before related, the
path of morphoea is situated on the head, the integument is greatly
thinned, and the hair-follicles are destroyed.
   In the case of morphoea  alba of the  general surface of the skin,  I
have shown that the  pathognomonic characters of the disease are such
as to point directly to elephantiasis as their source, and to leave no
doubt  on  the mind that morphoea is a relict of that bygone scourge 
376      DISEASES FROM SPECIAL  INTERNAL  CAUSES.

of this  country, the great leprosy; and  I also  believe that another
affection, more common than morphoea of the body, namely, alopecia
areata,-is  a morphoea  of the  scalp and hair-bearing skin; in other
words, a morphoea  alopeciata, bearing  the same relation to elephan-
tiasis as the*morphcea  already described.
  The specific characters of alopecia areata, or, as I shall henceforth
call  it,  morphoea  alopeciata, are, loss of hair  in a patch of circular,
and sometimes, when taking the course of a nerve, of lengthened form
(ophiasis,  tyria);  loss  of sensation;   loss of  color, from arrested
chromatogenesis  and  diminished circulation of blood; and thinning
of the skin, more conspicuous at the centre than at the border of the
patch, sometimes approaching to a real atrophy.  The surface of the
affected patch is smooth, from a greater or less degree of obliteration
of the papillary structure of the derma, from shrinking of the follicles
consequent upon  arrest of  their  function, and from  absence or
diminished  force of the linear  markings of the skin; and it is less
sensitive than natural,  or totally insensible,  from  altered nervous
function, probably a consequence of morbid alteration of structure of
the nervous fibrils supplying the affected spot of skin.
  Morphoea alopeciata is apt to occur at all ages, and in all ranks of
life, but is more common  in young persons than in the adult.  It is
sometimes permanent, more frequently transient, but  always tedious,
lasting  sometimes for  months, and sometimes for years.   When the
hair returns it may resume all the qualities of healthy hair, or remain
short, white, and impoverished.  It appears usually in the form of one
or more circular patches, from  which  the hair  falls off at once and
suddenly, leaving a bald spot of considerable size.  Sometimes, how-
ever, its origin is small, consisting in the fall of a few hairs only, and
it then increases more  or less quickly by the circumference.  At other
times the loss of hair extends to the entire head, and involves, besides,
the eyebrows and eyelashes.  These latter cases are usually inveterate,
though I have seen the hair return in several  instances.  But setting
aside all these varied appearances, the  one the most characteristic of
the leprous disease, is that in which the spot is of inconsiderable size,
the skin white, thin, smooth, and polished, as though stretched by
shrinking,  and devoid  of sensibility and every trace of hair, the very
follicles appearing to be obliterated.
  In children and young persons we are apt, and with a semblance of
reason, to refer this state of the  skin to defective nutrition:  and it no
doubt does result from defective nutrition; but a defective nutrition
originating in defective innervation, and the  latter in the materies
morbid of  leprosy.   In the adult this explanation is more obvious,
since the period of active nutrition is over, and the insensibility of
the skin points more directly to  a local disorder of a nerve.  A com-
mon  seat  of the  morphoea in the adult is the  chin, were the bald,
white, circular spot contrasts strongly in color with the hair-bearing
skin, and is peculiarly obnoxious to the sufferer.
  It not uncommonly happens, that this local deficiency of action in a
part of  the skin is  associated with general want of tone in the whole
system, and the treatment demanded will call for the use of alteratives 
                        ELEPHANTIASIS.                     377

and tonics.   At other times I have seen benefit result from the use of
mild mercurials, in combination with the iodide of potassium, where a
syphilitic affection had to be controlled;  but the special treatment for
morphoea alopeciata consists of  arsenic employed as a  cutaneous
stimulant and tonic, and local stimulants, such as acetum^ cantharidis,
compound tincture of iodine, liquor ammoniae, solution of  bichloride
of mercury,  &c.  For morphoea alopeciata of the scalp, plentiful fric-
tion with the  hair-brush, in  addition  to the stimulants already
enumerated,  is  indicated,  together with  the  use of the stimulating
wash or pomatum.   Where the scalp is  denuded to  a great extent,
advantage is often gained  by dipping the head in cold water, and ex-
citing the skin afterwards by friction with a towel.   In a few cases
this state of the skin has been attended with general emaciation, quick
pulse, and irritable  temperament, when I have had recourse to  cod-
liver oil, in addition to the preceding local  and  alterative  treatment.
In general, the  skin becomes restored to its natural appearance,  and
the hair returns,  although the curative change is always  slow  and
tedious; but occasionally, neither time nor treatment appears to have
any remedial power over the affected skin,  and the baldness becomes
established permanently.

                      THE LEVITICAN CODE.

  In further  illustration of the nature of the true leprosy, or elephan-
tiasis, it will be interesting to peruse the Scriptural account of  this
disease, contained in the thirteenth chapter of Leviticus, so frequently
referred to by medical  writers.   The following appears to me to be
an exact and accurate interpretation of this important chapter, so far
as it treats of the diagnosis of leprosy :—
  1. And the Lord spake  unto Moses and Aaron, saying,
  2. When a man shall have an eruption in the skin like the eruption
of leprosy, be it a tubercle, a scab, or a glossy  spot; then he shall be
brought unto the priest:
  3. Aud the priest shall examine the eruption, and if the hair grow-
ing on  the infected  skin be changed in  its color to white, and if the
morbid alteration  in the skin sink  deeply into  it,  and appear to in-
volve the entire thickness of the skin ; then the case is  one of leprosy,
and the disease is contagious.
  4. If the glossy spot be white, and affect only the  surface of the
skin, and the hair  be not changed in color  to  white, then  the priest
shall seclude the patient for seven days ;
  5. And on the seventh day, if the spot remain as it was, and have
not increased in extent, then the priest shall  seclude him  for seven
days more;
  6. And on the  completion of another seven  days,  if the spot be
somewhat dark, and  have  not spread, the priest shall  pronounce the
patient free from contagion ;  the case is one of simple scab.
  7. But if the scab  increase in size and spread, after he has been  dis-
missed by the priest as free from contagion, he  shall be again admitted
to examination;
« 
378      DISEASES  FROM SPECIAL INTERNAL  CAUSES.

  8. And if the priest find that  the scab is still appending, then he
shall pronounce the case to be one of leprosy, and contagious.
  9. When a man is affected with leprosy, he shall be brought to the
priest;
  10. And the priest shall examine him, and  if he  find the affected
skin to be white  and raised,  and if the hair growing upon it be
changed to white,  and if there be an open sore  [raw flesh]  in  the
affected skin:
  11. It is an  old leprosy and contagious.
  12. And if the leprosy invade the whole body from the head to the
feet;
  13. Then the priest shall consider, and even although the leprosy
cover the whole skin, yet if it be all turned white [hpra vulgaris] he
shall pronounce the patient free from contagion :
  14. But if there be an open sore; then there is contagion ;
  15. For the  open sore  is a proof of contagion, and  the case is a
leprosy.
  16. Or if the sore heal, and the skin become white, the patient shall
come to the priest;
  17. And if the  priest be satisfied that the sore  has healed and the
skin is white, then he shall pronounce the patient free from contagion.
  18. Even in the case of a common boil which is healed ;
  19. If there be  a  white  tubercle, or a glossy spot, white or reddish
in color;
  20. And the priest find the whole depth of the skin  to be involved
in the disease, and the hair to be turned white,  it is contagious, a
leprosy broken out of the boil;
  21. But if there be no  white  hairs,  if it be quite superficial, and
somewhat dark in color, then the priest shall  seclude the patient for
seven days;
  22. And if  it spread extensively in the skin, the priest shall pro-
nounce it a contagious eruption.
  23. But if the glossy spot remain, and spread not, it is a carbuncle,
and the priest shall pronounce it  not contagious.
  24. Or, if in the inflamed patch of skin there be an  open sore, and
in the sore there be a glossy spot, either reddish or white,
  25. And  if the  hair on  the  glossy spot be  turned white, and the
disease involve the entire depth of the skin, it is a leprosy broken out
ofthe carbuncle;  wherefore, the  priest  shall pronounce it contagious.
  26. But if there be no white hair on  the glossy spot, and it be not
depressed below the level of the adjacent skin, but be somewhat dark
in color, then  the  priest shall seclude him seven days.
  27. And if  on the seventh day it be spread to a considerable extent,
then the priest shall pronounce it contagious;  it is leprosy.
  28. But if  the  glossy spot  be stationary, and  spread not, but be
somewhat dark in color, it is an inflamed swelling  of  the carbuncle,
and not contagious.
   29.  If a man or woman have an eruption on the head; or a man, on
the hairy part of his face;
   30.  The priest shall examine it, and if he find that the disease sink
¥ 
ELEPHANTIASIS.
379
deeply into the skin, and the hair growing from it be yellow and thin,
he shall  pronounce the disease to be contagious, it is a dry scall, even
a leprosy of the head or beard.
  31.  If, however, it be no deeper than the surface of the skin, and it
be without hair, then the patient that hath the  scall  shall be secluded
seven  days:
  32.  And on  the seventh day, if the scall be not spread, and if there
be in it no yellow hair, and it affect only the surface of the skin,
  33.  The patient shall be  shaven, but the scall  shall not  be shaven,
and he shall be secluded another seven days:
  34.  And on the seventh day, if the scall be not spread, nor be deeper
than the visible surface of  the skin, then  the priest  shall  pronounce
the patient to be free from contagion :
  35.  But if after this the scall spread,
  86.  The priest  shall examine  him again, and if  he find that the
scall has really spread, he need not seek for yellow hair, the disease is
contagious:
  37.  But if the scall continue stationary, and black hair  has grown
up therein, it is healed, and no longer contagious.
  38.  If  a man or woman  have in  their  skin glossy spots or white
glossy spots,
  39.  The priest shall examine them; and if the glossy spots be dark-
ish white, it is  a freckled spot, and not contagious.
  40.  And a man may be bald, from the fall of his hair, without con-
tagion.
  41.  And a man may be bald on his forehead without contagion;
  42.  But if there be  on the  bald head  or bald forehead a  white
reddish sore, it is a leprosy :
  43.  Then the priest  shall examine it;   and if there be a  white
reddish tubercle like that which in leprosy appeareth on other parts
of the skin,
  44.  He is a leprous man,  and the disease is contagious.  .

  Now the pathognomonic signs of leprosy, as described  in  this
chapter, are:  1st, A glossy spot in the skin ;  2d, the disease pene-
trating the entire thickness ofthe skin;  and  3d,  the hair growing
from the affected skin  being white or yellowish and  faded ;  to  which
may be added, as signs of  an advanced stage  of the disease, 4th, a
rising  or tubercle  of a whitish or reddish-white  color, with or without
fungous granulations (quick, raw flesh) ; and 5th, an ulcer (raw flesh).
The favorable  signs, on  the  other hand,  are,  spots of a  dull white
(lepra  vulgaris), instead of  glossy-white, or glossy  and dusky;  the
limitation of the  disease  to the visible surface of the skin;  and the
absence of any change in the hair.
  Judging from the language employed in verses 3,  4, 21,  25, 30, 31,
32, 34, I am inclined to think that the Hebrews restricted the signifi-
cation  of the word " skin" to that part of the integument which at the
present day  we call cuticle; hence  the  distinction which is made
between the visible surface  of the skin, as  in verse 4, and  the entire
thickness of the skin, the  cutis  or derma of  modern writers, as in 
380      DISEASES  FROM SPECIAL INTERNAL  CAUSES.

verse 3.  The text of the two verses is as follows: Verse 4:  "If the
bright spot be white in the skin of his flesh, and in sight be not deeper
than the skin."  Verse 3 :  "And the plague in sight be deeper than the
skin of his flesh."  This distinction in reality constitutes one of the
most important points of diagnosis between real leprosy and affections
of the skin otherwise resembling leprosy; while,  on  the other hand,
I can see nothing, either in the expressions used or in any part of the
chapter, to lead to the inference that a subcutaneous disease is implied.
  In verses 20 and 21 some little difficulty is imported into the subject,
by the apparent  substitution of the word lower for deeper.  Thus, if
" in the place of the boil there be a white rising," and if " it be in sight
lower than the skin;" but " if it be not lower than the skin," &c.  It would
seem by these words as if depression of the affected skin were implied,
a condition distinct from depth, and having  reference to the morbid
alteration ofthe skin only in its effects as producing a disorganization
and thinning of the  skin, which actually does take place in elephan-
tiasis ; but the context is opposed to this signification of the word.   A
" rising" cannot  be said to be " lower" than the skin ; whereas lower
than the skin may mean deeper than the apparent surface.   I should
have thought it unnecessary to dwell on this variation of terms,  but
for the  fact  that in a subsequent verse  the  perplexity is increased,
inasmuch as the word lower can have no other meaning than depressed.
Verse 26: "But if the priest look on it, and behold there be  no white
hair in the bright spot, and it be no lower than the other skin, but be
somewhat dark, then the priest shall shut him up seven days."
  Another observation to be  made in  connection  with  the 13th
chapter of Leviticus, is, that the term " plague" is used synonymously
with  eruption; a plague of leprosy means simply  an eruption of
leprosy, while  leprosy  is employed  in a generic term, and  includes
any  spreading eruption,  as  well as the more malignant  disease,
elephantiasis  or true leprosy.   Thus, verse 8 :  "If the priest see  that
behold the scab spreadeth in the skin, then the priest shall pronounce
him  unclean; it  is a leprosy."  Again, verses  12, 13: "And if a
leprosy  break out abroad in the skin, and the leprosy  cover all  the
skin of him  that hath the plague, from his  head  even to  his foot,
wheresoever  the  priest looketh, then the  priest shall consider,  and
behold if the leprosy have covered all  his flesh, he shall pronounce
him clean that hath the plague;  it  is all turned white, he  is clean."
The  disease  here referred to is evidently the lepra  vulgaris of the
present  day,  the  boak or bohak of the Hebrews and the Arabians,
the alphos of the Greeks, a known noncontagious affection.
  If,  in the next place, we inquire what are the forms of disease se\
down as varieties of contagious leprosy in the Levitical code, we shall
find them to  be ten in number, as follows:—
  1.  A  glossy spot (verse 2.  Berat. Heb.)  penetrating  the  whole
thickness of  the skin, and on which the hair is white, is a contagious
leprosy (verse 3.   Tsorat, Berat lebena.   Heb.)
  2.  A  glossy spot, affecting the surface only of the skin, the  hair
remaining  unchanged (verse 4;  simple scab, verse 6), but spreading
in the skin (verses 7, 8), is  a contagious leprosy. 
ELEPHANTIASIS.
381
  3. A glossy  spot, white and  somewhat raised, having within it a
fungous-looking  sore, the  hair being white, is an  old contagious
leprosy (verses 10, 11).
  4. A fungous-looking sore  (verses 14, 15), occurring in a person
affected with a white leprosy  (boak) covering the whole body (verses
12, 13), is a contagious leprosy.
  5. A white elevation, or a glossy white or reddish spot (verse 19),
penetrating the  entire thickness of the  skin, on the site of  a healed
boil (verse 18), the hair ofthe affected skin being white (verse 20), is
a contagious leprosy.
  6. A glossy spot, either reddish or white, and  accompanied with
white hair, occurring in the midst of a carbuncle in course of healing,
and penetrating  the entire depth of the skin, is a contagious leprosy
(verses 24, 25);
  7. The same as variety 6, without white hair, not depressed, some-
what dark  in  color, but spreading  (verses 26, 27), is a contagious
leprosy.
  8. A spot on the head  or beard, accompanied by yellow, thin hair,
and affecting the  entire thickness of the  skin, is a " dry  scall" (verse
SO), a contagious leprosy.
  9. A spot  on the  head or  beard, perfectly superficial,  without
change in the hair, but spreading (verse 36), is a contagious disease.1
  10.  A  white, reddish,  elevated sore, occurring  in  a bald  person,
and where the absence of hair excludes one feature of diagnosis, the
reddish sore being like that which  appears on any other part of the
body in a leprous person (verses 42, 43, 44), is a contagious leprosy.
  In  other words, and  more summarily defined, the  ten varieties of
contagious leprosy of the Levitical code are :—
  1. The  Tsorat or Berat  lebena, Heb.; Beras bejas, Arab.; Lepra
leuce,  Gr.; Elephantiasis Grascorum; the bright white leprosy, true
leprosy.
  2. A spreading scab;  probably an eczema.
  3. The  Tsorat, with fungous sore.
  4. Fungous  sore  in conjunction  with lepra  vulgaris; the  latter
being the Boak, Heb.; Lepra alphos, Gr.;  dull-white leprosy.
  5. White elevation, with other signs  of Tsorat, issuing  from the
cicatrix of a boil.
  6. The Tsorat, issuing  from a carbuncle.
  7. The  dusky-spreading  Tsorat;  the  Berat  cecha,  Heb.;  Lepra
melas, Gr.; dusky or nigrescent leprosy.
  8. A dry scall  on the head or beard ;  deep.
  9. A dry scall  on the head or beard ;  superficial, but spreading.
  10. A white, reddish, elevated sore on a bald person.  A  Tsorat,
or Berat lebena.
  Now, ofthe ten  varieties of disease here designated under the generic
term leprosy, it would appear that only eight  deserve to be considered

  1 It is worthy of remark, that  the word  disease is used in  this place (verse 36)
instead of leprosy, although there can be no doubt, from the context, beginning with
verse 29, that the disease leprosy is intended. 
382        DISEASES FROM  THE SYPHILITIC  POISON.

as the true leprosy or elephantiasis: namely, the first, which may be
taken  as  presenting  the specific type of the disease;  the third and
fourth, which add the fungous sore to the specific type; the fifth, being
the specific type developed in the scar of a boil;  the sixth, the specific
type arising in a carbuncle; the seventh, a variety of the specific type
distinguished by its dusky color; the eighth, a " dry scall," involving
in morbid alteration the entire depth of the skin  ; and the tenth, being
the specific type occurring on the head of a bald person.  The remain-
ing two varieties are, the second, a spreading scab, probably an eczema;
and ninth, a " dry  scall,"  affecting the  skin only  superficially, but
exhibiting a tendency to spread.  For the latter  reason alone, namely,
they are classed with a contagious disease, as demanding, although not
contagious in themselves,  seclusion from healthy persons.
                    CHAPTER  XIV.

      DISEASES ARISING FROM THE SYPHILITIC POISON.

  The diseases of the skin arising from the poison of syphilis or lues,1
are the syphilitic eruptions or syphihdermata.  These eruptions are to
be considered as the manifestation of an effort on the part of nature to
excrete or expel the poison of the blood through the skin ; therefore,
before entering upon their description, it may be desirable to glance
at the phenomena of the syphilitic poison.
  It is a well-known  law of  animal  poisons, that, being once intro-
duced into the blood, they  excite  in that fluid an action which has
for its object the production of a similar poison, and this process goes
on until the blood becomes saturated or overcharged with the morbific
principle.  As soon as this latter condition occurs, an inflammatory
movement is set up, which results in the ejection or elimination of the
poison.
  This inflammatory movement, or syphilitic fever, is therefore a sign
of the accumulation of the poison within the blood to such a degree
as to disturb the healthy functions of the  body, and is attended with
symptoms which indicate derangement of the nervous, vascular, and
digestive systems, and  especially of those surfaces of the body through
which it  is possible for elimination  to occur.
  The blood is charged with a poisonous principle, and all the organs
and structures supplied  with that blood  suffer to a greater or less
extent.   The brain evinces  its  suffering  by mental dejection ; the
nerves, by a  general feeling of prostration and debility.   Everything
is couleur de  plomb  around the patient; he is unable to pursue his
avocations with comfort, and if they require the exercise of his mind,
scarcely  at  all.  He is  oppressed  with a sense of impending evil.
Besides the lassitude and languor which evince the poisoned condition
Der. Lues, ab xwiv, solvere, dissolvere. 
        SYPHILODERMATA, OR  SYPHILITIC  ERUPTIONS.     383

of the nerves, there is often neuralgia to an intense degree, sometimes
affecting the head  or face, and sometimes the joints, when it goes by
the name of rheumatism.  The neuralgia presents the  peculiarity of
being nocturnal, that  is, of being most severe  during the night, and
often, but  not always, entirely absent  by day.   The pulse is quick-
ened ; the tongue is coated, white, broad, and indented  by the teeth.
The fauces are more or less congested, the tonsils and soft palate being
frequently  swollen; there is irritation of the larynx, producing a
mucous cough, and often nausea.   The bowels are sometimes consti-
pated, sometimes relaxed; the urine sometimes clear and limpid, at
other times loaded with  salts.   The  conjunctiva is congested and
muddy, and the whole skin remarkable for its yellowish and  dirty
appearance, looking as if saturated with impure and discolored humors.
Sometimes it is dry ; at others, suffused with a greasy secretion; and
at night, pours out an abundant and fetid perspiration.
 . Such are the general symptoms of the syphilitic fever, or secondary
syphilis, but they may not all be present, and those which  exist may
be complicated by  local congestions of  the mucous membranes.   The
symptoms which may be selected as pathognomonic of syphilitic fever
are, mental and nervous depression and prostration ; congested fauces
with sore throat; congested and muddy conjunctiva ; congested and
discolored skin, the congestion being partial  or general,  and assuming
the form of an eruption ; and added to these, neuralgic pains.
  In this combination of symptoms, we are forcibly struck with the
resemblance which they bear  to those of the  exanthematous fevers,
measles, scarlatina, and smallpox.  Firstly, the nervous depression,
showing the stagnating influence of the accumulated poison. Secondly,
the congestion of the  mucous membrane, particularly of the  fauces,
showing the effort made by the bloodvessels  to eject the  poison
through that tissue.  And, thirdly, the cutaneous exanthema, which
completes the triumph of  the  pressure from within,  and is the sign
that the poison is driven to the surface and is in process of expulsion.
  Even the irregular  symptoms, the  partial and local congestions,
have their parallel among  the exanthemata.  Let me adduce  one or
two examples.   A printer,  aged fifty, six  weeks  after  suspicious
connection, was exposed, in the winter season, to the dangerous effects
of a heated and impure atmosphere during the day,  and cold and
rain at night.  At  this time he became the subject of nocturnal  head-
aches,  attended  with profuse fetid perspirations.  Que night,  after
more fatigue and exposure than usual,  his headache  was excessively
severe, his  breathing oppressed, he had intense pain in his chest, and
seemed in  danger  of suffocation.   These  symptoms of pulmonary
congestion, an effort on the part of nature to eliminate the syphilitic
poison through the mucous membrane of the air tubes, were relieved
by a general eruption of roseola.
  A married lady had for two years been  subject to a troublesome
bronchitis,  which the usual means had failed to cure.  It came on at
first in  the form of periodical attacks,  and was attended with  serious
dyspnoea.   Latterly, the disease had become more constant and less
severe.  Her application to me arose from her having an eruption on 
384       DISEASES FROM THE SYPHILITIC POISON.

the forehead, which  I recognized as syphilitic.  The eruption had
appeared with the first attack of bronchitis, and in her own mind, she
connected the disorders together.  It occurred to me also, that the two
disorders  might proceed from  the same cause; that the bronchitis,
like the cutaneous eruption, might be maintained by the syphilitic
poison.   I treated this lady  as I should have done an ordinary case
of constitutional syphilis, and both affections got well together.
  Thus far for resemblances to the exanthematic fevers;  but there
are also differences  between the syphilitic fever  and that  of the
exanthemata,  so  remarkable as  to call for  special consideration.
The exanthematous fevers are more violent, more  regular, and more
transient than  the syphilitic fever;  in other  words, they are acute,
while the syphilitic  fever  is chronic.   It is true that instances of
 syphilitic fever often hppen, which present all the symptoms of the
most violent fever, and are attended  with delirum; but such cases are
the exception, and not the rule.
  The cause of the difference of character perceptible between the
exanthematous and the syphilitic fever appears to me to  be  due to a
radical difference in the nature of the poison.    The poison of measles,
scarlatina, and smallpox,  probably originates  in conditions extraneous
to the animal body ; it reaches the blood as an  element foreign to its
nature, and as soon as it  has accumulated to  the saturating point, a
violent effort is made  for  its  expulsion.   The expulsive  effort  obeys
rigidly certain laws of order and time,  and the  poison being once  re-
moved,  the blood of the patient may enjoy  an immunity from a
re-excitement  of the same action for the rest  of life.
  How  different are the phenomena which characterize the poison of
syphilis.  The syphilitic poison originates in the human body; it is
probably little  more  than a  modification of the natural secretions; it
is consequently less irritant  in its nature; and  it tends to  assimilate
with the blood and  with the tissues, rather  than  to excite an  action
which may result in its removal.  Hence the poison is slow in accumu-
lating ;  its excitation of  febrile symptoms  seems rather a matter of
accident than the consequence of an irresistible law; the patient enjoys
no immunity from a recurrence of the morbid action;  and the poison
is only partially removed by the febrile effort.
  There is another striking  difference between  the exanthematic and
the syphilitic  poison. In the  former, a second febrile attack never
follows  from  the  same original  infection.  In  the latter, a  second, a
third, and, indeed, flu  indefinite succession of outbursts of the poison
is the common manifestation of its action.   In the exanthematic fever,
the blood and  tissues of the body are  so modified by the excitation
they have undergone, that  they are indisposed to  take on again a
similar action.  The poison of syphilis having once entered the system,
the blood and tissues appear to become accustomed to its presence; it
remains for years, or for life, and gives notice of its  existence from
time to time, by a variety of symptoms.  Nay,  more, it is transferable
to offspring, not merely to one, but, as I believe, to an indefinite series
of generations.
  I have said that the occurrence of syphilitic  fever seems rather the 
        SYPHILODERMATA, OR SYPHILITIC  ERUPTIONS.     385

effect of accident than the result of an immutable law.  I mean, that
the poison itself appears to be insufficient to light up the fever with-
out the intervention of an  accidental exciting cause, such as  cold;
and the exciting cause frequently determines the shape which the sub-
sequent systems assume.   Sometimes  the leading feature of the fever
is  sore-throat, sometimes  neuralgia or rheumatism, sometimes iritis,
sometimes cutaneous eruption, and sometimes periosteal inflammation ;
these differences of effect being partly due to the nature of the exciting
cause, and partly, also, to the constitution of the individual.
   One of the most striking of the phenomena of the syphilitic poison,
is  the modification or alteration which it undergoes in its manifesta-
tions, under the mere influence of time.  These modifications are ex-
pressed in the terms primary, secondary and tertiary.   With the morbid
phenomena appertaining to primary syphilis we have nothing to do
at present;  as the syphilodermata all belong to  secondary and tertiary
syphilis, and principally  to  the former.  Then  the syphilitic  poison
undergoes another  important modification, in  consequence of being
transmitted  through the  blood  of the infected person, and  being
presented to a new person or to new blood,  not  in its crude shape, but
as a modification.  This latter phenomenon forms  the basis of here-
ditary  and infantile syphilis.  Hence the syphilodermata admit of a
primary division into syphilodermata primitiva, or syphilitic eruptions
proceeding from the first poison;  and syphilodermata hereditaria, or
eruptions resulting from  the communication of the  poison   to the
foetus or infant.  To these  may possibly  be added at some  future
period a class of syphihdermata mitigata, to include,those modifications
of syphilitic eruptions which are observed where the poison has passed
through the blood of another, and is presented to a new person, in an
assimilated  condition, in the secretions of the infected individual.
   Then, taking syphilodermata as divisible  into these principal heads,
we have next to consider the eruptions  of the first period, or  those
which  correspond with the  so-called  secondary syphilis; and the
eruptions of the second period, or those of  tertiary syphilis.   In like
manner, we  have in syphilodermata haereditaria, a first, a second, and a
third period.
   To render  this classification  of syphilitic'eruptions more  clear, I
have arranged them in the form  of a table, as follows:—

                 I. Syphilodermata Primitiva.
   First Period—
           1. Syphiloderma erythematosum.
                               Boseola  syphilitica,
                               Maculae syphiliticae.
           2. Syphiloderma papulosum.
                               Lichen syphiliticus,
                               Lichen pustulosus.
           8. Syphiloderma tuberculosum.
                               Tubercula  syphilitica,
                               Tubercula  ulcerantia.
      25 
386       diseases from  the  syphilitic  poison.

          4. Syphiloderma pustulosum.
                             Rupia syphilitica.
          5. Syphiloderma pilare.
                             Alopecia syphilitica.
          6. Syphiloderma ungueale.
                             Onychia syphilitica.
  Second Period—
          1. Syphiloderma erythematosum.
                 Erythema (vel psoriasis) palmare et plantare.
                 Lupus erythematosus.
          2. Syphiloderma tuberculosum.
                 Tubercula mucosa,
                 Tubercula^ulcerantia, superficialia,
                 Tubercula ulcerantia, profunda,
                 Lupus ulcerosus, syphiliticus,
                 Tubercula gummata.
          3. Syphiloderma ulcerans.
              II. Syphilodermata Hereditaria.
  Fiest Period—
           1. Syphiloderma erythematosum.
                 Erythema syphiliticum infantile.
  Second Period—
           2. Syphiloderma tuberculosum.
 ,                Lupus syphiliticus.
  Third Period—Lepra.

             SYPHILODERMATA PRIMITIVA.
                        first period.
                       Secondary Syphilis.
             SYPHILODERMA ERYTHEMATOSUM
                     ROSEOLA SYPHILITICA.
  Roseola1 is one of the simplest of the forms of constitutional syphilis,
and presents the common characters of an exanthematous fever, usually
of a mild kind, but sometimes severe.  It is the form in which the
general effort for the elimination of the syphilitic poison is manifested:
is indicative of a certain  power on the part of the collected poison;
and is the common precursor of the other forms of eruption.  The
period at which it makes  its appearance is between six and nine weeks
after the development of the primary disease.
  Like measles, which it closely  resembles,  it begins with  general
febrile symptoms, prostration  of strength, and congestion of the mu-
cous membrane of the fauces.  Then follows  the exanthem, which is
spread more or  less extensively over the surface of the body, being
most perceptible on  those  parts which  are covered  by the  clothes.
1 Portraits of Diseases ofthe Skin, Plate XXIV., P. 
         SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.     387

 The efflorescence remains apparent for a variable period, a few days or
 as many weeks; it is brightest in the evening and under the influence
 of excitement, and is attended, on its decline, with exfoliation of the
 cuticle. Very commonly it leaves behind it a fawn-colored or brownish
 stain, and a dry and sordid state of the skin.
    Roseola syphilitica commonly presents  itself in the form of unde-
 fined patches, giving to the skin an appearance which is best described
 by the term " mottled," roseola versicohr.  The appearance is identical
 with that  of common idiopathic roseola, or measles, and is due, like
 the two latter, to the manner of distribution of the bloodvessels  in
 the skin.  Perhaps the congested patch represents the  ramifications
 of a single small arterial trunk; perhaps it embraces that small capil-
 lary system which is normally emptied by a separate venous  trunk;
 perhaps, again, it includes  the small district of skin, the circulation of
 which may be governed by the ultimate divisions of one small nervous
 twig.
    Occasionally, the roseolous congestion is defined in its boundary,
 forming circulur bhtches, roseola orbicularis ; and when this is the case'
 it often exhibits a tendency to  spread by the  circumference, while it
 fades  in the  centre, and so gives rise to an annulate form of roseola,
 roseola annulata.   This  annulate  spread  of congestion of the skin is
 another peculiarity of that structure, which is universal, and  which
 also depends, very probably, upon the distribution of nervous influ-
 ence.   Syphilitic roseola, therefore, may present itself to our exami-
 nation under three varieties of form, namely, as a patchy  and mottled.:
 redness, as circular blotches, and as congested rings.
   Besides the varieties which depend on differences of form, there are
 others which are due to degree of congestion of the skin.  In some the
 redness of the blotches is uniform, or nearly  so; others seem to deserve
 the appellation punctated,  from  the more vivid redness  and greater
 congestion of the follicular  plexus of capillaries, roseola punctata ; and
 in a third case, the latter condition has progressed so far  as to lift up
 the follicular pore, and produce an indistinct papule, roseolapapulata.
 These differences, however, are  mere differences  in degree of con-
 gestion; the  same morbid  action exerting itself with greater or less
 force,  or operating against a structure  of greater  or  less strength;
 they are mere varieties  of roseola, while roseola- is only  a variety or
 stage of the other forms of syphilitic eruption.
  When the congestion  of syphilitic roseola subsides, it leaves behind
 it a more or less stained appearance of the skin, and this is a common.
 eharacter of all the syphilitic eruptions.   The  stain generally corres-
 ponds  with the form  of the eruption which preceded  it, and is of a
 brown color of varying  tint;  deep, and almost  approaching to black
 in  persons of dark complexion ; of lighter hue, and verging to fawn.
 or a dead leaf-like tint, in the fair.  Sepia, tinged with red or yellow,
 would, in the hands of the artist, produce all the variations of  color
 which the syphilitic stain presents. These stains ofthe skin are termed
 macule syphilitice.  Sometimes the roseolous  congestion which pre-
cedes them is so slight that they appear to be independent of such an
jrigin; but this is not the case: they are always the effect of a con- 
388        DISEASES  FROM THE  SYPHILITIC  POISON.

gestive action in the skin.  Whether, therefore, the maculae syphili-
ticae are primary in  their appearance; whether they are consecutive
upon roseola, or consecutive upon other forms of syphiloderma, they
may be classed  under the head of erythematous congestions.  One
variety of  maculae I have had occasion  to  distinguish from the rest,
under the name of melanopathia syphilitica}
  Taking a general view of syphilitic eruptions, they will be found to
present two principal  forms;  the one  being simply congestive, and
unattended with  elevation of  the skin,  the other  presenting  the
obvious feature of elevation.  To the non-elevated group belong roseola
and maculae syphiliticae;  to the elevated group the  small  pimples of
lichen, and the  larger pimples or tubercles of turbercular syphilis.
These differences are, however, more apparent than real, and may be
regarded as stages of development of the same disease.   Roseola, by
an easy  gradation, is  converted into lichen, or  tubercular syphilis;
and  these  latter, by simple subsidence, become syphilitic maculae.
Roseola papulata constitutes a  link of transition between  the non-ele-
vated and the ehvated form of the syphilodermata.

                  SYPHILODERMA PAPULOSUM.

                      LICHEN  SYPHILITICUS.

  When the  eruptive force  is sufficiently powerful to elevate the
pores into distinct pimples, the  case is one of lichen.   It  is no uncom-
mon thing to find the mottled roseolous rash forming a base upon
which  the  papules of lichen are developed;  and their appearance,
under these circumstances, seems to warrant the designation which I
have given  to  the eruption,   namely, lichen  corymbosus ;2 for  the
papules in this case are  grouped in clusters, varying from three or
four to thirty in number, and suggest forcibly to the mind the idea of
clusters of fruit.
  Sometimes  the lichenous papules, instead of  being arranged  in
groups, are dispersed singly over the surface of the skin, constituting
a lichen  disseminatus ;3 and at other times they are packed almost as
closely as the pores which they represent, lichen confertus.*
  The transition of syphilitic  roseola  into  lichen is so obvious, that
it may be  observed through every stage of its progress.   A roseolous
patch  may be seen to develop papules by the  mere  swelling of the
pores of the congested  skin;  and  the small  papules  of lichen are
occasionally converted into those  larger elevations which are known
as tubercles, by a sudden aggravation of the syphilitic fever, or from
exposure to cold.
  In a few instances I  have  seen the eruption, of syphilitic  lichen
developed  into  the form  of rings, constituting a  lichen  syphiliticus
annulatus;1 and  a lichen syphiliticus pustulosus may be  distinguished

       1  Portraits of Diseases of the Skin, Plate XXXIV., M.
       8  Ibid., Plate XXVI., AH.            » Ibid., Plate XXVIII., 0.
       «  Ibid., Plate XXV., AL.             « Ibid., Plate XXVII., AN. 
        SYPHILODERMATA, OK SYPHILITIC ERUPTIONS.    389

as resulting from a pyogenic action in the papule, the consequence of
irritability of system, or depressed vital powers.
   In a case of lichen corymbosus the papulae offered some variety in
point of size, those of medium bulk being about equal in magnitude
to a millet-seed.   They were of a dull  red or purplish hue, and were
collected into groups or  clusters, varying iu  number from three or
four to thirty.  The  majority of the clusters contained ten or twelve
of these pimples; and, here and  there, a  few  solitary ones might  be
observed dispersed among the  clusters.   The patch of skin on which
the clusters were placed  was slightly raised, wrinkled, and of a  dull
red hue.  After a week of treatment the  greater part of the pimples
had  subsided, and were  each  covered with  a little, thin, brownish
scale of desiccated epidermis; there was also an epidermal exfoliation
from the altered  skin which formed the  ground of the patch.   The
patches had become  brownish in hue, and constrasted strongly with
the color  of the  adjacent  skin, although the latter presented  the
muddy  and yellowish tint of syphilitic cachexia.   Some few of  the
pimples, however, still  lingered, and  contained  at their summit a
whitish pus, and  here and there a single  fresh pimple showed itself.
At the end of another week every pimple was gone, and  the ground
ofthe patches was undergoing a general exfoliation.
   In  another case, one of lichen  disseminatus, the eruption chiefly
occupied the back and arms, but numerous pimples  were scattered
over the  rest of  the  body and face.  The pimples were large and
isolated, of a dull red color, attained their full growth in the course
of a few days, and then became  filled  at their summit, some  with a
turbid, sero-purulent fluid, and others with a whitish pus.
   Another mode  of termination of the  pimples  is  sometimes met
with, as in a case of  disseminated lichen, in which the pimples on the
face were  of the usual yellowish  red or copper color, which accom-
panies the syphilitic cachexia;  they were  large, prominent,  and
smooth, measuring one line in  breadth by half a line in height, and
rose abruptly from the unaltered skin.  The aperture of a  follicle was
apparent on the summitNof each, marking the seat of the inflammatory
congestion to be the  capillary plexus of the* follicle.  The summit was
evenly rounded, not  conical as in  acne, and,  unlike the  latter, they
were soft  to the touch, and  had no  tendency  to suppurate.  At  the
end of a week they had a yellowish tint at the summit, which  arose
from  the  thickening and commencing separation  of the epidermis,
and still later they were  surmounted by  a small conical  crust, of a
dirty-yellow color, consisting  of desiccated  sebaceous secretion, and
reminding one of the conical crusts of rupia.  After a time the little
cap of thickened epidermis fell off, or where the conical crust of con-
creted sebaceous  matter  had formed,  this also separated,  and  the
pimple  gradually subsided  to  the natural level of the skin, leaving
behind it a brownish stain.
   In  their growth, maturation, and  decline, these pimples, therefore,
offer three stages for consideration:  in  the first they are smooth, and
soft, and the color is  vivid ;  in the second they  are denser in structure,
their color is dull,  and  they are surmounted by a small, yellowish 
"S
390       DISEASES  FROM THE  SYPHILITIC POISON.

crust of hardened epidermis and sebaceous substance; in the third
stage, they are declining.

                SYPHILODERMA TUBERCULOSUM.

                     TUBERCULA SYPHILITICA.
  The tubercular eruption differs from  lichen only in the size of the
little elevations which give it its specific character.  In lichen  they
are  mere pimples, averaging from  half  a line to a line in diameter,
and representing the immediate circumference  of one of the  pores
of the skin.   Tubercles, on the other hand, have a minimum size
greater than that of the pimples of lichen, the smallest measuring
upwards of a line in diameter,  while some  that I  have  observed had
a diameter of three quarters of an inch, and even  more.   They include
many pores, and often a considerable portion of the skin.  In  other
and essential  respects there is  less difference between them; both
result from the action of the syphilitic poison in the skin ; both may
be a mere transformation of roseola.  I have already adverted to the
transition of roseola into lichen, and roseola into tubercula: and the
conversion of  lichen into tubercula is by no means uncommon.
  Tubercles present some differences among themselves  in respecC of
color, form, density, and elevation; and they also differ in the manner
of growth and arrangement.  In point of color they are sometimes
of a yellowish red, sometimes of that deeper hue which  is known as
" copper-colored," and sometimes purplish and  brownish.  In form,
they are round, oval, or  oblong, in  the  latter case being frequently
crescentic in shape.   In density $hey are sometimes soft and flabby
to the touch, at other times firmer, but  never hard; and, as regards
elevation, they rarely exceed  one  or two lines, but are sometimes
almost flat.  In growth, they sometimes spread in irregular rings, and
sometimes  the separate  tubercles  have  a tendency to  assume the
annular character; in one case the annular disposition being limited
to a mere central  depression (cupped   tubercles), and  in  another
extending to a  perfect ring of considerable size.
  The color of syphilitic eruptions is often referred to as a pathogno-
monic  character, and  it is quite true that they present in general a
remarkable  dulness of hue, such as would Tesult from an admixture
of brown, in various proportions, with the three primary colors, red,
blue, and yellow.  The early stage of development of the eruption is
that which possesses the  greatest amount of red; in its second stage,
and  even in the  primary when  developed in a languid  constitution,
the slower circulation of the blood  through the capillaries, and the
consequent carbonization of the blood, gives a bluish tint to the color,
in other words, forms a shade of the secondary color, purple.   In  a
third stage  of the eruption, when  the vascularity is subsiding,  and
renders visible the staining effects of the yelfow element  of the blood
upon the tissues of the skin, the color approaches towards the secon-
dary orange, or with less red becomes a grayish  yellow.   So that the
same eruption, seen at different  periods,  may be a red of greater or
less dulness, a purplish red, or a yellowish red; and the  same differ- 
SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.    391
ences of color may be distinguished in different individuals from the
beginning of the eruption.
  The color  brown  is called a neutral color, that is, it is neither red,
blue, nor yellow; but  at the same time a compound  of the three.
Hence the dirty  hue of the skin in syphilitic cachexia is the result of
the mal-composition  of the blood, and consequently, of the secretions;
the excess of blue is  probably occasioned by the presence of a surplus
quantity of carbon;  and the yellow, by a surplus of the pigmentary
principle which gives color to the serum, the urine, and the bile.
The admixture of this brown color with the red and purple of com-
mon vascular congestion produces the dull or dirty red and purple
above  spoken of; and, in like manner,  the bright, or  rather clear,
yellow stain  of  an ordinary bruise,  would become a dull or  dirty
yellow by a similar admixture.
  In making these remarks, I am  supposing the red to be the archaeus
or predominating color; the eruption  is primarily red, the red having
a blending with  blue on the one hand, and yellow on the other, but
in both instances being rendered dull by the presence of brown.  We
have now to  consider a series of tints in which the neutral admixture
brown predominates.  The brown may have an  excess of blue in its
composition,  and  be a  dark brown;  it may have an excess  of red,
and be a red brown; or it may possess  an admixture  of yellow in
different proportions, and be an orange brown or a yellow brown.  Now,
of all  these  separate tints, the red  brown with a slight  admixture of
yellow is that which most nearly approaches the hue of dull copper,
and is, therefore, the type of  the "copper-colored" eruption; the so-
called copper color being, in  fact,  a  reddish yellow brown.
  I have felt the necessity of giving  this explanation of the precise
meaning of " copper color,"  from  having observed that  medical men
were not agreed  as to the color to  which this name should be applied,
and, consequently, that it was liable to  be employed  more  loosely
than is consistent with  scientific  accuracy.  The copper color repre-
sents, in fact, a declining stage ofthe eruption, when the congestion is
subsiding, and the yellow stain of the altered fluids of the skin shines
through the purple of the blood.  The "copper color," therefore, may
have a greater or  less amount of  red and yellow in its composition,
and be either a reddish copper color or a yellowish copper color.
  As  the copper color represents only a stage  of an eruption, that
eruption having probably passed through  the tints of dull  red, and
dull purplish-red, before it reached the reddish-yellow brown of copper
color,  it is  clear  that the term  is objectionable, when taken as a
pathognomonic of syphilitic  eruption. For if we see the eruption at
any other period  than that of its  decline, the  characteristic tint  is
absent.
  In the loose  manner of using the term " copper colored, above
referred to, I have frequently heard the dull purplish red, the muddy
red, and the yellowish red, designated by  that  term.  These colors,
however are  by no  means  pathognomonic of  syphilitic eruptions;
they are' commonly met with in  chronic eruptions  of other kinds ;
for example,  in acne.  Any one looking upon a case of indurated and 
392       DISEASES FROM THE SYPHILITIC POISON.

chronic acne, associated, as is commonly the case, where the eruption
depends upon mal-assimilation, with a sallow and muddy skin, must
be struck with the close  resemblance of such an eruption to one of
syphilitic origin.   Indeed, I have often seen non syphilitic eruptions
possessing more  of the dull and  muddy hue,  which is generally
supposed to be  characteristic of syphilis, than  syphilitic eruptions
themselves.   The color of eruptions of the skin must not, therefore,
be relied on as proof of their syphilitic nature, although it may be
fairly taken  as a  pathognomonic  character where  other symptoms
tending to the same diagnosis are found to be present.
  Syphilitic tubercles present some varieties which have reference to
obvious diversities of character of development.  For example, some
are collected into patches of variable size, and are distributed, more
or less generally, over the surface of the body :  they correspond in
manner of distribution with the corymbose* form of lichen;  hence, I
have  named them tubercula corymbgsa.  Others constitute  groups
which are more or less solitary in their arrangement, and of variable
size.   The  group  is  bounded  by  a distinct border  of tubercles,
which creep along the skin, and increase gradually the dimensions of
the patch.   The circumscribed character of such a patch suggests the
name of tubercula circumscripta.1   Others are  scattered over one or
several regions of the body as separate tubercles, tubercula disseminata?
in some, the tubercles merge into each other and form a smooth bank,
which expands  into the form of a  ring, tubercula  annulata; while
others, again, belonging to either of the preceding groups, are apt to
take  on an  ulcerative action, and  establish a  variety which may be
distinguished as tubercula ulcerantia.
  Tubercula corymbosa.—In a well-marked case of tuberculacorym-
bosa,  the eruption  consisted of soft,  yellowish-red  tubercles, with
rounded summits, and but little raised above  the level of the skin.
The average size  of the  tubercles was one line and a half;  when
isolated they measured two lines, and  there were some which reached
four lines in  diameter.  They were  dispersed irregularly  over  the
surface of the skin, and had a  general distribution in  patches of
various size and form ; in some situations the  patches being as large
as the palm of the hand;  in others, small, and scattered between  the
former.  On a close examination it became apparent that there wras a
prevailing disposition on the part of the tubercles to form circles or
rings, and this character was discernible even in the large  patches,
which seemed to be composed of a number of rings confusedly clus-
tered  together.   The rings varied much in size, some having a mere
central depression, and measuring scarcely more than a quarter of an
inch in diameter, while others had an  ample  area, and measured from
an inch to an inch and a half. The tubercles presented  some differ-
ences of appearance common to these eruptions during the progress
of the disease.  In the first instance, while the  congestion was active,
they were bright in color and perfectly smooth  on the surface; when

            1 Portraits of Diseases of the Skin, Plate XXX.,  A B.
           ■ * Portraits of Diseases of the Skin, Plate XXIX., N. 
        syphilodermata, or  syphilitic eruptions.    393

the congestion was on the decline  they lost  their brightness of hue,
and  looked faded and shrunk, the epidermis covering them having
become opaque and wrinkled.  Later still, the epidermis became dry
cracked around  the  circumference of each tubercle, and peeled off,
leaving a fringe around their base, and  sometimes a small scale, the
last remains of the exfoliating cuticle,  on their summit.  When the
tubercles subsided altogether, leaving behind them brown stains, the
skin presented a very remarkable appearance.  The stains formed  a
number of brown rings, edged with a narrow margin of cuticle, and
inclosing a centre of natural skin.  In  this state the eruption would
pass very well among the inexperienced for a declining lepra, and the
broken laminae  of  desquamating epidermis suggests  a motive for
considering it a squamous affection.
   While the  general characters of the eruption may be such as are
now described on the body and limbs, it is not unfrequently consider-
ably modified when  developed  on the face.  Thus, in  another case,
the countenance of  the patient was deformed by a tubercular erup-
tion, of a dusky-red  hue.  On parts of the  face, and particularly on
the exposed  portions of the neck, the eruption consists of distinct
rounded tubercles, of large size.   On other parts of the face, the tuber-
cles had the form of oblong mounds, more or less curved, and again,
in other situations, formed complete circles.  On the  forehead, the
tubercles appeared to have become blended together, so as to constitute
one single tuberous mass, of irregular shape, which extended across
the brow, from one  temple to the other.  This mass was of a dusky-
red color, with a tinge of yellow, which gave it a coppery hue, and
there was a seeming transparency about it, which made it resemble
brawn, or a portion of coarse and thickened skin, in a state of oedema,
from  infiltration of a yellow serum.   To  the  touch,  however, the
swelling was  hard, and evidently occasioned by  a thickening of the
skin, and not by the infiltration of fluid.
   The trunk, as far as the waist, and the arms, were covered with the
eruption, the  tubercles being more or less developed, and thexjorymbi
more or less annular.  In  certain situations the tubercles were less
fully  formed, and appeared  to be made  up of a number of  papulae,
very  little  larger than those of common lichen ; and many of these
smaller pimples, of  a dirty hue, were scattered amidst the  patches of
eruption, or grouped around the clusters of tubercles.
   On the lower limbs and  lower half of  the trunk  of  the body the
clusters of  tubercles had subsided to the level of the skin, forming so
many  darkish-red or brownish stains, (maculae) of a circular  form.
Many of these maculae were sprinkled  over with the dark remains of
the papules, or with deeper-colored spots, which  indicated the  pores
of the follicles.   The maculae were,  for  the most part, dark in the
centre, fading away gradually to the circumference, and  in some situa-
tions had the appearance ofthe stains of a bruise.
  The general surface of the skin  was dry, sordid, and discolored, and
presented the character so constantly met with in cutaneous syphilis.
  Tubercula circumscripta.—The eruption of tubercula corymbosa
is general and acute;  the eruption of tubercula circumscripta belongs 
394        DISEASES FROM THE SYPHILITIC POISON.

to a later period in the existence of the poison, and is, consequently,
partial and chronic.  It occurs in patches, which vary in size from two
to twelve inches in diameter; they  are  solitary or  few in number,
rarely exceeding six or eight; they consist of a confused assemblage
of tubercles, among which there is  an obvious tendency  to assume
a circular arrangement, and they are  distinctly circumscribed, the boun-
dary being formed by a line of tubercles.
   The following is an illustration of a tubercula circumscripta, appear-
ing four years and a half after  contagion;  the subject was a man of
thirty, and the number of patches  seven, one large and  six  small.
The large patch measured nearly eight inches square, and covered the
greater part  of the left side of  the  abdomen.  It was  composed, as
were  the others, of numerous dull-red tubercles, having an average
measurement of two lines in diameter, dispersed, apparently without
order, upon a ground of a dirty brown hue, and bounded by  an irregu-
lar and slightly raised margin;  in  several places the tubercles  had a
circular  arrangement, the rings  being more or less complete.   The
smaller patches, about two inches in  diameter, consisted of  an irregu-
lar ring  formed  by a slightly elevated, reddish margin,  inclosing an
area of a yellowish-brown color, over which the eruption had  crept.
Within this area  the epidermis  was somewhat more wrinkled  than
that of the surrounding skin; and in  the greater number of the patches
there  were scattered here and  there  one  or  two tubercles,  which
remained in a chronic state,  while the rest had  disappeared.
   In  their irregularly circular form and marginate character, these
patches bear a near resemblance to lepra in the state of retreat; even
the scattered tubercles within the circles are met with in lepra.   But
there  are certain strongly distinguishing characters between lepra and
the leproid forms of cutaneous syphilis, namely, the coppery, or dull-
red color of the latter, the yellow-brown stain which they leave behind
on the skin, after their decline; the softness of the syphilitic tubercles,
as compared with those of  lepra; and, lastly  and chiefly, the  total
absence of  squamae.   In  old syphilitic tubercles, the epidermis may
frequently  be seen in a state of exfoliation ;  but the thin, ragged films
of exfoliating epidermis, peeling from  their summits, are  easily dis-
tinguished  from the thick, circular,  morbifieally elaborated scales of
true lepra.   Moreover, in a syphilitic patch of the kind now  described,
the cuticle  may generally be traced unbroken from margin  to margin,
over the whole surface ofthe diseased skin.
  If the large syphilitic patches (two inches  in diameter) be examined
carefully, and at various stages, with  reference to their mode of devel-
opment, they will be found to originate in simple tubercles, disposed
in irregular circles of four,  five, or  six.   The  skin, included within
and between these tubercles, partakes of  the  morbid  action ; the
tubercles become  fused at several points, forming an elevated margin;
and the margin extends by its outer  lip, and increases the area within.
In this way, a number of small rings, measuring about half an inch
in diameter, and  creeping onwards  by their circumference, become
blended  so as to form a single  patch.   The  onward growth is then
taken up by the peripheral margin of the collective patch  (hence its 
        SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.    395

 irregular outline, and its obvious composition of segments of small
 circles), the tubercles and margins left within the greater margin sub-
 side more or less completely, by virtue of a tendency on the part of
 the  disease to cease on the exhausted ground, and  prey  upon  the
 juices of the neighboring untainted soil; and, after a time, nothing of
 the  original elements  of the  disease remains—all is  lost but  the
 slightly elevated reddish margin, and its sombre leaf-brown area.
   In a case in which there existed a single patch of large size on the
 shoulder, the eruption commenced as a mere pimple, which  increased
 to the size of  a split pea ; some months afterwards, a second pimple
 appeared, and having attained  the  dimensions  of a  small  tubercle,
 both began to spread out, and  assume -a circular form;  then  one or
 two tubercles rose up between the rings, and connected  them, and in
 the course of a month, the whole together completed a patch as large
 as a hand.  The annular character of the patch was well marked, the
 boundary being formed of a broken line of confluent tubercles, which
 were flattened, and surmounted by a thin covering  of dry and desqua-
 mating epidermis.   There were several  tubercles with desquamating
 summits within  the areae ofthe rings, and the skin forming the ground
 of the patch had a reddish brown tint.
   When the patches of tubercles appear on the face and  exposed part
 of the neck, they have a brighter color than elsewhere.  This was the
 case in a woman, the side of whose face and forehead  was covered
 with a patch of  a bright copper  color,  which had continued  in  the
 same state, with very little change, for twelve months.
   On their subsidence, the patches of tubercula  circumscripta some-
 times leave very little trace of their  existence on the skin;  at  other
 times, they  leave a brown stain;  sometimes  an  injected state of the
 skin, and sometimes shallow pits.  The copper  color of the patches
 owes a  part of its  intensity to  a magnified  capillary,  -J^pjXTisV Tftd
 numerous meandering venules, which may be seeja on a close exami-
 nation of the skin.   Often, the tubercles seenVto possess the power of
 disorganizing the structure of the skin co/mpletely, without  suppura-
 tion and  without ulceration;  hence,  w^nen  they disappear, they seem
 to be absorbed, and  with them that- portion of  the skin which they
 had assimilated  to  their own structure, and they leave behind them
 deep and permanent pits, and, where they are of large size and extent,
 strongly  marked cicatrices.   TVie vascular congestion and shallow pits,
 are both characteristic  of the chronic form  of  syphilitic tubercular
 eruption  of the skin.     f
  Tubercula disseminata.—The  disseminated form  of tubercular
 eruption  is less acute and 'hss general in its eruption  than  tubercula
 corymbosa; thus evincing  a later  period  of the  poison, but more
 acute and more general  -than tubercula circumscripta; occasionally it
 has  been met with conjoined  with the former.  The  tubercles  are
 larger than those of th.e clustered eruption, perfectly  round, and  but
 little elevated  above the surface of the skin ;  in  their appearance and
elevation  succesting  an appellation by which  I  once  distinguished
them, namely, tubercula lentiformia.   In point of  measured  size, the
medium diameter of the disseminated tubercles may be roughly stated 
396       DISEASES FROM THE SYPHILITIC POISON.

to be four lines, while that of the clustered tubercles is two lines and
a half.
   In the case of a young woman, aged twenty-two, the eruption of
tubercles covered the face, neck, and upper region of the back, some
few being scattered over the arms.   They first appeared on the face,
and gradually  extended  downwards.  The tubercles were perfectly
circular, isolated, and lentil-shaped, of a dull  red, almost livid  color,
smooth and uniform in  size, measuring about a quarter of an inch in
diameter.   On the neck, the tubercles were less numerous than on  the
face, but somewhat more prominent and larger, one or two measuring
more than half an inch in  breadth.  On the back of the neck, and
between the shoulders, were about fifty tubercles, for the most part
isolated; some few, however,  were  grouped  in  pairs, and  in two
instances, a pair had become blended together.  They were all exactly
circular, and more  prominent than  those of the  neck, but the most
prominent, even here, measured only three-quarters of a line in eleva-
tion.  In breadth, the extremes of measurement ranged between one
line and six (half an inch);  the size  of the greater  number was five
lines;  the next common size measured two lines and  a half;  while
below these were a number of smaller  papules scattered among  the
rest, and representing either the common papules of syphilitic  lichen,
or the early stage of growth of the tubercles.   The developed tuber-
cles presented every degree  of completion and decadence; some were
smooth, others  wrinkled, others beginning to desquamate,  and  in
others,  desquamation had advanced some stages.
   In my observations on this case, I  remarked  that the tubercles  are
exactly circular in form, varying in size from one-quarter to three-
quarters of an  inch in diameter, very slightly raised above  the level
of the adjacent skin, evenly convex on the surface, and  subsiding
PJ^ttxrty-foanx the centre to the circumference, which merges insen-
sibly into the surrounding skin.  In  point of elevation and form, they
have very  much  the^ppearanee of  split lentils laid upon the skin,
only that they are much .broader.  Their color varies from a bright
coppery red, to a  dull, diri^v crimson.  Their  epidermal  covering
varies  with their  stage of gro»wth;  in the first  instance, when  the
tubercles are tumid, the cuticle  is smooth, and they have a polished
appearance; later, when the congestion of their vessels diminishes,
the cuticle is wrinkled;  and later still,  the cuticle  becomes  loosened
from their surface, cracks, and separates*.   Sometimes, but rarely, they
pass into a  state of ulceration, the ulcer Commencing on the  summit
of the convexity.                       v
  The manner  in which the exfoliation of cuticle commonly takes
place from  the  surface of the tubercles  is tyhe following: the cuticle
cracks in a circular direction, just within tho  boundary of the eleva-
tion, and then separates gradually from the surface  beneath ; the cen-
tral piece separating towards the centre  of th\e convexity;  the peri-
pheral piece separating towards the  sound skip, and forming a kind
of frill around its margin.  A crop of tubercles naay sometimes be seen
presenting every gradation of this process of desquamation at the same
moment.  There  are some in which the crack has just taken place; 
        SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.    397

others, in which the edge of the central piece has been worn away,
and has become reduced to a small disk, occupying only the central
part of the convexity;  others, in which the central piece is entirely
gone; some, in which the peripheral  portion is distinct; others,  in
which it is  partly, and others, again, in which it is wholly, removed.
The tubercle may now be left quite smooth, or secondary exfoliations
may commence.  The latter, however, are for the most part irregular
and partial, and are  not  to be confounded with the primary exfolia-
tion first described.   When ulceration occurs, a crust is formed on
the ulcerated surface;  and, in  proportion to  the quantity  of pus
secreted  by the ulcer, or the care with  which it is kept, the crust may
become very thick, or be a mere scale.
  The tubercles of the disseminated variety of the syphilitic eruption
are sometimes  less  distinctly  round than  those  just described, less
raised, and sometimes smaller, making it difficult to determine whether
to class them under the head of roseola, lichen, or tubercula; but the
elevation of  the  centre of the  spots, although very  slight, and the
manner of  exfoliation of the cuticle, generally determine the nature
of the eruption  when it belongs to the present group, assuming for the
tubercles, as a distinction from the  " lentiform" kind, the designation
of " flat."
  Tubercula  annulata.—The type of the present form of eruption
is a tubercle, which spreads in a circular direction, so as to form a. ring
of variable breadth.  Sometimes the tubercle itself seems to enlarge
and constitute the ring, leaving an area in which the skin returns by
degrees to its natural state ;  at other times, the tubercle would appear
simply to communicate the impulse of growth to the skin immediately
about its circumference, a ring being formed around the tubercle, and
gradually enlarging, while the tubercle remains stationary in the midst
of the area.  It is to this form  of  syphilitic tubercle that the term
syphilitic lepra has been applied,  and the resemblance is so great as  to
give a certain warrant to the  error.   The eruption is sub-acute and
partial in its distribution, and appears to result from the  agency of a
modified poison.
  In the case of a young woman who suffered under this eruption, the
tubercles were scattered over various parts of the body, but were most
numerous about the neck.  They commenced on the fore-arm by two
spots, and gradually extended, first to the neck and hips, and then  to
her limb3.  On the neck, the eruption presented every stage of pro-
gressive development.  There were papules scarcely a line in diameter;
tubercles, measuring from two to four lines; circular patches three  or
four lines across,  with depressed centre, and raised border; raised and
papulated rings from half an inch to one inch in breadth, of a circu-
lar or oval figure, inclosing in their centre a large and irregularly-shaped
tubercle; and one or two rings with a smooth area.
  Many of the patches were in a state of desquamation;  the exfolia-
tion of the  cuticle being chiefly apparent on the summit of the central
papules, and  upon the convexity of the rings.  The scales, however,
were obviously nothing  more than desiccated  epidermis, and  very 
398       .DISEASES FROM THE SYPHILITIC POISON.

thin;  and not, as in the case of lepra, epidermis altered in its anato-
mical structure, and thick and laminated.
  Sometimes the central tubercle spreads with the ring, and the whole
seems to form one broad, soft patch, the ring being distinguished from
the tubercle by a  mere groove.  In one case there were several  of
these broad  fleshy tubercular  patches bounded by an abrupt border.
  In another case, that of a young man of twenty, the entire number
of spots or patches did not exceed  twelve or fifteen, and were distri-
buted upon the hips, thighs, and penis.  Of two spots on the right hip,
one was irregularly circular, the other oval;  the former measured one
inch and a quarter, the latter one inch and a half in longest diameter.
They  consisted of a central, broad,  and fleshy tubercle, surrounded by
a raised  ring; both the tubercle and ring were of a deep, dull-red
color, and the redness extended  over the whole of the area included
within the ring.  The tubercle was wrinkled and smooth on the sur-
face ; the ring was marked by numerous transverse furrows, and was in
a state of desquamation, the portions of desquamating epidermis cor-
responding in shape with that of the intervals between the wrinkles.
On the right thigh there were four  patches, one was a simple tubercle
measuring one line and a half in  diameter;  it represented the  first
stage  of growth of the  patch; another was a raised, flat, oval-shaped
tubercle, half an inch in diameter,  and appearing, from the elevation
of its border, to be slightly depressed  in the  centre; the remaining
two measured an inch, an inch and a half in  diameter, were oblong
and oval in shape, and had each a broad and irregular cental tubercle.
Of the three  patches  on the penis, the largest, measuring an inch  in
longest diameter, had a central tubercle; the other two were smaller,
and mere rings, inclosing an area of brownish and slightly corrugated
skin, over which the ring had crept in its onward growth.  .
  The resemblance of these patches to those of lepra vulgaris was very
striking,  and I have no doubt that  they would  have been  called lepra
syphilitica by any  one who had seen  them ; and yet their origin and
mode of development was identical with that of tubercular syphilitic
eruptions in  general.   They differed  from lepra, however,  in the
absence of scales, an important point;  and also in the presence of the
central tubercle; the  patches  of lepra are depressed in the  centre;
these were more elevated in the centre than at  the circumference.
  In another example there was  no central tubercle, and the eruption
had more of the character of lepra vulgaris than the preceding cases.
The patient was a medical student; he consulted me for an eruption,
which  he considered  to be  common  lepra, and its appearance  was
certainly such that it  might  have  deceived men of  more experience
than himself.  On  the lower  limbs  were fifteen  or twenty  large rings,
of a medium size of two inches in  diameter.   The area of the ring
was perfectly smooth,  and of a yellowish-brown color; the ring itself
was, raised, of a dull-red color, and irregularly circular or oval in its
form.   On the side corresponding with'the area, the elevated  margin
rose abruptly from the surface; on  the  peripheral side it declined
gradually to the level  of the surrounding skin.  The breadth of the
rings  was between three and four lines.   The surface of  the rings 
SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.     399
 presented certain differences of appearance; in some, it was uniform
 and smooth ; in others, the rings were marked by numerous transverse
 wrinkles; and others, again, were either papulated on the surface, or
 looked as if formed by the aggregation  and fusion of numerous tuber-
 cles.  Ihere  was a slight condensation of the cuticle  covering some
 of the rings, and here and there an indication of epidermal exfoliation.
   Iubercula  ulcerantia.—One of the most striking of the pecu-
 liarities of syphilitic cutaneous  disease,  is the gradual and  almost
 imperceptible transition by which one form passes into another.   We
 have seen this peculiarity illustrated in the transition of  roseola into
 lichen  and tubercle; in the  close alliance  subsisting between  the
 varieties  of tubercles; and the same fact is perceptible  in the gradual
 conversion of tubercles into ulcerations.   These observations all point
 to the unity of the syphilitic poison ; and the varieties evinced in  the
 manifestation of the morbid effects of  the poison, are  such as mi^ht
 be anticipated from a knowledge of the varieties of constitution pre-
 sented  by mankind, and the varied  conditions to which the  poison
 must be subjected in its numberless mutations.
   Even ulceration  is presented to us  in a  transition state, in  that
 curious phenomenon wherein a tubercle disappears, or is removed by
 absorption, and leaves behind it a deeply pitted cicatrix, without any
 external  signs of ulceration  being perceptible; sometimes  a slight
 crust is formed on the subsiding mass ;  at other times, and especially
 under the influence of mercury, it sinks and is lost without a trace of
 change in its  outward appearance,  In  another series of  cases a thin
 crust covers the summit of the subsiding tubercle; if we remove  the
 crust a little  moisture of an ichorous nature  may  be  perceived, per-
 haps a globule of purulent secretion.  We might be inclined to admit
 that there was a slight abrasion of the surface, but scarcely that there
 existed a condition to which  we could correctly give the  name of
 ulceration.  In  a third  series ulceration is unquestionable,  but the
 nature of the ulceration of the superficial kind.

                 SYPHILODERMA PUSTULOSUM.

                        RUPIA SYPHILITICA.
  The only  eruption coming  strictly  under the denomination  of
 pustular syphilis is rupia;  an  affection depending especially on a
 pyogenic  condition of the constitution.   Other forms of pustule must
 be considered  as instances of suppurating  papules  and tubercles.   I
 have myself fallen into the error of denominating a pustular eruption,
 produced under the impulse of constitutional syphilis, "impetigo syphi-
 litica ;'" upon  further reflection I think it would have  been more
 correct to have regarded it as a lichen passing  into the state of suppu-
 ration.  Such cases are by no means rare, and a pustular lichen may-
 be fairly admitted among the occasional phenomena of that eruption.
 I recollect an instance in which the greater part ofthe papules devel-
oped on the arms and legs of a syphilitic patient were gradually con-
1 Portraits of Diseases ofthe Skin, Plate XXXI., Y. 
400       DISEASES FROM THE SYPHILITIC POISON.

verted into pustules.  The syphilitic ecthyma seems to me to be also
doubtful, but not so positively unlikely as the production of smaller
pustules.  Even  in the instance of ecthyma jt is  necessary that  we
should be well assured that the case is not one of suppurating tubercle.
  Rupia1 (Plate VIII.) is characterized  by the  eruption of  small
purulent bullae or large pustules, which are few in  number, dispersed,
and surrounded by a  narrow zone of redness.  The bullae contain, in
the first instance,  a  serous or sero-purulent fluid,  which speedily
becomes purulent or sanguinolent, and concretes  and desiccates into
dark greenish or blackish rough crusts.  These crusts arer variable in
point  of thickness; the 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, purulent, and fetid fluid, and are indisposed to
heal.   Rupia is tedious in its progress, and lasts for several weeks or
months.
   The  varieties of rupia are founded  on the extent and severity of
the disease, and on  the thickness and form of the crust; they are—
           Rupia simplex,            Rupia prominens.

                          RUPIA  SIMPLEX.

            Ecphlysis rhypia, Mason Good.   Sordid brain.
   In rupia simplex  (Plate  VIII., L,  M,  n), the purulent  bullae  are
circular in form, flattened on their summit,  and equal in diameter to
a sixpenny or shilling piece.  When first  developed, they contain an
opaline fluid, which soon  becomes purulent, and gradually concretes
and dries up.  As  the secretion'dries, the epidermis 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 epidermis of the sur-
 rounding skin.   It is thrown off after some days, and exposes a  red
surface, or a superficial  ulcer, which may continue for several days
longer.  In the latter case a new crust is  formed by the desiccation
of the  secretion upon the  surface  of the ulcer, and a succession of
crusts may in this way be produced.  When the  ulcer heals its  seat
is indicated by redness  or lividity of the skin around the cicatrix,
 which endures for a considerable  period.   The  more frequent situa-
tion of rupia simplex is the legs and lower parts of the body.

                         RUPIA PROMINENS.

   The prominent rupia  (Plate VIII., o) receives its designation from
the  projecting  and  conical form of  the crusts  which  succeed  the
 purulent bullae.  The  pustules  are of  greater  extent  than  in  the
 simpler variety, and  are followed by a troublesome ulcer of consider-
 able depth.
                          1  Der. finot, sordes. 
        SYPHILODERMATA, OR SYPHILITIC  ERUPTIONS.    401

  Rupia prominens is preceded by several circumscribed patches of
erythema or by tubercles, upon which  the epidermis is raised slowly,
and is distended with a turbid, dark-colored fluid.  The fluid soon
becomes concreted, and gradually desiccates into a thick and wrinkled
crust  of a brownish-black  color.   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 epidermis is raised, and a fresh  secretion of  purulent
fluid takes place beneath it,  which increases the breadth of the crust.
In this manner, by successive 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 growth
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 resemblance to  the scaly
shell of an oyster.  The crust  goes  on increasing  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,
aud this is the more frequent course, the ulcer  retains its open form,
presenting a foul surface, thin, livid, or pale, and  excavated edges,
and an inflamed areola.   The ulcer is difficult to  heal, and  after  the
formation of a cicatrix,  leaves a livid and purplish stain which  con-
tinues 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 sometimes  few in
number, sometimes numerous and successive; usually, however, there
is one only or a few at their height, while others  may be threatening
to appear or  on the  decline.  Sometimes the pustular bullae,  instead
of pursuing the tardy course described above, is  developed quickly,
and is filled with a lymph, which subsequently becomes opaque  and
purulent.  In other instances, again, the inflammatory redness  may
be dissipated without the appearance of a bulla.
   In  rupia the pyogenic constitution may be idiopathic or accidental,
or both, as in the case of a young man of twenty, who  received the
infection of syphilis while in a debilitated state from immersion in the
water during the winter season.  He had a chancre and suppurating
bubo, the former healed readily, but the latter confined  him to  bed for
nine weeks.  Six weeks after inoculation a crop of red tubercles made
their appearance on the face and head.  The tubercles  were  round, as
large as a  split pea, and, after increasing in size for a few days, be-
came filled in the summit with  a bright yellow  pus.  Two or three
days  later the centre of the pustule  had become  brown,  and was be-
ginning to desiccate into a yellowish-brown scab.   The margin of the
scab, where it was continuous with the  epidermis, was still  yellow
       26 
402       DISEASES FROM THE SYPHILITIC POISON.

from the effusion of fresh pus, while a narrow halo of redness indicated
the inflamed skin around its circumference.
  After another period of six weeks from the outbreak of the pre-
ceding attack, he was  seized with sore throat and severe pains in the
limbs, which increased  at night;  the fauces were much inflamed, and
there was ulceration of the tonsils and pharynx.   His  face at this
time was studded all over with yellowish-brown crusts; there were
several on the scalp, and a few on the limbs and back ; altogether the
number distributed upon the face and  head amounted to sixty-eight.1
The eruption presented itself in  all its stages of development and
growth : there were simple tubercles, others surmounted with yellow
pus, and  others covered with crusts possessing every gradation  of
growth.   The crusts bore  the aspect of being laminated; some were
irregular; others were pretty evenly limpet-shaped; while a few were
broken into  small  fragments, and had a mulberry-like appearance.
Upon the eyebrows they had uprooted the hair and carried it with
them, so that, on superficial inspection, they seemed tufted with hair.
There was also some difference of color: in the most recently formed
crusts a reddish-yellow predominated; the older  ones were brown,
with a tinge of green or yellow;  and those which had been caught by
the dress  or by the bed-clothes  were black from being  stained with
blood.
   The elevation of some of the crusts was three-quarters  of an inch,
and such crusts had generally the  conical shape  (Rupia prominens,
Plate VIII. o), that particular form being partly the result of freedom
from injury, and  partly the consequence of the  slow and  gradual
peripheric extension of disease in the skin.  On the side of the cheek
one of the crusts was  thicker below than  above, from gravitation of
the imprisoned  pus; and  on the upper lip, near the margin of the
prolabium, there were two,  of. a circular and  conical  form, which
curved downwards to the mouth, and were not unlike the beak of a
hawk.  The largest of the crusts was situated on the front of the thigh,
and measured nearly two inches  in diameter; it  was dark  colored
from effusion of blood, and thin.
   In its relation to the surrounding skin, the exterior pellicle of the
 crusts was continuous with the epidermis; this portion of the pellicle
 was  of a lighter color than the  rest, and  covered a layer of newly-
 effused pus.  By a little pressure the pellicle in this situation  might
 be broken through all round, and  by a slight  increase of force, the
 crust might be removed entirely, showing it to be a hollow cone filled
 with a thick and tenacious pus, and  based upon an indolent and un-
 healthy ulcer.
   The ulcers which constitute the base of the crusts of rupia have
 been aptly termed "atonic."'  When they have made but little pro-
 gress in depth, they present a coarsely granular surface, interspersed
 with irregular patches of undestroyed skin.   A little later, when the
 ulceration reaches the deepest stratum of the corium,/he tissue of the
 latter may be detected  among the granulations, forming an open net-
1 Portraits of Diseases of the Skin, Plate XXXII., W. 
        SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.     408

work ; while, at a still later period, the corium is entirely destroyed,
the exposed subcutaneous tissue is frequently smooth, or the granu-
lations are few and scattered, and the hollows are filled with whitish
and yellowish lymph.  The edges of these ulcers are generally pale
and  smooth, without being raised, and  they are undermined to a
greater or less extent.  When the ulcers of rupia heal, they leave be-
hind them ugly cicatrices, with more or less of a purplish hue of the
skin, and often a brownish stain.

                     SYPHILODERMA PILARE.
                      ALOPECIA  SYPHILITICA.
   The fall of the hair, alopecia, sometimes follows  the syphilitic fever,
in the same manner as it is met  with as a sequela of measles, scarlet
fever, or fevers of any other type.   Under the influence  of the con-
stitutional actions present in these fevers, the formation of the epider-
mis and hair is temporarily suspended, the epidermis as a consequence
exfoliates, and the hair falls.  Where the fall of the hair is  a chronic
action, it  probably depends  upon insufficient  nutrition of the skin; a
condition especially  characteristic of the syphilitic cachexia.
   In a disease so  important and serious as constitutional syphilis, the
fall of the hair, even as a symptom, is not calculated to  excite more
.than a passing notice.  If it be sought for, it  will be found very fre-
quently;  but  occasionally  it is brought  under our attention by the
immediate inconvenience to which it gives rise.
   I am often  consulted for  alopecia where syphilis is not suspected,
and  in these cases I subject my  patient  to a careful  scrutiny for the
detection  of any symptom which  might indicate its dependence on the
syphilitic poison.  Sometimes I have succeeded in discovering such a
symptom, however obscure, and then the treatment applicable to con-
stitutional syphilis has been remarkably successful.   In one case the
concurrent symptom was a tendency to neuralgia; in another, a muddy
skin, with occasional sore throat; and in a third, a milky spot or a fis-
sure on the tongue.
   The following is an example of alopecia, depending on syphilis: A
gentleman contracted a venereal sore, the nature of which was doubted
at the  time by his  medical attendant, and  a week  was allowed to
transpire  before he commenced taking mercury.   He then  took blue
pill  until his  mouth was affected; the sore  healed in three weeks.
Three months after  the sore, his hair began to fall off in considerable
patches, and a month  later  he  had sore throat.   On the occasion of
his visit to me the  hair was falling  abundantly,  it was parched  and
shrunken as if dead, and the scalp was dry and scurfy.  Upon exami-
nation I found the  stain of a syphilitic  tubercle  on the  nape of his
neck.
                  SYPHILODERMA UNGUEALE.
                      ONYCHIA SYPHILITICA.
   The  matrix of the nails is  not unfrequently affected by redness,
swelling,  suppuration, and often  ulceration, under the influence of the 
404       DISEASES FROM THE SYPHILITIC  POISON.

inflammation of syphilis, and the case is one of syphilitic onychia.
Sometimes one finger or  toe alone is attacked, -at other times several
may be affected at the same moment.  The skin immediately around the
nail is considerably puffed and swollen, often the whole extremity ofthe
finger or toe is  enlarged ; suppuration and superficial ulceration occur
between the skin and the edge of the nail, fungous granulations are
formed, which partly overlay the nail; the suppuration extends beneath
it, and the nail  is, in consequence, more or less loosened.  This state of
disease is  excessively painful, but quickiy gets well under the influence
of general remedies.
  Syphilitic degeneration of the nails is also-  met with  occa-
sionally as a consequence of the presence of the syphilitic poison in the
blood.   The nails are apt to be altered in structure! they are discolored
and brittle, thinner or thicker  than natural, and  rough and  fibrous in
texture.   Sometimes they fall off, and are succeeded by others more
faulty, than themselves, and sometimes  this  morbid condition of the
nails is accompanied with erythema of the matrix, or of the skin im-
mediately bordering the edge of the nail.


               SYPHILODERMATA PRIMITIVA.

                         SECOND PERIOD.
                         Tertiary Syphilis.
   The effects of the syphilitic poison  on the human constitution are
so altered and modified by time, that  the  distinction of the constitu-
tional symptoms of syphilis into secondary and tertiary is universally
recognized.   It does not, however, follow, that  these  are necessarily
connected with each other in the order of their apparent sequence; for
the secondary or constitutional disease  may be  present without any
primary disease having existed;  and the tertiary symptoms  may be
evolved without the intervention  of  any secondary affection.   Nor
does time necessarily bring about similar changes in similar periods;
the effects, besides being modified by time, also subserve the  powers
of constitution of the individual, and are consequently developed more
rapidly in one person than in another.   Again, the primary symptoms
sometimes merge into the  secondary,  and  the secondary pass so gra-
dually into the tertiary, that it becomes often difficult to draw with
certainty a line between  them.   These considerations  must always
be borne in mind in our  observation of  this class of diseases, and our
diagnosis as to  the period of the disease must be founded, not merely
upon time, but also upon decided pathological characters.
   The syphilodermata which  belong  to the second period, that  is, to
the  period of tertiary syphilis, may be  arranged under three heads,
according as the}' present, in chief, the characters of  erythema, of
tubercle,  or  ulcer.   To  the erythematous group  belong, psoriasis pal-
maris et plantaris, and an  erythema which occurs for the most  part
on the face, lupus erythematosus.  Under the  head of syphihderma
tuberculosum are to be considered, tubercula  mucosa,  tubercula ulce-
rantia, superficial and deep, lupus ulcerosus, and tumores  gummati; 
        SYPHILODERMATA, OR  SYPHILITIC ERUPTIONS.     405

while the syphihderma ulcerans  exhibits one of the destructive attri-
butes of syphilis when the latter  has gained long possession of the
system.

 ERYTHEMA PALMARE ET PLANTARE, SYPHILITICUM; VEL, PSORIASIS
               PALMARIS ET PLANTARIS SYPHILITICA.

  Erythema palmare comm^ces usually in the middle of the palm of
the hand, in one of the g^pves of flexion, as a  reddish spot, over
which the cuticle becomes hard and yellow, from destruction of its
vitality, and  soon  after cracks  and exfoliates, leaving a red surface
beneath, covered by a  new  epiderm.   Sometimes this  process com-
mences at the same moment in both hands: sometimes it exists in one
only ;  sometimes it takes place in the soles of the feet as  well as in
the palms of the hands.  Often there is only one of  these dry,  red,
cracking,  uncomfortable patches  on the  hand ; at other times, there
are several; for example,  around the ball of the thumb, on the wrist,
in the lines of flexion of the fingers.  The exfoliating erythematous
patch may continue in the state now described  for weeks, months, or
years, with little or no change.   Sometimes it exhibits a tendency to
spread, and then it creeps slowly along the fingers to their tips, along
their borders, around  the borders of the hand, or upwards upon the
wrist.   Occasionally, and  less frequently, it  reaches the back of the
hands and back of the fingers, and I once met  with a case in which
its principal seat was the back of the hand.  But whether it be partial
or general in its attacks on the hand, it is always the same red, inflamed,
hot, cracked, exfoliating  surface; sometimes, but rarely,  the tender
derma, newly exposed by the peeling off of the skin above, cracks,
then a little blood  escapes, and the crack heals;  sometimes the  dry,
cracked cuticle is the cause of the fissure of the skin; rarely, a little
suppuration takes place.
  Sometimes the patch exhibits a tendency to enlarge by  centrifugal
growth, erythema palmare centrifugum, vel psoriasis palmaris centrifuga,
and presents the annulate character already referred to under the head
of syphilitic  tubercles.  In the  case of a  centrifugal  growth,  the
border is defined, the  area presents the red,  dry, cracked, and exfoli-
ating character above  described.  The ring may be  small or large,
running out upon the fingers in one direction,  and upwards upon the
wrist in the other.   As soon as it becomes stationary, a new inflam-
matory action  may begin in the centre of the  ring, and a second,
a third, and  a  fourth ring may be  formed in  succession, affording a
curious and remarkable example of cutaneous disease.
  Sometimes the ring possesses a tubercular character, and is slightly
raised, is,  in fact, an instance of the annulate tubercle in the palm of
the hand.   I have delineated a  case of this  kind in my Portraits of
Diseases of the Skin, under the name of erythema annulatum palmare.1
I had not at that time detected the syphilitic nature of the affection,
and had only seen one  or two cases; I have  examined many since,
i Plate XIX., K. 
406       DISEASES FROM THE SYPHILITIC POISON.

and with a slight alteration in the arrangement of the words, I tbink
I may still retain the name I then gave to it, namely, erythema palmare
annulatum.
  The erythema palmare annulatum syphiliticum differs from  the
forms previously described, by getting well in the area while the circle
expands.  The circle may remain for a long time cracked and angry,
but the area recovers its healthy structure and appearance completely.
  In a case of erythema palmare of  one hand, with syphilitic tuber-
cles on other parts of the  body, the dis^fte of the palm was a circular
ring, the epidermis being  hard and  dry, and  slightly raised,  and  the
area of  the ring dry and cracked.  The patient bad several such rings
of small size on his  wrist,  a half circle on the breast, and a large
broken circle with a cluster of scattered tubercles within its  area, on
the buttock.   These eruptions  had been  in existence for ten years;
that on  the  hand had  got well and  broken  out repeatedly, but  the
patch on the buttock had continued from its first appearance, being
sometimes better, and sometimes worse.
  In another case, one of erythema palmare  centrifugum,1 with a
similar affection of the skin  of  the  penis, the eruption occupied  the
whole of the palmar surface of the hand and fingers, extending partly
to the back of the latter.  The  leading features in the appearance of
the hand,  were, a vivid redness  of the entire surface,  bordered by an
abrupt margin  of a deeper red than the rest; a  swollen  state of  the
diseased skin, a raggedness of surface, arising from irregular exfolia-
tion of the epidermis, and a cracked  and bleeding state of the deeper
grooves of flexion of the  fingers.  The cuticle had  been repeatedly
thrown off from the inflamed surface,  and  the centre of  the palm was
smooth, of a  vivid pink color, and covered by a thin coating of newly
formed and smooth epidermis.  On  other parts of the surface of  the
hand, the newly formed cuticle was  in a state  of exfoliation.  The
inflamed skin of the  penis had resulted from the extension of two
patches of  annulate  tubercle,  the  borders of  which  formed  the
boundary of  the disease.  The border was several lines in  breadth,
and covered by a broken layer of desquamating epidermis; while the
area of  the patches was  red,  furfuraceous,  and exhibited a tendency to
crack in the direction of the  lines of motion of the skin.
  Erythema  palmare syphiliticum is a  syphiloderma of the second
period, namely,  that of  tertiary syphilis, and is  among  the  latest of
the evidences  of the presence of the syphilitic poison  in the blood.
In  five cases,  in which I noted the period intervening  between  the
primary disease and the affection of the skin of the palms of the hands,
I found the time to be  respectively, four, eight,  nine, and ten years;
and, as an illustration of the  persistence of the disease in this region,
the same five cases gave, as the  periods of existence of the disease up
to the time  of  the patients  corning  before  me, nine  months, three
years, six, nine, and ten years.
  Occasionally I have met with  cases, and have one  now before me,
wherein the syphilitic infection is recent, dating back to a period of
1 Portraits of Diseases of the Skin, Plate XXL, AT. 
        SYPHILODERMATA, OR  SYPHILITIC ERUPTIONS.     407

twelve months, in  which simple erythema, like that which  occurs in
infants, is developed.  In this case, a copper-colored  redness spreads
over  the palms of the hands and palmar surface of  the fingers, the
integument is thickened, somewhat indurated, or stiffened, and cracked
in the lines of motion ; but there is no desquamation such as happens
in ordinary cases of psoriasis palmaris, where the affection is of many
years' duration. These cases yield to the iodide of potash, which the
psoriasis palmaris does not.
   Erythema plantare syphiliticum, vel psoriasis  plantaris  syphilitica, is
identical in its mode  of  origin and growth with erythema palmare
syphiliticum ;  a good  example of this eruption will be found among
the Portraits of Diseases of the Skin, Plate XXII., A v.

   Lupus  erythematosus is met with as  an  erythematous syphilo-
derma in  old standing cases  of tertiary syphilis, and  in conjunction
with  other forms of  syphiloderma, both tubercular  and  ulcerative,
thus placing its connection with the second period of syphilodermata
beyond question.  It is  also met with,  presenting exactly  the  same
characters, where  none but  hereditary,  or  the remains of infantile
syphilis can be present,  hence  I  have  termed it syphiloderma erythe-
matosum hsereditarium.  Thirdly, it occurs occasionally under circum-
stances of, and  with appearances involving, so  much obscurity, that I
have  thought it necessary, for the present, to transfer its consideration
to the group whose name it bears, namely, lupus.  At a future time,
I  hope to be  able to unravel more  completely the entanglement
which envelops this  very peculiar and very  troublesome  and obsti-
nate disease.

                SYPHILODERMA TUBERCULOSUM.

                          Second Period.

                       TUBERCULA MUCOSA.
   When syphilitic  tubercles occur on parts of the body where there
is naturally an increased  degree of moisture, or where they are kept
in a softened condition by  morbid secretions, they are apt  to assume
a state of chronic growth.  Such tuberculous growths are termed soft
or mucous  tubercles, or condylomata.   Their common situation  is
the perinaeum,  particularly  in the  female, where their  growth  is  *
favored by the secretions of the vulva.  They are also found occa-
sionally between the  greater labium and the thigh;  on the scrotum,
between the scrotum and the thigh; around the anus, in the groins,
in the  axillae,  and upon the  lips.  These tubercles belong to the
period  of tertiary  syphilis,  and are the  common  consequence  of
the modified  syphilitic  poison;  appertaining in that case to the
new group which  I propose to make,  under the name of syphilo-
dermata mitigata.   Mucous tubercles are far from uncommon on the
inside of the labia majora, and iu  the neighborhood  of the vulva  of
married women, where  they exist  for years without attracting any
attention.  In  their ordinary state they  are very little raised above 
408       DISEASES FROM THE SYPHILITIC POISON.
   the level of the surrounding integument, but occasionally they enlarge
   and are  troublesome;  and sometimes become the seat of superficial
   ulceration.
                       TUBERCULA ULCERANTIA.

     Ulceration of tubercles may be either superficial or deep; and in
   either state it may be stationary  or  progressive.   Ulceration is one
   ofthe phenomena of syphiloderma which serves especially to indicate
   the long period of existence of the poison, and is strongly diagnostic
   of the second period, or that which corresponds with  tertiary  syphilis.
   When the ulceration  is stationary, it commences on the summit of
   the  tubercle, and  extending its  circumference by degrees, it delves
   into the  substance of the skin more or less deeply.   When, however,
   it is progressive,  it creeps on by the  circumference,  and acquires the
   name of serpiginous, sometimes creeping over the surface  to a consi-
   derable extent.  At  other times the creeping and the delving action
   are combined, and the horse-shoe ulcer is the  result.
    The deeply ulcerated tubercles are more common than the superficial,
   and their common seat is the head  and face ; but they are also met
   with on other parts of  the body, as on the  back and loins, the limbs,
   and the scrotum.   The ulcers are more or less deep and hollow, they
   secrete an ichorous or semi-purulent  fluid, and are excavated in the
   midst of a thickened, red and congested skin.   Sometimes they occupy
   a patch of tubercula circumscripta, and are so numerous as to give a
   worm-eaten or honeycomb  appearance to the surface of the patch.
   Sometimes a solitary tubercle is the seat of ulceration, and sometimes
   the annulate form of tubercle is attacked by the ulcerative process.
 ,   Syphilitic ulceration has frequently a progressive and centrifugal
   action, and  in  most instances one side of the tubercle will be found
   more deeply ulcerated than the rest;  or the ulcer will  be observed to
   increase  by one side while  the  process of healing is  slowly taking
   place on the other;  this is the so-called "horse-shoe ulcer"  a  term
   which indicates its appearance sufficiently clearly.   In the horse-shoe
   ulcer, the integument is much congested and thickened  on the side of
   the ulceration, while On  the  opposite side it is uniform with the level
   of the surrounding skin.
    The centrifugal action of the ulcerative process is, perhaps, most
t  remarkably shown in the  superficial ulceration which  sometimes
   attacks the annulate tubercle; and the process is so rapid as  to have
   obtained the designation of serpiginous.  I once saw a man, partially
   bald, whose head  was covered with  these serpiginous wheals; they
   were 'coated with a thin, squamous scab, and  curved around  his tem-
   ples like a pair of ram's horns.   In another case the circles formed a
   necklace, descending for a short distance upon the breast and back.
   This latter  case  is  illustrated in Portraits of Diseases of the  Skin,
   Plate XXIII.,  A.  Q., under the name of psoriasis gyrata syphilitica;
   more properly, it is a syphiloderma annulatum ulcerans, or it may be
   termed, tubercula annulata syphilitica, ulcerantia, or tubercula ulcer-
   antia serpiginosa  syphilitica;  it  is  the syphilide pustuleuse serpi-
   gineuse of Alibert. 
SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.    409
                            LUPUS  ULCEROSUS.

      As tertiary syphilis becomes  settled in the skin, it is remarkable
    how exactly it acquires the resemblance, and assumes the characters of
    lupus, until  at last it becomes difficult, and sometimes impossible, to
    distinguish between  them; and a kind of lupus is generated; which
    is recognized as being the result of the syphilitic poison  in its tertiary
    state.   Such, in fact, is lupus uherosus syphiliticus. ■
      In lupus ulcerosus there may exist one or several tubercles grouped
    together;  the affected skin is thickened, hard, of a purplish red  hue,
    and upon one or  more of the tubercles a thin black crust is formed.
    If the crust  be removed, a deep  excavated pit, filled with unhealthy
    pus, and discharging a sanious fluid, is seen beneath it.  The ulcerative
    action is very slow and gradual,  lasting for months without change.
    At other  times the ulcerative action is more rapid; several  of the
    pits communicate, and a large   unhealthy ulcer is  formed,  which
    destroys the part upon which it is situated, and is followed, on getting
    well, by an indelible cicatrix, with puckering and contraction of the
    surrounding skin.  When the ulcer is situated on the nose, a portion
»   of that organ is destroyed, and  much deformity results; and equal
    mischief, although  unaccompanied by the like deformity, may occur
    upon any part of the body.
      When  a cluster of tubercles  are  assembled  together,  forming a
    patch of diseased and disorganized skin, and the surface is perforated
    by several deep ulcerated pits,  the  affection was  termed lupiform
    syphilis, a name which is  very characteristic.

                          TUMORES GUMMATI.

      The modification of syphilis by time is one of the most curious of
    its phenomena, and, at the same time, one which enables us, by tracing
    its mutations, to recognize it in a form so  very different from its
    original shape, that  nothing but a process of inductive reasoning could
    determine  its identity.  In a gentleman who had given evidence of
    the  presence  of  the  syphilitic  poison in his blood  for upwards of
    twenty-five years, there are now developed, since the completion of
    this period,   several   round  tumors  (tubercula gummata) in  and
    beneath the skin, which evidently originate in the same cause.  The
    tumors are about the size of  marbles, three or four in  number, and
    hard and somewhat elastic to the touch.   They are situated  in the
    left forearm, two or three being to  all  appearance in the cellular tissue
    under the skin, and one in the skin itself.   The latter is slightly red
    and tender, and looks as if it would pass into a state  of ulceration.
     The peculiarity of these tumors  is, the great distance of time which
    intervenes  between their occurrence  and the reception of the poison.
    And, in this  particular, they seem to  deserve a place  by themselves
    under the title of "chronic syphilis;" or, if it be preferred, tertiary
   syphilis.   In their  hardness they remind us of cancer, and are very
   likely to  be mistaken  for malignant  disease.  When  they "ulcerate,
   that process takes place very slowly, and generally on one side, while 
410       DISEASES FROM THE SYPHILITIC POISON.

by the other they continue to grow; hence the ulcer has more or less
of a horse-shoe form, and the tissues over which it has passed, heal,
but  leave^an indelible cicatrix.  The ulcer is slowly destructive, and
exhibits no tendency to granulate; sometimes it dissects out  certain
tissues with  great  neatness.  The situations in which I  have seen
these ulcers in a state of progress, is  the integument immediately in
front of  the ear; the following is an example: A gentleman, aged
fifty, has an ulcerated sore immediately in front of the tragus of the
left ear.  It has occupied its present position three or four  years, but
latterly has been enlarging.   It is now about the size of a  half-crown
piece.  On  the side next the temple it  is bounded by an elevated
mound of thickened skin, into the base of which the ulcer seems to
burrow.   The ulceration has dissected out two ligamentous bands in
front of the tragus, and has isolated them completely.  It  is  devoid
of  granulations,  gives  rise to no pain, and secretes  no  pus.  The
surface exudes a small  quantity of a transparent and colorless ichor,
which, left to itself, dries up into a thin scab.
   Another  gentleman, between fifty and sixty, has a  tumor of this
kind excavated at its  base by a deep ulceration, the latter being
covered  with a slough.  He has suffered  from the disease  sixteen
years; and  although existing for so long a time, the ulcer now  is
scarcely larger than a shilling.  It is of the horse-shoe form, and has
burrowed into the base of the hypertrophied skin constituting the
tumor.  The  ulcer  is situated immediately in front  of  the tragus.
The skin of the temple in front of the ulcer, and, indeed, as far as the
angle of the eye, presents the appearance of a cicatrix, and along its
border is an impetiginous eruption, which  has crept over,  and is the
cause ofthe cicatrized skin.   In this portion ofthe skin, and  particu-
larly in the neighborhood of the ulcer, are a number of enlarged
venules.

                    SYPHILODERMA ULCERANS.

   Syphilitic ulcers sometimes take on a more extensive character than
that already described; the ulcers are large, unhealthy-looking, and
frequently phagedaenic, their edges are angry and excavated, and the
skin around, red and indurated ;  sometimes their surface is dry, some-
times it pours forth an acrid ichorous discharge, and sometimes they
are filled with a transparent reddish jelly-like secretion. These large
ulcers are most frequently met with on the face, but they are also seen
occasionally on other parts  of the body.  In one case I found a large
phagedaenic sore on the calf of the right leg; a smaller sloughing sore
near the tendo Achillis, and several cicatrices, each as large as a half-
crown. On the left leg, near the ankle, was another unhealthy-look-
ing sore, of considerable magnitude.  The skin surrounding the sores
was of a deep-red color, indurated,  and  apparently infiltrated; the
edges  ofthe phagedaenic sore  were dry, black, and excavated perpen-
dicularly, and the floor was covered with a gray magma.  There was
no trace of pus, and in the large sore no secretion of any kind. 
SYPHILODERMATA,  OR SYPHILITIC ERUPTIONS.     411
             SYPHILODERMATA HEREDITARIA.

   We have next to consider the modifications of syphilis in another
 point of view, namely, in its effects upon the offspring of syphilized
 parents, constituting hereditary syphilis.  The transmission of the poison,
 in this instance, is indirect, passing from the father to the mother, and
 from the mother to the foetus, the mother, in this case, being  a sufferer
 by the transit or wholly unaffected, being, in fact, the  mere material
 of communication between the contaminated source on the one  hand,
 and the newly-formed being on the other.   In other cases, the mother
 may be herself the primary source of the poison, and the father quite
 free from inculpation, the  case being then one of  direct transmission.
 Of a similar kind is the propagation of syphilis to an infant by means
 of the milk of the nurse.   Infantile syphilis is therefore not always
 hereditary;  it is transmitted when the poison is imbibed with the milk
 intended for its nutrition, and is  hereditary only when it is received
 in the womb of its parent.  But the difference in the two cases  is not
 so considerable as might at first sight be imagined; the poison  is  in
 both instances a secondary poison, modified and  chastened  by  trans-
 mission through the blood of another.
   It is not impossible in the adult to have secondary syphilis, that is,
 constitutional syphilis, without any primary disease; I  have met with
 such instances.  In the transmission ofthe secondary poison, secondary
 disease is more frequent; thus, the  newly  contaminated  wife, her
 husband being locally sound, is probably affected from the first with
 secondary or constitutional syphilis, and has no local  disease;  or, if
 there be local disease, such disease is of a secondary or tertiary nature,
 such as morbid  secretion and mucous tubercles.  And, in the case of
 the infant, unborn or born, it is obviously the secondary disease,  or
 constitutional syphilis, which is transmitted.  But  we have now  to
 consider the after effects  of the poison on the infant, those  effects
 which correspond with the tertiary  syphilis of the  adult.  It would
 be contrary to all analogy to suppose  that  infantile syphilis ceased
 with its first outbreak; that it was eliminated from  the constitution
 by the remedies employed for its  cure; no,  it lingers  in the blood ;
 like syphilis acquired by the adult, it has its secondary and its tertiary
 characters; and it makes its appearance in after-life under a variety
 of forms, sometimes as a lupus, and sometimes a lepra.  The direct
 connection between  certain forms  of lupus and  syphilis cannot be
 doubted by the practical observer; and the relation between syphilis
 and lepra has appeared to  me, in some cases, to be equally clear.
   Hereditary syphilodermata present themselves to our notice in  three
 forms, which serve to represent the three periods of the poison.   The
first period, represented by  erythema, corresponds with the secondary
 spyhilis of the adult; the second period is tubercular, and brings to our
 notice tubercles in different forms, and lupus non exedens and  exedens,
 which correspond with the tertiary form of direct syphilis ;  while the
 third period belongs  to a stage later than tertiary syphilis,  a kind of
 quaternary gradation, and offers for our consideration another tuber- 
412       DISEASES FROM  THE SYPHILITIC POISON.

cular affection of a more permanent kind than most of the preceding,
namely, lepra.

     SYPHILODERMA HJEREDITARIUM ERYTHEMATOSUM.

              ERYTHEMA SYPHILITICUM INFANTILE.

Syn.  Syphiloderma  erythematosum marginatum.   Lepra syphilitica
             infantilis.  Psoriasis syphilitica infantilis.
  The more common form of manifestation of constitutional syphilis
in infants is erythema of the hands  and feet, with epidermal exfolia-
tion ; small  circular  and slightly elevated tubercles, with  depressed
centres (cupped tubercles), looking like lepra in process of peripheral
extension, and without scales: erythematous patches, of various extent
and  figure, also slightly raised  above the surface; and  excoriations
and fissures around the apertures of the body, the seeming consequence
of acrid  humors.  Then the disordered state of the mucous membrane
is manifested by acrid discharges from the eyes, nose, mouth, and often
ears; moist excoriations at the angles  of each of those apertures;
aphthae  and congestion of the  mucous  membrane of the mouth and
fauces;  a clogged state of the air-passages ; tumefaction of the mem-
brane of the trachea and larynx; and, not unfrequently, diarrhoea.
  Sometimes the exfoliation of the epidermis of the hands  and feet
takes place at birth, the process  having  commenced in  the  womb of
the mother; at other times  the first symptoms of syphilis are not
apparent for three weeks, six weeks, and even later.  In  an instance
of exfoliation at the  time of birth, the child, although arrived at the
full term, was small,  thin, and  shrivelled, and the blood oozed out
copiously from the denuded surface  of the hands and feet;  the blood
was  more diffluent than natural, and resisted all means to arrest it, and
the child died in the course of a few days.  The  appearance of the
feet and hands suggested to the accoucheur who attended the mother,
a total absence of the skin.
  The first  symptoms of the syphilitic  affection were evinced in an
infant of five weeks,  otherwise plump and well-looking, by the devel-
opment of  what seemed to be a common but  severe cold. Its mouth
and lips became dry  and parched; it had cough;  and its throat and
air-passages seemed clogged with a thick, viscid mucus.  It was nearly
in this state at the sixth week.  When I saw it, the mucous membrane
of the mouth, as far as could be seen, was congested, and  spotted with
the white films of aphthae, the voice was hoarse and husky, and the
lips and angles of the mouth cracked and excoriated.   There was a
viscous  secretion from  the nose; the child  was emaciated; and its
skin dry.  An inflamed state (erythema) of the feet was apparent at
birth, and was followed soon after by a similar state of the hands; the
cuticle was thrown off" in  large  flakes and  by repeated  exfoliations,
leaving the skin beneath very  tender, and giving  rise  to cracks,  of
various extent, in the  direction of the joints.  Some of the cracks
extended quite around the fingers, were of considerable depth, and bled
a good deal. 
        SYPHILODERMATA, OR  SYPHILITIC  ERUPTIONS.    413

   In another  child, three months old, there appeared  an extensive
 erythema covering  a  considerable part of the surface  of the body.
 The eruption was of a dull red hue. slightly raised above the level of
 the  surrounding skin, smooth  as  though tumid, lustrous like metal,
 exfoliating in some situations, and distinctly circumscribed, the border
 being slightly raised, and paler than the rest of the patch, reminding
 us of the wheals of  urticaria.  On the nates and  thighs were several
 circular spots about as large as a sixpenny-piece, very slightly raised,
 particularly at the border, and depressed, or cupped, in  the centre.
   On the face the erythema was chiefly situated  around the eyes, nose,
 and mouth, and on the cheeks, in the course of the tears.   The eyelids
 were inflamed and swollen, the eyes moist, and there were excoriations
 at their outer angles.  There were also excoriations around the aper-
 tures of the nose, and  at the commissures of the mouth.   The  nose
 was filled with mucous secretion, and the nasal  respiration  snuffling;
 the cry was hoarse.  On the limbs the eruption occupied chiefly the
 outer sides of the arms and legs.1
   In a more  advanced stage of the  disease,  the erythema having
 subsided on the feet and hands, had left behind it an exfoliation of the
 epidermis;  the head was covered  with dandruff  and scurf, while on
 the  nates there were numerous tubercular spots of  a  circular figure,
 about the size of a sixpence,  with raised margin and  depressed or
 cupped centre, of a  dull red color,  and bearing a close resemblance to
 the  spots of  lepra divested of  their scales.  The child  was thin and
 weakly, its skin muddy and rough,  the conjunctivae congested, and
 the eyes weeping; there was a copious discharge from the  nose, a thick,
 mucous secretion clogging the mouth  and fauces, a viscous phlegm in
 the  trachea, which impeded breathing, and a  hoarse cry, which  indi-
 cated swelling of the mucous membrane ofthe larynx ; the child was,
 besides, very uneasy and fractious; had been  suffering  from a some-
 what severe  diarrhoea, and-  was still  relaxed in its  bowels; at the
 angles  of the eyes, nose, and mouth, the mucous  membrane and skin
 were excoriated, and poured out an acrid secretion; and  there  were
 similar excoriations on the lips, which had produced a tender state of
 the nipples of the mother.

        •SYPHILODERMA H^EREDITARIUM TUBERCULOSUM.
                                »
          LUPUS SYPHILITICUS VEL TUBERCULA  LUPOIDEA.

   The  commonly recognized source of lupus is scrofula; and then we
' may ask, What is scrofula? Now,  scrofula, if not in all cases, certainly
 in some, takes its origin in syphilis.   Therefore, lupus, or scrofulous
 lupus,  may be considered as an appendage of syphilis, more or less
 direct.   But it is not my intention to  discuss an opinion which I put
 forth several years back, that scrofula was  the offspring of syphilis,
 nor to  interfere with those examples of undoubted lupus which I  have
 already considered  in a previous chapter; but simply to investigate

   1 A good example of this eruption will be found among the Portraits of Diseases of
 the Skin, Plate XVIII., A W. 
414       DISEASES  FROM  THE  SYPHILITIC POISON.

certain obscure forms of cutaneous disease which occupy the neutral
ground between syphilis and lupus, which must be classed with lupus,
if lupus be syphilis;  but, if such be not  the case, must, for the  time
being, be considered  as lupoid, and constitute a group  of  transition
between syphilis, from which they clearly  proceed,  and lupus, with
which they appear to be analogous.
  These lupoid affections originate in the syphilitic  poison conveyed
to the infant, either during its intra-uterine existence, or soon  after
birth; and they bear the same relation to the syphilitic poison, then
introduced, thatjtertiary syphilis bears to secondary syphilis proceeding
from the primary poison.  In a word, they may be regarded as syphi-
lodermata  of  the second period, or  as examples of tertiary  cutaneous
eruption.
  They are doubtless modified by a variety of conditions, and to this
circumstance may be attributed the great diversity which they exhibit
in respect of severity, and their nearer approach to, or farther removal
in appearance from, syphilis.  Thus, we should expect a different cha-
racter of eruption in a poison obtained from the mother, than from
one derived from a nurse;  and the difference of period or severity
would modify it in both of these sources.  Again, the modifications
might spring from the child itself;  its powers of nutrition,  its degree
of vital energy, its diseases, particularly those of an eruptive kind ; its
age, for sometimes these affections appear in youth, and at other times
may not be developed until manhood or womanhood.
  But, whatever the  cause or degree of modification, the lupoid dis-
ease may be classed, according to its pathological characters, into sim-
ple or non-ulcerating tubercles; uherating tubercles, the ulcers being super-
ficial or deep; and serpiginous tubercles.
  Of  the simple or non-ulcerating lupoid tubercles, the following is an
example.  A young lady, aged nineteen,  had an  incomplete ring of
tubercles situated on the cheek, near  the lower eyelid.   The line of
tubercles curved  upwards towards the temple, where they  we're met
by  a wheal-like tubercle, nearly an inch in length.  The color of the
elevations was a dusky red, approaching to purple; they were perfectly
smooth on the  surface, and  had occupied  their present position for
nearly two years. She had  been treated with lotions and ointments
of all kinds, and  nitric acid had been proposed to her.  The fear of a
scar resulting from the use of the cdustic, and the recent appearance
of  a similar tubercle on the nose, was the occasion of her visit to me.
She had no other spot of any  kind  about  her.  I treated her with the
bichloride  of mercury and sarsaparilla, and she gradually lost all trace
of the eruption.   It was not one of those cases of disorganization of
the skin which I have described in connection with syphilitic tubercles,
and therefore  there was no cicatrix, not even a stain, left behind.
  Of the uherating lupoid tubercles, the following may be taken as an
example: A young gentleman, under twelve years of age, was brought
to me with a cluster of lupoid tubercles on the scalp; some of the tuber-
cles were in a state of ulceration, and several large cicatrices showed
where other ulcers had healed.  He was an  unhealthy-looking  boy,
of short stature for his age, had large tonsils, and a tumid  abdomen. 
        SYPHILODERMATA, OR  SYPHILITIC ERUPTIONS.    415

His mother informed  me  that he had suffered from eruptions of the
same nature as that upon the  scalp, ever since his birth.   The age of
this boy precluded the possibility of his having  been in the way of
the syphilitic poison ;  and yet no one who had ever seen a syphilitic
tubercular eruption would have doubted for an instant as to the nature
of the one  under which he was suffering.   I have seen several cases
of a similar kind, which have been brought to me under the idea of
thdir being an obstinate form of ringworm.  A young lady and her
brother, the children of a college friend, not remarkable for his steadi-
ness as  a student, are  now under my care for this disease, and are
progressing rapidly under  the use ofthe iodide of potassium.
   Serpiginous  lupoid tubercles.—A common form of the lupoid
eruption is a roundish patch of a dull-red or purplish-red color, slightly
raised above  the level of the surrounding skin, indolent, sometimes
spreading by the circumference, so as to form  a ring, and healing
imperfectly in the centre;  sometimes spreading on one side only, and
healing  on  the  rest; sometimes ulcerating deeply, in one or several
points, in the latter case producing a worm-eaten  appearance of the
skin; sometimes ulcerating only superficially, and forming a dark,
irregular crust.   The secretion of these patches is  an unhealthy pus,
or a  mere watery ichor.  This form of eruption is very commonly
met with on  the limbs  and on the backs of the hands and feet; it
exhibits a tendency to a peripheral situation;  hence it may be deve-
loped also on the nose or on the ears.  On the limbs and hands it would
be recognized as a scrofulous eruption;  on the nose or ears, it would
be called lupus.   In  a lad at present under my care, the patch of mor-
bid skin occupies the dorsum of the thumb, and is perforated by  seve-
ral small openings, which  exude a healthy-looking pus.   In a young
man of eighteen, it affects the dorsum of the feet; by peripheric growth,
the disease has been carried forward upon the toes, and outwards to
the border of the foot, the central part having healed and left a per-
manent  cicatrix.  The greater part of the ring has also healed, so that
what remains is  only a portion of the original disease.
   A gentleman,  aged twenty-seven, has several patches of this kind on
his right arm, the worst being on the  dorsum of the hand.  He has
been  several years under my care, paying me a visit from time to  time.
When he first  came  to me, there were numerous holes in  the  skin,
which was thickened  and undermined, and the disease occupied the
middle of the back of the  hand.  Now, the part originally affected has
healed, the disease has advanced upon the knuckles; there is no longer
any deep ulceration, but the tubercular ridge which remains is covered
by a thick, dry  crust,  which  brings into view  an abraded surface
when raised.  The disease began as a tubercular blotch of small size on
the skin covering the carpo-metacarpal joint of the thumb.  In his
boyhood, he suffered  for a long time from  chronic ophthalmia;  a
younger brother is affected with enlargement of the lymphatic glands
of the neck, but the rest of his brothers and  sisters, older than him-
self, and five or six in number, are perfectly healthy, as are his parents.
   A  young lady, twenty years of age, was brought to me, in the year
1851, with an eruption on the dorsum of the right foot which had 
 416       DISEASES  FROM THE  SYPHILITIC POISON.

 troubled her since infancy.  She was a person of lymphatic tempera-
 ment, but otherwise enjoyed good health, and she  had no other dis-
 order of the skin of any kind.  The present eruption appeared on her
 foot as  a  patch  of redness, when she was two months  old, and con-
 tinued in an indolent state; at  four years, an abscess  formed on the
 spot, and  was succeeded by ulceration, which spread by degrees over
 the dorsum of the  foot, towards its  outer border and the toes.  The
 ulceration  continued until within the last few months, but has now
 healed.   As it moved onwards upon the skin, the parts behind healed,
 and formed a large and permanent cicatrix.
   At the present time, the skin along the roots of the tofts is thickened
 and uneven, of a purplish-red color, soft to the touch, fissured here
 and there by  deep  grooves, and in  some- parts incrusted with  small
 adherent scabs.  There is no ulceration, but when  the  scabs peel off,
 a little moisture oozes from the skin.  The entire surface is red, and
 in a state of epidermal exfoliation.  On the border of the foot, the
 erythema and epidermal  exfoliation cease abruptly, and the broken
 and irregular edge  of the  thick cuticle of the sole of the  foot  forms
 the boundary of the disease.
   The cure of these serpiginous ulcerations affords a good example of
 an unhealthy  healing process; large red granulations are thrown  up,
 which frequently become covered with epidermis, and produce a papil-
 lated and uneven surface; and  irregular patches of  granulations,
 sheathed  with epidermis,  are interspersed with small ulcerated hol-
 lows, which extend more or less deeply into the structure of the skin.
 In some instances, these granulations appear to be formed  independ-
 ently of ulceration, and a  large, raw, granulating or granulated sur-
 face is presented to view.   These granulations bleed very easily, and
 are so soft as to be frequently torn away in the removal of the dress-
 ings. When, by peripheric growth, the ulcerative action has reached
 the toes, and extended into the  clefts between them, a curious pheno-
 menon  occurs.  The opposite  surfaces of the toes being raw and
 granulated,  and  the granulations lying  for some time in contact,
 become adherent, and the  toes are united with each other to a greater
 or less degree.  In  a lady at present under my care, all the  toes of the
 right foot are so closely united  together, that no vestige of them, as
 separate organs,  exists; they form a single mass, and give the end of
 the foot the appearance of an amputated stump.
  There is another form of lupoid tubercle, which is commonly solitary,
and is met with on  the tip, or upon the aloe of the nose, and  chiefly in
 women.  It is generally recognized  as a form of  lupus  attended with
hypertrophy, and differs form lupus exedens, with which alone it can
be confounded, in the absence of the destructive activity of the latter.
A lady, aged  sixty, has suffered from  this disease more than four
years; it began with a feeling  of dryness of the mucous membrane
within the nose.   A small pimple, which formed a scab on its summit,
then appeared upon the ala nasi; it gave rise to no pain, but, from its
inconvenient position, was frequently picked with the finger-nail.  It
has never exceeded a quarter of an inch in diameter, and appeared to
be comrjosed of a mass of imperfectly formed granulations.   Latterly, 
         SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.    417

 it seemed to shift its situation, as  though it were enlarging on one
 side, and shrinking on the other; and on examining the part which it
 had  left, it was found that it had  imperceptibly eaten through the
 border of the nostril.
   The term, hypertrophous, must therefore be  taken to  refer only to
 the general appearance of these singular growths; they are destructive
 as well as hypertrophous, although  to an infinitely less degree than
 the  form of  lupus which has  been distinguished by  the  name of
 " exedens."   As I have already observed, with regard to  syphilitic
 tubercles, the hypertrophy of this form of lupus seems  to result from
 the  conversion of the normal  structure of the skin  into its own
 substance, a material of an inferior  type of organization, which mav
 be aptly compared to a vegetable fungus ;  and it follows, that, as soon
 as an absorbing action is set  up, either accidentally or  by the aid of
 medicine, the fungous tissue  vanishes, and a deep hole  is left in its
 place.  Hence the disappearance of  these  growths is always followed
 by a cicatrix, and, as I have  observed in  the case of  the  lady just
 referred to,  by a permanent loss of structure.
   This form of lupus offers some variety in point of color, a varietv
 which seems to depend more  upon the state of health or age  of the
 patient than  upon anything  special in the morbid structure itself;
 and partly, perhaps, also on its situation.   In a peripheral region, like
 the end of the nose, the circulation is less active than in more central
 situations, diseases occurring upon it are liable to congestion, and the
 gradual conversion of arterial into venous  blood gives  them a pur-
 plish bloom, or a duskiness or lividity of hue.

   Lepra, considered as a  syphiloderma, belongs to  a later period
 than  the preceding forms;   it  is not developed, like  them, in the
 individual who receives the  poison, but in a  succeeding generation,
 sometimes in the immediate  successor of the  syphilized person, and
 sometimes more remotely.   In  support of these views, I quote the
 following case, and am content to leave the subject to the reflection of
 the student.   All that belongs to the proper history of lepra will  be
 found in a previous chapter.   The case to which I allude is briefly
 this: A man  had  infantile  syphilis when a child; he married, arfd
 had eight children; two of whom died as infants;  of the  six surviving
 children, three are the subjects of lepra vulgaris.1

  Treatment.—In the treatment of syphilodermata, we must,  in the
 first  instance,  subdue the feverish symptoms which accompany  the
 eruption, in other words, the  syphilitic fever; we must remove  the
 poison from the blood by every means in our power; and thirdly, we
 must  support the powers of the system, to give it greater energy to
 eliminate  the  poison, and also  to resist its lowering tendency.  To
 remove the poison we have recourse  to remedies which are calculated
 to act on the natural emunctories of the system, the  bowels, liver,

  1 " On Syphilis, constitutional and hereditary, and on Syphilitic  Eruptions," by
Erasmus Wilson,  F.R.S., 1852, page 167.
       27 
418       DISEASES FROM THE SYPHILITIC POISON.
kidneys, and skin ;  and our means of support must be derived from
the catalogue of tonic remedies, amongst which the most useful is iron.
  It rarely  happens  that the syphilitic fever  rises so high as  to
require the abstraction of blood; but such  cases sometimes occur,
and if  the patient be full and strong, no inconvenience can arise from
the practice.  Local congestions  are relieved by the  bleeding; the
nervous system oppressed by the  weight  of the poison is lightened ;
and the blood  which remains is impressed with a different action  to
that  of generating  a  morbid ferment; namely, one of repairing  its
own loss.   On the other hand, it  must be borne in mind, that upon
the general powers of the system will fall the labor of eliminating
the poison,  and resisting its morbid effects; hence  the  constitution
must not be lowered, and  particularly so  in cities and  large  towns.
Indeed, the  power which  we possess of  relieving the blood through
the natural  emunctories is so great, that  venesection is only likely to
be required in very severe cases of local congestion, as of the brain
or lungs;  and,  even  in  such cases, the  quantity requiring to  be
removed is very small.   The general inflammatory excitement at-
tendant on  an outburst  of the  syphilitic fever is therefore to  be
combated by an active  purge, by diuretics, and  by diaphoretics.   A
dose of calomel and colocynth, followed by  a draught of senna and
Epsom salts,  will, effect  the  first  of  these  objects; and tartarized
antimony, with abundance of diluent drinks, the rest.   Opium is also
a  necessary element of the treatment,  its purpose being to calm
irritability and restlessness; with this object, aud for the  purpose  of
aiding the action of the mucous membranes  and skin, ten grains  of
Dover's powder, at  bedtime, will be found of  much service.
   As soon as the  inflammatory  excitement  is allayed, it is  time  to
begin the mercurial treatment.  I am not  aware  that  any particular
form of mercurial preparation is superior to another for this purpose.
I select usually the protioduret, which I  prescribe iu doses of a third
of a grain, in  combination with extract  of lettuce, or conium, three
times  a day.   This medicine agrees with  the stomach usually very
well;  but if it produce nausea or uneasiness, then * I  either exhibit
tihe  pills less  frequently, or have recourse  to some other form  of
mercurial preparation.  Where the alimentary canal evinces a decided
repugnance to the presence of mercury,  we may obtain its effects  by
means  of  inunction.   For  this purpose  a  drachm of  the  strong
mercurial ointment should be gently rubbed into  the inner side of the
 high  and  leg every night at bedtime, changing the leg each night to
avoid  too much irritation of the  skin.   In a case where  it was of
jonsequence that the inunction should not attract the attention ofthe
patient's family, I limit the frictions to  the  soles and inner sides of
 the  feet with perfect success.  Indeed, the  inunction may be made on
 any part of the body that shall be most  convenient to the patient.
   In pursuing the  mercurial treatment, it is ofthe utmost importance
lo pay attention to hygienic  conditions  and diet.  Stimulants of  all
icinds, either in food or drink, are to be  carefully avoided, as is also
 axposure to cold and fatigue.  And the  intention of the treatment
should never be lost sight of, namely, to  increase the natural functions 
        SYPHILODERMATA, OR  SYPHILITIC ERUPTIONS.    419

of the  depurating or emunctory organs, the  bowels, the liver, the
kidneys, and  the skin.   The  action of the mercury, and  especially
the functions of the  kidneys and skin, are very much  aided  by the
use of the compound decoction of sarsaparilla; the compound decoc-
tion of  guaiacum; the decoction of saponaria; or the effusion of
elder-flowers.  I have no belief in the specific powers of sarsaparilla;
but  I cannot  conceive  a remedy better suited  for  the purpose  of
soothing the alimentary canal, and at the same time of acting on the
depurating organs, than the compound decoction of that root.  For
this purpose it must be taken largely ; a pint and a half or a quart in
the course of the day.
   We have now the  plan of treatment of syphilodermata of the first
period,  or those  which  depend on secondary  syphilis,  before us,
namely, the careful  avoidance of all stimulants,  either mental  or
physical;  the patient to.keep his bed or his room; and to  defend
himself particularly from the risk of being chilled.   Medicinally ; if
the inflammatory symptoms run  high, and the powers of the system
be equal to the loss, abstraction of a few ounces of blood;  leeches or
mustard cataplasms for local congestions; a calomel and colocynth
purge,  followed by a black draught, together with liquor ammoniae
citratis  and  tartarized  antimony; or effervescent  salines, with anti-
mony;  and  a Dover's powder at  bedtime, until  the  inflammatory
stage is subdued.  Thirdly, mercury in  small  doses, with the com-
pound   decoction of sarsaparilla;  attention to  the  bowels,  and  an
opiate; if necessary, at bedtime.
   Besides this, which may be regarded as embracing the more essen-
tial points in the treatment of constitutional syphilis, there are several
appliances which may be added to the general treatment, or be made
to occupy a  prominent position, according to the  views of the surgeon
or the convenience of the patient;  for example,  the warm bath, and
vapor  bath.  The former  of these  is  soothing  and agreeable, and
may be used daily, or even twice a-day.  The latter might  also  be
used daily;  it is a powerful  and important remedy, and establishes
an active drain',  which  doubtless  carries  off a  large  share  of the
syphilitic  poison in its stream.  The vapor  bath, of late years, has
acquired additional importance, from its having  been made the chief
agent of treatment of constitutional syphilis by  Langston  Parker.
Mr. Parker raises the vapor of the  bath  by means of a lamp, and he
also introduces  beneath the  cloak  which  surrounds the  patient  an
oxide of mercury, furnished with a  separate lamp, for the purpose of
vaporizing  it;  hence,  he observes, the  patient is "exposed  to the
influence  of three agents, heated air, common steam, and the vapor
of mercury."  Here, it  will be seen, the treatment is made  to turn
upon the general emunctory property  of mercury, and the special
emunctory action ofthe skin.
   In Germany, in addition to several curative processes founded  on
the  limitation of supply, one method of  treatment, which may  be
briefly defined as a triple compound of starving, purging, and sweat-
ing, enjoys especial favor.  I mean  the treatment by Zittman's decoc-
tion.  This treatment is as follows:  On the first day the patient takes 
420        DISEASES FROM THE SYPHILITIC  POISON.
 a full dose of calomel and  the resinous extract of jalap.   During the
 next four days he  drinks daily two  quarts of Zittman's decoction;
 one quart of the  strong decoction, taken  warm in the morning, and
 one quart of the weak, cold, at mid-day.   On the sixth day he repeats
 his  calomel-and-jalap pills; and during  the  four  succeeding  days
 continues the decoction as before.   On the eleventh day, if the patient
 be strong, he takes another dose of the purgative pills; if not, this is
 dispensed with.  During the treatment the patient's diet is  carefully
 regulated; on the days when he takes the purgative medicine he has
 three meals of broth ;  on the decoction-days he is allowed  two ounces
 of roast-meat and two ounces of bread. He keeps his bed during the
 entire treatment, and at  its conclusion is not  permitted to quit his
 room for  some time longer, maintaining a low diet, and drinking the
 decoction of the woods.   If the patient be  suffering  under syphilitic
 ulcers, these are drest, simply, with lint soSked  in water; and if he
 be  weakly, he  takes of Zittman's decoction only one bottle a-day,
 instead of two, with a view to prolong the  treatment.  If he  be not
 cured at the  conclusion of the treatment, it  is to be repeated a second
 time, or until he is well.  This  treatment has the sanction of a sound
 and practical surgeon, whose practice I  had the advantage of following
 for some time—Chelius, of Heidelberg.
  The decoction keeps  up a constant state of perspiration from the
 skin, increases the quantity of urine, and  produces five or six watery
evacuations in the course of the day.  Its mode of preparation is as
 follows:—
                           Decoctum fortior.
R.—Sarsaparillae radicis concisae, §iv.    Sub fine coctionis admisce,
     Aquae fontanae, Oxxiv.              Sennae  foliorum, §iij.
Coque per quartam horae partem, et adde    Glycyrrhizae radicis, §iss.
     Aluminis,                       Anisi serninum,
     Sacchari albi, && Jvj.               Foeniculi seminum, aa 5SS.
     Hydrargyri chloridi, 3iv.         Decoque  ad octaria xvj.,
     Antimonii oxysulphureti, 3j,            et  cola.
         in nodulo ligato.
                            Decoctum tenue.
 R.—Decocti fortioris residui.               Pulveris cinnamomi,
     Sarsaparillae radicis, §vj.             Pulveris oardamomum, aa 3HJ.
     Aquae fontanae, Oxxiv.               Glycyrrhizae radicis, ^vj.
 Coque, et sub fine coctionis adde        Decoque ad octaria xvj, et cola.
     Pulveris corticis citronum.
  After the symptoms of constitutional syphilis have fairly  subsided
 under the influence of the mercurial  treatment, nitric acid may be
 exhibited for two or three weeks longer, to give tone to the  mucous
 membrane, and  remove  any remains of the poison which may still
 linger in the blood  or in the tissues.  The dose of the dilute nitric
 acid is twenty drops twice or three times a-day, in sweetened barley-
 water ; or it  may be combined  with  the fluid extract of sarsaparilla,
 as a vehicle; or, should there be any appearance of anaemia, we must
 restore the healthy  condition of the blood  by means of ferruginous
 remedies.
  We may now suppose  the  first  attack of constitutional  fever, or
 secondary symptoms, to have passed away; but it does not therefore 
        SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.    421

 follow that the syphilitic poison is entirely banished from the blood ;
 on the contrary, the probability is, that after the lapse of a few months
 a second attack will  occur, and  after that  we may have a third, a
 fourth, and even more; the attacks at last becoming irregular, and
 putting on a new shape and new characters.  We have, therefore, to
 consider what modification of treatment may be most suitable for these
 successive attacks; what change of remedies the chronic character of
 the syphilitic disease may require.
   It is a curious fact, that as the attacks of constitutional  syphilis
 become further  removed from the original  contagion, that is, as  the
 poison becomes more and  more assimilated, mercury seems to lose its
 influence, and other remedies acquire the control of the poison which
 it previously  possessed.   That may not be the case with regard to the
 second, or even the third,  outbreak of  the syphilitic fever;  the time
 varies in  different  constitutions;  but we  must be  prepared for  the
 manifestation of the peculiarity sooner or later.  In the second attack
 of constitutional disease, the protioduret of mercury will possibly be
 found to retain all its power; in the third  the bichloride may be more
 efficient;  in the fourth and successive attacks, the iodide of potassium.
 It is difficult to explain this peculiarity otherwise than by supposing
 that the tissues lose their susceptibility of being excited by the mercury
 after a number of repetitions.
   In syphilodermata of the second period, those forms which belong to
 the "tertiary  syphilis" of  Ricord, mercury is not only inadequate to
 the removal and cure of the disease, but is actually injurious, inducing
 irritability of system, producing new  and  more violent attacks of
 eruption, and forcing a simple  tubercular  eruption into a  state of
 refractory  ulceration.   It  is at this period that  iodide of potassium
 takes the lead as an  anti-syphilitic remedy, and its use is  attended
 with the most satisfactory  results.  Sometimes it effects a cure in  a
 short period; at others it seems to flag in its effects, and  requires to
 be increased  in dose;  and it may be beneficially assisted by bitters,
 or in case of an anaemic state of the constitution, by the preparations
 of iron.  I have before remarked that an useful and effective dose of
 the iodide of potassium in  the beginning of treatment is three grains ;
 this we may increase, if need be, to five, eight, or ten grains,  or even
 more, three times in the day; and, indeed, without such increase, we
 are liable, in  cases  rendered unusually rebellious by mal-treatment,
 and especially by  the abuse of mercury, to fail altogether, and  attri-
 bute to the remedy what is properly due to our own mismanagement.
 The iodide of potassium is the remedy  best suited  to  those  chronic
 forms of tuberculous eruption which I have distinguished as tubercula
 circumscripta, and it is especially indicated in the ulcerating tubercles,
 and those deeply-seated disorganizations of the skin and subcutaneous
 tissues which have received the name of " gummata."
  I have already observed that  in those chronic syphilodermata where
 mercury ceases to exert a beneficial influence;  where mercury is not
 merely negative in its effects, but obviously and plainly excites  an
irritable and destructive action both on the system at large and upon
 the local disease; our great remedial  agent is iodide of potassium, 
422       DISEASES FROM  THE SYPHILITIC POISON.

and this  medicine frequently  acts  as a charm in such  instances.  I
have in my  mind at this moment the  case of a gentleman, who one
morning staggered feebly into my consulting-room, accompanied by
his physician, and ordinary medical attendant.  He introduced him-
self as a lost and hopeless man ; and he certainly presented a vivid pic-
ture of exhaustion and decay.  He showed me several large, deep, and
foul ulcers upon his legs, and he  said that the surgeons of eminence
whom he had consulted, even a few days before his visit to me, would
insist upon his taking mercury, which he  knew was destroying him.
I prescribed for him the iodide of potassium;  and in less than three
months he called upon me, having  just .returned from the  country,
declaring that he had  never felt stronger  or better in his life.  I
should have been very sorry to have mentioned this case, if I thought
it could,  by any possibility, be used as an argument against  mercury.
Mercury, as I  have before  observed, is an invaluable medicine, but
one requiring to be used with judgment; to be watched in its effects,
and to be regulated according to  those effects  rather than upon any
scheme of theoretical results; indeed, mercury, like ioduje of potas-
sium, and every other  medicine,  must be exactly graduated in dose,
combination and period of administration, to  the special case of the
patient.  Each  patient, as he  varies in  physiognomy from  his fore-
goers,  varies also in constitution,  in the characters of his disease, and
in his  susceptibility to the influence of medicine.
   The iodide of potassium seems to act, generally, upon all the tissues
of the body, in a remarkably short space  of time, and  especially on
the kidneys.  Its combination with the compound decoction of sarsa-
parilla facilitates  its action, notably increasing its diuretic properties,
and supplying a  convenient vehicle with which the  poison may be
excreted by the mucous membranes and by the skiri.
   After  it has been taken for a time, it begins to excite an overaction
iu the various tissues ofthe body ; firstly, in the mucous membrane;
then  in  the  nervous system  and brain ; and  these actions may be
regarded as  evincing  the  poisonous properties of the medicine.  I
have  said that the symptoms now referred to are  first  perceived in
the mucous membranes, and especially in  that of the fauces,  the nose,
and the eyes.  All that is necessary, therefore, is to watch for these
symptoms, and, if it be thought desirable, as soon as they occur, the
use ofthe remedy should be suspended,  or the dose  reduced.  In this
way we  are enabled to put an immediate  stop to the continuation of
the morbid effects.   When  iodine begins  to act as au irritant to the
system, there is a feeling of stiffness and dryness in the  throat; more
or less coryza; and an uncomfortable feeling with increased  secretion
from the nose ; sometimes tenderness of the salivary glands and sali-
vation.   By degrees  the  congestion extends  to  the   trachea and
bronchial tubes,  adding bronchitis to the other symptoms.  These
indications of irritation of the mucous membrane generally precede
those of disturbance of  the nervous system, and give .sufficient warn-
ing  of a necessity  for putting  a  stop to the use of the medicine.
When the iodine has been carried further, the patients  complain of
dimness of sight, giddiness, and pain in the head; and in one patient 
        SYPHILODERMATA, OR SYPHILITIC ERUPTIONS.    423

I saw severe palpitations of the heart.  But although I have used the
medicine  extensively, I  have seen  very little of its morbid effects,
probably from always exhibiting it with  caution.
   My mode of administering the iodide of potassium, is to prescribe
five grains twice or three times a day, according to the power or consti-
tution of the patient.  If I begin with five grains three times a day,
I increase the dose during the second week to seven grains and a half:
and to ten  grains during the third  week;  always impressing on the
patient that if any disagreeable effects are  produced by the medicine
he is  to stop it immediately, and as soon as the disagreeable symptoms
have  subsided, begin  it  again,  but  in a  less dose.   If the cessation
should continue for  a week,T require that the dose for  recommence-
ment should be  that first  prescribed.  In this  way I get the full
effects of the medicine rapidly, and I avoid the risk of any mischievous
effects from its use.  I was first led to adopt this mode of employing
the iodide of potassium from meeting with  cases in  which  the medf-
cine had been continued for many months at the same dose, and had
lost its  effect  on  the  constitution of the patient  completely ; and
subsequent  experience has led me to believe that as much  and more
effect may be produced, by this mode  of administration, in three
weeks, than can  be obtained  by the unvarying dose in as  many
months;  indeed,  after a  time, the remedy  becomes utterly  useless.
Sometimes I find it convenient  to continue  the five  grain dose for a
longer period than a week, and the same with the others; I endeavor
to ascertain the  period during which the action of the medicine is
progressive, and  have the dose  increased immediately that period is
passed.
   Syphilitic eruptions of the skin,  when general, require no other
heal treatment than the occasional use of the tepid soap-bath.   When
situated on the face,  the diluted citrine ointment, or the nitricoxide-
of-mercury ointment, applied with gentle friction, are good  remedies,
and tend to hasten the absorption of the pimples and tubercles, and
the removal of the stains which they leave behind them.
   When tubercles pass into a state of ulceration, these ointments are
still of much service, as gentle stimulants ; but when  a more soothing
remedy is required, or when we  merely desire to protect  the ulcer
from the  influence of the atmosphere, we  may have  recourse  to the
benzoated ointment of oxide of zinc, either by itself, or in combina-
tion with a few grains of camphor, or a  few drops of liquor plumbi
diacetatis.
   For sloughing sores, an opiate lotion and water-dressing answer the
purpose well, and if  the ulcers be indisposed to heal, the black wash
and yellow wash,  either with or without  opium.  In these  cases, and
particularly in phagedaenic sores, a lotion of chloride of zinc will be
found to be of excellent service;  a medium strength  is one drachm to
the half pint, but this can be increased or diminished, according to its
effects, and  particularly  in reference to  the degree of pain which it
may occasion.
  Of course the local treatment is quite secondary to that of the gene-
ral system ;  but I have succeeded beyond my expectation,  in several 
424       DISEASES  FROM THE SYPHILITIC POISON.

instances, in causing the removal of local tubercular masses in a state
of ulceration, by frictions with the mercurial ointment, and the appli-
cation of a mercurial plaster.
   It is remarkable how soon the fall of the hair, which  accompanies
syphilis, is checked by means of the remedies employed  for the relief
of the other symptoms ;  the mercurial preparations or the compounds
of  mercury with iodine.  The  plan of treatment is therefore simple
and obvious.   Occasionally, however, alopecia  is  the only  evident
symptoms of the  presence of the syphilitic poison in the blood, in
which case we should  hardly be warranted in subjecting our  patient
to a mercurial course.   Under such circumstances  I have found the
iodide of potassium, in  three-grain doses, three times a-day, or five
grains twice a-day, answer every purpose ; continuing  the treatment,
in augmenting doses, for a medium period of six weeks, unless symp-
toms of iodic irritation arise.
   For local application the  best remedy is a pomatum,  consisting of
one part of the nitric-oxide of  mercury ointment, to three of scented
pomatum.  This should be well rubbed into the roots of the hair at
bedtime each night, and a proper degree of action  maintained  in the
scalp, by means of plentiful  friction with the  hair-brush. As an aid
to the stimulant  excitation  of  the skin, the ammoniated hair-wash,1
introduced among the roots of the hair by means of a sponge, may be
used in the morning before  brushing.   This wash,  besides  aiding in
the excitation of  the skin, assists in removing the scurf  which is apt
to form upon the sordid  skin of persons affected with constitutional
syphilis, and affords great comfort to the patient; and  it not only
checks the fall of the hair, but  causes its reproduction where it has
already fallen.
   The chronic affections of the nails, attended with dryness and  imper-
fect formation, come into the same category with  the erythematous
affections of the palms of the hands  and soles of  the feet, and their
treatment is mercurial; either the protioduret or the bichloride.  It is
quite remarkable how rapidly chronic erythemata  of the hands and
feet, attended with desiccation, cracking, and exfoliation of the cuticle,
and depending  on syphilis, give way  to the action of either of the
above preparations, in alterative doses.  In three weeks the misery of
years may frequently be entirely cured, after every  other remedy and
mode of treatment had  been tried in vain.  Medical men suffering
from this complaint have been startled at my audacity, when  I have
promised them  a cure, in three weeks, of that which has baffled them-
selves for months, and more frequently for years;  but my  promise
has rarely failed to be accomplished.
  I must mention, however, that these erythematous disorders are apt
to return from time to time ; but the remedy may be repeated as often
as they appear, and in  the end will prove triumphant. I  do not
believe that any good results from continuing the medicine for many
days beyond the period of cure; I order it to be left off at the  end of
a week, alter the skin is healed;  and prefer, in case of any return, to
resume the remedy as before.
1 Vide, Selected Prescriptions. 
         SYPHILODERMATA, OR  SYPHILITIC  ERUPTIONS.     425

   For  the  local treatment of these erythemata,  the camphor cerate is
 the best application, or the benzoated  ointment  of oxide of zinc with
 honey or spirit of camphor.  In either case the proportion is a drachm
 to the ounce.  An ointment  containing a drachm of glycerine to the
 ounce of simple cerate is a good  application; or a lotion  containing
 one part of glycerine to three of camphor mixture or rose-water.
   The  purpose of these  local remedies is  simply to  keep the skin
 moist;  and great comfort is  sometimes obtained by sleeping  with a
 water-dressing on the  parts; the cure is  to be  looked for from the
 internal remedies alone.
   Onychia and the painful granulating  sores which sometimes form
 under and around the nails, also derive their cure from  the constitu-
 tional  treatment;  but they at the same time require some  local
 management.  When in  an  inflamed  state, water-dressing, with Ali-
 son's prepared lamb-skin, or a solution of opium in place of simple
 water;  when  less  painful, a weak solution  of chloride of zinc, or
 acetate of lead, are the proper remedies.  Sometimes the zinc oint-
 ment, or simple cerate with camphor, or an  ointment  of Peruvian
 balsam, answer better than the lotions; and in two or three instances
■ I have  obtained the best results from  covering  the granulations with
 powder of charcoal.
   Mucous  tubercle, like other forms of syphilitic tubercle, obeys the
 will of  the  internal remedies employed against  the manifestation of
 the syphilitic  poison  in  the  skin.  It would get well  without any
 external application; but sometimes we  may be required to treat  it
 locally, when the nitrate of silver, the oxide of zinc ointment,  or a
 lotion of chloride of zinc, or alum, or the black or yellow wash, will
 be found the best suited to our purpose.   After  drying the  tubercles
 well, it has  been recommended to  powder them  with calomel.
   For infantile syphilis the treatment must  consist of mercury;
 and the best remedies  in  every respect, according to my experience,
 are the  bichloride, calomel, or hydrargyrum cum creta, which may be
 administered either to mother or child, or to both, according  to the
 judgment of the surgeon.  If the  mother  evince symptoms of  consti-
 tutional syphilis, it may be sufficient to exhibit the mercury  to  her
 only, the infant drawing its nourishment from her breast  being
 regarded  as part of herself.  If  the proportion of  mercury  thus
 conveyed to the infant be  deemed  insufficient,  there can  be no objec-
 tion to give it independently  to the  latter.  And in several instances
 I have satisfied myself with giving it to the infant only.  I have not,
 in this case, for an instant imagined that the mother was free from the
poison,  but only that her tissues were so far accustomed to  its presence,
that it was incapable of setting up  any  morbid  action, at least so long
as she continued to suckle, and the milk  performed the  office of an
emunctory current; an3 I was quite  prepared, should any retardation
in the cure of the infant occur, to  exhibit the remedy to the mother
also.  In a word, I consider the safest practice in these cases to be, to
give mercury to the mother as well as to  the  infant; taking care  to-
moderate  the  dose  to  such a degree as not to  check  or injure the
secretion of  milk. 
426       DISEASES FROM  THE SYPHILITIC  POISON.

  I have  heard it  suggested  that the infant  may be affected with
syphilis in the womb of its mother, without the latter being contami-
nated; and that contamination ofthe mother may subsequently occur
in consequence of transmission of the poison from the diseased child
to the tissues of the parent.   Such a theory  I consider to  be most
unphilosophical;  it is easy to comprehend  that, in the instance of
syphilitic  contagion, the child may be the seat  of manifestation of the
disease,  just as in a male the disease may fix  upon one spot or one
organ of the entire body; indeed, not merely because the foetus under
such circumstances  is a part of the whole, but because it is also a  part
of more recent formation, a new organ, and made up of new tissues,
which we may  conceive to be more susceptible of receiving, and more
easily influenced by, a morbid poison.
  It is also perfectly consistent with physiological laws, that the foetus
having become the  focus of excessive accumulation of the poison, the
latter may react upon the parent with such force as to cause a mani-
festation of the presence of  the poison  in her tissues as well.   The
problem,  therefore, resolves  itself simply into  one of  latency and
development.
  The dose of  the bichloride to the mother under the above circum-
stances should be one-sixteenth of a grain, in combination with syrup
of poppies and tincture of bark, or the compound fluid extract of
sarsaparilla, three times a-day ;  and to the infant one-twenty-fourth of
a grain  in syrup of poppies and  dill-water.
  The local treatment for excoriations around  the nose and mouth of
the infant is the benzoated ointment  of oxide  of zinc, or an ointment
composed of a drachm of the unguentum hydrargyri nitratis to the
ounce of ceratum eetacei.   The latter is especially applicable  to exco-
riations in the neighborhood of the eyelids.   For cracks upon the
hands and feet, and for excoriations around the  pudendum and anus,
the benzoated ointment of oxide of zinc is also the proper application;
and secretions in these parts  may be  absorbed by the  oxide of  zinc
powder.  For  discharges from  the  meatuses  of the  ears, soap and
water is the best remedy.
  Hereditary syphilis.—After the age of infancy, congenital syphi-
lis  gradually  merges into  what  may be termed hereditary  syphilis.
The infantile syphilis gets well, but  several  months or years after-
wards,  it breaks out again.   Sometimes, however, the patient has
been  free from any  indications of syphilis in his  infantile age, the first
manifestations  of its presence in the  system being  delayed to the
period of advanced  childhood, puberty, or even adult life. This  more
properly  constitutes hereditary syphilis.   The  kind  of syphilitic
disease  now under consideration, in  its more recent forms, yields
without much difficulty to the  bichloride of mercury ;  when  more
advanced, the iodide  of  potassium is an useful auxiliary;  and  in  a
more distant remove, the combinations of iodine, mercury, and arsenic,
and cod-liver oil, become  valuable remedies.   I have  had  little ex-
perience  of  the hydrochloride  of gold;  but  I  should apprehend
that it is  to the present form of  syphilis that  it  would be especially
applicable. 
        SYPHILODERMATA, OR SYPHILITIC  ERUPTIONS.    427

  Some of the forms of  hereditary syphilis are remarkable  for their
extreme obstinacy, refusing the slightest obedience to medical agents,
and maintaining their course unimpeded.   These cases are only to be
managed by opposing obstinacy to  obstinacy, by following  them up
with appropriate remedies, that is, with remedies directed upon a
proper principle, when even the most enduring will be found to yield
at last.  In  pursuing this  course, it is evident that we must seek to
obtain  a gentle and continuous influence over the system, such as that
by which  Nature conducts  her operations;  we give expression to our
meaning by the  term, " alterative;" our process should be essentially
alterative; large doses of medicine  and heroic action are only calcu-
culated to exhaust the powers  and do mischief.   In making these
observations, I have now in  my memory several  persevering " incur-
ables," who, by a steady  continuance of remedies for periods varying
between one year and four,  are fast approaching cure.  And in another
point of view, these observations  are not without  their value; the
patient frequently  tires, the surgeon despairs; in both instances, be-
cause an unwarrantable expectation has been created; but if, from the
first,  the  difficulty  be appreciated, both  move  onward with  more
comfort, and  with less prospect of disappointment.   The surgeon is
no  longer incited to make a bold  effort, which cannot but end un-
happily, and the patient takes no step to  urge him to such an attempt
by  impatient  suggestions.
  In some instances  of the lupoid  tubercle, I have found the iodide
of  potassium  a serviceable  remedy; in  others,  the bichloride  of
mercury has proved  most useful.  Sometimes the iodide of  iron  has
brought about a healthy  condition of the general system, which  has
been followed by an improvement  in the local disease ; and, at other
times, I have derived the best results from  the triple solution of  mer-
cury, iodine, and arsenic, given alone, or in conjunction with cod-liver
oil.  When the  arsenic, in the triple  compound,  has appeared  to be
objectionable, I  have had recourse to the tonic  properties of quinine
as an adjunct to the  iodide of mercury, and with a  very satisfactory
result.  The following formula  is  an excellent substitute for Dono-
van's solution, agreeing well with the stomach, and possessing the ad-
vantage of being in a more condensed and convenient shape for deglu-
tition :—          z
                     R.—Hydrargyri biniodidi, gr. £.
                        Quinae iodidi, gr. j.
                        Micae panis, gr. j.
                        Mucilaginis, q. s.
  In  these  very obstinate  cases, it is important  to  remember, that
when the  remedies disagree with the patient, or seem to cease to exert
a beneficial action, they should be immediately suspended, and re-
sumed after  such an interval  of time as  may  seem good in the
judgment of the surgeon.  Like food  and hygienic conditions, medi-
cines which are very beneficial at one moment, lose their power after
a time, and then require to be changed or modified, either in form* or
quantity,  until the appetite for  them returns.   This is a very neces-
sary rule  to be borne in mind in the management of so obstinate a
class of diseases as those of the skin. 
428     DISEASES FROM  UNKNOWN ANIMAL  POISONS.

  For the treatment of lupus and lepra, I must refer my readers to
the special essays on those subjects  in  a previous chapter; and for
further  illustrations of my views on the treatment of constitutional
syphilis, to my work on that subject.
                    CHAPTER  XV.

  DISEASES ARISING FROM ANIMAL POISONS OF UNKNOWN-
      ORIGIN, AND  GIVING RISE TO ERUPTIVE FEVERS.

  The diseases assembled under this group are  the  exanthematous,
or eruptive  fevers; the poisons from which they originate are the
rubeolous, scarlatinous, and variolous ; and the manifestations of these
poisons are as follows :—
                  Rubeola,              Variola,
                  Scarlatina,            Varicella,
                             Vaccinia.
  These  eruptions are  characterized by fever  of greater  or less
severity,  which precedes and accompanies the exanthem; by an ex-
anthem, or inflammatory congestion  of the  derma, which makes its
appearance in the form of red points, and pursues a specific course ;
and by their mode of  termination, namely, in resolution and desqua-
mation of the epidermis  in the first  two, and by exudation and
incrustation in the variolous affections; while all are liable to terminate
by delitescence.
  Taking this view of the exanthematous diseases, I conceive myself
warranted in placing the variolous affections in a group with  which
all their analogies  harmonize.  They correspond  accurately with the
definition given above; the premonitory symptoms  present a close
resemblance to those of  rubeola and scarlatina; the eruption is iden-
tical 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 retro-
grading on the mucous membranes.  At the present day we should
not hesitate to admit the variolous diseases to a place among the ex-
anthematous fevers, nor to  remove them  from  the  unpathological
position which they  occupy among  the Pustulae and  Yesiculae of
Willan's classification.
  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 evolution of the morbific action
upon the tegumentary textures. Secondly, it is modified by the extent 
ERUPTIVE  FEVERS.                   429
and severity of the exanthem, or, in other words, by the reaction of
the effects 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 peri-
pheral and sentient parts of a considerable proportion of the nerves of
the body are involved in the inflammatory disorder,  and, as a conse-
quence, the  spinal and cerebral symptoms reach their highest pitch of
severity and danger.
  The congestion of the  superficial capillary  vessels which accom-
panies the exanthematous fevers is not limited to the dermal  tissue
alone, but is distributed more or less completely over the tegumentary
surface of the entire body, including  the mucous membranes.   From
the great susceptibility ofthe 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.  But there  is this difference between
the inflammation of the cutaneous surface and that of the mucous mem-
brane : in the  former, the  inflammation either invades the entire sur-
face at once, or runs regularly and  more or less rapidly over it; but
in the mucous membranes, the different parts are affected irregularly
and in succession, while some escape altogether.  Thus, in scarlatina,
the mucous  membrane of the fauces is first invaded, then possibly that
of the lungs, while, perhaps, at the close of the disease, when a  favor-
able convalescence is expected, the inflammation may be transferred to
the alimentary canal,  or kidneys, and prove fatal  by exciting an un-
controllable diarrhoea or anarsaca.   The  same  remarks apply  to
rubeola; for after the violence of the cutaneous efflorescence has passed
away, there  is much to be apprehended from secondary inflammation
of the mucous membranes.
  The immediate seat of the inflammatory congestion of  the  exan-
themata is the vascular rete of the derma, and the difference of tint
observable in these diseases at their height and during their decline,
is sufficiently explained by reference to the structure and normal phe-
nomena 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
congested, and the redness produced  by this congestion  is slight; when,
however, the nervous activity is aroused to its highest pitch of energy,
as in scarlatina, the congestion is intense, and the bright scarlet of the
arterial  blood coursing through its vessels is little obscured by the
thin veil of epidermis which holds it in its sphere.  The congestion in
rubeola, scarlatina, and variola, is not confined to the horizontal strata
of the vascular rete of the derma, but implicates also the vertical rete
of the follicles, and in that  manner gives rise  to the punctiform and
papillar appearance of the  redness which is characteristic of these
eruptions.
  The crescentic, or, rather, the imperfectly circular, form ofthe con-
gested patches seen in rubeola, depends upon a  peculiarity in the dis-
tribution' of the  cutaneous nerves  and vessels, and corresponds with
that  natural appearance of  the skin, which is so frequently seen in 
430     DISEASES FROM UNKNOWN  ANIMAL POISONS.

healthy children, and which is denominated mottled.   Again, I have
observed, that, in  injecting the limb of an  infant with size and ver-
milion, I can imitate  all  the  forms of redness seen in the exanthe-
matous diseases,  by ceasing to inject  from time to time, or by filling
the capillaries to their uttermost.
   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 observed  to lose their vivid brightness, to become
duller in their hue, and  to pass through various shades of purple, until
they become bluish and livid.   These changes depend upon the degree
of excitement of the cutaneous nerves at the several periods indicated
by alteration in the color of the exanthem.  When the nervous energy
is  at its highest point, the capillaries contract actively upon their con-
tents, and maintain a rapid current  of arterial blood  through their
channels, but, as the nervous  excitement becomes gradually allayed,
the capillaries lose their power to contract, and become distended by
the full stream that moves more and more tardily onwards in its course,
giving time for the arterial current to combine with the carbon ofthe
tissues through which it flows, and be converted into venous blood.
   The above phenomena will explain,  also, the  differences of color
which the exanthem may assume at an earlier period than its decline,
and even from the commencement of its appearance, as, for instance,
in scarlatina  maligna, or more strikingly, in rubeola nigra.  The first
step or motive influence by which this change is affected, 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 capil-
laries,  which  they  were,  they are converted  into  a venous plexus,
through which the blood  moves feebly and  slowly, gathering  carbon
in its tardy course.
   Congestion of the capillary rete of the derma necessarily gives rise
to tumefaction, the extent of swelling being,  to a certain  degree, the
measure of the  increased quantity of blood distributed through the
part.  Hence  it  is obvious that all  exanthematous patches must  be
raised  above the level of the surrounding  skin, even although the
degree of tumefaction be really very  slight.
   Another cause of tumefaction in an inflamed and congested-tissue
also follows as a natural consequence from  the over-distension of its
vessels.  I  have endeavored  to  show that  the nervous excitation of
the part must have diminished before over-distension of the capillary
vessels can take  place, but, as soon as that change has ensued, another
phenomenon is  immediately developed, namely,  transudation of the
watery  part  of  the blood into  the surrounding  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 fibrin ; and  the seat of
transudation, for the most part, the subcutaneous cellular tissue, where
it gives rise to oedema.   I may instance scarlatina in some cases as a
particular illustration  of  this  kind of tumefaction, although it will be
found,  upon close observation, to  be much more extensively present 
ERUPTIVE FEVERS.                   431
among the exanthemata.  This  important phenomenon is  not con-
fined 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  oedema
of the glottis.
  As the present group of diseases 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  effected by a material  substance, and is
brought about by actual contact, the term contagion (immediate con-
tagion) is  employed;  but when  transmission is  effected through the
agency ofthe winds, afld 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 atmos-
phere, it is infectious ; but when this diffusibility is absent, it is simply
contagious.  The difference  between  infection and contagion  is, con-
sequently,  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 cases, the disease  is conveyed to the person of the recipient by
particles of matter proceeding from the person of the sick, and 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
commujiication  under  the  simple term, contagion.   This, in fact,
is what is done in common discourse: all disorders that are catching,
I shall take leave to consider contagious."1
  In whatever way the poisonous principle be brought to the body
of a sound person, a'nd with whatever part of his body it come in
contact, whether with the cutaneous surface, with or without abrasion,
as in contagion, or with both the cutaneous and mucous surface 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   imbibition 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 princi-
ple possesses the remarkable  power of exciting an action similar to
that which existed in the body whence it emanated, the intention of
that action being the  reproduction  of an  identical  poison.  Liebig
has  compared  this process to fermentation; as, when a particle of
yeast is brought into  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.
  In certain diseases  regarded as contagious, another mode of trans-
mission occurs;  the principle  of contagion exists in the form of germs

    1 Lectures on the Principles  and Practice of Physic.  First edition, p. 655. 
432     DISEASES FROM  UNKNOWN ANIMAL  POISONS.

or seeds of a parasitical  organism, which, wafted to a soil fitted  for
their nutrition, become developed, and assume an active growth.  Of
this kind are the parasitic fungi found upon the surface of the bodies
of animals, and, according  to some, the  mycoderma of the crusts of
favus.  Langenbeck found fungi in the  body of a man who  died of
tvphus fever.  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.
  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  affected 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 instances, entirely
abolished.  We might recur again to the simile suggested by Liebig,
for we are  incapable of again exciting fermentation in a fluid that
has already fermented.  It is  upon  this  important principle that
safety from a repetition of attacks of eruptive fever reposes; although
the cause is somewhat different  in the two cases;  for in the one, the
material  of fermentation is  exhausted;  while,  in  the  other, the
ferment is assimilated, and the blood therefore rendered insensible to
its presence.

                          RUBEOLA.

Syn.  Measles.   Morbilli,  Ali-abbas.   Blactise, Ingrassias.  Rubeola,
  Sauvages.  Rosalia.  Phenicismus.  Rougeoh, Fran.  Die  Masern,
  Kindspecken, Germ.                                     •*

  Rubeola, or  measles, is an acute inflammation  of the  tegumentary
investment of the entire body, both cutaneous and mucous, associated
with fever of an infectious and contagious 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 febrile symptoms, increases
for another four days,  and  is succeeded at its decline by furfuraceous
desquamation of the epidermis.
  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 the state of congestion of the  vascular rete of the folli-
cles, and the semilunar form of the patches, upon some unexplained
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 
ERUPTIVE FEVERS.
433
semilunar tracery, and an analogous state may be produced artificially
by incomplete injection with size and vermilion.
  The varieties of rubeola are four in number, namely:—
      Rubeola vulgaris,               Rubeola sine exanthemate,
               sine catarrho,             "    nigra.

                       RUBEOLA VULGARIS.

            Common Measles.  Morbilla benigni; erethrici.
  In rubeola vulgaris, the ordinary form of measles, the disease sets
in with  the usual symptoms of  fever,  namely, with chills, succeeded
by burning heat,  listlessness, languor, drowsiness, pains  in the  head,
in the back, and in the limbs;  frequent pulse; soreness of the throat,
white tongue, with red edges and tip;  thirst, anorexia, nausea, vomit-
ing,  frequent dry cough, and  high-colored  urine.  These symptoms
increase in violence during  the first  four  days.   On  the third the
conjunctivae look red and inflamed, there is intolerance of light, and
the eyelids are congested  and swollen, while a profuse secretion of
lachrymal fluid distils from the eyes, constituting coryza.  The mucous
membrane of the nose  also pours  forth a  large quantity of watery
secretion, and the irritation of this membrane gives  rise to  frequent
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 violent cough.
Moreover, children are affected occasionally  with spasm of the muscu-
lar system and convulsions, the consequence of reflex action of  the
spinal nerves; these spasmodic attacks are especially frequent where
rubeola is complicated by dentition.
  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 of the-skin,
on the fifth or sixth.  It is first  perceived on the forehead and front
of the  neck, next on the cheeks, and around the nose and  mouth;
and  if  the interior of  the  latter cavity be inspected, it  may he 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
succeeding 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 the  parts last affected, the rash  appearing  on them not
before the sixth day, and sometimes as late as the seventh.
  The  efflorescence  of  rubeloa, when  closely examined,  is  seen  to
consist of innumerable punctiform  dots and minute pimples, aggre-
gated into small  circular patches,  which,  by their  increase   or
coalescence, assume an irregularly crescentic figure.   The patches are
slightly raised above the surface, and the  entire skin  is somewhat
swollen.  The color of the rash at its acme is a bright raspberry red;
on the eighth day it presents a yellowish red tint, and then gradually.
      28° 
434     DISEASES FROM  UNKNOWN ANIMAL  POISONS.

fades to the normal  color of the skin.  The pimples  are most fre-
quently 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 Willan, inoculation
with  the  lymph of these vesicles was found  to produce a perfect
attack of  rubeola, which was communicated by infection to several
other children.
   The decline of the efflorescence takes place in the same order as its
invasion, fading upon 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 discover-
able only  by the presence of a pale yellowish discoloration, which
slowly disappears.  To these  changes, a furfuraceous desquamation
succeeds, which  is attended with considerable itching.
   Of the constitutional symptoms, some are relieved on the outbreak
of the efflorescence, while others are aggravated. Thus the nausea
and  sickness subside on  the fourth day, the restlessness and sense of
oppression disappear on the sixth  day, while the  coryza, the catarrh,
the hoarseness, and the cough, writh the frequency  ofthe 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.  In the  Archives Generales  de
Medecine is mentioned the case of a  child who  became dumb in con-
sequence of retrocession of measles.  The power of speech, however,
returned at  the end of two years.   The recital  of this case is accom-
panied by another, in which a dumb child was  restored to speech by
a severe rubeola.
   It has been already remarked, that the  mucous membrane of the
eyes and pharynx is visibly affected with the rash.   Other symptoms
which occasionally develop themselves during the  progress of rubeola,
indicate a  state of congestion  of the internal  mucous  membrane.
Thus, in some cases,  there is hemorrhage from the  nose;  in others,
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 constitutional systems are aggravated  and dangerous, the
congestion  of  the mucous membranes  is  greatly  heightened,  the
tongue becomes brown and dry, and the patient delirious.
   Although rubeola, when it runs its course regularly, is by no means
a  dangerous disease, yet, at its close, it  is occasionally attended with
severe and alarming  sequelae, which call for the  most vigilant atten-
tion on the part of the medieal practitioner.   Thus the cough, after the
subsidence of the rash, may return with increased  force and frequency,
be accompanied  by a  quickened  pulse,  impeded  respiration, and
symptoms of hectic fever, and  lead to a fatal  issue, by effusion into
 the lungs and chest, or by the  development of scrofulous tubercles.
 Children  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 disease during its 
ERUPTIVE FEVERS.
435
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 secre-
tion.  The mucous membrane 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 propaga-
tion ofthe inflammation along their excretory ducts.  In some instances,
abscesses  resulting in fistulous ulcers have been  formed in  these
glands.   The diarrhoea, which usually ceases spontaneously 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 mucous  membrane of the
vulva may participate  in the inflammation,  become ulcerated,  even
slough, and  give rise to  occlusion of  the aperture, as occurred in a
little girl operated on by Mr. Ferguson.1  The lymphatic system may
sympathize in the  effects of the cutaneous irritation, and occasion en-
largement of the glands,  which sometimes form  abscesses and ulcers,
or,  where the mesenteric  glands are affected, the little patient  may be
destroyed by interference with the current ofthe chyle.   In other in-
stances, secondary  affections 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 dis-
ease is considerably relieved, and the recovery favorable.
  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 hemis-
phere, the urine  changes with the varying stages of  the disorder.  In
most cases, it more or less resembles the inflammatory 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  catarrhal 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
eruption is slight, and there  is not much fever, it resumes the 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 ofthe eruptive stage.
  " During the period of desquamation and of convalescence, 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
1 Lancet, vol. ii. 1S50, p. 578. 
 436     DISEASES FROM UNKNOWN ANIMAL  POISONS.

 three cases, anasarca came on during convalescence, but the urine did
 not contain albumen."1

                     RUBEOLA SINE  CATARRHO.

   This form of measles is perfectly identical with rubeola vulgaris,
 with the exception of  the catarrhal and febrile symptoms, which are
 either exceedingly mild or wholly absent.  The efflorescence is pre-
 cisely 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  milder
 variety, while the greater number are seized with the  disease in its
 ordinary form.  It is not unfrequently met with in one member of a
 family, when the rest of the children have the more severe disease;
 and this is  especially the case where a number of children are con-
 gregated 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
 kind.

                   RUBEOLA SINE EXANTHEMATE.

   As measles  may occur, divested  of their mucous inflammation,
 constituting the previous variety, so, in more rare instances, 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, occurring 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 the  name of febris morbillosa, and
 Gregory contributes additional testimony  to its existence.  "Guer-
 sent," says Rayer,2 " has observed some individuals in families where
 measles prevailed,  exhibiting all the other symptoms of the disease,
 except the  eruption.   I have myself several times seen cases of
 measles in which the eruption was incomplete, and  which might have
 been referred  to the morbillary fever of Sydenham;   but I have
 never met with  any instances like  those  mentioned by De  Haen,
 Gregory, and Guersent, although my attention  has  been  turned to
 these some years past."

                        RUBEOLA  NIGRA.

                 Rubeola maligna.   Bhck measles.
  In a debilitated state of the system, the cutaneous capillaries become
over-distended,  and  the circulation  through them  retarded,  while
some portion of their contents is effused into the surrounding tissues.

     1 Simon's Chemistry, vol. ii. p. 269.
     2 " Treatise on Diseases of the Skin," translated by Dr. Willis, p. 145. 
ERUPTIVE FEVERS.
437
This condition of the vessels gives to the efflorescence 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 petechias.   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 constitutional
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; probably delirium and
effusion  into the serous cavities, with oedema of the cellular tissue.
With these aggravated  symptoms, the disease  is likely to terminate
fatally.  Rayer remarks that he has " seen various examples of  these
livid measles in children laboring under tubercles of  the lungs and
chronic  caeco-colitis,  and  who were  exhausted by  diarrhoea and
hectic  fever.
   Rayer has  also remarked  a  variety  of  "black hemorrhagic"
measles,  which are  unconnected with constitutional debility, and
characterized by a vinous-colored efflorescence not disappearing under
pressure with the finger.  He met with this form in strong individuals,
and be finds a transition to such a modification in the greater  depth
of  color, and  non-disappearance under  pressure  of  some of  the
patches in an ordinary case of rubeola vulgaris.
  Diagnosis.—The  diagnostic characters of rubeola  are, firstly, the
affection of  the mucous membrane, as indicated by redness of con-
junctivae, coryza, catarrh,  sneezing, sore throat, and cough, by which
the disease may be distinguished, even before the appearance of efflo-
rescence  ; and, secondly, the crescentic and annular patches of the rash,
with intermediate unaffected portions of the skin.
  From  scarlatina it is distinguished by the crescentic patches;  the
crimson  or  raspberry-like  hue of the  redness, and the  presence  of
coryza, catarrh, and sneezing.
  In roseola, although the rash is so similar as to have obtained for
it the name  of false measles, the accompanying fever and inflammation
are so  extremely slight as to suggest a doubt of its being measles.
  The  minute spots by which the efflorescence 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 difference is generally apparent between them, namely, that
in measles the red  points are mere  spots,  while in  variola  they  are
distinctly elevated papulae.
  The  cough of rubeola is  at first dry and harsh,  at  a later period
expectoration ensues, the  expectorated mucus presenting some  pe-
culiarities  which are  deserving of notice. Rayer describes  these
appearances as follows:  " At first mucaginous, clear, and limpid ;
at  the end of three  or four days the expectoration  becomes thick,
rounded  into  pellets, smooth on the  surface,  of a greenish-yellow 
438     DISEASES from  unknown animal  poisons.

color, remaining  perfectly  distinct from  each other, and swimming
in a  large  quantity  of ropy  and transparent  mucus,  similar to
the matter coughed up by some phthisical patients.  By-and-by this
form of expectoration is changed for another which  adheres to the
bottom of the vessel, and seems composed of a grayish homogeneous
mucus, mixed with air  and saliva, and very similar to the ordinary
matter expectorated during chronic  catarrhal affections.  In young
people the expectoration is wanting, or not at all abundant; and many
cases of measles occur in older  subjects, without being  attended with
expectoration."  Chomel remarks the following difference 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.
   Causes.—Rubeola seems to have originated  in Arabia, the birth-
place of variola and  scarlatina, and to have extended  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 historian ; and the epidemic of Plymouth
in 1741,  recorded by Huxham.
   Measles are the consequence of a special infection  or  contagion;
under the influence of which conjoined with a favorable state of the
system, rubeola is developed.  In many cases 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 vesicles which sometimes com-
plicate the rash, or with the secretions of those affected with the disease.
   Measles may occur at any period of life, but are most frequent in
children.   The disease  is more universally contagious than any of the
exanthematous fevers,  but is only partially protective of the consti-
tution ;  for instances are by no means rare, in which  the same indi-
vidual has been affected more than once.  The most obvious condition
influencing the attack  of  rubeola, is inflammation of  any of the
mucous membranes, such as catarrh, cough, &c.   This,  indeed, consti-
tutes 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 especial organs.
   Patients affected with measles must be secluded from those who are
sound, in order to protect the latter against contagion.  The period
 for the maintenance of seclusion is not rightly determined, but for the
 sake of security  should be prolonged  to at least three weeks.
   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, preg-
 nancy, after parturition, or in persons suffering  for some time pre- 
ERUPTIVE FEVERS.
439
viously 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  unfavorable  conditions above
specified.
  Treatment.—When the disease is mild and  regular in  its course,
milk diet, subacid diluents, a moderate and equable temperature of the
sick chamber, quiet and rest, with some simple mucilaginous drink to
ease the cough, will  be all the treatment required.  Indeed, the less
the patient be interfered with  by the  employment of medicines,  the
better.
  If the febrile  symptoms run high, effervescent  salines, saline ape-
rients and diaphoretics, such as the citrate of potash, liquor ammonia
acetatis, with or without spiritus aetheris nitrici, ipecacuanha, and cam-
phor mixture may be employed;  but active purgatives are calculated
to be  injurious, either by determining 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 occurrence of 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  difficult,
with pains in the chest denoting inflammation of the lungs, abstraction
of blood must be resorted to.  In children, weakly adults, or old per-
sons, leeches to the chest, or cupping in this region, will be sufficient.
In persons of stronger habit, general bleedingfrom the arm may be found
necessary.   In the country, many patients will  bear venesection with
advantage, while in  crowded towns and cities  this remedy must be
employed with circumspection.  As an  auxiliary to bleeding, or as a
representative when the system may be too weakly for its use, counter-
irritation by blisters or  stimulant liniments, will be found beneficial,
and both remedies will be assisted by ipecacuanha or tartarized anti-
mony.  Opiates  are  available  only after the violence of  the  febrile
symptoms has subsided, and then they may be advantageously com-
bined with a diaphoretic, as in Dover's powder.
  Cold  affusion 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
water, 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 affected, blood  must be withdrawn from the region of such
organ, and the rash recalled by means of a mustard-bath and the ap-
plication of a blister.
  The ammonia-treatment, so valuable in scarlatina, is equally appli-
cable to rubeola, and may be regarded as  specific  in this affection as 
 440     DISEASES FROM UNKNOWN  ANIMAL POISONS.

 well as in scarlatina.  The details of the treatment will be found under
 the head of  "Treatment of Scarlatina."   Dr.  Charles Witt, in his
 pamphlet on this subject, mentions the case of five boys of one family
 attacked with rubeola; four were treated with ammonia and one with-
 out;  the four former made a perfect cure;  the  latter, although origi-
 nally  the strongest,  was  weakly in health for two  years  after his
 recovery.   Dr. Witt's treatment consisted in the administration of a
 mild dose of jalap; and subsequently five grains of sesquicarbonate of
 ammonia dissolved in water, every three hours, beginning one  hour
 after the aperient dose.  In  a  few hours  the  cough ceased, and the
 efflorescence broke out.  After four days the  disorder declined; for
 the two following days the ammonia was given every six hours, and
 on the seventh day was no longer necessary.  The diet of the patients
 was beef-tea and veal broth.  In a case of rubeola in the adult, pre-
 ceded by intense  headache, ten grains of ammonia in solution  were
 given every two hours; after the third dose the pain ceased, the patient
 fell into a comfortable sleep, and awoke with an abundant efflorescence
 covering the skin.
   Rubeola  nigra requires no other treatment in addition to that above
 recommended, unless especial indications present themselves, 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.
   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 and oedema of the mucous membrane of the
 trachea and larynx, and where the local abstraction of blood by leeches
^ has failed to afford relief, tracheotomy must be performed.   Chronic
 conjunctivitis and ulceration of the eyelids are best treated by the
 application  of blisters behind the ears, or upon the nape of the neck,
 with a weak solution of nitrate of silver, or a collyrium of sulphate of
 zinc and opium to the parts affected; anointing the borders ofthe lids at
 bedtime 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 injec-
 tion of a weak solution 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 bi-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 prevented
 by the application of a  small blister over  the tumefied organ, or by
 blistering the surface with the nitrate of silver.   The diarrhoea may be
 permitted to continue, unless it be prolonged for too long a time, and
 occasion debility and constitutional irritation.  When such an event
 is anticipated, the best treatment will  be found to  be, the application 
ERUPTIVE FEVERS.                   441
of a blister on the abdomen;  frictions of 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
affected, the liniment of croton oil, rubbed on the integument covering
the enlarged glands, will be found of great service.   Indeed, any treat-
ment for the relief of the sequelae of measles will be inefficient, unless
it be accompanied by counter-irritation.  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 affec-
tions are therefore not to be repelled, without establishing in the first
instance a more managable 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 pulmo-
nary  affections by  warm apparel, and avoidance of a cold and damp
atmosphere.

                         SCARLATINA.

Syn.  Scarlet Fever.   Febris scarlatina.  Morbilli confluentes.  Rubeola
   rossalia.    Scarlatine,  Fran.   Scharlachfieber, Scharlachaufschlag,
   Germ.
   Scarlatina is an acute inflammation of the tegumentary investment
of the entire body,  both cutaneous and mucous, associated with fever
of an infectious and  contagious kind.   It  commences  with fever,
which invades at an  indefinite  period  between the second and the
tenth day1 after exposure to  infection 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 color. The rash terminates at the end
of six or seven days,  leaving  the skin rough and  harsh, and the epi-
dermis peeling off in furfurae and thin laminae.
   The  varieties  of scarlatina, which are  merely  modifications  in
degree of one typical affection, are four in number,  namely—
     Scarlatina simplex,           Scarlatina maligna,
         "     anginosa,              "     sine exanthemate.

                       SCARLATINA  SIMPLEX.

        Scarlatina benigna; erethrica.  Scarlatina sine angina.2
  Scarlatina simplex,  the most  benign form of scarlet  fever, com-
mences  with a feeling of  languor and  lassitude, with pains  in the
head, in the back, and in  the limbs; with  drowsiness,  nausea, and
rigors, these being succeeded by heat, thirst, and the usual symptoms
of pyrexia, and increasing towards evening.  Upon  the breaking out
of the efflorescence, the pulse is quick, but feeble;  the patient is

  1 An exceptional case is reported by Dr.  Duncome, of the Bahamas, wherein the
poison remained latent for eleven weeks.
  «Dr. Robert Williams. 
442     DISEASES FROM  UNKNOWN ANIMAL  POISONS.

anxious, depressed in spirits, agitated, restless, and  sometimes deli-
rious.   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 color, 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 ofthe hands and feet.  .Sometimes,
however, it happens that the eruption of scarlatina occurs without
pain or febrile symptoms.
  On the second day from the commencement of  these  symptoms,
the efflorescence appears upon the face, neck, and breast, in the form
of minute points, which become aggregated into patches of irregular
form  and size.  By the  third day, the rash has extended to the trunk
of the body and upper extremities, and to the mucous membrane of
the eyes, nose, mouth, pharynx, and air-passages; and by the fourth
day,  to the lower extremities.  The patch-like  distribution of the
eruption is it's normal character upon the trunk of the body.  On the
face,  the neck, and upon the limbs, it speedily becomes  continuous
and diffused.  The skin is hot and itching,  and  fully distended by
the congestion of its vessels.   The scarlet surface is sometimes uniform
and smooth (scarlatina plana vel levigata), 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 milliformis), and occasionally, though rarely, it is accom-
panied  by the development  of serous  vesicles (scarlatina vesicularis,
velphlyctenosa, velpustulosa).  The efflorescence attains its most vivid
redness upon the  evening  of the  third or fourth day after its com-
mencement.  It is always brighter  in the evening than in the morn-
ing, 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 a natural  hue begin to be apparent in the
midst of the redness, and epidermal  desquamation  occurs upon the
face  and neck.  On  the sixth day the efflorescence  has still further
decreased, and on the seventh has nearly  disappeared. On the eighth
and ninth days the desquamation of the  epidermis has become gene-
ral, and, in many  parts, laminae of considerable size are  thrown off.
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 frequently presents,"
as Schonlein remarks, "a peculiar  character, which  is due, in  many
cases, to  an admixture of the bile-pigment; it has a dark-brown
color, and  resembles badly fermented beer  in appearance.  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  color, and  possesses all the
properties  of inflammatory urine. 
ERUPTIVE FEVERS.
443
  "In children the urine is always less colored than in adults, and its
color, 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 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 quantity of mucus; blood-corpus-
cles are occasionally noticed.  When the urine is ammoniacal, viscid
whitish sediments of the earthy phosphates are deposited, and if there
is much gastric disturbance  the urine  becomes  jumentous (turbid).
Albumen is commonly 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."1
  Simon further observes, in  reference to the contradictory opinions
put forth with regard to the presence of albumen in the  urine: " We
have - dropsical  symptoms with albuminuria,  dropsical  symptoms
without albuminuria, and albuminuria without dropsical symptoms."
Solon found albumen in the urine in twenty-two out of  twenty-three
cases of scarlatina.  On the other hand, Philipp2 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.
Simon remarked that a desquamation  of the mucous membrane was
ascertained  by the presence of  numerous epithelial  cells in the sedi-
ment, a condition which frequently preceded the desquamation of the
epidermis.
                     SCARLATINA ANGINOSA.

              Scarlatina mitior?  Angina scarlatinosa.
  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 swelling and ulceration
ofthe sofFpalate and tonsils.
  The primary symptoms of  this variety of scarlatina are identical
with 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 jaw.  Upon the second day of the febrile symptoms,
the  throat  feels rough, the  voice  is hoarse,  there is a collection of
viscous mucus in the fauces, and deglutition is painful and  difficult.
On the third and fourth days the redness of the fauces has increased,
the mucous  membrane looks turgid and swollen, and is studded 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

   1 Simon, Animal Chemistry.
   1 Casper's Wochenschrift, 1S40, No. 35.          » Dr. Robert Williams. 
444     DISEASES FROM UNKNOWN ANIMAL POISONS.

with  red gems, from the  congestion  and elongation of its  papillae.
While the  local affection is  thus  rapidly progressing, the constitu-
tional symptoms are indicative of serious and dangerous disturbance.
There is nausea with vomiting, quickened  respiration, a quick and
feeble pulse, great  languor and restlessness, headache, delirium, and
excessive heat  of  skin,  104°  or  105°.   Heberden observed  the
temperature of the  surface, as indicated by the  thermometer, to  be
112 degrees of Fahrenheit.
  When ulceration ofthe mucous membrane ofthe fauces occurs, the
inflamed surface is seen to be studded on  the second or third day,
with 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 thrown  off, and  leaves a small superficial
ulcer, which quickly heals.  Ulceration takes place chiefly in irritable
constitutions, and at certain seasons of the year, as, for instance, during
the autumnal and winter months.
  The cutaneous eruption in  scarlatina anginosa is retarded by the
severity ofthe affection ofthe  mucous  membrane, and ofthe constitu-
tional  symptoms.  It fails to  appear until the third day, and is then
only partial in its efflorescence.  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 disap-
pears suddenly the day  after  its eruption, to return in a day or two.
This  occurrence takes  place  more frequently in  the  autumn and
winter 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  disappearance  of the
congestion of the mucous membrane are not accomplished4>efore the
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 postponed till a later period.  The
constitutional  symptoms follow  in  the train of  the affection of the
throat.
                     SCARLATINA MALIGNA.

       Scarlatina graviory1 torpida; nervosa; putrida; septica.
  Scarlatina maligna is a  highly aggravated form of scarlatina angi«
nosa, occurring in persons of debilitated constitution, principally  in
the winter months of the year, and  in damp, unhealthy and ill-venti-
lated situations.  Sometimes it makes its attack sporadically, while at
other times it invades suddenly and  unexpectedly during the progress
of scarlatina simplex or anginosa.
1 Dr. Robert Williams. 
ERUPTIVE FEVERS.
445
  The chief characteristics of  scarlatina  maligna are the extreme
prostration of the powers of the system, the absence of swelling of the
tonsils, and the extensive and deep sloughing ulceration ofthe fauces.
The pulse in this affection is irregular,  and scarcely  perceptible;
there is great restlessness, deafness, 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  fur.  The  tongue is enlarged
and tender,  or even ulcerated, and the tonsils are deeply ulcerated,
and covered with  dark-colored  sloughs.  Respiration  is  impeded,
quick, and  rattling;  there is a quantity of viscous phlegm  in the
pharynx;  the  breath is fetid; deglutition  painful and  difficult;
there is stiffness of the muscles of the jaws, diarrhoea, and sometimes
haematuria.
  The eruption in this form of scarlatina is late in appearance; it is
pale and indistinct, with  the exception of a few patches  of irregular
size,  which  speedily  become  dark  and  livid,  and  mingled  with
petechias.  " Their  whole skin," writes  Dr.  Sims,1 " instead  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 diffused
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 disappears 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 day, while others
withstand  its violence for a longer period.  Those who  perish early
exhibit appearances of  extensive ulceration  in  the fauces, larynx,
trachea, lungs, or in the oesophagus and alimentary canal, after death.
The great  fatality of this  disease may be inferred from the observation
of  Willan, that "in 1786-87 more than two-thirds of those who were
affected with the  scarlatina  maligna  died  between the seventh and
nineteenth day of the  fever."

                 SCARLATINA SINE EXANTHEM ATE.

                        Scarlatina sine eruptione.2
  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 efflorescence.
Such an instance once fell under my own notice,  in a weakly  child,
who slept  in the same apartment with three of his brothers and sisters,

  1 Memoirs of the Medical Society of London.          2 Dr. Robert Williams. 
446     DISEASES FROM UNKNOWN  ANIMAL POISONS.

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.

  When so extensive a surface 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 referable  to age, constitution,  season, &c.   Thus,
while, on the one hand, cases may occur in which all the constitutional
symptoms are present without the efflorescence, on the other hand, the
very reverse  of this may  happen.   Dr. Sims remarks: "In one child
the scarlet fever appeared without any  angina, and, having finished
its course, left the patient seemingly in perfeet health; but in a few
days the fever returned without any eruption, but with a very consi-
derable degree of sore throat, and much  pain and swelling of the ton-
sils and parotids, which likewise ran its course, as if the former symp-
toms had never appeared."  The  same  author observes, that  during
the periods of the year which are unfavorable for  scarlatina, namely,
in autumn and winter, "a frequent, short, backing 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 of the
disorder, a swelling attacked the face, but more  frequently the extre-
mities, attended with the most excruciating pain."   " Some first com-
plained of a violent toothache ; after two  or three days they complained
of an equally violent pain in the back, the first one gradually  subsid-
ing.   In a day or two more, or  even sooner, the pain attacked their
elbows, wrists, and hands, which were usually the parts last attacked."
  Dr. Watson1 and Dr.Corrigau3 have pointed out an occasional variety
of scarlatina anginosa, in  which there is great and rapid swelling under
the angles of the jaw, without  a  corresponding inflammation of the
fauces.  The patient suffers much  from pressure upon the cervical
vessels and nerves, and the cellular tissue frequently passes into the
state of sloughing.  At the outset of the swelling Dr.  Corrigan found
a few leeches of service; but he warns us against their use, if the
inflammation be fairly established, and he especially indicates the
danger of incisions.

                    SEQUEL.E  OF SCARLATINA.

  The development of the exanthema, upon certain parts of the body,
is always accomplished by more or less oedema of the subcutaneous
cellular tissue.   In the majority of cases this oedema is removed by
absorption of the serous effusion at the  decline of the eruption, but
occasionally  it terminates in  ulceration or  mortification.   "Two
1 Lectures on the Practice of Physic.       2 Clinical Lectures. 
ERUPTIVE FEVERS.                   447
instances of this tendency to mortification  occurred  in two children
lately admitted into St. Thomas's Hospital.  In one, the whole of the
toes of the right foot had sloughed off, and the integuments of the leg
had mortified 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 pre-
vailed 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 cor-
roded, that  most of the teeth fell out before she died.  The lips and
mouth of many also that recovered, were ulcerated, and continued  so
for a  long time."1
   In  other cases, at the close of scarlatina, and during convalescence,
namely, during the period intervening between the tenth and twentieth
day,  and sometimes as  early as the fifth or sixth  day,  anasarca is
developed.  This sequela, which  is referable to the transfer of inflam-
matory action to the structure of the kidneys, is indicated by languor,
headache, restlessness, and symptoms  of general constitutional dis-
turbance ; to these succeed oedema of the face and lower extremities,
and, in a short space of time, of the entire body.  Subsequently, effu-
sions, frequently containing urea, take place into the serous cavities,
and the case becomes serious.  The urine  is deficient in quantity, of
that peculiar smoky color which indicates the presence of albumen, {
and is frequently colored by the  presence of blood, the consequence
of impeded circulation in the kidney and rupture of  the capillaries of
the Malpighian bodies, or  turbid, and deposits a whitish sediment.
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; but it may also result from any cause capable of
arresting or diverting the natural course of the disorder; in other
words, of preventing the elimination of the animal poison, which is the
essence of the disease.   Hence an imperfect or checked eruption is the
common precursor of anasarca, or it may occur after the subsidence of
the cutaneous efflorescence, when an  undue  amount of  poison still
remains in the blood, and an  excess of duty is forced upon<the kid-
neys, the latter organs being already weakened by congestion, imper-
fect circulation, and accumulation of epithelium, and possibly, of fibrin-
ous cylinders  in their tubular structure.
   Anasarca sometimes proceeds from another cause than inflammation
and congestion of the structure of the kidneys, namely, from anaemia.
This  happens in children naturally weakly and pallid, and is less serious
than  the inflammatory form.  It may occur as early as the fourth day
of the eruption, or at any later period;  the features in this case are
contracted and pallid, the tongue and lips bleached, and the skin pale;

       1 Elements of Medicine.  By Robert Willams, M.D. Vol. i. p. 127. 
448      DISEASES FROM UNKNOWN ANIMAL POISONS.

there is little or no fever ; the urine is pale, often neutral from the pre-
sence of phosphatic salts, and contains  neither albumen,  blood-cor-
puscles, nor epithelial cells.  The cause of the dropsy in this instance
appears to be  defect of fibrin in the blood, and want of power to
excrete the urea.   The oedema begins in the vicinity of the joints.
   Besides the preceding, inflammation and effusion of serum and pus
may take place into the joints.  The mucous membranes also suffer; the
inflammation ofthe conjunctiva sometimes becomes chronic, and lasts
for a considerable time.   Inflammation of the  mucous lining of the
tvmpanurn and Eustachian tube may terminate in deafness, and that
of the meatus auditorius in chronic suppuration.  Occasionally ulce-
rations  are  formed around the nose and mouth; thickening of the
upper lip may also occur; aphthae of the tongue and mouth, or inflam-
mation ofthe 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., and, according
to Dr. Scot Alison,1 pericarditis.
   In scarlatina maligna the  sequelae are severe and dangerous, and
often prove fatal  after the secondary stages of the fever have subsided.
To the tertiary affections above detailed may be added, as occasionally
following in the train of scarlatina maligna, ulceration ofthe mucous
membrane  of the larynx, trachea, and oesophagus; ulceration of the
mucous membrane of the intestines, protracted cough, dyspnoea, sup-
puration of  the salivary glands, enlargement and suppuration of the
lymphatic glands ofthe neck, sloughing of the nates, and hectic fever.
   Diagnosis.—The  especial diagnostic  characters of scarlatina are,
firstly, the decided and acute  aff'ection of the fauces; secondly, the early
appearance (2d day)  and rapid extension of the efflorescence; and
thirdly, the bright scarlet and diffused character  of the rash, and its
frequent interspersion with red papulae.
   Between scarlatina and rubeola  the closest analogy undoubtedly
subsists, and when the natural characters of the  two affections are con-
sidered, 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 cutaneous efflorescence, 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 pre-
valence of the same epidemic, engendered apparently by the  same
infection; one  may follow on  the  other  as  a consecutive disorder;
both are infectious, and both are contagious.   In practice alone it is
necessary to distinguish between these exanthemata.  We will, there-
fore, inquire what are the distinctions which we are enabled to estab-
lish betweeen  them.
1 Medical Gazette, 1845. 
ERUPTIVE FEVERS.
449
             Scarlatina.

  1. Precursory symptoms of one day's
duration.              N-
  2. Mucous membrane of the eyes, nose,
and fauces, red and inflamed, without se-
cretion ; pain and soreness of throat; no
cough; no expectoration.
  3. Eruption  on  the second day of the
fever; invades the entire surface of the
body in the three days ; disappears by the
end of the seventh day.
  4. The efflorescence occurs in  large ir-
regular patches, or is more or less gene-
rally diffused:  is of a bright scarlet, com-
pared by Willan to a " boiled  lobster's
shell," and frequently interspersed with
numerous small red papulae.

  5. Odor resembling old cheese.

  6. Principal  sequelae: anasarca, inflam-
mation of joints, gangrene, chronic bron-
chitis, ulceration of fauces, conjunctivitis,
otitis, abscess of salivary glands, chronic
diarrhoea.
  7. Exfoliation of the epidermis in la-
minae.
  8. Less infectious and contagious than
measles.
  9. Rarely attacks the same person more
than once.
              Rubeola.

  1.  Precursory symptoms of three days'
duration.
  2.  Mucous membrane of the eyes, nose,
and  fauces, red and inflamed, with in-
creased secretion, coryza, sneezing;  dry
cough at first, subsequently expectoration.
  3.  Eruption  on the fourth day of the
fever; occupies three  days  in invading
the entire surface of the body; disappears
by the end of the eighth day.
  4.  The efflorescence  occurs  in small
crescentic and  annular patches, with in-
tervening unaffected  portions ofthe skin;
the color is darker than in scarlatina,
with  " nearly the hue of a raspberry,"  and
interspersed with numerous small red pa-
pulae, disposed in clusters.
  5.  Odor sweetish,  until the decline of
the eruption, then sourish.
  6.  Principal sequelae: the same as scar-
latina, with the exception of  anasarca,
inflammation of joints, and gangrene.
  7. Exfoliation of the epidermis in fur-
furaceous scales.
  8. More infectious and contagious than
scarlatina.
  9. Frequently attacks the same person
twice.
   The differences above  stated  amount at most to one of degree, the
 infection being the  same in both disorders.  Thus, while both are
 constituted by inflammation attacking the same textures ofthe  body,
 scarlatina, during  its first stages, is more rapidly  and actively deter-
 mined to the cutaneous surface; the mucous membrane, in an  equal
 ratio, escaping the violence of the inflammatory action.   The con-
 trary is  the case with  regard to  rubeola; here  the cutaneous deter-
 mination is tardy and partial, while the mucous aff'ection  is gradual,
 severe, and prolonged.  During  the second stages, on the subsidence of
 the cutaneous  congestion, the mucous membrane  may suffer more or
 less in both, 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 or previously 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  vascular 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 pro-
gress, extending, by  degrees, from  the  point first attacked along the
trachea and bronchial tubes, giving rise  to the  formation  of false
       29 
450      DISEASES FROM UNKNOWN ANIMAL POISONS.

membranes in its  course, and attended with little constitutional  dis-
turbance, 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.
   Causes.—The cause of scarlatina is an infection, or contagion, ap-
parently identical with that of rubeola.  It makes  its attack in the
form of an epidemic, and prevails  mostly in the  spring and  autumn
seasons of the year.  The atmospheric conditions favorable to scarla-
tina are cold and moisture combined, and the existence  of this state
ofthe weather for any  time  gives rise to a  medical constitution, in
which scarlatina is apt to be developed.   When epidemics of scarla-
tina  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 the numbers of the population who have
not yet suffered  from the disease,  and who are consequently  suscept-
ible 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  communicable by inoculation than measles.
For protection against the propagation of the   contagion,  patients
recovering from scarlatina should be secluded  for a month or six
weeks.
  It is worthy  of remark,  that an angina pseudo-membranosa, or
diphtheria, 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 months of the
year.  During the same period horses suffered  from a similar affec-
tion,  colts from  acute  enteritis,  and cattle, sheep,  and  pigs, from
phlyctenoid fever.
  Prognosis.—The prognosis of scarlatina will  be much influenced
by the nature of the prevailing epidemic.  It sometimes invades with
such overwhelming rapidity as to destroy life before any pathological
changes can  be  effected.  Scarlatina  simplex is  wholly divested of
danger when it  passes regularly through its course.   It  may, how-
ever, be rendered grave by retrocession, or by complication with dis-
ease  in  any  of the viscera.  " The prognosis is unfavorable if the
delirium  commence, as it frequently does in children, and sometimes
also in adults, a few hours after the seizure.   In  these cases the child
often dies on the third or fourth day,  and the adult on the eighth or
tenth.  The  tongue becoming  brown;  or, a clean tongue, with a
rapid, fluttering  pulse,  are unfavorable symptoms.  A sudden fading
of the eruption, or its  changing  to a livid  color, are symptoms of
danger.   The danger of scarlatina  is increased by dentition.  Preg-
nancy also adds  to the danger, as  the woman frequently miscarries.
The prognosis is also  extremely  grave when it  attacks women im-
mediately after parturition."  "The fauces becoming livid under any
circumstances, or an acrid discharge  from the  nostrils,  or else the
formation of an extensive abscess in the neck, accompanied with
4 
ERUPTIVE FEVERS.
451
severe purging,  are all unfavorable symptoms.  The appearance of
mortification in  any part is commonly, but  not universally  fatal.
Affection of the joints is a grave, but by no means a fatal symptom." 1
The appearance of hemorrhage from the mucous membrane of the
nose at the commencement of the exanthema is regarded as a favor-
able sign.
  Treatment.—The  principle of treatment  in  scarlatina  is  to  en-
deavor to purify the blood of the morbid poison which it  contains,
and which  is  the cause of  the  disease, by  calling into activity  the
various natural emunctories  of the  system,  namely,  the  skin,  the
bowels, and the kidneys. The degree in which these powers should
be set in action must be determined by the strength ftf the disease. In
the mildest  forms of the complaint the  treatment  should  be of  the
simplest  kind.   Sydenham  remarks,  that none  die of this  disorder,
except from a too great officiousness  on the part of the practitioner,
" nimia medici  diligentia."   The patient should be confined to  the
house, the sick Spartment should be kept well ventilated, the patient's
head cool,   his feet warm,  the bedclothes light; his diet  should be
sparing and unstimulating,  with an abundant supply of diluent and
acidulated drinks; conversation should be prohibited, and all sources
of  noise  or moral  excitement  removed.  To these hygienic means
should be  added, sponging of the skin with tepid vinegar; a daily
warm bath, if the process can be accomplished without  fatigue to the
patient and danger of exposure ;  effervescent salines ; mild diapho-
retics, if necessary ; gentle laxatives;  and, at the decline of the fever,
a mild tonic, such as the citrate of iron, or citrate of iron and quinine,
and a little wine.  During  convalescence and after recovery, flannel
should be worn next the skin.
   But scarlatina is not always so slight a disorder as to be  amenable
to  the simple  antiphlogistic method of treatment above laid  down;
the want of a power of neutralizing the poison present in  the blood,
of a specific power, in  fact,  has  long been felt by those  who have the
charge of treating  this disease ; and  in the absence of  such a power
the practitioner is compelled to deal with the disorder cautiously and
even doubtingly, for at  any moment  the fever may put on a serious
and dangerous aspect, and that which was benignant at first, may, in
a few days, assume a fatal character;  or the type of the fever may be
 dangerous from the outset,  for different epidemics of scarlatina differ
 in  their qualities of danger, and in certain localities the fever is habit-
 ually more formidable than  in others.  Under these circumstances the
 importance of a specific remedy cannot be too highly estimated;  a
 remedy which would control and neutralize the poison;  that might be
 administered  safely at  any stage of  the  fever; that at; the earliest
dawn of the complaint would be prophylactic, and a certain cure in
 more advanced stages;  that would prevent secondary affections, or
conduct them safely through their course; in  a word, that would
 render scarlatina one  of the slightest of human afflictions, instead of
being, as at present, one of the gravest of maladies.
> Dr. Robert Williams.  Opus cit., p. 145. 
452      DISEASES FROM UNKNOWN  ANIMAL POISONS.
  Such a remedy, a specific for scarlatina,  my own experience  tells
me does exist, and has been employed and advocated for a number of
years past by able practical men.   A remedy that,  in  its power over
scarlatina and rubeola,  and  probably  variola, may be ranked with
quinine in ague; iron in erysipelas ;  arsenic  in  eczema ; sulphur  in
scabies ; and mercury in syphilis.   This  remedy is the sesquicarbon-
ate of ammonia, and  has "for  its  promoters and  advocates,  Peart,1
Wilkinson,2 and Dr. Charles Witt.3  The average dose for an adult is
five grains in simple solution in water, administered every one or two
hours throughout the course of the complaint.  For an infant or child
the dose may be two grains ;  and in severe cases it may be carried as
high as ten grains.  " Dr. Peart gave  six-grain  doses in cases of un-
usual severity.   Mr. Wilkinson rarely gave  less  than three grains,
increasing the dose, according to the age of his patients, to ten grains,
and repeating it more or less  frequently according to the urgency of
the case."  Dr. Witt, in a case mentioned in  his pamphlet, adminis-
tered seven grains, " every hour, for the space of tw%nty-four hours,
and during every alternate hour for the next like space, not only with
perfect  safety,  but with  complete success."4  " Perfect  quietude is
especially required under the operation of this medicine.   The patient
is thrown by it into a sleepy state,  as nearly as possible resembling
the repose of health, and as long as that inclination remains, which is
much to be desired, it should not be interrupted.   In aid of this, the
room should be  somewhat  darkened."  The  remedy  possesses the
power of tranquillizing the nervous system,  calming  nervous  irrita-
bility, and  conducing  to sleep;  it  favors the development of the
cutaneous efflorescence; it reduces heat,  fever,  and delirium ;  and,
after a  few  hours, subdues any  urgent complications that  may be
present, whether of the brain, the lungs, or "the  bowels.  The  sick
apartment must  be  sufficiently ventilated,  with  an avoidance  of
draughts of  cold air  that might chill  the  surface  and repel the
eruption.
  It is important in the administration of ammonia, that it should be
given alone;  that nothing should be permitted in  the diet of the patient
that could neutralize  its effects, such as acid  drinks and fruits.   The
drink should be simple water, or toast and water;  the bowels should
be regulated by gentle  means, and the diet suited  to the progress of
the patient;  gruel, milk, and, as the fever subsides, broths and light
nourishing food.

  1  Practical Information on  the Malignant Scarlet Fever and Sore Throat.
  2  Remarks on Cutaneous Diseases.  18'22.
  3  An EllectuaLjind Simple Remedy for Scarlet Fever and Measles, with an Appendix
of cases.  3d etT^ion.  18(i2.
  4  The case here referred  to was peculiarly  interesting, as showing the occasional
irregular manifestation of the poison of scarlatina.  The patient,  a young lady, was
seized with symptoms of inflammation  of the bowels ; after recovering from this
attack, which oonfiued her to bed for three days, she was  attacked with violent
dyspnoea ; on  the  disturbance  of respiration subsiding,  she became restless and
sleepless, and evinced symptoms of great cerebral irritation ; it was feared that the
oase would terminate in mania, when, on a sudden, the efflorescence of scarlatina was
discovered on her skin.  In forty-eight hours this young lady took 252 grains of the
sesquicarbonate of ammonia. 
ERUPTIVE  FEVERS.
453
  Ammonia was introduced into medical practice for the treatment of
scarlatina by Dr. Peart in the beginning of the  present  century; it
was soon after adopted, on account of its unmistakable merits, by Mr.
Wilkinson, and  is now pressed upon the attention ofthe medical pro-
fession by a scholar of Mr. Wilkinson's, Dr. Charles Witt.  Out of
several hundred cases of scarlatina, one gentleman  has lost not more
than one per cent, during a period of six years.  Another  practitioner
rarely lost a patient during a practice of twenty years; but his successor,
Who rejected  the  treatment by ammonia, lost 74  out of 106 cases
during a single epidemic.  In a public school, where the quinine and
acid treatment prevailed, the number of deaths was rather more than
ten per  cent.  Mr. Henry Jackson, senior  surgeon  to the Sheffield
Infirmary, had, with his father, followed Dr. Peart's plan of treatment
for upwards of fifty  years,  and during  that period lost  only four
patients,  who died in  reality  from  typhus supervening on scarlatina.
Mr. Wilkinson had  not lost a patient from  scarlatina or rubeola in
twenty, years.   Dr. Peart himself records that after commencing the
treatment by ammonia he did not  lose one out  of three hundred
patients.  His formula was a  solution of two drachms of the  sesqui-
carbonate in five ounces of water;  and the  dose,  two  drachms every
two, three, or four hours, according to the urgency of the symptoms.
When the difficulty  of swallowing diminished, he permitted the addi-
tion of water to the dose of solution, if agreeable to the patient; and
he  gave it in every form and  stage of the  disorder. " Some  were
glowing  with universal efflorescence;  in some; the extremities were
swelled;  in others,  fetid ulcers  appeared ;  in most, the  throat was
swelled  and inflamed, often-  ulcerated, and  respiration  almost pre-
vented ;  but, in the most alarming cases, a scorching fever and raging
delirium rendered the patient's situation horribly distressing;  yet, in
all these variations of the disease, the volatile alkali was my specific,
which I  administered to between two and three  hundred patients,
successively and successfully."1
   If  the extension of the disease to the kidneys should  be indicated
by anasarca, or  the state of the urine, the warm  bath must be imme-
diately resorted to.   It may be given twice a-day, once a-day, or every
other day, according to the strength ofthe patient, and the relief it is
found to afford; and its action may be increased  by antimonial dia-
phoretics.   An  active purgative, and such as will relieve  the mucous
membrane by exciting secretion, at the same time that it moves the
bowels copiously,  must be administered. Calomel, with the compound
jalap powder, saline aperients, or drachm  doses of  the  bitartrate of
potash, are  the  best means for this purpose.  And, in addition, the
action of the kidneys may be gently aided  by mild diuretics, such as
the citrate of potash, acetate  of potash, or  liquor  ammonia? acetatis.
But diuretics should be used with caution ; judiciously selected and
administered, I  am of opinion that they would relieve the most con-

  1 Dr. Charles Witt reminds us that " it has been long and generally acknowledged
in those districts of England where the viper abounds, that when such poison has
been infused into the system ammonia is the antidote." 
454     DISEASES FROM UNKNOWN ANIMAL POISONS.

gested condition of the kidney; but, improperly chosen and mistimed
in their exhibition, there would  be danger  of their  increasing the
inflammation which they are intended to abate.   When symptoms
indicate a very considerable congestion of the kidneys, leeches to the
loins, sinapisms, or dry cupping,  may  become necessary.  The com-
pound tincture of iodine, containing an additional drachm of  iodine
to the ounce, I have  seen  used  as a counter-stimulant  with great
success and relief.  It possesses the advantage of ready application,
and  may  be used without  the slightest disturbance of the patient.
When symptoms denote effusion  into  the cranium or cavities  of the
brain, sinapisms or a blister should be applied to the nape of the
neck.
  During the progress of the  above  treatment for carrying off the
morbid poison, the powers of the digestive organs must be maintained
by a nourishing diet;  and, as the symptoms subside, wine  may  be
allowed for the same  purpose.   When the disease is exhausted, the
general tone of the system, and especially that of the kidneys, is to be
restored  by means of  mild chalybeate tonics, such as the  citrate of
iron, potassio-tartrate of iron, citrate  of iron and quinine, vinum ferri,
tincture  of the  sesquichloride, sesquioxide, or iodide of iron; or, as
recommended by Dr. Bobert Williams, salicine, from'combining the
properties  of a  tonic and diuretic,  in  five grain  doses, three times
a-day.
  When the cause of the oedema  or anasarca is an  anaemic state of the
system, tonic remedies are the appropriate treatment from the earliest
indication of the existence of such a state; the tonics best suited to the
purpose being the salts of iron, alone or in combination with a bitter
infusion ; or the sesquioxide of iron.
  In scarlatina anginosa, the same general  plan of management should
be adopted  as in the preceding form ;  and, if the heat of the skin be
excessive, great relief will be afforded  by sponging with cold or tepid
water, vinegar and water, or tepid vinegar.   The disposition to nausea
which exists in scarlatina anginosa should  be met by effervescing
salines, such as the citrate of potash or ammonia, with hydrocyanic
acid, combining with these remedies laxative doses of neutral salts.
But, as the leading feature of scarlatina anginosa is inflammation of
the mucous membrane of the fauces, this must be treated by the early
application of nitrate of silver in the solid state.  Some medical men
give a preference to a strong solution,  such as twenty or thirty grains
to the ounce, applied by means of a sponge, but the solid stick appears
to me to be most easily managed.  The application should be repeated
once or twice in the day.
   When the tonsils are enlarged  and  painful, and interfere  seriously
with respiration, or are  accompanied  by severe  pain in the  head,
leeches should  be applied to the submaxillary region, the number
 being regulated by the  age  and  strength  of the  patient.  In  mode-
 rately strong  children  ten or  twelve may be  employed, but the
abstraction of blood must  be conducted with caution.  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 
ERUPTIVE FEVERS.
455
of the cutaneous surface, they act as an additional source of irritation;
the tincture of iodine  is not  open to  the  same objection, and is an
excellent  remedy.  So long as  the inflammation  of the fauces con-
tinues, the saline remedies  must be  pursued;  but as soon as the
sloughs  are thrown off, and  ulceration  established, and the febrile
symptoms are on the decline, tonic medicines, with mineral acids and
wine, are  indicated.  Acid and astringent gargles or fumigations, or,
in young  children, aspersion of the throat,  with  an acid and slightly
astringent solution, are often useful in procuring the removal  of
the viscid mucus and exuviae which  are apt to  collect in the fauces
and excite  nausea.  They  also  serve to  remove  the fetor  which
accompanies the sloughing and ulceration.
   Emetics have been recommended  very strongly, as a  means  of
clearing the throat of its mucus, and, at the same time, of ridding the
stomach of  its peccant contents.  The violence of  the  remedy some-
times outweighs the inconvenience which  it is  proposed  to remove,
and, although supported by  the authority of Withering, emetics have
fallen into discredit.
   Purgatives, like emetics, have been much overrated 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. Hamilton also drew a favorable
deduction from their use; but Dr. Robert  Williams  has shown that
while the mortality in the cases treated by Dr. Hamilton was twelve  N
in ninety-five; in  those treated  by moderate  stimulants it was only
three per  cent.
   Dr. Currie, of Liverpool, the celebrated  advocate for the employ-
ment of cold water in fevers, pursued this practice in scarlatina with
remarkable success, washing the surface whenever the  skin was " hot
and dry."  Dr. Bateman,  and  several other  eminent  physicians,
adopted the practice of cold affusion, and gave the strongest evidence
in its favor.  The  method of using the 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
generally breaks out into a  moderate  perspiration.  If the feeling of
cold should continue  after the bath, a little warm wine and water is
administered.   The effect of cold affusion is, to diminish the frequency
of the pulse, to reduce the thirst and heat of skin,  and  to tranquillize
the  nervous system.  If needful it may be repeated  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
affusion,"  says Bateman, " combines in  itself all the medicinal proper-
ties which are indicated in this state of disease, and which we should
scarcely, d priori, expect it  to possess;  for it is not  only the most
effectual febrifuge, 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 perspiration  has broken
forth, the skin has become soft and cool, and the eyes have brightened, 
 456     DISEASES  FROM UNKNOWN ANIMAL POISONS.

 and these indications of relief have been speedily followed by a calm
 and refreshing sleep."
   Dr. Schneemann, of Hanover, speaks in high terms of eulogium of
 a very  simple treatment, namely,  inunction  with lard.1  He says:
 From the  first of the illness, and as  soon  as we are  certain of its
 nature,  the patient must be rubbed every morning and  evening over
 the whole body with a piece of bacon, in such a manner that a covering
 is everywhere applied.  In order to make this rubbing-in somewhat
 easier, it is best to take  a piece of bacon the size of the hand, choosing
 a  part still armed with the  rind, that we may have a firmer grasp.
 On the soft side of this piece slits are to be made in various directions,
 in order to allow the oozing of the fat; and this is still further pro-
 moted by placing the  bacon,  for some time  previously to  using it
 near the stove, in the oven, or on the  hob, but it must  be allowed
 to cool before its application.
   The rubbing must be most conscientiously  performed, and not too
 quickly, in order that  the skin may be thoroughly saturated; and
 during the process only that part of the skin subjected to the opera-
 tion should be exposed.  This treatment should be continued night
 and morning for three weeks, and once a day  for the fourth.  After
 that, the patient may be washed daily with cool water and soap, and
 not until the skin has become accustomed to the cool ablution should
 the warm bath be commenced.
   The advantages of  this plan  Dr.  Schneemann  states to  be  the
 shortening of the disease to such an extent, that the patient may leave
 the house at the end  of ten days;  the checking of all infection by  the
 end  of the third or fourth day; the relief of all uneasy and painful
 feelings in the skin, particularly those  that accompany desquamation ;
 the  diminution of the  amount of desquamation;  the prevention of
 taking cold; and a greater security against complications and sequela?.
 The treatment, he observes, is not likely to find much favor  with  the
 fastidious,  on account of being dirty, but the first  few days of its
 application produce results which make all this to be forgotten, and
 inspire  mothers  writh  enthusiasm.  With a rapidity  bordering  on
 magic, all, even the most painful, symptoms of  the disease are allayed;
 quiet, sleep, appetite, and good humor return, and there remains only
 impatience to quit the sick-room.
  Dr. Mauthner,2 of Vienna, adds  his testimony in  favor  of  the
 remedy; and  from  my knowledge of  the value of  inunction in
 erysipelas,  I am disposed to thiuk most favorably of it.  The principle
 of its action I believe to be the prevention of the too rapid oxygeni-
zation of the blood  at the surface of  the body, and the consequent
check to inflammation and  its  processes in the skin, one of the most
important of those processes  in diseases depending  upon an animal
poison being an augmentation of that  poison.  My  friend,  Mr. Grant-
ham, of Crayford,  in  Kent,  has for  many  years  j^ast relied  on

  1 On Scarlet Fever, by Dr. Schneemann, translated by John L. Milton, M.R.C.S.E.,
Lancet, September 15, 1S49.
 2 Revue Medico-Chirugicale, 1849. 
ERUPTIVE FEVERS.
457
 inunction in the treatment of violent sprains, and, at his recommen-
 dation, I have  pursued  the plan with  extraordinary success;  the
 principle is  the same, and falls into the same category as mercurial
 inunction in  smallpox.
   Belladonna has  obtained a high  reputation  among  Continental
 practitioners for its protective and curative powers in scarlatina.   It
 was first suggested  in 1807 by Hahnemann, who had observed that all
 persons  to  whom  this  medicine had  been  given  were  preserved
 against the infection of scarlet fever.  Several German  physicians,
 who have recorded their experience in Hufeland's Journal, unite in
 praise of belladonna; one gentleman remarks that during  an epidemic
 of scarlatina, fourteen  children out of 195 exposed to the contagion,
 alone took the disease, and  those were but slightly affected; another
 expresses his opinion, that belladonna  may be considered  as being as
 successful against scarlatina as vaccinia against smallpox.  Several
 repeat the observation  of  Hahnemann, that the medicine produces an
 efflorescence  on  the skin similar to that of measles; children in whom
 this efflorescence appears are at once regarded as safe.  The reporters
 exhibit some disagreement in reference to the strength of the remedy :
 one  recommends a solution of three grains of the extract  to an ounce
 of cinnamon-water; and of this solution he gives two or three drops
 to infants under a year, three or four drops  during the second  year,
 increasing the  dose progressively until twelve years, at and after
 which period he administers twelve drops: another makes a solution
 of one grain  to a  drachm  of water, and states  the  dose at ten to
 twenty drops, meaning, I apprehend, for an adult. Both these gentle-
 men  prescribe  the  remedy  twice a-day;  while a third  thinks it
 desirable  to  administer  it  four  or  five times  a-day, of course  in
 corresponding doses.  Dr. Schneemann, the  originator of the inunc-
 tion treatment, proposes a solution of two grains of the extract in an
 ounce  of  cinnamon-water,  and recommends, as the  proper dose,  as
 many drops, morning and night, as the child has years.  The remedy
 should be continued, he observes, for at least fourteen  days.
  Belladonna may also be given with  advantage after the attack and
 during the progress of the fever, in doses of half a g^in to two or
 three grains, according to  the  age of the patient, everv three or four
 hours.
  Both cold affusion and belladonna appear to me to act therapeutically,
 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 insure the  same
 desirable end.  Cold affusion  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 the 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 their sickening." 
458     DISEASES FROM UNKNOWN  ANIMAL POISONS.

  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  by 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 them invaluable
remedies in these cases; the quantity which may be taken daily by a
child is from one to  three ounces, and  by an  adult, 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 fumigated with the  steam of  warm  vinegar,  with  decoctions of
contrayerva  and  bark, acidulated  with acetic  acid, or containing
camphorated  spirit; or gargled with a weak  solution of chloride of
lime or capsicum pods.   Dr. Watson remarks, that a great improve-
ment upon the old plan of capsicum gargles, is a weak  solution of
common salt either used  as a gargle, or, if the disease 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 dis-
charge is rendered harmless; the running from the nose and diarrhoea
cease; and the  disease is  converted into a form which approximates
to the scarlatina anginosa."   The surface of the body may be sponged
with warm vinegar, but  the use of cold water, so  agreeable  and
beneficial  in scarlatina  anginosa, is  painful and  injurious  in the
malignant form.
   "  Of  late," observes Dr. Watson,  " I have been in the habit of direct-
ing  a solution of the chlorate of potash  in water (a drachm to a pint)
as a drink for patients in  scarlet fever, and in  the typhoid forms of
continued fever.   This practice was suggested to me by Dr. Hunt, who
tells me he lias long employed it with advantage.   Under the use of a
pint or a pint and a half  of this solution  daily, I  have remarked in
many  instances1 a speedy improvement of the tongue, which,  from
being furred, or brown and dry, has become cleaner and moist."  Dr.
Watson also remarks 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 hydro-
chloric 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 mixture, of  which  a table-
spoonful or two, according to the  age of the patient, may be given for
a dose, frequently."                                        ^
   Scarlatina sine  exanthemate will require the  treatment  adapted for
 scarlatina anginosa or scarlatina maligna, according as it may put on
 the  characters of  either of the preceding forms.   With the  view of 
ERUPTIVE  FEVERS.                   459
encouraging the development of the eruption,  the skin should be
stimulated by the hot  air bath, warm bath, or mustard  bath, by fric-
tions 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  eruption, evincing
a disposition to  metastasis, may frequently be fixed by means of a
blister.
   Complications of scarlatina.—The complications of scarlatina call for
a treatment especially directed to the organs affected.   Thus, when,
from the presence of delirium and comatose symptoms,  without much
inflammation of the fauces, 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 hemorrhage which frequently
occurs at  the close of the disorder, and blisters should be  placed be-
hind the ears, or upon the nape ofthe neck.  But when  the 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 sub-maxillary region.  It must, however, be borne  in  mind, that
the delirium of scarlatina is very frequently an  indication merely of
irritation  of the nervous system, and not of congestion ;  in  which case
the  treatment must consist of opiates instead of depletory remedies.
When  respiration is obstructed from  congestion  or oedema 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 per-
form tracheotomy.   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 restoration.  Diarrhoea 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 kid-
neys are  the  organs especially disordered, the therapeutic manage-
ment 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 surfaces through a quill.
   The inflammation of the joints that so frequently succeeds scarlatina,
is  combated by means of gentle purgatives, some simple sedative to
relieve pain, and fomentations to the diseased  articulations.   Other
sequelae should be treated according to the general principle of thera-
peutics.

                           VARIOLA.

    Syn.  Smallpox.  Variole ; Petite veroh, Fran.  Kinderpocken,
                       Kinderblattern, Germ.
  Variola is an acute inflammation of the tegumentary*  investment of
the entire body, both cutaneous and mucous, associated 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 pro- 
460     DISEASES FROM UNKNOWN ANIMAL POISONS.

gressive development, becoming, in quick succession, pimples (vari),
acuminated vesicles, flattened and umbilicated vesicles, pustules, and
hard  brown  scabs;  the  latter falling off7 from  the eleventh  to the
twenty-fifth day, and leaving behind them small, irregular pits, and
permanent cicatrices.   On the mucous membranes it produces  great
congestion of 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 discrete, and on
the eleventh  day in confluent, smallpox.
  Smallpox  admits of several divisions in relation  to the origin, dis-
tribution, and degree of  severity of the disease.  In respect of origin
it may occur sporadically, or be the consequence of the voluntary in-
troduction ofthe variolous virus into the  system, constituting the two
varieties termed natural smallpox and inoculated smallpox.  In reference
to distribution  and degree the eruption of smallpox may be discrete,
the pustules being distinct, and scattered over the surface of the body;
it may be coherent, the pustules  being very numerous, and, in some
situations, placed closely side by side, but still distinct; it may be con-
fluent, 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 modified, the pustules being altered in their
number, their size, and their course,  either by the previous invasion
of smallpox,  natural or inoculated, or by vaccination.  Modified small-
pox is a much milder affection than the parent variola, and is termed
varicella or varioloid.   Another  division of variola relates to its oc-
currence  for the first time, or as a second attack, a distinction which
is expressed  by the terms primary smallpox and  secondary smallpox.
Besides the preceding, we sometimes have occasion to remark, during
the prevalence of an epidemic of variola, the occurrence of the fever of
smallpox without its eruption ; this variolous fever constitutes a variety
which has been appropriately termed variola sine variolis.  These terms,
expressive of differences 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—Discrete,
                                     Coherent,
                                     Confluent,
                                     Modified,
                                     Secondary.
                     Inoculated variola.
                     Vario sine variolis.
   The course  of  variola admits of  consideration in five  successive
periods, this division being alike convenient in the treatment and de-
scription  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 comprehends
all that space of time which intervenes between the exposure of the 
ERUPTIVE  FEVERS.
461
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 indicate
serious constitutional disturbance.  It commences with languor and
lassitude, with shivering and horripilation, pains in the head, in the
loins,1 and in the limbs: the skin is hot, and either dry or moist; the
conjunctivae  suffused; the  pulse  and respiration quickened; there is
thirst and loss of appetite, with a white and coated tongue, dotted with
red papillae;  nausea, often  vomiting, constipation, pain and  heat at the
epigastrium, restlessness, and universal prostration.  To these succeed,
though various in degree in different individuals, oppression of breath-
ing, cough, lethargy, and  sometimes coma.  The tongue, at the com-
mencement of this period,  usually white,  soon becomes  red  at  the
point, and subsequently over its entire surface.  In  children, convul-
sions not unfrequently ensue  at this  stage of the  febrile  symptoms.
Throughout  all the periods there is exacerbation of the febrile symp-
toms during the night.
   In  confluent  smallpox 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 discrete 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  symp-
toms are instantly relieved by the succession of the eruptive period.
   III. The period of eruption is often ushered in by a manifest exacer-
bation ofthe constitutional symptoms, which  are  at  once and  imme-
diately  relieved by the outburst of  the  eruption;  the oppression and
languor are no longer felt, the nausea and sickness  cease, the pulse
returns to the natural standard, and  is full and regular.  The eruption
first appears upon  the lips and forehead, and  then upon  the rest of
the face;  from the face it  proceeds  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  appearance of
small red points,2 conical in their form, and hard  to the touch, which
are disseminated over  the surface  in  numbers proportionate  to  the
subsequent pustules.  Thus, in the discrete 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,

  1 M. Chamol regards the pain in the loins, which he refers to the kidneys, as pathog-
nomonic.  Dr. Heberden observed, that acute pain in the loins was generally followed
by a severe attack of the disease ; when the pain was higher in the back the disorder
was milder; and the most desirable indication was the absence of pain.   Mr. Marson,
of the London Smallpox Hospital, considers the pain in the loins to result from the
passage of the variolous poison through the vessels of the kidney, thus exciting a
painful state of the nerves of that organ.
  2 By some writers these points have been compared to the spots produced by ".he
bite of the flea. 
462     DISEASES FROM UNKNOWN ANIMAL POISONS.

they are closely aggregated, and so abundant as  to diffuse a general
redness over the surface.  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 papulae
(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 their 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 a transparent lymph, become whitish and milky, and a thin
layer of white coagulum is  formed on the derma.   The umbilicated
character  is apparent in many of  the vesicles on the third  day of
the eruption, and by the fourth or  fifth,  a distinct areola  is apparent
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 inconsequence of
the extension of the  inflammation to the larynx and trachea;  the
voice is hoarse and weak; and  there is  frequently a  hard, dry,  and
troublesome cough.  The eruption  is developed in the larynx  and
trachea, on the pharynx  and fauces, and  on the tongue, in  the form
of white points, which become converted, first into vesicles, then into
pustules.
  In the confluent variety the remission of febrile symptoms is imper-
fect, the eruption appears a  day earlier than in the discrete form, the
papulae are less raised, but so numerous  as to give  rise to a general
swelling of the skin, which  is of a deep red color, shining and granu-
lated.   The incipient pustules constitute one continuous vesicle over
the inflamed surface,  formed by the  effusion  of liquor sanguinis or
coagulable lymph  beneath the  epidermis.  This  fluid, at first trans-
parent and  limpid, becomes milky and  opaque,  and a thin whitish
pellicle of false membrane is deposited  on  the  derma, and may be
seen through  the raised epidermis.
  The  confluent and the  discrete variety  of  smallpox frequently
occur together in the same  individual, the eruption being confluent
on the face,1 and discrete on the rest of the  body.  When the con-
fluent form extends to the mouth and  pharynx, the mucous membrane
is covered with pustules, deglutition  is rendered exceedingly painful,
and respiration is seriously impeded. In the trachea the eruption
gives rise to cough, and in the nasal passages to sneezing and catarrh.
On the eyelids the pustules produce great  tumefaction  and severe
inflammation  ofthe conjunctiva.
  The eruptive period occupies five days: one  corresponding with
the varous stage, and  the four following with  the vesicular stage.

  1 The eruption is always confluent on those parts of the body where some external
source of irritation is added  to that of the  disease.   Hence the eruption is  most
abundant on the face, hands, buttocks, and inner sides of the thighs of children.
Sydenham  remarks, that  if there be 10,000 pustules  on the  entire body, 20UO of
these will occupy the face. 
ERUPTIVE FEVERS.
463
  IV.  The period of suppuration or maturation commences on the sixth
day of eruption (ninth or tenth of invasion), by augmentation 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 and  flattened, and
their whitish appearance 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 the 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 surface;
isolated pustules, consequently, are not formed, but the production of
pus occupies a district of considerable extent.   On the  face, the raised
epidermis frequently begins to desiccate into a thin yellowish crust
before  the formation  of pus  is completed; the pus in  this case is
effused beneath 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, showing 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 last observed to  undergo the  suppurative
change.  The completion  of the suppurative stage on the eighth day
of eruption, is attended with considerable pain and throbbing,  with a
vivid redness of the skin, great tumefaction, and a distressing sensa-
tion of tension of the integument.  The swelling affects, in the first
instance, the head and face,  from  these  it extends to  the trunk and
limbs,  and from the latter to the hands  and feet.  The eyelids are
often 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 sympathizes  in  the
general irritation ofthe mucous surfaces, as  may be inferred from the
presence of diarrhoea.   And the nervous system is greatly depressed,
as is shown by  the listlessness and lethargy  which are  conspicuous at
this period.
  With  this extreme of local disorder, the secondary fever is estab-
lished,  and continues unabated until the close  of the eleventh day of
eruption.  In mild cases  this stage is  accompanied  with 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 smallpox the secondary fever is not developed until
the eleventh day;  the symptoms are severe, and often accompanied
by restlessness, which increases towards night.   This state of restless-
ness is  a dangerous symptom.
  V. The period of desiccation is indicated by subsidence of tumefaction
of the  skin,  by the drying  up of the pus and purulent  discharge
produced during the preceding period, and by the conversion of these 
464     DISEASES FROM UNKNOWN  ANIMAL POISONS.

fluids into scabs of various thickness.  Desiccation commences on the
face much earlier (eighth  day of eruption)  than on the rest of the
body, and it not unfrequently 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 desiccation of the entire pustule
with  its investing epidermis.  The  former  is  the  more  frequent
method of  their production.  When the  crusts fall,  an event that
occurs upon successive parts  of  the  body,  from the eleventh to  the
fourteenth day of eruption, the skin  beneath is of a bright red color,
retaining this hue for several weeks,  and the newly-formed epidermis
is thrown off by repeated desquamation.   The  cicatrices also which
have been produced by  the ulcerations now become apparent.
  In the 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 remains attached for ten  or twelve days.  When it falls off,  the
skin beneath  presents  a  vivid  red color,  and desquamates freely,
bringing into view  a surface too frequently disfigured with deep pits,
and seamed  with extensive cicatrices.  The crusts of confluent small-
pox are softened with the fluids poured out by the inflamed skin, and
their fall is  not completed till the twentieth or twent}r-fifth day.
  The desiccation of the pustules of smallpox is attended with severe
itching, which induces the patient to scratch, and  often to tear  the
surface with his nails.   By this  proceeding hemorrhage takes place
from the ulcerated surface, and the drying of the blood gives rise  to
a black discoloration of the scabs which  form over the wounded parts.
The desiccation of the pus and of the purulent discharges is attended
with a nauseous and offensive odor.
  It is remarked by Simon, that the  urinary secretion • in variola
undergoes changes having relation to the various stages ofthe 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 color is deep and red:  it is frequently turbid, and often
contains a  small quantity of albumen.  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 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 frequently  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
Schonlein, 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 odor is
observed, and the urine  contains a turbid, apparently purulent mucous
sediment, of an unpleasant odor."
  "During  the suppurative stage of  variola, Becquerel observed that
the urine retained the synochal character  as  long as  the symptoms 
ERUPTIVE FEVERS.
465
continued."   And in cases in which this fever persisted  until death,
the state of the  urine  also remained the  same.  Sediments and fre-
quently purulent mucus occur in the urine'of this period.
  "During the period of  desquamation the urine is either normal or
anaemic."
  In the nervous form of variola the urine is very  changeable, and
often  dark.   "In the  putrid form the  urine appears decomposed,
ammoniacal,  and  not  unfrequently of a  dark red  color, from the
presence of haematin." J

                      INOCULATED VARIOLA.

  The intent of the operation of inoculation is to bring some portion
of the fluid contained within the smallpox vesicle into relation, either
with the papillary surface of the derma, or with the tissues situated
immediately  beneath  the epidermis of a sound person.   When this
object has been effected, the inoculated particles dissolved  in the fluids
of the tissues are conveyed by imbibition into the system, and commu-
nicate to the  whole mass of the blood a disposition to the production
of matter of a similar kind.
  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 skin feels hard and dense when
touched with the finger.   On the fourth and  the fifth day these signs
continue gradually to  increase;  there is a  sensation of prickling 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 produced by the effusion of liquor sanguinis beneath the
epidermis, the  vesicle at  this period begins to be  depressed at its
centre, and to assume the umbilicated appearance.  On the seventh
day there.is tenderness of the  integument  around  the  vesicle, and
some degree  of pain on moving  the arm ;  the vesicle 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 attained its perfect development.   After the com-
pletion of the pustule the areola declines in redness, and its contents
desiccate, the desiccation taking  place during the period  intervening
between  the  twelfth and the fifteenth day, and  forming a scab of  a
deep brown  color, and considerable thickness.  The crust is thrown
off during the period  ranging  from the twentieth to the twenty-fifth
day, and is succeeded by a strongly marked cicatrix, which remains
apparent for  the rest of life.
  The period of invasion  of the constitutional symptoms in inoculated
smallpox 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 recognizable.  Instances are occasionally met
with in which the symptoms of  invasion are developed, and followed

                       1 Simon, vol. ii. p. 282.
       30 
466      DISEASES FROM UNKNOWN  ANIMAL POISONS.

by eruption, without any signs of inflammation in the inoculated part,
and consequently without the formation of a pustule.
  The period of eruption in inoculated smallpox is irregular, the
eruption appearing generally on the second or third  day from inva-
sion, or on the eleventh or twelfth from inoculation.   Occasionally it
is observed at the end of  a week after inoculation, and sometimes is
protracted  to a  fortnight.  The eruption is ordinarily  very slight,
sometimes failing altogether, or being scarcely perceptible ;  while, in
rare instances, it may occur at several successive  periods, or the  con-
fluent variety of eruption be developed.
  The eruptive period of inoculated smallpox is sometimes compli-
cated  with an erythematous  inflammation of the skin,  constituting
variolous roseola.

                     VARIOLA SINE VARIOLIS.

  This form  of  variola is rare; it has, however, been occasionally
observed during  the  prevalence of an epidemic of  variola, and is
characterized by the presence of the constitutional  symptoms and
mucous inflammation of that disease without the  cutaneous eruption.
Sydenham assigned to this affection the name of variolous fever, and
the accuracy of his  observations has been confirmed  by subsequent
writers.  Bayer remarks that he has  never  seen an instance of this
variety of smallpox.

                   COMPLICATIONS OF VARIOLA.

  Hitherto the favorable 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, often, fatal disorder.  These
complications  may  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 excessive severity,
the accompanying  fever runs high, the rigor wrhich  precedes it has
been  long and enduring, and the pains in  the  head, the chest,  the
praecordia, and  the  loins, are so violent  as to lead to the suspicion of
inflammation of organs situated in  those regions.   TheTe is sometimes
delirium and coma, at  other times  convulsions:  and death may occur
before the eruptive stage is established.   In cachectic states of the sys-
tem  the period  of invasion  is  sometimes complicated with passive
hemorrhages from  the mucous  membranes and from any trifling
wound of the skin,  and by petechiae in the tissues of both structures.
  The period of eruption, like the preceding, is liable to its accidents;
instead of its favorable course already  noted, serious congestions of
one or more of the  internal viscera may ensue.   Sometimes the con-
gestion is directed upon the brain and spinal cord, producing twitching
of the muscles, restlessness, convulsions, or coma; sometimes on the
lungs, causing bronchitis, pneumonia, or pleurisy; sometimes on the
mucous  membrane of  the alimentary canal, giving rise to diarrhoea,
dysentery, or hemorrhage; and  sometimes upon other of  the abdo- 
ERUPTIVE FEVERS.
467
minal organs.  In the cachectic diathesis, passive hemorrhages  and
petechiae may accompany 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
complications;  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 symp-
toms, is also the most dangerous in its complications, and the most
frequently fatal in its  results. Alarming symptoms sometimes appear
with astonishing rapidity, and destroy 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 accompanied with petechiae  and passive  hemorrhages,  and
in rare cases  disappear by the absorption of their  purulent contents.
The latter occurrence  is always  fatal.  Other dangerous indications of
this period are, the absence of  tumefaction and redness of the skin,
the absence of salivation, the appearance of the brown tongue of typhus,
restlessness and anxiety, mortification of any part  of the skin, &c.
  The termination of variola is a period of much  anxiety; for when
the disorder has run  favorably  through its stages,  and the danger of
the disease has apparently passed away, secondary affections are  not
uncommonly developed,  as consequences of the variolous inflamma-
tion.  Such are, chronic inflammation of the  various mucous mem-
branes, producing deafness, ophthalmia, opacity of the cornea, staphy-
loma,  oedema glottidis,  haemoptysis,  pulmonary  tubercles, chronic
bronchitis, pneumonia,  pleuritis, empyema,  chronic diarrhoea,  &c,
glandular enlargement, caries of the bones of the face, subcutaneous
abscesses, furuncles, erysipelas,  gangrene of the skin, disease of joints,
menorrhagia,  miscarriage, haematuria,  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 scarlatina,
and sometimes with  petechiae.   The latter form of smallpox is very
severe in its affection  of the mucous membranes and viscera, but the
cerebral symptoms assume a milder type.

  Pathology.—On examination after death of those who have fallen
victims to smallpox, several of  the internal organs are found to  pre-
sent traces of congestion, particularly the brain,  the lungs, and the
surface ofthe gastro-intestinal mucous membrane.  The tissue of the
lungs is generally found congested and infiltrated, and the serous  coat
of the bloodvessels  stained  of a deep red color.  Pustules are dis-
covered upon the mucous membrane  only when  the patient chances
to perish at the commencement of the suppurative stage.  At a  later 
468     DISEASES FROM  UNKNOWN ANIMAL  POISONS. '

period they are usually lost, on account of  the early rupture  of the
epithelium, which from its thinness and softness, is less resistant than
the horny epidermis.  For the same reason, pustules on the mucous
membranes never attain a size equal to those  of the cutaneous surface,
and  rarely contain  pus.  When ruptured, the surfaces 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
sufaces are, the extremities of the alimentary canal, where the epi-
thelium is thick, namely, in the mouth, pharynx, oesophagus, and rec-
tum ; Bostan detected them throughout the entire intestinal canal, on
the respiratory mucous membrane,  namely, in the  larynx, trachea,
and bronchi, and in the urinary bladder.
   The form of the pustule of smallpox is strikingly modified in re-
ference to the seat of its development.  Thus, on  the face, where the
pustules advance very rapidly to maturity, they are flat and non-um-
bilicated.   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 white
margin, and  non-umbilicated.  Usually, the umbilicated centre pre-
sents a reddish or brownish tint, and sometimes, though rarely, is per-
forated by the  shaft of a hair.
   When a well-formed and mature pustule is examined by dissection,
it is found to be divided in its interior by a transverse  septum into
two chambers,  both containing pus.  The upper chamber is the larger
of the two, and they communicate with each  other, to a greater or less
extent, by the  rupture of the transverse septum  around its marginal
border. The epideYmis, forming the superficial boundary ofthe 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 color, 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 formation of pus
beneath it, and at the  same  time  it is broken around its edges, and
 permits the pus of the deeper cavity to communicate with that already
 contained in the superficial chamber.  In consequence of the peculi-
 arity in the mode of its production, this layer of false membrane gene-
 rally retains permanently 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 color, and highly
 vascular.
   Some difference of opinion subsists with  regard to the cause ofthe
 ujnbilicated appearance ofthe pustule of variola during its early stages.
 Dr. Heming many years since attributed  it  to the perforation of the
 pustule by the efferent duct of a sebiparous gland.  Velpeau, who
 believes that the  principal  seat  of smallpox is the  follicles of the 
ERUPTIVE FEVERS.                   469
derma, would, I suppose, entertain the same opinion.   Other writers
believe it to be produced by the pores of the skin, and Baver refers it
to the attachment of the false membrane.  I agree with Velpeau that
the follicles of the skin are the primary seat of the vascular conges-
tion, that this congestion gives rise to the  production of the papules
or van, and consequently that the epidermal sheath of the follicle is
the probable cause of the umbilication of the smallpox vesicle.  When
the vesicle is examined at its height of development, it is found  to be
multilocular in structure, and, when  divided by a transverse section,
exhibits  an appearance which Gendrin has compared  to a spice-box,
while Bousquet likens it to a severed orange.
   Diagnosis.—The precursory symptoms of smallpox 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 usual, and the  pains
in the limbs are  somewhat  greater than in other exanthemata, and
convulsions in children are more frequent.  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 the symptoms is
confessedly 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 pre-
vious^ symptoms as by the  more  decidedly popular character of the
eruption, and the rough sensation which the papulae communicate to
the finger.   It is utterly impossible to confound the mature pustules
of smallpox with any of the pustular affections of the skin.
   Causes.—It is affirmed by Mr. Moore,  in his " History of Small-
pox," that  this disease existed in China and Hindostan 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 Maho-
met, 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 communicated  to  the Crusaders, and the latter caused  s
its rapid  spread throughout Europe.  " There was no smallpox 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 smallpox, was landed on the Mexican coast.   From
him the disease spread with  such desolation, that within a very short
time, according to Robertson, three millions and a half of people were
destroyed in that kingdom alone.   Smallpox was introduced into Ice-
land 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 for  the first time 1733,
and spreading so fatally as almost to  depopulate the country.1
1 Dr. Watson's Lectures, first edition, vol. ii. p. 657. 
 470     DISEASES FROM  UNKNOWN  ANIMAL POISONS.

   Smallpox 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 affec-
 tion, or  epidemically.  In  the latter form its  invasion  is most fre-
 quently observed in the summer or the autumn season.
   The cause of smallpox  is  a  specific  animal poison j1 the  period
 when  transmission is most  likely to happen  being the  suppurative
 stage, and when developed epidemically, it is propagated  in the direc-
 tion of prevailing winds.   As a general rule, smallpox attacks but
 once in  a lifetime, but against this rule many  exceptions have been
 recorded.  Instances have  been observed, in which the disease has
 invaded  a second,  a third, and  even so often as a sixth time.   Some-
 times the subsequent attack is as severe as the first, but  usually the
 secondary affections are remarkable for mildness and rapidity of course.
   The protective agency of an attack of variola against subsequent
 invasions of the disease was known at a very early period in medical
 history; thus, inoculation  was practised  in  Constantinople 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 produce an attack of the disorder, at a
 period  when the physical powers are sound and capable of resisting
 its influence ; moreover, it is found that  the  inoculated  disease is
 always more mild than the  sporadic affection.  Several serious objec-
 tions, however,  raise themselves against inoculation, and one of these
 so  great as to have  been deemed worthy of a restrictive Act of the
 Legislature.  The most obvious  reasons that oppose themselves are,
 firstly, that the  system is equally, perhaps more safely protected  by
 the milder operation of vaccination;  and, secondly, that inoculation
 often produces  a severe and  dangerous disease.  But the most im-
 portant objection 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 the
 source of a fatal and devastating  epidemic.  An instance of this kind
 is related in the memoirs of Maria-Theresa of Austria, who, having
 inoculated a number of children, the smallpox was communicated
 by the latter to an entire village.
   Prognosis.—In the discrete form of  variola, or when the eruption
 is slight, and its course mild,  the prognosis is favorable, the disease
 usually terminating in from 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.   Smallpox is of unfavorable prognosis when
 it presents irregularities in its course ; when it is complicated  with
 much cerebro-spinal or pulmonary irritation; when the pustules contain
 a sanguineous fluid, or  are intermingled with  petechiae; when the

  1 Several authors have imagined the cutaneous eruption of smallpox to depend
upon the presence of minute animalcules : but careful observation affords no  ground
for this supposition. 
ERUPTIVE  FEVERS.
471
eruption is associated with debility of system in the patient, or with
signs of mental depression, as fear, &c.; when the pock does not pass
regularly through its stages, or when the persons affected are plethoric,
and unused to disease.
  Treatment.—The uncomplicated form  of smallpox requires  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  determination  to  the surface, 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 a congestion of  the
mucous  membrane of  the   alimentary  canal  that  may  terminate
seriously.
  The treatment of variola in its simple form is consequently expect-
ant ; 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 febrifuge salines, such as the citrate of potash, or liquor ammoniae
acetatis,  or effervescent  salines;  and at a more advanced period, a
continuance of gentle  laxatives  or enemata, and opiates  to  relieve
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 carefully watched.
  The sesqui-carbonate of ammonia treatment, so valuable in rubeola
and  scarlatina, is equally  applicable to variola, for ammonia  is, pro-
bably,  as Dr. Charles Witt observes: " The only medicine yet  known
which  appears to have any decided effect upon this terrible malady ;"'
that is as a specific remedy.  The manner  of  administration of the
ammonia should be the  same  as that laid  down under the head of
treatment of scarlatina; and  the general precautions taken, and  the
management of the patient, should be the same.  My own experience
of the sesqui-carbonate of ammonia fully corroborates the value of
Dr. Witt's suggestion;  and I feel  that the adoption of this method of
treatment  cannot be too forcibly  pressed on the attention of medical
men.  If it be capable of effecting only one-half of what its advocates
claim in its favor, it must, of  a necessity,  rank among the most valua-
ble of  our  remedial appliances.

  1 Dr. Charles Witt mentions a paper read at the Epidemiological Society of London,
from the pen of Mr. H. C. Miles, of the Royal Artillery, Halifax, on the subject of a
remedy for smallpox, used by the  Indian tribes,  in that portion of Canada.  This
remedy is an infusion of the Saracenia purpurea, a variety of the pitcher plant.  A
wine-glassful of the infusion throws out  the eruption ; and the same dose  repeated
once or twice, after an  interval of  four to six hours, puts an end to it completely.
During the prevalence of an epidemic a wiueglassl'ul is taken daily as a prophylactic. 
472     DISEASES FROM UNKNOWN  ANIMAL POISONS.

  If the cerebro-spinal system be  much disturbed, leeches to  the
mucous membrane of the nose or behind the ears, with mustard foot-
baths,  are indicated; gargles for inflammation  and dryness of  the
mucous membrane of the mouth and fauces;  leeches to the epigas-
trium  for pains in that region with violent vomiting; mineral acids
with infusion of roses,  for hemorrhages ; aud emollient applications
to the  eyelids where the conjunctivae are painful  and swollen.  If  the
eruption be tardy in its appearance, the patient may be immersed in a
warm bath, at the same time that tartarized antimony and sudorifics
are administered  internally.   Opiates are contra-indicated in  the
primary fever, on account of the extreme excitability of the nervous
system; in the secondary fever they are frequently useful.  Syden-
ham recommended a small bleeding at the commencement of  the
secondary fever, and following it  up with an opiate;  but he cautions
us against abstracting too much  blood.  The safer practice is not to
bleed,  and in this opinion  the profession are generally agreed.
  These are  the remedies  which are  applicable to  smallpox in its
ordinary and uncomplicated form ; but when the disease assumes any
of the unfavorable  characters which  have been described, 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 symptoms  indicate serious congestion of
viscera; the abstraction of blood must, however, be conducted with
caution, less  too great debility follow its use.  Counter-irritation is
applicable when the removal of blood  by bleeding would be inadmis-
sible.  Under the same circumstances, again, mild  purgatives may be
administered, when symptoms of gastro-intestinal irritation are absent.
But  purgatives, it must be recollected, are calculated to  excite and
keep up irritation ofthe mucous membrane, and  they may  frequently
be very judiciously superseded by emollient injections.   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 delirium,  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 hydrocephalus, or, still
better,  the cold cushions of Dr. James Arnott.1
  When the nervous system is especially affected,  as in that variety
termed by Dr. Gregory nervous variola, the administration of tonics
is called for; and similar  means must be adopted when there is evi-
dence  of a cachectic  state of constitution,  as in the occurrence of
petechiae, passive hemorrhages, &c.  Whatever the treatment adopted,
however, these cases are too frequently fatal.
  Cold affusion has, at various times, been extolled by eminent prac-
titioners, 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

                  1 See Lancet, vol. ii. 1S41-2, page 441. 
ERUPTIVE FEVERS.
473
 of the body, or the face alone.   Cold water does not appear  to have
 the effect of causing  retrocession  of the pustules, but is  thought to
 increase the congestion of the mucous membranes.  My brother, Dr.
 Marris Wilson, has pursued the practice of sponging the surface for
 several years, and he assures me with the best success.
   The belladonna treatment recommended for  scarlatina is  also ap-
 plicable to smallpox.  I have seen this remedy exhibited with benefit,
 both as a prophylactic and a curative measure.
   Vaccination has been observed to possess the power of modifying
 variola, even when an attack of  the latter has commenced.  Some
 remarkable cases are on record in which the good effect of this remedy
 was apparent; and it recommends itself by  its extreme simplicity.
 Eichhorn, who was the projector of the plan,  inserted the  vaccine
 lymph by forty or fifty incisions, immediately that the symptoms of
 smallpox became apparent.
   As regards local treatment, various plans have been adopted  and
 recommended for the purpose of bringing the pustules to a favorable
 issue, and preventing the  deep ulcerations  with  their  consequent
 cicatrices, which are apt to ensue when the eruption is left'to itself.
 We will now proceed to consider 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  desic-
 cating process  is accompanied.   The face  should  be frequently  and
 well bathed with an infusion of poppies, or mallow, with weak barley-
 water, or a weak  solution of common salt, particularly in the region
 of the eyes, nose, and lips.   The secretions from these 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.   But a better  means of relieving the
 heat and dryness of the skin, and that state  which conduces to  itching,
 is by anointing the surface plentifully with the benzoated ointment
 of oxide of zinc.  This should be applied pretty thickly, and repeated
 as often as it dries up or becomes thin from wiping or rubbing.  The
 ointment will not interfere with the  escape of secretions, or 'with the
 removal  of such secretions when effused  on the surface; but will
 tend very considerably to the comfort of the patient, by keeping  the
 inflamed skin soft and moist.  Some fragments of tissue paper pressed
 gently on the ointment will  further contribute to the protection of
 the skin.
   The importance of keeping the surface  moist, and excluding  the
 atmosphere, would seem to  have suggested  to Ferdinand  Hebra,  the
 renowned Dermatologist, of Vienna, the application of his apparatus
for maintaining a  permanent warm  bath, to cases of smallpox.  A
butcher's  apprentice,  eighteen  years of  age,  seized with confluent
variola, was placed in  the bath on the fifth day of invasion, and just as
the eruption was in course of development;  and  retained  there until
the seventeenth day, when the  crusts had  fallen.   Hebra expresses
his satisfaction at  the result of the experiment, although, during  his 
474      DISEASES  FROM  UNKNOWN ANIMAL POISONS.

confinement in the bath, the patient was attacked  with pleuro-pneu-
monia dextra, nevertheless, as far as the variola was concerned, the
fever remained moderate, and the eruption  passed favorably through
its course.   I should be sorry to prejudge this method of treatment;
but I am disposed to regard it less favorably than the treatment by
the sesqui-carbonate of ammonia, with the local  application of some
material which shall form a coating to the skin, capable of excluding
the air and possibly  the light, and at the same time of  maintaining a
permanent state of moisture by retaining the evaporated  fluids of the
cutaneous surface.
  Great benefit is derived from pursuing the practice of the Arabian
physicians, namely,  opening the matured  pustules,  gently pressing
from  them  their  contents,  and removing the latter  by means  of a
sponge  moistened 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.
  Various ectrotic1  methods of arresting  the  development  of  the
eruption of variola,  and, consequently, of preventing  the occurrence
of cicatrices, have, from time  to time, been suggested  and employed.
Nitrate of silver has  been used for this purpose by 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 necessarily attended  with pain, and requires
time for its  performance.   To obviate  these objections, it has been
proposed to  paint the entire  surface with  a solution of  nitrate of
silver, containing fifteen or  twenty grains to the  ounce; this applica-
tion 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.  Moreover, the solution
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 eruption 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 applica-
tion than the practitioner can devote; and thirdly, it  augments  the
febrility and  nervous exhaustion of the patient.
  Another ectrotic remedy has  been warmly eulogized by Dr. Midi-
vaine,* of Ghent.  It consists in the  application of sulphur ointment,
by means of slight friction, to the entire surface of this skin.  This oint-
ment 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 ofthe
disease.   The effects  of the  remedy, according to Dr. Midivaine,  are,
contraction and  hardening of  the papulae, diminution of  tumefaction

 1 'EHTiTfais-Ktiv, to render abortive.     2 Bulletin de la Soc. Me"d. de Gand, 1840. 
                        ERUPTIVE FEVERS.                   475

 of the skin, and subsidence of the gastro-intestinal irritation.  The
 appetite  of the  patients  quickly returns,  and  they are speedily
 restored to health.
   A more important ectrotic remedy than either of the preceding is
 one which was made the subject of an essay,1 read before the Parisia*n
 Medical Society, by their President, Sir Joseph Oliffe.  This remedy
 is mercury, applied to the external  surface of the body, and is  one
 which  is  deserving our most attentive  consideration.   Mercury
 administered internally has long been  known to possess  remarkable
 powers in modifying the influence of variola upon the system, but it
 was left to modern times to prove that this  agent has also the pro-
 perty 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 suc-
 cessfully pursued by Briquet.   The mercury was employed by these
 gentlemen in the form of a plaster, the emplastrum vigo cum raercurio,
 of which the formula in the French pharmacopoeia is as follows:—
      R.—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
         Spirit of Lavender......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 mer-
 curial plaster the  development  of the eruption  was arrested; 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 off during the night which followed 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 ofthe
 epidermis, and surrounded with  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 established, 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 ofthe mercurial ectrotic is thus stated by
 Sir Joseph 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 little  mercurial ointment is applied  to the eyelids."  "The
plaster is allowed to remain for three days in simple smallpox, and
for four in  confluent."   In the event of any  objection  to the plaster
1 Lancet, vol. i. 1840-41, p. 674. 
476      DISEASES FROM UNKNOWN ANIMAL POISONS.

arising, mercurial ointment may be substituted with a fair prospect of
benefit.  I recently suggested this plan of treatment to a young prac-
titioner who had several cases of smallpox under his care ; he reported
to me that withiu half an  hour  of applying the unguentum  hydrar-
gyri fortius to the skin, the troublesome itching was entirely stopped,
and the pustules ceased to grow.  Serres entertained the belief that
the mercurial treatment would effect the miscarriage of the eruption,
at whatever period it  was  used ;  but Briquet has satisfactorily 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 produce immediate resolution of the eruption, or to arrest it at
the papular or  vesicular  stage; it never  becomes purulent, and the
skin between the pustules  is never inflamed and swollen.  But, how-
ever powerless  as a perfect ectrotic the mercurial application may be
when used in the pustular stage, it would seem, from  the evidence of
Sir Joseph Oliffe, that the  local  inflammation is  much  modified and
ameliorated.  According to Briquet,  " the mercury acts as  an  anti-
phlogistic, or resolutive, in destroying or suppressing the local  inflam-
matory process; or it exercises a specific  action on the  cause, what-
ever it be, which-produces the variolous pustule."  From his researches
on other  inflammations 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 experiments,
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.
   The mercurial ectrotic treatment has been adopted with success by •
Dr. Hughes Bennett, in Edinburgh.   He  employed an ointment con-
sisting of the unguentum hydrargyri fortius, an ounce  mixed with one
drachm of starch powder.   The  ointment was applied pretty thickly
over the face night and morning, with the result of preventing  itching
and swelling of the skin,  the deep red stains which  smallpox com-
monly leaves behind it, and the  formation of pits.  In the instance of
two sisters, in whom  I employed  a similar means, all irritation and
discomfort of  the skin was prevented;  but symptoms  of salivation
showed themselves in the  course of a  few days, the mouth was tender,
and the salivary glands enlarged and painful.  If the same beneficial
result could be obtained without the mercury, the discovery would be
of much importance.
   I have not heard of any injurious  effects following the use of the
mercurial ectrotic, but M. Piorry has recommended in its stead the
application of blisters.  The advantages of  his method he conceives
to be the  avoidance of any risk of salivation, and of the danger of
repulsion.  The blister, he remarks,  is derivative in its action, and
not repellent; but  he, at  the   same time,  admits the  possibility of
ischuria as a consequence  of its  use.
   I cannot recognize  for a moment the doctrine of repulsion, or the
theory upon which it is  based,  in connection with  the arrest of the
serious effects of smallpox upon the face; the only part of M. Piorry's 
ERUPTIVE  FEVERS.
477
objeotion which merits attention is the chance of exciting salivation,
which is known to be an occasional  normal accompaniment  of the
variolous fever.   If this fear  should sway the. mind of any  of my
readers, and if salivation, on the one hand, and ischuria on the other,
■should seem to them  to prohibit the  use  of both remedies, there  is
another, against which neither objection holds;  although  I believe
it to be inferior in power to the mercurial ectrotic.  I allude to the
tincture  of iodine.  This  fluid is  to be pencilled  on the  eruption,
at as early a stage as possible, once or twice a day.  Dr. Crawford,
of Montreal, first  called attention to  the remedy, in 1844, and gave
a favorable  report of its success;  and  his report  has been cor-
roborated by the subsequent practice of other medical men in British
America and the United States.  Its good effects  are, the alleviation
of inflammation, pain, swelling, and itching, the arrest of development
of  pustules, the  prevention  of the  red  stains which  follow the
eruption, and the considerable reduction in extent of the pitting  of
the skin.   In this latter respect, the tincture  of iodine  is decidedly
inferior to the mercurial ectrotic.
   The impermeability, tenuity, transparency, and simplicity of appli-
cation of  collodion, have given  it a  place  among  the substances
which, acting upon the property of excluding air, have been employed
as ectrotic remedies.   It  possesses the advantages' of extreme clean-
liness, and of enabling the operator to see what  is passing beneath,
without requiring to disturb it.  Another  of its  properties, namely,
its contractility, must  also be considered as an agent in its  beneficial
effect, since by means  of the peculiar  pressure which it  exerts upon
the  skin,  it  will  disperse the  congestion of  that  tissue.  Being
incapable of producing ptyalism, it is free from any objection of that
kind.  It has been made the  subject of experiment in France, and
favorably reported on  by Dr. Aran, of the hospital Bon Secours.1
   The ethereal solution of mastich and iodine2 of Dr. Thomas Smith
Rowe, of the Margate  Infirmary, would, with less iodine, probably be
found to be an improvement on  the tincture of iodine or collodion,
and to combine the properties of both.
   An impression subsisted among  the ancient physicians,  that the
light of the apartment in which smallpox 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,3 of New Orleans, asserts, that in his practice no  instance
of pitting after  smallpox occurred  when  the light  was shut out.
Serres places a glass capsule over a smallpox pustule, and observed
the effects produced by excluding the  air and light.  He found that,
in proportion 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,  Serres

              i Bulletin de Therapeutique, vol. xxxix. p. 369.
              2 Vide il Selected Prescriptions."
              3 American Journal of Medical Science. 
478     DISEASES FROM UNKNOWN ANIMAL POISONS.

remarks that he never reaped  such successful results, in the cure of
smallpox,  as he  did at  La Pitie*, during one year  that the  patients
were  placed in a  kind  of cellar, which was very dark, and ill-ven-
tilated.    The same principle has been  recently  acted  on by M.
Legrand, who  proposed  to  the Academy  of Medicine, in 1839, the
plan of covering the surface of the body with gold leaf.   After the
experiments of M. Fourcault  (page 79), this practice would appear
somewhat hazardous.
                         VARICELLA.
Syn.  Modified Smallpox.  Varioloid.   Spurious Smallpox.   Variole
  pusille ; verrucose; crystalline.  Variola  lymphatica.   Verole volante.
  Fran.   Unachten Kindpocken.  Germ.
  During  the  prevalence  of an epidemic of smallpox, 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 extremes  has been denominated
benignant smallpox.  Upon closer investigation, it is  perceived that
benignant smallpox, and all the most  serious varieties  of this disease,
are characterized  by the  appearance  of eruption  pursuing a given
course within a   given  space of time, and presenting  a  regular
succession 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 constitutional nature,
and their course is limited to  a shorter period.  It  is to this second
group that the term varicella   (modified smallpox) properly applies,
and under this head I shall proceed to describe the  different varieties
which smallpox, in its modified form, is capable of  assuming.
  Variola, it has just been observed,  occasionally appears in  its  vari-
cellar 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 affected with varicella in
this instance may, during a future epidemic, be attacked with  genuine
smallpox.   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 smallpox.  Hence,
after the preparation of the system by either of these affections, the
contagion  of variola give's rise generally to varicella, and but rarely
to the genuine smallpox.  If other proof were needed of the close
relation subsisting between variola and varicella, it would be found
in the fact that the latter is infectious and  contagious,  and is capable
of communicating true variola to a sound person.
  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  smallpox.  Thus, if the variolous  disorder were to expend 
ERUPTIVE  FEVERS.
479
itself  in  its first stages, we should have a varicella resembling the
papular eruption of smallpox, in  other words, a papular varicella;  if
the variolous disorder progress beyond this stage, we shall then have
a vesicular varicella; 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 trans-
formed 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 globular pustular varicella;  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 umbilicated pustular varicella.   Moreover, it
has been remarked, that  in varicella, as in variola, the constitutional
affection may be present  without the  eruption, constituting  varicella
sine varicellis.
   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  on  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 down; 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 varicellis.
   Varicella makes its invasion with symptoms  resembling   those of
smallpox, but much milder in degree.  In some instances 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, nausea, vomiting, pains in the loins and
in  the  head,  with  accelerated 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 smallpox.   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  constitutional
symptoms,  and without  the secondary or suppurative fever which
occurs in smallpox.  The pustules speedily dry  up and form thin
brownish scabs, which fall in another few days, and leave but^a slight
and transient pitting ofthe skin, with a few discolored red or  purplish
spots.   When, however, the pustules are  broken and lacerated by
scratching, cicatrices of small size occasionally result.  Varicella  in 
480     DISEASES FROM UNKNOWN ANIMAL POISONS.

its progress, is accompanied by a broad and patchy areola of a pale
red color, which contracts its boundaries as the pustule advances and
ultimately forms a narrow, brownish circle around its circumference.
  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 color, and a specific gravity of 1.022-7."1

               UMBILICATED PUSTULAR VARICELLA.

   Syn.  Varioloid.  Modified smallpox.  Varicella cellulosa, Cross.
  The precursory  symptoms of this variety  of modified smallpox
usually continue for three or four days, and are succeeded by an
eruption of red spots, which soon become hard and papular in the
centre.  On the second day of eruption the papulae are conical in
form, and vesicular at their points.  On the third and fourth days the
vesicles increase in size, and become flattened and umbilicated, 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  with yellowish brown  scabs, which, in a few
days  more, are detached and fall off.  The  process of desiccation
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  successive 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.

                  Svn. Globular varioloid.  Hives.
  The globular variety of varicella is characterized  by the form and
large size of the pustules, which surpass those  of all the other vari-
cellas.  At its height the dome of 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 se-
vere.  They are succeeded by the eruption of a number of red spots,
having il their centre a small, prominent,  and globular papula, which
speedily increases in size and becomes  vesicular at  its summit.  On
1 Simon, vol. ii. p. 282. 
ERUPTIVE FEVERS.      ,            481
 the second or third day of the  eruption, the contents of the vesicles
 assume an opalescent and pearl-white color, particularly towards the
 centre   On the fourth and fifth davs, the vesicles go on increasing in
 size, the contained fluid becomes purulent,  and the areolae, by which
 their bases are surrounded, of a bright red  color.  On the sixth the
 vesicles attain their greatest bulk, their contents are  more purulent,
 and the areolae  still further increased in redness.   On the seventh and
 eighth  days they  begin to diminish,  their parietes  are flaccid and
 wrinkled, and desiccation is established.  On the ninth day the desic-
 cation of the pustules is completed on  the  greater part of the body
 and they are converted into brownish lamellated scabs, which are
 loosened and thrown off during the two or three succeeding days,
 leaving behind them some slight  impressions, and a temporarv con-
 gestion of the derma.
   Globular varicella is not unfrequently mingled with the pustules of
 the umbilicated and conical varieties.  The ordinary duration of this
 eruption is ten or twelve days, but if the pustules  be  developed  suc-
 cessively it may be continued for a few days longer.

                      VARICELLA CONIFORMIS.

                 Syn. Conical vanohid.  Swine-pox.
   The conical variety of varicella is recognized  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  epidermis.   During  the  third day the size of the
 vesicle is increased, its form has become more  distinctly  conical, and
 its base more hiefhly inflamed.  During the fourth  and fifth  day, the
 vesicles still 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 yellow-
 ish brown color, which falls 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 unfrequently intermingled with the pustules of the
 umbilicated variety.  The ordinary duration of the eruption  of vari
 cella coniformis  is  eight or ten days, but when it occurs iu successive
 attacks, it may be continued for  a fews days  longer.
   When the vessels are torn and  broken  in attempts made by the
 patient to relieve the itching, the spots become inflamed, they ulcerate,
 and secrete a thick pus, which concretes into scabs of a greater thick-
 ness than those of  the natural pustules.  These scabs  are of a dark
brown, or blackish color, they remain longer than the  thinner scabs
of the pustules, and  leave cicatrices at their fall.  Suqh accidents occur
most frequently  upon the face.                           ->
      31 
482      DISEASES FROM UNKNOWN ANIMAL POISONS.


                     VARICELLA VESICULARIS.

      Syn.  Varicella Untiformis, Willan.   Varicella lymphatica.
                           Chicken-pox.
  Vesicular varicella, or  chicken-pox, is preceded  by febrile  symp-
toms, which are very mild in the discrete form of the eruption, but
severe in the confluent kind.  The eruption  makes its appearance in
the form of small, red, and slightly 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, the vesicles go
on progressively increasing; they are flattened on their summits, and-
the contained 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 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 developed, so that the eruption  may be seen
at once  in all its stages, and may be prolonged to ten or twelve days,
and sometimes to  two or three weeks.  The  eruption of chicken-pox
appears first 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.

Syn.  Varicella verrucosa.   Horn-pox.   Variole verninose; verrucosa^.
  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  papulae, 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  pustules.  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.

   Varicellar fever occurs chiefly in those who have been  inoculated
or vaccinated, or have previously suffered from variola.  It is occa-
sionally, though rarely, observed during the prevalence of epidemic
variola.

   Diagnosis.-^Varicella  differs from  smallpox  in several  essential
particulars, namely, in the  lesser  degree of  severity of the  constitu-
tional symptoms;  in the shortness, of course, of the eruption;  in the
absence of secondary fever; in the appearance of the eruption at its
height;  in the minor degree of inflammation surrounding the pustules;
> 
ERUPTIVE FEVERS.
483
in the thinness of its scabs;  and in its freedom from permanent im-
pressions and cicatrices.
  At the earliest moment of eruption, it is impossible to establish a
distinction, since both affections are developed  in  the form of red
spots with central stigmata.
  Causes.—Varicella originates in the variolous contagion, and fre-
quently precedes or follows an epidemic of smallpox.   This observa-
tion would  lead to the  inference that,  at the  commencement, the
variolous contagion had  not yet gathered sufficient power to excite
true smallpox in any but the most susceptible, and that, at the con-
clusion of the epidemic, the contagion had lost the strength  necessary
to awaken  any but a modified affection.  The inference, in truth, is
correct; for when in a state of dilution, the  variolous contagion  is
capable of  producing only  varicella  in  persons of average suscepti-
bility.  In those who possess the susceptibility of infection  in a high
degree, true variola may be excited; and for the same reason, the con-
tagion of varicella is apt to communicate variola to individuals so
constituted.   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 modification of the system, pro-
duced by vaccination, by inoculation, or by a previous  attack of
variola.
  Varicella is infectious  and contagious, and  transmissible  by inocu-
lation.  Its  contagion may excite  either varicella or true  smallpox.
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 the nature of the contagion.  Varicella may occur
repeatedly in the same person, and it possesses less preservative power
against the contagion of smallpox than vaccination.
  Vesicular varicella, or chicken-pox, is stated to have occurred as an
epidemic, and independently of variola; Dr.  Mohl1  observes, that at
Copenhagen  the chicken-pox  occurred  annually between  the years
1809-1823, without any association with smallpox.  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 inoculated, varicella of the same kind is some-
times developed, at other times the pustular  form,  and again, true
smallpox.
  Prognosis.—Varicella is generally a mild disease, and one of favor-
able termination.  Sometimes,  however, it issues fatally, and during
certain variolous epidemics, is remarkable for the severity of its con-
comitant symptoms, or for a fatal tendency.  The umbilicated pustular
varicella is the  most serious of its varieties.
  Treatment.—The treatment of  varicella is to  be conducted on the
1 De Varioloidibus et Varicellis. 
484     DISEASES FROM UNKNOWN  ANIMAL POISONS.

same principles as 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 sim-
plest antiphlogistic management  is all that is needed.


                          VACCINIA.

 Syn.  Variola vaccina.   Variole vaccine.   Cowpox.  Cow smallpox.
  Variola vaccina, the smallpox of cattle, is a contagious inflammation
of the skin, prevalent among cattle, and occasionally communicated
to man.  It  is characterized by the development, 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 accompanied by constitutional symptoms, which are mild
during the first stages  of the  vesicle, but  become  more severe, and
constitute a  secondary  fever,  when the  local inflammation arrives at
its height, and the suppurative process  is about to be established.
  The existence of a disease identical with smallpox among the infe-
rior animals, is a theorem that might,  d priori, be predicted.  It is
perfectly consistent with our  knowledge  of the physiological  laws,
and comparative structure of man and  animals.   It is a position  well
established with regard to some other diseases, and there can  be no
doubt  that  still further  analogies in relation to pathology will be
unveiled by future research  in that  most interesting department  of
medical science.  The announcement of the discovery of a disease
analogous to  smallpox 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 physio-
logical education; but when  this  declaration was  made in 1796 by
the immortal Jenner, it was a bold soar of genius, and too enlightened
for the philosophy of his age.  It  is now, however, well established,
that smallpox has for centuries been prevalent among  animals in all
parts of the  world ; that it has made its invasion as an epizootic,  and,
for the most part, in  connection 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 engen-
dering in the latter animal an eruption that could not be distinguished
from the true vaccinia.  This disorder  in  the  horse was,  unquestion-
ably, the equine smallpox; it  was, however, from the circumstance of
its development in a situation  where, from  the thinness  of the skin,
eruptive disease in a mild form would most  naturally occur, namely,
in the heels, confounded with a more common disease of  that region,
the grease.   By a wrong  inference drawn  from  this observation, an
inference perfectly natural and perfectly excusable in the state of sci-
ence at that  period, an  inference which its distinguished author subse-
quently relinquished, namely, that the variolae vaccinae had their origin
in the horse, Jenner created an argument which, for many years, was
industriously  employed  as  an objection  to the philosophy of his 
ERUPTIVE FEVERS.
485
views;  with how little injury to the splendor of his discovery, we
who live can tell.
   In the excellent report1 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 Hima-
layas, in the plains of Lombardy, 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 disease the self-same
appellation that they give to the  smallpox in the human  subject,
namely, bussunt, mhata, 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 upon the question of the history
and analogies of cowpox, that I shall content myself with stating the
facts which I conceive to be established relative to this disease, and
the principal observations  by  which those  facts are supported.  The
facts to which I allude are—
   1. The prevalence,  at the same period,  of the cowpox among cattle,
and the smallpox among men.
   2. The transmission by contagion of the smallpox to cattle, and the
consequent development of cowpox  in those animals.
   3. The transmission by inoculation of the smallpox to cattle, and the
consequent development of cowpox  in those animals.
   4. The  transmission by  contagion of the cowpox to man, and the '
consequent development of a pustule similar in character to the vaccine
pock of the cow.
   5. The transmission by irtoculatian of the cowpox to man, and the
consequent development of a pustule similar in character to the vaccine
pock of the cow.
   6. The  transmission by  inoculation of  the cowpox to man, and the
consequent development of an  eruption similar to, if not identical
with, smallpox.
   The first of these theorems  appeals to history for its proof, 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  smallpox in  England.
Mr. Gibson,2 in a sketch of the province 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 Murshi-
dabad  in 1836,  observes, that the disease  among the 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 circum-
stances he infers " that the  unknown causes which favor the disease
in the human subject  have the same tendency in the cattle;  in fact,
that variola, and mhata  or gotee, owe their origin to the same cause."
Mr. Lamb, stationed  at Dacca, remarks, in  1836, that  during the

   1 Transactions of the Provincial Medical Association.  Vol. viii., 1840. p. 1.
   2 Transactions of the Medical and Physical Society of Bombay.  Vol. i. 
486     DISEASES FROM UNKNOWN  ANIMAL  POISONS.

prevalence of variola, the cowpox " appeared in one muhalla, and
carried off fifteen or twenty cows."
  The transmission by contagion of the smallpox  to cattle, which
rests upon the assertion of numerous observers, is strikingly illustra-
ted by  Mr. Ceeley,1 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 the hand of a  patient, Mr.
Pollard, aged fifty six, who had never had smallpox or vaccine, two
broken vaccine vesicles, which the patient said he had caught while
milking his own cows, some of which he knew were affected with the
same disease, and were then  very difficult to milk."   Mr. Pollard at
the same  time expressed  his conviction "that his  cows had been
infected from human smallpox effluvia,  to which  he  considered they
had been exposed."  It appears that the smallpox had been prevalent
in the village of Oakley, and  the last three persons attacked were two
women and a child.   " The two cottages in which these three patients
resided during their illness were situated on each side of,  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 full development of the
eruption, but frequently crossed the meadow to visit the other patients,
the woman and child, the  former being in great danger with the con-
fluent and  malignant  form of the disease.  She died  on Monday, the
seventh of September, and, according to custom, was  buried the same
evening.  The intercourse between the cottage across the close was,
of course, continued after this event. On  the following day the wearing
apparel of the deceased, the bed-clothes,  bedding, kc,  of both patients,
were exposed for purification on the hedges bounding the close, the
chaff of the child's bed was thrown into  the ditch, and the flock of the
deceased woman's bed was strewed about on the grass within the close,
where it was exposed and turned  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 morning
for this purpose, and were driven from it every afternoon, to be trans-
ferred 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 afternoon, the  infected articles above mentioned
were again exposed on the hedges, and the flock of the bed spread out
ou the grass, and repeatedly turned, where it remained till the morn-
ing, when the cows were  readmitted."   It appears, however, that the
removal of the infected  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 ou the grass, and the cows  amidst  it, and licking  it up.  The
proprietor  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

   1 Transactions of the Provincial Medical Association.  Vol. x., 1842, p. 211. 
ERUPTIVE FEVERS.
487
milch cows appeared to have heat and  tenderness of  the teats, upon
which, imbedded  in  the skin, were distintly felt  small hard  pimples,
which daily increased in magnitude 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 from 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 detachment 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 after  this  period, the cows became by degrees more and more
tranquil, as the tenderness and tumefaction  of the teats subsided, and,
finally,  milking was performed with comparative facility, 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 circum-
stance, 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 origi-
nated the disease in the other five animals,  whatever  that may have
been.   The sturk is not considered liable  to the vaccine; at least so
it is inferred in this neighborhood, because  no one has ever seen  the
animal  affected by it."
   It is  scarcely needful to add more evidence to that conveyed in  the
preceding paragraph, in proof of the communicability of the contagion
of smallpox 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.  Waterhouse,  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 an 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 smallpox ; the consequence was, the  cows had an eruptive
disorder on the teats and udders so like the  smallpox  pustule, that
every  one  in the  hospital, as well as the physician  who  told me,
declared the cows  had the smallpox."  Dr. Sonderland, of Bremen,
communicated  the smallpox contagion  to  cows, by  covering them
with sheets between which persons fatally affected with smallpox had
lain.  These experiments were successful in a few cases, after many
trials
   The  third proposition, namely, the transmission of smallpox to
cattle  by means  of inoculation, and the consequent development of
cowpox in those animals, is also established on abundant evidence,
for  the chief of  which we are again indebted to the zealous perse- 
488     DISEASES FROM UNKNOWN  ANIMAL POISONS.

verence of Mr. Ceeley, of Aylesbury.  It is stated by Dr. Macmichael,
in an essay read before the College of Physicians in 1828, that " vac-
cine matter having failed  in  Egypt, medical gentlemen were led to
institute certain experiments by  which it has been discovered that,
by  inoculating the cow  with  smallpox from the human body, fine
active vaccine virus is produced."  M. Viborg, of Berlin, is reported
to have inoculated cattle, and several other  classes of domestic ani-
mals, with success.
  Mr. Ceeley instituted  a series of experiments on  the inoculation of
the cow with variolous lymph in the month of February, 1839.   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 ofthe seventh
or eighth  day, presented the appearance 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  splen-
did."  Decline  commenced on the sixteenth  day, the crust was well
formed on the seventeenth, but was rubbed off prematurely.  In this
experiment  the vesicle  was retarded five days; the usual period of
maximum development ofthe variolo-vaccine  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 day.  By  the tenth day, they had attained their
acm6.   On the eleventh,  decline had commenced,  and  progressed
gradually till the twenty-sixth  day, when  the crusts fell, leaving
behind them smooth, rose-colored pits.
  The fourth proposition is one so well established as to  require no
especial remark.  The nature ofthe affection resulting from this con-
tagion is considered in the section entitled "Casual variolae vaccinae
in man."  The fifth proposition is equally satisfactory in its  proof;
the  effects of " primary lymph" from the variolae vaccinae will be
stated in a future page.
  In support  of the fact announced  in the sixth proposition, it has
been observed, that when the epizootic disease presented characters
of great severity, the symptoms produced on man by inoculation from
such cases were also severe, and often  serious,  contrasting strongly
with the mild affection  engendered  by the  virus from the  ordinary
discrete form of cowpox.  Mr. Macpherson, in  experiments with this
virus in Bengal, in 1837, found that  an eruption  was developed,
which was  identical  with smallpox.  Mr. Wood,  of Gowalpara,  in
1839, met with similar cases of so great severity, that he was led  to
contemplate the substitution of inoculation  with smallpox virus, as
a safer expedient.   At Silhet, Mr. Brown  removed some dark-colored
scabs from  a cow  laboring under variolous disease, and triturating
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 eighth day than  usual.
After two months, children inoculated from this stock were attacked
on  the eighth day  with severe fever, " followed by an eruption,  which
spread  over the whole  body, and, in one case, proved  fatal."  The 
ERUPTIVE
FEVERS.
4^9
 eruption so produced bore all the characters of true smallpox.  Thus,
 it would appear, that, as the smallpox virus, when introduced into the
 system of  the cow, is so modified by the vital laws which regulate
 the functions ofthe animal as to produce an eruption of cowpox; 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 smallpox.

                  VARIOLA VACCINA IN  THE  COW.
   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 mistaken for a more common vesicular disease of that
 animal, the grease.  The vaccine disorder is modified by a variety of
 conditions, such as the temperament of the animal, the  tone of its tis-
 sues, its state  of  health, the  thickness of its skin, and its color.  A
 slight difference is also observed in the disease, in relation to its origin
 in a spasmodic form, or as the result of contagion communicated by
 the hands of milkers; the former of these varieties Mr. Ceeley terms
 natural, the latter casual.
   Natural  variola vaccina makes its invasion with  heat and tenderness
 of the teats and udder,  unaccompanied by constitutional symptoms;
 the inflamed surface is uneven, and pimply to the touch, and papulae
 of a red color,  hard, and as large  as  a pea, are soon developed.  In
 three or four days from  invasion, the papulae have attained the size of
 a horse-bean; they are tender 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 epidermis is rubbed
 off', the surface of the corium  is of a vivid red color, with a small  cen-
 tral slough.  When uninjured, or merely ruptured, without the removal
 of the epidermis, the vesicles  desiccated into thick, dark-brown crusts,
 which  commence in the centre, and proceed  towards the circumfer-
 ence, appearing at  first inlaid in the marginal elevation,  and subse-
 quently extending completely over it.  The  surface from which the
 epidermis is removed becomes covered by thin, brownish scabs, which
 are termed  secondary.
   Casual variola  vaccina appears as an eruption on  the fifth or sixth
 day after contagion, in the form of small, tender papulae, which are
 developed upon the teats and neighboring surface of the udder.  By
 the sixth and seventh days the papulae have attained the size of a pea;
 they are reddish in color, and circular or oval in form.   On the sum-
 mit they become  gradually depressed, assume a yellowish-white and
pearlv  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 becomes more elevated, tense, and shining, more pearly or 
490     DISEASES FROM UNKNOWN  ANIMAL POISONS.

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 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 color
has acquired greater intensity, and the epidermis which invests them
becomes distended with an abundanceof 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
increase towards the circumference, until they reach and  overlap the
marginal border of the pock.   The induration and enlargement of the
latter diminish, and the crusts are  thrown off spontaneously between
the twentieth and twenty-third day, leaving a slightly depressed and
smooth cicatrix, of a  pale rose or whitish  color.  Such  is the usual
course of  the cow-pock, but it necessarily  presents many diversities
of appearance, dependent upon aggravation of symptoms, &c.  Thus,
instead of forming crust in the manner described, ulcerated and slough-
ing 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 eleva-
tions  with their central  depressions are intermingled with incipient
papulae, and while the crusts  are being perfected in some, the vesicles
are yielding in others to  the distension of their lymph.   This succes-
sion 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 the milker, and the  consequent revaccination of the
neighboring unaffected skin. Mr. Ceeley  has  observed  as many  as
sixty  pocks upon the udder and teats of a  single cow.

                   VARIOLA VACCINA  IN MAN.

  Variola vaccina may be communicated to man, either  accidentally,
or by voluntary  inoculation.  In the former case, the  contagion is
received directly  from the animal, usually from the cow,  but some-
times, as in  the case of variola equina, from  the horse.   It had long
been  observed, that persons who had suffered from this  disease were
preserved against the influence of smallpox, and thence originated the
practice, introduced  by Jenner, of transmitting  the contagion  artifi-
cially to man, by means  of inoculation.
  It is a principle, well established in pathological science, that the
animal system, once subjected to the  influence of any disease origin-
ating 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  undergoes 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 
ERUPTIVE
FEVERS.
491
 with regard to smallpox, 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,  smallpox,  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 mild form,  could be communicated  to man, life
 would be  spared, and the system equally defended against the subse-
 quent 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 smallpox.  Inoculation for smallpox, however, was
 not free from objection; the  disease  thus engendered  was always
 serious,  often fatal, and frequently became the source of a malignant
 contagion.   In this state of  demi-subjugation smallpox was found by
 Jenner,  when the well-known fact of the protective influence of cow-
 pox first engaged his  attention, and aroused  in  his  comprehensive
 mind the philosophic thought that spread happiness and security where
 gloomy  anticipations and uncertainty had previously prevailed.  He
 had the talent to perceive in cowpox, smallpox in its mildest possible
 form; and he trusted that  the  transmission of  this to  man  would
 insure 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.
   In the foregoing  remarks I  have endeavored 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,  more than half a century1 has
 glided away, half a  century, moreover, replete with  important and
 valuable discoveries,  both in general and medical science.  A portion
 of that half century  has  seen the attention  of medical practitioners
 again  engaged in considering the imperfections of our present  means
 of defence against smallpox.   A third era of discovery has  dawned.
 It is seen that although, as a general rule, the principle announced in
 the preceding paragraph, namely, that the invasion of the  contagious
 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  for further  investigation  into the  nature and
 history of smallpox, with a view to  afford additional security against
 its ravages.  Thus it  has been  observed, that  secondary attacks of
 smallpox are not unusual, and that smallpox after vaccinia very fre-
 quently  occurs.  Instances of the latter kind, indeed, are so often met
 with,  as  to lead to the belief that vaccinia  gradually  loses  its protect-
 ive influence over the system.2
   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 revaccination, retro-vaccination, variolo-vacci-
 nation, and an immediate return to  the variolae  vaccinae of the cow.

  1 Jenner'* first experiment was made on the 14th of May, 1796.
  - In a conversation, which I recently had with Mr. Marson, he made  the important
practical ol»ervation that, after an imperfect vaccination, revaccination will often
fail, while the person still  remains open to the reception of smallpox. 
492      DISEASES FROM UNKNOWN ANIMAL POISONS.

These various modes of re-establishing the protective powers of vaccinia
I 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 MAN.

  The transition of the cowpock contagion to man presents  all the
anomalies which are  known to accompany exposure to other sources
of contagion.   Milkers who  have never  been vaccinated will some-
times 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 disorder 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 ofthe ruptured vesicles.
On the backs of the  hands, and between the fingers, the epidermis 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  ofthe disease. When, however, the epidermis is abraded,
and  the skin chapped, the effects of the  virus  are  remarkable for
severity, subcutaneous abscesses are liable to form, and the lymphatic
vessels and glands frequently become inflamed.
  The signs which indicate that the  contagion has taken effect, are
the appearance of inflamed spots or papulae, which are  hard  to the
touch,  acuminated, and deep seated.   The papulae are  of  a deep rose-
red or  purplish color, and are soon  surmounted by an  ash-colored
or livid vesicle,  which assumes the umbilicated character as it
increases in size, and  then becomes yellowish in  the centre.  At this
period the areola  makes its appearance, lymph is effused beneath the
umbilicated epidermis, and a  vesicle of variable size, and of a bluish
or slate-colored aspect, is developed.   The  local inflammation is
sometimes so severe as to produce sloughing of the derma and  serious
constitutional disturbance.
  In illustration of this  affection, Mr. Ceeley1 has recorded the fol-
lowing 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 vesicles on  each teat.  He
milked  these four cows occasionally, and continued to do so till the
' Transactions of the Provincial Medical Association, vol. x. p. 216. 
ERUPTIVE FEVERS.
493
 eighteenth ofthe 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 the  temporo-frontal region, which he could not
 resist scratching.  On the day before that he observed on the 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  headache, general  uneasiness, and pains in the
 back and limbs, with  tenderness  and  pain in the  course of the  cor-
 responding lymphatic vessels and  absorbent  glands, particularly of
 the axilla, which increased till  the twenty-third, when nausea  and
 vomiting took place.  His  right  eyelids became swollen,  and  were
 closed on that day, but after  this period he became better, in all
 respects, never having been  confined 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-color, with a receding areola, and
 there  was an  inflamed, tumid, and completely  closed  state  of the
 corresponding eyelids.
   "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-colored, slightly elevated
 base.  On the thumb the vesicle was also flat and broad, but visibly
 depressed towards the centre, where  there appeared a transverse
 linear-shaped  crust, corresponding doubtless with  a fissure  in the
 fold of the cuticle. The vesicle  was .of a dirty, yellowish  hue, and
 visibly raised on  an  inflamed, circumscribed  base; lymph was  ob-
 tained from a vesicle on the temple, iii small  quantity, by carefully
 removing the central crust, and patiently waiting its slow exudation.
 In this, as in  most other respects, it strikingly resembled the vesicle
 on the cow, and appeared  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  interrup-
 tion of their natural course.
   " On the twenty-sixth  and twenty-seventh,  when the  redness and
 elevation of the base of the  vesicles had  materially dimisished, the
 vesicles themselves had become greatly enlarged.   On the thumb and
 finger they were loosely spread out at the circumference, 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 the twenty-
fifth of November."
INOCULATED VARIOLA VACCINA.
  The inoculation of variola vaccina, or, as it is popularly termed,
vaccination, consists in the transference of a small portion of the con- 
\
494     DISEASES FROM UNKNOWN  ANIMAL POISONS.

tents 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, by a
number of superficial scratches, with the point of a lancet or needle
imbued with the virus ; or, as recommended by Mr. Crosse,1 by means
of a small blister.  The blister is produced by retaining upon the arm
a piece of adhesive plaster, in the centre of which has been placed a
fragment of emplastrum lyttae, not larger  than the head of a small
pin.  When the blister is formed, the lymph is to be deposited on the
exposed surface of the derma.   Mr. Crosse found  this proceeding
very successful in the case of a strong child, who resisted the opera-
tion in the usual way ; and it is worth bearing in mind in cases where
the ordinary operation has more than  once failed.   Another, and
rarely practised mode of vaccinating, is to make a small incision, and
place within it a thread impregnated with  the vaccine- lymph.  The
punctures are made obliquely through the epidermis, in order that
the papillary surface may be attained without the  effusion of blood,
or with the escape of as little as possible.  The virus which is in this
manner introduced into contact with the derma is dissolved in the
fluids  of the tissues, and imbibed into the system, its agency thereon
being  indicated by .certain local and constitutional effects.
  The local signs indicating that the vaccination has taken effect 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 puncture, and a trifling blush of red-
ness immediately  surrounding it.  On the fifth and sixth day, a small
quantity of liquor sanguinis is effused beneath the epidermis, 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 become fully distended, and has attained its perfect de-
velopment.  On the ninth day it loses the umbilicated form, it  becomes
flattened on the surface, and sometimes  more convex than at  the cir-
cumference, 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 color (the pearl upon
llie  rose), which gradually increases  in extent from a few lines to more
than two inches in diameter.   The skin included by this areola is  in-
flamed 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 considerable itching in the  part, the move-
ments of the arm are somewhat painful, and the axillary glands are
liable  to become tender and swollen. It 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 con-
tained  within  the vesicle  has become  purulent, and  desiccation

                     1 Lancet, vol. ii., 1S30, p. (>42. 
ERUPTIVE  FEVERS.                   495
commences at its centre and proceeds gradually towards the circum-
ference.   During the succeeding days, the areola disappears  more
and more, the tumefaction subsides, and the vesicle desiccates into a
dark  brownish  crust, of an irregular  form.   The crust, by a con-
tinuance of desiccation, diminishes in  size, and assumes a  blackish
hue.  It is detached at the end of seventeen  days after vaccination,
and leaves upon the skin a depressed cicatrix, at the bottom of which
are seen numerous small pits, (foveolae), 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 incubation ;
the fourth is papular; the fifth, sixth, seventh and eighth, vesicular;
the vesicle presenting an umbilicated form, and attaining perfection on
the last of these 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;" the ninth, tenth, and eleventh days are pustular,  the
lymph becomes purulent, the  umbilicated form is lost, the areola  en-
larges, and constitutional fever is established;  the twelfth, thirteenth,
and fourteenth days are those of desiccation ;  the  fifteenth, sixteenth,
and seventeenth, of separathn; and these latter are succeeded  by  the
fall of the scab.
   Such is the course of the vesicle of vaccinia, which is considered
necessary to the protection of the system.  When its progress is ir-
regular, and its development  not perfectly effected, the  constitution
remains in the same  state in  relation to the occurence of variolous
contagion  as  before  the operation.   It must be borne in mind, how-
ever, that the local affection is never so well marked  in the adult as in
the child, although the extension of inflammation to the  neighboring
glands and the constitutional  fever are  often greater.
   The proper time for the performance of vaccination  is  infancy, be-
tween the third and seventh month.  At an earlier or a later period,
the diseases incidental to childhood may interfere  with the 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.
   The  constitutional symptoms accompanying vaccination are always
slight, and  often  scarcely perceptible.  In some instances,  however,
a little  fever is observed at about the eighth and three following days,
this febrile reaction corresponding with the progress of inflammation
of the areola.

                SECONDART ERUPTIONS OF VACCINIA.

                          Syn.  Vaccinelh.
   The  general  effects of vaccination  occasionally offer some pecu-
liarities.  Thus, it sometimes happens, that, during the courtee of the
vaccine pock, an eruption of vesicles appears upon the skin.  Such
au eruption lately fell under my observation, in  which  vesicles  and 
496
DISEASES  FROM  UNKNOWN  ANIMAL POISONS.
bullae' were developed upon inflamed patches on the greater part of
the surface of the body.   The principal features of this case were the
following:—
   Green, a child eighteen months old, was vaccinated at the London
Smallpox Hospital, on Monday, June 7th, 1841.   On  the ninth or
tenth day after the operation an eruption of  red spots was perceived
upon the forehead, which quickly extended to the face, neck, trunk,
and arms, and by the  thirteenth day was dispersed over 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, chest, and
back, the legs being rfearly 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  irregular form, of about
the size of a fourpenny piece, several of these latter patches being con-
gregated here  and -there, so as to form clusters of considerable size.
The margins  of the patches  were of a dull red color, and  somewhat
elevated,  while the centres presented a yellowish tinge,  and in some
situations were covered with numerous small vesicles,  containing a
limpid and transparent 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 epidermis was desquamating over their
surface,  particularly on  those patches where vesicles  had existed.
On the face the  vesicles  terminated in  thin, brownish,  and spongy
laminae.   I inoculated  a healthy child with lymph taken from  these
vesicles, but without any result.
   In the early part of  the present year I had an opportunity, through
the courtesy of Dr.  John Hall Davis, of seeing an infant  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 extend-
ed to the neck and chest.  On the  latter there were  more than one
hundred vesicles, presenting the characteristic flattened and umbili-
cated form of  the vaccine pock.  They were for the most part discrete,
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 child
had evinced a tendency  to  eczematous eruptions  from  its birth; a
circumstance deserving the attention of the medical practitioner.
  The following  case occurs  in the  Archives de Medecine  for Septem-
ber, 1841.   An infant a week old  was  vaccinated  July 3d; on  the
10th several papulae appeared on various parts of the body.  On the
15th 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.

  1 Mr.  Ceeley regards this  eruption of a pemphigoid character as "strictly a vaccine
eruption;" he has seen  it frequently on children, and occasionally on the cow and
dog. 
ERUPTIVE FEVERS.
497
    Dr. George Gregory lately communicated to the Royal Medical and
 tnirurgica  Society the case of a child in whom petechiae  appeared
 upon the skin four days after vaccination.  The child was to all ap-
 pearance  in  perfect health.   The areola was occupied on the eighth
 day  by an  extensive  ecchymosis, and  the body was covered with
 petechial spots.  By the sixteenth day, the petechiae had commenced
 to fade.  *ive 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 cowpox,
 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.

   I now come to a  question  of the utmost importance, namely, the
 efficacy of vaccination  as a protection  against smallpox.  But before
 I engage in  this discussion, it may  be necessary to define  precisely
 the meaning which I attach  to the term vaccination.  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 regu-
 larly through the course described in the preceding section.
   3.  That it has been procured from the vaccine vesicle, between the
 sixth and eighth day of its course.
   4.  That the vesicle produced by this lymph in the vaccinated sub-
 ject, shall  have  passed  regularly  through the  stages known  as  the
 natural course of the vaccine  pock, and described in the preceding
 section (page 494).
   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,  perhaps
 also, foveolated.                                                  '
   When the whole  of  these  conditions  are complete, vaccination is
 perfect, and the person so vaccinated may be regarded as protected
 against  smallpox.   But if  any of  these conditions  be incomplete, it
 would be  monstrous to expect that the full influence of the vaccine
 protection  could be exerted.  Again, it  has been observed,  that the
 nearer the approach of the conditions to the standard abovl estab-
 lished, the more  protective  will  be the influence  effected by the
 operation, and vice versa.
  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 due attention  has
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
      32, 
498      DISEASES  FROM  UNKNOWN ANIMAL POISONS.

as the attention necessary  for the assurance of this condition has,
unfortunately, in many  cases, been  omitted, much  spurious  lymph
has been mingled with that derived from the original source, and as a
consequence, smallpox after vaccination has become  more frequent,
and  vaccination has fallen into disrepute.  It  would, however,  be
unjust and unphilosophical, to attribute this apparent falling off in the
influence of the vaccine  lymph to any but its true cause, the one just
mentioned.
  On this topic I was much gratified by a recent conversation with
Mr.  Marson, the resident  surgeon  and  vaccinator  of the London
Smallpox Hospital.   He informed me that when, in 1835, he became
attached to the hospital, he  found  in  use a lymph which had been
employed there for nearly forty years, and which had  become greatly
enfeebled in its powers.   Two  years afterwards, namely, in  March,
1837, he fortunately met by accident with  some new lymph of a very
superior kind  to his own, and possessing more active properties.
That lymph he has continued to use until the present time (1856), and
without  injury to its powers,  although during the intervening  period
he has vaccinated  nearly 50,000  children, and distributed lymph  to
nearly 25,000 medical men.
  The period best  suited  for obtaining  the  vaccine lymph is  the
seventh day of the vesicle, which  corresponds with the eighth  day of
the operation; Jenner says between the fifth and eighth day, which is
too definite.1  If the vesicle appear incomplete on the  seventh day,
the removal of lymph might be deferred for a day, but it is important
to obtain it before the inflamed areola is formed.  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 transporting the virus to warm climates; but the
crusts for  this purpose must be selected with care, and even  then  are
liable to failure.
  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
referable 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 influence,  and of the completion of  the sub-
sequent conditions.3

  1  Mr. Marson requires the vaccinated  children to be brought back to him on the
day-week of their vaccination; consequently on the completion  of the seventh day
and dawn of the eighth; the lympth is therefore seventh-day lymph. On  this day
he generally finds the lymph fit for removal.
  * It may not be  out of place  here to remind the vaccinator of the importance of 
ERUPTIVE  FEVERS.
499
  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 pre-
servative influence of vaccination has not been established, provided
that a permanent cicatrix of the ordinary size be present.  But when
there is difficulty in  discovering  the  cicatrix, or the latter is small, it
may be unhesitatingly concluded  that the  pock did not complete its
necessary stages, and,  consequently, that  the  person is still  unpro-
tected.

                        VACCINATION TESTS.

  With the view to ascertain whether vaccination has been effective,
several plans have been adopted which are termed tests.  The most
efficient  of these is inoculating  with smallpox after  vaccination;
revaccination is a second  test; and a third is that described  by Dr.
Bryce, of Edinburgh.   Bryce's tes-t consists in  revaccinating a few
days after the first vaccination.  In  this case,  if the constitution be
already affected  by  the  vaccine  influence, the second pock hurries
through its stages, and  speedily reaches an  equal development with
the first, arriving at its acme at the same  time,  and desiccating and
forming its crust contemporaneously with its predecessor.

  RE-ESTABLISHMENT OF THE PROTECTIVE INFLUENCE OF VACCINIA.

  For several  years past opinion has been divided relative  to the
protective influence of vaccination against smallpox.  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 introduced by Jenner has degenerated
during the sixty six  years that it has been  transmitted through the
human race, and lost a  portion of its protective quality.   I shall not
stop toonquire 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  consequences
which they would imply.  As a  means of perpetuating the vaccine
influence, two modes of procedure have been recommended, namely,
revaccination, 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
from the cow.

being very particular with regard to the purity of the instrument used in performing
the operation, and indeed of the necessity for nicety and care throughout the entire pro-
cess.   I wa3 lately called upon to give my opinion in the Coroner's Court, upon a
case of death which had resulted from vaccination.   Another child, vaccinated at the
same time, had narrowly escaped the effects of inflammation of the absorbents and
suppuration of glands; and there was every reason to fear that these dreadful conse-
quences resulted from an impure lancet. 
500      DISEASES  FROM  UNKNOWN  ANIMAL POISONS.

                         REVACCINATION.

  The phenomena of contagion, as it affects the human frame, develop
two  important facts: firstly, 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 condition which it possessed previously to the
development of contagion.' In  the  abstract,  these  propositions are
incontrovertible, but they  require the  modification  implied in the
estimate of time, to render  them applicable to the thousand peculiar-
ities that occur in daily practice.   Thus, in relation to the first, we
have  to inquire, For what length of time  the susceptibility  is de-
stroyed? 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 vboth these questions the
answer  is,  We know not.   All that  we can  venture to affirm  with
regard to them is, that, in one  person, a single attack of contagious
disease  appears to be protective  of the  individual for life ; while, in
another  person, a second attack may occur  in a short  period, the
precise  limits of that period  not  being correctly established.  The
determination of the shortest period at which contagious disease may
resume its influence over the system is a point of  much importance,
and one of legitimate investigation.   It is 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 conta-
gion of smallpox.   A single attack of smallpox would appear, in the
majority of cases, to protect the individual for the rest of life, but in a
smaller number of  instances, the variolous constitution is still active,
and a second, a third, and  even  more  attacks may be experienced.
Now, that which is true with  regard to variola, is equally t»ue with
regard  to vaccinia; for  variola  and vaccinia are, in their essential
nature,  one and the same disease.1  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 mildest
form; and as vaccinia is variola in the mildest shape in which it can
be presented to the human organism, the question  of revaccination
resolves itself into the propositions stated above.
  If we admit that vaccination, although perfectly protective of the
constitution  against the recurrence of the smallpox contagion for an
unknown, and probably variable space of time, ultimately loses its
powers; and  if, in  the next  place,  we inquire what means present
themselves of perpetuating its protective influence, the most natural
and rational  method that suggests itself to our mind is revaccination.

  1 It is  proper to  mention, in this plaoe, that many  opinions  are opposed to this
belief. Dr. Robert Williams observes, " Vaccinia is a disease sui generis;" and further
on he remarks, " It is likewise by  no means proved, that the smallpox and the cowpox
are identically diseases ofthe same species."—Vol. ii. p. 49. Elements of Medicine. 
ERUPTIVE  FEVERS.                      501
 Revaccination, or a repetition of vaccination, is a simple and harmless
 operation, producing a mild and trifling indisposition when the system
 is unprotected, but no effect whatsoever when the  organism  is safe.

   p rif' •  !r'  -WG find  tiie °Peratioa  t0 ^e acting as a test of the safety
 of the individual, and  no objection can  possibly be raised against its
 use.  If the organism be safe, it produces no effects;  if the organism
 be unsafe, it produces a trifling inconvenience, but it leaves a bulwark
 of safety in  its train.                                                 v

    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 importance in com-
 parison  with the  principle which  it involves.   I would say, let vac-
 cination be performed every five years, or every seven years, or every
 ten years.   But, as our object is protection, let us not defer that pro-
 tection too long.   If the operation succeed at the end of five years,
 that fact affords the strongest  proof  that the repetition is not too fre-
 quent.   If it fail at the end of five years, let it be practised at seven;
 if it fail at  seven, make  a third attempt at  ten;  if  the operation fail
 then, it  may be adopted at successive intervals, but  the person inocu-
 lated has the satisfaction  of knowing himself safe, at a most insignifi-
 cant inconvenience.
   Numerous cases have been adduced in which an attack of smallpox
 has followed  vaccination.1  I care  not to inquire  if vaccination have

   1 It must not be imagined that  Jenner ever contemplated an infallible remedy in
 vaccination ; 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 pro-
 digious saving of suffering and danger.  In respect of this expectation, Dr. Robert
 Williams remarks, that it " has not altogether been verified, the evidence at present
 accumulated showing the attack of the latter (secondary smallpox) to be only in the
 ratio of a  half  to one per cent., while the attacks of the former (smallpox after vac
 cination) 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 profes-
 sion who have adopted it, to be able to state, that by the discontinuance of the prac-
 tice of inoculation, the total number of persons attacked by natural smallpox in this
 country, taking the most unfavorable 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 11,000; also, that the
 accidents incident to the disease, as blindness, deafness, lameness, and the endless
 catalogue of miseries that follow it, are also reduced 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 smallpox in every two thousand, annually;  so that, taking the
 army at 100,000 men, the mortality is only four from  smallpox  in the whole of that
 large force annually.  The navy appears also to experience a similar immunity, for
 out of a mean strength of 7985 seamen, seven only died, in seven years, of smallpox
 in the Mediterranean and Peninsular commands, while, in the West Indian and North
 and South  American  commands, none whatever.   On the Continent, 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 vac-
 cination is  consequently made of national importance in the matter of legislation, we
 find that the mortality from smallpox, though greater than in our army, is infinitely
 less than in 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 smallpox, or one in 122.   In  England and Wales, however, out of 141,607 deaths,
 5811 were occasioned by smallpox, or one in 25, nearly; thus showing that the country
 which gave birth to vaccination, suffers six times more by smallpox than that of its
wiser and more  considerate neighbor."—(P. 49.) 
   502     DISEASES FROM UNKNOWN ANIMAL POISONS.

•   been  perfect in those cases,  for instances are equally numerous in
   which smallpox has followed inoculation, and smallpox itself, both
   discrete and confluent.  These facts prove nothing unfavorable to the
   claims of vaccination as  a protective agent against  smallpox; they
   prove only that which daily  experience  tends constantly to  corrobo-
   rate, namely, that man has still much to learn.   There can 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 ofthe 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 frequently  we have
   occasion to  see the rule  nullified, and  secondary attacks developed.
   The following table, quoted from Dr. Heim, in the Report of the Vac-
   cination Section of the Provincial Medical Association, is exceedingly
   interesting, as showing the relative frequency of success in vaccinating
   after smallpox, and after vaccination:—
           Vaccinated after smallpox with success    .   .    .32
               "            "    modified   .    .   .    .26
               "            "    without effect   ...    .4:1
                                                        —100
           Revaccinated with success  ...... 34
                 "        "     modified   .    .   .    . 2.i
                 "        "     without effect   .   .    .41
                                                        —100

     Revaccination 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 operations, however,
   are calculated to increase  our knowledge upon this important subject.
     The following are  the  conclusions of the Commission of Vaccine,
   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 infallible  preservative
   against variola, it  is at  least  the most certaiu, and the most exempt
   from danger.
     3. That varioloid, in the majority of cases, is the only inconvenience
   to which the vaccinated 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 received less  security
   than those who preceded them.
     5. That the complete success of revaccination affords no proof that
   the individual had ceased  to be protected  by vaccination,  and that he
   had again become  susceptible of variola.
      6.  That a second vaccination does not appear to possess the power,
   any more than the  first, of protecting all persons indiscriminately from
   the risk of a future attack of variola.
     7. That Government ought  not to command a general revaccination. 
ERUPTIVE FEVERS.
503
   8. That the total extinction of variola  is to be effected by the uni-
versal adoption of vaccination.

                 variolation after vaccination.

   Inoculation  after vaccination has been proposed as an additional
security against the contagion of smallpox.  To those who regard
vaccinia and variola as  different diseases, such a suggestion is likely
to be received with approbation;  but if  we view these  disorders in
their true light, namely, as one and the  same affection, inoculation
after vaccination is but a repetition of  revaccination,  and is,  con-
sequently, incapable Of bestowing any superior advantage.

                       RETRO-VACCINATION.

   This operation is attended with some difficulty, in consequence 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 degree of inflammation.  The vesicles were produced
late, and good lymph was procured on the tenth day.
   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
firm than usual.  With these exceptions, no difference could be detected
between the retro-vaccine 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.

   Inoculation with the variolovaccine lymph is  attended with the
same difficulties of  transmission as are common in the case of unas-
similated 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 Jacock, 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-colored 
504     DISEASES FROM UNKNOWN  ANIMAL POISONS.

summits, and  seemed vesicular, two were doubtful.  On the seventh
day, there were five  small, distinct, reddish-gray, or ash-colored  vesi-
cles, one very  small.   On  the eighth day, the vesicles were advancing,
of unequal size, and of irregular form.  Here I was forcibly struck
with the strong resemblance some  of these vesicles bore to those of
the eighth day, depicted in Jenner's work, on the arm of Hannah Ex-
cell, which he thought so remarkably  like the results of smallpox
inoculation.   My patient  stated  that she felt  slightly indisposed on
the fifth and  sixth days,  that the axilla was  painful on the seventh
day, and that  she was then giddy and sick, but felt worse on this the
eighth day.  On the ninth day the  areola commenced, and  she  com-
plained only of headache.  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 circum-
scribed  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 descrip-
tion of  individual cases, after  adducing one example from the four-
teenth remove, as a type of what might be produced in similar  sub-
jects, 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, dis-
tinct papulation was apparent on  the second day ; on the third it was
not only visible but elevated and well-defined ; on the fifth and sixfh,
vesiculation was  abundantly obvious, and lymph was often  taken on
those days.    On the seventh day  vaccination was frequently per-
formed, and points were often charged;  on the  eighth the vesicle com-
monly 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  dulj white or cream  color, bold and ele-
vated, with a  narrow centre and  a broad margin, or flat and broad in
the centre, with  an acute margin, occasionally not raised above the
level of the skin;  on this and the eleventh day an extended and gene-
rally vivid areola  existed, with more or less tension and induration
ofthe integuments.  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-colored lymph,  from the congested or ecchy-
mosed subjacent adventitious structures,- proportioned to the- texture
and degree of translucency yielded  by its desiccating epidermis.   On
the thirteenth  and fourteenth  day,  particularly on clear skins mode- 
ERUPTIVE FEVERS.                   505
  rately thick, the vesicles attained a considerable size, measuring often
  in tl^eir longest diameter six and a half or  seven lines, and acquired
  a light brown centre, from  commencing desiccation, which was sur-
  rounded 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 protracted.   The
  crust commonly partook of the form of the vesicles; it was  often pro-
  minent and bold, varying in color from  that of a chestnut to that of a
  tamarind  stone.   It fell generally about the  twentv-third or twentv-
  fifth day,  often later."
   "The cicatrices were  of  variable  depth and extent.  When the
  vesicles remained unbroken on a thick sanguine skin, they were deep,
  but on a  thin skin, shallow; they we're not  always proportioned in
  width to that of the vesicle, 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 beautifully striated.  I
  need scarcely say, that where the vesicles were accidentally broken, or
  spontaneously burst, much  mischief ensued, deep sloughing of the
  skiri, &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.
   14 When the lymph in the first remove produced normal vesicles,
 and as soon as it had passed readily from arm to arm, the constitu-
 tional  symptoms, though mild,  were most commonly well marked.
 In jnfants, restlessness, fretfulness, 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  diarrhoea.  From childhood  up to puberty
 the primary symptoms from the fifth to the seventh day were unequivo-
 cally 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 couTse,
 more complaint was  made, headache, 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 gene-
 ral febrile  complaint, disinclination, and even  inability,  to leave the
 bed.  But  in several  instances, amongst young children, little or no
 complaint was made or indicated ;  all the members of the same family,
 vaccinated  from the same source, might be differently affected.  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 ofthe  primary disturbance.   If properly deve-
loped, small vesicles  often gave  rise to marked constitutional symp-
toms, and the most splended vesicles were often seen with trival, some-
times scarcely appreciable disturbance."
  '• The secondary symptoms are often  as active with three or four, 
506     DISEASES FROM  UNKNOWN ANIMAL POISONS.

as with six or eight vesicles;  acceleration ofthe pulse was frequently
noticed, when no  other  symptoms appeared.   Both primary and
secondary symptoms very commonly showed a remitting type."
   With respect to cutaneous  eruptions, Mr. Ceeley observed but one
in the adult, and  in children nothing  approaching the  varioloid
character.   "Roseola, strophulus, lichen, were the  principal erup-
tions."
   Dr. Basile Thiele,1 of Kasan, has succeeded several times in inocu-
lating  the udder  of cows.   When children were inoculated  with
matter taken from  these pocks, the effects produced were  more intense
than those  occasioned  by  the ordinary  vaccine lymph.   In some
cases, Dr. Thiele observed two febrile  attacks, one  between the third
and  fourth day, the other between the eleventh and  fourteenth, and
these severe consequences 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.

   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 Gloucester-
shire; Mr. Fox  and Mr.  Sweeting, of  Dorsetshire; and Mr. Ceeley,
of Buckinghamshire.  It has also  been obtained and  employed in
France, by M. Saunoy.
   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 humanized vaccine lymph, or with smallpox, great diffi-
culty 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 become assimilated, all difficulty is at
an end.   When inoculation  is effected,  a remarkable  difference is
perceived in the consequences of the  two kinds of lymph; thus, in
the transference of the lymph of smallpox to the cow,  the  virus is
greatly modified, and the resulting pock is chastened and mild;  while,
on the contrary, the lymph of the variolae vaccinae first introduced
into the tissues of man,  gives rise  to  symptoms of greater  severity
than those produced by humanized 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-carni
vorous  animal, I am unprepared  to say.   I  think  it  not improbable
that the cause might be found in this difference of character.
   The effects of vaccination  with primary  lymph are,  according to
Mr.  Ceeley, as follows :  On the second day after vaccination there is
an unusual  degree of  redness  around  the puncture;  the redness
declines on  the two following days,  and becomes concentrated in the
point where the papula arises.   The  elevation of the  papula com-

             1 Bulletin de l'Academie Roy. de Med., Jan., 1841. 
ERUPTIVE  FEVERS.
507
 mences  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 from
 the eleventh to the sixteenth day, and is  sometimes covered with
 small  supernumerary  vesicles, and  accompanied  by  a general erup-
 tion of papulae, vesicles, or bullae.  When the vesicle is ruptured in
 unfavorable constitutions, 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  deve-
 loped," at other times they are smaller, and " less developed than other
 vesicles;" but they " admit of a  very remarkable  improvement, 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 gene-
 ral 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 complexion, 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  diminished, the
 vesicles  acquire  a magnitude  and beauty, often greatly superior to
 what is daily witnessed; and in a short time the lymph may be  trans-
 ferred with  safety to others, even more  sanguine and robust, where,
 it is well known,  lymph, if good  for anything,  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 smallpox formerly so success-
 fully adopted  for their patients; for it is a long time before some
 individuals can  be safely vaccinated  with this active lymph, even
 though taken from the mildest vesicle."
   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 source r^ust necessarily be pure,
 and its use should therefore be encouraged.1
   Treatment.—Any  morbid  conditions  arising  accidentally  from

  1 Dr.  Lichtenstein, in a paper entitled, " On the sources from which matter preserva-
 tive against the smallpox has been derived," in Hufeland's Journal for 1841, remarks,
 that limpid lymph taken from the pustules produced by tartarized antimony, and
 inoculated in a person who has not been  vaccinated, produces vesicles, which cannot
 be distinguished from those of vaccinia.  These vesicles appear to be equally pro-
tective against smallpox with the cowpox, 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 from this source; and
these persons were protected during an  epidemic  of  smallpox, although placed in
association with patients affected with that disease.  Credat Judaeus, non ego ! 
508    DISEASES OF SPECIAL STRUCTURE OF  THE  SKIN.

vaccination should be treated in accordance with the general princi-
ples of therapeutics.  Febrile symptoms may call for the employment
of antiphlogistic remedies;  and the local dermatitis, when it assumes
a form of unusual severity, may be subdued by means of a compress
of linen wetted in a  spirituous lotion and covered with oiled silk, or
by means of a piece of Alison's prepared lambskin saturated in water.
If sloughing or ulceration occur, water-dressing should be continued
until the  inflammation is removed, and slightly astringent washes or
a mild ointment applied subsequently.
                    CHAPTER  XVI.

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN.

             DISEASES OF THE VASCULAR STRUCTURE.

  The disorders of the vascular structure  of the  skin  are two in
number, one affecting the cutaneous  veins, and  giving rise to enlarge-
ment of those vessels;  the other affecting the  capillary and arterial
system, and  producing  tumors of various magnitude.  These  states
are represented by the following terms:—
                    Hypertrophia venarum.
                    Naevi vasculosi.
  Hypertrophy of the  veins of the skin,  of its papillary and deeper
layers, is an accidental  affection occurring in the adult, or  more
commonly at an advanced period of life.  Naevus vaseulosus is gene-
rally congenital; but some  of its minor forms, such as the  ujsvus
araneus, may be developed at any subsequent age.

                    HYPERTROPHIA VENARUM.

  Hypertrophy of the veins of the skin occurs in two situations;  on
certain parts of  the face, where  it is the  result of a defective tone of
the tissues, or torpid action of the functions of the skin;  or, on  the
limbs, particularly on the lower extremities, where it is commonly
accompanied with a varicose state of the  subcutaneous veins.
  In the face, enlarged venules are most frequently seen on the nose,
on the cheeks, and upon the  chin.  On the nose they are accompanied
with a coarse state of the skin, and sometimes with actual hypertrophy
of that organ.   Occasionally I have  seen them so large, and their
presence has so  retarded the circulation of blood in the organ, as to
give a livid  and swollen appearance to the extremity of the nose.   In
their more usual state,  they are  met with on the sides of the nose,
where two or three, and sometimes as many  as six, large trunks may
be seen collecting their tributaries  from  the border of the ala,  and 
DISEASES  OF  THE VASCULAR STRUCTURE.       509
 from the extremity of the organ.   The trunks  vary in length, from
 halt to three-quarters of an inch, and sink into the depths ofthe skin
 above  the  alar cartilage, to  reach  the mucous  membrane.  On the
 sides of the bridge ofthe  nose, the enlarged venules sometimes consti-
 tute a p exus, as they do also on the cheeks.  This state of the veins
 of the  skin is simply one of  enlargement or hypertrophy, dependent
 on  vascular  determination or congestion,  and  a subsequent torpid
 function of the part, and is unconnected with disease of the skin, or a
 special morbid state of the system.   In this respect it differs from the
 venous plexus which is met  with  in patches of  the skin,  the seat of
 syphilitic tubercles, and also  from the enlarged state of the venules of
 the skin, which  is  found  in  association  with the non-ulceratin*  or
 superficially-ulcerating tubercles of lupus.
   On the limbs, and particularly on the thighs, the enlarged venules
 are larger than those of the face, and  more  deeply imbedded in  the
 skin, communicating, in fact,  with the subcutaneous veins.  They are
 sometimes straight, like the venules ofthe face, or disposed in a super-
 ficial plexus; but  more  frequently  they  form  patches,  which are
 uneven on  the surface from the projection of the coils ofthe distended
 veins, of a  purplish or bluish color, the  tint of  blue being greatest
 where  the  veins  come nearest  to  the surface,  and  of considerable
 thickness, but at the same time very little elevated above the surface
 of the surrounding skin.   They are, in fact, patches of varicose venules,
 and are usually associated with a varicose state of the subcutaneous
 and deeper  veins.
   Treatment—My practice  in the treatment of enlarged venules of
 the nose and face is to touch the  trunks with a fine point of potassa
 fusa, taking care  to carry the point  down  to the  vessels, so as  to
 produce coagulation of the  contained blood.  This  little operation
 requires care, in order to render as small as possible the pitted cicatrix
 which is apt to follow.   When the  hypertrophia  venarum  is spread
 more or less extensively over the face, it is necessary to improve the
 tone and  nutritive functions of the  skin  by means of the  stimulant
 and astringent action of the bichloride of mercury lotion,  or by the
 more general  stimulation of the  compound hypochloride of sulphur
 or juniper tar ointment.
   For the varicose venules of the  lower limbs, the only efficient treat-
 ment is, continued pressure, for which purpose the mercurial plaster
 spread on wash-leather, and a  bandage, are best suited.  These cases,
 however, from the nature of  their cause, are less remediable  than
 hypertrophous venules occasioned by altered nutrition  and innerva-
 tion of the affected part.
   Even in this slight affection it is  necessary to improve the vital
functions, and depurate  and  invigorate the  blood by constitutional
means.  Very few cases will be found in which elimination and restor-
ation of power are not needful. 
510    DISEASES  OF  SPECIAL STRUCTURE OF THE SKIN.


                         N^VI VASCULOSI.

Syn.   Teleangiectasia.    Vascular  nevus.   Erectile tumors.   Arterial
  nevi.  Venous  nevi.  Nevus araneus.   Nevus fiammeus.   Gefdss-
  muttermdler, Germ.   Signes; Tachesdevin, Fran.  Mother's marks.

  The vascular rete of the derma is liable  to become dilated,  and to
give rise to the formation of red patches and slightly  elevated tumors,
called vascular nevi.   Vascular naevi present considerable variety in
relation to  extent, tint of color, and  tumefaction.  Occasionally, the
vascular dilatation is  limited  to  a mere  point, from  which  several
enlarged venules pass off in different directions.   This kind  of naevus
rarely increases in size ; it is met  with on the face and limbs, and from
the peculiarity of its  appearance,  has  been  named nevus  araneus.
Proceeding upwards from this  naevus araneus, the diseased spots may
be found to present  every  degree of size, and  their dimensions are
frequently so  large that they have been seen to cover the wdiole of one
side of the face, the ear, and part  of the  scalp.   The tint of color of
vascular naevi is dependent on  two conditions, the extent of dilatation
of the capillary  rete, and  the  degree of excitation  of the  vascular
system.  Thus, if the capillaries 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 color, 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 naevus will present  a purple,
and even a livid hue. Intermediate degrees of dilatation  or impediment
to the circulation, will  naturally produce different-tints of red. Similar
changes of color 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 colored and
livid, while, in a state of temporary excitement, the  spot will assume
a most intense and  vivid red. The circumstances  which  affect the
color, modify  also the  degree of tumefaction.  In a  state of repose it
is ordinarily flaccid, and probably, scarcely raised above the surface;
but  in a state of excitement of the circulation,  it will become 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  surrounding  skin, while
others form prominent tumors.
   Vascular naevi, when of small  size,  give rise to little  or  no incon-
venience ;  but when large, they are hot, painful,  and throbbing.  In
the latter state they communicatee distant pulsation to the  finger,
synchronous with that of the heart's beat.   Vascular naevi  are some-
times 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 is not always limited to the
skin, for they are apt sometimes to extend more or less  deeply into
the subcutaneous tissues.  Left to themselves, they will often continue
the whole of  life, without giving  rise to any inconvenience; at other 
DISEASES OF  THE VASCULAR STRUCTURE.       511
 times they may ulcerate and slough, or throw out a fungous growth,
 this change being accompanied by repeated hemorrhage, and termi-
 nating fatally    At all times the hemorrhage is troublesome, and even
 dangerous, when vascular naevi are accidentally wounded.
   Dupuytren has the merit of first pointing out the analogy of structure
 of vascular naevi with the erectile tissue, and since the  announcement
 or this similarity, they  have been commonly termed,  erectile tumors.
 Inese naevi have been described  from  the earliest times as mother's
 marks, and have been referred to the influence of moral emotion on
 the  part of the mother  during  pregnancy.  In  pursuance of this
 explanation, we still hear them spoken of, in popular language, as,
 bunches ofc red  and black currants, strawberries, raspberries, black-
 berries lobsters, &c, and it  is supposed 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 differences, when they exist, are
 referable to more or  less dilatation of the  vascular rete.   Where the
 rete  is dilated  to  a moderate  extent, and  the color of the naevi is
 brightly red, we may call them, for the sake of distinction, arterial
 nevi; and where  the  capillary rete is very  much  dilated, and  the
 color is blue or livid, we may call them  venous nevi.  The term
 varicose naevi has been sometimes applied to the latter; but the use
 of this term is  objectionable, for two  reasons; in the  first place, it
 would seem to  indicate a difference of  structure,  which does not
 exist; and, in the second place, the term  is wanted  for those  bluish
 subcutaneous enlargements which consist  of a plexus of small vari-
 cose 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 number of capillary
 vessels in the affected part.  They are  enlarged  in calibre, with cor-
 responding hypertrophy of  their  coats, with  enlargement of  their
 meshes, with hypertrophy of the intervascular tissue, and  dilatation
 of their appertaining arterial and venous trunks.
   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 naevus 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  operation
 proposed by Mr. Liston, which combines  with  incision 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 hemorrhage.   In certain cases
 the ligature passed through the base of  the naevus may  be used with-
out the  incision; if the  naevus be extensive  or elongated, several
ligatures may be required ; and in some situations it may be desirable 
512    DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

to leave needles in the base of the tumor, and fasten the  ligature
beneath them; where  the  tumor is pedunculated, a simple  circular
ligature may be employed.
  The spider naevi, and those of very small size, may generally be
cured  by introducing into them a  point of potassa fusa; while, in
some instances, touching the exterior with  the caustic will suffice for
their destruction.
  Dr. Marshall Hall proposes the breaking up of the vascular struc-
ture of naevus  by  means  of a  cataract  needle with cutting edges,
avoiding any external opening,  save that through which the instru-
ment  has  entered.  Several  instances are recorded  in  which the
carotid artery has been tied for naevi of large extent.
  In flat naevi,  Dieffenbach recommends the use of a  compress of lint
to be firmly bandaged on the morbid structure, and frequently wetted
with liquor plumbi diacetatis, or a solution of alum.  The lint should
be disturbed as little as possible,' and the compression  maintained, if
necessary, for several weeks.  When the  naevus becomes white, flat,
and  firm,  its  speedy  cure  may  be  expected.  This  treatment  is
especially  applicable to those cases  where, from the  extent of the
disease, operative procedure is inapplicable. Dr. Behrend, of Berlin,
prefers the application of strong acetic acid, followed by  compresses
soaked in  vinegar.   Under this treatment, the blood is made to coagu-
late  in its vessels; the naevus becomes hard and yellow, and is thrown ,
off  in  the form  of a parchment-like layer by a process of exfoliation.
Collodion  is well suited to effect and assist  compression; but to do
any  good, the compression must  be continued for a considerable time.
  Numerous methods  besides the above  have  been suggested from
time to time for the treatment of  vascular naevi, such as exciting in-
flammation of the vascular growth by vaccination; applying potassa
fusa; nitric acid ; injecting them  with dilute  nitric acid; passing a
seton through them; applying  the actual  cautery;  quick-lime; tar-
tarized antimony, &c.
  At the present time I am interested in two cases of  vascular naevi
in children,  which  have been  left  alone, and are now  undergoing
spontaneous  cure;  and the observation of these cases  has led me to
believe that many of the vascular naevi of infancy would get well if
left  undisturbed.  In one  of these  cases the naevus was round, as
large as a small hazel-nut, and situated on the scalp, immediately over
the anterior  fontanelle.  I intended  to remove it by  means of  the
crucial ligature applied  around its base, but deferred the operation
until the closure of the fontanelle should have advanced towards com-
pletion, inspecting it from time to time, lest any considerable  increase
of growth might render an earlier operation necessary.   The naevus
made its appearance immediately after birth, and the child is now
nearly a year old.  The tumor  was vividly red, almost  transparent,
and apparently covered only by  a thin cuticle.  At my last inspection
it was  whitish,  shrivelled,  and the integument was  considerably
thickened ; spontaneous cure was rapidly  progressing.  In the other
case, the naevus was flat,  and occupied the shoulder of the child, to the
extent of nearly  an inch square.  The only remedy that suggested 
DISEASES  OF THE  NERVOUS STRUCTURE.        513
itself was compression, or nitric acid ;  but nothing was done.   It ap-
peared at birth, and  the  child is now two years old; the vascular
structure has become absorbed in various places; from being vividly
red, the  skin has recovered its  whiter tint in several parts, but, on
close  inspection,  has  a disorganized  appearance,  somewhat  like  a
cicatrix.   The curative change  is  most active  in the centre, and
through  one segment  of  the  patch ; the part still remaining active
being a portion of the  border.
                    CHAPTER   XVII..

 DISEASES  AFFECTING THE SPECIAL STRUCTURE OF THE SKIN.

              DISEASES  OF THE NERVOUS STRUCTURE.

   Under the influence  of disordered nervous excitability, depending
 sometimes on constitutional and sometimes on local*causes, the sensiP
 bility of the skin may be increased to a morbid extent, constituting
 hyperesthesia;  it may  also be reduced in  sensibility, constituting
 anesthesia; or it may be morbidly altered as well as simply augment-
 ed, and give rise to a painful sensation of itching, to which the term
 pruritus has been applied.  These disordered conditions of sensation
 are  independent of any local disease of the skin,  which retains its
 wonted appearance and structure.

                         HYPERESTHESIA.

   Hyperaesthesia or excessive sensibility of the skin, is more common
 in women than in men, and is generally  referable to hysteria.   In an
 instance of this disorder, at present* under my care, the sensitiveness
 of the skin is so great that the slightest touch with the finger occasions
 pain ;  so far as sensibility is  concerned, the patient is  as  though
 flayed, and  utterly incapable  of bearing the weight  and  pressure of
 her ordinary dress.  For several weeks she was unable  to lie down in
 bed, and at  present, though much better, the jolting of a carriage  oc-
 casions considerable suffering.   In other respects her health  is good,
 all  the  ordinary functions of life being performed  regularly and
 properly.  In this lady's case there is present a remarkable state of
 swelling of  the skin, which comes and goes with the increase or  di-
 minution of its sensitiveness.

                           ANESTHESIA.

  Anaesthesia, or deficient sensation of the skin, is  best illustrated in
those curious examples  of  cutaneous disease, namely, morphea alba,
which have been described under the head of Elephantiasis.   In the
       33 
   514   DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

   patches of morphoea alba  there  is a morbid change in the nervous
   fibrils, and not only the sensation but the nutrition of the skin suffers
   in consequence.  Anaesthesia is  also met with in a moderate degree
   in those round spots which form upon the scalp and chin, and cause
   destruction of the hair, namely, alopecia areata.  The treatment  of
   anaesthesia  must be determined  by the state of constitution  of the
   patient,  and by the disease with  which it is associated.


                             PRURITUS.

     Pruritus  is  sometimes  general, but more  frequently heal; of the
N   latter several forms deserve attention.  These are—
         Pruritus ani,                       Pruritus praeputii,
            u    scroti,                        "     urethrae.
                           Pruritus pudendi.

                          GENERAL  PRURITUS.

     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 torment begins.  Alteration of tem-
   perature has  the  same effect;  they  suffer immediately  that they
   change  their  dress, and especially as  soon  as  they experience the
   warmth of bed.   Scratching, instead of relieving, serves only to
   augment the evil, and they are kept iu 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 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 duration ;
   sometimes they continue for  hours without alleviation, while at others
   their  periods are  shorter, and  broken by  intervals 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 membranes is in  fault;  in  others the
   pulmonary  mucous  membraqe;  and  in  others, again, the genito-
   urinary.  The affection is sometimes associated with amenorrhoea, or
   dysineuorrhcea, and not  unfrequently with  pregnancy.   In some 
DISEASES  OF THE  NERVOUS STRUCTURE.
515
instances it is an attendant on jaundice, and is then attributed to the
presence of bile in the blood.

                          PRURITUS ANI.

  Pruritus ani  is a  severe and  distressing  itching of the mucous
membrane of the verge of, and  immediately within, the anus, and of
the neighboring integument.  The itching is  greatest  at night,  com-
mencing shortly after the sufferer  has retired to bed, and continuing
for several hours.  There  is no  trace of morbid alteration of 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 skin.  Unless relieved by
treatment, pruritus ani will continue for many months,  and  even
for years.
  The causes of pruritus ani are numerous, being partly referable to
the state of the constitution, and  partly to local irritation.  Among
those of the latter class are, ascarides, haemorrhoidal swellings, fistula,
and chronic  inflammation of the  mucous membrane  of the rectum.
The general causes are, sedentary  occupation, disordered health, heat
of  weather,  irregularities, of diet, cessation  of  catamenia,  &c.  Dr.
Lettsom was  of  opinion, that in certain cases  this disease acted  as an
useful  counter-irritant, and he records several  instances  in which
visceral and  cereberal congestions were relieved by its attack.

                         PRURITUS  SCROTI.

   Pruritus scroti  is identical  in  most  respects with  the  preceding
affection, and originates  in similar  causes.   It is  usually  dependent
upon the irritating  effects  of  the  lithic acid  diathesis,  upon the
presence 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 excoriations are often produced.   The
back of the scrotum is most frequently affected.

                      PRURITUS  PRJBPUTII.

  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  alkaline  ablutions.  It occurs, for the most part, in
the summer season, and is very distressing whilst it continues.

                       PRURITUS URETHRE.

  Pruritus urethralis occurs at the extremity and along the canal of
the uretha 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. 
516    DISEASES  OF SPECIAL STRUCTURE OF  THE SKIN.

                       PRURITUS PUDENDI.

  Pruritus pudendi is a most distressing affection.  It invades chiefly
the external labia and vulva, but sometimes extends inwards along
the vagina,  giving rise to excessive discomfort,  and often  exciting
symptoms  of  nymphomania.   The 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 of 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 ascarides in the
rectum, haemorrhoids, and varicose veins of the labia or vagina.
  Diagnosis.—Pruritus may be distinguished from prurigo by the
absence of the alteration in  structure which is characteristic of the
latter disorder; and from other  affections it is at once recognizable by
the sound state of the skin.
  Treatment.—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 indis-
pensable.   Arsenic sometimes  acts as a specific.   The diet should be
digestible and nutritious, and stimuli avoided.  The best local appli-
cations for soothing  the  pruritus are, the  juniper tar, the sesquicar-
bonate of ammonia lotion, a solution of acetic acid,  lemon-juice min-
gled with water, or the hydrocyanic acid lotion with emulsion  of bitter
almonds.
  For the local varieties, constitutional treatment  is equally necessary
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 subsequently fomented.  If ascarides
be present, they must be destroyed by a quassia or 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, juniper tar, either as  an ointment, or in combination with
alcohol; a weak solution of acetic acid,  or bichloride of mercury,
solution and tincture of opium, crea-ote,  compresses saturated with
liquor plumbi, 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 sponging  with the  spirituous
solution of juniper tar, or with the compound tincture of benjamin,
will be found  useful  in pruritus 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, or  an injection of a weak solution of nitrate of silver.
  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 upou the restoration ofthe secretions and the
administration of sedatives.  If there be heat and dryness ofthe vulva, 
          DISEASES  OF THE PAPILLARY STRUCTURE.       517

symptoms which indicate congestion of the mucous membrane of the
vagina, leeches should be applied to  the inner surface of the labia,
and fomentations of poppy-heads, or  a cold poultice  saturated with
liquor plumbi,- afterwards  used.  I have employed the juniper tar,
creasote lotion, and a solution of the bichloride of mercury with advan-
tage in this form of pruritus.  Frequent ablutions with  tepid water,
containing a small quantity of sesquicarbonate of ammonia, subcar-
bonate 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 pruritus by the application
of a 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 injec-
tion of hot water simply; and that the solution of bichloride of mer-
cury used hot has proved successful after yeaTs of unavailing attempts
with other remedies.  Lisfranc recommends, that in cases where the
pruritus bears relation  to the menstrual periods, several small bleed-
ings 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.   The juniper tar ointment considerably diluted
is a valuable remedy in these cases; as is also the juniper tar soap.
                   CHAPTER  XVIII.

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN.

             DISEASES OF THE PAPILLARY STRUCTURE.

v There are certain abnormal states of the cutaneous  textures, the
external signs  of which are, an increase in the growth of the skin
without  any appearance  of inflammation.  For example, there are
those prominences which are known by the name of warts, and those
other thickenings and  indurations of  the surface of the  body which
are termed callosities and corns.  Mason Good gives, as a name to these
enlargements, ecphyma,1 or cutaneous excrescence, and his definition
is, "a superficial, permanent, indolent extuberance, mostly circum-
scribed."  The most obvious character of these  enlargements  is the
accumulation of epidermis, not diseased epidermis, as in some of the
preceding affections, but  an epidermis in nowise, except thickness,
differing from that of the rest of the body.  Now, the epidermis, it is
well known, depends for its thickness  upon the papillary layer of the
derma, being  considerable when  the papillary  layer is highly de-
veloped, and vice versa.  Hence, an unusual thickening of the epidermis
is an evidence of an  abnormally developed or hypertrophous condition
iic^ua, educo, egero. 
518    DISEASES OF SPECIAL STRUCTURE  OF  THE SKIN.

of the papillary layer upon which it is fashioned and  rests.   This is
precisely the  pathological state of the diseases comprehended in the
present 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  enlarge-
ment is associated with an augmented formation of epidermis.   I have
already had occasion to remark, that in lepra there exists an hypertro-
phied  condition of the papillae of  the skin, but  the  enlargement is
associated with other morbid conditions, which give a speciality to that
disease.
   There is another form  of hypertrophy of  the  epidermis consequent
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 first edition of this work, pachulosis was described
under the title of ichthyosis spuria.
   The diseases included  in the present group are, therefore,
                   Verruca,              Tylosis,
                   Clavus,                Pachulosis.

                             VERRUCA.
Syn.  Ecphyma verruca, Mason  Good.   Warts.  Sessile  Warts.1   Die
                            Warze, Germ.
   A  wart is  a state of  hypertrophy of the  papillae  of the derma,1
attended with an increased production of epidermis.  (Plate VI., figs.
1, 2.)   Warts are usually  of  small size, and of a rounded figure, •
verruca simplex; sometimes, however, they appear in the form  of bands
several lines in breadth,  and of variable length.  They are generally
insensible, rough to the touch, and  their medium 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 on the trunk of the body,  the scalp, or face.
   Hypertrophy of the papillae of the derma  in the production of warts
takes place without apparent cause, and without premonition.   The
papillae, 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 epidermal  sheaths'are h,eld
 together, in the form of a  bundle, by  the epidermal  mesh formed

   1 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 epidermis, but the pedunculated  warts are invariably productions of the
 derma, and, in many iustauces, as I have  proved, the emptied tegumentary  sacs of
 small sebaceous tumors.
   2 My researches into  the structure of warts date as far back  as 1830, when my
 attention was directed to their nature by a remarkable bleeding wart, which I had at
 that time on my own finger.  Since this period, their structure has been investigated
 by Ascherson (Casper's  Wochenschrift, 1835), and  more recently by Dr.1 Gustav
 Simon, of Berlin (Muller's Archiv., 1S40).  The latter writer speaks doubtingly of
 their origin in all instances by hypertrophied papillre. and states that they  arise some-
 times where there are no papilla. I differ entirely from him in this opinion. 
           DISEASES OF THE PAPILLARY STRUCTURE.       5l'9

 between and around them by the bases ofthe hvpertrophied  and the
 surrounding normal papillae.  It very rarely happens that the whole
 ofthe 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 interfibrous epidermal mesh.1   When warts have grown to
 some length, their extremity becomes rough, and their fibrous struc-
 ture is distinctly apparent; it not unfrequently happens that warts of
 long standing split  and  break  up in the direction of these vertical
 fibres, verruca lobosa.
   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 ex-
 hibited by thin  sections cut horizontally and vertically, and examined
 under the microscope Vrith a lens of low power.
   Rayer compares warts  formed of  isolated  papillae, very  aptly, to
 " coarse plush."  He quotes from M.  Rennes a remarkable instance of
 a wart of great extent (verruca confluens), and  presenting the appear-
 ance 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 the arm  and
 forearm of the same side, till it reached the carpus, where it increased
 considerably in  breadth, and finally overspread the whole palm of the
 hand."
   Warts are generally known  as  isolated  growths, or dispersed in
 scanty groups on different parts of the body, but they are sometimes
 met with so numerously as to constitute an eruption of warts.   I have
 met with  numerous cases of this kind;  in one, a young tradesman
 about twenty-five years  of age, there  were  some hundreds  of small
 warts clustered on the backs of the wrists and hands,  and others upon
 the upper part of the forehead.   Another example occurred  in a girl
 of eighteen, whose hands and wrists on the dorsal aspect were covered
 with these morbid growths.  While on the forehead of young women
 they are far from being rare.
   But there is another kind of wart which is by no means uncommon,
 and which, from its appearance, may be termed verruca digitata.  This
 wart is found on the scalp, and sometimes exists in  that situation  in
 considerable numbers.   Fixed on the skin of the head, and throwing
 out on all sides its pale, finger-like  papillae, it  may be mistaken for an
 insect, until its fixed adhesion to the  skin and immobility prove  the
 contrary.   Sometimes the digitated wart is single, or  a few only  are
 met with;  at other times, they are so  numerous as to act as an impedi-
 ment to combing the hair.  They may be small, consisting of two or
 three digitated papillae only, or large, forming a tuft of hypertrophous
 papillae of considerable size.  They are longer than  ordinary  warts,
and commonly range from two to four lines  in height.

  1 This interfibrous mesh is not present in all warts; when it is absent,  the fibres
adhere but slightly  by means  of their surfaces, and are kept together by  the thick
rim of epidermis which surrounds them. 
520    DISEASES OF  SPECIAL STRUCTURE OF THE SKIN.

  Causes.—Warts  frequently originate  without  apparent  cause;
sometimes they seem to depend on local irritation of the integument:
and at other times result from a morbid state of the skin, commonly
associated with torpor of  function.  Some persons exhibit an especial
predisposition to the development of these productions.  It is popu-
larly believed that the blood proceeding from warts is capable of ex-
citing their growth in unaffected persons.   Such a supposition is too
absurd to deserve further attention.
  Treatment.—When warts are isolated they may be removed by
a caustic, but  when  they are numerous they call  for constitutional
treatment.  The best caustic for their  removal is  the potassa fusa,
which requires to be used with care, and could  not  be safely trusted
out of the hands of the medical man.   Other caustics,  which may be
employed for a  similar purpose, are, nitric acid, strong acetic acid,
tincture  of  iodine, and the nitrate of silver.   But the potassa  fusa
surpasses all these in  removing the wart at once and completely, while
at the same time it sets up sufficient inflammation to destroy the  en-
larged papillae, and modify the structure of the derma.  If too much
inflammation be created, the part  should be covered with  a piece of
Alison's  lambskin  saturated  with water,  with  water-dressing, or  a
poultice.  When other caustics than the potassa fusa are used, they
harden and dry the epidermis, and the dried and hardened part re-
quires paring each time that the caustic is repeated;  with  the potassa
fusa no such elaborate process is needed.1  For  the digitated warts on
the scalp, the  potassa fusa is the best  remedy, and the  plan is, to
soften them and rub them  away with  a  point of potassa  fusa, while
the patient is under operation.  When removed in this manner, they
rarely  return.
  But while the caustic removes the local  disease, it is clear that it
does nothing towards correcting the disposition in the system  to  the
reproduction of warts; and, therefore, when they are numerous, and
a verrucous constitution may  be said to exist, it becomes necessary to
have recourse  to a constitutional  treatment.   For this  purpose,  I
have prescribed arsenic with the greatest success, and it is curious to
see with  what rapidity the skin responds to the action of this medi-
cine, and how rapidly an  eruption  of warts,  apparently  so little
amenable to constitutional remedies, will disperse.   I lately treated  a
young lady in Cumberland, whom I had not the advantage of seeing,
in this way, and  with complete success.  She took the arseniate of
soda for  a brief period only,  a few weeks, and pencilled  the warts,
which were of  the digitated kind, and developed on the scalp, with  a
strong solution of bichloride of mercury.
  Other  and less efficient remedies for  warts are, the juice ofthe cheli-
donium majus, strong pyroligneous or acetic acid, the mineral acids,
liquor potassae, liquor ammonia, and the muriate of ammonia.  The
last is the safest and most manageable, and, with perseverance, is com-

  1 Mason  Good observes that in Sweden warts  are "destroyed by the Gryllus verru-
civorus, or wart-eating grasshopper, with green wings spotted with brown. The common
people catch it for this purpose ;  and it is  said to operate by biting off the excrescence
and discharging a corrosive liquor on the wound." 
          DISEASES OF  THE PAPILLARY  STRUCTURE.      521

monly successful, requiring to be rubbed upon  the  wart night and
morning for some weeks.
   Plumbe recommends  the use of a small piece of blistering plaster
laid on the crown of the wart, and covered by an  adhesive strap.  In
the country, the juice of the chelidonium majus is a popular remedy.

                        CLAVUS.  TYLOSIS.

                     Syn.  Corns.   Callosities.
   A corn is an increased  degree of thickness of the epidermis, result-.
ing from hypertrophy of the papillae of the derma; this hypertrophy
being determined and kept up by the irritation caused by undue pres-
sure and friction on the part  affected.   So long as the causes which
first gave existence to the corn continue, the epidermis accumulates,
and, by its pressure on the vascular  derma may give rise to ulterior
and serious  consequences.  But as soon as the  pressure  and friction
are removed, the^derma regains  its  natural state, and the epidermis
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.
   Corns present us with three modifications in relation to structure
and degree, which may be considered as  varieties; they are, laminated
corns, fibrous corns, and soft corns.

                       LAMINATED CORNS.

      Syn.  Tyhsis.   Callus.  Callosity.  Die Schwulle, Germ.
   Investigating the manner  of development and growth of a corn, 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 suffi-
ciently,  in consequence of its seat over a bone, to escape the pressure
or friction, the  vascular rete ofthe 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 friction are  continued from time to time, and
for some hours  together, for months and  years;  the  derma becomes
more and more habitually congested, and  the papillae are at first tem-
porarily, and afterwards permanently enlarged, the lengthening of the
papillae being most considerable in the centre, where the greatest amount
of 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 vascular determi-
nation to the part, and  subsequently iucreased vascularity,  with the
associated consequence, augmented nutrition.  With hypertrophy  of
the papillae, the' function of these organs is likewise increased, and a
proportion of epidermis corresponding with the enlarged papillae is
produced.  The formation of  this  epidermis  over the hypertrophied
papilhe  constitutes a callosity, or corn,  and the thickness of the corn
bears an exact  relation  to the thickness of the epidermis of the sur- 
522    DISEASES OF SPECIAL  STRUCTURE  OF THE SKIN.

rounding skin, plus the increased dimensions and vascularity of the
formative papillae.
  This is the mode of formation  of every corn, and this the structure
which all newly-formed and moderately sized corns present. It follows,
from this description, that if we make a vertical section of such a corn,
and examine the cut surface with a lens,  we shall find the. epidermal
thickening perfectly homogeneous, and this  is the general fact.  Some-
times, however, it happens that the section  of the corn presents a dis-
tinctly stratified texture, and the successive laminae differ from each
pther in  color.  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 than 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 epidermis,  or among  the  epidermal cells.  A new formation of
epidermis 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 lesser sanguineous effusions, and consequently
to lighter-colored or thinner laminae, and, moreover, the  effused and
desiccated blood will lose a considerable  proportion of its color as it
approaches the surface.

                         FIBROUS  CORNS.
                Syn. Clavus.  Die Hunerang, Germ.
  The preceding is a sketch of the history of the common laminated
corn, or  callus, but those who  have  paid attention to the  subject will
have observed  in certain  corns  sometimes more than this.   On the
summit  of the corn they will have  remarked an appearance resem-
bling the ends of fibres ; in cutting the summit horizontally, there is an
appearance as though these vertical fibres were cut across (eye of the
corn), and they may possibly associate with this appearance the popu-
lar belief in the existence of a  core and root to the corn.  If a vertical
and central section be made of a corn of this  kind, the  existence of
vertical  fibres, general  slightly different in tint of color from  the
homogeneous epidermis, and  frequently intermingled with  traces of
opaque  white,  is distinctly demonstrated.   The explanation of this
appearance is as follows:—
  The continuance of pressure on the central part of the convexity of
the corn causes undue pressure on the derma, and the common result
of pressure on a soft part ensues, the papillae are absorbed, next the
entire structure of the derma is thinned, and,  after a time, even the
tissues below the derma are injured by  the  compression.  The part
of the derma which in the early stages of the corn  was more convex
than the rest, now becomes de'pressed,  and, instead of being a promi-
nence, is a hollow cup of  greater or less depth.  We have, therefore,
two  conditions present in the derma, the bearing of which on the
production of the superjacent  epidermis is now to be considered.  The
derma being thinned almost to the state  of atrophy, "and the papillae
removed by absorption, the epidermis is necessarily altered in structure ;
it becomes horny and of a deeper color thau the surrounding cuticle. 
DISEASES  OF  THE  PAPILLARY  STRUCTURE.      523
In the second place, the secreting surface having lost its plane position
and  become concave, the epidermis is altered in  direction, and  the
continuity between the cup-shaped layers  corresponding  with  the
depression of the derma, and those of the  plane  surface around, is
disturbed.  It is this alteration of direction, and the uprising of the
edges of  the  layers corresponding with the rim of the cup  on the
surface of the corn, which produces the appearance of fibres; the whole
mass of altered epidermis constituting the core of the corn.
  The art of the chiropodist consists in  dislodging the core of the
corn from its concave bed, and when this is done, it is no uncommon
thing to  find a drop of serum or  pus, and sometimes extravasated
blood beneath its deepest part.  When  these fluids are removed, the
surface of the derma, congested and tender, is seen to be exposed.
  The description  of a  corn  which I have now  given appertains to
one  of long standing; in those of more recent formation every degree
of transition may be observed, from the simply congested and hyper-
trophous  condition of the papillae  to  their progressive and total
absorption.   The structure of the core of the  corn is often apparent
on  its surface from the gradual wearing away  of its summit; this
process being equivalent to an horizontal section.
  Corns  sometimes give rise to  serious consequences;  by  pressure
on  bursae 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 corn situ-
ated on the metacarpo-phalangeal articulation of  the little toe, which
had made its way into the joint,  and had produced  absorption of the
articulating ends of both bones.

                           SOFT CORNS.
  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 little or no  convexity on
the surface, and, from being  constantly irnmersed in the perspiratory
secretion  which collects in the situation of their growth, they are soft
to the impression of the knife.
  In manner of formation  and growth,  soft corns  are identical with
the preceding.  From the pressure of the toes one against another,
some point ofthe skin, either corresponding with or on the soft parts
immediately  opposite  the  prominent head  pf a  phalangeal  bone,
becomes slightly inflamed, and a  greater thickness of epidermis than
usual is formed.  At this stage of growth of the corn,  it frequently
happens that an increase of irritation gives rise to effusion of a serous
fluid beneath the white and thickened epidermis.  The epidermis is
rendered  soft  by saturation with  the fluid, and a small aperture is
formed in the centre of the  disk, through which  the serum escapes.
I have seen a soft corn remain for several months in this state during
the summer season, the surface  of the derma continuing to secrete
serum, and the serurn being retained, or escaping through the small
central aperture.   At other  times, and when the irritation  is less
severe, the epidermis is thickened by the addition of fresh epidermal 
524    DISEASES OF SPECIAL  STRUCTURE  OF THE  SKIN.  '

formations to its under surface, 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 extracted at  this period, it will be found to be plano-convex,
the plane surface corresponding with the level of the adjacent epider-
mis of the  toe, and the convex surface projecting more or less deeply
into the derma.
  The soft corn sometimes gives rise to the formation of an  ulcer,
and  being separated from  the  adjacent tissues by  suppuration  is
thrown off.  In one case I saw a sinuous ulcer, excited by a soft corn,
extend as far as the phalanx;  it was  followed  by exfoliation" of the
surface of the bone, and a permanent stiffness of the joint.
  Causes.—The  causes  of corns are pressure and friction.  They
occur at all periods of life, and under  various circumstances.  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  one another.
They may also  be the  consequence 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; of the oar in rowing.   On the
knees they result from much kneeling; and are also found on various
other parts of the body.
  Treatment.—The treatment of corns offers two indications, 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 horny  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 plasters of thick soft
leather, perforated in the centre by  a round aperture that fits the
summit of the corn, and relieves it from pressure.  Plasters of amadou
are well adapted for this purpose.  The  palliative treatment consists
in the removal of the thickened epidermis either by scraping or  filing,
after the corns have beeu* well soaked  and softened in an alkaline
solution; or  by cutting,  either  in  the soft or the hard state.  The
chiropodists dissect out  the central  part of the corn, the eye or root,
as they term  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 oT  remoVing the epidermis, are, by  nitrate of silver,
by  plasters containing the  solvents of  albumen, namely,  soda and
potash, &c.  It should, however, be recollected  that the formation  of
a corn is  not a morbid  process, but simply an  augmentation of a
natural function, kept up by irritation.
  The only cure for the soft corn is its entire  removal.   This may
most easily be accomplished by the help of a pair of scissors ; all the
thickened epidermis being taken away at the same time.  The forma-
tion of soft corns may be  prevented, and when present  they may be
rendered bearable, by daily ablution  with  soap, and  by  placing a
piece of cotton wool  between the toes  after each ablution. 
         diseases  of the  pigmentary structure.      525

                          pachulosis.
  After  certain chronic affections, in which the skin is secondarily
involved, particularly that of the lower extremities, the epidermis 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 Willan into his description of  ich-
thyosis, and referred to by other writers, under the title of accidental
ichthyosis,  but it  is quite clear, from the description of ichthyosis
given in  the chapter on  the diseases of the sebiparous system, that the
present disorder bears no relation to that affection.  As an inordinate
production of epidermis dependent  on hypertrophy of the papillae  of
the skin, it  has a  title to a place in  this group, while  its principal
character, namely,  that  of thickening and condensation of the skin,
seems to point to pachulosis (rta%bf, crassitudo) as a fitting designation.
  This state of the skin occurs for the most part in elderly persons,
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 eczema. It is sometimes a sequela of anasarca.
  Treatment.—The treatment of pachulosis consists in sponging the
scaly surface writh  a damp sponge, dipped in fine oatmeal, diligently,
for five or ten minutes, and then anointing the surface with a liniment
of lime-water and oil;  adding to this liniment, as the torpor  of the
skin gradually yields, a few drops of liquor ammoniae.  In the  course
of a short time, the natural tone of the skin may generally be restored
by this treatment.   Another mode of treatment, is to remove as much
of the hardened coating as possible with soap, then cover it up with
a plaster of  diachylon softened by melting with  an equal proportion
of almond-oil, and  bind  it closely to the skin with an elastic bandage.
The dressing should be repeated  every  second day; and every time
the plaster  is removed the diseased  surface should  be well washed
with soap.   This process should be  'continued  until the whole  of the
hardened cuticle is cleared away, and the skin  brought into a healthy
state.
                   CHAPTER   XIX.

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN.

            DISEASES OF THE PIGMENTARY STRUCTURE.
  Under this head, corresponding with the order MACULE of Willan,
epichrosis of Mason  Good, or  Dyschroma,  are  assembled  those
affections of the cutaneous textures  which are characterized by dis-
coloration of the skin.   The precise seat of these alterations is the
rete mucosum and papillary layer of the derma.  The cause may be
referred to three  principal conditions: firstly, the original organiza-
tion of the individual;  secondly, alteration of function of the derma 
526   DISEASES  OF SPECIAL STRUCTURE  OF  THE  SKIN.

without  apparent change of structure;  and  thirdly,  alteration  of
nutrition of the epidermal cells of the rete mucosum.
   Maculae may be arranged in three principal  groups, namely, those
which are characterized by augmentation of the  natural pigment of the
rete mucosum;  those in which  there is diminution of pigment; and
those which present a morbid alteration of  pigment.  To these charac-
ters, 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 a view of including that remarkable alteration
in  the color of the skin  which  is produced  by the  internal use  of
nitrate of silver.   The seat of this discoloration is different from the
preceding, inasmuch as it occupies the  papillary layer of the derma,
and may very properly be considered under the designation of chemical
coloration of the skin.

                I. AUGMENTATION OF PIGMENT.
                         MELANOPATHIA.
        Nigrities.  Nigredo cutis.  Die Schwarze Haul, Germ.
   When we  compare the distribution of the pigment of the skin
throughout the members of the human family, we are struck with two
remarkable extremes of difference,  as illustrated in the jetty black  of
the tropical  zone, and the fair complexion of the natives  of colder
climates.  Between these  extremities  every  shade  of tint may be
found in  intermediate latitudes;  and,  indeed, by the  alteration  of
the solar  influence only,  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 extent;  but we require to proceed no further than
our own hearths for an illustration of the fact, that the fair complexion
may be rendered dark by the stimulation of light during the summer
months, and  the quantity of pigment will be again reduced during
the winter 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 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 the  skin are  not  wholly referable to  external
agencies.  That which  the stimulus of light and of the suns rays  is
to the skin,  under natural circumstances,  the stimulus of morbid
action may be in  a disordered state of the system.  Hence,  we  occa-
sionally meet with instances in which the skin is altered in its color
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 contribute
very  largely  to  the  differences  of tint which are observed in the 
         DISEASES  OF THE  PIGMENTARY STRUCTURE.      527

human race.  The long winter of the colder climates, or protracted im-
prisonment in a darkened cell, would 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 to learn how far colonization for a
number of years would give rise to these results.   It is to especial
organization  that we must have recourse, to explain the great differ-
ence in shade of color 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 brown color, more
or less deep  in different individuals, while, in rare instances, the  skin
in this  region  presents a deep black.  Haller, in  his Physiology,
relates a case of this  kind.  The alteration of color 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 patdhes
of various size.  Again, patches of a darker color than the surround-
ing skin, but identical in every other respects, may be developed upon
any part of  the surface  of the  integument in individuals of every
shade of complexion.  Plenck seems to be under the belief that the
Tartars  have naturally a  mottled skin: " Cutis variegata nativa;  in
Tartarorum gente tigridis instar;"  while of another variety of Maculae
cutis, namely, " cutis  variegata morbosa," he observes, " Visa  est ad
semel in uno subjecto facies viridis, latus corporis dextrum nigrum,
et sinistrum flavum."
   The alteration of color which  takes  place around the  nipple  of
pregnant women, is  a curious  physiological change, but one which
comes so constantly  before our eyes, as to  meet with little attention.
This deepening of color corresponds with that part ofthe skin of the
breast which is termed the areola,  but occasionally, nature makes one
of those singular aberrations  from her ordinary laws, that stimulate
our curiosity and interest.  Such was  the case in  the following  nar-
rative, communicated to  me by  Mr. Jackson, of  High Wycombe,
Buckinghamshire.   "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
examination, I  found the anterior surface of the  body from  the cla-
vicles, 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 very dark,  but no
further  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 color.  Over the hips it extended laterally, but no part of
the posterior surface of the body was affected.  Her complexion was 
528    DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

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 labor, I was
called in by the  midwife to the Institution, in consequence of a pre-
sentation of the hand and umbilicus; turning was resorted to, and the
urirl did well.  She  left the house a month after her confinement, at
which time there was no alteration  in the blackness of the  skin; but
on my last meeting her, about a year afterwards, she assured  me it
had entirely disappeared."
  The following interesting case of general melanopathia  was  com-
municated to me by the late Dr. Pereira.
  "John  Daniels,  aged  seventeen,  weaver, applied  at the London
Hospital, on account^of the dark color of his skin.  He states that for
some months past he has been changing color 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-colored gipsy.
The  darkness 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-colored, and his eyes gray; these, his mother
states, have undergone no change during the alteration of the color 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
from the slate-color induced by the  use of nitrate of silver.   It some-
what 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 discolored; whereas, in Daniel'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 induced this
change of color 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 color obviously depended
on some alteration in the quantity or quality of the coloring matter of
the skin.   It could not depend on the presence of any coloring matter
in the blood, since neither the conjunctiva nor the mucous membrane
of the mouth was altered  in color.  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 color of  the skin re-
sided  in the derma, and  not in  the cuticle.   The mother states that
the intensity of the color 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 hos-
pital after a few  weeks."
  In  a case of melanopathia which I had an opportunity of seeing,
through the courtesy of  Mr. Acret, of Torrington-square, the black- 
ISEASES OF THE  PIGMENTARY STRUCTURE.
529
 ness 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 that period, to sleep, and being frequently delirious.
 Previous  to the illness, menstruation was regular and the menses co-
 pious; but since her recovery, she has suffered from amenorrhcea, 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 headache, has an eczematous eruption on the scalp
 and a dainty appetite.                      .
   It was  on her recovery from the above illness that the change of
 color  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 color 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, gave  her complexion a singularly Indian appearance.  And the
 peculiarity of her color is heightened by  the extension of the black-
 ness 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 uniform; there are small patches  in  which the depth of color
 is greater than in  others, the darker colored spots corresponding with
 the apertures  of follicles.  The  areola  of  the nipples approached  in
 depth  of color to  a negro-blackness.
   Another case, communicated to  me by the late  Dr. Sarti, was as
 follows:  Pietro Nanni, a peasant,  of St.  Martino al Castagna, fifty
 years of age, having unluckily got into a fray, was fired upon and put
 in danger  of  his life.  The shock  caused  a severe illness, and three
 months afterwards his skin gradually darkened, until it became quite
 black.   The  change was first perceived ou his  cheeks, and  thence
 extended over the entire body, being greatest  on the front and sides of
 his breast, the inner  sides of his  legs, and  the hands.   With the
 termination of this case I am not acquainted.
  Dr. Addison1 has lately called the attention of the profession to the
 association of melanopathia with disease of  the suprarenal capsules,
 and has adduced several examples of this union, of which the follow-
 ing are the  most striking.  A baker, aged  thirty-two, ill for three
years,  had, during that period,  two  attacks  of obstinate  cough,
accompanied  with extreme  weakness.  After the  cessation  of the

  1 On the constitutional and local effects of diseases ofthe suprarenal capsules; by
Thomas  Addison, M. D.  4to.  1655.
       34 
530    DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

cough, the first time, his skin, previously white, began  to darken ;  at
the end of the three years, it was so dark that he had the appearance
of being descended from  colored parents.   " The  cheeks are a little
sunken, the  nose is  pointed, the  conjunctivae are  of a pearly white-
ness;  the voice is puny and puerile."  "He complains of  a sense of
soreness in the chest, about the scrobiculus cordis."  There was no fault
about  ^he urine, and Dr. Golding Bird, under whose care  he was,
considered  the case to be one of anaemia.   He died, soon after these
observations were made, *of  "acute  pericarditis and pulmonic inflam-
mation."  On  examination  after death, besides  disease of  the lungs
and  pericardium, and a fragile  state of the liver  and spleen, the
kidneys being healthy, "the suprarenal capsules were diseased on both
sides, the left about the  size of a hen's egg, with  the head of the
pancreas firmly tied down to it by adhesions.  Both  capsules were as
hard as stones."  Dr .Addison concludes from this case, that  " the slow
and gradual  inroads  of the disease,  and the remarkable  excess  of
pigment, were sufficiently accounted  for by the universality of the
change that had taken place in the  structure of both capsules."
   A tide-waiter,  aged thirty-two,  of  bilious temperament,  having
dark hair and a sallow complexion, was observed during the last six
months of his life, to be growing gradually dusky in complexion, until
he became of ft dark olive  brown color; and black pigmentary patches
were  developed  on the mucous membrane of the  insides of the lips.
His duties were anxious, and exposed  him to alternations of weather;
but, with the exception of an attack of rheumatism and occasional
bilious vomitings, he had  enjoyed good health until six months since,
when  he was seized with a bilious attack  of greater  violence than
usual.  On  this occasion, the vomiting, headache, and constipation
were  succeeded  by delirium and  temporary insensibility, these latter
being  followed by numbness and  loss of power of the fingers and
legs, and extreme debility, which continued for  some weeks.   Three
months later  he returned  to his duties, but was  again laid up with
headache, vomiting, and constipation ;  and two months after this, was
admitted into Guy's Hospital, where he died after twenty seven days.
His symptoms while in hospital, under the care  of Dr. Gull,  were,
extreme physical depression and debility, sickness with vomitings of
mucus, containing a little altered blood; tenderness of epigastrium,
constipation, clear tongue, cool  skin, natural urine, small and feeble
pulse,  and  anxiety of countenance.  After death, the* suprarenal
capsules were  found to  contain  "compact fibrinous concretions,"
which, "superficially examined,  were  not unlike  some  forms  of
strumous tubercle."   "The brain, lungs,  heart,  spleen, liver, and
kidneys, were normal, but the mucous membrane ofthe stomach gave
evidence of subacute gastritis."
   A carpenter, twenty-six years of age, of strumous  constitution and
intemperate habits,  had observed  during   the  four months  which
preceded his death, black  patches of discoloration upon  the mucous
membrane of, his  lips, a general  change  in his complexion  to a
yellowish and olive hue, and patches  of black  upon the face and  in
the axillae.   He  had enjoyed good health until  six months before 
DISEASES  OF THE  PIGMENTARY
STRUCTURE.
531
death, when he was attacked with  pains in the right leg, extending
upwards to his back, and resulting in disease of the upper  three
lumbar vertebrae and lumbar abscess.  He died  twenty-seven  days
after admission  into  hospital, his  death being  preceded by extreme
debility, torpor, sickness of stomach, hiccough, and typhoid symptoms.
Dr. Rees, under whose care he was  during part of his illness, found
"white  corpuscles" in his blood;   after  death,  besides  strumous
deposits in the lungs, the suprarenal capsules were found "completely
destroyed, and converted  into a mass of strumous disease, the  latter
of all degrees of consistency."
  The inference which is drawn from these cases, is, that whenever
melanopathia of the skin, in conjunction with extreme prostration of
the physical powers  and anaemia, exists,  without other perceptible
cause, disease of the suprarenal capsules will be found after death.
The kind of disease of these  organs seems  to present considerable
variety, for of eleven cases recorded by Dr. Addison, both  capsules
were diseased  in  seven,  and one only in  four.   Of the forms of
disease,  one was  atrophy from inflammation; one, enlargement with
induration;  one,  deposits of compact fibrinous, concretions ;  four,
scrofulous  deposits;  and four, malignant  deposits.  Dr. Addison
expresses his  " belief that the  urgency of the symptoms,  and  the
quick or slow progress of the  disease, are determined by the activity
or rapidity of the morbid change going on  in the capsules, and by the
actual amount or degree of that change; and that  universal disease
of both capsules will, in all probability, be found to prove uniformly
fatal."   This opinion does not appear to be borne out with accuracy
by  the  evidence of  his  cases,  for,  of the  total  eleven cases now
referred  to, the period  of duration  of the disease  as ascertained in
seven,  ranges as follows: /three years, one  year, six months, four
months, three months, two months.  The four longest periods  are
those which correspond  with disease of  both capsules;  the  three
shortest, namely, from four months  to  two months, with disease of
one capsule only.  The order  of fatality as respects the nature of  the
disease was  as  follows:  three years, enlarged and indurated; one
year, enlarged and indurated, with tubercular  deposit; six  months,
fibrinous concretions; four months, softened strumous deposits ; four
months, atrophy from inflammation; three  months, malignant deposit
in one capsule ;  two months, tubercular deposit in one capsule.
  The subject, however, is in the infancy of its research, and we must
accept Dr.  Addison's observations  as a  valuable contribution  to
medicine, and  as a basis for further investigation.  It  cannot be
allowed that all cases  of melanopathia are also examples of disease of
the suprarenal capsules, any more than  that  every case of disease of
the suprarenal  capsules  must be necessarily  accompanied  by  the
deposit  of  a  dark  pigment  in the skin.   Dr.  Addison has  very
properly shown that melanopathia is only one of the symptoms, of a
series of those which  constitute  the  peculiar form of anaemia which
he so forcibly describes.   "For a long period," he writes, "I had,
from  time to  time,  met  with a  very  remarkable form of  general
anaemia, occurring without any discoverable cause whatever;  cases 
532    DISEASES  OF SPECIAL STRUCTURE OF  THE SKIN.

in which  there  had been  no previous loss  of blood, no exhausting
diarrhoea, no  chlorosis,  no purpura,  no renal,  splenic, miasmatic,
glandular, strumous, or malignant disease."   " The disease presented
in  every instance the same  general character,  pursued a similar
course, and, with scarcely a single exception, was followed, after a
variable period, by the same fatal result.  It occurs  in both  sexes,
generally, but not exclusively, beyond the middle period of life, and
so far as I at present know, chiefly in persons of a somewhat large and
bulky frame, and with a strongly marked tendency to the formation
of fat.  It makes its approach in so  slow and  insidious a manner,
that the patient  can hardly fix a date to his earliest feeling of that
languor, which is  shortly to become  so  extreme.   The countenance
gets pale, the whites of the eyes  become pearly, the general  frame
flabby rather than wasted; the pulse, perhaps, large, but remarkably
soft and compressible, and  occasionally with  a slight  jerk, especially
under the slightest excitement; there is an increasing indisposition to
exertion, with an uncomfortable feeling of faintness or breathlessness
on attempting it;  the heart is readily made  to palpitate ; the  whole
surface of the body presents a blanched, smooth,  and waxy appear-
ance ; the lips, gums, and  tongue, seem  bloodless; the flabbiness of
the solids increases; the appetite fails; extreme languor and faintness
supervene, breathlessness  and palpitations  being  produced by the
most trifling exertion  or emotion; some slight  oedema  is probably
perceived about the ankles ; the debility becomes extreme, the patient
can no longer rise from  his bed, the mind  occasionally wanders, he
falls into a prostrate  and half-torpid state,  and  at length expires."
" The leading characteristic features of the morbid state," are, anaemia,
general languor and  debility, remarkable feebleness  of the heart's
action, irritability of the stomach, and a  peculiar change of color in
the skin,  occurring in connection with  a diseased condition  of the
" suprarenal capsules."   Furthermore, " the great distinctive mark of
this  form  of anaemia is  the singular dingy or dark discoloration of
the  skin;"  " a dark, dingy,  or smoky-looking discoloration  of the
integument."  And Dr. Addison records his  belief, that  "the disease
is by no means of very rare occurrence."
  Returning now to the three cases of melanopathia, narrated by me,
with the view of ascertaining how far they accord with Dr. Addison's
description,  it will be evident that my first case, that of Martha Wes-
ton, must  be looked upon merely as a plrysiological phenomenon.  In
the second case (John Daniels), Dr. Pereira speaks of the sclerotica as
being remarkably white, but does not otherwise lead  us to infer the
existence of anaemia, or  any constitutional disease; the discoloration
had  been  in existence fifteen  months when it came under his obser-
vation. The patient, in the third case, was decidedly anaemic, and the
subject of some obscure organic disease which may have been that of
the capsulae suprarenales; I  regret, however, that I  am unable to
report her present state; she had been two years undergoing a gradual
change of color, and, according to Dr. Addison's views, ought by this
time to be dead.
  According to Dr. Addison,  disease  of  the  capsulae  suprarenales is 
DISEASES  OF THE
PIGMENTARY STRUCTURE.
533
attended with disturbance of the chromatogenous function ofthe skin,
such disturbance tending to the production of an excess of black pig-
ment.   Upon the announcement  of this proposition, we naturally
inquire whether these organs, which have heretofore been considered
of so little importance to the well-being of man, which we have been
taught to look upon as mere vestiges of an organ that  had fulfilled its
office, and was no longer of any use, are really so influential in the
economy of man, that a mere state  of atrophy, or a tuberculous con-
dition of one of them, is sufficient to set up a series  of  remarkable
symptoms which result in the death of the individual  in four months
in one case, in one month in the other; and which possess the singular
power of causing the development of an excess of pigmentary matter,
the latter being not merely limited to the skin and mucous membrane,
but in one case presenting itself as a true melanosis, "scattered in small
masses over the omentum, the mesentery, and the cellular tissue on the
interior ofthe abdominal parietes."   In taking this view ofthe supra-
renal capsules, we must not overlook their intimate relation with the
great abdominal centre of the organic system of nerves, nor shut out
from our minds the probable effects upon that centre of a disease which
will necessarily involve many of its filaments;  which, in one case, at
least, had extended  to the semi-lunar ganglion, and  produced fatty
degeneration of a portion of that ganglion and of the adjacent plexus,
and which, by producing irritation and probably disease of that plexus,
might lay the foundation for those gastric symptoms, and that state.
of physical prostration, and  anaemia to which  Dr. Addison  refers.
Admitting all this, we have, as an explanation of the phenomena indi-
cated by Dr. Addison, namely, spontaneous or idiopathic anaemia, with
melanopathia of the skin, and associated disease of the capsulae suprare-
nales—disease of the capsulae suprarenales, irritation or disease of the
solar plexus, arrested haematogenesis, augmented chromatogenesis, ex-
haustion,death. In a word, the solar plexus is the actual source of all these
successive phenomena, and the disease of the capsulae suprarenales only
the exciting cause.  A state of irritation or disease ofthe solar plexus will
explain all those symptoms which we have difficulty  to comprehend as
flowing from such apparently insignificant organs as the suprarenal cap-
sules.  It will explain, also, how similar effects result from diversity in
the nature of the disease of those organs ; how atrophy, hypertrophy,
induration, tubercular deposit, carcinomatous deposit, may all occasion
the same series of symptoms;  it will explain the arrest of formation
of the red coloring matter of the blood, and the consequent augment-
ation  of the white corpuscles;  and it may be a means of explaining
the hyperformation  of  pigment in the skin, and in  other tissues of
the body.  And further, it will remove an  objection  which I should
otherwise be  inclined to set up, namely, the diversity in the forms of
the melanopathia, described by  Dr. Addison.  For, as  the case at pre-
sent stands, every black  patch  of discoloration of. the skin becomes
the foundation of a diagnosis of diseased suprarenal capsules, and
prognosis of speedy death; a line of argument which is clearly un-
founded.  But I cannot object,  indeed, I think it worthy of our most
attentive consideration, to the diagnosis of irritation  and probable dis- 
534    DISEASES  OF SPECIAL STRUCTURE OF  THE SKIN.

ease of the solar plexus in these cases.  I should strongly protest
against a harmless chloasma being set down as a sign of a fatal cachexia ;
but my experience is altogether in favor of considering it a consequence
of irritation of the great centre of innervation of the  assimilative organs.
But Dr. Addison goes further  than this, and suggests the inference
that the  suprarenal capsules are the special regulators of the black
coloring principle of the body, for, in  relation to a case in which there
was  simple  extravasation of blood  into one of the  capsules, from
obstruction  of  its vein  by a malignant tubercle, he observes, " this
case would render it probable that the excess of dark pigment, so cha-
racteristic of renal capsular disease, depended rather  upon an inter-
ruption to some special function than upon the nature of  the organic
change ; for, with the exception of the manifestly recent sanguineous
effusion into its tissue, the capsule itself did not appear to  have under-
gone any considerable deterioration."  With  such an  inference I am
indisposed to agree, and the physiology of the suprarenal capsules in
no way inclines to such a conclusion.

                  SPILS  vel N.KVUS PIGMEXTOSUS.

 Syn.  Moles.  Ejn'chrosis spilus, Mason Good.   Pigmentmuttermaler,
                              Germ.
   Besides the  patches already described,  which  are  even with the
surrounding skin, and in every way identical in structure, excepting
as regards increased production of pigment, there are other discolored
spots and patches  found upon  the  integument,  which  are  termed
pigmentary nevi or moles.  The subject  of naevus, or mother's mark,
does not  belong to this division of cutaneous affections; but it is
necessary  here  to allude to these spots, on account of their dissimi-
larity to the rest of naevi, which latter are vascular alterations of the
skin (p. 510).   Pigmentary  naevi, on the other hand, are not more
vascular than the rest of the integument; they are characterized by a
yellowish or brownish, and sometimes a black color,1 are very slightly
or not at  all raised above the  level of  the skin,  and  are frequently
covered with short bristly  hairs.  The  dark color 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 naevi are  various in point of size, being some-
what 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 par-
ticularly 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  perfectl}'  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

                       ' Spilus,  ab o-Tnxo?, macula. 
         DISEASES  OF THE PIGMENTARY STRUCTURE.      535

cure.   When of small size, they may be  removed without incon-
venience by means'of a fine point of potassa fusa; but when of large
dimensions, they call for the use of the bistoury.  They should be in-
cluded within two incisions, embracing an elliptical portion of skin,
and in the direction of its  natural folds.   With this precaution, all
trace of the operation is speedily obliterated.

                  II. DIMINUTION OF PIGMENT.

                          LEUCOPATHIA.

  As,  in the preceding section, we  had occasion to  reflect upon the
production of an excess of pigment in the skin, originating in causes
wholly 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, leucopathia.  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 nerv-
ous 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.

                GENERAL LEUCOPATHIA; ALPHOSIS.

  Achroma, Alibert.  Epichrosis alphosis, Mason Gqpd.  Albino skin.
  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 region  of  the earth.   They are re-
markable 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 color.   The skin
in these persons is of a milk-white  color, the hair is  fair, and usually
soft and  silky; sometimes 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.1 There is  intolerance of light, the pupil is
small, from the contraction of the iris  to exclude the luminous rays,
and the person bows  his head  habitually  towards  the  ground, in
order to shadow the retinae  as much as possible.  At dusk, however,
when the  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
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

  1 In  India "the irides are blue and the hair is  silvery white."—Brett on tire
Surgical Diseases of India.  1640. 
536   DISEASES  OF  SPECIAL STRUCTURE OF  THE  SKIN.

to the entire surface.   Instances of accidental general leucopathia have
only been observed among the natives of Africa.
   An example of  complete  albinism in the negro, alphosis ethiopica;
leucethiopes, might have been seen frequently in the streets of London,
a few years back; the subject  was a tall, sickly-looking  man, who
styled himself. Henry Alexander Commotius  Stewart, the African
Albino.  This man was born  in  New Providence, of black parents,
his father being a negro from Guinea, and his mother a native of the
Island of Antigua, descended from African slaves.   His four brothers
and sisters were all black.  He is tall, has a  complexion like that of a
dead leaf, sprinkled over with large and irregular freckles, light-colored
eyes,  and  a  light red woolly  hair,  surmounting features obviously
bearing the African stamp.

                     PARTIAL  LEUCOPATHIA.

Ephelis alba.  Epichrosis pecilia, Mason Good. Cutis variegata. Piebald
                              'skin.
  Partial leucopathia, or the  diminution or absence of pigmentary
secretion upon one or more parts of the body, as a congenital peculiar-
ity, 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 scalp, the hair participates in the change, and  is produced  of
snowy whiteness.
  Partial leucopathia  is  sometimes accidental in its  development,
occurring without apparent cause as one of the natural changes of the
system.   A remarkable case of this  kind, the subject being a native
of Virginia, is recorded in the fifty-first volume of the Philosophical
Transactions.
  In my Portraits  of Diseases of the Skin,1 is represented the appear-
ance of the skin in  a  gentleman, who,  originally of  fair complexion,
became  brown (melanopathia), and  subsequently lost the cutaneous
pigment  on various  parts of the  body  (leucopathia).  Several  white
patches made their appearance on his  face;  one  nipple  was perfectly
divested of pigment, while the other was as dark as that of a woman
far advanced  in pregnancy ;  and, as if  to render the case  still  more
remarkable, the lost pigment  was accumulated on the side of the
trunk in blotches  of  deep  black.  He  had been  undergoing this
change for seven years before he came under my observation.
  In  Europeans, this  alteration is most frequently met with on the
scrotum  of old persons, in which situation 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 Arabs.  Mr. Brett remarks that in India,
partial leucopathia " occurs in circumscribed patches, which are quite

                         1 Plate XXXIII., H. 
         DISEASES OF  THE PIGMENTARY  STRUCTURE.      537

 insensible, though the disease commences by  itching,  pain, redness,
 and other marks of inflammation."  These latter are probably patches
 of morphoea alba, and appertain to elephantiasis.
   Treatment.—In a case of partial leucopathia which came under
 my observation, in a young lady, whose health was in other respects
 very considerably deranged, the natural hue of the  skin was entirely
 restored by means of tonics and the shower-bath, and by the applica-
 tion of stimulating liniments to the faded  spots.  Mr.  Brett,  in his
 Essay  on  the Surgical Diseases of India,  where this disorder is
 common, observes :  " The treatment consists in the exhibition of the
 asclepias gigantea in combination  with alterative  doses of  mercury
 and antimon}', 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.

   The affections which may  be arranged under this designation are
 four in number, namely,
              Ephelis,                     Chloasma,
              Lentigo,                     Melasma.
                            EPHELIS.

   Syn. Sun-burn.  Epichrosis ephelis, Mason Good.  Macule fusee.

   The term ephelis (ini jjTuoj,  the sun) is intended to express the change
 which  is produced on the skin of many persons  by exposure to the
 influence of the sun's rays.  The discoloration is developed in small
 patches of irregular form, and of  a variable 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 umbrosa and ephelis hntigo, the former refer-
 ring to  irregular  brown patches, and the latter to circular yellow
 spots, somewhat  resembling  those of lentigo.   Rayer introduces the
 mottled appearances seen upon the legs and  thighs of women who sit
 over a charcoal brazier  as a third variety, under  the name of  ephelis
 ignealis.
   Treatment.—The treatment  for sun-burn is the application  of a
 liniment composed  of  equal parts of white of egg  and olive oil; to
 which, if the heat of surface be  considerable, may  be  added  liquor
 plumbi, in the  proportiori of twenty minims to the ounce ; an emulsion
 of bitter almonds with spirits of  wine, or the  benzoated ointment of
 oxide of zinc  beaten into a cream with orange-flower water or elder-
flower water.  In the chronic stains called ephelis umbrosa, a lotion
of the  bichloride of mercury or nitro-muriatic acid  will be  found
 useful.
# 
538    DISEASES OF SPECIAL  STRUCTURE  OF THE SKIN.
                            LENTIGO.

Syn.  Freckles.  Epichrosis lenticula, Mason Good.  Sommersprossen,
                       Germ.   Phacia, Gr.
  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, yellow, or greenish yellow spots of various
size, but rarely  larger than the diameter of a split  pea.  They are
seated in the rete mucosum, and  most abundantly  distributed  upon
those parts  of the body which are exposed to the influence of the
light, as the face, neck, hands, &c.   On these parts they are sometimes
assembled in thick clusters, forming unsightly patches of considerable
size.  They are also  met with on those regions of the body which
are usually  protected by the dress; and are evidently dependent on
some morbid action of the skin.
  Lentigo  is sometimes a congenital affection, appearing soon after
birth, and continuing through  life, or subsiding and  disappearing at
the age of puberty.   Sometimes the spots vanish at other periods, and
without appreciable cause.   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, commonly
disappears during the winter, is excited by the sun's rays, and occurs
in persons of all complexions.
  Treatment.—The treatment of lentigo consists in the application
of some moderately stimulating therapeutic remedy which may excite
the  skin to a more healthy  function.  The lotion of bitter almonds
containing from five to fifteen grains of  the bichloride of mercury to
the half  pint, is well adapted for this purpose.  I have seen  the lini-
ment of lime water and oil, with a  small quantity of liquor ammoniae,
of use in this unsightly affection ; a lotion of the bichloride of mercury
with elder-flower water is also sometimes useful;  or a lotion of borax
and rose water.  Plenck  recommends  acetum  armoraciae;  pasta
amygdalarum  amarum ;  fel taurinum;  lac  sulphuris;  aqua phagae-
denica (yellow wash); and solution of sulphate of zinc.   Fel tauriuum
is a favorite cosmetic remedy among the older physicians.

                           CHLOASMA.

Syn. Pityriasis versicolor, Willan.  Macule hepatice.   Ephelis  hepatica.
                  Hepatizon.  Leberflecke, Germ.
   Chloasma1 is  characterized  by  the development of  one or  more
patches, of irregular form and size, and of a pale or saffron yellow, or
brownish yellow color, upon  any  part of the surface  of the  body,
particularly on the face, neck, and trunk.  The seat of discoloration

           1 Vide, Portraits of Diseases of the Skin, Plate XXXV., A.
« 
         DISEASES OF THE PIGMENTARY STRUCTURE.     539

is  the  rete mucosum;  it is  accompanied by a slight degree of local
irritation, 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 color, which increase in size, and present a yellow
tint, approaching more or less to a saffron, or brownish  yellow  hue,
or dead-leaf-like tint.   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, the
patches are sometimes so extensive that they may be mistaken for the
sound  skin, while the intervening parts  of the natural hue may be re-
garded as the discolored 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  annoyance.  The  pruritus  is  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 epidermis ensues, and is repeated
several  times after the total decline of the symptoms.
   The symptoms above detailed apply to chloasma when recent and
in an active state;  when  chronic, it gives rise to very little inconve-
nience.  Its  location on the skin offers some little variety.   In women,
I have generally observed it on the front of the chest, on the abdo-
men, pit of  the stomach,  groins, and bends of the arms; in men,  it
seems  most frequently to occupy  the  abdomen,  running upwards
along the sides of the trunk  to the armpits and back of the neck, and
downwards  into the groins and  inner parts  of the  thighs: it is also
commonly seen around the neck, becoming blended above with the
deeper color of the face.   In one gentleman, it affects also the bends
of the elbows; and, in another,  is situated only on the back, extend-
ing downwards on the  trunk to the waist.  On examination with the
lens, there is a conspicuous alteration and elevation of the skin, and
a mealy and pulverulent desquamation resulting from the fact of the
hyperpigmentous cells being more friable and less adapted to assume
the condensed character than the scales  of healthy epidermis.
   Diagnosis.—There is  little danger of mistaking chloasma for  any
other cutaneous affection; its yellow color,  the troublesome 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 mixture of soreness  with pruritus  after
scratching, and larger scales.
   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 usual cause of the aff'ection in females
is uterine irritation, induced by impending catamenia, amenorrhoea,
(maculae amenorrhceicae), pregnancy (maculae 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 some-
times lasts through a considerable period of pregnancy,  invading  at 
 540   DISEASES OF SPECIAL  STRUCTURE  OF THE  SKIN.

 its commencement and terminating in its course; or commencing at
 a  later  period,  and  ceasing  after  the  completion  of parturition.
 Other exciting causes of chloasma are,  gastrointestinal  irritation,
 stimulating food  and drinks,  hepatic  irritation; irritations, in fact,
 which are due to a morbidly sensitive state  of the solar  plexus of
 nerves.
   Dr. Gustav Simon places chloasma in his sixth group of diseases
 of the skin, which he entitles Parasites; considering this eruption as
 depending, like  favus, sycosis,  and alopecia circumscripta, on  the
 presence of a parasitical vegetable fungus.  I  do not agree with him
 in this opinion ; and have failed  to discover any vegetable organisms/
 although I have searched for them with care;  and hape seen what has
 been mistaken for them.
   Treatment.—Chloasma gives way  without much difficulty to the
 nitro-muriatic acid with gentian,  conjoined with a mild aperient; and
 the local application of a lotion of the -bichloride of mercury in emul-
 sion of bitter almonds, two grains to the ounce.  Indeed, it seems to
 yield to almost any  stimulant,  such as the nitro-muriatic acid  lotion,
 the nitric oxide of mercury ointment, or sulphur ointment.   But it is
 apt to return, and constitutional  remedies are necessary to alter and
 improve the functions, upon whose failure of proper action  this affec-
 tion depends.   I have seen it get well under small doses of the bichlo-
 ride of  mercury; and have sometimes found it necessary to have
 recourse to Donovan's solution, or one  of the  arsenical  preparations.
 It is perfectly curable.

                            MELASMA.

         Syn. Pityriasis nigra, Willan.  Der Schwarze Flecke.
   Melasma is  an  alteration of the chromatogenous function of the
 skin  analogous to  chloasma, and differing from the latter only in
 the darker color of the  abnormal pigment.  Melasma  is a  rare
 disease,  and has been chiefly observed in persons of a weakly consti-
 tution.   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 epidermis cracks and
 desquamates in furfuraceous scales.   On the  fall of the  morbid
 epidermis, the newly-formed membrane usually presents the normal
 tint.
   Willan observed  this  affection in children born  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 papulated state of the skin, and terminated in a black disco-
 loration, 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 recurrence in association with pellagra, 
         DISEASES  OF  THE  PIGMENTARY STRUCTURE.     5il

and observes, that it  "appeared among a certain number  of indivi-
duals of both sexes, and  of all ages, in the epidemic of Paris of 1828."
  The same characters  which distinguish chloasma from  pityriasis
form the principal diagnostic characters of this disease; substituting
the yellow tint of the former for the black of melasma.
  Treatment.—The indications for treatment are the same  as  in
chloasma.

         IV. CHEMICAL COLORATION OF  THE DERMA.

                     DECOLORATIO ARGENTEA.

  Persons who have taken nitrate of silver for  a certain  length  of
time are liable to be affected with alteration of color of the  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 color.  The  discoloration  takes place upon all parts of the sur-
face of the body  at the same time, but  is most remarkable in  those
regions  which are exposed habitually to the influence of light, as the
face and hands; and, in  the latter  situations, it not unfrequently as-
sumes a more or  less  deep black.  The color is curiously modified in
certain  localities  by admixture with  red; hence, in the conjunctiva,
and on the lips, it presents a livid brown tint, and on the general sur-
face it is much deepened by those causes which, under other circum-
stances, would produce pallor;  for the same reason the discoloration
is more apparent  upon persons naturally pale than  in those who pos-
sess a fresh complexion.
   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.
  Treatment.—Few persons  afflicted with this deformity would feel
disposed to endure it calmly, without making some attempt at its re-
moval ;  hence, it  becomes necessary to  inquire what remedies might
be employed with the best .chance of a successful result. The iodide
of potassium has"  been proposed for this purpose; and, as in moderate
doses it is a safe remedy, it deserves a trial, and may be continued for
a length of time.  Its known  powers of  removing nitrate of  silver
stains from the surface of the skin, are suggestive also of its use as a
local application.   For the same reason a lotion  of the bichloride of
mercury, with or without the hydrochlorate of ammonia, is a judicious
remedy. 
542    DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.
                    CHAPTER  XX.

DISEASES  AFFECTING THE SPECIAL STRUCTURE OF THE SKIN

            DISEASES  OF THE  SUDORIPAROUS ORGANS.

 ' Our knowledge of the existence and  nature of the sudoriparous
system  is comparatively recent.   It  was first made  known by the
researches of Purkinje, Breschet, and  Roussel de Vauzeme, and their
discovery has thrown much light on the pathology of the sudoriparous
organs.   It had  long been observed by dermatologists, that the  per-
spiratory secretion may become morbidly augmented without fever,
and  without apparent visceral disease, a disorder which  has been
termed ephidrosis.  The sweating sickness which prevailed in England
during the sixteenth century, and which still  continues to make its ap-
pearance from time to time in France,  receives much elucidation from
our  knowledge of the  anatomy and  physiology of the sudoriparous
organs.   The observation of this function will probably discover  to
us also certain  morbid phenomena,  which  may be  referred to  defi-
ciency 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.

               I. AUGMENTATION  OF SECRETION.

                             IDROSIS.

      Ephidrosis profusa, Mason Good. Hyperidrosis, Swediaur.
   Idrosis1 is an excited action of the sudoriparous  glands, attended
with symptoms which indicate  inflammatory determination.   It is
characterized  by  excessive perspiration, the perspiratory secretion
being altered in its qualities; by  more or less  redness ofthe skin;  by
heat and tingling or itching;  and by shooting and lancinating pains.
When  the  disease is  general  and acute, it is attended  with febrile
symptoms,  and often  with the development of serous vesicles,  or
sudamina (page 208).
   Idrosis presents two principal varieties, namely,
            Idrosis simplex,            Idrosis maligna.

                          1 Der. IJj&f,  sudor. 
DISEASES OF  THE SUDORIPAROUS  ORGANS.       543
                         IDROSIS SIMPLEX.

Syn.  Ephidrosis.  Sudatoria simplex.  Sudatoria miliaris.   Miliaria.
                   Miliaria rubra.  Miliaria alba.
  Simple idrosis is a subacute affection, sometimes general, but more
frequently partial in its attack.   When general, it is apt to be accom-
panied, after the lapse of three or four days, with sudamina, consti-
tuting that form of the  disorder termed  sudatoria 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  symptoms,
and torpor of the alimentary canal, and its sudden arrest is sometimes
followed by visceral congestion.  Subacute idrosis usually terminates
in a week or a fortnight.
  During the excessively hot weather which  occurred in the early
part of August, 1856, I had occasion to treat several cases of  idrosis.
The symptoms were these:  after taking food, and sometimes without
the stimulus of food, as during the night, the  patient was suddenly
seized with a feeling of faintness and oppression at the epigastrum ;
a profuse cold perspiration immediately bedewed  the whole  surface
of the skin, and continued for a space of time, varying  between a
quarter and half an hour.  In some  instances these symptoms were
repeated at every meal, in others only once in the day, at dinner or
supper, and gave rise to considerable exhaustion and debility.  I saw
about ten cases, and one  was followed by vomiting and slight fever.
I prescribed quinine with sulphuric acid,  and  cooler weather setting
in, the patient soon  got well.
   Chronic idrosis is less apt to give rise to constitutional  symptoms,
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 remedies, 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."1   "Hoffman makes mention of a very old
man, subject to continual perspiration, so  that his whole nourishment
passed through  the pores."  And Willis  notices  the case of a  lady
" whose  perspirations  were  so  prodigious,"  that basins were set
beneath her "to receive the trickling humor."
   Partial idrosis (ephidrosis partialis)  is more  common than the
general form; sometimes it is confined to tbe  feet or hands 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."2   I have, at present, under treatment,

  1 Raver  Translation, page 200.  The extract of aconite here referred to is much
inferior in'strength to the English  alcoholic extract, of which the do:>e is J to \ a
grain.                                               2 Rajer, he. c!t. 
544    DISEASES OF SPECIAL  STRUCTURE  OF THE  SKIN.

a young lady, whose hands are the seat of this disagreeable affection ;
under the influence of a slight nervous excitement, the hollow of the
palms fills with secretion, and perspiratory fluid drips from her fingers
as she stretches them out.  A gentleman whom I attended lately for
severe  gastric disorder, called  on me one  morning, with rills of per-
spiration, running down one side of his forehead and face, the opposite
side being perfectly dry ; and an eminent actor told me the following
anecdote  of himself: When a young man, starring  in America, he
had one night, in the summer time, been playing a tragedy, in which
he was violently heated, and had scarcely time to cool, when he was
obliged to come  on the stage again as  Sir  Archy  MacSarcasm, in
Macklin's comedy of Love a la Mode.  The make-up for this character
required that  he should convert his features, by means of paint, into
those of an old man.   In  the course of the play he was struck by
perceiving himself " the cynosure of  neighboring  eyes," particularly
those in the front rows of the pit, and concluding that it must be the
excellence of  his acting which was attracting so much  attention, felt
highly flattered, and exerted himself  to  the  utmost.   From  time to
time, however, he was startled at the  bursts of laughter and applause
falling in the wrong places, and  was  thoroughly  puzzled  at the
unusual sensation he was creating.  On retiring to his dressing-room,
after making his best and most grateful  bow to an hilarious audience,
the mystery was explained  ; it was not his brilliant acting alone which
had brought down 'such noisy honors on his head, but the drollery, of
his face,  one-half of which  was washed clean of  its wrinkles by
partial perspiration, and displayed the juvenile features of twenty;
while  the other half exhibited the care-worn  lines  and withered
sjaras of eighty.  In his case, while one-half the face was affected in
this peculiar manner, and the  other half was dry, his chest was acted
on in a precisely opposite way, the perspiratory side  being reversed.
At a later period of his life  the  perspiratory action  ceased over the
entire body, and, as a consequence, he suffered bitterly in his health.
   The perspiration in idrosis is acid, disagreeable in odor, and so pro-
fuse as to produce  softening and opacity of the  epidermis, which, on
the soles of the feet, is often corrugated, like  that of  washerwomen.
The disease is most commonly met with in the summer season, occur-
ring during extreme heat, excessive exercise, \c.

                        IDROSIS MALIGNA.

                        Sudatoria Maligna.
   The malignant  form of  idrosis  appears to correspond with the
sweating  sickness of the sixteeuth century, a disorder which  is no
longer met with in  England, but which  would seem by the numerous
reports made to the Acad6mie de Medecine, to be still prevalent  in
France.   The disease is infectious and contagious, and occurs epide-
mically.   The following brief notice of  the disorder is an abstract of
the description given by Rayer.
   Malignant idrosis is commonly associated with inflammation ofthe
stomach and intestines; inflammation of the  lungs; inflammation of 
          DISEASES  OF THE  SUDORIPAROUS ORGANS.      545

the bladder;  or inflammation of the cerebro-spinal  axis.  When the
digestive  organs  are  especially affected, the  disease is  characterized
from the commencement, or at an  early period, by  a severe constric-
tion at the epigastrium, spasm of the diaphragm affecting respiration,
distressing anxiety, deeply drawn sighs, feeling of weight in 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 inflam-
mation, there  is a  deeply-seated pain in the chest, crepitating rattle
in the  bronchi, oppressed breathing, frequent full pulse, and sangui-
nolent expectoration.   When the bladder is inflamed, there are pains
in the  hypogastrium,  difficulty in  passing the urine, with high color
and deficiency of  that secretion.  And when inflammation of the
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.
  The following 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.  Honore", in  whose wards the
patients  lay, had  never before seen cases of this disease; and  M.
Rayer, who is well acquainted with the disorder, had never seen it in
Paris.
  A young man, twenty-three years of age, was received into the
hospital, July  29, complaining of pain  in his head,  lassitude, great
prostration, thirst, and drowsiness.  His skin  was hot, pulse frequent,
tongue and teeth foul; had had no action of bowels, which could only
be  brought to move by medicine; no  rumbling  in the iliac fossae.
There  were none of the lenticular spots which accompanied the pre-
vailing epidemic.   The skin, though very  hot, was neither dry nor
burning; on the contrary, it was  moist.  He complained,  moreover,
of an uneasy sensation and feeling of anxiety at the pit of the stomach,
which  led to the administration of an aperient emetic.
  The present symptoms have lasted three days. His first indications
of disease were, general uneasiness and loss of appetite, but not suffi-
ciently pressing to induce  him to relinquish his duties.  Suddenly,
in the  middle of the  day, he was  seized with* pain in  the  head and
great prostration, which forced  him to take to his  bed; but he had
no  rigors, no diarrhoea; his skin was at the same time  covered  with
a moderate, though constant, perspiration.
  For  two or three days after admission the patient continued in the
state above described, without having been  benefited  by a bleeding
from the arm, practised previously to his application at the hospital.
After this period the  disease assumed all its  severity, the prostration
and drowsiness were  more marked,  the perspirations and oppression
became more intense.  The perspiration streamed  forth continually
from the skin, the heat of skin increased, the pulse became stronger,
and more  frequent;  the oppression was accompanied by cough and
mucous expectoration ; and auscultation discovered mucous crepita-
tion throughout the whole extent of the bronchi.
       35 
546    DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

  This combination of symptoms persisted in all their force for ten
or twelve days ;  at the expiration of that period the patient felt im-
proved.  His amendment seemed in some degree to have been effected
by a change in the position of his bed to a better ventilated situation.
Under the influence  of this change of position, the perspirations
diminished,  the  tongue became soft,  moist, and  simply furred, the
teeth became clean, and the thirst was diminished.
  On the 25th of August the patient is progressing; the surface is
still moist in situations where the skin is naturally perspirable.-  Vesi-
cles are dispersed about the neck and trunk, some being filled with a
milky  serum, and surrounded by a slight areola;  others being trans-
parent.  The return of appetite is more tardy.
  A second  case was  that of a man, upwards of six feet in height,
thirty  years of age, who had felt, every evening, a sensation of fever-
ishness, for about twelve days;  his appetite failed ;  he suffered from
thirst ; his skin felt burning hot, and  he experienced considerable
drowsiness.  Since his admission, the fever has become increased and
continued; his skin is covered  with  a  constant perspiration; he has
headache, pain in the left side, anxiety, and oppression  at  the prae-
cordia.
  In the course of five or six days, the anxiety and oppression have
assumed  an excessive  degree of intensity ; he has cough and expecto-
ration, and mucous rales are very obvious throughout the  whole  of
his chest.  The perspirations have increased, together with  the heat
of skin, and the hardness and frequency of the pulse.  The  abdomen
is distended, the tongue thickly furred;  there 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 phlyctenoid kind, which occupied the vacant spaces between
the papulae.
   As  the eruption  increased,  and  advanced  in development, the
oppression  decreased, the  pulse became  softer,  and the  abdomen
diminished  in bulk.   In this patient, as in  the former,  the  bowels
were  inactive, and required the aid  of medicine.   His  intellectual
powers were unaffected, and the appetite returned gradually to its
normal standard  during recovery.  On the 25th of August he was
convalescent.
   In a third case, the patient was a young  man, twenty-four years  of
age;  he  had, for some time, suffered from  uneasiness, loss of appetite,
and lassitude ; for which symptoms he was bled from the arm without
benefit.  He was next seized with headache, vomiting, diarrhoea, and
perspirations, and was forced to take to his bed, where he  remained
for eight days, suffering with perspirations during the whole  period.
   On  admission, August 16th,  he was in a state  of extreme prostra-
tion ;  heaviness was exhibited in his  features, his tongue and teeth
were covered with sordes, the perspirations were general and contin-
ual ;  his abdomen was distended ; and he suffered  from thirst.  For
several days he remained in this  state, answering with  difficulty the 
          DISEASES  OF THE  SUDORIPAROUS ORGANS.      547

questions that were put to  him.  He had retention of urine, and  a
full basin of clear urine was withdrawn by the catheter.  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 customary after
typhus fever;  he was not so much emaciated as are patients conva-
lescent from the latter disease, but  he  appears"more debilitated.
  M. Marrotte remarks with regard  to these cases, on  the exacer-
bation which took place at the close of the fifth or sixth day ; the con-
tinuous perspirations which  existed at that period both day and night ;
the intensity  of the  prostration  and  drowsiness;  the  cutaneous
eruption which at this period made its appearance, but without  being
critical;  the oppression and anxiety at the praecordia appearing with
the perspirations; the protraction  of  amendment to the term of two
weeks from invasion ;  the continuance of perspirations to the close
of the third week, and the marked benefit resulting from better air
and  ventilation; all of which  symptoms he  looks upon  as pathog-
nomonic.
  Contrasting the disease with typhus fever, he recalls the negative
characters of sudatoria.  There was no  diarrhoea  in the  commence-
ment ; there were no  headache, rigors, or vomitings; the  prostration
of the physical powers is rarely so great; it is rare that  the tongue
and teeth are so speedily covered with sordes, or that drowsiness is so
strongly  marked.  The first week  passed away without epistaxis, and
without  lenticular spots.  The  pulse of sudatoria, again,  has  never
the smallness and frequency of the pulse of typhus.
  Treatment.—The indications for  treatment in  idrosis  are,  to re-
store the secretions, to allay the irritation of the inflamed perspiratory
organs, to restore tone, 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 tepid bath.  The third is met by quinine, salicine,
and the  mineral acids.  The fourth  may require  general or local
bleeding, blisters,  mustard plasters,  mustard foot-baths, &c.;  these
remedies being employed according to the seat, and in  proportion to
the severity of the symptoms.   The suggestion of M.Dupont, relative
to the extract of aconite, is worthy of recolleetion. A sulphureous
bath is recommended  by Rayer;  and, in chronic  cases, sulphureous
vapor might be found  useful.
  After regulating the  secretions,  tannin will be  found  a valuable
remedy in these cases.  I have employed tannin in idrosis of the feet,
with considerable advantage, conjoining with it chloride of lime, as  a
lotion for local application.  A strong solution of alum is also very
serviceable, as  is also a spirituous solution of  the juniper  tar;  and  I
once saw a gentleman  who informed me that he had relieved himself 
548   DISEASES  OF SPECIAL STRUCTURE  OF THE  SKIN.

of  this discomfort by the use of a brine footbath every night.  Pana-
rolus,  remarking that perspiration of the feet doth very much torment
people, continues, "for which I can tell them a speedy  remedy;
namely, if they put some powder of myrtle into their  linen  socks;
but let them have a care they fall not into worse diseases by the cure
of  this, as I have often seen ; for this excretion preserves from many
diseases, and should rather be promoted than any ways  checked."


                II. DIMINUTION OF SECRETION.

                           ANIDROSIS.

  Diminution of perspiratory secretion from arrest of  function of the
sudoriparous glands has hitherto been observed only in relation with
febrile diseases.  It is probable, however, that  the perspiratory secre-
tion, like that  of other secerning glands,  may be diminished and
checked as a consequence of inflammatory disorder of the  sudoriparous
glands, independently of the  rest of the organism.  The dryness of
skin which we occasionally meet with  in  some individuals bears no
reference to the  sudoriparous system, but is dependent  on the absence
of secretion of the sebiparous glands.   In  the Philosophical Transac-
tions1 is recorded the case of a "gentleman near Leyden, who, being
much addicted to  the study of astronomy, and spending very many-
nights in star-gazing, had, by the  nocturnal wet and cold temper of
the air, in such manner obstructed the pores of his skin, that little or
nothing exhaled from his body; which  appeared hence, because that
the shirt he had worn five or six weeks was then as white as if he had
worn the same but one day."


                III. ALTERATION OF SECRETION.

                           OSMIDROSIS.

                   Ephidrosis olens, Mason Good.
  Alteration in the physical properties  and chemical  composition 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 odor, osmi-
drosis.2  The  perspiration frequently assumes an acid smell, probably
from containing a larger proportion than usual  of acetic acid, or a
rancid odor from excess of butyric acid, or a combination of both, con-
stituting  a fetid and disagreeable odor, 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 Charity,
affected with chronic peritonitis, and who, some time before her death,
exhaled a very decided odor of musk: the  pupil who called my atten-
tion to this circumstance had observed the smell for several days while
dressing  a blister, but thought it owing to a bag of  musk put pur-
Abridgment, vol. iii.               * Der. itr/*n, odor. 
           DISEASES OF THE SUDORIPAROUS  ORGANS.      549

 posely into the bed to overpower other bad smells.1  The woman, how-
 ever, assured us that she had no description of perfume about her, and
 I satisfied myself that her linen, which was frequently changed, was
 not impregnated with any perfume before being delivered to her from
 the laundry  of the  hospital.  The odor of musk,  the existence  of
 which was fully ascertained by myself and  several  physicians, and
 which was very perceptible on the arms and other regions of the body,
 did not become more powerful from rubbing.   After continuing for
 about eight days  the smell became fainter, and  nearly vanished the
 evening before the patient's death.  Speranza3 relates a similar case.
 Schmidt  has inserted  in  the  Ephemerides Nature  Curiosorum the
 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 valet de chambre, who
 could never  keep a  place in consequence  of the unpleasant odor  he
 left behind him in the rooms which he  had been occupied in cleaning.
 There have  been  instances of individuals who,  to obtain their dis-
 charge, or immunity from military service, have simulated these offen-
 sive perspirations, by rubbing their axillae 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 odor, while that  of syphilitic patients is said
 to smell sweet.  The sweat of rheumatic and gouty persons has an acid
 smell, while  in putrid fever and scurvy it has a putrid odor; in jaun-
 dice  it is said to resemble  musk in  its  smell.  In  Stark's  General
 Pathohgy we find it stated, that the odor of the sweat in scrofula
 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.  Behrend states that  the sweat in putrid and typhus
 fever is. ammoniacal, and in nervous diseases, according to Nanche, it
 becomes  alkaline.   All  sweat with a putrid  odor probably contains

  1 Mason Good  observes, that the odor of musk, although not often thrown forth from
 the human body, " is, perhaps, the most  common of all odors that escape from the
 skin of other animals.  We discover it in many of the ape kind, and especially in the
 simia jacchus; still more profusely in the opossum, and occasionally in hedgehogs, hares,
 serpents, and crocodiles.  The odor of civet is the production of the civet-cat alone,
 the viverra  zibetha, and viverra civetta of Linnaeus, though we meet with faint traces of
 it in some varieties of the domestic cat.  Among insects,  however, such odors are
 considerably more common, and by far the greater number of them are of an agreea-
 ble kind, andof very high excellence ; for the musk scent of the cerambix moschatus, the
 opis fragrans, and the tipula moschifera, is much more delicate than that of' the musk
quadrupeds ; while the cerambix suaveolens, and several species of the ichneumon, yield
the  sweetest perfume of the  rose; and the petiolated sphex, a balsam ether highly fra-
grant,  but peculiar to itself."  Vol. v. p. 551.   Second edition.
 2 Observation  d'odeur aromatique exhalee par la peau de l'avant-bras.  Archives
Generates de Medecine.   Vol. xxx. p. 399. 
 550    DISEASES  OF  SPECIAL STRUCTURE  OF  THE SKIN.

 free ammonia.  In cases of gouty and urinary concretions, the quantity
 of phosphate of lime appears to be increased."1
   Dr. Piutti, of Elgersburg, has made some analyses of morbid sweat,
 the leading feature of which is the absence of the salts of lime.  Simon
 thinks that the phosphate of  lime appertains to the epidermis, 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:—
                                          1.      2.        3.
          Water.....995.5 ...  993.0 ...  994.6
          Chloride of sodium  ...     3.0 ...    4.0 ...   3.3
          Phosphate of ammonia    .    .      .5 ...     .8 ...   1.1
          Acetate of ammonia .    ...      .5 ...     .6 ...    .5
          Hydrosulphate of ammonia    .   trace.........trace
          Extractive matters  ...      .5 ...    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;  and  the third from a
 girl of twenty-two, laboring under paralysis of the lower limbs.
   Of the abnormal constituents which  have been found in the per-
 spiratory  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-erythein, and fat.  " The following substances
 enter into, and  have been  detected in  the sweat: quinine, sulphur,
 mercury,  iodine, iodide of potassium, assafcetida, garlic, saffron, olive
 oil, rhubarb, indigo, Prussian blue, and  copper."2
   Treatment.—I have several times been consulted in cases of osmi-
 drosis, and have succeeded in relieving  ray patients  from a most dis-
 tressing  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 effected a perfect cure.   Locally, the
 chloride of  lime lotion, or a solution of  the  permanganate of potash
 (Condy's fluid) will be  found of service.

                           CHROMIDROSIS.3
                    Ephidrosis  discohr, Mason  Good.
   Numerous  instances  of abnormal coloration  of the perspiratory
 secretion are scattered through the works of the older medical writers,
 and through the various periodicals.  Cases of blue perspiration4 have

  1 Simon's Animal Chemistry, vol.  ii. p. 180.
  * Simon quoted from Stark's General Pathology, p. 1127; and Baumgartner, Ele-
 ments of Physiology and Therapeutics, p. 486.
  * Der. x?Zy.a, color.
  4 Conradi.  Blue perspiration of one-half the scrotum, Anat. p.  292.  Lemery,
 Histoire de l'Acadeniie  des Sciences, 1701.  Fontenelle, sur les sueurs bleues ; Jour-
 nal de Chimie-medicale, vol i. p. 330. Billard, Krorieps Notizen, No. 32.  Dr. Bleifuss
 in Wurteinburg Medical Correspond. Blatt. 1835. No. 26.  The occurrence of blue
 pus has been noted by  several observers; amongst others, by Dr. Apjohn, of Dublin,
 and Dr. Olioli.  Dr. Apjohn  considered the color  to be occasioned by the presence of
 Prussian blue.  In Dr.  Olioli's case, M. Bouchardat detected an organic coloring mat-
ter of unknown nature.  Dr. Semmola has recorded two  cases of blue urine.  The
coloring principle of blue perspiration is probably of a similar nature. 
           DISEASES  OF  THE SUDORIPAROUS ORGANS.       551

 been recorded by several authors.  Green  perspiration" has also been
 observed, as have those of a saffron and ruby color.  The rarest of the
 discolorations of the perspiration seems to be that in which the secre-
 tion is yellow.2  Black3 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 nigricans.
   In a case of green perspiration recorded by Mr. Pritchard,4 of Lea-
 mington, the cause was ascertained to be the accidental exhibition of
 copper with the food,  the food having been prepared in a copper ves-
 sel plated with tin, from which a portion of  the tin  had been rubbed
 away.  The  subject of the affection was a  young lady of  fourteen,
 who "had for some months evinced much general debility."  She was
 then " seized with  an attack of r.heumatic  fever, which yielded to
 remedies slowly and unsatisfactorily.  After  some days, during which
 the  perspiration was  considerable, my attention was  called to a col-
 lection of light green  perspiration between  the toes, and underneath
 the  nails of  the young lady's feet, whilst the  same  appearance was
 observable in a fainter degree on the upper, but more especially the
 under surface of the foot."
   Treatment.—I have never seen a case deserving of  being con-
 sidered as one of  chromidrosis.   Were such  a case to present 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.

                            H^EMIDROSIS.

           Ephidrosis  cruenta, Mason Good.  Bhody sweat.
   The most common of the morbid discolorations of the perspiration
 are those of  a red hue, which probably owe  their peculiar tint to the
 coloring principle of the blood;  hence they appear to me to call for
 separate consideration.  Landerer5 observed a red perspiration which
 flowed  from  the axilla of  a patient  laboring under fever.  Yoigtel,
 also, has  noticed  an instance of sanguineous perspiration."   M. du
 Gard has recorded the case of a child three months old,  that was "taken
 with a bleeding at the  nose and  ears, and  in the 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 happened 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

  1 Borrellus, Hist, et Obs. Med. Phys.  Cent. 2.  Observatio 54.  Paullini Cent-
 1. Observatio 38. John Peter  Frank,  De  curaudis  hominum  morbis.   Landerer
mentions an instance  of green milk, secreted by the peripheral lobules of the mam-
mary gland in a pregnant woman.
  2 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.
  * London Medical Gazette, vol. ii. p. 211. 1833.
  5 Buchner's Repertorium, 2d Series, vol. v. p. 234, quoted by Simon.
  8 Stark's General Pathology, p. 1131. 
552    DISEASES OF SPECIAL STRUCTURE OF  THE SKIN.

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."1
  The greater number of cases of effusion of blood, or of a sanguine-
ous fluid from the skin, occur in young  women, and  are referable to-
vicarious  menstruation.  I once  saw a  young lady, in whom  a  dis-
charge of this nature took  place every  fortnight from four 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.  And  more recently I have seen another young lady of
highly nervous temperament, whose face would become in a few hours
covered with  blotches of blood  without any lesion of the surface.
When I sponged away the blood the skin looked congested and ery-
thematous.  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  corner 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."3
  Mason Good remarks, that ephidrosis  cruenta, which he defines as
" cutaneous perspiration intermixed with  blood," has " taken place
occasionally during coition ;3 sometimes  during vehement terror, and
not unfrequently during the agony of hanging or the torture.4   It is
said also  to have occurred in some instances in new-born infants,4
probably from the additional force given to the circulation, in  conse-
quence of a full inflation  of the  lungs, accompanied with violent
crying."
  Treatment.—The treatment of haemidrosis depending on  an he-
morrhagic diathesis, must be regulated according to the various indi-
cations which present themselves.  When  the  cause  is imperfect
uterine function, the treatment must be the same as for amenorrhcea.

  1 Medical Essays, abridged from the Philosophical Transactions, vol. i. p. 52.
  2 Landerer mentions an instance of red milk secreted by a woman suffering under
suppressed menstruation.
  3 Paulini, cent. 3. Obs. 46.  Ephemerid. Nat. Dec. 2. Ann. 6.  Appendix, pp. 4.
45, 55.
  4 Bartholinus, Epistola, i. p. 718.
  5 EphemeridaB naturse curiae : Dec. 2.  Ann. 10. Obs. 65. 
DISEASES  OF  THE  SEBIPAROUS  ORGANS.        553
                    CHAPTER  XXI.

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN.

               DISEASES OF  THE SEBIPAROUS ORGANS.
   The sebiparous glands are subject to the same pathological laws
that govern other secreting glands.  The secretion may be increased,
diminished, or altered,  without  manifest disease of the structure of
the glands and their  excretory  ducts.  Fourthly, the  altered secre-
tion maybe accompanied by distension ofthe tubular structure of
the glands and of their related hair-follicles.  Fifthly, the  glands,
with their immediately adjacent tissues, may be the subject of inflam-
mation, the secretion being  at the same time more or  less  altered.
Sixthly, they may be  the subject of carcinomatous disease, constitut-
ing a malignant tubercle. And in addition to these changes affecting
the function of the glands, their structure may also undergo a patho-
logical alteration.
   The follicles of the skin, with their excretory apertures, the pores,
belong equally to the sebiferous  and  to the  capilliferous system.
Observation of the mode of  development of these organs has shown
that the formation of the follicle precedes that of the hair, and in like
manner that  the  sebiparous  gland  is an  offset from the neck of the
follicle;  and further, that the sebiparous gland is not  unfrequently
composed of lobes which constitute a kind of frill around the neck of
the follicle at no great depth from  the aperture of the  pore.   These
points of  anatomical detail must be fixed in the mind for the proper
understanding  of a morbid  affection, a  peculiar alteration  in  the
structure of the follicles, presently to be described.
   Again, the follicle is known to be composed of two parts, a vascular
portion constituting part of the structure of the derma, and an epithe-
lium, which belongs to the economy of the epidermis.  It is  perfectly
consistent  with analogy, that these two  parts may be separately in-
fluenced by morbid action, and that alterations of structure may take
place that may be referable to one or other of them.  Two  such alter-
ations  I have npted as  occurring in the  epithelium  of the  follicles;
and as one of the two involves especially the epithelium of the sebifer-
ous glands, I have selected the present chapter for their consideration.
   It is easily demonstrated that the epidermis forms a solid  conical
process which occupies the mouth of the dermal portion of the follicle.
It is this  solid cone of epiderm that gives transparency to  the sum-
mit of the papula of lichen, and suggests the idea of the presence of a
fluid.   Normally  this epidermal cone is not visible from the exterior;
but a case  at present under my treatment offers the singular phe-
nomenon of an  hypertrophy of the epidermal cone, and its projection 
554    DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

above the level of the surface, as a prominent papule of considerable
dimensions.  This morbid affection exists in a gentleman in good
health, and occupies the upper extremities, principally the forearms,
where the skin is studded over with some hundreds of horny papulae,
hemispherical in  figure, yellowish  in  color, smooth, transparent, and
extra-vascular, each papula presenting on its  summit the aperture of
a pore.   The epidermis in this case is perfectly  normal in structure;
and the disorder  appears  to  me to be  fittingly represented  by the
term—papular hypertrophy of the epidermis  of the cutaneous follicle
(papulae  epidermicae vel  epidermidis).  The  part of the  epidermis
specially  constituting  the  morbid  phenomenon  is not  the  rete
mucosum, but the horny  layer.
  Another disorder of the epithelium of the  follicles of the skin is
more  common than  the  preceding, and involves chiefly its  deeper
layer, spreading when  it  reaches the  surface into  the rete mucosum
of the epidermis.  The  pathological  nature  of this  affection is an
hypertrophy  and altered  color of the epithelium of  the sebiparous
gland and  of its excretory  tubuli.  The epithelium  is thicker than
usual, of a spongy texture, and  yellowish  in color, and lifts up  the
tissues immediately  around the  pores into rounded papulae of  con-
siderable  size, which are sometimes discrete and sometimes coherent.
The papulae are smooth,  hemispheroidal, sometimes flattened  on the
summit, perforated by  the aperture of a pore, elastic, insensible, and
of a buff or nankeen yellow color.  To the eye they suggest the idea
of a yellowish tubercular or cheesy matter  deposited beneath  the
cuticle, but a puncture proves them to be solid and vascular, in  con-
sequence of the vascular parietes of the gland being carried upwards
to the surface by  the growth of  the morbid epithelium.  They have
no tendency to suppurate or ulcerate, but remain permanently on the
skin, sometimes increasing slowly in  size.  In  pathological nature,
these papulae may be designated  a yelhw hyj)ertrophy of the  epithelium
of the sebiparous glands, and are deserving of the title of papule flave
epithelii cutis.   In a  gentleman,  at present under my care, suffering
from a chronic syphilitic affection of the  tongue and palms of the
hands, a  crop of these  papulae flavae are  dispersed over the forearms,
chiefly on the anterior surface;  a few are developed  on the backs of
the hands; there is a small cluster of coherent papules on the point of
the elbow, and several on the pinna of the ear.  In my remarks on
this case, I find that on his first visit to  me I noted the eruption as a
molluscum sebaceum ; but further observation induced me to alter my
opinion as to the nature of the disease, in accordance, with  the views
now put  forth.
  The commonest situation of this affection is the integument of the
eyelids (Plate XX.,  figs. 2, 3); and there the disorder more frequently
appears as plates of irregular dimensions than as papulae.  It is in the
eyelids that we most frequently have the opportunity  of  observing
the extension of the morbid  change in the  epithelium to the rete
mucosum; and it is there more  or less  extensive in  its distribution.
This disorder appears more commonly in women than in men; after
the mid-period of life  than  in youth  ; and is commonly permanent. 
            DISEASES  OF THE  SEBIPAROUS ORGANS.        555

It presents considerable variety in  tint of color, being  sometimes
cream-colored, or a light  buff, and  sometimes of a  bright  golden
yellow;  it also offers some differences of surface, having reference to
its discrete or confluent origin, and to a disposition to  spread more or
less actively to the neighboring rete  mucosum.  In the former case
(fig- 3), it preserves its  papular character, and  has a granular appear-
ance ;  in the latter (fig. 2), it is smooth.  This affection was described
some years since by Dr. Gull in the Guy's  Hospital Reports, under the
name of Vitiligoidea;   the papular variety he called  V. granulosa;
and the  smooth variety V. plana.  The name was suggested by the
discoloration of the skin in patches, but is not a happy designation,
as the disorder has no relation to the disease termed  vitiligo; the
morphoea,  which is a  companion of elephantiasis.  Following up the
idea of papulae flavae epithelii cutis, as applied to the discrete variety,
I should call  the confluent kind, as it appears  on the  eyelids, lamine
flave epithelii cutis, and  the granular  and the smooth kinds might be
distinguished  as papulosae or granulosae, and planae.
   Dr. Gull believes he has traced some relation between this disorder
and a morbid  state of the liver;  and  the fact of the occurrence of the
disease  after   the  mid-period of life, and  its association  with  an
accumulation   of yellowish and  dusky pigment  in  the rest of the
skin, are  circumstances favoring this hypothesis.   On  the other
hand I must remark, that I have twice seen  it in young  women in
whom there was no symptom of  torpid action  of liver present.  The
most extensive case I have met with occurred in a young woman who
was perfectly healthy in all her  functions.  Again, it  is remarkable
that the  disorder is almost exclusively confined to women.
   The treatment of this complaint suggests local  stimulation, with a
view to modify the innervation and nutrition  of the skin; and con-
stitutional remedies of  an  alterative kind.  I succeeded in removing
the disorder in one patient by the daily application externally of the
compound  tincture of iodine;   and  by  the internal exhibition of
Fowler's solution of arsenic; and I should recommend a trial of these
remedies in similar cases.  Generally, patients are little inclined to
give themselves any trouble with regard to it, as it occasions  no pain,
and no inconvenience beyond its somewhat remarkable appearance.

               I. AUGMENTATION OF SECRETION.

                       STEARRHOHA SIMPLEX.

           Syn. Sebaceous flux.  Seborrhea.   Cutis unctuosa.
   Great  diversity exists among individuals, in relation to the quantity
of sebaceous secretion naturally  poured out upon the surface 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 
556    DISEASES  OF SPECIAL STRUCTURE OF  THE  SKIN.

number.  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 with the unsightly appearance
of a greasy skin.   This affection may be often seen  in persons other-
wise enjoying excellent  health, in.whom an over-stimulating diet, or
some slight disorder of digestion, can alone be assigned as a probable
cause.  At other times it depends on torpor of the skin,  and is asso-
ciated with general torpor of the whole system.
  In  more severe cases of the sebaceous flux,  the skin is somewhat
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 epidermis.  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 accompanied with  pruritus,  and  often  with severe
shooting pains.

  Treatment.—Attention to regimen, laxatives,  alterative doses of
mercury, tonics, the fulfilment of such peculiar indications as the state
of health  of the  patient  may  offer.  Locally, the free use of soap
with astringent lotions, such as the bichloride of mercury  lotion, with
emulsion of bitter  almonds;  or the juniper tar soap.

                II. DIMINUTION  OF SECRETION.
                           XERODERMA.

  The term xeroderma (tyebs, aridus), or simply, dry skin, is intended
to convey the idea of a condition the opposite of the preceding; an
affection which is occasionally met with in  elderly persons, and some-
times 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 epidermis.  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 plentiful frictions with a rough
towel, are the proper expedients for procuring relief.  Indeed, in every
case, frequent sponging of the skin and friction are advantageous.
  When xeroderma exists  in  a more  severe and complete state, it
constitutes the affection  known as ichthyosis, the fishskin disease.

                    XERODERMA ICHTHYOIDES.

Syn.  Ichthyosis vera;  simplex;  vulgaris;  congenita;  mollis:  fur-
  furacea; reticulata; nitida;  serpentina.  Lepidosis  ichthyosis, Mason
  Good.  Ichthyose  nacree.   Eischschuppenaussatz, Germ.  Fishskin
  disease.
  That diseased state of  the  skin to which  the  term  ichthyosis, or
fishskin disease, has been applied, is greatly confused in the writings of 
            DISEASES  OF THE  SEBIPAROUS ORGANS.       557

 different authors, from the want of a distinction between two obvious
 forms which the disease is apt to present.  In one of these to which
 I  have given  the  term xeroderma ichthyoides, and which may very
 properly be called  ichthyosis vera, the epidermis is the seat of the
 morbid alteration;  while in the other, which I have termed ichthyosis
 sebacea, and which  may  also  be denominated ichthyosis spuria, the
 morbid appearances are due to the presence  of the sebaceous secre-
 tion altered in its quantity and quality, and deposited on the surface
 of the skin.
   The  characters  of xeroderma  ichthyoides are, a general dryness
 and roughness of the skin ;  modified in  appearance in different
 regions of  the body.  On the cheeks and forehead the  epidermis  is
 comparatively smooth,  but presents  a  number of ragged  edges, the
 result of constant exfoliation ;  around the mouth and eyelids, and on
 the  neck,  it  is rough, and  has a  mealy  or  branny appearance,
 ichthyosis furfuracea ; and on the rest of the body the breaking up  of
 the epidermis corresponds with the direction and form of the lines  of
 motion of the derma.  The pores of the follicles, both sebiferous and
 capilliferous, are prominent from the accumulation within them of a
 dry hardened substance, of which a portion often projects beyond the
 level of the aperture.  This  desiccated substance is the epithelial
 lining of the  follicle, altered in its  character by the absence of its
 oleaginous  element.  The hair undergoes  a similar change;  it  is
 either wanting altogether, or it is dry and brittle, and broken off on
 a level with the skin.
   The  texture of the skin exhibits  throughout a state  of defective
 nutrition ;  this is least conspicuous in the face, but it is very apparent
 in the  limbs, and particularly in  the arms; and there  is besides a
 marked  deficiency of  subcutaneous adipose tissue.    The skin  is
 sometimes  thinner, and sometimes thicker than natural, sometimes
 soft, and sometimes hard.   When soft it may be pinched up from the
 parts beneath in a remarkable manner, and in the different movements
 of the limbs is thrown  into folds which have  more the  character of
 a  loose vest than of  a  part of the body.   When  the  skin is hard
 it  cannot be  pinched  up, but it may be  moved backwards  and
 forwards on the subcutaneous fascia, as if  there were no binding
 tissues between the under surface of the corium  and the structures
 beneath ; and, instead of falling into folds during the movements of
 the body, it remains stiff like leather, and seems to depend entirely
 upon the lines of motion  for its power of adaptation  to the move-
 ments of the joints.  The lines of motion are therefore very strongly
 marked, and form deep grooves, while  the  inflexible areae between
 them are large and smooth.   The softer condition of the skin is met
 with on  the neck, the limbs  between the joints,  the flexures of the
joints, and the trunk of the body ; the harder condition  on the hands
 and feet, and the convexities of the joints.
   In a case which I have illustrated among my Portraits  of Diseases of
 the Sfa'n,} the subject was a little girl between five and six years of age,
' Plate XXXVII., S. 
558   DISEASES OF SPECIAL STRUCTURE OF THE SKIN.

and small of stature ; her face was polished and  moderately full, of a
dirty hue, and roughened by ragged edges of broken and exfoliating
epidermis. The skin of the rest of the body was dry and wrinkled,
and around the joints was thrown into folds, looking as if much too
large  for the body  which  it contained,  or like the parched and
shrivelled integument of a person of extreme age  and decrepitude.
The general  tone of color was a yellowish gray, but the  hands
were red; gentle pressure with the finger dispersed  the redness to a
considerable  distance  around  the compressed  spot, rendering  it
perfectly white,  and  the color was slow in  its  return.  The skin of
the backs of the hands  and fingers was thicker than natural, hard,
like parchment, and divided by deep grooves into large and irregular
compartments; this  was especially the case  upon the knuckles, and
every here and there the skin had broken  in  the lines of motion, and
formed  deep chaps.  The skin of the palms  of the  hands exhibited
the thickening of the derma, the parchment-like  yielding of the
unpliant tegument, the  large  compartments, and the deep  grooves,
more strongly than that of the back, and there were besides deeper
fissures and cracks.   At the  metacarpo-phalangeal joints the fis-
sures were so deep  as to sever the integument completely.  There
was another  singular peculiarity apparent in the hands, namely, a
want of proportion in length between the skin and the bones, so  that
the knuckles  of the metacarpo phalangeal  articulation  made  their
projection very near the middle of the hand, as though the metacarpal
bones had not grown in accord with  the  integument, or  as though
the fingers in their growth had carried with  them the integument of
Ihe body of the hand.  This appearance may be imitated by drawing
a glove forward  on the fingers, and then closing  the hand.
   The lower limbs were highly characteristic of the disease.  The skin
of the knees was thrown into numerous prominent wrinkles, on which
the epidermis was harsh, dry, thick,  and discolored, and in certain
parts, where the wrinkles were crossed by transverse clefts, resembled
ichthyosis cornea. On the sides of the  knee, near the ham,  a similar
structure existed.  From the knee to  the ankle the  skin was smooth,
grayish, silvery and  glossy, ichthyosis  nitida,  and in  an oblique light
might from  its refractive qualities, bear comparison with mother-of-
pearl (ichthyose nacrde,  Alibert). It was  marked by a reticulated
tracery of white lines, ichthyosis reticulata, the lines being occasioned by
the loosening and rupture of the epidermis at the abnormal grooves of
motion of the condensed skin.  The spaces between the reticulations,
from their regularity of shape and smooth polish, resembled more or
less closely the silvery scales of certain fish; hence the name of the dis-
ease ; and occasionally, when the reticulations were of small size and
irregular, and the  centre of each scale  thicker and  more  deeply
colored than its border, the idea of the  scales of  serpents was sug-
gested,  ichthyosis serpentina.  Around the ankle the  skin was thrown
into prominent  wrinkles, and across the instep were three grayish
bands, where the epidermis was  thicker than natural, and marked by
a number of longitudinal clefts  into  broken ridges running parallel
with  the foot.   On  the  rest of the back of  the foot the skin formed 
            DISEASES OF THE SEBIPAROUS ORGANS.        559

numerous wrinkles corresponding with the movements of the joints
and along its borders were several deep chaps.  The soles of the feet
exhibited the same peculiarity as the hands, namely,  a disproportion
in growth between the skin and the bones.  This was  apparent in the
great length of the foot and the shortness of the toes.   The epidermis
of the  under surface of the foot was very thick, yellowish in color,
very  much  broken, and  presented a number  of irregular  edges; on
the borders  of this surface were several deep  and long chaps.
  In  adults, the apparently normal state of the face, the dry, wrinkled,
and  mealy state of the skin of the limbs, and the absence  of sub-
cutaneous fat,  are  quite remarkable.  Sometimes, however, the face
has a peculiar coppery redness and an oily polish, which contrasts all
the more with the earthy, dried, and mealy or scaly epidermis"of the
rest of  the  surface.  The skin  of the hand is also remarkable for its
coarseness, and the hand  of the ploughman is met with in the man of
refinement,  to whom manual labor is unknown.   In  ladies, also, the
dry,  leathery,  wrinkled  skin  of the  hands  is very striking.  I
recollect well the shudder  that  passed  over me when I saw this
disease  for  the first time.  It was in a gentleman of  twenty-five or
thirty;  in appearance, in  freshness of face, and roundness of feature,
one would have believed him perfect in every point.   He took off his
coat suddenly, and drawing up the shirt sleeve, exhibited the withered
limb  of sordid age; dry, scaly, polished here, mealy and rough there,
while a cloud of small micaceous scales .flew into the air.
  Another character in connection with this disease is interesting in a
physiological point of view.  From the absence of all  secretion, or  at
least  great  deficiency of secretion,  from the  skin, the circulating
system  loses a natural source of relief when  in a state of excitement.
Hence active movement is attended with increased rapidity of respira-
ation  and action ofthe heart; and one of my patients informed me that
after a dance he panted for breath, he had violent palpitation of the
heart, and his brain  seemed to  reel,  for want  of air, and  from a
feeling of suffocation.
  The diagnosis, the prognosis, and the cause of xeroderma ichthyoides,
may be  very briefly stated.  The general dryness of the whole of the
skin  is  enterely distinct from  lepra,  which is never general, and
always  leaves a greater  or  less  extent  of sound skin between its
patches.  From psoriasis, xeroderma is distinguished by theabsence of
erythema and all signs of inflammation;  although erythema may, as
a matter  of course, be superadded  to this disease as an  accidental
complication; but  there  is a wide distinction  between a congenital
defect of nutrition  of the  skin and a disease consequently acquired.
The prognosis of xeroderma ichthyoides is favorable;  much may be
done  by treatment,  even if the skin cannot be restored  entirely to the
state of that of a person  who has never been so afflicted;  and I can
point  to several cases in  proof.   The cause of the  affection is con-
genital malnutrition, sometimes probably the result of malassimilation
commencing soon after birth.
  Treatment.—The  treatment of xeroderma ichthyoides is twofold
constitutional and  local.   After  the general functions of the  bodv 
560   DISEASES  OF  SPECIAL  STRUCTURE OF THE  SKIN.

have been regulated by the usual means, the patient  should be put
under a  course of cod-liver oil and arsenic; I have usually selected
for the  purpose the arseniate  of soda, or Fowler's solution; but in
some instances have derived advantage by changing those remedies
occasionally for Donovan's solution.   Locally, the  treatment should
consist of frictions with fresh and sweet  neats-foot oil;  the inunction
and friction should be made night and morning, and continued for as
long a time as the patience or leisure of the individual will permit.
For children  I prescribe a friction of  half-an-hour or an hour's dura-
tion.  When  the  skin is softened and made pliable by  the oil,  the
force of  the friction may be increased  by the use of the Indian flesh-
glove  or kheesah,1 instead of the hand.   A tepid soap-bath may  be
taken once or twice a-week, and a cold shower-bath, or sponging-bath
every morning on first rising,  the bath being preceded  and followed
by the frictions.  Sometimes,  particularly in children, and in adults
where there arose a difficulty as to the full extent of the friction and
inunction being employed, I have  found it necessary to increase the
stimulant effects of the local  application, by the addition  of liquor
ammoniae or  croton oil, to the  oil or ointment  employed  for that
purpose.   I may illustrate this method of treatment by reference to
the case  of a little boy whom  I  treated  in  1844, and who has since
continued perfectly well;  but I must at the same  time remark, that
the  rapid cure in his  case is to be ascribed  in some measure to the
disease  being  taken at an early  period of its existence, as well as to
the correctness of the principle of management.
   When I saw him for the first  time,  I ordered him a  soap ablution
every  night, and an ointment to be well rubbed into the skin  after
the bath, and in  the morning, as follows :—
                   R.—Olei olivae optatse, §iv.
                       Cerae albidse, 3U'
                     Liquefac simul dein adde—
                       Mollis, 5ij.
                       Olei Crotonis Tiglii, n\xx.—M.
   I  also  prescribed for him  a teaspoonful  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 epidermis ceased   to crack and

  1 The kheesah, or Indian ilosh-glove,  comes  recommended to us by the experience
of ages, and certainly  offers advantages superior to any other kind of rubber for  the
skin in existeuce.  It  is the glove, or  rather mitten, which has been used from time
immemorial in Hindoostnn,  Persia, and throughout the East, and by  a race of people,
both from  necessity  and luxury, more attentive to the skin  than any other upon the
face of the globe.  The glove was introduced into  England by Sir Ranald.Martin, of
Grosvenor  Street, and Messrs. Savory and  Moore have succeeded in  procuring the
manufacture of a similar glove in London.  Their imitation is perfect, both in appear-
ance and properties ; indeed is superior to the original; and it is satisfactory to me to
be enabled to recommend so admirable a contrivance for promoting the health of  the
body through the agency of the skin.  The glove  is made of goat-hair, the material
used in the manufacture of the Burruck or Persian glove cloth, of which the Oriental
kheesah is composed. 
DISEASES  OF THE  SEBIPAROUS ORGANS.       561
 break up into dry scales, and the skin was so sound that I was ena-
 bled to  dismiss  him, enjoining a continuance of the soap ablution
 once a-week, with cold sponging every morning, and the daily use of
 the kheesah.  The ointment  was now laid aside, as being no longer
 necessary.

                 III.  ALTERATION OF SECRETION.

    In  addition to simple  increase  in quantity, it not unfrequently
 happens that the  secretion of the sebiparous  glands is altered  in its
 quality.   For example, it may be changed in color, and by its accu-
 mulation 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 may break up into frag-
 ments corresponding with the linear markings of the skin, the frag-
 ments maintaining their adhesion to the epidermis, and increasing in
 size by  subsequent deposition.   These states of the sebaceous secre-
 tion constitute a small group of  cutaneous  disorders, which we will
 consider under the names of,
                       Stearrhcea flavescens,
                       Stearrhcea nigricans,
                       Ichthyosis sebacea.

                      STEARRHCEA FLAVESCENS.

    In this disorder the abnormal secretion  is  of a golden or  dirty
 yellow color, and forms a film on the surface, which gives the skin a
 coarse and disagreeable appearance. The substance  is soft, and may
 be removed more or less easily from the epidermis;  sometimes it can
 be wiped away with the handkerchief,  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 thick-
 ness.  The seat of this affection in the  cases which have come under
 my observation, is, the nose, cheeks, and scalp.  The  subjects of  the
 disorder on the face were ladies;  while  the affection of the scalp,
•though  more common in women than in men, I have seen in both.
    Stearrhcea flavescens sometimes assumes a chronic character, and
 the abnormal secretion, instead of being soft and removable by ablu-
 tion, forms a hard and dense crust, which adheres firmly to the skin,
 and can  only be separated  by means of the  water-dressing.  The
 skin becomes secondarily diseased in  consequence  of the irritation
 caused by this crust,  and the affection  puts on a troublesome  charac-
 ter.  A  case  of  this kind,  at  present  under  my  care, has  existed
 for six years, and was originally excited by exposure to the  heat of
 the sun'.
                      STEARRHGEA NIGRICANS.

    The abnormal  sebaceous substance poured out upon the skin'has
 occasionally a grayish appearance; and in some instances is perfectly
 black.  In  other respects,  namely, as relates to consistence and
       36 
 562   DISEASES  OF SPECIAL STRUCTURE  OF THE  SKIN.

 thickness, it resembled  the  deposits which are formed  in stearrhcea
 flavescens.
   Examined with the microscope, I found  this deposit to correspond
            with ordinary sebaceous substance,  but  the  nuclei of the
  Fis- p-     cells,  instead  of being colorless,  were black, and every
            here and there formed masses of considerable size.  Indeed
            they were identical in point of  structure with the deepest
            colored 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 corres-
 pond with  what  I had previously observed in some  black  matter
 removed from the skin of the face by Mr. Gregory Forbes, in a young
 lady who was under the care of Dr. Maclntyre.
   In Dr. Maclntyre's case, the abnormal secretion  could be removed
 by washing, leaving the skin beneath perfectly  natural, and 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 ofthe appearance of the patient, is published in the twen-
 ty-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 secretion; 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 occurrence of black vomitings, black dejections from the bowels,
 and a black pigment in the urine, when the secretion on the face was
 arrested.  The young lady who  was the subject of this unpleasant
 affection had been under the care of Dr. Read, of Belfast, 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, albu-
 minous matter, fatty matter, and chloride and phosphate of soda.
   In a case  at present under my treatment, the blackness is confined
 to the eyelids and  adjacent sides of the  nose, giving to  the young lady •
 who is the subject of this annoying aff'ection, the appearance of having
 extensive ecchymoses of  the eyelids (Plate XX. fig. 1). When  the
 discoloration is coming  on, she has a sensation of fulness about the
 eyes, with slight indistinctness of vision and a little headache.  The
 discoloration is usually greatest in  the evening,  and  is subject to
 increase  with anxiety or fatigue.   When wiped with a cambric hand-
 kerchief, the handkerchief is soiled.
»  It is more than probable that some of the cases of black perspiration
 recorded by the older writers were of  the  same nature as the cases
 quoted above.  The following instance of  a similar disorder is pub-
 lished in the Philosophical Transactions, by Mr. Yonge.  " 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
 
           DISEASES OF  THE  SEBIPAROUS  ORGANS.        563

very well till about a month  afterwards,  when  her face, so far as is
usually covered with 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 cured.  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
assistance.   By the  arguments  which T 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 discoloration;  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 warm 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 face; it feels  unctuous, and  seems like grease and
soot, or blacking, 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 SEBACEA.

                  Sauriderma.  Ichthyosis spuria.
  Just as the term ichthyosis vera, or xeroderma ichthyoides, has, in
a preceding section, been applied to a state of  the skin in which the
epidermis is broken  up into compartments, or scales, which have been
compared to the scales of  a  fish; so, the term  ichthyosis sebacea, or
ichthyosis spuria,  is now employed to designate  the production of
scales,  or horny masses, consisting of desiccated and altered sebaceous
substance, and  more or  less generally distributed on the skin.  In
xeroderma ichthyoides the scales are thin, and  have a certain bright-
ness and splendor which  gives a warrant  to their comparison with the
scales of a fish; but this is not the case in ichthyosis sebacea.   In the
latter disease, the  scaly masses  are  thick, more or less convex and
prominent, grayish or brownish in color; in a word, more  like  the
scales of the saurian reptile than the fish; hence, a more proper desig-
nation  for this disease would be  sauriderma.
  Sauriderma conveys at once the idea of a state ofthe skin resem-
bling that of the croi^oj, lacertus,  which is the most correct notion that
can be given of the disease by a single word;  while it prevents the
confusion which must always  result from the consideration of two
essentially different  diseases, one involving the epidermis, the other,
the secretion ofthe sebiparous glands, under the same common term,
namely, ichthyosis.  Xeroderma and sauriderma distinguish two es-
sentially different pathological states of the skin.
  Ichthyosis sebacea, or  sauriderma, presents two  principal varieties,
one in  which the scales or horny masses are not much raised, and are 
564    DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

either squamiform or irregular in  shape;  and, another, in which the
horny masses are lengthened considerably, and have the character of
spines.   They may be expressed as follows:—
                  Ichthyosis sebacea squamosa,
                  Ichthyosis sebacea spinosa.

                •ICHTHYOSIS SEBACEA  SQUAMOSA.
                     Sauriderma squamosum.
  We call that state  of the skin ichthyosis sebacea squamosa, or sau-
riderma squamosum, in  which, after the effusion 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 writh the
areae of the compartments  bounded  by  these cutaneous lines.  The
small polygonal divisions are increased  in thickness by the accumu-
lation of fresh sebaceous secretion, they become discolored from expo-
sure to dust and dirt, and they assume a brownish  or  grayish tint,
approaching more or less to dirt-color.   In the latter state, the small
masses have the  appearance of scales, closely adherent to the epider-
mis,  hard  and dense in  texture, and presenting 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, on
the abdomen, and on 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, as  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 affection  ofthe sebiparous glands is generally unaccompanied
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 color 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  th& excretory ducts, and  the latter become much dis-
tended.  The disease is rarely accompanied with constitutional symp-
toms, but, in a few cases, when general, some degree of gastro-intesti-
nal irritation may be present.
  In one instance of this affection which fell under my observation, I
had the opportunity  of examining  the skin after  the death of  the pa-
tient from visceral disease.   In this case, the  scales were remarkable
for their thickness;  after being well washed, they were grayish  in
color upon the surface, but white beneath, and evidently consisted of
concreted sebaceous  substance.  On removing a portion of the epi-
dermis by maceration, the ducts of the  sebiparous glands and  hair-
follicles were found  distended with  inspissated white secretion, and
had  a  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 
             DISEASES  OF  THE SEBIPAROUS ORGANS.        565

of the distended excretory ducts opened upon the  surface of the epi-
dermis, 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 the scale, and still more evidently when
the epidermis was separated by maceration.
   From the examination of this case, of which a preparation is now
before me, and of others which I have subsequently observed, I have
been led to the conclusion,  that the scales, in this disorder, increase in
thickness in two days; firstly, by addition  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
successfully made to the attached surface by the effusion  of  inspis-
sated secretion  beneath  them.  In  the  preparation  before me,  the
growth of the scales by both these processes is distinctly evident.
   A case of this  disorder, disseminated  in patches over the surface
of the  head, neck, and trunk, is recorded by Dr. Jacobovics,1 under
the  erroneous appellation of " tubercules bigarres," a new variety of
molluscum.   Dr. Jacobovics' case  differs from ordinary instances of
the  disease, in  the longer  duration of the malady, its disseminated
character, the excoriations which resulted from its continuance, and
the* presence of inflamed tubercles intermingled  with  the patches.
The patient was a tailor, of bilio-sanguine temperament, fifty-six years
of age, the nineteenth  child of healthy parents.  His mother  had  a
slight cutaneous affection on the neck; a brother  had  furfuraceous
desquamations on the face;  two  sisters had  small tubercles on  the
neck and bend  of the elbow; a  sister's  child  had  a  similar growth.
At the age of thirty he was attacked with severe  pneumonia,  which
left him in unsound health for  some years.  On reaching  his thirty-
seventh year, the cutaneous disorder  first  made its appearance; it.
commenced  on the  neck  in  the form of  small 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 affliction, the disease showed  a disposition  to increase, and
quickly spread over his neck, breast, and back.  The disorder now
assumed  the appearance of little crusts,2 having a roundish or irregu-

  1 Du Molluscum, recherches critiques, &c, suivies de la description detaillee d'une
nouvelle variete.  Par M. M. Jacobovics.  Paris, 1840.
  2 With no better reason, apparently, than that of adhering to the erroneous appel-
lation which he had assigned to this disease, Dr. Jacobovics  styles  the crusts,
tubercles, or tumois, throughout his essay. They were unquestionably extravascular
formations, and mere depositions on the  surface.  In accordance with this view, I
have in every instance, altered the terms tubercle, or  tumor, to crust.  Besides, it
does not accord with correct  notions of pathology to admit the possibility of a tuber-
cle, or tumor, being converted by progressive development into a crust.  But to agree
with Dr. Jacobovics, such a doctrine must be embraced ; for, after indicating a num-
ber of progressive stages of growth completed by the crust, he remarks, in conclusion,
" Les tubercules bleuatres et noiratres, les croCtes noires et verdatres, et les taches
qui leur succedent  sont des formes secondaires."  That is to say, that the black  and
greenish crusts are the secondary forms of " les tubercules brunatres."  Those who
peruse the statements of Dr. Jacobovics, I must refer to his essay presented to the
"AcadSmie Royale." 
566    DISEASES OF SPECIAL STRUCTURE OF THE SKIN.

lar figure, and various color; for instance, some were yellowish-white;
others fawn-colored  and brownish; others 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 ofthe disease, he presented  himself at Saint
Louis.  He was treated at this hospital for two  months without benefit,
and then 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 front of the neck, which
the author describes  as feeling viscous  and  unusually soft.  At the
roots of the hair  were  numerous  yellowish patches  and  scales of
sebaceous  substance; these greasy scales  were  also  met with dis-
persed over many  parts of the skin.  On  the forehead, the alae nasi,
the cheeks, the back, and in several other situations,  the apertures of
the sebiferous ducts  were very perceptible, and many  of them were
obstructed by inspissated secretion, which  was dark-colored in  some,
yellowish in others, and rose above the level of  the surrounding skin
in several.  In other situations the sebaceous substance  retained, its
softness and whiteness, and, distending  the excretory ducts, appeared
like white points in the midst ofthe yellowish and discolored laminae1
by which its  escape was  prevented.  The  crusts  commence 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 with pruritus, and, examined with a  Tens, a minute white
point may he discerned in the centre of  each.   In a  more advanced
stage the yellow  spot has increased  in diameter, and  is raised in the
centre, when it presents three or four white  points  in place of one.
By degrees  the  yellow  spots become  transformed  into  brownish
crusts, having a maximum  elevation from the  surface of  two lines,
and  a  maximum  diameter of six lines.  These brownish  crusts
appear studded beneath  the  surface  with white sebaceous points,
which give the mottled (bizarre") character to the production,  which
suggested to Dr. Jacobovics the specific  name  which he has given 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

  1 Dr. Jacobovics speaks of patches of a dirty yellow, or yellowish-white color; these
patches he seems to regard as discolored  epidermis, and  he describes the white points
as being beneath the epidermis. From the observation of cases of this kind, and
particularly of the one recorded above, I feel convinced  that the yellow patch is a
thin layer of inspissated sebaceous substance adhering very closely to the epidermis ;
this I conceive to be gradually raised by the deposit of fresh sebaceous matter beneath
it, until the elevated crusts  are formed, which are the distinguishing feature of this
case.  The white points will, consequently, be seen beneath the  sebaceous scale.  I
have already alluded to this appearance, and have before me a preparation in which
it is well shown. 
            DISEASES OF THE SEBIPAROUS ORGANS.       567

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,1 which adhere
firmly to  the epidermis, and assume a deep black color.  The desic-
cated 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  color, are also met with, resulting from the imme-
diate 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 inter-
spersed on this man's skin a number of small tumors and tubercles.
Some of these were round or oval, prominent in the centre, of a bright
red color, smooth, and shining, covered by a thin and desquamating
epidermis, and the seat of a troublesome pruritus.  Others were of a
bluish-gray  color, 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
lentil. But these tumors bore no proportion to the sebaceous crusts.
They were probably the consequence of irritation caused by the  seba-
ceous concretions, and can only be regarded as a  complication of the
sebaceous disease.
  As regards diagnosis, Dr. Jacobovics, after recapitulating the physi-
cal characters of the preceding case, e  g., hereditary tubercles, varying
in size from that of a lentil to that of a pigeon's egg (there  were  none
so  large  in his case), round or irregular, usually sessile, brownish
color, consistent or softish, generally  solid, no constitutional disturb-
ance, &c, remarks, "Among the tuberculous diseases of the   skin,
none but the present genus is capable of assuming the whole of these
characters, so I am bound  to establish this in the genus molluscum."
An unfortunate preference for molluscum is already synonymous
with heterogeneum.  In the treatment of this case the author employed
purgatives and warm baths, but with only partial success.
  I have lately met with a case in which the abdomen of a boy, par-
ticularly  its lower half, was in the state of sauriderma squamosum.
The surface was covered with small, brownish, gray, convex squamae,
of nearly uniform size and  thickness.   The scales were so regular in
their arrangement as to give the idea of a normal rather than a morbid
structure, and resembled  very  closely  the scaly skin of some of the
saurian reptiles.  In other respects  the skin was dry and harsh to the
touch.  When the squamae or crusts form upon the face, they occur,
for the most part, in clusters, upon small patches of dry and congested
skin • sometimes  they are  met with  on the sides of  the nose, some-

  1 The masses are  identical  with those  described at the commencement  of this
section. 
568    DISEASES OF SPECIAL STRUCTURE  OF  THE  SKIN.

times on the cheeks, and sometimes on the temples and forehead.   In
these latter situations, they are not uncommon in elderly persons, and
are apt to give rise to alarm, from the supposition  of their being of a
cancerous nature.   The latter  notion is suggested from their  being
occasionally met  with  surmounting small patches  of indurated skin.
When displaced from these patches of altered skin, the latter is apt to
bleed, and not unfrequently a superficial abrasion of small size is found
beneath the crusts.

                  ICHTHYOSIS SEBACEA SPINOSA.

              Sauriderma spinosum.   Porcupine disease.
  The spinous variety of ichthyosis is characterized by the formation
of hardened masses of  altered sebaceous substance, 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 of election in  the partial kind being the thick skin of  the outer
sides of  the  limbs,  the convexities of joints, more particularly  the
elbows, wrists and knees, and the dorsal surface of the trunk.  Ichthy-
osis spinosa is for the most part congenital; it  is associated with a dry
skin,  in which the  perspiratory function is deficient;  it is unaccom-
panied by redness, heat, or  local uneasiness,  and it endures  for a
lengthened period, often for the lifetime of the patient.   In the earlier
periods ofthe disease the  integument  is unaffected, retaining its natu-
ral softness and pliability ; at a later period, it becomes thickened and
hard from infiltration and deposition, 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
color.
  The form and length of the spines in  this disease are determined  by
certain laws, the former depending upon the shape of the small areae
of the epidermis  marked out by the furrows of the skin; 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  convexities of the elbows and knees, where  the
dermal areae are large and somewhat quadrilateral, the section  has a
similar form;  while, on the  anterior aspect  of the forearms, particu-
larly  near the joints, where  the  areae 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 which  they attained a full 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.  The base generally corresponds with  the  small area  of 
DISEASES  OF THE  SEBIPAROUS ORGANS.        569
Fig. Q.
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.
  Examined with the microscope (Plate VI., fig.  5),  the spines of
ichthyosis are found to possess all the  general  features which might
be expected d priori to be present in small cylinders of desiccated
sebaceous substance ; they are sub-fibrous, and obscurely laminated ;
the surface is more or less notched, and jagged,  the apex somewhat
split, and the base frequently connected with a broad  lamina of ex-
foliated epidermis.  Their internal structure is still more character-
istic ; they generally contain,  imbedded  in their substance, several
minute hairs, sometimes running in a  serpentine manner through
their entire  length, but  more frequently coiled and twisted,  and
evidently fixed in that position previously to  their excretion  by the
sebiferous ducts.   These observations lead to  the inference, 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 they 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  appearing to  enjoy a moderate  state
of health.  Sometimes irritation of the mucous
membranes is coincident  with  the cutaneous
affection; and Willan has observed, that in-
flammatory pustules  or  boils  occasionally
appear  on some part of  the  skin.  The epi-
dermis of the palms of the hands and soles of
the feet is dry and harsh, and  there is frequent
scaliness of the face.
  Willan  has pointed out two  appearances
which the local  forms of this disease some-
times 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 hornlike mass.   These peculiarities are rare,
and no purpose is gained by their separation from the typical disorder.
  Diagnosis.  Cazenave and Schedel, who refer to  Biett's  descrip-
tion of this affection, state that, when it has appeared  upon the nose,
it has been mistaken for  noli me tangere.  This error I have seen
committed; but it is not one  likely to be fallen into by those who
examine the scale-like masses with attention.   The presence of dense
scales or spines, and their regularity of position and form sufficiently
distinguish ichthyosis sebacea from every other disease of the skin.
  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,
 A spine from a " porcupine
boy."  The spine is magnified
19 times.  It contains in its
Btrncture a  group of downy
hairs,  which form convoluted
bunches here and there. 
570    DISEASES OF SPECIAL  STRUCTURE  OF THE  SKIN.
 but more frequently by a dry and parched condition of the epidermis,
 and shrivelled appearance of the skin.   Occasionally it has been seen
 after parturition.  The most frequent cause I  believe to be torpor of
 the skin and absence of proper excitation by ablution and friction.
    Ichthyosis spinosa is for the most part hereditary, 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.  Rayer alludes to a
 foetal monster preserved  in the Anatomical Museum of Berlin, the
 whole surface of whose body is covered by a layer several  line's  in
 thickness, which,  being   broken  up 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.    Buft'on states the
 disease to be endemic in   Paraguay; and several places on the sea-
 coast have, equally incorrectly,  obtained a similar reputation.
   Treatment.—The  first indication presented to the mind, in  con-
 sidering the nature of ichthyosis sebacea 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
 effected by means of the warm bath, or  warm alkaline fomentation, or
 by water-dressing.   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.   The  bichloride of
 mercury in emulsion of bitter almonds is  an  useful application in this
 affection ;  so also is the lapis divinus, in  the form of lotion or oint-
 ment.   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 sebacea spinosa the spines are to be softened by warm
 alkaline ablutions or baths, or  water-dressing, and then some stimu-
 lating  application 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, as alteratives
 and tonics; and Idler's and Donovan's solution will be found valu-
 able as determining an increased  action  and  improved condition of
 the skin.   The liquor potassae, with decoction of sarsaparilla, may also
 be tried with expectation  of relief.  Willan, Bateman, and Elliotson
 have recommended  pitch,  in doses of an ounce  daily.

                 IV. RETENTION OF SECRETION.

  The present group of diseases of  the sebiparous glands is charac-
terized by distension 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 
DISEASES OF  THE SEBIPAROUS ORGANS.        571
 two sub-groups or families, in one of which the excretory hair-follicle
 still remains open, the secretion is inspissated, and in  communication
 with the exterior.  In the second family the excretory hair-follicle is
 closed at its aperture, and the escape of the secretion prevented.

     (A.) Retention of secretion in the sebiferous ducts, the excretory
                      aperture remaining open.

                            COMEDONES.

               Syn.  Grubs.   Worms.  Mitesser, Germ.
   The simplest form of this disease  is that which  is popularly known
 under the  name of worms or grubs.  In this affection, the sebaceous
 secretion is inspissated, and produces  complete distension of the re-
 lated hair-follicle.   Reaching the mouth  of the  latter, the secretion
 hardens, and  becomes deeper in  color; and at the same time, from
 being exposed to the dust and dirt  of  the atmosphere, the extremity
 is rendered dingy and dark-colored.   This discoloration  of the seba-
 ceous  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  little white
 cylinder, about a line in length, and  blackened it  its extremity.  It
 is the lengthened form of this little cylinder, with  its dark extremity,
•that has gained for it  it's popular designation.
   Instead of being soft, and easily pressed out from the hair-follicle,
 it sometimes  happens, where the secretion has remained undisturbed
 for some time, that the little  cylinder has become desiccated, and re-
 sembles horn,  both  in appearance and density.  In this case the con-
 cretion requires to be dislodged by a pointed instrument, or with-
 drawn  by means of a pair of ciliary forceps.   In an  instance of the
 kind how 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 horny  comedones, every hair-follicle in the affected area
 being occupied by its little spine, slightly projecting beyond the plane
 of the surrounding skin.
   The disorder of the sebaceous glands here described is commonly
 met with on the face of persons in whom the cutaneous circulation is
 less active  than natural, and particularly among the inhabitants of
 cities and large towns, in whom the brain and  nervous system claim
 an undue proportion of the vital 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 in combination with acne.   Indeed, one form of acne,  acne punc-
 tata, is simply an inflammation  of  the sebiparous gland and related
 hair-follicle, excited by the overload of inspissated secretion.
   When the  substance  expressed from one of these comedones is
 examined with the microscope, the sebaceous mass  is found to be
 altered  in  its  composition.   Instead of flattened epidermal  cells or 
572    DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

scales,  intermingled with myriads of oil-globules, which compose the
normal secretion, the inspissated  substance consists of cells containing
a granular substance, and a variable number of oil-globules.  Besides
these cells, several minute hairs  are seen in the centre of the mass;
they are usually  twisted, or  bent, and sometimes to such an  extent
that the  tapering point is approximated  to the root.  Occasionally I
have observed the epidermal follicle still surrounding one ofthe hairs,
and more frequently so when one only exists 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 fre-
quently, the hairs are  broken at their larger ends, and  the fibrous
structure of the hair is 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  surrounded by its epidermal follicle;  but when the mass has
been impacted for  some time, I have counted  upwards of twenty.
(Plate III., fig. 18.)  Dr. Gustav Simon remarks, that  he  has seen as
many as forty in some comedones.1
  This observation  is an illustration of the physiology of the  invisible
downy hairs of the body, and serves to prove that which, d priori, we
should be led  to infer, and indeed that which their  presence in the
ceruminous substance of the meatus auditorius in such numbers also
testifies, namely, that they are continually thrown off, 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 diffused upon the skin, 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.
  Dr. Gustav Simon has recently discovered, in the sebaceous sub-
stance  of comedones, and in that which is squeezed out from the cones
of acne punctata, certain microscopic animalcules, supposed, by the
entomologists of Berlin, to be related to the genus acarus; hence, Dr.
Simon terms the animalcule acarus folliculorum.   A description of this
animalcule will be found in a separate chapter, at the conclusion of
the volume.
  Treatment.—The treatment  of comedones requires the employ-
ment 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 saturated 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 effect of this treatment may possibly be a red and patchy
state of the skin, which will speedily pass away.   It would be well in
1 Muller's Archiv., No. 2, 1S42. 
DISEASES  OF THE  SEBIPAROUS ORGANS.       573
these cases to extend the ablutions and  frictions 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 tof>e beneficial.  In some instances it may be necessary to
employ  some  medicinal  stimulant, in .which  case  the bichloride of
mercury lotion with spirits of wine, or with the emulsion of bitter
almonds, will be found to be the best application.

                  ACCUMULATIONES SEBACEAE.

                       MOLLUSCUM SIMPLEX.

Syn. Small sebiparous tumors, Wilson.   Molluscum contagiosum, Bate-
    man.  Molluscum sessih ; subghbuhsum ; parvum ; pisiforme.
   In a second group the secretion is not confined  to  the excretory
duct, but distends also the primary ramifications of that duct, so as to
give rise to a small tumor, about equal in size, in its fully developed
state, to  a  ripe currant.   (Plate VI., figs. 6, 7, 8.)  This resemblance
is not confined to size alone, for the sebaceous substance, rising to the
aperture of the follicle in the  centre of  the tumor, appears like  the
depression on the  summit of  the currant to  which the corolla is
attached, while the sebiferous ducts swell out in the circumference of
the tumor, and give it a slightly lobulated  appearance.  When a
transverse section of this little tumor is made, it is found 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  tumor, corres-
ponding with the aperture of  the duct, from which a portion of  the
concreted sebaceous substance can always be removed by  means of a
pointed  instrument, and  it also produces a constriction  around the
 base of the tumor.
   When these little tumors are left to  themselves, they terminate,
according  to my observation, in one of  two ways:  either by ulcera-
tion  of  the  summit, and  discharge of  the sebaceous substance  and
gland en masse, for the gland is but loosely connected with the integu-
ment ; or  by inflammation  and sloughing of the entire  tumor.  In
the former case, the collapsed integument, when the  base of the tumor
has become much  constricted, forms a small, pendulous,  pyriform
appendage, verruca acrochordon, which remains for the rest of life.  In
the latter,  the ulceration  sometimes extends deeply  into the  skin, and
leaves behind permanent and unsightly cicatrices.
   An instance of this disease lately (March, 1842) presented itself to
my notice, which was 'remarkable for the active development of the
tumors.   They were first perceived, about fifteen or twenty in number,
dispersed upon the skin of the neck, face, and shoulders of a little
girl, four years of age.   By the advice of the family medical attend-
ant, she was sent into  the country, and  in the course of a few weeks
became  quite well, all the tumors having disappeared, and no  new
ones being formed.  Soon after her return to town, the mother brought
to me her two other children, an infant and a girl of six years old.   The 
574   DISEASES  OF  SPECIAL STRUCTURE OF THE SKIN.

rrlother and  children  were of fair complexion, with light  hair, and
thin delicate skin ;  the mother was  alarmed at the development of
these little tumors on her two other children as well as on herself,
" caught," as she imagined, from the child first affected. •■! quieted her
alarms relative to contagion, but  was much struck by the fact of the
almost simultaneous appearance of the disease  upon four members of
the same family.   On the neck of  the mother I found four  or five of
these little tumors closely resembling and  of the  size of currants,
constricted at their base, and each presenting an umbilicated depres-
sion 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 tumors recently healed.   On the  neck,  face, and
shoulder of the eldest  child I found eight or ten little tumors, pre-
senting all their stages of growth.  One upon the  shoulder was so
completely pedunculated, that I was tempted to place a ligature around
it, and in a few days it fell off.  On the infant they were less advanced,
they were just rising from the integument, and each possessed  in its
centre the dark point of an  excretory sebiferous follicle.  The  little
tumors presented no signs of inflammation, they were of the natural
hue, or somewhat lighter than the  surrounding skin, from the white-
ness of the secretion which they contained, and there  was no areolar
redness round their base.1
  Since the above account was written I have  again (August, 1342)
been visited by this patient, on  account of the development of a small
angry tumor of a similar kind on the margin of the upper  eyelid of
her little girl, involving two or three ofthe Meibomian glands.  With
this exception the children have remained free from any return of the
tumors.  On inquiry as to the manner in which they disappeared, the
mother tells me that they became black, and shortly after were rubbed
off accidentally. One of large size, and situated behind the ear, in the
child first affected, was snipped off by Mr. Tyrrell.  The mother, who
is out of  health, has three still remaining, one of small size near the
angle of the right eye, and two upon the back of the hand.
  Upon examining these little tumors I found them to present all the
characters of a small conglomerate gland,2 consisting of several lobules
held together by cellular tissue, and the lobules composed of ramified
ducts and terminal sacculi.  The ducts were  remarkably dilated, par-
ticularly  the central one, and were filled with  inspissated  secretion.
The latter was identical in composition  with the concreted sebaceous
substance of the comedones.  The  cells were of the same size, had the
same appearance, and were intermingled in considerable number with
epidermal scales.  I disagree with  Dr. Paterson  in considering  these
cells as  peculiar organisms, capable of nucleolar propagation  when
transferred to an appropriate nidus in another individual, and simply
regard them as the normal sebaceous  cell,  which contains a granular
substance, filling it more or less completely.

 1 For an illustration of this disease, see  " Portraits of Diseases of the Skin," Plata
XXXVIII., AF.
 2 This observation confirms the description given by Dr Henderson. 
           DISEASES OF  THE  SEBIPAROUS  ORGANS.        575

  The difference  in the appearance of the cells examined by Dr. Pa-
terson and by myself appears to me to be immediately explained  by
reference to the physical difference in  the contents of the tumors.  In
Dr. Paterson's case  the  contents, as in Bateman's,  were milky, and
consequently semi-fluid;  and the conditions were  favorable to the
production of cells, having a considerable  interval  filled  with fluid
between the granulous nucleolar substance  and the membrane of the
cell, a disposition which induced Dr. Paterson to regard them as being
composed of an  external  vesicle and  an internal vesicle, the latter
containing the granular substance.  But, in my cases, the contained
substance was concreted, there was a deficiency of fluid, and the granu-
lous substance filled the cell, and in exceptional cases only were any
cells  perceived with a peripheral interval.  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 of oil-globules.  The cells were variable in figure,
some being more or less cuboid, others irregular from compression,
some oblong like the eggs of the ant, others 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, vary-
ing in their long diameter from ^ig to ggT of  an inch, and in their
short diameter from T^3o to Tjtt5 some ofthe cuboid cells measured
ysVo; the general size of the oval form was g^ long, and j^Vo broad;
there were several  oblong cells, measuring -g^  by tizv',  ar|d the
common dimensions of  the ovoid cell were ^-^ by  TAo"-   This size
corresponds very closely with the cells of ordinary  inspissated  seba-
ceous 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  superposi-
tion of a single cell by several connected scales of epidermis ; or again,
bv the accidental  position of the cell upon the epidermal scales in such
a "manner  as to constitute a thin margin around it.
  Treatment.—In the case above  detailed I prescribed  laxative
medicine,   and touched the  tumors 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 
576    DISEASES  OF SPECIAL STRUCTURE OF  THE SKIN.

mother of these children I opened several with a lancet, and touched
inside with nitrate of silver.   Their return may be prevented by the
plan of stimulation  of the skin, recommended  for the treatment of
comedones.   Dr. Thomson used sulphate of copper, and Dr. Paterson
potassa fusa, in their treatment.   In 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 tumors I perceive another argument
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 tumors fell off, and the disease got well under the use of
the compound senna powder.  The three at present on the skin of the
mother are attributable  to a  disordered state of health.  Indeed, the
family may be said to be the subject of a sebaceous constitution, and any
recurrence of disordered health will bring with it a disposition to the
formation of sebaceous tumors.
  After  having determined-  the  nature of  the  small tumors above
described, and havingassigned to them the position which they appeared
entitled to occupy among 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 ascer-
tain  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,1 that Bateman must have borrowed the appellation
from  the essay of Dr. Ludwig,2  the reporter of the  celebrated case
which occurred to  Tilesius.  The author in his preface remarks, " Rhein-
hardi, visu feedum, corpus tectum est verrucis mollibus sive molluscis."
Alibert, Biett, Cazenave, and Schedel, on the contrary, attribute the
origin of the term  to some  resemblance existing between the cutane-
ous tumors and the knots on  the  bark of the maple.
  The earliest case of this  aff'ection  on  record, and the one in fact
which, according  to the above  supposition, gave  the designation to
the disease, is that  of Tilesius,  recorded  by Ludwig.  I propose to
make an analysis of this case, as well as of those which have been
published on the same subject to the  present time, in order to ascer-
tain the opinions  entertained by their respective authors of the cases
which have appeared in their names.   The result of this inquiry will
be a confirmation  of my opinion  respecting the pathology and true
position  of molluscum.
   Case observed by Tilesius.—John Godfrey Reinhardt was born at
Muhlberg, of healthy parents, in 1742.  At birth, his body was covered
with excrescences  of small size.   When seen by Tilesius 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

  1 Du Molluscum, recherches critiques, &c.  Paris, 1840.
  2 Historia pathologica singularis cutis turpitudinis J. G. Rheinhardi viri 50 annorunij
&c.  By Dr. C. F. Ludwig. Lipsire, 1739. 
           DISEASES  OF  THE  SEBIPAROUS ORGANS.        577

patient or by pressure against an adjoining part.  The most remarka-
ble of these excrescences was one which was developed from the inte-
gument over the ensiform cartilage; it was wallet-shaped,  tuberculated
on the surface, flaccid,  and hung as low as the umbilicus.  Its tuber-
culated appearance indicates its constitution of several smaller excres-
cences.   The prevailing color of the tumors is  red; here and there
one may be seen of a  dull yellow or reddish brown hue; they are
spongy and soft in texture, and the skin which supports them is dirty-
looking and earthy.  " In medio quarundum maximarum excrescentia-
rum parvum foramen  conspicitur, ex quo nigra corpora  obhnga,  que
altius in cute albicantem atque lenerum processum habent, exprimi possunt,
que vulgo comedones appellantur."
  The excrescences  are most numerous by the side  of the vertebral
column, on the thorax, neck, and the sides  of the abdomen.   On the
head, one has the appearance of an encysted tumor.   Regularly every
month  some of the tumors become  congested, and itch  greatly,
forcing the patient  to scratch them violently.   He  is the subject of
habitual feverishness, which is increased at each  fresh attack  of con-
gestion of the tumors, and is accompanied by loss of appetite.
  Reinhardt  is  short of stature, has a large head, knees somewhat
incurvated, protuberant abdomen, and dull expression of  countenance.
His position in life is one of indigence  and  misery.  He  has invaria-
bly refused to permit the removal or puncture of one of the tumors,
so that their internal structure is entirely unknown.
  Such is the case observed by Tilesius.  The question now comes to
be, What is the nature of the disease?  Let  us review the evidence.
An  unhealthy  child, born with disordered  sebiparous glands, the
ducts of the glands loaded with inspissated secretion, and forming small
prominences on  the surface of the skin.   The child bred in "indi-
gence and misery;" the skin "dirt-colored, and earthy in appearance ;"
the child and man  unsound in  body, sluggish  in functions.  Here,
then, are precisely the conditions which we should  desire to bring
together, for the purpose of inducing the disease artificially.   For the
most conclusive of all evidence, mark the Latin  passage quoted from
the original; the  excretory  aperture  in the centre of the largest
tumors, the altered sebaceous substance squeezed out, nay more, its
comparison with "comedones."   One  of the  tumors  situated in the
scalp we find to have taken on  the usual  characters of a sebaceous
encysted tumor.  The  sebaceous  tumors 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
aggregation of several, growing  from a limited spot  of skin and one
richly supplied with  sebiparous glands.  The wallet is also favored 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
       37 
578   DISEASES  OF SPECIAL  STRUCTURE OF THE SKIN.

development of intermittent  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 molluscum, with which
all future observations must be compared; this  is the case which has
supplied dermatologists  with their definition of the disease, which
enabled Bateman to  announce that molluscum " is characterized  by
the  appearance  of numerous tubercles,  of slow growth and  little
sensibility, and  of various sizes, from that of a vetch to that of a
pigeon's  egg.  These contain an  atheromatous  matter,  and are of
various forms; some being sessile, globular, or flattish, and some
attached by a neck, and pendulous."
   None of the tumors were punctured in Reinhardt's case, but that
omission is of little moment, when  we  again   advert to the Latin
quotation.  The tumors  from which no sebaceous substance  escaped,
upon which no aperture  was  apparent, were undoubted instances in
which the excretory aperture  had closed,  as in encysted tumors.
   Cases observed by Bateman.—This author reports six cases  of sebi-
parous tumors, which he considers, in reference to the case of Tilesius,
"a singular species of molluscum."  In  my opinion, the  only differ-
ence 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 tumors 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 family ; two were children, apparently, of  another family; and
two  were servants in the  first  family—one an undoubted case, the
other supposititious.   But to  proceed :—
  "The face and neck of this  young woman," writes Bateman, "were
thickly studded with round, prominent tubercles, of various sizes, from
that of a large pin's  head to that of a small bean, which were hard,
smooth, and shining  on their  surface, with a slight degree of transpa-
rency, and nearly the color of the skin.   The tubercles were all ses-
sile, 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 child had received
the eruption from a servant, on whose  face it was observed.  Since 
            DISEASES OF THE SEBIPAROUS ORGANS.       579

my attention was drawn  to this species of tubercle, I have seen it in
another  instance, in an infant brought to me with porrigo larvalis;
and, on  investigation, it was found that she had apparently received
it from an older child, who was in the habit of nursing it.  In this
case the  milky fluid issued from the tubercles, and may be presumed
to be the medium of contagion."
   Cases  observed  by Dr. John  Thomson and Dr. CarswelV—The first
case occurred in the Canongate, in April, 1821, in three children of the
same family.  The eldest boy was supposed to have brought the dis-
ease 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 scratch-
ing those situated there during their inflammatory stage. Some of the
tubercles are small, others large; some in a state of active inflamma-
tion, others nearly of the  same color as the skin, and" quite free  from
pain.  A few of  them are pedunculated, but the greater number are
attached by broad bases." " The mother, though 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
tumors: he had taken the contagion from the child of a farm-servant.
Some of the tumors were  situated on the eyelids, and gave rise to con-
junctivitis. 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 tumors.
  These cases are narrated in  the true spirit of contagion, and with an
unconditional assent to the opinions of Baterhan.  I regret that less
attention was bestowed in ascertaining the state of the skin and  sebi-
parous system of the patients,  their health, and especially their habits
of cleanliness.
  Case observed by Alibert.  Alibert treats of the molluscum of Bate-
man, under the name of mycosis fungoides, and  he associates the dis-
ease with the Amboyna and Mollucca pox, with which it bears  con-
siderable 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 (fongueuses ?) and oval-shaped tumors, which arise and
are developed successively upon the face, upper and lower extremities.
These tumors, which are very analogous in texture with champignons,
after having reached their full growth, open like decomposing fruits,
and give exit to an ichorous fluid, which is often puriform, and sheds
around it a disgusting odor."
  The case from  which he derives his definition I will shortly narrate.
The mother of the patient had upon the face an ulcer that was cured
by the application of 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 furfuraceous
eruption, which was soon after  succeeded by the  development of small

  i Edinburgh MedicM and Surgical Journal, vol. lvi. p. 280. Dr. Paterson's paper. 
580   DISEASES OF SPECIAL  STRUCTURE  OF  THE SKIN.

tubercles, smooth and polished on their exterior, and  presenting, for
the most part, the ordinary hue ofthe skin, some few having a brown-
ish tint.  They were distributed over nearly all parts of the body.
They resembled  morelles or agarics  in form; some were shaped  like
an olive; and  they increased in number to such an extent that four-
teen 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
tumors into the form of a brownish  or grayish crust.  The majority
of the tumors terminated by bursting, and then falling into a flaccid
state, leaving in their place a withered skin, which the daughter of the
patient removed with scissors, without exciting pain.  After  experi-
encing considerable mental affliction, he had an attack of pemphigus.
The tubercular disease increased rapidly after this period; the tuber-
cles, on breaking up, gave rise to ulcers,  the  patient  suffering 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.
   This case is  not satisfactory:  the  seat of the disease in the sebi-
parous  glands  is  not proved ;  indeed,  Alibert suggests no  opinion
with regard  to  the pathology of the tumors,  but contents   himself
with classifying them with the molluscum 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 that the man died of the cutaneous disease.
   Rayer,  who  had never seen a case  of  this disease, remarks with
regard to it, that its " seat appears to be the sebaceous follicles."
   Cases observed by  Bielt.—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 tumors were  hard and con-
sistent,  and contained neither  atheromatous  matter1 nor liquid.  He
also cites the instance of an old man, whose skin was covered with
these little tumors, without any disturbance of his  health.  Biett  met
with  another form, " non-contagious molluscum,"  in  young  women
after  parturition.   In these cases the little  tumors were flattened,
slightly fissured (fendillees) at  their  summit, irregular in form,  and
brownish  or fawn-colored in tint.   They were indolent, and more
particularly distributed about the neck.
   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 opinion  with regard to the pathology of the tumors.  Nor can I
perceive any difference  between  the two forms of  non-contagious
molluscum, which he seems desirous  of  establishing.

  1 By the term " atheromatous matter" is  to  be  understood sebaceous substance
altered to the  appearance and cbnsistence of pap.  The word " liquid" no doubt
relates to the " milky fluid" of Bateman.  There was no such fluid  in my cases ; the
sebaceous substance was concreted and dense ; not soft,  as in the case of  Tilesius,
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 seen the  milky  fluid
described by Bateman. 
DISEASES  OF  THE  SEBIPAROUS ORGANS.        581
   Cases observed by Cazenave and Schedel.—These  authors relate that
they saw, in  the Hospital St. Louis, a patient affected with prurigo,
on whose body were a number of little indolent tumors.  The largest
were scarcely so large as a 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 " molluscum non con-
tagiosum," they continue, " Molluscum contagiosum  is a  very rare
disease, and does not appear as yet (1828) to have been observed  in
France.   It is characterized by tubercles, rounded, prominent,  hard,
different  in size, smooth, transparent, sessile, giving  exit by their
summit to^a white fluid," &c.
   Cases observed by Gibert.—This author does not conceive it  necessary,
in his treatise, to describe molluscum, 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. Biett, in a child
ten years of age, afflicted  with  chronic enlargement of  the  liver
and spleen, the  consequence of a fall on the abdomen.  The entire
skin was sprinkled over with  small whitish  tumors, of about the size
of peas.   They were  4iard,  indolent, and not unlike those little
cretaceous tumors we occasionally meet with in the substance of the
liver.   M. Biett considered that the disease  should be referred to the
genus  molluscum of Bateman, a rare affection in our climate, but not
unfrequent in India.
   Cases observed by Dr. Jacobovics.—In the Spring of 1839, this author
saw, at St. Louis,  two women, one sixty,  the other seventy years of
age, who were covered with fungiform tubercles.  To describe these
tubercles would be to repeat the  observation of Tilesius.  The face,
neck, head, and limbs, were closely 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 tumors was as large as the fist, and shaped like
a  wallet.  The  tubercles were red  in color, and the greater part
poured out a small quantity of ill-smelling sero-purulent fluid-, which
every here and  there concreted into thin crusts.   No other member of
the families of these two women had suffered from a similar  disease,
and on one the eruption had existed for two years.  These cases were
not further observed.
   In his essay on  molluscum, Dr. Jacobovics attempts the  classifica-
tion  of all the  known diseases possessing  the general characters of
those  of Tilesius  and Bateman, as  three varieties  of the genus
molluscum.  In this attempt he has signally failed ; he has  succeeded
only in bringing together the  most heterogeneous materials, under an
unmeaning title, a title that would be far better abolished altogether
from cutaneous pathology.   His three proposed varieties are tubercula
fongosa, tubercula  atheromatosa, and tubercula  variegata.   Under the
first of these, which, to illustrate  his meaning, should have been fun-
giformia, he has assembled  the Amboyna  pox, the cases of Tilesius
and Alibert,  the cancer mollusciforme! of Rayer, the cases of  Biett,
Cazenave, 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 
582    DISEASES OF SPECIAL  STRUCTURE  OF THE  SKIN.

Thomson;  and he reserves the third designation for his new variety,
the " tubercules bigarres," which I have already transferred to a more
appropriate place, namely, the section treating of sebaceous ichthyosis.
   Cases observed by Dr. Henderson?—Dr. Henderson has seen five cases
of this disease identical in their characters with those which fell under
my notice,  and closely corresponding with those of 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 family; one was a neighbor'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 situ-
ated on the lower part of the abdomen, the organs of generation, and
the inner sides of the  thighs; in these regions  there were three  or
four dozen; on the right arm there were four, 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
small dark-colored central point,  from 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  tumors,  Dr.  Henderson
found them to consist of vertical  cells opening towards the centre, and
discharging their contents into a common cavity, which communicated
with the exterior by the  excretory opening.  The large tumor was
lobulated in  structure, and upon its under surface had the* "general
appearance of a  conglomerate gland;" it illustrated, on a " larger
scale, the conformation of the  smaller  ones."  The contained matter
of these tumors consisted of nucleated cells, which, according to Dr.
Paterson, were about  the 1XJ\^ 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 sub-
stance would  not  be likely to take effect, unless it were brought in
contact with the internal surface of a sebiferous duct.8  Some excellent
figures accompany this paper; numbers 1 and  5 are admirable for
their truthfulness.

  1 Edinburgh Medical and Surgical Journal, vol. lvi., 1S41, p. 213.
  4 A more effectual mode of inoculation would be to rub the secretion briskly into
the skin in a situation where sebiparous glands are abundant. 
            DISEASES OF THE SEBIPAROUS ORGANS.       583

   Cases observed by Dr. Paterson?—This  physician 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 tumors had the pathogno-
monic 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 tumors 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 tumors occurred in a female child of two years old.  They
were between  thirty and forty in number, and were distributed on the
neck, shoulders, face,  and trunk.   Their development is ascribed to
being nursed by a girl who had some tumors on her skin.  The third
example is not so  satisfactory ; it  is that of a young  man who had
several little tumors on  the penis, which he said  resembled similar
tumors situated on the vulva of his wife.  Dr.  Paterson inoculated
with some of  the  milky fluid,  but without producing any effect; he
gives an admirable description of the minute structure of these tumors,
and  their contents, and a beautiful figure of the disease.
   The remarkable case of albuminous sarcoma of the integument, of
nearly the entire body, described by Mr. Hale Thomson,2 under the
title of "albuminous  molluscum," and  the case  of carcinomatous
integumentary tumors, detailed by Dr. Turnbull,3 physician to the
Huddersfield  Infirmary, must be  referred  to a  group, embracing
diseases in the form of tumors  affecting the integument in common with
other tissues of the  body.  They do  not  necessarily originate  in  the
skin; indeed,  they more frequently take their origin in the subcuta-
neous textures ; they are not limited to the skin, but involve adjacent
tissues; and they are generally met  with in  other parts  of 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 tumors described in the pre-
ceding pages.   Nothing is more easy than their removal, and of their
non-contagious nature  there cannot be a second opinion.
   Sebaceous   accumulations sometimes  present  themselves  in
another form,  wherein  the sebiferous duct and related hair follicle are
dilated to an enormous extent, and, pressing on  the structure of the
gland, finally cause its  atrophy and absorption: these sebaceous accu-
mulations attain considerable magnitude; they are  generally oval  in
form, and sometimes measure upwards of an inch in diameter.   Their
precise  seat is  the  tissue of the derma, and they are  more or less
flattened by  compression  between  the  deep layer of the  corium

  1 Edinburgh Medical and Surgical Journal, vol.  lvi., 1842, p. 279.
  2 Lancet, vol. ii., 1841.  The paper is illustrated with two excellent lithographic
drawings
  8 Edinburgh Medical and Surgical Journal, vol.  lvi. p. 463. 
584   DISEASES OF SPECIAL STRUCTURE OF THE SKIN.

within and the surface of the skin without.  The follicular sac is filled
with a white and concreted substance, which is more or less apparent
through the dilated aperture of the duct.   The opening of the duct,
however, bears  no proportion to the size of the accumulation, and,
from the' little projection of the impacted substance, is the principal
indication of  its existence.  The walls of the sac are extremely thin,
and are lined in their interior with epidermis.   Sometimes  they are
beset with hairs.
  On examining  the contents of one of these  sebaceous sacs, I was
much struck by finding the contained substance laminated in structure,
and presenting a silvery hue.  The lamination of the substance afforded
me a convincing proof that  the  mass was a product of the lining
membrane of the  sac, and its  silvery brilliancy further  led me  to
believe  that it must be composed of epidermal scales.   The micro-
scope established the correctness of this conclusion.  Hence, a disease,
originally  a  disorder of  a sebiparous  gland,  and of its secretion,
subsequently becomes one ofthe hair-follicle.
  Treatment.—The concreted substance  may be removed  without
much difficulty, by means of a  small scoop 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  concreted
mass, the  internal surface of the sac should  be touched with nitrate
of silver or potassa fusa.

                        CORNUA HUMANA.

                          Human horns.
   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 that situation, hardens, and  is  converted
into horn. By the addition of fresh 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 with a wedge, and finally increasing  incize to that of the entire
base of the hypertrophied  follicle.  The  process of formation of new
ephithelial layers by the  walls of the follicle,  now become the base
of the mass,  will go on, unless  interrupted by surgical interference,
for years, and in this manner those singular bodies, of which so many
remarkable examples are on  record, horns, are produced.
   A well-marked instance of horn was shown  to  me by Mr. Barkli-
 more, of Bloomsbury, during the month  of October of the year 1S43.
 The patient was an  old female servant in his family, fifty-seven years
 of age, and  gave the following history of her case: At the  age of
 five-andtwenty, 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  matter
 resembling " mashed potato."  Subsequently, a cavity always remained,
 from the bottom of which "scurfy" substance could be raised by the 
           DISEASES OF  THE  SEBIPAROUS ORGANS.       585

finger nail.  At the beginning of the current year the present growth
made its appearance in the situation of the cavity, and, increasing in
size, gave her  much pain and uneasiness.  The  skin around it was
red and inflamed, and she applied a poultice, which had the effect of
making it grow faster.  During the  summer she suffered much from
frequent jerks which the  growth received from her dress, and awk-
ward blows which it sustained, and  in the month of October applied
to her  master for  relief.  At this  period  the growth had acquired
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 color, dense and horny  in texture,
ribbed  on the 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 rose to  the height
of several lines, and in two  places  to half an inch.  The skin was
thin and attenuated, as though from the effects of stretching, the
epidermis  being continuous with the  surface of  the  horn, and  gave
the idea of a degeneration of the integument into the horny structure.
  On the 12th of October I removed the  horn, by cutting through the
integument around its base, and dissecting it from the subcutaneous
tissue.  The  removal  was  speedily and  easily accomplished, as the
growth was limited inferiorly by the under surface of the corium.
  On examining  the horn after removal, I found its base to be  formed
by the deep stratum ofthe corium, so that  it was obviously a cutaneous
formation.  The  base was  oval  in shape, and measured  in long dia-
meter one inch and a half, 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 surface was
one inch and a quarter.  The latter measurement was that  of the ver-
tical thickness of the horn ; for, in consequence of its mode of growth,
its long diameter lay parallel with the surface of the skin.  The seba-
ceous accumulation must originally have formed a prominent tumor,
from the side  of which the protrusion took place; the thin integument
covering  the other half still retaining its  elevation from  distension.
Traces  of this mode of formation are still apparent upon the  surface
of the horn.   Subsequently the thin integument became inflamed and
ulcerated,  and receiving no  granulations  from  beneath,  desiccated
upon its horny contents. The ulceration  was the cause of the redness
and pain  of which the patient complained, and its extent is marked
upon the  horn by a rough,  discolored surface of a circular figure, sur-
rounded for more than two-thirds of its extent by a margin of thinned
integument.   The weight of the horn  was six drachms.
  The section of the growth presents all the characters of a horn ; it
is laminated longitudinally,  the laminae being distinctly  traced,  by
their difference of tint, from the base to the apex.  At the apex, it is
split in the direction of its  laminae, and  several external lamellae 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 arrangement. 
586   DISEASES OF  SPECIAL STRUCTURE OF  THE  SKIN.

The epithelial scales are somewhat larger than those ofthe epidermis,
and possess nuclei;  a circumstance  which confirms the analogy be-
tween the inflected follicles of the  skin, and those larger inflections
lined  by mucous membrane.   The flattened cells  measured in long
diameter from ?£5 to ,£T of an inch 5 and in short diameter from TTVu
t0 7£T;  the average of these measurements being ^ for the long, and
5£0 for the short diameter.  The nuclei are, for the most part, oval in
shape, the long diameter measuring 5SVo, the short ^Vtt 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. Dublac has pub-
lished an analysis of human  horn in  the Journal  de Pharmacie,l
and another analysis was2 made ofk horn, which is deposited in the
Dupuytren Museum.  Both analyses go to show that human horn is
chiefly composed of albumen,  a small  quantity of mucus, phosphate
of lime, chloride  of sodium, and a trace of lactate of soda.
  Since  the occurrence of the  above case, I  have met with several
                             instances of horn in the human sub-
           Fig- R<             ject; one was on the shoulder, two at
                             the  root of the nose,  and one on the
                             penis.  The latter measures in its dried
                             state one inch  in length.  I have also
                             in my possession, the contribution of
                             an unknown friend, a fine specimen of
                             horn which  grew " on the head of an
                             adult  male during  a period of nine
                             years."   It  looks  as  if it had  been
                             broken  away from its attachment, and
                             is twisted like a ram's horn.  It mea-
                             sures,  in its  dried state, somewhat
                             more  than  four inches  and  a half in
length, and two inches and three-quarters in its greatest circumference.
   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 circum-
stance may be explained by referring to the improvement which  has
of late years been made in surgery, and to the more general diffusion
of a knowledge  of its elementary principles.  On  a  recent occasion,
namely, the presentation of a  paper to the Royal Academy of Medi-
cine of  France, by M. Lozes, the committee appointed to inquire into
this subject collected seventy-one observations of horny growths from
the skin, of which thirty-seven were  met  with  in  females, thirty-one
in males, and three in infants.   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.3
   In pursuing  this  inquiry, I have succeeded  in collecting  ninety
cases, of which forty-four were  females, and thirty-nine males; ofthe

   1 March, 1830.
  * Cruveilhier, Anatomie Pathologique, liv. 24, vol. 2; and Jour, de Med. Prat, de
Bordeaux, 1835.
  3 Memoires de l'Academie Royale de Mcdecine, Juin, 1830.
 
DISEASES OF  THE SEBIPAROUS ORGANS.       587
remainder  the sex is not mentioned.  Of this  number, forty-eighty
were seated on the head, four on the face, four on the nose, eleven on
the thigh, three on the leg and foot, six on the back, five on the glans
penis, and  nine on the trunk of the body.  The  greater frequency of
this disorder among females than males is admitted by all authors, but
this fact is most conspicuously shown  in the instance ofthe thigh and
of the head; for example, of  the eleven cases of horny growth from
the thigh, two  only were males; and,  of  the forty-eight affecting the
head, twenty-seven occurred in females, and nineteen in males; in  the
remaining  two the sex being unmentioned.  That old age is  a predis-
posing cause of the 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 ninety-seven ;1
three were young persons,2 and three were infants.3
   Cruveilhier, remarking on the relative  frequency of these  growths
on different parts of the skin, states that they occur on the  posterior
and inner part of the thigh, as often as on all the other regions of the
body taken together,  a circumstance which he attributes to the gene-
ral use  of  the chaufferette.  But Cruveilhier's statement is not borne
out by  facts, and numerical data are,  as we have seen above, opposed
to his opinion.  Moreover, he confounds horns with warts and corns,
and regards them as  the result  of  cutaneous  irritation, and  enlarged
papillae, with increased secretion of epidermis.4
   Several  authors have mentioned the development of horny growths
from  old encysted tumors, and  have remarked upon their  frequent
association with such tumors.  Sir Everard Home* was  particularly
struck  with this circumstance; it  was present in all the  cases which
he examined, but he fails to  account  for the horny secretion, which
he regards  as  an  imperfect  substitute for  epidermis.  Thomas Bar-
tholin,  who collected several cases of human  horns,  speaks  of  the
origin of one from an encysted tumor,6 and Soemmering,7 Gastellier,8
and Caldani,9 notice the same fact.
   Some curious speculations were excited in the minds of  the older
physicians by the observation of cases of horny growths.  Rhodius10
met with  a Benedictine monk  who  had a pair of horns,  and was
addicted to rumination, and  Fabricius,11 having seen  a man  with a
horn growing from his forehead, whose son ruminated, is willing to
give the father the credit of transmitting this disposition to the son,
by virtue of the ruminant character which he bore so obviously upon
his head.

  1 Gastellier, Hist, de la  Soc. Roy. de Me"d.,.vol. i. p. 311.  1776.
  2 Aldrovandus et Bartholinus.
  » Amatus, Cent. 1, Cur. 1, Zacutus Lusitanus, Prax. Med. Adm., lib. iii. obs. 83.
Joseph Lanzoni, Nat. Cur. Ephem. Germ.,  ann. 4, 1673.
  * Loc.  citat.
  6 Philosophical Transactions, vol. lxxxi. p.  95.  1791.
  6 Epistolis.                   7 Archives Generates de Med., vol. xiii. 1827.
  8 Loco citato.                  9 Diet, de Med., art. Cornee.
  '° Bartholinus, de unicorn, aphor.
  " De ventriculo. Also, Bartholinus, de unicorn, aphor.
            /
4 
588    DISEASES OF  SPECIAL STRUCTURE OF  THE  SKIN.

  The most remarkable case of human  horn on record is  that of a
Mexican porter,  named  Paul Rodriguez.1   The  horn  was  situated
upon the upper and lateral part of the head, was  fourteen inches in
circumference  around  its shaft,  and  divided above that point into
three branches.  Voigtel2 cites the case of an old woman  who  had a
horn with three branches growing from her forehead; and M. Dubois3
had  a woman  under his care, in  the  Hospice de Perfectionnement,
with  a horn that measured  seven or eight inches in diameter at its
base, and was six inches in length.  The length of the horn, in some
recorded instances, is also remarkable.  Sir Everard Home4 saw two
cases, in both of which the growth measured five inches, by one inch
in diameter.  They were curled, and had the appearance of  isinglass.
In one case the  horn was  fourteen years growing.  Dr.  Gregory3
mentions a horn which was removed from the temple of a woman in
Edinburgh, and measured seven inches.  Dr. Chariere,6 of Barnstaple,
saw one growing from the nape of a woman's neck,  which measured
seven inches.  A horn said  to be preserved in  the  British  Museum
measures eleven inches in length, by  two and a half in circumference;7
and  Bartholin,8 Faget, and  several other writers,  have  spoken  of
horns twelve inches long.  A singular instance of horn is mentioned
by Cruveilhier, in his " Anatomie Pathologique," as falling under the
notice of Dr. Faget, 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 appear-
ance, was  extirpated  by M.  Faget.   The portion  removed by M.
Faget, with the two portions previously cut  off, amounted in length
to about twelve inches.
  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 and stupendous
effect," continues the pamphlet, " began first from a soreness" of the
back part of the head where the  horns grew.  " This  soreness con-
tinued 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 tor-
menting her than before, after which time it was, by a strange opera-
tion  of nature,  changed into horns, which are, in show and substance,
much like  ram's horns, solid and wrinkled, but sadly  grieving 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 off by accident.   One of these was
presented to the King of France, the other  is stated to have been

     1 New York Medical Repository for 1S20.
     1 Handbuch citat.           3 Dictionnaire de M<aiecine, art. Cornee.
       Loco  citato.              * Sir E. Home's paper ; loco citato.
      Eodem loco.              i Eodem loco.       8 Epistolis. 
DISEASES  OF  THE  SEBIPAROUS  ORGANS.        589
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 Derbyshire.  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 than might be expected. Bartholinus and Borellus
have each collected numerous  cases.  Vicq d'Azyr1 treats of the sub-
ject in his essay  on Animal Concretions, in  1780; Franc,2  in an essay
de Cornutis, in  Heidelberg; Sir  Everard Home, in  the Philosophical
Transactions for 1791 ;  Alibert,  in his Precis Theorique  et Pratique
des  Maladies  de la Peau;  Rudolphi,3  in  a paper read before  the
Academy of Sciences  of Berlin, in 1815 ;  Dauxais, in a thesis, publish-
ed in Paris in 1820; Breschet, in the article "Corne'e," in the Diction-
naire de Medecine; Cruveilhier, in his AnatomiePathohgique.  The latter
author devotes the whole of his twenty-fourth fasciculus to horny
growths.   And Sir Astley Cooper and Mr. Travers in their Surgical
Essays.4
  The following case is strikingly illustrative of the mode of growth
and  appearance  of a horn when  developed  on the  face.   Louise
Marino, an Italian peasant, fifty-four years of age, perceived, in the
month of January, a small tubercle of about the size of a millet-seed
imbedded  in the integument  of  the  root of her nose.  The tubercle
was attended with a trifling degree of pain and pruritus, but continued
to grow with considerable rapidity.  On the 30th  of October (same
year), it had acquired the length of an inch, was of a grayish-brown
color, had the diameter of a writing quill, was grooved along its under
surface, and curved like the beak of a bird of prey.  It adhered firmly
by means of  a narrow base to the  skin and subjacent cellular tissue.
Dr. Portal removed it by incision;  the cellular tissue at its base, the
periosteum and bone, were perfectly sound.*
  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 imper-
fectly  adherent to its base, I  displaced it  with my nail, and applied
caustic to the surface of the sac, from which it had  originated.  This
treatment was successful in  preventing its return.   Another  case of
horn has lately been  recorded by Mr. Dalby,6 of Ashby de la Zouch,
under  the  incorrect term  of. " ichthyosis cornea."   The horn was six
inches in length, and two and a half in. circumference ; it originated
in an encysted tumor and grew from the back  part of the scalp of an
old lady, seventy years of age.  At one time it gave rise  to so much
pain when touched, that she  could not bear to lay her head on her
pillow.  Mr. Dalby's  narration is accompanied  by a wood-engraving.
  Treatment.—The examination  of the case mentioned  in the  pre-
ceding pages, by showing the true nature of the growth, suggests the
appropriate mode of treatment, and proves, at the same time, that the

  ' Hist, de la Soc. Roy. de Med., p.  184.  1780-81.
  2 Tract. Philolog. Med. de Cornutis.      3 Vol.  ii.
  « Part 2.                           6 H Filiatre, Sebezio, February, 1842.
  6 Lancet, vol. ii. 1850, p. 342. 
590    DISEASES' OF SPECIAL  STRUCTURE  OF  THE  SKIN.

practice heretofore adopted, of removal by incision, is  altogether un-
necessary.  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;  2. To modify the secreting surface, in such
wise as to prevent the continuance ofthe process of abnormal cell-
formation.  The first  of these indications is to be fulfilled by means
alkalies and water-dressing, or by a poultice; the second by the stick
of nitrate  of  silver.   By these  means the growth may be removed,
the disposition to its re-formation  checked,^nd a painful operation
avoided.

  (b.) Retention of secretion in the sebiferous ducts, the excretory aperture
                           being closed.

                      TUBERCULA  MILIARIA.

Syn. Exormia milium, Mason Good ;  Grutum,  sive milium,  Plenck;
  Follicular elevations, Rayer; Pearly tubercles.   Der Gries, Germ.
  Little tubercles of a white color, of about the size of a millet-seed,
and sometimes of a small pea, caused by  the collection of the seba-
ceous substance within an excretory follicle,' the aperture of that folli-
cle 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 tubercles more appropriate.  A very common
seat of these elevations 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 easily removed by puncture with a fine lancet, and
gentle  pressure ; the operation is by no means painful, for the integu-
ment covering them is reduced by distension to a mere film.  Touch-
ing the interior  of their sac with a  fine point of nitrate of silver
effectually  prevents  their return;  or if they be  too  numerous for
this operation, the attempt may be made to disperse them by means
of a weak solution of bichloride of mercury in almond emulsion.
  In place of  sebaceous substance  more  or less  inspissated, it some-
times happens that the secreted matter partakes  rather  of the  calca-
reous character, calcareous miliary tubercles, being more or less
dense and hard, and containing  carbonate and phosphate of lime in
combination.   Meckel found a  number  of these  concretions in the
skin of the gluteal region, and Voigtel1 records an instance as  occur-
ring on the forehead, and root  of the nose.  Dr. Julius Vogel2 has
described another case of this disease affecting the scrotum.  The integu-
ment of the scrotum was the seat of severe itching; on the cessation of
the itching a number of small conical tubercles were developed,  which
increased to the magnitude of a pea  or hazel-nut.   After reaching ma-
turity,  the little tubercles wasted and became dry, and were followed

  1 Handbuch der Pathologischen Anatomic
  2 Algemeine Zeitung fur Chirurge inuere Heilkunde und ihrer Hulfswissenschaften,
July, 1841. 
DISEASES OF THE  SEBIPAROUS ORGANS.
591
from time to time by successive crops.  At the period of detailing the
case, they were one hundred and fifty in number, seated in or beneath
the corium.  The  contents of the  tumors were a white,  greasy  and
softish substance, like atheroma.   Examined chemically, it was found
to consist of carbonate and  phosphate of lime,  with a trace of soda, a
small portion  of fat, and some extractive matter.
   Dalrymple called attention to a  similar fact  in  relation to a small
encysted tumor of the eyelid, and  showed  the  seat of the calcareous
matter.to be the epithelial scales of which the  tumor 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."   Gulliver
ascertained the earthy matter to be  phosphate of lime, with a trace
of the carbonate of the  same earth.1  Dalrymple informed  me  that
he had, since the publication of the preceding, seen a second instance
of the same disease.

                        TUMORES SEROSI.
                     Syn.  Milia. Phlyctenule.
   Sometimes, instead of sebaceous or calcareous substance, the excre-
tory follicles  of the sebiparous glands are distended with  a limpid
serous fluid,  and  attain  the size of millet  seed or small  grapes.  A
gentleman lately consulted me, in whom there were two of these grape-
like cysts, connected with the border of the  upper eyelid ; they were
semi-transparent and tense, and interfered with his vision.  I punctured
them with a cataract needle, and, after the escape of the fluid, touched
the shrivelled cysts with nitrate of silver; the integument soon healed,
and they are not likely to reappear.  The same method of treatment
is applicable to the smaller  kind.
   Occasionally, the  fluid  is contained  in a transparent  cyst, so
extremely firm that the tumor is unable to increase to the size above
indicated; and the tension  of the  sac is so  great that it appears to
have the density of cartilage.  The integument covering these little
tumors is extremely attenuated and semi-transparent, and small vessels
are seen meandering over their surface.  Their size, transparency, and
hardness  have suggested  the terms by which they are commonly
known ; namely, chalazion,  or grando, hailstone.   The treatment is the
same as that of the miliary and  serous cysts, namely, puncture and
the application of a point of nitrate of silver.

                        TUMORES SEBACEI.
Syn. Emphyma2 encystis, Mason Good.  Encysted tumors.  Follicular
           tumors.   Wen.  Meliceris.  Atheroma.  Sleatoma.
   These tumors, identical in manner of formation with the sebaceous
miliary tubercles,  but somewhat more deeply seated in the integument,

   1 Medico-Chirurgical Transactions, vol.  xxvi. p. 238.
   1 Der. <piiv, produco, erumpo.  Mason Good applies the term emphyma to a tumor
originating below the integument; and ecphyma to a tumor confined to the integu-
ment : therefore, he is in error in  naming the encysted tumor emphyma ; it should be,
ecphyma. 
592   DISEASES  OF SPECIAL STRUCTURE  OF  THE  SKIN.

attain to the size of a hazel-nut or walnut, and sometimes the magni-
tude of a small orange.   They may occur  singly,  or several  may  be
developed in the 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 have also  seen
them on the abdomen and in the groin.
  The sebaceous substance collected in these sacs is variously altered
in its qualities or appearance.  Sometimes it is limpid and fluid, like
serum, and contains crystals of stearine; at other times it  is  soft and
white, reminding us of  pap, or bread sauce, this constitutes the athe-
romatous tumor; again, it is yellowish, and  resembles  softened bees-
wax, the melicerous tumor;  or it may be white  and fatty, the steatoma-
tous tumor; at other times, it presents various peculiarities of character,
more or less referable to the above heads.   The parietes of these cysts
are the  walls of the excretory duct of the sebiparous gland and related
hair-follicle, in a state of hypertrophy, lined in the interior with epi-
dermis.   The sebaceous substance which they contain is mingled  with
epidermal scales and hairs, having a similar origin to those found  in
the sebaceous accumulation of comedones.   The contents of ihe cyst
are often exceedingly fetid, and the fetor is  increased when  the tumor
inflames.  In consequence of the pressure exerted on the scalp by these
tumors, the  neighboring hair-follicles are  frequently destroyed, and
the superjacent skin becomes bald.
  The encysted tumors of the eyelids, and  some of the polypi of the
meatus  auditorius, are of the  same nature.
  Treatment.—The common practice in the treatment of these tumors
is to dissect  them out, and this is usualljt done  with care,  under the
impression that a  particle of  the cyst reft behind will grow, and
develop another turrror.   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 ofthe 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 tumors is always a painful operation, and in certain cases, when
seated in the scalp, dangerous, from  the  possibility of the occurrence
of erysipelas.  I have generally succeeded in curing encysted tumors
by laying them open with a lancet or bistoury, pressing out  their con-
tents, 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.
  The contents of these tumors are sometimes too dense to  be simply
squeezed out, and not unfrequently  they  are soft in the centre and  as
dense as horn in the circumference, looking, in fact, like a horny  or
cartilaginous sac inclosing the softer material.   When this is the case,
after laying open the tumor, I pinch the edge of the horny cyst, and
gently draw it outwards, while, at the  same  time, I press back a thin
fibrous  membrane by which  it is invested; in this way the whole of
the horny cyst may be removed at once, and all subsequent inconve-
nience prevented ;  for, when completely removed in this manner the 
DISEASES  OF THE  SEBIPAROUS ORGANS.        593
application of caustic is unnecessary, and the wound heals, without
further attention, in a few days.   It may be necessary to remind the
 oung operator that the incision, which is least painful when effected
 y  puncture with  a  narrow-bladed knife,  should be  made in the
direction of  the  hair.   The operation, neatly performed, is so  little
painful, that I have sometimes removed as many as six  or  eight in a
young lady at a single sitting.

  V.  INFLAMMATION OF THE CUTANEOUS FOLLICLES WITH
    DERANGED EXCRETION OF THE SEBACEOUS SUBSTANCE.

  The only disease coming strictly under this definition is Acne.

                             ACNE.

Syn.  lonthus.   Varus.  Couperose,  Fran.  Hautfinne, Kuperfinne im
                      Gesicht, Germ.   Whelk.
  Acne (Plate XIV.) is a chronic inflammation of  the follicles of the
skin,  arising  from impaction of the sebaceous substance.  It is charac-
terized, by the eruption of hard, conical, and isolated elevations, of
moderate size, and various  degrees of redness.  The apices of the ele-
vations generally become pustular, and burst, while their bases remain
for some time  in an  indolent state before  they disappear.  On the
apices of some of these elevations the opening of the follicle is dis-
tinctly apparent, while in  others the  aperture is destroyed  by the
pustule.   In  some the purulent fluid is mingled with softened sebace-
ous substance, while   others subside  slowly without  suppuration.
Some, again,  scarcely  differ in  tint of color  from the adjacent  skin,
while  others  are highly congested  and surrounded  by  an inflamed
base of vivid redness.
  Acne  is usually  accompanied  with  other  signs of disorder of the
cutaneous follicles : thus, in some situations, the glands appear to be
excited to undue action, and  pour forth an inordinate  quantity of
secretion, which gives the skin a glossy  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 discolored, and has  the appear-
ance 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  not unfrequently be observed.
  The term acne seems to be derived from dx^ or axpn, 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 it is most frequently met  with where the
integument is thick, as the back, shoulders,  backs of the arms  and
       38
I 
594    DISEASES OF SPECIAL STRUCTURE OF  THE SKIN.

fore-arms, breast, or those parts which are exposed  to the  influence
of the atmosphere,  as the face and neck.
  The varieties  of  acne, according to Willan, are  four in number,
namely, acne simplex, acne punctata, acne indurata,  and acne rosacea.
The first three are mere  modifications of the same  form  of disease;
indeed, the same elevation may,  at  different periods  of its growth,
present each of the appearances indicated by these  designations.   I
shall therefore take the more simple  course of describing the affection
as appearing under two principal forms,  namely,
                          Acne  vulgaris,
                          Acne rosacea.

                        ACNE VULGARIS.
  Syn.  Ionthus varus simphx et punctatus, Mason Good.   Whelk.
                            Stone-pock.
  The common variety of acne  (Plate  XIV., A.  G.)  commences  by
small  red  and  inflamed elevations, which   gradually become pro-
minent and conoid, and secrete a small  quantity of  pus at their ex-
tremity,  while the base remains hard and of  a deep  red color, 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 effused
fluid desiccates into a thin brownish scab, which leaves at its fall  an
indolent tubercle of a purplish livid hue (twflos ab lov,  viola), and fre-
quently a small  white and  permanent cicatrix.  The tubercle remains
for a considerable period after the rupture  of the  pustule, and dis-
appears  very slowly.  The  eruption  of acne is  generally unaccom-
panied by pain or heat, and gives rise to little  inconvenience bevond
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 ele-
vations of acne are for the most part successive in eruption, and 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.1
   It frequently happens that in the centre of each of  the conical ele-
 vations,  and always  in  some, a small  round blackish spot may be
 perceived.  The presence  of this spot is the especial characteristic of
 acne punctata2  (Plate XIV.,  A. B. a);  it is  the  aperture of a hair-
 follicle, distended with inspissated sebaceous substance up to the level
 of the skin, and discolored at the surface by exposure to the dust and
 dirt contained in the atmosphere.   After having  suppurated and dis-
 charged the  sebaceous substance, the elevations diminish in size, they
 become  purplish  and livid, and, at a later period, whitish in  color,
 and disappear by degrees.   The  punctated form of  acne is generally
 intermingled with  that in which  the excretory puncta are obliterated.

   1 For a good example of acne vulgaris, presenting at the same view all its various
 forms, see " Portraits of Diseases of the t>kin."  Plate XXXIX., I.
    Acne  punctata, or maggot  pimple, is  consequently a comedo, with the super-
 addition of inflammation ofthe cutaneous follicle. 
DISEASES OF THE  SEBIPAROUS  ORGANS.        595
   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 frequently 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 XIV., D.) When
the indolent form of acne  affects  the face extensively, the features
are disfigured; the  entire  surface  is  more  or  less  covered  with
tubercles of a deep red or livid color and variable size,  and the in-
tegument between the tubercles  is  thickened and congested.   The
face and back are the more  common  seat of this error.

                          ACNE ROSACEA.
   Syn. Ionthus corymbifer, Mason  Good.   Bacchia.  Gutta rosacea.
        Rosy-drop. Carbuncledface.   Grog-blossom.   Bubukle.1
   Acne rosacea (Plate XIV., h.)  is especially characterized by  the
redness and congestion  which attend  its conoidal elevations ; 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  indolent 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 con-
gestion is increased by  a continuance 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 is the nose, which is often considerably enlarged by the "morbid
action ; the integument and subcutaneous textures become infiltrated
and hypertrophied, and the  cutaneous veins tortuous  and varicose.
From  the nose the disease extends  to the cheeks, forehead, 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.
   Diagnosis.—The diagnostic characters  of acne,  are, the conoidal
form ofthe inflamed elevations, the  suppuration of some  of these eleva-
tions  at their apices, the tardy growth  and  disappearance of others,
the livid and indolent tubercle left  behind  by both, their evident seat
in the cutaneous follicles, and the disorder of neighboring  sebiparous
glands evinced  by the increased secretion  of some, the concretion of
the secretion of others, and  the presence of sebaceous miliary tuber-
cles.  The particular characters distinguishing the varieties of acne
are, the absence of any appearance of excretory follicle in acne vul-
garis ; the presence of an excretory aperture in acne punctata; the indo-
lent course of acne indurata, and the general distribution  of all these
varieties over the  surface ofthe body.  Acne rosacea is distinguished
from  the preceding by the  greater vascularity of the elevations, the

  1 "His face is  all  bubukles  and whelks, and  knobs,  and flames of fire."—
Shakspeake.
  * " Portraits of Diseases ofthe Skin."  Plate XL., AP 
 596    DISEASES  OF SPECIAL STRUCTURE OF  THE SKIN.

* congestion and  thickening of the surrounding skin, and the especial
 seat of the eruption on the face.
    Causes.—Acne vulgaris is developed at all ages between the period
 of puberty and  the fortieth year, and occurs in both sexes, more fre-
 quently, perhaps, in the  female than in the male.   Acne rosacea is a
 disease of  adult life, and is also more frequent in the female than in
 the male.  The  presence of acne indicates a disordered state of cuta-
 neous innervation, and,  consequently, of the vascular action of the
 skin; in some instances it is induced by direct congestion ofthe integu-
 ment, as is acne rosacea, while in others it would  seem to depend on
 torpidity of the  capillary circulation, and obstruction of 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 fatigue.  This kind  of disorder
 of the cutaneous functions  is also associated with amenorrhoea.
    Congestion, on  the other hand, is the active agent in the eruption
 when  arising  from general plethora, from the partial plethora  which
 occurs at  the critical period of life in females, from exposure of the
 face to 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 appli-
 cation of irritating substances.  Of the latter it is proper to mention
 the abuse of certain stimulating washes and powders employed as cos-
 metics. Partial congestion would seem to be  the exciting cause of the
 eruption, when  it is induced  by  irritation of the gastro-pulmonary
 mucous membrane.
    Prognosis.—Acne vulgaris is removed with difficulty;  the rosace-
 ous variety is less intractable.
    Treatment.—The treatment of  acne must be adapted to the cause
 of the affection; in those cases in which a torpid action of  the cutane-
 ous system is evident, stimulating remedies must be employed, whereas
 in those which are dependent on congestion, stimulants would be inju-
 rious, and would prolong the morbid action. In  both cases the regi-
 men  should be  regulated;  it should be moderate and nutritious, all
 stimulants avoided.  To this hygienic management, laxatives, anta-
 cids, and tonics  may be added, with a view to order the secretions, and
 regulate the digestive functions.  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 func-
 tions must be ascertained,  and at the critical period of life derivative
 measures may be employed with advantage.  Whenever the indication
 is obviously congestive,  bleeding may be had recourse to locally.
    In applying  the local treatment, due  regard should be had  to  the
 ordinary principles of surgery; when  the pimple is  congested and
 painful,  it may  be punctured, and the bleeding  encouraged by water
 dressing or poultice; and  where pus or sebaceous substance is sus-
 pected to  exist  imbedded in the tubercle, a free puncture, succeeded 
diseases  of the  sebiparous organs.        597
by a poultice, is especially indicated.  When the local determination
has somewhat subsided, stimulants may be employed; for this purpose,
a lotion containing sulphur  sublimatum, two drachms; camphor, one
drachm; and distilled  water, four ounces, is often  of service; or the
hypochloride of sulphur ointment; or an ointment of ioduret of sul-
phur, in the proportion of ten grains to the ounce of elder-flower oint-
ment or simple cerate.  In the simple, as well as in  the other varieties
of acne, when they present a chronic character, a solution of the bi-
chloride of mercury in emulsion  of bitter almonds, or of the same salt in
eau de Cologne, in the  proportion of a grain to an ounce,  will be found
of 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.

        VI.  CARCINOMA OF THE SEBIPAROUS GLANDS.
                    TUBERCULUM  MALIGNUM.
                        Malignant tubercle.
   In  persons beyond the age of fifty, and in  elderly persons, we occa-
sionally meet with a small,  hard, indolent tubercle, on  some part of
the skin of the face.  This tubercle  is evidently of a malignant nature,
but differs from  other malignant affections in the extreme tardiness of
its progress, and the little inconvenience to which it gives rise.
  The characters of the malignant  tubercle  are as  follows: A tuber-
cle, rounded  or lobulated, elevated about one line above the surround-
ing skin;  convex  at  first,  subsequently flattened; hard, colorless,
yellowish,  or purplish,  and semi-transparent, having  small veins
meandering over its lobulated surface; increasing  slowly in circum-
ference by the development of new lobules;  superficial, being limited
to the skin, and  in its early stages to the superficial stratum ;  at first
not more than two lines in diameter, commonly reaching a diameter
of four or six  lines, and sometimes  one or two  inches; during its
growth becoming depressed in the centre from the fuller development
of the lobulated border.  Subsequently, the  centre  desquamates, then
becomes fissured and  split into several masses;  from  these cracks,
often  deep, there issues a colorless or semi-purulent ichor which  dries
on the surface., and forms a rugged, horny looking- crust; frequently
the cracks bleed and the crust  is blackened.  At  a more advanced
period, the whole central part becomes  covered with a  black crust,
which spreads almost to the border, leaving  the latter marked by all
the characteristic signs of  the original disease,  namely, rounded,
lobulated, semi-transparent, and traversed by small venous trunks.
By degrees, a slow destruction and removal of the central part of the
diseased growth, scarcely amounting to ulceration or sloughing, takes
place; the surface continues to be  concealed  from view by a thick
black crust, the  crust is cracked in  one  or two places for the  exit of
a sano-uinolent ichor, and is separated from the growing border of
the tubercle also, by a  deep fissure through which the same sanguino-
lent ichor escapes; the fissure gives the internal edge of the border
the appearance of a vertical section;  sometimes this border is exca- 
598    DISEASES OF SPECIAL  STRUCTURE  OF THE SKIN.

vated, and not unfrequently a little everted.  When -the black crust
is removed by means of a poultice, the  surface is  uneven, composed
of red,  tumid,  and  bleeding  granulations, sometimes  assuming a
fungous character, and sometimes rising in the centre above the level
of the border; immediately beneath the edges the sore is more deeply
excavated than elsewhere.
  The situations in which I have seen the malignant tubercle are, the
ala of the nose, the groove between the ala of the nose and the cheek,
the tip ofthe nose, the superciliary ridge near the temple, the temple,
the cheek, the  integument immediately in  front of the  ear, and  the
integument over the  mastoid process.  In seven cases, the measure-
ments were : three, four lines; two, six lines;  one, an inch and a half
in length, by  one  inch in breadth;  one, nearly  three inches in
diameter; six occurred  in the  male, one only in  the female.  The
respective periods during which  the  tubercles  had  been in existence
varied between two and fifteen years.
  The pain accompanying this tubercle is generally insignificant, and
is rather uneasiness  than pain;  sometimes there is a little itching,
sometimes a  throbbing; in a few instances an occasional lancinating
pain, but%more frequently a sensation of numbness or heaviness, or a
dull aching.   It generally fluctuates  with the state of health, being
comparatively easy  when the  functions are regular, and  painful or
congested when the digestive organs or general health are disturbed.
In one patient,  the tumor was always painful when  an attack of gout
was impending, and was relieved by its outbreak.
  Diagnosis.—The malignant tubercle might be mistaken for a wart,
at least by the patient;  not, however, by the surgeon, when the nature
of the two formations is considered;  the wart being a product of the
epidermis, the malignant tubercle an  organic alteration of  the derma.
I suspect, however, that some of the cases recorded as cancerous warts
were in reality the tubercles now described.  A more probable error
would be, to confound it with a hairless mole;  but the mole is simply
an hypertrophy of the  natural  skin, the skin retaining its  normal
qualities of  softness and  texture;  while the  malignant tubercle is
of cartilaginous hardness.   In its crusted state, it might  be taken for
a dilated sebaceous follicle, and  the crust  for desiccated sebaceous
substance, which  it much resembles.
  Cause.—The question of cause involves that of  the pathology of
the disease;  it has appeared to me to originate in a sebiparous gland,
to b§, in fact, a cancer of the gland; and  this belief suggested its
consideration among the group of diseases of those  glauds.  At first,
one gland alone may be affected, then a second, a third, and a  fourth
become added to the first; the next step would take the  immediately
adjoining gland around the  whole  periphery of the tumor; hence,
the extreme indolence of the  disease at first, and its quicker growth
afterwards.  From the glands the cancerous degeneration is  propa-
gated to the rest of the  skin, and the entire mass is involved in  one
diseased action.   With this view of the pathology of the  malignant
tubercle, which I regard as a carcinoma glandule sebipare,  we may
refer  its cause to a morbid process set up in the  structure of the 
DISEASES OF  THE HAIR.                599
gland.  Associated with this disease, there are always indications of
torpor of the skin, and irregularity of its secreting functions; and not
unfrequently concretions of sebaceous substance, analogous  to those
of ichthyosis sebacea.
   Prognosis.—The malignant tubercle  may  be removed with the
most  complete success, on account of its superficial  position in the
skin; and there is little probability of other glands becoming affected
in a similar manner.  The seven cases above referred to were all suc-
cessfully cured.
   Treatment.—The malignant tubercle must be destroyed thoroughly
by caustic; and, for this purpose, the potassa fusa, chloride of zinc, or
nitric acid, may be employed.   I have used all these caustics, and am
at a loss to give a preference to either.  The potassa fusa is, perhaps,
the least painful, and the chloride of zinc the most so; the potassa
fusa is rapid in its action, and sinks quickly into the substance of the
tubercle, while the chloride of zinc produces the cleanest sore.   Lat-
terly, I have selected the nitric acid;  the mode of using it is to mix
it with sulphur sublimatum  to the consistence of a thin paste, and
apply the paste to the surface of the tubercle by means of a small
glass or wooden spatula.  It requires no subsequent attention, unless
there be swelling and  pain, in which  case the part may  be fomented,
and covered with  water-dressing.  The pain lasts for five or six hours,
and then ceases; and the old  aching  or benumbed uneasy feeling in
the tubercle is found to be gone.  When the eschar falls, the surface
is generally healed, or nearly so, and  requires only a simple dressing
for a  few days.
                 CHAPTER,   XXII.

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN.

           DISEASES OF THE HAIRS AND HAIR-FOLLICLES.

  The  hair is liable to a  variety of modifications; some resulting
from altered nutrition, others from inflammation, either of  the forma-
tive structure  of the hair, or of the hair-follicles.   Mason Good groups
all these alterations under the general head trichosis, the ninth gen us
of his class eccritica; and he defines trichosis1 as a "morbid organiza-
tion or deficiency  of hair."   These  modifications,  alterations' and
diseases, I propose to consider, under the six following heads, namely,
                   Augmented formation of hair,
                   Diminished formation of hair,
                   Abnormal direction of hair,
                   Alteration of color of hair,
                   Diseases of the hairs,
                   Diseases of the hair-follicles.

  i Trichosis a term employed by Actuarius, is derived from rfi^nt, pilare malum,
morbid hair ; ab  Orf., pilus. 
600   DISEASES of special  structure of the skin.
             I. AUGMENTED FORMATION OF HAIR.

  Augmentation of formation of the hair calls for consideration in a
twofold point of view : firstly, as it relates to simple increase of quan-
tity or length in situations naturally occupied by hair, abnormal quan-
tity,  hirsuties; and, secondly, to  increase of quantity  or  length in
unusual situations, abnormal situation, nsevi pilosi.

                           HIRSUTIES.

          Trichosis hirsuties, Mason Good.  Die Haarigkeit.
  Great variety is met with among individuals in relation to quantity
of hair; in some persons the hairs are collected into groups of three,
and in many situations two issue from the aperture of the same folli-
cle;  while in others the  hairs are distributed  singly  at regular dis-
tances, and are not clustered.
  In  the  present  age, when  custom and convenience  call  for'the
frequent shortening of the hair, we can  form very little  notion of
differences involved in rapidity of growth.  There can  be  no 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 the 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.   Withof estimates that the hair
of the head 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.  Berthold  states the growth of the hair in persons between
the ages of sixteen nnd twenty-four to be nearly two lines a week, or
seven lines a month, and from six to eight inches a year.   He found
it grow more rapidly  after cutting;  during the day than at night;
and  in warm  than in  cold weather.1  Men with  long  hair are fre-
quently met with at our country fairs, and Rayer quotes the following
instance of remarkable development of  this  production:  ^1  once
saw  a  Piedmontese, aged twenty-eight, strongly  built, having the
chest broad and large, and.the muscles of  an  athlete;  the arm was
above twenty-one inches, and the calf of the leg  nearly two feet in
circumference.  This man  had little beard, and the trunk was very
scantily furnished with hair, but his scalp was covered with 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."
  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
1 Midler's Archiv. 1S50. 
DISEASES OF THE  HAIR.
601
effects produced upon the system by the habit of removal of the hair.
I have known  persons who always experience headache after having
the  hair cut, and many cases are  on record in  which  the  removal
of the hair  is supposed to  have given  rise to remarkable  results.
Moreau has published some excellent observations1 on the advantages
and  dangers  of cutting the hair; and tie especially details the 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
considered pathognomonic of strumous disease.  This is an  interest-
ing  observation  in  relation to phthisis, inasmuch as it  serves to
illustrate, in  another point of view, the vicarious activity which the
skin assumes in disordered function of  the lungs.

                          N^EVI P1LOSI.

       Syn.  Spilus.  Moles.   Naevi Materni.  Mother's Marks.
  When it is recollected that every part of  the skin, with the excep-
tion  of the palms of the hands and soles of the  feet, 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 nutrition of the hair-bulbs, determined
by local or constitutional conditions, the local conditions being either,
special organization  of the  skin or external irritation of that 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 the hair-bulbs and follicles.
  Local increase of length of hair, depending on special organization
of the skin,  is usually congenital, and  is exemplified  in  the  various
forms of pihus nevi, or  mohs.  In  naevi of this kind  there is  no
hypertrophy  of the capillary structure of the  skin, as  in vascular
naevi, but simple augmentation of color, the consequence of increased
activity; and augmentation of thickness, the'natural result of enlarge-
ment of the  hair-follicles and bulbs.   Pilous naevi appear, in  various
numbers, and in patches of  different size, upon all parts of the body.
They are slightly raised above the level of the surrounding skin, and
are covered with hair of variable length.  Alibert records the case of
a young  lady, whose skin was studded, over nearly every part of the
body,  with moles of a deep-black color, from  which a long, black,
thick, and  harsh  woolly hair was produced.   Villerme', in his article
on the Hair,  in the  Dictionnaire des Sciences Medicales, 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 with bair, shorter, and  not quite so thick as the
bristles of a wild boar, but presenting considerable analogy with them.
1 Journal General de Medecine, vol. iv. p. 280. 
602   DISEASES OF  SPECIAL STRUCTURE OF  THE SKIN.

The hair covering, with  the  spots upon which they grew, occupied,
perhaps one-fifth of the surface of the body."
  Sometimes the disposition  to the growth of hair is not confined 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 healthy aspect and constitution, who presented a most unusual
growth  of long, harsh, and black  hair  upon the  outer  side of the
arms, extending from the back  of  his hands to the shoulders.  The
integument upon which  the hair  grew was of a brownish color, and
contrasted remarkably with the lighter-colored 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 brownish tint termi-
nating imperceptibly in the ordinary color 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 from the  neighboring parts.   The hairs in this case were
about three-quarters of  an inch in length,-darker in color than the
hair of the  head, conical, and  differing from the  eyelashes in being
longer and finer.   Examining the skin with a lens, the hair might be
seen extending deeply, in oblique direction, into the integument.  On
plucking out some of the hairs, and placing them in the field of the
microscope,  I found  them provided with a bulb, and identical  in
appearance with the hairs of  the head, or  of the whisker.
  Schenkius and Ambrose Pare* record  instances  in which the body
was completely covered with hair;  and Daniel Turner relates, quoting
from  Peter Messias, on the authority of  Damascenus, " that upon the
confines of Pisa, at a place called the Holy Rock, a girl was born all
over hairy, from the mother's unhappy ruminating, and often behold-
ing the picture of St. John the Baptist, hanging by her bedside, drawn
in his hairy vesture."
  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.  Villerme*  states,  that hairs have beeu found on
the tongue, pharynx, in the rectum, uterus, and vagina, growiugfrom
the mucous membrane.
  Local increase  of length of  hair, depending on external irritation
of  the skin, is illustrated in the following cases:  In a little girl reco-
vering from 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 color as that ofthe 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 from an inflamed
tumor in the thigh, which subsequently became  covered with nume-
rous long hairs.  Rayer  mentions another case, occurring in a medical
student, who had several hairy patches on  the skin, induced,  appa- 
DISEASES  OF THE HAIR.                603
rently, by^ frequent bathing in  the summer season, and exposure to
the scorching rays of the sun.
  Augmented growth of hair  in  abnormal situations, arising  from
constitutional conditions,  is illustrated in numerous 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 eco-
nomy.  Of the former kind is the  case of a young lady, narrated  by
Ollivier:1 she was remarkable for the whitness 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-skin.  At the end of a few days the pimples
presented a small black head,  and  shortly after they were found sur-
mounted 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 closely planted.
   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 asso-
ciated 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  functions  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  both 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,  masculinity of  deportment and of
action.   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 attributes  of the
male, says,  " We find  something similar  taking place even in the
human  species, for that increase of hair observable  on the faces of
manv women in  advanced life is an approach towards  the beard,
which is one of the most distinguishing secondary properties of man."
"The female, at a much later time of life, when the powers of propa-
gation 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 herma-
phrodite."
                  1 Dictionnaire de Medecine,  article Poil. 
 604   DISEASES  OF SPECIAL STRUCTURE  OF THE SKIN.
                                                    4
   Treatment.—Where the growth of hair 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 care-
 fully performed in the direction of the natural furrows of the skin,
 scarcely leaves any trace  of the 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 forma-
 tive 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, subcarbonateof 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
 epidermis;  the hair-bulbs consequently remain, and  the hair is not
 long in being reproduced.   I have seen deep and troublesome ulcera-
 tions produced by the incautious use of depilatories.

             II. DIMINISHED FORMATION OF HAIR.

   Diminished  quantity of hair, from  diminished or  arrested forma-
 tion, presents itself in various degrees, of which, simple thinning of
 the hair, defluvium capilhrum, may be taken as the earliest stage,  and
 complete baldness or alopecia as the last.

                     DEFLUVIUM CAPILLORUM.

   Syn. Athrix simplex, Mason Good.  Xerasia.   Die Dunhaarigkeit.
   Defluvium capillorum, the simple and progressive fall of the hair,
 giving rise  to thinness, is an  affection of the general surface of the
 scalp, but more conspicuous at the partjngs,  and  more  obvious in
 woman than in man from the manner of wearing the hair.  Defluvium
 capillorum, in a small degree,  is the common physiological  phe-
 nomenon occurring once in the year, generally in the autumn season,
 and corresponding with the change of coat in quadrupeds, and the moult
of birds, but is less observable in man than among animals.  At other
 times it is occasional and accidental, being dependent on some change
 in the functions or health  of the individual, and most complete  and
 serious where the general  health has  undergone deterioration.  The
 change is often rapid;  in the course of a  few weeks an abundant
 head of hair may be transformed into a thin and scanty thatch, barely
 sufficient to-hide the white skin from  which it  grows.  If the scalp
 be  carefully examined  in these cases it will be  found to present
 various morbid characters;  sometimes the  skin is dry, scurfy,  and
 hot, and exhales an unpleasant  odor;  sometimes it  is polished,  and
 has the aspect of being relaxed, the pores are large and dilated ; and
 at other times there  may be  extensive concretions of  desiccated
sebaceous substance.   The hair also exhibits a variety of appearances, 
*
                    DISEASES  OF THE  HAIR.                605

of which the chief is a dry and parched look, and a degree of rough-
ness, resulting from the  admixture of  hair of  every length ;  this
roughness and unevenness being partly the result ofthe broken state
of the hair, and partly of irregular reproduction, some of the young
hairs being  moderately thick, but the greater part fine and silky, with
very little hold on the skin.
   In defluvium  capillorum the  hair  is  sometimes combed out  in
prodigious  quantities,  and  if the roots  be  examined they  will be
found thinner  than  the  shaft,  showing the  effects  of exhausted
nutrition, and, not  unfrequently, the  root is embraced by  a small
mass of  hardened  sebaceous substance.   The exhaustion of  the
follicle continues for a long time after the fall of the hair, making no
effort to reproduce it, and when at last  the effort is made, the resulting
hair is either  too thin to maintain its   position, or is  twisted  and
crinkled, giving rise to  the expression withered hair; or it is thick,
harsh  and  stumpy,  its  powers of growth being expended in bulk
instead of in length.
   In the treatment of defluvium  capillorum,  it  is necessary to adapt
our  remedies to  the state of the skin as now described: when  the
proximate cause of the  fall  is an erythematous state  of the hair-
follicles, we  must prescribe  a cooling  wash,  gentle  brushing, and
probably an abstinence from grease.   When  the pathological state is
want of tone  and vigor  in  the skin,  plentiful brushing becomes
desirable;  a more  or  less  stimulating wash; and  a  stimulant
pomatum.1  But  while these medical means are being pursued, it is
necessary to treat the hair surgically; the short hairs,  the growing
hairs, the broken and withered hairs must all be cut, and the operation
should, be performed once a month, until  the weak hairs  have grown
to a normal and uniform  length.  There  is  considerable art in  this
operation, the separate  hairs require different degrees of cutting;
some to be clipped down to the level of the skin ; others to have the
whole of the twisted or withered part  removed;  and others again to
be simply tipped.  This method of cutting was first brought to  my
notice some years back by a  hair-dresser  of  Cheltenham, Williams,
and I have been  much gratified by observing its success;  as a mere
physiological experiment  it is curious and extraordinary to note  how
much the human hair may be improved  in  appearance  and  growth
by so simple a process :—
            " There are more things in heaven and earth, Horatio,
              Than are dreamt of in your philosophy."


                          ALOPECIA.

   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 full  growth of the

  1 Forms of these applications will be found among the " selected formulae" at the
end of the volume. 
606    DISEASES OF SPECIAL  STRUCTURE  OF THE SKIN.

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 de-
fective state of formation of the hair.

                     CONGENITAL  ALOPECIA.

  Congenital baldness is  sometimes,  but  very rarely, observed in
newly-born infants, in whom,  though well-formed and healthy with
regard to every other function, the  hair has been retarded in its ap-
pearance until the end of the first year, and sometimes as  late as the
second and third year.  I have seen only a few instances of co'ngenital
absence of the hair of the head, but I have met with cases of deficiency
in other regions more frequently, as upon the chin and pubes.   " Con-
genital absence, and ulterior defective development of the hair," says
Rayer, "are phenomena of considerable rarity, which I have, never-
theless, had opportunities of observing.  Such was  the case  of the
man Beauvais, who was a  patient in the Hospital de la Charit^, in
1827.  The skin of this man's cranium  appeared completely naked;
although, on  examining it  narrowly, it was found to be beset with a
quantity of very fine, white, and silky hair, similar to the down that
covers the  scalp of  infants; here and  there, upon the temples, there
were a few black specks, occasioned by the stumps  of several hairs
which the patient had shaved  off.   The eyebrows were merely indi-
cated 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 were
•bserved on the breast and pubic region, as  in youug people on the
approach of puberty; there were scarcely any under the axillae: they
were rather more abundant on the inner parts of the legs;  the voice
had  the pitch and  intonation of that of a full-grown and well-con-
stituted man.  Beauvais is not deficient in the virile indications of his
sex; he has had syphilis twice. He tells us that his mother and both
his sisters  had  fine  heads of  hair; whilst his father presented the
same defect in the commodity  of hair which he does himself."

                     ACCIDENTAL  ALOPECIA.

  Syn.  Porrigo  decalvans.   Alopecia areata;  circumscripta.   Area.
             Area dijfluens; serpens.  Tyria.   Ophiasis.
  Accidental baldness is a more common affection than congenital
deficiency of development of hair.  I have seen numerous instances,
in which the baldness has been general and nearly complete upon the
scalp, one or two small islets of hair-bearing integument alone remain-
ing, while the hair of the  eyebrows, whiskers, and beard, was totally
lost.  In one of these cases the scalp was 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 ex- 
                    DISEASES  OF  THE  HAIR.                607
            •
amined closely, the scalp  was seen  to be studded with numerous,
superficial, minute, dusky points, the almost obliterated hair-follicles.
In the course of a few months from this  time, with appropriate treat-
ment, the tenseness, thinness, and polish of the scalp became dimi-
nished; 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 epidermis.   This  I regard as the commence-
ment of the second and  restorative stage of the disease; the entire
suriace at this period has the appearance of the cutis anserina, and, in
the course of a few days, a minute downy hair may be seen extending
from the apex of each little projection.   This stage of the case is fre-
quently accompanied with an itching sensation, produced by  the im-
prisonment of  the hair within its follicle, the aperture being partially
closed by the corrugated  edge of the epidermis, and  frequently by a
minute operculum formed  by the hardened secretion of the  follicle.
The operculum is rubbed off in the  attempts of the patient  to relieve
this itching by friction or scratching, and the downy hair,  before in-
visible, becomes apparent.  The newly-formed  hair is for some time
thin, dry, and slender, and  lighter in color than the natural hair, but
after a time it gains its proper thickness and hue.
   Instead of affecting the  entire head,  the hair sometimes falls offj
without any premonitory symptoms, to a limited and circumscribed
extent only (partial accidental alopecia), leaving one or  more round
patches on the scalp, of which the  surface is smooth, white,  and de-
pressed.  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 nearer the circumference.
This, like general  accidental alopecia of the scalp, is clearly an  atrophy
of the Siair-follicles ; and  has  had  various  names assigned  to it by
different authors.  From presenting a regular  circumscribed disk of
baldness, surrounded by long and unaffected hair, it has been named
"alopecia circumscripta," and  "area."   When several of the  patches
run into each other, so as  to present a serpentine figure, it has been
called " ophiasis ;" but its  more common designation is  that which it
received from Willan, "porrigo decalvans;" this latter term being in-
tended to ally  it with common ringworm.

                           CALVITIES.

  Syn. Athrix calvities ; Mason Good.  Senile baldness.  Der Kahlkopf.
   Alopecia, the natural consequence of age, is a change  taking place
gradually  in the follicles, by which the formative structure, from ex-
hausted nutrition,  becomes atrophied,  and the follicles obliterated.
The "change is usually preceded by dryness, and loss of color 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 re-
sults from  mental anxieties and severe afflictions;  but at other times
comes on without apparent exciting cause. 
608    DISEASES  OF SPECIAL STRUCTURE  OF THE  SKIN.

   In association with the baldness of age, it is  interesting to note that
alopecia occurs on the vertex of the head, in  the 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 with the parietal ridges, and pos-
teriorly by 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  baldness must be sought  for in  an impediment to  cir-
culation through the textures  of the scalp of the upper part of the
head;  and in  correspondence with this  inference, we remark the  ex-
ceeding paleness of  the cranial region.  But the same cause may be
supposed  to have existed also in  women, unless we  admit,  that a
larger quantity of adipose tissue  situated  beneath the integument of
the scalp, may afford more  easy and unimpeded transit for the minute
vessels to the capillary plexus  of the derma.
   I am the more induced  to suppose that this may  be  the case, from
observing  the frequency of baldness on  the pubes, where a thick
cushion of fat is interposed between the hard parts and the surface,
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  ob-
serves, that he examined the  scalp of several bald heads by dissection,
and he invariably found  that the internal  surface of the integument,
when raised from the fat and superficial  fascia,  was remarkably even.
There  was no trace  of the  numberless appendages constituting  the
follicles of the hairs which are found in the hairy scalp.  On the con-
trary, in  a man recently bald  from  typhus fever,  the follicles were
distinctly apparent, and contained each a minute, colorless, down-like
hair, the rudiment of a fresh growth.  Hence, he continues, there is
this important difference between the baldness of the  aged and that
which succeeds disease; that in the first, the whole of the secreting
structure dies,  or becomes atrophied, from  the cessation of circulation
in the  vessels  of the part, whereas, in the  latter, the hair alone falls,
while the follicle remains behind.
   Bichat also remarked, that the follicles of the hair, when seen from
the exterior, appear to become  more  and  more shallow, until  at last
they reach the surface, and  are obliterated completely.  The same
change may be observed on the surface  of tumors forming in  the
scalp.  The integument becomes gradually thinned, the hair follicles
becoming more  and  more shallow, until every trace of them has dis-
appeared, and  the hairs which they once contained fall off.
   Causes.—The  proximate  causes  of  baldness  have been already
stated; they are,  defective  development of the  formative organ,  de-
fective  circulation  in  the formative  organ,  and defective nutrition* of
the formative organ.   The remote causes are, hereditary peculiarity,
I 
DISEASES  OF THE  HAIR.                 609
 the termination of acute diseases, certain diseases of the skin, certain
 general affections, syphilis, mercury, coffee taken in excess, late hours,
 extremes  in  venery,  old age.  The fall of the hair,  which occurs
 during convalescence from fevers and diseases attended  with  extreme
 depression of the vital powers, must be ascribed to enfeebled vigor of
 the system  and  consequently to  defective nutrition  of the  hair.
 Lernery1  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 energetically to any one por-
 tion of the body to the impoverishment of the rest, 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 phthisis,2  in which disease, not
 onjy 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.  Instances in which alopecia is attri-
 butable to syphilis are not uncommon; mercury, also, when taken for
 a length of time, is supposed to affect the secreting organs of the body
 injuriously, and among these, the secreting apparatus of  the skin   M.
 Lagneau, in  his article  "Alopecia," in the  Diclionnaire de Medecine,
 expresses a different opinion, as relates to the operation 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,
 by mercury.
   Baldness is modified by sex: in  the male it is common, but in the
 female, rare.   I am disposed  to believe that the difference between
 the sexes in this respect, lies in the greater proportion of subcutane-
 ous fat existing in the female.   The scalp of bald persons is  usually
 thin; and  eunuchs, who are generally  fat, are remarkable  for  the
 length and permanency of their hair.
  Gustav Simon ascribes alopecia areata to the destruction of the  hair
 by  a vegetable fungus.   I am an unbeliever  in the doctrine.
  Treatment.—The principal indication to be fulfilled in the treat;
 ment 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  redness is produced, and then  applying
 some stimulating  application, rubbed  briskly into the scalp  for  the
space of five minutes.  In women whose long hair contra-indicates the

  1  Mom. de l'Acad. des Sciences, prem. mem. vol. ii. p. 39.
 ,2  Hippocrates remarks, " Quilms tabe laborantibus, capilli de capite defluuat, hi,
alvi fluxu superveniente, moriuntur."
       '69 
610    DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

use of the cold bath, stimulating applications with plentiful brushing
must be relied on.   From two  to four drachms of the  unguentum
stimulans,1 combined with  an ounce and  a half  of sweet-scented
pomatum, form an elegant and  useful compound for procuring the
proper amount of stimulation of the scalp in  alopecia.
  In addition to the trichogenous pomatum, it is sometimes convenient
to be in possession  of an agreeable stimulating wash for the hair.
The wash may be used either alone or alternately with the pomatum.
The best trichogenous wash,  according to my  experience, is the ammo-
niated spirit wash, of which  the composition  will be  found among the
"selected formulae."
  Various stimulating substances have been  suggested and used from
time to time, in the treatment of alopecia, with advantageous results;
such as mustard, horse-radish, walnut-leaves, the pomades of Dupuy-
tren and Gibert.   The pomatum ascribed to Dupuytren appears to me
to be too clumsy a compound to owe its origin to so elevated a source;
this  remedy, with the trichogenous ointment  recommended by Gibert,
will be found among the "selected formulae."
  Avicenna recommends the use of leeches, slight scarification or acu-
puncture in the first instance, followed by rubefacients.  The latter
were in  high favor among the  ancients, who have left a goodly list
of them in their writings: the following are some  of the principal:
oils of chamomile, wormwood, bay, laurel, and dill; hellebore, euphor-
bia, pomegranate, nasturtium, stavesacre, fcenugreek, rosemary, sage,
Peruvian balsam, tar, frankincense, mastich, myrrh, and laudanum.
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 treat-
ment of baldness  to  external remedies.   Where disturbance of the
secretive and digestive functions  is present, these require attention.
Where the energies of  the nervous  system are obviously  reduced
below their natural level, steel medicines and tonics may be used with
advantage.
  My practice in area, after  regulating the secretions, and, if neces-
sary, administering ordinary  digestive  tonics, is to prescribe my ferro-
arsenical mixture internally;  and the use locally of  some  moderately
stimulating pomatum, liniment, or lotion, such as the  diluted pomatum
stimulans, an ammoniacal liniment, or a  lotion of acetum  cantharidis.
With these remedies the cure is simply a question of time, the result
cannot be otherwise than successful.
  When  the hair begins to grow after baldness, it is  at first of a light
color, dry, soft, and  almost downy, like the  young  hair  of a newly-
born child; but, by degrees, under favorable circumstances, it resumes
the color and strength of the surrounding  hair.   At other times, this
colorless  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 said  to be  favored by shaving the
scalp, the object of this operation being to confine the nutritive fluids

            ' Vide "selected formulae" at the end of the volume. 
DISEASES  OF THE  HAIR.
611
to the formative  structure,  until it shall  have regained 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 strengthen-
ing the hair.  Fallopius upon this subject observes, " II y a quarante
ans que nous portons la barbe longue, en signe de notre de'shonneur
et de notre servitude; avant cette epoque  nous nous rasions et nos   >
poils ne tombaient pas.  Les Espagnols en envahissant lTtalie, y ont
introduit la tyrannie, la verole, et l'usage de la barbe longue."

           III. ABNORMAL DIRECTION OF THE HAIR.

   Under the head of abnormal direction of the  hair, may be assem-
bled two instances of irregularity in  its growth and arrangement, not
referable to the preceding groups.   They are,
                        Trichiasis ciliorum,
                        Trichiasis coacta.

                      TRICHIASIS CILIORUM.
   Trichiasis ciliorum is an irregularity in  the growth and direction
of the eyelashes.  The cilia in this  disorder grow inwards  towards
the surface ofthe eyeball, and, rubbing against the conjunctiva, give
rise to chronic inflammation of that  membrane.
   The treatment of  trichiasis ciliorum 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.

                        TRICHIASIS  COACTA.
                        Felling of the hair.
   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 iuextr'cable interlacement, 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 observed after child-bed, and in cases of extreme distress.

           IV. ALTERATION OF  COLOR OF THE HAIR.

   Alteration ofthe  color of the hair arises from disorder of the  chro-
matogenous  function of the formative organ, and is very commonly
associated  with a similar alteration of the rete mucosum of the  skin.
It is by no means rare to find a lock of hair different in color, trichosis
decolor, from that which surrounds it.  Less frequently, sudden altera-
tions of color have been  observed, while blanching  of the  hair, or
canities, trichosis cana, is the natural effect of the torpor of  function
which accompanies advancing age.

                       TRICHOSIS DECOLOR.
   Two instances  of reproduction of  hair  of different  color to the
original, after recovery from severe  illness,  are recorded by Alibert; 
 612   DISEASES OF  SPECIAL STRUCTURE OF  THE SKIN.

 in one of these, a head of bright red hair replaced one of dark brown,
 and in the other, hair  of a deep black color took the place of brown.
 In  the case of baldness  from hypercatharsis, mentioned in a preced-
 ing page, the hair, originally of a brown color, was reproduced fair;
 and gray hair has been known to fall off in advanced age,  and  a new
 crop, similar in color to that possessed  in youth, to be substituted.
  Dr. Isoard, in a paper entitled, " Observations relative a une famille
 dont chaque  individu presente plusieurs  anomalies remarquables,"
 in  the  Journal  Complementaire du Dictionnaire  des  Sciences  Medi-
 cales, amongst other  extraordinary physiological 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 con-
 stitution, undergoes a change in the color of her hair; from a pleasing
 blond to a dusky red, but that  as soon  as the  febrile  symptoms
 diminish, the natural color is restored.   In the second volume of the
 Memoirs   of the French  Academy  of Sciences, is  the narrative of a
 case in which the hair of a female was  changed from  brown to fair
 during her confinement, which otherwise  presented no remarkable
 feature.   M. Villerme*1 relates the case of a young lady, thirteen years
 of age, who, never having suffered from any more serious illness than
 slight pains in the head, perceived, during the winter of 1817-18, her
 hair fall  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 show a new growth, of a black-colored  wool, in  the  situa-
 tions 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 inches, while the rest changed
 their tint at a certain distance  from the point, and  became chestnut-
 colored for the rest of their extent towards the root.  The hair  had a
 singular  appearance, half white and half chestnut.  The  specimens
 sent to the society were mingled with a  number of short hairs entirely
 chestnut-colored.   In remarking on 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,   suc-
 ceeded by a crop of new hair of a darker color even than  the original
 hair of the patient.  The late Dr. Chaumenton presented this pheno-
 menon in a marked degree.
  Dr. Bruley,  of Foutainebleau,  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  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 large size, and gorged with dark pigment.
The roots of the white hairs were dried up, and  two-thirds  smaller
in size than those of the  black  hair.  In his comment on  this  case,
1 Journal Generate de Mt deciue, vol. lxix. p. 213. 
DISEASES  OF THE  HAIR.                613
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 naturally."

                         TRICHOSIS  CANA.

   Syn. Canities.  Trichosis poliosis, Mason Good.  Der Graukopf.
                       Blanching of the hair.
  Under the term trichosis cana, or canities, I propose to describe
whiteness  of the hair,  whether  its production  be congenital, or
dependent on 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 gray, hoary, or white."  Canities
presents two varieties in degree; in the one the  hair is "snowy," of
an  opaque white, and corresponds 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 finer than ordinary hair.  These two kinds of hair offer
remarkable chemical differences; the former containing an  abundance
of calcareous salts, and the  latter a  much smaller quantity, or even
none.
  Canities may be of three kinds: congenital, accidental, or senile; it
may also be, in either of the three groups, partial or general.
  Congenital canities of  the hair is  usually partial; I  have seen
two examples in young  children  where the phenomenon presented
itself in the form of round 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 con-
trasted  strongly  with the neighboring  integument.  Bartholin  saw
an  infant, the whole  of  whose hair on  one side  of the head was
brilliantly white, while the opposite  side was equally remarkable for
its jetty blackness.   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 the  tint of fair
hair.  I have before alluded to the whiteness of the hair of Albinoes,
both of the European and African race.   Rayer, in the Atlas accom-
panying his work on  diseases of the  skin, gives a delineation, copied
from  a  picture  in the  museum of  the Jardin  du 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 of
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 rendered the more striking, by presenting a roundish islet
of deep black  near its middle.  On  the same plate is a figure, repre-
senting the head  of an Albino negress, copied  from Buffon;  the skin
of the face 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.
  Accidental canities  and senile canities present varieties in 
611:   DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

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 gray.  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 grad-
ually 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 falls 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 gray sooner  than  the
men; the former are often bald,  the latter seldom."
   Blanching of the hair commences at the root, and the colored part
is gradually  carried onwards, further  and further  from the integu-
ment. It is  curious to see the hair  undergoing this change, parti-
colored in appearance, and reminding us of the  ringed  hair of the
gray cat and ichneumon.  The kinds of  hair most liable to the inva-
sion of whiteness are those of  a dark color, as black and brown ;  fair
and auburn hair rarely become gray, but are more liable to fall off.
   I have at present under my care a  little girl, not yet six  years of
age, in whom there is an abundance of white hair mingled  with that
of her natural color, brown;  and there are besides many of those
short, bent, and horny  white  hairs, which are  common in advanced
age.  She  is a pale, thin, and  excitable child; and  has a superadded
cause of nervous exhaustion  in a  large  clitoris.   At her birth  she
possessed an abundance of black hair, which, although retaining its
quantity, has gradually altered  to a rich brown; her eyebrows  and
eyelashes are still black.  About twelve  months back she received a
shock to her  nervous system  from  an  accident; and  some  weeks
afterwards her  hair was found to have changed  to white in parts of
the head.   It began  in  three  circular  patches, and has gradually
increased until the head has quite the  appearance of that of an elderly
person.  There is besides some tenderness of the head, and a furfura-
 ceous desquamation.  The change of  color of  the  hair in  this little
 girl is evidently a neuropathic phenomenon.
   Causes.—Congenital canities depends  upon  some constitutional
 peculiarity inherent in the  organization of the individual.  Senile
 canities  is the consequence  of  diminished powers of the cutaneous
 nervous system, as evinced, either by the alteration of  the pigment
 deposited in  the formative cells  of the hair, or by the entire absence
 of the coloring principle.
   The remote causes which have been observed to give rise to acci-
 dental canities are, mental emotion, physical suffering and privation,
 constitutional affections, disease, and injuries.   Of mental emotion, as
 of grief, anxiety, fear, terror, anger, acting as exciting causes of blauch-
 ing of the hair, there are numerous  recorded  instances.  In some of 
DISEASES  OF THE  HAIR.
615
these cases, the effects  were gradual, in others immediate, producing
the silvery tints of age in the course of a few hours.
  " The different passions of the mind," says Bichat, " have a remarka-
ble influence over the internal structure of the hair; often, in a short
period, grief effects chauges in its color, 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 color 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 gray 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 gray during the night preceding his  execu-
tion.  Borellus asserts that two gentlemen, one a native of Languedoc,
the  other  a Spaniard, were so violently affected, the first by the
announcement of his  condemnation  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 color 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 color of the hair.
   Dr.  Cassan, in a paper  in  the  Archives  Generales de  Medecine,
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, on her chest, and
on her back.  After the disappearance of the eruption, the  hair still
maintained its abnormal color.
   Henry III., of Navarre, on hearing that the edict of Nemours was
conceded, a condition favorable 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 with  white spots
over the arms and forearms,  in consequence of mental agitation.
   M. Moreau1 observes,  "I once knew an aged man, for whom 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
 frightful  remembrance."
' Journal Generate de Medecine, vol. iv. p. 280. 
616    DISEASES OF SPECIAL STRUCTURE OF  THE SKIN.

  The poets make frequent  reference to this remarkable and sudden
effect of violent mental emotion :—
              " O nox! quam longa es, quae facis una senem!"

  Byron, in the " Prisoner of Chillon,"  refers to the same phenome-
non :—
                 " My hair is gray, but not with years,
                    Nor grew it white,
                    In a single night,
              As men's have grown from sudden fears."

  I have myself seen several undoubted instances of blanching ofthe
hair  within the space of a few hours; and have  recorded some in my
treatise on Healthy  Skin;  and  my researches  into this  subject,
started in a skeptical spirit, and  with doubt as to the possibility  of
such  an occurrence, have resulted in a  conviction that the sudden
blanching of the  hair, although  rare, is nevertheless an  established
fact.
  After some diseases of the  scalp,  it  sometimes happens  that the
newly-formed hair  remains permanently white; the  same qhange is
occasionally observed upon cicatrices left by wounds.

                  V. DISEASES OF  THE HAIR.

  Two diseases only come strictly under this denomination,  as being
characterized by a morbid alteration in the structure of the hair. One
is amongst  the most  common of the diseases  of the scalp of this
country, namely,  ringworm ; 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 affec-
tions, in consequence 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  condition 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 the terms having
any  reference to the  nature of  the  disease.   Under these  circum-
stances, 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 trichonosis, or trichosis.1  I am
further induced to give a preference to this term by finding it to coin-
cide with what I believe to be  the  true pathological nature of the
disease, namely, a morbid action producing degeneration and destruc-
tion  of the hairs.
  The proper diseases  of the hairs are, therefore—
                    Trichosis  furfuracea, '
                    Trichosis plica.
1 Der. 0e'?, capillus ; voV»f, morbus. 
                     DISEASES  OF THE  HAIR.                617

                      TRICHOSIS FURFURACEA.

Syn. Common, or scurfy ringworm.   Tinea  capitis.   Tinea nummularis.
   Porrigo furfurans.   Porrigo  scutulata,  Willan.   Porrigo  circinata,
   Mason  Good.   Porrigo  tonsoria.   Pityriasis  decalvans,  Gibert.
   Squarra tondens.  Tinea tondens, Mahon.  Herpes  tonsurans,  Caze-
   nave.   Alopecia porriginosa, Sauvages,  Phyto alopecia, Gruby.  Tri-
   chophyton tonsurans; Trichomyces tonsurans, Malmsten.
   Common ringworm of the scalp (Plates XIV. XV.) is characterized
by a dry and furfuraceous state of the skin, occurring in circular or
oval  patches of variable  size.  The  patches  are slightly elevated,
papillated,1 and spangled, Or, as it were, dusted  over with minute
epidermal scales.   The hairs  growing  on the patches are whitish,
twisted or bent, shrwelled and brittle, in some instances broken off
near the skin,  in  others,  matted into  conical  prostrate bundles; or,
when augmented in thickness by an accumulation of scurf, condensed
into thin yellowish-gray and fissured crusts.  When  heads affected
with this disease are kept clean, the patches look parched, and the
hair covering them withered and dried  up.  At a later period, the
patches  are  left more or  less  bald, but  never completely  so  as  in
alopecia areata.
   In the early attack of common ringworm, the only  appearance  of
disorder that can  be detected is a thin layer of scurf,  either in sepa-
rate scales around single hairs, or in patches, including several,  or  a
more considerable number.  This formation is accompanied with  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  the  comb.  At a later
period,  the  skin  upon which the furfuraceous  scales are dusted
appears  reddish and  slightly  raised; the  papillae  next make their
appearance on the reddened patches, and subsequently the peculiar
alteration of the hair.
   When  the disease is recent, the papillae are very  conspicuous;  tbey
are small and  pyramidal,  and resemble very  closely  the papillae of
cutis anserina thickly grouped together; they  are, in fact, the mouths
of the hair-follicles swollen and prominent from congestion, and have
the appearance of being drawn up by the  growth of the hair.   The
papillae are inclined obliquely in the direction of the hair, are some-
what imbricated, and from the summit of  each there issue one or two
hairs surrounded by a whitish film, formed by  the accreted sebaceous
contents of the follicle.  In older patches the papillae are less evident.
  The hairs in this disease-have been compared, not unaptly, to "tow."
They are remarkable for their bent and twisted  shape, and resemble
the fibres of hemp, in color,  as  well as in apparent texture;  they are
irregular in thickness, and are broken off' at variable  distances from
the scalp, giving rise to the  moth-eaten  appearance from which com-
mon ringworm derives its synonym, tinea.   In dark-haired children,
the stumps of the broken hairs frequently  present  little black knobs

  • The MM. Mahon have compared this appearance to the skin of a plucked fowl ;
the papillae they term asperities. 
618   DISEASES OF SPECIAL  STRUCTURE  OF THE  SKIN.

at the mouths of the follicles ;  this is the first  effort of a restorative
process.
  The crusts  which form over the morbid patches when  the disease is
neglected are composed of furfuraceous scales and  diseased  hairs,
agglutinated  together by the moisture which rises from the skin ; they
are grayish and yellowish in color, and  when of large size, are apt to
break up, in  consequence of the  movements of the integument, 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
mav generally be perceived.
  The porrigo furfurans of Willan  and Bateman is  a medley  of
diseases  mingled together in a  single  description;  one while the
symptoms seem referable to eczema, another while they diverge into
pityriasis or psoriasis, and only belong to ringworm when the state of
the hair  is spoken of as partially fallen  off", thin and less strong in its
texture,  and  sometimes  lighter in its color, than natural.   The remark
that the  disease " occurs principally  in  adults,  especially in females,"
carries the mind to those disorders of the sebiparous glands and hair
follicles  in which the desiccated sebaceous substance  collects about
the  roots of  the hairs, and the  latter  fall off.  We  must  therefore
dismiss porrigo furfurans altogether  from consideration.
   The description given by Willan  and Bateman of porrigo  scutu-
lata, saving the  pustules, which  are a  complication  presently  to be
referred  to, evidently applies to common ringworm.  The  character
which principally occupied the attention of  these authors in portray-
ing the  disease, was the " distinct and even  distant patches  of  an
irregularly circular figure," and this  character forms the basis of their
specific  designation.  Indeed, the term "scutulata"  in reference  to
them is  not  inapplicable, for the rounded and well-defined patches,
studded  over with prominent  papillae, are  by no means unlike  the
scuta with which  they are compared.
   In the early part of  its course, common ringworm  is unattended
with discharge of any kind, and sometimes this absence of secretion
is conspicuous throughout its  entire  existence.  At other times, and
especially when neglected, the crusts give rise to considerable itching,
and the attempts made to relieve this annoyance aggravate the inflam-
mation of the skin, and occasion  discharges of ichor and pus.   Occa-
sionally, as a complication of disease dependent ou increased inflam-
mation,  pus forms around the apertures of the follicles, and a crop of
small pustules is the result.  Willan mistook  these pustules  for  the
primary form of the disease, and for that reason placed  it in his group
of  " pustulae."  The pustules,  when  they exist, are generally observed
in  the most active part of the patches, namely, along their edge,  and
in  this situation I have sometimes  seen them forming a double or a
triple row.
   Common ringworm is attended with  considerable  itching, and  the
irritation and inflammation excited  by  scratching are apt to give  rise
 to enlargement of the occipital and cervical lymphatic  glands.   These
 symptoms subside when the cutaneous inflammation is relieved. 
DISEASES  OF THE  HAIR.
619
  In England, the ringworm here described is one of the most frequent
of the diseases affecting the scajp.  In France, according to  Rayer,
the disorder is "extremely rare;  I have  only," he remarks " seen a
single case of it in a child."

  Ringworm of the  Body.—Common  ringworm, when it  attacks
the head, is frequently seen also on the neck, arms, and other parts ofthe
body.  The patches of the disease in these situations  are circular in
shape; they have a reddish ground, dusted over with  extremely fine,
white, furfuraceous or farinaceous scales; are slightly elevated  and
papulated at the margin, but uniform with the  surrounding skin in
the centre.  Sometimes the elevation ofthe margin  is absent;  and
then,  if the powdery scales be collected on the surface in great num-
bers,  the patches look  whiter than the adjoining  skin.   In children
having a brown hue of the skin the white appearance of the patches
is not uncommon.
   The differences which  common ringworm presents when  viewed
on the head and body at the same time, are easily explained, when we
remember the dissimilarity of organization  of the two  regions; the
highly-developed condition of the hair-follicles and hair of the one,
and the  smaller dimensions  of  those structures in the  other.   The
ringworm of the body  seems to have but little hold upon the skin in
comparison with that of the scalp, and runs  along it with great rapi-
dity.   The patches spread by their margin,  while  their area  returns
to its healthy state; and the rings (tinea annularis) resulting from this
mode of increase, are frequently  of considerable dimensions.  Some-
times the prominent margin  of one  ring  remains, while the  disease
propagated from its periphery throws up a  second, or even a  third
ring.
   I have observed this form of ringworm on the neck or arms of adult
females who have tended children suffering from trichosis furfuracea ;
but as frequently on others who have had no such association.
   Pathology.—The seat of disease in common ringworm is the hair
aud the epidermal lining of the hair-follicles.
   When examined with the microscope, the dry, discolored, and  fri-
able  hairs  of this disease are found  to  be more  than twice  their
natural size, and a great change is perceptible in their structure.   The
average  diameter of human hair, as ascertained by a measurement of
two thousand hairs from  the heads of different persons, is ?^of an
inch; while a number of hairs growing from the morbid patches of
common ringworm measured between 2^ and T|tf of an inch.
   A  healthy hair is composed of three portions, a cortical portion or
cuticle, which forms the surface;  a fibrous portion, which constitutes
the chief bulk of the hair; and a central  medullary portion or pith.
in the diseased hair,  the cortical portion  is little altered  from its
normal condition, but is apt,  in consequence of the  morbid state  of
the layer immediately beneath, to crack and peel  off, and so produce
a roughness of  the shaft.  The medullary portion is  apparently un-
affected ; the chief pathological changes being  found  in the  fibrous
portion, and particularly in its external part. 
620   DISEASES OF  SPECIAL STRUCTURE OF  THE SKIN.

  The fibrous portion of the diseased hair appears,  from the great
difference of structure  which  it presents,  to  be composed of two
layers an  outer layer of various  thickness,  made  up of colorless
nucleated granules,  and occupying  about one-third the diameter of
the shaft; and an inner layer, which retains more or less of the normal
fibrous structure.
  The external layer  of the fibrous portion of the  diseased hair  is
entirely formed  of transparent, globular, nucleated granules, closely
packed together, and constituting a tessellated structure. . The size of
the granules is about -g^xs of an inch, and they are somewhat flattened
from mutual pressure.  The cohesion subsisting between the granules
is slight, for when the cortical layer of the hair is torn and peeled off,
some  of the granules remain attached to it, and others are dislocated
from their natural position.
  The internal layer of the fibrous portion, at the same time that  it
retains its fibrous character, is evidently altered in texture; the fibres
are thicker than natural, they are  undulated in  arrangement, and
they appear to have entering into  their construction, from point to
point, one or two,  and even long  rows  of the nucleated granules.
The undulated and swollen character of the  fibres gives to the entire
shaft  an appearance of laxity and rottenness of texture, upon which
the friability of the  hair  obviously depends.   When a hair is broken '
across, the fibres give way at unequal lengths, and the ruptured ends
look uneven and ragged.
   The epidermal lining of the hair-follicles has the same  granulated
structure, as the external layer of the fibrous portion of the hair.
   In  essential nature, the morbid alteration now described is a modi-
fication of the normal  structure of the hair  and epidermal .lining of
the hair-follicles. In  a preceding page (58), I have  shown  that the
hair-fibres which enter into the construction of the great bulk of the
hair are composed  of cells, and that these latter are made up  of
granules.  Now, if from any  cause  the granules of the hair-cells
should undergo  enlargeaient or hypertrophy,  the state of the  hairs
will be  precisely that of common ringworm;  and  if the destruction
of the natural tissue of the hair be considered, it may be described
as a granular degeneration of the hair.
   The mode in which these nucleated granules are formed appears
to be identical  with that of the production of the analogous granules
of Favus.  On  the dermal surface of the  epidermal lining  of the
diseased follicles I discovered  corpuscles  perfectly resembling favus-
corpuscles, and I make no doubt that these corpuscles undergo the
same  changes of growth and  development.   There  is, however, this
difference between the two affections, namely, that in  common ring-
worm the  cell-development ceases with  the production of nucleated
granules; whereas  in  Favus, it is driven on another stage, namely,
to the formation of cellated and plant-like  stems.   It is  surprising,
under these circumstances, that favus is so rare in comparison  with
ringworm, and that the latter  does not occasionally assume the cha-
racters of the former.
   Gruby, who  has made the granules  of common ringworm  the
subject of examination, as well as the abnormal cell-tissues of favusi, 
DISEASES  OF  THE  HAIR.                 621
regards them in the light of vegetable formations, and places them in
the same category as parasitic mucediuous plants, under the name of
microsporum Audouini.  The granules are, of course, sporules; but
where the parent plant is  that produces  them I  am unable  to tell.
Dr. Malmsten,1 of Stockholm, seems to adopt2 the views of Gruby;
he gives the  disease a new name '(trichophyton tonsurans), and  illus-
trates his paper with an  engraving of the appearance  of one of the
morbid hairs when seen with the microscope.
  For myself, I am as  little  inclined to yield the point of this dis-
ease as in Favus;  on the contrary, the absence of the cellated shafts
is an additional ground of argument  against the* vegetable  theory.
It is perfectly consistent with the pathology of abnormal nutrition,
that the hair-granules should become enlarged, and thus be the cause
of the subsequent changes taking place in the bair.   But the hypothesis
of vegetable growth within the substance of the hair is to me impossible
to comprehend.
  Cause.—Common ringworm is a disease of deranged  nutrition, its
cause  being  debility of the  organization, originating,  probably, in
defective innervation.   In  popular language,  the  disease may  be said
to depend on "poorness of blood;" and this expression conveys much
in reference to  the system  of living which should be adopted for its
cure.  It must not, however, be  supposed, that " living" applies only
to food; the  other hygienic conditions, of air, exercise, ablution, and
clothing, are equally necessary to constitute a healthful  regimen.
  As an illustration of  the influence of  hygienic conditions in the
production of ringworm, I may  quote some remarks by Dr. Wilkin-
son,3 which were intended for a very different purpose.  " Two families
of fine children were brought to me from the  country and put under
my care, who had been for nearly two years affected with  porrigo;
these cases yielded, like  others, to the remedies employed, and in the
course of two months seemed entirely subdued.  One family remained
in London three weeks  after the disappearance of all complaint, yet,
soon after their return to the country, it reappeared, and became in a
short time as bad as ever."
  The affection is  met with only in children,  or, if it occur at all in
adults, it is extremely rare.  Unlike favus, it is not restricted to the
lower classes, but is found  in every grade of society, and  is often  more
obstinate in the children of the noble and the wealthy  than in  those
of the poor.   I have been struck by its frequent occurrence in children
born in India, and brought to this country for their education; and it
has appeared to me that this circumstance  admitted of explanation,
by supposing that  their systems had  been  relaxed and weakened by a
hot climate, and  that  they were consequently unable  to  resist the
morbid effects of the cold of England.
  Another predisposing cause of the disease is improper food, and this

  ' Trichophyton Tonsurans, Harskarande mogel.  Stockholm, 1845.
  2 I am obliged to  speak  hesitatingly on this point, for although I have Dr.
Malmsten's paper before me, I am not sufficiently master of the Swedish language to
make out his opinion.                    „,.,,_.    100o
  3 Remarks on Cutaneous Diseases.  By J.  H. Wilkinson, 1822. 
622    DISEASES OF SPECIAL  STRUCTURE  OF THE  SKIN.

is the cause which is most active in public schools and large establish-
ments of children.  I have sometimes  had occasion to regard  the
prolonged use of an exclusively vegetable diet as the cause of the
affection, and am convinced that a milk diet, continued for a long
time without change, will give rise to the disease.
  The restraints of mobility and amusement,  to which children  are
subjected  in  schools, is  another and frequent  cause  of  ringworm.
Confined  in  ill-ventilated  rooms, congregated in considerable  num-
bers, bending their little minds to distasteful labor, commencing their
studies the instant they have swallowed  their meals, and kept to their
books for several successive hours in the day,  it cannot be matter of
surprise that the nutritive functions of the body should suffer, and
that  derangement of one of the  simpler processes of  the economy
should be the consequence.  Under such circumstances, the disease
will  probably be endemic, and the greater part of  the  children of a
large school might be consentaneously or successively attacked.
  Is ringworm contagious?  I believe that it is not.   Nothing that I
have  hitherto seen, and  I  have  watched the  disease with care, has
satisfied my  mind with regard to its imputed communicability.  The
observation of a great number of children in  the  St. Pancras work-
house, as well as in private practice, leads me to  an  opposite con-
clusion, and  this conclusion seems confirmed by the  pathology of the
disease.
  Those who consider ringworm to be contagious, look upon it as a
local affection, engendering a kind of poison,  which is conveyed  to
another by means of combs, brushes, caps, or towels.  The  advocates
of the vegetable theory do  not hesitate  to assert, that  the  nucleated
granules are the seeds of  the disease.  Such a  supposition appears to
me to be highly'unphilosophical, and indeed, unwarranted by a more
correct comprehension of the nature of those bodies.
  If there be a poison, it must be more subtle in its  nature than these
nucleated granules,  and capable, like other contagious  principles, of
poisouing the entire circulation of the patient;  for the  disease
undoubtedly  lies in  the constitution, and is to be eradicated more  by
constitutional than  by local means.  In fact, ringworm  is not a
local disease,  but one which  pervades  the entire  economy, the
local disorder being simply the effect of the  constitutional disturb-
ance,  such as a multitude  of causes capable of deranging health ■
might occasion.
  It  is stated that ringworm has  not- been known as a  disease affect-
ing the middle  and higher ranks of society  more than fifty years,
although it  has  existed  for centuries among  the poor. If  this be
true, it is a fair argument against its contagiousness, unless, indeed,
it can be shown that the laws of  life and organization are different in
the plebeian  and in the patrician; that the  rich and ruddy  stream of
the latter repels a poison  engendered in the troubled  puddle of the
former.   But that such is not the case is proved by the fact that the
noble and the wealthy are now as liable to the disease  as  the poor.
Dr. Wilkinson, in suggesting a probable reason for the outbreak  of
the disorder among the better classes, observes:  " Of all the  various 
DISEASES  of the hair.
623
conjectures formed upon this subject, perhaps the  most plausible is,
that the number of children sent from the East and West Indies for
their education has been, during the 'period referred  to,' very much
increased, many of whom bringing the disease with them, introduced
it to the schools, and spread it rapidly through the island."  Few of
my readers  will, I think, be inclined  to admit this  explanation as
correct, but it corroborates the observation which I have myself made
of the liability of European children, born in a warm climate, to this
disease, when transferred to England.
  The same author, in another page of his work, observes: "As some
of the profession doubt whether the porrigo can be produced in any
other way than by contact, I have paid particular attention to this
point, and I am convinced that some children  are capable of gene-
rating the disease."
  " Four  children were brought  to me who had  never been  out of
their parents' house but in  their  carriage, never  had any other chil-
dren to visit them, and never visited any;  in short, the mother in-
formed me  that they were  so strictly particular on this point,  that
they never suffered the servants who attended upon the children to
have  any communication  with others.  One of these children gene-
rated the  porrigo furfurans; and  between two and three weeks after
communicated the scutulata to two of the others, and the decalvans to
the fourth."
  Can anything be more clear than that the predisposing cause ofthe
disease in the above instance was the artificial physical education and
mischievous  restrictions to which  the poor children  were subjected?
Dr. Wilkinson  admits that the disease was  generated in one  of the
children, but it may be asked: If so, why not in  all?  Why should a
disease generated in one, be transmitted in the rest?   The answer  is
obvious: Because Dr. Wilkinson was prejudiced in favor of the theory
of contagion.  The reader may be  reminded, also, in reference  to this
case, that porrigo furfurans and porrigo scutulata are the same disease,
and that porrigo decalvans  originates in the same causes which give
rise to ringworm.
  Dr.  Wilkinson further observes: " I  have had  several other cases
where I had as much reason to believe that the children generated it:
one was a child of only three months old, who had never been, since
her birth, in more than one room."  Thus it will be seen, that the too
great care of parents in regard of their offspring is frequently attended
with the same results as extreme neglect.  An important rule of con-
duct, in the management of children, may be deduced  from this ob-
servation.
  In reference  to a case already mentioned, in which the disease was
cured in London, and remained so for three weeks, but reappeared as
soon as the  patient returned to the country, Dr.  Wilkinson remarks:
"During  the last three  weeks spent in  town, as nothing was  used
to prevent the disease from reappearing, and as it is a contaghus and
active fluid, how is its action suspended for such a length of time? and,
where does  it lurk ? since its whole action in two or three of the va-
rieties seems confined to the cutis  and the cuticle.  I can account for 
624   DISEASES OF  SPECIAL STRUCTURE OF  THE SKIN.

this in no other way than by concluding that the patient generates
the disease, for in such a way, of course, however completely it may
be banished from the surface, it may be regenerated, unless the habit
of body or the secretions be entirely altered."
  Another author, Dr. Walter Dick, in an excellent  treatise on the
" different forms of porrigo," observes, " We have seen ringworm at-
tacking two or three  subjects in the same family, almost at the same
time, when the occurrence of the disease could not be traced to con-
tagion.  We have been  led to believe that the disease, under these
circumstances, originates from  some article of  food being of bad
quality."   And again, " from what we have observed, we are  inclined
to think that porrigo is not so contagious as many suppose."
  The only circumstance which has at all tended to shake my opinion
of the non-contagiousness of ringworm, is that of the occurrence of
patches, apparently of this  disease,  on the neck or  arms of adult
females who have had the care of diseased children.   These patches
never exceed three or four  in number; usually there is one only.   I
have never seen them on the scalp; they are easily cured ;  or soon
get well, if left to themselves; and they are not uncommonly met with
in those who have not  been within reach of children affected with
ringworm.
  But it must be remembered always, that ringworm is undoubtedly
epidemic, and  may be endemic-;  and this  fact will serve to explain
much that has heretofore beeu attributed  to the action of contagion.
In my medical  practice I often pass  many weeks without  seeing an
instance of ringworm; suddenly a  case comes before me, and then I
know that I shall have a succession of such cases, not from one lo-
cality, but from  many, an epidemic has begun and will continue for
some  weeks.  In  this way an epidemic seizes upon a school, and its
progress is regarded as a proof of contagion ; I can only see in it a mor-
bific atmosphere operating  on  constitutions predisposed to such dis-
order, in consequence of unhealthy nutrition.  A curious evidence of
the epidemic nature of ringworm came before me accidentally a short
time back.   A brother and sister, of ten or  twelve years of age, were
both seized with ringworm  at the same time, the one  being in Corn-
wall, the other in Essex; they had had no communication with each
other for  twelve months.  An epidemic of ringworm was  then pre-
vailing; but, had these children  been together, within three months
of the attack, every old woman in the empire, would have exclaimed,
"contagion," and commenced speculating upon the probable period of
latency ofthe poison; or, according to the modern trichophytic heresy,
upon the length of time that the  sporules of the  trichophyton main-
tain their vitality and their  aptitude for germination.
  Treatment.—The indications for the treatment of common ring-
worm are, firstly, to restore the defective powers of the constitution;
and, secondly, to restore the local power of  the skin.  These objects
are to be fulfilled by similar means; the first indications calling for
improved  hygienic  conditions, improved diet,  aud tonic-alterative
medicines; the second requiring stimulating applications.
  The importance of the hygienic principles, air, exercise, clothing, 
DISEASES  OF  THE  HAIR.
625
and  ablution, cannot be  too strongly urged  in common ringworm*
When the disorder first  appears upon the head at  school, the child
should be immediately removed, either to a more airy locality, or to
the sea-side.   I have seen several cases in which the disease has been
entirely cured by change of air, seconded  by a better assorted diet,
and by a local application of the simplest kind.
   It is much to be regretted that some provision is not made, by those
who have the care of the education of the youth, for supplying the
means of instruction to children laboring  under this complaint; for
combining, in fact, physical education with mental education, and the
advantages of sanitary regulations with both.  I am quite ready to
admit the necessity of separating boys afflicted with this disorder from
others; not, however, from  any apprehension  of contagion, or with a
view of protection to the latter, but that the diseased youths may be
placed under a training better adapted for their cure.  Nevertheless,
it is painful to reflect that this  isolation is generally accompanied with
a neglect of education, with a loss of months and years wholly unneces-
sary, and yet which may never be repaired ; in some instances, indeed,
amounting to the positive destruction of a boy's prospects in life.
   I would suggest as a remedy for this evil, that a school-sanatorium,
especially calculated for  this  object,  should  be established in some
healthy locality, and that the boys assembled in such a school  should
pursue their studies undisturbed, while the medical discipline necessary
for their cure was enforced.
   The masters engaged at such a school would be free from any dan-
ger of contagion.  Indeed, adults  are  not liable  to  take the disease
under any circumstances. Neither must it be supposed that the assem-
blage of affected  children would be either detrimental to themselves
or to those about them.
   In speaking of the cause of  this  disease, I mentioned, as tending to
 predispose  to the complaint,  improper diet.   I remarked that I had
seen cases in which I believed I could trace the origin of the disorder
to a too exclusively  vegetable or milk diet, and these are circum-
 stances to be borne in mind in regulating the regimen of our patients.
 I should give a  preference to  a sound /inimal diet, with a good beer,
 such as brewer's porter,1 for drink, and chocolate, cocoa, and  tea, in
 small quantity, for the morning and after-dinner meal. Butter I look
 upon as  highly  useful.  With a sound diet  and normal assimilative
 power there can  be no .ringworm.                            .
   The medicines which are best adapted for the disease are the citrate,
 acetate or hydrochlorate of iron;  iodide of iron; iron with quinine;
 nitro-muriatic acid, either  alone or with the tincture of cinchona  or
 gentian.                         ■ ,    .,,           i      i . j •
   The general  functions of the body will require to be regulated in
 the usual way; but aperients and purgatives are to be used sparingly,
 and with care.   As a laxative, there is none better than the confection
 of senna with sulphur and cream of  tartar.  If there be enlargement
 of lymphatic glands, having  a scrofulous origin, the oleum  jecons
10
1 In contradistinction to publican's porter. 
626   DISEASES OF  SPECIAL STRUCTURE OF  THE SKIN.

aselli is to be had recourse to, and if there be any  want of solidity in
the bones, lime-water.
   In common ringworm, which is not neglected, there are  no crusts
to be removed; but should there  be any collection of  this kind, they
are best cleared away with water and soap, after being softened by a
poultice, with  the  moist compress  and oiled silk, or  by means of a
piece of Alison's prepared corium.
   Shaving the head is a practice which I  rarely have recourse to, nor
do I think the advantage which it holds out at all commensurate with
its evils.  If the hair be moderately short, the head may be washed
and kept in proper order, and nothing more  than this is required.  I
do not  think that, as a general rule, shaving strengthens  the  hair.
Some time since, while  engaged in investigating the structure  and
phenomena of hair, I  compared  the hair  of persons who had  been
shaved, with that of others in whom that operation had not been per-
formed, and I found no difference between them.
   Washing with  soap and  water, followed by combing with a small-
tooth comb, is attended with advantage; the  latter process serving to
clear away the diseased hairs sufficiently.   I have already said that I
do not consider these  hairs  as irritants of the skin, and tending to
keep up inflammation, and therefore I  am not inclined to join  with
Plumbe in suggesting  ingenious contrivances for getting rid of them.
As respects the soap to be recommended in this disease, there is none
better than the old-fashioned common yellow soap, a soap of the finest
manufacture, but at present out of favor with housewives on account
of its color: the substitute, a lighter colored soap, is, however,  very
inferior.  Soft soap has been much  in use for washing heads affected
with ringworm, but is offensive and  disagreeable, and in  nowise
superior to  the soda-soaps;  indeed, I regard it as  inferior to the'
common yellow soap.
   When the patches are free from  their crusts and  loosened hairs, I
commence the local treatment by pencilling them with  acetum  can-
tharidis, or  the acidum aceticum  fortius,  and  then  anointing the
surface  with ceratum simplex cum  liquore plumbi (3j ad sj).  This
application I repeat once in the week ;  and on  the intermediate days,
as soon as the irritation caused by the  acid has subsided, I  prescribe
a  moderately stimulating ointment, such as the unguentum hydrargyri
nitratis,  or  unguentum hydrargyri nitrico oxydi, diluted  one  half
with the ceratum simplex.  Another ointment, which I have found
of service, is one composed of sulphate of zinc and  ceratum simplex
(3j ad 3j); and I have also obtained good results from the unguentum
sulphuris compositum.
   A remedy which I have found useful in common ringworm is the
liuimentum  ammoniae, accommodating  the proportion  of alkali to the
amount of stimulation which it is desired to effect.  Another excellent
remedy is  the oleum  crotonis tiglii, twenty drops to  the ounce of
unguentum florium sambuci, or unguentum eetacei.  The  iodide of
sulphur ointment, which I have frequently used, I find inferior to the
above remedies.          \
   As the principle of local  management  of  this complaint is cleanli- 
DISEASES  OF THE HAIR.
627
ness and moderate stimulation, many additional remedies might be
mentioned as applicable to its treatment.  Dr. Hamilton recommends
an  ointment of cocculus indicus, for  which picrotoxine might be
conveniently substituted.   Bateman  recommends  the  unguentum
gallarum.   Then there is the iodide of sulphur ointment (gr. x—xxx
ad 3j).  But a better remedy than either of these, though somewhat
objectionable in private practice, from its dirtiness and bad odor, is a
sulphur and tar ointment,1  originally  suggested, I  believe,  by Dr.
Wilkinson.
  Dr. Walter Dick, in  his Treatise on Porrigo, recommends  for
ringworm an ointment  of  subnitrate of bismuth  (3j ad 3j), to be
rubbed  into the diseased parts, night and  morning, after washing.
The same author refers to another remedy once in  high repute for
this complaint, an  ointment  of oleum laurini, sulphur and camphor.
Other remedies, which have been from  time  to time in vogue are,
sulphur ointment and soft soap, equal parts; the unguentum sabinae ;
and spirits of turpentine; adhesive plaster has also  come in  for its
share of praise.
   Plumbe was in  the habit  of  pencilling the patches with strong
sulphuric acid, taking care  to wash it  off as soon as smarting com-
menced ; his subsequent treatment was simple washing.  He was also
an  advocate for shaving the head.  In old-standing cases  where
secondary changes had occurred, such as the  formation of pustules,
and suppuration of the hair-follicles, he preferred that the hair should
be  cut with scissors, but as  short as possible, and he recommended
that every hair contained in a follicle in which suppuration existed
should be drawn out with the forceps.   This is a needless operation;
and, indeed, the supposed irritative property attributed by Plumbe to
the hairs, the apology  for the calotte, is altogether unfounded.  On the
whole, Plumbe's treatment is unworthy  his reputation.
   Ointments  are  undoubtedly better adapted for  ringworm  than
lotions ; but if any insuperable objection should be made to their use,
a lotion of sulphuret of potass (3j ad Oj);  sulphate  of" zinc, in rose-
water (3ss—3ij ad Oj); or bichloride  of  mercury, in emulsion  of
bitter almonds (gr. x ad Oss); might be prescribed.  In this case,
however, the consequent dryness  of the skin should be corrected by
cold cream  or some simple pomatum.
   After the cure  of  ringworm  there commonly remains for some
time, as a consequence of debility of the skin, a dry and scurfy state
of  the scalp.  The best treatment for relieving this is to dip the head
every morning in cold water,  and after drying it thoroughly,  to
anoint the skin well with some simple  pomatum; or, where dipping
the head in cold  water may  be objectionable,  the  scalp should be
sponged every morning, while brushing, with the lotion of borax and
almond oil.
                     1 Vide "Selected Prescriptions." 
628    DISEASES OF SPECIAL STRUCTURE OF  THE SKIN.
                         TRICHOSIS PLICA.

                 Plica polonica, or Polish ringworm.
  Plica polonica, so far as I am able to judge from the description of
the disease given by authors, is, in essential nature, analogous to the
common ringworm of this country.  There exists in it, as well as in
ringworm, an enlargement of the diseased hairs, a condition probably
depending on the larger size of the nucleated  granules;  and the latter
are the depositories of the  morbid fluids,  which are  found in  such
quantities  in that affection.   In other words, Plica  is a  state of
granular degeneration of the  hair, the  granules being  turgid with a
viscous sanguineous fluid.   The  state  of matting of the  hair, which
is thought to be peculiar to  Plica, has its analogue also in ringworm ;
and the conical bundles of which I have spoken, when describing the
latter,  are the  representatives of the  greater and more complete
fasciculation of the Polish disease.
  According to the best authors on plica polonica, the scalp is inflamed
and excessively tender;  the  hairs are swollen  and imperfectly formed;
they are tinged with a viscous and reddish-colored fluid, and the hair-
follicles secrete  an abundance of this  fluid,  which  agglutinates the
hairs, and then  by desiccation unites them  into a solid  mass.  The
tenderness 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 their extreme sensibility,
has given  rise  to the supposition of the  hairs being  sarcofied, and
pervaded with vessels and nerves.  The odor 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 swarms of pediculi.
  Plica is not confined to the scalp, but affects the hair on every region
of the body ;  the nails of the  fingers  and toes are also changed,
becoming rough, fibrous, and discolored.  Left to itself, the disease
lasts for ten or twelve months ; the symptoms then subside gradually;
the hair returns  to its natural diameter; and  the filthy mass is pushed
by  degrees further and further from  the surface, until it falls  off
spontaneously, or is cut away by scissors.
  The hair presents some  modifications, in  the  manner of its matting,
which  bear relation to its length.  Thus, in males, who wear the hair
short, numerous locks are matted separately, constituting the variety
known as plica  multiformis;  at other  times,  the matted hair forms a
single coil, plica caudlformis; or,  again, it  may constitute a large and
irregular mass without order in its matting, the usual character of the
disease in  women.
  Several authors have asserted, that, in  the  majority of cases, the
scalp is not affected in plica, and that the alteration in the hair occurs
at a certain distance from  the integument.   This assertion is incredi-
ble, and it seems more reasonable to conclude,  that in cases  adduced
in support of this statement,  the disease was  advancing towards  cure, 
DISEASES  OF THE  HAIR.
629
and consequently that the morbid mass of hair was removed by growth
from the surface of the scalp.  A recent writer on  this subject, Dr.
Bidder,1 makes the following remarks: " During the past summer I
remained for several weeks in a country where plica polonica is  fre-
quent.  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, per-
fectly 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
imbedded.
  " I had also an opportunity of observing the process  of separation
of the diseased from  the sound  hair.  Two individuals  presented
themselves in whom the morbid mass had fallen by spontaneous sepa-
ration, a rare occurrence.  Once alive to the possibility of such a pro-
cess, 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.  In some
hairs, the groove resembled a mere crack;  in others, it had proceeded
so far that the separation was nearly effected.  In other cases, I was
unable to discover the line of demarcation."
  Causes.—Supposing my opinion to  be correct with regard  to  the
nature of plica polonica, its causes  will probably be found to be analo-
gous to those of ringworm.  The  disorder is most  prevalent on  the
banks of rivers and in  the  marshy districts of Poland, in  which it
appears to  be  endemic.   It is met with, as is ringworm, among  the
noble2 and the wealthy, as well as in the poor;  and, unlike ringworm,
it occurs in adults as well as  in children.
  Treatment.—The  treatment which  is  applicable to ringworm I
should conceive to be  suited  also to plica.  Change of air, improved
diet, and altered  hygienic conditions must be indubitably necessary,
and the same tonic alterative medicines, particularly the ferro-arsenical
remedies.  A prejudice seems to prevail in Poland against the removal
of the mass by  mechanical means, which I am inclined to think unrea-
sonable.   It would be  necessary to subdue local inflammation in the
first  instance, and afterwards apply  moderately strong stimulating
local remedies.

             VI. DISEASES OF THE HAIR-FOLLICLES.

  The hair-folljcles and hairs are  so  intimately allied, that it  is
difficult to understand 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.

  ' Muller's Archiv., 1840.
  2 In one instance, I saw a mass of matted hair which had been cast from the head
of a Polish lady of noble birth. 
630   DISEASES  OF  SPECIAL STRUCTURE  OF THE SKIN.

But the reverse of this  proposition is not equally true;  for in that
greater morbid change, which is the cause of alteration in the struc-
ture of the hair, the follicles suffer to a greater or less extent.  Hence,
while the designation "diseases ofthe hair-follicles" must be regarded
as  applying  solely to  those organs, "diseases of the  hairs"  maybe
supposed to implicate the follicles also.
   Disease  of the  hair-follicles  manifests itself either as a  simple
erythema  or  chronic  inflammation; as  an erythema attended with
excessive formation and alteration  of secretion, constituting stearrhea
folliculorum; as a suppurative inflammation  of the follicles of the
scalp, or scall; as a suppurative inflammation  of the  hair-follicles of
the  face, sycosis; and  as a chronic inflammation attended with the
formation of a peculiar morbid product,  namely, fav>'s.  In a tabular
arrangement, they would stand as follows:—
               Erythema folliculorum,
               Stearrhcea folliculorum,
               Inflammatio folliculorum suppurans,
               Sycosis,
                Favus.

                    ERYTHEMA FOLLICULORUM.

   Inflammation of the hair-follicles is indicated by an erythematous
blush of redness of the skin, dryness, and the  production of a large
quantity of furfuraceous scales.  There  is, besides, considerable itch-
ing, and more or less decadence  of the hair.   Tins condition of the
follicles  is not unfrequently the  forerunner  of a morbid secretion
(stearrhcea folliculorum), which is  diffused  and  hardens  upon the
surface of the scalp.  The  following is an example of the disease:—
   A naval medical officer, while serving in the  West  Indies in 1833,
suffered from an attack of erythematous patches on the crown of the
head.  They were attended with  itching, and by a copious furfura-
ceous  desquamation, the itching being much  increased at night.  In
1837,  on his return to   England, 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 per-
spirations, the patches  coalesced, and  poured out  " an unctuous
exudation of a dark reddish color."  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 exceedingly
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  effectually
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 
DISEASES  OF THE  HAIR.
631
continued the practice for four months.  In 1811, whilst in China, he
had recourse to shaving for the third time.  "During our 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 1
am induced to  attribute to the impaired state of the digestive func-
tions, as I was  confined for months exclusively to  the  ship,  and  of
course debarred all suitable exercise.  The scales at this tirne assumed
a gummy character, tenacious and soft; the itching was  particularly
annoying, 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,  I jtried
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 without 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 concomi-
tants, and they were at times so annoying that I was obliged to apply
soap and water frequently during the day, which always afforded me
temporary relief.  Stimulants always increased the itching.
   "A deceased brother was similarly affected, but he never lost his
hair, and I am the only one of  my family who has felt its 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,  after your  second application, sunk to
the level of the surrounding integument,  the  squamae have not  been
reproduced to  a hundredth  part the extent that they were before, the
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."
   Besides attacking the head, erythema folliculorum is also met with
on the forehead and eyebrows,  and on the shoulders and  backs of the
upper arms.   Its characters are a punctated  redness with dryness of
surface, and a  roughness, which is partly d-ue to the prominence of
the pores, as in cutis anserina, and partly to  the follicles being filled,
and, as it were, choked  up with dry and harsh epithelial contents.   I
have commonly observed this disorder in  young ladies; it injures the
beauty of the  skin,  and when it attacks the eyebrows (erythema folli-
culorum  supercilii) is more serious in its consequences, as it causes
the fall of the hair,  and produces a papillated baldness  more particu-
larly of the outer half  of the eyebrow.   The absence of the  natural
sebaceous secretion ofthe skin, and the production of a dry sordes in
its place   exhibits a torpor of function which is at the root of this 
632    DISEASES  OF SPECIAL STRUCTURE OF THE SKIN.

complaint.  It is best  treated, locally, by daily ablutions with the
juniper tar soap,  and with the compound hypochloride of sulphur
ointment; and, constitutionally, by general  tonics and some of the
milder preparations of arsenic.

                    STEARRHffiA FOLLICULORUM.

                            Seborrhea.
   In  some  instances, the inflammation of the follicles is so slight as
to escape attention altogether; and the disease  does not come under
the attention  of the surgeon until the  altered secretion  has been
poured out  upon the skin, and forms a concretion  of  variable thick-
ness and extent.  To this stage of the complaint I  have assigned the
name of stearrhea folliculorum.  The  crust presents some variety in
point of color.  It is often yellowish, and resembles  the film which
drving-oil leaves  after  desiccation, and  sometimes  is  grayish  and
greenish in its hue.   Occasionally,  this state of the scalp is associated
with dryness of the skin, 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, sometimes constant, and
fall of the hair.
   There is another state of the scalp, narcosis follicuhrum, depending
on chronic inflammation of the hair-follicles, which is  far from being
uncommon, particularly in women and children.  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
furfuraceous scales.   Masses of this granular  substance are collected
at the mouths of the follicles, while others are threaded like beads
upon the hairs.   By  brushing, the skin may be completely cleansed
of this pulverulent substance, but  the granular particles still remain
threaded on the hairs,  and adherent to  them,  at  the mouths of the
follicles.  If a hair be  withdrawn, its follicular portion will be seen
to be inclosed in a small sheath of desiccated epithelium or sebaceous
substance, which  extends  almost to its root.   Moreover,  the  root is
slender and dry, and the entfre 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 the fall  of the hair, which comes off in  large quantity.
The fall of the hair is easily explained ; the torpidity of action, which
gives rise to the production of a dry, sebaceous  matter, and a dry and
pulverulent epithelium folliculi, extends its influence  to the growing
hair, which is deprived of its moisture and of its hold upon the skin,
 and  therefore  falls  before  the slightest force.  Another  change
 depending  on the same cause, is  not  unfrequently observed in this
 disease,  namely, grayness ofthe hair.
   When torpor of the follicles occurs  upon the  gene-ral surface of the
 body, it interferes, more or less, with the growth of  the hairs, and is
 termed morbus pilaris.  In this affection, the hairs become imprisoned
 within the follicles by the formation, at the mouth of the latter, of a 
DISEASES  OF THE  HAIR.
633
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 (Plate VI., fig. 10), 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 will be at once exposed.  This disorder is most frequently per-
ceived 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.
 . Treatment.—The treatment of the three preceding forms of disease
consists in the employment of moderately stimulant remedies locally;
and for the most part tonic medicines constitutionally.  Of course, the
common indications  of  disorder of stomach, kidneys, or uterine func-
tion will not be passed over. In the case of the naval surgeon reported
above, I found it necessary to modify the action of the skin by blister-
ing  the  surface occasionally with the acetum cantharidis, and  after-
wards employing the pomatum stimulans.  Indeed, the  latter prepara-
tion I find invaluable in this class of diseases; it should be sufficiently
strong to keep up a moderate action in the skin.  Another excellent
remedy is the emulsion of ammonia and olive  oil.  In some instances
a stimulating lotion  may be preferred  to oleaginous  remedies, but, in
the latter case, the skin must be kept  moistened with  cold cream or
some simple pomatum.
            INFLAMMATIO  FOLLICULORUM, SUPPURANS.
                           Scalled head.
  Scalled head is a  disease of young persons, extending in its  range
of period from childhood to puberty.   The first symptom of its attack
is a slight itching of the scalp;  on  the irritable spot  a thin whitish
crust is produced, and, after the lapse of a few days, rarely longer than
a week, the inflamed spot,  which is exactly  circular,  and of a size
varying from that of a sixpence to a crown-piece, or even the palm of
the hand, is swollen, and tender, and commonly bare, from the sudden
and unobserved fall  of  the hair.  The inflamed surface is red, tender,
swollen, more or less puffed, and studded over with whitish yellow
points, the achores of Willan, these yellow points being the mouths,
of the follicles distended with pus; while the  skin between the aper-
tures of the follicles  is red and glazed, and resembles the pulp of a ripe
strawberry. The scall is remarkable for the suddenness of its appear-
ance, and for  the rapidity of its progress; in a few days it is often
swollen to the height of three-quarters of an inch; and seems  as if
infiltrated with pus,  of which the follicles are the openings of exit.
  The copious exudation of pus from.the inflamed skin, not unfre-
quently  produces a matting of the hair over the diseased surface; and
disguises the morbid action taking place in the skin; and the morbid
structure is so tender as to render the removal of this matted coating
an operation of some difficulty.  The inflammation sometimes extends
to the surrounding  skin; and the occipital, and auricular, and even 
634   DISEASES OF SPECIAL  STRUCTURE OF THE SKIN.

the cervical lymphatic glands, become tender, and inflamed, and often
suppurate.   When  the scall is of large size it may be solitary; but
usually there are several dispersed over the head.
  When the suppurative action is on  the decline, a dirty  yellowish
crust is formed over the diseased patch, and, on the fall of this crust,
the skin is  left bald, and of a  deep  red color; the  redness being
greatest in the centre, and  being  slow to disperse.   When the deep
textures of the skin  are much disorganized, the hair is not reproduced,
but commonly the hair begins to grow in a few weeks after the fall of
the scab; and the new hair is acutely pointed like young hair.
  The diagnostic characters  of scall are: the rapidity of its progress,
its exactly circular  form, the extreme swelling, tenderness, and copi-
ous suppuration, and the sudden and complete fall of the hair.  The
medical man is not unfrequently  tempted to  puncture the swelling
with his lancet, under the expectation  of finding a collection of pus,
but in this expectation he is commonly disappointed; and, in bad cases,
the inflammation  and suppurative action seem to extend even to the
periosteum.
  Treatment.—The local treatment of suppurative inflammation of
the scalp, is the maintenance of water-dressing or poultices, until the
inflammation is subdued; and then the application of a mild ointment,
such as the benzoated ointment of oxide of zinc; or, the  red  precipi-
tate  ointment diluted in the proportion of one  part to three of the
diluting  medium.   The general or constitutional treatment must be
essentially  tonic and nutritive;  a substantial meat diet, with malt
liquor, aided by iron, quinine, and in chronic cases by arsenic.  The
ferro-arsenical mixture answers admirably in cases of scalled head.

                           SYCOSIS.

    Syn. Phyma sycosis, Mason Good.   Mentagra.  Ficous phyma.

  Sycosis (Plate XIV., i) is  a chronic  inflammation of the cutaneous
textures, somewhat  resembling acne, but limited to the hairy parts
of the face,  the chin, upper lip,  submaxillary region, region of the
whiskers, eyebrows, anji sometimes the nape of the neck. The disease
involves  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  color; they burst in the course of a few days, and
pour out their contents, which  concrete into dark  brownish crusts.
The crusts fall 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 ofthe  integument, and frequently
extends to the subcutaneous textures. In this  way the roots of the
hairs sometimes become affected, and fall out, leaving the skin totally
bald.                                            °             J
  The eruption of sycosis is preceded  by a painful sensation of heat
and  tension of the  skin; this is followed by several small red spots,
which rise in the course of a few days iuto conical elevations, and upon 
DISEASES  OF THE  HAIR.
635
the summits of these the pale yellow pus, characteristic of sycosis, 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.1   The eruption is variable in extent, sometimes affecting one
side of the 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  raised into tubercles and  tumors of considerable size,
which are more or less covered with  pustules and crusts, and have a
repulsive appearance.  In this state the integument retains its tuber- -
culated, thickened, and congested  appearance, sometimes for years.
As the disease  declines, the pustular elevations cease to be developed,
the tubercles diminish in size, and  the  epidermis is  thrown off' by
repeated desquamations.
   Sycosis  contagiosum.—Gruby, of Vienna,  so well  known for his
researches into the vegetable nature of favus, and his discovery  of ve-
getable organisms in other diseases, presented a paper to the Academy
of France in 1842, on a new cryptogamic plant, existing in  the roots
ofthe hairs of  the beard, and arotfnd that portion which is contained
within the hair-follicle.   By the transmission of the seeds of this plant
the disease is supposed to be rendered contagious, and he proposes for
it the name of mentagrophyte.
   Gruby gives the following account of the disease:  It is limited to
the hairy part  of the face, but is most frequently seen on the chin,
upper lip,  and  cheeks.  It covers all these parts with white, grayish
and yellowish  scales, which measure from two to six millimetres in
breadth, and from three to eight in length.   The scales  are slightly
raised in the middle, their borders are angular, and they are pierced
at all points by hairs ; they are but  loosely connected with  the skin,
but so closely with the hairs, that in removing a scale we at the same
time  pull out a hair.
   Examination with the microscope shows  that the scales are com-
posed of epidermal cells, but  the whole  of the dermal portion of the
hair  is surrounded  by cryptogamic formations, which constitute a
vegetable sheath around it, in such manner that the hair implanted in
this vegetable  sheath may be  likened to the finger  surrounded by a
glove.  It is worthy of remark, that these cryptogamia never rise
above the  surface of the epidermis, they originate in the matrix of the
hair,  and in the cells of which the follicle is composed, and ascend so
as to  surround all that portion ofthe hair included within the derma.
They present everywhere a prodigious number of sporules, which are
adherent, on one side, to  the  internal surface of the  follicle; and  on
the other to the cylinder of the hair; to the former they are closely
connected.  Each plant is composed of a stem, of several branches,
and of sporules.
   This1 disease of the skin, continues Gruby, is an  affection of a purely
vegetable nature, and is deserving of occupying a place among those
1 Portraits of Diseases ofthe Skin, Plate XLI., AE. 
636    DISEASES OF SPECIAL  STRUCTURE  OF THE SKIN.

disorders, such as favus and aphtha, which consist  in the  develop-
ment of parastic  plants, and  which might very  properly be termed
Nosophyta.
  Gustav Simon adds his testimony to that of Gruby, in  favor ofthe
vegetable pathology  of  sycosis.  For my own part I have  failed  to
discover  these vegetable fungi, and, for several  reasons, entirely dis-
believe in their existence.

  Diagnosis.—The  diagnostic characters of sycosis are, the conical
form of the pustular elevations,  the  bright red  color of their bases,
their deep-seated  relations with the integument, the purplish and indo-
lent tubercles which  succeed them, and the site of the eruption.  They
are distinguished  from acne by their situation, and by their relation
with the  hair.
  The pustular diseases, ecthyma and  impetigo,  have a different cha-
racter of pustule  to  that of sycosis; those of the former are large,
prominent, and phlyzacious : while the pustules of impetigo are small,
little raised above the surface, clustered, and psydracious.   The  mode
of termination ofthe pustules is equally different: in ecthyma they form
large and thick crusts; those of impetigo pour out an abundant secre-
tion  which  desiccates  into bright yellow crusts; while the crusts  of
sycosis are hard, thin, and of a deep brown color.   Moreover, ecthyma
and  impetigo  leave  behind  them no tubercular thickening of the
integument.
  Causes.—Sycosis  is a disease of the male sex, but in some instances
has been seen  in the  female ;  it may occur at any period of the year,
but commonly makes its attack in the  spring or autumn.  The most
frequent  exciting cause 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 predispo-
sition  are, exposure to the night air, intemperance, excess  in diet,
uncleanly habits, destitution.  A common direct cause is exposure
to heat;  hence we find sycosis to be prevalent among those who work
near a large fire,  as  founders and cooks. Foville has observed the
disease to be transmitted by contagion, from the use  of a razor em-
ployed in shaving an affected person.
  Prognosis.—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 pro-
tract the  chances  of cure.  The disease sometimes gets well spontane-
ously during the  summer, to reappear in the colder months of the
year; it is eventually curable.
  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 mode-
rate diet  enjoined. To these rules, which tend to diminish the general
excitement of  the system, may be added the use of laxatives, as the
milder neutral salts, Seidlitz and Rochelle, preceded, according to the 
DISEASES OF  THE HAIR.
637
judgment of the practitioner, by one  or  several doses of calomel  or
blue bill.  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 aff'ection, it may be desirable to subject the patient to the
influence of a course of the bichloride of mercury, and if the system
exhibit any signs of debility, tonic remedies  or steel  medicines  may
be  employed.   I have found  Donovan's solution  of service in this
affection, and have also obtained advantage from the  use of Fowler's
and De  Valangin's  solutions of arsenic.  In the congested  state  of
skin accompanying the eruption, leeches may be applied, or the part
well scarified with the point of a lancet, both  of these measures being
followed by a fomentation of half an hour or an hour's  duration, or
by a poultice.   In  the  chronic state of the affection, the iodide of
sulphur ointment (gr. x ad xx ad |j) may be tried, with a fair pros-
pect of success, or the nitrate of mercury  ointment, of its full strength
or diluted.   Other remedies that may be  beneficially used in this dis-
ease are, the benzoated ointment of oxide of zinc, the spirituous lotion
of bichloride of  mercury, a solution  of sulphuret of potash, nitrate of
silver, the juniper tar, &c.
   Whenever the hairs are loosened, they  may be pulled out,  as in this
state they are apt to increase the  local irritation.   Plumbe regarded
the hairs as the special cause of the obstinacy of this disease,  and laid
down rules for  their avulsion; and this  method of treatment has  re-
ceived the sanction and recommendation of Hebra of Vienna.  I used
avulsion myself for some  years;  but was  not  sufficiently impressed
with its advantages to continue the practice;  I  am induced,  however,
in deference to the opinion of  so great an authority as Hebra, to give
the plan a further and more systematic trial.  Hebra applies a plaster
to the diseased  skin at night,and removes it in  the morning; and any
hairs standing in the midst of a pustule  that are not  torn out by the
plaster, he removes  with the forceps.

                              FAVUS.

Syn. Crusted or honeycomb ringworm.   Kerion.  Porrigo lupinosa, Wil-
   lan.   Tinea lupinosa.  Tinea favosa.  Tinea maligna.   Teigne faveuse,
   Alibert.   Porrigophyta, Gruby.
   Favus (Plates XIV., XV.) is characterized by the presence of crusts,
of a bright yellow color, scarcely  rising  above  the level of the skin,
covered by epidermis, exactly circular in shape when distinct, favus
dispersus, bounded by an outline representing numerous arcs of circles
when  confluent, favus confertus, depressed or slightly cupped on the
surface, and pierced in the centre by the aperture of a  hair-follicle,
which wives passage to  one or two hairs.  To  these,  the special cha-
racters of favus, may be added, more  or less redness surrounding each
crust and cluster of crusts, a ragged and exfoliating state of  the epi-
dermis of the adjoining  skin, a thin  and glazed appearance  of those
parts of the scalp on which the disease has exhausted  its violence,
and a loss of hair in irregular  patches.
   Favus is a disease of the scalp; but, in  some few instances, has been 
638   DISEASES OF SPECIAL STRUCTURE OF THE  SKIN.

observed on other parts of the body.  Its crusts are altogether unlike
those of other  cutaneous diseases.  They are situated  not upon but
under the epidermis, and as a consequence of this peculiarity  of  posi-
tion, they are smooth on the surface, and very little raised above the
level of the skin.   They are  not the result of  a desiccated, morbid
secretion, poured out by a broken or  ulcerated surface;1 the  disease,
in fact, being unaccompanied by discharge of any kind, but are formed
of a peculiar substance, a remarkable and peculiar modification of cell-
formation and growth.
   The yellow color2 of the crusts of favus is a striking feature of the
disease;  the yellow is much brighter  than that of pus, and this  cha-
racter enables us to discover the first  traces of its appearance around
the apertures of the  affected hair-follicles.   At this early period, the
yellow substance may be seen forming  a yellow ring of uniform di-
mensions around  the margin of the hair-follicle; it  is quite  evident
that it is separated from the hair by the epidermal  lining of the fol-
licle ; indeed, the aperture of the follicle is free, and generally  remains
so throughout the entire growth of the crust, and no pressure  exerted
upon the skin  can force through it the morbid  formation, otherwise
than by  rupture.
   The growth of the crust is eccentric, fresh matter being deposited
in successive rings around that which was first  formed, the  breadth
of the ring undergoing  a gradual increase.   This mode of growth is
conspicuous on the  surface of some of the crusts  wherein  the  first
formed rings have  become altered  in color by desiccation, and  their
outlines  may be distinguished as a series of reddish-brown, and  con-
centrically-arranged  lines.  The alteration of color here referred to
being the  effect^ of desiccation,  the whole central  part of the crust
assumes  more or less of a reddish-brown  tint.
   This mode of growth of the  crusts also gives rise to another of its
characters,  namely, the depressed centre, which has gained for the
disease the appellation of favus (honey-comb).  But it is ludicrous to
compare the slightly depressed  and precisely circular crusts of favus
with the deep hexagonal cells of the honeycomb; and we cannot but
regret that the scientific denomination of the disease is so little appro-
priate.   The first formed rings of favous matter naturally shrink as
the latter loses its fluid by desiccation ;  but the last formed ring, retain-
ing moisture, is brighter colored  and more prominent  than the  rest,
and is the chief cause of the central depression of the crust.  Occasion-
ally, the  central part of the crust, namely, that which immediately
surrounds the hair-follicle, forms a slight prominence, and destroys the
exact concavity of its surface.
  At its outer margin  the crust gradually sinks to the level of the

  1 Bateman  is consequently wrong in speaking of the crusts as being formed "by
the concretion ofthe fluid which exudes when they (the pustules) break."
  2 From leaning with too much reliance on the  older writers, Bateman has  fallen
into the mistake of calling the crusts "yellowish white" and  •' white."' The source
of his error is the following quotation from the Arabian author, Hally-Abbas : " Quinta
est lupinosa, sicca, et colore alba." 
DISEASES  OF THE  HAIR.
639
surrounding skin, and  the epidermis passes from  one to the other
without change.
  Such is a description of the crust when uninjured  and entire, but
in many instances its surface,  being dry and brittle, cracks in a circle
around the  hair,  in consequence of the  contraction of  the  favous
matter during desiccation, and the component substance of  the crust
is more or less  exposed to view.  Occasionally, the central  follicular
piece of the crust becomes loosened from the rest, and either adheres
to the hair or is drawn upwards on its shaft, and has the appearance of
being strung like a bead upon its thread.  The exposed substance of
the crust  is lighter-colored (cream-colored) than its  surface, and more
or less broken  into  small masses, according to its degree  of dryness.
It is this latter  character that  Bateman alludes to when he says, that
the " central indentation or depression sometimes contains  a white,
scaly powder."   It will  be seen at once that Bateman  is wrong in  this
expression,  for  the surface of the crust is gone before the disintegrated
appearance  alluded  to comes  into view, and then  even it is not a
" scaly powder."  This  remark of Bateman's is evidently  the " a  qua
quasi cortices et squamae fluunt  albae" of Haly-Abbas.
  In  its early development the crust of favus  is exactly circular,  and
it maintains this form with remarkable  accuracy even when neigh-
boring hairs are implicated in  its progress, so that,  as it sometimes
happens, the crust is transfixed by several hairs, one  or two being
central, and representing the starting point of the morbid action, the
others being more or less peripheral.  Occasionally, two or  three crusts
approximate in their growth, and  become blended by their  margins;
and in the aggregated or confluent form  of the disease a number  are
thus united  together. In the  aggregated mass, however, the circular
form  and depressed centre of  the  originally separate  crusts are still
perceptible.
  The size of the crusts is something less than a quarter of an inch
in diameter, namely, between  two and three lines.  Bateman speaks
of them as acquiring the size of a sixpence, which is incorrect.
  Passing now from the outward  characteristics of  the disease to the
relation subsisting between the morbid  formation  and the  skin, we
find that if,  with a little care, we break through the epidermis around
the margin  of the crust, we are  enabled to raise up and remove  the
entire crust  without  drawing blood or injuring the skin.  And if we
perform this manipulation after the removal of an oiled-silk  covering
or poultice,  which has been allowed to remain on the head for a  few
hours, we may  succeed in peeling off' the whole of the crusts without
pain to the patient, and with the utmost  facility, the crusts' being un-
broken, and retaining their exact form.   Moreover, in  the  course of
withdrawal, the crusts will be unthreaded from the hairs, leaving  the
latter behind standing firmly in  their follicles.
  In this manner we are enabled to demonstrate that the under-surface
of the crust is smooth and convex, and of a honey-yellow color, and
that there is frequently a prominent  papilla, corresponding  with  the
aperture of  the follicle  of the hair, which is prolonged  downwards
from the centre of the convexity.  The  crust is thick throughout its 
 640   DISEASES OF  SPECIAL STRUCTURE OF THE SKIN.

 entire extent, but thicker in the middle than at the periphery, and, at
 its thickest part,  measures from one-half to one-third of a line.
   On the surface ofthe derma there exists a depression corresponding
 with the  dome-like convexity of the under part  of the  crust.  This
 surface is smooth, shining, and red ; and is evidently constituted by
 the basement membrane, which is transparent,  but somewhat thick-
 ened.  In the centre of the depression is the aperture of the hair-tube
 unaffected by the morbid action ;  and if the hair be withdrawn, it is
 evident that  it has no  direct participation in the  disease.  The under
 surface of the compound crust displays the numerous domes of the
 originally separate crusts, and the impression on the derma is that of
 a number of cups divided from each other by prominent  partitions.
   The structure of the derma has obviously suffered absorption, from
 the gradual and prolonged pressure which  has been  kept up on  its
 surface.   The derma has become thinned, all trace of papillae is lost,
 and the  hair-follicles are shortened.   A further continuance of this
 pressure, occasioned by  a  further addition  of favous matter to the
 under part of the  crust, would entirely obliterate the hair-follicles,
 and then  the formation of hair would cease.   This is  the explanation
 of the loss of hair which takes place in favous disease.
   After the removal of the crusts, it is curious to observe how quicklv
 the compressed derma becomes lifted up.  In the course of a few
 hours the depressions are almost effaced, and  a  film  of  epidermis is
 formed upon their surface.  But if the pressure have been great, or of
 long duration, the normal level is never completely regained, and the
 skin frequently  retains  its thinned and atrophied character for the
 rest of life.   The papillae of the derma having  been  destroyed, the
 restored surface is unnaturally smooth, and covered by a  transparent
 and flaky epidermis, which is  repeatedly thrown off by desquama-
 tion.   The injured hair-follicles  admit of  no regeneration, and  the
 diseased spots therefore remain permanently bald.
   The color  of these altered patches of skin  is that of a portion of in-
 tegument which has long suffered  under chronic inflammatory action ;
 in relaxed constitutions the veins are dilated, and the torpid circula-
 tion gives rise to a  blueness and lividity of hue.   In more healthy
 states of the system, the tint of color is paler than that of the surround-
 ing surface, in consequence of the diminished amount  of the  capillary
 rete of the skin.
   According to the preceding observations, the  precise   seat of the
 morbid formation ofthe favus is the surface  of the derma.  The mor-
 bid substance lies  in contact with the basement membrane of the derma
 on the one hand, and  with the epidermis  on the  other.  From the
 derma, as  I have already shown, the favous  substance is easily separ-
 able; but, with the epidermis, it is closely identified.   Its relation to
 the epidermal lining ofthe follicle of the hair is similar to that of its
connection with the epidermis.
   Pathology.—When we proceed to the anatomical analysis  of a
crust of favus, we find it to present  some diversity of texture  in dif-
ferent parts of its thickness.  The upper surface,  for  example, being
combined with the epidermis, evinces the lamiuated disposition of that 
DISEASES  OF THE  HAIR.
641
 membrane, and is brittle from its dryness.  The deep surface is of a
 darker yellow than the rest, of a honey-yellow color, and conspicuous
 for its density and toughness; tearing with difficulty when dissevered
 by needles  for  microscopical  examination.  The middle  portion,
 which constitutes the greater bulk of  the crust, is crearn-colored, be-
 coming, when moistened, as yellow  as the deep surface, and broken
 up into small irregular masses, like mud dried in the sun.
   Under the microscope, these  three divisions of the crust, namely,
 its deep, middle, and superficial portions, present differences of struc-
 ture which -I will now describe.
   The  deep portion is composed of globular corpuscles, measuring
 soarv to -30V0- of an inch in diameter, closely collected together and
 forming the  outward boundary of the crust.   Each corpuscle is con-
 structed of a cell-membrane inclosing numerous very minute second-
 ary cells i-qItss to g^s  ;  and the latter are  formed of several minute
 transparent granules (.2Tihan to TSi^).  In the centre of  each of the
 secondary cells is a dark point, which  might be regarded as a nucleus,
 but which, in reality, is  merely the  shade caused by the  approxima-
 tion ofthe elementary granules of which it is made up.
   The middle portion  of the crust is  composed of corpuscles  much
 larger than the preceding, namely, between 35V0- ar>d  ToW of an inch
 in diameter, and  consisting of a cell-membrane, containing from four
 to  seven  or  eight nucleated granules; of nucleated granules (45V0-)'
 separate and in  groups;  and of other nucleated  granules connected
 together in a linear  series, and  assuming a branched and plant-like
 form.
   The superficial portion is  remarkable only  for the large size of the
 nucleated granules, and  for the  more highly developed condition of
 the plant-like growth.  In it there are no corpuscular cells.
   In its essential nature, I believe the peculiar matter of favus to be
 a modification of the elements of the epidermis.  The grounds upon
 which I found this view I will now explain.
   The epidermis is originally a plastic fluid,  which goes through the
 successive forms of  elementary or primitive granules,  aggregated
 granules, nucleated granules, and cells, before it attains its ultimate
 condition of flattened scale.1
   Now, the favous matter  is necessarily in  a fluid state when first
 effused  through the capillary vessels on to the surface of the derma,
 and in its freshly elaborated condition  consists of granules, possessing
 a simple, aggregated, and  nucleated shape, and cells.  I  have ascer-
 tained the presence of these elementary forms.  The  primitive gra-
 nules measure from 2^J70- t0 12^0"  °f an in°h in diameter; the nu-
 cleated granules measure 45V0-; an(l  ^e ce^s between 55'^ and 3DVtr-
  The primitive  granule is the first  organic shape ofthe plastic  fluid
 effused by the blood, and the process by  which that shape is assumed
is  a kind of  vital coagulation or vital crystallization.   The granule
is endowed with  an independent life,  and is capable of acting  both
41
' Page 39. 
642   DISEASES OF SPECIAL  STRUCTURE  OF  THE  SKIN.
alone and in combination with  similar granules.   It  separates from
the plastic material by which it is surrounded the elements of growth,
and  attracting  towards itself other granules,  forms  an aggregated
granule; the aggregated granules  performing similar actions, con-
stitute nucleated granules;  and several of the latter combining in a
like manner  and forming around themselves a peripheral boundary,
constitute a  cell.  The growth of the cell is the result of the vital
agency of the whole of the contained primitive granules.  These gra-
nules draw nutritive material from the blood, which nutritive material
serves the double purpose of contributing to their own growth and
giving origin to new granules, so that the same changes occur within
each cell as  had taken place in the plastic fluid  poured out on the
surface of the derma.
  Reasoning  from analogy, the mode of development  and growth of
a cell must be the same in whatever part of the body it is produced,
and whatever special purpose it may have to perform; and microsco-
pical investigation establishes the existence of an identity of structure
among them.   The blood-cell,  the  mucus-cell, the pus-cell, the pig-
ment-cell, the epithelial  or epidermal-cell, for example, resemble each
other closely  in construction, and in some instances appear to be con-
vertible the  one into  the other.   The cells or corpuscles of favus
possess a  striking resemblance  to  pus-cells, and,  excepting in  their
form, are closely allied  to young epidermal  cells; so  that  it would
require no stretch of imagination to suppose the epidermal cell, altered
in its actions  by disease, capable of assuming the character of the pus-
cell; or the latter, from  a similar cause, passing into the'likeness of a
favus-cell.
  In the early development of favus it is no uncommon thing to see
around the aperture of a hair-follicle a circle of pus in place of favous
matter.  There is no difficulty in distinguishing between the two, for
pus is  much  lighter colored than the matter of favus,  and when the
epidermis is punctured,  issues from  its cavity in the form of a drop.
In a very short time, however, this little collection of pus loses its
characteristic color; it becomes, as it were,  dried up, is no  longer
recognizable as  pus, and merges into the yellow crust of favus.   Now,
in this fact, we  have evidence that the same tissue  may produce, one
while,  epidermal cells;  another while,  pus cells;  and  thirdly, favus
cells.   Can we close our minds against the signification of so remark-
able a phenomenon ?
  The fact of pus  being so easily distinguishable from the matter of
favus may,  at first sight, appear to offer a contradiction to the analogy
which I wish to establish, but the difference between the two is more
apparent than real.  Pus is fluid, from the presence  of a large quantity
of water, and  this dilution with water necessarily alters the color and
modifies the  development of the corpuscles.  Favous matter,  at its
softest, appears  in the state of paste.
  A drop of pus from the situation  referred to was composed of glo-
bular corpuscles ,^0T  of an inch in diameter floating in liquor  puris.
ine  corpuscles  presented the ordinary granular appearance of pus;
but when water was  added, they swelled to the  size of ^  of an 
DISEASES  OF THE HAIR.
643
inch; and, in place of the minutely granular structure which they
previously had, displayed in their interior from four to seven or eight
large granules or  nuclei.   I will not stop to inquire  by what means
this change was effected. Imbibition of water was evidently one of the
phenomena,  but  what  the process might  have been by which  the
minute granules,  or rather cells, which were previously seen, were dis-
persed, is a matter of no importance to the present investigation.
   Now the corpuscles which form the deep layer ofthe crust of favus
are composed of seven or eight granules, which represent the nuclei
of the cell.   The size of the granules varies between tx>Ut> an^ e Ao-
of an inch, while that of the entire cell  is ^v.  So that these cells
correspond very accurately with the multi-nucleated pus-cells, the only
difference between them being the distension ofthe cell-membrane of
the pus-cells with water.
   It is  interesting  to observe the development of these  favus-cells as
they become displaced, by successive formations, from the surface of
the basement membrane, and  proceed onwards towards  the centre of
the crust.  The nuclear granules gradually enlarge until they attain
the ^gVcr °f an inch, a size nearly approaching the bulk ofthe original
cell; and the cell in which they are contained measures between ^-stst;
and j-gjjxr of  an inch.   At this  period the function of the  cell appa-
rently ceases, for its membrane becomes broken and lost; many of the
nuclei are dispersed, but  many also  remain adherent to each other,
and may be observed in linear groups of two, three, and even four or
five, already assuming a plant-like character.
   In  recapitulating the changes referred  to in the preceding para-
graphs, it would appear that the vital force-inherent in a plastic fluid
is employed  in the development of molecules of extreme minuteness,
primitive granules; that these granules  combine and co-operate  for
the formation of cells; and that the aim ofthe cells is the production
of nuclei or secondary cells.  We will now examine these secondary
cells, and follow the subsequent changes which take place through
their means.
   It  is  quite  evident that these  secondary  cells are themselves
nucleated.   In some  instances a single nucleus only is perceptible;
in others, two; and in others, again,  three.  When  two nuclei  are
apparent, the secondary cell assumes an oval or oblong form; and
when there are three it has a three-cornered shape.  As soon as  the
cell has attained  an elongated form a slight contraction is apparent
around  its middle,  and a septum is thrown up which divides it into
two cells;  in a short  space of time each of these cells develops two
nuclei, which separate by degrees, and are finally parted  by a septum,
as in the previous  case; a third repetition of similar actions might
convert the four into  eight cells, and  in  this way an elongated stem
is produced,  which has all the appearance of a vegetable formation.
When, in place of two, three nuclei  are developed at the same  time^
the stem has  a dichotomous  character, and seems to have resulted
from the growth of two branches from one stem; and the occurrence
of a trinucleated  cell in the course of  growth of a stem is the usual
mode of origin of a branch. 
644    DISEASES OF SPECIAL  STRUCTURE  OF  THE SKIN.
   When  the  process of growth which is  here described is accom-
panied  by an  active nutritive  force  on the  part  of the  cells, the
cellated stems maintain the original ^diameter of, the cells from which
they spring.  But when the nutritive force is less active, or the growth
is more energetic, then the stems dwindle in size in a corresponding
ratio.  This, I apprehend, is the signification of the considerable range
of variety  in  breadth  which  these stems exhibit; the thicker ones
measuring  s^v to ^v of an inch, and the smaller TyfoT.  It cer-
tainly has no reference to'trunks or bra'nches, as the idea of a vegeta-
ble growth might suggest.
  The thickest and largest cellated stems  are found in the  upper
portion of  the  favous crust, the  most slender in its deeper  portion;
while in the'  middle portion, stems of every  intermediate  size are
found mingled with secondary cells in vast numbers.   These, namely,
the stems and  secondary  cells, together with the primary cells and
primitive granules, being the real constituents ofthe crust.
  The stems offer some slight differences in relation to the contents
of their cells;  in some, and especially in the large ones, the contents
are transparent and the nuclei manifest, while in the smaller stems,
they are finely granular.
  The resemblance  which the cellated  stems of favus  bear  to  some
of the inferior vegetable organisms, and especially to the  mucedines,
has caused them to be considered  as plants.  They have been described
                      as originating in the cortex of the crust and
                      growing  inwards towards the centre, as giving
                      off" numberless branches, and producing seeds
                      or sporules in vast abundance; the so-called
                      sporules  being the secondary cells of the pre-
                      vious description.   With all these plant-like
                      characters, hypothesis  speedily reached the
                      conclusion that  the sporules  must be  the
                      means of disseminating the disease;  in other
                      words, were the-elements of contagion.  Now,
 A portion ofthe yellow matter  I tn}nk t|,at &n   OQe ^q ha&  f0M.owed With
from the crust of honevcomb   ,,  •   ,,     J            .   -  .   ,
ringworm, lowing its piant-nke  attention the argument  contained  in the pre-
utructure                ceding narration,  will  agree  with  me, that
                      mere  resemblauce to a vegetable formation
is  not sufficient to constitute a plant.  The statement of the origin of
the vegetable formations by roots implanted in  the cortex  of the crust
is unfounded, the secondary cells bear no analogy to sporules or seeds,
and it is somewhat  unreasonable to assign to an organism so simple
as a cell  the  production  of seeds  and reproduction  thereby, when
each cell is endowed with  a separate life and separate power of repro-
duction.
  Again, it has heretofore been  assumed that the favous  matter was
contained  in the hair-follicles, and consequently in  communication
with the exterior; a presumption which rendered the idea of a plant-
like formation the more probable.  But if, as  I have shown, the favous
matter is sub-epidermal, and has  no communication with the exterior,
it will be necessary to admit the production of a vegetable organism
 
DISEASES  OF THE  HAIR.                 645
 within the animal tissues, before such a phenomenon can be received
 as possible.  The mucedinous formations which have been described
 hitherto as having been discovered in the animal body, have always
 been found on the surface of  membranes, and not in the substance of
 tissues, as is  the case with favus.
   In chemical compositions, the  crusts of favus,  according to  the
 analysis of Thenard and Chevillot, consist in qrvery hundred parts, of
              Albumen......70 parts.
              Gelatine.......17  "'
              Phosphate of lime    .   .   .    .   5  "
              Water......3  "
              Loss.......5  "
   State of the hair in favus.—In a preceding paragraph I  have stated
 that the hair remains standing in its follicle  when a recent crust is re-
 moved, and,  I may add, that if the hair be drawn out, it will be found
 unaltered in  appearance.  It is only when the favous  matter  has in-
 creased to the' extent of obliterating the follicle that the hair falls.
 If the obliteration of the follicle be complete, no new hair is formed,
 but if it  be  only partially destroyed, then  a hair  may be produced
 of smaller diameter than the original hair, or somewhat lighter in
 color.  It is  unreasonable to expect that so  serious  a  disturbance of
 cell-formation, as  that which occurs in favus, can exist in the scalp,
 without interfering in some degree with the structure of the  hair,
 itself a product  of  cell-formation.  Such an interference does take
 place, and the nature of the morbid alteration I shall now explain.
   When  a hair from the midst of a crust of favus is placed under a
 microscope,  it is seen to be traversed in the direction of its length by
 a number of cylindrical  tubes  measuring  in diameter  TT),Tro-  °f an
 inch.  A close examination shows that  these tubes are  divided  by
 transverse septa  into small spaces a very  little longer  than  their
 breadth, and are filled with air.   Now, an observer imbued with the
 vegetable  theory  of favus would  be likely to conclude  that these
 were the stems of a  mucedinous plant, and so indeed they have been
 considered.  They have  also been described as branching dichoto-
 mously, an assumption  altogether unfounded in fact.
  To understand the true nature of these tubes, it is necessary to  go
 back to the structure of the  hair.  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 epidermis, 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 easy in all cases to discover the cells, but their
 component granules  are always obvious, and from the  plan of dispo-
 sition of the  cells  and their oblong shape, the granules have a linear
 arrangement, and assume the  appearance  of fibres.  The  hair-fibres
 offer some variety of aspect according 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 
646   DISEASES OF SPECIAL  STRUCTURE  OF THE  SKIN.

of granules appear 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 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.
  Now the hair-fibres here described, are corriposed  of cells arranged
in a linear series, and the cells are filled with a homogeneous albu-
minous  substance, having a certain consistency, and possessing the
characters of  a  solid.   Under the influence of disease,  the  contents
of the cells are so far modified as to be deposited in a fluid form, and
the subsequent evaporation  of the fluid, during  the growth  of the
hair, leaves the fibres hollow and empty, and to all appearance tubular.
This is 4,he explanation of the hollow tubuli which are  found in the
structure of the hairs  in favous disease; generally they are distri-
buted in small  numbers throughout the thickness  of the hair, and
produce no influence on its shaft; when more numerous they occasion
the lightness of color ofthe hairs before mentioned,  and their some-
what shrivelled  appearance. But it is evident  that they offer no
analogy with  the plant like formation of the crusts of favus.   When
the hairs present the tubular structure to any great extent, they be-
come brittle,  and are easily broken.
  Symptoms of favus.—The early part of the course of this disease is
attended with a moderate amount  of itching.  At a  later  period,
when the crusts  have  enlarged,  and  are producing pressure on the
inflamed skin, the scalp is tender and painful, particularly in resting
the head on the pillow at night.   When the disease is neglected, the
pressure of the crusts, together  with  scratchng with  the  nails, may
give rise to ulceration, and, according  to  the  French writers, these
ulcerations have been seen extending even to the bones of the cranium.
The dried crusts give out a  particular odor, like that  of mice; and
when the skin falls into a state of ulceration, the discharge is said to
be most offensive, resembling, according to  Alibert, the urine of cats ;
and pediculi are apt to be engendered in great numbers.
  When the state of irritation and inflammation of the scalp are great,
the occipital and cervical lymphatic glands are apt to become painful
and enlarged.  This is  a common occurrence  in inflammation  of the
scalp, and one that I have had frequent occasion to  observe, even iu
cases of inflammation artificially excited.   I make  this  remark,
because some dermatologists would lead us to infer,  that enlargement
of the lymphatic glands of the neck is pathognomonic of  favus.  In
the most severe and neglected cases of favus,  the inflammation of the
lymphatic glands has gone on to  suppuration  and ulceration.
  Causes.—Favus is a disease of deranged nutrition, and generally
occurs  in  childhood, at a period of life  when the nutritive functions
are rnost active, and when, as a consequence, they are most susceptible
of disturbance.   At this  age, any circumstance which  may tend to
reduce the powers of the system may become a predisposing cause of
favous disease.   Favus is generally met with among the children of
the poor, and in those institutions for the children  of a.better class 
                    DISEASES OF THE HAIR.                617

that are so mismanaged  in respect of diet, clothing, ventilation, and
cleanliness, as to engender a disposition to disease.
  The more frequent occurrence of favus in France than in England
is, I believe, attributable to the greater  poverty and  wretchedness of
the lower classes in the former country, added to a practice which is
happily almost unknown  in England, namely, the  putting out of  the
children to nurse.   The remark has been handed down, from author
to author, that children afflicted  with favus  remain stunted  in their
growth, are slow  in displaying  the  changes  which take  place at
puberty, and  are  wanting in their intellect.  " I have seen," says
Biett, " individuals affected with this disease evince no signs of puberty
at the age of twenty, and even more."
   In  my opinion,  these phenomena of retarded development are not
the effect, but a  part of the general deficiency  of  power,  in other
words, of  the defective nutrition, which is  the real cause of  the
disease.
   Is favus contagious ?  The  transmitted records of the older writers
and modern authors* both agree  in according to favus a high  degree
of contagious power.  The supporters of the vegetable theory of the
disease are still more ardent  in this belief;  for, with a distinct muce-
dinous growth and a host of  sporules, it would be hard  indeed if the
disease were  not  susceptible of  propagation.  This theory will  also
win admirers  and  disciples from the simple and truth-like explanation
which it seems to  offer of the manner of transmission.   The seeds are
conveyed directly to the soil in which they take root and grow;  they
are carried by combs, or brushes,  or hands, or they are wafted by the
winds.  Gruby made the contagious property of  favus  the subject of
experiments; he  inoculated  with the substance  of  the favous crust
mammiferous animals, birds, reptiles, insects, and  himself, but without
any success.  He also inoculated vegetables  with the  same  matter,
and,  after  seventy-six trials, he found  a mycodermis similar  to  that
of favus produced on a  cryptogamic plant.
   I am exceedingly doubtful of all that has been recorded with regard
 to the contagiousness of favus.  The experiments of Dr. Gruby prove
 nothing in its favor, for the instance to which he refers is merely one
 of the formation of a mucedinous plant, in other words, of a crop of
 mould, upon  a wounded cryptogamic plant.  The  identity  of  this
 mucedo, with the " porrigophyte," or plant of favus, being far from
 being established.
   The seat of development of favus affords a common-sense negative
 to the notion of propagation by  seeds or sporules; and if it be true,
 as I  have endeavored to prove, that the  plant-like production has
 nothing in common with plants but its form, a form which is as  con-
 stant in  animal  structures as in  plants, the vegetable  theory of the
 disease must  necessarily fall to the ground.
   I will now adduce a different  line of argument.  In the course of
 my long connection  with the St. Pancras Infirmary, I have seen not
 more than six cases of favus;  in no one instance was there reason to
 suspect  the disease to  have originated in  contagion, and  certainly
 there was no example of its transmission to others.   In a well  marked 
6i8   DISEASES OF SPECIAL  STRUCTURE  OF THE*SKIN.

illustration of this disorder, the features of which I have preserved by
delineation,1 the patient, a boy, ten  years of  age, had suffered from
favus for seven  years.  He was brought up with a brother and sister;
and  on  the last occasion of  the outbreak  of the disorder, was one of
a school of one hundred  and fifty-eight boys.  He remained in the
school until the disease was fairly developed over the greater part of
his head, and was then transferred to the Infirmary, where he was
accustomed to  play with  several invalid companions.   Now, during
the whole course of his association with other children, although he
partook of  their games without restraint, although he washed in the
same water, and used the same towel  and comb, the disease was never
communicated to others ; it never extended beyond himself.
  Bateman, who was an ultra-contagionist, and gave the specific title
of " contagiosum" to a very harmless  form  of disease of the sebiparous
glands, namely, the "small  sebaceous tumors" of my  classification,
opens his history of diseases of the scalp by the observation that " the
porrigo  is  a  contagious disease."  This  sweeping  condemnation is
immediately followed by an exception in favor of-porrigo larvalis; to
which might have been  added, without any hesitation, porrigo favosa,
and porrigo decalvans;  so that, on the threshold of inquiry into the
contagiousness of porrigo, one-half the species of that  writer might
have been declared at once to be free from imputation.  The remaining
three species, or, as I  have shown,  two,  for  porrigo  furfurans and
porrigo  scutulata are stages of the  same disease, are, therefore, the
only affections about which any doubt can exist in the minds of per-
sons conversant with cutaneous diseases.
  The impression made on my mind by the perusal of the account of
favus (porrigo lupinosa) which is given by Bateman, is, that he cannot
have been familiar with the disease,  and that  his  description  is not
drawn  from  nature, but composed from  the  writings of the  older
medical  authors, who, in  this instance, had certainly observed the
disorder very imperfectly.   The  term "porrigo,"  he  tells us, was
adopted by Willan,  " nearly in the same sense  in which  it was used
by Celsus, who  included the moist and ulcerating, as well as the dry
and  furfuraceous, eruptions of the scalp  under this denomination."
He further observes, that " numerous  writers,, ancient  and  modem,
have designated the  varieties of  the disease (porrigo) by distinct
names, such as crusta lactea, alopecia, pityriasis, favi, achores, scabies
capitis, &c.; but the most intelligent  observers have pointed out the
identity of the nature and  causes of  these  eruptions;" from which
it may be inferred that the "ancient and modern writers" were greatly
superior, in point of discrimination,  to the " most intelligent observ-
ers;" for, of a surety, nothing can  be more widely dissimilar or non-
identical than  the  diseases  represented  by   the  six  designations
mentioned above.  In the absence, therefore, of facts, and something
in the shape of  proof to the contrary, I must  be permitted to doubt,
not only the contagion of favus, but also the  qualification of Bateman
to speak to the  subject.   It is further worthy  of remark, that  in  the

         1 Portraits of Diseases ofthe Skin, Plates XLIL, XLIII., B, C. 
DISEASES  OF THE HAIR.
649
plates of cutaneous diseases published by Willan and Bateman, there
is not one which represents favus.
  Plumbe  commences his treatise on  porrigo by adverting to " its
known  infectious nature."   He  alludes to*favus only as the crusted
stage of common ringworm, and that so lightly that it is evident that
he cannot have observed the disease with attention. On its contagious
property he is obviously no authority.
  It appears that favus, which is rare  in this country, is common in
France.  "Next to eczema and impetigo," says  Rayer, "favus is the
most common ofthe chronic inflammations ofthe hairy scalp."  Again,
he  observes, " favus is a contagious  disease, and is readily communi-
cated among children who  make  use of the same comb and brush,
especially if any slight excoriation  happen to exist on the scalp.   He,
furthermore, adduces the evidence of  Willan, in proof of the conta-
gious qualities of the  disease,  and concludes  with  the  erroneous
observation, that "the complaint is very common in England."
   Biett records that favus is " evidently contagious, but in some cases
the attempt to produce infectiou "has  entirely  failed."   Gibert ob-
serves,  that the " contagiousness of favus is acknowledged by almost
all  pathologists;" he then unfortunately adduces the evidence  of
Bateman, and, after making mention of some instances which prove
too much, he finishes up with  the  following remark:  "The conta-
giousness of favus is then an  established fact."   In fairness  to him I
will now quote his  illustrations, however little weight they may have
with myself. " In the wards of Biett, two or  three instances have been
seen of the propagation of this disease by the act of kissing, the dis-
order making its appearance in these cases around the mouth and on
the chin.   In a patient who wore a wig which had belonged to a per-
son affected with favus, the  latter disease broke out on the arms and
legs.  This curious  circumstance  was explained when it was ascer-
tained that the wig always came off during the man's sleep, and was
found in the bed in contact either with his arms or legs.   Some years
since M. Guersent had occasion to see, in a school, twelve  children
who were  successively attacked with favus within the space of  a few
weeks  or months, in consequence  of the admission of a child affected
with that disorder."
   There is too much of a blind and unthinking deference to the state-
ments  of  predecessors in all  these  examples.   In some instances, I
make no doubt, the case was not favus at all; and in others, commu-
nication by contact  has  been  admitted with too little consideration.
The breaking out of  a disease in a number  of children breathing the
same  air,  partaking of the same food, and living  under the same
hygienic  influence,  is a circumstance of daily occurrence, and  one
totally distinct from  contagion; and if, as I have shown, a free asso-
ciation continued for years  between an affected individual and others
has failed  in transmitting the disease, the power  of transmission may
be reasonably doubted.  It is encouraging to find an original thinker
like Alibert refusing his assent to  the current belief in the contagious-
ness of favus.                      ......
   Finally, whether we regard favus in its origin, in its development, 
650    DISEASES OF SPECIAL  STRUCTURE  OF THE  SKIN.

or in its  essential nature, or whether we look  at its phenomena in a
social point of view, its extreme  rarity, and the indisposition to trans-
mission which it evinces when closely observed; in each and every of
these features of the disease we shall find reasonable grounds for
doubting its propagation  by contagion.   My  own careful investiga-
tions of the subject have forced on my mind the conclusion that favus
is not contagious.
  Treatment.—The indications for the treatment of this disease are
two in number, the first being to restore the defective powers of the
constitution; the second, to restore the local power of the skin.
  The fulfilment of the first indication calls  for improved hygienic
conditions, improved diet, tonic alterative medicines;  that  of the
second requires the aid of local remedies belonging  to the class of
abluents, stimulants.  The four great hygienic principles, namely, air,
exercise, clothing, and ablution,  deserve the first, and especial  atten-
tion in this disease.  Favus is usually engendered in the confined and
malarious homes of squalid misery, and the most opposite conditions
to these  should be  selected in our treatment;  the patients should be
sent  to a spot located on a dry soil, breathed  upon  on all sides by a
bracing,  healthy air, uncontaminated by  the  steams and  impurities
which  rise from the congregated abodes of human beings.  The apart-
ment in  which he  sleeps should be thoroughly ventilated; it  should
be large and lofty;  he should lie in a separate bed, and the  number
of persons sleeping in the  same room should be as few as possible.
  The subjects of this disease are for the most  part children, therefore
exercise  is  a paramount  necessity.   The  physical, and not  least
important, education of children, consists  in,  eating, drinking, sleep-
ing,  moving, building up a  healthy structure, and furnishing that
structure with a sound constitution and sound  mind.   If the physical
phenomena of life are well and truly performed, Nature will have no
time for  pathological actions.
  The clothing of children suffering  under this disease should be
carefully adapted to their own feelings, and to  the temperature of the
season.   It should  be kept  strictly clean, and frequently changed.
Ablution is  another important   consideration.  The  sponge  bath
should be used daily; local ablution is  of little value in comparison
with general sponging.
  Attention to the  diet of persons suffering  under favus is of the
utmost importance.   As a general  rule  it should  be  animal and
nutritious, and only moderately fluid.  Much  vegetable food  should
be avoided,  and all matters which  obviously disagree with the
stomach.   The  best directed medical treatment can do but little when
the diet is based on a meagre standard.
  The  medicine which, above all others, is best adapted for favus  is
iron.   The  formula  is not very material; I  have  used  the  citrate,
acetate, and  sesquichloride;  the  latter  I prefer.  The dose which  I
prescribe for a child  of ten  years is ten  drops of the tinctura ferri
sesquichlondi on sugar, twice or three times in the day.   The iodide
of iron is also an useful remedy.  When  the-powers of the  system
are much enfeebled, the citrate  of iron and quinine  is an excellent 
DISEASES  OF THE  HAIR.
651
remedy.  When  iron  produces heat  and dryness  of the mucous
membranes with  feverishness, I use the nitro-muriatic  acid, either as
a sherbet, or combined with tincture of orange-peel or gentian; and
in chronic and rebellious cases, the ferro-arsenical mixture.
  If there be  any tendency  to strumous enlargement of the lym-
phatic  or  mesenteric glands, I recommend the  oleum jecoris aselli;
and if any tendency to slenderness and flexure of bones, lime-water,
or  phosphate of  lime.  It is  hardly necessary  to  observe that  the
ordinary functions of the body should be watched and regulated  by
the usual means; but, as a general rule, aperients and  purgatives  are
injurious, and to  be avoided.
  To restore the local powers of the  skin,  it  is necessary to have
recourse to.local remedies.  In  the first place, the crusts must be
removed, a manoeuvre which is easily accomplished, by impregnating
the scalp  thoroughly with oil  at  bedtime,  and washing it  in  the
morning with water and soap.  A few repetitions of this process will
suffice  to clear away the  crusts effectually.  The same end may be
attained by means of a linen compress moistened with a  weak solu-
tion of  subcarbonate of potass, and an  oiled silk cap worn for two or
three nights; by a poultice; or, better  still,  by means of a piece of
Alison's prepared lambskin.  I am not favorable to the  practice of
frequent ablution with soap.  When the  crusts are once  removed, a
saponaceous  ablution is not again  required until they  recollect;  nor
do  I approve of shaving the head ; the only  ground for this practice
being cleanliness.
  I now come to the means to be adopted to alter and suspend  the
abnormal actions taking place in  the  skin, while nature restores by
degrees its wonted functions.   The agents for effecting this purpose
are local stimulants, and the best of these the ceratum  tiglii, contain-
ing from ten to thirty drops of the  oil to the ounce; the unguentum
hydrargyri  nitratis,  diluted  one-half; the   unguentum  hydrargyri
nitrico-oxydi, diluted  in similar proportion;  the compound sulphur
ointment;  or the sulphuret of potash  lotion  (3j  ad Oj), with ceratum
camphorae, half a drachm to the ounce.  In chronic cases, where  the
above  remedies may  have failed, they might be used in a more con-
centrated form.  I am less favorable to strong applications now than
when I began the treatment of cutaneous  diseases;  but  in  some
instances  I  have derived  benefit  from  tincture of  iodine,  and a
spirituous solution of bichloride of  mercury.  Devergie recommends
touching  the crusts with a solution of nitrate  of mercury in nitric
acid.  Creasote and  tar I  rarely use,  on  account of their powerful
odor; and in this disease they possess no especial virtuq.   The iodide
of sulphur  I have  found  to exhibit  no superiority over simpler
remedies.
  An unfounded  notion has long prevailed among writers on cutane-
ous disorders, that the hairs in this disease act as a source of irritation.
Some have considered  the  roots of the hairs to be  the seat of origin
of the  morbid  action, and the loosening of  the hairs  is an idea that
has been commonly entertained.   Plumbe was  an  advocate for  the
removal of  all loosened  hairs by means  of  the  forceps.   Rayer 
652    DISEASES  OF SPECIAL STRUCTURE OF THE SKIN.

observes  " In old standing cases of favus of the scalp, every  method
of treatment into which the avulsion or removal of the hair does not
enter as an  element is incomplete, and unworthy of being  entitled
curative."  " The  oldest system of this kind consisted in tearing out
the  hair violently by means of some  adhesive plaster, which was
applied to or spread over the scalp.   To prepare this plaster, it was
customary to mix four ounces  of rye-flour in a pint of cold white-
wine vinegar;  the mixture  was set upon  the fire  and stirred con-
tinually,  whilst  half  an ounce of the  deuto-carbonate of  copper
(verdigrise),  in powder was added; it was boiled for an hour, after
which four ounces of black pitch,  the same quantity of resin,  and six
ounces of Burgundy pitch were added.  When all these  ingredients
were melted and  incorporated,  six ounces of  antimonial ethiops (an
alloy of mercury and antimony obtained  by long trituration) in fine
powder,  were thrown into the mixture, which was stirred till it had
acquired what was held to be a proper consistency.  The plaster thus
prepared was spread upon a stoutish  black cloth, which was slit in
different directions before being applied, to prevent it from forming
a crease, and to admit of its  being subsequently removed in  stripes.
   " The plaster was applied  to the head, after  having got rid of the
incrustations, by  softening them with cataplasms, and having  clipped
off the  hair  as close to the  skin  as  it could  be done with scissors.
After the  lapse of  three or four days,  the  plaster was  removed
rapidly the contrary way of the  hair, and a  second was put on, which
was  likewise removed in  the same manner, three or four days after
its application.   The plaster  was subsequently renewed, every  second
day, taking care  to have the head shaved whenever this measure
appeared  necessary.  As  may be  conceived, and as was intended,
these plasters,.each time they were removed, tore out a  quantity of
hair, more or less considerable.  The first applications were attended
with  cruel sufferings;  the agony  became  less  and  less  severe  as
progress was made in the  treatment.  Nevertheless, the panrwas still
so great  at a month's end, that  children might be heard screaming
dreadfully when the plaster was  removed;  after the third month, the
pain of  the dressing became  less intolerable."   As a commentary on
this barbarous proceeding, the Messrs. Mahon affirm, " that  they saw
a  child die two  days after having had this horrible operation per-
formed on its scalp.
  The Messrs. Mahon pursue a different process for wythdrawing the
hair  in this disease.  They cut it to the length  of two inches, apply
poultices to soften, and thorough  washing  with  soap to remove the
crusts, and then corhb the  hair repeatedly, in order to draw out all the
loosened hairs.  After this preparatory process is accomplished, they
rub daily into the scalp, for  about a  fortnight, a moderately stimu-
lating application, consisting chiefly  of  lime  and  subcarbonate of
potash,1 in the form of ointment, and continue  washing and combing

  1 According to an analysis made by M. Chevallier, the remedies of the MM. Mahon
are composed of slaked lime, subcarbonate of potash, and charcoal.  They use three
applications of  different degrees of streimth, and  once a week they sprinkle a
depilatory powder among the hair, which they subsequently comb out. 
DISEASES OF THE  NAILS AND  NAIL-FOLLICLES.
as before.  For the next three or four weeks, and  until the cure is
established, this treatment  is pursued with  longer  intervals, no day
being permitted to pass over without a thorough ablution.
   It is obvious that  this treatment of  the Messrs. Mahon, which has
proved the most successful ever pursued, does no more than fulfil the
local indications laid down at the commencement of the principles of
treatment  developed in this chapter.  These gentlemen  call their
ointment " depilatory," but in this they fall  into the popular error of
regarding  the hairs, which are really harmless, as  irritants.   Their
system  is simply a  moderately stimulating  plan, wanting,  to  give it
perfection, the constitutional treatment above recommended.
   M. Petel has proposed, as an imitation  of MM. Mahon's  remedies,
an ointment and powder as follows: —
        R.—Sodse subcarb. gr. ix.          R.— Calcis vivi, gij.
            Calcis vivi, 3j.                   Carbonis ligni, 5ij.—M.
            Axungiae, 3jij.—M.
   The  ointment is  to  be used  daily, after washing, and after the
removal of the crusts ; and the powder is to be sprinkled on the scalp
with the view of causing the fall of the hair.
                  CHAPTER   XXIII.

DISEASES AFFECTING THE SPECIAL STRUCTURE  OF THE SKIN.

           DISEASES OF THE NAILS AND NAIL-FOLLICLES.

  The disorders of the nails and nail-follicles are referable to altera-
tions in the disposition of the skin around the margin of the nail;  in
the development, growth, color, and texture of the nails themselves;
and, to  inflammation, suppuration, and ulceration of  the matrix and
adjacent soft parts.
  In  reference to the first of these alterations, we sometimes  meet
with  cases in  which the epidermis of  the  margin of  the nail follicle
remains attached to the  surface of the nail, and  advances with  its
growth until the nail is more or less  completely  covered,  lhis  is
termed pterygium unguis.  When less complete, the epidermis is apt
to break up into little bands, which curve back and project from the
skin around the root of the nail, giving rise  to much inconvenience,
and often  from being accidentally torn, causing soreness and tender-
ness of the skin.  These little ragged bands of  cuticle  are  called
aqnails, on account  of  the pain and suffering which  they not unfre-
quently occasion.  At  other times, instead of growing  forward with 
654   DISEASES OF  SPECIAL STRUCTURE  OF THE  SKIN.

the nail, the cuticular margin of the follicle recedes, and exposes the
root of the nails.  This affection is rare, but has received the name
of ficus unguium.  Bayer remarks that  he  has observed it among
curriers; I have a few times seen  it myself,  where there existed a
chronic state of inflammation of the nail-follicle.
  Abnormal development of the nails is evinced in the occasional
congenital absence of those  organs; in their disposition to fall from
time  to time, with and without apparent cause; in their irregular
shape, their occurrence in greater number than natural, and in their
abnormal position.  The  congenital absence of one or more of the nails
is rare, but  such cases are sometimes seen.  Of the fall of  the nails
(lapsus unguis),  I have met with  several examples, in which they
were regularly shed;  new nails being  formed beneath, while the old
ones were becoming loosened previously to falling off.   This morbid
peculiarity  has been recognized by pathology, and  has received the
name of ahpecia unguealis.   More frequently,  the  fall  of the nail
results from inflammation of the  matrix, as in scarlatina, syphilis,
&c.;  and chronic inflammation of that organ, induced by local injury,
burn, frost-bite, or other causes.  Faulty shape ofthe nails, deformitas
unguium,  usually results from some disturbance of the secreting
organ, the matrix, and sometimes from malnutrition, the consequence
of deficient innervation, as  in cases of paralysis.  The nail may be
unnaturally long or short, too broad or too much compressed a: the
sides, too  prominent, too flat, or too much arched or curved, arctura
unguis.  Sometimes the nail projects longitudinally, like the  angular
ridge of a house-top,  and, when thickened, has rather the character of
a talon than a nail; sometimes it is concave on the surface, the direc-
tion  of the concavity being longitudinal, or horizontal;  and some-
times, it is remarkable for its curve over the end of the finger, as in
the ungues adunci, the arched and hooked nails so frequently seen in
scrofulous and consumptive persons.  Now and then  we meet with
supernumerary nails, generally in the form of  two rudimentary nails
blended together, evincing an intention of bifurcation  of  the  finger
                    or toe.   And, occasionally, from some accident of
       Fi6- T*        development, we find the nail occupying an aimor-
                    mal situation.   The most remarkable illustration
                    of the  latter phenomenon is the production of a
                    nail-like growth on the extremity  of  amputated
                    fingers; even  on the stumps  of  the first  and
                    second phalanges, where no rudiment of the  ori-
                    ginal matrix can  have existed.
                      Abnormal growth ofthe nails is  illustrated,
                    sometimes by deficient growth; sometimes  by
                    growth in excess ;  and  sometimes by unnatural
                    growth.  I have  met with instances in  which
                    the growth of the nail has  been  so remarkably
slow, that they might almost  be taken for examples  of complete
arrest of growth.  In other cases,  the growth of the nail has been as
striking for its rapidity of extent; the nails sometimes grow to be of
 
       DISEASES OF THE NAILS AND NAIL-FOLLICLES.    655

enormous size in Barbadoes leg; and a case of extraordinary growth
of the nails is recorded by Saillant, as occurring in a woman named
Melin, and named from  this peculiarity  the "femme aux ongles."1
Where there has been neglect, as in bedridden  and elderly persons,
the nails are apt  to attain an extravagant size,  I have in my pos-
session several toe-nails of this kind, measuring two and three inches
in length.   Bohout, in a  paper addressed to the Academy of Sciences
of Paris,  has described a  toe-nail which  measured nearly  five inches.
Rayer mentions two great toe-nails which measured three inches, and
were  spirally  twisted like the horns of a ram; and  Saviard " saw a
patient in the  Hotel  Dieu, who had  a horn instead of a nail  upon
each  great  toe."   Musaeus, in  his "Dissertatio de  TJnguibus  Mon-
strosis,"  records  a case  of unnatural growth  of the nails, in which
those organs resembled talons, and were five inches in length;  while
similar horny growths were developed on the skin of other parts of
the body.
   Discoloration of  the nails is met with in some diseases of the
skin affecting the  matrix of the nails, as in eczema and lepra; and it
also results from injury, as in ecchymosis beneath the nail, the conse-
quence of a bruise, ecchymoma unguis.  Not unfrequently the nail is
speckled with  small roundish white spots, selene unguis, figuratively
named by the  ancient writers, flores unguium; and, by the moderns,
less elegantly  termed  mendacia, or lies.   These spots are more com-
mon  in  the nails of  children than  adults, and  result  from  some
slight injury done to the matrix of the nail during the  progress of
growth.
   Abnormal texture of the nail may present itself in the threefold
form  of,  increased thickness, altered density, and altered  smoothness
of the nails, constituting  the state of disease  known as degeneratio
unguium.  Or the matrix of the nail may be the subject of inflamma-
tion, suppuration,  and ulceration, constituting onychia.  We may now
proceed to the  consideration of these two forms of disease.

                     degeneratio unguium.

              Defedatio unguium.   Scabrities unguium.

   The nails sometimes acquire an excessive degree of thickness, and
the increase of bulk is accompanied with a yellow and dirty discolora-
tion, the  nail  resembling horn, rather than its own natural texture,
both  in color and density.   In this state  it is not uncommon to find
the nail  separating from it matrix, and a dry, whitish, broken sub-
stance collected in large  quantity beneath it. Two such cases are now
before me, in  which the greater part of the fingers of both hands are
affected in this manner.
   In  another case, also under my observation at the present time, the
nails  are reduced to a mere film, and so soft and brittle in texture, that

  1 Saillant MOmoire sur la maladie de la femme dite aux ongles.  Paris, 1776, Svo. 
656    diseases ©f special  structure  of  the  skin.
Fig. V.
they split and break with  the slightest pressure, mollities  unguium;
             the texture of the nail is healthy, but its quantity defi-
             cient, and with  the absence of quantity there is also, as
             a  matter  of course, an equal defect of firmness and
             tenacity.   This state of the  nails is  a  subject of much
             annoyance to the lady who is the sufferer from the affec-
             tion ; the ends of the  nails  are always ragged and bro-
             ken, they catch in  her clothes  and in almost every-
             thing she touches; and when  they are  torn, they occa-
             sion bleeding and soreness of the  matrix.   Sometimes
             the nails  are brittle from a morbid alteration of texture,
             being converted into a white earthy matter which breaks
             up into shapeless granules on the application of a slight
             degree of pressure.
               Another change in the nails for which I have been
             several times consulted, is a fibrous state of those organs,
             which appear to be made up of a thick stratum of fibres.
             closely packed together, but becoming loosened here and
             there, so  that separate fibres are  met with on the sur-
             face.  The surface of  the nail is necessarily rough, rag-
             ged, discolored, and  marked by numerous dark longitu-
             dinal lines; and, besides  being very  unsightly, adheres
             like a burr to  any rough material with which it comes
             in contact.
               Another variety of degenerated  nail  has the appear-
             ance of being eroded, or worm-eaten, tinea unguium, and
             sprinkled over more or less abundantly  with hollow pits.
             This state  of the nail, like  the preceding, is very un-
             sightly,  and the sufferer applies for relief,  rather on
             account of the  ugliness of appearance, than from any
             real inconvenience.   Unhappily,  medicine  can afford
             very little aid in these cases.
A. B.
     C. Fore-
finger,  mirddle,
and  ring-finger,
showing the bro-
ken  and disfig-
ured state of the
nail, in degen-
eratio unguium ;
fisaura unguium.
                            ONYCHIA.

  Onychia is an inflammation of the matrix of the nail, sometimes
confined  to that  structure only,  but more frequently involving  the
immediately surrounding soft  parts.  The inflammation is succeeded
by suppuration, and ulceration Jo a  greater or less extent, the produc-
tion of granulations of large size and unhealthy texture, of a fungous
character, and an ichorous, sanious, and fetid discharge.  The inflam-
mation is sometimes superficial, sometimes extends to the deeper parts;
sometimes  terminates in the loss of  the nail, or a part of the nail; and
sometimes runs on to disease of the periosteum and bone.  It is always
a painful, and sometimes a troublesome and rebellious disease.
  Onychia may be partial, that is, may attack a single nail  only, or
it may affect a greater number;  it  may  also involve  a  part or  the
whole ofthe nail  in destruction.  It may occur along the edge ofthe
nail, or at its root; and it may be either acute or  chronic in respect
of its^ progress. 
       DISEASES OF THE NAILS AND  NAIL FOLLICLES.    657

  It varies also according to the cause which shall have given rise to
it;  whether that cause be one of external injury, as a bruise, a splinter,
a puncture,  or a foreign body lodged  beneath the nail.  Whether it
shall have been produced and  kept up by the pressure of  the  side of
the nail against the soft parts, giving rise to the growing in  of the nail.
Or whether its cause  may be internal and constitutional, as that pro-
duced by eczema, scrofula, or syphilis.
  In onychia resulting from external injury the treatment should be
such as is applicable to a similar injury, when occurring in any other
situation.   If pus be formed beneath the nail, the nail should be thin-
ned by scraping until reduced to a mere  film,  and then it should be
punctured to allow the escape of the  matter; the same  manoeuvre is
applicable to the relief of the inflamed matrix when swollen  by con-
gestion ;  or to the  removal of a foreign body  lodged beneath the nail.
  Onychia  from  in-growing nail  originates frequently, and  indeed
generally, in interference with  the growth of the nail  in length by
contact with the boot or shoe.   Prevented from growing forwards, the
nail is apt to spread laterally,  and  the skin pressed forcibly against
it, becomes  inflamed; the inflammation increases from day to day ; or
after much walking the skin becomes red, swollen, and painful,  adding
s$l further to the pressure; then suppuration takes place, next ulcera-
tion, the production of fungous granulations and an unhealthy dis-
charge.  The medical management of this case consists in the with-
drawal of the cause by rest and position ; then the  removal of  the
offending border of the nail; and the general relief of the inflamma-
tion by scraping the whole surface of the nail, until it  becomes thin
and pliable, and capable of yielding to  the swelling of the inflamed
parts.
  Eczematous onychia is usually accompanied with eruption on other
parts of the fingers and hands, and frequently on several regions of the
body.  It does not  call for any special treatment, but usually gets
well when the general eczema  is relieved.
  Scrofulous onychia commonly attacks the nail-follicle, and the inflam-
mation  spreads to the whole of the skin immediately bordering the
nail;  by degrees the entire end of the finger is  inflamed and enlarged,
and the nail looks as if it were sunk  into a deep hollow, surrounded
by a tumid  border of a deep red or purplish hue.  The finger has the
appearance  which  is commonly denominated clubbed, and  as  the dis-
ease advances, and fungous granulations spring up from the ulcerated
surface, the nail is sometimes completely concealed from view.
  Syphilitic onychia has already been considered  in  the  chapter on
svphilitic eruptions; like scrofulous onychia it  may attack the follicle
of the nail,  and is not confined to the lateral border, as in the case of
in-growing nail.   It is always  accompanied by other signs  of syphilis,
and frequently with syphilitic eruption  in other regions of the body.
  Onychia maligna is a name  assigned  to a  peculiarly obstinate and
severe form of the disease,  apparently of idiopathic origin.   It begins
in the follicle of the nail, and is attended with excessive pain,  and  the
secretion of an offensive discharge.   It is the malignant onychia, which
      42 
658    DISEASES OF SPECIAL STRUCTURE OF  THE SKIN.

sometimes extends so deeply as to affect the periosteum and bone;  and
is often many months under treatment.
  The diagnosis of onychia is self-evident, the only disease with which
it can possibly be confounded being panaris, or common whitlow.
Whitlow, however, begins in the skin at the end of the finger, or in
the vicinity of the nail, and does not attack the matrix; it is simply a
phlegmon in this situation; but when of large  size, or, in its com-
mencement, attacking the skin close to the border of the nail, the pus
not unfrequently  extends beneath the latter.
  The causes of onychia  have been already stated; they are, direct
violence or injury, continued irritation from in-growing nail, and the
constitutional and specific affections, eczema, scrofula, and syphilis.
The cause of onychia maligna  must be referred  to some  general de-
rangement of the constitution, probably mal-assimilation and cachexia.
  Treatment.—The medical management of onychia from external
injury, must be the same as that for injury in other parts of the body,
with the exception of reducing the thickness of the nail by scraping,
which is applicable to every form of the  disease, and paring the nail
so that it may  not press on the  inflamed skin, and increase the local
irritation.   Thinning of the nail,  besides rendering it pliable,  also
facilitates the  evacuation of pus, or the removal of foreign bodies
impacted beneath it.
  In  onychia,  from  in-growing nail, the removal of the cause,  the
relief from pressure, complete rest, thinning and paring the nail, and
the application, if necessary, of nitrate of silver to the exuberant granu-
lations, are generally successful.   Where  a fetid discharge is secreted,
the solution of the chloride of lime is a necessary part of the treat-
ment  in all cases of onychia,  and is, besides, an useful stimulant.
Other local remedies are, the benzoated ointment of oxide of zinc, an
ointment of Peruvian balsam, the yellow basilicon ointment, and strap-
ping  with adhesive  plaster.  It is sometimes useful to introduce  a
piece  of lint, either dry, or coated with ointment, beneath the swollen
and overhanging  skin along the border of the nail.
  The constitutional forms of onychia call for a treatment adapted to
the particular disease of which they are a part, whether eczematous,
scrofulous,  syphilitic, or  malignant.   And constitutional remedies
must  be made  a leading part of the general management.  The best
local  application  in  eczematous onychia is the benzoated ointment
of oxide of zinc.  Scrofulous onychia  will  require gently  stimu-
lating remedies, after the primary heat and inflammation have been
subdued by cooling lotions,  fomentations, and water dressing,  or
poultices.   For  the  syphilitic onychia,  besides  local antiphlogistic
treatment as long as  inflammation continues, the applications should
consist of mercurial ointments.  But this  form of onychia will always
yield  to constitutional  means.  Onychia  maligna calls for the use of
alteratives and tonics;  and severe local  treatment is  sometimes re-
quired, such as caustics, the actual cautery,  and  avulsion of the  nail. 
HISTORY OF  THE  ITCH-ANIMALCULE.
659
                  CHAPTER  XXIV.

   HISTORY AND DESCRIPTION OF THE ITCH-ANIMALCULE.

                        ACARUS SCABIEI.

  A popular  knowledge of the existence of the itch-animalcule 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 synonym.  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.
  The earliest  scientific  information  relative to the itch-animalcule
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, anti-
quitate ignotum fuisseTho. a Veiga falso memorat, nam ipsum axo^iSiov
Aristoteles vocat."  (5 Histor. Animal., cap. 32.)
  That the itch-animalcule was well known to the Greeks may also
be inferred from the names siro and acarus  by which it is designated,
for, according to Moufet, both of these terms are derived from  the
Greek language.  " Syrones item dici videntur, d*6 toi ove.$r;v, 'sertsw quia
tractim sub cute  repunt"   And again he observes, " tb yae dxa^sj, teste
Polluce et Suida, exiguum ilium dicitur, quod ab exiguitate non pos-
sumus xt^oi, id est, dividere."
  The Arabians were also acquainted with the animalcule at a very
early period, for we  find Abinzoar, in  the  twelfth century, thus
speaking of  them:  " Syrones Assoalat et Assoab dicti, sunt pedicelli
subter manuum  crurumque  et pedum cutem  serpentes et pustulas
ibidem  excitantes aqua plenas : tarn  parva animalcula, ut vix visu
perspicaci discerni valeant."1  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 praeter  Abinzoar qui morbum hunc vidit
et curationem ejus recte instituit."
  The Romans named the itch-animalcule pedicellus; and from several
quotations made by Moufet,  we learn that the Boman physicians were
well acquainted with  it.
1 Moufet, Theatrum Insectorum, p 266. 
660
HISTORY OF THE ITCH-ANIMALCULE.
   Scaliger, in his letter to Cardan us in 1557, remarks that the acarus
is globular in form, and so minute as to be scarcely perceptible.  The
Turinians, he observes, called it scirro, and the Gascons, brigant.  The
little creature  lives in canals which it  burrows in the  epidermis, 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.1
   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, observes,
"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 unfortunately
invalidates this testimony by supposing them to be the hidden cause
of porrigo, for, says he,  " nascuntur saepe in capite et pilorum radices
exedunt, quos Graeci  *e<>xo$e«>*(n>$,  te^xooe^xta-i, <»?*«$, -re^xo^ovt, tineas
peculiari nomine appellant."
   Aldrovandus, also,  in 1596, draws attention to the minute size of
the pedicello, its resort  in burrows  beneath  the  epidermis, and its
excitation of vesicles,   ne remarks that we need sharp  eyes and good
light in order to perceive it.
   Moufet, in his  famous work already referred  to, the " Theatrum
Insectorum," published  in 1634, by Sir "Theodore  Mayerne, after the
death of its author, but commenced during the preceding century by
Wotton, Gessner, and Penn, gives the first  account of the itch-ani-
malcule published by an  English  writer.  In  this  volume we find
recorded a very complete description of the  creature, and the most
important  facts with regard to  its habits are accurately noted.  In
truth, little is known on the  subject,  at the present day, that was not
already pointed  out by that distinguished writer.  In reference  to
their size and form, he  observes,  "Syronibus nulla expressa forma
(ut recte  Scaliger  notavit)  preterquam  globi:  vix oculis  capitur
magnitudo tam pusilla, ut non atomis constare ipsum, sed unum esse
ex atomis Epicurus dixerit."  In another place he remarks, " Animal-
culum  est  omnium minutissimum;" its  color,  "est  albicante, capite
excepto; propius 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 the situation in which it is usually found,
" Ita sub  cute  habitat, ut actis  cuniculis pruritum maximum  loco
ingeneret;" and  again,  "Mirum est quomodo tam  pusilla bestiola
nullis quasi pedibus incedens, tam longos sub  cuticulla sulcos peragat.
Hoc obiter est observandum, syrones istos non in ipsis pustulis sed
prope  habitare."   He,  moreover,  rebuts  the notion of their being

              1 Exercitatio 194; de Subtilibus; num. 7. 1557. 
           observations of  moufet—ETMULLER.        661

allied to  pediculi, and defends Aristotle against such an insinuation.
"Neque syrones isti sunt de pediculorum genere ut Johannes Languis
ex Aristotele videtur asserere: nam ilia extra cutem vivunt, hi vero
non :  neque revera Aristoteles ullo quod sciam scripto inter pediculos
acaros numeravit."   His inference respecting their orign, drawn from
their habitation, savors rather of the times than of the truth.  " Illorum
quippe proprium est non longe residere ab humore aqueo in" vesicula
vel pustulacollecto: quo absumpto, vel exsiccato, brevi omnes intereunt.
Unde  colligimus, quemadmodum  ex sero putrefacto  exoriantur, sic
eodem vicissim sustentantur."   Moufet  falls  into  the pardonable
error, since repeated by several modern authors, especially by Lin-
naeus, 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 mites, " sed in homine wheale wormes
dicuntur, et Germanice, Seuren."
  In  the year 1654; Augustus  Hauptmann, a German physician,
published  a  work  on  baths,1 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 first figure of the animalcule; which
is referred  to by Bonanni, both in his own work and in his edition of
Kircherius, in the following terms:  "Monstrosam eorum figuram
cum permultis et oblongis post tergum caudis depinget."
  Haffenreffer, in 1660, also  a German  physician, alludes to the
acarus as a species of pediculus of very minute size, breeding between
the epidermis and the derma.2
  In 1682, a short notice of the  animalcule, attributed to Etmuller,
is given in the first volume  of the Atta Eruditorum Lipsie?  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: " Dorsom sit squammosum seu squamis cooper-
tum."  The author gives the following description of them : " Colore
sunt  albicante et  pedibus  exceptis, qui  propius  intuenti nigricare
videntur, pedibus sex instructi sunt, binis utrinque mox juxta cafput
positis, quibus talparum  ritu canaliculos  sub cuticul&  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  afford a  tolerably fair  representation of  the
general characters of the animalcule.
  During  the  following year, namely, in  1683,  Giovanni  Cosimo
Bonomo published his letter to  Bedi,5 which  was  translated  into

  1 TJhralten Wolkensteinischen Warmen Bad und Wasser schatze, 8vo.  Dresden.
  * Nosodochium cutis afTectfts.  Ulmse, 1660.
  3 For September, 1682, p. 317.             4 Trac. Physic., par. i. cap. 21, 1798.
  6 Observazioni intorno, a pelicelli del corpo umano del G. Cos. Bonomo, in  una
lettera al Fr. Redi. 
662
HISTORY OF THE  ITCH-ANIMALCULE.
Latin by Lanzoni,1 in 1692.  An  abstract of  this letter was read
before the Royal Society by Dr. Mead, and published in the Philoso-
phical transactions2 for 1702.  Bonomo gives a more perfect  account
of the acarus  scabiei than had  hitherto  existed.  His  attention was
first drawn to the subject by meeting  with the  popular name of the
itch-animalcule in his Vocabulario delV Academia della Crusca, followed
by  the   accompanying  explanation : " Pellicelh  e  un piccolissimo
Bacolino, il quale si genera a Rognosi in pelle e rodendo cagiona un!
acutissimo pizzicore."  He then betook himself to researches with the
view  of  determining the  truth  of  this definition, in  which he was
aided by his  friend  Hyacintho  Cestonio, who informed him  that he
had seen " mulierculas propriis  e scabiosis filiolis acus extremitate,
nescio quid educere, quod in  laeve maniis pollicis ungue,  alterius
maniis pollicis  ungue compressum, in  ipsa compressione aliquem
parvum sonum facere videtur, hoc autem educi a minutioribus tuber-
culis  scabiosis,  perfecta  nondum sanie scatentibus, vel ut vocitant
immaturis ; mutua quod itidem charitate  inter remiges et mancipia
Balnei Liburnensis, si scabies  infestaret  fieri, adnotavit."   Having
obtained  one of  the  animalcules,  Bonomo examined it with the
microscope, and " found  it to be a  very minute living creature, in
shape resembling a tortoise, of a whitish color, 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 the snout.3
  Bonomo gives two rude figures of the animalcule, which are inferior
to those in the Acta Eruditorum, and must have resulted from the use
of 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 deserving of attention  ; the  first is,
his comparison  of  the siro with a  little  bladder  of water; and the
second,  his  observation  relative   to their  habitation in  vesicles,
" immaturis ;" both of which are invaluable as aids in seeking for the
animalcule.
  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.
  In  1691, Philip Bonanni, in  Observationes circa viventia que in rebus
non viventibus reperiuntur, as well as in his edition of  the Rerum Xatura-
lium of Kircherius, refers to the opinions of Bochartus, Kircherius, and
Borellus.  Kircherius found these minute creatures, "candidi puncti
similitudinem,"  when examined with the microscope, to be "animalia
pilosa et prorsus urso  similia."  Borellus, he  observes,  " histrici
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 Historiarum et
Obscrvattonum Medico-physicarum, under the title of " Ulcera pedicu-

  1  Observationes circa humani Corporis  Teredinem.  In Miscell. Natur.  Curios.
for 1692.
  8  Philosophical Transactions, vol. xxiii. p. 1296, pi. 283.
  3  Philosophical Transactions, abridged, vol.  v. p. 199. 
           OBSERVATIONS OF BAKER —WICHMAN N.        663

losa,"' he records an instance of vesicular affection apparently identical
with scabies.  Bonanni gives four figures of the animalcule, one from
Bonomo's letter, two from 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."2  In size it was
about equal  to a grain of sand;  and he concludes his description
with the following question : "Unde nam istos animatorum semiato-
mos erupisse judicabimus?"  From  the examination of his figure,
which is of large size, and exceedingly rude, and from  his statement
that four of the little animals were  sent to him  by Baldigianus, a
professor of mathematics in Rome, and who had extracted them from
the face of one of  his  scholars, it  is quite  evident that they are
pediculi pubis, and not acari.  Bonanni recopies the four figures from
Kircherius.3
   In 1744,4 Baker, in a curious work, entitled the Microscope made
easy,  for the  perusal of  a copy of which I am indebted to my kind
friend,  Dr. Grant, remarks, "The  microscope has discovered what,
without it, could scarcely have been imagined, 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.
   In 1762, Casal, a  Spanish physician, in a  work, entitled  Medical
Researches  on the Asturias, referring  to  the burrowing and grubbing
habits of the acari, remarks, " Vocantur aratores, et  inerito, arant
enim semper inter cuticulam et cutem."
   In 1786, Dr. Wichmann, of Hanover was induced to verify  the
prevailing opinion of the existence of an animalcule in connection
with scabies, and the results of his labors are published in a  volume
entitled  jEliohgie der Kraetze?   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, Schaeffer has
antenne pediformes articulate,  while 'Baron  de Geer expressly says,
they have no antennae, but two arms  with  joints, which resemble
those of spiders, which have likewise no antennae."  He alludes also
to the opinion  of Linnaeus,  that  the acari  farinae might  be con-
veyed, 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,6 "that pre-
vious to any appearance of pustules (in scabies),  there 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

         i  0bs. 20.            * Fig. 114.         s  Fig. 95.
         *  This is the date of the third edition.
         5  .svo. 17S6 ; and Loudon Medical Journal, vol. ix. 17','5, p. 28.
         e De verniibus in Lepra obviis.  Gottin^en. 1709, p. 9. 
664
HISTORY OF THE ITCH-ANIMALCULE.
species by Pallas,1 for that author  remarks, "Acarus scabiei, acaro
farinae est consanguineus."  De Geer, however, distinguishes the two
species very accurately, for of the acarus farinae he observes, " Acarus
oblongus albus capite refuscente, pedibus conicis crassioribus  aequa-
libus;" and ofthe acarus scabiei, "Acarus subrotundus albus, pedibus
rufescentibus brevibus ;  posticis quatuor seta longissima, plantis qua-
tuor anticis fistulatis capitulo terminatis."  The author points out the
vesicles as the seat of habitation of the animalcule, but he observes,
that  " even before such a  transparent  vesicle  is formed, we may
often discover traces ofthe 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 themselves."   The furrows he discovers
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 give a better idea of the little  creature, as seen by  that
instrument, than any other delineations  published.  Like his pre-
decessors, he makes no attempt to describe  the zoological  characters
and structure of the animalcule.
  In  1805, Dr. Adams gives two excellent  figures of the itch-animal-
cule in a paper2 addressed to Sir Joseph  Banks, and read before the
Royal Society  in the month of April of that year.  This paper is en-
titled, "  An Account  of  the Acarus Siro, Acarus  Exulcerans of Lin-
neus ; by some considered  as the Itch Bisect."   The figures of the acarus
which accompany  this paper are superior to any  that have been pub-
lished either before or since, and are sufficient to  identify the animal-
cule completely with the acarus scabiei.  The author's observations
were  made in  Madeira,  where, it would appear,  the  creature  is ex-
tremely common, and is called ocao,  oucou, oucam.   Dr.  Adams gives
no zoological description  of the animalcule, but confines himself chiefly
to the disease engendered by its presence, and to the mode of detecting
the ocao.  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  the  end of  a "somewhat knotty" reddish
line, extending from 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 examining it under a convex  lens."   In  this he  is en-
tirely  mistaken ;  for the creature  is  deficient in the organization
necessary for such an effort, and its sudden disappearance  from the
field of his lens is rather to be ascribed to some untoward  movement
occurring during the adjustment of his optical apparatus.  Dr. Adams
expresses himself unwilling to accord to Bouomo all the credit which
that  writer claims :  and in  reference to the discovery of the  egg,
remarks, " without suspecting  the good  intention   of this  writer, you
will  readily  admit  the  uncertain  discrimination  of the egg  of an

         1 Dissertatio de infestis viventibns, 1760, p. 2.
         1 Published in his work on morbid Poisons, 4to.,  1807, p. 293. 
              OBSERVATIONS  OF ADAMS—GALES.           665

insect, described by De Geer as about the size of a nit,  but which, on
placing it under a microscope, by the  side  of a  nit,  did not appear
more than  a fourth  part of its bulk.  For myself, I could never
discover what could satisfactorily be called an egg."
  Hitherto Dr. Adams has spoken of the ocao 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
oucoes, and that of the itch, are perfectly distinct, and  he founds this
opinion upon'the following data:—
  1. The disease of oucoes, is attended with considerable febrile dis-
turbance, 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 the  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 animalcules 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 sarna ; whereas the oucoes give them no discomfort.
  6. The dictionaries of all languages are opposed  to the similarity of
the affections, since they indicate a name for the animalcule 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 fall to the ground the moment that the  animalcule is
shown to be present in the itch, and to be the cause of that  affection.
Nor would  it be difficult to prove, seriatim, that  each of the objections
above cited is unfounded.   The figures appended  to Dr.  Adams' papers
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 is
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 endeavor to exhibit texture
also.
  The year 1812 witnessed the performance of a remarkable scene in
the memoirs of the acarus scabiei.  M.  Gales,  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 the notabilities of Paris.  The Academy applauded, the crowns were
paid, and the pencil of the artist of the  Mus6e Royale was  called to
perpetuate  the juggle.  He  drew to the life the common meal-mite!
(acarus farinae.)   It°is needless to say, that the statements put forth by
M.  Gale'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 pan-
taloon to M. GaleVs clown. 
666          HISTORY OF THE ITCH-ANIMALCULE.

  The discovery of the treachery of M. Gales was not, however, made
for a considerable  number of years, when, with some difficulty, Ras-
pail succeeded in proving the identity of the insect of Gale's with the
acarus farinae. The consequence of the exposure was universal dis-
trust, and in this  state the question 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 discovering its  lurking place in the epidermis.1
  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  treatise2 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 experiments made by himself, in reference to
the mode of treatment of the disease.   The habits of the acarus, when
placed upon the  skin, are  detailed in a chapter  of this volume, as also
are M.  Gras's experiments  with medicinal  agents  on its  powers of
vitality.  After giving a description of the animalcule inferior to that
of M. Raspail, the author  remarks,  " If we observe the mode of pro-
gression of the insect on the epidermis, 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 creature
to effect its object in this manner, but it lifts the  epidermis 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 fre-
quently perceive them to  lay several small, white, oblong, and trans-
parent eggs,  the eggs, according to  M. Duges,  being  one-third the
length of the animal."  " If we place an acarus on the epidermis, we
perceive it to dodge about here and there, following  by choice the
course of the folds, of the skin, and  every  now and the fixing itself
upon  the epidermis, and raising the posterior part of its body."
  In 1834, Raspail published his "Memoire comparatif sur l'histoire
naturelle de  I'insecte de la Gale," in which  he details the history of
modern discovery  in  France relative to the itch-animalcule, a  narra-
tive  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  first 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 indi-
cated by a white point.  His description of the animalcule is the fol-
lowing.  It  is white,  scarce a millimetre 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

  1 Some account of M. Renucci's mode of procedure will  be found in the Gazette des
Hdpitaux, and Gazette  MSdicale for 1834.
  2 Recherches sur l'Acarus, ou Sarcopte de la, Gale  de l'homme.  Par Albin Gras.
Paris, Octobre 11, 1834. 
OBSERVATIONS  OF RASPAIL.
667
presents three prominences, one, of very large size, in the middle; one,
next in size, over the abdomen; and  one near the head.  Along the
literal border of the creature, the dorsal and ventral surface join like
the carapax and  plastrum of a tortoise, and the resemblance to the
shell of this animal is increased by the projection of the head and ante-
rior legs from the space between the carapax  and plastrum in front,
between which they appear capable of retraction.  The head is pro-
vided 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 anterhr legs have four joints, and a
haunch-piece at the base of each; they are terminated by a stiff ambu-
lacrum, furnished at its extremity with a sucker.  The posterior legs
have the same number of pieces as the anterior, but are not more than
one-fourth  their  length, and scarcely project beyond  the abdomen.
Each leg is terminated 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 horny in texture; the former is surmounted  by stiff
horny  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 animal
do  great injustice to the  text; they are  inferior to those of Adams,
and also to those of Wichmann, neither of which appear to have been
know to the author; while he praises the figures of Dr. Geer, which
are inferior to both.
  Besides the authors above referred to,  some account of the acarus
scabiei will be  found  in Schenkius, Obs. 676;  in Rosenstein, on the
diseases of children; Pallas, de infestis viventibus, 1760;  Sauvages,
Maladies de la Eeau; Miscellanea Curiosa, 1692 ; Annales des Sciences
dObservation,  vol. ii. p. 446, vol. iii. p. 298,  1830 ; Lancette Francaise,
Aout,  1831; Bulletin de  Therapeutique, vol. vii;  Journal des Connais-
sances Medicates, Septembre 15, 1834.   And for the comparative his-
tory of the animalcule, Walz, de la Gale de Mouton.
  Linnaeus, from an imperfect acquaintance with the acarus  scabiei,
has been the cause of much of the confusion  and obscurity 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, eylindrica,  palpis
duobus compressis, aequalibus,  haustelli longitudine.
  Oculi duo ad latera capitis.
  Pedes octo.
  Tentacula duo,  articulata, pediformia.
  In the first edition  of  the Fauna  Svecica,2  Linnaeus describes the
animalcule under the specific  designation  of  "acarus  humanus sub-
culaneus."   In the  second edition5  he considers the acarus  humanus

       1 Systema Naturae, 1767.
       * Entomologia Faunae Suecicae.  Viller's edition, 1789.  No. 1194.
       » Anno 1761.  No. 1979. 
663
HISTORY OF THE ITCH-ANIMALCULE.
subcutaneus as belonging to the same species as the flour-mite  and
cheese-mite;  and  in  the Systema  Nature, observes, " inter sirones
Farinae, Scabiei, Phthiseos, Hemitritaei  vix etiamnum reperiri alias
differentias quam a loco petitas ;" while he admits the itch-animalcule
as a new species, under the name of " acarus exuherans."   The specific
characters of the two species he thus indicates.1—
   " Acarus siro.—A.  lateribus sublobatis, pedibus quatuor posticis
longissimis, femoribus capiteque ferrugineis; abdomine setoso.

                   " /3.  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 cuticula delitescens  observatur ab adsueto
acu facile eximitur, ungui impositus vix movetur,  si vero oris calido
halitu affletur agilis in uogue cursitat.
   "Descriptio.—Minimus, magnitudine vix lendis subrotundus, capite
vix  conspicuo, ore ut  et  pedibus  rufis sive  testaceis;  abdomen
ovatum hyalinum; in  dorso  duplici linea  lunari  seu pari linearum
fuscarum recurvatarum notatum et quasi lobo  utrinque.
   "Acarus exuherans.—A. pedibus longissimis setaceis; anticis duobus
brevibus.
   " Habitat in scabie ferine, cujus caussa est."
   In the Entomohgia  Faune Suecice of Linnaeus, edited by Yillers,2
the editor retains the above  "Descriptio" in connection  with  acarus
siro, but the " Habitat" he transfers to  acarus exulcerans, commencing
it  thus: "Habitat  in scabie ferina, sub cute hominis."  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. 1. In  Fauno Suecica, ed. 1,  acarum farinae et scabiei
separaverat Linnaeus, postea conjunxit, sed DD. Geoff, Fab., De Geer,
pro  diversis speciebus  rite"  habuerunt;  ergo vere  distincti.   Obs. 2.
Scabiei certe hie acarus caussa est."
   In the 13th edition3  of the Systema Nature, the acarus siro, com- >
prising the meal-mite and cheese-mite, is separated from acarus scabiei,
but the acarus exulcerans is retained.  The specific characters of  the
acarus scabiei are thus stated:—
   "Acarus scabiei.—A. Albus, pedibus  refuscentibus; posterioribus
quatuor seta longissima.
   "Habitat in ulceribus scabiosorum, cutis rugas sequendo penetrans,
titillationem excitans; utrum causa, an  potius, symptoma mali? Sirone
multo minor."
   Of the acarus exulcerans, Linnaeus remarks, "Habitat  in ulceribus
scabie feritiS laborantium.   An satis distinctus ab A. scabiei?"
   In the Amenitates  Academice* the  following  passages, which  are

  1 Fauna Suecica.  Editio altera, auctior, 1761, Nos. 1975,1976.
  1 Anno 1789.              ' Edited by Gmelin, anno 1788, vol. v.
  * Miraculo Insectorum.   By G. E. Avelin.  Upsal, 1752.  Amoenitat. Acaed., vol.
iii. p. 333. 
           OBSERVATIONS  OF LINN.EUS—FABRICIUS.       669

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;  the latter puts forth the unfortunate  observation
which  led Linnaeus into  error with regard to the classification of the
itch-animalcule. Speaking ofthe vesicles, the writer observes, " Parum
vero ab ilia in ruga cutis punctum quoddam fuscum quod nondum in
vesiculam se extulit, fit tamen duobus diebus progressis;  acus aculeo
lens minima eximitur, quae  ungui imposita et halitu oris afflata, in
ungue cursitat.   Oculis armatis ulterius appareat  insectum hoc octo
habere pedes, setas quasdam in dorso et acarum esse jam allatum."
"Si mater aut nutrix infantem farina cereali, in qua acari saepissime
habitant, adsperserit, infans in ea parte primo et toto tandem corpore
scabie laboravit."
   In  Sweden, Linnaeus  remarks  that the  itch-animalcule is named
Klamask.
   Schaeffer also describes the animalcule in  his Ehmenta Entomoh-
gie, in 1766.
   Baron de Geer was  thoroughly well acquainted with the itch-ani-
malcule, and has left an  admirable description of the creature, as well
as two excellent figures.1  The latter, however, are not equal to the
description.  He points  out the error of Linnaeus with regard to clas-
sification, and expresses  his conviction of the identity of acarus scabiei
and acarus exulcerans.  The specific characters of the acarus scabiei
he states to be as follows:—
   "Acarus subrotundus albus, pedibus rufescentibus brevibus; pos-
ticis 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
m6me 1'unique cause de cette vilaine maladie."
   FABRICIUS,2 in his Systema Entomohgice, places the acarus  in the
order antliata, which he characterizes as possessing  "os, haustello, sine
proboscide."  The characters of the genus he  thus designates :—
   "Acarus.—Haustellum, vagina bivalvi, cylindrica; palpi duo  longi-
tudine haustelli." To which, in the amended edition of 1794, he adds,
"antennae filiformes."
   With regard to specific characters, Fabricius adopts the definitions
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, vesiculum et titillationem excitat.  Caussam,
nee syrnptoma morbi esse  evincunt observata analogia cum  Gallis  ■
contagium cura."                  ,.«•*«
   And of the latter: "Habitat in scabie fenna.
   In  the Fauna Grenlandica,3 the same  author observes, with regard
to  acarus siro:  "Habitat in  vesicula scabiei Grcenlandorum, qui ilium

   ' Memoire pour servir a l'histoire des  insectes.  Vol. vii., 1778, p.  94, pi. 5, figs.

^Johannes Christ. Fabricius.  El. 1775, p. 813.         » Anno 1780, p. 221. 
670           HISTORY OF THE ITCH-ANIMALCULE.

acu apte eximere scientes, mihi miranti, ut vivum animal incedentem
ostenderunt.   En  Groenlandos Entomologos."   "Varietatem farinae
quidem etiam  in farina mea vidi:  an vero in Grcenlandia domi habeat,
incertus sum dum Grcenlandi farinaceis non  utuntur."  He remarks,
also, that  in Greenland the  animalcule is named  " Okok," and that in
the natural history of Bomares it is termed " Scab-orm."
  In the Entomohgia Syslemica, emendata,1 Fabricius  adopts the opi-
nion 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 following characters: Acarus
scabiei.  Albus, pedibus rufescentibus,  posticis quatuor longissima."
It is, he continues, "multo minor et  distinctus ab acaro sirone."  He
observes,  also, that this species corresponds  with the acarus exulce-
rans, and  quotes a passage from Linnoeus to the same  effect.
  Muller, in his  Prodromus Zoohgie Danice,2 adopting  the early
classification of Linnaeus,  treats of  the  itch-animalcule under the
designation of acarus siro.   In Denmark, he  observes, the creature is
called  Krid-orm, Ring-orm,  and Meel-mid.  The latter term, which,
translated, would  be  meal mite, indicates  the  popular  extension, or
possibly  the  popular  origin, of the  error of  the  great  Swedish
naturalist.
  Latreille established the itch-animalcule as a new genus  under
the name  of Sarcoptes  hominis, with  the following description:  Body
apterous;  no  distinction of head or segments;  manducating  organ
prominent, without apparent palpi; eight short  legs.   Subsequently,
however,  on the occasion of the memorable juggle of  Gales, Latreille
omitted the genus altogether.
  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 them 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 still  active,  living for several  hours
after  my  examination.  I have  alread}' 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  form,  and very aptly  resembling  the  little
bladder of water of Bonomo.  There is no difficulty in extracting it
from the  skin; the cuniculus is seen  without  difficulty; the end of
the cuniculus is perceived to be a little raised, while a reddish brown
semilunar speck is seen beneath it. As soon as this little eminence of
epidermis 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 epidermis 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.

  1  Anno 1794, vol. iv.                * Otho Fredericus  Muller.  Anno 1776. 
OBSERVATIONS  OF LATREILLE.
671
  When the acarus is seen running  upon the surface of a plate of
glass, it  may be perceived that its anterior margin presents a dusky
tint of color, and the examination  of this part of the creature with
the microscQpe 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 the cases of  certain insects,
or of the bright part of a thin  layer of tortoise-shell.  Proceeding
with our examination, we perceive 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
surface of the acarus is flat, and occupied by the head  and eight legs ;
the dorsal surface  is arched, uneven, and covered  by numerous
spines;  and projecing backwards from the posterior  segment of  the
animal are twelve hair-like filaments,  some long and others short.
  With  the view of determining the size of the acarus, I measured
ten specimens, and  found them vary  between yiT and fa of an inch
in length, and between ,fo and J* in breadth.   The following were
the measurements of seven of this number :—
Length.
  i
  i
 T2S
  1
 T 15
  1
  54
Breadth.
   ]
  T52
  _ 1
  3C3
   1
  1 4 7
  _1_
  1 43
Length.
7^
Breadth.
   l
  i 0 5
  1(7(5
   1
  53
  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 disposed with regard to the axis
ofthe animal, but chiefly transversely, and resembling a coat of plate
armor.   The connecting  membrane  of these  plaits permits of a
certain  degree of  movement between  them.  The  dorsum  of  the
creature is  convex, but  uneven,  and exhibits  upon its borders a
tendency  to division  into a  thoracic and abdominal segment,  the
former being somewhat broader than the latter.  Anteriorly the dorsal
case terminates  in  a  sharp border, which is  scalloped, and forms a
jutting roof of protection to the head, and 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  hair-bearing tubercles,  regularly and  very  remarkably
disposed.  The venter of the acarus 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  divergence of the  anterior  pair of  legs. The 
672          HISTORY OF THE ITCH-ANIMALCULE.

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 stiff hairs.   The mouth is an
oblong aperture situated  upon the under surface of the bead, and be-
coming 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 elonga-
tion or retraction beneath  the dorsal plate or carapax.
  The Ugs 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 composed 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 at each
side by the  junction of the hip-pieces of the anterior and lateral leg,
the crest being  directed backwards and inwards towards the termina-
tion of the sternal crest.  Each of the annular segments of the anterior
legs is furnished  with three or four  bristly  hairs, which stand out at
right angles from  the segment.  Moreover, the extremity of each
anterior leg is provided with a tubular cylinder [tarsus] 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 with a strong case of
chytine, which  presents the ordinary color of insect cases, namely,  a
brownish  red.  The plastrum  is slightly tinted with a similar hue,
but the three crests formed by  the  hip-pieces are, iu virtue of their
thickness, of a deep color.   These are the red lines of Gras, Raspail,
and others.   The posterir legs have  but a-thin  case of chytine, and
are less deeply colored.  The colored 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 thoracic
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, mem-
branous, 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 mounted on
short tubercles are found on each side of this opening, near the poste-
rior  margin of the abdomen.  These four  filaments, with the  four
hair-like organs of the posterior legs, and the four directed backwards
form the lateral  part of the thoracic segment, from the twelve hair- 
STEATOZOON FOLLICULORUM.
673
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 effectually to  prevent the  retro-
gression 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 differences 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 ; and 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.


     HISTORY AND  DESCRIPTION OF THE  STEATOZOON
                         FOLLICULORUM.

   In the course of some researches directed  to the investigation 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 designa-
tion acarus folliculorum?  Dr. Simon's researches have hitherto been
directed  principally to the  cutaneous  follicles of the nose,  where he
finds the parasite with astonishing frequency, even in cases where the
skin presents  all the characters of ordinary health.   Of living persons,
he detected the animal in three out of ten men  in the sebaceous matter
squeezed out by pressure from the follicles; but in the dead he dis-
covered them  in almost every individual examined, the only excep-
tions 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 imbedded in the sebaceous matter are found in the
hair-follicles near the outlet, their long axis corresponding with that
ofthe 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
from 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 found them
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 creature
varies  from 0.085 to 0.125 of a line (German) in length, and 0.020 of

  1 Miiller's Archiv., 1S42, p. 218.  Ueber eine in den kranken und normalen Haars-
&cken des Menschen lebende Milbe.
       43 
674
HISTORY AND DESCRIPTION OF  THE
 a line in breadth ; it has an elongated figure, 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 a proboscis situated between the
 two.  The palpi are bi-jointed, and terminated by several small teeth-
 like  processes.  The proboscis, which  is capable of elongation  and
 retraction, 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 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 \eg is
 terminated by three claws, one long, the  other two short.   From the
 anterior part of the basis of each leg a double line  runs transversely
 inwards across the under surface of the thorax, towards the  middle,
 where one ofthe lines passes forwards and the other backwards, serving
 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 cor-
 responding with the second pair of legs.  The abdomen is marked by
 a number of transverse lines produced by  a series of grooves or con-
 tractions,  which give the margin a resemblance to a file.  The contents
 of the abdomen are granular,  and similar to those of pigment cells,
 and among  these  granules are several large transparent spots,  of a
 round, oval, and sometimes quadrate form,  like globules of oil.   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 abdomen
 is more or less  obtusely pointed posteriorly, and marked  by the  cha-
 racteristic 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  contents are
 more lightly tinted.
  To what part ofthe 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  organization, and especially the
 great distinctness of its different pairs of legs,  betoken  it  to belong
 to the great  division Insecta, of Linnaeus.   Of this extensive group,
 the parasite before us appertains  to  the class Arachnida, for there is
 no separation between the head and thorax,  there are no antennae, and
 it has four pairs of legs.  Judging from  the  form of  its mouth it
 should belong to the order Acarus.   The proboscis is the under lip
 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 proboscis are the maxillary 
                 STEATOZOON  FOLLICULORUM.              675

palpi.   The different forms in which the creature has  been seen  are
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 abdominal 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.  On,the other hand, Hartig
has observed and  described in the mite of the pinegall (Oribata geni-
culata, 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
joint-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 between 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 (Tricho-
monas  vaginalis),  which this observer considers to belong to  the
Infusoria, and, according to others,  is more nearly related to Acarus,
differs in many points, according to Donne"'s description and figure,
from  the  acarus of  the  hair follicles.   For instance, it is  often  not
more  than double  the  size of a blood-corpuscle, and at  most y^ of a
line long;  it has a round or elliptic-shaped  body, with a  whip-like
appendage in front, and along one of its sides several fine fibres.1
  Again,  as  the  animalcule of the hair-follicles has not  yet, as we
conjecture, been seen in  its perfect shape, it is possible, although little
probable,  that this last  stage of development may correspond with
some  already  known mite.  In no case, however, could the animal-
cule, for the before-mentioned reasons,  become  one of the ordinary
parasites of  the  human skin ;  but 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 folliculorum.
  About six times have I seen, both in the comedones of living per-

  1 The trichomonas  vaginalis, with which I am well  acquainted, bears no resem-
blance whatever to the steatozoon  folliculorum.  The trichomonas  is a globular sac,
slightly drawn out to  a point, and having connected with this point a flexible and
mobile pedicle, which acts  the part of a  sucker.  The sac measures about J5»5(J of an
inch in diameter.  I have not seen Donne's figure. 
 676         HISTORY AND DESCRIPTION OF THE

 sons, and in the hair-follicles of the dead, a heart-shaped body, having
 a  small  process projecting from its  broader  end.   This body was
 somewhat longer than the breadth ofthe animal, of a brownish color,
 and appeared to be filled with a granular substance.  In the hair-
 follicles it was always close to the animalcule, but not connected with
 the latter. This observation, with the fact of the non-resemblance of
 the heart-shaped body to 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 sometimes drawn back.
 The legs can also be moved in various directions, and the creature is
 often seen to move them backwards and forwards, like a pendulum;
 they can also be retracted  or stretched forth.  The thorax and body
 admit of being curved.  Although the creature makes all these move-
 ments, it does not walk, but merely changes its position  from side to
 side; once, indeed, I saw an acarus walk 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., the latter six per cent.  But  he 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.
  After perusing the account of the steatozoon folliculorum, as given
 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.
  I was not long in obtaining subjects;  almost every face I met sup-
 plied me with abundance;  and the difficulty seems to be, not to find
 the creature,  but to find any individual, with the exception, according
 to Dr. Simon, of newly-born children, in whom  these  animalcules do
 not exist.  It is  by no means necessary to commence our search  by
 selecting an acne punctata,  or even a comedo; almost every collection
of sebaceous  substance which can be squeezed forth from the num-
berless cutaneous apertures upon the nose, the forehead, the face, and
 probably  from other parts of the body, will furnish  subjects.   More-
 over, 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 animalcule.
  The steatozoon folliculorum would seem to give rise to no uncom-
 fortable effects  by its presence, unless, perchance, it should multiply
 to such' an extent as to become a source  of irritation  to the follicle, a 
STEATOZOON FOLLICULORUM.
677
supposition which Dr. Simon admits, for it is found in 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 imbedded, 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 held together.  Hitherto, I have
confined my examination to living persons, having levied for con-
tributions among my more intimate friends, and  have not as yet had
recourse 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 described
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 fractions of
an English inch, according to my examinations:—
         Entire length.      Length of abdomen.    Breadth of thorax.
            T35                527"               555
             1                  1                  1
             B4"                55               555
  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 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 considerable  portion of the
head.  Each is composed of three segments, and 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,  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.
On the under part of the first segment of the maxillary palpi I have
observed a circle, which appears to me to bear some resemblance to
an eye; upon this point, however, I am not perfectly satisfied.
  The triangular organ, which includes the mouth of the creature, is
composed of three elementary  parts, namely: 1.  Of a triangular pro-
cess a prolongation of the membranous case of the animal from the
neck along the middle line of the upper surface 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 posi- 
678           HISTORY AND DESCRIPTION  OF  THE

tion  with regard to all the other cephalic organs.   3. Of another tri-
angular narrow process, situated on the under part of  the head, and
composed of two lateral pieces.

               Fig. W.                         Fig. X.
Fig. Y.
 Fig. W —The steatozoon seen upon its rentral surface.  The structure ofthe head, feet, and plastrum
is shown, as well as the annulate character of the abdomen.  The figure is drawn to a scale of a line
to the 1-2500th of an inch.
 Fig. X.—The steatozoon viewed upon its dorsal aspect.  The head is retracted within the thorax.
 Fig. Y.—The steatozoon viewed upon its lateral aspect.  The serration of the abdominal segments is
somewhat exaggerated in all the figures.

  The head is connected to the  anterior segment of the thorax by a
loose membrane, marked on its  surface  by transverse lines,  which
indicate its susceptibility of being thrown into folds.   This membrane
is intended to admit of the retraction and  extension 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, the
fold of  the cervical membrane forming a  perfectly straight border in
front.  This is a peculiarity in the structure of the animal which has
been  passed  over by Dr. Simon;  he makes  no allusion  to any such
power,  and he undoubtedly would have done so had he observed it,
for the effect  of the  retraction  is too remarkable not to be instantly
recognized.   In fact, when an animalcule is alternately retracting and
extending its head, the impression to 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 seg. 
STEATOZOON FOLLICULORUM.              679
ment of the thorax.  The appearance presented by the animal during
the retraction of its head is represented in the wood engraving, fig. X.
  The movements of the  maxillary palpi are flexion of the last two
segments, the first segment appearing to be  firmly connected with its
fellow of the 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 segments 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
extremity 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 laterally to a slight  extent.
  The thorax, which is the  broadest and thickest part of the animal,
and somewhat tun-shaped, is flattened on its under surface.   It is com-
posed of four broad segments, which are joined by a connecting mem-
brane on the dorsum and sides  of the creature, but are continuous
inferiorly with the broad and strong plastrum which covers the whole
inferior 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 the 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 interspaces
between  the  legs and  centrally  bifurcate, one passing forwards  to
unite with the line in front, the other passing back, to become con-
tinuous with that behind.   The same arrangement takes place on the
opposite side, and  a sternal line, consisting  of a double crest, is con-
sequently formed.   The ridges of the plastrum here described being
thicker than the rest of the covering of the animal, are strongly and
characteristically marked.
  The segmented structure of the thorax, permits of a certain degree
of movement in this part of the creature.
  The legs, which  are eight in number, are  connected with the sides
of the 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
fino-er-like claws.  Each leg is composed of three segments, of a proxi-
mal segment, which is large, and almost triangular in form, the base
of the  triangle (scalene) being directed 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
\e<* and places it on a flat surface, the two small segments are directed 
680
STEATOZOON FOLLICULORUM.
forwards, and, by their under side,  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  observation 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
from 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 itself.  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 from 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  from  before  backwards.  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 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 on  the under surface of
the abdomen, near its extremity.
  The annulated structure of the abdomen which is here described,
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-globules.  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  are variable in point  of size,
some being  exceedingly minute, and others of moderate bulk; they
are assembled in such considerable number in the abdomen, as to give
it a dark appearance, and forming a thin stratum on the inner surface
of the integument,  they obscure the alimentary canal.   Sometimes
the cells are confined to the abdomen,  but more  frequently they ex-
tend into the thorax, forming a  narrow line, that may  be traced
almost as far as the head.   By careful 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  infundi-
buliform extremity at the anus.   The transparent cell-like organs
seen in the abdomen of the perfect animal, I  regard as dilatations,
or convolutions of the alimentary canal; and a dark, brownish mass
in the  commencement  of  the abdomen I  consider to  be the liver.
I have been unable to discover any sexual differences in the numerous
examples which I have examined. 
SELECTED FORMULA.
681
                       CHAPTER  XXV.


                         SELECTED  FORMULAE.

   Solutio solventis mineralis ;  De Yalangin ; vel,  Liquor aciDi
                         arseniosi hydrochlorici.
         R.—Acidi arseniosi .......  gr. xxx.
              Acidi hydrochlorici  ......  gr. xc.
              Aquae destillatae......|xx.
  Dissolve the arsenious acid in the hydrochloric acid diluted with one ounce of the
distilled water ; then add the rest of the water.  This solution contains one grain in
a little more than five drachms, consequently is somewhat less than half the strength
of Fowler's solution, which contains one grain in two drachms.

                 MlSTURA ACIDI ARSENIOSI HYDROCHLORICI.
         R.—Solut. solventis  mineralis, De Valangin   .    .  3ij. ^ij.
              Acidi hydrochlorici diluti     .     .     .    •  3J« 9J-
              Syrupi simplicis    ......  §iss.
         M.
  A drachm to be taken in an ounce of water, with meals, three times a-day.

              MlSTURA  HYDRIODATIS HYDRARGYRI ET ARSENICI.
         I£.—Liq. hydriodatis hydrargyri et arsenici, Donovani §ss.
              Syrupi simplicis......3"iss.
         M.
  A drachm to be taken in an ounce of water, with meals, three times a-day.

                 MlSTURA FERRO-ARSENICALIS, INFANTIBUS.
         R.—Vini ferri,                                                      ^
              Syrupi simplicis    ......  aa §ss.            J
              Liquoris potassae arsenitis     .    .     .     .  n\, xxxij.
              Aquae  anethi.......3J«
         M.
  A drachm to be taken, with meals, twice or three times a-day.  Each drachm con-
tains two minims, and may be  increased to three or four minims if found desirable.

                        MlSTURA FERRO-ARSENICALIS.
         ty.—Vini ferri........3^ss-
              Syrupi simplicis,
              Liquoris potassae arsenitis.....aa 3ij.
              Aquae destillatae......3*1-
         M.
  The  dose  of one drachm contains somewhat less than four minims, and may be
administered three times a-day;  either with  or directly after meals.
MlSTURA OLEI MORRIIU-ffi CUM ARSENTCO.
j£.—Olei morrhuae .
            Vitelli ovi
            Liquoris potassa? arsenitis
            Syrupi simplicis
            Aquae destillatae
        M.
A drachm to be taken with, or directly after meals, three times a-day; for infants.
3iJ-
no. j.
ttL lxiv.

q. s. ad. i1^. 
682
SELECTED  FORMULAE.
• gr-	ij-
• &■	xij
• gr-	▼J-
• 3J-	
                          PULVIS SOD^E ARSENIATIS.
          fy.—Sodae arseniatis......gr. j.
              Sacchari albi.......gr. xlviij.
          Misce bene, ut fiat pulvis ; et divide in chartulas xxiv.

  One to  be taken three times a-day  with meals; the powder to be placed on the
tongue; for infants.  The dose for adults should be T'? or i of a grain.

                   PlLULuE SOD^E ARSENIATIS, COMPOSITE.
          R.—Sodas arseniatis......gr. ij.
                Solve in aqua destillata, q. s.
              Pulveris antimonii oxysulphureti   .     .     .  gr. xxiv.
              Pulveris guaiaci     ......  gr. xlviij.
              Mucilaginis acacias, q. s.
          Misce bene, et divide in pilulas xxiv.
  One to be taken, with meals, three times a-day.

                    PlLULjE arsenici,  quince, et ferri
          ]£.—Sodae arseniatis     ....
              Quinae disulphatis   ....
              Ferri sulphatis .....
              Extracti anthemidis  .....
          Misce bene, et divide in pilulas xxiv.

  One to be taken, with meals, three times  a-day.

                   Pilules quin^: arsenitis, composite.
          R.—Quinae arsenitis......gr.  x.
              Antimonii oxysulphureti .    .     .     .     •  9j.
              Pulveris guaiaci     .    .    .     .     .     •  3J-
              Mucilaginis acacias, q. s.
          Misce bene, et divide in pilulas xxiv.
  One to be taken, with meals, three times  a-day.

                             Pilule Asiatics.
          R.—Arsenici protoxydi......gr.lv.
              Piperis nigri.......?ix.
              Asclepiadis gigantea radicis  corticis      .     .  )|iv. ^iv.
          Misce bene, ut fiat pilulas 800.
  For mode of preparation and exhibition of these pills, see page 367.

                   Unguentum oxydi zinci, benzoatum.
                                Bell's Formula.
          I£.—Adipis preparatae......£vj.
              Gummi Eenzoini pulveris .    .     .     .     .  zj.
          Liquefao, cum leni calore, per boras viginti quatuor, in vaso clauso ; dein
               cola per linteum, et adde
              Oxydi zinci, purifioati.....§j.
          Misce bene, et per linteum exprime.

          Unguentum oxydi zinci benzoatum cum spiritu vini.

          r>.—Unguenti oxydi zinci, benzoati .     .     .     .  ~ij.
              Spiritus vini  rectiflcati.....3ij.
          Misce, ut fiat unguentum.

  Instead  of spirits of wine,  spirits of camphor,  distilled glycerine, liquor plumbi
diacetatis,  Peruvian balsam, or the juniper  tar ointment, may be combined with the
benzoated  ointment of oxide of zinc, in the same proportion as above, one drachm  to
the ounce.                                                      ' 
SELECTED  FORMULAE.
683
                       Unguentum picis juniperi.
         IJl.—Olei juniperi pyrolignici1.....%}.
             Sevi ovilli purificati......3VJ-
             Adipis purificat33......59-
         Liquefac cum leni calore et agita bene ut fiat unguentum.
  This ointment may be used of the above strength, or diluted in any suitable degree.

           Unguentum sulphuris hypochloridi, composttttm.
         r>.—Sulphuris hypochloridi.....3JJ-
             Potassae subcarbonatis   .    .    .    .    .  gr. x.
             Adipis purificatae......gj.
             Olei amygdalae essentialis.....n\x.
         Misce bene, ut fiat unguentum.

                     Unguentum sulphuris et picis.
                           For ringworm, Wilkinson.
         R.—Sulphuris sublimati,
             Picis liquidae,
             Adipis purificat.....aa .^ij.
             Cretae preparatae......§j.
             Ammonias hydrosulphureti    ....  3ss.
         Misce, ut fiat unguentum.

                Unguentum sulphuris cum oleo laurino.
                       For ringworm, Dr. Walter Dick.
         $.—Olei laurini.......§iss.
             Sulphuris vivi .    .    .    .    .    .    .  Jss.
             Pulveris camphorae .    .    .    .    .    .  gr. x.
         Misce bene, ut fiat unguentum.

                         Unguentum stimulans.
         ]£.—Pulveris cantharidis.....3VJ-
             Adipis purificati......§ iij.
         Macera, cum leni  calore, per horas viginti quatuor, et, per chartam bibulam,
             cola.
  This ointment is too strong  for use in  its  present state,  and when required  as a
stimulating remedy  should be reduced by means of any agreeable  pomatum [adeps
odorata], in the proportion of one part of unguentum stimulans to four or eight of the
diluting medium.

                       Unguentum trichogenosum.
         I£.—Unguenti stimulantis,
             Butyri oacaonis theobromatis  .     .    .    .  aa  5ij-
             Butyri jasminae.......,?ss.
             Adipis odoratae......§j«
         Misce bene, ut fiat unguentum.
  To be well rubbed  among the roots of the hair, daily, after thorough brushing.

                 Unguentum trichogenosum, Dupuytren.
         R.—Purified beef marrow.....Ij-
             Acetate of lead......3J;_
             Peruvian balsam......3jij-
             Tincture of cantharides.....§j
             Essential oil of cloves and canella  .    .    .  aa H\xv.
         Miice bene, ut fiat unguentum.

                   Unguentum trichogenosum, Gibert.
         R.—Purified beef marrow.....3vj.
             Oil of sweet almonds.....Jjij.
             Powder of cinchona bark.....3j.
         Misce bene, ut fiat unguentum.
■ The Hmle da Cade is an impure oleum juniperi pyrolignicium. 
681:                     SELECTED  FORMULA.
                       LOTIO CAPILLARIA STIMULANS.
         R.—Olei amygdalae dulcis.....§j-
             Liquoris ammoniae fortius     ....   ,^j.
             Spiritus rosmarini......%]?•    .
             Aquas mellis   .......   Jij.
         Misce, fiat lotio.

                      LOTIO CAPILLARIA REFRIGERANS.
         R.—Olei amygdalae dulcis.....§ss.
             Sodae biboratis.......9J-
             Aquas florium aurantii    .....   ^iss.
             Aquae destillatae......SVJ-
         Misce, fiat lotio.

      LOTIO HYDRARGYRI BICHLORIDI, EX EMULSIONE AMYGDALARUM.

         I£.—Amygdalarum amarum.....no. xx.
             Aquas destillatae......§vj.
         Contunde et tere simul dein cola et adde
             Hydrargyri bichloridi.....gr. xvj.
             Spiritus vini rectificati.....§ij.
         Misce, ut fiat lotio.

                         Tinctura crotonis tiglii.
         R.—Seminum contusorum    .    .     .     .    •  3J-
             Spiritus vini rectificati   .    .     .     .    .  3iv.
         Macera per dies quatuordecim et cola.

  A valuable cutaneous stimulant.

                Solutio ^therialis iodinii et mastiches.
                           Dr. Thomas Smith Rowe.

         R.—Spiritus vini rectificati   .....   gv.
             iEtheris sulphurici  ......   §iij.
                  Misce; et adjice,
             Gummi mastiches  ...    .     .     .    .   gr. xxv.
                  Solve et cola, dein adde
             Iodinii........J^ij.
         Fiat solutio.
  This solution will be found to be a valuable application for scrofulous tubercles and
eruptions, and for  the  tubercular forms  of lupus and elephantiasis.  The mastich
forms a varnish-like film on  the skin, which detains the iodine, and facilitates its
absorption.
                             Adeps benzoata.
         fy.—Adipis purificatse    .     . '  .    .     .    .  §vj.
             Gummi benzoini, pulveris.    .     .     .    •  3j«
         Tere simul, dein liquefac cum leni calore, per horas viginti quatuor, in
              vaso clauso, et cola per linteum.

  This ointment, which, with the addition  of  oxide of zinc,  is  the benzoated zinc
ointment, may be used alone, or combined with other substances ; or, it may be used
with advantage to dilute other ointments, tending to preserve  them from  rancidity,
as well as communicating an agreeable  odor.

  Note.—Since the above formulae were in print, my attention has been called to the
liquor arsenici chloridi of  the  London  Pharmacopoeia; which  corresponds  with the
liquor acidi arseniosi hydrochlorici de Valaugin, and may be taken as a proper sub-
stitute for it, but is somewhat stronger, containing about  (somewhat less) one grain
of arsenious acid in four drachms.  The liquor  arsenici chloridi is consequently less
than half the strength of the liquor potassae arsenitis, which contains two grains and
a half in four drachms.  Therefore, taking the standard dose of the  latter at five
minims,  the dose of the liquor arsenici  chloridi  should be ten minims. 
I K D E X.
	PAGE		PAGE
Abinzoar, on the acarus scabiei	. 659	Asiatic pills ....	. 367,682
Absorbent property of skin .	. 73	Atheroma ....	. 591
Acarus autumnalis	. ' . 277	Athriz calvities	. 607
folliculorum .	. 677	simplex	. 604
scabiei ....	263, 659	Atonic ulcers	. 402
Stockholmii .	. 275	Axile corpuscles	36
Achroma ....	. 535		
Acne ....	. 594	Bacchia ....	. 595
indurata	. 595	Baker, on the acarus scabiei	. 663
punctata . .	. 594	Baker's itch	. 171
rosacea	. 595	Baldness ....	. 605
simplex	. 594	Barbadoes leg	. 335
vulgaris	. 594	Barbadoes tar	. 109
Acret, Mr., case of melanopathia	. 528	Basement membrane	. 48
Adams, Dr., on the acarus scabiei	. 664	Beau, Dr., growth of nails	. 70
" on scabies in Madeira	. 265	Becquerel and Breschet, animal h<	sat . 80
Addison, on melanopathia	. 529	Bichat, abnormal situation of hair	. 602
.ffistus volaticus	. 175	Black measles	. 436
Affusion . . . .	. 455	Blactiae, vide rubeola .	. 432
Agnails ....	. 653	Blanching of the hair .	. 612
Agria .....	. 170	Bloody sweat	. 551
Albinismus ....	. 535	Bojl.....	. 245
Albinoes ....	. 535	Bonanni, on the acarus scabiei	. 662
Aldrovandus, on the acarus scabie	i . 660	Bonomo, on the acarus scabiei	. 661
Alley, Dr., on hydrargyria	. 186	Borellus, on the acarus scabiei	. 662
Alopecia ....	. 605	Bricklayer's itch .	171, 204
accidentalis	. 606	Briquet, M., treatment of variola	. 475
areata ....	. 374, 606	Bryce, Dr., vaccination test .	. 499
circumscripta	. 606	Bucnomia tropica	. 335
congenita . • y	. 606	Bullae.....	. 223
porriginosa	. 617	Bullous eruptions .	. 223
senilis ....	. 607	Burns.....	. 285
syphilitica	. 403	Burnt holes ....	. 239
unguealis	. 654		
Alphos ....	. 300	Cacochymia ....	. 99
Alphosis ...	. 535	Calcareous miliary tubercles	. 590
sethiopica	. 536	Callosities ....	r . 521
Ambustio .	. 285	Callus.....	. 521
erythematosa	. 286	Calvities ....	. 607
gangrenosa vesicularis	. 287 . 287	Cancrois .... Canities ....	. 324 . 613
Anaesthesia .	. 513	Capillaries ofthe derma	. 37
Angina scarlatinosa Anidrosis •	. 443	Carbuncle \	7, 243, 247
	. 548	Carcinoma glandulae sebiparae	. 597
Anthrax . . . • •	7, 243, 247	Casal, on the acarus scabiei .	. 663
Area . • • *	. 606	Caustics ....	. 326
Arreotores pilorum	. 35	Ceeley, Mr., on vaccination .	. 75
Arsenic, its therapeutic effects	. 109	Cerumen ....	.. 53
Arsenical preparations	. 110	Chalazion . . . . .	. 591
Arteries ofthe skin	36	Chapped nipples	. 128
Asclepias gigantea	. 366	Chaps, treatment of	. 128
 
686
INDEX.
	PAGE		PAGE
Chelois .	. 324	Ecphlysis eczema .	. 184
Chicken-pox . Chiggre Chilblain	. 482	herpes ....	. 224
	. 281	pemphigus	. 235
	. 295	pompholyx	. 235
Chloasma	. 538	rhypia ....	. 400
Chromatogenous disorders . . . 611		Ecphyma ....	. 517
Chromidrosis	. 550	Ecpyesis ecthyma .	. 220
Cimex lectuarius .	. 281	impetigo .	. 212
Cingulum......228 Classification of skin-diseases . . 82		scabies .... Ecthyma ....	. 263 . 220
Clavus ....	. 521, 522	acutum ....	. 220
Cnidosis	. 153	cachecticum .	. 221
Cod-liver oil .	. 114	chronicum	. 221
Cold affusion	. 455	infantile	. 221
Comedones	. 571	luridum	. 221
Commission of Vaccine,	report . . 502	syphiliticum	. 399
Contagion, nature of	. 431	vulgare ....	. 220
Contractility of the skin	. 34	Ectrotic treatment of variola	. 474
Copper-color, definition of . 390		Eczema ....	95, 184
Corium .	. 33	articulorum .	. 203
Corns ....	.521	aurium ....	. 202
fibrous	. 522	capitis ....	. 200
, laminated	. 521	chronicum	. 199
soft	. 523	digitorum	. 203
Cornua human a	. 584	faciei ....	. 201
Corpus papillare, vide papillary layer . 35		furfuraceum, vide pityriasis	
Corpusculum tactus	. 36	impetiginodes	. 188
Couperose	. 595	infantile	. 189
Cow-pox	. 484	madidans, vide rubrum	
Crab-louse	. 279	mamillarum .	. 202
Crusta lactea	. 189, 216	manuum	. 203
Cryptogamia in favus .	. 644	mercuriale	. 186
in sycosis	. 635	papulosum vide lichen.	
Cuticle, anatomy of	33, 39	pedum ....	. 203
Cutis, anatomy of	. 33	pudendi	. 202
Cutis anserina	. 35	rubrum ....	. 185
Cutis unctuosa	. 555	simplex ....	. 185
Cysts, serous .	. 591	solare .... squamosum, vide pityriasis.	185, 203
Dandruff.....124, 125 Dartre.......224 crustacee.....212 crustacee flavescente . . . 213		vesiculosum, vide simplex. Eczematous eruptions . Elephanta .... Elephantiasis alopecia anaesthetica	. 182 . 334 . 333 . 340 . 340
crustacee stalactiforme . 214			
de-la graisse .	. «J24	Arabum	. 336
erysipelateuse	. 185	cases of . . .	. 345
erythemoide furfuracee	. 117 124, 300, 304	existing forms of Grsecorum	. 361 . 333
rougeante	. 319	legitima	. 336
squameuse squameuse humide	300 . 184, 200	leonina .... nodosa ....	. 336 342
Decoloratio argentia Defoedatio unguium Defluvium capillorum De Geer, on the acarus i Degeneratio unguium Depilatories .	. 541 . 655 . 604 cabiei . . 669 . 655 . 604	oriental is pathology treatment of . tuberculosa Emphlysis erysipelas miliaria .	'. 336 . 343 . 357 . 336 . 131 208
Derma, anatomy of Diapompholigos . ■ Diet, in diseases of the s	33, 34 . 294 kin . . . 102	pemphigus . . vaccinia	'. 235 . 484
Dobson, Sir Richard, er Donovan's solution Dupuytren's pomade for Dyschroma	fsipelas . .141 . 313 the hair . . 683 . 525	varicella Emphyma encystis Enanthesis .... Encysted sebaceous tumors . Endermio medicines	. 478 . 591 . 153 . 591 . 74
		Ephelis ....	. 537
Ear-wax	53	alba ....	. 536
Eating hive .	. 239	hepatica	. 538
Eochymoses .	. 254	ignealis ....	. 537
spontaneae	. 255	lentigo ....	. 537
 
INDEX.
687
Ephelis scorbutica				PAGE . 540
umbrosa .			. 537	
Ephidrosis			. 542	
cruenta .			. 551	
discolor .			. 550	
olens			. 548	
partialis			. 543	
profusa .			. 542	
Epichrosis			. 525	
alphosis			. 535	
ephelis .			. 537	
lenticula			. 538	
poecilia .			. 536	
spilus			534, 601	
Epidermis, anatomy of			33, 39	
Epinyctis			. 244	
Erectile tumors				510
Eruptive fevers				. 428
Erysipelas				131
x bullosum				134
capitis . -				. 135
erraticum				134
faciei				. 135
gangrenosum .				137
mammae				135
metastaticum				. 134
miliare				134
neonatorum .				136
oedematodes .				134
phlegmonodes				136
phlyctenodes .				134
simplex .				132
umbilical e				136
vesiculare				134
Erythema			9	3, 116
centrifugum				316
chronicum				123
circinatum				118
erysipelatosum				131
folliculorum .				630
fugax				118
gangrenosum				137
ichorosum			18	6, 200
intertrigo				121
iris				230
laeve				119
marginatum .			11	9, 165
mercuriale				186
nodosum				122
cedematosum .			11	9, 134
palmare syphiliticui	n			405
papulatum				122
paratrimma .				121
pityriasis				124
plantare syphiliticu	en			405
syphiliticum .				412
tuberosum				122
vesiculare				186
volaticum				175
Essera			15	3, 168
Esthiomene serpigineuse				319
Etmuller, on the acarus scabi		ei		661
Exanthema labiale				226
Exanthemata				428
Exanthesis				144
Exormia lichen				163
milium .				590 177 174
prurigo .				
strophulus				
                ,                    PAGE
Fabricius, on the acarus scabiei   .    .   669
False measles     ....  144, 145
Favus.......637
    confertus.....637
    dispersus     .....   637
Febris erysipelatosa    ....   132
    morbillosa   .....   436
    scarlatinosa  .....   441
Felting of the hair     .    .     .    .611
Ficus unguium   .....   654
Fiery spots       .....123
Filaria medinensis     ....   282
Fish skin disease      .    .     .  556, 563
Flores unguium.....655
Follicular elevations   ....   590
    tumors       .....591
Fourcault, M.,  his experiments       .    79
Freckles......538
Frostbite......295
Furuncular eruptions   ....   243
Furunculus  .          .     .    96, 243, 245
    anthracoides.....249

Gabucinus, on the acarus scabiei         660
Gale.......263
Gales, M., on the acarus scabiei   .    .   665
Gelatio.......295
Glycerine        .....   115
Goose-skin  ......    35
Gown, red......174
Grando......591
Grantham, Mr., on erysipelas     .    .   140
Gras, Albin, experiments    .       268, 273
Grayness of the hair   .    .     .    .612
Gregory, Dr., on petechial cow-pox    .   497
Grocer's itch     ....  171, 204
Grubs      ......571
Gruby, Dr.,  on mycodermis  .     .    .   620
    researches on sycosis    .         .   635
Grutum......590
Gryllus verrucivorus   ....   520
Gum-rash.....174, 176
Gutta rosacea     .....   596

Haedromisis       .....551
Haemorrhagic measles  ....   437
Haemorrhoea petechialis      .     .    .   339
Haffenreffer, on the acarus scabiei    .   661
Hair, abnormal direction    .     .    .611
    alteration  of color       .     .    .   611
    anatomy.....54
    augmented formation    .     .    .   600
    chemical composition    ...    67
    color   .'   .     .     .    .    .59
    development.....66
    diminished formation    .     .    .   604
    diseases      .....   599
    downy.....57, 67
    felting of the.....611
    growth of the.....61
    number.....65
Hair follicles, anatomy      ...    60
    diseases      .....   629
    inflammation ....  630, 633
Hall, Marshall, on naevi     .     .    .512
Harvest bug.....277
Hauptmann, on the acarus scabiei     .   661
Hebra, burns, treatment of   .    .    .   294
    perpetual warm bath    .    .    .   294
    smallpox, treatment of   .     .    .   473 
688
INDEX.
Helmintiasis      •     •
Henderson, Dr., on molluscum
Hepatizon
Hereditary syphilis
Herpes
    auricularis
    circinatus
    esthiomenes  .
    exedens
    furfuraceus circinatus
    iris
    labialis
    miliaris
    nasalis
    palpebralis
    phlyctenodes
    praeputialis
    proserpens
    pudendalis
    squamosus
    squamosus madidans
    tonsurans
    zoster
 Herpetic eruptions
 Higginbottom, Mr., on erysipelas
 Hirsuties
 Hives
    eating
 Hordeolum
 Horn-pox
 Horns, human
 Huile de Cade
 Humid tetter
 Hydrargyria
     febrilis
     maligna
     mitis
 Hydroa
     febrile
 Hydrocotyle asiatica
 Hyperaesthesia
 Hyperidrosis
 Hypertrophia  venarum

 Iatraleptic medicines
 Ichthyosis
     congenita
     cornea
     furfuracea
     mollis
     nitida
     reticulata
     sebacea  .
     seipentina
     simplex
     spinosa
      spuria
     squamosa
      vera
      vulgaris
  Idrosis
     'maligna
      partialis
      simplex
  Ignis, persicus
      sacer
      Sancti Anthonii
  Impetiginous eruption
  Impetigo
      capitis
  PAGE
  .  282
  .  582
  .  538
  .  411
  .  224
  .  227
  .  230
  .  319
    319
300, 305
  .  230
  .  226
209, 225
  .  227
  .  227
  .  225
  .  227
  .  228
  .  227
  .  300
  .  185
  .  617
  .  228
  .  223
  .  141
  .  600
 239, 480
  .   239
 244, 247
  .  482
  .   584
 109, 683
  .   184
  .   186
  .   187
  .   187
  .   186
  .   208
  .  226
  .  367
  .  513
  .  542
  .  508 i
         I Land-scurvy
       74  Lanugo
  .  556 ' Latreille, on the acarus scabiei
   .  556 ' Legrand, M   treatment of variola
   .  569 ! Lentigo .
   .  556 ■ Leontia .
     556  Leontiasis
   .  556  Lepidosis lepriasis
   .  556 !      pityriasis
     563  Lepra   .
     556 !      alopecia medii sevi
     556 I      alphoides
     568 i      Arabum  .
      563          anaisthetos
      5641     articulationum
      556      capitis
      556      circinata
   .  542      diffusa
      554      elephantia
      543      Graeoorum
      543      guttata
      247      inveterata
  131, 228      leontina .
      131      leuoe
    .  210      medii aevi
   96, 212      merourialis
    .  216      mortificans
Impetigo erysipelatodes
    erythematica
    faciei
    figurata  .
    lactantium
    scabida  .
    sparsa
Infection, nature of
Inflammatio folliculorum
Ingrassias, on the acarus scabiei
Insensible perspiration
Inunction in erysipelas
Iodide of arsenic in lepra
Ionthus
Iron in erysipelas
Itch
    baker's  .
    bricklayer's
    grocer's .
    washerwoman's
Itch-animalcule

Jackson, Mr., case of melanopathia
Jacobovics, Dr., on molluscum
Jobertus, on the acarus scabiei
Johnson, Dr. J., on lichen tropicus
Joint evil.....
Eelis   .
    clavata
    cylindracea
    genuina  .
    ovalis
    radiciformis
    spuria
    treatment of
    vera
Keloides, vide Kelis
Kelois, vide Kelis
Kerion
Kheesah
Kibe
  PAGE
 .   215
 .   215
 .   216
 .   213
 .   216
 .   215
 .   215
 .   431
 .  633
 .   660
 .    76
 .   141
 .   312
 .   594
 .  139
 .  263
 .  171
171, 204
171, 204
 .  171
263, 267

 .  527
 .  581
  .  660
  .  169
  .  342

  .  324
  .  324
  .  324
  .  324
  .  324
  .  324
  .  331
  .  331
  .  324
  .  324
  .   324
  .   637
  .   560
  .   295

  .  255
  57,67
  .  670
  .  473
  .  53S
  .  334
 334, 338
  .  300
  .  124
   .  300
   .  340
   .  304
   . 333
   . 340
   . 340
   . 303
   . 305
   . 306
   . 336
   . 336
   . 304
   . 307
    . 334
 304, 337
    . 336
   . 186
    .  340 
INDEX.
 Lepra, nigricans
     nodosa
     phlegmntica
     rheumatica
     syphilitica
     taurica  .
     treatment of
     tuberculosa
     unguium
     vulgaris .
 Leprosy of the Arabians
     Crusaders
     Jews
     Middle Ages
 Leuce
     vulgaris .
 Leucopathia .
 Leucoethiopes
 Levitican code
 Lichen  .
     agrius
     annulatus
     circumscriptus
     confertus
     corymbosus
     disserainatus
     eczernatosus
     gyratus  .
     ichorosus
     lividus  .
     marginatus
     pilaris
     pustulosus
     serpiginosus
     simplex .
     syphiliticus
     tropicus .
     urticatus
 Lichenous eruption
 Lichenstein, Dr., on inoculation
 Line's  of motion
 Linnaeus, on the acarus scabiei
 Liquor hydriodatis  arsenici et
       gyri  ....
 Liston, treatment of erysipelas
 Lotions, in cutaneous diseases
 Lunula  ....
 Lupiform syphilis  .
 Lupus  ....
     erythematosus
     exedens .
     non exedens .
     syphiliticus
     treatment of .
     ulcerosus syphiliticus
     vorax
 Lymphatic plexus ofthe derma

 Maculae
    fuscae
    hepaticae
    nigra)
    syphiliticae
Mahon, MM., treatment of favus
Mal de la Chersonese
Mal  de la Crirnee .
Malnssimilation
Malignant tubercle
Malis acari  .
    cimicis  .
        PAGE |
       .   307 ' Malis filariae .
          836 I      pediculi .
       ■   340 j      pulicis
       .   340 Mandl, researches on the hair
       .   307 Measles
       ■   335 Meibomian  glands
       .   310 Melanopathia
       •   336      syphilitica
       .   808 Melanosis, cell3 of
       .   305 Melasma
          333 Meliceris
       .   333 Melitagra
       .   333 Mendacia unguium
          333 Mentagra
 304, 317, 337 Mentagrophyte
       .   340 Mercurial eczema
       .   535 Midivaine, Dr., treatment of
       .   536 Milia
       .   377 Miliaria
      94, 163      alba
          170      rubra
          165 Miliary eruption
       •   166      vesicles  .
       .   388 ( Milium .
       .   388 ! Moles   .
          388 Molluscum contagiosum
       ■   170      parvum  .
       •   165      pisiforme
          170      sessile
          164      simplex .
       •   165      subglobulosum
       .   165 Morbilli
          388     benigni   .
       •   165     confluentes
          164     erethrici
       .  388 Morbus heracleus
       .  168     herculeus
       .  167     inaculosus
         161      pedicularis
       .  507      pilaris
          47      pulicaris
       .  667  Morphoea
hydrar-           alba anaesthetica
       .  313      atrophica
         140      lardacea .
         103      tuberosa.
          69      alopeciata
       .  409      nigra
      .  315 Morpiones
    316, 407 Mother's marks
         319 Moufet,  on the acarus scabiei
         317 Mower's mite
      .  413 Mudar or Muddar .
      .  320 Muller, on the acarus scabiei
      .  409 Muscular fibre of skin
      .  319
          37 ' Naavi materni
                  pigmentosi
      .  525      pilosi
      .  537      vasculosi
      .   538 Naevus  .
      .   255      araneus  .
      .   387      arteriosus
      .   652      flammeus
      .   334      maternus
      .   334      pigmentosus
          99      treatment of
         597      venosus  .
      .   274 Nail-follicles  .
      .   281 Nails, anatomy
variola
    PAGE
      2S2
      277
   .   280
       62
      433
       53
    ' 526
      388
       45
      540
      591
      212
      655
      634
      635
      186
      474
   .   591
 208,  543
 208,  543
 208,  543
   •   208
 * •   208
   .   590
 534,  601
   .   573
   .   573
   .   573
   .   573
   .   573
   .   573
   .   433
   .   433
   .   441
   .   433
   .   334
   .   334
   .   255
   .   277
   .   632
   .   255
   .   369
   .   372
   •  372
   .  369
  .  369
  .  375
  .  375
  .  279
534, 601
  . 660
  . 277
  .  366
  .  670
  .    34

  .  601
  .  534
  .  601
  .  510
  .  510
  .  510
 .  511
 .  510
510, 601
 .  534
 .  511
 .  510
 .    68 
690
INDEX.
			PAGE
Nails, chemical composition		. 71	
diseases ....		. 653	
Narcosis folliculorum		. 632	
Nerves of the derma		37	
Nettlerash.....		. 153	
Nigredo cutis		. 526	
Nigrities ....		. 526	
Nirles.....		. 225	
Nitrate of silver in erysipelas		. 141	
Noli me tangere ....		. 319	
Nosophyta ....		. 636	
Ointments in cutaneous diseases		. 104	
Oliffe, Sir J., treatment of variola		. 475	
Olophlyctis ....		. 224	
labialis .		. 226	
miliaris .		. 225	
Onychia		. 656	
maligna .		. 657	
scrofulosa		. 322	
syphilitica		. 403	
Ophiasis		374, 606	
Oribata geniculata		. 675	
Osmidrosis		. 548	
Oxide of silver stain		. 541	
Pachulosis......525			
Pacinian corpuscles			38
Panaris .....			658
Papillae ofthe derma			35
Papillary layer of the derma .			35
Papulae, Willan's first order .			161
Papulae epidermicae			554
Papulous eruptions			161
Parker, Langston, on syphilis			419
Paterson, Dr., cases of molluscum			583
Pathology of the skin			91
Pearly tubercles .			590
Pediculus capitis .			278
corporis ....			278
ferox ....			279
pubis ....			279
Pemphigus ....			235
acutus ....			235
apyreticus			235
chronicus			238
confertus			235
confluens			235
congenitus			235
contagiosus			240
gangrenosus .			239
indicus ....			240
infantilis			239
iris ....			230
pyreticus . . .			23;-)
simultaneus			235
solitarius			. 238
successivus			. 235
vulgaris ....			. 235
Pemphix ....			. 235
l'en-ira, Dr., case of melanopathia			. 528
Pernio .....			. 295
Perspiration ....			51, 76
chemical composition of .			. 80
colored ....			. 550
disorders of .			. 542
morbid ....			81
Perspiratory glands			. 49
tubes			50
Petechiae
    after vaccination
Petechial scurvy  .
Phacia  .
Phaenicismus.
Phasnigmus petechialis
Phlyctenular  .
Phlyzacia
Phthiriasis
Phyma  .     <
    anthrax  .
    furunculus
    hordeolum
    sycosis
Physiology ofthe skin
Phyto-alopecia
Picton, Dr., treatment of variola
Pigment, chemistry of
    cells
Pigmentary diseases
    naevi
Pilous naevi  .
Pimply diseases
Pityriasis
    capitis
    decalvans
    labiorum
    nigra
    oris
    palmaris.
    palpebrarum .
    plantaris
    praeputialis
    pudendalis
    rubra
    versicolor
    vulgaris
Plica polonica
    caudiformis
    multiformis
Plumbe, treatment of favus
Pompholyx   .
    benignus
    diutinus
    solitarius
Porcupine disease
Pores of the sudoriferous ducts
Porphyra
    hemorrhagica
    nautica  .
    simplex  .
Porrigo abestina   .
    circinata
    decalvans
    favosa
    furfurans
    granulata
    larvalis
    lupinosa
    scutulata
    tonsoria
Porrigophyta
Prickly heat
    Johnson's observations
    Winterbottom's
Prima  .
Prurigo
    formicans
    mitis
    podicis 
INDEX.
Prurigo, pudendalis			PAGE . 179	i Roseola, orbicularis	
scroti senilis			. 179	papulata	
Pruritus			. 179 . 177, 514	punctata rheumatica	
ani general .			. 515 . 514	syphilitica vaccina	
praeputii pudendi			. 515	variolosa	
			. 516	versicolor	
scroti treatment of urethrae .			. 515 . 516 . 515	Rose-rash Rougeole Rubeola	
Psora, vide scabies Psorias confluens diffusa discreta .		94,	. 263 35, 183, 199 . 306 . 306 . 304	maligna, vide rubeola ni . nigra rosalia . sine catarrho sine exanthemate	gra
guttata .			. 304	vulgaris .	
gyrata . infantilis			. 408 . 189	Rumex gigantea . Rupia ....	
inveterata			. 307	escharotica	
labialis .			. 124	prominens	
palmaris			. 405	simplex .	
palpebrarum			. 124	syphilitica	
plantaris			. 405		
praeputialis			. 124	Saracenia purpurea	
serotalis			. .124	Satyria	
Psoriasis syphilitica			. 412	Satyriasis	
vulgaris .			. 306	Satyriasmos .	
Psydracia			. 212	Sauriderma .	
Pterygium unguis			. _ .653	spinosum	
Pulex irritans			. 280	squamosum	
penetrans			. 280	Scabies	
Puncture in erysipelas			. 141	cachectica	
Purpura apyreta .			. 255	lymphatica	
cachectica			. 255	papuliformis	
chronica			. 255	purulenta	
haemorrhagica			. 258	Scabrites unguium	
senilis			. 260	Scalds	
simplex .			. 256	Scaliger, on the acarus scabi	ei
urticans .			. 259	Scall, crusted	
Pustulae, Willan's fifth <	)rder		. 211	erythematic .	
Pustular eruptions			. 210	humid . . ■ .	
Pustule, definition of			. 211	papulous	
				running	
Rainbow ringworm			. 230	vesicular	
Raspail, on the acarus scabiei			. 666	Scalled head	
Red-gown, or red-gum rash			. 174	Scalp, diseases ofthe	
Remedies for the skin .			. 101	alopecia	
Renucci, M., on the acarus scabiei			. 666	canities	
Rete Malpighianum			. 33	eczema capitis	
Rete mucosum			. 33	erysipelas	
Retro-vaccination			. 503	favus	
Revaccination			. 500	impetigo figurata .	
Ringworm, common			. 617	sparsa	
crusted .			. 637	inflammatio folliculorum	
honeycomb			. 637	lepra vulgaris	
impetiginous			. 214	narcosis folliculorum	
rainbow			. 235	pityriasis capitis	
vesicular			. 230	psoriasis capitis	
Rosa ....			. 131	stearrhoea folliculorum .	
Rosalia, vide rubeola			. 432	trichosis furfuracea	
Roseola			. 144	plica	
aestiva			. 145	Scarf skin .	
annulata			146, 387	Scarlatina . . . .	
arthritica			. 1^0	anginosa	
autumnalis			. 146	benigna	
cholerica			. 150	erethrica	
febris continuae			. 151	gravior, vide maligna	
infantilis			. 145	laevigata	
miliaris .			. 150	maligna	*
 
692
INDEX.
Scarlatina, milliformis
    mitior, vide anginosa
    nervosa .
    papulosa
    phlyctaenosa
    plana
    putrida .
    pustulosa
    septica .
    sequelae of
    simplex .
    sine angina, vide simplex
    sine eruptione
    sine exanthemate
    torpida .
    treatment of .
    vesicular
Scarlet fever
Schaeffer, on the acarus scab
Scorbutic eruption
Scrofuloderma
    treatment of .
    ungueale
Scrofulous tubercles
Scrofulous ulcers
Scurvy
Sebaceous accumulations
    flux
    secretion
        alteration
         augmentation of
         composition of
         diminution of
         retention of
    tubercles, miliary
    tumors, encysted
         small
 Sebiferous ducts  .
 Sebiparous glands
    diseases of
 Seborrhoea  ....   555
 Sensibility ofthe skin
 Serous cysts
 Serres, Bretonneau, &  Velpeau,
     treatment of variola
 Shintrles
 Simon, Dr. G.. acarus folliculorum
 Skin, sensibility of
     absorbing power of
     anatomy of
     pathology of .
     physiology
 Smallpox
     inoculated
     modified, vide varicella
     Bpurious
     pathology of
 Soft corns
 Spasmus periphericus  .
 Spedalskhed
 Spiloplaxia indica
  Spilus
  Squamae, Willan's second orde
  Squamous diseases
  Siiuarra tondens
  Stearrhoea flavescens
      folliculorum  .
      nigricans
      simplex  .    .
  Steatoma
 PAGE
 .  442
 .  443
 .  444
 .  442
 .  442
 .  442
 .  444
 .  442
 .  444
 .  446
 .  441

 '.  445
 .  445
 .  444
 .  451
 .  442
 .  441
 .  669
 .  254
 .  322
 .  323
 .  322
 .  322
 .   322
 .  258
 .   583
 .   631
 .    75
 .   561
 .   555
 .    75
 .   556
 .   570
 .   590
 .   591
 .   590
 .    53
 .   52
 .  555
561, 632
 .   72
 .  591

    474
    228
    673
 .   33
 .   91
     7°
 !  459
 .  465
 .  4 78
 .  478
 .  467
    223
 ''.  "35
  .  335
  ..  340
534, 601
  .  2'.'8
  .  298
  .  617
  .  561
630, 632
  .   561
  .   555
  .   592
MM.
Steatozoon folliculorum
Stigma
Stimulunt remedies
Stone-pock   .
Strophulus   .
    albidus
    candidus
    confertus
    intertinctus
    volaticus
Sty, or Stigh
Sudamina
Sudatoria
    maligna .
    miliaris
    partialis
    simplex
Sudoriparous glands
    disorders of
Sunburn
Swinepox
Sycosis
    contagiosum
Syphilis, erythematous
    hereditary
    infantile
    lupiform
     papular
     pustular
     secondary
     tertiary
     treatment of
     tubercular
 Syphilitic eruption
     ecthyma
     fever
     lepra
     lichen
     maculae
     papulae  .
     psoriasis
     pustules
     roseola .
     rupia
     tubercles
 Syphiloderma
     erythematosum
     haereditarium
     papulosum
     pilare
     pustulosum
     tuberculosum
     ulcerans
     ungueale
 Syphilodermata
     classified table
     haereditaria
     mitigata
     primitiva
Tar and pitch as remedi
Teleangiectasia
Terminthus .
Tertiary syphilis
Tetter  .
    crusted .
    diffused
    dry
    humid
Therapeutics of the skin
of
316,
386,
316,
    PAGE
   .    62
   .   254
   .   106
   .   594
  94, 174
   .   176
   .   176
   .   175
   ,   174
   .   180
   .   247
   .   203
   .   542
   .   544
   .   543
   .   543
   .   543
   .    49
   .   542
   .   537
   .  481
   .  634
   .. 635
  405, 407
   .  412
   .  412
   .  409
   .  390
    .  399
   .  386
   .  404
   .  417
  390, 404
      382
    .  400
    .  382
  397, 417
    .  388
    .  387
    .   38S
    .  412
    .   399
    .   386
    .   399
    .   390
'•>, 405, 407
       3S6
    .  411

    .  403
    .  399
  390, 407
    .  410
    .  403
  .   412
  .   385
3S6,  404

109,  114
     510
244,  248
     404
     224
     212
     300
     300
     185
      97 
INDEX.
Thomson, Hale, on moll	uscum			PAGE 583	Urticaria, subcutanea		
Tilesius, case of molluscum .				. 576	tuberosa		
Tinea amiantacea				200			
capitis				617	Vaccination ....		
favosa				. 637	tests		
furfuracea				. 200	Vaccinella		
granulata		18	9, 200, 216		Vaccinia		
• lactea			189, 216		Vallecula unguis		
lupinosa			. 637		Varicella		. 478
maligna .				. 637	cellulosa		
mucosa .			18	9, 216	coniformis		
nummularis				617	globularis		
tondens .				617	lentiformis, vide vesicularis		
Tooth rash				. 174	lymphatica, vide vesicularis		
Touch .				72	papularis		
Trichiasis ciliorum				611	sine varicellis		
coacta				611	umbilicated pustulat		
Trichogenous remedies			61	0, 683	verrucosa		
Trichomonas vaginalis				675	vesicularis		
Trichomyces tonsurans				617	Varicose venules .		
Trichophyton tonsurans				621	Variola ....		
Trichosis cana				613	coherens		
decolor .				611	confluens		
furfuracea				617	discreta ....		
hirsuties				600	inoculated		460
plica				628	inserta ....		
poliosis .				613	lymphatica		
Tsorat			29	9, 304	modified, vide varicella.		
Tubercles cupped .				390	nervous ....		
miliary .				590	pathology of .		
pearly				590	secondary . . .		,
syphilitic				390	sine variolis . • .		460
Tubercula				298	spurious ....		
miliaria				590	treatment of .		
mucosa .				407	vaccina ...		
sebacea .				590	Variolation . .		
syphilitica				390	Variolae crystallinae		
annulata				397	pusillae ....		
circumscripta			39	2, 393	vaccinae		
corymbosa				392	verninosae		
disseminata				395	verrucosse		478
gummata				409	Varioloid, vide varicella		478
lupoidea				413	Variolo-vaccination		
mucosa				407	Varus .....		
uleerantia			39	9, 408	Vascular naevus		
Tubercules bigarrts				565	Veins, hypertrophy		
Tuberculum malignum				597	Vellarine ....		
Tumores gummati				409	Velpeau, treatment of erysipelas		
sebacei .				591	Verruca ....		
serosi				591	achrocordon .		
Tumors, atheromatous				591	confluens		
encysted , .				591	digitata ....		
erectile .				510	lobosa ....		
follicular				591	. maligna ....		
gummated				409	sessilis .... Vesiculae ....		
melicerous				591			
sebiparous				573	Vesicular eruptions		
steatomatous .				591	ringworm		
Turkish bath				73	Vibices ....		
Tylosis Tyria				521	Vienna paste		
			374, 606		Vigo plaster in variola . Vitiligo ....		
Ungues adunci Uredo				654 153	alba .... Vitiligoidea ....		
Urticaria				153	,		
ab ingestis conferta .				155 155	Warts .... Washerwoman's itch		
evanida . ■ -				155 Weber's experiments			
febrilis				154 Wen.....			
perstans				156	Whealworm .		
 
694
INDEX.
White blisters
Whitlow    ....
Wichmann, on the acarus scabiei
Williams, Dr. Robert, treatment of ery-
Witt, Dr., treatment of scarlatina

Xerasia     .....
Xeroderma  .....
PAGE		PAGE
. 239	Xeroderma, ichthyoides	. 556
. 685		
. 663	Zinc ointment, benzoated	104, 682
	Zittman's decoction	. 419
. 139	treatment of syphilis	. 417
. 471	Zona .....	. 228
	herpetica	. 230
. 604	ignea ....	. 228
. 556	Zoster ...	. 228
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 endeavored to carry out the author's plan by introducing such new matter and modifications of
 the text as the progress of science has  called tor.  Notwithstanding the  utmost care to keep the
 work within a reasonable compass, these udditious have resulted  in a considerable enlargement.
 [t  is, therefore, hoped that it will be found fully up to the present condition of the subject, and that
 the reputation ofthe volume as a clear, complete, aud compendious manual, will be fully maintained.

               BENNETT  (J. HUGHES),  M. D.,  F. R. S.  E.,
               Professor of Clinical Medicine in the University of Edinburgh, tec.

 THE PATHOLOGY AND  TREATMENT  OF PULMONARY TUBERCU-
  LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken
  tor or associated with, Phthisis.  One vol. 8vo.,extra cloth, with wood-cuts. pp. 130.  $1 25.

                        BARLOW  .GEORGe H.),  M.D.
                         Physician to Guy's Hospital, London, &<i.

A  MANUAL OF THE  PRACTICE  OF MEDICINE   With Additions by D.
 F. Condib, M. D., author of'' A  Practical Treatise on Diseases of Children," &c.  In one hand-
 some octavo volume, leather, of over 600 pages.  52 75.
  We recommend Dr. Barlow's Manual in tne warm-
est manner as a most valuable vade-mecum.  We
have had frequent occasion to consult it, and nave
found it clear, eoncise, practical, and sound —Bos-
ton Med. and Surg. Journal. 
4                    BLANCHARD  & LEA'S  MEDICAL
                       BUDD (GEORGE),  M.  D., F. R. S.,
                     Professor of Medicine in King's College, London.
ON DISEASES OF THE  LIVER.    Third  American, from the third  and
  enlarged London edition.  In one very handsome octavo volume, extra cloth, with four beauti-
  fully  colored plates, and numerous wood-cuts.  pp. 500.   $3 00.
  Has fairly established for itself a place among the
classical medical literature of  England.—British
and Foreign Medico-Chir. Review.
  Dr. Biidd's Treatise on  Diseases of the  Liver is
now a standard work in Medical literature, and dur-
ing  the intervals which have elapsed between the
successive editions, the author has incorporated in to
the text the most striking novelties which have cha-
racterized the recent progress of  hepatic physiology
and  pathology; so thatal though the size ofthe book
is not perceptibly changed, the history of liver dis-
eases is made more complete, and is kept upon a level
with the progress of modern science. It is the best
work on Diseases of the Liver in any language.—
London Med. Times and Gazette.
 This work, now the standard book of reference on
the diseases of which it treats, has been carefully
revised, and many new illustrations of the views of
the learned author added in the present edition.—
Dublin Quarterly Journal.
BY THE SAME AUTHOR.
ON  THE ORGANIC  DISEASES  AND  FUNCTIONAL DISORDERS OF
  THE STOMACH.  In one neat octavo volume, extra cloth.  $150.
       BUCKNILL  (J. C),  M. D.,     and    DANIEL  H. TUKE, M. D.,
Medicai Superintendent of the Devon Lunatic Asylum.    Visiting Medical Officer to the York Retreat.
A MANUAL OF  PSYCHOLOGICAL  MEDICINE;  containing  the History,
  Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY.  With
  a Plate.  In ore handsome octavo volume, of 536 pages.   $3 00.
  The increase of mental disease in its various forms, and the difficult questions to which it is
constantly giving rise, render the subject one  of daily enhanced  interest, requiring on the part of
the physician a constantly greater familiarity with this, the most perplexing branch of his profes-
sion.  At the same time there has been for some years no work accessible in this country, present-
ing the results of recent investigations in the Diagnosis and  Prognosis of Insanity, and the greatly
improved methods of treatment which have done so much in alleviating the condition or restoring
the health  of the insane.  To fill this vacancy the publishers present this volume, assured that
the distinguished reputation and experience of the authors will entitle it at once  to the confidence
of both student and practitioner.  Its scope may be gathered from the declaration of the authors
that "their aim has been to supply a text book which may  serve as a guide in the acquisition ol
such knowledge, sufficiently elementary to be adapted to the wants of the student,  and sufficiently
modern in its views and explicit in its teaching to suffice for the demands of the practitioner."
                          BENNETT  (HENRY),  M. D.
A PRACTICAL  TREATISE  ON  INFLAMMATION  OF  THE  UTERUS.
  ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease.  To which
  is added, a Review of the present state of Uterine Pathology.  Fifth American, from the third
  English edition.  In one octavo volume, of about 500 pages, extra cloth. S2 00.
                           BROWN  (ISAAC  BAKER),
                       Surgeon-Accoucheur to St. Mary's Hospital, &c.

ON SOME DISEASES OF WOMEN  ADMITTING OF SURGICAL TREAT-
  MENT.  With handsome illustrations.  One vol. 8vo., extra cloth, pp. 276.  $1 60.
  Mr. Brown has earned for himself a high reputa-' and merit the careful attention of every surgeon.
tion in the operative treatment of sundry diseases accoucheur.—Association Journal.
and injuries to which females are peculiarly subject, i   „  ,
We can truly say of his work that it is an important   Ve have  no hesitation in recommending this book
addition  to obstetrical literature.  The operative '. J"ta* c*reful attention of all surgeons who make
suggestions and contrivances which Mr. Brown de- j female complaints a partof their study anr1 practice.
scribes, exhibit much practical sagacity and  skill, ] — Dublin Quarterly Journal.
                          BOWMAN  (JOHN  E.), M». D.
PRACTICAL HANDBOOK  OF  MEDICAL  CHEMISTRY.  Edited  by C.
  L. Bloxam. Third American, from the fourth and revised English Edition. In one neat volume
  royal 12mo.,extra cloth with numerous illustrations.  {Just Ready )
                                 BY THE SAME AUTHOR.

INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING  ANA-
  LYSIS.  Second American, from the second and revised London edition.  Withnumerousillus-
  trations.  In one neat vol., royal 12mo., extra cloth, pp. 2W9. $125.
DEALE ON THE LAWS OF HEALTH IN RE-
  LATION TO MIND AND BODY. A Series of
  Letters from an old Practitioner to a Patient.  In
  one volume, royal  12mo., extra cloth,  pp. '296.
  B0 cents.
BUSHNAN'S PHYSIOLOGY OF ANIMAL AND
  VEGETABLE LIFE; a Popular Treatise on the
  Functions and Phenomena of Organic  Life.  In
  one handsome royal 12mo. volume, extra cloth,
  with over 100illustrations,  pp.234. 60cents.
BUCKLER ON THE ETIOLOGY,PATHOLOGYi
  £5«\XftE£F,¥.ENT OF FIBRO-BRONCHI-
  TIS AND RHEUMATIC PNEUMONIA.   In
  one 8vo. volume, extra cloth,  pp. ISO.  SI 25.
BI£2X AND  URINE (MANUALS ON). BY
  £°/£LWILL,lAM  GRIFFITH,  G.  OWEN
  REESE, AND ALFRED MARKWICK.  One
  thick volume,  royal 12mo.,  extra cloth, with
  plates, pp.460. «1 25.
BRODIE'S  CLINICAL  LECTURES ON  SUR-
  GERY. 1 vol.8vo. cloth. 350pp. 81 M. 
AND SCIENTIFIC  PUBLICATIONS.                     5
                        BUMSTEAD  (FREEMAN J.) M.  D.,
      Lecturer on Venereal Diseases at the College of Physicians and Surgeons, New York, &C.

THE  PATHOLOGY  AMD   TREATMENT   OF  VENEREAL  DISEASES,
  including the results of recent investigations upon the subject.  With illustrations on wood.  In
  one very handsome octavo volume, of nearly 700 pages, extra cloth; $3 75.  {Now Ready.)
  By far the most valuable contribution to this par-
ticular branch of practice that has seen the light
Within the last score of years. His clear and accu-
rate descriptions of the various forms of venereal
disease, and especially the methods of treatment he
proposes, are worthy of the highest encomium.  In
these respects it is better adapted for the assistance
of the every-day practitioner than any other  with
which we are acquainted.  In variety of methods
proposed, in minuteness of direction, guided by care-
ful discrimination of varying  forms and complica-
tions, we write down the book as unsurpassed.  It
is a work which should be in tlie possession of every
practitioner.— Chicago Med. Journal. Nov. 1861.
  Tne foregoing admirable volume comes to us, em-
bracing the whole subject of syphilology, resolving
many a doubt, correcting and confirming many an
entertained opinion, and in our estimation the best,
completest, fullest monograph on this subject in our
language.   As far as the author's labors themselves
are concerned, we feel it  a duty to say that he has
not only exhausted his subject, but he has presented
to us, without the slightest hyperbole, the best di-
gested treatise  on these diseases in  our language.
He has carried its literature  down to the present
moment, and has achieved his task  in a manner
which cannot but redound  to his credit.—British
American Journal, Oct. 1861.
  We believe this treatise will come to be regarded
as high authority in  this branch of medical practice,
and we cordially commend it to the favorable notice
'of our brethren in the profession.  For our own part,
we candidly confess that we have  received n.uny
new ideas from its perusal, as well as modified many
views which we have long, and, as we now think,
erroneously entertained on the subject of syphilis.
To sum up all in a few words, this book is one which
no practising physician or medical student can very
well afford to do without.—American Med. Times,
Nov. 2, 1861.
  The whole work presents a complete history of
venereal diseases, comprising much interesting and
valuable material that has been spread through med-
ical journals within the last twenty years—the pe-
riod of many experiments and investigations on the
subject—the whole carefully digested by the aid of
the author's extensive personal experience,  and
offered to the profession in an admirable form.  Its
completeness is secured by good plates, which are
especially full in the anatomy of the genital organs.
We have examined  it with great satisfaction, and
congratulate the medical profession in America on
the nationality of a work lhat may fairly be called
original.—Berkshire Med. Journal, Dec. 1861.
  One thing, however, we are impelled to say, that
we have met with no other book on syphilis, in the
English language, which  gave  so full, clear, and
impartial views of the important subjects on which
it treats.  We cannot, however, refrain from ex-
pressing our satisfaction with the full and perspicu-
ous manner in which the subject has been presented,
and the careful attention to minute details, so use-
ful—not to say indispensable—in a practical treatise.
In conclusion,  if we may.be pardoned the use of a
phrase now become stereotyped, but which we here
employ in all seriousness and sincerity, we do not
hesitate to express the Opinion that Dr. Bumstead's
Treatise on Venereal Diseases is a " work without
which  no medical library  will hereafter be consi-
dered complete."—Boston Med. and Surg. Journal,
Sept. 5, 1861.
                              BARCLAY (A. W.), M. D.,
                         Assistant Physician to St. George's Hospital, &c.
A  MANUAL  OF  MEDICAL DIAGNOSIS;  being an Analysis of the Signs
  and Symptoms of Disease.  Second American from the second and revised London edition.  In
  one neat octavo volume, extra cloth, of 451 pages. $2 25.  {Now ready.)
  The demand for a second edition of this work shows that the vacancy which it attempts to sup-
 Ely has been recognized by the profession, and that the efforts of the  author to meet the want have
 een successful.  The revision which it has enjoyed will render it better adapted than before to
afford assistance to the learner in the prosecution of his studies, and to the practitioner who requires
a convenient and accessible manual for speedy reference in the exigencies of his daily duties.   For
this latter purpose its complete and extensive Index renders it especially valuable, offering facilities
for immediately turning to any class of symptoms, or any variety of  disease.
  The task of composing such a work is neither an
easy nor a light one; but Dr. Barclay has performed
it in a manner which meets our most unqualified
approbation.  He is no mere theorist; he knows his
work thoroughly, and in attempting to perform it,
has not exceeded his powers.—British Med. Journal.

  We venture to predict that the work will be de-
servedly popular, and soon become, like Watson^s
Practice, an indispensable necessity to the practi-
tioner.—iV. A.  Med. Journal.

  An inestimable work of reference for the young
practitioner and student.—Nashville Med. Journal.
  We hope the volume will have an extensive cir-
culation, not among students of medicine only, but
practitioners also. They will never regret a faith-
ful study of its pages.—CincinnatiLancet.
  An important acquisition to medical literature.
It is a work of high merit, both from the vast im-
portance of the subject upon which it treats, and
also from the real aoility displayed in •■>"  elabora-
tion.  In conclusion, let us bespeak for this volume
that attention of every student of our art which it
so richly deserves - that place in every  medical
library which it can  so  well  adorn.--Peninsular
Medical Journal.
                            BARTLETT (ELISHA), M.  D.

THE  HISTORY,  DIAGNOSIS,  AND  TREATMENT  OF  THE  FEVERS
  OF THE UNITED STATES.  A new and revised edition.  By Alonzo Clark, M. D., Prof.
  of Pathology and Practical Medicine in the N. Y. College of Physicians and  Surgeons, &c.  In
  one octavo volume, of six hundred pages, extra cloth.  Price $3 00
  It ii a work of great practical value and interest.
containing much that is new relative to the several
diseases of which it treats, and, with the additions
of the editor, is fully up to the times.  The distinct-
ivefeatnrea of the different forms of fever are plainly
and forcibly portrayed, and the lines of demarcation
carefully and accurately drawn, and to the Ameri-
can practitioner  is a more valuable and safe guide
than any work  on  fever extant.—Ohio Med. and
Surg. Journal,
  This excellent  monograph on febrile disease, has
stood deservedly high since its first publication.  It
will be seen that it has now reached its fourth edi-
tion under the supervision of Prof. A. Clark, a gen-
tleman who, from the nature of his studies and pur-
suits, is well calculated to appreciate and discus*
the many intricate and difficult questions in patho-
logy.  His annotations add much to the interest of
the work, and have brought it well up to the condi-
tion of the science as  it exists at the present day
in regard to this class of diseases.—Southern Med.
and Surg. Journal. 
6
BLANCHARD &  LEA'S m*.*,xVA*.
 BRANDE (WM. T.) D. C. L.,  and ALFRED  S. TAYLOR, M. D.,  F. R. S.
       Of her Majesty's Mint, &c.             Professor of Chemistry and Medical Jurisprudence in
                                                            Guy's Hospital.

CHEMISTRY.   In  one handsome 8vo. volume of over 700 pages.   (Just Ready.)

  "Having been engaged in teaching Chemistry in this Metropolis, the one for a period of forty,
and the'other for a period of thirty years, it has appeared to us that, in spite ofthe number of books
already existing, there was room for an additional volume, which  should be especially adapted for
the use of  students.  In  preparing such a  volume  lor the press, we have endeavored to bear in
mind, that the student in  the present day has much to learn, and but a short time at his disposal for
the acquisition of this learning."—Author's Preface.
  In reprinting this volume, its passage through the press has been superintended by a competent
chemist,  who  has sedulously endeavored to secure the accuracy so necessary in a work of this
nature.   No notes or additions have been introduced, but the publishers have been favored by the
authors with some corrections and revisions of the first twenty-one chapters, which have been duly
inserted.
  For fulness of matter, for  lucidity of arrange-   This book gives in the clearest and most summa-
ment, for clearness of style, without a rival.—Lan-  ry  method possible, all the facts and  doctrines of
eet, Dec. 20,1862.                               chemistry.—Med. Times, Nov. 29, 1662.
                       BARWELL (RICHARD,)  F- R. C. S.,
                         Assistant Surgeon Charing Cross Hospital, &c.

A TREATISE  ON  DISEASES  OF  THE  JOINTS.   Illustrated  with engrav-
  ings on wood   In one very handsome octavo volume, of about 500 pages, extra cloth; $5 00.
  {Lately Issued.)
  At the outset we may  state  that the work is ' to be of much use  to the practising  surgeon who
worthy of much praise, and bears evidence of mach | may be in want of a treatise on diseases of the joints,
thoughtful and careful inquiry, and here and there  and at the same time one which contains the latest
of no slight originality. We have already carried  information on articular  affections and the opera-
this notice further than we intended to  do, but  not  tions for  their cure.—Dublin Med. Press, Feb. 27,
to the extent the work deserves.  We can only add, ! 1661.
that the perusal of it has afforded us great Pleasure. |   Thlg volume ^11 be we\eomea  both  by  the pa-
The author has evidently worked very  hard at  his j tholo<jist and the surgeon, as being the record of
subject, and his investigations into the  Physiology : muc^honest research and careful investigation into
and Pathology of Joints have been carried on in a
manner which  entitles him to  be  listened to with
attention and respect.  We must not omit to men-
tion the very admirable plates with which the vo-
lume is enriched.  We seldom meet with such strik-
ing and  faithful delineations of disease.—London
Med. Times and Gazette, Feb. 9, 1861.
                               vestigation I
the nature and treatment of a most important class
of disorders.  We cannot conclude this notice of a
valuable and useful book without calling attention
to the amount of bona fide work it contains.  In the
present day of universal book-making, it is no slight
matter for a volume to  show laborious investiga-
tion, and at the same time original thought, on the
  We cannot take leave, however, of Mr. Barwell, I part of its author, whom we may congratulate on
without congratulating  him on  the  interesting j the successful completion of his arduous task.__
amount of information which he  has compressed! London Lancet, March 9,1661.
into his book. The  work appears  to us calculated I
             CARPENTER (WILLIAM  B.), M. D., F. R. S., Sic,
          Examiner in Physiology and Comparative Anatomy in the University of London.

PRINCIPLES  OF HUMAN  PHYSIOLOGY; with  their chief  applications to
  Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from
  the last and revised London edition. With nearly three hundred illustrations.  Edited, with addi-.
  tions, by Francis Gurney Smith, M. D., Professor ofthe Institutes of Medicine in the Pennsyl-
  vania Medical College, &c.  In one  very large and beautiful octavo volume, of about nine hundred
  large pages, handsomely printed and strongly bound in leather, with raised bands.  94  25.

  For upwards of thirteen years Dr.  Carpenter's i   To eulogize this great work would be superfluous.
work has been considered by the profession gene-  We should observe, however, that in this edition
rally, both in this country and England, as the most  the author  has remodelled a large portion of the
valuable compendium on the  subject of physiology  *
in our language. This distinction it owes to the high
attainments and unwearied industry of its accom-
plished author.   Thepresentedition (which,like the
last American one, was prepared by the  author him-
self), is the result of such extensive revision, that it
may almost be considered a new work. We need
hardly say, in concluding this brief notice, that while
the work is indispensable to every student of medi-
cine in this country, it will amply repay the practi-
tioner for its perusal by the interest and value of its
contents.—Boston Med. and Surg. Journal.
  This is a standard work—the text-book used by ali
 medical students who read the English  language.
 It has passed through several  editions in order to
 keep pace with the rapidly growing science of Phy-
 siology.  Nothing need be said in its praise, for its
 merits are universally known ;  we have nothing to
 say of its defects, for they only appear where the
 science of which it treats is incomplete.—Western
 Lancet.

  The most complete exposition of physiology which
 any language can at present give.—Brit, and For.
 Med.-Chirurg. Review.

  The greatest, the most reliable, and the best book
on the subject which we know of in the English
language.—Stethoscope.
former, and the editor has added much matter of in-
terest, especially in the form of illustrations.  We
may confidently recommend it as the most complete
work  on Human Physiology in  our  language__
Southern Med. and Surg. Journal.
  The most  complete work on the science  in our
language—Am. Med. Journal.
  The most complete work now extant in our lan-
guage.—JV. O. Med. Register.
  The best text-book in the language on this ex-
tensive subject.—London Med. Times.
  A complete cyclopaedia of this branch of science.
—N. Y. Med. Times.
  The profession of this country, and perhaps also
of Europe, have anxiously and for some timeawaited
the announcement of this new edition of Carpenter's
Human Physiology.  His former editions have for
many years been almost the only text-book on Phy-
siology in all our medical schools, and its circula-
tion among the profession has been unsurpassed by
any work in any department of medical science.
  It is quite unnecessary for  us to speak of thia
work as  its merits would justify.  The mere an-
nouncement of its appearance will afford the highest
pleasure to every student of Physiology, while its
perusal  will be of infinite  service in  advancing
physiological science.—Ohio Med. and Surg. Journ 
AND  SCIENTIFIC  PUBLICATIONS.
7
                CARPENTER (WILLIAM  B.), M. D., F.  R. S.f
          Examiner in Physiology and Comparative Anatomy in the University of London.

THE MICROSCOPE  AND  ITS REVELATIONS.   With  an Appendix con-
  taining the Applications of the Microscope to Clinical Medicine, &c.  By F. G. Smith, M. D.
  Illustrated by four hundred and thirty-four beautiful engravings on wood.  In one large and very
  handsome octavo volume, of 724 pages, extra cloth, $4 00; leather, $4 50.

  Dr. Carpenter's position as a microscopist and physiologist, and his greatexperience asateacher,
eminently qualify him to produce  what has long been wanted—a good text-book on the practical
use of the microscope.   In the present volume his object has been, as stated in his Preface,  " to
eombine, within a moderate compass, that information with regard to the use of his 'tools,' which
is most essential to the working microscopist, with such an account of the objects best fitted for
his study, as might qualify him to comprehend what he observes, and might thus  prepare him to
benefit science, whilst expanding and refreshing his own mind "  That he has succeeded in accom-
plishing this, no one acquainted with his previous labors can doubt.
  The great importance of the microscope as a means of diagnosis, and  the number of microsco-
 pists who are also physicians, have induced the American publishers, with the author's approval, to
 add an Appendix, carefully prepared by Professor Smith, on  the applications of the instrument'to
 clinical medicine, together with an account of American  Microscopes, their modifications and
 accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is
 hoped, will adapt the volume more  particularly to the use of the American student.

  Those who are acquainted with Dr. Carpenter's ' medical work, the additions by Prof. Smith give it
  frevious writings on Animal and Vegetable Physio- a positive claim  upon the profession, for which we
  ogy, will fully understand how vasta store of know- doubt not he will receive their sincere thanks.  In-
 leuge he is able to bring to bear upon  so comprehen- deed, we know not where the student of medicine
 sive a subject as the revelations of the microscope;  will find such acomplete and satisfactory collection
 and even those who have no  previous acquaintance  of microscopic facts beating  upon physiology and
 with the construction or uses of this instrument, | practical medicine as is contained in  Prof. Smith's
 will find abundance of information conveyed in clear ; appendix; and this of  itself, it seems to us, is fully
 and  simple language.—Med.  Times  and  Gazette,  worth the cost of the volume.—Louisville Medical
   Although originally not intended  as a strictly! ^■ev'''ew-

                                  BY THE SAME AUTHOR.

 ELEMENTS (OR MANUAL) OF  PHYSIOLOGY, INCLUDING   PHYSIO-
    LOGICAL  ANATOMY.  Second American, from a new and revised London edition.   With
    one hundred and ninety illustrations.  In one very handsome octavo volume, leather,  pp. 566.
    $3 00.
    In publishing the first edition of this work, its title was altered from that of the London volume,
  by the substitution ofthe word "Elements" for that of " Manual," and with the author's sanction
  the title of " Elements" is still retained as being more expressive of the scope of the treatise.
                                                Those who have occasion for an elementary trea-
                                              tise on Physiology, cannot do better than to possess
                                              themselves ofthe manual of Dr. Carpenter.—Medical
                                               Examiner.
                                                The best and most  complete  expose of modern
                                              Physiology,  in one volume, extant  in the English
                                              language.—St. Louis Medical Journal.
  To say that it is the best manual of Physiology
now before the public, would not do sufficient justice
to the author.—Buffalo Medical Journal.
  In his former works it would seem that he had
exhausted the subjectof Physiology. In the present,
             ace, as it were, ofthe whole.—N. Y.
he gives the essence,
Journal of Medicine.
BY THE SAME AUTHOR.
PRINCIPLES OF COMPARATIVE PHYSIOLOGY.   New American,  from
  the Fourth and Revised London edition.  In one large and handsome octavo volume, with over
  three hundred beautiful illustrations,  pp. 752.  Extra cloth, $4 80; leather, raised bands, $5 25.
  This book should not only be read but thoroughly
studied by every member of the profession.  None
are too wise or old, to be benefited thereby.  But
especially to the younger class would we cordially
eommend it  as best fitted of any work in the English
language to  qualify them for the reception and com-
prehension of those truths which are daily being de-
veloped in physiology .—Medical Counsellor.
  Without pretending to it, it is an encyclopedia of
the subject,  accurate and complete in all respects—
a truthful reflection of the advanced state at which
the science  has now  arrived.—Dublin Quarterly
Journal of Medical Science.
  A truly magnificent work—in itself a perfect phy-
siological study.—Ranking's Abstract.
  This work stands without its fellow.  It is one
few men in Europe could have undertaken; it is one
no man, we believe, could have brought to so suc-
cessful an issue as Dr. Carpenter.  It required for
its production a physiologist at once deeply read in
the labors of others, capable of taking  a general.
critical, and unprejudiced view of those labors, ana
of combining the varied, heterogeneous materials at
his disposal, so as to form an harmonious whole.
We feel that this abstract can give the reader a very
imperfect idea of the fulness of this work, and no
idea of its unity, of the admirable manner in which
material has been brought, from the most various
sources, to conduce to its completeness, of the lucid-
ity of the reasoning it contains, or of the clearness
of language in which the whole is clothed.  Not the
profession only, but the scientific  world at large,
must feel deeply indebted to Dr. Carpenter for this
 great work. It must,  indeed, add largely even to
 is high reputation.—Medical Times.
                           BY the same author.  {Preparing.)

PRINCIPLES  OF  GENERAL  PHYSIOLOGY,  INCLUDING  ORGANIC
  CHEMISTRY AND HISTOLOGY.  With a  General Sketch ot the Vegetable and Animal
  Kingdom.  In one large and very handsome octavo volume, with several hundred illustrations.

                                  BY THE SAME AUTHOR.

A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH
  AND DISEASE   New edition, with a Preface by D. F. Condie, M. D., and explanations of
  scientific wordt. ' In one neat 12mo.  volume, extra cloth, pp. 178.  50 cents. 
8
BLANCHARD  <fe  LEA'S  MEDICAL
                           CONDIE (0. F.),  M. D., &c.
A PRACTICAL  TREATISE ON THE DISEASES OF  CHILDREN.  Fifth
  edition, revised and augmented.  In one large volume, 8vo., leather, of over 750 pages. $3 25.
  {Just Issued, 1859.)
  In presenting a new and revised edition of this favorite work, the publishers have only to state
that the author has endeavored to render it in every respect " a complete and faithful exposition ot
the pathology and therapeutics of the maladies incident to the earlier stages of existence—a full
and exact account ofthe diseases of infancy and childhood."   To accomplish this he has subjected
the whole work to a careful and thorough revision, rewriting a considerable portion, and adding
several new chapters. In this manner it is hoped that any deficiencies which may have previously
existed have been supplied, that the  recent labors of practitioners and observers have been  tho-
roughly incorporated, and that in every point the work will be found to maintain the high reputation
it has enjoyed as a complete and thoroughly practical book of relerence in infantile affections.
  A few notices of previous editions are subjoined.
  Dr. Condie's scholarship, acumen; industry, and
 practical sense are manifested in this, as in all his
 numerous contributions to science.—Dr. Holmes's
 Report to the American Medical Association.
  Taken as a whole, in our judgment, Dr. Condie's
 Treatise  is the one from  the perusal of which the
 practitioner in this country will rise with the great-
 est  satisfaction.—Western Journal of Medicine and
 Surgery.
  One of the best works upon the Diseases of Chil-
 dren in the English language.—Western Lancet.
  We feel assured from actual experience that no
 physician's library can be  complete without a copy
 of this work.—N. Y. Journal of Medicine.
  A veritable psediatric encyclopaedia, and an honoi
 to American medical literature.—Ohio Medical and
 Surgical Journal.
  We feel persuaded that the American medical pro-
fession will soon regard it  not only as a very good,
but  as the vert best  "Practical  Treatise on the
Diseases of Children."—American Medical Journal
  In the department of infantile therapeutics, the
work of Dr. Condie is considered  one of the best
  We pronounced the first edition to be the best
 work on the diseases of children in  the English
 language, and, notwithstanding all that has been
 published, we still regard it in that light.—Medical
 Examiner.
  The value of works by native authors on the dis-
 eases which the physician is called upon to combat,
 will be appreciated by all; and the work of Dr. Con-
 die has gained for itself the character of a safe guide
 for students, and a useful work for consultation by
 those engaged in practice.—N. Y. Med. Times.
  This is the fourth edition of this deservedly popu-
 lar treatise.  During the interval since the last edi-
 tion, it has been subjected to a thorough  revision
 by  the author;  and all new observations in the
 pathology and therapeutics of children have been
 included in the present volume.  As we said btfore,
 we do not know of a better book on diseases of chil-
 dren, and to a large part of its recommendations we
 yield an unhesitating concurrence.—Buffalo Med.
 Journal.
  Perhaps the most full and complete work now be-
fore the profession ofthe United States; indeed, we
may say in the English language. It is vastly supe-
which has been published in the English language,  rior to most of Its predecessors.—Transylvania Med
—The Stethoscope.                            [journal.
            CHRISTISON (ROBERT), M. D., V. P. R. S. E., *tc.
A DISPENSATORY;  or. Commentary on  the  Pharmacopoeias of Great Britain
  and the United States; comprising the Natural History, Description, Chemi>try, Pharmacy, Ac-
  tions, Uses, and Doses of the  Articles of the Materia Medica.  Second edition, revised and im-
  proved, with a Supplement containing the most important New Remedies.  With copious Addi-
  tions, and two hundred and thirteen targe wood-engravings.  By R. Eglesfeld Griffith, M. D.
  In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50.

                       COOPER (BRANSBY  B.), F. R.  S.
LECTURES  ON  THE PRINCIPLES  AND  PRACTICE  OF  SURGERY.
  In one very large octavo volume, extra cloth, of 750 pages.  $3 00.
COOPER  ON  DISLOCATIONS AND FRAC-
  TURES OF THE JOINTS—Edited by Bransby
  B. Cooper, F. R. S., &c.  With additional Ob-
  servations by Prof. J. C. Warren.  A new Ame-
  rican edition.  In one handsome octavo volume,
  extra cloth, of about 500 pages, with  numerous
  illustrations on wood.  $3 25.
COOPER ON THE ANATOMY AND DISEASES
  OF THE BREAST, with twenty-five Miscellane-
  ous and Sirrgical Papers. One large volume, im-
  perial 8vo., extra cloth, with 252 figures, on 36
  plates. «2 50.
COOPER  ON  THE STRUCTURE AND DIS-
  EASES  OF THE TESTIS, AND  ON  THE
  THYMUS GLAND.  One vol. imperial 8vo., ex-
  tra cloth, with 177 figures on 29 plates.  *2 00.
COPLAND ON THE CAUSES, NATURE, AND
  TREATMENT OF PALSY AND APOPLEXY.
  In one volume, royal 12mo., extra cloth,  pp 326
  80 cents.

CLYMER ON FEVERS;  THEIR DIAGNOSIS
  PATHOLOGY, AND  TREATMENT.  In one
  octavo volume, leather, of 600 pages.  81 50.

COLOMBAT DE L'ISERE ON THE DISEASES
  OF FEMALES,  and on the special  Hygiene of
  their Sex. Translated, with many Notes and Ad-
  ditions, by C. D.  Mkios, M.D.  Second  edition,
  revised and improved.   In one large volume, oc-
  tavo, leather, with numerous wood-cuts.  pp. 780.
                           CARSON (JOSEPH), M. D..
           Professor of Materia Medica and Pharmacy in the University of Pennsylvania

^ndph^rSTc^^  COhURShE t?F LECTURES ON MATERIA  MEDICA
  AND PHARMACY, delivered in the University ol Pennsylvania.  Second and  revised edT
  Hon.  In one very neat octavovolume, extra cloth, ol 208 pages.  $] 50

                          CURLING  (T.   B.),   F.R.S.,
.  ™ 4 «„,,   ge°n t0 the L°ndon Ho8Pital> President of the Hunterian Soeiety, Ac

SrcRC(Su)ICA^S™E  <>N DISEASES OP THE  TESTIS, SPERMA. 
AND SCIENTIFIC  PUBLICATIONS.                    9
r\xr mnn  mi?™ RCH,LL 'FLEETWOOD), M. D., M. R. I. A.
  £J,?Er TIJEORY AND PRACTICE OF MIDWIFERY.   A new American
  f W™  MUn  reT ed and enlarged London edition.  With Notes and Additions, by D. Francis
  iihwtwTti™,;   r    °r °f a, "Practical Treatise on the Diseases of Children," &c.  With 194
  {Just Issued.)   °ne VCry handsome «*»▼<> volume, leather, of nearly 700 large pages.  $3 50.

iJi?M*Ti!!Mn «M be,.n.g0 ,on? Lan established favorite, both as a text-book for the learner and as a
£ oal  »mp„ ?™?l   °" '°r ,he Petitioner, that in presenting a new edition it is only necessary
of w  ^vWnn. h, ?ie VCryuexl™ded improvements which it has received.  Having haJ the benefit
Dr PhnrVnilP« ™J ■ ie aUth°r Sln?e ,he last American reprint, it has been materially enlarged, and
ronirhlv h,nIthMm t^.H Conscienti<»"s industry is a guarantee that every portion has been tho-
encf and art rff oh^T'-h the'a,e8t resu'ts of European investigation in all departments of the sci-
for theAmericant%\2 t ■ The/eCe?.1 date f lhe last ^lin edition has not left much of novelty
toLthl;w£h*Z,t?„    lntroduce- bu« he has endeavored to insert whatever has since appeared,
2KS iTo tZ?«£  F8 aS u " exP«|-ience .has shown him would be desirable for the American
^n £  n m of Lng»«i! ^ nUmbef °[ ,lluslrations.  With the sanction of the author he has added
ZntW £ Li^ tW? dlx'fome chapters from a little "Manual for Midwives and Nurses," re-
SSti^nM™?      ,.'.beltev.ng that the details there presented can hardly fail to prove of
Tains fX Zl  hTfm  Pfa t 10neur'  Tune ,result of a11 ,hese additions is that the work now con-
 "1" ^h-"t^i^,i.re.m?-ter.Lhan the 'aSt American edition, with nearly one-half more illus-
pageTmore than Ee      "g     "^            type'the Volume Contains alrao^two hundred

*nSlSh«!,wh^n.l^r!d/?MCUre-mJimp^ven,ent in the mechanical execution of the work
EL^.tiT^   .if   r hkas received, and the volume is confidently presented as one of the
«nhfTZ !  $   a  ^USiJar been iald- befo,re tbe  Arae«can profession; while the very  low price
at which it is offered should secure for it a place in every lecture-room and on every office table.
  A better book in which  to learn  these important
points we have not met than Dr. Churchill's.  Every
page of it is full of instruction; the opinion of all
writers of authority is given on questions of diffi-
culty, as well as the directions and advice  of the
learned author himself, to which he adds the result
of statistical inquiry, putting statistics in their pro
per place and giving them their due weight, and no
more.  We have never read a book more free from
                                                                        every i
                                                 The most popular work on midwifery ever issued
                                               'rom the American press.—Charleston Med. Journal.
                                                 Were we reduced to the  necessity of having but
                                               tne work  on midwifery, and permitted  to choose,
                                               we would unhesitatingly take Churchill.—Western
                                               Med. and Surg. Journal.
                                                 It is impossible to conceive a more useful and
                                               slegant manual  than Dr.  Churchill's Practice of
                                               Vfidwifery.—Provincial Medical Journal.
                                                 Certainly, in our opinion, the very best work on
                                               he subject which exists.—JV. Y. Annalist.
                                                 No work holds a higher position, or is more de-
                                               serving of  being placed  in the hands of the tyro,
                                               the advanced student, or  the practitioner.—Medical
                                               Examiner.
                                                 Previous editions, under the editorial supervision
                                               of Prof  R. M. Huston,  have  been  received with
                                               marked favor, and they  deserved it; but this, re-
                                               printed from a very late Dublin edition, carefully
                                               revised and brought up by the author to the present
                                               time, does present an unusually accurate and able
                                               exposition  of every important particular embraced
                                               in the department of midwifery. #  # The clearness,
                                               directness, and precision of its teachings, together
                                               with the great amount of statistical research which
                                               its text exhibits, have served to place it already in
                                               the foremost rank of works in this department of re-
                                               medial science.—JV. O. Med. and Surg. Journal.
                                                 In our opinion, it forms one of the best if not the
                                               very best text-book and epitome of obstetric science
                                               which we  at present possess in the English lan-
                                               guage.— Monthly Journal of Medical Science.
                                                 The clearness and precision of style in which it is
                                               written, and the greatamountof statistical research
                                               which it contains, have served to place it in the first
                                               rank of works in this departmentof medical science.
                                               —N. Y. Journal of Medicine.

                                                 Few treatises will be found  better adapted as  a
                                               text-book for the student, or as a manual for ths
him to one book, should select in preference to all I frequent consultation of the young practitioner.__
others.—Southern Medical and Surgical Journal.   \ American Medical Journal.
                         by the same author.  {Lately Published.)

ON THE  DISEASES OF INFANTS  AND  CHILDREN.  Second American
  Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In
  one large and handsome volume, extra cloth, of over 700 pages.   $3 00, or in leather, $3 25.

  In preparing this work a second time for  the  American profession, the author has spared no
labor in giving it a very thorough revision, introducing several new chapters, and rewriting others,
while every portion of the volume has been subjected to a  severe scrutiny.  The efforts of the
American editor have been directed to supplying such information relative to matters peculiar
to this country as might have escaped the attention of the author, and the whole may, there-
fore, be safely pronounced one of  the most complete works on the subject  accessible to  the Ame-
rican Profession.  By an alteration in the size of the page, these very extensive additions have
been accommodated without unduly increasing the size of the work.

                                   BY THE SAME  AUTHOR.

ESSAYS  ON  THE  PUERPERAL FEVER, AND  OTHER DISEASES PE-
  CULIAR TO WOMEN.  Selected from the writings of British Authors previous to the close ol
  the Eighteenth Century. In one neat octavo volume, extra cloth, of about  450 pages.  $2 50.
 professional jealousy than Dr. Churchill's.  Itap
 pears to be written with the true design of a book on
 medicine, viz: to give all that is known on the sub-
 ject of which he treats, both theoretically and prac-
 tically, and to advance such opinions of his own as
 he believes will benefit medical science, and  insure
 the safety of the patient.  We have said enough to
 convey to the profession that this book of Dr. Chur-
 chill's is admirably suited for  a book of reference
 for the practitioner, as well  as a text-book for the
 student, and we hope it may  be extensively pur-
 chased amongst our readers.  To them we most
 strongly  recommend it. — Dublin Medical  Press,
 June "20, 1860.

  To bestow praise on a book that has received such
 marked approbation would be superfluous.  We need
 only say, therefore, that if the first  edition was
 thought worthy of  a favorable reception by the
 medical public, we can confidently affirm that this
 will be found much more so. The lecturer, the
practitioner, and the student, may all have recourse
to its pages, and derive from  their perusal much in-
terest and instruction in everything relating to theo-
retical and practical  midwifery.—Dublin Quarterly
Journal of Medical Science.

  A work of very great merit, and such as we can
confidently recommend to the study of every  obste-
tric practitioner.—London Medical Gazette.

  This is certainly the most perfect system extant.
ft is the  best adapted for the  purposes of a text-
book, and that which he whose necessities confine 
10                  BLANCHARD  & LEA'S  MEDICAL
           CHURCHILL (FLEETWOOD),  M. D.,  M. R.  I. A., tec.
ON THE DISEASES  OF WOMEN; including  those of Pregnancy and Child-
  bed. A new American edition, revised by the Author.  With Notes and Additions, by D. Fran-
  cis Condie, M. D., author ot "A Practical Treatise on the Diseases of Children."  With nume-
  rous illustrations.  In one large and handsome octavo volume, leather, of 768 pages.  $3 00.
  This edition of Dr. Churchill's very popular treatise may almost be termed a  new work, so
thoroughly has he revised it in every portion.  It will be found greatly enlarged, and completely
brought up to the most recent condition of the subject, while the very handsome series of illustra-
tions introduced, representing such pathological conditions as can be accurately portrayed, present
a novel feature, and afford valuable assistance to the young practitioner.  Such additions as ap-
peared desirable for the American student have been  made by the editor, Dr. Condie, while a
marked improvement in  the mechanical execution keeps pace with the advance in all other respect9
which the volume has undergone, while the price has been kept at the former very  moderate rate.
  It comprises, unquestionably, one of the most ex- I extent that Dr. Churchill does. His, indeed, is the
act and comprehensive expositions of the present I only thorough treatise we  know of  on the subject;
state of medical knowledge in respect to the diseases  and it may be commended  to practitioners and stu.-
of women that has yet been published.—Am.Journ. I dents as a masterpiece in its particular department.
Med. Sciences.                                \ —Thi Western Journal of Medicine and Surgery.
  This work is the most reliable which we possess i   As a comprehensive  manual for  students, or a
on this subject; and is deservedly popular with the  work of reff-rence for practitiimers.it surpasses any
profession.—Charleston Med. Journal, July, 1857.   other that has ever issued on the same subject from
  We know of no author who deserves that appro-  the British press.—Dublin Quart. Journal.
bation, on "the diseases of females," to the same
                             DICKSON (S.  H.),  M.  D.,
          Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia.
ELEMENTS  OF  MEDICINE;  a Compendious View  of Pathology and  Thera-
  peutics, or the History and Treatment of Diseases.  Second edition, revised.  In one large and
  handsome octavo volume, ol 750 pages, leather.  $3 75.  {Just Issued.)
  The steady demand which has so soon exhausted the first edition of this work, sufficiently shows
that the author was not mistaken in supposing that a volume of this character was needed—an
elementary manual of practice, which should present the leading principles of medicine with  the
practical results, in a condensed and perspicuous manner.  Disencumbered of unnecessary detail
and fruitless speculations, it embodies what is most requisite  for the student to learn, and at  the
same time what  the active practitioner wants when obliged, in  the daily calls of his profession, to
refresh his memory on  special points.  The clear and atlractive  style ofthe author renders  the
whole easy of comprehension, while his long experience give~ to his teachings an authority every-
where acknowledged.   Few physicians, indeed, have had wider opportunities for observation and
experience, and few, perhaps, have used them to better purpose   As the result of a long life  de-
voted to study and practice, the present edition,  revised and brought up to the date of publication,
will doubtless maintain the reputation already acquired as a condensed and convenient American
text-book on the  Practice of Medicine.
                     DRUITT  (ROBERT), M.R. C.S.,  &c.
THE PRINCIPLES AND PRACTICE  OF MODERN  SURGERY.  A new
  and revised American from the eighth enlarged and improved London edition.  Illustrated with
  four hundred and thirty-two wood-engravings   In one very handsomely printed octavo volume,
  leather, of nearly 700 large pages.   $3 50.  {Just Issued.)
  A work which like Druitt's Surgery has for so many years maintained the position of a lead-
ing favorite with all classes ofthe profession, needs no special recommendation to attract attention
to a revved edition  It is only necessary to state that the author 1ms spared no pains  to keep the
work up to its well earned  reputation of presenting in a small and convenient compass the latest
condition of every department of surgery, considered both as a >tience  and as an art; and that the
services of a competent American editor have been employed to introduce whatever novelties may
have escaped the  author's  attention, or may prove of service to  the American practitioner.  As
several editions have appeared in London since the issue of the last American reprint, the volume
has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and
improvement.   The extent of these additions may be otimaled from the fact  that it now contains
about one-third more  matter than the previous American  edition, and that  notwithstanding the
adoption of a smaller type, the pages have been increased by about one  hundred, while nearly two
hundred and fifty wood-cuts have been added to the former list of illustrations.
  A marked improvement will also be perceived in the mechanical and artistical execution of the
work, which, printed in the best style, on new type, and fine paper, leaves  little to  be desired as
regards external finish; while at the very low price affixed it will be  found one of the cheapest
volumes accessible to the  profession.
  This popular volume, now a most comprehensive I nothing of real practical importance has been omit-
Unrnv'i.J.T1'*'' ^'s undergone many corrections, ; ted ;  it presents a faithful epitome of everything re-
 h^DraeUoe nf *fj ,ldd",,,M'"d the principles and lating t, surgery up to the present hoar. *It is*de-
th* F»t«t t?£L\  ?Tl have been J&°?*ht down t0 *ervedly a popular manual, both with the student
£ sir/erVi^                              ' and P""tit,oner.-Lo*do» Lancet, Nov. 19, 1859
in surgery it is impossible to tpeak  too highly.  The
descriptions are so clear and concise, and the illus- I  In closing this brief notice, we recommend as cor-
trations bo accurate and numerous, trfct the student I d"illv as ever this most useful and comprehensive
can have no difficulty, with instrument in hand, and i hand-book.  It must prove a vast assistance, not
book by his side, over the dead body, in obtaining i only t0 the student of surgery, but also to the busy
a proper knowledge and sufficient  tact in this much practitioner wht may not have the leisure to devote
neglecteddepartmentofmedicaleducation.—British himself to the study of more lengthy volumes__
and Foreign Medico-Chirurg. Review, Jan. 1S60.    London Med. Times and Gazettt, Oct. SS, 1869.


tK"ario™sK                               ! Mttnual «?f *ur8«y »■» 'hat the surgical  student
me various improvements and additions in modern  or pructit oner  could  desire _ Dublin  OnmntrU
surgery. On carefully going over it, we find that i Journal of Med. Sciences,"noiTl859.    Qumrt,tlt 
AND SCIENTIFIC PUBLICATIONS.
11
                            DALTON,  JR. (J.  C),  M. D.
                 Professor of Physiology in the College of Physicians, New York.

A  TREATISE ON HUMAN  PHYSIOLOGY, designed for the  use of Students
  «?™nt?CL1,1°-,ll.r. 0f .Medlci"e-   Second edition, revised  and enlarged, with two hundred and
  ol.Tih  «j on l'lu^ratlonr «n  wood.  In one  very beautiful octavo volume, of 700 pages, extra
  cloth, $4 00; leather, raised band*, $4 50.   {Just Issued, 1861.)

.n^nn^rtlf^t1 faV<?. Whi — has *? soon exhai>st«l an edition of this work has afforded the author
Th£PE?In«."yJVt8.rev,SIon °' ""PP'yins; the deficiencies which existed in the former volume.
hih tinn  Fv^f0,-   'nT!!°nP°f l™° new ^apters-one on the Special Senses, the other on Im-
Smil ?J-m™,  #    .*. &at hue Fm!ctl0lls °f the Lymphatic System-besides numerous additions of
nnS th*Z"'pattered through the work, and a general revision designed  to bring it thoroughly
Zini.X/J^T  TdltT °fr,he s,^nce wi,h reg*rd toa" points which may be considered as
tf iu uUrrllZh    "Umber °f "eW ,llustrations has been  introduced, and the work, it is hoped,
tended                "^ Continue to comma"d «he  confidence of those for whose  use it is in'

effor^havVbeen Sm'^h" Di'rt0n'8 b£Bt  0Vfn ?TiSinfll ™ws and experiments, together with
work  The adTfioi. »rt m^ h k Ptlrfeclin«,h,»  *.d«i™ "> supply what he considered some deficien-
work.  J he additions are marked by the same fea-  cies n the first edition, have alreadv made the nre-
tures which characterize the remainder of the vol-  sent one a necessity, and U will no doubt be even
ume, and render it  by far the most desirable text-  more  eagerly  sought for than the first  That i7is
 "1?J&rt?" P1!^ * l„hl hand8 f»f.  the  not ™A a^eprint will beseen fromtheAuthor's
ed, satisfied as we are that it is better atapted to  ble tor their'clearness
                                                                               : truly admira-
«,».....».., wc a.c umi ,u ,» udier acapteu to  Die tor their clearness in expressing exactly what
their u«e than any other work of the kind to which  their author intended.-*™*.,* Medial and Surgi-
they have access.—American Journal  of the Med.  cal Journal, March 28 1861
Sciences, April, 1861.                            j                    '
  T. .   ..    ,        ..               ,         |  It is unnecessary to give a detail of the additions;
  It is,  therefore, no disparagement to the many  suffice it to say, that they are numerous and import-
books upon physiology, most excellent in their day,  ant, and such as will render the work still more
to say that Dalton's is the only one that gives us the  valuable and acceptable to the profession as a learn-
science  as it was known to the best philosophers ; ed and original treatiseon this all-important branch
throughout the world, at the beginning of the cur-  of medicine.  All that was said in  commendation
rent year.  It states in comprehensive but concise  of tne getting up of the first edition, and the superior
diction,  the  facts established by experiment, or  style of the illustrations, apply with equal force to
other method of demonstration, and details, in an  this. No better work on physiology can be placed
understandable manner, how it is done, but abstains ! in the hand of the student.—St. Louis Medical and
from thediscussion of unsettled or theoretical points.  Surgical Journal, May, 1861.
Herein it is unique; and these characteristics ren  :  T1]ese additions, while testifying to the learning
ology thus presented that lies at the foundation of  r^esentative on this .Vde of the Atlantic.-New
correct pathologica knowledge; and this in turn is  Orleans Med. Times, May, 1861.
the basis of rational therapeutics; so that patholo-                   '   ■"
gy, in  fact, becomes of prime importance in  the', A second edition of this deservedly popular work
proper discharge of our every-day practical duties,  having been called for in  the short space of two
—Cincinnati Lancet, May, 1861.                  ' years, the author has supplied deficiencies, which
                                               existed  in  the former volume, and  has thus more
  Dr. Dalton needs no word of praise from us.  He  completely fulfilled his design of presenting to the
is universally recognizee as among the first, if not , profession a reliable and precise text-book, and one
the very first, of American physiologists now living,  which we consider the best outline on the subject
The first edition of his admirable work appeared but  of which it treats, in any language.—N. American
two years since, and the advance of science,  his i Medico-Chirurg. Review, May, 1661.
           DUNGLISON,  FORBES,  TWEEDIE,  AND  CONOLLY.

THE CYCLOPAEDIA  OF  PRACTICAL MEDICINE: comprising Treatises on
  the Nature and Treatment of Diseases, Materia Medica, and Therapeutics,  Diseases of Women
  and Children, Medical Jurisprudence, &c. &c.  In four large super-royal octavo volumes, of
  3254 double-columned pages, strongly and handsomely bound, with raised bands.   $ 12 00.
  *** This work contains no less than four hundred and eighteen distinct treatises, contributed by
sixty-eight distinguished physicians, rendering it  a  complete library of reference for the country
practitioner.
  The most complete work on Practical Medicine
extant;  or,  at Feast,  in  our  language.—Buffalo
Medical and Surgical Journal.

  For reference, it is above all  price to every prac-
titioner.— Western Lancet.
  One of the most valuable medical publications of
the day__as a work of reference it is invaluable.—
Western Journal of Medicine and Surgery.

  It has  been  to us, both as learner and  teacher,  a
work for ready and frequent reference, one in which
modern English medicine is exhibited in the most their own doctrines witr high and just authority.—
advantageous light.—Medical Examiner.          I American Medical Journal.
  The editors are practitioners of established repu-
tation, and the lisi of contributors embraces many
ofthe most eminent professors and teachers of Lon-
don, Edinburgh, Dublin, and Glasgow.  It  is, in-
deed, the great merit ol this work that the principal
articles have been furnished by practitioners who
have not only devoted especial attention to the dis-
eases about  which the) have written, but have
also enjoyed opportunitiei  for an extensive practi-
cal acquaintance with them and whose reputation
carries the assurance of their competency justly to
appreciate the opinions of  others, while it stamps
DEWEES'S COMPREHENSIVE  SYSTEM  OF
  MIDWIFERY.  Illustrated by occasional cases
  and many engravings.  Twelfth edition, with the
  author's last improvements and corrections.  In
  one octavo vol ume, extra cloth, of 600pages. $320.
DEWEES'S TREATISE  ON  THE  PHYSICAL
  AND MEDICAL TREATMENT OF  CHILD
  REN.  The last edition.  In one volume, octavo,
  extra cloth, 548 pages.  $2 80
DEWEES'S TREATISE  ON  THE  DISEASES
  OF FEMALES.  Tenth edition.  In one volume.
  octavo  extra cloth, 532 pages, with plates.  S3 00 
12                     BLANCHARD  & LEA'S  MEDICAL
                         DUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

                        NEW  AND ENLARGED EDITION.

MEDICAL LEXICON;  a Dictionary of  Medical Science,  containing  a concise
  Explanation ofthe various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene,
  Therapeutics.  Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry,
  ore.  Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic
  Preparations, &C.  With French  and other  Synonymes.   Revised  and very greatly enlarged.
  In one very large and handsome octavo volume, of 992 double-columned pages, in small type;
  strongly bound in leather, with raised bands.  Price $4 00.

  Especial care  has been devoted  in the preparation of this edition to render it in ever/respect
worthy a continuance of  the very  remarkable favor  which it has hitherto enjoyed.  The- rapid
sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by
the profession as the standard.authority.  Stimulated by this fact, the author has endeavored in the
present revision to introduce whatever might  be necessary " to make it a satisfactory and desira-
ble—if not indispensable—lexicon, in which the student may search  without disappointment for
every term that has  been  legitimated  in the nomenclature of the science."  To accomplish this,
large additions have been  found requisite, and ihe extent  of the author's labors may be estimated
from the fact that about Six Thousand subjects and terms have been introduced throughout, ren-
dering the whole number of definitions about Sixty Thousand, to accommodate which, the num-
ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size
ofthe page.   The medical press, both in this country and in England, has pronounced the work in-
dispensable to all medical students and practitioners, and the present improved edition will not lose
that enviable  reputation.
  The publishers have endeavored to render the mechanical execution worthy of a volume of such
universal use in daily reference.   The greatest care hns been exercised  to obtain the typographical
accuracy so necessary in a work of  the kind.   By the  small but exceedingly clear type employed,
an immense amount of matter is condensed in its thousand ample pages, while the binding will be
found strong and durable.  With all  these improvements and enlargements, the price has been kept
at the former very moderate rate, placing it within the reach of all.

                                              tells us  in his preface  that he has added about six
                                              thousand terms and subjects to this edition, which,
                                              before, was considered  universally as the best work
                                              of the kind in any language.—Silliman's Journal,
                                              March, 1858.
                                                He has razed his gigantic structure to the founda-
                                              tions, and  remodelled and reconstructed the entire
                                              pile. No less than six thousand additional subjects
                                              and terms are illustrated and analyzed in this new
                                              edition, swelling  the  grand aggregate  to beyond
                                              sixty thousand !   Thus is placed before the profes-
                                              sion a complete and thorough exponent of medical
                                              terminology, without rival or possibility of rivalry.
                                              —Nashville Joum. of Med. and Surg., Jan. 1858.
                                                It  is universally acknowledged, we believe, that
                                              this  work is incomparably the best and most com-
                                              plete Medical Lexicon in the English language.
                                              The amount of labor which the distinguished author
                                              has  bestowed upon it  is truly wonderful, and the
                                              learning and research  displayed in its preparation
                                              are equally remarkable.  Comment and commenda-
                                              tion are unnecessary, as no one at'the present day
                                              thinks of purchasing any other Medical Dictionary
                                              than this.—St. Louis Med. and Surg. Joum., Jan.
                                              1858.
                                                It is the foundation stone of a good medical libra-
                                              ry, and should always  be included in the first list of
                                              books purchased by the medical student.—am. Med.
                                              Monthly, Jan. 1858.
                                                A  very perfect work of the kind, undoubtedly the
                                              most perfect in the English  language.—Med.  and
                                              Surg. Reporter, Jan. 1858.
                                                It  is now emphatically the Medical Dictionary nt
                                              the English language, and for it there is no substi-
                                              tute.—JV. H. Med. Joum., Jan. 1858.
                                                It is scarcely necessary to remark that any medi-
                                              cal library wanting a copy of DuncrHson's Lexicon
                                              must be imperfect.—Cin. Lancet, Jan. 1858.
                                                We have eveT considered it the best authority pub-
                                              lished, and the present edition we may safely say has
                                              no equal in the world.—Peninsular Med. Journal,
                                              Jan. 1858.
                                                The most complete authority on the subject to b*
                                              found in any language—Ko. Med. Journal, Feb. '58.
  This work, the appearance of the fifteenth edition
of which, it has become our duty and pleasure to
announce, is perhaps themost stupendous monument
of labor and erudition in medical literature.  One
would hardly suppose after constant use of the pre-
ceding editions, where we have never failed to find
a sufficiently full explanation of ever j medical term,
that in this edition " about six thousand subjects
and terms have been added," with a careful revision
and correction of the entire work.  It is only neces-
sary to announce the advent of this edition to make
it occupy the place ofthe preceding one on the table
of every medical man, as it is without doubt the best
and most comprehensive work of the kind wh ich has
ever appeared.—Buffalo Med. Joum., Jan. 1858.

  The work is a  monument of  patient research.
skilful judgment, and  vast physical labor, that will
perpetuate the name of the author more effectually
than any possible device of stone or metal.  Dr.
Dunglison deserves the thanks not only ofthe Ame-
rican profession, but of the whole medical world.—
North Am.  Medico-Chir. Review, Jan. 1858.
  A Medical Dictionary better adapted for the wants
of the profession than any other with which we are
acquainted, and of  a eharucter which places it far
above comparison  and  competition.—Am. Joum.
Med. Sciences, Jan. 1858.
  We need  only say, that the addition of 6,000 new
terms, with their accompanying definitions, may be
said to constitute a new work, by itself.  We have
examined the Dictionary attentively, and are most
happy to pronounce it unrivalled  of its kind.  The
erudition displayed, and the extraordinary industry
which must have been demanded, in its preparation
and perfection, redound  to the lasting credit of its
author, and have furnished us with a volume indis-
pensable at the present day, to all who would find
themselves  au niveau  with the highest standards of
medical information.—Boston Medical and Surgical
Journal, Dec. 31, 1857.
  Good lexicons and encyclopedic works generally,
are the most labor-saving contrivances which lite-
rary men enjoy; and the labor which is required to
produce them in the perfect manner of this example
is something appalling to contemplate. The author
BY THE SAME AUTHOR.
THE PRACTICE OF MEDICINE.   A Treatise on Special Pathology and Tko-
  rapeuticB.  Third Edition.  In two large octavo volumes, leather, of 1,500 pages.  J6 35. 
AND SCIENTIFIC  PUBLICATIONS.
13
                         DUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

HUMAN   PHYSIOLOGY.   Eighth  edition.   Thoroughly revised  and  exten-
  sively modified and enlarged, with five  hundred and thirty-two illustrations.  In two large and
  nandsomely printed octavo volumes, leather, of about 1500 pages.   $7 00.

  In revising this work for its eighth appearance, the author has spared no labor to render it worthy
a continuance ofthe very great favor which has been extended to it by the profession.  The whole
contents have been rearranged, and to a great extent remodelled; the investigations which of late
years nave been so numerous and so important, have  been carefully examined and incorporated,
and the work  m every respect has been brought up to a level with the present state of the subject.
  u i° f a   r  u au,hor h*s ^en to render it a concise but comprehensive treatise, containing the
whole body of physiological science, to which the student and man of science can at all times refer
With the certainty of finding whatever they are in search of, fully presented in all its aspects: and
on no former edition has the author bestowed more labor to secure thi* result
  We believe that it can truly be said, no more com-
plete repertory of facts upon  the  subject  treated,
can anywhere be found.  The author has, moreover,
that enviable tact at description and  that facility
and ease of expression which render him peculiarly
acceptable to the casual, or the studious reader.
This faculty, so requisite  in setting forth  many
graver and less attractive subjects, lends additional
charms to one  always fascinating__Boston Med.
and Surg. Journal.

  The most complete and  satisfactory system  of
Physiology in the English  language__Amer.Med
Journal.
  The best work of  the kind in the English lan-
guage.—Siltiman's Journal.
  The present edition the author ha"8 made a perfect
mirror of the science as it is at the present hour.
As a work upon physiology proper, the science of
the functions performed by the body, the student will
find it all he wishes.—Nashville Joum. of Med.
  That he has succeeded, most admirably succeeded
in his purpose, is apparent from the appearance of
an eighth edition. It is now the sreat encyclopaedia
on the subject,  and worthy of a place in every phy-
sician's library.—Western Lancet.
                         BY the same author.  {A new edition.)

GENERAL  THERAPEUTICS   AND  MATERIA MEDICA; adapted for a
  Medical Text-book.  With Indexes of Remedies and of Diseases and their Remedies.   Sixth
  Edition, revised and improved.  With one hundred and ninety-three illustrations.  In two large
  and handsomely printed octavo vols., leather, of about 1100 pages.  $6 00.
  In announcing a new edition of Dr. Dunglison's
General Therapeutics and Materia Medica, we have
no words of commendation to bestow upon a work
whose merits have been heretofore so often and so
justly extolled.  It must not be supposed, however,
that the  present is a mere reprint of the previous
edition:  the character of the author for laborious
research, judicious analysis, and clearness of ex-
pression, is fully sustained by the numerous addi-
tions he has made to the work, and the careful re-
Vision to which he has subjected the  whole.—N. A.
Medico-Chir. Review, Jan. 1658.
  The work will, we have little doubt, be bought
and read by the majority of medical students: its
size, arrangement, and reliability recommend it to
all j  no one,  we venture to predict, will study it
without profit, and there are few to whom it will
not be in some measure useful as a work of refer-
ence.  The young practitioner, more especially, will
find the copious indexes appended to this edkion of
great assistance in the selection and preparation of
suitable formulae.—Charleston Med. Joum. and Re-
view, Jan.  1858.
                        by  the same author.  {A new Edition.)

NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND
  ADMINISTRATION.  Seventh edition, with extensive Additions.  In one very large  octavo
  volume, leather, of 770 pages.  $3 75.

  Another edition of the " New Remedies" having been called for, the  author  has endeavored to
add everything of moment that has appeared since the publication of the last edition.
  The articles treated of in the former editions will  be found  to have undergone considerable  ex-
pansion in this, in order that the author might be enabled to introduce, as far  as practicable,  the
results of the subsequent experience of others, as well as of his own observation and reflection;
and to make the work still more deserving of the extended circulation  with which  the  preceding
editions have been favored by the profession.  By an enlargement of the page, the numerous addi-
tions have been incorporated without greatly increasing the bulk of the volume.—Preface.
  One of the most useful of the author's works.—
Southern Medical and Surgical Journal.
  This elaborate and  useful  volume  should be
found in every medical library, for as a book of re-
ference, for physicians, it is  unsurpassed by any
other work in existence, and the double index for
diseases and  for remedies, will be found greatly to
fttthance its value.—New York Med. Gazette.
  The great learning of the author, and his remark-
able industry in pushing  his researches into every
source whence information is derivable,have enabled
him to throw together an  extensive mass of facts
and statements, accompanied by  full reference to
authorities; which  last  feature renders the work
practically valuable to investigators who desire te
examine the original papers.—The American Journal
of Pharmacy.
                            ELLIS (BENJAMIN), M.O.

THE MEDICAL  FORMULARY:  being a Collection of Prescriptions, derived
  from the writings and practice of many of the most eminent physicians of America and Europe.
  Together with the usual Dietetic Preparations and Antidotes for Poisons.  To which is added
  an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform.  The
  whole accompanied with a few brief Pharmaceutic and Medical Observations.  Eleventh edition,
  revised and much extended by Robert P. Thomas, M. D., Professor ol Materia Medica in the
  Philadelphia College of Pharmacy.  {Preparing.) 
14
BLANCHARD  <fe  LEA'S MEDICAL
                                 ERICHSEN  (JOHN),
                     Professor of Surgery in University College, London, &e.

THE SCIENCE  AND ART OF SURGERY; being a Treatise on Surgical
  Injuries, Diseases, and Operations. New and improved American, from the second enlarged
  and carefully revised London edition.  Illustrated with over four hundred engravings on wood.
  In one large and handsome oetavr  volume, of one thousand  closely printed pages,  leather,
  raised bands.  $4 50.  {Just Issued.)
  The very distinguished favor with which this work has been received on both sides of the Atlan-
tic has stimulated the author to render it even more worthy of the position which it has so rapidly
attained  as a standard authority.   Every portion has  been carefully revised, numerous additions
have been made, and the most watchful care  has been exercised to render it a complete exponent
ofthe most advanced condition of surgical science.  In this manner the work has been enlarged by
about a hundred pages, while the series of engravings  has been increased by more than a  hundred,
rendering it  one of the most thoroughly illustrated volumes before the profession.   The additions of
the author having rendered unnecessary most of the noles of the former American editor, bit  little
has been  added in this country; some few notes nod occasional illustrations have, however,  been
introduced to elucidate American modes of practice.
                                              step ofthe operation, and not deserting him  until the
                                              Bna!  issue ofthe case is decided —Seihoseope,
  It is, in our humble judgment decidedly the hesi
book of the kind in the English language  Strange
that jusl such books are noioftener produced by pun
lie teachers of surgery  in this country and Great
Britain  Indeed, it is a matter of great astonishment
hut no less true than astonishing, thai ofthe many
works on surgery republished in this country within
the last fifteen or twenty years ns text-books  for
medical students, this is the only one that even ap-
proximates to the fulfilment of the peculiar wants of
youngmen just entenngupon the study of this branch
ofthe profession.— Western Jour .of Med. an'l Surgery

  Its value is greatly enhanced by  a very copious
well-arranged index.  We regard this as one of the
most valuable contributions to modern surgery. To
                                                 Embracing, as will be perceived, the whole surgi-
                                               cal domain, and each division  of itself a/rrost com-
                                               plete and perfect, each chapter foil and explicit, each
                                               subject faithfully exhibited, we can only express oui
                                               estimate of it in the aggregate.  We consider it an
                                               excelleni  contribution to surgery, as prohabfy the
                                               he*' single volume now  extant on the subject, and
                                               vriib great pleasure we  add  it to our text-books.—
                                               Nashr-iTle Journal of Medicine and Surgery.
                                                 Prof.  Erichsen's work, for its  size, has not been
                                               surpassed; his nine  hundred and eight pa;»es, pro-
                                               fusely illustrated, are rich in physiological, patholo-
                                               gical, and operative suggestions, doctrines, details,
one entering his novitiate of practice, we regard it I  and  processes;  and  will prove a reliable  rcsonree
the most serviceable guide which he can consult.  He  for information, both lo physician and surgeon, in ths
will find a fulness of detail leadinghim through every '  hour of peril.— N. O. Med. and Surg. Journal.
                             FLINT (AUSTIN),  M. D.,
        Professor of the Theory and Practice of Medicine in the University of Louisville, Ac.

PHYSICAL EXPLORATION AND DIAGNOSIS  OF  DISEASES  AFFECT-
  ING THE RESPIRATORY ORGANS.   In one large and handsome octavo volume  extra
  cloth, 636 pages.  $3 00.
  We regard it, in point both of arrangement and of l   A work of original observation of the highest merit.
the marked ability of its treatment of the subjects, We recommend the treatise to every one who wishes
as destined to take the first rank in works of this t.» become a correct auscultator.  Based to a very
class.  So far as our information extends, it has at large extent upon cases  numerically examined  it
present no equal.  To  the practitioner, as well  as carries the evidence of careful study and discrimina-
the student, it will be invaluable in clearing up the | tion upon every page   It does credit to tne autnor
diagnosis of doubtful cases, and in shedding light i and through him, to the profession in this conntry'
upon difficult phenomena.—Buffalo Med. Journal.   It, is, what we ennnot call every book upon ausenJ-
                                             I tation, a readable book.—Am. Jour. Med. Sciences.

                           BY THE samb author.  {Now Ready.)

A PRACTICAL  TREATISE ON  THE  DIAGNOSIS,  PATHOLOGY  AND
  TREATMENT OF DISEASES OF THE HEART.   In one neat octavo volume, of about
  500 pages, extra cloth.  $2 75.
   We do no* know that Dr. Flint has written any-
 thing which is not first rate; but this, his latest con-
 tribution to medical literature, in our opinion, sur-
 passes all the others. The work is most comprehen-
 sive in its scope, and most sound in the views it enun-
 ciates.  The descriptions are clear and methodical:
 the statements are substantiated by facts, and are
 made with such simplicity and sincerity, that with-
 out them they would carry convic'ion   The style
 is admirably  clear, direct, and free from dryness
 With Dr. Walshe's excellent trearise before us, we
 have no hesitation in saying that Dr. Flint's book is
 the best work on the heart in the English language
 —Boston Med. and Surg. Journal.
   We have thus endeavored  to present our readers
 with a fair analysis of this remarkable work. Pre-
 ferring to employ the very words of thedistmguished
 author, wherever it was possible, we have essayed
 to condense into the briefest  space n general view of
 his observations and suggestions, and lo direct the
 attention of our brethren to the abounding stores ol
 valuable matter here collected and arranged for their
 use and instruction.  No medica library will here
 after be considered complete without this volume;
 and we-trnst it will promptly find its way into the
 hands of every Ame'ican student und physician.—
 JV Am. Med. Chir. Review.
  This last work of Prof. Flint will add much to
his previous well-earned celebrity, as  a wiiier of
 great force and beauty, and, wilh his previous work,
 nlaees  him at the head of American writers upon
 diseases of the chest.  We nave adopted his work
 upon the  heart as a text-book, believing it to  be
 more valuable foT that purpose than any work of the
 kind that has yet appeared.— Nashville Mtd Joum.
  With more than pleasure do are hail the advent ot
 this work, for it  fills a wide gap on the list. f text-
 books for  our schools, and  is,  for tne practitioner,
 the n.oBt valuable practical work of its kind.—N  O
 Med. Neun.               ,

  In regard to the merits of the work, we have  no
 hesitation  in pronouncing it full, accurate, and ju-
 dicious Considering the present state of science,
 such a  work was much needed. It should t>e in the
 hands of every practitioner—Chicago Mt cl Journal.
  But these are very trivial spots, and in nowise
 prevent us from declaring our moBt heartv approval
 of the author's uhiijty, industry, and conscientious-
 ness.—.Dms/in Quarterly  Journal of Med. Sciences.
  He haslaboreri on with the same industry and care,
and his place among the^VriJ authors of our country
 isbeeoming fully established.  Tothisend, the work
whose title is given above, coniributes in no small
decree.  Our spa:e will  not admit of »n extended
analysis, and  we will closi  this  orief notice by
commending it without  reserve to everv class  of
readers in the profession.—Peninsular Med. Joum. 
AND SCIENTIFIC PUBLICATIONS.                   15)
                        FOWNES (GEORGE), PH. D., &.G.
A  MANUAL OF ELEMENTARY  CHEMISTRY;  Theoretical  and Practical.
  From the seventh revised and  corrected London edition.   With one hundred and  ninety-seven
  illustrations   Edited by Robert Bridges, M. D.  In one large  royal 12mo. volume, of 600
  pases.  In  leather, $1 65; extra cloth, $1 50.  {Just Issued.)
n^S^*8111 °f t,le author having placed the editorial care of this work in the practised hands of
Drs  cence Jones and A. W. Hoffman, everything ha^ been done m its revision which experience
could suggest to  keep it on a level with  the rapid advance of chemical science.  The additions
requisite to this purpose have neces>it»ted an enlargement of the page, notwithstanding which the
work has been  increased by about fifty pages.  At the same time every care has been  used to
maintain its distinctive character as a condensed manual for the student, dive-ted/>f all unnecessary
detail or mere theoretical speculation.  The additions have,  of course, been  mainly in the depart-
ment of Organic Chemistry, which has made such rapid proxies- within the last few years, but
yet equal attention has been bestowed on  the other branches  of the subject—Chemical Physics and
Inorganic Chemistry—to present all investigations and discoveries  of importance, and to keep up
the reputation ofthe volume as a complete manual ofthe whole science, admirably adapted for the
learner.  By the use of a small but exceedingly clear type the matter of a large octavo is compressed
within the convenient and portable limits of a"moderate sized duodecimo, and at the very low price
affixed, it is offered as one of the cheapest volumes before the profession.
  Dr. Fownes'excellent wotk has been universally
recognized everywhere in his own and thiseountry,
as the best elementary treatise on chemistry in the
English tongue, and is very generally adopted, we
believe, as the standard text-book in all • ur colleges,
both literary and scientific.—Charleston Med Joum.
and Review.
  A standard manual, which has long enjoyed the
reputation of embodying much knowledge in a small
■pace.  The author hasacliieved the difficult task of
condensation with musterly tact.  His book is con-
cise without being dry, and brief without being too
dogmatical or general.—Virginia Med. and Surgical
Journal.
  The work of Dr. Fownes has long been before
the public, and its merits have been fully appreci-
ated  ns  the best  text-book on chemistry now in
existence.  We do not, of course, place it in a rank
superior to the works of Brande, Graham, Turner,
Gregory, or Gmelin, but we say that, as a work
for students, it is preferable to any of them.—Lon-
don Journal of Me.dicine.
  A work well adapted to the wants of the student.
It is an excellent exposition of the chief doctrines
and facts of modern chemistry. The size of the work,
and still more the condensed yet perspicuous style
in which it is written,  absolve it from the charges
very properly unred against most manuals termed
popular.—Edinburgh Journal of Medical Science.
FrSKE  FUND  PRIZE  ESSAYS —THE EF-
  FECTS OF CLIMATE ON TUBERCULOUS
  DISEASE. By Edwin Lee, M.R.CS .London,
  and THE INFLUENCE i»F PREGNANCY ON
  THE DEVELOPMENT OF TUBERCLES   By
  Edward Warren, M.D , of Edenton,Na C.  To-
  eether in one nent Svo volume, extra cloth. 81 00.
FRICK ON RENAL AFFECTIONS; their Diag-
  nosis and  Pathology.  With  illustrations.  One
  volume, royal 1'imo., extra cloth. 75 cents.
                       FERGUSSON (WILLIAM),  F. R. S.(
                     Professor of Surgery in  King's College, London, ice.
A  SYSTEM  OF PRACTICAL  SURGERY.   Fourth American,  from the third
  and enlarged London edition. In one large and beautifully printed octavo volume, of about 700
  pages, witb 393 handsome illustrations, leather.  S3 00.

                          GRAHAM  (THOMAS),  F. R. S.
THE ELEMENTS  OF  INORGANIC  CHEMISTRY,  including the  Applica-
  tions ofthe Science in the Arts.  New and much enlarged edition, by Henry Watts and Robert
  Bridges, M. D.  Complete in one large  and  handsome octavo volume, of over 800 very large
  pages, with two hundred and thirty-two wood-cuts, extra cloth.  $4 00.
  **$. Part II., completing the work from p. 431 to end, with Index, Title Matter, &c., may  be
had separate, cloth backs and paper sides.   Price $2 50.
  Frowt Prof. E. N. Horsford, Harvard College,   i afford to be without this edition  of Prof. Graham's
  It has, in its earlier and less perfect editions, been ■ Element..—S«I»m«|-* Journal, March, 1858.
familiar to me, and the excellence of its plan  and   prcm prnf. Wolcott Gibbs, N. Y. Free Academy.
the  clearness and completeness  of its discussions,                 admirable one in all respects.and
have long been my admiration.                  | |tg republication here eana,lt fltU  t0 exert a positive
  No reader of English works on this science  can  tnflueuce upon the progress of science in thiscountry.

                     GRIFFITH (ROBERT  E.)f  M.  D., &c.
A  UNIVERSAL FORMULARY, containing the methods of Preparing and Ad-
  ministering Officinal and other  Medicines.  The whole adapted to Physicians  and Pharmaceu-
  lists.  Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas,
  M. D. Professor of Materia Medica in the  Philadelphia College of Pharmacy.  In one large and
  handsome octavo volume, extra cloth, of 650  pages, double columns.  $3 00; or in sheep, $3 25.
                                               This is a wort of six hundred and fifty-one pages,
                                              •mbraeing all on the subject of preparing and admi-
                                              iisteriiig medicines that can be  desired by the physi-
                                              '.ian and pharmaceutist.— Western Lancet.
  It was a work requiring much perseverance, and
when published was looked upon as by far the besi
work of its kind that had issued from the American
press.  Prof Thomas has certainly "unproved," as-
well as added 'othis Formulary, and has rendered ii
additionally deserving of the confidence of pharma-
ceutists and physicians.—Am. Journal of Pharmacy
  We are happy to announce a new and improved
edition of this, one ofthe most valuable and useful
works that have emanated from an American pen.
ft would do credit to any country, and will be found
of daily usefulness to practitioners of medicine; it r
  The amountof useful, every-day matter.for a prac-
ticing physician,  is really immense.—Boston Mtd.
and Surg. Journal.
  This edition has been greatly improved by the re-
vision and ample additions of Dr  Thomas, and is
now. we believe, one of the most complete works
of its kind in any language.  The additions amount
to about -evenly pages, and no effort has been spared
better adapted tot heir purposes than the dispensato  t0 include in them all the recent improvements.  A
ries.—Southern Mtd. and Surg. Journal            work of this kind appears lo us indispensable to the
  Itio one ofthe mo*t nsefu' books a country pracli  | physician, and there is none xe can more cordially
turner can possibly have.—Medical Chronicle.       'recommend.  N  Y Journal ofMedicine. 
16                    BLANCHARD  &  LEA'S  MEDICAL
                           GROSS (SAMUEL DJ, M. D.,
             Professor of Surgery in the Jefferson Medical College of Philadelphia, ice.
                      Enlarged Edition—Now Ready, January, 1862.

 A SYSTEM  OF  SURGERY: Pathological, Diagnostic, Therapeutic, and Opera-
   tive.   Illustrated by Twelve Hcndred and Twenty-seven  Engravings.  Second edition,
   much enlarged and carefully re"i*ed.  In two large and beautifully printed  octavo volumes,  of
   about twenty-two hundred pages; strongly bound in leather, with raised bands.   Price $12.
   The exhauMion in little more  than two years of a  large edition of so elaborate and  comprehen-
 sive a woik as this is the best evidence that the  author was not mistaken in  his estimate  of the
 want which existed of a  complete American System of Surgery, presenting the science in all  H
 necessary de'ails and  in all its branches.  That he has succeeded in  the attempt to supply this want
 is shown"not only By the  rapid sale ofthe work, but  also by the very favorable manner in which it
 has been received by the  organs ofthe profes-ion in this country and in Europe, and by the fact that
 a transhuion  is now preparing in Holland—a mark of appreciation not often bestowed on any scien-
 tific work so extended in  size
   The author has not been insensible to the kindness thus bestowed upon his labors, and in revising
 the work for  a new edition he has spared no pains.to render it worthy of  the favor with  which .!
 has been received.  Every portion has been subjected to close examination and revision ;  any defi-
 ciencies apparent have been supplied, and the results of recent progress  in the science and art  ot
 surgery have been everywhere introduced; while the series of illustrations has been enlarged by
 the addition of nearly three hundred wood-cuts, rendering it one of the most thoroughly illustrated
 works ever laid before the profession.  To accommodate these very extensive additions, the work
 has been printed upon a smaller type, so that notwithstanding the very large increase in the  matter
 and value of  the book, its size is more convenient and le»s cumbrous than before.  Every care hi.s
 been  taken in the printing to render the  typographical execution unexcep'ionab'e, and it is confi-
 dently presented as a  work in every way worthy of a place in even  the most limited library  of Lie
 piaciitioner or student.
   A few testimonials ofthe value ofthe former edition are appended.
   Has Dr. Gross satisfactorily fulfilled this object? |  Of Dr.  Gross's  treatise on Surgery we can say
 A caieful perusal of his volumes enables us to give  no more than that it is the most elaborate and ct "-
 an answer in the affirmative.  Not only has he given  plete Work on this  branch of the healing art which
 to the reader an elaborate and well-written account j has ever  been published in any country.  A sys-
 of his o*rn vast experience, but he has not failed to j tematic work, it admits of no analytical review;
 embody in his pages the opinions and  practice of  but, did our  space permit, we  should gladly give
 surgeons in this and other countries of Europe.  The  some extracts from it, to enable oar readers to judge
 result has been a work of such  completeness, that it , of trie c'assical style of the author, anil the exhaust-
 has no superior in the systematic treatises on sur- ' ing way in which each subject is treated.—Dublin
 gery which have  emanated from English or C>nti- I Quarterly Journal  of Med. Science.
 rental authors.  It has been  justly objected  that I  The work u §0 8Uperior to  it8  prede(.eilllorg  ;.,
 these have been far from complete in many essential  mfUter  and extent, as well as in illustrations and
 particulars, many of them  having been deficient in  ....i» nf nnKii„_.i„'_  n.„. '..»„» ",u"w""ou" Kaa
 some of the most important points whi,h should  *ll'' ft P"b£ath'OD' i^l^f, ft? £?"? .'V.°":"
 characterize such works   Some of them have been ' Zmt bv the I™  r\ZlL»L   /j, V^r *****
 elaborate-too elaborate-with respect  to certain , ho,™! bJ they°unK  practitioner.-^™. Med. Jnm.
 diseases, while they have merely  glunced at, or i  With pleasure we record the completion  of t:iia
 given an unsatisfactory account of, others equally I l"ng-anticipited work.  The reputation which t.-.e
 important to  the surgeon.  Dr. Gross has avoided  »"'"<>' hHS for maitv years sustained, both as a car-
 ting error, and has produced the most complete work  geon and  as a writer, had prepared us to expect a
 that hasyet issued from the press on the science and I treatise of great excellence and originality:  but we
 practice of surgery. It ismot, strictly  speaking, u , <"""tess we were by no means prepared lor the work
 Dictionary of Surgery, but it gives to the reader all  which isbeforeus—the most complete treatise upon
 the information thathe may require for his treatment  "uigery ever published, either in this or any on. r
 of surgical diseases.  Having said so much, it might | country, and we  might, perhaps,  safelv say, the
 apnear  superfluous to  add another w ird ; but it is \ most original. Then is no subject  belouging pr<>-
 only due to Dr. Gross to state that he has embraced , perly to surgery which has not received from the
 the opportunity of transferring to his pages a vast , »"thoi a due share of attention.  Dr. Gr.is has snp-
 numberof engravings from English  and other »u- ! ^Mt.i R  want in surgical  literature which has loig
 tnors, illustrative ol the pathology and treatment >f , heen felt ''V practitioners; he has furnished us \vi i
 surgical diseases. To these are added several hun  | a complete practical treatise upon surgery in all  its
 dred original wood-cuts. The work altogether com- i <,epartni''ntii   As A nenc ms, we are proud of the
 mends itself to the attention  of BritUh surgeons, , achievement;  as surgeons, we are  most sincere.y
 from  whom it cannot  fail to  meet with extensive I thankful to him for his extraord nary labors in i, r
 patronage.—London Lancet, Sept. 1. 1860.         , henalf —N. Y. Monthly  Review and Buffalo Mid
                                             I Journal.
                                   BY THK SAME AUTHOR.
 ELEMENTS  OF PATHOLOGICAL  ANATOMY.  Third c-lition,  thorough^
   revised and greatly improved.   In one large and very handsome octavo volume, with n! out three
   hundred  and fifty beautiful illustrations, of which a large number are from original drawing
   Price in extra cloth, U 75; leather, raised bands, i1) 25. (Lately Published.)
   The very rapid advances in the Science of Pathological Anatomy during the last few years have
 rendered essential a thorough modification  of this work,  with a view of making it a correct expo-
 nent of the present state  of the subject.  The very  carelul manner in which this task has been
 executed, and the amount of alteration which it has undergone, have enabled the author to sav that
   with  the many changes and improvements now introduced, the work may be regarded almost  as
 a new treatise "while the efforts ofthe author have been seconded as regardlThTmechan <3
 execution of  the volume, rendering it one of the handsomest productions of the American pre™

 succe^S                           , ra^r^S^^


 exist  in this department of medical lifcratu^e and \ Zl mu'ch X^?S^£SSXiV^Si"i
 as such must become ver> widely circulated amongst  our reader, us we believe onT weKserTn,  t

 fi^^i^T^:^.^ Quarurl*\ct:^^ -^ KiS1^
 .   ._._, , _—__  . ,.                BV THE SAME At'THOR.
AJr?^CTICAL  TREATISE  ON  FOREIGN  BODIES IN THE  \IR-PAS-
  feAGrLS.  In one handsome octavo volume, extra cloth, with illustrations,  pp. 46S.  $2  75. 
AND  SCIENTIFIC PUBLICATIONS.                    17
                         GROSS  (SAMUEL  D.),  M. D.,
           Professor of Surgery in the Jefferson Medical College of Philadelphia, Ac.

M?iRt.A5T,1(lAL   TREATISE  ON   THE  DISEASES,  INJURIES,  AND
THE irHETtrRANSe°F_TS?. URINA«-Y BLADDER,  THE PROSTATE GLAND, AND
                                                                 ith one hundred and eighty-
                                                                  over nine hundred pages.
  fom-iii. ,  .       T  &econd Edition, revised and much enlarged, with.
  inuf       J u   l)ne lar&e and very handsome octavo volume, of ov
  In leather, raised bands, $5 25; extra cloth, $4 75.

raneement^mniL11 'tgi desi^n' methodical in its ar- i agree with us, that there is no work in the English
it mavTn tn^' l^ ?  , V U,nd ln lta Pract*^' detail.,  language which can make any just pr
le deJired on .o fm^,»t0 V*™ f'^^ely anything to . be its equal—*, y. Journal of Medici
Deaesirea on so important a subiect__R/.«»o.  jit.j     .   m                  ...
and Surg  Journal*""1™1 * *abi«*-Boston Med.

  Whoever will peruse the vast amount of valuable
practical information it contains, will, we think,
                                pretensions to
                            Medicine.
  A volume replete with truths and principles of the
utmost value in the investigation of these diseases.—
American Medical Journal,
                              GRAY (HENRY),  F. R. S.,
                    Lecturer on Anatomy at St. George's Hospital, London, &.c.

ANATOMY,  DESCRIPTIVE  AND  SURGICAL.    The Drawings by H. V.
  Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly
  by the Author and  Dr. Carter.  Second American, from the second revised and improved
  London edition.  In  one magnificent imperial octavo volume, of over 800 pages, with 388 larRe
  and elaborate engravings on wood.   Price in extra cloth, $6 25; leather, raised bands, $7 00.
  {Now Ready, 1802.)

  The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and exe-
cution have been found  to  present superior practical advantages in facilitating the study of Anato-
my.  In presenting it to the profession a second time, the author has availed himself of the oppor-
tumty to supply any deficiencies which experience in its  use had shown to exist, and to  correct
any errors of detail, to which the first edition of a scientific work on so extensive and complicated
a science is liable.  These improvements have resulted  in some increase in the size ofthe volume,
while twenty-six new wood-cuts have been added to  the beautiful series of illustrations which
form so distinctive a feature of the work.  The American edition has been passed through the press
under the supervision of a competent  professional man, who has  taken every care to render it  in
all respects accurate, and it is now presented, without any increase of price, as fitted to maintain
and extend the popularity which it has everywhere acquired
   With little trouble, the busy practitioner whose
  knowledge of anatomy may ha ve become obscured by
  want of practice, may now resuscitate his former
  anatomical lore, and be ready for any emergency,
  It is to this class of individuals, and not to the stu-
i  dent alone, that this work will ultimately  tend to
  be of most incalculable advantage, and we feel sat-
  isfied that the library ofthe medical man will soon
  be considered incomplete in which a  copy  of this
                                                to exist in this country.  Mr. Gray writes through-
                                                out with both branches of his subject in view.  His
                                                description of each particular part is followed by a
                                                notice of its  relations to the parts with which it is
                                                connected, and this,  too, sufficiently ample for all
                                                the purposes of the operative surgeon.   After de-
                                                scribing the  bones and muscles, he gives a concise
                                                statement of the fractures to which the bone* of
                                                the extremities  are most liable, together with the
 work does not exist.— Madras Quarterly Journal I amount and direction of the displacement to which
 of Med. Science, July, 1861.                      | the fragments are subjected by  muscular action.
   This edition is much  improved and enlarged, and | Tne section on arteries is remarkably full and ac-
 contains several new illustrations by Dr. Westma- . curate-  Not only is the surgical  anatomv given to
 cott. The volume is a complete companion to the | every important vessel, with directions for its liga-
 dissecting-room, and saves the necessity of th«stu  I tion, but at the end of the description of each arte-
 dent possessing a variety of" Manuals.''—The Lon  j rial trunk we have a useful summary of the irregu-
 don  Lancet Feb 9 1861                          tanties which may occur in its origin, course, and
   mu     '    '  '            . , j   ,.  .. .    ! termination.—N. A. Med. Chir. Review, Mar. 1659.
   The work before us is one entitled to the highest i
 praise, and we accordingly welcome it as a valu- j   Mr.  Gray's book, in excellency of arrangement
 able addition to medical literature.  Intermediate 'and completeness of execution; exceeds any work
 in fulnesR of detail between  the treatises of S lar  | on anatomy hitherto published in the English lan-
 peyandof Wilson, its  characteristic  merit lies in ' guage, affording  a complete view of the structure of
 the  number and  excellence of the engravings  it . the human body, with especial reference to practical
 contains.   Most  of these are original, of  much I surgery. Thus the volume constitutes a perfect book
 larger than ordinary size, and admirably executed. I of reference for the practitioner, demanding a place
 The various parts are also lettered after the plan
 adopted in Holden's  Osteology.   It would be Diffi-
 cult to over-estimate the advantages offered by this
 mode of pictorial illustration.   Bones,  ligaments,
 muscles, bloodvessels, and nerves are  each in turn
 figured, and marked with their appropriate names;
 thus enabling the student to comprehend, at a glance,
 what would otherwise often be ignoied, or at any
 rate, acquired  only by  prolonged and irksome ap-
 plication.  In conclusion, we heartily commend the
 work of Mr. Gray to the attention of the medical
 profession, feeling certain that it should be regarded
 as one of tne most valuable contributions ever made
 to educational  literature —N. Y.  Monthly Review.
 Dec. 1859.
  In  this view, we regard the work of Mr. Gray as
 far better adapted to the wants of the profession,
 and especially  of the student, than any treatise on
 anatomy yet published in this country. It is destined,
 We believe, to supersede ill others, both as a manual
 of dissections,  and a standard of reference to the
student of general or  relative anatomy. — N.  Y.
Journal of Medicine, Nov. 1859.
  For this truly admirable work  the profession is
indebted to the distinguished author of  "Gray on
the Spleen."  The vacancy it fills has been long felt
in even the most limited library of the physician or
surgeon, and a work of necessity for the student to
fix in his mind what he has learned by the dissecting
knife from the  book of nature.—The Dublin Quar-
terly Journal of Med. Sciences, Nov. 1858.

  In our judgment, the mode of illustration adopted
in the present volume cannot but present many ad-
vantages to the student of anatomy.  To the zealous
disciple of Vesalius, earnestly desirous of real  im-
provement, the book will certainly be of immense
value; but, at  the same time, we must also confess
that to those  simply desirous of "cramming" it
will be an undoubted godsend.  The peculiar value
of Mr. Gray's mode of illustration is nowhere more
markedly evident than in the chapter on osteology,
and especially  in those portions which treat of the
bones of the head and of their  development.  The
study of these parts is thus made one of comparative
ease, if not of positive pleasure: and those bugbears
of the student,  the temporal ana sphenoid bones, are
shorn of half their terrors.  It is, in  our estimation,
an admirable and complete text-book for the student,
and a useful work of reference for the practitioner;
its pictorial character forming a novel element, to
which  we have already  sufficiently alluded.—Am.
Joum. Med. Sci., July, 1859. 
18
BLANCHARD &  LEA'S MEDICAL
GIBSON'S INSTITUTES AND PRACTICE OF
  SURGERY. Eighth edition, improved and al
  tertd. With thirty-four plates. In twohandsome
  octavo volumes,  contain up about  1,000 pages,
  leather, raised bandi.  $6 50
GARDNER'S MEDICAL CHEMISTRY, for the
  use of Students and the Profession.  In one royal
  12mo. vol., cloth, pp. 30fi, with wood cuts.  SI.
GLUGE'S ATI.AS OF PATHOLOGICAL HIS-
  TOLOGY.  Translated, with Notes and Addi-
 tions by Joseph  Leidt, M. D.  In one volume,
 very large imperia1 quarto, extra cloth, witl 3*u
 copper plate figures, plain and eolored, 85 00.

HUGHES' INTRODUCTION TO  THE PRAC-
 TICE OF AUSCULTATION  AND  OTHER
 MODES OF PHYSICAL DIAGNOSIS  IN DIS-
 EASES  OF THE LUNGS AND HEART.  Se-
 cond edition    1 vol. royal 12mo., ex. cloth, pp.
 304.  SI 00.
TOLOGY. Eighth ediMon. Extensivly revised
and modified,   in two Urge octavo volumes, ex-
tri cloth, of more Hi ui 1000 pages, with over 300
illustrations.   *t> 00.
                         HAMILTON  (FRANK  H.),  M. D.,
                     Professor of Surgery in the Long Island College Hospital.

 A  PRACTICAL  TREATISE  ON   FRACTURES  AND  DISLOCATIONS.
   Second edition, revised and improved.  In one large and handsome octavo volume, of over 750
   pages, with nearly 300 illustrations.   (Just Ready)

   The earlv demand for a new edition of  this  work shows that it has been  successful in securing
 the confidence ofthe profession as a standard authority for consultation and reference on its import-
 ant and difficult subject.  In again passing it through the press, the author has taken the opportu-
 nity to revi.-e it carefully, and introduce whatever improvements have been  susrzested by further
 experience and observation   An additional chapter  on Gun-shot Fractures will be found to adapt
 it still more liilly to the exigencies of ihe  time.

   Among themanygood workers atsurgery of whom  When we say, however, that we believe it will at
 America may now hoast rot the leaf t is Frank Hast- I once take its place as the best book for consultation
 ings Hamilton; and the volume before us is (we say \ by the practitioner; and that it will form the most
 it with a pang of  wounded  patriotism.' the best and  complete, available, anrt reliable guide in emeTgen-
 handiest book on the  subject in  the Ei glish lan- j ciesof every nature connected with its subjects; and
 gusge.   It  is in  vain to attempt a review of it;  also that thestudtutof surgtry may make it his text-
 nenrly as vain to seek  for any sins, either of com-  book with tntire confidence, and with pleasure also,
 mission or omission.  We have seen  no work on  from its agreeable and easy style—we'hink our owa
 practical surgery which we would sooner  recom- | opinion  may be gathered as to  its value.— Boston
 mend to our brother surgeons, especially those  of  Medical and Surgical Journal, March 1,  1860.
 '• the services," (  r those whose practice lies in dis-   The work Ig c<,ncisr, judicious, and accurate, and
 tricts where a man has necessarily to rely  on hi;  adapted to the wants of the student, practitioner,
 own unaided resources.  The practitioner will find  and lnVe8tigator, honoTahle U> the author  and to the
 in  t directions for nearly every possible  »c;ident,  profession.—CAieag-o Med. Journal, March, 1860.
 easily found and comprehended; and much pleasant   „T       ...     .      ,            .
 rending for him to muse ov.-r in the after contid-ra-   We regard thii work ■■ an honor not only to its
 tion ofhis cases— Edinburgh Med. Joum Feb 1&61.  author, but to the profession of our country.  Were
                                               we to review it thoroughly, we could not  convey to
   This is a valuable contribution to the surgery  of j the mind of ihe  reader more forcibly our honest
 most important affections,and is the more welcome,  opinion expressed in the few words—we think it the
 inasmuch as at the present time we do not possess  best book ol its kind extant.  Every man  interested
 a single complete  treatise on Fractures and Dislo-  in  surgery will soon have this work  on  his desk.
 cations in the English language. It has remained for  He who doe* not, will be the loBer.—New Orleans
 our American brother to produce a  complete treatise  Medical News, March, 1860.
 upon the subject, and bring together in a convenient   Dr Hamilton is fortunate in having succeeded in
 form those alterations and improvements that have  fillj  thc vojd< BO lon  feU wi,h  wgat CMnot fai,
 been made from time to time in the treatment of these  to be at once accepted a's a model  monograph in some
 affections.   One great and valuable fealuie in the  re,pect8, and a work of classic! authority.  We
 work before us is  the fact that it comprises  all the  ,jncereiy congratulate the  profession of the United
 improvement  introduced into the practice of both  Sw,e, on the rtppeatanc,. „f sucn a publication from
 English and American surgery, and though fur from  onP of th(.,r munber.  We have  reason to be proud
 omitting mention of our continental neiphbors, the  of  it ag an orlgjna| worl both ln a literary and s.'i-
 author by no means < ncourages the not .on-put too  enljfic p„illt 0°f viaWy a„^ ,„ elteem lt ag , vaiuai,le
 prevalent in some quarters- that  nothing is good  „„{<,„ in , mo„ difficu|t „nd imp„rtant  branch of
 unless imported from  France or  Germany.  Tne  ,tudy and practice.  On every  account, therefore,
 utter half of the work is devoted  to the considera- , we hope ,hat it lnay ,onn he wjdery kmnvn abroJ
 tion of the various dislocations and their appropri-  a„  an fy^eace of genuine  progress on this side of
 ate treatment  and its merit is fully equal to  that  of  the Atiantic, and  further, that it may be  still more
 the preceding portion—The London Laneet,M*y  5,  Wldeiy known at  home ai HI1 authoritative teacher
 *°  ■                                           from which every one may profitably learn, and sj
  It is emphatically the book npon the subjects  of, a tf. ird ing an example  of honest, well-directed, aud
 which it treats, and we cannot doubt thut  it will  uctiring industry  in authorship which every surgeon
 continue so  to be for an  indefinite period of tune. , may emulate.- Am. .lie J. Journal, April, I860.


                          HOBLYN (RICHARD  D.),  M. D.

 A DICTIONARY  OF  THE  TERMS  USED IN  MEDICINE AND THE
  COLLATERAL SCIENCES.  A new American edition.   Revised, with numerous Additions,
   by Isaac Hays, M.  D., editor ol the " American Journal ofthe Medical Sciences."  In one large
  royal  12mo. volume, leuiher, of over 500 double columned pages.  £1 50.

  Tn both practitioner and student, we recommend  use; embracing every department of medical scienca
this dictionary as bruin convenient in size, accurate  down to the very latest date.—Western Lancet.

ll^l^HM?UlIiCrilly/a!1 HH!r' JT|,le,e for >   Hoblyn's Dictionary has long  been a favorite with
ordinary consultation - ( harleston Med. Joum.    ( u,   ,t>, ,he h(.gl ,„,;,,, of den\,ition, we have.and
  We know of no dictionary better arranged and  ought always to be  upon  the  student's  table-
adapted. Itisnotencumbercd with the obsolete terms  Southern Med. and Surg. Journal.
of a bygone age, but it contains all that are  now in I
HOLLAND'S  MEDICAL  NOTES  AM)   RE.
  FLECTIONS.   From the thud Lm.a.n  edition.
  In one handsome octavo volume, extra cloth. S3.
HORNER'S SPECIAL  ANATOMV AND  1US- 
AND SCIENTIFIC  PUBLICATIONS.
19
Pr ,      ,,,..,  .,           HODGE (HUGH L.),  M.D.,
rrotessor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, Ac

°tt.  DIS^SES  PECULIAR TO  WOMEN, including  Displacements of th
  Uterus.  With original illustrations.  In one beautifully printed octavo volume, of nearly 50
  pages, extra cloth.  S3 25.  (Now Ready.)
  We will say at once thnt the work fulfils its object
capitally well; and we will  moreover venture the
assertion that it wiU inaugurate an imnroved prac-
tice throughout this whole country.  Tl*e secrets of
tne author's success are so clearly revealed that the
attentive student cannot fail  to insure a goodly por-
tion of similar success in his own practice.  It is a
credit to all medical literature; and we add, that
the physician who does  n»t  place it in his library
and who does not faithfully con its pages, will lose
a vast deal of knowledge that would be most useful
to himself and beneficial to  his  patients.   It is a
practical work ofthe highest order of merit; and it
will take rank as such immediately.—Maryland and
Virginia Medical Journal, Feb. 1&6I.

  This contribution towards the elucidation of the
pathology and treatment of  some of the diseases
peculiar to women, cannot fail to meet with a favor
able reception from  the medical profession.  The
chsraster of the particular  maladies of which the
work before us treats; their frequency, variety,and
nbscuiity; the amount of malaise and even of actual
Buffering  by  which they are  invariably attended;
their obstinacy, the difficulty with which they are
overcome, and tl eir disposition aeain and again to
lecur—these, taken in connection with the entire
competency of the author to render a correct  ac-
count of their nature their causes, and their appro-
  e
500
priate management—his ample experience, his ma-
tured judgment, and his perfect conscientiousnesii—
invest this publication with an interest ano value to
which few of the medical treatises of a recent date
can lay a stronger, if, perchance, an equal claim.—
Am. Joum. M'd. Sciences, Jan.  1861.
  Indeed, although no part ofthe volume is not emi-
nently deserving of perusal and study, we think tfrat
the nine chapti rs devoted to this subject, are espe-
cially so, and we know of no more valuable mono-
graph upon the symptom*, prognosis, aiid  manage-
ment of these annoying maladies than is eomtituted
by this part of the work.  We cannot but regard it
as one ofthe most original and m ist practical works
of the day; one which every accoucheur and physi-
cian should most carefully re id; for we are per-
suaded that he will arise from its perusal with new
ideas, which  will induct  him into a more rational
practice in regard  to many a suffering fern lie, who
may have placed her health in his hands.—British
American Journal, Feb. 1661.
  Of the many excellences of the work we will not
speak at length. We advise all who would acquire
a knowledge of the proper management of the mala-
dies of which it treats,  to study it with care.  The
second part is ot itself a most valuable contribution
to the practice of our arc.—Am. Med. Monthly and
New York Review, Feb. 1861.
The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size.
                            HABERSHON (S. O.),  M.  D.,
   Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c.

PATHOLOGICAL  AND  PRACTICAL  OBSERVATIONS  ON  DISEASES
  OF THE ALIMENTARY CANAL, CESOPHAGUS, STOMACH,  CAECUM,  AND INTES-
  TINES.  With illustrations on wood.   In  one handsome octavo volume of 312 pages, extra
  cloth   SI 75.  (Now Ready.)
                         JONES (T. WHARTON), F.R.S.,
          Professor of Ophthalmic Medicine and Surgery in University College, London, &c.
.THE  PRINCIPLES  AND  PRACTICE  OF  OPHTHALMIC  MEDICINE
   AND SURGERY.  With one hundred and ten illustrations.  Second American from the second
   and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills'
   Hospital,fee.  In one large, handsome royal 12mo. volume, extra cloth, ol 500 pages.   $1  50.
JONES (C.  HANDFIELD),  F.R.S., &. EDWARD H. SIEVEKING, M.D.,
               Assistant Physicians and Lecturers in St. Mary's Hospital, London.
A MANUAL  OF  PATHOLOGICAL  ANATOMY.   First  American  Edition,
  Revised.  With three hundred and ninety-seven handsome wood engravings.  In one large and
  beautiful octavo volume of nearly  750 pages, leather.   $3 75.
  Asa concise text-book, containing, in a condensed | obliged to glean from a great namber of monographs,
form, a complete outline'of what is known in the
domain of Pathological Anatomy, it is perhaps the
best work in the English language.  Its great merit
consists in its completeness and brevity, and in this
respect it supplies a great desideratum  in our lite-
rature. Heretofore the student of pathology was
and the field was so extensive that but few cultivated
it with any dsgree of success.  As a  simple work
of reference, therefore, it is of great  value to the
student of pathological anatomy, and  should be in
?very physician's library.—Western Lancet.
                   KIRKES (WILLIAM SENHOUSE), M. D.,
               Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c.
A  MANUAL  OF  PHYSIOLOGY.    A new  American, from  the  third  and
  improved London edition.  With two hundred illustrations.  In one large and handsome royal
  12mo. volume, leather,  pp. 586.  $2 00.  (Lately Published.)
  This is a new and very much improved edition of
Dr. Kirkes' well-known Handbook of Physiology.
It combines conciseness with completeness, and is,
therefore,admirably adapted for.consultation by the
busy practitioner.—Dublin Quarterly Journal.
  One ofthe very best handbooks of Physiology we
possess—presenting just such an outline of the sci-
ence as the student requires during his attendance
upon a course of lectures, or  for reference whilst
preparing for examination.— Am. Medical Journal
  Its excellence is in its compactness, its clearness.
*nd its carefully cited authorities.  It is the most
convenient of text-books.  These gentlemen, Messrs.
Kirkes and Paget, have the gift of telling us what
we want to know, without thinking  it necessary
to tell us all they know.—Boston Med and Surg.
Journal.

  For the student beginning this study, and the
practitioner  who has but  leisure  to refresh his
memory, this book is invaluable, as it contains all
that it is important to know.—Charleston  Med.
Journal. 
20
BLANCHARD  &  LEA'S  MEDICAL
KNAPP'S TECHNOLOGY ; or,Chemistry applied -
  to the Arts and to Manufactures.  Edited by Dr.
  Ronalds, Dr.  Richardson,  and  Prof. W. R.
  Johnson. In two handsome 8vo. vols., withabout
  500 wood-engravings. $6 00.
LAYCOCK'S LECTURES  ON  THE PRINCI-
 PLES  AND METHODS OF MEDICAL  OB-
 SERVATION AND RESEARCH. For the Use
 of Advanced Students and Junior Practitioners.
 In one royal 12mo. volume, extra cloth. Price $1.
                        LALLEMAND AND WILSON.
A  PRACTICAL  TREATISE  ON  THE  CAUSES,  SYMPTOMS,  AND
  TREATMENT OF SPERMATORRHOEA.  By M. Lallemand.  Translated and  edited by
  Henry J McDougall. Third American edition.  To which is added-----ON  DISEASES
  OF  THE VESICULA SEMINALES; and their associated organs.   With special refer-
  ence to the Morbid Secretions of the Prostatic and  Urethral Mucous Membrane.  By Marris
  Wilson, M.D.  In one neat octavo volume, of about 400 pp., extra cloth. $2 00.  {Just Issued.)
                          LA ROCHE  (R.), M. D.,  &c.
YELLOW FEVER, considered in its Historical, Pathological, Etiological, and
  Therapeutical Relations.  Including a Sketch of the Disease as it has occurred in Philadelphia
  from 1699 to 1854, with an examination ofthe connections between it and the fevers known under
  the same name in other parts of temperate as  well as in tropical regions.  In two large and
  handsome octavo volumes of nearly 1500 pages, extra cloth.  $7 00.
 From Professor S. H. Dickson, Charleston, S. C,
             September 18,1855.
  A monument of intelligent and well applied re-
search, almost without example.  It is, indeed, in
itself, a large library, and is destined to constitute
the special resort as a book of reference, in  the
subject of which it treats, to all future time.
  We have not time at present, engaged as we are,
by day and by night, in the work of combating this
very disease, now prevailing in our city, to do more
than give this cursory notice of what we consider
as undoubtedly the most able and erudite  medical
publication our country has  yet produced   But in
view of the startling fact, that this, the most malig-

                                 BY THE SAME AUTHOR.

PNEUMONIA; its Supposed  Connection, Pathological and Etiological, with Au-
  tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria.  In one
  handsome octavo volume, extra cloth, of 500 pages.  $3 00.
nant and unmanageable disease of modern  times,
has for several years been prevailing in our conntry
to a greater extent than ever before; that it is no
longer confined to either large or small cities, but
penetrates  country villages, plantations, and farm-
houses ; that it is treated with scarcely better suc-
cess now than thirty or forty years ago; that there
is vast mischief done by ignorant pretenders to know-
ledge in regard to the disease, and in view of the pro-
bability that a majority of southern physicians will
be called upon to treat the disease, we trust that this
able and comprehensive treatise will he very gene-
rally read in the south.—Memphis Med. Recorded.
                        LAWRENCE (W.),  F. R. S.,  «tc.
A TREATISE  ON  DISEASES   OF  THE  EYE.  A  new  edition, edited,
  with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi-
  tal, &c.  In one very large and handsome octavo volume, of 950 pages, strongly bound in leather
  with raised bands.  $5 00.

                             LUDLOW (J. L.),  M.  D.
A MANUAL  OF  EXAMINATIONS  upon  Anatomy, Physiology^  Surgery,
  Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics.   To
  which is added a Medical Formulary.  Third edition, thoroughly revised and greatly extended
  and enlarged.  With 370 illustrations.  In one  handsome royal 12mo.  volume, leather, of 816
  large pages  $2 50.
  We know of no better companion for the student I crammed into his head by the various professors to
during the hours spent in the lecture room, or to re- whom he is compelled to listen.—Western Lancet
fresh, at a glance, his memory of the various topics | May, 1857.
                              LEHMANN  (C. G.)
PHYSIOLOGICAL   CHEMISTRY.   Translated from the second  edition  bv
  ?*??G M*a DVj\M- D-' F- Ri-S:' &rcT>edile« by R.  E.  Rogers, M. D., Professor of Chemistry
  in the Medical Department of the University of Pennsylvania, with illustrations selected from
   UJ ue *.          y8'° °glCal Chemiftry> and an Appendix of plates.  Complete in two large
  Tration"   $6e0°0CtaVO V°lumeS'eXUa clotk' containing 1200pages, with nearly two hundred illus-

  The work of Lehmann stands unrivalled as  the
most comprehensive book of reference and informa-
tion extant on every branch of the subject on which
it treats.—Edinburgh Journal of Medical Science.
  The most important contribution as yet made to
Physiological Chemistry—Am. Journal Med. Sci-
• ares, Jan. 1856.
                        by the same author.  (Lately Published.)

MwifJN^L °Ja?,HEMIkC^^ PHYSIOLOGY.    Translated  from the  German,
  with Notes and Additions, by J. Cheston Morris, M. D., with an  Introductory Essav on Vita
  Force, by Professor Samuel Jackson, M. D, of the University of  Pennsylvania   Whh illus
  trationsonwood.  In one very handsome octavo volume, extr Jcloth, of?sSTp^es.  $2 25.
  r   .  ..   ..      „    F™*''Prof. Jackson's Introductory Essav.
..,!lnt°W tCt hand*ook 0'' Pr Lehmann as a manual of Organic  Chemistry for the u«e of the
students of the University and in recommending his original work of Phys omgicaiCh^trv
for their more mature studies, the high value of his researches, and the erea? weYi^t of his anth,!
rity in that important department of medical science are fully recogn^ed 
AND SCIENTIFIC  PUBLICATIONS.
21
                         LYONS (ROBERT  D.),  K.  C. C,
                 Late Pathologist in-chief to the British Army in the Crimea, tec.
A TREATISE  ON FEVER; or, selections from a course of Lectures on Fever.
  Being part of a course of Theory and Practice of Medicine.  In one neat octavo volume, of  362
  pages, extra cloth; $2 00.  {Now Ready.)
  We have great pleasure in recommending  Dr.
Lyons' work on Fever to the attention of the pro-
fession. It is a work which cannot fail to enhance
the author's previous  well-earned reputation, as a
diligent, careful, and  accurate observer.—British
Med. Journal, March 2, 1861.
  Taken as a whole we can recommend it in the
highest terms as well  worthy the careful perusal
and study of every student and practitioner of medi-
cine.  We consider the work a most valuable addi-
tion to medical literature, and one destined to wield
no little influence over tlie mind of the profession.—
Med and Surg. Reporfr, May 4, 1861.
  This is an admirable work upon the most remark-
able and most important claBS of diseases to which
mankind are liable.—Med. Joum. of N. Carolina,
May, 1861.
                          MEIGS (CHARLES D.), M. D.,
         Lately Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia.

OBSTETRICS:  THE  SCIENCE  AND THE  ART.   Fourth  edition, revised
  and improved.  With one hundred and twenty-nine illustrations  In one beautifully nn'nted octavo
  volume, leather, of seven hundred and thirty large pages.  $4 00   (Now Ready, Feb. 1863.)

  In his Preface the  author remarks:  ' In this  edition I have endeavored to amend the work by
changes in its form, by careful corrections of many expressions, and by a few omissions and some
additions as to the text."  The student and practitioner may therefore rely on finding the subject
thoroughly brought up to the present time, and that the new edition is worthy a continuance ofthe
very great favor with which the work has been  received by the profession.
  Though the work has received only five pages of
enlargement, its chapters throughout wear the im-
pressof careful revision. Expunging and rewriting,
remodelling its sentences, with occasional new ma-
terial, all evince a lively desire that it shall deserve
to be regarded as improved in manner  as well as
matter.  In the matter, every stroke of the pen has
increased the value of the book, both  in expungings
and additions —Western Lancet.
  The best American work on Midwifery that is
accessible  to the student and practitioner—N. W.
Med. and Surg. Journal.
  This is a standard work by a great American Ob-
stetrician.   It is the third and last edition, and, in
the language ofthe preface, the author has "brought
the subject up to the latest dates  of real improve-
ment in our art and Science."—Nashville Joum. of
Med. and Surg.
                            BY THE SAME AUTHOR.  {Just Issued.)

WOMAN: HER  DISEASES  AND  THEIR  REMEDIES.   A Series of Leo-
  tures to his Class.  Fourth and Improved edition.  In one large and beautifully printed octava
  volume, leather, of over 700 pages.  $3 60.
  In other respects, in our estimation, too much can-
not be said in praise of this work. It abounds with
beautiful passages, and for conciseness, for origin-
ality, and for all that is commendable in a work on
the diseases of females, it is not excelled, and pro-
bibly not equalled in the English language.   On the
whole, we know of no work on the diseases of wo-
men  which we  can  so cordially commend to the
student and practitioner as the one before us.—Qhio
Med. and  Surg. Journal.
  The body of the book is worthy of attentive con-
sideration, and  is evidently the production of a
clever, thoughtful, and sagacious physician.  Dr.
Meigs's letters on  the diseases of the external or-
gans, contain many interesting and rare cases, and
many instructive observations. We take our leave
of Dr. Meigs, with a high opinion of his talents and
originality.—The British and Foreign Medico-Chi-
rurgical Review.
  Every chapter is replete with practical  instruc-
tion, and bears theimpress of being the composition
of an acute and experienced mind.  There is a terse-
ness, and at the saYne time an accuracy in his de-
scription of symptoms, and in the rules for diagnosis,
which cannot fail to recommend the volume to the
attention of the reader.—Ranking'* Abstract.

  It contains a vast amount of practical knowledge.
by one who has accurately observed  and retained
the experience of many years.—Dublin Quarterly
Journal.
  Full of important matter, conveyed in a ready and
agreeable manner.—St.Louis Med. and Surg. Jour.

  There is an off-hand fervor, aglow,  and a warm-
heartedness infecting the effort of Dr. Meigs, which
is  entirely captivating, and which absolutely hur-
ries the reader through from beginning to end. Be-
sides, the  book teems with solid instruction, and
it  shows the very highest evidence of  ability, viz.,
the clearness with which the information  is pre-
sented.  We know of no better test of one's under-
standing a subject than the evidence of the power
of lucidly explaining it.  The most elementary, as
well as the obscurest subjects, under  the pencil of
Prof. Meigs, are isolated and made to stand out in
such bold relief, as to produce distinct impressions
upon the  mind and  memory ofthe reader. — The
Charleston Med. Journal.
                                   BY THE SAME AUTHOR.

ON  THE   NATURE,   SIGNS,  AND   TREATMENT   OF  CHILDBED
  FEVER.  In a Series of Letters  addressed  to the Students of his  Class.  In one handsome
  octavo volume, extra cloth, ol 365 pages.  $2 50.
                                              lectable book. *  *  * This treatise upon child-
                                              bed fevers will have an extensive sale, being des-
                                              tined, as it deserves, to find a place in the library
  The instructive and interesting author  of this
work, whose previous labors have placed his coun-
trymen under deep and abiding obligations, again
challenges their admiration in the fresh and vigor-
ous, attractive and racy pages before us. It is a de-
of every practitioner who scorns to lag in the rear.—
Nashville Journal of Medicine andSurgery.
BY THE SAME AUTHOR J  WITH COLORED PLATES.
A TREATISE ON  ACUTE  AND CHRONIC DISEASES  OF THE NECK
  OF THE  UTERUS.  With numerous plates, drawn and colored from nature in the highest
  ityle of art.  In one handsome octavo volume, extra cloth.
$4 50. 
22
BLANCHARD «  LEA'S  MEDICAL
                        MACLISE  (JOSEPH),  SURGEON.
SURGICAL  ANATOMY.   Forming  one  volume,  very large  imperial quarto.
  WUh sixty-eight large and splendid Plates, drawn in the best style and beautifully colored.  Con-
  taining one hundred and ninety Figures, many of them the size of life.   Together with copious
  and explanatory letter-press.  Strongly and handsomely  bound in extra cloth, being  one of tne
  cheapest and best executed Surgical works as yet issued  in this country.  $11 00.
  * * The size of this work prevents its transmission through the post-office as a whole, but those
who desire to  have  copies forwarded by mail,  can receive them in five parts, done up in  stout
wrappers.  Price $9 00.
  One of the greatest artistic triumphs of the age f  A work which has no  parallel in  point of accu-
in Surgical Anatomy.—British American Medical  racy and cheapness in the English language.—£1. I.
Journal.                                       \ Journal of Medicine.
  No practitioner whose means will  admit should j          extremely gratified to  announce to tht>
fail to possess it.-Rankmg's Abstrrtt.             profession the completion of this truly  magnificent
  Too much cannot  be  said in its praise;  inneed,  w.ori{) which, as a whole, certainly stands  unri-
we have not language to do it justice.—Ohio Medi- , va|ie(i  both  for accur-acy of drawing, beauty  of
cal and Surgical Journal.

  The most  accurately engraved and  beautifully
colored plates we have ever seen in an American
book—one of the best and cheapest surgical works
ever published.—Buffalo Medical Journal.
coloring, and all the requisite explanations of the
subject  in hand.—The  New  Orleans  Medical and
Surgical Journal.

  This is by far the  ablest work on Surgical  Ana-
tomy  that has come under our observation.  Wa
  It is very rare that so elegantly printed, so well  know of no other  work that woald justify a stu-
illustrated, and so useful a work, is ofTered at so  dent,on any degree, for neglect of actual dissee-
moderate a price.—Charleston Medical Journal.     I tion.  In those sudden  emergencies that so often
                                              ' arise, andwhich require the instantaneous command
  Its  plates can boast a  superiority which places  „f minute anatomical knowledge, awork of thi* kind
themalmost beyond the reach of competition.—Medi- j keepg the details of the dissecting-room perpetually
tal Examiner.                                   rresn jn tne memory.—The Western Journal of Mtdt-
  Country practitioners will find these plates of im-  cine and Surgery.
mense value.—N. Y. Medical Gazette.             '

                             MILLER (HENRY), M. D.,
      Professor of Obstetrics and Diseases of Women and Children in the University of Louisville.
PRINCIPLES AND  PRACTLCE OF OBSTETRICS,  &c; including the Treat-
  ment of Chronic Inllammation of the Cervix and Body of the Uterus considered as a frequent
  cause of Abortion.  With about one hundred illustration^ on wood.   In one very handsome oc-
  tavo volume, of over 600 pages.  (Lately Published.)  S3 75.
  We congratulate the author tnat the task is done,  tion to which its merits justly entitle it.  The style
 We congratulate him that he hasgiven to the medi-  is such that thedescriptionsare clear, and each sub-
 cal public a work which will secure for him a high  ject is discussed and elucidated with due regard to
 and permanent position among the standard autho- ' its practical bearings, which cannot fail to make it
 rities on the principles and practice of obstetrics,  acceptable and valuable to both students and prae-
 Congratulations are not less due to the medical pro-  titioners.   We cannot, however,  close this brief
 fession of this country, on the acquisition of a trea- : notice without congratulating the  author and the
 tise embodying the results of the studies, reflections,  profession on the  production of such  an excellent
 and experience of Prof Miller.  Few men, if any,  treatUe.  The author is a western man of whom we
 in this country, are more competent than he to write j feel proud, and we cannot  but think that  his book
 on this department of medicine. Engaged for thirty-  will find many readers and warm admirers wherever
 five years in an extended practice of obstetrics, for ' obstetrics is taught and studied as a science and an
 many years a teacher of tins branch of instruction  art.—The Cincinnati Lancetand Observer.
 in one of the largest of our institutions, a diligent ■   A most re,peclable and valuable addition to our
 student as well as a careful observer, an original and ' -
 independent  thinker, wedded to no hobbies, ever
 ready to consider without prejudice new views, and
 to adopt innovations if they are really improvements,
 and withal a clear, agreeable writer,  a practical
 treatise from his pen could  not fail to possess great
 value.—Buffalo Med Journal.
  In fact, this volume must take its place among the
 ■tandard systematic treatises on obstetrics j a posi-
hoine  medical literature, and one reflecting credit
alike on the author and the  institution to wnich he
is attached.  The student will find in this work a
most useful guide to his studies; the  country prac-
titioner, rusty in  his reading, can obtain from its
pages a fair resume of the modern literature of the
science; und we hope to see this American produc-
tion  generally consulted by the profession.— Va,
Mid. Journal.
                             MACKENZIE (WJ,  M.D.,
                 Surgeon Oculist in Scotland in ordinary to Her Majesty, Ac. 4c
A PRACTICAL  TREATISE  ON  DISEASES  AND  INJURIES  OF  THE
  EYE.  To which is prefixed an Anatomical  Introduction explanatory of a Horizontal Section oi
  the Human Eyeball, by Thomas Wharton  Jones, F. R. S.  From the Fourth Revised and En-
  larged London Edition.  With Notes and  Additions  by Addinkll Hewson, M. D., Surgeon to'
  Wills Hospital, &c. <fcc.  In one very large and handsome octavo volume, leather, raised bands, with
  plates and numerous wood-cuts.  $5 25.
                                              able manner in which the nuthor's storesof learning
                                  $5 25
  The treatise of Dr. Mackenzie indisputably holds
the firstplace, and forms, in respect of learning and
research, an Encyclopedia unequalled  in extent by
any other work ofthe kind,either English or foreign.
.—Dixon on Diseases of the Eye.
  Few modern books on any department of medicine
or surgery have met with such extended circulation,
or have procured  for their authors a like amount of
European celebrity.  The immense research which
it displayed, the  thorough  acquaintance with the
subject, practically as well as theoretically,and the

MAYNE'8 DISPENSATORY  AND THERA^
  PEUTICAL REMEMBRANCER.  With every
  Practical Formula contained in the three  British
  Pharmacopoeias  Edited, with the addition ofthe
  Formulae of the U. S. Pharmacopoeia,  by R. E
  GbiffitHjM.D  1 12mo.vol.ex.cl.,300pp. 7fic.
and experience were rendered available for general
use, at once procured for the first edition, as well on
the continent as in this country, that high position
as a standard work which each successive edition
has more firmly  established.  We consider it the
duty of every one who hits the love of his profession
and the welfare of his patient at heart, to make him-
self tamiliar with this the most complete work in
the English  language upon the diseases of the eye
—Med. Times and (iazette.

MALGAIGNE'S OPERATIVE SURGERY, based
  on Normal and Pathological Anatomy.  Trans-
  Aat«d ^r "V the- French °y  Fredhrick  Brittan,
  A B., M. D. V\ ithnunierousillustrationson wood.
  In one handsome octavo volume, extra cloth, of
  nearly six hundred pages.  *2 26 
AND  SCIENTIFIC  P [J B LTC ATI ONS.                   23
                          MILLER (JAMES), F.  R. S. E.,
                     Professor of Surgery in the University of Edinburgh, &o.

P?!NhCT^LES 0F SURGERY.   Fourth American, from  the third  and revised
  h.',„u^,i   jdrtIon-...In one lar*e  and very beautiful  volume, leather, of 700 pages, with two
  hundred and forty illustrations on wood.  S3 75.

.»Tv k,^rnk«°i.Mr- MHler 1B to° weM ,ril*'oo favor- I   The work takes rank with Watson's Practice of
tnr«<lHW.na^                                 Physic;  it certainly does not fall behind that great
annoSneemeL nf n^11'  1C^?^,t •^•"•■"V tf"»" the j work in  soundness of principle or depth of reason-
SnSnrVJ Tn?.! ,?  ? ■?  W edlt'.on> the /««"•«* in  our  ine and research  \n physician who values his re-
„.  l'„ „£„*L   a  e*te«5»lve circulation among ! putation, or seeks the interests of his  clients, can
*L* JfIS?,    reliable exposition of the sci-  acquit himself before his God and the world without
™lnJ,J? n„»71 S"r&ei?> U 8t2nd8 deservedly high— I making himself familiar with the sound and philo-
7Ln~y       superior.—Boston Med. and Surg,  sophical  views developed in the foregoing book.-
J0Hrnal'                                      | New Orleans Med. and Surg. Journal.

                           BY THE same author. (Just Issued.)

THE  PRACTICE  OF  SURGERY.   Fourth  American  from the last Edm-
  burgh edition.  Revised by the American  editor.  Illustrated by three hundred and sixty-four
  engravings on wood.   In one large octavo volume, leather, of nearly 700 pages.  $3 75.
  N;,.e"c;,m,iunl0f ours could add to the popularity t hie works, both on the principles and practice of
Of Miller s >urgery  Its  reputation in this country ; surgery have been assigned the highest rank.  Ifwe
isunsurpassedby that of any other work, and, when  were limited to but one work  on surgery, that one
taken in connection with the author's  Principles of should be Miller's, as we regard itas superior to all
Surgery, constitutes a  whole, without reference to l others.—St. Louis Med. and Surg. Journal.
which no conscientious surgeon would be willing to
practicehisart.—Southern Med.andSurg. Journal    The author has in this and his" Principles," pre-
  Itis seldom that two volumes have ever made so I "T ,V" 'heprofessiononeof the most c..mpleteand
profound an impression in so  short a ta   as the i re,,?-b,r  *yStem* f .SaT%eTY extant-   Hls style of
"Principles" and the « Practice" of Sureery by < Wr,Uln* '" °nglna VmP,re'"ive' and engaging, ener-
tir. \r;n»r  r,r .» ,i„n„ m«»jVlja.u      ..$CI>"> i getic, concise, and lucid.  Few have the faculty of
K^cnu^n   T,  Iiw    the rePuU\V°n the7  condensing so much in small space, and at the same
hU nr-nticni^ J wJ»£?  " "P emine ""y^™" | time so persistently holding theattention. Whether
~-'*?iv™— tCitZl ;,nf°hrm«d man' who know.  as a tex  -book for students8 or a book of reference
exactly what he i. talking about and exactly how to  for practjtionerit it clinnot be too  strongly recom-
talk it.-X«iift>e*y Medical Recorder.              mended.-Southern Journal of Med. and Physical
  By the almost unanimous voice of the profession, | Sciences.
                           MORLAND (W.  W.), M.  D.,
                       Fellow of the Massachusetts Medical Society, ice.
DISEASES OF THE  URINARY ORGANS;  a Compendium of their Diagnosis,
  Pathology, and Treatment.  With illustrations.  In one large and handsome octavo volume, ol
  about 600 pages, extra cloth.   (Just Issued.)  $3  50.
refer. This desideratum has been supplied by Dr.
Morland, and it has been ably done.  He has placed
before us  a  full, judicious, and reliable  digest.
Each subject is treated with sufficient minuteness,
yet in a succinct, narrational style, such as to render
the wonc one of great interest, and one which will
prove in tne highest degree  useful  to the general
practitioner.—N. Y. Joum. of Medicine.
  Taken as a whole, we can recommend Dr. Nor-
land's compendium as a very desirable addition to
the library of  every  medical or surgical practi-
tioner.—Brit, and For. Med.-Chir. Rev., April, 1859.
  Every medical practitioner whose attention has
been to any extent attracted towards the class of
diseases to which this treatise relates, must have
often and sorely experienced the want of some full,
yet concise recent compendium to which he could

                           BY the same author —(Now Ready.)

THE  MORBID  EFFECTS  OF  THE  RETENTION  IN  THE  BLOOD  OF
  THE ELEMENTS OF THE URINARY SECRETION.  Being the Dissertation to which the
  Fiske Fund  Prize  was  awarded, July 11,1861.  In one  small octavo volume, S3 pages, extra
  cloth.  75 cents.
              MONTGOMERY (W. F.l,  M. D.,  M.  R. I. A., &c,
        Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c.

AN EXPOSITION OF THE SIGNS  AND  SYMPTOMS OF  PREGNANCY.
  With some other Papers on Subjects connected with Midwifery.  From the second and enlarged
  English edition.  With two  exquisite colored plates, and numerous wood-cuts.  In one very
  handsome octavo volume, extra cloth, of nearly 600 pages.  (Lately Published.)  $3 75.
  A book unusually rich in practical suggestions— • fresh, and  vigorous, and classical is our author's
Am Journal Med. Sciences, Jan. 1857.            style; and one forgets, in the renewed charm of
  „,,         ,....•      . ••„ n,..™  Nverv page, that it, and every line, and every word
  These  several subjects so interesting in them- hag  ^     hed  and reweighed through years of
selves, and so important, every one of them, to the       ation. 6that  this ig of au others  the book of
moBt delicate and precious of social relations, con- 5b8(;etri<< L'  on each 0f its several topics; on all
trolling often the honor and domestic peace of a    intg connected with pregnancy, to be everywhere
family, the legitimacy of offspring, or the life ot its ^eceived ag a manuai  ()f 8pecial jurisprudence, at
parent, are all treated with an elegance of diction, on(je unnouncing fact affording argument, establish-
fulness of illustrations, acuteness and justice ot rea-     precedent, and governing alike the juryman, ad-
soning, unparalleled in obstetrics, and unsurpassed in   s>}    Und judge.—iV. A. Med.-Chir. Review.
medicine.  The reader's interest can  never flag, so , ,u,""re'    J  6
      MOHR (FRANCIS), PH. D., AND REDWOOD (THEOPHILUS).

PRACTICAL   PHARMACY.   Comprising the  Arrangements, Apparatus, and
  Man mutations of the Pharmaceutical Shop and Laboratory.   Edited, with extensive Additions,
  byTrof^William Proct^k, of the Philadelphia  College of Pharmacy.  In one handsomely
  printed octavo volume, extra cloth, of 570  pages, with over 500 engravings on wood.  *2 75. 
24                    BLANCHARD  & LEA'S MEDICAL
                              NEILL  (JOHN), M.  D.,
                        Surgeon to the Pennsylvania Hospital,ice.; and

                      FRANCIS  GURNEY  SMITH, M.D.,
             Professor of Institutes of Medicine in the Pennsylvania Medical College.

AN  ANALYTICAL  COMPENDIUM  OF  THE  VARIOUS  BRANCHES
  OF MEDICAL SCIENCE;  for the Use and Examination of  Students.  A new edition, revised
  and improved.  In one very large and  handsomely printed  royal  12mo. volume, of about one
  thousand pages, with 374 wood-cuts.   Strongly bound in leather, with raised hands.  $3 00.
  The very flattering reception which has been accorded to this work, and the high estimate placed
upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex-
hausted two large editions, have stimulated the authors to render the volume in its present revision
more worthy of the success which has attended it.  It has accordingly been thoroughly examined,
and such errors as had on former occasions escaped observation have been corrected, and whatever
additions were necessary to maintain it on a level with the advance ot science have been introduced.
The extended series  of illustrations has been still further increased and much improved, while, by
a slight enlargement  ofthe page, these various additions have been incorporated without increasing
the bulk of the volume.                                                ..•.•■_  u-.u _4
  The work is, therefore, again presented as eminently worthy of the favor with which it has Hitherto
been received.   As a book for daily reference by the student requiring a guide to his more elaborate
text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate
examination, or as a source from which the practitioner* of older date may easily and cheaply acquire
a knowledge of the changes and improvement in professional science, its reputation is permanently
established.
  The best work  of the kind with which we are I the students is heavy, and review necessary for an
acquainted.—Med. Examiner.                    examination, a compend is not only valuable, but

nSSS^StS -wf ca^Sk*^ ^UE  £ ^^t^isl^e -^S
^"rrecomnfeTding TJZ ^M^RSd  <* "» <"»*' °f *■ J'™» ** ^J^f latest 2"
for students, and as especially useful to preceptors I »««*  a»d •f'u"de8t ^°rJt"n" "^ftltfc1 "S„i»h
who examine their pup Is.  It will save the teacher  Pavements and discoveries are explicitly, though
much  labor by enabling  him readily to recall all of  eoncisely, laid before the St»^t-Th"eis^a class
the noint« nnnn whirl, his  n.inils should be ex-  to whom we very sincerely commend this cheap book
the points upon which his pupils should  be ex
amined.  A work of this sort should be in the Hands
of every one who takes pupils into his office with a
view of examining them ; and this is unquestionably
the best of its class.—Transylvania Med. Journal

  In the rapid course of lectures, where work for
as worth its weight in silver—that class is the gradu-
ates in medicine of more than ten years' standing.
who have not studied  medicine since.  They will
perhaps find out from it that the science is not exactly
now what it was when they left it off.—The Stetho-
scope.
               NELIGAN (J.  MOORE), M. D., M. R. I. A., &c.

ATLAS OF  CUTANEOUS DISEASES.   In one beautiful quarto volume, extra
  cloth, with splendid colored plates, presenting nearly one hundred elaborate representations  of
  disease.  $4 50.
  This beautiful volume is intended as a complete and accurate representation of all the varieties
of Diseases of the Skin.  While it can be consulted in conjunction with any work on Practice, it has
especial reference to the author's "Treatise on Diseases ofthe Skin," so favorably received by the
profession some years since.  The publishers feel justified  in saying that few more beautifully exe-
cuted plates have ever been presented  to the profession of this country.
  Neligan's Atlas of Cutaneous Diseases supplies a j give, at a coup d'otil, the remarkable peculiarities
long existent desideratum much felt by the largest | of each individual variety.  And while thus the dis
class of our profession.  It presents, in quarto size.
16 plates, each containing from 3 to 6 figures, ana
forming in all a total of 90 distinct representations
rase is rendered more definable, there is yet no loss
of proportion incurred by the necessary concentra-
tion.  Each figure is highly colored, and so truthful
has the artist been that the most fastidous observer
could not justly take exception to the correctness of
the execution of the pictures under his scrutiny.—
of the different species of skin affections, grouped
together in genera or families. The illustrations
have been taken from nature, and have heen copied
with such fidelity that they present a striking picture  Montreal Med. Chronicle.
of life; in which the reduced scale aptly serves to I

                                  BY THE SAME AUTHOR.

A  PRACTICAL   TREATISE  ON  DISEASES  OF THE  SKIN.   Third
  American edition.  In one neat royal 12mo. volume, extra cloth, of 334 pages.  $1 00.

  !©■* The two volumes will  be sent by mail on receipt of Five Dollars.
^■F^iSLTS?  DIFFERENT  FORMS OF I  One vol. royal 12rao., extra cloth  with numeroui
  THE SKELKTON, AND  OF  THE TEETH. |  illustrations.  8125                numerous


                        PI RRIE (WILLIAM), F. R. S. E.,
                      Professor of Surgery in the University of Aberdeen.

THE  PRINCIPLES  AND  PRACTICE   OF  SURGERY.   Edited  by  John
  Neill, M D. Professor of Surgery in the Penna. Medical College, Surgeon tothe Pennsylvania
  Hospital, &c. In one very handsome octavo volume, leather, of 780 pages, with 316 illustrations.




   °                r                        ■. lg ■" tu\i upon the science of the art of surgery.—
  Prof. Pirne,  in the work before us, has elabo- j Nashville Journal of Medicine and Surgery. 
AND SCIENTIFIC  PUBLICATIONS.                   25
                               PARRISH  (EDWARD),
  Lecturer on Practical Pharmacy and .Materia Medica in the Pennsylvania Academy of Medicine, &c.

AN INTRODUCTION TO PRACTICAL PHARMACY.   Designed as a Text-
  Book lor the  Student, and as a Guide for the Physician and Pharmaceutist. With many For-
  mulae and Prescriptions.   Third  edition, greatly enlarged and improved.   In  one handsome
  octavo volume, with several hundred Illustrations, extra cloth.  *3 50.   (Preparing.)
  That Edward  Parrish, in  writing a book upon
practical Pharmacy some few years ago—one emi-
nently  original and unique—did the medical and
pharmaceutical professions a great and valuable ser-
vice, no one, we think, who  has had access to its
pages will deny; doubly welcome, then, is this new
edition, containing the added results of his recent
and rich experience as an observer, teacher, and
practicil operator in the pharmaceutical laboratory.
The excellent plan of the first is  more thoroughly,
and in detail, carried out in this edition__Peninsular
Med. Journal, Jan. 18G0.
  Of course, all apothecaries who have not already
a copy of the first edition will procure one of this;
it is, therefore, to physicians residing in the country
and in small towns, who cannot avail themselves of
the skill of an educated pharmaceutist, that  we
would especially commend this work.  In it they
will find all that they desire to know, and should
know, but very little of which they do really Know
in reference to this important collateral  branch of
their profession; for it is a well established fact,
that, in the education of physicians, while the sci-
ence of medicine is generally well taught, very
little attention is paid to the art of preparing them
for use, and we know not how this defect can be bo
well remedied as by procuring and  consulting Dr.
PaTrish's excellent work.—St. Louis Med. Journal.
Jan. 1860.
 We know of no work onjhe subject which would
be  more indispensable to the physician or  student
desiring information on the subject of which it treats.
With Griffith's " Medical Formulary" and this, the
practising physician would be supplied with nearly
or quite all the most useful information on the sub-
ject.—Charleston Med. Jour.and Review, Jan. 1860.
                             PEASLEE (E.  R.), M. D.,
         Professor of Physiology and General Pathology in the New York Medical College.
HUMAN HISTOLOGY, in its  relations to Anatomy, Physiology, and Pathology;
  for the use of Medical Students.  With four hundred and thirty-four illustrations.  In one hand-
  some octavo volume, of over 600 pages.  (Lately Published.)  $3 75.
  It embraces a library upon the topics discussed
within itself, and is just what the teacher and learner
need.  Another advantage, by no means to be over-
looked, everything of real value in the wide range
which it embraces, is with  great skill compressed
into an octavo volume of but little more than six
hundred pages.  We have not only the whole  sub-
ject of Histology, interesting in itself, ably and fully
discussed, but what is of infinitely greater  interest
to the student, because of greater practical value,
are  its relations to Anatomy, Physiology, and Pa-
thology, which are here fully and satisfactorily set
forth.—Nashville Joum. of Med. and Surgery.
  We would recommend it to the  medical student
and practitioner, as containing a summary of all thut
is known ofthe important subjects which it treats;
of all that is contained in the great works of Simon
and Lehmann, and the organic chemists in general.
Master this one volume, we would say to the medical
student and practitioner—master this book and you
know all that is known of the great  fundamental
principles of  medicine, and we have lo hesitation
in saying that it is an honor to the  American medi-
cal profession that one of its members should have
produced it.—St. Louis Mid. and Surg.  Journal.
                             PARKER (LANGSTON),
                        Surgeon to the Queen's Hospital, Birmingham.

THE  MODERN TREATMENT OF SYPHILITIC  DISEASES, ROTH PRI-
  MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi-
  lis by a safe and successful method.  With numerous Cases, Formula;, and Clinical Observa-
  tions.  From the Third and entirely rewritten London edition.  In  one neat octavo volume,
  extra cloth, of 316 pages.  $1 75.

ROYLE'S  MATERIA  MEDICA  AND  THERAPEUTICS; including  the
  Preparations of the Pharmacopoeias of  London, Edinburgh, Dublin, and  of the United  States.
  With many new medicines.  Edited by Joseph Carson, M. D.   With ninety-eight illustrations.
  In one large octavo volume, extra cloth, of about 700 pages.  $3 00.

                         ROKITANSKY (CARL),  M.D.,
    Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, &c.

A  MANUAL  OF  PATHOLOGICAL  ANATOMY.   Four  volumes, octavo,
  bound in two, extra cloth, of about 1200 pages.   Translated by W. E. Swaine, Edward Sieve-
  king, C. H. Moore, and G. E. Day.  $5 50.
  The profession is too well acquainted with the re-
putation of Rokitansky's work to need our assur-
ance that this is one of the most profound, thorough.
and valuable  books  ever issued from the medical
press. It is sui generis, and has no standard of com-
parison.  It is only necessary to announce that it is
issued in a form as cheap  as is compatible with its
size and preservation, and its sale follows as a
matter of course.  No  library can be called com-
plete without it.—Buffalo Med. Journal.
  An attempt to give our readers any adequate idea
of the vast amount of  instruction accumulated in
these volumes, would be feeble and hopeless.  The
effort  of the distinguished author to concentrate
in a small space his great fund of knowledge, has
so charged ms text with  valuable truths, cnat any
attempt of a reviewer to  epitomize is at once para-
lyzed, and must end in a failure.—Western Lancet.
  As this is  the highest source of knowledge upon
the important subject of  which it treats, no real
student can afford to be without it. The American
publishers have entitled themselves to the thanks of
the profession of their country, for this timeous and
beautiful edition.—Nashville Journal of Medicine.
                           RIGBY  (EDWARD), M. D.,
                    Senior Physician to the General Lying-in Hospital, &c.
A  SYSTEM  OF  MIDWIFERY.   With  Notes and Additional Illustrations.
  Second American Edition.  One volume octavo, extra cloth, 422 pages.  $2 50.
                        BY the same author.  (Lately Published.)
ON TTTF CONSTITUTIONAL  TREATMENT OF FEMALE DISEASES.
  Iu one neat royaf12mo. volume, extra cloth, of about 250 pages,  fl 00. 
26                    BLANCHARD  & LEA'S MEDICAL
                     RAMSBOTHAM (FRANCIS H.),  M.D.

THE  PRINCIPLES AND  PRACTICE OF OBSTETRIC  MEDICINE AND
  SURGERY, in reference to the Process of Parturition.  A new and enlarged edition, thoroughly
  revised by the Author.  With Additions by W.V. Keating, M. D., Professor ofObstetrics, &c, in
  the Jefferson Medical College, Philadelphia.  In one large and handsome imperial octavo volume,
  of 650 pages, strongly bound in  leather, with raised bands;  with sixty-four beautiful Plates, and
  numerous Wood-cuts in the text, containing in all nearly 200 large and beautiful figures.  $5 00.

                          From Prof. Hodge, of the University of Pa.
  To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being
the best authorized exponent of British Midwifery.  Its circulation will, 1 trust, be extensive throughout
our country.                      •
  It is unnecessary to say anything in regard to the I truly elegant style in which they have brought it
utility of this work.  It is already appreciated in our
country for the value of the matter, the clearness of
its style, and the fulness of its illustrations.  To the
physician's library it is indispensable, while to the
student as a text-book^froin which to extract the
material for laying the foundation of an education on
obstetrical science, it has no superior.—Ohio Med
and Surg. Journal.
  The publishers  have secured its success by the
out, excelling themselves in its production, espe-
cially in its plates.  It is dedicated to Prof. Meigs,
and has the emphatic endorsement of Prof. Hodge,
as the  best exponent  of  British Midwifery.  We
knt.w of no text-book which deserves in all respects
to be more highly recommended to students, and we
could wish to see it in the handsof every practitioner,
for they will find it invaluable for reference.—Med.
Gazette.
                                RICORD (P.), M. D.

A TREATISE ON THE VENEREAL DISEASK.   By John Hunter, F. R. S.
  With copious Additions, by Ph  Ricord, M.D.  Translated and Edited, with Notes, by Freeman
  J. Btjmstead M. D , Lecturer on Venereal at the College of Physicians and Surgeons, New York.
  Second editim, revised, containing a resume of Ricord's Recent Lectures on Chancre.  In
  one handsome octavo volume, extra cloth, of 550 pages, with eight plates.  &3 25. (Just Issued.)

  In revising this work, the editor has endeavored to introduce whatever matter of interest the re-
cent investigations of syphilographers have added to our knowledge of the subject. The principal
source from which this has been derived is the volume of "Lectures on Chancre," published a few
months since by M. Ricord, which affords a large amount of new and instructive material on many
controverted points.  In the previous edition, M. Ricord's additions amounted to nearly one-third
of the whole, and with the mailer now introduced, the work may be considered to present his views
and experience more thoroughly and completely than any other.

                                             secretaries, sometimes accredited and sometimes not.
                                               In the noies to Hunter, the master subsututes him-
                                             self forhis interpreters, and give? hisoriginal thoughts
                                             to the world in a lucid and perfectly intelligible man-
                                             ner.  In conclusion we can say that this is incon-
                                             testably the  best treatise on syphilis with which we
                                             are acquainted, and. as we  do not often  employ the
                                             phrase, we may be excused for expressing the hope
                                             that it may find a  place in the library of every phy-
                                             sician.— Virginia Mid. and  Surg. Journal.
  Every one will recognize the attractiveness and
value which this work  derives from thus presenting
the opinions of these two masters side by side.  But,
it must be admitted, whai has made the fortune of
the book, is ihe fact thai ii contains me "most com-
plete embodiment of the veritable doctrines of the
Hdpital du Midi," which has ever been made public.
The doctrinal ideas of M. Ricord, ideas which, if not
universally adopted.aremcontestabiy dominant, have
heretofore only been interpreted by moreor less skilful
BY THE SAMS AUTHOR.
RICORD'S LETTERS ON  SYPHILIS.  Translated by W. P. Lattimore, M. D.
  In one neat octavo volume, of 270 pages, extra cloth.  S2 00.
   SMITH  (HENRY H.),  M.  D.,  AND  HORN ER (WI LLI AM  E.), M.  D.

AN ANATOMICAL ATLAS, illustrative of the Structure of the Human  Body
  In one volume, large imperial octavo, extra cloth, with about six  hundred and fifty beautiful
  figures.  $3 00.

  These figures are well selected, and present a
complete and accurate representation of that won-
derful fabric, the  human body. The plan of this
Atlas, which  renders it so  peculiarly convenient
for the student, and its superb artisticul execution,
have been already pointed out.  We must congrutu-
                                fifty beautiful


late the student upon the eorr.nletion of this Atlas
as it is the most convenient work of the kind that
has yet appeared j and we must add, the very bean-
tiful manner in which it is ■• got up" is so creditabls
to the country  as to be dattering  to our national
pride.—American Medical Journal
       SHARPEY (WILLIAM),  M. D.,  JONES  QUAIN, M. D.. AND
                        RICHARD QUAIN,  F.R.s!, &c.         -»«niu

HUMAN  ANATOMY.   Revised, with Notes and Additions, by Joseph Leitjy
  M. D., Professor of Anatomy in the University of Pennsylvania  Comnl-u. in »«,« u „T  .  '
BOLLY ON THE HUMAN BRAIN ; its Structure,
  Physiology, and Diseases.  From the Second and
  much  enlarged  London edition.  In  one octavo
  volume, extra cloth, of 500 pages, with U0 wood-
  cuts.  $2 U0.
BKEY'S OPERATIVE SURGERY.  In  one very
  handsome octavo volume, extra cloth, of over 630
  pages, with about one hundred wood-cuts  S3 35

8Ih^;n?hiiWiiA1' ETHOLOGY, as condue^
  ivetothe LstabliSi„,ltut of Rational  Principles
  for the prevention nno Cure of Disease   In on'
  octavo volume, extra cloth, of 212 pages   SI jtf 
AND SCIENTIFIC  PUBLICATIONS.                   27
                              STILLE (ALFRED), M.D.

THERAPEUTICS  AND MATERIA  MEDICA; a Systematic  Treatise  on  the
  Action and Uses of Medicinal Agents, including their Description  and History.  In  two large
  and handsome octavo volumes, of 1789 pages.  {Just Issued.)  $8 00.

  This work is designed especially for the student and practitioner ofmedicine. and treats the various
articles ot the Materia Medica from tbe point of view of the bedside,  and not of the shop or of the
lecture-room.   While thus endeavoring to give all practical information likely to be useful with
respect to the employment of special remedies in special affections, and the results to be anticipated
trom their administration, a copious Index of Diseases and their Remedies renders the work emi-
nently fitted for reference by showing at a glance ihe different  means which have been employed,
and enabling the practitioner to extend his resources in difficult cases  with all that the experience
ot the profession has suggested.
  Rarely, indeed, have we had submitted to us a
work  on medicine so ponderous iu its dimensions
as that now before us, and yet so fascinating in its
contents.  It is, therefore, with a peculiar gratifi-
cation  that we recognize in Dr. Snlle the posses-
sion of many of those more distinguished qualifica-
tions which entitle him to approbation, and which
justify him in coming before his medical brethren
as an  instructor.   A comprehensive  knowledge,
tested by a sound and penetrating judgment, joined
to a love of progress —which a discriminating spirit
of inquiry has tempered so as to accept nothing new
because it is new, and abandon nothing old because
it is old, but which estimates either accon ing to its
relations to a just logic and  experience—manifests
itself everywhere, and gives to  the guidance of the
author all 'he assurance of safety which the diffi-
culties of his subject can allow.  In conclusion, we
earnestly advise our  readers to  ascertain  for them-
selves, by a study of Dr. Stille's volumes, the great
value and interest of the stores of knowledge they
present.  We have pleasure  in referring  rather to
the ample treasury of undoubted truths, the real and
nssured conquest of medicine, accumulated by Dr.
Stille in his pages ; and commend tiie sum of his la-
bors to the attention  of our readers, as alike honor-
able to our science, and creditable to the zeal, the
candor, and the judgment of him who has garnered
the whole so carefully.—Edinburgh Med. Journal.

  Our expectations of the value of this work were
based on the well-known reputation and  character
of the author as a man of scholarly attainments, an
elegant writer, a candid  inquirer after truth, and a
philosophical thinker; we knew that the task would
be conscientiously performed, and that few, if any,
among the distinguished medical teachers in this
country are better qualified  than 1 e to prepare a
systematic treatise on therapeutics in accordance
With the present requirements of medical science.
Our preliminary examination of the work has satis-
fied us that we were not mistaken in our anticipa-
tions.—New Orleans Medical News, March, 1360.
  The most recent authority is the one last men-
tioned, Stille.  His great work on " Materia Medi-
ca and Therapeutics," published  last year, in two
octavo volumes, of some sixteen hundred pages,
while it embodies the results of the labor of others
up to the  time  of publication, is enriched with a
great amount of original observation and research.
We would draw attention, by the way, to the very
convenient mode in which the Index is arranged in
this work. There is first an " Index of Remedies;"
next an "Index of Diseases and  their Remedies."
Such an arrangement of the Indices, in our opinion,
 treatly enhances the practical value of books of this
 ind.  In tedious, obstinate cases of disease, where
we have to try one remedy after another until our
stock is pretty nearly exhausted, and we  are almost
driven to our wit's end, such an index as the second
of the two just mentioned,  is precisely what we
want.—London Med. Times and Gazette, April, 1861.
  We think this work will do much to obviate the
reluctance to a thorough investigation of this branch
of scientific study, for in the wide range of medical
literature treasured in the English tongue, we shall
hardly find a work written in a style more clear and
simple,conveying forcibly the facts taught,and yet
free from turgidity and redundancy. There isa las-
cination in its pages  that will insure to it a wide
popularity and attentive perusal, and a degree of
usefulness not often attained through the influence
of a single work.  The author  has much enhanced
the practical ucility of his book  bypassing briefly
over the physical, botani -al, ai.d commercial history
of medicines, and directiug attention chiefly to their
physiological action, and their application for the
amelioration or cure ol disease.  He i»n ires hypothe-
sis and theory which ate soalluring to ntany medical
writers, and so liable to lead them astray, and con-
fines himself to such facts as have been  tried in the
crucible of experience.—Chicago Medical Journal.
                              SIMPSON (J.  Y.), M. D.,
                 Professor of Midwifery, &c, in the University of Edinburgh, &c.

CLINICAL  LECTURES  ON  THE   DISEASES  OF  WOMEN.   Wilh nu-
  meious illustrations.  In one handsome octavo volume, of over 500 pages, extra cloth, $3 00.
  (Now Ready.)

  This valuable work having pussed through the columns of " The Medical News and Library"
for I860, 18bl, and 1862, is now completed, and may be had separate in one  handsome volume.
  These Lectures were delivered bv Professor Simpson at the Royal Infirmary of Edinburgh and
were published in the "London Medical Times and Gazette" during ihe years 1859,18G0, and 1861.
The distinguished reputation ofthe author, and the valuable practical matter contained in the Lec-
tures have seemed to entitle them to a more permanent lbrm than the evanescent pages of a pen-
odical.  Embracing a wide range of subjects, and  each one elaborately treated  and complete in
itself, the volume can hardly fail to prove a valuable addition to the library of the pracusn.g phy-

WThe" principal topics embraced in the Lectures are Vesico-Vaginal  Fibula, Cancer of the Uterus,
Treatment of Carc.noma by Caustics, Dysmenorrhoea, Amenorrhcea, Closure*, Contractions, &c.,
of the Vagina, Vulvitis, Causes of Death after  Surgical Operations, Surgical Fever, Phlegmasia
Dolen«  Coccvodinia, Pelvic Cellulitis, Pelvic Haemaloma. Spurious Pregnancy,  Ovarian Dropsy,
OtotomyCran.oc'lasm, Diseases of the Fallopian Tubes, Puerperal Mania, Sub-Involution and

^l^^lnno^^ibZ important topics-many of which  receive little attention
in the ordinary text-bookVeluoidated with the extensive experience and readmessof resource for
which PrEor Simpson is so  distinguished, there  are  >ew practitioners who wdl not find in  Us
pases matter ofthe utmost importance in the treatment  of obscure and difficult ou*es. 
28                   BLANCHARD  &  LEA'S MJSlMUALi
                            SARGENT  (F. W.), M. D.
ON BANDAGING  AND  OTHER OPERATIONS OF  MINOR SURGERY.
  New edition, with an additional chapter on Military Surgery.   One handsome royal 12mo. voJ.j
  of nearly 400 pages, with 184 wood cuts.  Leather, $1 50. (Now Ready.)
  The value of this work as a handy and convenient manual for surgeons engaged in active duty in
the field and hospital, has induced the publishers to render it more complete for .those purposes by
the addition of a chapter on gun-shot wounds and other matters peculiar to military surgery. In
its present form, therefore, with no increase in price, it will be found a very cheap and convenient
vade-mecum  for consultation  and reference in the daily exigencies of military as  well as  civil
practice.
  We have read Bourgerie's Minor Surgery with j  The instruction given upon the subject of Ban
pleasure and profit, but in many respects the volume
now before us immeasurably transcends  it.  We
consider that no better book could be placed in the
hands of an hospital dresser, or the young surgeon,
whose education in this respect has not been per-
fected.   We most  cordially commend this volume
as one which the medical student should mostclose-
ly study, to perfect himself in these minor surgical
operations in which neatress ar.d dexterity are so
much required, and on which a great portion of his
reputation as a future surgeon must evidently rest.
And to the surgeon in practice it  must  prove itself
a valuable volume, as instructive on many points
which he miy have forgotten.—British American
Journal, May, 1862.
daging, is alone of great val.ue, and while the author
modestly pr ip'ises to instruct the students of medi-
cine, and the younger physicians, we will say that
experienced physicians will obtain many exceed-
ingly valuable suggestions  by its perusal. With-
out attempting to particularize further,  we will
conclude our brief notice by saying, that it will be
found one ol the mod satisfactory manuals for refer-
ence in the field, or hospital yet published;  thor-
oughly adapted to the wants of Military surgeons,
and at the same time equally useful for ready and
convenien' reference by  surgeon* everywhere.—
Buffalo Med. and Surg. Journal, June, 1862.
                           SMITH  (W.  TYLER),  M.D.,
                       Physician Accoucheur to St. Mary's Hospital, *c.

 ON  PARTURITION,  AND  THE  PRINCIPLES  AND  PRACTICE   OF
  OBSTETRICS.  In one royal 12mo. volume, extra cloth, of 400 pages.  $1 25.
                                 BY THE SAME AUTHOR.
 A  PRACTICAL  TREATISE ON  THE PATHOLOGY AND TREATMENT
  OF LEUCORRHQSA.  With numerous illustrations.  In one very handsome octavo volume,
  extra cloth, of about 250 pages.  $1 50.

                            TANNER (T. H.),  M. D.,
                          Physician to the Hospital for Women, &c.

 A  MANUAL OF CLINICAL  MEDICINE  AND  PHYSICAL DIAGNOSIS.
  To which  is added The Code of Ethics  of  the American Medical Association.  Second
  American Edition.  In one neat volume, small 12mo., extra cloth, 87j cents.

                    TAYLOR (ALFRED S.), M. D.,  F.  R. S.,
               Lecturer on MedicalVurisprudence and Chemistry in Guy's Hospital

 MEDICAL JURISPRUDENCE.  Fifth American,  from the seventh  improved
  and enlarged London edition.  With Notes and References to A merican Decisions, by Edward
  Hartshorne,M. D. In one large 8vo. volume, leather, of over 700 pages.  $3 25.
  This standard work having had the advantage of two  reviMons at the hands ofthe author since
 the appearance ofthe last American edition, will be found thoroughly revised and brought ud com
 pletely to the  present state of the science. As  a work of authority, it must therefore maintain its
 position, both  as a text-book for the student, and a  compendious  treatise to which the practitioner
 can at all times refer in cases of doubt or difficulty.                               v
  No work upon the subject  can be put into the  American and British legal medicine.  It should be
 hands of students either of law or medicine which  in the possession of every physician  as the suhi^t
 Will engage them more closely or profitably; and  is one of great and increasinginipoUance to'the
none could be offered  to the busy practitioner of  public as well as to the profession -St  Louis Mid
either calling,  for the purpose of casual or hasty  and Surg. Journal.                 ^ouismia.
 reference, that  would be more likely to afford the aid
desired.  We thcreforerecoinmeud it us the best and j  This work of Dr. Taylor's is generally acknow-
safest manual for daily use.—American Journal oj  ledgtd to be one of the ablest extant on the subject
 Medical Sciences.                             I of medical jurisprudence,   it is certainly one ofthe
  It is not excess of praise  to say that the volume j nJ°8t altwct've bo jks that we have met with ; sup-
before us is the veryl
               of praise to say that the volume i n!08t altmctlv«- Dojks 'hat we have met with : sup-
            ... ery best treatise extant on Medical i P^K «° rnueh both to interest and instruct, that
Jurisprudence.  In  saying this, we do not wish to i     ° not hesitate to affirm that after  having once
be understood as detracting from the merits of the  .ommenced,ltB perusal, few could be prevailed upon
excellent works of Beek,Ttyan, Traill, Guy, and I ™ d?B'»'before completing it. In the  last London
others; but in interest and value we think  it must  CUIt,oy».a11 'he newly observed and accurately re-
be conceded that Taylor is superior to anything that j fu r?e ,ttCU   , e been mseited, including much
has preceded it.—N. W. Medical and  Surg. Journal i J? , u re<jM" of Chemical. Microscopical, and Pa-

  It is at once comprehensive and eminently prac-  SaoKta  nevVr^5rebDUDlii£Jper* °D/ nu,I,erou«
tical, and by universal consent stands at the Lad of I Journal Md Review  Publlshed—<**rl,ston Med.

                                BY THE SAME  AUTHOR.

°LS?N|eINHAELATI?NT0  MEDICAL JURISPRUPENCE  AND
  ^^^L^^^^^ST^ - «*"* ^ndon edition.   In one  large


naf/aJvYn'tteSt;^ ^^^t^^t^X St? °? "* ^T^


Mited, and presented in  he clear and in.ellig^                               weWh«d **
as an acknowledged authonty, and « •  gW! E^ 
AND  SCIENTIFIC PUBLICATIONS.       '           29
                 TODD (ROBERT  BENTLEY),  M. D., F. R. S.,
                    Professor of Physiology in King's College, London; and
                         WILLIAM BOWMAN,  F.  R. S.,
                     Demonstrator of Anatomy in King's College, London.

TI*E PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN.  With
  about three hundred large and beautiful illustrations on wood.  Complete in one large  octavo
  volume, of 950 pages, leather. Price S4 50.
  EST Gentlemen who have received portions of this work, as published in the " Medical News
and Library," can now complete their copies,  if immediate application be made.  It will be fur-
nished as follows, free by mail, in paper covers, with cloth  backs.
  Parts I., IL, III. (pp.  25 to 552), *2 50.
  Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), S2 00.
  Or, Fart IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25.
                                            so well adapted to the wantsof the medical student. (
                                            Its completion has been thus long delayed, that the
  A magnificent contribution to British medicine,
and the American physician who shall fail to peruse
it, will have failed to read one of the most instruc-
tive books of the nineteenth century__N. O. Med
and Surg. Journal.

  It is more concise than Carpenter's Principles, and
more modern than the accessible edition of Mailer's
Elements; its details are brief, but  sufficient;  its
descriptions vivid; its illustrations exact and copi-
ous; and its  language terse and perspicuous.__
Charleston Med. Journal.
  We know of no work on the subject of physiology
authors might secure accuracy by personal observa-
tion.—St. Louis Med. and Surg. Journal.

  Our notice, though it conveys but a very feeble
and imperfect ideu of the magnitude and importance
of the work now under consideration, already tran-
scends our limits ; and, with the indulgt nee of our
readers, and the hope that they will peruse the book
for themselves, as we feel we can with confidence
recommend it, we leave  it in their hands. — The
Northwestern Med. and Surg. Journal.
                      TODD  (R. B.)   M. D., F. R. S., &c.

CLINICAL LECTURES ON CERTAIN  DISEASES  OF  THE  URINARY
  ORGANS AND ON  DROPSIES. In one octavo volume, 284 pages, f 1  50.

                                  BY THE SAME AUTHOR.
CLINICAL LECTURES ON CERTAIN ACUTE DISEASES.    In one neat
  octavo volume, of 320 pages, extra cloth.   $1 75.
                         TOYNBEE (JOSEPH),  F. R. S.,
               Aural Surgeon tq, and Lecturer on Surgery at, St. Mary's Hospital.
A PRACTICAL  TREATISE ON  DISEASES  OF  THE  EAR; their  Diag-
  nosis, Pathology, and Treatment.  Illustrated with one  hundred engravings on wood.  In one
  very handsome octavo volume, extra cloth, $3  00.  (Just Issued.)
  The work, as was stated at the outset of our no-
tice, is a model of its kind, and every page and para-
graph of it are worthy of the most thorough study.
Considered all in all—as an  original work, well
written, philosophically elaborated, and happily il-
lustrated with cases and drawings—it  is by far the
ment, and with a sincere and unbiassed judgment,
when we affirm that as a treatise on Aural Surgery,
it is without a riva 1 in our language or any other.—
Charleston Med. Joum. and Review, Sept. I860.
  The work of  Air. Toynbet is undoubtedly, upon
the whole, the most valuable production of tne kind
ablest monograph  that has ever appeared on the \ ln any ianguage. The author has long been known
anatomy and diseases of the ear, and one of the most j by hig nuiIierou8 monographs upon subjects  con-
valuable contributions to the art and science of sur- , neuted wlth diseases of the ear, and is now regarded
gery in the nineteenth century.—N. Amer. Medico- j as tne mghest authority on most points in his de-
Chirurg. Review, Sept. 1860.                    partment of science.  Mr. Toynbee's work, as we
  To recommend such a work, even after the mere : have already said, is undoubtedly the most reliable
hint we  have given of its original excellence and  guide for the study of the diseases of the tar in any
value, would be a work of supererogation.  We are  language, and should be in the library of every pny-
speaking within the limits of  modest acknowledg- ' smiaa.—Chicago Med. Journal, Jul>, 1S6U.
                    WILLIAMS (C.  J. B.>, M.D.,  F.R.S.,
                Professor of Clinical Medicine in University College, London, fcc.

PRINCIPLES OF MEDICINE.  An Elementaiy View of  the Causes, Nature,
  Treatment, Diagnosis, and Prognosis of Disease;  with brief remarks on Hygienics, or the pre-
  servation of health.  A new American, from the third and revised London edition.  In one octavo
  volume, leather, ol about 500 pages.  $2 50.  (Just Issued.)
  We find that the deeply-interesting  matter and
style of this book have so far fascinated us, that we
have unconsciously hung upon its pages, not too
long, Indeed, for our own profit, but longer than re-
viewers can be permitted to indulge.  We leave the
further analysis to the student and practitioner. Our
judgment of the work has already been  sufficiently
expressed.  It is a judgment of almost unqualified
praise.—London Lancet.
  A text-book to which no other in our language is
comparable.—Charleston Medical Journal.

  No work has ever achieved or maintained a more
deserved reputation.— Va. Med. and Surg. Journal.
                               WHAT TO OBSERVE

AT  THE   BEDSIDE   AND   AFTER  DEATH,  IN   MEDICAL  CASES.
  Published under theauthority ofthe London Society for Medical Observation.  A new American,
  from the second and revised London edition.  In one very handsome volume, royal 12mo., extra
  cloth.  *1 00.
  To the observer who prefera accuracy to blunder* I  One of the finest aids to a young practitioner we
and precision to carelessness, this little book is:u- have ever seen.—Peninsular Journal of Medicine.
valuable.—N. H. Journal of Medicine.           J 
30                    BLANCHARD &  LEA'S  MEDICAL
                  New and much enlarged edition—(Just Issued.)
                       WATSON (THOMAS), M.  D.,  Sec,
                        Late  Physician to the Middlesex Hospital, ice.
LECTURES  ON  THE  PRINCIPLES   AND  PRACTICE  OF  PHYSIC.
  Delivered  at King's College, London.  A new American, from the last revved and enlarged
  English edition, with Additions, by D. Francis Condie, M. D., author of "A Practical Treatise
  on the Diseases of Children," &c.   With one hundred and eighty.five illustrations on wood.   In
  one very large and handsome  volume, imperial  octuvo, of over 1200  closely printed pages in
  small type; the whole strongly bound in leather,  with raised bands.  Price $4 25.
  That the high reputation of this work might be fully maintained, the author has subjected it to a
thorough revision; every portion has been  examined  wnh the aid of the most recent researches
in pathology, and the results of  modern  invesiigalions in both  theoretical and practical subjects
have been carefully weighed and embodied throughout its pages.   The watchful scrutiny of  the,
editor has likewise introduced whatever possesses immediate importance to the American phy-ician
in relation to diseases incident to our climate which are little known  in England, as well as  those
points in. which experience here has led to different modes of practice; and he ha« also added largely
to the series of illustrations, believing that in this manner valuable  as.-istance may be conveyed to
the student in elucidating the text.  The work will,  therefore, be found thoroughly on a level with
the most  advanced state of medical science on both  sides of the Atlantic.
  The  additions which the work has received are shown by  the tact that notwithstanding an  en-
largement in the  size of the page, more than  two hundred additional  pages have been necessary
to accommodate the two large volumes of the London edition (which  sells at ten dollars), within
the compass  of a single volume, and in its present form it contains the matter of at  least  three
oulinary octavos.  Believing it to be a work which  should lie on the table of every phvsician, and
be in the hands of every student, the publishers have put it at a price within ihe reach of all, making
it one of the cheapest books as yet presenied to the  American profession, while at the same time
the beauty of its mechanical execution renders it an  exceedingly attractive volume.
  The fourth  edition now appears, so carefully re- I   The lecturer's skill, his wisdom, his learning,are
vised, as to add considerably to the  value of a book I equalled by the ease of his graceful diction, his du-
al ready acknowledged, wherever the English  lan-  quence, and the far higher qualities of candor, of
guage is read, to be beyond all comparison the best
systematic work on the Principles and Practice of
Physic in  the whole range  of medical literature.
Every lecture contains proof of the extreme anxiety
ofthe author to keep pace with the advancing know-
ledge of the day, and to bring the results of the
labors, not only of physicians, hut of ctiemists and
histologists, before his readers, wherever they can
be turned to useful account.  One scarcely knows
whether to admire most the pure, simple, forcible
English—the vast amount of useful practical in-
formation condensed into the Lectures—or the man
courtesy, of modesty, and of generous appreciation
of merit in others.—N. A. Med -Chir Review.

  Watson's unrivalled, perhaps  unapproachable
work on  Practice—the copious additions made to
which (the fourth edition) have given it all  the no-
velty and much of the interest of a new book.—
Charleston Med. Journal.

  Lecturers, practitioners, and students of medicine
will equally  hail the reappearance of the work of
Dr. Watson in theform of anew—a fourth—edition.
We merely do justice to our own  feelings, and, we
ly, kind-hearted, unassuming character of the lee-  are Bure, „f the whole profession, if we thank 'hiin
turer shining through his work.-Lond. M,d. Times. \ [oT having, in the trouble and  turmoil of a laree
  Thus these admirable volumes come before the  practice, made leisure to supply the hiatus caused
profession in their fourth edition, abounding in those I by the exhaustion of the publisher's stock of the
distinguished attributes of moderation, judgment, I third edition, which  has been severely lelt for the
erudite cultivation, clearness, and eloquence, with | last three years.  For Dr. Watson has not merely
which they were from the first invested, but yet  euused the lectures  to be reprinted, but scattered
richer than before in the results of more prolonged | through the whole work wt find additions or altera-
observation, and in the able appreciation of the  tions vvhicli prove that the author has m every way
latest advances in  pathology and medicine by one I sought to bring up his teaching to  the level of .he
of the most profound medical thinkers of the day.—  most recent acquisitions in science.—Brit, and For.
London Lancet.                                j Medico-Chir. Review.
                             WALSHE (W.  H.), M. D.,
       Professor of the Principles and Practice of Medicine in University College, London, &e.
A PRACTLCAL TREATISE  ON DISEASES  OF THE LUNGS; iucluding
  the Principles of Physical  Diagnosis.  A new American, from the third revised and much en-
  larged LonLon edition.  In one vol. octavo, of 4bS pages.  S- 25.
  The present edition has been carefully revised and much enlarged, and may be said in the mam
lo be rewritten.  Descriptions of several diseases, previously  omitted, are now introduced; the
causes  and mode of production of the more important affections, so fai as they pos-ess direct prac-
tical  significance, are succinctly inquired into; an effort has been mnde to bring tne description ol
anatomical characters lo the level of the wants of the practical  physician; and the diagm,<i- and
prognosis  of each complaint are more completely considered.   Tne sections on .Treatment and
the Appendix (concerning the influence of climate on pulmonary disorders), have, especially  been
largely extended.—Aut/ior's Preface.
BY THE SAME AUTHOR.
 A  PRACTICAL  TREATISE  ON THE DISEASES OF THE HEART AND
  GREAT VESSELS, including the Principles of Physical Diagnosis   Third American from the
  third revised and much enlarged London edition.  In one handsome octavo volume of 4 '0 Daves
  extra cloth.  $2 25.  (Just Ready.)                                               "  v *  '
                                 From the Author's Preface.
  The present edition has been carefully revised ;  much new matter has been added, and the entire
 work in a measure remodelled.  Numerous (acts  and discussions, more or less completely novel
 will be found in the description ofthe principles of physical diagnosis;  but the chief additions have
 been made in the practical portions of the book.  Several affections, of which  little or no account
 hud been given in the previous editions, are now treated of in detail.  Functional disorders of the
 heart, the Ireqitency of which is almost rivalled by the miseiy thev inflict, have been closely recon-
sidered ;  more especially an attempt has  been maue lo render their essential nature clearer and
oonoequently their treatment more successful, by aii unalysis of their dyuaimc e eiueuts      ' 
AND SCIENTIFIC  PUBLICATIONS                   31
                   New and much enlarged edition—(Just Issued.)
                          WILSON  (ERASMUS),  F. ft. S.
A  SYSTEM OF HUMAN ANATOMY, General  and  Special.   A new and  re-
  vised American, from the last and enlarged English Edition.  Edited by W. H.Gobrecht, M. D.,
  Professor of Anatomy in the Pennsylvania Medical College, &c.  Illustrated with three hundred
  and ninety-seven engravings on wood.   In one large and exquisitely printed octavo volume, of
  over 600 large pages; leather.  $3 25.
  The publishers trust that the  well earned reputation so long enjoyed by this work will be more
than maintained by the present  edition.  Besides a very thorough revision by the author, it has been
most carefully examined by the editor, and the efforts of both  have been directed to  introducing
everything which increa-ed experience in its u>e has suggested as desirable to render it a complete
text-book for those  seeking to obtain or to  renew an acquaintance with Human Anatomy.  The
amount of additions which it has thus received may be estimated from the fact that  the present
edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged
page requisite to keep the volume within a convenient size.  The editor has exercised the utmost
caution to  obtain entire  accuracy in  the text, and  has largely increased  the number  of illustra-
tions, of which there are about one hundred and fifty more in this edition than  in  the last, thus
bringing distinctly before the eye ofthe student everything of interest or importance.
                                              beauty of its  mechanical execution, and the clear-
  It may be recommended to the student as no less
distinguished by its accuracy and clearness of de-
scription than by its typographical elegance. The
wood-cuts are exquisite.—Brit, and For. Medical
Review.
ness of the descriptions which it contains is equally
evident.  Let students, by all  means examine tne
claims of this work on their notice, before they pur-
chase a text-book  of the vitally important science
which this volume so fully  and  easily unfolds.__
Lancet.
  We regard it as the best system now extant for
students.— Western Lancet.
  An elegant edition of one of the most useful and
accurate systems of anatomical  science which has
been issued from the press  The illustrations are
really beautiful.  In its style the work is extremely
concise and intelligible. No one can possibly take   It therefore receives our highestcommendation.—
up this volume without being struck with the great Southern Med. and Snrg. Journal
                         BY  THE SAME AUTHOR   (Now Ready.)
ON DISEASES   OF  THE  SKIN.   Fifth American, from the  Fifth  enlarged
  London edition.  In one handsome octavo volume, of nearly 700 large  pages, with illustrations
  on wood, extia cloth.  $3 25.
  This classical work, which  for twenty years has occupied the position  of the leading authority
in the English language on its  important subject, has just received a thorough revision at the hands
ofthe author, and is now presented as embodying ihe results ofthe latest investigations and expe-
rience on all matters connected with disea-es of the skin.   The  increase in the size of the work
shows the industry ofthe author, and his determination that it shall maintain the position which it
has acquired as thoroughly on a level with the most advanced condition of medical science.
  A few notices of the last edition are appended.
  Thewritingsof Wilson, upondiseases of the skin, i about fourteen years ago, Mr Erasmus Wilson had
are by far  the most scientific  and practical that  already given some years to the study of Diseases
i______________i___________________.„.i  ... .).. „....!;....i ...,..l/l ..«
have ever been presented to the meaical world on
this subject.  The presenteaition isa great improve-
ment on all its predecessors.  To dwell upon all the
great merits and high claims of the work before us,
seriatim, would indeed be an agreeable service;  it
would  be a mental homage which we could freely
offer, but we should thus occupy an undue amount
of space in this Journal.  We will, howtver look
at some of the more salient points with which  it
abounds, and which make it incompuiD uiy superior in
excellence to all other treatises on the subject of der-
matology. No mere speculative views are allowed
a place in this volume, which, without a doubt, will,
 f the Skin, and he then expressed his intention of
devoting his fu ure life  to the elucidation of this
particular branch of Medical Science   In the pre-
sent edition Mr. Wilson presents us with the results
of his matured experience, gained after an extensive
acquaintance with the pathology and  treatment of
cutaneous affections; and we nave now before us
not merely a reprint of his former publications, but
an entirely new and rewritten volume.  Thus, the
whole history ot the diseases affecting the skin,
whether they originate in that structure or are the
mere manifestations of derangement of internal or-
gans, is brought under notice, ana the book includes
for a very long period, be acknowledged as the chief | a mass of information which is spread over a great
standard work on dermatology.  The principles of j part of the domain of Medical and Surgical Patholo-
an enlightened and rational therapeia are introduced  gy.  We can safely recommend it to the profession
on every appropriate occasion.—Am. Jour. Med.  as the best work, on the subject now in existence in
Science  Oct  1857                              | the English language—London Medical Times and
  When  the'first edition of this work  appeared, | <*«««*, Alaich 2^1857.
                                     ALSO, NOW READY,
A SERIES OF PLATES  ILLUSTRATING WILSON  ON DISEASES OF
  THE SKIN; consisting of twenty beautifully executed plates, of which thirteen  are exquisitely
  colored, presenting the Normal Anatomy and  Pathology of the Skin, and containing accurate re-
  presentations of about one hundred varieties of disease, most of them the size of nature.  Price
  in  cloth.  $4 50.
  In  beauty of drawing and accuracy and finish of coloring  these plates will be found equal to
anything of the kind as yet issued in this country
  We have already expressed our high appreciation
of Mr. Wilson's treatise on Diseases of the Skin.
The  plates  are  comprised  in a separate volume,
which we counsel all those who possess the text to
purchase.  It is a beautiful specimen of color print-
ing, and the representations of the various forms of
skin disease are as faithful as is possible in plates
of the size.—Boston Med.and Surg. Journal, April
8, 1858.
  The plates by which this edition is accompanied
leave nothing to be desired, so far as excellence of
delineation and perfect accuracy of illustration are
concerned.—Medico-Chirurgical Review.
  Of these plates it is impossible to speak too highly
The representations of the various forms of cutane-
ous disease are singularly accurate, and the color-
ing exceeds almost anything we have met with in
point of delicacy and  finish.—British and Foreign
Medical Review.                                                                 .   „-, .„
  Also the TEXT  and PLATES done up in one handsome volume, extra cloth, price $7 50.
                                    BY THE SAME AUTHOR.

THE  DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy.   Third
  American, from the last revised and enlarged English edition.  Modified and  rearranged, by
  WhliamHunt M  I)., Demonstrator of Anatomy in the  University ot Pennsylvania.  In  one
  large and handsome royal 12wo. volume, leather, of 582 pages, with 154 illustrations.  $2 00. 
32         BLANCHARD & LEA'S  MEDICAL  PUBLICATIONS.
                         WILSON  (ERASMUS) F.  R.  S.
ON  CONSTITUTIONAL  AND  HEREDITAHY   SYPHILIS,  AND  ON
  SYPHILITIC ERUPTIONS.  In one small octavo volume, extra cloth, beautifully printed, with
  four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 25

                                 BY THE SAME AUTHOR.

HEALTHY  SKIN;  A Popular Treatise on  the Skin and  Hair, their  Preserva-
  tion and Management.  Second American, from the fourth London edition.  One neat volume,
  royal 12mo., extra cloth, of about 300 pages, with numerous illustrations.  $1 00; paper cover,
  75 cents.

                 WINSLOW  (FORBES), M.D., D. C.  L., &c.

ON OBSCURE  DISEASES OF  THE  BRAIN AND  DISORDERS OF THE
  MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis.  In one
  handsome octavo volume, of nearly 600 pages.  $3 00.
  We close this brief and necessarily very imperfect
notice of Dr. Winslow's great and classical work,
by expressing our conviction that it is long since so
important and beautifully written a volume has is-
sued from the British medical press.—Dublin Med.
lJress, July 25,1860.
  We honestly believe this to be the best book of the
season.— Hanging's Abstract, July, 1860.
  The 'after portion of Dr. Winslow's work is ex-
clusively devoted to the consideration of Cerebral
Pathology.  It completely exhausts the subject, in
ihe same manner as the previous seventeen chapters
relating to morbid psychical phenomena left nothing)
unnoticed in reference to the mental symptoms pre-
monitory of cerebral disease. It is impossible to
overrate the benefits likely to result from a general
perusal of Dr. Winslow's valuable and deeply in-
teresting work.—London Lancet, June 23, I860.

  It contains an immense  mass of information.—
Brit, and For. Med.-Chir. Review, Oct. I860.
                            WEST  (CHARLES),  M.  D.,
Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for
                                    Sick Children, ice.

LECTURES  ON  THE  DISEASES OF WOMEN.   Second American, from the
  second London  edition.  In one  handsome octavo  volume, extra cloth, of about 500 pages:
  price $2 50.

*#* Gentlemen who received the first portion, as issued 1n the " Medical News and Library," can
  now complete their copies by procuring Part II, being page 309 to end, with Index, Title matter,
  &c, 8vo., cloth, price $1.
  We must now conclude this hastily written sketch
with the confident assurance to our readers that the
work will well repay perusal.   The conscientious,
painstaking, practical physician is apparent on ever}
page.—iV. Y. Journal of Medicine.
  We know of no treatise of the kind so complete
and yet so compact.—Chicago Med. Jour.

  A fairer, more honest, more earnest, and more re-
liable investigator of the many diseases of women
and children is not to  be found in any country.—
Southern Med. and Surg. Journal.

  We have to say of it, briefly and decidedly, that
it is the best work on the suoject in any language ;
and that it stamps Dr. West as the facile princept
of British obstetric authors.—Edinb. Med. Joum.
  We gladly recommend his Lectures as in the high-
est degree instructive to all who are interested in
obstetric practice.—London Lancet.
  Happy in his simplicity of manner, »nd moderate
in his expression of opinion, the author is a sound
reasoner and a good piactitioner, and  his book is
worthy of the handsome garb in which it has ap-
peared.— Virginia Med. Journal.

  We must take leave ot Di. West's  very useful
work, with our commendation oi the  clearness of
iis style, and the intustry and sobriety of judgment
of whicn it  gives evidence.—London Med  Times.

  Sound judgment and good sense  pervade every
chapier of the oook.  From its perusal we nave de-
rived unmixed satisfaction —Dublin Quart. Jourr.
                          by the same author.  (Just Issued.)

LECTURES  ON  THE  DISEASES   OF  INFANCY  AND  CHILDHOOD.
  Third American, from  the fourth enlarged and  improved London edition.   In  oue  haudsome
  octavo volume, extra cloth, ot about six hundred ami fitly pages.  S< 75.

                                             diseases it omits to notice altogether.  But those
                                             who  know anything of the present condition of
                                             paediatrics will readily admit ihat it would be next
                                             to impossible to effect more, or effect it better, t.ian
                                             the accoucheur of St. Bartholomew's has done m a
  The three former editions of the work now before
us have placed the author in tne foremost rank of
those physicians who have cevoted special attention
to tne diseases of early life   We attempt no ana-
h sis of thisedition, but may refer the reader to some
ot" the chapters to which the largest additions have
been made—those on Diphtheria, Disorders of the
Mind, and Idiocy, for instance—as a prooi  that the
work is really a new edition; not a mere reprint.
In its present shape ic will be iound of  the greatest
possible service in Jhe every-day practice of nine-
tenths of the profession.—Med. Times and  Gazette,
London, Dtc. 10, 1859.
  All things considi red  this book of Dr.  West is
by far the best treatise in our language upon such
modifications of morbid  action and disease as are
witnessed when we have to deal with  infancy and
childhood.  It is true that it  confines itself to such
disorders as comewuhiu the province  of the phy-
sician, and even with respect to these it is unequal
as regards minutentss of consideration, and some
single volume.   The lecture (XVI.) upon Disorcirs
ol the Mind in children is an admirable specimen of
the value ot the later information convejed in  tne
Lectures  of Dr. Charles West.—London  Lancet.
Oct.  >-i, 1859.                                 '

  Stnce the appearance of the first edition, about
eleven years ago, the experience of the  author has
doubled; so that, whereas the lectures at first were
founded on six hundred observations, and one hun-
dred andeigniy dissections made among neatly four-
teen thousand children, they now embody the results
of nine hundred observations, and two hundred and
eighty-eight post-mortem examinations made among
nearly  thirty thousand children, who,  during the
past  twenty  years, have been under his  care.—
British Med. Journal, Oct. 1,185».
BY THE SAME AUTHOR
^™QSFm^™   PATHOLOGICAL IMPORTANCE OF ULCER-
  aiikjss u* Irlh Ob UTERI.  In one neat octavo volume, extra cloth.  $1 00. 
 
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