&\ ■ NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland ^6^^fev ! L c*§ ^sp^ ■ ALCOVE SECTION SHELF Works of this Section cannot be taken from the Library except by written permission of the Bureau of Medicine and Surgery. \ WR \00 Wp ON DISEASES OFJIHE SKIN A SYS' CUTANEOUS BY ERASMUS "WILSOX, F.R.S. SEVENTH AMERICAN \SSfcW* FROM THE SIXTH AND REVISED KNGLISH EDITION. ■iifir-ftWWrtS^iSSw1^**'1^'.'' WITH TWENTY PLATES AND ILLUSTRATIONS ON WOOD. PHILADELPHIA: HEISTRY C. LEA 1868. * I PHILADELPHIA : COLLIKS, PRINTER, 705 JAYNE STREET. PUBLISHER'S ADVERTISEMENT. In the present edition of these Plates, the Publisher has added those prepared by Mr. Wilson to illustrate his work on "Constitutional Syphilis and Syphilitic Eruptions." In the recent editions of his "Diseases of the Skin," the affections arising "from Syphilis have been more promi- nently and thoroughly treated, rendering appropriate the introduction of the Plates descriptive of them; and it is to be hoped that the series will therefore be found im- proved in value, as well as completeness. Philadelphia, May, 1868. PREFACE. Cutaneous Medicine is a branch of General Medicine of no insignificant importance. , 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 know- ledge 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 otganism of the skin. In the former character 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 character, it comprehends, in an equal degree, all that belongs to the organization 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. The skin, in its physiological and pathological relations to the general system, no less than in its individual structural derangements and morbid phenomena, must be regarded as an organ capable of exerting a considerable influence over the well-being of the animal economy and worthy of our closest and most earnest investigation and study. Its physiological relations are manifested in its sensibility and secreting capacity, its pathological relations in its sympathies and nutritive attributes; while its morbid phenomena are replete with signification and interest. The scheme of the present book is to consider the cutaneous organ, in the first place, in its healthy condition and integrity; in the second, in its pathological and morbid states; and thirdly, in reference to its treatment by the aid of means which have been found capable of restoring its healthy condition when its structure is VI preface. invalidated by disease. The details of this plan are developed in the successive chapters of the volume; the first three chapters are devoted to the anatomy, physiology, and pathology of the skin, together with the therapeutical principles which should be our guide in the treatment of its morbid conditions. The fourth chapter takes into consideration the classification of its diseases, the diseases them- selves being collected into twenty-two groups, each comprehended in a separate chapter. Twelve of these chapters, from the fifth to the seventeenth, are engaged with the discussion of the diseases of the skin proper; three with the cutaneous manifestation of the presence in the system of a blood-poison, namely, the zymotic, syphilitic, and leprous affections; and the remaining seven, excepting the last on traumatic affections, with the diseases of the epidermis, the hair, and the cutaneous glandular system. After much study of the principles of classification, we have succeeded in framing one, which, deriving its origin from the nature of the diseases,themselves, will, we believe, after careful analysis, be found to be the most simple and the most practical that could be adopted. The suggestion of this arrangement arises from our ex- perience at the bedside of the patient; hence we have termed it the clinical classification ; and the idea which it embraces, is, that of taking the most common and remarkable example of the diseases of the skin, namely, eczema; of studying it thoroughly with its multiple lesions and mutations; of arraying in its train diseases which are linked with it by natural affinity, and so to create our first group, namely, eczematous affections. A beginning being in this manner accomplished, the other groups fall into their places almost sponta- neously, erythema and bulla by virtue of a tie of relationship, and furunculus a no very distant connection. In this combination we find the material of our first four groups, and the three following are supplied by the nerves, the bloodvessels, and the blood; develop- ment, nutrition, and growth furnish the two next groups, namely, developmental and nutritive affections, with hypertrophy and atrophy; and diathesis the tenth, eleventh, and twelfth, namely, alphos, struma, and carcinoma. Older authors and writers were content with these twelve groups; hence an apparent greater sim- plicity in their works than in those of the present age ; but, accord- ing to modern views, about half the affections of the skin were omitted in consequence of this curtailment. For example, our thir- teenth, fourteenth, and fifteenth groups are devoted to zymotic affec- tions, syphilodermata, and elephantiasis Grsecorum; our sixteenth, PREFACE. vn seventeenth, and eighteenth groups to diseases of the epidermis, namely, pigmentary, phytodermic, and ungual affections; then follow from the nineteenth to the twenty-first, affections of the hair system, sebiparous system, and sudoriparous system; and the twenty-second and last, traumatic affections. Twenty-two groups of cutaneous affections may sound somewhat startling to the ear, but when they are investigated by the understanding, the classification will not be found more copious than is necessary for the clear and precise development of the subject. It would be difficult to curtail the number with advantage, and it may be desirable at some future time to increase the sum, for example, by the separation of the hyper- trophic from the atrophic affections which are at present assembled under one head. Next to precision of classification there is no one thing more needed in cutaneous medicine than precision and accuracy of nomen- clature. Dermopathology has reason to boast of a noble ancestry and an ancient literature; the terms that we employ at the present day are the language of the Fathers of medicine. To the student of derma- tology the terms, psora, lepra, lichen, alphos, melas, leuce, herpes, &c, have a deeper and more suggestive signification than that conveyed by the mere words, and, in the following pages, we have endeavored to invest these terms with the meanings which were attached to them by our ancestors. As a further help to this branch of the subject, we have added to the present edition a glossary of dermatological terms, which will not only give the derivation of the words and their proper application, but will also, it is hoped, act as a restraint upon the terminological innovations of modern nomenclators. We trust that we have not failed in doing justice to our European and Transatlantic colleagues; we have been anxious to acknowledge the usefulness of their researches, and bestow upon their labors the honors which they deserve. If any have been omitted in our pages, we must beg of them to attribute the oversight to no lack of sympathy with their exertions and appreciation of their merits, but simply to the want of leisure for literary pursuits, necessarily associated with the onerous duties of medical practice. Amongst the earnest laborers in the field of cutaneous medicine we mention with veneration and respect the eminent names of Hebra, Danielssen, Boeck, von Barensprung, Virchow, Eayer, Cazenave, Bazin, Hardy, &c, but we feel, at the same time, that we are omitting the names of many others who are also entitled to honorable distinction. Among ourselves also, in Britain, we have a rising and emulous phalanx, in Vlll PREFACE. whose hands we feel sure that the honor of cutaneous medicine may be reposed with confidence, and the science and practice with a fair expectation of enrichment and improvement. Britain, distinguished by the names of Daniel Turner, of Willan and Bateman, has long been a favored seat of learning of cutaneous medicine, and shall not be wanting in our personal exertions to maintain and perpetuate that distinction. Elephantiasis Grsecorum, the lepra melas and leuce of the ancients, or simply, leprosy, has long engaged our attention, and occupies a somewhat prominent position in the following pages. Our interest in this remarkable disease received its first impulse from the re- searches of Danielssen and Boeck, and was further stimulated by the very interesting antiquarian inquiries of Sir James Young Simpson, and by the occurrence of several examples of the disease in our own practice. More recently, our interest in that terrible malady has been increased by the evidence supplied to the Leprosy Committee of the College of Physicians, and by the unexpected discovery that the disease is spreading by degrees to the European population of our settlements in Hindostan and in the Indian seas. Ten cases of leprosy have fallen under our observation during the current and past year, and certain important questions force themselves upon our attention ; for example: How shall we protect our Indo-European population from the invasion of this disease ? How shall we treat the disease when already established ? and, What shall we do with our lepers in the nature of a refuge and an asylum ? If, by the extension of territory, we subject our population to the invasion of a malady unknown to them at home, we incur the duty, as it seems to us, of finding the means of relieving them of that disease, when, un- fortunately, they become the victims of its attack. In near association with leprosy, is syphilis; the phenomena of the syphilitic poison are replete with interest, and the closer we investi- gate those phenomena, both in respect of contagion, and manner of evo- lution and development, the more we are assured of our power and mastery over the disease which that poison is capable of engender- ing. The syphilitic poison, in its manifestation by the skin, has the remarkable property of stimulating the common characters of the exanthematous fevers, and of presenting, at different periods of its existence, the whole of the recognized pathological lesions of the cutaneous tissues; one while it gives rise to an erythema, then to a papule, next to a pustule, a vesicle, or bulla; again, to a tubercle, a squamous exfoliation, an ulcer, or a crust; and finally to a macula PREFACE. IX and a cicatrix. Our attention was early attracted by these curious and extraordinary phenomena, and to the interest so excited is due the extensive elaboration and considerable space which we have devoted to the subject of constitutional syphilis. The present edition has been carefully revised, in many parts re- written, and our attention has been especially directed to the practical application and improvements of treatment. And, in conclusion, we venture to remark, that if an acute and friendly critic should discover any difference between our present opinions and those announced in former editions,1 we have only to observe, that science and knowledge are progressive, and that we have done our best to move onwards with the times. 1 The dates of the several editions of this work are: 1S42, 1S47, 1851, 1857, 1863, 18C7. Henrietta Street, Cavendish Square. December, 1866. I / CONTENTS CHAPTER I Anatomy and Physiology of the Skin Pigment of the skin Sudoriparous system Sebiparous system Hairs Nails Physiology of the skin CHAPTER II. Pathology of the Skin page 17 27 30 34 35 50 53 64 CHAPTER III. Classification of Diseases of the Skin 97 CHAPTER IY Therapeutics of the Skin 115 CHAPTER V. Group 1.—Eczematous Affections . 123 Eczema .... . 125 Psoriasis 162 Pityriasis . 164 Lichen ..... . 171 Strophulus . 174 Impetigo . 189 Gutta rosacea . 192 Scabies .... 195 CHAPTER VI. Group 2.—Erythematous Affections .... 211 Erythema ........ 212 Pellagra ....... 222 Acrodynia ....... 226 Erysipelas ....... 227 Urticaria . . . . ' . 239 Roseola ..... 246 Xll CONTENTS. CHAPTER VII. Group 3.—Bullous Affections Herpes ...... Miliaria, ...... Pemphigus ..... CHAPTER VIII, Group 4.—Furuncular Affections Ecthyma Furunculus Hordeolum Anthrax Pustula maligna Pustula Aleppensis CHAPTER IX. Group 5.—Nervous Affections Hyperesthesia Anaesthesia Pruritus Prurigo CHAPTER X. Group 6.—Vascular Affections Ntevi vasculosi congenitales Nsevi vasculosi accidentales Phlebectasia, seu hypertrophia venarum . PAGE 2.18 259 269 272 278 282 285 285 293 294 296 296 296 297 299 302 303 3()4 305 CHAPTER XI. Group 7.—H^emic Affections Purpura CHAPTER XII. Lffec \ Group 8.—Developmental and Nutritive Affections Xeroderma Ichthyosis Sauriosis ...... Cacotrophia cutis ..... CHAPTER XIII. Group 9.—Hypertrophic and Atrophic Affections Nsevus hypertrophicus Ecphyma . Molluscum simplex Acrochordon . Verruca Clavus Papillosum 308 308 316 317 320 322 324 32o 326 32 8 328 328 329 331 334 CONTEXTS. Xlll page Dermatolysis . 335 Pachylosis . 336 Kelis .... . 337 Sclerosis dermatos 345 Spargosis, sea boucnemia . 346 Atrophia cutis . 349 CHAPTER XIV. Croup 10.—Alphous Affections . 352 Alphos .... . 353 CHAPTER XV. Group 11.—Strumous Affections . 367 Scrofuloderma . 368 Lupus .... . 369 f CHAPTER XVI. Group 12.—Carcinomatous Affections . 379 Carcinoma cutis . . 379 C II APTER XVII. Group 13.—Zymotic Affections . 382 Rubeola . . . . 386 Scarlatina .... . 392 Variola .... . 402 Varicella .... . 428 Vaccinia .... . 432 Vaccination . . 441 Equinia .... . 462 Frambcesia . 465 CHAPTER XVIII. Group 14.—Syphilitic Affections . . 467 Syphilodermata . 471 CHAPTER XIX. Group 15.—Leprous Affections . 513 Elephantiasis Grsecorum . . 519 Cases of Elephantiasis . 531 Existing forms of Elephantiasis . . 584 Morphcea ..... . 585 CHAPTER XX. Group 16.—Affections of the Pigment Syst EM . 593 Melanopathia .... . 594 Xanthopathia .... . 606 Lentigo .... . 606 Chloasma .... . 607 Cyan op at liia .... . 610 Leucopathia .... . 610 XIV CONTENTS. CHAPTER XXI Group 17.—Phytodermic Affections Nosophyta CHAPTER XXII Group 18.—Ungual Affections Deformitas unguium Desreneratio unguium Onychia CHAPTER XXIII Group 17.—Affections of the Hair System Hirsuties . Alopecia . Trichonosis decolor Trichonosis versicolor Trichonosis cana, seu canities Trichiasis . Fragilitas crinium Trichonosis tonsurans, seu tinea Trichonosis plica . Stearrhcea capillitii Narcosis folliculorum Morbus pilaris Favus Kerion Sycosis CHAPTER XXIV Group 20.—Affections of the Sebiparous System Epidermic hypertrophy Epithelial hypertrophy Xanthelasma Cancerous hypertrophy Stearrhoea . Asteatodes Allosteatodes Stearrhcea flavescens Stearrhcea nigricans Stearrhoea caerulea Comedones Tumores sebipari . Molluscum sebaceum, seu contagiosum Tumores encystici. Cornua humana Tubercula sebacea Acne PAG 614 614 616 617 618 619 CONTENTS. XV CHAPTER XXV Group 21.—Affections of the Sudoriparous System 701 Hyperemia glandularum . . . . . 701 Atrophia glandularum 701 Hydro-adenitis 701 Idrosis .... 702 Anidrosis .... 708 Osmidrosis, seu bromidrosis 708 Chromidrosis 710 Haemidrosis 711 CHAPTER XXVI, Group 22.—Traumatic Affections ..... 713 Malis acari ....... 714 Malis pediculi ....... 717 Malis pulicis ....... 720 M alis cimicis . . . 721 Malis filariae ....... 722 Malis cestri ....... 725 Ambustio . 726 Gelatio 736 CHAPTER XXVII. History and Description of the Itch-animalcule and Entozoon follicu- lorum . . . . . . . . 739 Acarus scabiei " . . . . . . . 739 Steatozoon folliculorum ....... 755 CHAPTER XXV III. Formulary of Selected Remedies . 764 Arsenical remedies ... . 764 Sulphur remedies Tar remedies 766 770 Ointments 771 Glycyria . Lotions Spirits and tinctures Zittmann's decoction 773 773 774 775 Caustics 775 Baths Benzoated ointments 777 777 CHAPTER XXIX Clossary of Dermatological Terms Index ....••• 780 797 '- snrug^/Klsan., del H. Jordan, sc DESCRIPTION OF THE PLATES. Plate l.1 STRUCTURE OF THE EPIDERMIS. Fig. 1. A small portion of epidermis from the palm of the hand, magnified 19 times. The parallel arrangement of the ridges, and the manner in which they terminate abruptly every here and there, is shown in this figure; as well as the circular pores of the perspiratory tubes, a. A vertical section, showing the elevation of the ridges of the preceding, b. Represents the tufts of papillae of the derma, which are the cause of the ridges. The spiral coil running up from each tuft is a perspiratory tube. Fig. 2. The under surface of a portion of epiderm is from the palmof the hand, magnified, like the preceding, 19 times. The ridges and grooves are the reverse of fig. 1. In each of the three grooves represented in this figure are seen numerous oval-shaped depressions for the tufts of papillae of the derma, and running along the middle of each groove, a slightly elevated line, a, upon which, at short distances, are the conical sheaths of the perspiratory tubes, b. One of the conical sheaths in question, c. A vertical section of the preceding figure. If this be compared with fig. 1, a, the correspondence of the two will be seen. d. One of the conical sheaths of a perspiratory tube, projecting from the middle of the groove ; similar conical sheaths are seen in the other two grooves. Fig. 3. A portion of epidermis from the armpit, magnified 19 times. The numerous lines crossing the figure are furrows adapted to the motions of the body. In the compartments between these furrows, smaller divisions are seen corresponding with the papillae of the derma. The round spots scattered over the surface are the pores of hair-follicles and sebiferous follicles. Fig. 4. A portion of the epidermis from the back of the thumb, magnified 19 times. The lines of motion and compartments have a different arrange- ment from those in the preceding figure, but in nature are the same. The little prominences caused by tufts of papillae are more strongly marked, and there are several pores of hair-follicles scattered over the surface. Fig. 5. A portion of epidermis from the back of the hand, viewed upon its under surface, and magnified 38 times. The depressions correspond with the papillae of the derma. This figure illustrates the irregular distribution of the dermal papillae, as compared with fig. 2, in which the depressions are arranged in rows. Fig. 6. A thin fragment of epidermis, magnified 155 times, showing its con- 1 The figures in the first six plates were drawn with the camera lucida; their relative size is consequently preserved. B XV111 DESCRIPTION" OF THE PLATES. struction of flat, polyhedral, overlapping scales, in some of which a nucleus is seen. Fig. T. Vertical section of a portion of epidermis from the palm of the hand magnified 155 times. In the lower part of the figure the section has cut across, and then proceeds nearly parallel with, a tortuous perspiratory tube. The cells, of which the epidermis is composed, are more open in the lowest than in the upper parts of the figure ; a nucleus, also, is seen in the cells of the lower stratum, while in the upper the cells are converted into thin scales. Fig. 8. A series of epidermal cells, magnified 310 times, showing the mode of growth of the cells, and their ultimate conversion into scales. These changes take place in the lowest stratum of fig. 7.. a. Primitive isolated granules, measuring about jo, fe, e^ Fiq .4 ^■■ii* 1 c*v - Erasmus "WHson, del H. Jot dan, sc. < * ♦ »^ \ 8 * ' '**■*?&* <*> PLATE VIII. PEMPHIGUS A Bigov, Dei. f Sinclair's lx£n Phil1 DESCRIPTION" OF THE PLATES. XX111 A. A. Urticaria evanida (page 241). The subject of this eruption was a little girl, six years of age, and otherwise in good health. The simple round elevations and the stripe-like wheals of urticaria are both seen in this figure. b. Urticaria conferta (page 241). In this variety the elevations or wheals are closely aggregated, and form thickly-set clusters. c Urticaria febrilis (page 240). A single, red, hemispheroidal wheal of this variety of the eruption. d. A small group of the pale hemispheriodal wheals of chronic urticaria. roseola. e. f, represent typical appearances of Roseola (page 246); the cases for illustration being selected from the varieties—corymbosa, annulata, and maculosa. e. Roseola corymbosa, or false measles (page 248). f. lloseolous patches of an irregular, anuular, and circular figure; roseola annulata and maculosa. erythema. g. Erythema papulatum (page 216). The patch was developed on the convexity of the elbow. The case is reported at page 217. h. Erythema tuberculatum (page 216b The drawing was made from the leg of a young woman suffering under this disease. Two of the spots are at their height, the others are fading.' The case is reported at page 218. I. Erythema nodosum (page 216). The case from which this drawing was obtained is reported at page 218. K. Erythema circinatum (page 217). The border of the ring is broad and smooth, and very little raised above the level of the surrounding surface. The area is yellowish, from the subsidence of hyperemia. L. m. Tinea annulata. The margin is prominent and papular, the area yellow, from subsidence of hyperaeinia. Plate 8. BULLOUS i#FECTIONS. PEMPHIGUS. RUPIA. a. Circular erythematous spots, which precede the formation of the bullaa of Pemphigus (page 272). B. A bulla of Pemphigus filled with transparent fluid. C A bulla in which the fluid is whitish and opalescent. D. A partially collapsed bulla, out of which a drop of serum is seen issuing. E. A partially collapsed bulla filled with sanguineous fluid. F. The thin, corrugated, brownish scab, formed by the desiccation of the bulla. g. The appearance left upon the skin by the removal of the scab. H. The stains left upon the skin some weeks after the fall of the scab. I. A group of the smaller bullae of Pemphigus, assuming a circular arrange- ment. X.X1V DESCRIPTION OF THE PLATES. RUPIA. K. Erythematous spots on the skin, which precede the formation of the bulla? of Rupia (page 485). L. Small bullae, distended and collapsed. m. Rupia simplex. A small bulla converted into a scab. n. A larger scab of rupia simplex. It is thick, hard, and corrugated. o. Rupia prominens (page 486). A well-formed and characteristic scab. p. The unhealthy ulcer left by Rupia prominens. This figure and the large conical crust, were drawn from the same patient. q. A depressed mark left on the skin after the fall of the scab of Rupia sim- plex. r. The papular and pustular origin of rupia. s. The appearance of the integument in a case of rupia, in which the skin was permitted to heal previously to the removal of the crusts. Plate 9. phlyct.exoid and eczematous affections. HERPES. ECZEMA. a. Herpes zoster (page 261). A patch of this eruption on its first appear- ance. The vesicles have not yet attained their complete size. b. Another patch of Herpe3 zoster, three or four days later, when the vesi- cles have attained their full size ; some have coalesced, and their contents become yellow. This cluster illustrates the irregular patches of Herpes phlyct^enodes (page 262). c. Groups of vesicles exhibiting the first stage of collapse, when a central depression is formed, and the vesicle is consequently umbilicated. d. e. In a stage further advanced, the depressed centre of the vesicle dries up into a small scab, which is surrounded as by a rim, with the remains of the vesicle. The eruption now acquires a purplish hue. f. Still later, nothing remains of the eruption- but a small brown shrivelled crust; except in instances where ulceration has taken place. a. Herpes circinatus (page 264). A small cluster of vesicles assuming the circular or circulate form. ^ h. Herpes iris (page 266). This is tI rare and curious form of phlyctaanoid eruption. ECZEMA. i. k. Eczema vesiculosum (page 134). The vesicles are minute, and raised on a surface but little deeper in tint than the surrounding skin. l. l Eczema pustulosum (page 135). The diseased surface is covered with broken crusts, between which the skin is seen to be highly inflamed, while large drops of ichorous fluid (eczema ichorosum) are oozing from the exposed surface. To the left of the crusts are numerous sero-pus- tules, and in the right-hand corner (m) the eruption is less highly inflamed and may be supposed to be passing into the stage of Eczema squamo- sum. As Eczema not unfrequently presents, upon the same person, and at the same time, all the stages illustrated in this engraving, the figure may be regarded as exhibiting a complete picture of the disease. PLATE LX HERPES. mat*?* &<■*E ECZEMA <■"-,« /' ,.'• * A Bigot, del T Sinclair's Ml. Phi1 PLATE I IMPETIGO. & ■tf*^fc ***# ECTHYMA s '"4a». •I *V' 1° * IK P *■« /I Biiol Bel T Sinclair's ML,Kula DESCRIPTION OF THE PLATES. XXV A small cluster of vesicles of eczema, somewhat larger than usual, and presenting a circular arrangement. This appearance is by no means uncommon. * Plate 10. pustular affections. IMPETIGO. ECTHYMA. A. Impetigo figurata (page 191). A small patch of this eruption; incipient pustules are seen around its circumference. b. Other patches of the same eruption, in its crusted state; also-exhibiting incipient pustules around their border. c. Impetigo sparsa (page 191). The pustules dispersed irregularly over the surface, singly and in small clusters, belong to this variety. The pustules are seen at every stage of progress, namely, red points; minute pustules; ripe pustules, surrounded by a halo of redness ; fading pustules, collapsed and wrinkled ; and others further advanced, surmounted with a scab. D. Impetigo sparsa of the scalp. The pustules are oval in shape, one of them being covered by a newly formed crust. e. Another crust of this eruption, from the scalp. ecthyma. g. Ecthyma (page 2T8), in its several stages of pustule, scab, ulcer, and fading-spot. H. An incipient pustule. i. i. Perfect pustules. k. k. Umbilication and incipient desiccation of the pustule. l. A perfect scab. m. Ulcerated state of the skin brought into view on the separation of the scab. n. The discolored mark which remains upon the skin after the healing of the pustule. o. A cluster of pustules in their scabbed or crusted state. p. A fully distended pustule from an elderly person ; the purple hue of the areola is characteristic of Ecthyma cachecticum ; page 280. q. A crusted pustule from the same person. r. A pustule from the back of the hand of a boy affected with scabies; the complication of scabies with such a pustule constitutes the scabies purulenta of Willan (page 198). XXVI DESCRIPTION OF THE PLATES. Plate 11. liciienous or papulous affections. lichen, strophulus, prurigo. a. Lichen simplex (page 173). A cluster of the papula? of this eruption from the arm. They exhibit various degrees of inflammatory activity ; those in the upper part and around the circumference of the cluster being very little deeper in tint than the surrounding skin. B. Lichen pilaris (page 184). A small cluster of the papulae of lichen simplex developed at the appertures of hair-follicles, so as to involve the hairs. The figure was drawn from the leg of the same patient as A. c. Lichen .syphiliticus (page 474). 1?our clusters of the larger and duller papulae of this eruption ; from the breast. D. Lichen urticatus (page 175). The large papulae of this eruption ; three of the pimples are surmounted with small crusts. This figure was drawn from the leg of the little patient reported at page 175. E. Lichen circumscriptus (page 174). A patch of this eruption at an early stage, before the centre begins to subside and the margin to extend. F. Lichen circumscriptus in a more advanced state. G. Lichen agrius (page 142). The white specks on the surface of the patch are furfuraceous scales. These and small oozing points are characteristic of this form of eruption. h, h. Lichen agrius, in its chronic and crusted state. The isolated papulae around the margin of the patch are an important diagnostic sign. strophulus. i. Strophulus intertinctus (page 174). From the cheek of an infant. Towards the centre of the patch the eruption puts on the character of strophulus confertus. k. Strophulus volaticus (page 174). l. Strophulus albidus (page 174). m. Strophulus candidus (page 174). prurigo. n. Prurigo (page.173). The papulae of the three varieties of this disorder. Some of the pimples are bleeding, from fresh abrasion; while others are covered with a small black crust. Intermingled with the papulae are the brownish-yellow stains which this eruption leaves behind it. We have not attempted to give the specific appearance of the skin, as nothing but a magnified drawing would do justice to the subject. Plate 12. ALPHOUS AFFECTIONS. Alphos circinatus seu vulgaris (page 356), a well-marked laminated and imbricated scale of the eruption. Alphos papulosus seu punctatus, the pimples or tubercles, by which alpho3 commences. The tubercle to the right is already surmounted by a scale. The tubercles continue to enlarge until they attaiu the size of a. PLATE XI LICHE N STROPHULUS '& ., PRURIGO WW »\. »"* .w fc ww »t w , . www «« _%w* ••* ■ *** S% v *>* g v "w «• "I «. *•£„ .1 «Yw*j tv <• w- r W»" «- « c \ riijjot Del T Sinclair's Mi PH^ FLATS MI LEPRA. PITYRIASIS. PSORIASIS PLATE XIII LUPUS NON EXEDENS. A Bi£dI Dei T. Sinclair's Inn Phil*- DESCRIPTION OF THE PLATES. XXV11 c Alphos guttatus (page 356), that is, spots which remain stationary when they have reached to about the size of the patches represented in the figure. They are but little or not at all depressed in the centre, and hence have a whiter aspect than the larger patches of alphos vulgaris. D. A patch of alphos vulgaris, clearing in the centre, while the scales which cover its margin are breaking up. This is the first step towards cure, the stage of retrograde metamorphosis. E. Another patch in which the centre is cleared to a greater extent, and a part of the margin has also subsided. This is a further advance towards cure. f. A nother patch, exhibiting a more advanced stage of the curative move- ment. G. Alphos vulgaris, as it affects the convexity of the elbow ; the drawing is made from the same patient as A. In this situation the patches are generally confluent, and lose their circular figure. h. Alphos diffusus (page 357), with deep chaps ou the morbid skin. The drawing was made from a patch situated on the back of the hand. I. This figure, if the patch were no larger than represented in the drawing, would be an illustration of alphos diffusus; if, however, it extended over a considerable portion of a limb, it would be termed alphos in- veteratus. It is intended to illustrate the latter disease. K. Svtphiloderma palmare (page 473). The irregular margin of thickened epidermis and the chaps are characteristic. This is clearly an erythma. l. A portion of a patch of chronic eczema (eczema furfuraceum vel squamo- sum), in its dry state, from the nape of the neck. The disease covered the whole of the back of the neck, the scalp, the^hest, and the shoulders. Plate 13. lupus non exedens. An example of this obstinate disease which has existed for thirty-three years. The tuberculated and salmon-colored margin of the patch, its variegated area streaked with white and cicatrix-looking lines, and the erosion of the border of the ala nasi, are characteristic of this disease (page 373). # Plate 14. diseases of the sebiferous follicles. hair-follicles, and hairs. ACNE. GUTTA ROSACEA. SYCOSIS. FAVUS. TRICHONOSIS. A. Acne vulgaris punctata (page 698). Several groups of the pimples of this eruption, in their early state. They are characterized by the black point which is perceived in the centre of each. b. Acne punctata in a more advauced stage ; they are now becoming slightly inflamed. c Comedones (page 677). These black spots on the skin, caused by inspis- sation of the sebaceous substance and discoloration of the external end of the small piles so produced, generally accompany the development of SXV111 DESCRIPTION OF THE PLATES. acne. They frequently precede the form a, the pimples of acne punctata being comedones with elevation and induration of the skin immediately around their apertures. d. Acne vulgaris (page 699). Conical elevations with inflamed bases, and suppurating at the summit. f. A. Pimple of acne vulgaris, on the summit of which the pustule is in pro- gress of desiccation into a scab. g. Acne vulgaris indurata (page 699). This is a chronic variety, and consequently the pimples are less vividly inflamed thau those of D, F. e. Stains, pits, and scars left on the skin by acne vulgaris. GUTTA ROSACEA. h. Gutta rosacea pustulosa (page 193). The drawing was made from a patch on the cheek of a gentleman of middle age. SYCOSIS. I. Sycosis (page 667). A patch of this eruption, from the side of the chin of a young man of twenty-five. trichonosis. k, k. Trichonosis tonsurans, or ringworm (page 642). Patches of com- mon ringworm, in its papular and tonsurant form. l. Separate papulae of the same disease, produced by the affection of isolated follicles. m. Trichonosis tonsurans, in its crusted form ; the crust being constituted of flakes o£ epidermis and towy hairs matted together by a small quantity of sero-purulent discharge. The crust is broken into angular compart- ments by the movements of the scalp. N. A magnified section, showing a pimple of this disease, together with two hairs issuing from its summit; the latter being inclosed for a short dis- tance by a sheath of inspissated sebaceous substance. 0. A magnified hair, showing the state of disease which exists in that struc- ture in trichonosis tonsurans: a. The root of the hair. b. Its shaft. c. The external or cortical layer of the hair broken from its continuity with b, and stripped back, so as to expose its internal surface. Several of the granules of the diseased hair are adherent to the surface of this layer, d. The granular layer of the hair surrounding its fibrous central part. p. The appearance presented by the granules when viewed with the micro- scope. • q. A group of granules more highly magnified. Each granule is seen to possess a nucleus. FAVUS. r. Favus dispersus (page 654). The saucer-shaped, bright yellow crusts of this disease. Each crust is pierced by one or more hairs. s. Favus confertus (page 654). The yellow saucer-like crusts of the ag- gregated form of the disease are clustered together so closely as to con- stitute a more or less coalescent mass. T. A diagram section of the crust of favus, which is intended to show the insertion of the base of the crust into the hair-follicle, and its relation to the hairs. A CNE. tf <« •\. >''.'i*-v*-'.'fW2f''/ iJb ■'^ B" \\!j &■ <&i fc' P ■:!?>cjf if f?-ssa^ --iiE; /.I '•v^,d *v & & '-, it* ; *■ '■'' ■ ite?' ^ .-..aa-V, l]*.Piula T Fuji. *>%<,, ^ TfeiBB '^ 1) •' ^.^ • ■' @ "»; |»C| X— % « m ^ -^ a r* ■x' A^ Jg*rf. & to - ,#fc? ■C" C^^r w Ma.jo. lij^mm^i \\ffm 2fy.fi. v5: \ mm '% t/ T. Sinclair's 14, Phil" — -A'W-^% DESCRIPTION OF THE PLATES. XXIX Plate 15. diseases of the hair-follicles and hairs. FAVUS. trichonosis. Fig. 1. Favus (page 654). A group of crusta of Favus; natural size. The prominent rim; the cupped surface; the aperture of the hair-follicle; the slight elevation frequently surrounding the aperture of the follicle, and forming a kind of crater ; and the one or two hairs issuing from the folli- cles, are all shown. a. Is an incipient crust, b. Is a crust which has extended so as to include four neighboring follicles, c. Separate crusts becoming con- fluent as a consequence of growth. Fig. 2. Side view of a crust of Favus, showing its elevation from the skin. Fig. 3. Section of a crust of Favus, showing its thickness ; the papilla cor- responding with the hair-follicle; and its relation to the latter. • a. The hair inclosed in its follicle. Fig. 4. Under surface of the crust of Favus, magnified 310 times. It is composed of granules and corpuscles closely aggregated together, the former occupying the interstices of the latter. The corpuscles are seen to be filled with nuclear granules. Fig. 5. Favus-corpuscles from an incipient favous deposit, magnified 310 times. A. Favus-corpuscles without admixture with water, measuring s^u of an inch in diameter. B. The same corpuscles swollen to the size of ^sW or* an uic'h by the absorption of water ; the riper secondary cells or nuclei are brought into view. Fig. 6. Favus-corpuscles, or cells, exhibiting stages of progressive develop- ment, magnified 310 times. A. Corpuscles, showing the nuclear granules much enlarged by growth, but still contained in a cell-membrane. B. A further stage of growth of the corpuscles, the nuclear granules much enlarged, and the cell-membrane lost. Fig. 7. Favus-corpuscles, still further advanced in growth, magnified 310 times. The corpuscles are now resolved into groups of nuclear granules, measuring ^J^ of an inch in diameter. At the left-hand side of the figure the groups retain somewhat of a circular form, while on the right they are gradually becoming elongated. Fig. 8. In this figure, the nuclear granules are seeu gradually passing from the single and grouped forms through the stages A and B, to the plant- like form represented at G. The figure is magnified 310 times. Fm. 9. Diagrams representing some of the appearances of the favous forma- tion during its growth. a. A stem composed of five cells, showing their mode of growth. b. A cell in which four nuclei are in progress of development; such a cell as this is the cause of the dichotomous division of the favous stem. c. The appearance presented by the cellated divisions of some of the stems. d. The appearance of the cellated -stems when seen with an imperfect focus. XXX DESCRIPTION OF THE PLATES. Fig. 10. One of the hairs removed from the centre of a favous crust, magni- fied 155 times. Fig. 11. Trichonosis tonsurans (page 642). A diseased hair from a patch of common ringworm, magnified 155 times. The external layer is removed at a; at b it still remains. Fig. 12. A group of nucleated granules from the outer surface of the fibrous portion of the preceding hair. They are magnified 310 times. Plate 16. exaxthematous and papular syphilitic eruptions. A A. Roseola versicolor vel vulgaris (page 472). B. Roseola punctata (page 472). C. Roseola orbicularis (page 472). D. Uoseola annulata (page 472). E. A blotch of roseola orbicularis, from which the epiderma has peeled off and forms a white frill around its circumference. The color of the blotch is intended to show the true " copper color." F. Roseolous blotches in process of fading, and passing away as brownish stains (page 472). # G G. Lichen syphiliticus corymbosus (page 474). II. Lichen syphiliticus disseminatus (page 474). I. Lichen syphiliticus confertus (page 474). K. Lichen syphiliticus aunulatus (page 474). The natural color of the eruptions has been adhered to as nearly as possi- ble in tliis plate; and in several places, the color of the stains left by the declining and fading eruption is shown. Plate 17. tubercular syphilitic eruptions. L. Tubercula syphilitica corymbosa (page 477). M M Blotches of tubercula corymbosa assuming a circular and annulate form. X X. Smaller blotches found intermingled with the preceding forms in syphiloderraa tuberculatum corymbosuni. These latter may be dis- tinguished as " cupped" tubercles. All the three forms are frequently met with in the same person. 0. A small patch of tubercula circumscripta (page 477). P. Larger patch of tubercula circumscripta. The tubercles are covered with stales formed by (he exfoliation of the cuticle. Q Q. Tubercula disseminata (page 478). R. Tubercula disseminata, in process of exfoliation ; each tubercle being sur- rounded at its base by a frill of cuticle (page 481). S S. Tubercula annulata. Between the two larger rings are seen incipient rings, having the characters of " cupped" tubercles (page 482). T. An annulate tubercle from the penis. V V. Rings of annulate tubercle. PLAIF Zi-7 £ ymjjjfr. i %# W' <* *W PLATE F/i: IJF*% PLATE XVJij -¥,. &l ^*v. ^ PLATE XIX A DESCRIPTION OF THE PLATES. XXxi W. Tupped tubercles; the common form of the separate eruptions in infantile syphilis. Plate 18. A. Patch of rupia simplex from the knee (page 486). B. Rupia prominens; below the lower eyelid is seen one of the pustules by which rupia prominens ordinarily commences (page 486). C. Erythema palmare syphiliticum (page 490). D. Erythema palmare annulatum centrifugum (page 491). E. 'Aphthous exfoliation and syphilitic tubercles of the tongue. Plate 19. A. Ulcera syphilitica ; the figure represents the hand of the patient, and the state of distortion occasioned by syphilis (page 493). B. Hereditary syphiloderma of the nose. C. Erythematous syphiloderma of the nose. D. Syphiloderma lupoides, or lupus non exedens (page 494). E. Syphiloderma lupoides (page 494). Plate 20. affections of the sebiparous system. Fig. 1. Stearrhoea nigricans (page 675), affecting the skin of the lower eyelid, and adjacent part of the nose. Fig. 2. Xanthelasma planum, seu lamina flav,e epithelii cutis, plan^e (page 671). Yitiligoidea plana, of Dr. Gull. Fig. 3. Xanthelasma papulosum, seu laminae flav;e epithelii cutis, papulosa (page 671). Vitiligoidea granulosa, of Dr. Gull. PLATE 20 &" F16 2. El6. 1. Fip 5 T Sinclair's lnhjau]* 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, corium, or true skin (Plate II.), is chiefly com- posed of white fibrous tissue; besides which it has entering into its structure, elastic or yellow fibrous tissue and smooth muscular fibre, together with bloodvessels, lymphatic vessels, and nerves. The white fibrous tissue exists most abundantly in the deeper strata of the derma, which are consequently dense, white, and coarse, while the superficial stratum is fine and spongy in texture, reddish in color, 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 consideration as consisting of two layers, the superficial or papillary layer, and the deep or fibrous layer. 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 mem- brane, like the derma, offers two strata for our observation, the outer- most 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 sebiparous glands; and the appendages, the hairs and the nails.^ The derma or corium presents considerable variety of thickness in different parts of the body. Upon the more exposed regions, as 2 18 ANATOMY' OF THE SKIN. the back, the outer side of the limbs, the palms,1 and the soles, it is remarkable for its thickness; while on protected parts, as the inner side 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 palm of the hands, the pulps of the fingers, and the sole 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 papillas are little apparent. Some contrariety is observed, besides, in the relative proportion of the layers of the derma; for on the back, where the fibrous layer is exceedingly thick, the papillary layer is only moderately developed, while on the pulps of the fingers, where the latter is strikingly manifest, the fibrous portion is thin. The 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 areola or cellular substance, and of fibres of elastic tissue, presenting their characteristically curved ends, and branching and anastomosing distribution. In the superfi- cial strata of the corium, the white fibres are collected into small fasci- culi, 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 fasciculi 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 fasci- culi are continuous with the subcutaneous cellular membrane. The yellow elastic fibres are solitary in their arrangement; abundant in the superficial layers of the corium, rare and scanty 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, have a reddish hue, but no transverse striae. They are fusiform in shape, of variable length, and 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 the fibre a knotted appearance; and the nuclei are sometimes oval and sometimes elongated or columnar in figure. The fibres are united into fasciculi by an adhesive interstitial substance; and the 1 In the palm of the hand the derma measured three-fourths of a line in thickness; on the heel the measurement is more than a line, sometimes a line and a half; the thickness of the derma of the back of the trunk is three-quarters of a line, while that of the general surface has an average of half a line. PAPILLARY LAYER OF THE DERMA. 19 fasciculi, which are sometimes round and sometimes flat, are inter- mingled in greater or less proportion with the fasciculi of the white fibrous tissue. Kolliker found small bundles of smooth muscular tissue measuringT^ to ?g of an inch, in connection with the hair folli- cles ; these small bundles, which have been termed by Bylandt arrec- tores 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 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 a§ protruding, the hairs." These muscles are the agents of erection of the hairs, and also of that erec- tion of the pores of the skin termed 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 prominence to the pore, but, taking 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 lias 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; Lister describes them in the deepest part of the corium of the areola mammae as a " deli- cate, pale, reddish-yellow fasciculus, circularly arranged." Henle thought that he had seen similar muscular tissue in conjunction 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 situa- tions, 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 long and abundant on the prolabium of the lips, on the nipples, the glans penis, glans clito- ridis, and nymphae. The longest papillae are one-half or two-thirds longer than their breadth at the base, the shorter ones being as broad and sometimes broader than their length ; on the nipple they measure A t0 in °f a line> and on the matrix of the nail T'2 of a line. 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 surface, they are distributed at unequal distances, singly and in groups, whereas, on the palms and soles, and on the 1 Microscopical Journal and Transactions, vol. i. 1S53, p. 2 J2. 20 ANATOMY OF THE SKIN. corresponding surface of the fingers and toes, they are collected into little square clumps, containing from ten to twenty papillae, and these little clumps are 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 researches1 have showu that the papillae of the skin are pro- perly divisible 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 the 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 some- times 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 termination " 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 extending 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 found principally in the hand and fiugers, on the red edges of the lips, and at the point of the tono-ue. 1 Wagner ; Meissner; Kolliker ; Huxley. 2 Kolliker finds nerves in the 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. 21 The arteries of the derma, which enter its structure through the areolae of the under surface of the corium, divide into innumerable 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, corresponding with the plane of the surface of the skin; while in the papillae it is disposed perpendicularly to the same plane. To see the capillary plexus of the.papillae, it is necessary to examine the injected skin by means of a vertical section; but if the horizontal rete is to be observed, no section is needed. In the papillae of some parts of the derma, 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 capillary rete of the horizontal stratum presents a number of circular areas, some of which correspond with the bases of the papillae, while the greater number occupy the walls of the follicular passages through which the sudoriferous and sebiferous ducts and hairs make their way to the surface. After a certain extent of course, the intermediate vessels unite to form the veins by which the blood circulated in the skin re- turns 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 would they be likely to perform any useful office in that situation. We once succeeded 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 research throws doubt over this mode of termination. 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." Ac- cording to the same observer, the termination 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 nervous 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, are remarkable for the presence, on their smaller twigs, of minute, 1 Loc. citat. 22 ANATOMY OF THE SKIN. 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 in the pulps of the fingers; 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 between 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 iDifid or trifid extremity. Huxley, however, who confirms the ana- logy subsisting between the axile corpuscles and the Pacinian bodies, observes: that there are no spaces filled with fluid between the cap- sules ; that the so-called capsules or layers are united by a transparent glanular, or fibrillated substance; that there is no central cavity, but a central solid homogeneous substance, which envelops the nerve fibre, and in which the nerve-fibre ends; that the appearance of con- centric 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 neuri- lemma. 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 con- clusion 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 promi- nence, 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 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 developed 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 scle- rotic coat, the gelatinous substance the vitreous humor, and the promi- nence of the peduncle the point of penetration of the optic nerve and the vessels of the retina. A similar analogy may be traced with the organ of hearing; and all the organs of sense may thus be shown to be developed according to one simple and primitive plan, of which STRUCTURE of the epidermis. 23 the nervous papilla of the derma, with its axile corpuscle, may be taken as the type. The epidermis (Plate I.) is a membrane of defence spread out upon the surface of the derma. As we have previously observed, this mem- brane 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 composed of cells. Moreover, the epidermis is laminated in structure, the laminae presenting a progressively increasing density, as they advance from the inner to the outer surface. This difference in density is depend- ent on the mode of growth of the epidermis; for, as the external sur- face is constantly subjected to destruction by attrition and chemical action, so the membrane is continually reproduced by its internal surface, new layers being successively formed upon the derma, to take the place of the old. Examined with the aid of the higher powers of the microscope, the under surface of the rete mucosum presents the appearance of an irregular mosaic composed of elements of four different kinds, namely : granules, measuring about 2555^ of an inch in diameter; aggregated granules, measuring about yuooo 5 nucleated granules, measuring 5555 to 4Vo"u> and cells, measuring 3^55 tp 555$ of an inch. (Plate I. fig. 8.) The granules are globular in form, homogeneous, solid, brightly illumined by transmitted light when the centre is under the focus of the microscope, but dark when viewed upon the surface, the dark- ness being increased whenever they are congregated in clusters. The aggregated granules, measuring about T5|5B of an inch in diameter, are minute masses, composed of four, five, or six of the preceding, or as many as can be aggregated without leaving an 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^^ and ^-J^ of an inch in diameter, are in point of construction an "aggregated granule," with a single layer of aggregated granules arranged around it, so as to give the entire mass a circular or oval form. The central " aggre- gated granule" is the nucleus, and affords evidence, by an increase of density of its component granules, and their partial separation by in- terstitial substance, of more complete maturity than the aggregated granules which immediately surround it. The interstitial substance, which is transparent and homogeneous, sometimes 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 witfi the secondary tier of "aggregated granules," and in this situation gives a defined character to the nucleus. Close observation and a 24 anatomy of the skin. 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; the latter circumstance gives the facility of determining their mode of construction. The cells of the deep stratum of the epidermis, measuring gnos t0 35^3 of an inch in 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 by their structure, in the nucleated granules previously described, and consist of a transparent layer added to the exterior of the former. Or, if we may describe them as they appear in their tesselated position, they are constituted by the addition of a transparent border to the last described nucleated granule. The periphery of this transparent border is bounded by a dark interstitial substance, which gives the border a defined outline, and in the latter situation the cell-membrane probably exists, or is subsequently de- veloped, for the difficulty of isolating these cells, and their roughness of outline when 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 proof, that there exists a boundary membrane to the bodies we are now de- scribing, we have termed them " cells;" the cavity of the cell we 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." Again, the "transparent border" just described is a tier of "aggregated granules;" the nucleolus, therefore, is an " aggregated granule," the nucleus a tier (taking its flat surface) of aggregated granules surround- ing the former, and the cell-chamber a tier of aggregated granules inclosing the whole. The largest of the pieces composing the mosaic-like plane of the under-surface of the epidermis 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 inter- cellular spaces are occupied by the "nucleated gran- ules," "aggregated granules," and "primitive granules," irregularly set in a homogeneous interstitial substance, which fills up all vacuities. The granules and inter- ne! o7the 7vi- stitial SUDstance modify the light transmitted through dermis, showing them variously at different foci of the microscope; the mosaic-iike sometimes the granules look dark, while the interstitial newiy^TrLed su1^stance is ^gK and sometimes the reverse is the layer. case. The process of development appears to consist in the successive production of granules, one layer of granules succeeding another, so that, if the organizable principle exist in each separate granule, the organizable force may be supposed to GROWTH OF THE EPIDERMIS. 25 be more and more weakened in successive formations until the mo- ment arrives when it ceases entirely, and the cell is complete. Admitting the nucleolo-nucleated bodies now described to be cells in their earliest state of formation, their size is -5^-$ to jJp of an inch in the long diameter, and that of their nucleus from g^ to ^g of an inch. In the stratum immediately above the deepest layer we find cells measuring 5^5 of an inch, with nuclei of ^Vo- Above these, cells measuring 1E\^, with nuclei varying from ^g to so\j)> and above the latter, cells measuring y^1^, with nuclei of 55^5. In 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 T/5Tj and g^, 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 cell reaches its maximum only at the surface; we 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 gran- ules by the deposition between them of interstitial matter, and the cleavage and consequent multiplication of the granules; in cells mea- suring jo-^q- and yg'fjfl of an inch, the granular character of the nu- cleus was very manifest. Besides growth, it is apparent that other changes are taking place in the nucleus ; imbibition 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 oqotj °? an inch and less, the en- tire nucleus is rendered transparent and less discernible than before ; but when cells of a somewhat larger size, and consequently larger growth, are submitted to the same process, the nucleus is rendered much more distinct than it was previously. But the body which is made so conspicuous in this latter experiment is not the entire nu- cleus, but simply the central and older granules of the nucleus; the younger granules retain the character of those of the young cells; they are made more transparent than they were before, and have faded from sight. It may also be observed, that the nucleus brought into view by the acetic acid is more or less irregular in form, and has the appearance of being composed of an aggregation of granules. In reference to the growth of the cells, we 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" ex- ternally to the nucleated mass which we have described 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 26 anatomy of the skin. cell-membrane being consentaneous with the development and growth of aggregated granules within it. In cells of yg1^ to T^^ of an inch, the aggregated granules of the periphery are not easily discernible, but in cells measuring TTfov, 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 us 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, and we sought in vain for the watch-glass cells, elliptical cells, and globular cells in the epidermis. But, according \o our view of the growth of epidermal cells, they never possess anything approach- ing to a globular form; 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 manifest 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 relative size as the cells of earlier forma- tion. Again, the complete size of the cell is very quickly attained, and its growth, taking place in the deepest stratum of the epidermis, could not be expected to produce any difference of character in the middle and superficial strata. The process of growth here described explains also the fact of the disappearance of the nucleus in the scales of the epidermis. The outermost granules of the nucleus have become the nuclei or nucleoli of secondary cells, and have consequently been moved away from their original position in the performance of the office of centres of growth to secondary cells. The original nucleus, therefore, is not lost, but merely robbed of some of its component granules, which may be dis- covered in many parts of the epidermal scale, instead of being con- centrated 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 epidermal scale, measuring g^ of an inch in long-diameter, we found several secondary cells measuring Tj05, others measuring -g^^, and in the interstices, primitive granules, aggregated granules, and nucleated cells. We have observed the same structure in the epithelium of the mouth and fauces, and also in that of the bladder and vagina. Incom- plete epithelial cells from the fauces, measuring 540 and 7^ of an DEVELOPMENT of the epidermis. 27 inch, had a rounded lobulated border, evidently composed of a row of secondary cells, and a depressed centre, as though the action were subsiding in the latter while it was progressing in the circumference. We found another illustration of the structure now described, in the cells of melanosis, and in the pigment cells of the choroid membrane of the eyeball. The corpuscles of melanosis, according to our obser- vation, are parent cells, having an average measurement of ynuu of an inch, containing secondary cells and nucleated and aggregated granules, as well as separate primitive granules. The aggregated granules measured from yTO-o-o- to Woo" °f an iQon> aQd the primitive granules about s^o-flu- There is another feature in the history of development of the epi- dermal cell, which we regard as interesting, namely, an organic change taking place in the assimilative powers of the primitive granules, by which the latter are altered in their color, and converted into " pig- ment granules." Pigment granules appear to differ in no respect from the primitive granules, excepting in tint of color and chemical com- position. 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 con- sist wholly of pigment granules; while, in the European, there is a greater or less admixture of colored and uncolored granules. The central granules are generally 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 com- posing particular cells. For example, intermingled with cells of a dark hue, there are others less deeply tinted, which give the tissue in which thev 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 ac- cumulation ; some have the hue of amber, while others scarcely exceed 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 beino- less strongly colored, and also from the addition of a consider- able mass of colorless cell membrane. The epidermal scale of the neoro has a mottled appearance, from the numerous secondary nuclei, and their attendant colored granules, which are scattered through its texture.1 1 The above observations on the development and growth of the epidermis, are an abstract of a paper read before the Royal Society, June 19th, 1645. 28 ANATOMY OF THE SKIN. 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, correspond- ing with the papillae, are, as it were, polished down, and the surface is consequently rendered smooth and uniform. The palmar and plantar surface 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 epidermis. (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 palm1 of the hands, where the papillae are large, the epidermis is thick; while on the back of those organs, or on the scalp, where the papillae are small, it is com- paratively thin. Another character presented by the epidermis is also to be con- sidered as the consequence of its connection with and dependence on Fig. B. the derma, namely, the network of linear furrows, which everywhere intersect each other, and trace out the surface into small polygonal and lozenge-shaped areae. These lines correspond with the folds of the derma produced by its movements, and are most numerous where those movements are greatest, as in the flexures, and on the convexi- ties of joints. Some difference is perceived in the form of the areae, 1 In an individual not exposed to much manual labor, we found the epidermis in the palm of the hand to measure one-fourth of a line in thickness. The horny cover- ing of the foot of the dog is produced by papillae of unusually large size, and highly vascular. PIGMENT OF THE EPIDERMIS. 29 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 move- ments 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 arrange- ment 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 {b, b), or areae, within which are other and more minute pores, probably perspiratory pores. From the latter a similar number of radiating lines are given off, and abut against the coarser lines, dividing the surface into smaller triangular areae (c, c), and giving to the entire network the appearance of a num- ber of nicely-adjusted angular wheels. On the shoulder of a child of about five years of age, we 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 minuter lines of motion of the skin may possibly be produced by the action of the arrectores pili muscles. The deeper tint and color of the skin observable among the nations of the South, and in certain regions of the skin of fairer races, is due to the presence of pigment granules in the cells of the epidermis. 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, con- stituting the lining of the sudoriparous and sebiparous glands, and hair- follicles. It is in consequence of the presence of these granules in the 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 Soherer.1 The principal elementary substances composing this pigment, and also composing the epidermis, were found in the following proportions:— 1 Liebig, Organic Chemistry. 30 ANATOMY OF THE SKIN. Pigment. Epidermis. Carbon.....58.27 50.34 Hydrogen.....5.97 6.81 Nitrogen.....13.76 17.22 Oxygen.....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. Bowman directs our notice1 to this fact, and adduces another 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, homogene- ous 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." It is, in fact, the boundary layer of all vascular mem- branes, and as such is met with in serous as well as in mucous struc- tures. The extreme tenuity of the basement membrane may be inferred from the measurements instituted by Bowman; in the urini- parous tubuli its thickness does not exceed s^uo" of an inch ; in the seminiparous tubuli T5^0o °f an inch; in the lungs, it constitutes almost the entire thickness of the air-cells; and in no situation has it been found to exceed goW °f an inch. Eeasoning from analogy, he infers the existence of a corresponding membrane on the surface of the derma, but finds it difficult to demonstrate, in consequence of its close adherence to the vascular rete, and deeper seated stratum. The same difficulty exists on the general surface of the mucous mem- branes, and for the same reason; but, in the minute tubuli of the secreting glands, the connection between the basement membrane and the vascular rete is so slight, that they separate on the gentlest pres- sure. In like manner he finds no difficulty in distinguishing this membrane in the tubuli of the sudoriparous and sebiparous glands; and he remarks, that it is it which gives firmness and form to the minute tubuli of secreting glands. 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 1 Cyclopaedia of Anatomy and Physiology ; Article, Mucous iMembrane. SUDORIPAROUS SYSTEM. 31 subcutaneous cellular tissue. They are small round or oblong bodies, of a reddish-yellow color, and composed of the convolutions of a mi- nute tube, which commences by a ccecal extremity, and after quitting the gland mounts to the surface of the epidermis and becomes its effe- rent duct. The efferent duct ascends through the structure of the derma and epidermis, to terminate Fig« c- by a funnel-shaped and oblique aperture or pore upon the surface of the latter. Sudoriparous glands are found in every part of the body with the excep- tion of the inside of the concha of the external ear, 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£0 of an inch in diameter; and largest in the areola of the mamma at the base of the scrotum and penis, and in the ~i axilla, in the latter situation reaching 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 g'a of an inch; and in the palm of the hand we found them range between 2£0 and T0^ of an inch. The entire length of each tubulus, comprising that which constitutes the gland, as well as the excretory duct, 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. The spiral course of the duct is especially remarkable in the thick epidermis of the palm of the hand and 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 aper- tures of the pores seen upon the surface of the epidermal ridges give rise to the appearance of small transverse furrows, intersecting the ridges from point to point. On the palm of the hand and palmar sur- face 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 2,381,243. A sudoriparous gland with its tubule. a. The pore. b. That portion of the tube which is situated in the epi- dermis; the spiral coil is close, c. The tube with- in the sensitive skin ; the spiral coil is more open than the preceding d. The gland. 32 ANATOMY OF THE SKIN. On the cheeks, the back of the trunk, and thighs, he estinates the num- ber 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. The aggregate bulk of these organs, includ- ing 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 (PlateI. fig. 2). A good view of the sudoriferous ducts is obtained by gently separating the epidermis of a portion of decomposing skin; or they may be bet- ter 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 epi- dermis which is drawn out from the duct (Plate III. fig. 17). The diameter of the tubular epidermal lining of a sudoriferous duct exam- ined in the palm of the hand was 7JU of an inch, two thirds of this diameter being constituted by the wall of the tubule, and the remain- ing third by its area. The parietes of the tubule were composed of two or three layers of cells, of which the most external, namely, those next the corium, measured 3^^ 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 three, and, in some instances, of four coats; the three coats are, an outer fibrous coat, the limitary membrane, and an epithelial lining identical in structure with the deep layer of the rete mucosum. In certain of the glands, especially those of larger size, there is a coat of smooth muscle between the fibrous and limitary membrane, and a similar coat is found on the efferent ducts 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 dichoto- mously 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 con- tents to a greater or less degree, and there is no cavity present except- ing 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 contents are of the mixed character already described, the epithelial lining is more or less deficient or entirely absent; or, rather, is identified with the cel- lular contents. Hence the perspiration participates in the double mode 1 Kolliker. SUDORIPAROUS SYSTEM. 33 of secretion common amongst glands, namely, transudation and cell elaboration. The sudoriparous gland is inclosed in a network of capillary vessels, which in an injected preparation "have an elegant and beautiful ap- pearance ; 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 importance of the system to which it belongs; but when the vast number of similar organs composing this system are considered, for it includes the sebiparous 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 indi- vidual. To arrive at something like an estimate of the value of the perspiratory system in relation to the rest of the organism, we counted the perspiratory pores on the palm of the hand, and found 8528 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, 2800 might be taken as a fair average of the number of pores in the square inch, and 700, consequently, of the number of inches in length. Now, the number of square inches of surface in a man of ordinary height and bulk is 2500 \l the number of pores, there- fore, 7,000,000, and the number of inches of perspiratory tube, 1,750,000, that is, 145,833 feet, or 48,600 yards, or nearly twenty- eight miles. 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 ccecal 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 arrangement they were afterwards to possess. Subsequently they pur- sued their progress with rapidity; continuous cell-multiplication en- abled them to reach their full length ; the convolutions increased until the gland was perfected; and the central cells yielding to the process of softening and liquefaction common in the formation of tubular glands, their cavity was established. So thai/, at the time of birth,, the sudoriparous system is complete throughout the entire skin. 1 Ilaller's estimate of the extent of surface of the body is fifteen square feet, that is, 2160 square inches. 3 34 ANATOMY OF THE SKIN. SEBIPAROUS SYSTEM. The sebiparous glands (Plate III.) are the special producing organs of the sebaceous substance or fatty secretion of the skin ; they are associated with 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 corium, and are either simple follicular sacs, or are more or less subdivided 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 and on the breast there are four or five ; and in the mons vene- ris, labia majora, and scrotum, often as many as seven or eight, which surround the neck of the hair-sac and have a radiated or rosette-like appearance. They are whitish in color, and vary in size from the five or six hundredth of an inch to a line in diameter. The racemose glands of the scalp measure between g'g and T'D of a line in diameter; those of the beard and axilla between T3a and T'5 of a line; and those of the pubes, scrotum, and labia majora, a quarter of a line to one line. The largest of the sebiparous glands of the body are those of the eylids, 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 product 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 Fig^ix more exposed parts, as the nose ; in the hol- low 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 Meibomian glands; natural size; ceruminous glands of the ear-tubes have been imbedded in the cartilage of the i i TT.,lri . , . . upper eyelid. shown by Kolliker to belong to the sudori- parous system ; they are not the producers of the cerumen, or ear wax, which is a sebaceous matter secreted by sebiparous glands, the latter being as abundant in the meatus audito- rius as elsewhere. In structure, a sebiparous gland is composed of a fibrous membrane, consisting of areolar or connective tissue ; a middle coat derived from the limitary layer; and an internal epithelial lining of nucleated cells, which is continuous through its excretory duct with the outer root- sheath of the hair-sac, or with the rete mucosum. The excretory or sebiferous duct is the medium of communication between 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 num- ber, until in the glandular vesicles of the periphery there remains only a single layer. Within the cavity of the gland is found a gru- mous pulp, more or less fluid, consisting of cells containing a yellow- ish and transparent homogeneous substance, others containing small globules of oil, and others again filled with oil; this, with some free ANATOMY OF THE HAIRS. 35 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; the vessels are distributed like those of the hair follicles, 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, beginning with the eyebrows. 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 com- pletion 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 separation 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 multiplication; the production of a succession of new cells out of the elements of the older or parent cells. HAIRS. Hairs (Plate IV.) are horny filaments, appertaining to the structure of the skin, and distributed more or less extensively and abundantly over its surface. Every part of the cutaneous surface is organized for the production of hair, with the exception of the palm of the hands, the sole 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 numerously 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 follicle, the root. The root is somewhat thicker than the shaft, and cylindrical in figure, while its 36 ANATOMY OF THE SKIN. 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- wehhoeck 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 a greater or lesser degree of flattening in consequence of desiccation by the air of the part of the shaft which has escaped from the follicle. 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, trunk, pubes, and axillae; 3. Short and stiff hairs, such as those of the eyebrows, 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 y^1^ and S-Jj0 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 mea; the latter in seven persons, two men with black hair, and five women, four with brown and one with chest- nut hair. The coarsest hair in the same heads ranged between 7^ and T{g 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 (T^0T5 of an inch), next in the man (5^), and lastly in the women (j&g). The coarsest hairs of the same individuals were 24ri of an inch in the man and woman, and 5}^ 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 4^, and the coarsest 2^ 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 j^^, and the coarsest 4-^ of an inch. For conve- nience of reference, we have arranged these measurements in a tabular form, as follows :— Number of hairs examined. Finest. Coarsest. ?rit?V • • rV • * 2?L°' - T;W-7rh ... jAt-tId South American Indians . 155 ... T0\fB-ji5 ... 5|o:-sU New Zealander . . . 50 ... 5|a ... r£r, Scrofulous child ... 97 ... j-,1^ ... 5]s The average thickness of the 2000 hairs above examined ranged 1 The measurements were in all cases made as close to the head as possible, to avoid the influence of stretching and wear. FORM AND SIZE OF THE HAIRS. 37 between z^ of an inch, the flaxen hair of a female child, and ^i^ of inch, the brown hair of an adult woman. The average thickness of the hairs of the three South American Indians was ^i^ of an inch in the child, 3^ in the woman, and 3^ in the man. The average mea- surement of the hair of the New Zealand chief was 3^, and that of the scrofulous child, g^ of an inch. In a tabular form, these mea- surements would stand as follow :— B"tif,h.......sh *<> ih South American Indians .... 5£ff to 5^fl New Zealander......3y5- Scrofulous child......5^ff The average dimension in thickness of human hair, according to the above table, is 3^o °f an inch. Leeuwenhoeck and Eosenmiil- ler state it to be g^ of a Paris inch,' 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......t J-to 5^5 Paris inch. Mulatto.......?£5 to jfo Senegambian negro, woolly . . . TJjtOgJj " Nubian negress......3^5 to ^fa " Rosenmiiller's table is as follows :— Adult.......f^jt to T£jy Paris inch. Child........59L5 t» 70*5 Lanugo from body of foetus . . . T^-6S " 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, our observations are in favor of the coarsest hair being found ■ in the female, and the finest in the male; and of the hair of children being finer than that of the adult, thus :— Number of heads. Number of hairs. Range of thickness. Child.....6 ... 269 ... *h-Tfa Man.....18 ... 1016 ... sh-sU Woman . . . .18 ... 940 ... .shs-jh This is the reverse of what might have been anticipated; we 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 a selection from a number of observations:— 1 A Paiis iuch is 1'J longer than an English inch. 38 ANATOMY OF THE SKIN. Number of hairs. Finest. Coarsest. Medium range. Averag 67 tsVo" 5^0 ?3D" ~ "335 •• ,*ff 81 TsW 3o"0" 33o" ~ 6o5 Itfff 79 iVsff shu 335 ~ 130" ?iff 97 735 ■zifi gi(5 ~ 330" 4 0 0 57 335 slo" Z^O"- zlff zio" 64 355 J45 sio " ■ 4 iff 40"0" 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 an individual hair. Thus, a hair six inches long, and apparently of uniform dimensions, ranged between ^^ and -g^ of an inch at various points of its length ; another ranged between 4 5s an(* TSO ) while a white hair, which was obviously enlarged at short distances, presented a range of j^^ to s-J-0, the di- ameter of its point measuring 30W °f 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 overstretching in dressing the hair, but this cause cannot apply in the case of the vari- cose hairs. It has been shown by experiment that hair is so elastic that nothing but inordinate stretching could occasion the permanent constrictions to which our 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, our 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. The most extensive range in thickness is enjoyed by light brown hair. The average measurements of hairs of different colors are as follows; corresponding pretty closely with those of Whithof. Flaxen Chestnut . Red . Dark brown Light brown White . Black 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. 336" tO 4^5 of an inch sh to ^U a %h to ?o-ff u 30*0" tO 3^5 f< 300" tO ^-0 " 450" tO 3^ (( 40"<5 tO 3^5 li STRUCTURE OF THE HAIRS. 39 Man, chestnut. Man, black. Man, brown. Woman brown Head . • 3Z5 330" 40"0~ Z3o" Beard . • Z0"0" z3. p. 149. 3 Muller's Archiv. 1S50. 44 ANATOMY OF THE SKIN. 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 lifetime 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 we 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 lin- ing of the follicle 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, however, 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; the steato- zoon folliculorum. 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 succes- sive layers, each layer becoming gradually smaller in diameter, until the hair eventually assumes the form of a fine point. This structure, he sa}'s, is indicated on the tapering extremity of a hair by a series of annular lines. The mode of growth here described he believes to be proved by the production of a pointed end upon hairs which have been cut, and also by the whitening of hair which sometimes commences at the point. The latter fact he 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. Mandl is clearly in error with regard to his 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 situa- tion, from external conditions, sooner than in the rest of the shaft, but the process is purely physical. Again, the annular lines to which this author refers, are simply the margins of the overlapping scales of the 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 towards the surface; and the "set" of the hair, from the root to the point, is governed by a law as precise as that which regulates any other of the secondary vital functions. Thus, on the head, the hair radiates or whirls from a single GROWTH OF THE HAIR. 45 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 direc- tion of this sweep or whirl, 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 situ- ation 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 fore- head 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 the 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 central 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 cir- cumstance that gives to the hairs of the inner end of the e}rebrows a direction towards the middle line ; and occasionally we see instances in which, from the unusual development of these hairs, the eyebrows meet at the base of the forehead, and form a little crest, for a short distance, along the root of the nose. The lower and inner rays from the angle of the eye diverge from the preceding, and are directed downwards and inwards upon the side of the nose; when strongly developed, they meet those of the opposite side on the ridge of the nose, and at their point of divergence from the ascending current necessarily form another lozenge. This latter is a lozenge of diver- gence, that of the forehead being one of convergence. The upper and outer rays from the angle of the eye curve along the upper lid, form- ing, 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 of the side of the nose, mouth, and chin, make a gentle sweep over the cheek, side of the face, and jaw, to be lost, the upper ones in the front of the whisker, the middle rays, after passing beneath the ear, in the middle line of the back of the neck, and the lowest rays in the angle of bend of the jaw, in which latter situation they come into 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 di- rected inwards upon those parts. On the upper lip they are met by a current directed from the apertures of the nose, outwards, and form- ing the sweep of the mustachio; a similar disposition is observed in the middle line of the lower lip, near its free edge, while the beard is 1 Sometimes there are two crowns, as in a little girl now before us, in whom the sweep from the left crown is to the left, ami the right to the right, so that the hairs from the two crowns converge and meet in a crest along the middle line of the head. 46 ANATOMY OF THE SKIN. 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 backwards beneath the ear, with the current from the face, to the middle line of the nape; while those which pass down behind the ear converge with those from the back of the head also to the middle line of the nape. On the trunk of the body there is a centre of radiation from each armpit, and two lines of divergence, one of the latter proceeding horizontally to the middle of the front of the chest; the other, from this horizontal line, just in front of the axilla, vertically along the side of the trunk, across the front of the hip, and down the inner side of the thigh to the bend of the knee. From the axillary centre, and from the upper side of the horizontal line, a broad and curved cur- rent sweeps upwards and inwards over the upper part of the front of the chest, and outwards, around the neck to the middle line of the nape, the outermost part of the current passing over the shoulder to the middle line of the back. From the lower side of the 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 extremity 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 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- QUANTITY OF THE HAIR. 47 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 a 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 " Four years after this calculation was made, the man having married in the meantime, 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 our own observations directed to this point, we ascertained that 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 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, we may fairly take the number in a superficial square inch at 1000, which would give as the number on the entire head, 120,000. Whithofs calculation would give 70,560 for black hair; 77,760 for chestnut; and 87,360 for fair hair; while another German author states the number 48 ANATOMY OF THE SKIN. as 88.740 for red hair; 102,962 for black; 109,440 for brown; and 140,000 for fair hair.' 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, the strength, and the durability of so delicate and slender a thread. The former of these properties, tested by the experiments of Weber, has been referred to at page 38. A single hair of a boy eight years of age, says Kobinson, in his "Essays on Natural Economy," supported a weight of 7812 grains; one of a man, aged twenty-two, 14,285 grains; and the hair of a man of fifty-seven, 22,222 grains. Muschenbroeck found that a human hair fifty-seven times thicker than a silkworm's thread would support a weight of 2069 grains, and a 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 durability of hair is shown in its endurance of chemical processes, and in its dis- covery, a few years since, in the tomb of a Theban mummy, supposed to be 2000 years old. The development of hair has been made the subject of research by Heusinger, Simon,2 and other physiologists. The earliest trace of 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 excep- tion of the hands and parts of the forearm and leg. Development of the hair commences by the formation of small globular masses, re- sembling buds, on the under surface of the rete mucosum. These buds grow inwards into the corium, and after a time have the appear- ance of flasks, composed of nucleated cells, identical in structure with those of the rete mucosum. Subsequently, the central cells become elongated in form and darker colored than the peripheral cells, and separate from the latter; and at a 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 com- pleteness, 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 pene- trate 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 papilla and hair. The point of the hair is in this way brought to the surface of the epi- dermis, and bursting through the cone of the inner root-sheath, is 1 London Review, September 23, 1865. 8 Zur £i;twickelungsgeschichte der Haare. Von Dr. Gustav Simon. Miiller's Archiv. Is41. DEVELOPMENT OF HAIR. 49 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 back 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 eyelashes 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 con- sisting only of fibrous 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 of the skin. The cells of the root-sheath protrude, and form a bud, and the bud gradually elongates in the deeper layers of the corium, carrying 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 longitudinal prolongation; the latter remaining clear, and be- coming transverse; 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 predecessor. By this mode of development 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 the same 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 horn, and also from albumen and fibrin. Its chief constituents are, 50 ANATOMY OF THE SKIN. 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; and the white hair of old persons, a maxi- mum 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 Nitrogen, . . . 17.936 Hydrogen, . • . 6.769 Oxygen with Sulphur, . 24.643 Fair hair contains the least carbon and hydrogen, and most oxygen and sulphur; black hair follows next; while brown hair gives the largest proportion of carbon, with somewhat less hydrogen than black hair, and the smallest quantity of oxygen and sulphur. The hair of the beard was found to contain more carbon and hydrogen than the hair of the head, and less oxygen and sulphur. The quantity of nitro- gen 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 development and 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 over- laps 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, and by the successive formation of cells in that situation push the nail onwards in its growth. The concave surface of the nail is in contact with the derma, and the latter is raised into 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 at the under sur- face of the nail, co-operating with the continual reproduction taking place along the margin of the root, which insures the growth of the Liebig, Organic Chemistry. STRUCTURE OF THE NAILS. 51 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 con- cavity 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 laminae 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 de- veloped 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 laminae may be seen in the act of parting from the grooves of the plaits. This laminated structure upon the in- ternal surface of a nail is seen in a magnified form in animals; for instance, in the perpendicular wall of the hoof of a horse. Moreover, 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 consequently continuous with that of the epidermis. That nothing may be wanting to complete the analogy of structure of the nails and 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 element, 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 bedridden persons, and amongst those nations of the East, as amongst the Chinese, who permit the 52 ANATOMY OF THE SKIN. growth of the nail to. its full extent. A French physician, Dr. Beau,1 has observed that the nails of the feet are 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. Accord- ing to him, the length of the thumb-nail, including the root, which is hidden from sight, is eight lines, that is, twenty millimetres; conse- quently, the period occupied in the growth of that nail would be twenty weeks, or five months. In like manner, the nail of the great toe, mea- suring in length nine lines and a half, or twenty-four millimetres, and requiring four times the period of the thumb-nail, would 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 extent. 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 that in disease, the materials of growth are supplied by the blood in diminished quantity. Hence, the portion of nail formed during the existence of illness 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 boun- dary of the groove will be abrupt, and vice versa. And if the disease be one in which the nutritive functions 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 observa- tions, the possibility of determining the period 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, of which the distal margin is situated at the distance of eight milli- metres 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 continued 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 accom- plished, and the vestige of disease consequently obliterated. The great toe-nail, however, may now be appealed to. At five months the groove indicative of the above disease 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 milli- metre. In making these observations, 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, we noted an illness which took place in ourself, commencing on the 14th of December, and lasting a fortnight. On the first of May following, we 1 Archives Generates de Medecine, vol. xi. p. 447. GROWTH OF THE NAILS. 53 found 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, our illness should have lasted two weeks and a half instead of two weeks. We therefore came to the conclusion that, either our feelings of convalescence preceded the perfect restora- tion of the functions of nail-formation, or that the rate of growth of the nail was more rapid in us than in other persons. We next measured the I distance between the distal margin of the groove A thumb-nan bearing the and the epidermal margin at the root of the "Ti^0*™™**™*. nail, and adding to that quantity three milli- 6kiu which „v0eriap8 the nan metres for the depth of nail concealed by the at its root. 6. The lunula. follicle, obtained as a result seventeen milli- c- The «roove °™f™°* *J ' . . , . deficient formation daring the metres; in other words, a space representing period of the illness dm Tne seventeen weeks, whereas the real time was nine- free extremity of the nail. teen weeks and a half. This was exactly the reverse of our first observation, and went to prove that, in us 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 deserving 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 ; 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 nar- rower at the free edge than elsewhere, and is commonly broken off, 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 Nitrogen . . . 16.901 Hydrogen . . . 6.824 Oxygen with Sulphur . 25.186 The chief nitrogenous element is protein with sulphamide; the amount of ash is the same as for epidermis, about one per cent., but there is more sulphur and carbon; and, according to Lauth, more phosphate of lime, which gives additional hardness to the nail. 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 1 Liebig, Organic Chemistry. 54 PHYSIOLOGY OF THE SKIN. 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 between 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.1 The sensibility of the skin varies normally in different parts of the body; thus, it is greatest on the pulps of the fingers, and least in the middle of the limbs, as of the thigh and arm. This has been proved by the curious results of the researches of Weber, who applied the points of a pair of compasses to the skin, in various parts of the body, in order to ascertain the degree of sensibility of the skin in the 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.2 The same author has pointed out some remarkable instances of differences in the perception of temperature; thus, he has shown that if the two hands be immersed in water of the same temperature, that in which the left is placed will feel the warmest, while the right is the most sensitive of touch; and again, that a weak impression made upon a large surface of skin, pro- duces a more powerful effect upon the nervous system than a strono- impression upon a small surface. This is practically illustrated by taking hot water and immersing in it 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 temperature 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 intolerable to the entire skin. In pursuing the investigation of the 1 It is noteworthy that dealers in human hair determine the qualities, and conse- quently the commercial value, of the article, chiefly by the touch; and, as we were recently informed, a buyer of silk is enabled by the touch alone to distinguish forty different varieties of texture of that substance. 2 We have repeated these experiments, and the results are very surprising SENSIBILITY OF THE SKIN. 55 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 connection 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 compara- tively 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 by the skin is effected by an active endosmpsis, which is more and more controlled by vital influence, as it reaches the strata of the epidermis most nearly in contact with the derma. This function of the skin is calculated to enact an important part in the health of the individual, in relation to the purity or impurity of the 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 our request the following observations on himself, and repeated them many times with precisely similar results, and we 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°; 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 reco- vered 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 promoters 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 in moisture, having rills of water streaming over its heated floor, and which therefore restores as quickly as it withdraws the watery fluid from the body, establishing, in fact, a circulation in the • 56 PHYSIOLOGY OF THE SKIN. aqueous fluid of the system, and changing its nature without altering its' quantity. AVhen 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 for some time, it increases in weight by absorption of the fluid. The fact is proved by the experiments of several physiologists. Westrumb2 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 containing 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 absorption 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 system, 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 it is found necessary to resort to the additional aid of friction, and more- over, to select those parts of the skin in which the epidermis is most thin. The substances to be absorbed must be presented to the skin in the 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 through 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 instance of mercury, croton oil, strychnine, &c. The epidermis acts as an impediment to absorption, and as such, is an im- portant 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 ' Berthold, in Muller's Arohiv., 1838. 2 Journal Hebdomadaire, No. 7. ABSORBENT FUNCTION OF THE SKIN. 57 with loathing by the patient. In the adoption of this method of ad- ministering medicinal agents, it is necessary to raise a blister in the most expeditious and least painful manner, unless there be an op§n wound already present, and then sprinkle the substance, in a state of fine powder, upon 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, belladonna, lead, mercury, &c. The absorbent power of the skin is sometimes painfully evinced in the inflammation of the kidneys consequent on the application of a blister, in the constitutional effects resulting from the absorption of lead, or in those which succeed the use of arsenic to ulcerated surfaces. An observation made by Mr. 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 skin of children especially, and young persons, by keeping lymph in contact with the skin, and excluding it from the air by a coating of blood. Active lymph blended with blood casually trickling down the arm, and drying in the most dependent part, will often give rise to a vesicle." In this case it is obvious that the lymph will become gradually dissolved in the perspiratory secretion, an important con- sideration in respect to the prolonged contact of poisonous substances 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. The secretion is most abundant in situ- ations where, from the influence of physical action, the skin would be liable to injury were it deprived of a similar covering. Thus we find it in large quantities on the head and face, upon the trunk of the body, in the armpits, in the pudendal region, and in the perineum. The sebaceous secretion is an oleaginous fluid, containing water, stearine, oil globules, pigment granules, and salts, together with epidermal cells thrown off by the parietes of the glands and ducts. The secretion is modified in its 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 pudendal 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 composition sebaceous substance consists, according to Esenbeck,2 of 1 Observations on the Variola Vaccina, in the Transactions of the Provincial Medical and Surgical Association, vol. viii. * Gerber's General Anatomy, edited by Gulliver. 58 PHYSIOLOGY OF THE SKIN. Fat,...... Osmazome, with traces of oil, Watery extractive (salivary matter), Albumen and casein, Carbonate of lime, Phosphate of lime, ' . Carbonate of magnesia, . Acetate and muriate of soda and loss, 24.2 12.6 ll.fi 24.2 2.1 20.0 1.6 3.7 100.0 "The ear-wax is an emulsive compound which contains a soft fat, albumen, a peculiar extractive bitter matter, epithelial 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 con- densed or poured out in a fluid state, sensible perspiration. The in- sensible 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 us, 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, and assign to the pulmo- nary 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 Southwood 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 de- gree of loss occurring on a cold and foggy day, the greater on a warm, clear, and somewhat windy day ; and that, of two 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 gene- ral results of Southwood Smith's experiments tend to show that the amount of perspiration, in other words, of loss of weight by perspi- ration, presents considerable variety in different men; that it offers considerable variety in the same individual at different ti mes; that the subsequent absorption or recovery of the lost fluid exhibits equal 1 Simon, Animal Chemistry, translated by Dr. Day. 2 The Philosophy of Health, &o. 1837. Vol. ii. p. 391. SECRETION OF PERSPIRATION. 59 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 circumstances which affect the body physically, or through the agency of the nervous system. Of the former kind are, the temperature, current, and h}*gro- metric condition of the atmosphere, and stimulation of the skin; of the latter, excited or depressed nervous powers. When the tempera- ture of the atmosphere is unusually elevated and the air dry, perspi- ration takes place with so much readiness as to preserve the heat of the body at its natural standard. If, instead of being still, the atmos- phere pass over the surface in a current, the quantity of perspiration 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 perspiration 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, anxiety, and also in syn- cope. The perspiratory secretion possesses its highest amount of ac- tivity during digestion, and is at its minimum immediately after taking food. The secretion of perspiration is also modified by the greater or less activity of 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 sud- denly and actively called into exercise. The same fact is observed in certain diseases; the excessive sweats of phthisis may be regarded as vicarious of the diminished exhalation from the lungs, while diabetes is accompanied with a remarkably dry state of the skin. The arrest of perspiration again, from cutaneous disease, is often attended with congestion 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 follow :l— Perspiration. Urine. July, ........ 86.41 43.77 May.........68.11 56.15 October,.......40.78 46.67 February,.......37.45 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- 1 Dr. Robley Duuglison on Human Health. 60 PHYSIOLOGY OF THE SKIN. ported a temperature of 260° for nearly ten minutes. The furnace in which Sir Francis Chantrey dried his moulds, and which was fre- quently entered by his workmen, is said to have been kept heated to a temperature of 350° ; and the oven used by Chabert, during his ex- hibitions 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 an elevation of nine to fourteen degrees above the natural standard.1 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 Romans, 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 150°-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 evaporation 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 feel- ing 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 tempera- ture, but evaporation is rendered more active by the increase of heat. In a temperature of 250° of dry air, we experienced no inconveni- ence for the first few minutes, whilst evaporation and temperature were pretty equally balanced. Soon, however, we felt faint and uncomfortable, in consequence of the excessive demand suddenly made upon the watery fluid 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 the mouth and fauces, the throat felt dry; there was a dazzled sensation in the eye- balls, 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, we were glad to put an end to the experiment. 1 It is interesting to note, that in animals made the subjects of these experiments, the blood was found in the opposite position to that which it wonld have occupied 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 seems to have been 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 temperature, and without losing weight; in dry air they lost weight. SECRETION OF PERSPIRATION.# 61 In a damp atmosphere the cooling influence of the perspiration is necessarily^ost; and the effects upon the system of prolonged exposure to a moist atmosphere at a high temperature have been recorded by a gentleman who recently visited the baths of Nero, near Pozzuoli, the ancient Posidianse. 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 3 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 with dense vapor, of a temperature of 118° above, and 111° below; and over the bath it was 122°, the heat of the spring being 185°. After proceeding for about one-third the length of the passage, he began to feel a sense of oppres- sion and discomfort, his pulse rising from 70 to 90 beats in the minute. A short distance farther, the oppression increased, his breathing be- came 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 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 calculation ; 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 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 pulmonary 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, caused vicarious congestion of the mucous membranes, and also of the serous membranes and nervous system. A horse had intense congestion of the mucous membrane 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 enlargement 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 1 Gazette Melicale, April 27, 1844. 2 Examinateur Medicale, Oct. 1811. 62 PHYSIOLOGY OF THE SKIN. were found gorged with dark-colored blood, while on the opposite side the blood was of a scarlet hue, and small in quantity. In 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, repeating the experiments of Fourcault in reference to animal tem- perature, conceived that if they prevented transpiration by the skin, they could 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 tem- perature 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 pro- duced 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, ani- mal extract, fat; carbonic acids 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, hydrochlorate of ammonia, phosphate of soda and lime, sulphate of soda, salts of potash, and peroxide of iron. Anselmino gives the following analysis1 of the dried residue of the perspiratory secretion. In one hundred parts there were of— Matters insoluble in water and alcohol, chiefly calcareous salts, . . 2 Animal matter soluble in water, insoluble in alcohol, regarded by Ansel- mino as salivary matter (?), and sulphates . . . . . 21 Matters soluble in dilute alcohol; chloride of sodium and osmazome, 48 Matter soluble in alcohol, osmazome, and lactates, .... 29 Simon collected the perspiratory fluid from the arms and face, and found it to be a turbid, dirty-looking fluid, which deposited gray fioc- cules on standing. By the microscope these floccules were ascertained 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-fours hours ; and a rod moist- ened with hydrochloric acid, held over it at this period, detected the vapor of ammonia. The results of the investigations of Simon estab- lish the existence in the normal perspiratory secretion, of—■ "Substances soluble in ether: traces of fat, sometimes includinc butyric acid. 1 Miiller's Physiology, Translation, page 579. ANALYSIS OF PERSPIRATION. 63 " 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."1- Dr. Landerer found urea in healthy perspiration in addition to phos- phates, sulphates, acetates,lactates, chloride of sodium, and osmazome.2 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 earth}'phosphates are barely discoverable; lactic acid is pre- sent 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 combina- tion witfi the alkalies ; the potash is chiefly combined with the organic acids, the soda with the mineral acids; the composition of the perspira- tion 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 versa; the proportion of water to the solid constituents remains the same during the entire continuance of forced perspiration.3 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 alphos 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 hydrosulphate of ammonia, and gave off, when evaporated, a pene- trating odor of sulphuretted hydrogen, which ultimately merged into a nauseous animal smell. " It yielded 9.9 of solid constituents, which, after being exposed to the influence of a red heat, were found to con- sist 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 exer- tion, the former being most abundant where the food has been vege- table, and the latter where the food has been animal.4 The quantity i Animal Chemistry with reference to the Physiology and Pathology of Man. By Dr. J. Franz Simon. Translated and edited by Dr. George E. Day, for the Sydenham Society, vol. ii. p. 103. * Heller's Archiv., vol. iv. p. 196. 3 Archives Genfirales de Medecine, vol. ii. 1853. * Collard de Martigny, in Magendie's Journal, vol. x. p. 162. 64 PATHOLOGY OF THE SKIN. of water excreted by the skin bears reference to the circumstances above detailed, namely, the comparative activity of the exhaling organs, the condition of the atmosphere, and the state of the system. The nitro- gen, according to Liebig, originates chiefly in the decomposition of the atmospheric air carried into the stomach with the saliva, or ab- sorbed from the exterior by means of the skin. During digestion, the oxygen of the atmospheric air enters into combination 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 nitro- gen set free in the stomach, and, consequently, the quantity exhaled by the skin, is proportioned to the duration of digestion. Thus, in certain herbivorous animals in whom the process of digestion occupies a long period, and is further delayed by rumination, a large quantity of atmospheric air is conveyed into the stomach, and a larger propor- tion of nitrogen is extricated from the skin, than in carnivora. The same circumstance must take place when any cause exists which re- tards digestion. The quantity of carbon also bears reference to the nature of the ingesta ; where a large quantity of carbonic acid is gene- rated in the stomach, the gas makes it way directly to the lungs, as did the nitrogen, or to the skin. Dr. Dal ton estimates the proportion of carbon eliminated by the skin, irrespective of variety in food, at one-twentieth of the entire quantity of perspiratory secretion. To the animal matters, the ammonia, the acetic acid, and the lactic acid, are to be ascribed the powerful odor of the perspiratory fluid, while its acid reaction is determined by the latter. CHAPTER II. PATHOLOGY OF THE SKIN. The pathology of the skin is similar to that of other organs of the body, and especially of those with which it most nearly coincides in structure, for example, the membranous organs, and notably the mu- cous membranes; any differences of manifestation which it may pre- sent having reference to the external position pf the integument, its great extent, and its peculiar relation to deeper seated parts. Like other organs, it is subject to inflammation, in which all its tissues are more or less involved ; to morbid conditions of its special component structures, namely, its nerves, bloodvessels, and blood; to alterations having reference to development, nutrition, and growth ; to metamor- phosis of tissue; and to morbid states of its epidermal and capillary covering, and of its glandular apparatus. Inflammation of the skin is denoted by redness, pain, heat, and more or less swelling. The redness is sometimes uniform, sometimes punctated, sometimes general, and sometimes partial; sometimes it pathology of the skin. 65 has the scarlet hue of arterial blood, and sometimes the purple tint of venous blood, or the deep livid hues of blood in a state of stagnation. The uniform flush of redness is due to congestion of the entire vascular rete of the skin, and particularly the horizontal capillary plexus ; the punctated redness, to congestion of the vertical or follicular capillary plexus; general redness is commonly associated with constitutional excitement of the circulation; while local redness may depend upon a partial manifestation of a constitutional cause, or upon local causes. Simple vascular congestion of the skin, or hyperaemia, is termed erythema? a word signifying redness; while from the same Greek root is derived the term erysipelas. The erythema which accompanies the eruptive fevers, rubeola, scarlatina, and variola, is termed exanthema, and the fevers themselves exanthemata. An erythema is, in general, a state of congestion or hyperaemia of the horizontal or surface capil- lary plexus, but an exanthema is always .punctated, in consequence of the congestion attacking the glandular system of the skin. In rubeola this punctated character is very manifest; so also is it in scarlatina, in which it causes an elevation of the pores of the follicles into minute papuloa; while, in variola, the congestion of the follicles, beginning as puncta, passes through the subsequent forms of papules, vesicles, and pustules. One kind of erythema, namely, roseola, is usually,punctated ; it holds a position intermediate between erythema and exanthema, and is commonly denominated "false measles." An erythema may be bright in color, or it may be dull, varieties which are ordinarily due to differences of energy of circulation through the capillary plexus; but the tint of general erythema approaches more or less closely to arterial blood ; scarlatina is remarkable for its scarlet or arterial redness; and rubeola for its purplish-red or rasp- berry hue; while roseola, like rubeola, is distinguished by a roseate tint. Another modification of color is seen in syphilitic eruptions and in elephantiasis, a dull coppery red, that seems to be occasioned rather by a discoloration of the skin than of the blood. The redness of ele- phantiasis is sometimes a bright pink, sometimes lilac, then purple, livid and leaden, and sometimes brownish ; and in morphcea the red- ness is often lilac or delicately purple. Varieties of redness are also recognized in other affections, as in eczema, in the pityriasis rubra of Hebra, in alphos, in scrofuloderma, and in lupus; while in urticaria, the red ground is mottled with white elevations, resulting from muscu- lar spasm of the derma. Cutaneous affections differ from other diseases, more perhaps in the nature of the local suffering by which they are accompanied, than in any other respect. The commonest form of pain is itching, to which may be added a morbid sense of heat and cold, together with tingling, pricking, darting, shooting, creeping, and, in deep-seated affections, weight and throbbing. Itching, or pruritus, would sometimes seem to result from the stimulus of the ordinary capillary circulation upon a weakened tissue; sometimes from inordinate circulation; sometimes 1 For the derivation and signification of this term, and other technical terms, the reader is referred to the " Glossary" at the end of the volume. 5 66 PATHOLOGY OF THE SKIN. from pressure caused by congestion; sometimes from the pressure accompanying exudation into the tissues; and sometimes it seems to take origin in the nerves, and be in its nature neurotic, constituting a species of neuralgia. The first symptom of an incipient eruption is, not unfrequently, itching, and a large group of cutaneous disorders are distinguished especially by this symptom, and are termed prurigi- nous affections. Itching brings to its relief scratching—hence the psora of the Greeks, the scabies of the Latins, both corresponding with the eczema of our own times. The papular eruptions are remarkable for the severity of their itching ; the itching depending obviously on the congestion and infiltration which constitute the mass of the pimple; for if the pimple be torn, and a drop of lymph or blood escape from its summit, the itching is immediately at an end. The lichen agrius is an example of inveterate itching, as is also that form of lichenous or papular eruption which is denominated prurigo. Itching is also remarkable for its energy in chronic thickening of the skin, such as follows prolonged hyperaemia, or hypersemia with infiltration, as in the dry forms of psora, namely, psoriasis, the chronic and squamous stage of eczema, and in pityriasis. Itching, as a consequence of the ordinary and extraordinary capillary circulation through the skin, is illustrated by the intense pruritus which in some instances accompanies the use of the cold bath, and in its influence upon weakened tissues, as in pernio or chilblain. Certain eruptions, such as alphos, are one while almost free from pruritus, and at other times the itching is severe; in the latter case, generally from the interposition of infiltration similar to that which occurs in chronic eczema. While certain other eruptions, although accompanied with ample vascular congestion, are remarkable for their freedom from itching. Such is the case with the syphilitic eruptions; the absence of pruritus being one of the characteristic signs of those affections. Pruritus, which is local at first, is sometimes propagated to the cerebro-spinal system, and gives rise to a graver form of nervous irritation, one in which frantic and almost convulsive efforts are made to appease the itching. At other times, from the first, or as the result of continued irritation acting upon a susceptible temperament, the character of the suffering is of a neuralgic character, either a severe shooting pain, or a pain in which burning and pricking and tingling are combined ; the latter is the kind of pain which accompanies herpes zoster, and has gained for it the name of zona ignea, while its patholo- gical status is regarded as a neurosis. Sensations of biting and creep- ing are also neuralgic, and the latter possibly influenced by the muscular movements of the skin. Heat must be regarded as the natural result of the heightened action of the morbid tissues; and certain flushes and chills which are com- monly associated with hyperaemic eruptions of considerable extent, such as eczema, must be looked upon as depending upon disordered innervation of the skin. Swelling is always present in hyperaemia, although its degree in erythema and in the exanthemata is often very trifling; while in certain forms of erythema, such as the varieties termed papulatum, SWELLING — EXTENSION. 67 tuberculatum, nodosum, and tumescens, the swelling is considerable, and is sometimes increased, as in erysipelas, by an cedematous infiltra- tion of the derma, or of the subcutaneous tissue. The first effect of motion of the skin, until the latter becomes smooth and tumid. The swelling of the tissues immediately surrounding the cutaneous follicles occasions papulae; and the extension of this process gives rise, to tubercles of various size, and of various degrees of prominence and hardness. In this way are produced the cones and tubercles of acne, sycosis, the papules and tubercles of syphiloderma, the tubercles of scrofuloderma, the tubercles of tubercular leprosy, and the brawnlike and infiltrated blotches of elephantiasis anaesthetica. Certain of these swellings are temporary, and accompanied with cutaneous muscular spasm, such as urticaria, lichen urticatus, and some of the forms of erythema; but others, resulting from infiltration into the tissues of the part, are more or less permanent; such is the case in a moderate degree with erythema nodosum, but in a greater degree with acne, sycosis, syphiloderma, scrofuloderma, and elephantiasis tuberculosa. When of a chronic nature, tubercles sometimes terminate by ulcera- tion. A tendency to spread, to run on by the circumference, to occupy fresh ground, sometimes deserting the old, and sometimes simply en- larging, is a common character of cutaneous affections, as it is of inflammation of surface membranes in general. Sometimes the spreading takes place in one or several directions without regularity; at other times the extension proceeds from a centre, and the periphery increases uniformly ; and sometimes, again, the movement is centrifu- gal, the congestion subsides in the centre, the skin returning to its normal condition, while the circumferential ring encroaches more and more on neighboring parts. The first kind of extension is met with in erysipelas, so remarkable for its migratory habits; the second is seen in pemphigus, in herpes iris, and in the early stages of tubercu- lous syphiloderma and alphos; the third or annular form of increase is observed in roseola annulata, erythema circinatum, lichen circinatus, tinea annulata, herpes circinatus, tuberculous syphiloderma, and in the latter or dispersing stage of alphos. In some instances the movement of extension is rapid, rings are formed in the course of a few days; in others, as in alphos, the process is slow, occupying several months ; in certain forms of erythema, the annuli are narrow, in others the congested band retains a breadth of half an inch or an inch. In the chronic examples of centrifugal dispersion, as in alphos, the ring, after attaining a certain size, breaks up into segments, and the segments not unfrequently into isolated patches. These irregular figures have suggested the term gyrated as applied to alphos, and especially to certain forms of centrifugal tuberculous syphiloderma; the annular form may be converted into a C, the approximation of two rings may produce an 8 or an S, three rings would form a trefoil, and so on for a variety of figures. Hvpersemia or inflammation, wherever it occur, is accompanied with disturbance of nutrition and derangement of function, and the skin is no exception to this general law; innervation is disordered, as 68 PATHOLOGY OF THE SKIN. we see by the production of itching and other forms of pain; the harmony of relation of the fluid and solid elements of the part is dis- arranged, as we observe in the tendency to exudation and infiltration into the tissues; secretion is suspended, and so also is the process of cell-formation concerned in the production of the epidermis. The cause of all these changes is the lowered vitality of the organ, whilst a return to the state of health demands a gradual restoration of vital power. In simple hyperemia or erythema, the loss of tone and con- tractile power is marked, when the congestion subsides, by a wrinkled appearance of the surface, and the suspension of epidermic formation by exfoliation of the cuticle in layers of varying thickness and vary- ing extent; sometimes the cuticular exuvias are small and thin, and may be compared to bran, that is, they are furfuraceous or pityria- ceous, as in pityriasis; at other times they are larger, as in the chronic form of eczema, denominated psoriasis; and, again, they may be of considerable extent, as in rubeola and variola, and especially in scar- latina ; in the latter eruption it is no uncommon thing to find the whole of the cuticle of the hand or foot thrown off by exfoliation in a single piece. Suspension of cell-formation in the production of cuticle, and con- sequent exfoliation or desquamation of that layer, is one of the patho- logical alterations or lesions resulting from inflammation of the skin ; but besides cuticular desquamation, there are other changes which are denominated "lesions;" for example, papulation, or the production of papulae, termed tubercula; vesiculation, or the production of vesicles, and larger vesicles called bulla?.; pustulation, or the production of pustules; and squamation, or the production of scales of morbid cuticle. We may, therefore, consider the pathological lesions of the skin as divisible into two groups, primary and secondary ; the primary lesions being vascular congestion, papulation, tuberculation, vesicula- tion. vesication, pustulation, and squamation; the secondary lesions, cuticular exfoliation or desquamation, serous and purulent secretions, crusts formed by the desiccation of those secretions, thickening and condensation of the skin from infiltration into its tissues, ulceration, and stains produced by the escape of blood into the cutaneous tissues, constituting hemorrhagic maculae, or by excessive accumulation of pigment in the rete mucosum. The primary group of pathological lesions, together with the last named of the secondary lesions, is the basis of Willan's classification of cutaneous diseases, thus : exanthe- mata, papulae, tubercula, vesiculae, bullae, pustulse, squamae, and maculae; and it is to Willan that medical science is indebted for the precise definitions which have been affixed to these pathological lesions. According to Willan, a papula or pimple is " a very small and acuminated elevation" of the skin, " with an inflamed base, very seldom containing a fluid or suppurating, and commonly terminating in scurf." A squama or scale is " a lamina of morbid cuticle, hard, thickened, whitish, and opaque." - Exanthema or rash consists of "superficial red patches variously figured and diffused irregularly over the body, leaving interstices of a natural color, and terminating in cuticular ex- foliations." Bulla or bleb is " a large portion of the cuticle detached ERYTHEMA. 69 from the skin by the interposition of a transparent watery fluid." Pcstula is " an elevation of the cuticle, with an inflamed base, con- taining pus." Vesicula is " a small orbicular elevation of the cuticle, containing lymph, which is sometimes clear and colorless, but often opaque, and whitish or pearl colored." Tuberculum is "a small hard superficial tumor, circumscribed and permanent, or suppurat- ing partially." Macula or spot is "a permanent discoloration of some portion of the skin, often with a change of its texture." In adopting the language of Willan, we prefer to take exanthema as the first instead of the third order, because it comprehends that vascular congestion or hyperaemia of the skin which is the " fons et origo" of the pathological changes constituting the rest of the orders. namely, papulaj, tubercula, vesiculae, bullae, pustulae, and squamae. But the arrangement adopted by Willan himself is not without its interest in a pathological point of view. Beginning with papulae, which often, as he says, terminate in scurf, he takes as his second order, squamae, a slightly elevated prominence, surmounted by a thicker kind of scurf, namely, a scale. Following in the next place with exanthemata, which includes erythema, he doubtless intended to note the rapid transition of an erythema into a bulla, by making the latter his fourth order. Then he takes pustulaa, and after pustulae, vesiculae, leaving tubercula and maculae to complete the series. We may therefore look upon inflammation of the skin as pursuing the usual and normal course of inflammation in general, making itself conspicuous by redness, infiltration of tissuef exudation of the colorless portion of the blood, and sometimes of the blood itself, and exudation of pus or suppuration, or, to adopt the language of cutaneous medi- cine, inflammation presents the states of erythema or exanthema, papulae, vesiculae, bullae, pustulae, and tubercula. It is no uncommon thing to observe the whole of these pathological forms developed in succession in the course of one and the same disease, and representing stages of inflammation, as in variola, wherein we find an erythematous, a papulous, a vesiculous, and a pustular stage. In scarlatina the normal stages are only two, erythematous and papulous; but abnor- mally we sometimes meet with a vesiculous, and sometimes with a pustulous stage, superadded to the usual forms. The poison of syphi- lis, again, is remarkable for presenting a multiple form in its develop- ment on the skin; being one while erythematous, then papulous, sometimes pustulous, sometimes vesiculous, and sometimes tuberculous. We may, therefore, regard these pathological forms in the twofold character of types of eruption and as stages of inflammation. In the former capacity they constitute so many groups of diseases, as is exemplified by the classification of Willan; in the latter they serve to mark the successive changes and the precise form of the same disease at different periods of its growth ; and dermatography derives im- portant help from the use of the terms erythematosum, papulosum, vesiculosum, bullosum, tuberculosum, squamosum, maculosum, &c. Erythema, taken as a type of cutaneous disease, is intended to ex- press simple redness, resulting from superficial hyperaemia of the skin, and without any secondary changes, with the exception of cuticular 70 PATHOLOGY OF THE SKIN. exfoliation. The redness may be a general suffusion, or it may be punctated, according to the precise seat of the congestion, whether affecting chiefly the surface capillary plexus or that of the follicles. It is sometimes stationary, sometimes spreading, and sometimes mi- gratory. Sometimes it is accompanied with swelling, the result of contractility of the skin and transient effusion, and sometimes with a more permanent state of effusion, constituting oedema. In the latter case, the distended tissues may relieve themselves by effusion of serum beneath the cuticle, and become an erythema bullosum ; a pathological state, common in erysipelas. Erythema and erysipelas are chiefly distinguished by the extent of the inflammation in depth; in erythema the hyperaemia is very superficial, commonly reaching no deeper than the papillary layer of the derma; whereas in erysipelas, the whole thickness of the derma, together with the subcutaneous cellular tissue, is involved; besides hyperaemia there is dermatitis and cellulitis, and the disorder is consequently more grave. But erythema, when it at- tacks certain parts of the body, such as the eyelids—which are prone to swelling—may be accompanied with so much tumefaction as to admit of being easily confounded with erysipelas, and the diagnosis is somewhat difficult. The erysipelas which could be so mistaken, must, however, be slight; in its more decided form, associated with dermatitis and cellulitis, the difficulty is very unlikely to occur. Tumefaction is sometimes a remarkable concomitant of erythema, as in the papulous, the tuberculous, and nodose forms of that eruption, and especially in the tumescent form. In the latter, the swelling rises to a considerable height in the course of a few hours, sometimes block- ing up the eyes, sometimes enlarging the lips and tongue almost to the extent of producing suffocation, and in another interval of a few hours subsiding completely. In the latter case, there is present all the tumefaction of erysipelas; but the dermatitis and the oedema are obviously absent. Another occasional symptom of erythema is a pricking, and tingling, and intense itching of the skin; this symptom is generally present in erythema tumescens, but is most remarkable in association with urticaria. In the latter affection there also exists a spasmodic condition of the muscular structure of the skin. Mus- cular spasm of the skin is not limited to urticaria, but is met with in other forms of eruption, and has suggested the term urticatus, as in the instance of a papular eruption of children, termed lichen urticatus, and it is also associated occasionally with scabies and purpura. The extreme tingling and pricking are suggestive of an irritation of the cutaneous nerves, and the symptom is indicative of a neurosis. When erythema has been in existence for a considerable time, the skin is apt to become thickened from infiltration into its tissue, and the surface is rendered coarse and uneven. In this state the cuticle no longer exfoliates in a single layer, as occurs in the more recent period of hyperaemia, but is produced and cast in small flakes or scales, which have sometimes been compared to bran, furfuraceous or pityriaceous, and sometimes to meal, farinaceous; this is the form of affection which has received the name of pityriasis, and, in reference to its scaly product, has been described as a squamous disorder. Xot PAPULA—LICHEN. 71 unfrequently the hard and inelastic skin breaks into cracks under the movements of the part, and bleeding fissures and chaps are sometimes superadded to the desquamation; we have an example of this form of affection in the erythema a gelu, which gives rise to "chapped hands" in the winter season; and in the erythema produced by the prolonged action of moisture, as of morbid secretions, upon the skin. Erythema is pre-eminently a hyperaemia of the papillary layer of the derma; but many cutaneous affections evince a special disposition to attack the follicular and glandular structure of the skin; and as the position of the follicular plexus is vertical to the surface, the result of the hyperaemia is a punctated appearance of the skin, the red puncta corresponding with the pores of excretory outlets of the follicles. In some instances, it may be that the effort of the constitution is elimina- tory, and the vascular congestion is determined towards the secreting organ; in others, an error of secretion may be the cause of the con- gestion; or it may be that the inflected surface is more sensitive than that which is exposed habitually to the atmosphere. Without stop- ping to discuss these incidental questions, we may observe, that the congestion of the follicles is remarkable in the exanthemata resulting from zymotic poisons, in roseola corymbosa and punctata, and also in the syphilodermata, and in these affections we have the best evidence of the pathology of papulae. Under the influence of that muscular contraction of the skin which is termed spasmus periphericus, we per- ceive a state of erection of the follicles, the cutis anserina, which is temporary, and subsides with the muscular spasm. So, when the vascular rete of the follicles is distended in hyperaemia, the outlets of the follicles are raised above the level of the surface of the skin and constitute papulae; and the size and permanence of the papulae will depend upon the degree of congestion of the bloodvessels and the sub- sequent phenomena of inflammation. The congestion is accompanied with exudation into the inter vascular tissue, and an enlargement takes place, which is evident on the surface as a pimple, more or less conical" in form, and hard to the touch. In this way are produced the papulae of rubeola, scarlatina, and variola; the subsequent changes in the latter being vesication and pustulation; in a similar manner, also, are pro- duced the papules of syphiloderma papulosum, which occasionally becomes pustulous. The typical papula of Willan is termed lichen, "summae cutis aspe- ritas;" lichen is a crop of papulae produced in the manner already described ; occupying the circumference of the pore or outlet of the follicle ; hard to the touch ; for the most part conical in figure; and perforated at the summit by the aperture of the follicle more or less compressed by the surrounding infiltration. On close inspection, the papule of lichen is seen to be transparent at the summit from the ele- vation of the cone of cuticle which occupies the aperture of the folli- cle ; and this transparency has led to the supposition of the presence of fluid, a supposition which is evidently erroneous. The papules of lichen present some variety of size, and also of figure ; they are small and hard on the thicker parts of the skin, and on the outside of the limbs; larger on the softer skin of the front of the body, the inside of 72 PATHOLOGY OF THE SKIN. the limbs, the neck and the face; they are large also on the thin and soft skin of infants, where they are called strophulus, and they are absent altogether on the scalp, and on the palmar and plantar surface of the hands and feet. They are large also in gutta rosacea, and are remarkable for their size in lichen syphiliticus or syphiloderma papu- losum. And they are large and flat, depressed on the summit, and angular in outline, in a form of the eruption which we have described under the name of lichen planus, and which corresponds with the lichen ruber of Hebra. Papulae are remarkable for their disposition to itch; and the papular eruptions are generally pruriginous: this is the case with lichen, one va- riety of which is distinguished as lichen pruriginosus; it is seen also in the papulae of eczema and scabies, and has given origin to the term "pru- rigo," as applied to one of the varieties of papular eruption. Another of the varieties of lichen has received the name " agrius," from the fierceness and intensity of the itching by which it is accompanied ; and the only exception to the itching character of lichen is met with in lichen syphiliticus, which, like other forms of cutaneous syphilis, is distinguished by the absence of pruritus. When a papule pursues its normal pathological course, and is approaching its decline, the cuticle covering its summit becomes loos- ened and falls off in a small thin scale; but if the skin be infiltrated with serum, and there be much itching, as occurs in lichen agrius, and if the pimples be rubbed or scratched, they become excoriated, and exude a watery discharge. The discharge does not commence by the formation of a vesicle, as in eczema, but resembles the second stage of eczema, when exudation is poured out from the excoriated and in- flamed derma. Such an observation brings before us the true charac- teristics of lichen, which is a dry pimple, as compared with eczema, which is a moist pimple or vesicle; and it further affords the clearest evidence, that the difference between lichen and eczema is not one of nature, but simply of manifestation, the ichorous element being as we have seen, subordinate to the infiltration of the tissue of skin. Lichen agrius, therefore, that is, a papular eruption with icho- rous exudation, is a lichen plus an eczema; in other words, it is a lichen ichorosus, or lichen eczematosus. As a further proof of the identity of the two affections, it may be observed that they are very commonly seen together; in one part the papulae are moist and icho- rous, in another dry; hence, modern dermatology has sanctioned the consideration of both under the "single term, eczema. When papulae are permanently dry, they are called lichen ; when they become moist, they constitute an eczema papulosum or lichenodes. When lichen appears as an eruption of some extent, or as a general eruption, it passes very quickly into a desquamating state, and be- comes a lichen squamosus, an eruption of dry pimples, attended with a copious exfoliation of cuticle in the form of furfuraceous scales. In the moist form, the exuded fluids dry up into crusts, which are thin or thick, yellowish or gray, brown or black, according to the nature and abundance of the exudation. In either case, if the hyperaemia con- tinue for a considerable period, the derma becomes thickened from in- VESICUL.E. 73 filtration; it is uneven on the surface; it breaks into chaps, caused by the movements of the body; it has periodical fits of violent pru- ritus ; and it throws off a copious desquamation of dry furfuraceous scales. This is the state which is properly denominated psoriasis, which resembles the chronic stage of erythema, termed pityriasis, and which is identical with the similar chronic stage of eczema. The type vesiculae is eczema, "eas tx^pata, ab ebulliente fervore, Graeci vulgo appellant," writes iEtius, in the fifth or sixth century. The term is suggestive of the seething and bubbling of a boiling fluid, and conveys the idea, not only of vesicular bubbles thrown up to the surface, but also of an inward heat which causes their production. If the skin be stimulated by an irritant, such as the heat of the sun's rays, there may be developed on the surface, either papulae, when the case would be termed lichen Solaris, or minute vesicles, when the case would be one of eczema solare or eczema vesiculare; the difference, as far as the eruption is concerned, is the difference of a Willanean order, the one being papular, the other vesicular. The difference of patholo- gical nature is, exudaticm into the cutaneous tissue in one, and exuda- tion out of the cutaneous tissue, namely, on the surface in the other; the cause is the same in both, the disease equally the same, only differing in manifestation, differing in the accidental qualities of the part or of the constitution. The phenomenon is still more striking when both forms of pathological lesion appear in the same individual, and at the same time: lichen, for example, on the back of the hands; eczema on the face. It is facts such as these that have led modern authors to consider lichen and eczema as being closely allied, in some instances identical, and have suggested the use of the terms eczema papulosum, equivalent to eczema lichenodes or lichenosum,and eczema vesiculosum. The same train of reasoning has established the distinction of lichen and eczema to be, the former a dry pimple, never assuming a moist stage; and the latter, a vesicle or a moist papule. But the fact cannot be denied, that a papule may at any time pass into a moist stage; and, therefore, the necessity has arisen for a more comprehensive definition of eczema than that given by Willan. Eczema may be a mere hyperaemia, eczema erythematosum; it may be a papule, eczema papulosum; it may be a vesicle, eczema vesiculosum ; or a pustule, eczema pustulo- sum ; it may be an inflamed skin pouring forth a copious exudation, eczema ichorosum ; or, the exudation may have dried upon the surface into crusts, eczema crustosum, or scales, eczema squamosum, &c. In other words, an eczema may be perfect in its manifestation without the presence of a single vesicle; therefore, the recognition of eczema as a vesicular eruption must be accepted with a considerable amount of reservation. The vesicle of eczema is the smallest of the cutaneous vesicles; it is sometimes apparent in the cuticle without being raised above the level of the surface; this is especially the case in the palm of the hands, in the sole of the feet, and on the fingers and toes where the cuticle is thick ; it is generally very unequal in figure, and sometimes is confluent and multilocular. Its rarest form is that of a distinct vesicle. Its seat, like that of lichen, is the aperture of a follicle; and 74 PATHOLOGY OF THE SKIN. here, one or a small chaplet of vesicles, may be clustered ; when single, its dome is hemispherical; and in some situations, as between the fingers, it is conical. A vesicle of larger dimensions, distinct in posi- tion, hemispherical in form, and dispersed upon the skin, is, from its size being similar to that of a millet seed, termed miliaria. And a still larger vesicle, assuming the bulk of a small pea, is met with in herpes. By the ancient Greeks, vesicles, and probably the vesicular eruptions, were termed phlyctense; and we still distinguish one of the varieties of herpes as herpes phlyctenodes. The fluid of the vesiculae is a transparent and colorless lymph, which, after a while, becomes slightly opaque, and, in the course of time, is prone to become purulent. Purulent vesicles are commonly termed i?npetigo ; and, in an attack of eczema, accompanied with much inflam- mation, there frequently occur small pustules, developed in the midst of the ichorous vesicles; this state of the eruption is called eczema impetiginodes, but is better expressed by the term eczema pustulosum. In the larger vesicle of miliaria, the scarlet hue of the congested derma is so reflected by its transparent medium, as' to produce a red tint, miliaria rubra; while, in a semiopaque and lactescent change of the contained fluid, the vesicles are white and pearly, miliaria alba. The larger vesicles of herpes exhibit the same changes and in the same order, beginning with the transparency and brilliancy of water, some seeming pink from the reflection of their deep red base, then becom- ing lactescent and pearly, and lastly acquiring the yellow tint of pus. The vesicle of vaccinia passes through similar changes, and so also does that of variola. When a vesicle takes the regular course already described, it ends as a thin crust or scab, which adheres to the skin for a time and is then cast off; such is the case with miliaria, and notably with herpes; and sometimes eczema follows a similar process. But in eczema, it frequently happens that an exudation continues after the vesicle is broken or rubbed off, and a red and inflamed surface is presented, denuded of epidermis, from which an oozing is taking place of a glutinous transparent lymph or ichor, in considerable quantity, remind- ing us of the flux from the mucous membrane of the nose in coryza, or that from the air passages in catarrh, or from the intestinal mucous membrane in diarrhoea; this is the eczema rubrum of Willan, also named eczema madidans and eczema ichorosum. The quantity of fluid in this way exuded from the skin is sometimes remarkable, amounting, where a large surface is concerned, to many ounces ; fold after fold of linen is soaked through, and the exudation for a time seems to be inexhaustible. The vesicles of miliaria, herpes, vaccinia, and variola, have their regular course. The first becomes opalescent, and desiccates into a thin scab in *he course of a few days. Some of the irregular forms of herpes do the same. Herpes itself passes through a purulent stage before it dries up; and so also do the vesicles of vaccinia and variola. But eczema has no specific course; it may linger for a while in the vesicular form, then become an exuding excoriation, and, after being incrusted for another while, the exudation may return. VESICUL.E — BULLAE. 75 In its least common and most favorable form, the skin may recover its normal state after exfoliation of its crusts; but most commonly, the skin becomes thickened, from infiltration into its tissues, coarse, hard, and uneven. Although it ceases to exude a fluid discharge, the epi- dermis is thrown off in thin scales: it is extremely itchy; bleeds when rubbed or scratched; frequently cracks in the direction of the lines of motion (eczema fissum), and assumes a persistent and chronic charac- ter. This is the state to which the term psoriasis is properly ap- plicable, and corresponds with the chronic stage of erythema, termed pityriasis, and with the chronic stage of lichen. Eczema was called by the ancient Greeks, psora; and psoriasis is a derivative of psora, both in expression and in nature of disease. The psora and eczema of the Greeks was called by the Latins scabies, hence the mutual association of these terms; but by scabies we at present understand a different affliction, of the nature of ecze- ma, but originating in the presence of an animalcule in the skin, the acarus scabiei. Scabies is a good example of the multiple form often assumed by cutaneous disease; sometimes it is papular, sometimes vesicular, and sometimes pustular; while, for the most part, two of these forms are associated, and not unfrequently all are present to- gether. Bullae, as an eruption of magnified vesicles, may claim to take a position next to vesiculae, although, from the development of the vesicles on a simple erythematous base, it is equally closely related to erythema, the place assigned to it by Willan. Their size is neces- sarily arbitrary; the vesicles, in some of the forms of herpes, not un- frequently attain a magnitude which makes it difficult to distinguish them from those of pemphigus; they are, in fact, small bullae, and are as widely separated from eczema, with which they are associated by the intervention of miliaria, as they are from the group of the larger bullae. On the other hand, bullae, especially when solitary, may attain the dimensions of an egg or of an orange. Bullae are essentially asthenic, a simple effusion of serum beneath the cuticle raising it into the form of a bleb or bubble; hence the term pemphigus and pompholyx. The effused fluid is identical with the serum of the blood; aqueous, of a yellowish tint of color, and sometimes, when commingled with blood, more or less purple. In this respect, bullae differ from the vesiculae of eczema, the fluid con- tents of the latter being glutinous, and apt to pass into a muco-puru- lent state, a change less common in bullae, or occurring only in their latter stage. We have an illustration of a bulla in the action of a vesicant upon the skin, in the aesthenic vesication of a chilblain, or in gangrene, in anasarca, in erysipelas bullosum, and in elephantiasis anaesthetica. The simplest erythema in some constitutions may termi- nate in a bulla, and especially, when a serous infiltration pervades the tissues, or takes place quickly as a consequence of hyperaemia. Miliaria, a vesicle produced under the relaxing effects of warmth and perspiration, may be regarded, in pathological nature, as a bulla of the smallest kind ; the large vesicles of herpes zoster are more nearly allied to pemphigus, both as to neurotic origin and subsequent course 76 PATHOLOGY OF THE SKIN. than they are to eczema ; and the vesicles of herpes phlyctenodes are undoubted bullae in all their associations. The alliance of erythema, herpes, and pemphigus, is strikingly manifested in herpes iris, which, in the frequent absence of a central vesicle, is termed erythema iris, and, in a different constitution of skin, is a pemphigus iris; and a combination of eczema and pemphigus is met with in a pruriginous form of eruption, termed by Hardy pem- phigus pruriginosus. We have already noted the occasional hemor- rhagic and neurotic character of bullae; pemphigus is not unfrequently associated with purpura, sometimes with hemorrhage from the mucous membranes; and is often accompanied with burning heat, with ting- ling and pricking, and sometimes with neuralgic or rheumatic pain. Herpes zoster is a neurosis, sometimes preceded by neuralgia; an active hyperaemia follows the nervous disorder; there is a sensation of intense burning, sometimes a violent tingling and pricking, and after this, acute neuralgic pains of a darting and lancinating charac- ter. During the burning and tingling period the vesicles arise, and the contents of the vesicles, at first aqueous and transparent, shortly become lactescent, then yellowish, sometimes purplish, and finish by drying up into a black scab, firmly imbedded in the skin and closely adherent. The form of pain accompanying vesicular eruptions is not without its interest; where the nervous plexus of the immediate surface is concerned the sensation is one of heat and pruritus; the vertical nervous fibrils give origin to burning, tingling, and pricking; deeper nerve fibrils produce darting, shooting, and lancinating pains; and, the trunks of the nerves, general aching and deep-seated pains. Ec- zema is an illustration of the first of these morbid states, pemphigus of the second, and herpes of the second and last. The group of pustulae is represented by impetigo and ecthyma, to which Willan has added, under the name of porrigo, pustules oc- curring in the scalp, the pustules of scabies purulenta, and the pustules of variola. Impetigo we have already considered as the purulent stage or a pustular complication of eczema; and we have noted the possibility of the transition of eczema into impetigo, as in the exam- ple of eczema impetiginodes or eczema pustulosum. The pustules of impetigo are commonly very small and superficial, and, in many in- stances, they begin as vesicles, and gradually merge into pustules by the mere pyogenic alteration of their contents ; moreover, in one very troublesome form of impetigo, which we have designated by the name of impetigo phlyctenodes, the eruption begins as a small pustule, and throws out, subsequently, around its circumference, an annular vesi- cle or phlyctena more or less complete. Again, impetigo is commonly met with where eczema is most frequent, as on the delicate skin of women and children, and especially on the face and head of infants, where it constitutes the crusta lactea. The pustule of scabies is another illustration of a pustule in a su- perficial position, occupying the papillary layer of the derma, associ- ated with vesicles, and, in truth, no better than a vesicle filled with a muco-purulent or purulent fluid. Scabies is essentially an eczema SQUAMA. i i consisting of papulae, vesiculae, and pustulae. If we were called to classify it upon the basis of its pathological lesions, we must place it amongst papulae by virtue of its pimples, amongst vesiculae in refer- ence to its vesicular character, and among pustulae in its least frequent and pustular form. Willan adopted the latter arrangement as an alternative of evils, and for the want of an order representing multiple forms. Even variola, which, in its pustular stage, must be admitted to be a true pustule, passes through the vesicular form as a transition stage. Ecthyma is the 'only illustration of a pustule complete from its first development. It is the product of a deeper seated inflammation than that which accompanies impetigo; it has a hard, deeply red base; forms, on desiccation, a black imbedded scab, and leaves a cicatrix at its fall. In these particulars it resembles the pustule of variola, which also produces a thick imbedded scab and leaves be- hind it a cicatrix ; while in impetigo there is formed only a thin crust, which separates without any permanent mark remaining. The chief differences between the pustule of impetigo and that of ecthyma, are, consequently, depth of tissue involved, and degree of inflammation : impetigo, mounting upwards in the pathological scale from the simple transudation that occasions a vesicle; and ecthyma, carrying the pro- cess onwards, through suppuration, to the deeper seated lesion that results in gangrene of the fibrous tissues of the derma, and occasions a furunculus and an anthrax. The squamae of Willan, constituting the squamous affections, are founded on the presence on the skin of laminae of " morbid" cuticle; the determination of these diseases turns, therefore, upon the diagnosis of morbid cuticle. The desquamation of a blister, of the exanthe- mata and erythemata, of the vesiculae, bullae, papulae, and pustulae, is not sufficient to constitute a squamous affection, and for the simple reason, that the cuticle is not morbid, however morbid the process may be by which it is separated and displaced from the derma. Moreover, it would be irrational to designate as an independent dis- ease that which, in reality, is nothing more than a stage of another disease. If we turn to the diseases included by Willan under the head of squamae, we shall find as the first illustration, lepra and pso- riasis, names applied by Willan to the same affection, to a disease which, to avoid confusion, we prefer to designate by its ancient name alphos. Now, the squama or scale of alphos is an undoubted example of "morbid" cuticle; it is white, with a metallic and sometimes sil- very lustre, laminated, imbricated, opaque, and porous. Here, then, we recognize a true squamous affection, one in which the scale is the primary and essential character, for the morbid derma which produces it, and on which it rests, differs very little from the chronic congestion met with in other cutaneous diseases, so little, in fact, that Hebra con- joins it with lichen, and places it by the side of eczema under the head of exudata chronica. If we take the term psoriasis as synonymous with lepra Willani, or more correctly, alphos, it must be regarded as a squamous affec- tion • but if we look upon psoriasis as a modification of psora or 78 PATHOLOGY. OF THE SKIN. eczema, clearly its true meaning, it ceases to be a squamous affection, and is simply the squamous stage of chronic eczema, and often, in appearance, so closely resembling alphos, as to be distinguished with difficulty from that disease; nevertheless the distinction is essential, for however closely psoriasis may resemble alphos, there is always the difference between them, of one producing a squama of morbid cuticle, and the other, a squama of sound cuticle. The same obser- vations apply to pityriasis; the squama of pityriasis is one of sound cuticle, and not of morbid cuticle, as in the case of alphos, the type of the Willanean order. But the remaining disease included in Willan's group, namely, ich- thyosis, is, according to the definition of squama, a lamina of morbid cuticle, a true example of a squamous affection ; nevertheless, there is a wide difference between alphos and ichthyosis, and we recognize some serious error in an arrangement which brings together such dis- similar members. The squama of morbid cuticle developed by alphos is the product of a disease set up in a previously healthy skin; the squama of morbid cuticle of ichthyosis, is the consequence of defective nutrition of the skin, and is not morbid, but simply abnor- mal. These considerations have led us to regard alphos as a peculiar affection, standing apart from every other disease of the skin, and to class it as the sole member of a group of "alphous affections ;" ichthy- osis, we place in a group of "developmental and nutritive affections," while, as we have already shown, we look upon psoriasis as a squam- ous psora or eczema ; and pityriasis, as a squamous erythema. Hebra takes another view of ichthyosis, and regarding the epidermal product, rather than the state of the skin which produces it, distinguishes it as an hypertrophy of the epidermis conjoined with hypertrophy of the papillae cutis. The true squamous affections, alphos and ichthyosis, are accompa- nied with but little pruritus, such pruritus, when it exists, being the consequence of exudation into the dermal tissues in the early stages of alphos, and mechanical irritation of the sensitive surface of the skin in the squamous stage of both affections. But pityriasis vulgaris and psoriasis are remarkable for their pruritic tendencies, the pruritus originating in exudative alteration of the derma. Alphos, like papulae, vesiculae, and pustulae, makes its first appearance in the skin at the aperture of a follicle, and is hardly to be distinguished in size and appearance from a papula of lichen; by degrees, a small white cap of morbid cuticle appears on the summit of the papule, the papula then spreads by its circumference, without increasing in height, and the scale goes on enlarging in proportion. By this process, the scale thickens and becomes imbricated, and when the papule has grown to be a circular disk, probably an inch in diameter, slightly raised at the circumference and depressed in the centre, the scale presents a remarkable appearance, and the patient looks as if he were stuck over with white wafers; to the hand and to the eye, the surface is leprous or rough, but the latter organ recognizes the most conspicuous charac- ter of the disease ; it is truly alphous, albus, white. It warrants the title given to it by the Hebrews, namely, " Berat Boak;" the dull TUBERCULA. 79 white spot or leprosy, and the equally significant designation of the Greeks, "lepra alphos," and of the Latins, "vitiligo alphos." Alphos is remarkable for symmetry of arrangement on the skin, and for its selection of certain situations, for example, the convex side of the elbows and knees, the scalp, the coarse skin of the outer side of the limbs, the trunk, the back of the hands, and the nails, while it is rare on the face and neck, the bend of the joints, and the inside of the limbs. The portion of skin attacked by the disease is thickened and hard, is apt to break during the movements of the body into chaps, from which a few drops of blood exude, and bleeds easily on scratch- ing with the nails. In their normal state, there is never much conges- tion in and around the patches, but, they are prone to sympathize with the morbid state of the constitution; they are highly congested and very itchy in gout, and they become hot and inflamed, and pour out a watery ichor in eczema. But these symptoms it must be remembered, do not belong essentially to alphos, they are merely acci- dental. One of the special characters of alphos we have already referred to, when we describe it as arising as a mere pimple, and increasing in dimensions by peripheral growth until it attained the diameter of an inch or more. This is its progressive stage, constituting alphos circi- natus ; but, having attained its full size, the desquamation begins to cease in the centre, and the skin to recover its natural appearance. This is the beginning of a retrograde stage; the dimensions of the area enlarge, while the circumference continues its peripheral growth, and a ring of considerable size is produced, alphos annulatus; the ring- divides at one or several points, leaving broken segments, and finally these isolated portions gradually disappear. We may therefore trace, in the origin and course of a patch of alphos, a papula, a tubercle, a circular blotch with an elevated and circumscribed border, a ring, the broken fragments of a ring, and, in the end, not unfrequently a melas- mic stain. The Tubercula of Willan is open to similar objections to those just made against the order Squamae. It brings together diseases dissimilar in appearance and pathological nature, and whose only point of correspondence is one of prominence and bulk. The term tuberculum is well applied to those papulae of larger growth that are met with in syphilis, and constitute the form termed syphiloderma tuberculosum, prominences that, without much elevation, attain a breadth of several lines, and sometimes an inch or more. But this is not the idea intended to be conveyed by Willan ; his first genius is phyma, comprehending boils and carbuncle ; he next takes those " cuticular excrescences" termed verrucae; then molluscum ; next, a something which he misterms vitiligo (probably lupus non exedens); then acne, sycosis, lupus, elephantiasis, and framboesia. It is evident from this catalogue that bulk is the prevailing idea; but as the diseases which he has brought together have especial characters of their own, independently of their size, let us endeavor to arrange them according to a better principle. The signification of the word tubercle, in modern cutaneous nomen- 80 PATHOLOGY OF THE SKIN. clature, is an enlargement of the skin, to a bulk greater than is com- monly understood by the term papula, but less than is conveyed by the word tumor. We employ it as an index of size in the instance of erythema tuberculatum ; we note the enlargements which occur in the chronic stage of gutta rosacea, as gutta rosacea tuberculosa; then we have an acne tuberculosa, a sycosis tuberculosa, syphiloderma tubercu- losum, and an elephantiasis tuberculosa. But in furunculus and anthrax we recognize another quality than mere size, an inflammation attended with prominence, but accompanied with suppuration and gangrene. These properties are peculiar to those diseases, and unite them under the head of" furuncular affections." Verruca is a hyper- trophic affection; molluscum and acne are affections of the hair system and sebiparous system; sycosis is an affection of the hair system; lupus is a strumous affection, and elephantiasis a leprous affection. The term vitiligo is employed incorrectly by Willan, and he describes under this name two different diseases; we do not re- member to have met with anything corresponding with the first part of his description, namely, " smooth, white, shining tubercles . . . inter- mixed with shining papulae," which decline at the end of a week, and become flat in ten days; while the latter part of his narrative bears a close resemblance to the occasional progress of lupus non exedens, con- sisting of tubercles that are " more permanent, and, as they gradually subside to the level of the surface, they creep along in one direction, as, for example, across the face, or along the limbs, checquering the whole superficies with a veal-skin appearance. All the hairs drop out, where the disease passes, and never sprout again, a smooth shining surface, as if polished, being left, and the morbid whiteness remaining through life." Framboesia, the yaws, is a tubercular affection occur- ring among the negroes in Africa and in the West Indies, and not met with amongst ourselves; and, moreover, a disease which appears to be gradually wearing out. Macule is the designation of Willan's eighth and last order; and in this group he assembles diseases which are marked by their color, and have no place in his other orders. He distinguishes color as pro- ceeding from two different sources; from the deposit of pigment in the skin, as illustrated by ephelis and spilus ; and the coloration which results from abnormal vascularity of the skin, as in the instance of naevi vasculosi. With a more advanced school of pathology, we consider the first of these affections as disorders of the chromatogenous function of the skin, and the last we place in our group of vascular affections. The pathological lesions above indicated, namely, erythema, papulae, vesiculae, pustulae, squamae, bullae, tubercula, and maculae, upon which the eight orders of Willan are founded, and which supply us with terms of the utmost importance to the comprehension of cutaneous diseases, we have designated as primary lesions; in order to distin- guish them from other lesions, equally necessary to be understood, but of secondary value and frequently the consequence of the pre- ceding, for example, desquamation, discoloration, incrustation, ulcera- tion, cicatrization, &c. DISCOLORATION. 81 Desquamation of cuticle very commonly follows hyperaemia of the derma, and is present in every instance in which the congestion is sufficient to interrupt the normal function of nutrition and epidermic cell-formation. It is remarkable, in the exanthemata accompanying the zymotic fevers, as occurring over the whole body; in certain situations, as the hands and feet, peeling in extensive laminae; in the upper parts of the limbs and back, in smaller flakes ; and on the front of the trunk of the body, and in the flexures of the joints, being fur- furaceous, or even farinaceous. In eczema erythematosum and papu- losum, the desquamation is furfuraceous; but this character is most remarkable in eczematous psoriasis, and in pityriasis; in the latter it is, besides, occasionally farinaceous. One of the varieties of eczema is especially distinguished by its desquamating character, namely, eczema squamosum ; but desquamation is seen, in its highest degree, in the pityriasis rubra of Hebra. Discoloration of the skin is a frequent consequence of cutaneous eruptions. Sometimes, the color is red or purple, and presents vary- ing degrees of intensity ; at other times, it is brown, of various shades. The red and purple tints are the result of a dilated condition of the capillary plexus ; and a more or less retarded circulation through the weakened vessels; the brown marks are produced by the deposit of pigment in the rete mucosum. The red marks are conspicuous after variola; purple discoloration very frequently accompanies gutta rosacea, acne, and furunculus; while brown stains may follow any form of stimulation of the skin, whether proceeding from inflamma- tion or otherwise. We see them occasionally produced by the rays of the sun, by the heat of fire, or by the action of a blister on the skin. They are common on the legs after eczema and lichen; they often take the place of the-disks of alphos; and they are remarkable in diseases of cachexia, such as syphiloderma and elephantiasis Grae- corum. An universal duskiness of the skin has also been noted, as a consequence of the stimulant action of arsenic; and the deep brown stains of alphos are referable as much to this agent as to the irritation caused by the disease. Discoloration of the skin also accompanies any operation by which the blood, or the red coloring matter of the blood, finds its way into the tissues. Sometimes, the blood may escape from the vessels, as in purpura; at other times, it may be forced out of the bloodvessels by pressure or contusion. In this way is produced the black, the purple, the greenish, and the yellowish stain of a bruise. Urticaria, or a state of spasm of the muscular structure of the skin, is sometimes followed by a discoloration such as succeeds a bruise; and so also are some of the deeper-seated forms of erythema. In some instances it would almost seem that the red corpuscles of the blood were disintegrated in the capillary vessels, and that the coloring principle was diffused in the tissues in a state of solution. In certain states of constitution, particularly the cachectic, stains resembling bruises are produced by the slightest pressure, as by the mere weight of the body or of a limb, by the simple grasp of the hand, or by the ligature of the ties and supports of the clothing. 6 82 PATHOLOGY OF THE SKIN. The CRUSTS accompanying cutaneous eruptions are sometimes very remarkable, and suggested to the early nosologists a separate group of diseases. Crustae constituted the sixth class of Plenck's classifica- tion, and, under this head, he assembled ten genera, the chief of which were, eschara, achores, crusta capitus neonatorum, crusta lactea, tinea, mentagra, exanthema labiale, and exanthema subaxillare. Willan very judiciously rejected this head of classification, and grouped the diseases included under it, according to their primary and more essen- tial pathological forms. Nevertheless, as a secondary character, crusts are worthy of our observation and study. They are produced by the accumulation and desiccation of the morbid secretions of the inflamed skin, and in this respect they are distinct from squamae, which are cuticular exuviae. As a product of morbid secretions, crusts exhibit considerable variety of color, density, and thickness; sometimes they are gray, sometimes yellow, and sometimes brown or black. They may be hard, tough, or friable; and they may present themselves as a mere film, or may attain a thickness of a quarter of an inch or more. The most striking example of crustae are those selected by Plenck, namely, the eschar of gangrene ; the thick coating formed on the scalp by the accumulation and desiccation of the muco-purulent discharges of eczema and kerion; the thick concretion, consisting chiefly of the vernix caseosa, sometimes met with on the heads of infants, and form- ing the crusta capitis neonatorum ; the honey-colored mask of eczema pustulosum or eczema impetiginodes of infants, termed crusta lactea; the thick plates of tinea and favus; the firmly adherent casing of mentagra; the horny sheath of the lips in eczema mucosum; and the accumulated muco-purulent crusts of eczema in the hollows of the joints. The thickness of crusts is very much favored by their seat, and particularly by the presence of hair, which detains the secretions, and gives time for their accumulation and desiccation. Exposure to the atmosphere affords another element of variation ; hence the muco- purulent secretions from the lips become as hard as horn, while those that are more sheltered remain soft and friable. The crusts covering ulcerated surfaces are often remarkable for their thickness and figure, as we see illustrated in those covering a neglected lupus, or the conical and oyster-shell-shaped crusts of rupia. But the most peculiar crusts are those of favus, which are cup-shaped in figure, imbedded in the skin, of a sulphur yellow color, and composed of a phytiform sub- stance, apparently consisting of an accumulation of the ramifications and fructification of a mucedinous fungus, the achorion Schoenleinii. A crust of similar structure, but without any regularity of figure, being, in fact, a mere stratiform crust, is met with in trichonosis, the mucedinous fungus in the latter instance being the trichophyton ton- surans. Crusts, therefore, may be the product of desiccated secretions, or they may be the result of an abnormal change in the epidermis, a morbid cell-proliferation, such as the phytiform metamorphosis in this instance referred to. Ulceration, as a pathological lesion, is met with in furunculus, anthrax, pustula maligna, ecthyma, variola, scrofuloderma, lupus, syphiloderma, elephantiasis graecorum, and sometimes in herpes zoster. CICATRICES. 83 Plenck included in his group of ulcerations, excoriatio purulenta, the equivalent of eczema pustulosum; intertrigo, the eczema mucosum; fissura?., and rhagades; but in modern surgery the term ulceration is applied to loss of substance of a vital tissue, and not to simple excoria- tion or fissure, and is evidently misused by the German author. The ulceration of furunculus, anthrax, and pustula maligna, is accompanied with gangrene of cellular tissue; that of ecthyma, variola, and herpes zoster is consequent on suppuration ; while the ulceration of scrofu- loderma, lupus, syphiloderma, and elephantiasis, proceeds from the solution and decay of degenerated tissues of low vital organization. Cicatrix of the skin is an evidence of a reparative action and of a foregone loss of substance, whether that loss of substance have pro- ceeded from ulceration or degeneration and absorption of tissue with- out external lesion or solution of continuity. Cicatrices are usually white, and are composed of one of the lowest forms of organic tissue; the tissue especially- employed in the operation of repair, namely, white fibrous or connective tissue. Sometimes this tissue has a fibrous character, and the cicatrix the appearance of being composed of inter- lacing bands. At other times it is homogeneous; but in both instances is perforated from point to point by small bloodvessels, which throw out a scanty and partial ramification over its surface. A cicatrix must be regarded as a substitute for a lost portion of skin ; consisting of white fibrous tissue, scantily supplied with vessels and nerves, and covered by epidermis. It is pale, dense, thin, and inelastic as compared with the surrounding skin, and presents some differences of character having reference to the more or less complete destruction of the dermal tissue; sometimes, the papillary layer only is removed, and its place supplied by an imperfectly fibrillated tissue, through which the fibrous rete of the corium may be seen forming the base of the cicatrix; at other times, the whole thickness of the derma is destroyed, and the cicatrix is imbedded in the subcutaneous tissue, or is adherent to deeper parts. The cuticle covering the cicatrix is also diversely modified, being generally smooth, thin, and glistening, and sometimes roughened by desquamation; its most striking character being, the absence of the modelling of surface which results from the presence of a highly organized papillary layer. When a large extent of skin is destroyed, the white fibrous tissue which supplies its place, draws together the borders forming the cir- cumference of the ulcer, and produces a puckered appearance of the surrounding integument; and sometimes, as in the case of burns, con- siderable inconvenience and commonly distortion is occasioned by this contractile action. Generally, as we have stated, the fibrous tissue constituting a cicatrix is thinner than the rest of the skin, and is depressed below the level of the surrounding surface, but sometimes, under the influence of an aberration of nutrition, the white fibrous tissue is produced in excessive quantity, and forms prominent cords and ridges, which have received the name of kelis spuria; kelis vera being a disease of hyperformation of white fibrous tissue taking place spontaneously. As cicatrix is a consequence of ulceration, it is absent in all those 84 PATHOLOGY OF THE SKIN. cutaneous affections in'which there is no destruction of tissue, however severe they may be in other respects; for example, eczema and alphos. But it follows the true pustules,for example, ecthyma; vesico-pustules, for example, yariola, and herpes zoster; gangrenous pustules, such as furunculus, anthrax, and pustula maligna; and the ulcerations of struma, syphilis, and elephantiasis. Cicatrices without ulceration present some interesting pathological phenomena; the simplest is the cicatrix of pregnancy. When the skin is overstretched, as in pregnancy, obesity, and oedema, the corium is apt to give way, and occasion partial fissures of the derma; some- times, this process is accompanied with erythematous lines indicating congestion of the corresponding portion of the papillary layer; at other times, there is no erythema, and the occurrence is not discovered until the white glossy lines of a cicatrix make their appearance. Some- times this phenomenon takes place in an abnormal state of the skin; from the pressure of a fold of the derma against an adjoining fold, and may be quite superficial; or it may be deep, and extend through the whole thickness of the derma, and also through the subcutaneous fat. But the most important of the cicatrices produced without ulceration, are those which are found in association with some forms of tubercu- lar syphilis, lupus non exedens, lupus erythematosus, and elephantiasis. The destruction of tissue in these instances results from interstitial absorption; the papillary layer of the derma is first altered in its nature, reduced from a higher to a lower type of organization; from a highly vitalized vascular structure to a semitransparent cell-tissue, and subsequently removed by absorption, leaving the white fibrous web of the corium exposed to view, and presenting all the appearance and all the characters of a cicatrix, with the exception of not being a second- ary formation deposited in the place of a lost structure. In tubercular syphilis we often meet with cicatrized pits where no ulceration has pre- viously existed ; the streaked cicatrix-like surface of lupus non exedens and of one form of sycosis has a similar origin; so also have the atro- phied blotches of lupus erythematosus; and the leucose patches of mor- phcea alba atrophica. In some instances, as in lupus non exedens, the interstitial absorption produces a kind of dissection of the layers of the skin; the papillae are first removed, which brings into view the vascular plexus of the papillary layer; then the sebaceous glands are seen, with their lobulated structure as distinctly exhibited as if the tissues were transparent; and, lastly, the fibrous substratum alone remains. Taking a general review of the pathological operation of inflamma- tion on the skin, we may conclude, that its effects, are, 1. Simple redness, with or without exfoliation of cuticle, as in erythema and exanthema; 2. redness with effusion of serum beneath the cuticle, constituting bullae ; 3. redness with interstitial infiltration of the colorless part of the blood and effusion of serum beneath the cuticle, as in vesiculae, and especially in eczema; 4. redness with interstitial infiltration affecting single follicles, as in papulae, or spreading from a follicle into the sur- rounding tissues, as in tubercula ; 5. redness, with tuberculation and gangrene of cellular tissue, as in furunculus and anthrax ; 6. redness TRAUMATIC AFFECTIONS—NEUROSES. 85 with the formation of pus beneath the cuticle, as in pustulae; 7. red- ness, with the production of scales of morbid cuticle, as in squamae ; 8. redness, followed by an alteration of pigment, as in some forms of maculae; and 9. its secondary consequences, namely, exfoliation of cuticle; discoloration, the production and accumulation of crusts; ulceration ; and cicatriation. To which it may be proper to add, trau- matic affections or injuries inflicted on the skin. Traumatic affections imply an injury done to the tissues of the skin, by heat or by cold, or by irritation, whether occasioned by insects, or by chemical or mechanical means. Excessive heat may act simply as a stimulus, or it may destroy the vitality of the skin; cold also may weaken and even annihilate the life of the integument, as in pernio or chilblain, and gelato or frostbite. Insects may produce inflammation by simply crawling upon the surface and feeding on the softer layers of the epidermis, as in the case of the acarus scabiei; or they may pierce the papillary layer of the derma in search of food, like the pediciilus, the pulex, or the cimex; or they may burrow in the subcu- taneous tissues, like the filaria. Finally, inflammation may be excited in the skin by the stimulus of chemical means, as by cantharides, by croton oil, tartarized antimony, strong liquor ammoniae, or powerful acids; or by mechanical means, as by friction and contusion; the effects of friction being illustrated by erythema intertrigo and of contusion by erythema ab ictu. Inflammation involves the whole of the tissues of the skin, although its effects may be manifested by its operation on one part of the cu- taneous structure more than the rest, for example, the papillary layer, in erythema; the follicular structure, in lichen; the epidermis, in alphos; and the corium, in furunculus. But there are certain affections which are not due to general inflammation, even if they be not entirely independent of inflammatory action, neither do they involve the whole of the tissues of the skin, but are limited to one or other of its parts, as of its nerves and bloodvessels. In the former case, our attention is drawn to the morbid condition, by aberration of function of the nerves, for example, heightened sensibility, deficient sensibility, or altered sensibility; and> in the latter, by aberration of structure, as in the case of naevus, and by the spontaneous escape of the colored elements of the blood from its vessels, as in purpura. The pathology of the nerves, constituting neuroses, is little under- stood, in consequence of the difficulties which attend its investigation; and the morbid changes, heretofore observed, are inadequate to explain many of the known phenomena of aberration of function of the cu- taneous nervous system. We can appreciate a suspension of function from atrophy of the nervous fibrils, or from thickening of and effusion into the neurilemma and obliteration of the nervous tubule, as happens in elephantiasis; but we have no means of detecting those subtler alterations of the nervous fluid or of its containing sheath, that occa- sion the various forms and degrees of hyperaesthesia, of neuralgia, and pruritus. In some instances, no doubt, the nerve is the mere agent of transmission of a sense of irritation from a distant part; but in other instances it is equally certain that the morbid condition of the 86 PATHOLOGY OF THE SKIN. nerve is local. We may often relieve an obstinate prurigo by local remedies; but we should not expect to exert much influence over an urticaria by similar means. As little does the observation of the aberrations of function of the trophic element of the nervous system help us to the comprehension of its pathology ; we may possibly seek in vain for those physical changes in the nerve, which give origin to an attack of shingles ; we have not yet discovered the morbid changes in the nervous fibril, that contribute to the growth of a strumous tumor or a cancer; and, we have still to investigate those alterations in the organic nerve that determine the destruction of the blood corpuscle, and its conversion into an atom of pigment. The pathology of the bloodvessels of the skin presents us with the phenomena of increased magnitude of the vessels; and of an al- teration of structure of their coats that permits the escape of the red elements of the blood into the surrounding tissue. That which is im- perceptible, otherwise than as a pink blush, in a healthy state of the cutaneous tissues, may be developed, under the influence of an aber- ration of nutrition, into a prominent tumor of considerable size, con- sisting almost wholly of a plexus of bloodvessels, held together by a small quantity of cellular or connective tissue. The old term, " aneu- rism by anastomosis," expresses the nature of the morbid affection with considerable clearness ; it is a tumor containing blood, not in a single vessel, as in ordinary aneurism, but, in the myriad of anasto- mosing tubes which compose a capillary vascular plexus ; the vascular mass has been compared to the structure of the erectile organs, and was termed by Dupuytren, "erectile tumor;" its more common appel- lation being, naevus. In naevus the whole structure of the skin is sacrificed to the growth and development of its vascular structure; the papillary layer and corium are in a state of atrophy; the sensi- bility of the part is lowered; the hairs and glandular organs remain undeveloped; and the cuticle is smooth and attenuated ; finally, when the tumor subsides by spontaneous cure, the disorganized skin has the appearance of a cicatrix, or of a wrinkled atrophied mass, composed of loose cellular tissue, covered by epidermis. Vascular naevus varies in color in proportion to the activity of cir- culation through its vessels; when the vessels are small and the cir- culation rapid, the tumor has the red tint of arterial blood; but, if the vessels be larger, and the energy of circulation be thrown upon the venous system, the blood moves more slowly through its tubes, it has time to acquire a purple tint in its course, and the tumor is bluish or purplish in hue. Vascular naevi begin in the capillary plexus of the skin; they are for the most part congenital, and indicate a perversion of nutrition; sometimes they subside after birth and gradually dis- appear, but at other times they continue to increase. Certain of the smaller kinds of naevus, such as the naevus araneus, may be developed at any period of life, but are most common in children and young persons, in those, in fact, in whom delicacy of skin is likely to prevail; while others, originating in debility of the cutaneous tissues, are most common in advanced age. A varicose condition of the venules of the skin is not unfrequent PURPURA—EPIDERMIS. 87 in adults and elderly persons, as a consequence of impeded circulation and hypertrophy of those vessels; varicose venules are sometimes met with in the face, especially on the nose, and are also, not unfre- quently, seen in the lower limbs. In the latter, they may be asso- ciated with varicose veins, but they may also exist independently of a varicose state of the venous system. Purpura is another affection with which the bloodvessels are inti- mately if not principally concerned. There is a lax condition of the tissues of the skin, as well as of the bloodvessels, a state in which the blood itself participates, and the red portion of the blood transudes through the vessels into the neighboring tissues ; hence the spots which are denominated purpura, and hence also the names which, according to their size, are given to the spots, namely, stigmata, petechiae, vibi- ces, and ecchymoses. The weak and lax state of the tissues of the body in purpura, is shown by the frequent association of pemphigus with that disease, and also by the occurrence of hemorrhage from the mucous membranes. Morbid states of the epidermis are commonly due to an unhealthy condition of the general system, and are usually associated with some degree of inflammation of the skin; such is the case with derange- ment of formation of the nails, with the development of the phyto- dermic affections, and of some of the pigmentary affections. The most marked state of disorder of the epidermis known, is one originating in faulty development and nutrition of the skin, namely, xeroderma or ichthyosis, and is unaccompanied by inflammation ; and the same may be said of certain forms of melasma, in which the rete mucosum would seem to perform a simple secreting function, while other ex- amples of melasma are preceded by, and sometimes accompanied with, hyperaemia of the skin, as in the case of ephelis. One of the functions of the epidermis, is the formation of pigment; and the quantity of pigment produced in the rete mucosum is subject to considerable variation. It is governed physiologically by those constitutional states of the body which are termed " temperament;" it is influenced by local stimulation, both normal and abnormal; and it is often accumulated in great excess as a consequence of disease. It is necessary to distinguish between physiological and pathological excess of pigment, the skin of the pudendum acquires a deeper tint at puberty, the eyelids during menstruation, and the areola of the mamma during pregnancy, these are physiological changes ; but if the discoloration extend beyond the usual limits, or the depth of the tint be remarkable, the change must be regarded as pathological, and this is especially the case if the seat of the discoloration be abnormal, such as the forehead, the face or neck, or the trunk of the body, or limbs. Addison observed and pointed out a given relation between me- lasma and disease of certain abdominal organs, namely, the suprare- nal capsules. We have shown a connection between melasma and injury of the organic nervous system, whether such injury result from nervous shock, or deranged function, or disease of the abdominal organs in general, or of the uterine and reproductive organs; and 88 PATHOLOGY OF THE SKIN. Frerichs has noted the formation of pigment in actual operation in the veins of the portal system, and especially in the splenic vein, and has demonstrated the production of pigment to be the conse- quence of destruction of the blood corpuscle. Plence, two prominent symptoms are present together in melasma, namely, excess of pig- ment, and loss of the red particles of the blood, constituting anaemia ; and we are made aware of the fact, that any exhaustion of power of the organic nerves of the abdomen, may be accompanied with destruc- tion of the blood corpuscle and the production of pigmentary matter, and consequent anaemia; whether the cause of exhaustion be simply physiological, as in the case of ordinary menstruation, or pathological, as in painful menstruation, disordered digestion, or organic disease; and, as the cause resides in the organic nervous system and not in the organ, the particular organ, whether a degenerated gland, such as. the suprarenal capsule, or the stomach, spleen, liver, or uterus, is un- important. In melasma, therefore, there will be, conjoined with excess of pigment, loss of nervous power, and loss of the red corpuscles of the blood or anaemia. We may infer from these observations that the pigment of the skin is a modification of the red element of the blood, and that the normal pigmentation of the skin is due to the presence of a large quantity of blood in the cutaneous capillaries, and the changes which that blood undergoes in the performance of the natural functions of the skin; while, abnormal pigmentation results from the production of an excess of pigment in the bloodvessels of the body, and its elimination by the skin. It is well known, that the erythema, caused by the action of the rays of the sun on the skin, often leaves behind it a brown patch, which is termed ephelis ; the heat of the fire produces a similar change (ephelis ignealis), as we have occasion to see frequently on the lower limbs; and so also does erythematous congestion, however induced. But these cases are very different from those extreme examples of perversion of coloration, in which an excess of pigment is present on one spot, while upon another, there may be a complete state of achroma or absence of pigment. It is clear, therefore, that while normal pigmentation is under the governance of and is controlled by the nervous system, abnormal or morbid coloration is equally of neurotic origin; and that every ex- ample of morbid coloration is preceded by, or accompanied with, dis- ordered function and exhaustion of the nervous system. Pigmentary affections present various tints of color; the more common are brown and black in different degrees, constituting melas- ma or melanoderma; sometimes they are bluish in tint, cyanoderma; sometimes yellowish, as in xanthoderma; and sometimes greenish, as in chloasma. The pigmentary principle is probably alike, or very nearly alike, in all, and is derived from those sources that give color to the blood, the bile, the urine, and the various fluids of the body. Another function of the epidermis is, the elaboration of a horny material that bestows on the cuticle its special characters of tough- ness, pliancy, smoothness, and transparency, qualities that are seen in their most exalted form in the nails. The absence of these qualities HORN—EPIDERMIS. 89 indicates a pathological state of the epidermis, under which, the cuticle may be brittle, hard, fragile, rough, and opaque. A minor degree of this pathological condition is perceived after every hyperaemic dis- turbance of the derma, as in erythema, exanthema, eczema, and syphiloderma. It is seen, in a more decided form, in the chronic erythema and eczema that go by the name of pityriasis and psoriasis, and more characteristically in alphos and scabrities unguium; and especially in ichthyosis, and the phytodermata, namely, trichonosis, favus, and chloasma pityriasicum. In erythema, exanthema, and eczema, there is no departure from the normal structure of the epidermis; the existing cuticle simply exfoliates. In chronic stages of the same disorder the cuticle is pro- duced in small plates corresponding with the lines of motion of the skin; but the cuticular plates or scales of alphos differ in structure from normal cuticle, and exhibit a porous texture that seems to result from the accumulation of crude and imperfectly developed epidermic cells. Another degree of crudity and imperfect development of epidermic cell is seen in xeroderma and ichthyosis; but the most remarkable of all is met with in trichonosis, chloasma and favus. In these latter affections, the component granules of the epidermic cells undergo an independent proliferation, like the organic granules of mucedinous fungi, and have all the appearance of a mass of mucedin- ous matter: consisting of granules, shafts, and branches. The morbid changes in the cuticle at present under consideration take place in the growing layer of the epidermis, namely, the rete mucosum; the cells of that structure, arrested in their development, checked in their natural function of ripening into horny scales, are capable, by their accumulation and desiccation, of producing the hard and irregular masses or plates of ichthyosis, the pulverulent exuvia- tion of xeroderma, the laminated and porous scales of alphos, the flocculent desquamation of chloasma, trichonosis, sycosis, and the pale yellow and friable cups of favus. The phytiform character of the latter has suggested the belief that they are not composed of altered cuticular cells, but are an accumulated mass of mycodermic vegeta- tion, originating in sporules or seeds coming from without, piercing the horny cuticle to reach the rete mucosum, feeding on the juices of the rete mucosum, destroying its life and that of the epidermis, and breaking up the structure of the latter, and converting it into exuviae. This theory, which we believe to be incorrect, has of late years met with such ready acceptance, that, as historians of the progress of cutaneous medicine, we are under the necessity of mentioning it. It starts with an assumption which is physically impossible, namely, that of a sporule or seed penetrating the thick horny stratum of the cuticle before it can reach the seat of its food and means of growth, and it presumes upon a morbid state of the juices of the body favorable to its development and growth ; while it overlooks the fact, that myriads of wombs of these granules normally compose the rete mucosum, namely, the nascent and growing cells, subsequently to become horny plates; and, that a simple aberration of nutrition of these organic granules, may rob them of their destined power, and prostrate them 90 PATHOLOGY OF THE SKIN. to a lower function, common to the lowest forms of organic matter, whether animal or vegetable, namely, that of proliferous develop- ment and growth. Nevertheless, these mucedinales are associated with the names of distinguished physiologists, and have received con- siderable attention both in England and abroad. The pathology of the hair involves the consideration of its forma- tive energy, the consequences of aberration of that energy being an alteration in the quantity, length, color, or texture of the hair. The hair may be excessive in quantity, on the head or on other regions of the body, hirsuties; it may be longer or shorter than the normal standard; and, in certain 'states of health of the individual, it may remain permanently short. The hair may be scanty, alopecia, from deficient constitutional and local power; and it is remarkable that this condition frequently succeeds a state of superabundance of hair; or, the trichogenous function of the skin may be totally suspended, on parts or on the whole of the body. In the latter case, the absence of hair may occur in spots of limited size, sometimes circular, as in alopecia area; sometimes oblong and serpentine in figure, alopecia opiasis; or it may include the entire scalp, and, indeed, the whole body, alopecia calva vel calvities. The color of the hair, light in the infant, becomes darker in tint with the advance of age; and, when the vital powers of the skin are weakened by age or exhausted by acquired feebleness or disease, the chromatogenous function may be suspended, and the hair become white, canities. Sometimes the whitened hair has the qualities of horn, it is harsh, stiff, and straight; at other times the color seems due, not to a corneous transformation, but to the substitution of a white calca- reous material for the natural pigment. When hair returns upon a part which has been bald for a while, it follows the normal development of infantile hair; it is at first fine and pale; the fine hair is shed, and is succeeded by a thicker and stronger growth; but bulk and color return only by degrees. And, when the powers of the skin are exhausted, as in leucosma and leuce, the subsequently produced hair remains permanently white. An illustration of the pathology of the hair is very commonly seen after fevers, syphilis, puerperal confinement, and chronic inflammation of the scalp of whatever kind. In these cases the nutrition of the skin is suspended, the adhesion of the hair to the derma is consequently weakened, and the hair falls more or less extensively. The hair, how- ever, is renewed as soon as the skin re-acquires its tone; and more speedily and completely in proportion to the degree of restoration. Sometimes the new hair is as vigorous as the old; sometimes, how- ever, it remains weak and feeble for the rest of life, this is alopecia vulgaris, and is due to general debility of the skin; but the absolute exhaustion of the hair formative power which is seen in area, ophiasis, and calvities juvenalis, is neurotic, and is accompanied with loss of innervation and normal sensibility of the skin. We have before discussed the physiological function of the epider- mis; namely, to develop horny plates out of moist granular albu- minous cells, and we have shown the existence of a point upon HAIR. 91 the scale of progressive development which may be taken as the stan- dard of perfection, that, at this point, the horny tissue* is complete in all its properties; but that short of this point, or in excess beyond it, the normal structure is impaired. The same principle is applicable to the hair; the function of the hair papilla is to produce cells which are soft and moist and granular; and subsequent development converts these cells into elongated fibres for the construction of an organ, the hair, which possesses some remarkable qualities; it is firm, flexible, tough, smooth, transparent, and uniform in size; it is not horn, although resembling horn in some of its characters; and it is widely different from epidermis both in its origin and attributes. As a departure from the physiological standard brings the organ into the category of a pathological state; an aberration of develop- ment may reverse the normal qualities of the hair, and make it soft, rigid, brittle, rough, opaque, and uneven. Brittleness of the hair, fragilitis crinium, is a not unfrequent accompaniment of pathological alteration of texture ; sometimes it is indicated merely by dryness of the hair, and a snapping through of the entire shaft, or a splitting of the ends ; and, sometimes, especially in the thick hairs of the whiskers and beard, there is a partial break of the shaft, with a separation of the fibres at the point of fracture, which shows as a white speck upon the hair, and gives a speckled character to the mass. There are often three, four, or many of these bruised rings on the shaft of the hair ; and they resemble a white dust or scurf, dispersed in the beard. Sometimes the hair, in a pathological condition, resembles tow; some- time it is harsh and wiry ; sometimes it is rigid and tough like horn; sometimes discolored and apparently dead ; and sometimes twisted and bent. But the most important pathological alteration of the hair is that which, with good reason, is termed trichonosis. The hair in trichono- sis is evidently disorganized, it is dry, brittle, shrivelled, flattened, collapsed, bent, and bleached, every normal character is gone, and were it not found upon the head it could hardly be recognized as hair. If we follow it into its follicle, we find its cylinder to be larger than natural; it is tumefied, infiltrated with fluid, pale and soft; we per- ceive that its shrivelled appearance externally to the follicle is due to desiccation of the fluids with which its cells are charged; and we are led to the conclusion that the organ is imperfectly formed; that its cells are in the same crude state in which they were produced by the hair-papilla; that they are unhealthy and bloated in their origin; and that the subsequently corneous, or rather crineous, development has been wholly suspended. This we believe to be the true pathology of trichonosis or ringworm, the tinea tonsurans of Authors; and we also think it probable that it may be the correct pathology of plica polonica. Many years ago, we pointed out the fact, that the newly-formed epidermal cells, and also the hair-cells, were composed of granules of oro-anic matter arranged in a special manner. These granules are the agents of the normal function of the cells; their ascensive action is to produce horn and crineous tissue. If they remain stationary, they 92 PATHOLOGY OF THE SKIN. retain the qualities of albumen; but they may descend in the animal scale to the lev.el of mucus, and like mucus they may assume a germi- nating action, by which they may produce a tissue resembling a muce- dinous growth, or a fungous plant. The newly-formed cells in tricho- nosis are enlarged cells, filled with bloated granules; it is these large cells and large granules, and the fluids contained within and between them, that give the unusual bulk to the shaft of the morbid hair ; and, it is these cells and granules, retaining their crude albuminous charac- ter, shrinking- by desiccation on exposure to the atmosphere, that are the cause of the pallor, the collapse, and the brittleness of the hair. In normally developed hair-cells, the granules would be converted into fibres, they would lose their shape and their qualities ; and, although their presence may be detected with great care and close observation in the healthy hair, they are so far reduced in bulk, and altered in appearance, as to be discernible with difficulty; but in the morbid hair, they retain permanently their globular figure and gross dimen- sions ; they appear to be almost the sole constituent of the shaft of the organ; and, in certain parts, they seem to have assumed a plant-like form, by the elongation of their cylinder and the mutual apposition of a number of cylinders, or the germination and growth of the granule in a longitudinal direction. Modern theory regards these granules as sporules or seeds of a mucedinous plant; and the cylindrical shafts as the branches of the plant. The sporules are believed to come from the atmosphere, to take root in the hair-follicles, to creep inwards to the fundus of the follicle, to bore their way into the bulb of the hair, and then to grow upwards in the shaft. The plant is called trichophyton; and the phytiform structure is found in trichonosis tonsurans, in sycosis, and in favus. The pathology of the glandular system of the skin comprehends aberration of function of the secreting apparatus, together with inflam- mation and structural changes of the glands themselves. The secre- tions are, the sebaceous substance and the perspiratory fluid, and these products maybe altered in quantity and quality. Inflammation of the follicles and glands of the skin is seen in acne, sycosis, and in kerion or scalled head. While the structural changes of the glands ma)r be evinced by occlusion of the aperture of the follicle, morbid alteration of its epithelial lining, or morbid changes in the proper tissues of the gland. Excessive secretion of sebaceous matter is termed stearrhaia or seborrhcea, the secretion is more fluid and oleaginous than usual, flows freely over the skin, and gives to the latter a greasy appearance. It is commonly met with on the face and scalp, and is sometimes remark- able in elephantiasis. On the scalp, the sebaceous matter often con- cretes and becomes troublesome. An absence of sebaceous secretion, asteotodes, produces a dry and parched state of the skin, and is present in xeroderma and ichthyosis; while a state of altered composition of the sebaceous matter, allosteotodes, is sometimes remarkable for an ab- normal color or density of the substance ; it is sometimes yellow, stear- rhcea flavescens; sometimes colored by a blue pigment, stearrhoea caerulea; and sometimes brown or black, stearrhcea nigricans. And GLANDULAR SYSTEM. 93 an accumulation of a grayish sebaceous substance in the form of polygonal crusts or scales like those of a lizard, or elongated spines, on the morbid skin of xeroderma, gives rise to the affection which we have termed ichthyosis saurioides, or simply sauriosis. In an altered state of physical or chemical composition, the seba- ceous secretion sometimes remains impacted in the excretory ducts of the sebaceous glands and in the hair-follicles, constituting comedones and sebaceous tumors ; and, sometimes, the glands themselves are dis- tended with this secretion and rise above the level of the surface, forming small currant-shaped tubercles or tumors, to which the term molluscum contagiosum has been inaptly applied. With accumulation of sebaceous matter in the follicular or excretory portion of the gland, there is also thickening of the walls of the duct; and in advanced stages of the hypertrophic process, the coats of the follicle grow into importance, and become the cyst of the accumulation, while the tumor in this state, is termed an encysted tumor. An encysted tumor may be either open or closed, the closure of the aperture of the follicle very commonly taking place from the growth of the cyst and the pres- sure of its contents. Sometimes, doubtless, an encysted tumor origi- nates in closure of the aperture of the follicle ; and, in another form of sebaceous tubercle, namely, in the miliary or pearly tubercle, we have the example of an aborted follicle, which has never possessed an external aperture; which, as far as the cyst is concerned, is an arrest of development of the sebiparous gland. The contents of the sebaceous tumors with open apertures are sim- ply a normal sebaceous substance, composed of epithelial cells and scales, entire and disintegrated, and commingled with short hairs and with a greater or less quantity of water and oil; but, in the closed encysted tumors, the contents undergo various changes, the result of confinement, and sometimes of inflammation of the cyst and surround- ing integuments, induced by pressure or injury. Very commonly, the epithelial cells nearest the cyst are condensed into a horny capsule, while the central mass is sometimes laminated^ sometimes disinte- grated and broken up into an atheromatus or pap-like substance, sometimes steatomatous and apparently composed of fat; sometimes melicerous, like a semifluid wax; and sometimes wholly fluid; the softened matter being often mingled with hairs and crystals of stearine, and often extremely, fetid. When these accumulations of sebaceous matter are exposed to the desiccating effects of the air, they become hardened into a kind of horn, and the gradual extrusion of this substance through the normal opening of the cyst, or through an accidental opening resulting from ulceration, is the ordinary method of formation of the so-called human horns, corneous masses, sometimes several inches in length, and often an inch or more in diameter. Encysted tumors containing fluid only, are sometimes met with along the edges of the eyelids; one of these, a serous cyst, attains the dimensions of a grape, while a smaller kind, from its hardness and transparency, has been termed grando and chalazion. In a few in- stances, we have seen these cysts on other parts of the skin, notepider- 94 PATHOLOGY OF THE SKIN. mic vesicles, but positive fibrous cysts formed in the substance of the derma, and apparently produced by the occlusion of sebaceous follicles subsequently distended with a serous fluid. Inflammation of the sebiparous glands and of the sebiferous follicles is illustrated by acne and kerion. In acne the inflammation of the follicle occasions a conical prominence, and terminates in suppuration, the follicle being distended with concreted or inspissated sebaceous substance. It is developed amidst the large sebiparous glands of the face, the shoulders, the back, and the chest; and is remarkable for its occurrence at the period of puberty, tueflos setatis, or blossom of life, of our forefathers. Kerion is a suppurative inflammation of the hair- follicles of the scalp, accompanied with much swelling, with extreme redness and congestion, and by unwonted patency of the follicles; the follicles shed their hairs and pour out, in excessive quantity, a muco- purulent fluid; and, at the decline of the inflammation, the spot re- mains for some time of a dark red or livid color, and scalled or devoid of hair. Sycosis, which bears some analogy to acne, is a disease of the hair-follicles and not of the sebaceous follicles. Structural changes of the glands of the skin are shown in the occa- sional occlusion of the apertures of the excretory ducts, whether such occlusion be the consequence of the inflammatory process, or of im- perfect development; in hypertrophy and atrophy of the glandular tissue; in alterations of the epidermic and epithelial portion of the gland, or of its follicle or duct; and lastly, in the degeneration of the gland, whether innocent or malignant. We have already given examples of occlusion of the excretory outlet of the sebaceous follicle in the encysted tumors, and we have pointed out especially an occlusion resulting from arrest of develop- ment of the follicle, in the instance of the miliary tubercle. The glands are sometimes hypertrophied, and form prominences on the skin, especially those of the face, and sometimes all trace of them in the tissue of the derma seems to be lost. The epidermic funnel which occupies the mouth of the follicle is sometimes abnormally enlarged, producing transparent horny non-vascular papules, papulse epidermicse; and, sometimes, the epithelial lining of the follicles is increased in dimensions. Under the name of papulae and laminae flavae epithelii cutis, we have described a yellow hypertrophy of the tissues surrounding the mouth of the excretory duct; the epithelial lining of the duct is seemingly increased in bulk, but minute vessels straggling in the midst of the yellow matter indicate that the vascular coats of the duct are also im- plicated in the disease. The yellow matter is lobulated and soft, it sometimes forms permanent papulae dispersed over the body and limbs, but is most frequently met with in the skin of the eyelids. In the latter, it appears as papules, which, after a time, unite by their bases and form laminae of various size, sometimes extending along the upper or the lower eyelid, and sometimes along both, and meeting at the outer canthus. The papulae and laminae flavae vary in their color, from a primrose tint to a golden yellow, and are harmless in their nature. SUDORIPAROUS SYSTEM. 95 A more grave alteration of the coats of the sebaceous glands and ducts is the cellular degeneration of tissues, which gives rise to epithe- lioma or cancer. ' This change begins near the aperture of the follicle, and gradually spreads inwards to the gland and outwards into the immediately surrounding cutaneous tissue. It forms small tubercular masses, which are hard and semitransparent, and traversed by minute bloodvessels. At a later period, the morbid tissue softens and ulcerates, and troublesome sores are produced. The epithelial lining of the follicles is subject to a remarkable morbid change, which we have already described as a phytiform or granular degeneration of its component cells. It is this transforma- tion that produces trichonosis tonsurans or tinea capitis, tinea corporis, and favus; and a similar alteration in the epithelial cells has been observed in sycosis. The pathology of the sudoriparous system is comprised in the consideration of the defective development and atrophy of the glands; and, their errors of secretion, for example, deficiency of secretion, or anidrosis; excess of secretion, idrosis or ephidrosis; alteration of se- cretion affecting its odor, osmidrosis; or its color, chromidrosis and haemidrosis. In chromidrosis the prevailing tints of color are, black, blue, green, and yellow ; while in haemidrosis, the red tint is derived from the pigment of the blood. Our arrangement of the subjects comprised in the pathology of the skinfc is based upon a threefold division, namely, diseases affecting the whole of the tissues; diseases affecting parts of the tissues; and errors of development, nutrition, and growth. The first two of these heads we have already sufficiently considered, and we now pass on to that which remains, and which we may further divide into four groups, namely, defective development, defective nutrition, excessive nutri- tion and perverted nutrition. Cases are on record in which infants have been born with a skin so imperfect on parts of the body, more or less extensive, as to resemble a cicatrix rather than the true skin; both the papillary layer and the reticular layer are absent, and all that presents itself is, a thin layer of connective tissue, covered by a smooth and laminated epidermis. Such an imperfect state of the skin is met with inclosing the sac of spina bifida; and, one of our patients, at present under treatment for eczema, exhibits a large patch on the side of the chin, on which the true skin is absent, and its place occupied by a thin layer of connective tissue, covered with a smooth epithelial layer. To our question, as to the origin of this scar-like patch, the gentleman replied, that it was congenital, and the mark of an oyster, and that it shed its scales regularly in the oyster season. The congenital defect may involve all the tissues of the skin, or it may be limited separately to the papillary layer, to the reticular layer, or to the glands. Cases occasionally occur in which there is an evi- dent absence of the glands of the skin, associated with a weak and imperfectly developed dermal tissue; and a congenital deficiency of the hair may be attributed to a similar agency. Defective nutrition of the skin is manifested by a weakly and deli- cate construction of the organ, and by an appearance resembling that 96 PATHOLOGY OF THE SKIN. of an infant; at other times it is shown in a thin, hard, and dry tegu- ment, or xeroderma, covered by a morbid cuticle in a perpetual state of exuviation, ichthyosis vera; while another form of defective nutri- tion is exhibited in atrophia cutis. Atrophy of the skin sometimes assumes the characters of a contraction of the tissue, so that it be- comes too small for the body which it contains ; the lower eyelids are drawn down, the skin is stretched over the malar bones, the lower lip is pulled towards the chin; the joints are flexed, and an ulcerative action is set up at the tips of the fingers and over the projections of the joints. Atrophia cutis is also met with in elephantiasis, in mor- phoea alba, in tubercular syphilis, in sycosis, in lupus non exedens, and in lupus erythematosus. Excessive nutrition of the skin is evinced by abnormal growth of the organ, either as a whole, or of parts of its structure; and the hy- pertrophic action may involve the entire skin, as in naevus hypertro- phicus, verruca acrochordon, and tegumentary molluscum ; or it may involve, with the integument, the subcutaneous connective tissue, as in boucnemia tropica, the Barbadoes leg. A state not very dissimilar to this we meet with in old standing congestions of the skin and of the legs, and especially in association with chronic ulcers, in which, not only the fibrous tissue of the skin is augmented in quantity and bulk, but also the papillae cutis are enlarged ; or the hypertrophy may be one, of the papillae of the skin, as in the various forms of ver- ruca vulgaris. Hypertrophy of the fibrous tissue of the skin is illus- trated independently in kelis, both vera and spuria; and hypertrophia epidermidis is seen in tylosis, pachylosis, and clavtis. Perverted nutrition of the skin gives rise to alterations in its color, texture, and general appearance, a state of real cacotrophia cutis. It is not uncommon, in a cachectic state of the constitution, to find the skin of youthful persons more nearly resembling leather or parchment than living skin. In advanced age this state pervades the entire in- tegument ; while, even in the adult, a similar condition is sometimes met with. We have often examined the skin of the trunk on which growths of various kinds, molluscous, verrucous, and vascular, were to be seen, and on which gray and brown concretions had been de- posited. Cacotrophia cutis often shows itself on the face of elderly persons, in the form of concretions of epithelial matter, partly follicu- lar and partly epidermic; these concretions are closely adherent to the skin, and their removal frequently leaves an excoriated surface, from which a few drops of blood escape. Close inspection shows that the papillary layer of the skin is in a state of partial atrophy; fre- quently the sebiparous glands are exposed to view, and a gradual degeneration of structure is taking place. Sclerosis of the skin, or scleroderma, is another form of cacotrophia cutis; the skin has sometimes the density of horn or cartilage, and contracts upon the subcutaneous tissues, or around the limb like a plate of metal. A case of this kind affecting the leg, in a lady of middle age, is at present before us ; the hardened skin clasps the limb a little above the ankle. This portion of the limb is reduced in dimen- sions by the pressure, while the foot is swollen and somewhat oedema- CLASSIFICATION OF DISEASES OF THE SKIN. 97 tous. Sometimes.the sclerosis invades the subcutaneous cellular tissue, as in the induration of skin met with in newly-born infants, and also in boucnemia tropica. In a case at present under our treatment, the induration affects the face, the neck, the shoulders, and the upper part of the trunk. It began, a few weeks since, as an imperfectly developed erythema. The skin is hard to the touch, reminding us of ivory or marble; there is no redness or change of appearance on the surface ; but it is thicker than usual, and impedes the free movement of the jaw and of the neck. Under the head of cacotrophia cutis we may also consider those examples of metamorphosis of tissue which are frequently associated with the tertiary forms of syphilis, with lupus non exedens, lupus erythematosus, morphcea, and elephantiasis; as, also, epithelioma, and carcinoma cutis. In syphiloderma, lupus non exedens, and morphcea lardacea, the altered and degenerate tissue is removed by absorption without lesion of continuity; in elephantiasis a similar action takes place, but more frequently the skin is so much disorganized that it falls into ulceration ; while in epithelioma and carcinoma, ulceration is the common sequel. The morbid tissue of morphcea alba lardacea is probably amyloid in its nature. CHAPTER III. CLASSIFICATION OF DISEASES OF THE SKIN. The ancient records of medicine afford ample evidence of the early attention given by medical philosophers to cutaneous diseases. The external position of these diseases, and the admiration of the ancients for manly beauty, no doubt contributed to this attention; and, we have had handed down to us, and make use of, at the present day, terms that were employed by ^Esculapius, by the Asclepiadae, and by Hippocrates and his successors. The growth of these diseases on the skin very naturally suggested a comparison with the parasitic growth found on the bark of trees, and the adoption of the term lichen1 and lichenes; while their spreading character is distinguished by the term herpes. The habit of breaking forth over the whole surface, like a plant bursting into blossom, suggested the term ex- anthema; their roughness and scaly quality is expressed by the word lepra ; their itchiness by psora ; and their proneness to vesication by phlyctense. Their color contributed the terms alphos, leuce, melas, erythema; their occurrence at a certain period of life, acme; and, their general eruptive quality, the term eczema. The word eczema occurs for the first time in the writings of iEtius; but this term, like 1 Vide Glossary at the end of the volume. 7 98 CLASSIFICATION OF DISEASES OF THE SKIN. the rest, was probably in common use among the people from whom the whole of the terms apparently took their origin. If, therefore, we assemble these terms in a group, we arrive at the conclusion that a very practical diagnostic classification of cutaneous diseases existed among the ancients from the earliest times. For ex- ample :— Lichen, Phlyctenae, Melas, Herpes, Exanthemata, Acme, Lepra, Alphos, Eczema. Psora, Leuce, Lichen, or lichenes, is a general expression for " an eruption," and more recently became associated with the synonymous expression, eczema; herpes would be used to distinguish the spreading forms of eruption generally; lepra, the squamous eruptions; psora, the itchy eruptions; phlyctenae, the vesicular and bullous eruptions; exanthe- mata, the general efflorescences; erythemata, hyperaemic blotches of all kinds; and alphos, leuce, and melas, the so-called discolorations. In the minds of the Greeks, these terms were evidently generic expressions, but, in their descent to ourselves, they have under- gone considerable modification of meaning, and have at present a specific signification often totally different from that originally in- tended. Since the days of Willan, lichen, no longer used in the plural, is an eruption of pimples, and herpes is one of large vesicles. Willan was faithful to the ancient signification of lepra, namely, squa- mous ; but, at present, we restrict that term to a disease which is not squamous, namely, the elephantiasis of the Greeks. Psora, which so admirably represented the pruriginous affections, which corresponds with the eczema of our own times, and so long retained a place as a synonym of scabies, is at present almost disused; the term being only revived in its derivative psoriasis, the psora leprodes of earlier writers. Phlyctenae we occasionally employ as a term significative of large vesicles, as in the instance of herpes phlyctenodes. Exanthemata is now confined to the eruptive fevers; and erythema, to simple hyper- aemia of the skin. Alphos we have endeavored to retain in the sense in which that term is used by Celsus; not as an achromatous affection, but as a representative of the lepra of Willan. Leuce and melas are dyschromatous disorders, both associated with the elephantine lepra, and, at the same time, the type of existing forms of achroma and dyschroma. The leading characters of distinction of cutaneous diseases recog- nized by the ancients would seem, therefore, to have been their well- known qualities of itching, spreading, desquamating, vesicating, general efflorescence, and discoloration. We may arrange them as follows:— Psoric, Squamous, E xanthomatous, Herpetic, Vesiculous, Maculous. Now, these are among the chief of the characters which have en- gaged the attention of nosologists in the classification of those diseases, CLASSIFICATION OF THE GREEKS. 99 from the earliest to the present times. Sometimes, their classification has been framed on the signs and symptoms of the disorder, some- times on the cause, and sometimes on the supposed nature of the dis- ease, as inferred from its relations and phenomena. The signs and symptoms of disease are for the most part conspicuous to the eye, and are, therefore, least liable to occasion error. The cause and the nature of a disease are subject to the interpretation of the mind, and can be deduced only from long and varied observation and experience; the first, is the foundation of a classification suitable to the infancy of science, or to assist the early days of study; the second is the conse- quence of the first, and is especially adapted to the management and treatment of disease. The first has its type in the classification of Willan, which has been compared with the classification of the vege- table kingdom by Linnaeus; the last, in the classification of Alibert, which, in comparison with the botanical arrangement of Jussieu, has been termed the " natural" classification. There is still a third classi- fication ; one which takes its inspiration from general pathology, and is purely scientific in its plan, not arising especially out of the con- sideration of the skin, like the preceding, but a framework of the general pathology of the body applied to the special organ, the skin; this latter is the classification of Hebra. A moment's reflection will make apparent to the reader, that no classification can be framed upon a large group of diseases that shall be complete in every particular ; and, therefore, in the construction or adoption of a classification, it becomes necessary to bring before the mind the precise object which we have in view in employing it. The student seeks to acquire a knowledge of individual diseases; and, therefore, to him the visible signs and appearances of the disease are the most important study; but, having mastered this his first lesson, and having attained the knowledge which enables him to deal with these diseases as a whole, and, with the aim of treating them medi- cally, he is led to seek for other combinations, and to create a classi- fication which is founded on the nature and affinities and cause of a given disease, or of a group of diseases. The Willanean classification may teach him to distinguish between a roseola, a lichen, an eczema, a pemphigus, and an acne; but he must look to a different arrange- ment to enable him to acquire the diagnosis of an eruptive fever, a | syphiloderma, or a scrofuloderma; and, in the treatment of these latter affections, every consideration of classification must be merged in the obligation of treating successfully a blood-poison or a'diathesis. We have, therefore, come to the conclusion, that not one classification, but several are necessary to the understanding and management of cutaneous complaints, and that the attainment of a single classification that shall fulfil the double object of learning and treating, is a specu- lation that is alike unnecessary and impossible. It was common in the early days of medicine to divide diseases of the skin into : affections of the body, and affections of the nobler part of the body, the head; and, so recently as the beginning of the eighteenth century, our countryman Daniel Turner followed a similar topographical classification. He arranges them in two groups, diseases 100 CLASSIFICATION OF DISEASES OF THE SKIN. of the general surface, and diseases of parts of the surface; under the former head he includes, lepra Arabum; lepra Graecorum; knesmos or pruritus; the eruptions of children, embracing psydracia, phlyc- tenae, and sudamina; herpes; erysipelas; variola, rubeola, and spotted fevers; carbuncle, cancer, and lupus; furunculus, epinyctis and terminthus; diseases of perspiration; diseases of pigment; and marks, and naevi materni; while, under the title of local affections, he treats of diseases of the hair; scall-head and porrigo; phtheiriasis; diseases of the face; of the hands and feet; of the prepuce; of the anus, including haemorrhoids; of imperforate passages; hurts; burns; bites of venomous creatures; and hurts from venomous insects, and enve- nomed instruments.' Celsus, who records the state of knowledge of medicine at the period immediately preceding the Christian era, and describes between forty and fifty cutaneous diseases, foreshadows a therapeutical classifi- cation ; he arranges these diseases in the first place, remedially, accord- ing to their amenability to hygiene and diet, to drugs, or to surgical manipulation; and secondly, topographically, according to position, whether general, partial, or topical; and groups them under four heads, namely: 1. Diseases general in their nature, to be treated by diet; 2. Diseases which may occur on any and every part of the body, to be treated by medicines; 3. Diseases limited to a part, to be treated by medicines; and, 4. Diseases to be treated by surgical means. In the first group, elephantiasis Graecorum stands alone. The second group includes the large majority of cutaneous diseases, and his mode of arrangement, is to take the largest, the most prominent, and, to the eye, the most important, first, for example, carbuncle, and gradually descend from decided prominence to mere asperity; in the latter in- stance, placing asperity with inflammation as represented by exan- thema and scabies (eczema), before asperity without inflammation, as in alphos; and following these with smoothness, as in the case of leuce. The third group is devoted to affections of the hairy scalp, the eyelids, and the face; and the fourth to encysted tumors. The diseases occur- ring on any and every part of the body, and amenable to treatment by medicines, are: erysipelas from wounds; bites and stings of animals; carbuncles; therioma, a syphilitic or strumous ulcer; ignis sacer, also, probably, a syphilitic or strumous ulcer; pernio; struma; furunculus ; phyma; phygethlon, a cutaneous abscess; kerion; acrochordon ; thy- mion, a kind of wart; myrmecia, also a wart; clavus; pustulae; Exan- themata ; phlyctenae; phlyzacion; epinyctis; scabies; impetigo; papulae ; vitiligo; alphos; melas; and leuce. The affections of the hairy scalp, and face, are: defluvium capillorum; calvities; porrigo ; sycosis; area ; alopecia; ophiasis; varus; lenticula; semeion; ephelis; and phtheiri- asis. Of the diseases to be treated by surgical means, the examples are, the encysted tumors of the scalp, which he terms, ganglion; meli- ceris and atheroma.2 1 De Morbis Cutaneis ; a treatise of diseases incident to the skin. By Daniel Turner, M. D. Fourth edition, 1731. 2 See our Essay on the Dermopathology of Celsus ; read at the meeting of the British Medical Association, 18t>3 ; and published in the British Medical Journal. plenck's and willan's classification. 101 Another classification, and one which, more than any besides, has stood the test of time and of opinion, is founded on the visual appear- ance of the morbid skin, and takes, as its groundwork, the physical signs of the disease appreciable to the eye; in other words, the patho- logical signs or lesions. Biolanus, a French author of the sixteenth century, informs us, that some physicians, among whom was his dis- tinguished contemporary, Mercurialis,1 include all diseases of the skin under three heads; namely, alterations of smoothness, of color, and of magnitude; but that, as by this arrangement, no place is given to dis- orders of the hair, he prefers to arrange them into pustules, deformities, and tubercles; pustules comprehending all eruptions attended with roughness of the skin, whether pimples, vesicles, pustules or scales; deformities, marks of all kinds, morbid colorations, and diseases of the hair; and tubercles, warts, corns, and condylomata.2 In this simple arrangement, we have the foundation of the classification of Plenck; and, subsequently, that of Willan. Plenck divided diseases of the skin into fourteen classes, and the latter into one hundred and fifteen genera; his fourteen classes being as follows :— Plenck's Classification (1776).3 Maculae. Crustae. Vulnera cutanea. Pustulae. Squamae. Insecta cutanea. Vesiculae. Callositates. Morbi unguium. Bullae. Excrescentiae cutaneae. Morbi pilorum. Papulae. Ulcera cutanea. Twenty years later, Willan published the classification which goes by his name. He adopts, as Orders of his class of cutaneous diseases, six of the classes of Plenck ; namely, maculae, pustulae, vesiculae, bullae, papulae, and squamae; combines callositates and excrescentiae cutaneae under the head of tubercula; adds to these a new order, exanthemata, and omits altogether, crustae, ulcera cutanea, vulnera cutanea, insecta cutanea, morbi unguium, and morbi pilorum. His eight orders are as follows:— Willan's Classification (1798). 1. Papulae. 4. Bullae. 7. Tubercula. 2. Squamie. 5. Pustulae. 8. Maculae. 3. Exanthemata. 6. Vesiculae. It must not, however, be supposed that the classification of Willan was a mere adoption of certain of the classes of Plenck; in the hands of Willan these orders had acquired a new and deeper signification ; and, it is to Willan, that we owe the exact definitions of the terms of 1 De Morbis Cutaneis, et de omnibus corporis humani excrementis ; access, de deco- ratione. 4to. 1585. Natus 1530; obiit. 1606. « Joannis Riolani, ambiani, medici Parisiensis viri clarissimi opera omnia. 1610. Natus 1539 ; obiit. aetatis 6<5, anno salutis 1605. ■* Josephi Jacobi Plenck ; doctriua de morbis cutaneis, qua, hi morbi in suas classes, qenera et species rediguntur. Editio secunda aucta, 1783. 102 classification of diseases of the skin. cutaneous pathology which we use at the present day, and which must continue to be used as long as cutaneous medicine is made a subject of study. The definition of the papulae, squamae, exanthematae, bullae, pustulae, vesiculae, tubercula, and maculae, is precise, and identified with the language of cutaneous medicine; whatever differences may exist among authors with regard to the classification which, to them, seems the best for the illustration and development of the subject. A papula, says Willan, " is a very small and acuminated elevation " of the skin, "with an inflamed base, very seldom containing a fluid, or suppurat- ing, and commonly terminating in scurf." Squama " is a lamina of morbid cuticle, hard, thickened, whitish and opaque. Scales, when they increase into irregular layers are denominated crusts." Exan- themata are " superficial red patches, variously figured, and diffused irregularly over the body, leaving interstices of a natural color, and terminating in cuticular exfoliations." Bulla is " a large portion of the cuticle detached from the skin by the interposition of a transparent watery fluid." Pustula is "an elevation of the cuticle with an inflamed base, containing pus." Vesicula is " a small orbicular eleva- tion of the cuticle, containing lymph, which is sometimes clear and colorless, but often opaque, and whitish or pearl-colored. It is suc- ceeded by scurf, or by a laminated scab." Tuberculum is " a small, hard, superficial tumor, circumscribed and permanent, or suppurating partially." Macula is "a permanent discoloration of some portion of the skin, often with a change of its texture." These definitions have remained fixed since they were first given forth by their author, and have become a necessary and unchangeable part of the language of dermopathology. Their value is further enhanced when we turn to the pages of Plenck and note the manner in which the same terms were employed by him. The class of papulae of the latter author, includes among other diseases, acne, tuberculum^ phygethlon, lepra Graecorum, and lepra Arabum. In his group of squamae, we find, furfuratio, porrigo, lichen, impetigo, and ichthyosis. Among bullae, occurs phyma or abscess; pustulae includes, besides elevations of the cuticle containing pus, scabies, variolae, varicellae, and terminthus, a kind of boil. Vesiculae, in addition to sudamen, and miliare, has uritis or the blisters following a burn; tubercula, represented by-excrescen- tiae cutaneae, is composed of, verruca, cornua, condyloma, and fram- boesia; and maculae, of six genera, viz., fuscae, rubrae, lividae, nigrae, albae, and incerti coloris; maculae rubrae, containing gutta rosacea, stigma, erythema, morbilli, scarlatina, urticaria, maculae venereae, esserae, psydraciae, rubedo cutis, zona, and macula lata Plateri seu ignis sacer. The above comparison between the classification of Plenck, and the more precise and better defined signification of the terms employed by Willan, is sufficient to explain the popularity of the classification of the latter, and its adoption by a distinguished line of successors, among whom may be enumerated most of the dermatologists of France. It is to be regretted that Willan did not carry his classification a little further, so as to embrace, not only the skin proper, to which his defini- tions are restricted, but also the hair system, the glandular system, and biett's classification. 103 the epidermal system ; and his scheme would have been more complete had he besides, noted the varieties of disease which, in their several stages, present a multiple elementary form. Among the earliest of the French dermopathologists who adopted the classification of Willan, are Biett, Cazenave, Schedel, Rayer, and Gibert. The last named author calls his book a practical treatise on the special diseases of the skin, and limits his field of research, as did Willan and Bateman, to the diseases of the skin proper, making no effort to extend the list of the eight orders of Willan. Biett, who stands first among the followers of Willan in France, altered for the better, the arrangement of the eight orders of Willan, and at the same time, thought it desirable to add to their number, as follows:— Biett's Classification (1828). 1. Exanthemata. 9. Lupus. 2. Vesiculae. 10. Pellagra. 3. Bullae. 11. Syphilides. 4. Pustulae. 12. Purpura. 5. Papulae. 13. Elephantiasis Arabum. 6. Squamae. 14. Diseases of the seba- 7. Tubercula. ceous follicles. 8. Maculae. 15. Keloide. It must be admitted that the order of arrangement of the eight groups of Willan, adopted by Biett, is superior to that of their author, inasmuch as it corresponds more closely with the successive develop- ment of the morbid phenomena as they appear in the skin; hyperae- mia, represented by exanthemata, commonly precedes exudation, as instanced by vesiculae, bullae, and pustulae; while papulae, squamae, and tubercula, are unaccompanied with exterior exudation. His further additions are also important, as illustrative of struma; syphi- lis ; haemorrhagic dyscrasis; kelis ; diseases of the sebaceous system; and the exotic affections, pellagra, and elephantiasis Arabum or boucnemia. But he omits, as did Willan, diseases of the hair, a sub- ject notably indicated by Eiolanus and Plenck. Another eminent physician of the French school, Rayer,1 enlarges still further the system of Willan, and availing himself of the more advanced progress of anatomy and physiology of his day, takes into his classification that division of the whole subject which we have al- ready pointed out as an omission on the part of the English author. Rayer established three primary divisions, namely, diseases of the skin proper; diseases of the dependencies of the skin, comprising the se- baceous system, hair system, and nails; and diseases resulting from the presence of foreign bodies on the surface, under, or in the sub- stance of the skin; the latter having reference to parasitic animals. Diseases of the skin proper he divides into the six following heads:— 1 Rayer published the first edition of his work in 1828, the second in 1835. 104 classification of diseases of the skin. Rayer's Classification (1835). 1. Inflammatory affections. 2. Non-inflammatory affections. 3. Diseases of the secreting functions. 4. Neuroses. 5. Faulty structure; or unusual state of one or other of the ele- mentary components of the skin. 6. Degenerations. His first division, inflammatory affection, he subdivides into two groups, under the heads of, diseases presenting a single elementary form, and diseases presenting several elementary forms. As examples of the first of these groups, he includes all the orders of Willan with the exception of maculae, and adds two additional groups, furunculi and gangrenae. His arrangement is as follows :— Exanthemata, Pustulae, Papulae, Bullae, Furunculi, Squamae, Vesiculae, Gangrenae, Tubercula. The diseases presenting several elementary forms, are:— Syphilis, Ambustio, Pernio. The elementary forms which he signifies by this arrangement, are, as respects syphilis, exanthematica, bullosa, vesiculosa, pustulosa, squamosa, papulosa, tuberculosa, and vegetativa; and as respects am- bustio and pernio, exanthematica, bullosa, and gangrenosa. The non- inflammatory affections are, anaemiae, congestus sanguinis, and haemor- rhagiae; diseases of the secreting functions, ephidrosis and epidermidis exfoliatio; and neuroses,' anaesthesia and hyperesthesia. Faulty structure or unusual state of one or other of the elementary compo- nents of the skin, embraces: disorders of pigment; hypertrophiae, as of the papillae and epidermis, of the vessels, constituting naevus, of the corium as in kelis and elephantiasis Arabum; gangraena simplex ; cicatrices; defectus congenitus cutis; and extensio vel relaxatio in- solita cutis. While the degenerations of structure are, fibrous, melano- tic, and tuberculous. I Turning from the visible to the invisible; from the particular to the general; we shall find that efforts have not been wanting to es- tablish a classification upon the presumed cause of the disease. The theory of the dependence of a disease upon a constitutional or upon a local cause, dates back to the age of Hippocrates, and has been adopted in modern times by Lorry, and more recently by Baumes in his " Nouvelle Dermatologie." We have ourselves attempted an etiologi- cal classification, in which we arranged the diseases of the skin proper into five groups, as follows:— 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 poisons of unknown origin, and givino- rise to eruptive fevers. alibert's classification. 105 The general causes here referred to, are such as originate in nutri- tive, assimilative, and nervous debility; and the diseases included under this head, the erythemata, for example, erythema, erysipelas, urticaria, and roseola; the papulae, lichen, strophulus, and prurigo; the vesiculae, eczema and sudamina; the bullae, herpes and pemphi- gus ; the pustulae, impetigo and ecthyma; the furunculi including anthrax ; and purpura. Special external causes are illustrated by the irritation of animals upon, or under the skin, and by the action of heat and cold; and special internal causes, by diathesis, as in the case of alphos, lupus, scrofuloderma, kelis, and elephantiasis Graecorum. The syphilitic poison as a cause of syphilodermata is self-evident; as also are the poisons which give origin to rubeola, scarlatina, variola, and vaccinia. The idea of constructing a classification which should have for its object a practical aim ; which should be founded on the nature, affini- ties, and cause of cutaneous disease, and consist of a few primary groups, each containing a number of diseases, more or less closely united by family resemblance, and amenable to a similarity of treat- ment, is a merit which is due to Alibert; and although the classifica- tion of Alibert has not become popular, probably from defective com- position of his groups, the idea of a natural classification must be regarded as an important step in the progress of dermatological medi- cine. The scheme of Alibert was composed of twelve divisions, and these twelve groups, the so called branches of the "tree of the der- matoses," are as follows:— Alibert's Classification (1810). Eczematous. Cancerous. Scabious. Exanthematous. Leprous. Haematous. Tineous. Syphilous. Dyschromatous. Dartrous. • Strumous. Heteromorphous. The term eczematous is used in the sense of " eruptive," and has no reference to the disease which we at present term eczema; the ecze- matous dermatoses being, erythema, erysipelas, pemphix, zoster, phly- zacia, cnidosis (urticaria), epinyctis, olophlyctis (herpes), ophlyctis (aphtha), pyrophlyctis (bulla ambustionis), anthrax, and furunculus. The exanthematous dermatoses comprehend: variola, vaccinia, cla- vele'e (variola ovina), varicella, nirle (a varioloid), roseola, rubeola, scarlatina, and miliaria. The tineous dermatoses are: achor, porrigo, favus, and trichoma (plica polonica). The dartrous dermatoses consist of herpes, under which name he comprises the squamous diseases, lepra vulgaris, psoriasis and pity- riasis ; varus (acne and sycosis), melitagra (impetigo), and esthiomene or lupus. The cancerous dermatoses include, carcinoma, and keloid;— The leprous dermatoses, leuce, spiloplaxia, elephantiasis, and radsyge (a syphiloderma);— The syphilous dermatoses, syphilis, and mycosis (framboesia) ;— 106 CLASSIFICATION OF DISEASES OF THE SKIN. The strumous dermatoses, scrofula, and farcinoma ;— The scabious dermatoses, scabies, and prurigo;— The hcemalous dermatoses, peliosis (purpura), and petechiae; The dyschromatous dermatoses, pannus (a generic term for lentigo), ephelis, pityriasis versicolor, and pityriasis nigra; and— The heteromorphous dermatoses, namely, ichthyosis, tylosis, verruca, onygos (onychia), dermatolysia (abnormal extensibility of skin), and naevus. If we run the eye over the classification of Alibert with the view of discovering the special features represented by the terms which he has employed; we shall find them to be as follows: 1. eruptions having the general characters of inflammation ; 2. febrile affections; 3. affections of the scalp; 4. tetters, or chronic scaly eruptions; 5. cancers; 6. affections related to leprosy ; 7. diseases originating in the poison of syphilis; 8. scrofulous affections; 9. pruriginoiis affections; 10. diseases of dyscrasis of the blood; 11. alterations of color; and 12. diseases not included in preceding groups. One of the most recent of the professors of the French school, Hardy, after doing full justice to the classification of Willan, gives a prefer- ence to the natural classification as advocated by Alibert, and arranges the diseases of the skin proper into ten classes, as follows:— 1. Maculae: deformities. 6. Dartres. 2. Local inflammations. 7. Scrofulides. 3. Parasitic affections. 8. Syphilides. 4. Eruptive fevers. 9. Cancers. 5. Symptomatic eruptions. 10. Exotic diseases, Maculae, deformities; include morbid alterations of color, ephelis, lentigo, together with warts, molluscum, ichthyosis, and kelis. The local inflammations are, erythema, urticaria, herpes, ecthyma, pem- phigus, &c; and parasitic affections, scabies, sycosis, herpes cir- cinatus, and favus. The eruptive fevers are scarlatina, rubeola, variola, &c, and the symptomatic eruptions, herpes labialis, typhus spots, sudamina, and purpura. The dartres are, eczema, psoriasis (lepra vulgaris), lichen, and pityriasis. The scrofulous, syphilitic, and cancerous affections speak for themselves; while the exotic diseases comprehend, among others, lepra tuberculosa and pian.1 Another eminent dermopathologist and author of the French school, a predecessor of Hardy, namely, Devergie, expresses dissatisfaction with all existing classifications; criticism, he remarks, is an easy task; but what shall we substitute in place of these classifications ? To this question he replies by a confession of incapacity; the efforts of Bazin and Hardy, he says, are as little successful as those of their predecessors, and Bazin, like ourselves, has criticized, without elevat- ing anything in the place of that which he destroys. Nevertheless, we are under the necessity of framing a scheme which shall have the appearance of logical order; and, therefore, we have submitted to the idea of creating certain morbid groups: the motives which have 1 Lecons sur les Maladies de la Peau, etc., 1863. DEVERGIE'S CLASSIFICATION. 107 guided us in the construction of these groups being : 1. Analogy of cause and treatment; 2. Morbid forms; 3. Morbid products; 4. Cli- matic origin. In this way we have succeeded in assembling diseases of the skin, in fourteen groups, as follows :— Devergie's Classification (1857). 1. Erythema, urticaria, roseola. 2. Eczema, herpes. 3. Pemphigus, ecthyma cachecticum. rupia, purpura, scorbutus. 4. Impetigo, ecthyma, sycosis, acne simplex et rosacea. 5. Lichen, prurigo, strophulus. 6. Pityriasis, psoriasis, lepra vulgaris, ichthyosis. 7. Tinea, herpes tonsurans, porrigo decalvans, sycosis, herpes circinatus, pityriasis versicolar, plica. 8. Scabies, phtheiriasis, acne punctata. 9. Lupus, scrofulo-s}rphilides. 10. Syphilides. 11. Pellagra, lepra, Aleppo boil, pian, kelis, molluscum, plica. 12. Abnormal and accidental products. 13. Diseases of nails. 14. Affections of the hair; especially that of the suckling infant. Diseases of particular regions of the body. Lastly, we have the classification of Hebra, who advocates the idea of the homogeneity of the skin with the rest of the economy, and takes, as the groundwork of his arrangement, the pathology of the general system, adapting this pathological framework to the special organ, the skin :—his classification is as follows:— 1. Hyperaemiae. 7. Atrophiae, 2. Anaemiae. 8. Neoplasmata (homoeo- 3. Anomaliae secretionum et plasiae). organorum secernentium 9. Pseudoplasmata (hetero- cutis plasiae). 4. Exsudationes. 10. Ulcerationes. 5. Haemorrhagiae. 11. Neuroses. 6. Hypertrophiae. 12. Parasitae. The hyperaemiae are active and passive, and each division idiopathic and symptomatic; the active idiopathic diseases being, erythema traumaticum, caloricum, et ab acribus seu venatum; the symptomatic, erythema seu roseola infantilis, variolosa, et vaccina ; the passive idio- pathic diseases are, livedo mechanica et calorica; the symptomatic, cyanosis. 2. The anaemiae, are, anaemia ex jactura sanguinis ; and anaemia ex inervatione anomala. 3. Anomaliae secretionum et organorum secernentium cutis, are applicable to the sebaceous and perspiratory secretion; the sebaceous secretion may be excessive, deficient and faulty; both in quality and excretion ; giving rise to seborrhoea, dryness of skin, also to comedo, milium, and molluscum contagiosum. The sudatory secretion may present anomalies of quantity, as in ephidrosis and anidrosis; and, 108 classification of diseases of the skin. anomalies of quality, as in odor hircinus, uridrosis, galactidrosis, and menidrosis. 4. Exsudata: that is, inflammation of the skin accompanied with exudation from the bloodvessels of inflammatory products, are arranged as follows: acute contagious, morbilli, scarlatina, variola, vaccinia; non-contagious, erythemata polymorpha, roseola, urticaria ; dermatitis idiopathica; dermatitis symptomatica, erysipelas, furunculus, anthrax, pseudo-erysipelas, farcinoma, pustula maligna; phlyctaenosen, herpes, miliaria, sudamina, pemphigus acutus. Chronic; dermatoses squa- mosa^ psoriasis seu lepra Willani, lichen exsudativus, pityriasis rubra; dermatoses pruriginosae, eczema, scabies, prurigo; dermatoses acne- formae, acne vulgaris, sycosis, acne rosacea; dermatoses pustulosae, impetigo, ecthyma; dermatoses pemphigosae, pemphigus chronicus. 5. Haemorrhagiae: purpura. 6. Hypertrophiae: epidermis, lichen pilaris, tyloma, clavus; pity- riasis simplex, ichthyosis, verrucae, naevus verrucosus; pigment, len- tigo, chloasma, melasma, naevus spilus, pityriasis versicolor et nigra; corium, elephantiasis Arabum ; follicles, sebaceous, hair-follicles; ap- pendages, excess of hair, cornu cutaneum, supernumerary nails, thick- ening of nails. 7. Atrophiae: epidermis, pigment, cutis, follicles, appendages as hair and nails. 8. Neoplasmata : epidermis, condyloma; areolar tissue, molluscum simplex, acne rosacea, lupus ; fibrous tissue, cicatrices, keloid, callus; fatty tissue; vascular tissue;'cholesteatomatous; osseous tissue; me- lanotic. 9. Pseuddplasmata: cancer, tubercle. 10. Ulcerationes: idiopathicae, symptomaticae. 11. Neuroses: hyperaesthesia, anaesthesia, dermatospasmus. 12. Parasiticae : dermatophyta, favus, alopecia, sycosis; dermatozoa, pediculi, acarus folliculorum, sarcoptes hominis. Of the twelve classes of Hebra, six rest upon a foundation of visual characters, for example : hyperaemiae, anaemiae, haemorrhagicae, hyper- trophiae, atrophiae, and parasitae; and the remaining six, upon cha- racters partly physiological, but chiefly pathological, namely: anomaliae secretionum et organorum secernentium cutis, neoplasmata, exsudata, pseudoplasmata, ulcerationes, and neuroses. The class, exsudata, com- prehends inflammation and the products of inflammation, and, conse- quently, includes, the great proportion of diseases of the skin, indeed, nearly the whole of the diseases composing Willan's classification; therefore, in comparing the different classifications, we see a reason for the apparent simplicity of that of Willan, namely, that it divides among seven orders, diseases, which are embraced by Hebra, under the single word, exsudata; but seeing this to be the case, if it be our intention to subdivide, with a view to simplification of comprehen- sion and of study, the group of exsudata calls for a special classifi- cation of its own. The exsudata of Hebra contains upwards of twenty-six separate diseases, held together by the slender thread of their origin in inflammation, and their evolution of inflammatory pro- ducts, whether in the shape of infiltration or exudation of serum, pus, hebra's classification. 109 or abnormal epidermal tissue; and these twenty-six diseases are divided primarily, into acute and chronic; and, secondarily, into nine sub-groups; thus : the acute exsudata are divided into, contagious, non-contagious, dermatitides, and phlyctaenosen; and the chronic exsudata into, squamous affections, pruriginous affections, acneform affections, pustular affections, and pemphigous affections. The four- teen constituents of the acute exsudata are: rubeola, scarlatina, variola, vaccinia, erythema, exsudativum, roseola, urticaria, dermatitis idio- pathica, erysipelas, furunculus, anthrax, herpes, miliaria, and pem- phigus acutus, with some others. The twelve constituents of the chronic exsudata are: psoriasis seu lepra Willani (alphos), lichen, pityriasis, rubra, eczema, scabies, prurigo, acne, sycosis, acne rosacea, impetigo, ecthyma, and pemphigus chronicus. In reviewing the preceding classifications, for the purpose of ascer- taining the leading idea which has suggested their construction, we shall find these ideas, with the exception of that of the pathological classification of Hebra, to be five in number; namely, seat of the dis- ease ; amenability to treatment; cause, as being constitutional or local; visual characters; and, nature and properties of the affection. The seat of the disease is suggestive of certain peculiarities evinced by cutaneous disease when it attacks different regions of the body, as the scalp, the face, the hands, and the feet; but does not afford sufficient ground for a classification of the whole of the diseases of the skin, and the less so, as the same disease may one while be a general affection, and another while be limited to a part. If we were required to in- stance a disease peculiar to the scalp, we might name tinea or favus, but tinea and favus are both found occasionally on other regions of the body, the only possible reason for the distinction in question being, the modification which diseases of the scalp undergo from the presence of hair. Amenability to treatment affords as little scope for classification as that which is founded on the seat of the "disease, and is an uncertain ground of distinction ; diseases which, in the time of Celsus, may have been classed as fit to be treated by diet alone, may, with our present knowledge, be more successfully controlled by medicines; the incu- rable diseases of a few years back may at present be perfectly curable ; and that which seems indomitable to-day may, a few years hence, be conquered with ease. Similar objections may be raised to the group- ing of diseases under the head of specific remedies, for example, arsenic, sulphur, tar, &c. The cause of the disease, if it could be determined with accuracy, would be a legitimate ground of classification; but the proposed cause of a disease is, in many instances, a mere matter of opinion, and obeys the leading theory of the day. In our early study of medicine all local diseases were referred to a constitutional cause; functional dis- turbance of the chylopoietic system was supposed to give rise to morbid humors, and the manifestation of this morbid state might be evinced by any of the organs of the body, and among others, by the skin; or, there existed a morbid alteration in the constitution of the blood ; and the operation of these morbid elements, either in the sens j 110 CLASSIFICATION OF DISEASES OF THE SKIN. of deposition or elimination, became the explanation of cutaneous dis- ease. One while, the theory of the day inclined to humoralism and constitutional management; and another while, to solidism and favored local treatment. Whilst, at the present time, the tissue or cell-theory of disease, is gaining favor, and still further creating a preference for local measures. If it were possible to fix the theory of medicine by a given standard, there might be found a solid basis for an arrange- ment of disease founded on an acknowledged cause; but until that is the case, our attempts in this direction must be in vain. If we reject regional position, therapeutical control, and constitutional or local influence, as affording sufficient grounds for the construction of a classification, there remain for our consideration only, the physical signs, which form the groundwork of the classification of Willan ; and, the special characters of the disease in reference to nature and cause, as suggested by Alibert. And, if we now turn to the diseases them- selves, and measure their capabilities by this standard, we shall find that it is impossible to bring the whole of the diseases of the skin under either of these two heads; that some will conform better to the former and others to the latter; and that a rational or practical classi- fication requires that we should retain the best parts of both. The advocate of the Willanean system discovers the imperfection of his method when he comes to the consideration of diseases of diathesis, such as scrofuloderma, or of blood poisons, as in the instance of the eruptive fevers, syphiloderma, and elephantiasis; and, the follower of the natural system is equally at fault, in the case of those diseases whose only conspicuous character is the external appearance or patho- logical lesion. Considerations of this kind have led us to frame a classification upon a purely practical basis, without regard to the distinctions hereinbefore referred to; and this classification we have taken as the plan of arrangement of the subject matter of the present volume. We assume that we are placed by the bedside of the patient, and that the view that should be taken of the disease before us ought to be such as will embrace all the practical bearings of the disease, and lead inferentially to the soundest method of treatment. The clas- sification in question, which we call the clinical classification, is as follows:— 1. Eczematous affections. 2. Erythematous affections. 3. Bullous affections. 4. Furuncular affections. 5. Nervous affections. 6. Vascular affections. 7. Haemic affections. 8. Developmental and nutritive affections. 9. Hypertrophic and atrophic affections. 10. Alphous affections. 11. Strumous affections. 12. Carcinomatous affections. 13. Zymotic affections. 14. Syphilitic affections. 15. Leprous affections. 16. Pigmentary affections. 17. Phytodermic affections. 18. Ungual affections. 19. Diseases of the hair-system. 20. Diseases of the sebiparous system. 21. Diseases of the sudoriparous system. 22. Traumatic affections. CLINICAL CLASSIFICATION. Ill These twenty-two groups include all the diseases of the skin, of the skin proper, as well as of the hair system, and the gland system. Tak- ing them in their order, it will be seen that the first four, namely, eczematous, erythematous, bullous, and furuncular affections, embody the diseases which involve the general structure of the derma. The fifth, sixth, and seventh groups are devoted to the consideration of the nerves, the vessels, and the blood, constituting a part of the special structure of the derma. The eighth and ninth groups comprehend the morbid changes taking place in the skin, the consequence of errors of development, nutrition, and growth. The tenth, eleventh, and twelfth groups consist of the diseases of diathesis: for example, alphos (lepra Willani), struma, and carcinoma. The thirteenth, fourteenth, and fifteenth groups include the diseases resulting from a blood-poison, namely, the zymotic affections, syphilitic affections, and the leprous affections. The sixteenth, seventeenth, and eighteenth groups consist of diseases limited especially to the epidermis, for example, the pig- mentary affections, phytodermic affections, and ungual affections. The nineteenth, twentieth, and twenty-first groups include the dis- eases of the follicles of the skin and their dependencies, namely, the hair system, sebiparous system, and sudoriparous system; and the twenty-second group is devoted to diseases induced by injury, in other terms, traumatic affections. If we assemble the individual groups ac- cording to this arrangement of the subject, they may be stated as follows:— 1. Diseases of the general structure of the derma. 2. Diseases of the special structure of the derma. 3. DUeases of development, nutrition, and growth. 4. Diseases of diathesis. 5. Diseases resulting from blood-poison. 6. Diseases of the epidermis. 7. Diseases of the follicular apparatus and hairs. 8. Traumatic diseases. And the eight groups might, upon a physiological basis, be further reduced to half that number, as follows:— 1. Dermal affections. 3. Follicular affections. 2. Epidermal affections. 4. Traumatic affections. The dermal affections, including:— a. Diseases of general structure. b. Diseases of special structure. c. Diseases of function. d. Diseases of diathesis. e. Diseases of blood-poisoning. The individual diseases arranged under the above twenty-two groups, are as follows:— 112 classification of diseases of THE SKIN. 1. Eczematous affections. Eczema, Strophulus, . Psoriasis, Impetigo, Pityriasis, Scabies, Lichen, Gutta rosacea. 2. Erythematous affections. Erythema, Urticaria, Erysipelas, Roseola. 3. Bullous affections. Herpes, Miliaria, Pemphigus. 4. Furuncular affections. Ecthyma, Anthrax, Furunculus, Pustula maligna, Hordeolum, Pustula Alleppensis. 5. Nervous affections. Hyperaesthesia, Pruritus, Anaesthesia, Prurigo. 6. Vascular affections. Naevus vasculosus, Hypertrophia venarum. 7. H^EMODYSCRASIC affections. Purpura. 8. Developmental and nutritive affections. Xeroderma. Sauriosis, Ichthyosis, Cacotrophia cutis. 9. Hypertrophic and atrophic affections. Naevus hypertrophicus, Dermatolysis, Ecphyma, Kelis, Verruca, Boucnemia, Clavus, Atrophia cutis. 10. Alphous affections. Alphos, seu lepra Willani. 11. Strumous affections. Scrofuloderma, Lupus. 12. Carcinomatous affections. Epithelioma, Carcinoma cutis. clinical classification. 113 Rubeola, Scarlatina, 13. Zymotic affections. Variola, Varicella, 14. Syphilitic affections. Syphiloderma. 15. Leprous affections. Elephantiasis Graecorum vel Lepra, 16. Pigmentary affections. Vaccinia, Equinia. Morphcea. Melanopathia, Xanthopathia, 17. Lentigo, Chloasma, Cyanopathia, Leucopathia. Phytodermic affections. Nosophyta. 18. Ungual affections. Degeneratio unguium, Onychia. 19. Diseases of the hair system. Ilirsuties, Fragilitas crinium, Alopecia, Trichonosis vel Tinea, Canities, Morbi sebacei, Favus, Kerion, Sycosis. 20. Diseases of the sebiparous system. Epidermic hypertrophy, Comedones, Epithelial hypertrophy, Tumores sebipari, Cancroid hypertrophy, Tumores encystici, Stearrhoea, Tubercula sebacea, Asteotodes, Acne. Allosteotodes, 21. Diseases of the sudoriparous system. Idrosis vel ephidrosis, Anidrosis, Osmidrosis, Chromidrosis, Haemidrosis. 22. Traumatic affections. Malis seu maliasmus, Ambustio, Gelatio. The Clinical Classification is founded on a certain knowledge of the diseases which it assembles together; it assumes that its terms, for example, eczematous, erythematous, bullous, furuncular, &c, embody a precise idea, and carry with them, not only a notion of the nature of the disease, but also of the method to be pursued in its treatment. It has another practical bearing; it brings together diseases, which, taken alone, would seem to be distinct and independ- 114 CLASSIFICATION OF DISEASES OF THE SKIN. ent of each other, for example, eczema, lichen, impetigo, and gutta rosacea; but which, in reality, are due to a similar pathological con- dition, and yield to the same principle of treatment. These are the objects which are sought for by the promoters of a natural classifica- tion, and the aim of such a classification is evidently of a practical nature. But it must be remembered, also, that the first object of study of cutaneous disease, is not to treat, but to know disease, to know, to acquire the power of correct diagnosis; that, at a future time, we may be able to treat successfully. And then the question arises, is a natu- ral system the best for the study of disease, as we admit it to be the best for the practice of treatment ? Clearly it is not; the details of study will be acquired best through the aid of the classification founded on the signs and appearances of disease, the Willanean classification. The Willanean system is the grammar of cutaneous medicine, and should be thoroughly studied and understood before the views em- bodied in the natural classification are undertaken. Hence, also, instead of rejecting the Willanean classification, we should use our best endeavors to improve it as far as possible. With this view, we would propose an amendment of the Willanean classification, suitable to the purposes of the student, as follows :— Willanean Classification (amended). Erythema, Erysipelas, Urticaria, ' Roseola, Pemphigus, Herpes, Miliaria, Vaccinia, Impetigo, Ecthyma, Variola, Lichen, Strophulus, Prurigo, * The diseases marked with an asterisk will be repeated in other groups. 1. Exanthemata. Rubeola, Scarlatina, * Syphiloderma roseolosum, * Eczema erythematosum, * Gutta rosacea erythematosa. 2. Bullae. * Syphiloderma bullosum. 3. Vesiculae. Varicella, * Eczema vesiculosum, ■ * Scabies vesicularis. 4. Pustule. * Eczema pustulosum, * Scabies purulenta, * Gutta rosacea pustulosa. 5. Papula. * Gutta rosacea papulosa, * Scabies papuliformis, * Syphiloderma papulosum. THERAPEUTICS OF THE SKIN. 115 6. Tubercula. Phyma, Lupus, Verruca, Elephantiasis, Molluscum, * Gutta rosacea tuberculosa, Acne, * Syphiloderma tuberculatum. Sycosis, 7. Squama. Alphos (lepra Willani), Pityriasis (erythema squamosum), Psoriasis (eczema squamosum), Xeroderma (ichthyosis). 8. Maculae. Vascular hypertrophy; naevus. Alteration of pigment; ephelis, spilus. To which may be added the diseases presenting several pathologi- cal forms, namely:— Polymorphic group. Eczema, Variola, Scabies, Syphiloderma. Gutta rosacea, The amended Willanean classification will also serve as an aid to diagnosis; thus, a disease being ascertained to be vesicular, it is pro- bably a herpes, a miliaria, or a varicella; but, it may also be an eczema, or a scabies; or, a pustular affection, probably an impetigo or an ecthyma, might also be an eczema, a scabies, a gutta rosacea, or a variola. CHAPTER IV. THERAPEUTICS OF THE SKIN. For the purposes of therapeutical treatment, cutaneous diseases may be regarded as a state of lowered vitality of the skin, originating in a debility which is either local or general. In the former case the treatment required is simply local, and in the latter it must be constitu- tional as well as local. The commonest form of manifestation of lowered vitality of the skin is accompanied with inflammation; but, there are other forms, in which no inflammation is present; hence, a very natural division of cutaneous diseases into inflammatory and non- inflammatory. We have therefore to ascertain, when a cutaneous disease is brought under our observation, in the first place, whether it be inflammatory or non-inflammatory ; secondly, whether it be ac- companied with constitutional symptoms or not; and thirdly, whether 116 THERAPEUTICS OF THE SKIN. the constitutional symptoms be such as result from common or specific functional disorder. We may quote, as examples of these diversities of manifestation of cutaneous disease, namely, of the inflammatory type, eczema and erysipelas; of the non-inflammatory type, prurigo and ichthyosis; the two former affections are'accompanied bycon- stitutional symptoms; the two latter are not; the constitutional symptoms accompanying eczema and erysipelas are, common disor- der of the organic functions of the body; but in another group of diseases of the inflammatory type attended with constitutional symptoms, those symptoms have a specific character, for example, the exanthematic fevers and syphiloderma. Therapeutical treatment, therefore, resolves itself into treatment of the part alone; and treatment of the part conjointly with the general constitution. There are certain forms of disease in which local treat- ment may be all that is called for; but, whenever any disturbance of general health exists, such disturbance will tend to aggravate the local affection, even if it have no relation to it as a cause; and, conse- quently, requires an equal attention with the local disease. In some instances, it is evident that the local disease is first in importance, as in the case of eczema; while in others, as in syphiloderma and the zymotic affections, local treatment is entirely secondary, and often unnecessary. Local treatment has for its object, to subdue irritation and pain; to remove irritants; to shield and protect from irritation; to cause and to check exudation ; to restore tone by judicious stimulation ; and, in some instances, to remove and destroy, either by the aid of caustics or with the knife. Constitutional treatment is intended to regulate the whole of the organic functions, and particularly digestion and secretion; and sub- sequently, to restore power by the aid of tonics. Not unfrequently, the mere regulation of the organic functions, by withdrawing an im- pediment to healthy action, is sufficient in itself to restore power; as in cases, where languid and imperfect digestion, or torpid secretion of the liver or bowels interfere with sanguification and nutrition; at other times, these functions being put in order, the vital action de- mands the further impulse to be obtained from digestive tonics, and sometimes, neuro-tonics. Under the head of constitutional treatment, diet occupies an im- portant place; as also do the hygienic principles, air, exercise, and ablution. The local remedies applicable to cutaneous disease may be ranged under the seven following heads, namely: aqueous, spirituous, ole- aginous, pulverulent, antipruriginous, discutient, and caustic. Aque- ous remedies present themselves in the form of simple water, in its various states of cold, tepid, warm, hot, and steam; water impreg- nated with saline matter, as in the sea-bath and saline solutions, lotions, fomentations, and poultices. Water may be sedative, emol- lient, or stimulant, according to the manner in which it be employed. As a tepid bath or fomentation it is sedative, and its sedative qualities are increased by the addition of various substances, such as oatmeal, OLEAGINOUS REMEDIES. 117 starch, gelatine, and soda in small quantity. It is emollient when used as a water dressing, or in the condition of steam; and it is stimulant when cold or hot. When hot, it is the best means known of relieving pruritus; and in its cold state, it refreshes and gives vigor to the skin; hence the morning bath, the sea-bath, and daily ab- lutions with soap. On this principle it is that we advise daily cold ablutions with soap of the face in cases of acne, and to other parts of the body, particularly the axillae and perinaeum in chronic eczema or chronic pruritus. Aqueous lotions of liquor plumbi are refrigerant and sedative; while lotions of carbolic acid, sulphuret of potash, acetate of ammonia, and bicarbonate of ammonia are anti-pruritic. Warm fomentations are sedative and anodyne, and their properties are increased by the addition of decoction of poppy heads. Poultices also are a means of applying moisture to the skin, sometimes cold, as in the instance of the starch poultice; sometimes hot, as in the bread and linseed poultice; and sometimes in conjunction with carbonic acid, as in the yeast poultice. Poultices are emollient and sedative; but their protracted use, as of all aqueous applications, macerates and weakens the skin, and tends to perpetuate the disease, or to generate boils. As a rule, all aqueous applications, except simple bathing, must be employed with great judgment and caution in cutaneous dis- eases. Saponaceous ablutions commonly aggravate eczematous affec- tions, but there are certain forms and stages of that disease which are benefited by their use. Spirituous lotions are refrigerant and sedative; and we combine with them, sometimes other sedatives, such as acetate of lead, tincture of opium, and hydrocyanic acid; and sometimes stimulants, when we intend them to act as discutients, as in the instance of a spirituous solution of the bichloride of mercury; or, by direct stimulation, when we make the addition of cantharides, iodine, or the tincture of croton seeds. A lotion of spirits of wine and sulphuric aether is a means of great relief in erythema of the eyelids; and a lotion of emulsion of bitter almonds with spirits of wine and hydrocyanic acid, an useful remedy for pruritus. Oleaginous applications have for their especial purpose, the relief of a dry, parched surface ; they serve also to sheath a tender and ex- coriated derma; they exclude the atmosphere and external causes of irritation; and they preserve the moisture of the disordered skin. Sometimes these results are obtained by simply moistening the surface with a glycerine lotion or with the glycerine paste, with an emulsion of almonds, or an oily emulsion, such as the linimentum calcis. At other times, we may have recourse to ointments and cerates, and employ them by merely smearing the surface; or use them as dressings, to be kept steadily applied by means of a bandage. For the relief of irritation and pruritus we may obtain valuable aid from the unguentum plumbi subacetatis, or camphor combined with ben- zoated lard. As an unirritating protection and sheath to the exco- riated skin, the benzoated ointment of oxide of zinc is superior to every other; and. for a similar purpose, the unguentum plumbi com- positum is also useful. As stimulants and discutients, we have valua- 118 THERAPEUTICS OF THE SKIN. ble remedies in the unguentum sulphuris; the unguentum sulphuris hvpochloridi; and an ointment of the iodide of sulphur (gr. x—xx ad I]). Belonging to the same class are the mercurial ointments, diluted in accordance with the purpose required ;_ the unguentum hydrargyri oxidi rubri; the unguentum hydrargyri nitratis; the un- guentum hydrargyri ammoniati; and the unguentum hydrargyri bichloridi: while, in ulceration, we possess an admirable ointment in the unguentum resinae or the unguentum balsami peruviani. Pulverulent remedies are absorbent and desiccative; sometimes cooling, and frequently sedative, from their property of maintaining an equable temperature and protecting the surface from the action of the atmosphere. A pulverulent application is popularized in erysipe- las in the use of the flour dredger. Starch powder also is useful for a similar purpose, and is suitable to erythema, pemphigus, and some forms of eczema. For other purposes we may combine the oxide of zinc with starch powder, the pulvis calaminaris, precipitated chalk, or the powder of Peruvian bark. The latter alone is an excellent remedy in the sloughing stage of carbuncle; in ulcers; and in dis- eases attended with sphacelus. On extensive surfaces, as in cases of erythematous burn and moist eczema, we may derive advantage from the application of chalk in a fluid state, leaving it to dry upon the inflamed surface. Antipruriginous remedies are intended to relieve that most annoy- ing and vexatious symptom, pruritus, which accompanies so many disorders of the skin. First, among these remedies, is water as hot as it can be borne, applied by means of a sponge ; then follow, vine- gar, hot and cold; lemon juice; solutions of carbonate and acetate of ammonia; camphor cerate; refrigerant salts ; hydrocyanic acid ; oint- ment of cyanide of potassium; the juice of the chelidonium majus in solution in glycerine; and the various preparations of tar, unguentum picis juniperi, unguentum picis liquidae, the juniper tar lotion, juniper tar soap, coal tar lotion, carbolic acid lotion and soap, and creosote. In neuralgic pruritus, and in the neuralgia of shingles, we prescribe with much benefit frictions with a liniment consisting of linimentum belladonnae, cajeput oil and chloroform, or the linimentum aconiti. Discutients form a very valuable class of remedies in cutaneous complaints. They are stimulant in their operation, and take the place of tonics among external medicines. The simplest but not the least important members of this class, are the various soaps, simple and medicated, the hard or soda soap, potash or soft soap, the juniper tar soap, carbolic acid soap, petroleum soap, larch soap (sapo laricis, Moore), sulphur soap, zinc soap, fuller's earth soap, and glycerine soap; alkaline solution, solution of sulphite of soda, strong potash solution, solution of chloride of zinc, solution of pentesulphide of cal- cium ; with ointments of tar, sulphur, mercury, and iodine. And we may include in this enumeration, the hypochloride of sulphur oint- ment, the iodide of sulphur, and the ointment of sulphur and tar ; the nitric oxide, nitrate, and ammoniated chloride of mercury, ointments ; the ointments of iodide, biniode and chloriodide of mercury ; the iodide of potash ointment; solutions of iodine in spirit and glycerine ; CONSTITUTIONAL REMEDIES. 119 and solutions of nitrate of silver in nitric ether and water of various strength. The caustic remedies are, nitrate of silver ; acid nitrate of mercury ; potassa fusa, in stick and solution; chloride of zinc ; nitric acid; the mixture of potassa caustica and quicklime, called Vienna paste; arse- nicated glycerine; arsenical paste; iodine; biniodide of mercury; anhydrous sulphate of iron or zinc; and the fluor caustic ether of Dr. Richardson. Constitutional remedies should have for their object to regulate digestion and secretion ; to promote assimilation and nutrition ; to improve tone and innervation ; in a word, to strengthen and invigo- rate, and establish the maximum of vital power and health. Very few instances of cutaneous disease occur in which a fault may not be discovered in the assimilative, the nutritive, or the nervous power, and this should in the first instance be redressed : it may be that the error is one of the stomach or alimentary canal; of the liver or kid- neys ; of the uterus; the lungs or heart, or of the organic nervous system. Disordered tissue, unless it proceed from a direct local cause, implies weakened general restorative power; sometimes, as in nutri- tive debility, the normal standard of power has never been attained; sometimes, exhaustion of power is greater than its growth ; sometimes, the organs of supply are deranged ; and, sometimes, power has declined from the advance of age. All these considerations must be carefully appreciated and weighed before we can hope to treat cutaneous dis- eases, or, indeed, any diseased action correctly and successfully. Our internal remedies belong principally to the class of aperients, tonics, and alteratives ; and theiF dose must be regulated by the age and power of the patient, as well as by the nature of the disease. As aperients, in the form of pill, we may employ colocynth, aloes, scam- mony, rhubarb, podophyllin, blue pill, and calomel, in combination with ipecacuanha, squill, assafoetida, hyoscyamus, belladonna, or soap, according to the indication required; while, in a gouty diathesis, we may make the addition of the acetous extract of colchicum. If we prefer powders, we have the hydrargyrum cum creta, rhubarb, jalap, scammony, sulphur, and guaiacum. While, for fluid aperients, we may select the neutral salts of magnesia, soda, and potash, or the vegetable infusions of rhubarb, or senna, or castor oil. Our tonic remedies may be grouped into digestive tonics, or such as act specially on the mucous membrane of the alimentary canal; muscular tonics, which give tone to the muscular system; and neuro- tomes, which exert their influence on the nervous system. The di- gestive tonics include the vegetable bitters, gentian, orangepeel, calumba, cinchona, quassia, hop, and chamomile, which may be com- bined with the mineral acids, hydrochloric, nitric, sulphuric, and phosphoric ; or, if the intention be to neutralize acid secretions, or act chiefly upon the urinary mucous membrane, they may be made the vehicle of soda, potash, or ammonia. The muscular tonics are, nux vomica, strychnine, and ergot; and the neurotomes, quinine, iron, bismuth, phosphoric acid, and arsenic. In the administration of ape- rients it is judicious to combine with them a tonic; as in the instance 120 THERAPEUTICS OF THE SKIN. of sulphate of magnesia, quinine, sulphuric acid and infusion of orange- peel. With the tincture of gentian and nitromuriatic acid we may prescribe a compound rhubarb pill. A combination of tonics is gene- rally preferable, also, to their separate use, as in that admirable medi- cine, the citrate of iron and quinine, or in the superphosphate of iron. Arsenic is a neurotonic of the first importance in the treatment of cutaneous diseases, from its remarkable property of stimulating the peripheral plexus of nerves ; and this action is not limited to the skin, but extends to the peripheral nervous plexus of all the surfaces of the body, internal as well as external. We have evidence of this action in the production of heat in the skin, sometimes tingling, and sometimes hyperaemia, and, when the medicine is too strong in dose, or has been continued for too great a length of time, we may have numbness, cramps, and loss of muscular power. When administered with proper caution, there is no remedy more valuable in cutaneous medicine than arsenic ; but to secure its successful use, it should be properly regulated in dose, in mode of administration, and as to pe- riod of continuance. Ordinarily, its exhibition in proper doses pro- duces no symptoms apparent to the patient; sometimes the patient has the sensation of a strengthening influence ; sometimes one of pros- tration of muscular power and depression of spirits ; while, generally, the most obstinate condition of constipation is removed, and the bowels become regular. When the action of arsenic is unfavorable, its use must be immediately suspended ; and its saturation of the system may be detected by redness and moisture of the conjunctiva, and some- times dryness of that membrane. As the vascular condition of the gums is the test of the saturation of the system by mercury, so hy- peraemia of the conjunctiva is the test of saturation of the system by arsenic. Redness of the conjunctiva is not, therefore, to be regarded as a symptom of the morbid influence of arsenic, but simply as a proof of its constitutional operation ; and, unless the redness increase to an in- convenient degree, the remedy need not be stopped. Vigilance of observation of our patients is always necessary where arsenic is ad- ministered, and the redness of conjunctiva gives a reason for increase of vigilance; while it is always judicious to give strict injunctions to the patient to stop the medicine the instant that any morbid symp- toms are apparent; whether, in fact, they proceed from the remedy or not. Besides hyperaemia of the conjunctiva and tingling or numbness of the fingers, arsenic sometimes produces loss of appetite, nausea, colic, and swelling of the subcutaneous tissue of the face, hands, and feet, and sometimes of the abdomen ; and another reason for caution is evinced in the suddenness with which the morbid symptoms will sometimes take place; a phenomenon usually ascribed to accumula- tion of the remedy in the system. Whether any such accumulation really takes place, is a question difficult to determine ; and, where the medicine is administered in small doses and with care, such effects very rarely occur; indeed, can only occur as an idiosyncrasy. But its suddenness of action on the system is a fact beyond dispute; it may be taken for many months, as in the instance of alphos, without ARSENICAL REMEDIES. 121 any influence on the disease being apparent; but suddenly, and in a week, the greater part of an extensive eruption may be gone. We cannot ascribe this suddenness of change to " cumulation;" and, it is not unlikely that the symptoms designated by that name may owe their existence to a similar suddenness of operation. The loss of appetite which accompanies the adminstration of arsenic, has led us to the belief, that, besides being a neurotonic, it may also tend to the prevention of waste; and it may be, that to this circum- stance, its known property of causing fattening of the body is due; possibly it arrests the destructive metamorphosis of the tissues, and may, therefore, become a valuable remedy in many diseases, besides those of the skin, where destruction of tissue is a conspicuous symp- tom. It is, possibly, for this reason also, that it acts so well in con- junction with iron and cod-liver oil. There can be no doubt that arsenic is an improver of assimilation and nutrition. Arsenical remedies are somewhat numerous: there is the liquor arsenicalis, or Fowler's solution; the liquor arsenici chloridi, or solutio solventis mineralis of de Valangin ; the liquor sodae arseniatis ; liquor ammonite arseniatis; the arseniate of quinine ; arseniate of iron ; arse- niate of soda ; the liquor hydriodatis hydrargyri et arsenici, or Dono- van's solution ; and, arsenic acid, as in the combination termed the "Asiatic pill;" while arsenic also affords several applications for exter- nal use, such as the solution of arsenic in glycerine, and in Dupuytren's powder, and the arsenical paste. One of the best, and the most convenient of the arsenical remedies, is the liquor arsenicalis, or liquor potassae arsenitis, or Fowler's solu- tion, which we prefer to have made without the compound tincture of lavender, as the latter gives a flavor to the medicine, and is nauseous when taken for a length of time, or with the meals, as is necessary in the exhibition of arsenic. The dose of the potash solution ranges from one to five minims, that is from T.\c to 2'? of a grain of solid arsenic; one drachm of the solution containing half a grain, and one ounce four grains. The ammonia solution is of a similar strength to the potash solution, and the dose the same; but the acid solution of de Valangin is somewhat less than half the strength of the potash solution, con- sequently the dose should be double that of the latter. And the dose of the triple solution of Donovan may range from ten to thirty minims, taken three times in the day. There is no age, and scarcely any circumstances, under which arsenic may not be administered when employed with judgment; to the youngest and most delicate infant, or to the most elderly person; and, if the account of its virtues which we have just given be correct, it is evident why it may be so universally used. If it be a nerve-tonic; a suspender of waste; and an improver of nutrition and sanguification; there can be no obstacle to its administration other than that, which arises from the development of its poisonous properties; and these poisonous properties we may control by a proper regulation of the dose; and, as we have already intimated, it is not in cutaneous diseases alone that the medicine is valuable, but possibly, in many diseases wherein arrest of waste and increase of nervous tone are desirable con- 122 THERAPEUTICS OF THE SKIN. ditions. The formula which we prefer for its exhibition is the ferro- arsenical mixture; which will be found among the "selected formulae" at the end of the volume. Arsenic, as a medicine and as a food, has obtained additional interest of late years, from the discovery in Cumberland of a river which con- tains a notable quantity of that mineral in solution. The river runs through the village of Whitbeck, and the inhabitants of the village use the water exclusively for every purpose of life. Mr. Arthur Church1 reports it to be so strong of arsenic, that ducks and trout are unable to live in the stream ; but that, nevertheless, the inhabitants and their children are conspicuous for health and longevity. That, upon a late occasion, a railway was constructed near the village; and that some of the men and horses were inconvenienced by the use of the water; but, after a short time, the men acquired more than their usual strength, and the horses the sleekness of coat, for the production of which, arsenic is so remarkable. The unpleasant symptoms developed in the men, were soreness of mouth and a sense of constriction in the throat. The river takes its rise in the Black Combe mountain, and the source of the arsenic is stated to be arsenical pyrites by Dr. John Davy,2 and arsenical cobalt by Mr. Church. The mineral was first detected by Mr. Zenner of Newcastle; and the water has been recom- mended for medical purposes, and as likely to agree with the stomach better than an artificial solution, by Dr. George Robinson.3 Dr. Davy remarks, that "It had the general character of the mountain streams of the Lake District, was perfectly clear and colorless, and tasteless. Of the several specimens obtained I found the specific gravity the same as that of distilled or rain water. When evaporated to dryness the residue was very small, a pint yielding about .25 of a grain; and, from the different specimens tried, not varying more than one-tenth of a grain. In each instance this residue was found to consist chiefly of common salt; it tasted of this salt, and in solution was copiously precipitated by nitrate of silver. Mixed with the common salt was a little magnesia and lime, both probably in combination with sulphuric acid, as sulphate of lime and magnesia, the presence of the acid being denoted by nitrate of barytes; a trace, too, of oxide of arsenic was detected in each, and, it may be inferred, in combination with potash, a trace of which was also obtained. The arsenic was detected, not only by the test of the ammoniaco-nitrate of silver, but also by reduc- tion to its metallic state by sublimation, after mixture with ferrocyanide of potassium. Of the several specimens of water tried, that procured in October, when the stream was about its ordinary size, afforded a somewhat stronger trace of the metal than either the earlier or the later." In this case the quantity of the mineral present was about .008 of a grain in the pint, or .064 of a grain in the gallon; the precise form of combination being similar to that of Fowler's solution, namely, the arsenite of potash. 1 Chemical News, August, I860. 2 Edinburgh Philosophical Journal, 1863. 3 On the Medicinal Use of Arsenicated Mineral Waters; with special reference to that of Whitbeck.—Lancet, 1863. ECZEMATOUS AFFECTIONS. 123 The alterative remedies used in the treatment of cutaneous diseases are, arsenic, sulphur, tar, cantharides, iodine, and mercury. An alter- ative is a remedy that requires to be continued for a considerable time ; hence the dose should be smaller than for other purposes. This is especially the case in the instance of arsenic, iodine, and mercury ; and these remedies may be given in a combined form as well as separately. For example, the triple solution of arsenic, iodine, and mercury; the iodide of mercury, &c. The arsenical preparations are especially use- ful in alphos; tar in the shape of pills or capsules has been found useful in the same disease; and so also has the tincture of cantharides, either alone or combined with arsenic; while mercury and iodine are especially serviceable in syphilodermata. Other remedies of the alterative class are dulcamara and sarsaparilla. CHAPTER V. ECZEMATOUS AFFECTIONS. Eczema, eruption—for the word means nothing more—is the name of a large and important group of cutaneous affections. The term is met with in the writings of Dioscorides Phacas, who flourished one or two centuries before the Christian era; and a precise idea of the mean- ing of the term is given to us by iEtius, an author of the fourth cen- tury, in the following passage: " eas sx^ara, ab ebulliente fervore, Graeci vulgo. appellant." According to this signification, the word eczema conveys the idea of heat, of the raising of bubbles upon the surface of a boiling fluid; the bubbles being the type of the vesicles of the eruption. The ancient Greeks fixed upon another character of eczema in order to distinguish it, and called the disease psora, from 4-afi* or 4-cottv, to rub, because, on account of the itchiness of its nature, it created the necessity of rubbing or scratching. And the Romans, pursuing the same idea, termed it scabies, from scabere, to scratch. Thus we see, that in their original application, the three words, psora, scabies, and eczema, were synonymous; and for a long time the terms psora and scabies were associated with the same disease, the itch, eczema ab acaro; while, at the present day, we give the precedence of import- ance to eczema; scabies we regard as an eczema taking its origin in a special cause, the acarus scabiei; and the term psora we discard altogether, or retain only in its mitigated form, psoriasis, a term, the correct application of which has still to be settled; we, on the one side, maintaining that it should be assigned to a chronic eczema; while Hebra, Hardy, and others attach it to the lepra of Willan, the alphos of Celsus, and of ourselves. The terms eczema, psora, and scabies are not, however, without their use in conveying an idea of the nature of the disease; it is an 124 ECZEMATOUS AFFECTIONS. eruption which is hot, vesicular, and attended with an itching of so severe a degree as to incite to rubbing and scratching. Eczema is the commonest of all the affections of the skin; in one thousand cases of cutaneous diseases of all kinds, and taken indiscrimi- nately, it occurs three hundred times, or in the ratio of thirty to every • hundred, or three in every ten, or very nearly one in every three; so that we may say that every third case of cutaneous disease coming before us is a case of eczema. It is for this reason that we make the study of eczema our first consideration in the investigation of indi- vidual diseases, and give it a place to which it becomes entitled, not only on account of the inconvenience and suffering which it occasions, but also, as we have shown, on account of its absolute numerical im- portance. Eczema is remarkable for its variety of manifestation. We have already pointed out two of its characters, namely, its eruptive or ecze- matous, and its pruritic or psoric or scabietic character; but the charac- ters to which we especially allude, are such as belong to the progressive development of the disease. It is sometimes erythematous ; sometimes papulous ; sometimes vesiculous; sometimes ichorous; sometimes pus- tulous; and sometimes squamous ; or these varieties of manifestation maybe more or less blended; or several of the forms may occur sepa- rately on the same individual. When a combination of the forms is present, such as redness, papulation, and exudation, we have no hesi- tation in pronouncing the case to be one of eczema; indeed it may at once be declared that the polymorphic or multiple form constitutes the real diagnosis of eczema. But we frequently meet with cases in which the separate characters above designated, namely, the redness, the papulation, and the pustulation, stand out so distinctly alone, that we are constrained to admit them as independent eruptions, and assign to them separate names, such as pityriasis, lichen, and impetigo. Nevertheless, their alliance with eczema is too manifest to be over- looked ; and, while treating them independently in one sense, we at the same time recognize their affinities with eczema, and associate them under the general head of " eczematous affections." The diseases belouging to the eczematous group, taking their origin in the eczematous diathesis, and constituting the family of eczematous affections, are as follows:— Eczema Lichen, Psoriasis, Impetigo, Pityriasis, Gutta Rosacea, Scabies. Eczema is the manifestation of the disease in its multiple form; psoriasis is a chronic and squamous eczema, retaining its pruritic or psoric character in a heightened degree; pityriasis is a squamous eczema erythematosum, the squamae being fine, like bran, and some- times it is a sequel of exudative eczema ; that which is a psoriasis on the limbs would be regarded as a pityriasis on the scalp. Lichen is a development of the papulae of eczema without the other signs of that disease. Impetigo is a pustulous lichen, and the pustular element of ECZEMA. 125 eczema without the other signs. Gutta rosacea is an eczema of the face, modified by its situation and cause; and scabies, also, is an eczema, modified by the nature of its cause. If we apply our numerical examination to the eczematous affections as a family, instead of to eczema alone, we arrive at the important conclusion, that 526 in 1000, or more than half, of the whole of the cutaneous diseases of the body, are eczematous; and we thereby add double force to our argument as to the importance of eczema, the advantage of regarding it as a substantive disease, of placing it in the front of all other cutaneous affections, and of making it a standard of reference and comparison. Willan and Bateman, with the view of making eczema conform to their scheme of classification, saw in it only its vesicular and ichorous character; consequently, the eczema of to-day is no longer the eczema of those authors. Of the three hundred cases already referred to, the eczemata admitted by Willan and Bateman would have amounted only to ninety; consequently to one-third of the entire number recog- nized at the present time. The eczematous affections constitute a true natural family or group ; they resemble each other in their manifestation ; in their symptoms ; in their cause; and they are amenable to the same general principle of treatment. ECZEMA. Syn. Ecphh/sis eczema, Mason Good ; scabies humlda ; herpes squamosus madidans; dartre sguameuse humid e, Alibert; dartre vive ; dartre erysipelateuse ; niissende Flechte ; humid tetter or seal I; running scall; hrat eruption. Eczema1 is an inflammation of the skin, accompanied with altera- tion of its structure and derangement of its functions; the skin is more vascular, and consequently redder, than in health, its vessels being in a state of congestion; its sensibility is morbidly increased, sometimes taking on the character of itching, tingling, or smarting, and sometimes that of pain; it is thickened by infiltration of serum into its tissues, sometimes fissured and sometimes oedematous; it exudes a serous lymph, at various times and in various quantity, sometimes in exces- sive abundance; its cuticle is sometimes raised into papules, some- times into vesicles, sometimes wholly removed, and is reproduced unhealthily, so as to form muco-purulent secretions and squamae of various size; and sometimes the cuticle is replaced by a crust of greater or less thickness, resulting from desiccation of the morbid secretions. In a few words, the characteristic signs of eczema are, redness, itchiness, interstitial and sometimes subcutaneous thickening, exuda- tion, papulation, vesiculation, incrustation, and desquamation. Eczema has no proper constitutional symptoms belonging to itself; the symptoms which accompany it being such as appertain to the form of constitutional debility, which occupies the place of its predis- posing cause. There are three forms of debility which predispose to 1 Plate IX. 126 ECZEMATOUS AFFECTIONS. eczema; namely, nutritive, assimilative, and nervous. In nutritive debility the symptoms are chiefly those of deficient nutritive power, with waste of the tissues of the body, a state which gradually passes on to exhaustion and atrophy. In assimilative debility the symptoms are such as accompany disorder of the digestive and assimilative func- tions, and the secretions dependent on those functions.^ In nervous debility the symptoms take their origin in a weakened, irritable, and exhausted nervous system, and are such as would accompany that form of debility irrespective of the cutaneous eruption. The consti- tutional symptoms of eczema, therefore, are such as result from the presence of the eruption on the skin; either the irritability of the nervous system induced by a painful and itchy disorder, that destroys comfort and sleep, and sometimes gives rise to the wildest paroxysms of suffering; or, the exhaustation of the digestive, assimilative, and nervous powers, occasioned by the drain from the system of an abundant and constant discharge. It very commonly happens that an attack of eczema is preceded by symptoms of general disturbance of the digestive organs; by a feel- ing of fulness and oppression at the epigastrium, and by a feverish reaction of a mild type. These symptoms may last for several days, or for several weeks, and they cease immediately that the eruption makes its appearance; but it would be an error to regard them as part of the eruptive disease; for they are occasional only, and not constant, and the same symptoms might precede a temporary diar- rhoea, or a cholera, or, in fact, the evolution of a causa morbi in what- ever shape it may be developed. It would be impossible to determine from such symptoms that an eczema was about to follow ; and an eczema is in general produced without any forewarning or premonitory symptoms of any kind. The relief occasioned to the symptoms of general disturbance just described, by an outbreak of eczema, is due to its derivative action simply. And this derivative influence is manifested in a variety of ways; sometimes the eczema takes the place of an inveterate head- ache ; sometimes of a neuralgia ; of a rheumatism ; of a fit of gout; of a bronchitis; and in fact may supersede any chronic ailment to which the body is liable. The phenomena of derivation suggest to the mind of the uninstructed the idea of the exit, or the expulsion from the body, of some innate evil, and a consequent alarm lest the cure of the eruption may act as a repercussive, and throw back upon the economy the material of disease. And this impression is strength- ened by the fact, that, after the sudden and spontaneous disappearance of the eruption, some new malady has immediately sprung up. But the proper way of viewing the case is, to recognize a causa morbi, the consequence of debility, and the possibility of the determination of that cause upon any point of the economy, the weakest being the one usually selected. And if there be several weak points, then each may be attacked in succession, or the irritation existing in one may be suddenly transferred to another. Admitting these data, it must be clear, that if we can cure the manifestation in one spot, we relieve it in the whole; because a cure can only be effected by removing the ECZEMA. 127 debility which is the real predisposing cause of the disease. We have no reason to fear repercussion ; our fear should be, our incapability of mastering the disease ; and we neglect our duty when we allow the disease to run on for months and years without attempting a cure, placing our reliance on morbid nature, and hoping, if the patient be an infant, that the cutting of the teeth, or the development of puberty, or menstruation, or manhood, will eventually bring about a cure. There is another evil in deferring a cure, namely, the setting up in the constitution of a tendency or diathesis. Diathesis is of two kinds, hereditary and accidental. The latter is the consequence of a protracted continuance of the disease, and in another generation may become hereditary. When a diathesis exists, a patient may be subject to attacks of eczema during his whole life, and every little disturbance of function of the digestive or nervous system will, in place of any other ailment, occasion an eczema. Eczema is not contagious, although it is often met with pervading a family, or even a community, or assuming an epidemic character, and, like other chronic disorders, it may be more common in certain localities than in others. We have in our memory a case in which a weakly mother nursing an eczematous infant, had eczema on the arm against which the head of the child rested. The discharges from the eruption of the child were the undoubted cause of the eczema in the mother; but this was no proof of contagion ; any discharges or any irritant would have caused irritation of the mother's skin, and in her existing state of debility, eczema is just the result that might have been anticipated ; even apart from the fact that she might also have been an example of the eczematous diathesis. Eczema is a chronic affection and has no specific course. Like other chronic inflammations, it has a beginning and an ending; in other words, its rise and its decline, with an intermediate period of activity, of greater or less duration. In a severe case the rise may present redness, heat, swelling, papulation, and sometimes vesiculation: this may be regarded as a first stage or first period of the disease. Next, there may succeed exudation, incrustation, and sometimes suppuration ; this is a second stage or second period, the stage of exaltation. Lastly, there will follow the third stage, the stage or period of decline, com- prising desquamation, with redness, and often thickening of the skin. These three periods, when they exist, may be termed, the first* the erythematous, the papular, and the vesicular period; the second, the exudative and incrusted period ; and the last, the squamous or desqua- mating period. But eczema rarely presents all these characters complete, nor do they follow in regular succession ; they are modified by constitution, by temperament, and also by situation; and these modifications are the foundation of its varieties. Sometimes redness or vascular congestion of the skin is the dominant character, and the variety an eczema erythe- matosum; sometimes, with the redness, the vascular congestion and serous infiltration of the follicles give rise to pimples, and the resulting variety is an eczema jiapulo^um ; in a third instance the predominating character may be vesicles, eczema vesiculosum ; in a fourth, the leading 128 ECZEMATOUS AFFECTIONS. character may be exudation, and the eruption an eczema ichorosum ; again, there may be pustules, which are commonly of the type termed psydracious pustules, mingled with the other signs of pathological lesion, and the variety is an eczema pustulosum ; or, in the most chronic form, the principal feature of the eruption may be desquamation, and the variety, eczema squamosum. These terms comprehend the principal forms of eczema dependent on symptoms; but different terms suggest themselves naturally for other different conditions; for example, the skin is sometimes cracked and fissured, eczema fissum; sometimes the thickening and condensa- tion, in a chronic stage of the affection, suggest the terms eczema sclero- sum and eczema verrucosum; sometimes the state of the part is aptly expressed by the term eczema cedematosum ; sometimes, from the nature of the secretion, eczema mucosum; and more than once we have met with a case, to which, on account of the severe pain by which it was accompanied, the term eczema neurosum would be correctly applicable. It is rare, however, to find an eczema perfectly simple in its erup- tion, and capable of being represented singly by any one of the terms already mentioned. More frequently two, or indeed, several of the forms may be present at the same time, and sometimes even, the whole. Thus, in one case we may have an erythematous eczema accompanied with papulae, an eczema erythematosum et papulosum; or, it may be an eczema erythematosum et ichorosum ; or, if the exudation of fluid be the chief feature, we- might name it eczema ichorosum, and in a less degree erythematosum et papulosum, or even pustulosum. Or the case might be one of eczema vesiculosum et erythematosum; or an eczema squamosum (eczema chronicum), which is at the same time, in part fissum, and in part ichorosum. Varieties of eczema are also deduced from situation: hence we have eczema capitis, faciei, aurium, palpebrarum, oris et labiorum, axillarum, mamillarum, umbilicale, inguinum, pudendi, perinei, ani, articulorum, manuum et pedum, dorsi mantis, palmare et plantare, digitorum, and unguium. Moreover, we are taught by experience that in certain situations we are likely to meet with one or other of the preceding varieties; for example, eczema capitis et aurium is commonly ichorosum in a recent attack, and squamosum at a later period ; eczema articulorum, eczema axillarum, eczema inguinum, and eczema pudendi are very frequently ichorosum, and sometimes mu- cosum. Eczema of the fleshy parts of the forearms and legs is not unfrequently vesiculosum, as is also eczema digitorum. Eczema dorsi maniis is usually papulosum; while eczema palmare is squamosum, and often, as are the tips and joints of the fingers, fissum. The extent of the eruption will also come in for a share of consi- deration in the designation of varieties. The eruption may be general or partial. When partial, the patches may 'be single or multiple; they may be defined (figuratum), or diffused (diffusum). Sometimes they suggest the idea of the dimensions and figure of a piece of money (nummulare), and sometimes are bounded by a prominent ridge (mar- ginatum), and spread by the circumference, while the inflammation within the included area subsides. ECZEMA. 129 The classification of Willan as applied to eczema has the effect of making its different pathological appearances separate diseases; for example, in its early stage, and in one part of the body, the eruption might present the characters of an erythema, and be placed in the order exanthemata; in another stage, or on another part of the body, it would be classed with papulae ; in a third, it would belong to pus- tulae ; in a fourth, to squamae; and in a fifth only, to the order in which it is placed by Willan, namely, vesiculae. But in truth, the rarest of all the varieties of eczema is its vesicular form; we have already drawn attention to the not uncommon circumstance of the same cause, namely, the sun's rays, giving rise in different persons to separate forms of eruption. And, it appears to us to be in- finitely more philosophical, and certainly practical, to regard such an eruption as three forms of the same disease, namely, as eczema, in the three varieties, erythematosum, papulosum, and vesiculosum, than to treat it as three separate diseases, belonging to different orders, under the names of erythema, lichen, and eczema. It follows from this mode of viewing eczema, for the suggestion of which we are indebted to Hebra of Vienna, that many varieties of eruption, which by Willan would have been classed in various of his orders, are, at' present, considered as forms of eczema. A step had already been taken in that direction by Willan himself, when he named one of his species, eczema impetiginodes; and our own labors for several years past have tended to the development of the same idea.1 The varieties, or, as he preferred to name them, species, of eczema admitted by Willan, are three in number ; namely, solare, rubrum, and impetiginodes. Eczema solare corresponds with eczema vesiculo- sum ; eczema rubrum with eczema ichorosum; and eczema impeti- ginodes with eczema pustulosum. Hardy arranges the varieties of eczema in three groups, having rela- tion to the appearance, the figure, and the situation of the eruption. The first of these consists of eczema simplex, rubrum, fissum (fen- dille'), and impetiginodes; the second, of eczema figuratum, nummu- lare, sparsum, and diffusum ; the third, of eczema pilare, eczema capitis, and the rest of the local varieties corresponding with our own. To designate the varieties of eczema, Hebra employs the suggestive terms, squamosum, papulosum (lichenodes), vesiculare (solare), madi- dans (rubrum), and impetiginosum; he makes eczema squamosum the first of his forms of eczema; whereas we take it to be the last. Eczema erythematosum is commonly accompanied with desquama- tion ; and when the eruption is general, this is remarkably the case. Now, Hebra selects the moment when it is coated over with scales as the type of this form of disease. But it must be remembered that the scales may be disposed of in a variety of ways; there was a time before which they were formed; there is a time when they have ceased to be productive ; there is an intermediate time when they may be removed artificially by dressings, poultices, or baths. What are 1 Vide an Essay on Eczema Infantile, read at the meeting of the British Medioal Association in 1*56. y 130 ECZEMATOUS AFFECTIONS. we to call the disease when the scales and desquamation are no longer present? The answer is plain; the redness, the erythema remains; indeed, the erythema is always there; from, the beginning before the scales existed, at the end, after they exist no more; hence the term " erythematosum" appears to us to be more appropriate than " squa- mosum." Again, there are forms of eczema in which there is redness, but nothing deserving to be called scales; and, to these cases, which are numerous, the term "erythematosum" is especially applicable. On the other hand, when eczema reaches its latest period, when it is chronic, there is still redness; but scaliness and desquamation are a more predominant character than redness ; and it is to this period, that we prefer to attach the term " squamosum." Eczema squamosum, we regard as the chronic stage of eczema ; whilst eczema erythematosum, which may also be chronic, applies with special aptitude to the earliest stage of the eruption. Eczema squamosum is, therefore, in our view of the pathological indications of the disease, an eczema chronicum squamosum, and is the true representative of the much abused term psoriasis. Psora represents the more active, and especially the exuda- tive forms of eczema; and psoriasis its chronic, its dry, and its des- quamating form. In a tabular arrangement, the varieties of eczema admit of being grouped under three heads, in conformity with their pathological characters or their appearance, their distribution, and their locality; the three groups being as follows:— Erythematosum, Papulosum, Fissum, Sclerosum, PATHOLOGICAL FORMS. {Regular) Vesiculosum, Ichorosum, {Irregular Forms) Verrucosum, (Edematosum, Pustulosum, Squamosum. Mucosum, Neurosum. FORMS OF DISTRIBUTION. Universale, Diffusum, Figuratum, Nummulare, Marginatum. Capitis, Faciei, Aurium, Palpebrarum, Oris et labiorum, Axillarum, LOCAL FORMS. Mamillarum, Umbilicale, Inguinum, Pedendi, Perinei, Ani, Articulorum, Manum et pedum, Dorsi manus, Palmare et plantare, Digitorum, Unguium. The Romans, who designated eczema by the name of scabies, drew attention to a characteristic distinction between its moist and its dry ECZEMA. 131 form, scabies humida and scabies sicca.1 Our Greek fathers appear to have had the same object in view in employing the words psora and psoriasis; the former term corresponding with scabies humida, the latter with scabies sicca. The distinction is a radical one, and of the first importance in the study of eczema. Eczema siccum, which is represented by eczema erythematosum, eczema papulosum, and ecze- ma squamosum, is specially distinguished by an absence of exudation, or by its presence in a very moderate degree ; whereas, eczema humi- dum, represented by eczema vesiculosum, eczema ichorosum, and eczema pustulosum, is remarkable for the exudation of a serous and sometimes a muco-purulent fluid, often in astonishing quantity, a posi- tive flux. According to our observation, the dry forms of eczema more than double in frequency those of the moist or humid kind; therefore a classification that assumes for eczema a definition depen- dent on exudation as a pathognomonic sign, must, of a necessity, be incorrect. A well-marked example of eczema is an open page, upon which we may read, with the utmost distinctness, the pathology of the disease; and anything that may be wanting upon this page is supplied by the examination of a succession of cases. Let us note what such an obser- vation teaches. In the first place, there is redness; one while, uniform ; another while, punctated. The cause of the redness, is congestion of the capil- laries and smaller vessels of the skin. When the redness is uniform, 4he congestion is uniform; when the rednesss is punctated, the vascu- lar plexus of the follicles is also congested. Sometimes the congestion of the vascular rete of the horizontal surface is primarily and chiefly apparent; sometimes the vascular rete of the vertical walls of the fol- licles is the first to show congestion, and the latest to retain it. AVhen the latter is the case, our patients speak of an eruption under the skin; and we, ourselves, perceive a resemblance to the punctiform conges- tion of the exanthemata. Another phenomenon follows the congestion of the vessels of the follicles; namely, the erection of their apertures or pores; these latter become raised above the level of the adjacent surface, and constitute small pimples. This is the mode of formation of eczema papulosum. Occasionally, we have the opportunity of observing another process by which an eczema is developed. There may exist a slight itching of a part of the skin ; if the part be carefully examined, a reddish punctum is apparent in the substance of the derma ; the finger passed over this punctum discovers a hard granule; this is a congested folli- cle. It', to relieve the itching, we scratch the part, a papule arises; the head of the papule is torn off; a serous exudation follows, and then a small crust, which covers its summit. But, while the one 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 eczema papulosum vel lichenodes. Scabies sicca, according as it pro- duces small and furfuraceous scales, or larger ones like fish scales, he denominates psora porrigo and psora lepra. Psora porrigo, therefore, corresponds with the pityria- sis of modern nomenclature, and psora lepra with psoriasis. 132 ECZEMATOUS AFFECTIONS. original papule runs its course, the follicles around participate in^the same pathological process, and soon a small patch is formed, which presents all the characters of an eczema : there is an erythematous redness; there is papulation; there is slight exudation, papular at first, but afterwards general; there is incrustation, and there is des- quamation. Congestion, therefore, gives rise to redness; it gives rise, also, to papulation, and to a moderate amount of swelling; but there is another important pathological change which results from congestion, and that is, effusion or transudation. The congested vessels are relieved of their distension'by the exudation of the fluid portion of the blood, and this exudation causes thickening and condensation of the substance of the skin. Sometimes the transudation from the vessels occasions oedema (eczema oedematosum); sometimes it is effused beneath the epidermis, at the apertures of the follicles, and produces vesicles (eczema vesiculosum); 'a continuance of this process causes the separation of the cuticle from the cutis, and the discharge from the latter of a serous lymph (eczema ichorosum). In a different constitution, or in another region of the body, the distension of the tissues of the skin may occasion cracks and fissures (eczema fissum) ; from which an ichorous discharge may be poured out in greater or less quantity. There is yet another pathological operation which occurs in the morbid skin, and that is, an alteration in the formation of the epider- mis. Where two folds of integument have lain in contact for a while, and where, from the constant presence of heat and moisture, the cuticle , has no power of acquiring its natural horny density, but remains soft and cellular, the surface of the derma is red, is. denuded of epidermis, and secretes a copious muco-purulent discharge, which is, in reality, an aborted and morbid cuticular substance; a cuticle arrested at its cellular stage, and partly transformed, under the influence of inflam- matory action iand the low vitality of the part, into a fluid, which is principally mucus, but is mingled with a small proportion of pus. There is no lesion of continuity, or destruction of the epidermis, in this case ; the muco-purulent matter is a simple secretion produced at the expense of the epidermis, a morbid conversion of that tissue into a fluid matter, which performs the same office to the otherwise unpro- tected derma, as that of mucus to the mucous membrane. This is intertrigo mucofluens; or, more properly, eczema mucosum. Now, in ordinary eczema, a morbid alteration in the formation of the cuticular tissue takes place, similar to that just described. The copious exudation of eczema ichorosum is not merely a serous fluid expelled from the vessels in consequence of the over-distension of their parietes ; it is a positive secretion in which the cellular elements of the cuticle take an active part, and bestow upon the fluid its special properties; for example, its density, vicosity, and frequent opalescent appearance. That same influence which causes the discharge of such immense quantities of fluid from the mucous membrane of the bowels in diarrhoea and cholera, is also active in eczema ichorosum. In the course of a few hours, several pints of fluid may be poured out from the denuded surface of the derma, partly, no doubt, by way of excre- tion, but not less actively also by way of secretion. * ECZEMA ERYTHEMATOSUM. 133 The pathological phenomena present and in operatiou in eczema, therefore, are not simply those of inflammation, but also involve a morbid aberration of secretion. The inflamed derma, which, at an early period of the disease, exudes largely a colorless lymph, at a later period may exude an opalescent and even a yellowish fluid ; the consequence of the conversion of the mucous elements of the cuticle into pus. And the continuance of inflammation of the skin may so far lower the vitality of the surrounding tissues, that pustules may be developed around the circumference of the patch of eruption, and add fresh purulent matter to the morbid secretion; the case is, then, one of eczema pustulosum, or eczema impetiginodes. In a disease of a secreting tissue, where inflammation is apt to con- tinue for a considerable period, and where secretion is so greatly dis- turbed ; where exudation takes place as the result of inflammatory changes, and as the result also of modified secretion, we may expect to find crusts of various kinds formed on the inflamed surface ; some resulting from the desiccation of altered secretions, and some from imperfect formation and altered structure of the epidermis. It is in the power of the medical man to prevent these crusts from appearing at all; but where the case has been left to itself, or where the treat- ment has been misdirected, we may find spongy crusts of a grayish, yellowish, greenish, or brownish tint, or almost black; we may find them loose or adherent; we may find scabs of various degrees of density; or we may find, where alteration of the epidermis is diiefly concerned, scales of various thickness and magnitude, thicker, larger, and rougher in more recent cases; thinner and smaller in more chronic forms; and diminishing by degrees to the furfuraceous and farinaceous desquamation of psoriasis and pityriasis. REGULAR FORMS OF ECZEMA. Eczema erythematosum is recognized by redness, thickening and hardening of the skin from infiltration of serum into its tissues, itching, and successive desquamation of the cuticle in laminae or scales. When this form of eczema is associated with other forms of the eruption, or when the patient has previously suffered from eczema and has a tendency to eczema, in other words, an eczematous diathesis, the diagonosis of eczema erythematosum is plain; but if it be a first attack, and is slight in its nature, like the instance we have already given as resulting from sunburn, it may be difficult to distinguish it from simple erythema. If, as is commonly the case, it is accompanied with papulae, and gives out a serous moisture or exudation on rubbing or scratching, the case is an undoubted eczema erythematosum. Eczema erythematosum is apt to occur upon the eyelids, behind the ears, about the pudendum, and, generally, in the flexures of the joints. It is the form which erythema in an eczematous constitution would naturally assume. From its proneness, in the latter stage, to perpetuate itself by desquamation, a tendency of all the forms, Hebra names it squamosum ; but we prefer to distinguish the congestion of the early stage and slighter forms of eczema by the term erythema- * 134 ECZEMATOUS affections. tosum ; reserving the term squamosum for the latter stage and more chronic and severer forms. Eczema papulosum.—The association of papulae with eczema is one of the commonest of its phenomena; sometimes they enter into the composition of the eczematous blotches; sometimes they are found in the circumference around them, or dispersed more or less abund- antly over the body and limbs, while eczema ichorosum holds sway in other parts; it is, however, the predominance of papulae over the other pathological forms which especially characterizes eczema papu- losum. In universal eczema, and in eczema infantile, which is fre quently universal also, the papulous element of the eruption is very conspicuous; but it is nowhere more so than in the combined ichor- ous and papular eruption that takes possession of the back of the hands, the lichen agrius of Willan, which, in other words, is an eczema lichenosum, or lichen eczematosus, or, more properly, an eczema papu- losum et ichorosum. Eczema vesiculosum1 (eczema solare of Willan) is the rarest of the forms of eczema, although the type of the vesicular eruptions. It is most characteristically seen on the back of the hands of persons of lymphatic temperament who have been exposed to the heat of the sun's rays ; and then presents itself as a confluent crop of minute vesi- cles corresponding with the pores of the follicles of the skin, and at- tended with more or less oedema of the subcutaneous cellular tissue, and interstitial infiltration of the skin itself. Another common situa- tion ft its outbreak is the fingers, especially their palmar surface. From the thickness of the cuticle in this situation, the vesicles are indistinct, and the serous fluid collects beneath it in minute beads, and pushes up the cuticle in plates of considerable extent, hollowed upon the under surface into vesicular cavities. In this manner the cuticle may be raised off the greater part of the circumference of the fingers. In the course of a few days, the serum of the vesicles is absorbed; the oedema of the corium and subcutaneous cellular tissue subsides, the cuticle dries and exfoliates, and the skin returns to its normal condition. Not unfrequently, however, the newly-formed cuticle is produced unhealthily, and is thrown off by desquamation in furfura- ceous scales. Eczema ichorosum (eczema rubrum, Willan; eczema madidans, Hebra) is characterized by intense redness, denudation of the inflamed surface, more or less thickening from infiltration of tissue, and exu- dation of a colorless ichor or lymph, often in abundance, and sufficient to justify the term " madidans" applied to it by Hebra. Eczema icho- rosum may commence as an erythematous or as a vesicular form, and pass on to the more exalted stage of exudative activity implied by the term ichorosum. Or, an ichorous exacerbation may break out at any period of the course of a chronic eczema, and recur from time to time during its existence. The ichorous discharge is not simply the effusion of serum from the congested vessels and tissues, but it is also an altered secretion of the 1 Portraits of Diseases of the Skin, Plate III., X. ECZEMA PUSTULOSUM. 135 skin itself; and the unformed elements of the epidermis mingling with the ichorous discharge, give it an opaque and mucous, and some- times a muco-purulent character. The discharge is tenacious, often viscous, and forms, on desiccation, a yellowish or grayish, and more or less brittle and spongy crust, which adheres firmly to the inflamed corium, and sometimes attains to considerable thickness. Not unfre- quently, at this stage of the eruption, the crust breaks up into plates of various size, and the muco-purulent secretion oozes up through the fissures. This is peculiarly the case, on the scalp and on the face; on the scalp because the crust is mechanically detained by the hair; on the face, because, from the difficulty of covering it up, evaporation and desiccation are more active than in other parts. Eczema ichorosum, therefore, presents three characters, which in it are more strikingly developed than in the other forms of eczema; namely, the redness of the inflamed corium, the copious exudation, and the consequent formation of an extensive and thickened crust. It must be borne in mind, that the exudation is not the result of ulcera- tion, as might sometimes be supposed from its muco-purulent cha- racter, but is chiefly derived from secretion. Indeed, in one form of eczema, namely, eczema intertrigo, there is often a copious muco- purulent secretion from the surface of the unbroken skin, with no other pathological change than erythema in a moderate degree. The ichorous form of eczema is most commonly met with in the joints, as in the axilla, the elbow, the groin, and the ham; upou and behind the ears; on the face; around the nipples; about the umbili- cus ; and in the pudendal region. A characteristic form of the eruption in the latter region, and extending for a short distance down, upon the upper and inner part of the thighs, is well described by Willan under the head of eczema rubrum. Eczema pustulosum (eczema impetiginodes, Willan) is a more or less confluent eruption of small psydracious pustules, accompanying any of the forms of eczema, but most frequently associated with eczema ichorosum. The pustular eruption must be regarded as an aggravation of the ichorous form of the disease, and is most commonly met with in regions exposed to an excessive degree of irritation, as the face and hands; in young persons of irritable temperament; or in persons con- siderably reduced in strength. Eczema squamosum represents the last period of the other forms of eczema, when the pimples have subsided, the exudation has ceased, and only the redness, the thickening from interstitial infiltration, and the desquamation, remain; the desquamation no longer presenting the character of exfoliation, as in eczema erythematosum and papulosum, nor crusts, as in eczema ichorosum and pustulosum; but of small thin scales, for the most part furfuraceous, or even farinaceous. Eczema may from the first present these characters, and in them, that is in the redness, thickening, itching, and desquamation in small scales, we recog- nize psoriasis, the sequence of psora; and, where the thickening of the skin is less, and the scales thinner and finer, pityriasis; the whole of these forms belonging, in fact, to the chronic period off eczema. 136 ECZEMATOUS AFFECTIONS. IRREGULAR FORMS OF ECZEMA. Eczema fissum.—When the skin has been subjected for some time to inflammatory congestion, and has become thickened and condensed by infiltration into its tissues, it chaps and cracks with extraordinary ease; the mere stretching of the fingers will cause the skin to break; and a new pathological element is added to those previously noted in connection with the disorder. Eczema fissum is a common associate of eczema squamosum, and is most frequently met with where the skin is naturally the thinnest, the hardest, and the densest; for example, the tips of the fingers, the joints of the fingers, the palm of the hand, the dorsum of the hand, and the wrists; but it may exist in the con- cavities or upon the convexities of all the joints, or at the bottom of folds in any part of the skin; for example, in the angle of attachment of the ear to the side of the head, the nose to the face, or at the angles of the eyelids or mouth. Eczema squamosum of the palms of the hands, or psoriasis palmans eczematosa, is remarkable for the number and depth of its fissures; and, in eczema infantile, and chronic eczema in children, the fingers have sometimes the appearance of being almost severed through at the joints. Eczema sclerosum.—When chronic eczema has existed for a con- siderable time on some part of the limbs, the skin is apt to acquire the hardness and toughness of leather; such patches are usually circum- scribed in form, are somewhat elevated above the surface, attended with occasional fits of severe itching, and throw off a dry and scaly scurf. They are commonly designated psoriasis, and are sometimes so like patches of diffused alphos, as to be liable to be mistaken for that eruption. When scratched or rubbed, they give forth a serous exudation. Eczema verrucosum is an aggravated form of eczema sclerosum; harder, harsher, and more prominent; rough on the surface, and resem- bling the summit of an old fibrous wart. This latter appearance seems due to hypertrophy of the papillae in conjunction with general thick- ening of the skin. The pruritus of eczema verrucosum is sometimes unusually severe and troublesome, particularly in elderly persons. The verrucous patches are commonly of small size, and more or less numerously dispersed over the limbs, commonly the lower extremities. Eczema gsdematosum.—Serous effusion and serous infiltration are common symptoms of eczema, particularly in lymphatic subjects; hence an oedematous state of cutaneous and subcutaneous tissues is a not infrequent occurrence. It is important only in a therapeutical point of view, for the eruption rarely heals until the excess of serum in the tissues is dispersed. Eczbma mucosum (intertrigo).—Eczema sometimes presents itself as a mucous discharge, occurring between folds of the skin in infants or fat persons; and sometimes also in the axillae, around the nipples, in the hollow of the umbilicus, in the groins, about the anus, and in the perineum. The mucous character is given to the secretion by the intermixture, with the serous exudation, of the newly formed material ECZEMA MARGINATUM. 137 of the epidermis. A predisposition to exudative eczema of the mucous character is not unfrequently met with, without being followed by erup- tion ; in this case, the surface is itchy, but without redness, and when rubbed becomes moistened with a viscous secretion having a strongly acid smell. This condition of the skin is commonly experienced on the scrotum and in the perineum, but may occur on any part of the body, and especially in the joints. Eczema neurosum.—We have given this name to a very distress- ing association of neuralgia of the cutaneous nerves with eczema. The most painful case that we remember was one in which the pain occu- pied the axillae; and, from its severity, weakened the nervous tone of an already weak heart. The patient was of Asiatic origin and highly irritable temperament. FORMS OF DISTRIBUTION OF ECZEMA. Eczema is rarely so general in its attack as to affect the entire body; but such cases are occasionally seen in the adult, and more frequently in the infant. More commonly, eczema occurs in patches of limited extent, and usually of a rounded or oval form, eczema figuratum ; but at other times is diffused, eczema diffusum, over a considerable part of the body, as of the limbs, or a portion of the trunk. Its occurrence in small circular blotches, that in size and form have suggested the idea of pieces of money, eczema nummulare, is not very rare. But a rarer form, is one which we have named eczema margi- natum, from the presence of an abrupt ridge which bounds it on all sides, and remains active and irritable when the skin within its area is in great measure restored to its natural state. The common seat of eczema marginatum is the perineum, and the boundary-line extends for a short distance down the thighs in front, and upon the buttocks behind. We have met with this form of eruption chiefly in officers who have returned from India or China for their health, and some- times it has been associated with circular rings or marginate blotches on other parts of the skin. The eruption is excessively itchy and very obstinate, and the patients have usually spoken of it as a disease com- mon in the East, and considered to be a kind of ringworm. A gentle- man lately under our care became attacked with it in Burmah, and called it the Burmese ringworm; it originated, he said, from the moist heat of the climate, combined with the habit of frequent bathing. Another patient called it the Concanee itch, and said that it was common in the Concanee district; while a third termed it the Hong Kong ringworm. LOCAL FORMS OF ECZEMA. The LOCAL forms of eczema derive th^ir chief interest from the existence of conditions favoring the development and permanence of the disease in the localities attacked, and also from the complications that are consequent on their position. Sometimes the complication is due to the structure of the part, as in eczema capitis, where the hair is 138 ECZEMATOUS AFFECTIONS. a source of much inconvenience. Sometimes the aggravation proceeds from the unavoidable operation of irritants upon the diseased organ; for example, the atmosphere, in eczema faciei, aurium, et manuum; heat, moisture, and friction, in eczema axillarum, umbilicale, inguinum, pudendi, perinei, and ani; friction, and, during lactation, moisture, in eczema mamillarum; and motion, in eczema oris, labiorum, and articulorum. Eczema capitis.1—The forms of eruption common to the scalp are, eczema ichorosum, pustulosum, and squamosum. In eczema ichoro- sum the hair becomes matted and stiff, a thick casing composed of desiccated crusts and matted hair is formed upon the head, and, beneath this matted case, is a profusion of a tenacious and colorless, and some- times, a muco-purulent exudation (tinea mucosa.) The disease gives out a disagreeable odor, which may be compared to putrid straw, and if a portion of the crust be raised, the skin beneath is seen to be viv- idly red, and excoriated to a greater or less extent. There are never any vesicles or papules on the scalp; but around the circumference, on the forehead, the temples, and the neck, there is redness, eczema erythematosum; often papulae, eczema papulosum; and desquamation, eczema squamosum. The transition of eczema ichorosum into eczema pustulosum is simple enough; psydracious pustules are developed on any part of the scalp where the cuticle is unbroken, and particularly in the circum- ference of the disease; and the originally ichorous and limpid exuda- tion passes quickly into the puriform state. When the ichorous secretion is poured out in large quantity, it dries upon and amongst the hair, frequently drawing it together in little bundles, and inclosing the little bundles and separate hairs in a thin transparent membranous sheath; and when the hair has been cut short, the bundles taper to a point like a camel's hair brush, and give rise to a peculiar and remarkable appearance.2 The hairs, covered with these white films, have a striking resemblance to asbestos, and suggested to Alibert the terms teigne amientacea, and porrigo asbestina, by which he has designated this form of eczema capitis; if, however, a specific name were given to it, it would be more correct to term it eczema amiantaceum. 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 dis- persed 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. When eczema capitis has exhausted its secreting power and much of its activity, the scalp is left red, rough, thickened, itchy, and scaly ; this is eczema squamosum; this also is the state, the exhausted psora, 1 Synonyms: Erythema ichorosum; tinea mucosa, amientacea, furfuracea, granulata; porrigo furfuracea, asbestina; dartre squameuse humide ; running scall. 1 Portraits of diseases of the skin ; vide eczema capitis. ECZEMA FACIEI. 139 to which the term psoriasis is correctly applicable; the psora that is no longer humid and weeping (psora humida), but the dry psora (psora sicca). Psoriasis signifies the dry and prurient condition of the eruption, and not the scaliness, which is a consequence of the in- flammation. The scaliness of eczema or psora is expressed by the term pityriasis, which also indicates the kind of scales, thin, fine, and bran-like, in a word, furfuraceous. *These terms, therefore, represent three stages or forms of eczema ; firstly, the moist and active stage, or psora; secondly, the dry and indurated stage, or psoriasis; and thirdly, the squamous stage, or pityriasis. Much of the complexity attaching to the nomenclature of cutaneous diseases arises from the mingling of the Greek and Roman names, and the misconception of their true meaning. We have endeavored to show that the vulgar name of the disease before us was eczema, or rather eczemata, for the Greeks spoke of it in the plural number; and that another popular synonym of eczema was psora; that psora in its tamed, or exhausted, or chronic state, was known by two names, psoriasis and pityriasis; psoriasis being intended to distinguish its itchy state, and pityriasis its squamous state. Moreover, it must be mentioned, for the more full understanding of these terms, that pityri- asis was limited in its application to the scalp, while on any other part of the body the disease was called psoriasis. The Romans ren- dered the words psoriasis and pityriasis by their own term, porrigo (a porro, quia ut porrum in tunicae involucra, ita cutis velut in squa- mas resolvitur); but its proper synonym is pityriasis. Pityriasis and porrigo must therefore be regarded as synonymous, the former being the Greek, the latter the Roman term, for the same form of disease. It must also be mentioned in connection with eczema capitis that the lymphatic glands of the head and neck, and particularly the mastoid and occipital glands, are apt to enlarge and become painful, and sometimes to become involved in suppuration. Eczema faciei.—Eczema in all its varieties may appear on the face; in its more active forms it occurs chiefly in infants and young persons; in its more chronic forms in adults. Eczema erythematosum and papulosum combined are common to infants, and have received the name of strophulus, or tooth-rash ; and the same forms are some- times seen in the face of debilitated persons, and especially women, and are distinguished by the appellation of gutta rosacea. Eczem'a ichorosum of the face, as it occurs in infants, gives rise to the formation of the crust known as crusta lactea, and is very apt to degenerate into eczema pustulosum (eczema impetiginodes), and not unfrequently, the pyogenic tendency being in excess, the case has the character of a true impetigo.1 The crusts vary in degree of thick- ness, porosity, and color ; sometimes they are gray or brownish, some- times yellow or amber-colored, and sometimes, from admixture with blood, almost black. The yellow and amber-tinted crusts suggested to Alibert the euphonious appellation, melitagra. Of the chronic ' Vidt Portraits of diseases of the skin; the plate marked impetigo faciei is of this kind ; and, adopting our present nomenclature, should be termed eczema pustulosum. 140 ECZEMATOUS AFFECTIONS. forms of eczema of the face, none is more obstinate than that which attacks the nose in adults. Eczema aurium.—Eczema of the ears is either ichorous, pustulous, or squamous. In the former the pinna is very much swollen, the meatus is obstructed by the swelling, and the limpid ichor is seen to distil from the follicles in separate drops, and often with a rapidity that reminds us of a spring. The'exudation quickly dries up into yel- low crusts, under which, accumulations of lymph or muco-purulent fluids are detained. The inflammation occupies both surfaces of the pinna, and spreads more or less extensively to the side of the head. In its squamous form the eczema is very obstinate ; it occupies chiefly the fissure behind the ear ; the secretions are dried up; but the skin is red and thickened, scaly, and often cracked. Eczema palpebrarum.—On the eyelids eczema is usually met with in the erythematous and squamous form ; but sometimes also, in young persons, has the ichorous and pustulous character, and is asso- ciated with conjunctivitis. This latter constitutes the disease termed psorophthalmia. When attended with ©edematous swelling, and much surrounding inflammation, eczema palpebrarum may be mistaken for erysipelas. Eczema oris et labiorum.—A squamous and fissured form of eczema is not unfrequently met with around the mouth and upon the lips of young persons. The eruption is unsightly and troublesome, and often, from the extension of the cracks, very painful, and is slow and obstinate under treatment. As a necessity, where there exist cracks and fissures (rhagades), the skin is more or less thickened and condensed by serous infiltration. Eczema axillarum is commonly of the ichorous kind, and some- times erythematous. The ichorous exudation is due to the heat and moisture, and somewhat to the friction of the part; and the debility of the skin and the continuance of the irritation commonly give rise to enlargement of the superficial lymphatic glands, and not unfre- quently to furunculi and cutaneous abscesses. Whenever eczema attacks the body generally, in adults, the axillae invariably participate in the disease. Such an affection is not unfrequently met with as a consequence of the exhaustion of the puerperal state, or of prolonged lactation; and is sometimes accompanied with cutaneous neuralgia. Eczema mamillarum is a painful, and often an obstinate complaint. It is usually ichorous, pustulous, not unfrequently squamous, and deeply chapped and fissured. It is most painful and most intractable when it occurs during lactation. Eczema umbilicale et inguinum belongs to the kind of eruption which results from the heat and moisture and friction which are the inseparable consequences of the apposition of folds of the skin, as in natural depressions like the umbilicus; in the fold between the mam- ma and the wiaist; the thick folds of the neck and abdomen in fat persons and infants; the fissure between the buttocks, or, between the thighs and the scrotum or labia majora. This form of the eruption is usually termed intertrigo; it is sometimes erythematous, sometimes ichorous, and sometimes squamous. When ichorous, the exudation eczema manuum et pedum. 1-11 is apt to assume the mucous or muco-purulent character, and continue as a morbid secretion for a considerable length of time; or the ichor- ous alternates with the squamous form for a long period. In the squamous variety there are often cracks or rhagades of considerable depth and extent. Eczema pudendi, perinei, et ant.—Eczema is especially a pru- ritic affection; but the itching is nowhere more strongly manifested than in the region of the pudendum, perineum, and anus, both in the male and in the female. In other respects it does not differ from the eruption in other situations, except perhaps in endurance; for it is in no situation more lasting and obstinate. In the deepest hollows there is always a moist secretion, and in the cleft between the scrotum and the thighs, and around the anus, there are frequently painful rhagades or fissures. The scrotum is peculiarly subject to itching; it is apt to be much torn by the nails, and that which before was a mere pruritus of the skin is rapidly converted into an erythematous and ichorous surface, tender, painful, and thickened. Eczema not unfrequently attacks also the deep furrows of the folds of the prepuce, and assumes a chronic character. It is erythematous, dry, squamous, and fissured ; the skin being indurated and thickened, and apt to contract around the glans, and occasion phimosis. It is also met with similarly situated upon the mucous covering of the clitoris. Eczema articulorum.—The thin skin of the flexure of joints is especially susceptible of eczema, and in an eczematous diathesis the eruption will always be found there, although it may be absent in other parts. It is commonly either ichorous or squamous, is accom- panied with rhagades and fissures, and frequently bleeds during the movements of the limbs. Euze.ma manuum et pedum.—Eczema is always more inveterate and obstinate at the extremities of the body than elsewhere, and is more frequently met with in the hands, which are exposed to the action of irritants of various kinds, than in the feet, which are shel- tered from similar causes. A form of eczema, of the squamous and fissured kind, and produced under the influence of the irritation of the wash-tub, was called by Willan the washerwoman's itch; a similar form of eruption, induced by dust and lime, he called the bricklayer's itch. The same eruption existing in the grocer and in the baker, were, respectively, the grocer's itch and the baker's itch. The erythema of the wrists and back of the hands which comes on in cold weather, and after a while becomes chapped and scaly, the so-called chapped hands, is, in its latter stage, a chronic eczema, an eczema squamosum et fissum. The influence of the sun's rays upon the back of the hands has already been mentioned; and the illustration is an interesting one, inasmuch as it is that which suggested to the mind of Willan his definition of a vesicular eruption. But, as we have already seen, it is also the best illustration that can be adduced for the purpose of showing the faultiness of his system. The same cause, namely, the sun's rays, * 142 eczematous affections. which in one case will produce an eczema solare, will in another occa- sion only an erythema solare, and in a third a lichen Solaris; and, as it would be unphilosophical to admit in these different appearances three separate diseases, we are constrained to embrace the whole under the more appropriate designation of eczema ; namely, eczema erythe- matosum, papulosum, and vesiculosum. In this form of eruption, there is another element present that must be noted: in eczema erythematosum there is probably no swelling ; in eczema papulosum there is a little swelling; but in eczema vesiculosum there is swelling to the extent of oedema, because the latter variety of eruption is most apt to •occur in a lymphatic constitution, in which there is an excess of serous fluids, and consequently all the material necessary for an effusive or exudative eruption. Eczema dorsi manus.—Eczematous eruption of the back of the hands is generally circular in its form, eczema figuratum, and presents itself either as a cluster of pimples with exudative summits (lichen agrius, Willan,) or as a red, dry, thickened, and uneven patch, that is commonly termed psoriasis. The patches are very itchy, and on being rubbed, exude a quantity of serous lymph; sometimes ^n the squa- mous stage they are more or less chapped; and sometimes pour out a little blood as well as lymph. Occasionally, these patches extend to the knuckles, and are accompanied with cracks which are painful and difficult to cure. Eczema palmare et plantare.—In the palm of the hand the eczema squamosum constitutes one of two forms of psoriasis palmaris which it is important to distinguish; the other being a syphilitic affec- tion. The eczema palmare presents the usual characters of the squa- mous form of the disease; its dryness, its scaliness, the thickening and hardening and contraction of the skin, and its long and deep cracks in the lines of motion. The contraction of the skin is often so great that rupture seems to be its only relief; and we are led to feel that, pain- ful as is the alternative, the previous state must have been far less endurable. Eczema plantare is less frequent than the palmar form, on account of the protection which is afforded to the feet by their cus- tomary coverings. Eczema digitorum et unguium.—Eczema on the fingers some- times assumes the vesicular form, but more frequently is squamous, and accompanied with rhagades or cracks, which one while take the direction of the wrinkles of the joints, and another while cross longi- tudinally the tips of the fingers. The thick cuticle of the palmar sur- face of the fingers is generally raised in laminae, through which dark globules indicating the effused lymph are seen ; but on the sides and back of the fingers true vesicles are produced; and in the thin skin of the clefts of the fingers the vesicles have a conical instead of the semi-globular form. When the eczematous inflammation extends to the walls of the nails, the secretion of the nails is interrupted, they become discolored, brittle, ragged, and uneven, and take on a morbid character; this is eczema unguium. Eczema unguium is very commonly accompanied with a ECZEMA INFANTILE. 143 red and swollen state of the walls of the nail, particularly the posterior wall, and is often throbbing and painful. ECZEMA INFANTILE. 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 treatment, will 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 originates for the most part in mal-assimilation, and, with good reason, is commonly ascribed to a faulty secretion of milk on the part of the mother or to the faulty diet; but when once established, is not remedied, as might be expected, by the withdrawal of the cause and the substitution of a different and less objectionable 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 dis- ease will subside. The milk teeth are all cut, but still the eczema lingers, and then a new expectation is raised that 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. 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 under our care some months afterwards. This day, a neighbor brought us her infant covered with eczema from head to foot; the child was a few months old; in her confinement the mother had lost her husband under pain- ful circumstances ; the distress caused by this affliction was transmitted to the offspring as an eczema. How small the cause of mal assimila- tion in these cases; and yet they may be taken as the type of the whole family; how easily is the assimilative function of infants dis- turbed ; 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 eczematous disease. At the same moment, and on the same child, may be seen erythema, lichen, strophulus, impetigo, pityriasis, and psoriasis, and an observant nurse seems to take a special delight in pointing out the various forms of disease which pervade the flesh of the poor little sufferer. In certain parts of the body eczema erythematosum is apt to prevail; but a broken or cracked state of the skin, with however small a decree of ichorous oozing, must determine the case to be an 144 ECZEMATOUS AFFECTIONS. eczema ichorosum. On the back eczema papulosum or lichenodes is apt to predominate; on the head, in the bends of the joints, and on the pudendum, eczema ichorosum ; and on the cheeks and ears, eczema pustulosum, vel impetiginoides. The predominance of one or other of the typical forms of eczema 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 poor 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 softness of its mus- cles ; 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, attributa- ble to progressive anaemia; then follows emaciation; the skin shows signs of wrinkles, becomes dry and discolored, and ultimately caco- trophia With these, the outward signs of the disease, of mal-assimi- lation 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 sus- pended biliary secretion; but there is nothing beyond the commonest gastro-intestinal derangement, and that in a very insignificant 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 increase of irritation, consequent on the exces- sive 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 adds to the local disease, by irritating the parts over which it flows. The case up to this time is one of eczema erythematosum and papulosum. The state of eczema vesiculosum has hardly existed, and is only to be seen oc- casionally ; but the disease still runs on, its violence increases, and the morbid secretion, from being a transparent and colorless ichor, like water in appearance, eczema ichorosum, becomes slightly opaque and milky, eczema mucosum, then yellowish and semipurulent, and the case is transformed into eczema pustulosum vel 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, as in 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 eczema erythematosum, an eczema papulosum, an eczema vesicu- losum, or eczema pustulosum vel impetiginodes. Again, as we have before said, whatever the predominating character may be, whether ECZEMA INFANTILE. 145 erythema, lichen, 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; an erythema here, an erythema with strophulus or lichen there, a few scattered vesicles in a third place; or a few congre- gated psydracious pustules in a fourth. In this description of the general characters of eczema infantile, we 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 dry up into a thin, transparent, amber-colored crust; in eczema ichorosum, with a more copious discharge, the crust is less transparent and thicker; and in eczema impetiginodes, from the desiccated matter being pus, it is thickest of all, and has the appear- ance of dried honey; melitagra. As may be supposed, the crust presents considerable variety of appearance, according to the preva- lence of accidental circumstances in a greater or less degree, such as, accumulation of • secretion, amount of desiccation, &c. Not unfre- quently, as a consequence of pressure or friction, blood is mingled with the discharges, 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 severed fragments. Sometimes this tormenting 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, exco- riations, and scabs of every variety of size and dimensions, and giving out an 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 commouest seats of the eruption being, the head and face, the front of the chest, the umbilicus, the pudendal region, and the flexure 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 including 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, or more properly porrigo granulata. Many of these particles of crust being pierced by the hairs, have the appearance of a string of rude beads. Later in the history of the eruption, and when it has become decidedly chronic, when ervthema of the scalp with copious furfuraceous desquamation 'are the leading characters of the disease, it has been termed tinta or 2)orrigo furfuracea; and later still, when, with a slighter degree of 10 146 ECZEMATOUS AFFECTIONS. erythema, the epidermal exfoliation is finely furfuraceous or 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 inflamed 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, unnatu- ral mask covering the child's face, suggested the term larvalis, given to one of his species of porrigo by Willan ; only that, instead of por- rigo 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 icho- rosum or eczema impetignodes, 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 pinna, 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 glands. The pudendal region, both in the male and female infant, is not uncommonly the seat of the eruption, being determined to that region partly by the heat and moisture resulting from its function, and partly by the thinness and sensitiveness of the skin. For the latter reason it is commonly met with in the flexure of the elbows and knees, and sometimes in the axillae. In the flexure of the joints, the inflamed skin is apt to crack into fissures of considerable 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- siderable size, several inches square, and to attack 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 the circumscribed patches which are seen upon the skin in the lichen agrius of Willan; 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 resolution or spontaneous cure; it is apt to merge progressively into a chronic form, and undergo that kind of modification which is com- mon to cutaneous disease when passing from an acute to a chronic stage. By degrees the ichorous discharge diminishes, and the erup- tion retires to certain situations, where it continues to linger, sometimes* subsiding into a state of calm, and sometimes breaking out afresh like ECZEMA INFANTILE. 147 a slumbering volcano. The situations on which it most commonly re* treats, are the scalp, the eyelids, the ears, particularly the back of the ears ; the integument around the mouth, the armpits, the groins, and bend 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 desquamation, 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 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 when 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 bend of the joints, the skin is more, or less red, thickened, uneven, cracked, and chapped, and the ichorous secretion having ceased, it throws off 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 defluxion of time, chronic eczema infantile, eczema pity- riasicum ; or, psoriasis infantilis. The 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. 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 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 become sufficiently obvious to attract the attention of the unobservant; and later still, the poor little child is strangely altered from its normal state; mal-assimila- tion, cacochymia, cacotrophia, are traced in conspicuous lines on every part of the surface, in every feature. The limbs are thin, showing 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 expres- sion of care, anxiety, of thought, upon the little face ; from the general emaciation of the body, the head looks larger than natural; 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 listless, and sometimes bright and t'lear. The eve tells an eloquent tale of defective nutrition. Wc have remarked above that the symptoms of internal disorder are but trifling at the commencement of the disorder; and far from being severe throughout its course; they attract little of the attention either of the mother of the child or of the medical man. The great, 148 ECZEMATOUS AFFECTIONS. the urgent symptom of the whole, is the teasing, the intense, the vio- lent iching ; 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 exhaustion, the child sleeps, probably to be awaked again several times in the night by a repetition of the same agony. This constant suffering natu- rally wears out the child's powers, and added to the mal-assimilation, brings about the state of atrophy previously described. But it is 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, some- times aphthae and augmented secretion; and the eczematous conges- tion 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 calculated to give us some anxiety, and requires dexterous management; 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 mem- brane, as is whiteness of the eye of general anaemia. Diagnosis.—The distinctive characters of eczema, its physiognomy, so to speak, are, redness, with more or less disturbance of the cuticle; sometimes the cuticle is raised into pimples, sometimes into vesicles, and sometimes it is broken up in lines or in blotches, and an ichorous lymph oozes from the crevices or weeps from an abraded surface; lastly, the skin may be red, coarse, thickened, and in a state of desqua- mation, without any exudation whatever. Of all these signs, exuda- tion is the most pathognomonic, and next to exudation, desquamation, and a cracked or broken surface. Cause.—To conduct the treatment of eczema with success, it is necessary not only to know the habits and phenomena of the disease, in other words, its pathology, but also to be able to form some judg- ment as to its cause. Careful observation has convinced us that the CAUSE OF ECZEMA. 149 essential cause of eczema is debility, debility of constitution or general debility ; and debility of tissue or local debility. And further investigation has shown, that constitutional debility may present itself in three forms ; namely, as an assimilative debility, in which the organs of digestion and secretion are principally at fault; as a nutritive debi- lity, wherein the powers of nutrition are chiefly concerned; and, as a nervous debility, in which a morbid state of the nervous system takes the lead. In 300 cases of eczema, 278 were referable to general debility, and 22 to local debility; and of the 278 instances of general debility, the examples of assimilative debility were 143, nutritive de- bility 103, and nervous debility 32. Debility stands in the position of a predisposing cause of eczema; but, as debility is itself due to certain causes, these latter must be re- garded as bearing the relation of remote predisposing causes of the eruptive disease. Of the 278 cases of general debility already referred to, the remote predisposing causes, taken in physiological order, admit of being arranged under twenty-four heads, as follows: 1. hereditary diathesis; 2. strumous diathesis ; 3. weakly parentage; 4. errors of diet; 5. errors of hygiene, namely, air, exercise, cleanliness, and cloth- ing; 6. vicissitudes of cold, heat, and moisture; 7. transitions of sea- sons; 8. ungenial climate; 9. excessive labor, mental and physical; 10. anxiety and affliction; 11. sexual excess; 12. vaccination; 13. dentition; 14. excessive growth; 15. deranged digestion; 16. de- ranged menstruation; 17. uterine, reproductive, and puerperal de- rangements ; 18. fevers, eruptive and malarious ; 19. gouty and rheu- matic diathesis; 20. constitutional and organic disease; 21. nervous shock and fright; 22. general cachexia; 23. hemorrhage; 24. local injury or disorder. If we consider them in the order of their numerical importance, the arrangement in reference to the leading remote predisposing causes would stand as follows : Deranged digestion, 51; errors of diet, 33 ; weakly parentage, 21; vicissitudes of cold, heat and moisture, 21; anxiety and affliction, 16; hereditary diathesis, 16 ; ungenial climate, 14; constitutional and organic disease, 14; excessive labor, mental and physical, 11; uterine, reproductive, and puerperal derangements, 11; errors of hygiene, 10 ; gouty and rheumatic diathesis, 8 ; deranged menstruation, 7 ; fevers, eruptive and malarious, 7 ; excessive growth, 7 ; vaccination, 7. In reference to the three subdivisions of the remote predisposing causes, namely, assimilative, nutritive, and nervous, the most nume- rous remote predisposing causes of assimilative debility are met with under the heads of—deranged digestion, 49; vicissitudes of cold, heat, and moisture, 13 ; constitutional and organic disease, 12 ; and anxiety and affliction, 11. The chief remote predisposing causes of nutritive debility occur under the heads of—errors of diet, 28 ; weakly parentage, 13; hereditary diathesis, 12; vaccination, 7; excessive growth, 7 ; and errors of hygiene, 6. The most numerous remote pre- disposing causes of nervous debility are met with under the heads of __anxiety and affliction, 5 ; excessive mental and physical labor, 4 ; ungenial climate, 4; uterine, reproductive, and puerperal derange- 150 ECZEMATOUS AFFECTIONS. rnents, 4; nervous shock and fright, 3; weakly parentage, 3; and vicissitudes of cold, heat, and moisture, 3. After the remote predisposing and the predisposing causes of eczema, follow the exciting causes, which are best illustrated by the group of local causes. Of the twenty-two cases referable to locaL debility, the exciting causes admit of being assembled under the fol- lowing heads: namely, cold; heat; moisture, with cold or heat; clothing, bedding, etc.; friction; local irritants ; local injury; varicose veins. The most important groups in numerical value were, cold; local injury; heat; local irritants ; and varicose veins. Among other exciting causes of eczema may be noted mercury, opium, copaiba, &c. Eczema excited by mercury has received the name of hydrargyria; erythema mercuriale; and lepra mercurialis. These are examples of common eczema induced by an irritant medi- cine, but they have been described erroneously as specific affections. Dr. Alley has gone the length of making three varieties of hydrargy- ria, namely, mitis, febrilis, and maligna,.the latter being nothing more than an eczema excited by mercury and complicated in its symptoms by salivation. We knew a lady in whom a dose of mercury, however small„produced an attack of erythematous and papulous eczema ; she immediately detected the minutest quantity inadvertently given, and on one occasion had an attack of the eruption from the accidental tem- porary contact of gray powder with her skin; she was the subject of an eczematous diathesis. Several examples of eczema from the use of opium are on record, and the eczema of copaiba is sufficiently well known. A poultice or water dressing not unfrequently determines an eczema, and we have several times seen it induced by the tincture of arnica, used as a lotion for a bruise. Prognosis.—Eczema presents itself in such an infinite number of degrees, that the prognostics of the disease must be determined chiefly by the powers of constitution of the patient. It is not in itself grave ; but as it always indicates the presence of a causa morbi in the system, it is right to infer that the patient cannot be restored to perfect health until that causa morbi, whatever it may be, is removed. For the same reason, eczema is sometimes an indication of what is popularly termed a " break up" of the constitution, and is never to be looked upon lightly: it is commonly, not the disease, but the mere symptom of the disease under which the patient labors, and will get well without trouble when the patient is restored to health. Treatment.—If the foregone premises with regard to the causes of eczema be correct, and we believe them to be so, the treatment of eczema resolves itself into a treatment of debility, a treatment of constitutional debility, and a treatment of local debility ; and the influence which we are called upon to exercise over our patients is one which shall have for its object to restore power, and thereby to regulate function and to confirm health ; for health is nothing more than correct function united with normal power. In general terms, our constitutional treatment must be directed to the regulation of the functions ; and, concurrently with regulation of functions, to the restoration of the tone, the vigor, the vitality of the TREATMENT of eczema. 151 general system. In the most numerous group of cases, those which depend upon debility of assimilation, our attention is principally di- rected to the digestive organs and the secretions. In the next most numerous group, those which are due to nutritive debility, the diges- tive and secreting organs must also be carefully examined, although they are less likely to be faulty than in the preceding group ; and we are enabled, sooner than in the former case, to resort to our strength- ening remedies. The same remark applies to the third group, origi- nating in nervous debility; while, in these latter, we have to deal with the special indication of weakened power of the nervous system. A more particular direction is given to our treatment by the recog- nition of the remote predisposing cause. The commonest of the remote predisposing causes of eczema we have seen to be derangement of digestion and errors of diet; we have but to include the consideration of these causes in our general treatment for regulating the digestive organs and secretions and restoring tone, and our treatment will be complete. Next to the preceding comes a group of causes in which the laws of hygiene have been infringed : for example, vicissitudes of cold, heat, and moisture; errors of air, exercise, cleanliness, and clothing; climate; and seasons. These various causes are too suggestive to call for special comment. The same may be said of another group of re- mote predisposing causes; namely, weakly parentage, hereditary diathesis, and strumous diathesis. Then comes a group, of which labor in excess, both mental and physical, together with anxiety, affliction, nervous shock and fright, and mental distress of every kind, are the leading features. Next we have debility proceeding from the morbid operation of functions natural to the body; for example, den- tition ; excessive growth ; and sexual excess. After these, there are the disorders of female functions; deranged menstruation; together with uterine, reproductive, and puerperal derangement. And, lastly, there is the debility which is due to the existence of other diseases: for example, vaccination; general cachexia; eruptive and malarious fevers; gout and rheumatism ; hemorrhage ; and visceral disorder. The question, therefore, How shall we treat a case of eczema ? is not so simple in one sense as might be imagined, inasmuch as it de- mands a lengthened inquiry into constitution and cause; but simple enough in another sense, because it involves no more, but quite as much, as the treatment of any other disease to which the human con- stitution is liable. To treat an eczema judiciously and correctly, we must know the sex and age of the patient, together with the predis- posing cause, the remote predisposing causes, and the exciting cause of the disease. It may be that our treatment must be directed to the restoration of digestion and secretion; or to the strengthening of an exhausted vitality; or to combating an inherent and inherited weak- ness ; or to the improvement and sustainment of defective power ; or to the regulation of disorders of the female system; or to the cure of visceral or of organic disease. In a word, the highest and best quali- ties of medical art and science must be put in practice, with foresight and discretion, for the treatment of an eczema; the universal must submit to become the handmaiden of the special. 152 eczematous affections. The agents of the constitutional treatment of this disease, our reme- dies, belong chiefly to the class of aperients and tonics; while, as adjuvants, we have recourse to sedatives, alteratives, and stimulants. Our best aperients are: sulphate of magnesia ; guaiacum; and the purgative extracts, either alone or when specially indicated, united with blue pill or calomel. These remedies clear away accumulated ingesta and secretions from the alimentary canal; they restore a torpid and lethargic function, in this sense performing the part of derivatives from the inflamed tissues; and they promote healthy secretion. But aperients require to be used with judgment; they must neither be carried too far, nor continued too long; our object should be to imi- tate nature as closely as possible; and above all, to avoid lowering the powers of the constitution. Nothing reanimates the energies of the organism so much as the healthy operation of the natural functions of the body; this should be our aim: and, when so applied and skilfully used, an aperient, instead of produci-ug exhaustion, becomes a power- ful tonic to the entire frame. The sulphate of magnesia in small doses possesses all these good qualities; it restores the function of the alimentary and urinary mucous membrane, and agrees with most con- stitutions. Some there are, to whom the warmer aperients or the mineral purgatives are more suitable; but this is a matter that can be determined only by observation. Again, we are influenced in our selection of an aperient, often by the season, and often by some col- lateral object, such as derivation ; in the spring and summer saline aperients and neutral salts may be indicated; whereas in a colder season we should prefer the warmer remedies; and, in seeking for a derivative we should possibly prefer aloes to Epsom salts. Besides their direct effects of removing obstacles and promoting normal secretion from the mucous membrane, aperients have the pro- perty of rendering absorption and nutrition more active. How use- fully, on many occasions, do we put this property of aperients to a purpose, in removing effused fluids from the tissues, in carrying off waste humors, and stimulating nature to be more eager in the assump- tion of fresh material. It is marvellous how much may be accom- plished by the judicious use of remedies ; and with what certainty the results which we seek to obtain may be secured. If we run the eye down our list of remote predisposing causes, other remedies suggest themselves which may be combined with our aperients to adapt them to a particular purpose; let us instance rheumatism, which draws our thoughts towards the iodide of potassium ; gout, towards colchicum ; and uterine diseases, towards alkalies and iodine or bromine. If we turn our attention, in the next place, to the tonics, which may be found suitable for the treatment of eczema, we find : simple vege- table bitters, cinchona and quinine, chalybeates, the mineral acids, hydrochloric, nitric, sulphuric, and phosphoric ; and above all, arsenic. Among simple vegetable bitters, with what respect may we not speak of gentian, calumba, orangepeel, quassia, chirayta, strychnia, chamo- mile, and hop; in infusion or decoction; in extract or in tincture; in combination with the mineral acids, or with ammonia, soda, or potash. How admirably cinchona and quinine perform their part; TREATMENT of eczema. 153 cinchona in decoction or tincture, or liquor, with sulphuric acid or with ammonia; and quinine in solution, with an excess of sulphuric acid. How perfect a remedy is one grain of quinine, with one drachm of sulphate of magnesia, seven minims of dilute nitric or sulphuric acid, and an ounce and a half of infusion of roses or orangepeel, as a gentle aperient, a corrector of acidity, a promoter of mucous secretion, and as a tonic. Then the chalybeates, iron and its salts, the sulphate, tincture of the perchloride, the citrate, the superphosphate, the iodide, and the citrate of iron and quinine. Next, the mineral acids com- bined with the bitter tonics, and especially the nitro-muriatic and the phosphoric. Again, as a nutritive tonic, we have the cod-liver oil; and our list of remote predisposing causes will discover several sections in which that remedy is peculiarly applicable ; for example: strumous diathesis, excessive growth, and sexual excess. All that precedes applies to any disease of the human frame; whether it be of the lungs, the heart, the liver, the brain, the kidneys, or the womb; the treatment now under consideration is catholic and not special; its aim, to bring back normal function, and so to restore health ; it is the routine of the physician's art; but there is a remedy which possesses a special influence on the skin, and has long been held sacred in cutaneous medicine, namely, arsenic. When all has been effected that can be accomplished by aperients, alteratives, deri- vatives, and tonics, then comes the reign of arsenic; and at that mo- ment arsenic is majestic. But arsenic must be regarded, not as our common weapon, but as our reserve; to be administered when it can do no harm, and when there is every probability of its doing good. Arsenic is a tonic, a tonic which influences chiefly the nerve-substance, and not only gives force to, but improves the nutrition of the nervous matter; in this way it operates upon the trophic system of nerves throughout the economy; and in cutaneous medicine we have evidence of its remarkable powers upon the skin. Arsenic accelerates those actions of the skin which tend to its nutrition and renovation, and therein it becomes a healer of its eruptions, and a valuable aid to the cure of eczema. But arsenic, above all medicines, must be handled with judgment and care; it must be jealously watched, lest it give rise to any unfavorable symptoms, and its use must be suspended at once if there exist even a doubt of its healthful operation. Above all, it is to be borne in mind that only at the right moment is arsenic applicable, and that right moment can alone be determined by watch- ful care, or by long experience. Our Pharmacopoeia is rich in preparations of arsenic; but the most valuable are, the liquor arsenicalis, or liquor potassae arsenitis, and the liquor arsenici chloridi; the dose of the former applicable to an adult suffering with eczema, is two to four minims ; and of the latter, double that quantity. Many years ago, in a paper on Eczema Infantile, we published a formula for the administration of Fowler's solution; and experience has assured us that no better form can be employed for its use ; the formula will be found at the end of the volume. Arsenic should always be administered in small bulk, and the formula in question gives one drachm of fluid as the dose, to be taken on a full 154 ECZEMATOUS AFFECTIONS. stomach, or, if possible, in the midst of a meal. The object of these precautions is obvious; arsenic is intended especially as an improver of nutrition, and therefore should be made to enter the stream of blood with the chyle; in its nature it is an irritant of the mucous membrane, and, therefore, it should be administered at a time when the lining membrane of the stomach is coated with mucous secretion, and at the same time when, by mixing with the mass of the meal, the remedy is largely diluted. Other preparations of arsenic are, arseni- ate of soda, arseniate of ammonia, and arseniate of quinine. The alkaline salts of arsenic are probably immediately decomposed in the stomach when taken with a meal; and the acid solution is already in a state the most favorable for combination with the gastric juice. The arseniate of soda may be administered either in powder or pill; as a powder, it should be well rubbed down with sugar, and given in doses of ^ to T'2 of a grain three times in the day. All the processes of renovation which depend upon nutrition are slow ; hence, as we look for the good effects of arsenic in the improve- ment of nutrition, we must be prepared to continue its use for a con- siderable time. This is another reason for administering arsenic in small doses, independently of the suggestions to the same effect gathered from experience. Indeed, by employing it in larger doses we natu- rally frustrate the objects which we ourselves have in view ; we set up the irritant action of the medicine; we excite nausea, sickness, pain in the stomach or alimentary canal, prostration of nervous power, or cough, and then we are compelled to suspend it prematurely. While, on the other hand, administered with judgment and discretion, there is no safer medicine in the Pharmacopoeia; and at the same time, in our opinion, there is none to equal it in excellence and usefulness. To be a successful practitioner in the treatment of eczema, a medical man must be an accomplished physician; to manage the local treat- ment with success, he must also be an able surgeon. The local treat- ment of eczema must be conducted according to the general principles of surgery. The inflamed part must be soothed in the acute stages of the disease, it must be supported and stimulated during the chronic stages, and it must be excited to a new action in the most chronic stages of all. To soothe, we must employ water-dressing, lotions, unguents, cerates, well-adjusted bandages, and rest. To give local tone, we must have recourse to stimulant applications of various kinds. The water-dressing is useful where there is heat, pain, itching, or tension, but should not be continued beyond the period during which those symptoms exist; for, when prolonged for too great a time, it lowers the tone of the tissues and perpetuates the eruption. In our list of remote predisposing causes, it will be seen that one amongst them is " moisture with heat," the exact condition which at one moment of the disease we employ with advantage in the use of the water-dressing. Whereas, we could hardly adopt any more certain means of producing eczema artificially, than by the application for a long time of water-dressing to a healthy part of the skin. This opera- tion is often seen in practice, in the eruptions which follow the length- ened use of poultices. TREATMENT OF ECZEMA. 155 When the local inflammation partakes of the subacute character rather than the acute, and when, in the latter, the water-dressing has effected the purpose for which it was applied, we may have recourse to cerates or ointments. As a preliminary to both these appliances, all crusts and sordes should be carefully wiped or washed away from the inflamed part; if they be dry and hard, the water-dressing or the ointment dressing maybe applied with a view to soften them, and then they should be removed, and the dressing with the ointment nicely adjusted, and, wherever practicable, secured in position by a bandage; where this cannot be done, then we must have recourse to adhesive straps. In selecting an ointment, the best with which we are acquainted is the benzoated ointment of oxide of zinc. It should be spread thickly on the linen or lint, or better still, a piece of fine flannel; the dressings should be shaped so as not to overreach the sound skin; and the roller of elastic cotton bandage should be put on smoothly, and with a view to produce equable pressure on the erup- tion, and support to the vessels of the limb. On a part of any extent it is more convenient, and we avoid wrinkles thereby, to apply the dressing in slips, and dispose them in the manner of a many-tailed bandage ; and when a limb affected with eczema is carefully packed up in the manner described, it may be left for twenty-four hours, and in more chronic cases for forty-eight hours, without disturbance; then it should be unpacked, re-dressed, wiped with a soft napkin to remove sordes, and packed up again for a similar period. While packed up in this way, the itching of an eczema commonly ceases, and the patient is saved from the annoyance and suffering of that disagreeable symptom ; while the skin returns gradually to its healthy condition. If there should be heat and burning of the limb when packed, the bandage may be sopped with water, and then we get the advantage of the water-dressing superadded to the tonic treatment. Where great irritability prevails in the constitution of the patient, we require to have recourse to sedatives; and where irritability is present in the part, we may find it difficult to contrive a dressing which will perfectly suit the eruption. Sometimes grease of all kinds acts as an irritant, and then we are driven for a while to the use of lotions, saponaceous paste, or powders. Sometimes a sedative, such as the acetas plumbi, added to the ointment, relieves the irritability; sometimes a more stimulating application, such as the unguentum resinae, or the ointment of tar or juniper tar. Sometimes we shall derive a successful result from a lotion of soda (3ss, 3j ad Sviij) with which the eczema should be kept constantly moist. At other times, we may put an end to the irritability by pencilling the surface with a weak solution of the nitrate of silver in nitric ether. Again, we rarely fail to relieve the irritability by undressing the part, washing it thoroughly with the juniper tar soap, drying it, and dressing and packing it up again as before. The successful treatment of eczema needs many resources, but only such as may be.explained on the re- cognized principles of physiology and surgery. The erythematous form of eczema yields very kindly to the benzo- ated ointment of oxide of zinc; so also do the moist forms of the 156 ECZEMATOUS AFFECTIONS. eruption, the dressing being aided by moderate compression with a bandage. Eczema ichorosum must be followed up patiently with this plan of local treatment, until the ichorous secretion ceases to be formed, and the eruption heals. But the chronic forms of the disease repre- sented by eczema squamosum, require a stimulant treatment; washing with the juniper tar soap, dressing with the tar liniment, or the un- guentum resinae, pencilling with a solution of nitrate of silver, or a strong lixivium of potash. Whenever these stronger local remedies are used, the eruption should be subsequently dressed, more dicto, with the benzoated ointment of oxide of zinc, and then carefully packed up. When the. chief feature of the local affection is pruritus, we find the juniper tar in all its forms, namely, soap, lotion, and ointment, in- valuable. The lotion is made by mixing an ounce each of the oleum juniperi pyrolignici, sapo mollis, and alcohol, with five or ten ounces of water. This lotion, if need be, may be sponged over the whole body; while for local purposes a formula given to us by Hebra, com- posed of equal parts of oleum juniperi, sapo mollis, and alcohol, is an admirable remedy; or a lotion of carbolic acid, half a drachm, or a drachm to the eight ounces, and either alone or combined with an ounce of glycerine. Besides tar, as an antipruritic remedy, we may have recourse to lotions of hydrocyanic acid, and bichloride of mer- cury, in emulsion of bitter almonds. In the moist forms of eczema, there is always a considerable quan- tity of serous lymph present in the tissues of the skin ; and, until that serous fluid is removed, either by absorption from within or by excre- tion from the part, the skin cannot return to its normal state. It is to the presence of this fluid infiltrated in the substance of the skin, that the chronic forms of eczema owe their thickening, their induration, and their rupture; the latter giving occasion to fissures and cracks, and being most conspicuous where the skin is naturally thin, or thick and wrinkled, as on the hands and fingers, on the feet, behind the ears, along the borders of the mouth, and in the cleft of the podex. For this state of the skin, in an aggravated form, there is no remedy to compare with a solution of caustic potash. That application seems to purge the skin of its abnormal fluids, to promote absorption, and to give energy to nutrition ; and it is amazing with what rapidity the cracks will heal, and the most chronic state of disease get well under this treatment. The potash solution (3j—3iv ad Ej) is also the appro- priate treatment for eczema sclerosum, eczema verrucosum, and all the more obstinate or psoriasic forms of the disease. When this solution is sponged on the tough and thickened skin, a copious exudation takes place, and the disease is moved back at once from the third to the second stage of the eruption, and becomes amenable to the milder remedies suited to that stage. It would seem as if the tissues were too weak of themselves to throw out the serous lymph with which they are interstitially infiltrated, and that, when this is effected' by artificial means, they become by degrees restored to their normal state. After the application has been effected, the exudative matter should be wiped away, and the excoriated surface dressed with strips spread TREATMENT OF ECZEMA. 157 with the benzoated ointment of oxide of zinc and roller as already described. In the vesicular, the ichorous, and the pustular forms of eczema, the heat, tension, and itching may be relieved by fomentations of hot water, a decoction of oatmeal, or one of poppy-heads, previously to the application of the strips and roller; and the infiltration which occurs in eczema oedematosum is best treated with strips and roller; but if there exist also infiltration and thickening of the corium, one of the weaker potash solutions may be used. In eczema mucosum, the inflamed surface should be washed with tar soap, and afterwards pencilled with the stronger tar solution ; and, as soon as the exudation is conquered, the surface should be dusted over with the pulvis amyli et oxydi zinci vel calaminae praeparatae vel cinchonae. In eczema neurosum, we have found no remedies so potent in relieving irrita- bility and pain as a solution of nitrate of silver in nitric ether (gr. x ad 3j), and the stronger solution of the juniper tar. In eczema mar- ginatum, the best remedies are, washing with the juniper-tar soap; sponging with the lotion of the bichloride of mercury in emulsion of bitter almonds, with spirit; and pencilling the margins with the solu- tion of nitrate of silver in nitric ether; or frictions with the ungu- entum hydrargyri nitratis, or with an ointment composed of equal parts of unguentum picis liquidae and unguentum sulphuris. In eczema capitis the hair constitutes a complication, and when the means of cleanliness are not of easy access, it may be necessary to remove it: that is a practice, however, which we have never occasion to adopt; soap, especially the juniper-tar soap, tepid water, the comb, the brush, these are all-sufficient means for removing the worst kinds of sordes and crusts; and with these it must be done even when the hair is shortened or thinned. After drying the scalp, it should be thoroughly anointed with a diluted pomade of the nitric oxide of mercury ointment (3ss ad |iss), and left for twelve hours. The combing and brushing and anointing may be repeated every twelve hours; but unless the head have been previously neglected, or the accumulation of crusts excessive, the ablution will not require repeti- tion. When eczema capitis has entered the squamous or chronic stage, and has become a pityriasis, then the treatment must be somewhat more stimulant; for example, daily matinal ablution with the juniper- tar soap; active friction with the nitric oxide pomade; and plentiful combing and brushing; the intention of this treatment being to re- move sordes and scurf, and restore healthy nutrition and tone. In this case, the combing and brushing and inunction must be practised twice in the day. For the face, the ears, the axillae, the nipples, the umbilicus, the groins, and the limbs generally, the benzoated ointment of oxide of zinc is the best application; and, in the chronic stages, ablution with soap, previously to the ointment dressing. For the eyelids, and the more delicate parts of the pudendum, an ointment of acetate of lead (gr v ad 5j), or a cerate of camphor of the same strength, will be found useful. For the pudendum, perineum, and anus, when the 158 ECZEMATOUS AFFECTIONS. itching is very troublesome, relief may be obtained by the applica- tion of the diluted ointment of juniper-tar (3j ad 3j), after ablution with the juniper-tar soap ; while on the hands and fingers it may be necessary to have recourse to the strongest mercurial ointments, after previous ablution with the juniper-tar soap. In our remarks on the treatment of eczema in general, we have already pointed out the advantage of careful dressing, clever bandaging, and in the very chronic forms of the complaint, particularly on the palms of the hands, the necessity of arousing a new action by the strong- stimulus of a potash solution. The treatment of eczema ungium must be directed to the skin of the walls of the nails, and to the surrounding integu- ment. In eczema infantile, our first attention must be given to the diet of the infant; we must assure ourselves of the healthy state of the mother and of her milk; we must ascertain that the bowels are regu- lar and the secretions natural; and in default of the latter being healthy we must have recourse to an aperient; we prefer for this purpose one grain of calomel rubbed down with one grain of white sugar to an impalpable powder; but we have no objection to a tea- spoonful of castor oil, or syrup of senna, or fluid magnesia. The dose of calomel may be regulated by the age of the child; under one year, one grain; one to two years, one grain and a half; and two years and upwards, two grains. The dose must be modified according to the »apparent strength of the child in the first instance, and in accordance with the action of the medicine subsequently, the object to be attained being such an one 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. 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 repercussion of the eruption by the use of local soothing remedies ceases; 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 neces- sary step, at the very commencement of the treatment. After the first dose, the calomel may be repeated 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. We usually find once a week sufficient, and we are guided to a repetition of the dose by the state of the little patient; very frequently we are enabled to bring the case to a successful conclusion without any calomel at all. If there be feverishness, fractiousness, irritability of temper, in- crease 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 proper moment for a powder, and whatever prejudices they may TREATMENT OF ECZEMA. 159 have against the name of calomel, they are always ready to resort to it after they have once seen its action in this disease. We have no objec- tion 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. Occa- sionally, one or two grains of nitrate of potash make a useful addi- tion to the calomel and sugar. The diet and animal functions being regulated by the above means, and no contra-indication being apparent, such as diarrhoea or bron- chitis, we proceed in the next place to our cure, namely, our ferro- arsenical mixture,1 which we administer in doses equivalent to two minims of the liquor arsenicalis three times in the day. To the proper administration of this remedy there are certain necessary in- junctions : it must be administered with the meals, the best time being the middle of the meal; and the rule applies to all ages; it is best to administer it in one drachm doses, and without the addition of water; and it must be left off if it occasion, or even be suspected of producing, any unpleasant symptoms; for example, nausea, loss of appetite, colic, or prostration of power. In the latter case, its use should be suspended for three or four days, or for a week, and then it may be resumed as before, in the same or in a small dose. If these instructions be complied with, there cannot but be one result, namely, cure.; and often, speedy cure; and whether the cure be speedy or slow, the remedy may be steadily continued, so long as it give rise to no unpleasant symptoms, until the cure is actually attained. For infants under two years we prescribe one minim of liquor arsenicalis the dose, three times a-day; from two years upwards to seven, the dose may be two minims; from seven to fourteen, three minims. At all ages we prefer to begin with two or three minims to test the susceptibilities of the patient, and then, if desirable, we increase the dose. Five minims is a maximum dose, and only admis- sible in alphos, for which arsenic is the specific remedy. It is re- markable 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 spe- cific ; it cures rapidly, perfectly, unfailingly; it would be difficult to say as much for any other medicine in relation to any other disease; and we pronounce this eulogium on arsenic after a large experience in its use. In eczema infantile we alleviate the local irritation and distress; in other words we soothe and heal the eruption, subdue the pruritus, and arrest the morbid discharge, 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 1 The formula for the ferro-arsenical mixture will be found with the other selected formulae at the end of the volume. 160 ECZEMATOUS AFFECTIONS. should be applied morning and night, and if accidentally rubbed off, or used upon parts exposed to the air and friction, it must be repeated more frequently. When once applied, the ointment should be con- sidered as a permanent dressing to the inflamed skin, and never re- moved until the skin is healed, unless special conditions arise which render such a proceeding necessary. To secure undisturbed posses- sion to the ointment, a piece of thin flannel or linen rag, a sheetof cotton wool, or a slip of tissue paper, should be laid over it and main- tained in position by any convenient method. Thus, when the erup- tion covers more or less of the entire body, 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, is the best method of effecting our purpose. 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 in- flamed and irritated skin, and its saturation with ointment, which necessarily ensues, only contributes to its greater utility in that capa- city. Where the eruption is chiefly confined to the arms or legs, linen sleeves, with or without cotton wool, or an elastic cotton band- age, 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 virtue 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 dislodge them, and sub- stitute a thin stratum of ointment in their place. When the eruption passes from the acute into the chronic state, and the process of exfo- liation of the cuticle is active, gentle friction of the skin with the ointment is even more desirable than in the acute 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. We are rigorous in enforcing the non-disturbance of the ointment; but some- times our 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 shell 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 occur- rence takes place, the whole of the ointment should be carefully washed off the part with yelk of egg, or with the juniper-tar soap, and after drying the skin, fresh ointment substituted. This excessive accumulation of the ointment takes place the most frequently on the TREATMENT OF ECZEMA. 161 scalp, encouraged by the matting of the hair, a reason for keeping the hair brushed whenever the nature of the eruption permits. Another of our instructions is to avoid 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. 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, we rarely order or recommend lotions in this eruption. In cases of chronic eczema infantile, that is, in pityriasis capitis and psoriasis partium aliarum, the stimulant properties of the nitric oxide, and nitrate of mercury ointment may be brought into operation; the former is specific for pityriasis capitis, in the proportion of one part to three of benzoated 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 of use as an emol- lient, but when any inflammation exists, it generally proves irritant as compared with the zinc ointment. With the three remedies above recommended, namely, the calomel powder, the benzoated ointment of oxide of zinc, and the ferro-arseni- cal mixture, representing, as they do, the three indications for treat- ment of eczema infantile, we regard the cure as certain and rapid, and failure impossible ; and if success were not complete, we should seek for the cause, not in the remedies, but in the mode of administering them. So confident are we of success, that we have often undertaken the treatment of this disease without seeing the patient, and at hun- dreds of miles distant, being satisfied, for our only aid, with the vigi- lance of an intelligent mother or nurse. We have never known any evil effects, present or future, result from this treatment, but we never fail to give strict injunction, that if the medicine seem to disagree with the child, it should be given less frequently, say twice, instead of three times a day, or suspended 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 some- times occupies three weeks, and sometimes more. And if a recur- rence 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. We 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 other food. The consideration of diet and food brings us to an important dietetic medicine of ureat value in eczema when the latter is attended with 11 162 ECZEMATOUS AFFECTIONS. emaciation, and in the chronic stage; in acute cases it is less applicable: 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 given with safety to the youngest infant. In children some- what older, and particularly in chronic cases, the cod-liver oil chocolate becomes an useful ingredient of diet; sometimes we com- bine the oil with arsenic, as in the formula at the end of the volume. 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. PSORIASIS. Syn. Psoriasis leprodes ; psoriasis eczematosa ; eczema chronicum squamosum ; eczema sclerosum. Psoriasis is a mitigated and chronic form of psora or eczema; and the term is especially applicable to that period of eczema when the skin is red, coarse, thickened, wrinkled or smooth, brittle, dry, itchy, desquamated, and disposing to become moist on being rubbed. In these symptoms we recognize the squamous form of eczema, and com- prehend the transition of eczema into psoriasis as noted by Willan. Psoriasis has been confounded with another cutaneous disease, the lepra of Willan and lepra alphos of the Greeks; but the latter, although presenting a red, thickened, and squamous surface, is not in its ordinary state remarkable for a pruriginous disposition, and gives out no fluid secretion on being rubbed; never takes on the eczema- tous character, which psoriasis is prone to do, and is more decidedly chronic than psoriasis. Psoriasis is very rarely general, although we have seen such cases as a sequel of congenital eczema; usually, it is partial and distributed in patches (psoriasis figurata) upon various parts of the body, or limit- ed to a single region. In its general form, the skin is dry, parched, discolored, and leathery; the hairs are harsh, scanty, and broken; the face very commonly discolored and uneven; the lips thickened, cracked, and furfuraceous; the hands, and sometimes the feet dry, harsh, and thickened ; the fingers and back of the hands rough and wrinkled ; the flexures of the joints cracked and desquamating; and the whole surface of the body highly pruriginous, and disposed to exude a viscous secretion on being rubbed or scratched with the nails. In its local forms, psoriasis may occur, as condensed and tough patches more or less raised above the level of the skin (eczema sclero- sum); sometimes cracked, and coated over with a thick cuticular crust; sometimes in smaller and more numerous patches, not unlike laro-e warts, and intensely pruriginous (eczema verrucosum); and PSORIASIS. 163 sometimes, with more or less thickening, in cracks and fissures of the skin, often very painful, and not unfrequently ichorous and bleeding (eczema fissum). There are certain situations in which eczema in its most chronic form or psoriasis more especially occurs; for example, the flexure of the joints (eczema articulorum), the fold of the ear, the back of the neck, the anus and perineum, the legs below the knees, the back of the hands, the fingers, and the palm of the hands (psoriasis palmaris). In the palm of the hands the term psoriasis has been used in a generic sense for inflammatory congestion of the skin associated with desquamation, whatever its nature and origin; hence it becomes neces- sary to distinguish the true or eczematous psoriasis palmaris from a syphilitic psoriasis palmaris; while, occasionally, we meet with a third psoriasis palmaris having its origin in alphos; alphos palmaris. The diagnosis of psoriasis rests on its alliance with eczema; the ichorous element is always present at some period of the disease, and is equally ready to be roused afresh; and its psoric or pruritic char- acter is strongly marked. It is not to be confounded with alphos, the lepra of Willan, although the term psoriasis has long been in use in connection with the latter disease. There are wide differences between them; alphos is a specific affection, for the most part hereditary, not susceptible of being excited by external causes, and independent of the general health: it is essentially diathetic. Whereas, psora and psoriasis originate in the common disturbing causes of the economy, may be excited by external irritants alone, or by any constitutional disturbance affecting the digestive, the nervous, or the nutritive sys- tem. Psoriasis is essentially psoric or pruritic; alphos is pruritic only accidentally, and by virtue of the local inconvenience which its presence creates, or as the consequence of a complication with eczema. Psoriasis is curable; whereas, alphos is only removable, curable merely for a time; its tendency being to return. The treatment of psoriasis offers special indications; it is a chronic and obstinate local affection, with or without constitutional disorder. If any error of constitutional health can be discovered, such error must be corrected; if there be, as is more than probable, debility in any shape, that debility must be removed by all the means at our disposal; and the virtues of arsenic may be appealed to as a special tonic, not only as an improver of nutrition, but also as a stimulant of the cutaneous tissues. But our chief remedies in psoriasis are local: the tar soap ; carbolic acid soap; tar ointment; the ointment of tar and sulphur; the tar tincture; the nitrate, nitric-oxide, ammonio-chloride, iodide, and bin- iodide of mercury ointments; and as a stimulant for emptying the tissues of their excess of fluids, the potash solution of a strength pro- portioned to the purpose to be attained, ranging from one-eighth to one-half of potassa fusa. It is in these cases that we derive advantage from a carbolic acid lotion, a lotion of the bichloride of mercury, the juniper-tar lotion, and also, from a solution of nitrate of silver of moderate strength. 164 ECZEMATOUS AFFECTIONS. PITYRIASIS. Syn. Lepidosis pityriasis, Mason Good; erythema pityriasicum ; eczema pityriasicum ; psoriasis furfuracea ; dartre furfurace1e, Alibert; branny tetter; dandriff. Pityriasis is a superficial inflammation of the skin, accompanied with a furfuraceous or bran-like desquamation and a considerable degree of pruritus. Its special seat is the scalp; but it is also met with occasionally upon the eyebrows, and among the hair of the whiskers and sternum, and not unfrequently on the face of young per- sons and children. Its particular signs are, redness, heat, pruritus, and desquamation of the cuticle in minute scales, which have been compared to fine bran, and are sometimes so small as to be termed mealy or farinaceous. The degree of redness of pityriasis and the depth of cutaneous tis- sue involved, present some variety ; in certain instances the redness is almost absent, and we are struck with the whiteness of the affected part; in another case, the redness is more marked, but very superfi- cial, a mere erythema ; while in a third case, the vascular congestion extends more deeply; there is some degree of serous infiltration with coarser scales. This latter is the common type of pityriasis capitis, and is a state not unfrequent in persons of an eczematous diathesis, or as a sequel of eczema capitis; a condition which, on the general sur- face of the skin, would be termed psoriasis, but on the scalp goes by the name of pityriasis. On the scalp the disease is apt to cause the fall of the hair, and the trichorrhcea sometimes runs on to decided alopecia. Willan and Bateman distinguished four varieties of pityriasis; namely, pityriasis capitis, rubra, versicolor, and nigra. Pityriasis capitis is an erythematous desquamation of the heads of infants and old persons, which is prone to degenerate into eczema, or, in their language, into "porrigo." They also include in the same term.the little broken clots of sebaceous substance which are so frequently seen on the heads of infants. Pityriasis rubra is an eruption of elderly per- sonsv and a slight form of " psoriasis diffusa." Pityriasis versicolor is an affection that will be treated of among discolorations of the skin, under the name of chloasma; and Pityriasis nigra is an eczema erythematosum of "children born in India and brought to this country." We may therefore regard pityriasis as a convenient term for distin- guishing a more superficial congestion of the skin than that of psori- asis; although, in reality, merely a milder form of psoriasis, associated with a lighter and thinner kind of desquamation. In this sense we apply the term to small, circular, scurfy spots that are apt to show themselves on the face and neck of children. In the majority of instances, pityriasis proceeds from nutritive debility; it is chronic in its .nature, often lasting for several years. In conducting the treatment of pityriasis, its frequent origin in nutritive debility must be borne in mind, although it is usually amenable without much difficulty to local means. In recent and mild cases, the use of an ointment composed of one part of the nitric oxide pityriasis rubra. 165 of mercury ointment to three of benzoated lard, gently rubbed into the scalp night and morning, will generally restore the skin to a healthy state; while, in more obstinate and severe cases, the diseased skin should be thoroughly washed every day with the juniper-tar or carbolic acid soap, and afterwards anointed with the same pomade. For the spots in the faces of children, the diluted nitric oxide of mer- cury ointment and soap ablutions are usually all that is necessary ; or, in obstinate cases, a lotion of emulsion of almonds with the bichloride of mercury, one grain to the ounce. Hardy recommends the use of sulphur both internally and externally; for external use, extremely diluted (gr. xv ad 3j), or a little acid ointment ("I xv ad 3j). In the above acceptation, and in accordance with the definition of Willan, pityriasis is an exfoliation of small, thin, white scales, from a chronically and superficially inflamed derma; the scales being com- parable in size and appearance with the bran of wheat. But under the name of pityriasis rubra, Hebra has singled out and described a very remarkable form of cutaneous disease, characterized by a chronic and deeper inflammation of the derma, associated with a pro- fuse exfoliation of thin, white shreds or flakes of epidermis, which break away in the form of scales; the latter being considerably larger than the scales of bran, and therefore only analogically related to pityriasis. The pityriasis of Willan is always local, and generally limited to a small extent of surface; the pityriasis rubra of Hebra occupies the entire surface of the body, and is distinguished by certain definite characters, for example, deep redness; absence of moist excoriation, pruritus, or rupture of the derma; and the production of scales in such profusion, that the surface looks to be covered with thin white flakes, which break away and may be collected in large quantities daily in the clothes or bed of the patient. And this profuse desquamation is accompanied with waste of the tissues of the patient, and consequent emaciation. Hebra has seen three examples of this remarkable and rare disease, where the entire integument was affected; we have seen only two instances of pityriasis rubra universalis, and one of pityriasis rubra localis, and these cases we shall presently narrate.1 Hebra describes the affection as follows: An intense redness of the entire skin, dis- appearing on pressure with the finger, and displaying a yellowish ground ; a constant exfoliation of fine, white, loosely attached scales; persistent deep redness, without infiltration, papulae, fissures, moisture, or vesicles; scarcely any itching, and no excoriation. The disease begins suddenly, quickly spreads over the whole body; is rarely local; 1 The case described by Dr. Wilks in the Guy's Hospital Reports for 1861, under the name of "general inflammation of the skin, or dermatitis," appears to correspond with pityriasis rubra. The general features of the case were as follows : A man ane'l thirty-four, on April 4th, was covered over the whole body with a thick rOseolous rash ; in a few days, the skin was acutely inflamed, red, and slightly swollen. A week later, the surface " was beginning to be rough from desquamation, and on the 14th, large flakes of epithelium were peeling off the body and limbs." The palms of the hands and soles of the feet did not show redness at first, but in the desquamating stage peeled like the rest of the body, and he subsequently lost the nails of his fingers and toes. " The desquamation was universal, and at the end of a month the man was convalescent." 166 ECZEMATOUS AFFECTIONS. and undergoes scarcely any variation of appearance throughout its course, which may be prolonged for years. Sometimes it presents a crimson and purplish hue from sanguineous changes, loses its depth of color as death advances; and subsequently becomes yellowish, tawny, or gray ; but after death leaves no trace of its existence beyond the squamous state of the epidermis. In the early period of the disease, the patient experiences no inconvenience whatever beyond the strange appearance; he pursues his ordinary avocations and believes himself well; by degrees he feels a sense of weakness and incapacity for exer- tion ; his appetite previously good begins to fail; his muscular power flags; he becomes emaciated ; and finally sinks from exhaustion. Our own experience corroborates exactly the description given by Hebra, as is shown in the following cases, which serve to illustrate besides, some additional features of the disease in relation to its origin and associations. Case 1.—A retired merchant, aged sixty-eight, with an habitually dry skin, has been subject for more than twenty years to dryness and desquamation of the palm of the hands, accompanied occasionally with dry fissures in the lines of motion. This state of the hands has continued to teaze him from time to time until the present date, June, 1866. He was otherwise well in health, and his health has always been good until the last few years. Two years ago, namely, in May, 1864, he suffered a fresh attack of inflammation of the palm of the hands with thickening and desqua- mation of the cuticle; the latter breaking at the lines of motion and peeling off in broad laminae. He was advised to go to the seaside, and while there took a chill which was followed by a smart attack of dermatitis of the face and head, which was treated as erypsipelas. On his return home in the autumn the hands were improved, but still retained their wonted dryness and roughness. In April, 1865, the hands again became troublesome; strong stimu- lants were applied, with active internal treatment, and he again went to the sea. While at the sea coast we were consulted as to his case ; he was well in health, without a symptom of constitutional disorder; but the palmar surface of the hands was stripped of its cuticle from the wrist to the tips of the fingers. The exposed derma was intensely red and glazed ; without swelling, discharge, excoriation, or cracks, and was bounded at the circumference by a ragged margin of thick- ened cuticle. He made no complaint of soreness ; his only inconve- nience was a feeling of burning heat and stiffness; and he was free from eruption on every other part of the body. The treatment he was pursuing was water dressing, which we exchanged for the ben- zoated ointment of oxide of zinc and a bandage ; and under the latter application the comfort of the hands quickly improved, and the skin put on a more healing appearance. Having had a similar case, somewhat less extensive, under our care on a previous occasion, we regarded this as one of a peculiar form of psoriasis palmaris, and headed our notes of the case with the term psoriasis squamosa rubra. In January, 1866, this gentleman called to consult us for a dermatitis PITYRIASIS rubra. 167 of the feet, similar to that which he had previously suffered in the hands. The derma was intensely red, denuded of cuticle,- smooth, glazed, and dry, and so tender as to deprive him of his usual exercise; while the inflamed surface was bordered around the circumference by a ragged edge of broken epidermis. The palm of the hands was normal in color, but rough, and he was otherwise in good health. At a second visit he complained of great soreness of the heel of one foot; and at this part a blister was raised. On returning home he felt the cold severely, and two or three days later was seized with phlegmo- nous erysipelas, which began at the tender heel, and spread up the leg to the middle of the thigh. The phlegmonous erysipelas ran its course from the latter end of January to the middle of April, when the last sinus healed up. He suffered a good deal constitutionally during this period; was delirious, had a black, coated tongue, and was greatly debilitated. During the progress of the erysipelas, the'dermatitis of the soles of the feet dis- appeared ; but as the erysipelas subsided, a blush of redness gradually, but in a short time, spread over the whole body from the crown of the head to the sole of the feet, no part of the skin escaped. A few days subsequent to the complete development of this attack we were called to see him, wheu he presented a very remarkable ap- pearance. His skin was scarlet over the whole surface, the redness terminating abruptly at the edge of the eyelids, like a mask, and the conjunctivae being somewhat suffused. But everywhere, next to the redness, the most singular feature of the disease was the projection from every part of the surface of thin white laminae of cuticle, ar- ranged for the most part in undulating parallel lines, and standing out from the skin like the edges of plate armor. On the limbs, the fingers, and nose, the free edges of broken cuticle, placed at regular distances, and running transversely in undulating and jagged lines, suggested the idea of the ripple of a calm sea, or of lines drawn in chalk upon a deeply red ground. And when the hand was passed down the arm or the leg the surface felt smooth, and no impediment occurred; but when the hand was carried in the opposite direction it was interrupted by the edges of the laminae; and the latter were broken off in scales, which accumulated in great numbers in his bed. At one moment the prominent laminae gave the idea of imbricated scales; at another, when the lamina was broader and broken and somewhat rolled, of fringes and rags. The contrast of the deep scarlet ground, and the whiteness of the free edges of the cuticular laminae, was very curious. The edges of the laminae were commonly half an inch apart, and the breadth of the free edge about a quarter of an inch. The back of each phalanx of the fingers was crossed by three or four lines, and the nose by six or seven. On the limbs, as also on the face, the free edge of the laminae was directed downwards; on the convexity of the joints it presented a curve, having the prominence of the joint for a centre; on the forehead and scalp the lines were segments of a circle, of which the centre was the summit of the head; and on the trunk, as also on the palms and soles, the desquamation and the resulting 168 ECZEMATOUS AFFECTIONS. scales were irregular, for the most part taking prominent points as their centre. The general surface of the skin was soft to the touch, but that of the fingers was hard, and looked glazed and stretched; the fingers themselves were rigid and crooked ; and the nails thickened and rough and uneven on the surface. On the rest of the integument there was no thickening, no infiltration, no moisture or discharge, very little pruritus, and no rhagades, excepting on the heels and along the outer border of the feet, where the fissures were dry. The general appear- ance of the skin, in fact, suggested the idea of a dermatitis squamosa rubra; a name by which we designated the first case that came under our notice, and before we had read Hebra's description of pityriasis rubra. It is surprising, with all the appearance of local disorder occurring in this case, that there should exist so little personal suffering and inconvenience. Our patient has a good; even a large appetite ; enjoys his food; digests well; sleeps soundly; and, to adopt his own expres- sion, has "neither pain nor ache." But there are two symptoms that are unsatisfactory and lead to apprehension; the tongue is soft and pulpy, and tremulous, and the pulse has never fallen below one hun- dred during the whole course of the disease, and is" often intermittent. For a long time it was never less than 110; and there is some little quickness of manner that seems to be associated with the rapid circu- lation. The phlegmonous erysipelas necessarily kept him in bed for many weeks, but he now gets up daily, enjoys his warm bath, his garden, and the society of his children. The disease has presented the same unvarying appearance for two months; there is no difference in the tint of redness, and none in the amount of exfoliation of the epidermis. Subsequently, however, to this period, a gradual improvement is visible in the skin. The trunk of the body and the inner side of the limbs are losing their redness and returning to their normal tint of color; and on those parts there exists some pruritus and a slight glu- tinous exudation or dampness that is suggestive of eczema. And, it would seem not unlikely, that the correct pathology of the disease is, an eczematous inflammation in which cuticular exuviation takes the place of ichorous exudation. This view of the nature of the disease would suggest the term eczema foliaceum as not inappropriate; or if, adhering to the idea conveyed by the absence of ichorous exudation, we regard the malady as a pityriasis, we might employ the term pityriasis foliacea, as synonymous with the pityriasis rubra of Hebra, or pityriasis foliacea rubra. Some mark of distinction is obviously necessary to avoid confusing so grave and serious an affection with the insignificant pityriasis rubra of Willan. Case 2.—A well-marked example of psoriasiss squamosa rubra, similar to the incipient attack in the case above described, occurred in an old lady seventy one years of age; it began by thickening and hardening of the cuticle of the palm of the hands, followed by crack- ing and subsequent peeling of the horny layer; and this case further illustrated the extreme obstinacy of the disease and its resistance of pityriasis rubra. 169 remedies. It had existed twelve months when it came under our notice for the first time; we watched it and treated it for ten months, and it was almost as extensive when we left it, as when we undertook its management; although, during that period, we had directed an arsenical course of three months; a course of Donovan's solution for three weeks; bichloride of mercury for one month; nitro-muriatic acid with a bitter; small doses of sulphate of magnesia with quinine, with nitrate of potash, and with colchicum; iodide of potash with col- chicum ; citrate of iron and quinine; liquor cinchonae with ammonia, and with sulphuric acid; gentian with soda; and various remedies besides ; whilst locally, we employed, oxide of zinc ; chloride of zinc ; acetate of lead; ammonio-chloride, nitrate, and nitric oxide of mer- cury ; sulphur; iodine; carbolic acid, and tar. The disease sometimes improved and sometimes retrograded without any explicable cause. On first seeing the patient the cuticle had exfoliated from nearly the whole of the palmar surface of the hands and fingers; the derma was of a deep red color, dry and glossy, and coated by a thin stratum of new cuticle; there were no cracks in the derma, but the fingers were stiff and hard, and she dreaded to bend them for fear of breaking the skin. There was no discharge and no pruritus; and, in places where the cuticle still remained adherent, it was yellow, transparent, and horny, and evidently deprived of its vitality. In the course of this attack the lady suffered from pain and aching in her limbs, appa- rently of a rheumatismal character; but there was little disturbance of her general health; she took her food with appetite, and digested well; but she grew thin and became exhausted in strength, and shrunk very considerably in bulk. In this case the dermatitis did not reach the matrix of the nails, which were consequently unaffected. Case 3.—The first case of pityriasis rubra foliacea that came under our notice occurred in an old gentleman sixty-nine years of age; it attacked him suddenly in the month of November, and in a few days spread over the whole body. He was scarlet from head to foot, while the skin was ragged with shreds that looked like feathers adherent to the surface. He could eat and drink, and suffered no inconvenience from his apparently skinless state. He remained in this condition during the winter, but recovered in the spring, and by the summer was perfectly well. In October of the following year, he paid us a visit, complaining of a slight return of his old complaint, and a few days later caught a severe cold which ended in bronchitis, and in a sudden reappearance of the pityriasis rubra over the whole body. The disease presented the same characters as before; namely, intense redness, copious exfo- liation of cuticle, absence of moisture and pruritus, and unchange- able persistence. We requested that the scales which came off into the bed might be saved, and in one week the quantity amounted in weight to eight ounces; another week seven ounces; a third six ounces; and so on week after week; the case might be regarded as one of epidermal flux. But with all this loss he retained his appetite and cheerfulness; and although he grew thin, declared that he suffered no inconvenience. He recovered from the bronchitis, but a few months 170 ECZEMATOUS affections. afterwards, unfortunately suffered another attack, from which he died. Had it not been for this accident, there seemed to be every probability of his recovery, as on a former occasion. The last visitation of the .cutaneous disease lasted from October to February. The diagnosis of the pityriasis rubra of Hebra, or pityriasis rubra foliacea, rests on its strongly-marked and peculiar characters, for example: intense redness without exudation; cuticular exfoliation exposing a red and glazed surface without swelling, excoriation, or rhagades; profuse foliaceous desquamation; frequent occupation of the entire surface of the body; increased severity in the hands and feet; persistent and unchanging appearance ; resistance of treatment; absence of pruritus or personal suffering; normal state of the digestive functions; and gradual emaciation and loss of muscular power. Eczema is very rarely general in its attack; and is remarkable for ichorous exudation, infiltration of the cutaneous tissues, severe pru-( ritus, and the formation of crusts or scabs; and when, in its chronic stage, exudation ceases to appear, the integument is thickened and rough, and the cuticular scales small and partial, not exfoliations of the general surface as in pityriasis rubra, but of the uneven and rugged subdivisions of the thickened and infiltrated portion of skin. In a few instances the red and glazed freshly healed surface of eczema articulorum may remind us of pityriasis rubra; but the previous history of the case removes the suspicion; these appearances are secondary in eczema, but primary in pityriasis rubra. The pityriasis of Willan is so slight in its nature and superficial in its grasp upon the skin, as to offer little chance of confusion with pityriasis rubra. Not so, however, with regard to alphos; the latter disease, when general and much inflamed, approaches very nearly to pityriasis rubra; there is the redness, the abundant desquamation, the dryness and glossiness of surface, and the absence of infiltration. Hebra would doubtless call our attention besides to the pruritus of alphos, and to bleeding resulting from scratching; but alphos, in Britain, is not a pruritic affection, lesions resulting from scratching are very rare, and it is evident, from Hebra's account of the disease, that it is dissimilar to that which prevails amongst the inhabitants of this country. So few examples of pityriasis rubra foliacea have come before us, that we are unable to express any positive opinion as to the cause of the disease. Our own cases, it will be seen, occurred in elderly persons, in whom there existed a certain proclivity to nutritive debility. Hebra's cases manifest to a greater extent the same tendency; while, in those that we have narrated, there was associated with this in- firmity, erysipelas, simple and phlegmonous, rheumatism, and bron- chitis. These considerations will serve as our guide in the prognosis of the disease. If we found our conclusions on the experience of Hebra, our prognosis must be unfavorable; but the cases which have fallen under our own observation have given us a more encouraging degree of hope. We believe that the gentleman who forms the sub- ject of the first of our cases will recover, indeed, has since recovered. We see no reason why a similar good result, as far as the cutaneous LICHEN. 171 disease is concerned, may not happen to case No. 1; while we are confidently of opinion, that but for a very severe bronchitis, in an unusually inclement season, and in a man above seventy years of age, our third case would have issued in cure on the last as on a previous occasion. Treatment.—In his treatment of pityriasis rubra, Hebra took alphos as his standard, and had recourse to those remedies which are known to be of service in the latter disease. We, on the other hand, selected the treatment of chronic eczema as our guide. We are able to corroborate the experience of Hebra, that arsenic, mercury, iodine, sulphur, and tar,failed entirely in being of any service; and, that the most favorable results followed the use of warm baths, taken daily and prolonged for an hour or more at a time; and subsequent inunc- tion with a soothing and sheathing pomade, such as that of the ben- zoated ointment of oxide of zinc. In Case 3 we applied the ointment with strips and roller, as advised for eczema. Of internal remedies, we derived the best results from nitro-muriatic acid with a bitter in- fusion, the citrate of iron and quinine, and the phosphate of iron. Hebra made trial of cantharides, antimony, decoction of the woods, and sarsaparilla, in addition to the remedies already mentioned, and includes the whole under the denomination of useless means. LICHEN. Syn. Exormia lichen, Mason Good; Schwindfietche, Germ. ; lichenous rash; papular rash. As eczema is the type of the vesiculae of Willan, lichen is the type of his order Papulae. But, as it has been already shown that vesicles are not necessary to constitute an eczema, and that eczema is a papu- lar as well as a vesicular eruption, we have now only to treat of those papulae which may fairly be considered apart from eczema, and which may be regarded especially as a papular eruption. In fact, we pur- pose to assemble under this head only those affections which are not admissible into the family of eczema, under the comprehensive defini- tion of that.disease already given, and which are obviously different in their nature. We hope in this way to avoid the confusion which Willan himself, as well as more modern authors, have introduced into this group. By lichen we intend to convey the idea of papulae which are dry in their nature throughout their entire existence, and are never associated with an exudation of any kind ; whereas, all papulae which at any period of their course are affected by exudation, or are asso- ciated with exudative diseases in any other part of the body, should at once be turned over to eczema, the mother of moist pimples aud exudation. On this principle it is clear that we must banish lichen agrius from the family of lichens and restore it to eczema, to which, from its exu- dative nature, it obviously belongs; indeed, this transfer is anticipated by the term lichen eczematosus, which has already been attached to it; the eruption being, according to its character, an eczema lichenodes, or, more simply, an eczema papulosum et ichorosum. 172 ECZEMATOUS AFFECTIONS. And also with the view of simplifying the group, we shall consider under the head of lichen, the strophulus of Willan, or rather such of the varieties of strophulus as are true to the characters which he has laid down as the type of the affection. It is obvious that several of his varieties of strophulus should be regarded as forms of eczema in- fantile rather than true papulae, and have been retained in consequence only of their occurrence in infants; strophulus being especially an eruption of children. But as a lichen strophulosus, a lichen of infants and children, strophulus will occupy its proper place in the lichenous group, and especially by the side of lichen urticatus, which it resem- bles in several respects. Lichen (Plate XL) is an eruption of papulae, resulting from con- gestion of the vascular plexus of the follicles of the skin, and some degree of infiltration into the tissues of the walls of the follicles. The pimples are conical in figure, minute, more or less deeply red, transparent at the summit, and itchy; and may be compared to the normal asperity of the skin, termed cutis anserina, although, from the presence of vascular congestion and infiltration, they are neces- sarily larger and more prominent than those of the latter.1 They are solid, and contain no fluid, the transparency of their points being due to their anatomical structure, namely, the conical wedge of cuticle which occupies the aperture of all the follicles; and when scratched, they give forth a drop of blood, followed by an oozing of a minute drop of serum. When the pimples of lichen are dispersed singly over the skin, they subside by degrees, and are followed by a slight exfoliation, corresponding with the summit of the papule. When they occur in clusters, they are accompanied with a diffused redness, and on the decline of the redness, are succeeded by a laminated exfoliation of the cuticle. When, however, they have been rubbed or scratched, each pa- pule becomes covered on the summit with a small scab, which is some- times thin and grayish, sometimes thick and amber-colored, or brown, and sometimes, when arising from desiccated blood, almost black. The pruritus of lichen is of the hot and tingling kind, and some- times very severe. Like eczema, lichen is non-contagious, and is un- attended with special constitutional symptoms. The varieties of lichen are founded on the manner of distribution of the eruption, on its symptoms, on its cause, on its situation, and on the figure of its pimples. The distribution of the pimples is some- times dispersed and general, as in lichen simplex; sometimes aggre- gated, as in lichen circumscriptus, lichen circinatus, and lichen gyratus. The symptoms are sometimes remarkable for the pungency of the itching and tingling, as in lichen urticatus, or for the color of the pimples, as in lichen lividus.' Heat of climate gives a distinctive character to lichen tropicus, and situation to lichen pilaris and lichen strophulosus. 1 The papulae of lichen are very little larger than the prominent papules of cutis anserina; the measurement of the latter being half a line in breadth when round, and three-quarters of a line by half a line when elliptical in figure. LICHEN SIMPLEX. 173 Hebra classes lichen under the head of dermatoses squamosae, a group consisting of three members, namely, alphos, lichen, and pity- riasis ; and the kinds of lichen of the same author are lichen ruber and lichen scrofulosorum. Lichen ruber we believe to correspond with our lichen planus; lichen scrofulosorum is a variety which we have not seen; but we have introduced his definition of the disease after our description of lichen planus. In a tabular scheme we should arrange the varieties of lichen as follows:— Lichen simplex, Lichen urticatus, " dispersus, " tropicus, " circumscriptus, " planus. " strophulosus, To which may be added as sub-varieties:— Lichen pilaris, Lichen circinatus, " lividus, " gyratus. Lichen lividus and pilaris, appertaining in chief to lichen simplex ; and lichen circinatus and gyratus to lichen circumscriptus. Lichen simplex (Plate XL A).—In the simplest form of lichen the papulae are more or less thickly set or dispersed over the surface of the body. They are of moderate redness, pretty uniform in size, and attended with considerable itching and tingling; and when they subside, are followed by a moderate degree of laminated and furfura- ceous desquamation. When the eruption is scanty but general, they present more or less of a corymbose arrangement like the blotches of measles; and in some parts of the body this disposition is remarka- ble. It is to be noted also that in certain situations the papulae are larger than in others; for example, on the face and upon the limbs. Sometimes the extent of the eruption is exactly bounded by the limits of an article of dress, as in a well-marked case of lichen simplex illus- trated in our Portraits of Diseases of the Skin,1 and in another and similar example which we have more recently seen. Lichen dispersus, vel pruriginosus.—Instead of being thrown out in crops and distributed more or less abundantly on parts or on the whole of the skin, lichen sometimes presents a dispersed charac- ter; the papulae are solitary and scattered; the commoner seats of election being the front of the forearms, the lower part of the abdo- men, the inside of the thighs, and the ankles. The papules are hard to the touch, only slightly red at first, but more conspicuous after they have been scratched, and especially remarkable for a severe and teasing itching, the eruption bearing no proportion in appearance to the annoyance and suffering which it occasions. This variety may be regarded as representing especially the pruritic element of lichen, while lichen simplex represents its papular character; hence we have termed the eruption lichen pruriginosus. It is the commonest, al- though not the typical form of lichen, and is frequently met with as 1 Plate IX. Q. 174 eczematous affections. a sequel of scabies. This eruption is probably the same as that de- scribed by Willan under the name of prurigo mitis. Lichen circumscriptus (Plate XL E F) is an aggravated form of the eruption, in which the papulae are elevated in considerable num- bers, and constitute one or more patches of a circular or oval form. The remarkable characters of the eruption are the close aggregation of the pimples, and the abrupt line by which they are separated- from the adjoining skin. They are met with chiefly on the chest, the hips, and the limbs; and when they subside, the skin remains for some time rough, wrinkled, and furfuraceous. Lichen strophulosus (Plate XL K L M).—The strophulus of Willan is clearly a lichen, modified by its development on the sensi- tive skin of infants and children, instead of the firmer and less irrita- ble skin of the adult. The papulae are large as compared with those of the adult; they are sometimes of a vivid red color, sometimes only reddish ; at other times whitish, with a reddish areola ; and sometimes white and smooth. They are accompanied with pruritus, subside in a period varying from a few days to a few weeks, and are followed by a furfuraceous desquamation of the cuticle. Willan describes five varieties of this eruption, namely, intertinc- tus, albidus, confertus, volaticus, and candidus. Strophulus intertinctus, the red gum or red gown,1 is distinguished by papulae of a vivid red color, interspersed with red dots (probably congested follicles without prominence), and large erythematous patches. Sometimes, he says, there are vesicles on the hands and feet, but the fluid is absorbed without rupture. The rash occurs for the most part on the cheeks, the forearms, and the back of the hands; but is sometimes distributed generally over the body. Strophulus albidus is a sub-variety of strophulus intertinctus; the papulae being hard, minute, whitish, and only slightly elevated, and sometimes encircled by a halo of redness. They are met with chiefly on the face, neck, and breast. Strophulus confertus (rank red gum, tooth-rash) seems to belong to eczema infantile rather than to lichen. The papulae are more exten- sively distributed and less vivid in color than those of strophulus intertinctus. They are sometimes developed in patches of large size, and sometimes the cuticle cracks, and they present the characters of intertrigo. Sometimes the eruption fades and disappears in a fort- night, and sometimes its duration is prolonged by repeated recurrence for two or three months. Strofulus volaticus is a rarer form of the eruption, and belongs to the group of lichen circumscriptus. It breaks out in circular patches or clusters of papulae, which turn brown in four days and disappear. Other patches appear in succession, and the disease acquires a duration of three or four weeks. Strophulus candidus is a hybrid that would perhaps be better omitted altogether. The papulae are large, smooth, and shining, and have no redness around their base. They would seem to be whiter, smoother, Evidently a mispronunciation of "gum." LICHEN URTICATUS. 175 larger, and more passive than the papulae of strophulus albidus. They have been met with on the shoulders, the upper arms, and the loins ; and they disappear in about a week. Willan saw them once asso- ciated with strofulus confertus, appearing on the face and neck ; and, in another instance he found them on the arms of a child three years and a half old, who was cutting some double teeth, and likewise had porrigo larvalis, or, in modern language, eczema ichorosum and pus- tulosum of the face. Lichen urticatus (Plate XL D), the lichen urticosus of Mason Good, is a natural transition from lichen strophulosus, inasmuch as it is an eruption which belongs especially to children; begins with inflamed spots, which are succeeded by larger pimples than ordinary lichen, and is accompanied with severe pruritus. This form of lichen was first described by Bateman, and is extremely well marked; the spots at their first appearance resemble gnat-bites or bug bites, and remain inflamed for a day, after which the redness and pimple subside. When, however, they are rubbed or scratched, the pimple becomes more pro- minent, and bleached like the wheal of urticaria, and instead of sub- siding, remains for several days; and if the scratching be such as to remove the head of the papulae, a small drop of blood escapes, and dries up into a minute black scab. As the eruption is successive, a few spots appearing each night, and occasionally also in the day, the body and limbs become spotted all over with pimples in every stage of progress. They are commonly single in their outbreak, but occa- sionally form, here and there, a small cluster. The term urticatus is warranted not only by the occurrence of mus- cular spasm in the pimple, which gives it a bleached appearance similar to that of the wheals of urticaria, but also by the severe and frequently intense, tingling and itching, which destroy sleep, and often affect seriously the child's health. The pruritus is commonly set up by the heat of bed, and sometimes by mental emotion. The eruption is obstinate in its nature, and often lasts for many months. The fol- lowing 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. Latterly 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 iso- lated, but frequently in clusters, particularly on the face, neck, and shoulders. The pimples are excited by warmth; for example by the warmth of bed, so that she is sometimes 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 expression, she can at all times " rub them up wherever she likes." When left to themselves, the pimples subside in the course of twenty-four hours; but when scratched, a little blood oozes from their summit, and desic- cates 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 vesicle. Each pimple, when it does not subside at once, continues for about a fortnight; but as fresh ones are constantly appearing, 176 eczematous affections. the eruption has now been prolonged without amendment for three , months. Lichen tropicus, or prickly heat, is the usual form of lichen as it attacks Europeans in hot climates. Dr. Winterbottom describes it as consisting "of numerous papulae, about the size of a small pin's head, and elevated so as to produce a considerable roughness 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 palm of the hands, sole of the feet, nor on the hairy scalp. The num- ber of the papulae is much increased by wearing flannel, or clothes too warm and thick for the climate. When perspiration is very copious, small vesicles, containing a limpid humor, are often intermingled with the prickly heat, more especially on the breast and about the wrists; but they terminate in scales, having no disposition to ulcerate, though violently scratched. A troublesome itching attends the prickly heat, and prevents sleep during the night. There is likewise a frequent sensation of prickling, as if a number of pins were piercing the skin. This often take place suddenly after drinking 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 papulae. They sometimes dis- appear on a sudden, and return again as suddenly, without any obvious cause; but whenever 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 con- sidered as a salutary eruption ; whence we are cautioned not to repel it from the skin by cold or other external applications. Such a repul- sion cannot, however, be easily effected ; it is certainly not produced by bathing, which has been hitherto thought highly prejudicial. A vivid eruption of the prickly heat is a proof that the person affected 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 happens, is rather an effect than a cause of internal disor- der, as of fever, or of any slight complaint of the stomach; in the latter case a temporary stimulus applied to the stomach, as by spirits, tea, or other warm liquids, has the power of 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 lichen tropicus. 177 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 com- pelled 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 succeeded." " The sensations arising from prickly heat are perfectly indescriba- ble, 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 fore- head. This eruption often disappears in a great measure when we are sitting quiet, and the skin is cool, but no sooner do we use any exercise that brings out a perspiration, or swallow any warm or stimu- lating fluid, such as tea, soup, or wine, than the pimples become ele- vated, so as to be distinctly seen, and but too sensibly felt." In reference to the imagined dangers of repelling the 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 dur- ing 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 pro- ductive of any good effect in mitigating its violence, till the constitu- tion 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 with- out being roused into motion, the enemy, like the foiled tiger, will generally sneak away, 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. We have ourselves suffered from its annoying attack on one or two occasions, and can add our testimony to that of Dr. Johnson. 12 178 eczematous affections. Lichen planus.—The term lichen planus or flat and smooth lichen, is intended to distinguish a variety of this eruption especially remark- able for the flattening of the summit of the papule, its chronic charac- ter, and the absence of pruritus and desquamation. The papulae have a dull red color; they are slightly elevated, dis- crete, one or two lines in diameter ; flattened, depressed, or umbilicated and glazed on the summit, and marked in the centre by the aperture of a follicle and the outline of its epidermic plug. Sometimes when the eruption is abundant a small cluster of neighboring- papulae are connected by an infiltrated base, and form a patch of various size; at other times the papulae covering a large extent of surface, such as the entire length of the forearm, are connected in a similar manner; and the papulae are sometimes so thickly clustered as to appear co- herent. At their first appearance the papulae are always discrete, and gene- rally remain so during their entire course. They are commonly an- gular at their base, corresponding in outline with the area of the lines of motion of the skin, and they increase in numbers by successive eruptions, fresh pimples cropping up in the interspaces left between their predecessors. Even in the compound patches constituted by the thickening and infiltration of the skin upon which they are developed the separate forms of the papulae may be easily traced. The papule never enlarges by its circumference, but retains its original breadth ; the production of broad patches resulting from congestion and infiltra- tion of the integument at their base. When the papule declines, it subsides in elevation, and at this period has somewhat of an annular character, its glazed and horny summit being depressed below the level of its circumference. The glazed summit is also remarkable for transparency and opalescence, and for the appearance, through the horny cuticle, of the aperture of a follicle surrounded by the annular outline of its epithelial lining. The total subsidence of the papule is followed by a deep brown stain; and where the eruption has been abundant, the skin is singularly speckled by these stains. In a few instances another mode of decline is percepti- ble, namely, the dispersion of the papule and the production of a small red desquamating patch a few times larger than its base. In the diffused form of the eruption, resulting from a congregated assemblage of papulae, and their conversion into a single large patch by hyperaemia, infiltration, and thickening of the skin upon which they are produced, the disease undergoes a change of character; it is more or less pruriginous, and desquamates freely like a patch of chronic eczema; but the pruritus is less in degree than occurs in the latter disease, and there is no exudation whatever. Lichen planus is regional in its distribution ; its more common sites being, the front of the forearm just above the wrist, the abdomen, the loins, the hips, the back of the sacrum, the convexity of the knee, the lower extremity, the nape of the neck, the front of the chest, the front of the forearm, and sometimes the bend of the elbow, and the axilla. In one instance, that of a lady fifty-six years of age, who had suffered from the disease for two months, the eruption appeared on the tongue, LICHEN PLANUS. 179 the buccal membrane, and the prolabium of the lower lip, in the form of round, white spots, having the normal size of the cutaneous papules, but without elevation; she complained of a feeling of roughness of the tongue without dryness or thirst; and the same sensation extended to the throat, making it probable that a similar state might exist in some cases in the alimentary canal, and be one of the causes of the marasmus described by Hebra. Like other cutaneous affections, it offers certain varieties in its characters; most commonly, and always at the beginning, it is dis- crete in eruption, lichen planus discretus. Occasionally it forms dif- fused patches of various extent, lichen planus diffusus; but in this instance is always accompanied by the discrete form in other parts, and by a scattering of isolated papules in the immediate neighborhood of the conglomerate patches. In a few instances, and especially in the flexure of the elbows and hollow of the axillae, we have found an annulate form of the eruption, resulting from the growth of the mar- gin and subsidence of the centre of the patch, lichen planus annulatus; and in these cases, when a part of the circle disappears, the eruption has a marginate character, lichen planus marginatus. Generally, as already stated, lichen planus is remarkable for the absence of pruritus, its discovery by the patient resulting from its visible presence with- out any preceding irritation; but in one instance, that of a highly nervous woman, we saw it begin with itching, and the subsequent pruritus was intense and almost maddening, lichen planus pruriginosus; but pruritus, nevertheless, must be regarded as an exceptional symp- tom. Lichen planus is always associated with symptoms of constitutional derangement, generally referable to the digestive and nutritive system, and accompanied with more or less of nervous irritability and pain. But, as a whole, the numerous patients who have come under our no- tice affected with this complaint, with one exception, the nervous lady already alluded to, have not seemed much out of health, and are fairly represented by the four cases which we append to this description. These cases are drawn, without selection, from patients immediately under our observation at the present time. The question now arises, Is this the lichen ruber of Hebra ? We believe it to be so,' and that the credit of first describing it is due to that distinguished man. We have been long acquainted with the eruption, and many years back named it planus, in consideration of one of the most remarkable of its visual characters, namely, the flat- ness and glass-like smoothness of the summit of its papules; a char- acter, as it appears to us, more striking than its redness, and one by which it would be more easily recognized by the physician. This glazed and horn-like epidermal layer retains its continuity with the rest of the epidermis, and therefore is not a scale, and does not usually desquamate as a scale when the papule subsides; but when it is cast off as a scale, as occurs in the infiltrated patches, the connection of its under surface with the epithelial lining of a follicle is also remarkable. Judging from Hebra's description, the disease is more deeply rooted in the constitution in Austria than it is in this country. With us it 180 ECZEMATOUS AFFECTIONS. is mild, but obstinate, and ultimately yields to treatment; it produces neither emaciation nor marasmus; does not attack the skin around the joints, occasioning rhagades and interfering with their motions; and we have never seen it on the hands or feet, or causing any inter- ference with the growth of the nails. Hebra describes lichen ruber as presenting three stages, the defi- nition of the three stages being as follows: 1. The papulae; millet- sized, red, discrete, covered with little scales, not excoriated, not clustered, not general, but limited to a part, chiefly to the limbs. 2. The infiltrated patch, caused by the contact of a great number of papulae developed close together, is of a dull red color, covered with grayish, moderately adherent scales of the thinness of paper; the scales, on removal, exhibit dilated hair-follicles; no moisture; no bleeding from slight scratching; very superficial excoriation of the surface, proving the slightness of the pruritus. However much this eruption may resemble other forms*of cutaneous disease, it may always be distinguished by the character of the papulae developed around the circumference of the infiltrated patch; and it may be seen that the patch does not owe its origin to the growth of the papulae in circumference, but to their development in numbers. 3. As a consequence of*the continued eruption of papulae, the skin is at last wholly reddened and thickened; and the epidermis, especially its horny layer, converted into thin, grayish, yellow, easily stripped scales, without a trace of papulae remaining. There is, besides, de- generation of the nails, restricted movement of the joints, and rha- gades. The general symptoms are: arrest of nutrition, emaciation, marasmus, and unfavorable issue, particularly after a duration of years. The following cases illustrate lichen planus as it comes before us in ordinary practice:— Case 1.—A merchant of the city of London, aged thirty-five, con- sulted us, on the 8th of March, 1866, for an eruption of lichen planus which covered the whole of the abdomen, the loins and pelvic region of the back, the outside of the hips, and the front of the forearms. He stated that the eruption had existed four months; that his attention was first drawn to it by seeing it on the abdomen ; that it was unat- tended with inconvenience of any kind; that there was a trifling itch- ing when he became warmed by exercise, but not sufficient to induce scratching, and none which could disturb sleep. The eruption presented the usual characters of lichen planus, namely, papulae, slightly elevated, flattened, or rather depressed, m glazed on the summit, marked in the centre by the aperture of a folli- cle, discrete, smooth, and of a dull red color; their size varying between one line and two lines in diameter. In three or four situa- tions a cluster of papulae had become blended by infiltration of the subjacent skin, and formed a patch of irregular outline a quarter of an inch in breadth; and one spot of quadrangular figure, produced in this manner, measured half an inch in diameter. There were neither scales nor desquamation. The eruption had reached its pre- sent extent by the successive elevation of new papulae developed in LICHEN PLANUS. 1S1 the interspaces of the old, and the papulae showed no tendency to in dividual increase. He has always enjoyed a good average state of health, is occupied in business every day from half-past nine until six, is regular in his habits, and has lately quitted the volunteer service on being married. His skin is swarthy, and he presents melasma oculi in a slight degree, an indication of disordered function of the digestive organs. Pre- viously to the attack of lichen planus he suffered from weight at the praecordia, nausea, and flatulent dyspepsia, and also from piles; but these symptoms disappeared on the occurrence of the eruption. There being no general indications to be considered, we prescribed for him our ferro-arsenical mixture, at a dose equivalent to three minims of Fowler's solution three times a-day ; with the use of a lotion of bichloride of mercury, two grains to the ounce, in emulsion of bitter almonds, night and morning, the skin being previously thoroughly washed with the juniper tar soap. On the 22d of March the eruption had subsided very considerably, and as he had experienced no incon- venience from the internal medicine, we increased the dose of Fowler's solution to four mimims. On the 14th of April following, the erup- tion was gone, leaving only brown stains, with which the surface was speckled over. The papulae had subsided without desquamation, and in one place only was there a slight degree of desquamation of the cuticle. Case 2.—A lady, aged twenty-seven, the wife of a clergyman, has been the subject of lichen planus for four months. The" eruption began in December, 1865, by the appearance of half a dozen pimples sprinkled on the front of one forearm, just above the wrist; and the pimples have increased in number until they are now accumulated pretty thickly on both forearms, the back of the neck, the upper part of the chest, the waist, and the legs, from the lower third of the thigh downwards. They have a dull red color; are but little elevated; are flat, and slightly depressed on the summit; glazed and opaline on the surface, and marked in the centre by the circular outline of the mouth of a follicle. In some situations, as on the back of the neck and front of the chest, the smooth, horny, flat, white, and shining summit is the most conspicuous character of the pimples, which are also smaller in this situation than elsewhere. The redness is scarcely perceptible, and these white spots look like small spangles glittering on the skin ; they are not scales, because they are continuous with an unbroken epidermis, but the corneous epidermis of which they consist is somewhat thicker than that of the surrounding integument. On the waist numerous small clusters of papules have become blended by the congestion and infiltration of their base; and this is especially remarkable in the groove produced by the pressure of the garter, the whole line of this groove being occupied by a chain of such blended clusters. The front of the forearm is occupied by a diffused blotch of these papules, united by a red and infiltrated base; the blotch occupies the whole breadth of the forearm, and extends from the bend of the elbow nearly to the wrist. The blotch is slightly raised, circumscribed, un 182 ECZEMATOUS AFFECTIONS. evenly papular on the surface, and covered by small scales, produced by the separation of the horny surface of the papules; while along the circumference of the blotch may be seen here and there a few scattered papulae, marking the nature of the composition.of the blotch. The blotch was formed originally by an accumulation and aggregation of distinct papulae; and the infiltration and congestion which subsequently united the papules together and blended them, was developed only six weeks back. After a week of treatment, many of the papulae had subsided to the level of the integument, while their horny plates were removed, and in their place there remained deep brown stains. At this period could be seen, on different parts of the surface, the chief characteristic features of the eruption, the papulae, the diffused blotches, and the pigmentary spots; the papulae, some red ; some almost colorless ; some marked by a thin, glassy, transparent surface ; and others by a thicker horny polished plate, glistening, but smaller in dimensions. The papular eruption was wholly unattended with pruritus; but the infiltrated and desquamating patch was moderately itchy ; by no means so much so as chronic eczema squamosum, to which it bears consider- able resemblance, but giving forth no ichorous discharge, and a less abundance of scales. The patient suffered much at the beginning of the eruption from general depression, both mental and physical, with neuralgia of the fifth pair of nerves; and on the occasion of her visit to us she com- plained of weakness and pains in the sockets of her eyes. Her com- plexion was muddy, her skin and conjunctiva pale, and the tongue pale and indented by the teeth. She had no disorder of the feet or hands, or of the nails. Case 3.—A gentleman, a student of Oxford, aged twenty-two, was attacked with an eruption of lichen planus in the beginning of Febru- ary, 1866, and came under our notice towards the end of March. The eruption began as a crop of flat, red, and glazed papulae on the hips; it then showed itself on the front of the forearms, next on the abdomen, and thence spread over the entire trunk*. On the hips and forearms the eruption is discrete, intermingled with a few coherent patches a third of an inch in diameter. The abdomen has a very remarkable appearance, from being thickly studded essential differences between them being the difference of moist and dry; the latter being associated with a greater degree of irritability of the nervous system. The kinds of debility also resemble those of eczema, namely, ryutritive, assimilative, nervous, and local; while the remote predisposing causes are: cutaneous irritability, the sequel of scabies; deranged digestion; coldness of season and climate; errors of diet; errors of air and exercise ; the eczematous diathesis ; vacci- nation ; dentition ; and excessive lactation. With regard to strophulus, Bateman remarks that it arises from an "irritability of the skin at that period of life when the constitution" is easily " disturbed by irri- tation, either in the alimentary canal, the gums, or other parts." Prognosis.—Lichen is by no means serious, and is only of import- ance from the irritable pruritus by which it is accompanied, and which, by destroying rest, tends to weaken the system and to produce general disorder of the economy. It is usually a milder malady than eczema, particularly the local forms, and of shorter duration, lasting, commonly, only a few weeks, but sometimes prolonged for several months, and even for years. The time of life at which it is most frequently met with is childhood and maturity; but it is also observed at other periods. Lichen strophulosus is an eruption of infants, and lichen urticatus is met with chiefly in young children. Treatment.—The constitutional treatment of lichen requires the mildest aperients to regulate the digestive organs and secretions, fol- lowed by bitters and the mineral acids, by chalybeates, by quinine, or by quinine and iron. In chronic cases, arsenic, as prescribed for eczema, will generally effect a cure. The internal remedies recommended by Bateman for strophulus are, gentle laxatives, when any feverishness is present, followed by decoction of bark, or chalybeates; of the latter, he particularly favors the tartrate of iron. Doubtless, had the superphosphate been in use in his day, he might have given it a preference, as being peculiarly suitable to children. With the internal treatment he enjoins, a care- fully selected diet, proper exercise, and the use of ablutions with tepid water, plain and with the addition of milk. He likewise expresses an old-fashioned dread of repercussion of the eruption from exposure to cold draughts of air, or the use of cold water, and he suggests that 188 ECZEMATOUS AFFECTIONS. in such an event we should administer some slight cordial, such as a few drops of sal volatile, and apply a blister externally. At the pre- sent day we prefer the stimulus of mustard to that of cantharides for the skin of infants, or frictions with a mildly stimulating liniment, such as cajeput oil or the oleum sinapis with soap liniment. Our treatment of lichen planus, and that which we find most suc- cessful,.is the ferro-arsenical mixture; and as a local application, the bichloride of mercury in lotion; or the solution of-the pentesulphide of calcium. Hebra has found no remedy serviceable in lichen ruber with the exception of arsenic. The local treatment of lichen calls for the use of ablutions with the juniper-tar soap, tepid bathing, and anti-pruriginous and moderately stimulating lotions, such as an emulsion of bitter almonds with hydro- cyanic acid, or with bichloride of mercury and spirits of wine; or a lotion of carbolic acid. But the most certain and powerful anti- pruriginous lotion is one composed of the pyroligneous oil of juniper, spirits of wine (of each an ounce), and water (six ounces). The latter remedy is very successful in lichen urticatus. When lichen circum- scriptus is obstinate, it may be dispersed by gentle friction with the ammonio-chloride, or nitric oxide of mercury ointment; but with the unguentum picis liquidae. In the treatment of prurigo, baths are of much value, and should be used daily. The temperature of the baths must not be higher than ninety 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 tincture of croton, either pure or diluted with an equal part of spirit of rosemary, may be prescribed. Previously to the use of the croton, the skin should be prepared by repeated frictions with a damp sponge dipped in fine oatmeal, and then washed; and after tlie 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 five or ten grains to the half-pint, will often complete the cure. We have also seen considerable benefit result from the use of the tincture of iodine painted on the morbid surface. Another local remedy frequently of service in allaying the itching of prurigo senilis, is glycerine, 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, ointment of cyanide of potassium, lotion of hydrocyanic acid, aconite, acetate of ammonia, muriate of ammonia, sulphuret of potash, chlorate IMPETIGO. 189 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 effectual for this purpose in one case may be utterly useless in the next; we subjoin several for- mulae recommended by French dermatologists, and quoted by Gibert. One of these is an ointment consisting of hydrate of lime, 3\j; sub- carbonate of soda, laudanum, aa 3ss ; and lard, *j. An anti-prurigi- nous ointment recommended by Alibert is as follows: Laudanum, sublimed sulphur, aa 3ss; oxide of zinc, 3j 5 oil of almonds, 3j ; lard, oiij. Biett employed successfully, for an obstinate prurigo of the hands: cinnabar, laudanum, aa 3ij ; sublimed sulphur, §ss; lard, Sv. And for local prurigo, the following was found of service: muriate of ammonia, 3j; powder of white hellebore, sss; lard, |iij. IMPETIGO. Syn. Ecpyesis impetigo, Mason Good ; psydracia ; melitagra; dartre crustace'e Jiavescente, Alibert; crusted tetter or scall. Impetigo is a Latin term, derived, according to Pliny, ab impetu, impetu agens, acting with force, with severity, and conveying the idea of a more energetic form of inflammation than that which accompanies the two preceding affections, eczema and lichen. Eczema, as we have seen, is essentially an exudative, a lymphatic,or a moist affection, an affection in which the exuded material is a serous lymph; lichen is a dry affec- .tion, without exudation, but with an excrement of pruritic irritation ; while impetigo must be regarded as representing the pyogenic or pu- rulent element. These terms are purely arbitrary, and therefore arises the great necessity for making them definite. Eczema conveys in its meaning no idea of exudation; lichen, no idea of solidity and pruritus ; and as little does impetigo amy notion of pus-formation. Moreover, in eczema we find all the three affections combined: with exudation in one part, there are lichenous papules in another, and impetiginous pus- tules in a third j and to express the combination dermopathologists have invented the compound terms, eczema lichenodes, or eczema papulosum, and eczema impetiginodes, or eczema pustulosum. If we turn to our authorities, we discover another argument for pre- cision of definition. The impetigo of Celsus is throughout an eczema j1 ' "Of impetigo there are four specie? : The milder kind resembles scabies (eczema) ; it is attended with hardness of the skin, redness, ulceration, and erosion.' It differs from scabies (eczema) in a more extensive erosion, and in the presence of pustules similar to the pimples of acne (vari) ; it is also accompanied with large vesicles (bul- lulze), which in course of time are converted into small scales. The disease is apt to recur at certain periods of the year. "Another kind is more severe, almost like a papula, but more rough and red, and presenting a variety of figure. It throws off superficial scales ; there is more erosion ; it spreads more quickly and extensively ; and is more regular in its periods both of recurrence and cure than the preceding species. It is termed impetigo rubra. " The third kind is even more severe than the last; the skin is more thickened ; it is harder and more swollen; the surface of the skin is cracked, and more violently eroded; it is covered with scales of a black color; is more regular in its periods 190 ECZEMATOUS AFFECTIONS. he gives us no hint of any distinction dependent on the presence of pus. The impetigo of Willan, although founded on the notion of pus, fails to make the pustule definite, and embraces every form of eczema in which a purulent or muco-purulent secretion prevails. Hence the necessity of representing these distinctions each by a substantive malady ; namely, eczema, the impersonation of sero-lymphatic exudation; lichen, the impersonation of the solid, and dry, and itchy papule; and impetigo, the impersonation of pus, or of a purulent secretion ; and establishing an identity between eczematous and vesiculous, or more properly, exudative; between lichenous and papulous; and between impetigi- nous and pustulous. There remains, however, this further and very important distinction, that eczema, being the mother disease, embraces in itself all the papulae and pustulae which may chance to be associated with it; whereas, the term lichen is to be strictly limited to papulae without vesicles, exudation, or pustules; and impetigo, to pustulae without vesicles, exudation or papules. By this arrangement we gain precision; and we gain confidence in the use of the language of our science, an important consideration. Impetigo (Plate X. A-F) is an inflammation of the skin, accom- panied with the formation of pus, which raises the cuticle into small pustules. The redness is more or less vivid; there is some swelling; the pus is light-colored and of the kind termed sero-purulent; but may present every tint of yellow in its hue; and dries up in a grayish or amber-colored crust. The crust remains adherent for several days, and at its fall leaves the skin red and shining, but without any permanent mark or scar. The eruption is non-conta-. gious, like its congeners eczema and lichen, and is unattended with special constitutional symptoms. The absence of cicatrix marks the fact of the superficial operation of the inflammation, and affords evidence that the pus is not generated at the expense of the vascular tissues of the skin, but is simply a morbid transformation of the newly-formed cells of the rete mucosum. Indeed, it would be incorrect to regard the pustule of impetigo as a true pustule, such as that of ecthyma or variola; the .latter is the result of a destructive alteration of the cutaneous tissue, and conse- quently leaves behind it a permanent cicatrix; the former being a mere modification of the serous vesicle, a vesicle, in fact, containing a sero-purulent fluid. Hence, it is no uncommon phenomenon to see one of these sero-pustules, of larger size than usual, surrounded by several coherent vesicles, which invest it in a circle, and form together a small composite patch. The reading of such an appearance is briefly this, an energetic burst of inflammatory action in the produc- both of occurrence and decline, but is not completely curable. This is the impetigo nigra. " The fourth kind is wholly incurable; it differs in color from the others ; it is whitish, and resembles a recent cicatrix ; it throws off light-colored scales, sometimes whitish, sometimes lentil-colored (yellowish); and often, when the scales are removed, blood issues from the diseased skin. Otherwise the humor is colorless, the skin hard and fissured, and the disease extensively spread out. " All these affections occur chiefly in the feet and hands, and also attack the nails." impetigo. 191 tion of the primary or central pustule, and a weakening of energy in the formation of the secondary, the circumtangent, and subordinate vesicles. The pustule of impetigo is of the kind termed psydracium, and in the plural psydracia (4fzp» vtipaxia, frigidae guttulse), that is, a pustule or pustules produced with little heat or inflammation, commonly aggre- gated or confluent, and, after the discharge of their pus, pouring out "a thin, watery humor, which frequently forms an irregular incrusta- tion." Impetigo is an affection indicative of a lower grade of vitality than eczema or lichen, and is met with most frequently in persons of ca- chectic habit, and particularly in children and women. It is rare as com- pared with the former affections; and is more commonly seen amongst the poor, and in workhouses, than in the middle rank of society. The varieties of impetigo are two in number, namely, impetigo figurata and impetigo sparsa; the former indicating a state of aggre- gation of the pustules, the latter their dispersion. To these Willan added three others, namely, erysipelatodes, scabida, and rodens, of which the first and second evidently belong to eczema, the third being a syphilitic ulceration. An impetigo capitis, formerly admitted by ourselves, must also be transferred to eczema capitis. Impetigo figurata (Plate X. A B) appears in the form of clusters of small pustules developed upon a more or less inflamed and swollen ground, and forming a circumscribed and often circular patch. There may be several of these patches on the trunk of the body or limbs; but they are most frequently observed on the face, and particularly around the mouth. They are often chronic, and often successive in their occurrence. Impetigo sparsa (Plate X. C) is the scattered form of the eruption. The pustules appear singly or in smaller cluster than in impetigo figurata, and are dispersed over the whole body, being not unfre- quently met with, in children, on the hands and feet. The impetigo sparsa very commonly presents on certain parts of the body, and especially upon the hands and feet of children, the characters before referred to of a central pustule with a surrounding circle of confluent vesicles or phlyctenae. This form is so frequent that we have thought it deserving of a separate designation, and we have named it impetigo phlyctenodes. Diagnosis.—The pustules with which impetigo may be confounded are ecthyma and modified variola ; the characters of distinction, how- ever, are sufficiently obvious. The small congregated sero-pustules of impetigo standing upon a slightly swollen but not much inflamed ground, are in striking contrast with the large, well-formed, deep yellow, solitary semiglobes, with inflamed and hardened base, of ecthyma; the former a psydracious, the latter a phlyzacious pustule; the former disappearing without leaving a trace behind, the latter leaving a cicatrized pit of greater or less permanence.. Modified variola when mild in its eruption, and appearing chiefly on the face and hands, in the form of sero-pustules, is very much like impetigo; 192 ECZEMATOUS AFFECTIONS. but a few days put an end to the doubt, even when the constitutional symptoms of variola are too slight to attract special attention. Cause.—The cause of impetigo, as of the other eczematous affec- tions, is debility ; the debility being chiefly of the nutritive kind, and the most prominent of the remote predisposing causes are, general cachexia, bad ventilation and drainage, errors of diet, and the after- irritation of scabies. Prognosis.—Impetigo is not a serious affection; but as it betokens constitutional debility, a pyogenic diathesis, and a tendency to cachexia, might possibly lay the foundation of a more grave disturb- ance of health, if not speedily and effectually checked. Treatment.—The indications for treatment are the same as those which are applicable to the previous forms of eczematous affection, and the remedies of a similar class: the regulation of the digestive and secreting organs when they are found to be faulty, and the suc- cession of bitters with the mineral acids, chalybeates with the mineral acids, quinine, and, where the disease assumes a chronic character, the ferro-arsenical mixture, or one of the other forms of arsenic. The heal treatment should be simrlar to that for eczema : saturnine lotions if there be much heat, and subsequent dressing with a cerate of acetate of lead; or the benzoated ointment of oxide of zinc with spirits of wine; lastly, in the squamous stage of the eruption, ablu- tions with the juniper tar soap and slight inunction with the benzoated ointment of oxide of zinc, or one of the mercurial ointments consi- derably diluted (sij ad Ij). Where ointments are unsuitable we must trust to lotions, and dredging with a desiccative powder, such as the pulvis cinchonae, or oxide of zine and calamine, of each one drachm, diluted with six drachms of powder of starch. GUTTA EOSACEA. Syn. Acne rosacea; gutta rosea; ionthus corymbifer, Mason Good ; bacchia; rosy-drop. Gutta rosacea1 (Plate XIY. H) has heretofore been confounded with acne, under the name of acne rosacea; we shall endeavor to show that the two diseases are essentially different. Gulta rosacea is the red and pimply face of the mid-period of life, a disease of inflam- matory congestion, and depending on constitutional causes; acne is a disorder of secretion, of nutrition, of growth, and an accompaniment of youth and the development of the cutaneous tissues. Gutta rosacea is an inflammatory congestion of the skin of the face, accompanied with erythematous patches, red spots, papulae sometimes small and sometimes large, pustules, and tubercular thickening of the integument. It is chronic and progressive in its course, and the greater or less development of its pathological signs constitutes its varieties; for example, gutta rosacea erythematosa, papulosa, tuber- culosa, and pustulosa.2 1 Portraits of diseases of the skin (Plate XL. A P). 2 Gutta rosacea, according to Plenck, is a genus of the class maculae ; his definition of the term heing " corymbus macularum rubrarum in facie et naso." The genus comprises nine species, e. g. : simplex, cenopotarum seu bacchia, hydropotarum, febrilis, pernionalis, herpetica, syphilitica, lactautium, variolosa. GUTTA ROSACEA. 193 Gutta rosacea makes its beginning with simple flushes of the face, which are transient; they are produced under the influence of the stimulus of food, commonly at dinner, and sometimes of emotion. These flushes, at first occasional, soon become habitual, and, frequently repeated, they give rise to a permanent distension of the vascular plexus of the skin, and the red face is established. This is the erythematous stage of the affection, and in conformity with the degree of congestion and the energy of the circulating power, we find cer- tain obvious modifications. At first, and in persons of firm tissue and healthy muscular system, the cutaneous circulation is vigorous, and the color of the skin has the scarlet tint of arterial blood; after a time, months probably or years, or in a person possessing soft tissues and weakly muscular power, the circulation is languid, the blood undergoes its venous transformation in the skin, and the tint of redness is changed to crimson, purplish, or roseate, and occasionally also be- comes livid. It is the frequency of this alteration of color that has suggested the term " rosacea," applied to the disorder; but it will be seen that the roseate hue is by no means a necessary accompaniment of the affection, and, when it exists, represents an advanced stage of the morbid process. We have previously directed attention to the deep circulation of the skin, the follicular circulation, as compared with the surface cir- culation ; this difference is conspicuous in every congestion of the skin, and is sometimes very striking in gutta rosacea. Congestion of the follicular circulation is known by a dotted or punctated appear- ance in the skin (gutta rosacea punctata), each dot corresponding with a separate follicle; and the presence of these dots is the indication of a commencing development of papulae (gutta rosacea papulosa), the papulae having the same origin and structure as those of eczema or lichen. An accumulation of papulae at some one point produces the more extensive rising known as a tubercle (gutta rosacea tuberculosa), and the formation of pus in the summit of a papule or tubercle con- stitutes the pustular form of the disease, or gutta rosacea pustulosa. Gutta rosacea is attended with sensations of heat, burning, itching, and, in the pustular form, lancination and throbbing. When the pimples are rubbed or scratched, a little serous lymph oozes from their summit and forms a small crust; but there is never the amount of exudation which exists in eczema, and, as a consequence, never the same thickness of crust. Gutta rosacea, in a chronic form, necessarily occasions considerable thickening of the skin of the face, and in aggravated cases produces those unsightly blotches and tubercles which have been noted by Shakspeare:— " His'face is all bubukles and whelks and^nobs, and flames of fire." From its occasional association with habits of intemperance, it has been termed "Bacchia," and the tubercles "grog-blossoms" and "car- buncles." And when the nose is the seat of the disease, the whole organ is swollen, and the end of the nose thickened and hypertro- 13 19-4 ECZEMATOUS AFFECTIONS. phied, marked by large superficial veins, often very blue or livid, and studded with yellow pustules and ugly crusts. The characters already described bring gutta rosacea into the cate- gory of eczematous affections; namely, the kind of eruption; its tendency to exudation, although in a slight degree; its development in the form of a rash or an eruption ; and we may add, its dependence on constitutional causes. We have frequently seen it associated with eczema existing in other parts.of the body, and in persons possessing the eczematous diathesis. It is essentially a chronic affection, lasting, when not restrained by treatment, for years. It has no constitutional symptoms of its own, and is obviously non-contagious. It is more frequent than would be imagined, occurring in private practice once at least in every ten patients: it is nearly six times more frequent in the female than in the male, and is commoner in the unmarried female than in the married.1 Diagnosis.—Gutta rosacea may be mistaken for an eczema erythe- matosum and papulosum, for a lichen, or for an impetigo; but the general history of the affection will determine its identity; in a prac- tical point of view, the blunder is not of much consequence, for the treatment is the same. With regard to acne, it is to be borne in mind that the latter disorder is one of torpid glandular action, accumulation of altered sebaceous substance in the gland and its follicle, and inflam- mation resulting from the mechanical pressure and irritation caused by the impacted matter. Moreover, it is commonly associated with other indications of disordered function of the sebaceous glands and follicles, and occurs in young persons, beginning at the age of puberty. Whereas gutta rosacea is a disease of middle life, has little of the sebaceous complications referred to above, is primary instead of secondary in its inflammatory congestion, and is the consequence of general ailment and disorder of the economy. Cause.—The cause of gutta rosacea is similar to that of the eczema- tous affections already enumerated, namely, debility; debility which is nutritive, assimilative, nervous, or local, or all, in greater or less proportion, combined. The eruption is excited by reflex irritation, originating in the nervous plexuses of the stomach and organs of digestion, and also in the reproductive and uterine system. And the remote predisposing causes are as follows: uterine, reproductive, and puerperal derangements; deranged menstruation; languid vital power; anxiety, fatigue, and affliction; loss of rest; deranged digestion ; abuse of alcoholic drinks; ungenial climate; errors of air, exercise, and clothing; constitutional and organic disease; rheumatic diathesis; hemorrhage; eruptive fevers; rapid growth; sexual excess; excessive mental and physical labor; deficient food; adult vaccination: syphi- litic cachexia, &c. A common local cause is neglect of the use of soap in the daily matinal ablution. Prognosis.—Not grave; but as the local disease implies a derange- 1 Vide An Enquiry into the relative Frequency, the Duration, and Cause of Diseases of the Skin, 1864. SCABIES. 195 ment of general health, in which digestion and nutrition, as well as physical comfort and mental ease, are concerned, it cannot too soon be relieved; and were there wanting an additional reason for prompt treatment, it might be found in the fact that the disease is more diffi- cult of removal when confirmed by time and neglect. And this is the more apt to be the case from the fact that gutta rosacea is too frequently looked upon as a deformity rather than as a disease, and as affecting vanity rather than life. Treatment.—There is no disease more amenable to treatment than is gutta rosacea, when properly understood. As a disease of debility, the first indication is to improve the tone of the system and restore the general health; as a preliminary to the tonic course, the digestive organs will require to be regulated, the secretions to be set right; and when the ordinary tonics, bitters, mineral acids, and chalybeates, have exhausted their good effects, we may have recourse to the unfailing specific influence of arsenic. The head treatment should be mildly stimulant and soothing, and afterwards more stimulating. Our plan is to prescribe daily, and sometimes twice daily, washing with cold water and the juniper-tar or carbolic acid soap. If the local irritation be increased by these means, we omit the evening ablution, and apply the benzoated ointment of oxide of zinc, or smear the ointment gently on the face after the even- ing ablution. Then, if the congestion of the skin be relieved by this process, we follow it up by a stronger stimulant, the compound hypo-' chloride of sulphur ointment. The latter ointment should be rubbed into the pimples with moderately firm friction at bedtime, left on the skin during the night, and washed off in the morning by the usual ablution with the juniper-tar soap and cold water. This plan is gene- rally successful; but if it be found too severe, we modify it accord- ingly, and have recourse to milder cutaneous stimulants, such as the bichloride of mercury in emulsion of bitter almonds. In very obsti- nate cases we prescribe an ointment of the iodide of sulphur, ten grains to the ounce of benzoated lard. SCABIES. Syn. Itch. Scabies papuliformis ; papulatis / vesiculosa ; vesicularis; lymphatica ; pus- tulous ; pustttlo*a ; purulenta ; ulcerans : cachectica; Willan. Scabies vermicularis, Sauvages. Ecpyesis scabies, Mason Good. Gale, Fran. Kraetze, Germ. Scabies is an affection of the skin, characterized by scaliness of the epidermis, by erythematous redness, papules, vesicles, and in some cases by pustules; to which may be added, excoriations, accidental abrasions, and scratches produced by the nails.1 It is accompanied with excessive itching, the itching being augmented by warmth, and especially by the heat of bed. The above appearances are due to the presence in the skin of a mi- nute animalcule, the acarus scabiei, which burrows within the epider- 1 Portraits of diseases of the skin ; Plate XVII. A A, in which a good example of scabies is shown. 196 eczematous affections. mis, and excites irritation in the papillary surface of the derma. The burrowing of this little creature gives rise to the scaliness (scabrities) and undermined state of the epidermis. The vesicles, which are few and scattered, bearing no proportion to the number of 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 late- ral surfaces of the fingers they are conical and acuminated; 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 contained fluid is transparent and viscous; in the rounded vesicle the fluid is also transparent, but in some it is more or less opaque and puriform. The pustules are present only in severe cases, or in persons with an extremely sensitive skin, 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 atten- tion, a minute spot or streak may be observed upon some one point of its surface. This is the aperture originally made by the animalcule 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 ter- mination, under a slightly raised dome-shaped elevation, the little creature lies concealed. The acarus may be distinguished easily by the experienced eye as a small dark crescent, or as a minute white glist- ening orb, with a dark crescentic edge, at the end of the cuniculus, and if the thin dome-shaped capsule of epidermis be raised in this situation, with the point of a needle, the animalcule is brought into view. The spot or streak which is here described is not met with on all the vesicles, for the same animal may excite a number of these in the vicinity of its habitation, while in the primitive vesicle alone—that formed by the entrance of the acarus—can the trace of its entrance be expected. The aperture, again, does not communicate with the interior of the vesicle; it is the too close neighborhood of the animal- cule that acts as the cause of formation of the vesicle; the acarus scabiei 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 illustrate 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 desiccation. The next por- tion of the cuniculus, for about half its length, was an open groove SCABIES. 197 with a ragged border, while the remainder of Fig- H. the cuniculus was an arched canal or tunnel, t somewhat expanded from point to point, where the animal made its temporary rest in its molelike progression. 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 in- vestment 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 cuticle which covers it as with a watch-glass. The vesicle at the beginning of the cuniculus is not, however, a constant occurrence; very commonly there is no other trace of the commencement of the burrow than a double line of rao-o-ed border, and neither papule nor vesicle in its immediate vicinity; and the cuniculus itself, which is pathognomonic of scabies, is simply the dwelling and nest of the fecundated female, which pushes on her tunnel by short and pretty regular stages, and deposits her ova at each halt. The unimpregnated female digs short burrows for her temporary abode, which are scarcely appreciable with the aid of a common lens; and the male, who shifts his position every night, con- tents himself with the first ragged edge that can afford him protection. 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 elbows, axillae, inner side of the thighs, lower part of the abdomen, nates, and the organs of generation. In children it is met with on the feet as well as the hands, and in infants may be dis- persed on every part of the body. In weakly constitutions it may be limited to the hands for a considerable period without extending further, while in severe cases and sanguine 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 erup- tion ; but the scratching only diffuses the pruritus, and the skin is often severely torn and abraded. When the points of the vesicles are broken, they become covered with small, thin, yellowish scales, and when they are made to bleed, they are occasionally followed by little black scales, like those of prurigo. When, also, in consequence of superadded irritation, from susceptibility of the skin, from scratching, from injudicious remedies, or from a plethoric state of the system, the vesicles take on the character of pustules, the disease assumes the 1 The only case on record with which we are 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 mamma? of its nurse. 198 ECZEMATOUS AFFECTIONS. 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* modified by circumstances. For instance, while in the generality of cases, the disease is observed between the fingers and on the wrists, in those wh<^ 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, as Rayer remarks, the vesicles are first perceived upon the breech. Its occur- rence on the genital organs, the lower part of the abdomen, and the inner side of the thighs, is probably attributable to conveyance by the hands. John Hunter-alludes to the limited distribution of scabies in this country as compared with a warmer climate, and notably with that of Jamaica. In England, he observes, "the itch commonly appears between the fingers, about the wrists, .... but this is not the case in the West Indies; the disease spreads almost uniformly over the skin, which is probably to be imputed to the heat of the climate." And he further goes on to narrate that he has sometimes seen "alarming symptoms, which so far disguised the disease that it could not, for a time, be known to be the itch. The small pointed watery vesicle or pustule, which characterizes the itch, has been changed into an eating sore, that in part destroyed the substance of the skin." The activity and extent of scabies are strikingly modified by the state of constitution of the patient, its energy maintaining an appa- rent 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 diseases, 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 Adams1 in Madeira, it is accompanied with pyrexia, and the local effects are often very severe. The itch-animal- cille is very common in the island of Madeira, where it is called oucou or oucam. The following case, illustrative of these remarks, is quoted from Adams's account of this disease :2— "A patient (an 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 1 On Morbid Poisons. 2 Page 298. SCABIES. 199 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 witn before, that 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." Scabies norwegica Boeckii.—The celebrated Hebra, under the above head, pays a graceful compliment to one of the most amiable and learned of European physicians. Danielssen and Boeck, in their early investigations into elephantiasis Graecorum, had noted the fre- quent complication of that disease with scabies, lichen, prurigo, ecze- ma, impetigo, and ecthyma; and the favoring of those eruptions by the dirty habits of the people. Boeck had also observed a peculiar form of inveterate eruption which came before him for the third time in 1851, in the hospital of Christiana; the palm of the hands and sole of the feet, the anterior surface of the forearms and arms, the elbows, the posterior surface of the legs and thighs, the podex, together with the neck and scalp of this patient, were covered with a thick, hard, adherent crust of a dirty greenish-gray color; the crust impeded the flexion of the fingers, and was so dense as to yield only to cutting with a knife; the nails of the fingers were thick and deformed; and when the crust was removed the exposed surface of the skin was red, moist, and uneven. Subjected to the microscope, the crust was found to contain in vast numbers, dead acari, ova, and particles of fecal matter. And the more recent researches of Hebra served to identify these acari with those of scabies, and to determine the existence of burrows and living acari in the crusts; and of living acari, both male and female, and in extraordinary numbers, in the rete mucosum. Subsequently to the notice of this disease by Boeck, and the corro- boration of Boeck's observations by Hebra in Norway, cases resem- bling the Norwegian scabies have been seen in other countries, and by other investigators, for example, by Fuchs in Gottingen, Bam- berger in Wurzburg, Rigler in Constantinople, Hebra in Vienna, and Bergh also in Wurzburg. It has been termed scabies crustosa, in con- sideration of the most striking feature of the disease, namely, its hard and dense bark-like formations; and it has been thought that the terms lepra scabiosa of Plenck and impetigo scabiosa of Willan must have been suggested by this disease. With reference to the field of observation enjoyed by Plenck we are unable to form an opinion; but in regard to our esteemed countryman Willan we may safely affirm that no such disease ever came under his notice. There seems good reason to believe that scabies crustosa is no more than common scabies aggravated by dirt and neglect; and it reminds us of those extraordinary accumulations of sordes and acari which are sometime-s 200 ECZEMATOUS AFFECTIONS. met with in mange in unhealthy and neglected horses. In ordinary scabies, it is well known that the hairy parts of the body always escape, but in scabies crustosa, the crusts are found to be as extensive and almost as thick amongst the hair as elsewhere. In a case of this disease lately published by Bergh, the patient was sixty-six years old, and had been troubled with general pruritus for two years. The skin was rough, scabrous, and desquamating, while on the scalp was a thick firmly adherent crust; and in and about this dense crust were numerous acari, ova, larval exuviae, and fecal accu- mulations. The crust retained the moisture of the skin, which was damp and red on exposure; and the fluids excreted by the inflamed skin seemed to serve as the means of nutrition of the acari. 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 are, firstly, a peculiar scaliness and undermined state of the epidermis, which are not met with in other cutaneous affections; secondly, its papulae and conical vesicles, the latter having acuminated and transparent points; and thirdly, and principally, the presence of the acarus, which may be extracted from its retreat beneath the loosened epidermis with the point of any sharp instrument.1 The diseases with which scabies is apt to be confounded are, eczema, prurigo, lichen, impetigo, and ecthyma. For eczema, it may easily be mistaken; seeing that the eruption is really an eczema excited by the presence of the acarus. The same remark applies to lichen, the papulous element of the eruption is a true lichen; and it is by no means uncommon to find the eruption of lichen, excited in the first instance by the acarus scabiei, perpetuated as an independent eruption. To this latter we have given the name of lichen pruriginosus. 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 side 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, 1 Dr. Gull suggests the exploration of the detrita of the epidermis in the course of the cuniculi for the detection of the ova of the acarus as one element of diagnosis of the disease : Lancet, July 4, 1857. And Mr. Holthouse, in the following number of the same Journal, reports that of 126' cases of scabies occurring in the " foul wards" of St. Bartholomew's Hospital, only thirty presented the cuniculi of the acarus ; and in every instance, in the hands and feet only. From which we must infer, that the remaining 96 cases were examples of an eruption excited by the male.or unimpreg- nated acarus, neither of which dig burrows jn the epidermis, or that, more probably, they were instances of eczema mistaken for itch. SCABIES. 201 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 usually 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. Scabies can only be mistaken for impetigo and ecthyma when complicated with pustules; however, the limitation of the pustules to the hands or flexures of the joints, and the presence of the scaly epi- dermis, together with the papules and vesicles of itch, will be sufficient to determine the diagnosis. Another complication of scabies frequently results from the irri- tation of substances employed in the treatment of the disease; namely, an eruption of eczema. We have seen cases wherein the treatment of scabies had been continued for upwards of six months, and the disease, to all appearance, had resisted the remedies employed for its cure. But in these instances the scabies was long since eradicated, and the obstinate eruption which continued was an ecze'ma, induced and per- petuated 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 transmission consequently greater. When the disease makes its invasion in re- spectable families, its source may generally be traced to laundresses, servants, and their connections. Until recently scabies was hardly known in London, nor probably in England; it had diminished in our workhouses, and was rarely met with among nurses and children in private families. But since the spread of war throughout the world the disorder has revived ; it has extended remarkably, and has found its way into a higher class of society than that in which it previously moved. Immediately after the close of the Crimean war, scarcely a day passed without bringing before us a case of scabies, chiefly in the person of a military or naval officer; and at present we see several such cases in the course of a week, nQt, however, so much among the original introducers of the disorder as in those to whom it has extended. The source of the disease in this case was probably the ships in which the troops were transported, a suspicion confirmed by the fact that families coming from the East or Australia are very frequently attacked on their voyage by the itch. 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 person. But there are many circumstances predisposing to its influence, such as luxuriant health and vigor, san- guine or lymphatic temperament, the spring or summer season of the year, warm climate, youth, confined atmosphere, want of cleanliness, &o. The period at which the eruption makes its appearance after the invasion of the acarus presents several important and remarkable 202 ECZEMATOUS AFFECTIONS. 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 vesicles have been observed at the end of two days, the ordi- nary period for children being four or five days, while in those that are weakly the period of eruption may be 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 develop- ment of the eruption, particularly in the winter season. The proximate cause of scabies is the acarus scabiei,1 which is trans- ferred by the infected to those who are sound by actual contact; and the period most favorable for transmission is the night and during sleep. During the day the acari remain buried in their retreat beneath the cuticle, and contagion is improbable; but after the first half hour of bed, when the body has attained a genial warmth, the male acari issue from their haunts in search of the unimpregnated females, and the larvae and young acari change their retreat. At this time they pass undisturbed from one region of the body to the other, from one person to another, or from the person to the bedclothes, to be trans- ferred the following night to another person sleeping in the same bed. In illustration of this subject, Bourguignon gives the following account of an experiment which he performed on himself on the 14th of Feb- ruary. He placed on his left forearm a female acarus, which took at once to the epidermis. The next morning the animalcule was found established in a burrow which it had made in the interdigital space between the thumb and forefinger of the same hand. It pushed its burrow onwards at the rate of half a millimetre a-night, without evinc- ing any other sign of life. Each night, about half an hour after re- tiring to bed, Bourguignon experienced a sensation of itching, at first fugitive, then persistent, but yielding, after a while, to sleep. The pruritus was most troublesome on the left forearm, about the shoulders, and at the inner side of the thighs; and in these situations a few papulae made their appearance. On the 28th of February, papulae appeared on the outer side of the left forearm and on the back of the left hand, the itching on the latter being gnawing in sensation. On the first of March, at night, a sharp piercing pain was felt in the scrotum, and repeated several times at intervals of ten minutes; these sensations were followed by an acute smart, as though from a pinch; the pinch was repeated every five minutes, and for the time was almost unbear- able. When in bed the pricking became more severe, and was asso- ciated with a general pruritus of the most annoying description; and the sufferer was driven to have recourse to the stavesacre ointment, which relieved the pain in twenty-four hours, and effected a cure in three days. Bourguignon now turned his attention to the burrow in the hand, which had given him no uneasiness whatever, although the acarus had been buried in the epidermis for twenty days. In this burrow he discovered the animal, with ten eggs, and in the skin be- ' The history and description of this animalcule will be found in a separate chapter at the conclusion of the volume. SCABIES. 203 tween the middle and ring-finger a young acarus several days old; and he inferred, with apparent reason, that the painful sensations in the scrotum had been produced by another of the young. Twelve days later he found a cuniculus near the seat of that occupied by the first animalcule, and in the burrow, besides a young acarus, four ova. Later on he discovered a fourth young acarus between the fingers of the left hand. And during the whole of this period, now prolonged to a month, he had suffered from teasing itching and a papular erup- tion. A month had proved sufficient, not only to produce ova and young, but also the means of impregnating one at least of the young females, namely, that which was found with her train of four ova in the cuniculus between the fingers. Some interesting and conclusive experiments on the habits of the animalculae were made, on the revival of the acarus scabiei in France, by Albin Gras, a pupil at St. 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 forearm, 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 cuniculi having become obliterated, had disappeared." Exp. 2.—"On the first of September I placed seven living acari on my forearm, and covered them with a fold of linen, and piece of diachylon plaster. Four days after we found four or five well-marked cuniculi. On the sixth of September two of the acari being extracted from their cuniculi, were found active; they were then replaced. On the twelfth another animalcule was removed and examined ; it was quite lively. On the fourteenth there was considerable itching, with the development of a vesicle ; the cuniculi were two lines long. On the sixteenth there were several new vesicles near the cuniculi, but not on their line. On the seventeenth the vesicles of the previous day had been rubbed off by the linen, but two or three new ones were visible. On the following day I put an end to the experiment, by rubbing some sulphuro-alkaline ointment into the part. During the course of the experiment I suffered pruritus from time to time." Exp. 3.—"On the ninth of the month I imprisoned six acari on my ring finger, by means of the finger of a glove. Next day there were two cuniculi half a line long. The acarus of one of these burrows was apparent for ten days, the other for three weeks, but after this period they both disappeared. During this interval I cauterized several sus- picious vesicles developed on the same finger, and discovered two new 1 The dark brown cresceutic speck produced 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. 204 ECZEMATOUS AFFECTIONS. 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 forearm." Exp. 5.—"Having placed two acari in the flexure of the elbow of two persons, who expressed their willingness to submit to my experi- ments ; on one, three or four vesicles were apparent on the fifth day, and were accompanied by severe itching. On the other there were two cuniculi, with pruritus, but no vesicles." Prognosis.—Scabies is a mild disease, and trespasses but little on 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 disorders have occasionally been developed, upon the sudden retrocession of scabies. These statements are not borne out by obser- vation, 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 otherwise, as a counter-irritant. Treatment.—The treatment of scabies is purely local, and numer- ous therapeutic remedies have been employed from time to time for its cure; moreover, as the object to be attained is simply the exter- mination of the acarus, many have been successful. Several of these midicines 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 their object without causing irritation, or they give rise to much less inconvenience. In selecting our mea- sures of treatment, therefore, our attention should be directed to the employment of remedies which will act with certainty, and will pro- duce the least possible degree of excitement in the cutaneous surface. Such a remedy is presented to us in sulphur, which may be regarded as specific in the treatment of scabies. To effect the cure, the sulphur is rubbed into the skin, and is conveyed by imbibition into the tex- ture of the epidermis. Here it probably combines with hydrogen, and sulphuretted hydrogen gas is evolved, which acts as a deadly poi- son on the acarus, and destroys its ova. In some instances the sul- phuretted 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 generation of the gas in the tissue of the epidermis, in the latter case. The sulphuretted hydrogen lotion gives rise to less irritation than the sulphur 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 soap, or with SCABIES. 205 a warm solution of subcarbonate of potash, containing about half a pound of alkaline salt to a gallon of water. To effect the cure of scabies in the shortest possible time, the best preparation of sulphur is the simple sulphur ointment of the British pharmacopoeia, of which, in the adult, two to four ounces should be well rubbed into the affected portions of the skin, morning and even- ing, for two days. It is desirable also that the patient should wear a woollen shirt, and retain the same during the whole treatment. When this covering is not sufficiently large to envelope 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 alka- line ablution and the friction of the affected parts shall have been performed. 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. We are in the habit of combining with this plan the in- ternal administration of sulphur, in doses of ten grains to a scruple, with a like quantity of bitartrate of potash ; or a drachm of confectio sulphuris, night and morning. And this we should recommend to be done when the cure by 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 concentrate the sul- phurous vapor on the skin; but this plan is highly inconvenient, and often impossible, to persons engaged in occupations which require daily attention, let alone the annoyance that a man in perfect health must feel at being buried in blankets for a couple of days. Appre- ciating this difficulty, we have, for some years past, had recourse to a very simple method, which we have found to answer the purpose com- pletely, and which has the advantage of demanding no confinement, and none of the heroic rubbings in above described. Our plan is to require the patient to rub into his hands, and particularly 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 smears the ointment on any other part of the body where irritation or eruption may exist. Then, besides the outward application, he takes from ten to thirty grains of the sulphur praecipitatum or a drachm of confection of sul- phur twice 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 acarus can resist. The quantity of sulphur ointment required is small, and such as may 206 ECZEMATOUS AFFECTIONS. be allowed to remain on the skin and between the fingers without detection by an indifferent person, and yet sufficient to answer every 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, 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 we also recommend the sprinkling of sulphur within the bed. Another excellent remedy is the solution of pentesulphide of cal- cium, made by boiling lime and sulphur in water, and straining off the clear. This fluid, on being sponged upon the skin, leaves behind it a film of sulphur, and is a convenient application. It was originally introduced by Dr. Astley Price for the destruction of the oidium of the vine in France, and was attended with remarkable success. When used for the cure of scabies, it may be sponged upon the eruption twice in the day, or at bedtime only, according to the convenience of the patient and the special circumstances of the case. .The sulphuretted hydrogen treatment consists in bathing the sur- face 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 diluted mixture of two solutions, the one containing sulphuret of potash, the other hydrochloric acid. 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 prepa- rations, sulphurous and non-sulphurous, and each possessing, accord- ing to its advocates, peculiar advantages, have been recommended by different authors. Formulae of the more deserving of these remedies will be found in the chapter devoted to remedies at the end of the volume. In the treatment of scabies it is necessary to make a distinction into the management suitable for private or public practice, and also for the degree of the disease. In the first case, a partial or at least a modified use of the sulphur treatment may be all that is necessary; time is less an object than the avoidance of inconvenience and expo- sure ; but in public practice, rapidity of cure is the most important consideration, and must take the place of every other; and where the disease is universally present upon the surface of the body, the treat- ment must be equally general. In private practice, we have con- stantly succeeded in effecting a cure by the application of the sulphur ointment to the hands alone; and we have been prepared, had the occasion presented itself, of adopting instantly a more general plan; but in public practice this kind of observation is impossible, and therefore the use of a general and speedy method from the first is a SCABIES. 207 matter of necessity. The most striking example of a speedy method, and at the same time of a most undiscriminating one, is that which is in use in the Belgian army, and was first put in practice by the Medi- cal Director General, Vlemingkx. The process is as follows : The patient is thoroughly rubbed all over with soft soap or common soap, applied by means of a woollen pad, for the space of half an hour; secondly, he is soaked and washed for half an hour in a warm bath; thirdly, he is well rubbed for another half hour, by means of a woollen pad saturated with a solution of pentesulphuret of lime, holding the lime in suspension; and fourthly, the skin is washed free from the sulphur and lime by means of a tepid or cold bath, or by a shower- bath or douche, and having dried and dressed, he returns at once to the duties of his regiment. There can be no doubt, that as far as the destruction of the acarus and its ova is concerned, this plan is most efficacious; but the eruption primarily induced by the acarus remains, and indeed is seriously aggravated by the severe treatment which the patient has undergone. The principle of the speedy methods is in every instance the same half an hour of soaping, half an hour of soaking, and half an hour of medication, to be followed after a longer or shorter period by a final bath. Hardy, like others, has his speedy method, which he calls a two-hour cure, but which in reality is a twelve-hour cure estimating the period of time included between the soaping and final bath; and he prefers for inunction an ointment of sulphur and carbonate of potash, containing one part in seven of sulphur, his object being to \ avoid as much as possible the irritation caused^ by the latter. He begins with a general friction with soft soap for the space of half an hour; secondly, a warm bath of half an hour's duration to saturate the epidermis; and thirdly, a thorough inunction over the whole body with eleven ounces of his diluted ointment. The ointment re- mains on the skin for twelve hours, for example during the night, and is washed off in the morning in a tepid soap-bath. In private prac- tice he modifies this process by ordering two inunctions instead of one, with an interval of twelve hours between them; or, to avoid the unpleasant smell of sulphur, advises, instead of the latter, the essential oil of mint or lavender dissolved in water or glycerine. He remarks that the sulphur purifies the garments of the patient; and for the purpose of disinfecting the clothes, he recommends fumigation with sulphur vapor, or a high temperature, namely of 200° or upwards. It may be mentioned, that, for the same purpose, Bourguignon suggests a low temperature as being highly destructive to the acarus. The treatment pursued at the hospital of St. Louis in Paris, is as follows: A soap-bath, followed twice a-day with inunction into the bands and feet of the sulphuro-alkaline ointment; the quantity em- ployed is about an ounce at each friction, and the friction is continued for ten minutes, a bath being taken between the frictions. The cure is effected in eight days, the eruption taking a week longer to subside. Bourguignon mentions an empirical treatment remarkable for its success, and which consisted in two frictions of a quarter of an hour 208 ECZEMATOUS AFFECTIONS. each, with an interval of twelve hours, of an ointment composed of gunpowder and sulphur. Young children in St. Louis are washed four times daily with soap, the treatment being prolonged for nineteen days. The great frequency of the presence of the acarus upon the hands and feet only, has led to the adoption of sulphur frictions solely to those parts, but the occa- sional detection of the animalcule upon other regions of thebody has led to the use of general frictions to the entire surface. It is important in every case to begin with a warm soap-bath, and after this prelimi- nary bath, if one or two ounces of the sulphuro-alkaline ointment be thoroughly rubbed into the epidermis twice in the day, and for half an hour at each friction, a cure may be effected with certainty at the end of two or three days, and without the chance of relapse that some- times follows more partial frictions. At the conclusion of the frictions as at the beginning, a warm soap-bath should be administered. Hebra sanctions the speedy methods for public practice, but for private treatment, gives a preference to an ointment composed of juniper or beech tar, chalk, soft soap, and lard, and containing one eighth part of sulphur. The body is to be thoroughly soaped and washed for an hour at bedtime, the ointment is then to be well rubbed into the whole surface of the body, with the exception of the head and face, and in the morning the patient cleanses his skin with a tepid bath and soap.' This process is to be repeated for three or four nights, and the ointment may be made more agreeable for use, by the addition of the essential oils of aniseed and rosemary. Pyhorel recommends the friction of half a drachm of sulphurite of lime with sweet oil into the palm of the hands, without any applica- tion to the surface of the body, the treatment being continued for fifteen or twenty days. Fantonetti advocated the use of chloride of lime; and Delpech the employment of frictions of sweet oil alone. This last remedy would, doubtless, act most destructively upon the acarus, could the oil reach the animalcule. In our own practice we 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, we have also employed inunction with lard alone with a satisfactory result. The lard must be well rubbed into 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 of this plan ; and 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. Bazin prefers, however, 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 sulphuro-alkaline treat- ment. His formula for making the ointment is to mingle equal parts of fresh chamomile flowers, olive oil, and lard, and heat them together SCABIES. 209 on a sand-bath. It appears to us 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, used by Am- brose Pare;' hellebore, scabious, sweet-scented rush, elecampane, and onions. The use of stavesacre and hellebore has lately been revived, and, according to their respective suggestors, with flattering success. 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, for a quarter of an hour ; 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. Bour- guignon'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 suffi- cient 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 produces a feeling of heat in the skin. Hellebore is also well known to be a constituent of the compound sulphur ointment. Bourguignon was led to the restoration of stavesacre by the hope of escaping the inconveniences of irritation which attach to the use of sulphur. He found that the acarus immersed in tincture of staves- acre died in fifteen minutes ; and carrying this observation into prac- tice, that not only the acari but the ova also were totally destroyed by soaking and washing the hands in warm water with soap, and afterwards submitting them to a manuluvium of the concentrated tincture of stavesacre for two. hours. In other words, supposing all the acari to be present in the epidermis of the hands, as occurs in seventy per cent, of cases of scabies, the disease would be entirely cured in that space of time; while, in the remaining thirty cases, it would be necessary to apply the remedy to the whole body, and con- sequently, by the aid of an ointment of the same seed. His observa- tion of the action of the remedy upon the inflamed skin leads him to conclude further, that it relieves pruritus, checks the development of eruption, subdues inflammation, and soothes the painful and irritated skin. In these experiments he made use of an ointment of delphinine without the benefit resulting from a pomade of the powder of the seeds; and made trial of the virtues of bichloride of mercury, spiritus cam- phorae, spirits of turpentine, and iodide of sulphur combined with iodide of potash. All these remedies, with the exception of the last, 1 Ambrose Pare's remedy for scabies consisted in a decoction of equal parts of vine- gar, seeds of stavesacre, and table salt. 14 210 ECZEMATOUS AFFECTIONS. were inferior to the stavesacre ; and although a solution of iodide of sulphur and potash destroyed the vitality of the acarus in eight minutes, the discoloration and irritation to the skin, when used as a manuluvium, was so great that the experimenter came to the conclu- sion that, as a remedy for scabies, it was utterly inapplicable. Especial care should be taken that the garments worn by the pa- tient, and the bedclothes in which he has lain, should be disinfected by exposure to sulphurous acid gas, or to a very hot or a very cold temperature. This is a measure of importance, since the acari and their young are apt to remain attached to articles of apparel, and are easily communicated by them. To complete the eradication of the animalcules, perfumes should be worn in the dress for several weeks; and articles not admitting of purification must be destroyed. The treatment of scabies has been enriched by the observations of 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's solution it lived alter 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 an hour; in vinegar in twenty minutes; in alcohol also in twenty minutes; but in naphthaline still more quick- ly ; 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 overnight 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." 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. One of the most remarkable of the phenomena of scabies, is the localization of the acarus to a few regions of the body, and especially to the hands; other situations in which it is found, being the borders of the armpits, the abdomen, penis, buttocks, and feet; and these are the situations in which the eruption is most abundantly developed, although the latter is also met with more or less extensively over the entire body. The animal is the excitant, and the excitation of the sensory nerves of the hands is communicated to the whole of the nervous apparatus of the skin, hence the itching and eruption on parts ERYTHEMATOUS AFFECTIONS. 211 of the skin which the acarus never reaches. Hence, also, the principle of cure, to remove the local irritation, and thereby to subdue the reflex phenomena which take their rise in the local irritation. But the morbid sensibility of the skin induced by the acarus is often aggravated by the occurrence of the disorder in a person of ecze- matous 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 is to be treated locally by the usual means; or, as the eczema 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 unmanage- able 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 wrests, the treatment should be continued as for an ordi- nary and uncomplicated example of eczematous eruption. CHAPTER VI. ERYTHEMATOUS AFFECTIONS. The Exanthemata of Willan are naturally divisible into two groups, the eruptive fevers, comprehending rubeola, scarlatina, and variola, of which we treat in our thirteenth group, under the designa- tion of zymotic affections; and those superficial hyperaemiae of the skin which take erythema as their type, the erythematous affections, and form the subject of the present chapter. The exanthemata and erythemata are the efflorescences and rashes of the skin; the former term being most appropriately rendered by efflorescence, a blossoming out like flowers, which the little corymbi of rubeola might be taken very fairly to represent; while the latter term, erythemata, derived from tpvBaivtw, to redden, may be equally well rendered by the word rash, or inflammatory blush. The definition of exanthema given by Willan is, with slight modi- fication, applicable also to erythema; namely, " superficial red patches, variously figured, and diffused irregularly over the body, leaving 212 ERYTHEMATOUS AFFECTIONS. interstices of a natural color, and terminating in cuticular exfolia- tions." The modification relates to the words " leaving interstices of a natural color :" these words have in view the general efflorescence of rubeola and scarlatina, and also of a member of the present group, namely, roseola; the rest of the erythema being local, and requiring no such limitation. The leading distinction between the erythemata and the eczemata is the difference of relative importance of the local and constitutional disorder in the two kinds of affection. In eczemata the principal interest attaches to the local affection; in erythemata the constitu- tional disorder is of most consequence, the local manifestation being often a mere symptom of derangement of the stomach and digestive organs, and following, like the eruptive fevers, a more or less regular order of development. Thus, in several of the forms of erythema, in erysipelas, and in roseola, the beginning of the attack is announced by nausea, prostration of power, weariness, and headache; these symp- toms are followed by fever; on the second or third day of the general illness the rash makes its appearance, goes on increasing for four or five days, and then gradually declines. At the outbreak of the rash there is commonly a marked relief to the constitutional symptoms, and in some instances the latter quickly disappear. Hence the rela- tion between the local affection and the constitutional affection is very manifest. The diseases included in the present group are:— Erythema, Urticaria, « Erysipelas, Boseola. ERYTHEMA. Syn. Inflammatory blush ; efflorescence cutane'e; dartre erythemoide, Alibert; Hautrothe, Germ. Erythema, or inflammatory blush (Plate I. G K), is a superficial inflammation of the skin, more or less partial in its distribution, occurring in spots and patches of various size, sometimes diffused and sometimes circumscribed, and attended with more or less swelling and pruritus. The redness is sometimes scarlet, sometimes crimson and purplish; and on dispersing, is followed by a bluish and yellowish stain, like that of a bruise; the resolution of the inflammation beino- succeeded by exfoliation of the cuticle.1 Erythema comprehends a very considerable range of pathological variety in the vascular condition of the skin, from the simplest tem- porary distension of capillaries with blood, to effusion or transudation of certain of the elements of blood into the circumjacent tissues; from a simple hyperaemia, which subsides without leaving a trace of i,ts existence, to a suspension of cell nutrition, which results in exfo- liation or furfuration of the epidermis; or to effusion of serum in sufficient quantity to produce veritable oedema. At the one extreme, 1 Plenck's definition of erythema is as follows: " Macula rubra, solitaria, apyreta, et topica." erythema. 213 we have simple blushing from emotional excitement, or the stimulus of the cutaneous nervous system through the agency of the gastric nerves; and at the other, the sudden swelling of erythema tumescens, or the more permanent swelling of erythema nodosum. Another expression of the same pathological condition is conveyed by the terms hyperaemic and erudative; and as these two phenomena are the basis of two of the classes of Hebra, namely, hyperaemiae and exsu- data, we find erythema occupying a place in both those classes; the former comprehending erythema from injury, heat, or irritants, erythe- ma seu roseola infantilis, variolosa and vaccina, livedo, and cyanosis; the latter, erythema exsudativum multiforme, including the varieties papulatum, tuberculatum, iris, annulare, and marginatum, and also erythema nodosum. When not due to purely local causes, erythema is commonly symp- tomatic of some disturbance of the digestive, the nutritive, or the uterine functions, or its symptoms are secondary and limited to a slight degree of irritative fever. It is not contagious, and in duration varies from a few days to several weeks. The varieties of erythema admit of division into two kinds, which, in the language of Hebra, may be designated erythema hyperaemicum and erythema exsudativum; and each of these forms will be found to present certain sub-varieties; thus, under the head of erythema hyper - semicum may be assembled erythema simplex, fugax, and laeve; and under the head of erythema exsudativum, erythema papulatum et tuberculatum, nodosum, circinatum, marginatum, and iris. In tabular arrangement they would stand as follows:— Erythema Hyperaemicum. Erythema simplex, " fugax, " laeve. Erythema Exsudativum. Erythema papulatum et tuberculatum, " nodosum, "' circinatum, " marginatum, " iris. Erythema simplex may be taken as a general expression for the entire group of hyperaemic erythemata of Hebra; for example, its active forms, erythema traumaticum, caloricum, and ab acribus seu venenatum; and its passive forms, livedo mechanica, calorica, and cyanosis. Erythema fugax is the appropriate designation of those superficial erythemata which originate in constitutional causes; and erythema laeve, the cutaneous inflammation resulting from oedema and anasarca. Erythema exsudativum, which represents the immediate conse- quences of congestion as well as hyperaemia itself, is well illustrated in the smaller and larger prominences of erythema papulatum, tuber- 214 erythematous affections. culatum, and nodosum; the circles and rings of erythema circinatum ; the broken rings of erythema marginatum ; and the concentric rings of erythema iris. Viewing the affinities of certain of the forms of erythema, Hebra includes under the term erythema polymorphicum or multiforme, the prominent varieties papulatum and tuberculatum, as also the annulate forms, circinatum and iris, and an advanced stage of erythema circinatum in which the rings are confusedly mingled together, termed by Fuchs erythema gyratum. Moreover, Hebra enlarges the group by an appendix of two remarkable forms of ery- thema, the one a native of Italy, the other of France, namely, pella- gra, the leprosy of Lombardy, and acrodynia, an epidemic erythema which was first noticed in Paris in 1823-9. Erythema simplex is known by the presence of simple vascular congestion of the skin, with little or no swelling, and of a tint of color varying with the activity of the circulation through the part. It is termed erythema traumaticum when it is produced by pressure, friction, or any other kind of violence. Sometimes the exciting cause is the pressure and friction of ill-fitting garments, which give rise to erythema ab attritu ; sometimes undue pressure on the skin, as in bed- ridden persons, the erythema paratrimma of Sauvages, and erythema a decubitu of Plenck; by the pressure and friction of. riding on horse- back, rubedo clunium in equitantibus ; or, by the friction of two folds of the skin, as in fat and flabby persons and in infants whose skin is naturally sensitive, erythema intertrigo, and the evil is increased if the integument be in a moistened state, as by the condensation of perspira- tion or the flow of secretions over the part. In lymphatic constitu- tions the erythema is apt to be accompanied with exudation, in the first place of a serous fluid, and subsequently of a muco-purulent secretion. The presence of exudation, however, transfers the affection from the erythematous to the eczematous group, and the case becomes one of eczema mucosum. When erythema is induced by heat or the absence of heat, it is termed erythema cahricum. The first stage of scald or burn is deno- minated erythema ab igne, or ambustio erythematosa; and the period of reaction after extreme cold, erythema a gelu, or pernio erythema- tosa. Erythema ah acribus seu venenatum is shown in the action of certain mechanical and chemical irritants, and in the bite or sting of venomous insects, as of the ant or wasp. Passive erythema is instanced in the livid discoloration of the skin, which is induced sometimes by mechanical force, sometimes by a lowered state of temperature, and sometimes by visceral malformation or disease. Livedo mechanica is a passive hyperaemia of the capilla- ries of the skin, resulting from mechanical interruption of the current of blood through the veins; the cause may be pressure on the trunks of the veins, as by a tumor, or pressure on the surface, as by ligature; the circulation is retarded by these means, and the blood has time given it to undergo its venous transformation, and assume a deep crimson purple, and even livid and black tint. In these cases there is sometimes a slight degree of swelling, and the arrest of oxygeniza- tion of the blood is accompanied with a lowered temperature. When erythema fugax. 215 the congested skin is pressed with the fingers, the color disaDpears, but slowly returns when the pressure is withdrawn. The lividity of the skin induced by cold, and seen in various degrees in the winter season on the extremities, the tip of the nose, the lobes of the ears, and other parts of the surface, is known as livedo calorica. It is espe- cially remarkable in association with chilblains, and frequently pro- duces a singular mottling of the skin in young children, a mottling in which purple, crimson, white, and blue are curiously intermingled. Another form of lividity of the skin is termed cyanosis, and owes its origin to imperfect oxygenization of the blood, as a consequence of arrested development of the heart, and generally of the permanency of the foramen ovale. In this case the blueness of the skin is gene- ral, but most remarkable in the face and extremities. Erythema fugax is chiefly remarkable for its evanescence; it occurs in the form of patches, which are red, hot, itchy, and slightly swollen; sometimes successive, and sometimes changing their place as though by metastasis. Bateman compares the redness of the patches to that produced by pressure, and remarks upon its association with various febrile affec- tions. He also mentions the opinion of Hippocrates that it denoted a 'tedious and dangerous disease. Our own experience associates it with disorders of the mucous membrane of the digestive, secreting, and uterine organs, and especially of the former. Erythema fugax is sometimes more remarkable for a tendency to swell {erythema tumescens) than for its redness, and this form of the disorder is often very annoying. A little itching is felt in the part attacked, it swells quickly, and in the course of an hour has attained a considerable size. The swelling lasts for a few hours, and subsides almost as rapidly as it arose. We know a military officer who was the subject of this curious malady. The swelling would take place so suddenly that he was sometimes seized with it while on duty; occasionally it affected the integument of the eyelids; his eyes were quickly closed, and it was necessary to lead him to his quarters com- pletely blinded. But a more painful case was that of a clergyman, in whom the disorder attacked the lips and sometimes the tongue: when it occurred in the latter situation, he was once or twice nearly suffocated. Erythema fugax is also associated with another curious affection, namely, vicarious menstruation {erythema menstruate). A sudden flush with a little swelling appears upon some part of the skin, generally the face; a sanguineous exudation takes place, which lasts for a few days and then subsides. The exudation is not continuous throughout the whole period, but intermittent, and during the intermission, the skin has the appearance of having been scorched. We have seen three well-marked examples of this affection; the patients were young, and suffering from amenorrhoea; they were also hysterical. Erythema l.eve, vel csdematosum, is a local form of erythema, depending upon the inward pressure of oedema of the subcutaneous cellular tissue. It occurs for the most part in the lower extremities, or in any depending portion of the body. Sometimes it is met with 216 erythematous affections. in the eyelids, and is mistaken for erysipelas; and not unfrequently, in the lower limbs, the cuticle breaks up into a series of retiform lines; the exposed cutis exudes a serous secretion; there is considerable pruritus, and the case becomes transformed into one of eczema. Ery- thema laeve is a frequent accompaniment of anasarca, in which case the surface of the skin is red and glazed. Erythema papulatum et tuberculatum (Plate I. G H). The two forms papulatum and tuberculatum only differ in size of the eruption, the symptoms being the same; and not unfrequently they are intermingled in the same person, or on the upper extremities assume the smaller or papulous forms, and on the lower extremities the larger or tuberous form. Both commence with itching and tin- gling, increased by the stimulus of meals and heat of bed; both are slightly raised at their first appearance, and subside to the level of the skin in a few days; and both are brightly red at first, become purplish by degrees, and fade away into a greenish and yellow stain which resembles a bruise. The smaller kind are met with on the face and neck, the chest, the upper extremities, and particularly in the neighborhood of the joints and upon the back of the hands; the larger kind are chiefly found upon the lower extremities and around the knees and ankles. Both are associated with disorder of the di-' gestive organs, and the latter with disordered menstrual function. The tuberous kind is commonly met with in female servants who have been recently introduced into London kitchens from the country: the eruption is tender to the touch, and frequently accompanied with feverish symptoms and rheumatic pains. In the papulous form of the eruption the largest of the papulae scarcely exceed a split pea in dimensions; they frequently increase by the circumference, and present a raised rim with a depressed centre; the rim being red. and the centre pale or yellowish, their subsequent appearance is that of a bruise. In the tuberous variety the spots are circular and fade towards the circumference, while their diameter varies from half an inch to an inch or more; they are ex- tremely tender to the touch, and are followed by a well-marked bruise- like stain. Erythema nodosum (Plate 1.1).—Erythema nodosum only differs from the preceding in a larger development of the inflamed spots, and a somewhat more violent attack of disorder of the digestive organs and feverishness, by which it is preceded. The patches are oval in figure; are hot, painful, and tender, and appear chiefly on the lower extremities, corresponding by their long diameter with the vertical axis of the limb. Occasionally, however, they are disposed trans- versely, and we have seen two patches so placed as to form a kind of bracelet just above the ankle. They are hard to the touch at first, and sometimes seem to sink deeply into the tissues of the limb, in- volving even the muscles; in a few days they become softer, and in eight or ten days subside and disappear. At the commencement they are brightly red ; as they attain maturity they become purplish, and at their decline have the green and yellow tinge of a bruise {derma- titis contusiforrrlis, Hebra). In prominence they rise gradually to the ERYTHEMA CIRCINATUM. 217 centre, and are commonly associated with considerable derangement of the digestive organs, and frequently with rheumatism. Their size varies from one inch to two or three inches in longest diameter. 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 we have more than once seen erythema papulatum on the face and hands, while erythema nodosum existed on the legs. Erythema circinatum (Plate I. K) begins in the form of circular and slightly raised patches, which increase by the circumference and fade in the centre, forming rings of various size, with borders of various breadth, being sometimes narrow and sometimes broad. The skin over which the inflammation has passed throws off its cuticle in furfuraceous desquamation, and the rings, meeting and crossing in their course, give rise to a variety of irregular figures, consisting of broken segments of circles {erythema gyralum, Fuchs). This form of eruption is often met with in the course of ailments accompanied with perspiration, and when the patients have been kept hotly covered up with bed-clothes, as in rheumatic fever. It is also seen, in the spring season of the. year, on the lower extremities of young persons, and commonly associated with rheumatism. Erythema marginatum is a chronic form of erythema circinatum; the border is more raised, particularly at the periphery ; the congestion is deeper tinted, often crimson or purple, and the rings broken and irregular. They are chiefly met with in elderly persons on the ex- tremities and loins, and, according to Willan and Bateman, are asso- ciated with some internal disorder, their occurrence being deemed an unfavorable sign. Erythema iris is a circinate and centrifugal form of erythema, developed in concentric rings, and commonly taking its starting-point from a central vesicle, hence we have preferred to describe it under the name of herpes iris. In an aborted form it retains the erythema- tous character, and is commonly met with on the hands and feet, and next in frequency on the lower limbs. The following cases illustrate some of the phenomena of Erythema:— Case 1. Erythema papulatum et tuberculatum.—A married lady, habitually dyspeptic, became overheated on the 16th of December, 1815; she was afterwards chilled by exposure to cold in an open car- riage 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 un- palatable dish to her, and suffered in the evening from nausea and headache. 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 back of her hands and fingers; the rash was more vivid at night, and attended with considerable itching. 218 ERYTHEMATOUS AFFECTIONS. 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 back 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 iso- lated. On the back of the hands were spots of a larger size than those above mentioned, as large in diameter as a sixpence or shilling (erythema tuberculatum); 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. 23d. 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 tenderness subsided; the redness diminished; and each little papula, as it gradu- ally disappeared, formed a distinct ring of red, with a light yellowish area. Traces of the eruption lasted until the end of the second week. Case 2.—Erythema papulatum et nodosum.—A .widow, forty-five years of age, 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 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 swell- ing (delineated in Plate VII.) made its appearance, attained 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 eruption were nausea, feverishness, and extreme lassitude. The languor, with great depres- sion of spirits, continued until the termination of the disease. Case 3.—Erythema tuberosum.—A young woman, aged twenty-two, enjoyed good health until nine months ago, when she obtained service in London as housemaid. Since that period she has suffered constant illness; sometimes her bowels were constipated, sometimes she had nausea, at other times cough; menstruation was disturbed, becoming scanty and light-colored; she had leucorrhcea, 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 disorders. Asso- ciated 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, accom- panied with headache and the usual train of febrile symptoms ; and a copious eruption of erythema tuberosum made its appearance on her forearms, knees, and legs. The majority of the spots were of the size of a shilling piece, they were distributed regularly over the skin, and cases of erythema. 219 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. Water-dressing was used to the eruption. Case 4.—Erythema laeve 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 ©edematous, 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 be- fore suffered from any affection of the legs. We ordered her to bed, gave her an active purgative with salines, had the leg supported on an inclined plane, the inflamed parts wetted with a layer of lint dipped in a saturnine and alcoholic lotion, and the whole of the lower leg en- veloped in oiled silk. By the next morning the redness had diminished very considerably, and the oedema was much reduced. We then moistened the limb with camphorated spirit, and bandaged it firmly, from the foot upwards 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, was intrusted to herself, it was found necessary to con- fine her again to bed, where in a short time she recovered. Case 5.—Severe erythema laeve of both legs.—In the autumn of 1841 we saw, with Mr. Coulson, 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 deep red tint, highly congested, and covered with a rough and exfoliating 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 pur- pose of relieving the congested state of the skin we recommended free scarification with the point of a lancet, to be followed by fomentation and bandaging. To this, however, she objected. We then ordered strict attention to position, painting the surface with tincture of iodine, and carefully adjusted compression by means of strips of soap plaster spread upon leather; the local treatment being assisted by an occa- sional aperient, and tonics. In the course of a few weeks she had entirely recovered. Case 6.—Erythema Iseve, 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. We directed her to remain in bed, and apply fomentations to the limb, at the same time recommending her to the attention of a neighboring medical 220 erythematous affections. friend. In a few days the part became discolored, and sphacelus com- menced, 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 deposition, and some of the smaller vessels were completely obstructed. Diagnosis.—Redness, bright at first and subsequently becoming purplish; slight elevation, sometimes with a tendency to sudden swelling; itching and tingling ; and very slight, if any, exfoliation of the cuticle, unlike the decided desquamation of the eczematous affec- tions ; bruise-like stains on disappearance ; these are the signs which distinguish erythema from other disorders of the skin. Erythema papulatum bears some resemblance to urticaria in size of prominence, in situation, and in the sensation of tingling pruritus; but there the likeness ceases; one is permanent for several days, the other, main- tained only by muscular spasm, is lost in an hour; moreover, the papules of erythema are red, and the wheals of urticaria white and bloodless." Cause.—The cause of erythema is debility, general and local; the general forms being assimilative, nutritive, and nervous; and the pre- disposing causes, derangement of digestion, derangement of uterine function, variations of climate, errors of air and exercise, alternation of seasons, rheumatic diathesis, hereditary diathesis, and irritating ingesta, such as certain articles of diet and certain mediciues, for ex- ample, quinine and copaiba. Local erythema may result from heat and cold, irritants of all kinds, and friction; stimulation by the heat of the sun is a not infrequent exciting cause. Prognosis.—Erythema is rarely grave; but as it indicates a state of disorder of the economy, the health should be restored as quickly as possible. Its common duration is from one to three weeks. Treatment.—As the most frequent of the predisposing causes of' erythema are those which conduce to assimilative debility, the diges- tive organs and the uterine system call for our especial attention. Mild purgatives, salines, and subsequently bitters with the mineral acids, will4)e found to be the proper remedies in the majority of cases. Where the function of the stomach is principally at fault, the trisni- trate of bismuth, with liquor cinchonae and infusion of orange-peel, will be useful; or the more decided tonics, quinine with sulphuric acid; or quinine with iron and citric acid. If the cutaneous disorder be associated with rheumatism, the iodide of potassium may be advan- tageously combined with the salines or bitters, according to the stage of the affection. 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 an useful remedy, particularly in females. TREATMENT of erythema. 221 When the system is reduced, and the powers are enfeebled, tonic remedies are especially indicated; bitters combined with acids are of great service, 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 often very valuable. Locally, the benzoated ointment of oxide of zinc will be found useful in the more irritable forms; and where there is oedema, an elastic cotton bandage, carefully applied. In erythema papulosum, tube- rosum, and nodosum, a spirit lotion may be used, or a lotion or cerate of Goulard's extract. In erythema intertrigo and paratrimma, the parts should be washed with the juniper-tar soap, and afterwards dressed with the benzoated ointment of oxide of zinc, combined with spirits of camphor. In erythema paratrimma especially, the inflamed part should be pencilled with a liniment of white of egg and spirits of wine, and afterwards dressed with the unguentum resinae flavae ; or, if there be any moisture of the surface, dusted over with pulvis cinchonae. Chronic erythemata are to be managed according to general prin: ciples; the excitement of the affected part is to be reduced in the first instance by soothing applications, and then astringents and stimulants are to be used. The chapping of the hands may be prevented and relieved by the use of a small quantity of honey, which should be rubbed into the inflamed part each time the hands have been washed, and then wiped off, so as to remove any stickiness that may remain. Glycerine may be applied in the same way, or the benzoated ointment of oxide of zinc. Erythema of the nipples (chapped nipples) is best relieved by the application of the benzoated ointment of oxide of zinc 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 gum 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. We have also seen great benefit result from the use of collodion, which, judiciously applied, and assisted by other means, will be found an invaluable 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 incon- venient, a shield and teat should be applied, without interfering with the nitrate of silver ointment. For erythema of the vulva and anus, the most soothing applications are, the superacetate of lead ointment, or the benzoated ointment of oxide of zinc with liquor plumbi diacetatis. Over these an evapo- 222 ERYTHEMATOUS AFFECTIONS. rating lotion may be used, if requisite; and when the acute stage is passed, the milder ointments may be replaced by the nitrate of mer- cury ointment, more or less diluted, as the feelings of the patient may permit. The nitrate of silver ointment is also found to be of great service in some instances. For chilblains, in their erythematous state, the treatment is friction with moderately stimulant liniments; such as the linimentum cam- phorae, with chloroform; soap liniment and oil of cajeput; or a lini- ment composed of the contents of one egg, one ounce of spirits of turpentine, and one ounce of distilled vinegar, well shaken together. PELLAGRA. Syn. Mai del sole; risipola lombarda ; mal rossa; cattivo male ; mal del padrone ; male delta vipera ; scorbuto alpino; elephantiasis italica, Mason Good ; lepra asturiensis, Sauvages ; mal de la rosa; mal de misere ; elephantiasis asturiensis, Mason Good ; erythema endemicum, Alibert; raphania maistica, Guerrichi. Pellagra is an erythema affecting parts of the skin exposed to the sun, and associated with symptoms of disorder of the nervous system, cerebral, spinal, and organic. It is endemic in certain countries, for example, Italy, and especially Lombardy and Venetia, Spain, and some districts of France; makes its attack in the spring season; and is ex- cited and aggravated by the heat of the sun, hence its synonym mal del sole.1 The subjects of pellagra are for the most part peasants and agricultural laborers; and these people are probably predisposed to disease by some degree of debility induced by unwholesome or insuf- ficient diet, and possibly by malaria. After prolonged and, perhaps, daily exposure to the sun for a certain space of time, or after working or sleeping in the sun, the individual experiences a sharp tingling and prickling pain in the exposed skin, accompanied occasionally with a sense of giddiness and nausea, and his gait is staggering when he attempts to walk. He is restless and feverish at night, and for some weeks or months he experiences loss of appetite, nausea, burning heat at the epigastrium and in the throat, diarrhoea, a frequent repetition of giddiness, sometimes disturbance of vision, insomnia, frightful dreams, noises in the head, fugitive neuralgic pains, muscular spasms, cramps, lassitude, and depression of spirits. Subsequently, in con- junction with the diarrhoea, there exists excessive appetite, with a clean but red and fissured tongue. These symptoms continue with greater or less severity for three months, and gradually subside, leaving the patient, to all appearance, well; but he remains morbidly sensitive to the stimulus of the sun, the symptoms are instantly aggravated during the progress of the disorder, even by a momentary contact with the sun's rays; and on the approach of hot weather, the following spring, all the symptoms return, but with greater severity, to be repeated successively for a number of years until, in the end, they exhaust the powers of the 1 Dr. G. M. d'Oleggio, of Venice, published a treatise on Pellagra in 1784 under the title of the disease of "vernal insolation." PELLAGRA. 223 patient, and cause his death. Besides being successive or remittent, the attacks of pellagra are progressive; they are more severe at every return ; and, after a while, from being evanescent and temporary, they become fixed and permanent. The progressive aggravation of the symptoms in successively re- curring attacks of the disease has led to its distinction into three stages. In the first stage, the fever is comparatively slight, the ery- thema superficial, the diarrhoea, the pains in the head, and vertigo, moderate. In the second stage, the symptoms are more severe and prolonged; the fever is greater; the erythema more confirmed, and attended with more decided desquamation, as also with the occasional appearance of vesicles, pustules, rhagades, excoriations, and scabs. The diarrhoea is more continuous, and accompanied with a red tongue and voracious appetite; the affection of the nervous system, namely, the pains in the spine and limbs, the trembling of the limbs, the pains in the head, and the vertigo, more distressing; there is a greater de- gree of despondency, more or less delirium, and increasing debility with emaciation. In the third stage, the disease assumes a persistent character; the emaciation is more marked; the complexion sallow; the skin squamous, incrusted, and attenuated; the diarrhoea, constant: and the appetite still voracious; the despondency and cerebral symp- toms have also increased, sometimes assuming the character of de- mentia, melancholy, or mania; there is loss of motion of the limbs, with tremors and partial loss of sensation; loss of power of deglu- tition and speech; loss of vision; often convulsions, asthenia, exhaus- tion, and death. On the skin the erythema presents a deep red color; sometimes in patches, and sometimes diffused ; the surface is dry and parched; the substance of the skin attenuated; and the subcutaneous fat removed. The nutrition of the skin is evidently arrested, probably from para- lysis of the trophic nerves; the integument, after a while, assumes the character of parchment; and, in consequence of its thinness, permits the tendons and veins to stand out in strong relief. When the ery- thema subsides, a deep melasmic stain is left upon the spot; but the skin never recovers its normal texture. In the early attacks of the disease, the affection of the skin is limited to redness of a deep tint, without swelling, a painful sensation of tingling and prickling, attenu- ation of structure, and some slight exfoliation of the epidermis. In subsequent attacks, desquamation of the epidermis is more decided; after that, dark colored crusts are formed upon the surface, and are accompanied with cracks and ichorous excoriations. In some in- stances, vesicles, phlyctenae, and pustules, have been noted in asso- ciation with the cutaneous affection. The most important feature of the disease is the cerebral disturb- ance ; this is not always primary, as in ordinary coup de soleil, but comes on gradually during the progress of the attack, as though it were a secondary consequence of the injury of the»nervous apparatus of the skin; in like manner we must explain the rachitic neuralgia, the spasmodic cramps of muscles, the partial paralysis of motion of the lower limbs, and the irritability of the alimentary canal, inducing 224 ERYTHEMATOUS AFFECTIONS. diarrhoea, and sometimes dysentery; the latter being a reflex nervous irritation. The affection of the brain is evinced by giddiness, vertigo, insomnia, noises in the head, and disturbance of vision; that of the spinal cord by muscular spasms, defective power of motion, and partial loss of sensation; and that of the organic nervous system, by nausea, voracious appetite, and diarrhoea. While, to the general disturbance of the nervous system we must refer the lassitude, the depression of spirits, and the mental aberration ; the melancholy and dejection being often so great as to prompt to suicide. Stambio, one of the early writers on pellagra, remarks that the suicidal tendency very com- monly takes the direction of drowning, a state which he terms " hy- dromania." After successive annual repetitions of the disease, the diarrhoea is apt to become unrestrainable and colliquative, and the patient sinks from exhaustion (marasmus pellagrosus, tabes pellagrosa). Prior to this event, however, there exists a state of fever, which is accom- panied with fetid perspirations, and sometimes with delirium. The features are drawn and anxious, marked with the deep furrows of age; and the complexion is pallid and muddy. Sometimes death is hastened by typhoid fever, and sometimes by dropsy of the visceral or cerebro-spinal cavities, and sometimes by softening of the brain and spinal cord. Dr. Peacock, who had an opportunity of seeing the disease in Italy in the autumn of 1862, remarks that " in the last periods of the disease the appearance of the patients was most charac- teristic. Their expression of countenance was usually desponding; they were thin and emaciated, pale and sallow, with sunken and glassy eyes, pale lips and tongue, and the latter was usually clean but fissured. The pulse was uniformly feeble and slow, 60 to 70 in the minute; the extremities, cold, tremulous, and almost powerless. Some could not raise themselves or walk; were incapable_of leaving their beds, or were secured in chairs; but others who possessed greater power, when they attempted to walk, did so with a tottering step, with their heads bent forwards, their backs curved, and in a kind of run, as if constantly on the point of falling.1 The kinds of insanity, consequent upon pellagra are stated to be, dementia, melancholia, and mania; of 310 cases admitted into San Servolo, the relative number of the three preceding forms of disease were 130, 95, and 82, two of the number presenting monomania. And the paralysis subsequently met with in association with the dis ease, is shown by Ballardini and Baillarger " to be identical in its symptoms and morbid appearances with the general paralysis of the insane." Dr. Peacock determined the absence in pellagrous patients of struma or renal disease, and states the chief post-mortem appearances to be congestion of the alimentary canal, with a " peculiar thinning of the mucous membrane," reminding us of the similar condition of the skin, and effusions into the serous cavities. 1 Notes on Hospitals in Northern Italy, and on Pellagra, by Thomas B. Peacock, M.D., F.R.C.P., in the British and Foreign Medico-Chirurgical Review, for January, 1863. CAUSE — PROGNOSIS. 225 Cause.—In the countries where pellagra is endemic, the disease is a grave affliction; Ballardini states the number existing in the Milanese provinces, in 1836, to have been 37,628, upwards of one- sixteenth of the population; while in the Milan hospital alone, the average number of pellagrous patients during the years 1832-42, was 636. The persons chiefly affected are agricultural laborers, in the proportion of nearly 90 per cent.; it attacks all ages and both sexes, and is clearly hereditary, the hereditary tendency being greatest on the mother's side. According to Calderini, the disease is most fre- quent between 30 and 50 years of age; and of 184 pellagrous families, representing 1319 individuals, nearly one-half suffered from the affec- tion. The action of the sun upon the skin, a sunstroke of the skin, must be taken to be only the exciting cause, while the predisposing causes are numerous in the shape of hygienic influences of various kinds, namely, exposure to malaria, poor and insufficient diet, and defective clothing and habitation. An almost universal diet in those parts of Italy affected with pellagra, is the Indian maize, and Peacock has collected evidence which goes far to prove that maize imperfectly ripened and dried generates a fungous mucedo, which may act as a poison on the blood and be the prime cause of the disease. He traces a relation between the first introduction of maize into these countries and the appearance of pellagra; he further shows the difficulty of ripening maize between the 42 and 46 degrees of latitude, the exist- ence of pellagra where the maize is imperfectly ripened and dried, and its absence where the opposite conditions prevail; and he suggests that pellagra may occur from a similar unwholesome condition of the cereals in general. Ballardini detected the fungus in the groove of the germ of the seed in the form of a green pulverulent substance; and Cessati, who was the first to examine this substance with the microscope, found it to consist of small round diaphanous globules without sporidioles, and smaller than the cells of farina; and ho named the fungus sporisorium maydis; while Guerreschi proceeds a step further, and distinguishes the disease produced in man as the raphania maistica. Prognosis.—While pellagra may be as certainly cured by removal from the pellagrous districts and the adoption of a better diet, as ague, it nevertheless happens, that amongst those who are unable to quit their native villages the disease is a severe affliction, and often fatal. Its ordinary duration is several years, but it would seem to be capable of extending its limits to almost any period; of a given number of patients in the hospital of Milan, the disease, according to Calderini, had lasted from one to three years in 114; from three to twelve years in 138 ; and from twelve to sixty years in 100. And Ballardini gives, as the results of his carefully prepared statistics of the pellagra in the Milanese provinces, the following facts : the number of cures amounted to 78 per cent., uncured 13 per cent., 9 per cent, suffered from mental diseases, 6 per cent, died from natural causes, while the figures 0.029 represent the number of deaths by suicide. Treatment.—The treatment the most successful in pellagra, is that 15 226 erythematous affections. which may be reasonably deduced from the observation of the causes of the disease, namely, improved hygienic conditions, a sound diet of mixed animal and vegetable food, beer or wine, and tonic medicines, especially quinine with chalybeates. To this general plan may be added repose, warm bathing, and a careful avoidance of exposure to the sun. ACRODYNIA. Syn. Erythema epidemicum. Acrodynia is an erythema of the palm of the hands and sole of the feet, attended with burning heat, pain, and numbness, with numbness of the limbs, pains throughout the body, and general disorder of the digestive and nutritive functions. This disease made its appearance in Paris in an epidemic form, in the year 1828, during a cold and damp summer, and continued the following year, subsiding on each occasion during the succeeding winter. It was first described by Cayol, and subsequently by Chomel and Rayer. Acrodynia begins with symptoms of disorder of the digestive organs, for example, loss of appetite, nausea, weight at the epigastrium, some- times vomiting, colicky pains, and diarrhoea. The eyes are suffused and sensitive ; there is lachrymation and puffing of the face; and with these symptoms, or a little later, a patchy redness appears upon the palms and soles, sometimes extending upwards to the forearms and legs, and subsequently spreading more or less extensively over the rest of the body. The erythema is at first brightly red, but gradually becomes brownish and dark-red; while some of the patches have been compared to ecchymoses, and not unfrequently there is a dark-brown and even black discoloration of the epidermis from the deposit of pigment; moreover, there appear occasionally prominent papulae, phlyctenae, pustules, and oedema. After a time the cuticle exfoliates, and the exfoliation is repeated from time to time, the denuded surface being smooth and glossy, and of a bright red hue. Sometimes the exfoliation of the epidermis is accompanied with per- spirations, and occasionally the cuticle of the whole of the palm or of the sole of the foot is shed in a single piece. The erythema is attended with stinging and smarting pains, a sense of numbness, and an extreme burning heat, which is greatest during the night, and disturbs sleep. Not unfrequently the numbness in the limbs amounts to a partial paralysis, and is sometimes associated with loss of muscular substance and spasmodic cramps. Occasionally the sensibility of the palms and soles is excessive, and the pains severe, and in different instances the separate symptoms take on an extreme degree of intensity; sometimes the suffusion of the eyes runs on to conjunctivitis, and sometimes the gastro-intestinal symptoms are espe- cially severe. Acrodynia commonly lasts from a few weeks to several months, and is liable to relapse, but is rarely fatal except in aged persons. It re- sembles pellagra in some of its features, but is more acute, less liable to repetition, and manifests a more superficial injury of the organism. ERYSIPELAS. 227 The treatment adapted for its cure must be directed in the first place to the relief of the constitutional symptoms, while locally mild stimu- lants, and especially tar have been found of service. ERYSIPELAS. Syn. Erythema erysipelatosum, Mason Good ; febris erysipelatosa, Sydenham ; dermatitis symptomatica, Hebra; rosa, Sennertus; ignis sancti Anthonii; rothlauf; haut-rose ; erysip≤ risipola; St. Anthony's fire. Erysipelas is a specific inflammation of the skin and subcutaneous cellular tissue affecting a part of the surface of the body, and accom- panied, and often preceded, by derangement of the digestive organs, and more or less severe fever. The local inflammation has a special disposition to spread; it is attended with swelling, a pungent, burning, and tingling heat, a sense of tension or weight in the part, and by a redness which disappears under pressure with the finger, to return so soon as the pressure is remitted. It is often accompanied with vesi- cations containing a limpid amber-colored serum, which quickly burst, and form thin, dark-colored crusts ; and the inflammation is apt to be communicated to the lymphatic vessels and glands. Erysipelas terminates generally in resolution with desquamation of the epi- dermis, sometimes in delitescence, or suppuration, and more rarely in mortification. The disposition of erysipelas to spread is evinced by its habit of creeping onwards upon the neighboring skin, and subsiding on the part first attacked; and sometimes vanishing suddenly on one spot to appear upon another at some distance. It is this ambulant or wander- ing character, and the tendency to sudden disappearance, that has gained for two of its forms the names of erraticum and metastaticum. The swelling is sometimes very moderate; at other times there is a degree of infiltration into the subcutaneous cellular tissue amounting to oedema, and with the oedema an interstitial infiltration into the corium, producing thickening and coarseness of the skin. An advanced degree of this serous infiltration gives rise to the development on the inflamed surface of vesicles, constituting erysipelas miliare; while larger vesicles or bullae distinguish the forms known as erysipelas phlyctenodes, or bullosum, that which is marked by simple oedema being erysipelas cedematosum. Erysipelas has a tendency to invade by preference certain regions of the body ; for example, the head and face ; next in frequency it is met with on the limbs and genital organs; and in newly-born infants is apt to attack the umbilicus and abdomen. It also manifests a remarkable difference in respect of depth, the forms heretofore referred to being superficial, while one form is distinguished by its invasion of the deep structures of the body as well as the skin, namely, ery- sipelas phlegmonodes. Another diversity in the forms of erysipelas has reference to its cause, the ordinary eause being constitutional, while a very dangerous form, traumatic erysipelas, has its origin in wounds, as in the erysipelas which comes on after surgical operations Erysipelas generally runs a course of ten days to a fortnight or 228 erythematous affections. three weeks; the local inflammation commonly makes its appearance without premonitory symptoms; at other times constitutional disturb- ance precedes the inflammation of the skin for an uncertain period ranging between a few hours and two or three days ; and the symp- toms of general disorder go on increasing for four or five days longer, and begin to decline on the eighth or ninth day. In erysipelas phlyctenodes the bullae are formed on the fourth or fifth day, each bulla having an existence of twenty-four hours before it bursts; and erysipelas capitis reaches its height about.the fourth or fifth day, and its decline about the seventh or eighth. The termination of erysipelas usually takes place by resolution : the swelling subsides, the redness disappears, the tenderness and pain cease, and the cuticle is separated by desquamation. The thin scabs formed by the desiccation of the cuticle covering the broken vesicles also desquamate in a few days. The constitutional symptoms of erysipelas are those of invasion, course, and decline. The symptoms of invasion are : weariness and lassitude; depression of spirits; pains in the back and limbs; chills or rigors, with flushes of heat; headache and giddiness or drowsiness; thirst; loss of appetite; white, coated tongue ; bitterness of mouth ; nausea; often vomiting; weight and oppression at the epigastrium; diarrhoea or constipation; quick, and sometimes hard pulse, and hot dry skin. These symptoms are rarely if at all mitigated by the appearance of the inflammation of the skin, and are prone to take on more or less of a nervous character ; the pulse, usually 100 to 120 in frequency, becomes soft and extremely quick; the tongue is brown and dry; sordes accumulate on the gums and lips, and there is more or less delirium. At the decline of the local inflammation, the bad symptoms either subside by degrees, and a diarrhoea or lithic acid sediment shows a return of normal energy of the organic functions; or the patient falls into a state of coma from effusion between the membranes of the brain, or, asthenia, from exhaustion ; and gradually succumbs. Not unfrequently, at the close of the fever, there is some degree of hemorrhage from the mucous membrane, sometimes from the pulmonary or alimentary mucous membrane, and sometimes from the womb. Simon observes, that in the early stage of erysipelas the urine puts *bn 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 being 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 GENERAL FORMS OF ERYSIPELAS. 229 are as follows ; Becquerel's analysis of healthy urine being placed for comparison in a third column:— Ounces of urine in 24 hours Water, Solid constituents, Urea, . » Uric acid, . Fixed salts, Extractive matter, Specific gravity, Anal. 1. Anal. 2. Health. 27.0 30.8 45.0 965.5 961.9 972.0 34.5 38.1 28.0 12.5 12.7 12.1 1.2 1.3 0.4 — 8.2 6.9 — 15.9 8.6 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 spontan- eously, and had a specific gravity of 1023.1. It contained— Water, Solid constituents, Urea, Uric acid, Fixed salts, Extractive matters, 961.7 38.3 11.7 1.3 9.2 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 de- gree ; 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 varieties of erysipelas may be arranged in two groups, general and local, as follows :— GENERAL VARIETIES. Erysipelas erraticum, Erysipelas phlyctenodes, " metastaticum, " cedematodes, " miliare, " phlegmonodes, LOCAL VARIETIES. Erysipelas faciei, Erysipelas umbilicale, " capitis, " genitalium. " mammae, GENERAL FORMS OF ERYSIPELAS. Erysipelas erraticum is the erratic form of the disease. It is rarely accompanied with much swelling, or with the development of vesicles. It occurs most frequently upon the head and face. Erysipelas metastaticum.—Metastasis is one of the dreaded phenomena of erysipelas, and the especial danger that is feared is metastasis or transfer of the inflammation from the skin to the brain. 1 Simon's Animal Chemistry, vol. ii. p. 278. 230 ERYTHEMATOUS AFFECTIONS. This danger is, of course, very much increased when the seat of the disease is the head or face. The true explanation of metastasis is that which has already been discussed in connection with the proba- bilities of repercussion of eczema; a causa morbi exists in the economy, and some organ must be the sufferer; so long as the vital power is able to exert a conservative control, the disease will run its normal course in the organ already attacked, whatever that may be; but if the vital power be much weakened, then no human caution or con- trivance can prevent the transference of the causa morbi from one organ to another, without any rational explanation being possible. The metastasis of erysipelas, says Dr. Watson, is rare ; " I do not re- collect 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." Erysipelas miliare et phlyctenodes represent two degrees of effusion beneath the cuticle of the serous fluid already infiltrated into the tissues of the skin. In the slighter of the two, the serum is exuded in small quantity, and gives rise to vesicles of the size of millet-seeds (erythema vesiculare, Mason Good); in the other, the quantity of serum is greater, and the vesicles assume the character of phlyctenae, or bullae (erysipelas bullosum). The bullae are commonly developed on the fourth or fifth day of the fever, and go on enlarging for twenty- four hours, when they usually burst. Their contents are sometimes pale and watery, and sometimes opalescent; more frequently they are amber-colored, and sometimes, when there is a tendency to dyscrasis of the tissues, they are purple, from intermixture of the coloring prin- ciple of the blood with the serum. When the bullae burst, their base becomes covered with a thin scab, which, at first yellow, soon becomes brownish, and almost black. Erysipelas ohdematodes is a modification, due to the accumula- tion of serous fluid in the subcutaneous cellular tissue; it occurs most frequently in the lower extremities, and sometimes in the organs of generation. When the inflammation subsides, the fluid is gradually absorbed. Erysipelas phlegmonodes (dermatitis phlegmonosa, Hebra) is more deeply seated, and more severe in all its phenomena, than sim- ple erysipelas. The subcutaneous cellular tissue, the superficial and deep fascia, and the intermuscular fasciae, are all involved in the in- flammation, which, instead of being circumscribed like ordinary phleg- mon, puts on the true erysipelatous character of spreading on all sides, and involving a considerable extent of tissue in destruction, and sometimes the greater part of a limb. It occurs most frequently in the extremities, but may attack any part of the skin; and runs on to suppuration, and commonly to gangrene of the cellular tissue and fasciae, erysipelas gangrsenosum. The local signs of phlegmonous erysipelas are, redness, swelling, hardness, extreme tenderness, and an acute burning pain; when, at about the fifth or sixth day, suppuration is established, the pain is throbbing, an obscure fluctuation is felt, and pressure with the hand local forms of erysipelas. 231 communicates a boggy sensation. When sphacelus is set up, the color of the skin changes to purple, or assumes a livid tint. But when the case is disposed to terminate in resolution, an amelioration of the symptoms takes place at the fifth or sixth day. The constitutional symptoms of erysipelas phlegmonodes are the same as those of erysipelas simplex, but more severe ; delirium is not uncommon, the tongue is dry and brown, and there are sometimes diarrhoea and profuse perspirations. LOCAL FORMS OF ERYSIPELAS. Erysipelas faciei is a serious form of the affection, as it involves parts of high organization, and closely associated with the nervous system and brain. The inflammation begins at the root or side of the nose, in the ear, or at the border of one of the apertures, and spreads over the whole face, swelling the features to such an extent as to ren- them barely recognizable. The eyelids, the ears, and the lips are greatly tumefied, the inflammation is apt to extend to the conjunctiva, and to the mucous membrane of the nose, mouth, and throat, produc- ing blindness, deafness, and obstruction of nasal respiration, and ofte* involving the parotid and submaxillary glands, and occasioning sup- puration among the deep tissues of the neck. The constitutional symptoms are very severe: there is violent headache, sleeplessness, restlessness, delirium, and finally, coma. Sometimes death results from exhaustion or asthenia; and sometimes from apncea, in conse- quence of obstruction of the glottis by infiltration of the mucous mem- brane. Erysipelas of the scalp is usually the consequence of a wound (traumatic erysipelas) and occurs in about a week or ten days from the reception of the violence; the integument is oedematous, smooth, shining, and very sensitive, the inflammation is apt to run on to suppuration and gangrene of the cellular and fibrous tissues, and not unfrequently the inflammation is transferred to the brain. Erysipelas of the mamma is apt to assume the phlegmonous cha- racter, in consequence of the presence of the large quantity of cellular tissue which enters into the structure of the female breast: suppura- tion takes place, and burrowing abscesses are formed, with gangrene of the fibrous tissues. Erysipelas of the umbilical region occurs in young infants (erysipelas neonatorum), from mismanagement of the umbilical cord, particularly in crowded and ill-ventilated public institutions, and under the influence of an epidermic malaria. The inflammation spreads more or less extensively over the whole of the abdomen, and frequently extends to the organs of generation. Erysipelas of the external organs of generation, both in the male and in the female, is peculiarly painful and difficult of man- agement, on account of the great swelling which occurs, the incon- venience of keeping the parts clean; of applying dressings; and the great disposition to suppurative cellulitis and gangrene. It is most commonly seen in connection with the metastatic form of the disease. 232 ERYTHEMATOUS AFFECTIONS. Diagnosis.—The distinguishing characters of erysipelas are, a deeper affection of the tissues than occurs in erythema, a greater amount of tumefaction, a proneness to spread, and especially the more severe constitutional symptoms. Erysipelas phlegmonodes is known by hardness, which indicates a deep implication of tissues, a greater amount of pain, and the suppuration of the subcutaneous tissues. Cause.—The previous consideration of erythema has taught us that a derangement of the digestive functions may be sufficient to excite an inflammation of the skin ; so in the present instance we must have recourse to a similar explanation in some instances of erysipelas; for example, in idiopathic and traumatic erysipelas. In other cases, ery- sipelas appears to be referable to malaria, and sometimes to infection and contagion, and is apt to prevail epidemically. Puerperal fever would seem to be one of the sources of the infection of this disease, and erysipelas and puerperal fever are reciprocally transmissible. The predisposing cause of the disease is debility, and the remote predis- posing causes, those conditions that tend to lower the tone of the sys- tem and the energy of the vital powers; for example, anxiety, afflic- tion, and exhausting excesses of every kind. Some persons seem to possess an erysipelatous diathesis, and in such individuals the most trivial wound, such as a scratch with a pin, or the bite of a leech, or a gust of wind, are sufficient to induce an attack. One of our friends has been subject to attacks of erysipelas of the face and head every spring and fall for sixteen years. On the last occasion he had been prevented from dining at his usual hour, and late in the evening, and somewhat exhausted by hunger and fatigue, he indulged in an over- full meal. In the night he was seized with diarrhoea, but was well the next and two following days. On the evening of the third day the side of his face and neck was chilled by the air while riding in a railway carriage, and on the next morning he became aware of a seiz- ure of his old enemy. The erysipelas began in the lobe of the ear and the integument immediately behind it, and travelled round the back of the neck to the opposite ear, and thence along the forehead and across the left eye to the root and right side of the nose, where its progress was arrested. It also extended to the summit of the head. The attack was mild, and he was well in ten days. Prognosis.—Erysipelas being always serious, and often dangerous, demands the utmost care, and is generally of doubtful prognosis; and this is especially the case with some of its forms; for example, ery- sipelas faciei et capitis, and erysipelas phlegmonodes. Treatment.—The treatment of erysipelas presents the usual two indications, constitutional and local; the first being directed towards the subjugation of the fever, the second to the relief of the local affection. Erysipelas being essentially a disease of debility, of asthenia, and its progress being marked by that form of morbid inflammation which is termed irritability, we have to bear in mind the necessity of sustaining the vital powers, and of putting in practice a conservative plan of treatment. All that is signified in the expression " regulate the digestive organs and secretions," must be accomplished in the first % TREATMENT OF ERYSIPELAS. 233 instance and quickly, that no fermenting irritant may be allowed to exist in the alimentary canal, and no torpidity of operation of the liver or kidneys complicate the future progress of the case; moreover, we gain another point by this preliminary clearance of the alimentary system ; we excite a derivative action, which is an important element in the treatment, while we perform artificially that which nature would otherwise neglect. Nevertheless, we must not fail to keep in mind the asthenic nature of erysipelatous inflammation, and the necessity of a strictly conservative policy in its management. The remedies the best suited to the regulation of the digestive organs and secretions, are a full dose of calomel with the compound extract of colocynth, say two to four grains of the former, with six to eight of the latter, and two of extract of hyoscyamus, followed after a lapse of twelve hours with a senna or rhubarb draught. If there be any objection to calomel, half a grain of podophyllin may be substituted in its place. When the bowels have acted freely, the tendency to constipation which is apt to succeed the use of purgative medicines must be corrected, if necessary, by the daily exhibition of a mild aperient. The derivative action once established must be sus- tained; the digestive mucous membrane, once prompted to a natural action by remedies, must not be permitted to relapse into a sluggish state; but we must be particularly cautious to avoid any unnecessary irritation of the alimentary canal. If the fever run high, we may find it necessary to have recourse to effervescent salines with ammonia, or to use the neutral salt sulphate of magnesia as our laxative; or administer the chlorate of potash, dissolved in water or barley-water, as the daily drink. One drachm of this salt may be taken in the twenty-four hours. But the moment the alimentary canal is pronounced to be free, we must be ready with our tonics; they may be conjoined with aperients, as in the combination of the sulphate of quinine with sulphate of magnesia; or they may be administered independently. We may select bitters with the mineral acids; cinchona with sulphuric acid; or the citrate of iron and quinine. But there is one tonic which, above all others, is suitable for erysipelas, in fact is declared to be specific, and, as far as our experience is concerned, seems to be lite- rally so; namely, the tincture of the perchloride of iron. The chalybeate treatment of erysipelas was recommended very strongly by Hamilton Bell and Charles Bell in 1851 ;J and by Dr. George W. Balfour in 1853.2 Mr. Hamilton Bell was led to the adoption of the remedy under the belief that " in erysipelas the capil- lary vessels are in an atonic state," that, in fact, they are " inert tubes." The tincture of the perchloride of iron may be administered at all ages, and in every stage and variation of the complaint. In the beginning the bowels should be relieved of any irritating ingesta, and subsequently they should be kept properly regulated. In mild 1 Edinburgh Monthly Journal, 1851, vol. xii. p. 497. " The Treatment of Erysipelas by the Muriated Tincture of Iron ;" a paper read before the Medico-Chirurgical Society of Edinburgh, by G. Hamilton Bell, F.R.C.S.E., and Charles Bell, M. D. ' Monthly Journal of Medical Science, vol. xvi. 1853, p. 426. 0 234 ERYTHEMATOUS AFFECTIONS. cases the adult dose is fifteen minims in an ounce of water every two hours; in severe cases, twenty-five minims; and in infants and children, two minims and upwards; and these doses should be persevered with until the fever is subdued. It is important that the medicine should be administered with regularity, with a view to saturate the system as speedily as possible; the point of saturation being the moment when the remedy exerts its great curative power. It removes pain, lessens the heart's action, cleans the tongue, and acts as a diuretic; it is admissible in every stage of the fever, even in high delirium; it never produces headache, but relieves it; it arrests suppuration in phlegmonous erysipelas, and brings about a cure in less than a week. Ammonia is a favorite remedy in erysipelas with some practitioners, and in all its forms; the citrate and acetate as an antiphlogistic remedy, and the carbonate as a specific. The latter may be administered in doses of five grains every two or three hours by itself, or combined with cinchona. Sedatives are also valuable when great irritability prevails, and when they really act as sedatives, and not, as too frequently happens, as excitants of the brain and stimulants. Aconite and belladonna have gained a reputation in erysipelas, and so also have hyoscyamus, morphia, and the liquor opii sedativus. If belladonna answer the purpose, we should give it a preference, on account of its known aperient effect on the bowels when administered in very small doses, say an eighth of a grain of the extract every six or twelve hours. But in matters of detail, such as doses, the practitioner must depend on his own judgment; all we can hope to do is to lay down general princi- ples, and point out what remedies have the credit of being the best. Another department of the constitutional treatment is diet; a milk diet with farinaceous puddings, then eggs, then broths, next fish, and afterwards poultry. For drinks, toast-water and barley-water. To this, which is the ordinary antiphlogistic diet, may require to be added wine, with a view to support the vital powers of the sick per- son. The quantity may be six to twelve ounces of sherry or port wine in the day, according to its effect and according to the previous habits of the patient; and at proper intervals. Dr. Robert Williams remarks with regard to the treatment of ery- sipelas : "The mode, then, in which I am in the habit of treating idiopathic 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."1 1 Page 284. TREATMENT OF ERYSIPELAS. 235 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 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 distinguishable. 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 sunk 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 im- mediately 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 camphor mixture, as an alkaline mode of treatment, which is generally indi- cated 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 sulphuricum aromaticum. The diet should be liquid and nutritive, wit^i 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 treatment as stimulants. The dose of carbonate of am- monia 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 accom- panies 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 pro- 236 ERYTHEMATOUS AFFECTIONS. moting cutaneous transpiration, and for this purpose should be admi- nistered in half grain doses every four hours. 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 blisters applied to the calves of the legs. The local treatment of erysipelas is of two kinds, palliative and curative; the former being intended to relieve symptoms, namely, the heat, the tension, and the pain; the latter to set up a new action, and supersede and alter the quality of the* inflammation. The remedies suited to the first of these purposes are : sedative fomentations, dredg- ing with flour, and inunction with lard ; the second purpose is attained by pencilling the surface with a solution of nitrate of silver. As a general rule, cold "and chilling applications are objectionable; sloppy remedies are equally so; and both these inconveniences are obviated by inunction with lard, which we regard as by far the best palliative treatment of the disease. The manner of applying this admirable remedy, which we consider to be as thoroughly specific for outward use as is the tincture of the perchloride of iron for internal adminis- tration, we shall explain in the words of the surgeon1 who first called our attention to its use: " My plan is to relax the skin with hot water or steam fomentations, and after each fomentation to saturate the in- flamed surface with hot lard." He then covers the part with a sheet of cotton wool, and keeps the wool in its place by means of a bandage not too tightly applied. When fomentations are used, they should be laid on by means of a fold of flannel saturated with the hot solution, and covered with oiled silk or gutta percha; or the fotus, if substantial, as in the case of chamomile flowers or hops, may be applied in a muslin bag. But these remedies are in every way inferior to the dressing with lard and cotton wool. In severe cases the congestion of the vessels of the skin may be 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. Liston advo- cates the same plan. We have sometimes practised this method in the local treatment of erysipelas, and always with good effect. It is remarkable how. quickly the tension and pain are diminished, and the tumefaction reduced. 1 John Grantham, of Crayford, Kent. TREATMENT OF ERYSIPELAS. 237 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 cutaneous 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 frequently as may be necessary. The curative local treatment consists in blistering the inflamed surface by means of the application of a strong solution of nitrate of silver. Mr. Higginbottom, of Nottingham, who is the author of this plan, directs that the solution should be applied freely by the aid of a dossil of lint attached to a piece of stick, and not only to the in- flamed part, but to the sound skin bordering it, to the extent of an inch or more, if the case be severe. The solution should be used more freely in bad than in slighter cases. The inflammation rarely travels beyond the limits of the caustic, and even when it does, is easily controlled. Mr. Higginbottom considers the line of nitrate of silver drawn around the circumference of the inflammation as of very little use, and notes that on the scalp the solution rarely produces vesication. The caustic solution is equally applicable to phlegmonous and simple erysipelas. After the use of the caustic solution, we are in the habit of smearing the surface with lard and covering it with cotton wool, as in ordinary lard inunction. Mr. Higginbottom 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 in- flamed 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 surrounding healthy skin, to the extent of an inch or more beyond it, in severe cases. The nitrate of silver may then be passed over these surfaces once, twice, thrice, or more times, according to the degree of inflammation; <5nce 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 Sir. Higginbottom has found a solution of eight scruples of nitrate of silver with twelve drops of nitric acid in an ounce of water, more convenient than the solid salt. He regulates the application of the solution 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 in- flammation depends upon its strength and its proper application. The method of applying it by some practitioners appears to me to be quite 238 ERYTHEMATOUS AFFECTIONS. trifling with the remedy. Instead of covering the whole inflamed surface and the surrounding healthy skin with the nitrate of silver, so as to cover the whole of the inflammation, they simply apply it around the inflamed surface, a mode of proceeding which has seldom the power of even preventing the spreading of the disease or the deeper mischief when the inflammation itself is unarrested. Some- times, 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 per- fectly safe. I have seen no case of metastasis or any other bad effects from the use of it during upwards of twenty years."1 Mr. Higginbot- tom 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 us, " it scarcely ever produces vesication." M. Jobert2 has used, with great success, an ointment composed of nitrate of silver and lard, in the proportion of from two to four drachms of the salt to an ounce. This is applied night and morning to the in- flamed 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 at- tacked. 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 sil- ver 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 recall- ing the disease, where it has suddenly disappeared by metastasis. Velpeau recommends a solution of sulphate of iron, in the propor- tion of an ounce to the pint of water, as a local application in erysi- pelas. This solution, he remarks, produces a sudden improvement in the patches, and causes their decline in one or two days. As frequently as new patches make their appearance, they are to be treated in the same manner, until the constitutional morbific influence is ex- pended. In situations where a lotion would be inconvenient, this sur- geon employs an ointment, containing a drachm of the salt to an ounce of lard. Dr. Fahnestock, of Pittsburg, speaks in great praise of pure crea- 1 Lancet, vol. ii. 1843, p. 515. 2 Gazette des Hopitaux, May 11, 1848. URTICARIA. 239 sote 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 superficial 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 erysipelas, and adduces numerous cases as examples of its success. In the vesicular form of erysipelas, the bullae should be punctured with a needle and gently pressed with a sponge squeezed out of warm water, in order to absorb the serum and flatten the raised cuticle upon the surface of the corium. When this has been accomplished, the inunction and cotton wool may be reapplied. In erysipelas of the scalp, it is often necessary, for the purpose of relieving tension and pain, to make an incision through the inflamed tissues down to the bone, and in erysipelas phlegmonodes, one or two incisions are required to liberate the pus and sloughs, and especially to ease the pain which is created by the diffusion of pus beneath the fasciae. The incision has the double effect of giving exit to pus and sloughs, and also of emptying the vessels of the congested skin. After incision, the parts must be covered with a poultice and placed in a position favorable for the escape of the discharges. URTICARIA. Syn. Febris urticata; enanthesis urticaria, Mason Good ; cnidosis, Alibert; flevre ortie'e porcelaine ; urticaire; nesselsucht; nesselfieber; nesselauschlag; porcellanfriesel; wie- i belsucht; nettle-rash. Urticaria, or nettle-rash (Plate VII.), derived from urtica, a nettle, is an ephemeral congestion of the skin, accompanied with a burning and tingling itching, with more or less redness, and with the develop- ment on the red ground of small elevations or wheals, which are sometimes round and oval, and sometimes elongated in narrow stripes. The rash is sometimes preceded by symptoms indicative of considerable derangement of stomach, and sometimes, in a chronic form, is wholly unaccompanied by constitutional symptoms. It is not contagious. The resemblance of urticaria to the effects of stinging the skin with a nettle is twofold; firstly, the hot, burning, and tingling itching is similar to that of the sting of a nettle; and, secondly, the white eleva- tions or wheals are due to the same cause, namely, spasm of the mus- cular structure of the corium. In lichen urticatus we have had the opportunity already of noticing the influence of muscular spasm of the skin in the production of papulae; it is seen also in the spasmus periphericus, which occasions that common physiological condition of the skin, cutis anserina ; and the white wheals raised upon the integu- ment by the lash of the whip in flogging, or by the bite or sting of an 240 ERYTHEMATOUS AFFECTIONS. insect, are the'result of a similar operation. In some persons the skin is so sensitive and the muscular tissue so irritable, that wheals may be produced at any moment by touching it with a feather, or lightly with the finger. We may thus sometimes trace figures and letters upon the skin, or write our name, and the figures and the writing will instantly stand up in relief in the form of white wheals. We have sometimes noticed in the white wheals of urticaria an alternate con- traction and relaxation of the muscular structure, which gave them the appearance of pulsation, or of an ebb and flow of blood in the capillary vessels. Urticaria is sometimes transitory and sometimes very enduring, lasting even for years. We have thus a kind of division of the dis- order into acute and chronic The acute forms are preceded and accompanied by symptoms indicative of great derangement of stomach, and its sympathetic influence on the nervous and vascular system, producing a temporary fever; while the chronic forms exhibit no traceable disorder of the economy. In the acute form of urticaria there is generally a little swelling, reminding us of the swelling of erythema, and in a less degree of that of erysipelas; and at the close of the rash there is sometimes a little oedema. But the most striking character of the rash differs essen- tially from anything observable in either one or other of those affec- tions, namely, the nervous irritation that occasions the muscular spasm. In the acute forms also, the skin is somewhat altered in color at the decline of the congestion ; it is purplish and yellowish, like a bruise; and if the congestion have run high, as in urticaria ab ingestis, there will probably be some degree of furfuraceous desquamation of the affected part. Its varieties are founded on its occasional febrile character; on the confluence of its wheals ; on its evanescence or permanence ; and on the extension of its local symptoms deeply into the skin and sub- cutaneous tissues, and involving a greater breadth of muscular tissue in spasmodic action. They are as follows :— ACUTE. CHRONIC. Urticaria febrilis, Urticaria evanida, " ab ingestis, " perstans, " conferta. " subcutanea, tuberosa. Urticaria febrilis is distinguished by the occurrence of symp- toms denoting great irritation of the stomach; for example, weight' and fulness at the epigastrium, nausea, faintness, thirst, white tongue, quick pulse, pain in the head, and general lassitude and prostration. After an interval of- one or two days there is an outburst upon the skin of a number of irregular blotches, vividly red, covered with white wheals, and intensely itchy. This outbreak commonly relieves the gastric symptoms; but as the cutaneous irritation subsides, the internal symptons return. The heat and tingling and itching of the skin are always worst at night, and the internal and external symp- toms are apt to alternate for a week or ten days before they decline URTICARIA ab ingestis. 241 and disappear. Willan narrates a fatal case of urticaria febrilis; the patient had been intemperate, and was much out of health. Urticaria ab ingestis is the name given to an attack of febrile urticaria dependent on the presence in the stomach of some irritant or deleterious article of food. The symptoms are apt to come on a few hours after having partaken of the noxious aliment, sometimes in the night, encouraged by the suspension of digestion during sleep, and are very severe, and occasionally fatal. They commence with a a feeling of fulness and weight at the epigastrium, with nausea, faint- ness, giddiness, and sometimes vomiting and diarrhoea. There is a prickling in the throat, with a sense of constriction of the fauces, cough, a feeling of impeded respiration, and swelling of the tongue. From the mucous membrane the irritation spreads to the skin; the nose, the lips, and ears are swollen, hot, and itchy; the features are enlarged ; the rash extends to the trunk and limbs, and is particularly troublesome in the neighborhood of the joints. The rash sometimes continues to be annoying for a day or two, but more commonly sub- sides after a few hours, and is followed by a furfuraceous desquama- tion of the cuticle. These severe symptoms are not necessarily the consequence of a highly irritating or poisonous principle present in the food, but are sometimes induced by the most harmless articles of diet; for example, rice, eggs, pork, goose, fruit, &c. A more frequent cause of urticaria is shell-fish, and particularly mussels. Willan has put on record a case evincing a disposition to periodicity on the part of urticaria, and we have met with a somewhat similar instance. In Willan's case, the rash recurred weekly for a consider- able time; in our own, it reappeared once at the end of a week. Urticaria conferta (Plate VII. B).—Instead of being scattered, as they commonly are, the wheals of urticaria are sometimes collected into thick clusters, and give rise to the present variety. This diver- sity of character is chiefly due to the constitution and susceptibility of the patient, and not to any difference of cause. Its symptoms bring it into the group of the acute forms, bearing some resemblance to those of urticaria febrilis. Urticaria evanida et perstans (Plate VII. A A) represent the chronic form of the disorder, in which there are no febrile action and no symptoms of gastric derangement, and wherein the disease con- tinues for an indefinite period of time. In the evanescent form, urti- caria evanida, the rash is accompanied with tingling and itching, is apt to come out several times in the day, and is very troublesome at night. It appears also under the influence of exercise, after taking meals, and on mental emotion. After a continuance of a few hours, the rash dis- appears, and no trace can be discovered of its attack. In the per- sistent form urticaria perstans,1 the general symptoms are the same, but the rash, with its crop of irritable wheals, continues for several days or weeks, and sometimes for months. The separate wheals do not remain the whole of the time, but are reproduced in succes- * 16 1 Portraits of diseases of the skin, Plate I. L. 242 ERYTHEMATOUS affections. sion; and the* entire eruption acquires thereby the character of per- manence. Urticaria subcutanea.—Under this name Willan has described an affection in which the tingling, burning, and itching are present without the wheals; or the latter are occasional and developed in a minor degree. It is not uncommon in diseases attended with a variety of symptoms to meet with examples in which one or other of these symptoms may be in excess, while another is wanting. Under these circumstances, if the existing symptom be characteristic, we adopt it as the type of the doubtful affection. In the present variety, the sensation of tingling and stinging, and of puncturing with fine needles issuing from within, are characters of urticaria, while the rest of the symptoms point to some more deeply-seated morbid change in the nervous system. The affection is rare. Willan remarks that it is partial, and that he had seen it only on the loins and thighs, and some- times on the arms; but he conceives that it might spread over the greater part of the body. Urticaria tuberosa is the result of a blending of the symptoms of erythema tuberosum and nodosum with those of urticaria; the deep-seated morbid alteration of the former is combined with the muscular spasm and pricking and tingling itching of the latter. The tuberous prominences are of large size, varying in diameter between half an inch and two inches, few in number, flat on the surface, hard to the touch, the hardness being felt to sink deeply into the substance of the limb, and extremely tender. They rise in a few hours, com- monly in the course of the night, and when they subside they leave behind them a green and yellow stain like that of a bruise. The disorder is rare, and is only met with in persons beyond the middle age, whose constitution is debilitated by intemperance and chronic disease. The most marked example that we have seen was in a fat man of gouty diathesis, who was at the same time suffering from cedematous eczema of the lower limbs. On his thighs were several of these tubera, and between them the greenish-yellow stains of those that had dispersed. Their outbreak during the night was accompanied with severe stinging and itching. Pathology.—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 PATHOLOGY OF URTICARIA. 243 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. Mac- lagan, its composition was found to be as follows:— Urea,.........6.91 Uric acid, ........ 0.05 Inorganic salts,.......12.03 Organic matters and water, . . ... . 981.01. " The chief peculiarity in the present case was a deficiency in the ordinary characteristic ingredients of the urine, the urea and uric acid. This could not arise from mere excess of water: first, because the urine was not excessive in quantity; second, because the inorganic salts were above the normal standard,, whereas, had the water merely been in excess, they, too, ought to have indicated a diluted condition of the urine. Dr. Maclagan ventured, therefore, to propose, as the pathological view of the case, that the defect here was merely a defi- ciency 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 retention 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 With the view of modifying the imperfect transformation of tissues here referred to, the patient was treated with colchicum, upon which the specific gravity of the urine was found to have risen to 1029.9, 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 with a deficiency of the organic salts of the urine, and their probable retention in the system. 2. " That the colchicum has an action capable of restoring the defi- cient 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."2 Diagnosis.—The distinguishing signs of urticaria are, the tingling, burning, pricking, and stinging sensations; the development of white wheals; and the evanescent character of the eruption. The papules of lichen urticatus are permanent, although their white or spasmodic stage is transient; and the tuberous elevations of erythema papu- latum, tuberosum, and nodosum, are never white like the wheals of urticaria, while the eruption is more permanent. 1 Edinburgh Monthly Journal. 2 Lancet, vol. ii. 1846, p. 160. 244 ERYTHEMATOUS AFFECTIONS. Cause.—Gastric irritation is clearly established as an exciting cause of urticaria in the acute forms, and is not improbably a cause of its chronic forms. To gastric irritation as a cause of chronic urticaria may also be added irritation of any of the mucous membranes of the body, particularly that of the uterine system; and shock to the nervous system, as from affliction. As a predisposing cause, we have detected the presence of debility, generally of the assimilative and sometimes of .the nefvous kind. Not unfrequently urticaria is associated with rheumatism, and we have also seen it intermittent with neuralgia. Dr. Maclagan has suggested that the disease may arise from a want of proper transformation of the waste tissues of the body, and the deten- tion in the blood of the elements of the organic salts of the urine. And he notes the relation subsisting between urticaria, rheumatism, and purpura. 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 con- gestion ; hence, also, the gradual subsidence of the wheals, the recovery of the natural tint of the skin, and their sudden 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 case of urticaria excited by poison- ous 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 distinguished from erythema and roseola, which are homoeopathic disorders. This view of the pathology of urticaria explains its association with other eruptions of homoeopathic origin; indeed, it is matter for surprise, that a spasmodic state of the muscular structure of the skin so.rarely accompanies its inflammation in other diseases. In some persons the cutaneous susceptibility is so active that urti- caria may be excited at any moment by merely scratching the skin, or by the mere pressure of a fold of the dress, or by the pressure of the bed or bedclothes. In a lady lately under our care we have watched the red streaks and blotches appear and creep along the skin and disappear, while we purposely engaged her in conversation on indifferent subjects. A word, a look, the slightest excitement, would immediately bring out a copious eruption. Urticaria 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 also frequent in children, particularly 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 TREATMENT OF URTICARIA. 245 the mucous membrane of the alimentary canal. In some instances this irritation is referable to the natural susceptibility of the indivi- dual; 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, oatmeal, almonds, strawberries, raspberries, cucumber, mushrooms, &c. Rayer mentions oatmeal gruel as occasionally producing this effect; and certain medi- cines, as valerian, copaiba, quinine &c, sometimes do the same. A member of our own family suffers, constantly, after taking rice milk. Dr. Gregory was affected by the disease after eating part of a cucum- ber ; 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. Prognosis.—Urticaria is not a serious disease, and the premonitory symptoms of the febrile forms, although violent, and for the moment dangerous, are not difficult of relief. Chronic urticaria is very trou- blesome and obstinate, and indicative of an existing debility, asso- ciated with chronic functional disturbance. Urticaria subcutanea, from its connection with nervous irritability, and urticaria tuberosa, from its alliance with a broken-down state of the constitution, are necessarily of doubtful augury. Treatment.—Febrile urticaria requires the exhibition of an effi- cient purgative at first, and the subsequent administration of effer- vescent salines, combined with ammonia and hydrocyanic acid. When the feverishness has subsided, and the secretions are natural, we may then have recourse to bitters, with the mineral acids ; and chalybeates, either alone, or with quinine. In urticaria ab ingestis it may be necessary to relieve the stomach of its load by means of an emetic ; and we may select sulphate of zinc or ipecacuan wine as the most suitable. Bearing in mind the faint- ness and extreme prostration which sometimes accompany the nausea and sickness of this complaint, Willan cautions us against the use of tartarized antimony as likely to increase that kind of suffering; and Plumbe, with the same idea, suggests the administration of sulphuric ether in doses of twenty to forty minims every half hour until reac- tion is restored. At the present day he would probably have given the preference to chloric ether. Chronic urticaria is to be treated by the restoration of the general health. In every instance some one or more functions are deranged, possibly unknown to the patient, and these nothing but an improve- ment in vital power and general vigor will set right. We have found of great service, the mineral acids with a bitter; cinchona with sul- phuric acid; quinine with sulphuric acid, and quinine with iron; while very chronic cases will yield to nothing but arsenic. Where any special indication presents itself, such as the gouty or 21() erythematous affections. rheumatic diathesis, we may call in the aid of colchicum, or in a neuralgic complication, that of quinine. The local treatment of urticaria consists in the employment of reme- dies which are calculated to relieve the itching, tingling, and smarting. For this purpose we find sponging with hot water serviceable; ablu- tion with the juniper-tar or carbolic acid soap ; sponging with the lotion of juniper-tar; frictions with the juniper-tar ointment; the use of a lotion of emulsion of bitter almonds with hydrocyanic acid; a lotion of bitter almonds, with spirits of wine and bichloride of mer- cury ; a lotion of carbolic acid; sponging with hot vinegar, with a lotion of carbonate of ammonia; a lotion of aconite ; and liniments of opodeldoc and chloroform or laudanum. When one application fails, another must be tried, until the intended effect is produced. Where convenient of access, the tepid bath affords almost instantaneous relief. ROSEOLA. Syn. Exanthesis roseola, Mason Good ; false measles ; rose-rash ; cutaneous blush ; roseole. Roseola, or rose-rash (Plate VII.), so named from its dull crimson or roseate hue, is distinguished not only by the color of the efflor- escence, but also by the manner of its distribution, and by its assso- ciation with congestion of the mucous membrane of the fauces, and a moderate amount of general fever. The color of roseola varies in degree of brightness; occasionally, as in some of the local forms, it is quite vivid; in the general forms it is less bright, and is influenced by the clearness or muddiness of the skin; whilst in the form termed by Willan roseola autumnalis, the congested patches "are of a dark damask-rose hue." Associated with this purplish tint of color of the rash is the tendency exhibited by some of its forms to merge into purpura, and to-leave behind them at their decline a green and yellow stain, like that of a bruise. The vascular congestion of roseola affects both the follicular and , the papillary plexus of the skin; in the former case giving rise to a punctiform efflorescence; in the latter to a blotch, resembling erythe- ma in its pathological character. The general forms of the exanthem are for the most part punctiform, and distributed in small clusters or corymbi {roseola corymbosa), like those of rubeola. This corymbose distribution of the rash is a point of some importance in distinguish- ing roseola from rubeola; the mechanical elements of the rash are identical in the two affections, and the resemblance is often so exact as to render distinction, by the aid of the exanthem alone, a thing impossible. After the punctiform and corymbose distribution of the rash, the most frequent form is that of a ring {roseola annulata), which some- times springs from the circumference of a corymbus, and circles it around; and sometimes begins as a circular patch, and fades in the centre while it spreads by the circumference. In the former case the rings are narrow and fine, and may constitute a general exanthem ; in the latter the rings are broad and local, being limited to some one region of the body, such as the lower extremities. ROSEOLA. 247 Under the name of roseola punctata we have described a third form, in which, not the corymbi but the separate puncta afford the most con- spicuous character ; the congested puncta in this case being sprinkled more or less thickly over the surface of the skin, and also constituting a general exanthem. Following the corymbose, the annulate, and the punctated varieties, comes a fourth form, pointed out by Willan, namely, a circular blotch, retaining permanently that figure, and remarkable for its deep roseate and almost purplish hue. To dis- tinguish this form from the preceding, we have named it roseola maculosa. Next in interest to the cutaneous exanthem is that which affects the mucous membrane of the fauces. This is a dull crimson blush ; and coincident with the congestion of the fauces, there is commonly some degree of swelling and tenderness of the submaxillary glands, and often of the neighboring lymphatic glands. The participation of the mucous membrane, or internal skin, in the irritations of the external skin, is a pathological phenomenon that our physiological studies teach us to expect; and the chief point of importance deserving of note in the present instance, is the fact of a similar, but more grave congestion, occurring in rubeola, scarlatina, and variola; and we may also bear in mind that we have noted the same circumstance already, but in a less degree, in erythema papulosum, in urticaria, and in erysipelas. The febrile symptoms of roseola are similar to those which ac- company the exanthematous fevers generally, but much less in degree, and often so slight as to be hardly appreciable. They consist for the most part of nausea, headache, aching in the back and limbs, rest- lessness, languor and lassitude, chills succeeded by flushes, quick pulse, white tongue, thirst, sore throat, and arrested secretions of the skin, kidneys and bowels. And often, in conjunction with the febrile symptoms, there occur rheumatismal pains. Moreover, it must not be omitted, in the general history of roseola, that there is no swelling or prominence of the skin, as happens in erythema, erysipelas, and urticaria; and that the affection, although often prevailing epidemically and endemically, is not contagious. The varieties of roseola may be divided into two groups, idio- pathic and symptomatic; the former being independent or primitive in origin, the latter symptomatic of other forms of disease. In a tabular arrangement they may be grouped as follows:— idiopathic. Roseola corymbosa, Roseola punctata, " annulata, " maculosa. symptomatic. Roseola variolosa, Roseola arthritica, " vaccina, " cholerica, " rheumatica, " febris continuae. 248 ERYTHEMATOUS AFFECTIONS. ROSEOLA IDIOPATHICA. Roseola corymbosa1 (Plate VII. E) is the roseola infantilis and aestiva of Willan, the false measles, or rubeola notha, of other writers; but as the exanthem, although most common in childhood, may occur also in the adult, and, although much under the influence of seasons, may happen at any period of the year, we have thought it desirable to affix to it a designation which is characteristic and unalterable, and which furnishes also grounds of comparison with the other forms of roseola. Roseola corymbosa may be regarded as the typical form of the roseolous eruption, as the special form, which, from its resemblance to measles, may be mistaken for that complaint and treated as secondary measles, mild measles, false measles, or rubeola notha. It is developed on the skin as a punctiform and corymbose or rubeoloid rash, of a brighter or duller roseate hue, and distributed more or less extensively over the surface of the body; sometimes appearing on the face and trunk only, and sometimes both on the trunk and limbs. The exanthem is commonly preceded by slight febrile symptoms of one or two days, and sometimes as much as a week's continuance. The rash makes its appearance in the evening or during the night, being perhaps first perceived on leaving bed in the morning, and lasts for three or four days, commonly subsiding on the fifth. It is crimson in the beginning, soon becomes deeper-tinted, and assumes a dull roseate hue as it fades away. Its eruption is commonly attended with a moderate amount of itching and tingling; but this symptom is often absent, and in its development it follows more or less closely the path of the exanthemata, appearing first on the face, next upon the chest and trunk of the body, and lastly on the limbs, but not un- frequently invading the entire surface at once. Absence of regularity is one of the features of roseola as compared with rubeola; it is variable in color, in extent, in succession, in erup- tion, in duration; and it may also be mentioned that it is liable to recur when it has seemingly disappeared. In the rubeola notha of 1863-4, the exanthem was identical with • that already described, but had a more decided character; the corymbi were partially papular; the congestion of the fauces was greater; there was more or less coryza; the febrile symptoms were more acute; and the affection formed part of a rubeolous epidemic. Nevertheless, it was often doubtful whether to consider it as a roseola or a mild rubeola. Sometimes it was curiously intermingled with varicella, sometimes with diphtheria, and sometimes with rheumatism. The early part of the year 1864 was remarkable for depression of temperature and want of sun; diseases in general assumed a low type, and among children, and not unfrequently among adults, there pre- vailed an exanthematous epidemic, generally distinguished by mild- ness of character, and consisting in a congestion of the fauces, 1 Portraits of diseases of the skin ; roseola is well shown in Plate XXIV. P, which represents a case of syphilitic roseola. roseola corymbosa. 249 enlargement of the salivary and lymphatic glands of the face, and an exanthem on the skin, which one while put on the appearance of roseola, another while of rubeola, and sometimes of varicella. It is curious to note, that the same persons in some instances experienced the several forms of the exanthem in succession. The epidemic was first brought under the attention of the profession by the Epidemio- logical Society, and the president of that society, Dr. Babington, gave the name of " rubeola notha," or spurious rubeola, to one of the forms. When a deposit of lymph was formed on the fauces, the case was regarded as a mild form of diphtheria. The following cases illus- trative of the epidemic in question, may serve as a record of its leading features:— Case 1.—A young gentleman, twelve years and a half old, was, to use his mother's phrase, "born with red gum," and a few weeks after birth became the subject of eczema infantile. He has now been free from eczema for many years, and has grown to be a fine, manly boy. On Wednesday, the 27th of April, he had enjoyed a game of cricket, and had possibly somewhat over-exerted himself. On Thursday, the 28th, he awoke with an eruption of papular varicella; and was brought to us for advice. He said that his skin had itched a good deal during the night, and that he had scratched himself, but that his sleep had not been disturbed, and that he felt as well as usual. His tongue was perfectly clean, there was a slight suffusion of the fauces, but no feeling of soreness of throat, no thirst, and no weariness of limbs. On Friday the papulae had become more prominent; they were isolated, without surrounding redness, and dispersed; some few be- came vesicular at the summit, and one or two on the face were slightly pustular. On Saturday, the third day, the eruption was at its height, and remained prominent on Sunday, the fourth day; still there were no constitutional symptoms; he looked a little paler th an usual, but nothing more, and declared that he had no uneasy symptom; his appetite remaining good all the time. On Monday, the fifth day, the eruption subsided rapidly; and on Tuesday, the sixth day, he was considered to be quite well. Our little friend continued well until Saturday, the 14th of May; for the two or three days preceding this date, his mother thought that he looked pale, and was dark under the eyes. On Thursday he had received a blow from a cricket-bat on the knee, which gave him pain ; but the next morning, after being well bathed with a spirit lotion, the knee was well, and he went to school as usual on Friday and Satur- day. At midday on Saturday, his mother observed that his face and eyelids were red, and the face a little swollen in the region of the sub- maxillary glands, more particularly on the right side. The fauces were „ somewhat reddened, but he had no soreness on swallowing; several of the lymphatic glands about the face were also a little enlarged and tender, more particularly one situated on the parotid gland just in front of the ear on the left side, and another situated under the chin on the mylo-hyoid muscles. Nevertheless, his tongue was clean, the secretions natural, he had no thirst, and no feelings of lassitude or illness. 250 ERYTHEMATOUS AFFECTIONS. On Sunday, the second day of the attack, he was brought to us, and was then covered with a papular rash which extended from his face down to his wrists and ankles, but was most marked and most abun- dant on the front of the trunk, ^he papules were minute, the papules in fact, of rubeola; not the larger, conical, dispersed papulae of the previous varicellar attack. They were disseminated somewhat closely, and each papule looked as if it represented the small corymbus of rubeola, the rest of the corymbus being imperfect or absent. There could be as little question as to its appertaining to rubeola as there was in the previous eruption of its being a varicella. The color of the papules was of the proper rubeolous hue ; and the prominence of the papule on the one hand, and the absence of imperfect development of the erythematous corymbus on the other, distinguished it from simple roseola. Moreover, it must be mentioned, that dispersed among the papules were the foveolated traces of the varicella of the previous eruption. With this papular, rubeolous eruption, there was a slight suffusion of the conjunctiva, a little stiffness of the eyelids, and a slight redness of the tonsils, but no soreness of the throat in swallowing; the tonsil of the left side was depressed in the centre and covered by a thin whitish film ; but puffed and red around the circumference; and, at the upper part, inclined to bleed. There were still some enlargement and a little tenderness of the submaxillary glands, and also of the pre- auricular and submental lymphatic glands. There had been in the morning a little sneezing, and some running at the nose, but there was no coryza; no orbital or ocular pains; the tongue was clean and moist; there was no thirst; and there were no signs of constitutional irritation. It must further be mentioned that he had had rubeola in infancy; and scarlatina somewhat severely; while on his arm was exhibited the proper foveolated cicatrix of vaccinia. On Monday, the third day of the attack, the eruption subsided rapidly; and on the fourth day was quite gone, together with the swelling of the glands. On this day his mother considered him as being quite well, he had regained his spirits, his appetite, and his ' strength. This young patient may be regarded as an example, not by any means rare, of a dermatopathic diathesis ; he was born with strophu- lus ; next suffered from eczema; had rubeola and scarlatina ; next varicella; then roseola corymbosa or rubeola notha ; and the follow- ing summer, the severest attack of lichen urticatus we have ever seen ; the eruption covering the whole of the trunk of the body and limbs. Case 2.—A young man, aged twenty-three, a medical assistant, of ¥ delicate frame, had variola in October, 1863, having been properly vaccinated as a child. The eruption came out abundantly, particu- larly on the face, and left him much exhausted in strength. He remained debilitated during the winter and spring, and towards the end of May, the symptoms which ushered in the variola appeared to return. ROSEOLA CORYMBOSA. 251 He was under the impression, from the similarity of the symptoms, that he was about to have a repetition of variola ; he felt great weari- ness, with pain in the loins, giddiness, and feverishness. These symp- toms had been preceded, for about a week, by the special symptoms of rubeola notha, namely, soreness and congestion of fauces, tender- ness and enlargement of the salivary glands and of the lymphatic glands of the head and face, sneezing, and coryza; to which were added, swelling of the lymphatic glands of the arms, and slight diar- rhoea. A few days after the commencement of the more severe symp- toms, a rubeolous exanthem showed itself on the skin, extending from his head to the lower part of the trunk, but not intruding upon the legs. On the face and chest the exanthem was papular, but, lower down, gave rise to no elevation of the surface. The more severe con- stitutional symptoms subsided on the appearance of the rash; but the congestion of fauces, tenderness of salivary glands and diarrhoea, have lasted for six weeks with little abatement. The exanthem has also continued for this long period, but is less vivid than at first, and the papules have subsided. Case 3.—A young lady's maid, nineteen years of age, complained of headache and weariness, with soreness in the submaxillary region, on Sunday, June 26; the symptoms were not sufficiently severe to prevent her from pursuing her usual duties until Thursday, when the pain in the head had increased in severity, and her face looked swollen and flushed. It was on this day that we were called to see her; her tongue was moist, as was her skin; her pulse was soft and weak ; her bowels free; there was no fever, but considerable weariness and lassi- tude. The face was covered with red blotches, and in the centre of each blotch was a papule, suggesting incipient variola; while the trunk and upper limbs were mottled with a rubeolous rash which did not reach down to the lower limbs. We ordered her a drachm of sulphate of magnesia, with one grain of quinine and seven minims of diluted sulphuric acid in solution in one ounce and a half of compound infusion of roses, twice in the day ; with repose in bed. On Saturday the rash had nearly disappeared, and on the following day the patient was convalescent. The characters of this protean epidemic are well exhibited in the preceding cases; and we are led to infer from their consideration, that the varicella, the rubeola, and the roseola, were simply varieties of manifestation of the same "causa morbi." That the disease is not always so mild as is here depicted is, however, shown by the following quotation from the Registrar-General's Report:—■ " The total number of deaths in London in the week that ended Saturday, June 18, 1864, was 1296. The average number for the twenty-fourth week in ten years, 1854-63, is, with a correction for increase of population, 1173. The excess in the present return above the estimated number is considerable; it amounts to 123. "Measles continues to be the most prevalent in the epidemie class of diseases. It was fatal in the week in 85 cases. In the second week of May there were 50 deaths from it; in the following week 252 ERYTHEMATOUS AFFECTIONS. they rose to 87, and since that time the weekly mortality has been of nearly the same amount." Roseola annulata (Plate VII. F) sometimes makes its appear- ance as a corymbose exanthem, and the patches throw off small linear rings, or it begins from the beginning as an annular rash, and follows the course of roseola corymbosa, both in the development of its efflo- rescence and in general symptoms. In the latter case the rings are at first one or two lines in diameter, and increase to the dimensions of half an inch. Sometimes this form of roseola exists as a chronic affection. We had lately under treatment a delicate woman, aged twenty-one, who had been the subject of this exanthem intermit- tingly for several weeks. She was pale and anaemic, her powers of digestion were weak, and she suffered under assimilative debility and great depression of spirits. There is, however, another form of roseola annulata' which com- monly attacks the lower limbs: it begins in the form of circular blotches of about a quarter or half an inch in diameter, and spreads by the circumference, while the centre fades and forms an area sur- rounded by a broad ring. These rings attain a breadth of one or two inches, are of a bright crimson at first, and as they disappear, fade off into a greenish-yellow bruise-like tint. The constitutional symptoms are the same as those of common roseola, and the course of the local exanthem a week or ten days. We have seen this form only a few times, and then in children under puberty. The following case of roseola annulata has a double interest, in consequence of forming part of the exanthematous epidemic of 1864: A young gentleman, aged ten, tempted by a warm day in the middle of April, and regardless of an easterly wind, abandoned his winter coat, and took a long country walk. He returned home much heated, and the next morning awoke with sore-throat and some enlargement of the submaxillary glands. The attack was thought to be an ordi- nary cold, and he continued for a week feeling a little unwell. At the beginning of the second week, the soreness of throat having terminated, a blotchy eruption appeared on the face, and was found to occupy the whole surface of the skin. It had a dull crimson-red hue, appeared at first as a blotch of the size of a sixpence mottled with dull red and white, not elevated, and without pruritus; and in the course of a day threw off from its circumference a well-defined narrow ring, which encircled the mottled blotch, and increased to the size of a shilling, and in some instances of a two-shilling piece. Moreover, the whole skin had a dusky or dirty hue, so frequent in some forms of cachexia. The roseolous exanthem having persisted for five days, suddenly declined; and was followed by rheumatic pains in the joints of the limbs, particularly in the ankles, knees, and hips. The rheumatic pains lasted for three days, and then subsided, leaving him free both from exanthem and rheumatism. 1 Portraits of diseases of the skin, Plate II. A K, exhibits a good example of rose- ola annulata. ROSEOLA ANNULATA. 253 The third week was one of respite both from the eruption and the rheumatism ; but with the beginning of the fourth week both returned in a slighter degree than at first, and continued for four days; they then disappeared for another period of four days; but at the end of this interval the exanthem burst forth afresh, and more abundantly than before ; but without the rheumatic pains. Such was the state of the skin at the conclusion of the fifth week of the disorder, the fourth of the eruption. With the exception of the first week his appetite had been good throughout the attack; his tongue was clean, and rather pale; he perspired a good deal at night; his urine was somewhat high colored, and his bowels a little confined. He had had no shivering; no fever- ishness; no redness of conjunctiva or coryza ; no sneezing or running at the nose; and only a moderate amount of congestion of the fauces with the sore-throat, during the first week. His medical adviser had given him quinine; and this was supposed to have arrested the exanthem at its first appearance, but ceased to control it afterwards. We prescribed for him a mild aperient pill, with nitromuriatic acid and tincture of orange-peel; the exanthem quickly subsided, and at the end of three days had entirely disappeared. The whole period of dura- tion of the last attack of the exanthem was, consequently, nine days. If, now, we assemble the symptoms presented by this case in their order of occurrence, we shall have a fair word-picture of roseola: for example, the slight sore-throat, enlarged and tender salivary glands, rheumatic pains in the joints, muddy skin, dull crimson blotches, mottled, without elevation, and dispersing at the circumference into narrow, well-defined rings; their appearance on the whole surface of the skin at once; and especially their sudden recurrence after disap- pearing. Then the negative symptoms as compared with rubeola; no suffusion of conjunctiva, no coryza, no running from the nose, no sneezing, no cough, no fever. Next, the absence of rheumatic pains in rubeola; but the presence of a well-defined, papulated, clustered exanthem, distinguishable, although imperfectly defined, even in rubeola notha; and the succession of the eruption, coming out first on the upper part of the body, then descending to the lower half, and appearing lastly upon the legs. Roseola punctata is a rare form of the exanthem, of which the following are the characters : Febrile symptoms of a subacute 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 membrane and skin ; on the latter, in the form of small red spots occupying the mouths of the follicles, then becoming dif- fused 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 roseate 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 254 ERYTHEMATOUS AFFECTIONS. period, three to the exanthema, and four to its decline, the dark stains being perceptible for some days afterwards; the rash assuming a dif- ference 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, we are indebted to Mr. Marson, the resi- dent-surgeon of the Smallpox Hospital, who, during a connection of twelve years with that hospital, has seen about ten similar 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 the 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 pro- fuse 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 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 confluent, 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, roseola punctata. 255 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 figure, 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 r.ed 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 we have assumed as the specific character of the eruption, were the original red points by wRich 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 transudation of the coloring principle of the blood; and in some few situations, as around the ankles, and upon the back of the shoulders, where the weight of the body rested, there was a decided ecchymosis from the latter cause. It was obvious that these red points repre- sented the follicles of the skin, in which the inflammation commenced, 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 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. We 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 we 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. 256 ERYTHEMATOUS AFFECTIONS. Roseola maculosa (Plate VII. F).—The roseola autumnalis of Willan, occurs in the form of circular patches of about the size of a shilling, and of a " dark damask-rose hue," seeming at a distance " as if stained by the juice of black cherries or mulberries." The consti- tutional symptoms are very mild, and the eruption subsides in a week or ten days, leaving behind it a slight furfuraceous desquamation. This form of roseola is chiefly met with in children, and principally upon the arms and legs. Occasionally it may take on the annular mode of extension mentioned above; in which case it would consti- tute a roseola annulata, with broad margin. ROSEOLA SYMPTOMATICA. Roseola variolosa is a blotchy redness of the skin, of roseolous hue, which sometimes accompanies the eruptive stage of variola. When inoculation for smallpox was practised, the rash was not un- frequent, occurring once in every fifteen cases; at present it is rare. It follows the usual order of eruption of the exanthemata, beginning on the face, chest, and arms; then descending to the trunk, and after- wards to the lower extremities. It is regarded as a not unfavorable sign when the rash is of bright color, but less favorable when dark in its hues, and the eruptive fever runs high. It commonly makes its appearance on the second day of the constitutional symptoms, the ninth or tenth after inoculation, and has a course of three or four days. Roseola vaccina is an exauthem similar to the preceding, which accompanies sometimes the development of the vaccine vesicle, appear- ing at the ninth or tenth day after vaccination. The rash begins in the neighborhood of the vaccinated spot, and spreads upon the arm and trunk, and sometimes over the greater part of the body. Its course is rarely longer than two days, but it is attended with some feverishness. Roseola rheumatica et arthritica.—Rheumatism and gout are both occasionally accompanied with a roseolous rash, appearing in the form of a circular blotch {roseola maculosa), and usually on the lower extremities. Sometimes the roseola precedes the attack, and sometimes makes its invasion during the progress of the principal disorder. Roseola cholerica has been described by Rayer as a roseolous exanthem accompanying the progress of the Asiatic cholera. It some- times resembled scarlatina, sometimes measles, and sometimes urtica- ria; was associated with congestion of the fauces and the usual train of febrile symptoms; and was brightly tinted at first, but subsequently acquired a dirty pink or rose-color. Roseola febris continue is the punctated exanthem which so commonly accompanies continued fever, and is met with in all the three varieties, typhus, typhoid, and relapsing fever. It makes its appearance at the beginning of the second week, and is scattered sometimes over the entire body, sometimes on the trunk alone, and sometimes on the limbs, particularly the back of the hands, but rarely on the face. In typhoid fever the exanthem has a bright rose-color, TREATMENT of roseola. 257 and disappears on pressure with the finger and after death. In typhus it is mulberry-colored: it continues on pressure with the finger, and remains after death, when it presents the appearance of petechial spots. The exanthem of relapsing fever also acquires very quickly a dark color, and passes into the state of petechiae. Each spot has a course of three days, and fresh spots appear every day; so that after the first three days they may be seen in all their stages—crescent, mature, and fading. Under the very objectionable name of roseola miliaris, Bateman has noticed the occurrence of miliary vesicles or sudamina in conjunc- tion with the roseolous spots of continued fever. These vesicles are most frequent in relapsing fever; but they appear in all the three forms, and most abundantly during the prevalence of copious perspira- ' tions. They are met with chiefly on the neck and breast, in the arm- pits, and on the sides of the chest. Diagnosis.—Color, figure, and febrile symptoms, are the three leading signs by which roseola is to be distinguished from other cutaneous affections; the pink or bright crimson tint deepening into the hue of the damask rose, and fading often into the shades of a bruise; the punctiform, closely-set dots grouped in cluster; the rings, commonly narrow and fine, but sometimes broad; the puncta, and the blotches; the congested fauces; and then the fever sometimes slight and ephemeral, and sometimes severe. But even with all these symptoms before us, it is often difficult to decide between a case of roseola and one of mild rubeola, and we are constrained to call other evidence to our aid. If there exist an epidemic of rubeola, if the patient be affected for the first time; moreover, if there be coryza and a catarrhal cough, the case is undoubtedly rubeola. In roseola there is rarely any coryza, and still more rarely catarrh. Cause.—The cause of roseola is debility which may be nutritive, nervous, or assimilative. The exciting cause is probably change of weather or seasons ; alternations of heat and cold ; fatigue; and errors of diet. Hence we find it occurring very commonly in the spring and autumn, in the summer, and sometimes prevailing in an epidemic or endemic form. Reduced power of the system, and a relaxed and weakened state of the skin, are conditions favorable to the development of roseola; hence probably its association with diseases of debility, such as rheumatism, gout, fever; and hence also the tendency of the exan- them to pass in the condition of purpura. Prognosis.—Roseola is by no means a serious affection, either in its idiopathic form, or as a complication of more serious maladies. In a chronic shape it indicates a general state of disorder of the economy, which we must endeavor to correct. Treatment.—Gentle laxatives, effervescent salines, light bitters with the mineral acids, small doses of quinine with sulphuric acid, mild chalybeates, constitute the pharmacopoeia of roseola, both in its idiopathic and in its chronic form. If special indications be present, such as obstructed dentition, fever, rheumatism, gout, diarihjea, or 17 258 bullous affections. any other form of complication, the symptoms of these affections must be met by their appropriate remedies. Locally, it is better left alone; but if much irritation be present, the skin may be washed with the juniper-tar or carbolic acid soap and tepid water, or sponged with hot water, or with a tepid ammonia lotion, one drachm of the carbonate to half a pint of water, or with a lotion of hydrocyanic acid in emul- sion of bitter almonds. Where any fear of repercussion of the exan- them prevails, the benzoated ointment of oxide of zinc may be rubbed upon the skin with gentle friction. The diet should be of the antiphlogistic kind: namely, toast-water and barley-water, with or without chlorate of potash or lemon juice, for drinks; with milk diet, farinaceous puddings, broths, eggs, fish, • poultry; returning by degrees to the ordinary diet of health. CHAPTER VII. BULLOUS AFFECTIONS. Bullae is the type of one of Willan's orders, and presents an unmis- takable character. His definition of bulla or bleb, is, " a large portion of the cuticle detached from the skin by the interposition of a transparent watery fluid." This definition applies very exactly to one of the mem- bers of the present group, namely, to pemphigus; but less well to herpes, which Willan treated as a vesicle, and admitted into the same order with eczema; and still less to miliaria, which is truly a vesicle. Herpes is a large vesicle, or small bulla; and although differing entirely in its nature both from vesicular affections and from pemphi- gus, seems entitled from the possession of this special pathological form, to a place, for the present at least, in the bullous group; and the more so, as some of the varieties of herpes are really allied more closely to pemphigus than they are to herpes. And as we have broken up the order Vesiculae, by the dispersion of its different mem- bers, this is also the proper place for the consideration of the small bleb or vesicle of miliaria. The diseases constituting this group are three in number; namely, Herpes, Miliaria, Pemphigus. Herpes is derived from the word i^ttnv, " quod est," says Actuarius, " serpere per summam cutem ;" but this is clearly an error as applied to the typical form of herpes, herpes zoster ; for herpes does not creep, although some of its chronic varieties, which belong rather to pem- phigus than to herpes, namely, herpes circinatus and herpes iris, really do so. The term t^rtr^ was applied by the ancients to a creeping and eating form of eruption, sometimes vesicular and sometimes ulcerative, and appertaining to the strumous, the syphilitic, and the cancerous affections. HERPES. 259 Pemphigus is derived from rttn$ii, bulla, a water-bubble, and is used synonymously with pompholyx, an air-bubble; nofupoxvye5 being "the bubbles of air which appear upon water;" and no^oc, according to Galen, " eminences of the cuticle containing a fluid." Another term was applied by the ancient Greek writers in this affection, namely, VKvxtawa, latinized into phlyctenae, from $%vtiv, to bubble or boil up, or over; hence the name of one of the varieties of herpes, videlicet, herpes phlyctenodes. The general signification, therefore, of these terms, as applied to the diseases contained in this group, is: herpes, an eruption of bullulae or small bullae; miliaria, an eruption of large vesicles; and pemphigus, an eruption of large and undoubted bullae. HERPES. Syn. Ecphlysis herpes, Mason Good ; Olophlyctis, Alibert. Herpes (Plate IX.) is an inflammation of the skin, occurring in patches of a more or less circular figure; upon these patches are de- veloped a crop of vesicles, which gradually rise up from the inflamed ground, and attain a semi-globular figure. The vesicles begin to appear on the second day of the inflammation; they are at first trans- parent, and reach their full size, that of a small pea, in one or two days; on the second or third day, they are opalescent; sometimes of a grape-yellow color, sometimes purplish and wrinkled. On the third or fourth day, they shrink still further, and produce a reddish-yellow wrinkled scab. On thejfourth, fifth, and sixth days, the scab becomes dark-colored and hard, and has the appearance of being imbedded in the skin; and on the three following days the scabs fall, and leave behind them purplish pits. This is the history of an individual patch, and of an individual crop of vesicles; but as the patches come out in succession for two or three days, the eruption is generally prolonged until the tenth or twelfth day. The patches are commonly oblong in figure, the long diameter of the patch corresponding with the course of the cutaneous nerves of the region on which they are developed; and they vary in size from half an inch to two inches in diameter. They are brightly red, very slightly swollen, and the number of bullulae varies from three or four to twenty or more. Generally, the vesicles are separate and discrete, but sometimes confluent; in which case, several may run together, and constitute a bullula of irregular form. The yellow tinge in the vesicles seen at the beginning of their decline, is probably due to the conversion of the cells of the rete mucosum into pus; and their purple hues to the admixture of blood with the original lymph, the effusion of blood being due to pressure or friction against the patches. Sometimes, and particularly in elderly persons, the eruption does not finish so simply, but terminates in deep and painful ulcers, which may last for a considerable time. The ulcers are occasioned by undue pressure or friction of the eruption, in a state of skin lowered in vi- tality by age, or by a cachectic condition of the constitution. The scabs which form upon the ulcerated spots are very adherent, and 260 bullous affections. , when they are removed, leave deep pits of a purple hue, like those of smallpox; and permanent cicatrices. It follows from this description that herpes is not simply an erup- tion of large vesicles or bullulae; it is, besides that, an inflammation, having a given course, and running that course in a given time; in other words, it is a specific affection, obeying special laws of its own, and differing from the ordinary physiological laws of the economy. But there is another phenomenon of considerable importance in con- nection with herpes, namely, an affection of the nerves of the part, a neuralgic affection. Herpes is essentially an inflammation of nervous origin; the first irritation is that of a nerve; the inflammation and its vesicular development are the consequences. Herpes is therefore ac- companied with severe nervous pains, but not always, and not in the majority of cases, and therefore a difficulty arises in regarding it as a pure nervous affection. The pain of herpes is of two kinds, one being constant, the other occasional; the constant pain is local in its situation, the occasional pain is that of a nerve, commonly a single nerve, and sometimes of all the nerves of the affected region. The neuralgic pain sometimes precedes the eruption, and ceases as soon as the cutaneous inflamma- tion begins; sometimes it accompanies or follows the eruption; and sometimes continues for weeks,, months, or even years, after all erup- tion has ceased; and the patches commonly travel in the direction of the branches of a nerve. For example, herpes zoster, the true cingula or shingles, takes the course of an intercostal nerve; the first patch is probably developed near the middle line on the front of the body, at the spot where the anterior cutaneous nerves are distributed in the skin; the second patch will possibly occur upon the seat of distribu- tion of the posterior cutaneous nerves, and the third patch over the lateral cutaneous nerves; other patches taking up intermediate posi- tions upon the same line; while in a partial form of the eruption, a single patch only, or two patches may be present, namely, the anterior, or the posterior, or both, without any intermediate patches to form a link. The local pain of herpes is one of intense burning; hence its ancient titles ignis sacer, ignis sancti Anthonii, associated with tingling, prick- ling as with hot needles piercing from within, and itching; and this pain continues throughout the whole course of the eruption. It is not contagious. The varieties of herpes may be considered as constituting two groups—a neurotic group, corresponding with the typical form of the affection just described, at the head of which stands herpes zoster; and a phlyctenoid group, represented by herpes phlyctenodes. They are as follows:— ACUTE. Herpes zoster, Herpes palpebralis, " phlyctenodes, " nasalis, " labialis, " auricularis, " preputialis, " pudendalis. HERPES ZOSTER. 261 CHRONIC. Herpes circinatus, " iris. ACUTE FORMS OF HERPES. Herpes zoster,' or shingles (Plate IX. A F), is remarkable from its embracing one-half the trunk of the body ;2 in other words, taking the course of the anterior branches of the spinal nerves. It is com- monly met with in association with an intercostal nerve, sometimes with a cervical, a brachial, or a crural nerve. Its usual position is around one-half the waist; and as it has never been known to attack the two sides of the trunk at the same time, the popular notion, re- ferred to by Pliny, has arisen, that were it to do so the result would be fatal.3 From half-encircling the waist, it has been termed zona or girdle, and again cingula, from which latter term its popular name shingles is derived. Besides the waist, we have seen it on the flank, on the hip, on the thigh, on the shoulder, on the neck, and upon the head. On the head and face it occupied chiefly the occiput, the temple, and the forehead, while one vesicle was developed on the con- junctiva. On the limbs it takes the course of the cutaneous nerves, as of the shoulder and thigh. Bateman terms a case of the latter kind herpes proserpens. Usually the eruption of zoster appears without any premonitory sign, and runs through its course without much suffering, with no other pain, in fact, than the burning and tingling which constantly accompany it, and which have gained for it the name of zona ignea ; at other times, when the neuralgic affection is severe, the internal organs are apt to suffer also, from the communication of their nerves with the intercostal nerves; thus, there may be intense shooting pains through the chest, with tumultuous action and palpitations of the heart. And sometimes the eruption is accompanied with febrile symp- toms, which are as likely to arise from the ordinary cause of the eruption, namely, a chill, as they are from the nervous perturbation accompanying the disease. On the subsidence of the eruption, the neuralgic pains, of a very severe kind, are apt to be continued for some weeks, and to resist every kind of treatment. It has been stated that the eruption attacks one side of the body more frequently than the other. This is not the case; the two sides are equally the subject of the affection. Its seat of eruption is commonly determined by the direction in which the cold, which causes it, is applied, and sometimes by a temporary or permanent debility of the part. We lately saw a case which had arisen from a chill in bathing, and an inordinately long walk which 1 Syn. Zona; zoster; zona ignea; ignis sacer ; ignis sancti Anthonii; cingulum ; shin- gles ; der giirtelausuchlag, feuergurtel, Germ. 2 See Portraits of diseases of the skiu, Plate V. A Y. In this figure, besides the zona around the trunk of the body, a large patch of herpes phlyctenodes is seen on the flnnk, just above the hip. 3 "Zoster appellatur, et enecat, si cinxerit."—Pliny. 262 bullous affections. had strained the muscles of the hip: the eruption broke out on the weakened part. Herpes zoster enjoys no immunity from the variations that accom- pany most other natural phenomena, and especially those of disease. This affection may be said to have three principal symptoms, namely, inflammation of skin, eruption of vesicles, and neuralgic pains. We have now to state that one or other of these symptoms may be oc- casionally absent; for example, there may be inflammation and pain without vesication ; or there may be inflammation and vesication with a scarcely appreciable amount of pain. And in a fully-developed zoster some of the patches may be studded profusely with vesicles, while on others they are scanty or absent. In these cases we signify our meaning by the use of the term "arrest of development." Herpes phlyctenodes1 (Plate IX. B) differs from herpes zoster only in situation, being identical in every other respect. Thus, when herpes attacks the trunk of the body and forms a demizone around it, the'case is one of herpes zoster; but when, as we have already described, it appears upon a limb, upon the neck, or upon the head and face, it no longer forms a demizone, and then it is more correct to term it herpes phlyctenodes. Herpes phlyctenodes may occur as a single patch, or as a cluster of several, on any part of the body. The patch rarely exceeds in size the palm of the hand, and consists of an inflamed surface studded over with vesicles, sometimes discrete and sometimes confluent; oc- casionally the vesicles are so small as to have suggested the term herpes miliaris ; more frequently they attain the size of peas of mode- rate dimensions. The patches commence with a sensation of burning, tingling, and smarting; some red puncta are seen on the painful spot, a blotch of redness succeeds, and on the inflamed surface the vesicles are deve- loped. Sometimes there is a deep-seated soreness and pain as well as that already described. It is rare for any constitutional symptoms to be present. 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 10, 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, possessed 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 1 Syn. Herpes miliaris; olophlyctis miliaris, Alibert; nirles. HERPES LABIALIS. 263 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 labialis1 represents the local varieties of herpes, all of which, like herpes zoster and herpes phlyctenodes, are acute forms of the affection, and have their regular course, never exceeding ten or twelve days. Some occur only once, or if the attack be repeated, it is accidental, and occurs at an uncertain period; while one of the local forms, herpes preputialis, is intermittent, and breaks out at short in- tervals for a considerable period of time. Herpes labialis, a frequent consequence of an inflammatory cold, or of slight febrile disturbance of the system, begins with itching, redness, heat, swelling, and painful tension of the lip and adjacent mucous membrane. On the day following the beginning of the in- flammation, five or six small vesicles appear on the affected spot; some of the vesicles congregate and form small cellular bullae of the size of a split pea. On the third or fourth day the lymph of the vesicles becomes turbid and lactescent, and subsequently semipuru- lent. On the fifth or sixth day the vesicles desiccate into a brownish crust, and on the eighth or tenth day the crust falls. When the crust is meddled with during its progress, or the inflammation is aggravated by interference, a hard scab is formed, which remains adherent for a longer period than the natural crust. Herpes palpebralis, nasalis, et auricularis, are identical with herpes labialis, but usually less extensive and less severe. In herpes palpebralis the inflammation and vesicles are developed on one eyelid; in herpes nasalis along the margin and upon the ala of one nostril; and in herpes auricularis upon the lobe of one of the ears and not on the other. In symptoms, course, and termination, these forms correspond with herpes labialis. Herpes preputialis may occur upon the mucous or upon the cutaneous surface of the prepuce: it consists, as do the other local forms, of a blotch of redness surmounted by a small crop of vesicles, and attended with a sensation of smarting and burning; on the prepuce the blotch is rarely larger than half an inch in diameter; the vesicles found on the cutaneous surface subside after a few days, from the ab- sorption of their fluid contents, and dry up into small thin brownish scabs; but the vesicles on the mucous surface are generally broken, and produce minute excoriations, which are often slow in healing, and are liable to be mistaken for syphilitic ulcerations. Herpes preputialis presents the peculiarity of being intermittent, returning from time to time for several months or even years. It rarely occurs without a foregone irritation of the organ, either in the shape of a gonorrhoea or chancre; and then seems to perpetuate a remembrance of the original disorder. We know a gentleman who, after the cure of a chancre, suffered during two years with fourteen 1 Syn. Exanthema labiate; hydroafebrile, J. Franck ; olophlyctis labialis, Alibert. 264 BULLOUS AFFECTIONS. attacks of herpes preputialis, each attack lasting about ten days. The last time that the eruption made its appearance it showed itself on the body of the penis near its root; whilst sometimes it makes its appearance on the glans. Herpes pudendalis corresponds in every respect but situation with herpes preputialis; it is developed on one labium. CHRONIC FORMS OF HERPES. The chronic forms of herpes are distinguished from the acute forms by their more general distribution; by their longer duration ; by a more superficial inflammation of the skin; by a tendency to spread; by less severe local suffering; by an absence of neuralgic pain; and by a disposition to the production of larger vesicles, and often bullae, herpes bullosus; in a word, the chronic forms of herpes prepare us for a transition to the bullous affection pemphigus. The varieties belonging to the chronic group are herpes circinatus and herpes iris; they have no special constitutional symptoms. Herpes circinatus (zona herpetica, Plate IX. G), makes its ap- pearance as red and slightly raised spots, which are accompanied with considerable tingling and itching, and are apt to be mistaken for the bites of insects. In a few hours the spot spreads into a blotch "half an inch in diameter, and soon after increases to the diameter of an inch or two inches. When it is larger than half an inch, it is found to be slightly depressed in the centre; and with a further increase of dimensions, the redness of the centre fades and becomes yellowish, and a ring is produced. In the growing disk and growing ring the peripheral border is observed to be a little raised above the level of the rest of the surface, and is somewhat brighter in its tint of red; it is at this part that vesication begins, and the cuticle is.raised into vesicles as large as peas upon the belt of the rings, in the course of a few hours. The progress- of the eruption is so rapid that that which is a sprinkling of mere itchy spots at night, and a disturber of sleep, may, in the morning, be a crop of annular rings, each surmounted with a circle of glistening bullulae as large as moderate-sized peas. The vesicles are filled with limpid lymph, sometimes changing to opalescence and milkiness; they become wrinkled and collapsed in the course of the following day, and in a day or two more are con- verted into thin brownish and blackish scabs. The redness of the patch fades with the collapse of the vesicles; its cuticle exfoliates, and in a few days no trace of it remains. But as the eruption is successive in the development of the annuli, it may continue for ten or twelve days, or even for a longer period of time. The development and maturation of the disks and rings is accom- panied with more or less tingling, itching, and smarting, and these sensations subside with the disappearance of the patches; but as the latter are produced in succession, and commonly during the night, the pruritus is often exceedingly severe. The ordinary size of the annuli is two inches in diameter; sometimes they are a little larger; and when the eruption takes place suddenly, at the first outburst of HERPES circinatus. 265 the disease they may be smaller. In a case in which the limbs and part of the trunk of the body were nearly covered with the eruption in the course of two days, the physician who attended the patient remarked that it was a sight worthy of being remembered. The eruption was still troublesome in this case, although progressing towards cure, at the end of two months. Occasionally from the beginning, but more frequently in the course of a chronic case of this disease, there are modifications of develop- ment of the eruption which are deserving of note. In the first instance there may be, scattered among the vesiculated rings, red blotches or disks, showing no disposition to vesicate; and secondly, there may be disks of moderate size completely covered by a single large bulla; and were it not for the general history of the complaint, we might be induced to pronounce the case to be one of pemphigus. In the example of herpes circinatus above noticed, in which the first attack of the eruption was developed suddenly, both the rings and the vesicles were pretty uniform in size over the whole body. As the case went on, the dimensions of the patches diminished, and in place of a row of vesicles, a single large bleb was produced; and later, when the patient's general health was improved with the aid of tonics, the effusion ceased to occur, and irritable erythematous disks only were apparent. We have twice seen herpes circinatus bullosus associated with pregnancy, beginning with conception and ending with the completion of parturition. Both cases were remarkable for perpetual irritation and intense pruritic suffering. The bullae were of the flat and folia- ceous kind, some filled with limpid serum and others with a muco- purulent fluid, and were associated with moist excoriations, thin crusts, papulae, and pruritus. In one patient the cutaneous disease was the first intimation of pregnancy; the disease continued during the whole period, accompanied four or five pregnancies in succession, and completely exhausted her strength and health. In other respects, and in the intervals of being pregnant, she was a strong and hand- some woman. The other patient came before us at the age of thirty- six; she had had nine children; the eruption made its first appearance with the fourth pregnancy, and has accompanied every pregnancy since. When parturition was over the eruption ceased; but on the last occasion, nine months ago, it remained, and has now assumed a permanent character. She thinks, moreover, that at the present time she may be in the family way again. In both cases the eruption was accompanied with sympathetic gastric disturbance, and with a duski- ness and cachexia of the skin. Hardy has described this form of eruption under the name of pemphigus pruriginosus ; he points out with great precision its promi- nent characters, namely, the small bullae, sometimes serous and some- times purulent; the violent pruritus subversive of comfort and sleep; the excoriations effected by scratching; the papulae covered with small black scabs, as in prurigo; the duskiness of the skin; and the diffusion upon the skin of a serous fluid resulting from the rupture of the bullae and the secretion of the excoriations, and attended with 266 BULLOUS affections. an unpleasant odor. And he illustrates the disease with the case of a woman of thirty-five, who had had nine children and was far advanced in pregnancy with the tenth. The eruption in her case appeared with every pregnancy a few weeks after conception, and subsided and got well after parturition. Between her pregnancies she enjoyed good health; and, as in our own cases, the children were healthy. Herpes iris1 is a lower form of herpes than herpes circinatus. It is essentially, like some of the exhausted patches of the latter com- plaint, a herpes bullosus propagated from the centre by a series of efforts, too feeble to produce a row of independent vesicles, and result- ing only in the formation of annular ridges more or less distended with serous fluid ;2 it is, in fact, an aborted form of herpes circinatus. Herpes iris occurs very commonly on the back of the hands of elderly persons ; and here the disks are small, and the central vesicle equally so. When the affection shows itself on the limbs, and in persons of reduced power, the central vesicle is an undoubted bulla, and the disk or patch may attain the dimensions of one or two inches in diameter. The process of formation of herpes iris is as follows: an inflamed spot or disk first makes its appearance; the day following, this disk is covered by a vesicle or bleb, while a narrow border of red appears around its circumference ; on the third day the narrow border of red is raised into a vesicular ring, and the redness has crept on for another stage, forming another narrow border of red; on the fourth and suc- cessive days, the same phenomena are repeated until the disk has attained its full size. The effusion, it will be observed, is most abundant in the central vesicle, and diminishes as the rings increase in number. The first ring is more distended than the second, the second than the third; with the third, the effusion generally ceases, and the rings developed beyond the third are simply erythematous, and distinguished only as shades of red. The development of the disk of herpes iris undergoes some modi- fications : occasionally, as in the disks observed on the back of the hands and feet of elderly persons, it never reaches beyond the erythe- matous stage, and has been named, in consequence, erythema iris. At other times the central bulla creeps on with the enlarging erythe- matous line and forms a bleb, often of considerable size, pemphigus iris; absorbing, as it proceeds, the annular vesicles of the circum- ference.3 In the erythematous form, as seen upon the hands, there are commonly not more than three shades of color; the centre red, the first ring whitish or yellowish, and beyond this a narrow halo of light crimson. On other parts of the body the number of rings may be increased to five or six, or even more. By watching the disk from day to day, we have observed in some cases that a new ring is 1 Syn. Erythema iris; pemphigus iris. 2 Portraits of diseases of the skin ; Plate VI. A Z, exhibits a well-marked case of this curious form of eruption. 3 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. HERPES—DIAGNOSIS — CAUSE — PROGNOSIS. 267 produced daily, so that the number of rings determines the length of duration of the patch. In one disk we 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; while in another disk, only half an inch in diameter, there were 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, yellowish-white, and crimson blush. This appearance of the eruption sufficiently warrants the designation " iris," given to it by Willan. Herpes iris has no constitutional symptoms: it is always associated with debility, as in the debility of elderly persons, and sometimes, as in children, with nutritive debility and cachexia. It is in an asthenic state of the constitution that it more frequently takes on the pemphi- goid form. Diagnosis.—The diagnosis of herpes turns upon the size of the vesicles, larger than those of eczema and miliaria, smaller than the bullae of pemphigus; upon the burning, tingling, pricking, and smart- ing itching; upon the frequent presence of neuralgic pains, and upon the orderly course of the eruption. The local varieties have small vesicles, sometimes multilocular vesicles; but they are always de- veloped upon a patch of redness, and are accompanied with the pathognomonic tingling, smarting, and burning of herpes. Herpes circinatus is recognized by its circle of vesicles or bullulae, and herpes iris by its centrifugal rings starting from a central umbo. Cause.—The cause of herpes zoster, herpes phlyctenodes, and herpes auricularis is a chill, sometimes proceeding from a cold current of air, as in the prevalence of easterly winds, or sitting in a draft when the body is heated; or sometimes from the direct application of cold, as from sitting or lying on the ground, or the wearing of damp clothes. Herpes labialis, nasalis, and palpebralis, usually pro- ceed from irritation of the adjoining mucous membrane, and follow a feverish cold or catarrh; and herpes praeputialis and pudendi originate in some irritation of the neighboring mucous membrane. We have never seen an instance of herpes praeputialis in which there has not previously existed a gonorrhoea, or some syphilitic affection. The cause of herpes circinatus and iris is a debility, a lowered tone of the system, sometimes referable to nutritive, sometimes to assimilative, and sometimes to nervous causes. We have at present under our care a patient who has suffered from herpes phlyctenodes, spring and autumn, for several years, the eruption being each time preceded by a bilious attack. The cases above narrated, accompanying pregnancy, must be referred to nervous debility. Prognosis.—Herpes is not a grave affection, and is sometimes very trivial. In the neuralgic forms the pain is often terrible, and very difficult to conquer. The circinate form and herpes iris, as they indi- cate a constitutional debility proceeding from a general derangement of health, are of most importance in reference to the health and safety of the patient. 268 BULLOUS AFFECTIONS. Treatment.—The treatment of herpes zoster, phlyctenodes, and the local forms, when unaccompanied with neuralgic pain, is purely local; if neuralgia be present, constitutional as well as local treatment will be requisite ; and the chronic forms also call for constitutional as well as local remedies. As the acute forms of herpes are limited in extent, and have a reg- ular course of a certain number of days' duration, all that we are called upon to do in the .majority of cases is to protect the inflamed skin from pressure or friction. To this end we shall find no better means than dredging the eruption copiously with flour, and confin- ing it there by means of a sheet of cotton wool, held in its place by strips of adhesive plaster or a bandage, not too tightly applied. We have also found a thick coating of the benzoated ointment of oxide of zinc, afterwards covered with a sheet of cotton wool, and retained in its place by strips of adhesive plaster, very successful. When the burning heat and tingling are very troublesome, we have obtained ease from arrowroot poultices, made by filling a muslin bag with ar- rowroot jelly and applying it cold; from a thin paste of precipitated chalk, applied with a brush; and at other times from folds of flannel saturated with a decoction of poppy-heads. Bateman recommends lotions of sulphate of zinc, sulphate of alumina, and borate of soda. Experiments have been made with ectrotic remedies, but their ad- vantage has not been fully established; the best of these is a solution of nitrate of silver in nitric ether, which we have known to give con- siderable relief. It is a good application for all the local forms, par- ticularly herpes preputialis. We have sometimes applied a solution of potassa fussa, in equal parts of water, with the result of immedi- ately checking the course of the eruption. Another mode of using the nitrate of silver is to puncture the vesicle, and, after absorbing the lymph, to touch its base with a point of the caustic. With the local forms this plan answers extremely well. The patches may also be pencilled with carbolic acid. Plumbe suggested a strip of blistering plaster as a means of checking the extension of the inflammation, and also of " producing a shrivelling of the vesicles, and cutting short its progress altogether." Collodion and Goulard's extract have had their advocates, and also a solution of perchloride of iron with laudanum. In the neuralgia of herpes we must have recourse to quinine, citrate of quinine and iron, and arsenic ; or if there be evidence of a rheumatic diathesis, iodide of potash; and of a gouty diathesis, colchicum ; and as sedative remedies, to belladonna, hyoscyamus, morphia, and chlo- rodyne. Locally, the treatment must be sedative and stimulant; pre- parations of aconite, belladonna, morphia, chloroform, cajeput, may all be used in their turn. We have employed blisters without much re- sult, but have derived the greatest advantage from the oleum juniperi pyrolignici, combined with chloroform and tincture of aconite. In three cases of this kind we 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 we once asked to give us an idea in words of the nature of his MILIARIA. 269 suffering, 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, one at each end of the towel, sawing it backwards and forwards; that is what it is like." In the region of the scapula, around the thorax and around the abdomen, the pain is sometimes dreadfully severe. Dr. Ranking records the opinions of Dr. Palmer and Mr. Humpage on the local treatment of this painful affection; the former recommends the appli- cation 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. Flying blisters have also been recommended. The chronic forms of the eruption should be washed with the juni- per-tar soap, and sponged with a lotion of the juniper tar, or with hy- drocyanic acid in emulsion of bitter almonds, to allay the itching; and afterwards anointed with the benzoated ointment of oxide of zinc, combined with spirits of wine or spirits of camphor, or a simple cam- phor cerate. When the vesicles are broken and the corium excori- ated, dressings of the benzoated ointment of oxide of zinc on lint should be applied; or the surface dusted over with pulvis cinchonae. MILIARIA. Syn. Miliary vesicles; miliary eruption; herpes miliaris; hydroa; sudamina; die Friselblattern, die Schweisblattern, Germ. Miliaria is the name which is given to an eruption of small globular vesicles of a size corresponding with that of the milium, or millet-seed. They are the consequence of a weak and exhausted state of the skin, induced by heat and perspiration, and are commonly associated with fevers, with the puerperal state, with rheumatism, or any ailment which renders confinement to bed for a lengthened period a necessary condition. From the latter circumstance the eruption has been termed miliaria clinica, and, from its combination with perspira- tion, the vesicles have been named sudamina. The vesicles of miliaria are larger than those of eczema, but smaller than the vesicles of herpes, and necessarily, very much smaller than the bullae of pemphigus; nevertheless, they are frequently of a size to suggest the idea of the former, while in their origin they have some of the characters of the latter. They originate in a debilitated condi- tion of the cutaneous tissues, like pemphigus; like the latter disease also, they indicate an exhausted state of the vital power, and they are produced with little cutaneous congestion. But unlike pemphigus, they are generally symptomatic of an independent febrile state of the constitution, and their course is acute. At their first eruption the vesicles are filled with a transparent and limpid serum, which reflects the color of the denuded derma at their base. This gives them an appearance of redness, and has gained for the disorder the name of miliaria rubra. But in twelve or twenty- four hours the serum becomes opalescent, whitish and milky, and in 270 bullous affections. this state the appearance of the vesicles has given origin to the term MILIARIA ALBA. The vesicles are met with most frequently on the sides of the trunk of the body; on the inner side of the upper arms; in the axillae ; on the back and on the neck; in situations, in fact, the most likely to suffer from heat and perspiration during illness. They are sometimes evolved in patches of various size, but, more commonly, are scattered singly over the surface. They appear in succession, each fresh out- break lasting three or four days, but the eruption, as a whole, contin- uing for one or two weeks. The vesicles sometimes break, but more frequently collapse, from absorption of their contained serum; and the desiccated cuticle forms a small thin scab, which in a short time is removed by desquamation. Miliaria has no constitutional symptoms; but its association with fevers suggested the term miliary fever, formerly applied to it. Indeed, there seems to be good reason for the belief that its frequency in for- mer times, and its comparative rarity at present, are to be explained by the better method of treating fever in our own days, and the pre- servation of a cooler state of the body; the condition the most favora- ble for the production of miliaria, being a hot -and perspiring state, such as would result from hot rooms, excess of bedclothes, and heating regimen and remedies. To these latter conditions in particular is to be referred the miliaria of puerperal patients. Miliaria is generally accompanied with sensations of languor, of extreme exhaustion, a feeling of faintness, and oppression of breathing; symptoms which are attributable to the perspirations, rather than to the eruption; and the perspiring state of the skin is also made evident by the strongly acid odor of the sick-room. In chronic miliaria the urine is very commonly albuminous. Since the days of Sydenham, who advocated so powerfully the adoption of a cool temperature and cooling regimen in fevers, suda- mina have become rare; but previously to his time they were exceed- ingly frequent, and from their connection with fever, were regarded as a specific disorder, preceded and accompanied by severe and dan- gerous fever. This fever was termed miliaria, and for many years was regarded as a dangerous and fatal disease, spreading like an epi- demic, and destroying multitudes of lives; but since a more rational method of treatment has been employed in medicine, miliary fever has ceased to exist. Bateman remarks, " It is scarcely necessary now to enter into any detail of proofs that the miliary eruption is the result of a highly heated and perspiring state of the skin, and that in its severe and fatal degree it is solely the effect of a stimulating regimen in a confined atmosphere. The almost total annihilation of the dis- ease, of late years, since the general adoption of a better practice, is of isself unequivocal evidence of its origin." " Hippocrates, whose mode of treatment in febrile diseases was not calculated to produce excite- ment, 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 TREATMENT OF MILIARIA. 271 the occasional appearance only of miliary vesicles, which he ascribes to their proper cause." "Among the various circumstances," continues Bateman, "under which the miliaria was formerly excited, the puerperal state appears to have been most frequently the source of it; insomuch that it was first described as an epidemic among puerperal women. This is suffi- ciently accounted for by the treatment which was unhappily pursued during the confinement after child-birth, and of which an impressive description is given by Mr. White. For not only was the mother immediately loaded with bedclothes, from which she was not allowed to put out ' even her nose,' and supplied with heating liquors from the spout of a teapot; but to her room, heated by a crowd of visitors and a fire, all access of air was denied, even through a keyhole. From these causes fever was almost necessarily'induced, with the most profuse sweats, oppression, anxiety, and fainting; and these again were aggravated by spicy candles, spirits, opiates, and ammoniacal 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." Diagnosis.—The size of the vesicle is pathognomonic, as is also the absence of inflammatory congestion at its base. It is smaller than the vesicle of herpes, generally scattered, and wanting in the burning, tingling, and pricking of the latter; while it is too small to be mis- taken for pemphigus; indeed, is a vesicula and not a bulla. Cause.—Debility of cutaneous tissue, generally the consequence of too much heat, and a resulting excess of perspiration. Prognosis.—The prognostics of the eruption are dependent on the illness which it accompanies, or upon the degree of power of the constitution. Treatment.—The constitutional management of miliaria must be directed to the cure of the disease with which it is associated. Quinine, with sulphuric acid, or the aromatic sulphuric acid, is generally of service. Its local or special treatment must have for its object, to give tone to the tissues of the skin, by means, for example—of tepid baths; of washing.with tepid water and the juniper-tar soap.; of spong- ing with a tepid solution of ammonia, of a strength sufficient to act as a mild or tonic stimulant; or with tepid vinegar and water. These are means that cannot affect injuriously the disorder in chief, but may possibly be of use to it. In a more prostrate condition of the system, we may prescribe the powder puff; and as the body acquires strength, may venture to reduce still further the temperature of our local appli- cations. 272 BULLOUS AFFECTIONS. PEMPHIGUS. Syn. Pompholyx; pemphix; ecphlysis pompholyx et pemphigus; Mason Good ; fievre bulleuse, Fran. ; Blasenausschlag ; Wasserblasen, Germ. Pemphigus is an eruption of bullae arising from a very slightly inflamed ground, and distributed more or less extensively over the surface of the skin. The bullae arise in the course of a few hours, with some tingling and smarting, and often without redness. They are distended with a serous fluid, burst in one or two days, and leave an excoriated surface, which soon becomes covered with a thin brown- ish or blackish scab. On the desquamation of the scab, the skin is left of a dull red tint, sometimes livid, and frequently stained with a brownish discoloration. The bullae vary in bulk from the size of a pea to that of the hemi- sphere of a walnut, or a hen's egg; they commonly cover the whole of the inflamed disk on which they arise; and their contents, at first limpid and straw-colored or amber-colored, become opalescent and milky, sometimes semipurulent, and not uncommonly purple, from admixture with blood. Sometimes, instead of bursting and leaving a red and angry excoriation prone to bleed, the bullae become wrinkled and collapsed, and dry up into a thin corrugated scab, which is either grayish, light-brown, or black, according to the character of the serous contents; and sometimes the collapse is only partial, covering part of the base, and leaving a vesicular roll around a part of the circum- ference; and sometimes this last-described corrugated and collapsed form is present from the beginning, and never rises to a fully devel- oped bulla, but produces on desiccation a thin corrugated scab, which being frequently oval in outline, suggests the idea of a dried leaf ad- hering to the skin: this appearance has given origin to the term foliaceous, applied to one of the varieties of pemphigus. The bullae of pemphigus are commonly thrown up in clusters of three or four, to twelve or even a greater number, and not unfre- quently have separate bullae dispersed between the groups. Each bulla runs its course in one or two days; but as others appear in suc- cession, a few fresh clusters occurring every day, or every two or three days, the eruption is prolonged for some weeks, and more com- monly for several months or years. The affection is therefore essen- tially chronic, and differs in different persons only in degree of chro- nicity: the term acute is not reasonably applicable to pemphigus. Occasionally the disease is limited to the production of a single bulla, pemphigus solitarius, which attains a very considerable size, often as large and even larger than a large orange. Pemphigus has been called acute, in consequence of being occasion- ally preceded by a little fever, and terminating in a few weeks; but in general it is chronic and lasts for a considerable period. It usually denotes a low and debilitated and asthenic state of the constitution, and is associated with bleeding from the excoriated skin; vesication of the mucous membrane of the mouth, nose, vulva, and vagina; and hemorrhage from the bowels, from the kidneys, and sometimes from PEMPHIGUS VULGARIS. 273 the stomach and lungs. The skin in general corresponds with this morbid state, and is often dry, shrivelled, and discolored. The local suffering attendant on pemphigus is a moderate amount of itching, tingling; and smarting on the first appearance of the erup- tion, and extreme soreness and sensitiveness in the state of excoriation. It is a rare affection, and more rare possibly in this country than in others ; it is also more frequent in women, and especially in young women, than in men, and is most common in children. Amongst the children of the poor it is apt to show itself in the form of purple and livid spots that tend to gangrene, pemphigus gangrasnosus ; and amongst the ill-fed poor in Ireland, the gangrenous form sometimes prevails as an epidemic. There are few affections to which so many varieties have been assigned as pemphigus, and its synonym pompholyx; for example, pemphigus congenitus, infantilis, simultaneus, successivus, solitarius, confluens, confertus, acutus, chronicus, pyreticus, apyreticus, vulgaris, benignus, diutinus, contagiosus, gangraenosus, foliaceus, pruriginosus, &c.; but for practical purposes they may all be included under the five following heads; namely,—■ Pemphigus vulgaris, Pemphigus foliaceus, solitarius, " pruriginosus. gangraenosus, Pemphigus vulgaris1 (Plate VIII.) is the common and usual form of the affection: in its milder aspect, and lasting only a few weeks, it has been termed pemphigus acutus and pompholyx benignus; but as we have already shown, its symptoms are not sufficient to charac- terize an acute disease; and all we can accord to it is; that it is less chronic in some cases than in others, and undoubtedly milder, benignus. Sometimes some slight febrile disorder precedes the eruption; but at other times it is unattended with any symptoms but those which belong to the depressed state of health in which the disorder origin- ates. In several instances we have seen it associated with that form of nervous debility and irritability which is commonly termed hys- teria ; in one case the eruption occupied the sternal region of the chest and epigastrium; in another, the inner side of the thighs; and in a third, the hands and fingers, and one hand in particular. This latter case was remarkable for the excessive fetor of the exuded fluid, a fetor resembling that of the ozaena of young hysterical females, and suggested a comparison with that distressing malady. We regard the pathological process as identical in the two affections, and have thought it worthy of being distinguished for further observation by the name of pemphigus ozaenodes. The patient was a girl of nineteen, somewhat anaemic, with pallid, puffy, and somewhat bloated coun- tenance, and subject to occasional fits of hysterical affection. The chronic form of pemphigus vulgaris, the pompholyx diutinus of Willan, is distinguished by the prolonged continuance of the erup- 18 1 Portraits of diseases of the skin, Plate VII. 274 BULLOUS AFFECTIONS. tion, lasting sometimes for several years, and its obstinate resistance of treatment. A patient before us, a young unmarried woman, aged twenty-six, suffering from this complaint for six months, had purpura which covered the lower half of the body, and was accompanied with epistaxis, seven years ago, and for the last five years has been the subject of amenorrhoea. And 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 pem- phigus since the age of five years. The fluid of pemphigus has been made the subject of chemical analysis by Scherer. It had a yellowish tint, an acid reaction, a spe- cific gravity of 1018, and deposited a sediment composed of corpuscles, which Scherer states to have resembled mucus or pus-corpuscles, but which were probably newly-formed epidermal cells. On evaporation 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 result:— 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, 3.75 0 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, .... . 24.63 Uric acid, .... 0.58 Extractive matters, . 11.79 Fixed salts, 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." In the case of a little boy, affected with acute pemphigus, Dr. Marris PEMPHIGUS SOLITARIUS. 275 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 con- taining minute crystals of oxalate of lime, and was loaded with urea. In a thousand parts the quantity of solid constituents was 76.89. Bamberger, in 1860, found the urine scanty, acid, of high specific gravity, rich in urea, uric acid, and the earthy phosphates; poor in phosphoric and sulphuric acid; but abundant in ammonia. He also found ammonia in the blood and in the fluid of the bullae; the blood being poor in solids, especially albumen; hence he suggests as a proper treatment, the use of an easily assimilable albuminous diet, and hydrochloric acid. Pemphigus solitarius is a peculiar variety of the eruption, re- markable for the production of a single bulla, which reaches a very large size, often as big as an orange. It is preceded by a sensation of tingling and smarting, and in a few hours the bulla has attained a considerable bulk. At the end of two days it bursts and leaves behind it a painful excoriation, which becomes covered with a thin grayish scab. After the lapse of a few days, a second bulla appears near the seat of the former, and runs a similar course, to be followed in suc- cession by five or six more; so that the attack is prolonged for ten days or a fortnight. Willan remarks that pompholyx solitarius " 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." Biett met with a chronic variety of the disease. Pemphigus gangraenosus.—Under the name of pemphigus in- fantilis, Willan describes an eruption which has since received from Dr. Whitley Stokes the more appropriate name of pemphigus gangrae- nosus. It occurs in children; and in Ireland sometimes prevails among the poor as an epidemic. It makes its appearance in the form of small, imperfectly developed, generally flattened bullae, rising upon a purplish and livid base. The bullae are filled with a sanguino- lent and sanious fluid; they burst in two or three days, and expose an ulcerating and frequently sloughing base ; these ulcers are painful, have thin livid edges, and secrete a sanious and fetid pus; frequently they enlarge by the circumference, and when they heal, are slow and tedious in their, progress towards cure. By successive eruption the disease is continued for some weeks; it gives rise to irritative fever, destroys rest, induces a general disturbance of nutrition, and finally exhausts the power, and vitality of the patient. In Ireland this eruption is popularly known as white blister, eating hive, and burnt holes, and " death takes place about the tenth or twelfth day, often preceded by convulsions, sometimes by extreme lividity." Pemphigus foliaceus is a variety of the eruption, arising from imperfect development of the bulla; the cuticle is raised from the corium to a superficial extent, and instead of going on to the full development of a bulla, dries up into a thin corrugated grayish or brownish scab. When partially separated, the scabs give a ragged 276 BULLOUS AFFECTIONS. appearance to the skin, particularly when they are abundant; and when they are shed, are frequently replaced by other scabs of similar formation. At first, there is a sprinkling of fully or partially-formed bullae, with the scales; but after a while, the desquamation exists alone, the skin being deeply congested and exuding a serous secre- tion. The foliaceous scabs are produced with such activity, that in a few hours, according to Hardy, the bed of the patient is filled with them. At a later period of the disease, when the skin is about return- ing to its natural state, there is a reappearance of the bullae. Pemphigus foliaceus is rare, and commonly begins on the breast by a single bulla; the bulla spreads by the circumference ; other bullae are produced around it; in a short space of time vesiculation extends to the greater part of the surface of the body, and the derma is more or less completely denuded ; it is attended with extreme prostration of power, and is generally fatal. Pemphigus pruriginosus is a name given by Hardy to an aggra- vated form of herpes circinatus associated with general redness and infiltration of the skin and troublesome pruritus. We have described this disease as a herpes circinatus, occurrring during utero-gestation. Its chief peculiarity is excessive itching, and Willan seems to allude to a similar affection in remarking that chronic pemphigus is some- times complicated with prurigo. In elderly persons, he observes, this complication excites the most distressing irritation, and often causes a fatal termination. The bullae are imperfect, frequently forming no more than a serous roll along the circumference of the patch ; but they exist very numerously distributed over the surface of the body. In one of our own cases the eruption occurred with every pregnancy, and at last grew to be insupportable. Diagnosis.—The distinctive characters of pemphigus are, its large vesicles or bullae. The large vesicles of herpes circinatus often approach in size those of pemphigus, and, as we have seen, constitute a transition-link with pemphigus itself. Cause.—The cause of pemphigus is a general and local debility, approaching to cachexia. We have recorded two instances which followed local injury; in one of them, a servant girl "poisoned" her hand with a red paste, with which she was cleaning brass; a few days afterwards a crop of bullae, intermingled with ecchymosed spots, came out on her wrist and forearm, and continued to trouble her from time to time for seven years. The other case was that of a medical man, who punctured his right hand; three or four weeks afterwards, an eruption of bullae made their appearance on his left thigh, and were repeated from time to time for eighteen months. Their outbreak was preceded by feverish symptoms; there was a scalded sensation in the skin, and the next morning a fully-developed bulla would be dis- covered. It is often sympathetic with irritation or defective function of some part of the mucous membrane, and especially that of the uterine system; and sometimes is met with in an epidemic form. Prognosis.—As pemphigus is indicative of a serious amount of local and general debility, and as the cause of that debility is difficult TREATMENT OF PEMPHIGUS. 277 of detection, and may depend upon some radical defect in the economy, the prognosis must always be doubtful and unsatisfactory. The ulti- mate result must depend upon the powers of the constitution, and these will be influenced very much by age, position in life, and other circumstances. 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. He also observes that the cure of pemphigus has, in some cases, been observed to be followed by various ill con- sequences. Treatment.—Treatment must be chiefly constitutional; any dis- order of digestive function and secretions should be regulated, and then we must rely upon tonics; the bitters with mineral acids, espe- cially the hydrochloric; cinchona with sulphuric acid; quinine; and citrate of quinine and iron. We have also derived good results from the use of arsenic. If there be feverish symptoms, we may find it necessary to have recourse to effervescent salines, with ammonia; to sulphate of mag- nesia, with quinine and infusion of roses; and to chlorate of potash. Locally we should puncture the bullae as soon as they are fully developed, in order that the cuticle may fall down upon the denuded corium, and form upon it a covering of protection; then we should dress the eruption with the benzoated ointment of oxide of zinc spread on lint, and afterwards cover the dressing with a sheet of cotton wool. We may, if occasion arise, vary this dressing with one of ceratum calaminae, or simple cerate with which a few grains of the superacetate of lead (gr. v ad ij) have been rubbed down. If there be much sensitiveness of the excoriated skin, we may allay it by the use of a weak solution of nitrate of silver (gr. j—iij ad 3j), and dress it as above, renewing the dressing night and morning, and keeping it in its place with adhesive strips or with a bandage. And in case o£ moist discharges, the excoriations may be dusted over with pulvis cinchonae. We have also derived good results from lotions of car- bolic acid, chloride of zinc, and the tinctura picis cum sapone. In pemphigus foliaceus and pruriginosus we shall find ablutions with the juniper-tar soap and warm water of great use in removing the scales and relieving irritation; and afterwards we must anoint the surface with the benzoated ointment of oxide of zinc; or if the pru- ritus still be annoying, with the ointment of the pyroligneous oil of juniper; the excoriations being dressed as above with the benzoated ointment of oxide of zinc rubbed down with spirits of wine or spirits of camphor. In the epidemic pemphigus gangraenosus, Dr. Stokes recommends an ointment of scrophularia nodosa, containing as much green vege- table matter as possible. He remarks that this is a traditional remedy, but he found it more successful than any other plan of treatment. The ointment should be warmed until it possesses the consistence of honev, and then laid on with a brush, and dressed with the same spread upon lint. The utmost gentleness should be used, and the 278 FURUNCULAR AFFECTIONS. 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 should be of the nourishing kind, meat and wine, unless any contraindication arise. CHAPTER VIII. FURUNCULAR AFFECTIONS. Under the head of Furuncular affections, which properly includes Furunculus, Hordeolum, Anthrax, and Pustula Maligna, we have likewise grouped Ecthyma, as being otherwise isolated, and as pre- senting several points of affinity with furunculus; for example, it is sometimes associated in the same eruption with furunculus; it is a disease of a pyogenic character; it very commonly ulcerates and sloughs; is essentially an affection of low constitutional power, and evinces a tendency, on the part of the constitution, to cachexia. Ecthyma is a pustule; indeed is the type of the order Pustulae of Willan, and is consequently united in that group with impetigo. From impetigo, however, it differs more than from furunculus; for impetigo is a psydracious pustule, a sero-pustule, a surface affection, an exudative pustule, developed not singly like ecthyma, but in clusters, with less local inflammation, and without any tendency to ulcerate. Moreover, the alliance between ecthyma and impetigo is dissolved by the union of the latter with eczema; and in consequence of the removal of other diseases from the same order, would be left alone unless joined with furunculus. The essential points of difference between ecthyma and furunculus are, the frank suppuration of the former, and the presence of a core of cellular tissue in the state of grangrene, in the latter. ECTHYMA. Syn. Ecpyesis ecthyma, Mason Good; phlyzacia; papulous scall. Ecthyma (Plate X. H-Q) is an eruption of large pustules dispersed over the body and limbs more or less extensively; rarely general, more commonly limited to a part, as to the lower extremities. The pustule is hemispherical in figure, distended with a deep yellow pus, mounted on a hard and prominent base, and surrounded by a red and highly inflamed areola. The pustule ulcerates more or less deeply; has an average duration of ten or twelve days; dries up into a thick grayish-yellow or brownish scab, which is firmly adherent to the skin, and leaves at its fall a purplish-red and pitted cicatrix. The pustules ECTHYMA. 279 are successive, and the eruption is consequently prolonged for several weeks or months. The eruption begins with a little itching and tingling, and with the appearance of a small inflamed pimple; the pimple increases in size, a little pus is formed on its summit, and it is quickly converted into a round hemispherical pustule, with a hard and inflamed base. The pustule bursts in three days, and the pus, together with the plastic lymph secreted by its base, dries up into a yellowish-gray and brown scab. If the scab be detached too soon, a small ulcer is exposed, which forms a secondary scab, and the latter remains attached for a considerable time, and at its fall leaves a more extensive and deeper pit. This is the course of the pustule in the acute form of the disease, lasting for eight or ten days; and the eruption is said to be acute when it is composed of pustles of this kind, following each other in succession for three or more weeks; but in a cachectic state of the constitution, the pustules have a chronic character; the redness is deeper in hue, approaching to livid; the pustule is purplish from ad- mixture of blood with the pus; at its rupture a painful, ulcerated, and often sloughing surface is exposed to view; the crust formed over this ulcer is more or less black; the edges of the sore are thin and livid; and the ulcer is slow in progress, very painful, and of long duration. This character of the eruption is the basis of the varieties termed ecthyma luridum and ecthyma cachecticum; while in an ex- treme degree of cachexia there may be a gangrenous condition of the ulcer, a condition warranting the adoption of the term ecthyma gan- graenosum. The pyogenic tendency of ecthyma, its proneness to ulceration, to sloughing, and sometimes to gangrene, indicate a low tone and debility of the constitution, that may be associated with symptoms of general disturbance of health and more or less fever of the irritable or hectic kind; but there are no constitutional symptoms that can be attributed especially to ecthyma. The pyogenic condition of the system in ecthyma is indicated by the frequent presence of superficial abscesses; a disposition to sup- purate in slight wounds and scratches of the skin, and the formation of whitlows; and the cachectic tendency of the constitution is shown by the frequent occurrence of inflammation of the lymphatic vessels and glands. It is not contagious; although not unfrequently epi- demic. The varieties of ecthyma are acute and chronic. Acute ecthyma is the ecthyma vulgare of Willan, to which Hardy adds a form almost unknown in England, ecthyma gangraenosum. The chronic varieties are, ecthyma infantile and ecthyma cachecticum; the latter includ- ing the ecthyma luridum of Willan. In a tabular form they are as follows:— ACUTE. CHRONIC. Ecthyma vulgare, Ecthyma infantile, " gangraenosum. " cachecticum. 280 FURUNCULAR AFFECTIONS. Ecthyma vulgare (Plate X. H-N) is the more common and simple form of the eruption, that in which the pustules run the acute course already described, although the eruption may be prolonged by the successive appearance of pustules for two or three or more weeks, or by its continuance deserve to be considered as chronic. There is more tone and power of constitution in this than in the other forms, and the symptoms are milder in character. The pustules are for the most part developed on the extremities, particu- larly the lower limbs, the shoulders, and the neck, and more commonly in children than in adults. Ecthyma gangrenosum is the name given by Hardy to an acute form of ecthyma, which he appears to have seen only once, and in a man exhausted by age and misery. The eruption made its appear- ance in the shape of phlyzacious pustules, with an areola of a brown- ish-red color at first, and afterwards gray. A circular eschar succeeded by unhealthy ulceration, formed on the second day, and was followed in five or six days by death. Hardy asks whether this may not be the rupia escharotica of authors ? We think it not unlikely; for substituting children for the aged, it corresponds very nearly with the pemphigus gangraenosus of Dr. Whitley Stokes/the true representa- tive of the older rupia escharotica. Ecthyma infantile (Plate X. H-Q) is more commonly chronic than acute, that is, its pustules are slower in their course; they are more commonly surrounded with a purplish or livid areola, and are more prone to fall into a state of unhealthy ulceration. They are met with in infants at the breast, and in ill-fed and ill-nourished children. Bateman remarks that they not only make their appear- ance on the extremities and trunk, but also on the scalp, and even on the face, situations in which only ecthyma cachecticum ordinarily occurs. Ecthyma cachecticum is the chronic ecthyma of the adult, as is ecthyma infantile of infants and children. Its milder characters bring it under the denomination of ecthyma luridum of Willan ; while in a more advanced degree of cachexia it may present every shade of dark red, purple, and livid in color, and every variety of ulceration, sloughing, and painful irritability. Although common to every age in the adult where the powers of the constitution are reduced, it is more frequently met with amongst the elderly. There can be no doubt that many syphilitic eruptions were treated as forms of ecthyma by Willan and Bateman, and that the prevailing cachexia noticed by them originated in syphilis. At present we are better informed as to the characters of constitutional syphilis, and less likely to fall into errors of that kind; and in proportion to our advance in knowledge in this respect, our examples of ecthyma have become reduced in number. Diagnosis.—The distinction of ecthyma is simple; its large well- formed pustules, scattered singly over the body, with hard and in- flamed bases, are unlike everything else. The pustules of impetigo, are only half-pustules, sero-pustules, in fact; they are small, clustered TREATMENT OF ECTHYMA. 281 without hardness or much redness of base, and are commonly associated with other characters denoting eczema. The pustules of smallpox are phlyzacious, like ecthyma; but they are more numerous; they form part of a general eruption, and they are accompanied with special constitutional symptoms. The pustules of syphilis may also be phlyzacious, and only distinguishable from ecthyma by the other symptoms of that disease; indeed a pustular syphiloderma may be an ecthyma developed under the influence of the syphilitic cachexia. Cause.—The cause of ecthyma is debility, both constitutional and local; the constitutional debility in children and elderly persons being of the nutritive kind, and in adults sometimes assimilative and sometimes nervous. To this may be added local debility, or debility of tissue. In infants and young children, errors of diet, dentition, and errors of hygiene, take a prominent position as remote predisposing causes; and in adults and elderly persons all those causes which tend to exhaust the powers of the constitution. A child two years of age has an attack of ecthyma with every tooth she cuts; a lad of fifteen, of strumous habit, determined by nutritive debility, has been the subject of ecthyma of the legs for four years. All causes tending to occasion cacochymia and cachexia are favorable to the production of ecthyma. Among the local causes may be enumerated irritants of all kinds: a common one in lympathic and weakly children is the acarus scabiei. The pustules excited by the action of tartarized antimony on the skin are phlyzacious and ecthy- matous; and Hardy calls our attention to an example of excito- sensory action manifested by the development of a crop of ecthy- matous pustules on the back, at a point opposite another crop on the front of the chest, the latter being determined by the direct irritation of a blister. Prognosis.—Like other diseases manifesting a constitutional de- bility, a tendency to pyogenic transformation, to ulceration, and cachexia, ecthyma is grave without being serious or dangerous. It requires careful watching, and calls for the combination of all the resources of the medical art. Treatment.—The treatment of ecthyma is constitutional and local. The constitutional treatment embraces a tonic regimen in the way of air, exercise, and diet; and tonic remedies, including bitters, mineral acids, bark, quinine, steel, and cod-liver oil. Arsenic is not indicated otherwise than as a tonic. The local remedies are such as will stimulate the skin moderately; for example, ablution with the juniper-tar, or carbolic acid soap and tepid water night and morning, and dressing with the benzoated oint- ment of oxide of zinc, with calamine cerate, or with the unguentum resinae. In a cachectic habit, an ointment of friar's balsam or cam- phor will be found an useful stimulant; and if there be much irrita- bility, a weak solution of nitrate of silver may be used to pencil the inflamed surface; or the pustules may be touched with a weak solu- tion of carbolic acid or chloride of zinc. In a sloughing state of the 282 FURUNCULAR AFFECTIONS. ulcers, stimulating remedies are especially called for, and the surface may be dusted over with pulvis cinchonae. Poultices and sloppy reme- dies of all kinds are undesirable. FURUNCULUS. Syn. Ph yma furunculus ; boil. The general character of the furuncular eruption is an inflamma- tion of limited extent, sinking 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 sub- stance 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 superficial, involving parts which are looser in tex- ture and more 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 carbuncle there is more than one core, and the 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 furun- culus, sometimes reaching to a diameter of six or even a greater number of inches. 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 furun- culus, 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 colander. 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 $vp.u derived from $w, produco, signify- ing a tuber, tubercle, or small swelling, and applied by Hippocrates FURUNCULUS. 283 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 a genus of his class Bullae, under the popular term " eiterblasen," 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 expres- sive of the severity of the pain which often accompanies the eruption ; while the term anthrax, vus flammeus; nmvus san- guineus; Gefassmuttermaler, Germ. ; signes; taches de vin, Fran.; mother's marks. N^avus vasculosus arteriosus, the vascular mother's mark, pre- sents a bright arterial color, and is sometimes raised above the level of the skin, and sometimes almost flat. It is composed of a plexus of minute bloodvessels or capillaries in a state of hypertrophy, covered by a very thin layer of corium, and has a spongy texture in the in- terior. It differs in bulk in proportion to the distension of its vessels with blood; in a passive state being corrugated and more or less flaccid, and in an active state smooth and distended, almost to burst- ing. This quality of the naevus of swelling under the influence of a more active state of the circulation, has gained for it the name of erectile tumor, and in, the same language, it is said to be composed of erectile tissue. The vascular naevus offers some differences of figure and extent. The flat naevus is irregular in outline, uneven on the surface, and sometimes of considerable breadth. The elevated naevus is round or oval in shape, of less considerable extent, and more or less smooth superficially. The variety of shape of these tumors, their color, and their prominence,'associated with the fact of their being congenital, have suggested a number of fables with regard to their origin, founded for the most part on the imagination. It is believed by the people that they result from the mental influence of the mother operating upon the foetus during pregnancy; that sometimes they proceed from unnatural longings, and at other times from violent mental emotion or fright. Hence the popular designation, mothers' marks ; and hence also the objects which they are supposed to represent. These objects must, of course, be red in color, to correspond with that of the naevus; for example, fruit, such as currants, cherries, raspberries, strawberries, the boiled lobster, and blood. In the case of an infant afflicted with a naevus of this description lately brought under our notice, the mother said that about the fourth month of her pregnancy she had an intense longing for some raspberries that she saw growing in a gentleman's garden, that she was unable to divest her mind of this impression during the whole of the subsequent period of gestation, and that she was haunted with the dread lest her child should be marked. It is needless to say that the longing had no share in the production of the naevus; but the coincidence of these longings and defects of structure of the child is sometimes very curious. The arterial vascular naevus very frequently disappears gradually in course of time, especially when the disorganization is not very deep or extensive; at other times it enlarges and spreads, and is apt to give rise to considerable deformity of appearance, particularly when it has its seat upon the face. The situations in which it most frequently occurs are the head and the face, the shoulders, and the front of the trunk of the body. N.evus vasculosus venosus.—The venous form of vascular naevus is distinguished from the arterial naevus by its purple or livid color. This difference of color is due to a slower and more languid circula- 304 VASCULAR AFFECTIONS. tion through the vessels, which gives time to the blood to undergo its venous transformation ; and under the influence of an exciting cause capable of increasing the rapidity of the circulation, the blood becomes redder and assumes a less purple character. The venous vascular naevus, like the arterial naevus. may be either flat or prominent, and present similar characters. The popular fancy sees in this form of naevus, fruits of a deep purple or black color, such as blackberries and black currants, or the hue of the unboiled lobster; and the longing of the mother is supposed to have taken that direction. When the naevus is superficial and but little raised, it is termed a claret stain (naevus flammeus, Plenck), and may spread over a con- siderable extent of surface, as the whole of one side of the face. These naevi sometimes occupy the eyelids, the ears, and the lips, and in those situations are apt to swell to a considerable size, and produce much deformity. Naevus araneus is an accidental form of the affection, and may appear at any period of life, being most common in children and women, and persons possessing a delicate and weak skin. It consists of a small globular prominence, from which several radiating vascular lines pass off around, like rays from a centre. The globular promi- nence is an aneurismal loop of a minute artery, and the radiating lines are the veins which carry the blood away. At a short distance from the central umbo they sink into the skin and are lost in its deeper circulation. The peculiar shape of the naevus, a red centre, with radiating lines, that might be compared to the legs of a spider, has suggested the name by which it is known, namely, spider nosvus. There is, however, another form of naevus araneus in which the venules communicate with each other at a short distance from the central boss, by means of a network of anastomoses, and give a different character to the appearance of the spot. This we have distinguished as the ncevus araneus reticulatus; in other respects it corresponds exactly with the ordinary naevus araneus. The naevus araneus is most commonly met with on the cheeks, near the eyelids, and sometimes on the eyelids themselves. It is also seen on other parts of the face, and occasionally on the neck and chest; less frequently it is found upon different parts of the body where the skin is firmer and tougher. N-^VUS sanguineus is another form of accidental vascular spot, occurring for the most part upon a discolored and unhealthy skin, the consequence of age or neglect. It resembles a small drop of blood effused beneath the cuticle; is sometimes flat, but more commonly convex, and varies in color from a bright crimson to a purple or leaden tint. It is generally solitary ; sometimes dispersed upon the skin, but never numerously. Its common seat is the breast, the neck, and the face, and it is not uncommon to find it associated with other indications of cacotrophia, for example, acrochordones or areolar warts, sebaceous concretions, and sometimes verrucae. Although the naevus sanguineus resembles a minute bleb of effused blood, it is in reality a varicose condition of a small tuft of capillary HYPERTROPHIA VENARUM. 305 vessels, and in this respect conforms to the general type of structure of naevus vasculosus. Hypertrophia venarum is a term applicable to enlargement of the minute veins of the skin, vessels that in a normal condition of the organ are imperceptible to the eye. Their enlargement is principally due to weakness of tissue, but in a measure also to causes which give rise to obstruction in the current of the venous circulation. They are met with chiefly on the face and lower extremities, but sometimes on other parts of the body, and are unaccompanied by any pain or in- convenience beyond the deformity of appearance which they neces- sarily occasion. On the face they are seen principally on the nose, the cheeks, and the chin; on the nose they are most conspicuous at the sides of the alae and at the tip of the organ. In these situations the venules some- times attain a considerable size; they are formed by the confluence of smaller venules derived from a plexus which occupies the fleshy border around the apertures of the nares, and proceed upwards in parallel lines to the upper border of the alar cartilage, where they dip into the substance of the nose and join the veins of the Schneiderian membrane. On the sides of the bridge of the nose, and on the cheeks, they form a coarse plexus; and on the lower limbs, particularly the thighs, they constitute a superficial plexus of small extent, which is bluish in color, nodulated and uneven on the surface, and gives a feel- ing of hollowness and sponginess to the touch. It the latter situation they empty their blood into the subcutaneous veins, which are also more or less varicose. This state of hypertrophy of the venules, when it occurs upon the face, is accompanied with more or less hypertrophy of the cutaneous tissues; the skin has a coarse appearance, is thickened to a certain extent, and in an advanced state of varicosity becomes generally en- larged, purple, and even livid. These phenomena occurring in the nose produce swelling and enlargement of that organ; infiltration into the subcutaneous tissues takes place subsequently, and a foundation is laid for those huge lobulated noses which are occasionally met with in the world. Hypertrophia venarum occurs only at the adult period of life, and amongst elderly persons, and commonly results from a lowered tone of health. On the face and nose it is sometimes due to sedentary habits, or to exposure to inclemency of weather or climate; and on the lower extremities is referable to retardation of the circulation caused by a varicose state of the receiving venous trunks. We have a case of hypertrophia venarum nasi under treatment, that resulted from sunburn, from the scorching heat of the sun experienced in crossing the snowy passes of the Himalaya mountains; the intensity of reflection from the snow producing at the same time an attack of snow-blindness. Diagnosis.—A prominence formed by bloodvessels in the substance of the skin is so easily distinguishable as to call for no special remark. The flat varieties of vascular naevus, with smooth and unbroken cuti- 20 \ 306 VASCULAR AFFECTIONS. cle, are not likely to be mistaken either for erythema or eczema, and the papulated and compressible elevations of naevus araneus and the smaller vascular naevi are wholly dissimilar to the solid papulae of lichen or strophulus. Cause.—The cause of naevi is essentially a weakness of tissue, com- bined with abnormal nutrition; in the instance of congenital naevi it is an abnormal growth centred in a part instead of distributed through the entire organ. The minute aneurism constituting wevus araneus is commonly the result of muscular efforts which subject the vessels of the skin to sudden distension ; such as coughing, sneezing, strug- gling, the forced muscular throes of labor, or inordinate efforts of any kind. Naevus sanguineus is a consequence of the want of a healthy and vigorous life in the skin. Hypertrophia venarum is commonly slow in its development, and results from exhaustion of tone of the vessels by frequent and excessive distension. Prognosis.—Unless in very extreme cases, either of excessive depth or breadth, naevus and hypertrophia venarum are removable by sur- gical means. They are very rarely of a fatal character. Treatment.—The treatment of naevus is almost entirely local. If there be evidence of a weak and relaxed state of tissue, a constitu- tional treatment may be had recourse to, with a view of strengthening the part through the whole ; and in naevus sanguineus and hypertro- phia venarum there may arise good reason for this practice. The local treatment consists in the application of surgical means, which have for their object either the obliteration of the naevus; or its ablation, either by ligature or by the knife. We have said that congenital vascular naevi often get well sponta- neously; the undue supply of blood requisite for their maintenance is apt to diminish, their vessels contract, gradual obliteration follows, and nothing but the cicatrix remains. A cicatrix is inevitable, be- cause the skin has become disorganized; its vessels have been developed at the expense of the other tissues, and the structure of the skin has been spoiled beyond the means of restoration. Relying upon this process of cure, there is no occasion for an early application of treatment, and especially so when the naevus exhibits no tendency to enlarge. The practice of obliteration is an imitation of nature's process of cure; we effect it by compression ; but the compression must be con- stant, so as to empty the vessels completely, and prevent the return into them of the blood ; we thus put them into a state the most favor- able to insure the contraction of their walls; and if this contraction be preserved for a while, it will continue permanently. There is a probability also of the deposition of plastic lymph in the areae of the vessels, and its subsequent organization; in which case complete ob- literation is attained. We further aim by our treatment to produce this effusion of plastic lymph ; and to this end we add the use of stimulants to simple com- pression. The simplest form of stimulant is a styptic solution, such as the liquor plumbi diacetatis, or a solution of alum, applied by means of compress and steadily retained in its place; indeed, speedy cure, treatment of naevus. 307 or cure at all, may be said to depend wholly upon our power of keep- ing up a steady and constant pressure. The above plan is that of Dieffenbach ; and a severer method founded on the same principle is recommended by Behrend, namely, the application of strong acetic acid, followed by compresses wetted with vinegar; this process is apt to produce ulceration of the skin. From the known corrugating and styptic properties of creasote when applied locally, this also might be found to be an useful remedy. When there exists no objection to setting up an ulcerative action, which to us appears wholly unneces- sary, we may have recourse to nitric acid or potassa fusa. The plan of treatment considered above applies chiefly to the flat forms of naevus, and is not so suitable in general to the more promi- nent forms. Nevertheless, the principle of action must be the same for both, the actual treatment differing only in its manner of applica- tion. Thus it has been proposed to induce the deposit of plastic lymph in the naevus by exciting in it the inflammation caused by the vaccine virus; in other words, by vaccinating the tumor. Again, it has been suggested that a seton should be passed through it, or that it should be injected with some astringent solution. An elegant and very promising method was recommended by Marshall Hall, namely, puncturing the tumor with a cataract needle, breaking down its tis- sue, and then applying a compress. Actual cautery also has had its advocates. When a more speedy cure is sought for, we may have recourse to ligature, the ligature passing beneath one or two needles with which the base is transfixed. To obviate the loss of integument with which this process is accompanied, Liston proposed to make a crucial inci- sion across the tumor, to reflect the flaps, and then to introduce a lig- ature through the base of the tumor. Smaller tumors have been taken out at once by simple incision ; but loss of blood is always to be guarded against, and therefore the ligature is usually preferred to the knife. Nevus araneus is best treated, by a little operation of our own, namely, touching with a sharp point of potassa fusa; and naevus san- guineus and the enlarged venules of hypertrophia venarum we treat in a similar way. Our plan is to break a small piece of potassa fusa into fragments, to select a fragment with a sharp point, and, with the aid of a small pair of forceps, to use the angular fragment as a needle. We scratch the summit of the boss in naevus araneus with this sharp point and press it into the cavity; we hold it there for an instant, and upon withdrawing it, the drop of blood in the vessel is coagulated and charred. If there be hemorrhage, we press the spot until the bleed- ing ceases, and repeat the operation. When the blood contained in the umbo of the naevus is charred, the charring commonly extends to the radiating vessels; but if these remain pervious, the caustic is to be drawn briskly along their course, so as to char the blood which they contain. The little capillary varix of naevus sanguineus and the venules of hypertrophia venarum we treat in a similar manner; car- rying the caustic along the trunks of the varicose*venules of the lat- ter as we do along the radiating vessels of the naevus araneus. 308 H^EMIC AFFECTIONS. CHAPTER XI. H^EMIC AFFECTIONS. H-EMODYSCRASIA, derived from alp.a, blood, and &vaxe,aet>s, bad consti- tution, signifies an alteration in the blood, which results in the depri- vation of its healthy qualities. The blood is more watery than natural; its coagulable part is deficient in quantity and density; its fibrinous elements and plastic properties are below the average; and in extreme cases, the blood-corpuscles have a tendency to break up and decompose, and permit the solution of their coloring principle in the serum. In other words, the blood is weak, poor, thin, and unequal to the proper nutrition of the body, and the maintenance in health of the tissues. This state of the blood is associated with, and is a part of a general cacochymia and cachexia, which lowers the vitality of the body, and subjects it to the invasion of a series of morbid phenomena repre- senting every degree of debility, from a state not wide in its de- parture from health to a state more nearly approaching the changes which take place after death. The morbid change in which we are the most interested at present is the altered relation of the bloodvessels and of the blood, of the containing and of the contained part. On the one hand, the vessels are weakened and relaxed, and lose their power of retention; while, on the other, the blood is more thin and watery than natural, and more prone to escape through their porous walls. There results from this combination of morbid conditions an escape of blood from the capillary vessels of the skin, in the form of spots more or less profusely dispersed over the surface. The spots are purple in color, and the affection so engendered is termed purpura. PURPURA. Syn. Purpura apyreta; purpura chronica; porphyra, Mason Good ; hozmorrhoza petechialis, Adair; phcenigmus petechialis, Sauvages ; petechias sine febre ; petechial mendaces; morbus pulicaris sine febre, Amatus Lusitanus ; morbus maculosis; maculae nigra sine febre ; ecchymoses spontanece ; land scurvy ; petechial scurvy. Purpura, therefore, is a morbid affection of the skin, denoted by the presence of purple spots dispersed over its surface, and having their seat in the papillary layer of the corium. The spots may be developed on every part of the skin, but are most abundant on the limbs, particularly the lower extremities, and are successive in their appearance, fresh spots becoming visible every day until the body is more or less completely covered. The spots are at first of a bright purple hue; they, gradually become darker, livid, or almost black; PURPURA. 309 at a later period they lose their brightness and their sanguineous color, and as they fade, assume the varied tints of a declining bruise, namely, brown, green, and yellow, until they are entirely lost. As the seat of these changes is the surface layer of the corium, the cuticle escapes alteration, and there is no desquamation. Such is the history of simple purpura,purpura simplex; it is unac- companied with specific symptoms, the symptoms with which it is joined being those of cachexia in general sometimes aggravated by the feverishness common to cachexia; namely, irritative or hectic fever. In consideration of this simple course, purpura has received a variety of names, all of them being illustrative of the same idea of mildness of character of the disease; for example, purpura apyreta, purpura sine febre, purpura chronica, &c. But purpura from its very nature, namely, involving a tendency of the blood to escape from its vessels, and a degraded condition of the blood itself, may be much more serious than is here described; the blood may be effused in larger quantity; the effusion may not be limited to the skin, but may extend to the mucous membrane of the alimentary canal; of the air-tubes; of the uterine organs; of the urinary apparatus; or it may take place into the serous cavities, as of the arachnoid, and even into the parenchyma of the different organs of the body. We may thus have a series of aggravations that must convert a very simple affection into one of the serious kind; a mild and comparatively unimportant disease into one of a grave and fatal character. The phenomena above described belong to the variety of purpura termed purpura haemorrhagica. Simple purpura has been also called purpura spontanea, in order to mark the distinction of a purpura which is commonly associated with continued fever; namely, with typhoid, typhus, and the relaps- ing fever. We have already noticed these fever-spots under the head of roseola, to which they appear to belong, rather than to true purpura; the first effort of nature being the production of a roseolous eruption, the dyscrasis of the tissues determining instead, an exosmosis of the blood, and, consequently, a purpura. It is also to be re- membered that a mitigated form of purpura is a common sequence of roseola; the purple and yellowish bruise-like stains being of a pur- pureous or porphyritic nature. The relation of purpura to the healthy condition of the body is illustrated in a peculiarly interesting manner by the purpura of sail- ors, purpura nautica, who have been for a long time restricted to a deficient and unwholesome diet. Scorbutus or sea scurvy is a purpura haemorrhagica, and in pursuance of the same idea, purpura simplex has been termed, in popular language, land scurvy. Sea scurvy is not, however, confined to the sea; but as it depends upon want of food and proper ventilation, may exist equally on land when those condi- tions prevail. Hence it is a frequent accompaniment of the famines which sometimes overtake populations. The skin of elderly persons, particularly those in the lower ranks of life, is subject to an effusion of its blood into the superficial portion of the corium, and giving rise to purple and livid spots of various size. These appearances are commonly observed in the forearms, and 310 H^MIC AFFECTIONS. have received the name of purpura senilis. This, however, must be regarded simply as a courtesy title, and the best we can say of the spots is, that they resemble those of purpura, but are independent of the symptoms accompanying that disease. They are, in fact, more interesting to the pathologist than they are to the practitioner, as they indicate, not a disease, but a state which resembles disease, and which forms a link of some value in the comparative pathology of this curi- ous complaint. We retain also among the varieties of purpura a purpura urticans, and we regard it as a purpura complicated with the spasmus periphe- ricus and pruritus of urticaria. It might sometimes be a question which of the two diseases was in the ascendant, the purpura or the urticaria; but it is evident which is the most conspicuous and perma- nent, namely, the former; and it is not an uncommon phenomenon, and one of more importance than is at first apparent, to find a sub- stantive disease sometimes performing the secondary part of a symp- tom. Thus, in purpura urticans, purpura is chief, while urticaria plays a subaltern or secondary part. We have already adverted to the relation of roseola and purpura in continued fever, and we remind the reader of the association of purpura with lichen, in the variety of the latter termed lichen lividus; we have likewise seen it conjoined with eczema. We must also call attention to the association of pur- pura and pemphigus, or, for the gratification of the lovers of compli- cated nomenclature, we might say, purpura pemphigoides. That purpura and pemphigus should be united is by no means remarkable ; it is a concurrence that we might predicate d priori; and it possesses interest as a pathological fact. Both diseases taken sepa- rately are diseases of cachexia, of dyscrasia, and their union in the same individual suffering under that state is no more than we might expect. Purpura is a dyscrasia in which the coloring principle of the blood filters through the capillary vessels probably in solution in its serous or liquid part. Pemphigus is a disease in which the serum of the blood exudes through the capillaries of the skin, and raises the cuticle in bladders of various size. If, in the case before us there were no purpureous spots, we should call it pemphigus; but in the presence of those spots we are apt to regard, and on reasonable grounds, purpura as the major disease. Purpura, like pemphigus, may accom- pany any form of cachexia, whatever its source, or any disease which determines a cachectic habit; thus, it might occur with the syphilitic cachexia, and only does not do so more frequently than we see it at present because it demands for its development, besides the cachexia resulting from the presence of poison in the blood, the more exhaust- ing cachexia that results from bad and insufficient food. Pemphigoid purpura is not especially a disorder of the lymphatic diathesis, but is generally accompanied with a tendency to oedema of the subcutaneous cellular tissue. The milder forms of purpura may exist with little or no constitu- tional disturbance; but the severer forms are accompanied with symp- toms of prostration and exhaustion. Purpura is also not unfrequent- ly associated with diseases of a neuralgic character, and particularly PURPURA. 311 with rheumatism. The local symptoms of the disease are, a mild degree of prickling and tingling, with tenderness and soreness to the touch. These symptoms in general attract very little attention ; but the prickling and tingling are raised to an inordinate and painful degree in purpura urticans. The spots of purpura have received several names in accordance with their figure and dimensions. The smallest kind of spot, which is a mere speck or dot, is termed stigma ; next in size to the stigmata is the petechia, a round spot resembling a flea-bite, from which the term is derived. The petechia, however, is wanting in the deep red centre which indicates the point of perforation of the haustellum of the insect; although, as it is always formed around the aperture of a pore, a central indentation may be frequently observed. Of a larger size than the preceding, and frequently the product of the union of several petechiae, are the' vibices; they are irregular in figure and of various size. Lastly, there may be blotches of larger dimensions than the vibices, and which owe their origin to a palpable extravasation of the blood in more considerable quantity; these are termed ecchymoses, or ecchymomata. They may present every variety of figure, and at their decline have the appearance of a bruise of considerable extent. Willan includes purpura in his order Exanthemata, and associates it with rubeola, scarlatina, urticaria, roseola, and erythema. Its total separatiori in character and nature from these diseases must be suffi- ciently obvious; and its occasional association with urticaria and roseola, as an urticaria porphyretica, and roseola porphyretica, affords no grounds for this classification. The varieties of purpura may be stated as follows:— Purpura simplex, Purpura urticans, " haemorrhagica, senilis. Purpura simplex is represented by the mildest series of the symp- toms enumerated above; there are no ecchymoses, and the stigmata, the petechiae, and the vibices, are distributed more or less partially over the body, chiefly upon the lower extremities; but also on other parts, as the arms, and the front of the abdomen and chest. The erup- tion of the spots is successive; they are preceded and accompanied by a little prickling and tingling, and by a feeling of soreness and tenderness of the skin, while the constitutional symptoms are such as to indicate general debility and cachexia; for example, languor and lassitude, depression of spirits, loss of appetite, and interruption of the functions of digestion and secretion. The mode of invasion of purpura simplex and the chief features of the disease are shown in the following cases: We were consulted by a gentleman, the first week of May, for erythema attended with pruritus; he complained at the same time of a slight feeling 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-continued application to his duties. In other respects, he was a man of asthenic diathesis, some- what over temperate, and in the habit of fasting too long. We saw 312 H.EMIC AFFECTIONS. him twice, at intervals of a week, and were disappointed with the slow progress of improvement which he exhibited; and on his third visit at the end of a month, he presented a well-developed purpura simplex with yellow cachectic countenance, and oedematous lower limbs. The purple spots were numerous and discrete, 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 axillae 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 petechiae continued to appear, a crop of vibices suddenly broke out upon the lower limbs; the vibices became the seat of bullae, 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 bullae at a time. These symptoms continued for six or seven weeks, when the petechiae 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 axillae, extend- ing across the 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 petechiae, and then as vibices on the legs, covered with bullae. With the petechiae and vibices the legs became swollen and hot, the muscles were sore, and he was unable to move. At the end of a month the symptoms began to subside, and he was sufficiently well to come to London from a distant county to seek our advice. On the occasion of his visit, in July, 1856, we found him complain- ing of languor and lassitude; his tongue was pale, there were no petechiae in the mouth, no sponginess of gums, or bleeding from any internal organ; his appetite was moderately good; and his bowels, usually costive, were regular. He made an average quantity of water, PURPURA. 313 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 petechiae ; on the legs there were vibices as well as petechiae, but the bullae were dried up, and the cuticle was in a state of exfoliation. He remarked that he could always foretell an eruption of petechiae 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 in- convenience. 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. We 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 our friends, of gouty diathesis, and subject to occasional attacks of eczema of the legs, has not unfrequently, in combination 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 neu- rotic nature of the disease is evinced by these symptoms; and to an exhausted condition of nervous tone, may, in all probability, be attri- buted the altered plasma of the blood, and the non-retentive power of the capillaries and small bloodvessels. Purpura hemorrhagica is recognized by an aggravated develop- ment of. the general symptoms of purpura; the spots begin in the lower extremities, and gradually creep upwards until they invade every part of the body, with the exception of the hands and face. The spots are of all the kinds above enumerated, stigmata, petechiae, vibi- ces, and ecchymoses. The most moderate pressure produces a purple mark or ecchymosis, and the ridges of the folds or wrinkles of the skin are traced in purple or livid lines. Moreover, there are mingled with the spots, not unfrequently, vesicles or bullae containing blood, and there is a tendency to oedema of the subcutaneous tissues. The spots are not limited to the skin, but are seen also on the mu- cous membrane of the mouth and fauces, and on the conjunctiva. The gums are spongy and bleeding, and the presence of a similar condi- tion of the mucous membrane in hidden parts of the economy is recog- nized by hemorrhagic discharges from the nose, lungs, bowels, uterine cavity, and sometimes from the bladder and kidneys; and after death, spots of ecchymosis are found in the greater number of the organs of the body, beneath the serous membranes, and between the coats of the arteries and veins. The constitutional symptoms of purpura haemorrhagica are a repe- tition of those of purpura simplex, but in a more severe degree ; there 314 HEMIC AFFECTIONS. is more languor, lassitude, prostration, and muscular debility. The pulse is feeble and quick; there is 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 an hemorrhage, or from the effusion taking place in a vital part. 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 vicissitudes 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 exagge- rated character. There is more physical prostration, 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 blad- der 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 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 less pruritus, and the wheals are less evanescent. When of a reddish hue, they have seemed to belong rather to erythema tuberosum than to urtica- ria ; they are somewhat elevated, generally well-defined, and soon become purple and livid, after which they subside slowly, leaving behind them brownish-yellow stains; as they are successive in erup- tion, they may be seen in all their stages at the same moment. They occur, for the most part, on the lower limbs, and are commonly attended with some degree of oedema. We 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 we have also seen it associated with eczema in a person of gouty diathesis and intemperate habits. Purpura senilis is not very unfrequent in elderly women, par- ticularly in those whose arms have been much exposed to local irri- tants of different kinds, such as the sun's rays, water, &c, and is always to be met with in our workhouses. It is associated with a preter- natural degree of thinness of the integument, which is embrowned, TREATMENT of purpura. 315 yellowish, and mottled, sometimes smooth and sometimes rigid and wrinkled. " It appears," says Batemen, " 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 arms was left of a brown color." The general health is in nowise affected, 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 ; and the persistence of the spots under pressure with the finger, 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 gene- rally 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 wakening 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, pur- pura is easily induced, and the affection is unimportant; in others, the system of the individual only yields when overpowered, and the dis- ease is therefore grave. In the first of the cases of purpura simplex above narrated, the mal-assimilation was induced by fatigue, absti- nence, and a certain degree of mental anxiety, perhaps aided by some unknown miasma, proceeding either from the 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 was 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 not very important; but purpura hemorrhagica is always serious, in consequence of its complication with internal hemorrhage, which may take place in a vital organ, as in the lungs, and prove suddenly fatal. Treatment.—Originating in debility, our treatment must be strengthening in its operation. It may be necessary at first to regu- late the digestive organs aud secretions; and when this is effected, 316 developmental and nutritive affections. we must have recourse to tonics, such as bark with sulphuric acid, the citrate of iron and quinine, or the nitro-muriatic acidwith bitters. The diet should be generous but moderate, and consist of meat and wine, to which, in sea scurvy, we may add lemon juice and potatoes, with a proper allowance of malt or spruce beer. Locally, benefit may be obtained from the use of tepid baths, with the free use of the juniper-tar soap. Moderate stimulation of the skin may also be attempted by means of lotions containing the sesquicar- bonate of ammonia, or the bichloride of mercury with the emulsion of bitter almonds. These latter applications are especially suitable in the urticating form of the disease. CHAPTER XII. DEVELOPMENTAL AND NUTKITIVE AFFECTIONS. Under this head we have assembled some important alterations of structure of the skin, alterations which are not the result of inflam- matory action, but which are nevertheless equally grave in their ten- dency to determine disease of the cutaneous organ. The terms defect of development and defect of nutrition, taken in their widest sense, express the fundamental cause out of which these affections have their origin; and if we assume a series of conditions precisely opposite to those of health, we shall then have before us the leading features of these diseases. Thus, if we assume the skin to be entirely abnormal in its character, to be hard, dry, thin, inelastic, brittle, discolored, rough, scaly, and in parts too small for the body it has to contain, we shall then have a fair-word picture of a state of disease to which we give the name of xeroderma, or dry skin (l^goj, aridus). If, in the next place, we regard only the surface, and look upon an epidermis which is rough, uneven, sordid, broken up into ragged plates, or into smaller fractions corres- ponding with the areae of the lines of motion of the skin, we shall then have suggested to us the idea conveyed by the term ichthyosis {iz9va, fish-skin), a scaly covering like that of a fish. If, in addition to these two conditions, we suppose an altered state of the sebiparous function, and an accumulation of the sebaceous substance on the skin in the form of dark gray or greenish scales or spines, suggesting the idea of the coat of a lizard (oav^o?), we then have a form of the affection to which we have attached the term sauriosis. Or if, instead of the extreme degree of abnormality indicated by these terms, we have before us a skin which is less dry, less hard, but equally or even more discolored, that is, sordid, or, in other words, apt to the accumulation of concretions of the exuviae of the sebaceous and epidermic matter on the surface, which has originated in a previously healthy skin, and which has come on by degrees, which is, in fact, a disease, and has ZERODERMA. 317 originated out of morbid causes, we shall then have a state which we have denominated cacotrophia vel cachexia cutis. The diseases included under this head are, therefore, four in number:— Xeroderma simplex, Xeroderma saurioides, ichthyoides, Cacotrophia cutis. XERODERMA. • Xeroderma is congenital; it presents the appearance of a dry, impoverished, discolored, ill-developed, and ill-nourished skin. In'a young child possessing such a skin, we may find, instead of the smooth, pliant, elastic, fresh, healthy pellicle of infancy, the dry, wrinkled, tough, and discolored skin of extreme old age. We see at a glance defect of development and defect of nutrition. The characters of the disease are too obvious to be mistaken. The defect of development and growth of the skin is often curiously manifest on the face, where the skin appears to be too small for the features. The eyelids are insufficiently large, the nose looks pinched, and the skin is stretched across the cheeks. It is equally exhibited on the hands and on the feet; the bones have grown faster than the skin; the fingers look contracted, and the knuckles of the metacarpo-phalangeal articulation crop up in what should be the middle of the back of the hand. The same singular want of relation between the substance and the envelope is seen in the feet. On other parts of the body, as on the neck, the skin forms wrinkles, from its hardness and want of elasticity; and on the upper arms and legs hangs loosely about the limb, from the total absence of fat in the subcutaneous cellular tissue. Another peculi- arity is observed in the palms of the hands, where the skin is thick, dense, and rigid, dry to the touch, and deeply marked by the lines of motion; and the nails are very generally brittle and imperfect. The color of the skin is a grayish yellow, which gives it a dirty look that no washing will remove; and the scarlet tint of the arterial blood seen through the more vascular parts of the integument, as of the face, has a strangely dull and unnatural appearance. The epidermis necessarily participates in the abnormal state; besides being discolored, it is imperfectly elaborated ; it is inelastic and fragile, and breaks up into segments of various size and shape; the size of the broken particles being in some measure dependent on the organi- zation of the cuticle, and in some measure upon the distribution of the lines of motion of the part. On the scalp the detrita of the epider- mis are furfuraceous, as is common in that situation; on the face and cheeks the cuticle exuviates in thin plates, and the surface is rough- ened by the ragged edges of these plates; behind the ears, on the eyelids, around the mouth, upon the neck, over the front of the chest and trunk, and in the bends of the joints, the exuviation is farinaceous; on the limbs and back the cuticle is broken up into polygonal scales; and on the palm of the hands and sole of the feet it is thrown off in plates of considerable extent. 318 developmental and nutritive affections. These various appearances assumed by the epidermis in the exuvia- tion of its superficial layers, varieties that admit of a simple physiolo- gical explanation, have suggested an equal number of distinguishing terms. Thus the squamous form of marking of the epidermis gave origin to the specific term ichthyosis, and the varieties of ichthyosis, according to different authors, are numerous; for example, the branny and mealy exfoliation of the cuticle, as seen on the head and neck, and flexures of the joints, is an ichthyosis furfuracea and farinacea. The net-like tracery of the lines of motion, marked by a white ragged edge, and usually seen upon the legs, has originated the term ichthyo- sis reticulata ; the areae of these same lines, usually smooth and glossy, have given rise to the term ichthyosis nitida; and a certain nacreous translucency of the same areae is the ground of a nacreous variety (ichthyose nacre'e) admitted by Alibert. The modifications in the form of the scales of xeroderma ichthy- oides are referable, as we have seen, to those anatomical relations of the epidermis to the corium that we have already studied in the first chapter of this book; and we may, by a careful inspection of the sur- face of the skin in a state of health, predict the form and arrangement of its elements in a state of disease. In the minute subdivision of the surface by the lines of motion on the eyelids, on the front of the neck, and the flexures of the joints, we see a contrivance for the production of a powdery or farinaceous desquamation; in the smooth interstices between the hair-follicles of the scalp we see the mould of the fur- furaceous scales which it casts off in such great abundance. On the legs we see the broader areae, that are sometimes rough and dirty, and sometimes glossy and silvery in hue; in other parts we find small polygonal beds, that create a scale which is small and thick; is apt to adhere very firmly, and to be cast seldomer than in other situa- tions. Such parts are the abdomen, the inside of the thighs, and the convexities of the joints; and these smaller, harder, thicker, and generally dirty scales, have suggested the idea of a serpent's skin, ichthyosis serpentina. The history of xeroderma and ichthyosis is a narrative of a general degradation of structure of the skin, in which all the tissues partici- pate ; the corium is hard and thin, and ill-nourished; not unfrequently, in the hands and feet, breaking into deep fissures; the cuticle and the nails are imperfectly formed and brittle, and the former prone to break up into scales; and the glands of the skin are equally involved in abnormal action. Not unfrequently there is a total absence of per- spiration, or only a partial perspiration; and sometimes the sebiparous glands fail in their function completely, or, continuing to secrete, pro- duce a sebaceous matter, which is altogether altered in its quality from the ordinary standard. Instead of flowing forth upon the skin and being lost, it seems to become blended with the cuticle, to inspis- sate and dry up into horny masses, which go on increasing in size until they attain considerable length. We are thus introduced to a new form of ichthyosis, one in which the sebaceous substance plays a conspicuous part, and one which presents characters so widely different from epidermic ichthyosis as XERODERMA SIMPLEX. 319 to deserve a different designation. The disease in question is a seba- ceous ichthyosis, and as the sebaceous matter dries up into a kind of horn, we may also term it horny ichthyosis, ichthyosis sebacea cornea. Horny ichthyosis, like epidermic ichthyosis, is dependent on the organic state of alteration of the skin that we have previously termed xeroderma; and the abnormal skin may remain stationary in its xerodermatous form ; or it may become an ichthyoid desquamation ; or it may assume the characters of the form of disease at present under consideration, namely, a corneous ichthyosis ; or, and not improbably, the whole of these forms may be present together on different parts of the surface; on one part we may find simple xero- derma ; in another, squamous ichthyosis; and in a third, as upon the abdomen, the inside of the thighs, and around the joints, the character of the affection may be an ichthyosis cornea. The sebaceous substance poured out upon the surface of the skin adheres to the epidermis with considerable tenacity ; so much so, that an attempt to pick off one of the* scales generally results in tearing the cuticle and producing an excoriation. At its escape from the sebife- rous ducts, it is a greasy paste of a whitish hue, speedily becoming gray and brown in color, and is moulded into a scale-like shape by the form of a little area to which it adheres, and by the mutual pres- sure of similar concretions, occupying neighboring areae. This pecu- liarity is the more conspicuous when the scale, by constant addition to its surface and growth from below, assumes a more considerable length, and is converted into a spine. The spines may attain the length of a quarter or half an inch, are uniform in height, rounded at the angles, and have a rounded base. Ichthyosis sebacea, from the nature of its growth, presents two varieties. In the one, the concretion never exceeds the dimensions of a pretty thick scale, this is ichthyosis sebacea squamosa; while in the other the scales go on increasing in length until they acquire the character of spines, this latter is ichthyosis sebacea spinosa. The gen- eral appearance of ichthyosis sebacea, as compared- with ichthyosis epidermidis; its thick and convex scales, firm and horny, of a green- ish-brown color, and uniform in dimensions, is such as to suggest the skin of a saurian reptile, for example, of a lizard rather than a fish; and with this view, we have termed it "sauriderma:" sauriderma squa- mosum and sauriderma spinosum. There are no constitutional symptoms belonging to xeroderma ichthyosis and sauriosis; they are purely local in their nature, dependent on congenital mal-development and subsequent mal-nutri- tion. Xeroderma simplex.—This term is reserved for the milder form of the affection, in which the all-prevading dryness of the skin, with constant desquamation, is the predominating character, a state that hardly deserves to be distinguished by the term ichthyosis, but which by neglect might degenerate into that disease. Ichthyosis, in its progress towards cure, passes through the state of xeroderma, and a cured ichthyosis not unfrequently presents the characters of xero- derma for the rest of life. 320 DEVELOPMENTAL AND NUTRITIVE AFFECTIONS. The signs of xeroderma are, a dry and parched state of the skin of the whole body, especially remarkable in the hands; the back of the hands being dry and wrinkled, the palm thick and hard; a dryness and roughness, often a glossiness of the face and sometimes a seem- ing greasiness of its surface; and an unpleasant odor of the whole integument. The hair is usually scanty; the person is thin ; there is commonly an absence of perspiration; and the pulse is apt to be unnaturally quickened by violent or rapid muscular action. The appearance of the skin is not very unlike "that which succeeds eczema infantile; the chief difference being the absence of the dispropor- tionate growth of the skin to that of the body it invests, and par- ticularly the hands and feet, which is met with in xeroderma. XERODERMA ICHTHYOIDES. Syn. Ichthyosis vera, simplex, vulgaris, congenita, mollis, furfuracea, ■reticulata, nitida, serpentina ; lepidosis ichthyosis, Mason Good«$ ichthyose nacrie, Alibert; Fischschuppe- naussatz, Germ. ; fish-skin disease. Xeroderma ichthyoides, or ichthyosis vera, is known by the squamous forms assumed by the exfoliating and desquamating epi- dermis. The epidermis has a grayish or dirty tint; it is more or less broken up into polygonal scales, corresponding with the size and form of the areae bounded by the lines of motion of the skin ; the lines of motion are ragged; and in the hands and feet the corium is apt to split in the course of these lines. The texture of the skin exhibits throughout a state of defective nutrition; this is least conspicuous in the face, but 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 move- ments 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 for- wards on the subcutaneous fascia, as if there were no binding tissue 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 movements 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. The pores of the follicles, both sebi- ferous 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 xeroderma ichthyoides. 321 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. In a case which we have illustrated among our " portraits of diseases of the skin,"1 the subject was a little girl between five and six years of age, 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 decrepi- tude. The general tone of color of the skin was a yellowish gray, but the hands wer*e 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 back 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 palm 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 metacarpophalangeal joints the fissures were so deep as to sever the integument com- pletely. 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 metacarpophalangeal articu- lation 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 the 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 nacrce, 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 reticula- tions, from their regularity of shape and smooth polish, resembled ' Plate XXXVII. S. 21 322 DEVELOPMENTAL AND NUTRITIVE AFFECTIONS. more or less closely the silvery scales of certain fish ; and occasionally, when the reticulations were of small size and irregular, and the cen- tre of each scale thicker and more deeply colored than its border, the idea of the scales of serpents was suggested, 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 elsewhere, 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 numerous wrinkles correspond- ing with the movements of the joints, and along its borders were several deep chaps. The soles of the feet exhibited the same pecu- liarity 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 sur- face 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 subcutaneous fat, are quite remarkable. Sometimes, however, the face has a peculiar coppery redness and an oily polish, which con- trasts all the more with the earthy, dried, and mealy or scaly epider- mis of the rest of the surface. The skin of the hand is also remark- able 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. We recollect well the shudder that passed over us when we 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 respi- ration and action of the heart; and one of our patients informed us that alter a dance, he panted for breath, he had violent palpitation of the heart, and his brain seemed to reel, from want of air, and from a feeling of suffocation. Xeroderma saurioides, sauriosis or ichthyosis spuria, is a xero- derma, in which, besides the ordinary symptoms appertaining to that disease, there is also an accumulation of sebaceous substance on the surface of the skin, the sebaceous substance undergoing inspissation by desiccation, and one while assuming the form of scales, sauriosis squamosa, vel sauriderma squamosum; and another while of spines, sauriosis spinosa, vel sauriderma spinosum. sauriosis spinosa. 323 Sauriosis squamosa, when congenital in its origin, is a general affection; and when it does not present the squamous form, the state of skin constituting xeroderma is present. Sometimes, however, it is accidental in its development, and partial in its manifestation. The squamae are most abundantly developed on the abdomen; on the thin skin of the inside and front of the thighs ; on the inside of the arms : on the flexures of the limbs, and on the neck. Dr. John Ogle has published the case of two sisters, aged ten and fourteen, in whom the disease made its appearance after perverted nutrition of the skin consequent on vaccination. Ecthymatous pustules and ulcers followed the vaccination, and at a later period the skin in certain situations became hard and dry, a dark-colored sebaceous secretion formed on its surface; and this sebaceous deposit, taking the shape of the normal areae of the skin intervening between the lines of motion, presented the character of prominent horny scales. The situations chiefly affected were the hollow between the deltoid and pectoral muscle; the sides of the chest; the knees and legs; and especially the ankles and dorsum of the feet.1 The accidental form of sauriosis squamosa is commonly met with in elderly persons, and is developed on the face; usually on the cheeks, and sometimes on the temples or on the side of the nose. It is a con- cretion of sebaceous substance, of a dark gray color, hard and closely adherent to the skin, generally implanted on a patch of congested skin, and leaving an excoriation when removed with force. These inflamed spots are usually obstinate, and indisposed to take a curative action. Sauriosis spinosa, or ichthyosis sebacea spinosa, is a form of the affection in which the scales grow to a considerable length, and are termed spines; the disorder being named in consequence, the porcu- pine disease. The spines are developed more or less generally over the surface of the body, and are sometimes partial, being limited to the region of the joints. With regard to length, we 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 the 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 skin upon which it is implanted, and to which it is firmly adherent; but by degrees, as the activity of the secreting func- tion subsides, the base becomes reduced to a slender pedicle, and is easily broken off. Examined with the microscope (Plate VI. fig. 5), the spines are found to possess all the general features which might be expected a 1 Medico-Chirurgical Transactions, vol. xlvi. 18i!3. 324 DEVELOPMENTAL AND NUTRITIVE AFFECTIONS. A spine from a " porcupine boy." The spine is magnified nineteen times. It contains in its structure a group of downy hairs, which form convoluted bunches here and there. priori to be present in small cylinders of desiccated sebaceous sub- stance ; they are sub-fibrous, and obscurely laminated; the surface is more or less notched and jagged, the apex somewhat split, and the base frequently con- nected with a broad lamina of exfoliated epi- dermis. Their internal structure is still more characteristic; they generally contain, im- bedded in their substance, several^ minute hairs, sometimes running in a serpentine man- ner through their entire length, but more fre- quently coiled and twisted, and evidently fixed in that position previously to their ex- cretion by the sebiferous ducts. These obser- vations lead to the inference, which we believe to be true, that the spines 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. 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 horn-like mass. These peculiarities are rare, and no purpose is gained by their separation from the typical dis- order. Cacotrophia cutis is a state of the skin which is common to every period of life, but which we have met with most frequently in young women. It occurs for the most part in the face; the skin loses its tint and its freshness; becomes thin and discolored, and resembles parchment or leather rather than living integument. Of two cases which have recently come before us, two ladies of the age of twenty and twenty-five, one originated in a state of cachexia induced by dis- order of the womb, and the other in defective nutrition of the skin, the sequel of typhoid fever. Diagnosis.—The only disease with which xeroderma can be con- founded is eczema squamosum, or the dry, harsh, and thickened state of the skin which sometimes follows eczema infantile. Ichthyosis is essentially a pathological condition of the epidermis, the latter being produced in scales resembling those of a fish, while sauriosis is distin- guished by thicker and harder scales, sometimes spines, resulting from accumulation of the sebaceous substance; the former are white, translucent, and shining; the latter grayish or brownish dirt-colored, and opaque. Both are unlike any other affection, and totally dis- similar to the desquamation of inflammatory disorders of the skin. Sauriosis squamosa of the face we have known to be mistaken for a malignant disease. hypertrophic and atrophic affections. 325 Cause.—The cause of xeroderma and its allies is a special debility of the skin, originating probably in general debility. These affec- tions are congenital, and frequently hereditary. In a family of four children born in India, two are the subject of xeroderma, the other two being free; the disease is congenital and idiopathic. Dr. Ogle's cases of sauriosis took their origin in a debility of tissue consequent on vaccination, and possiblytin neglect of the skin. Prognosis.—As a modification of development and nutrition rather than a disease, these disorders are free from any danger, and admit of being greatly improved by proper treatment, if not wholly cured. Treatment.—The treatment of xeroderma and cacotrophia cutis is to strengthen the skin by moderate stimulation, applied both ex- ternally and internally; externally by local means, and internally by the judicious and careful administration of arsenic. The local remedies are, ablutions with the juniper-tar or carbolic acid soap ; the Turkish bath, when it can be obtained conveniently ; alkaline lotions or ointment; and anointing the skin thoroughly with neat's-foot oil or benzoated lard after the ablution or bath. As the cure advances, some mild stimulus may be added to the local remedy. By the aid of a few washings and a few baths, all the scales and sordes can be removed from the skin, and it is not difficult after- wards to keep them in subjection. In the sauriderma squamosum of the face of elderly persons, the squamae should be removed in the first instance with the help of the starch or arrowroot poultice. The juniper-tar soap should be used twice in the day, and a mild stimulating ointment after the ablutions. The best ointment for this purpose is one of the ammonio-chloride of mercury (one part to three of benzoated lard), with ten grains of camphor to the ounce; or, if a lotion be preferred, the bichloride of mercury in emulsion of bitter almonds will be found of service; alka- line lotions and ointments are also very serviceable. For cacotrophia cutis, ablutions with the juniper-tar or carbolic acid soap, a lotion of the bichloride of mercury in emulsion of bitter almonds, and the internal administration of arsenic is the proper treatment. The resort to arsenic presupposes that all the usual indi- cations of regulation of the digestive organs and secretions have been attended to, in addition to any special indications belonging to the particular case. CHAPTER XIII. HYPERTROPHIC AND ATROPHIC AFFECTIONS. By hypertrophic and atrophic affections, we mean on the one hand enlargements of the skin resulting from superabundant growth, and the opposite condition to this, namely, wasting of the skin. Hyper- trophic affections are illustrated by the common tegumentary mole, 326 hypertrophic and atrophic affections. naevus hypertrophicus; by the ecphymata or excrescences of the skin, a group which includes tegumentary molluscum, verruca, and clavus: by excessive growth of the integument, tending to throw it into pendulous folds, dermatolysis; by a thickening of the epidermis, pachylosis; by an abnormal growth of the fibrous tissue of the skin, kelis; by induration of the corium, and also of the subcutaneous cellular and adipose tissue, sclerosis; and by excessive growth of the integument and subcutaneous tissues, with infiltration constituting boucnemia tropica or Barbadoes leg. Atrophic affections are less numerous, and are limited to wasting of the skin, or extreme indura- tion and contraction. In a tabular form, the hypertrophic affections may be enumerated as follows:—■ Naevus hypertrophicus, Pachylosis, Ecphyma, Kelis, Dermatolysis, Sclerosis, Boucnemia tropica. NAEVUS HYPERTROPHICUS. Syn. Spilus; noivus maternus ; epichrosis sjo27ms, Mason Good ; Pigmentmuttermdler, Germ. ; moles; mother's marks. Naevus hypertrophicus, or common tegumentary mole, is for the most part congenital, but is occasionally developed at a later period of life. It is a simple enlargement of a portion of the skin, with an increase in some instances of one or other of its component tissues, but without any morbid alteration. In one form of the affection the hypertrophy extends to all the tissues of the integument without distinction, and we have as the result a simple prominence of the skin of small extent, and usually circular in its form ; this is the naevus hypertrophicus vulgaris. In another instance, besides simple enlarge- ment of the integument, there is an increase in the quality of the pigment of the part, rendering it brown or more or less black on the summit, this is naevus hypertrophicus pigmentosus ; and a third form is distinguished by a growth from the summit, of a tuft of hair more or less considerable, this is the naevs hypertrophicus pilosus. The varieties of naevus hypertrophicus may therefore be stated as follows:— Naevus hypertrophicus vulgaris, " " pigmentosus, " " pilosus. Naevus hypertrophicus vulgaris is a tegumentary prominence of the skin, of circular figure, bald and smooth or wrinkled, and not distinguishable in color from the surrounding skin : it is most com- monly met with on the face and on the back. Naevus hypertrophicus pigmentosus, or pigmentary mole, is commonly less prominent than naevus vulgaris, and is remarkable for its color as compared with the surrounding skin. With increased energy of growth of the affected spot, there is also a more energetic N.EVUS HYPERTROPHICUS. 327 production of pigment, which varies in tint of color from a yellowish brown to a deep black. Pigmentary naevi are generally of small size, and circular in form; at other times they are large and irregular in figure, and occasionally have been known to cover one-half the face, or a considerable portion of the trunk or limbs. They are most fre- quently met with on the face, and next in frequency on the back. Njsvcs hypertrophicus pilosus is a prominence of the integu- ment of a similar character to naevus vulgaris, but covered by a growth of short and stiff hairs, sometimes of considerable length, and associated with an increased production of pigment in the rete muco- sum. Pilous naevi are met with on all parts of the skin which are normally organized for the growth of hair, and are only constantly absent in the palm of the hands and sole of the feet. We see them often on the face as a single small prominence covered with hair; sometimes there are more than one, and they are not unfrequently intermingled with naevi pigmentosi; at other times they occur on the trunk of the body or limbs in single patches of considerable extent, or as numerous patches dispersed over the skin. 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. ViHerine*, in his article on the hair, in the Dictionnaire des Sciences Medirales, 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 hair, shorter, and not quite so thick as the bristles of a wild boar, but presenting considerable analogy with them. This hairy covering, with the spots upon which they grew, occupied per- haps one-fifth of the surface of the body." Cause.—Tegumentary naevi are for the most part congenital, and sometimes hereditary; and we must regard their origin as being phy- siological rather than pathological. Like vascular naevi they are termed mother's marks, from the popular belief in their dependence on the imagination of the mother during pregnancy. Daniel Turner records the case of a girl who "was born all over hairy, from the mother's unhappy ruminating and often beholding the picture of St. John the Baptist hanging by her bedside, drawn in his hairy vesture." And, on questioning a boy as to a naevus pilosus of some size on the side of the jaw, he informed us that the patch represented a sucking pig that his mother had longed for during her pregnancy. Treatment.—We are sometimes consulted as to the removal of tegumentary naevi, not on account of any inconvenience attending them, but on the ground of their occasioning deformity. They are easily removed by the knife, care being taken to direct the incisions in the line of the ordinary folds of the skin. But we prefer to effect their destruction with the potassa fusa. A point of potassa fusa is introduced into the centre of the naevus, it diffuses itself through the areolar mass; the disorganized tissues dries up into a scab, and falls 328 HYPERTROPHIC AND ATROPHIC AFFECTIONS. off in ten or fourteen days, leaving very little trace of its existence. This method of treatment is applicable to naevi of small size only: when of considerable extent, they are beyond the control either of knife or caustic. . ECPHYMA. Ecphyma, from tx a sea bank, a mole; in other words, a ridge protruding above the level of the surface. Besides the preceding, Alibert had another reason for employing the term "cancroide," namely, that of associating the disease with cancer. The cancroides, 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, 340 hypertrophic and atrophic affections. if ever, pass 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 spontaneously. 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. War- ren calls it a " troublesome and dangerous disease." Troublesome it is certainly, but not dangerous; and the case upon which Warren founds his inference of the danger of kelis, we believe, to have been 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 con- siderable 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 enlarge- ment, including all the textures of the face and gums." Alibert records twelve cases of kelis; Rayer, five; Biett, three; Gibert, two; and Warren, one. Of the twelve cases reported by Alibert, eight occurred 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 seven cases noted by ourselves were, on the contrary, 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. In a good example of kelis illustrated in our " 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 us. 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 its border. On a first inspection, the morbid excrescence had the appearance of the cicatrix of a burn, and, upon closer examination, the only char- acter at variance with that idea was its elevation from the surround- ing 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 1 Portraits of diseases of the skin, Plate XLIV. R. KELIS. 341 diameter of the kelis, 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 depression 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, several small meandering bloodvessels, apparently veins, collecting the returning blood from minute tributaries. To the touch the kelis gave the 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 us 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 par- ticularly as the pain was evidently on the increase. At times he suf- fered from excessive itching; at other times the pain was smarting, burning, and 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 move- ment which produced pressure on the growth, such as bringing the 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 has 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 cylin- drace'e, Alibert), and, like the preceding, is accompanied by its satel- lite, 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 at the extremities than in the middle ; measuring at its narrowest point one-quarter of an inch; at is upper end three-eighths of an inch; and at the lower end five-eighths of an inch. Its elevation was about one line. The patient is not aware of any cause for this disease, either local or 342 hypertrophic and atrophic affections. 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 anything 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), 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 at one end than at the other, and the connecting ridge 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 some- what 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 Assur- ance Society, had his attention drawn about eight years since, in con- sequence 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 sur- rounding skin frequently recurred, more especially after any kind of mental or physical excitement, after taking wine, after walking, or KELIS. 343 upon getting warm. Occasionally there were, superadded to the pru- ritus, sensations of smarting, stinging, burning, and prickling, par- ticularly on the occurrence of atmospheric changes. In speaking of these sensations, 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 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 in- distinct 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 circum- ference. In consequence of the tension of the skin, the prominences 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 longitudinal 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 us that, at the acme of its growth, it had an elevation of three-quarters of an inch at the 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. Since the date of our special inquiry into the nature of kelis, in 1851, we have seen many cases of the disease; one occupying a large extent of surface on the left breast, occurred in an American gentle- man. When the tumor first appeared, it was removed by operation, and the result of the operation has been a great increase of the disor- der. In another case the patient is a lady, whose chest is covered with a crop of small tubercles, twenty or thirty in number, and vary- ing in diameter from three to six lines; and another case is also that 344 HYPERTROPHIC AND ATROPHIC AFFECTIONS. 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. Diagnosis.—Kelis is dissimilar to every other affection of the skin; its resemblance to a cicatrix where there has been no previous injury; its elevation; the sensation communicated to the finger, soft on the surface, and like fibro-cartilage more deeply; its manifestly fibrous structure; its scanty supply of bloodvessels; the absence of any ten- dency to ulcerate; these are its characteristic signs. The tubercular form is recognized by the hardness and whiteness of its little tumors, and the absence of signs of cutaneous cancer, such as dilated veins and enlarged lymphatic glands. The traumatic form is nothing more than the unseemly growth of a cicatrix, a cicatrix which, instead of remaining smooth, throws up ridges and bands and cords of white fibrous tissue, and becomes uneven and ugly. We saw lately a little child that had a traumatic kelis on the hip in the cicatrix of a scald; and the motions of the limb are considerably impeded by the thick- ness and rigidity of the injured skin, and will probably remain so for the rest of life. Cause.—The cause of kelis is the development of a normal process in an abnormal position. Its essence is debility, for the change that takes place is one of degradation of structure; it is the accumulation of a lower in the place of a higher form of tissue, of a non-vascular white fibrous tissue, in lieu of the highly organized corium, and the still more highly organized pars papillaris. These considerations, it is true, do not help us much to the comprehension of the nature of the cause which determines the abnormal physiological process, but they may help us somewhat in laying a sound basis of treatment. In one instance we have evidence of a diathesis; the daughter of the physi- cian whose case is mentioned above, has her shoulders and back sprinkled over with small keloid tumors which have succeeded the papulae of acne. In this example, we perceive that the exciting cause may be trivial; Rayer has noted the development of kelis from the cicatrices of smallpox ; from a punctured wound ; and Alibert from a slight scratch; while in three cases seen by ourselves, one followed a boil, another the application of a stimulating liniment to the chest, and another rose upon the seat of a blister. Mr. Longmore has pub- lished two cases of kelis, one idiopathic, the other traumatic, and resulting from the injury to the skin done by military flogging; and he mentions that Dr. Maclean had seen two cases which followed flogging. In the traumatic case the tumor was an inch thick; and in that which was idiopathic, the disease formed an irregular trellis work of ridges and hollows over the whole back; while other tumors were developed on the face, on the front of one shoulder, and the lower part of the chest, those parts of the body which were pressed by the belt and shoulder-straps being the ones chiefly affected.1 In the Guy's Hospital Reports there is also a notice of a case which followed syphilitic ecthyma. 1 Medico-Chirurgical Transactions, vol. xlvi. 1863. SCLEROSIS DERMATOS. 345 Prognosis.—Kelis will sometimes undergo absorption and disperse spontaneously; but it must be confessed that this desirable change is very rare; more frequently it preserves a permanent hold on the skin, sometimes passive, at other times active and disposed to spread. Our prognosis as to cure is far from favorable. Treatment.—The treatment of kelis offers the two usual indica- tions, namely, constitutional and local. By constitutional treatment we may hope to modify and strengthen the structure of the skin, and bring about a change similar to that which happens in examples of spontaneous cure. The remedy suited for this purpose is arsenic, and we believe that we have seen very good results follow its use, and that of the liquor hydriodatis hydrargyri et arsenici. A protracted course of iodide of potassium or iodide of ammonium, or the bromide of potassium, may also be tried with a fair prospect of success. Locally, steadily continued pressure would undoubtedly be benefi- cial if it could be attained; and frequent pencilling with the liquor plumbi diacetatis not only allays irritation, but has seemed in some instances to be of service in contracting the size of. the tumor. An ointment of the iodide of lead is also suitable, with the same object. We may endeavor to disperse it by the application of the compound tincture of iodine, by compresses soaked in a solution of the iodide of potassium or ammonium, by the use of ointments containing the same salts; or by chloride of zinc, creasote, or carbolic acid. The destruction of the tumors has been attempted with the potassa fusa, but with no good results; and there is always the danger in employing irritant remedies, of their increasing instead of diminishing the evil, by provoking a more rapid spread of the disease. A similar remark applies to operation with the knife; the knife removes the tumor, but it does not remove the diathesis; and there is every pro- bability of the cicatrix of the wound being converted into a keloid growth. Dr. Warren reports a case operated on by the knife in which the disease broke out, not only in the cicatrix left by the wound, but also at the points through which the ligatures had passed; so that, as the result of the operation, there were seven tumors instead of one. Nevertheless, there is the hope that at some period or other of the disease the diathesis may have ceased, and then, if the patient were very desirous for an operation, it might be conscientiously attempted. As a rule, however, the less the tumors of kelis are interfered with the better; and, in some cases, with all the disposition for surgical assistance on the part of the patient, an operation would be useless, in consequence of the extent of surface covered by the morbid growth. SCLEROSIS DERMATOS." Sclerosis, or induration, may present itself in several forms in relation with the cutaneous tissues, in one instance affecting the derma proper, scleroderma or sclerosis corii; in another, the subcutaneous tissues, sclerosis telae cellularis et adiposae; and besides, manifesting itself as a congenital disorder in scleroderma infantile. A remarkable case of sclerosis corii lately presented itself to our 346 HYPERTROPHIC AND ATROPHIC AFFECTIONS. notice in the instance of an elderly lady; the part of the body affected was the leg; and the skin for the extent of five or six inches was as dense as horn or cartilage, and formed an unyielding clasp around the limb; the tissues above and below the clasp were puffed and swollen, and the foot was enlarged and tender. Sclerosis tel^ cellularis et adipose was shown in the case of a lady of thirty, who after some degree of praecordial suffering, con- sisting principally in a sense of weight and nausea, was attacked with slight erythema of the face, neck, and shoulders. The redness was inconsiderable and but slightly pruritic, but there existed an uncom- fortable feeling of weight, or pressure and stiffness, accompanied with a little swelling and a sense of rigidity, which interfered with the motion of her jaws and neck. We first saw her a few weeks after the commencement of the attack, when the erythema had subsided without desquamation, and when the more striking symptoms of the affection were paleness and a yellow tinge of the skin, with a sensa- tion to the touch of thickening, solidity, and hardness of the skin and subcutaneous cellular and adipose tissue. It was clearly evident that the density of the integument was not due to oedema; and although there was some degree of pitting on pressure, it was the kind of pitting that would be produced by pressure on a skin of lard rather than upon a portion of skin infiltrated with serous fluid. When the hand was pressed upon the skin it left a pale impression, which very slowly recovered its normal color. The lower border of this altered skin could be distinctly traced with the finger, and gradually merged into the healthy integument. The pathological changes above described are doubtless such as usher in the boucnemia tropica, which in a mild form is called the " rose," and appears to be an erythema or erysipelas of the integument, resulting in thickening and condensation. The " rose" is met with in Bermuda, and the boucnemia farther south, in Barbadoes. BOUCNEMIA TROPICA. Syn. Elephantiasis Arabum; Barbadoes leg. Boucnemia is an hypertrophy of the skin, not limited to one of its parts, as the epidermis, the pars papillaris, or the corium, but involv- ing the entire integument, together with the subcutaneous tissue, and in general the entire cellular tissue of the affected limb. It occurs for the most part in the lower extremities, and not unfrequently in the scrotum, and, as its name implies, is a disease of hot climates, being met with in the East and West Indies, in Africa, in China, and in the Polynesian Islands of the South Pacific Ocean. Its prevalence in one of the West India Islands, Barbadoes, has gained for it the name of the " Barbadoes leg," while in the East it is termed the "Cochin leg." Boucnemia attacks the foot and ankle, and gradually ascends the leg, until it involves the entire limb; and sometimes it invades both legs. The affected parts grow to a prodigious size; the thick and brawn-like integument overlaps and obliterates the toes; the integu- ment of the leg forms a thick fold, which overhangs the ankle and BOUCNEMIA TROPICA. 347 foot, and conceals the latter to a greater or less extent; and the limb is so altered from its original shape, and so deformed, as to have more the character of an elephant's leg than of that of a human being. This resemblance is all the greater from the corrugated, rough, and dis- colored appearance which the epidermis presents, and very naturally suggested to the Arabian physicians the designation dal fil, the elephant disease. The European translators of the works of the Arabian physicians conceived that the term dal fil was intended to signify the disease familiar to themselves, and described by the Greeks under the name of elephantiasis, and named it accordingly. Subsequent writers, how- ever, discovered the difference of the two diseases, and distinguished them by the name of elephantiasis Arabum and elephantiasis Graeco- rum; and thence has resulted a considerable amount of confusion, that for a long time has complicated the history of these diseases, and is not yet entirely cleared .away. We, however, diminish the difficulty very materially when we call the elephantiasis Graecorum by its proper name, Lepra, and elephantiasis Arabum by the more appropriate name of boucnemia. The characteristic features of boucnemia are the prodigious enlarge- ment of the limb, due to augmented growth and infiltration into the tissues, and a coarseness and degradation of structure of the tissues themselves. The patients whom we meet with in this country suffer- ing under the disease, are either natives of a hotter climate or have resided in warm climates for a considerable time. We have, however, seen one case of this kind of hypertrophy affecting the scrotum, in a gentleman who had never left England. Another case, which invaded the entire lower extremity of one side, the limb being three times the size of that of the opposite side, was imported from Australia; and recently we have advised an English gentleman affected with this dis- ease in the foot and lower leg, who had resided in China. The swell- ing began eighteen years previously, after a sprain of the ankle. It was unattended with pain, but had on two occasions been the seat of ulceration, which for the time had greatly diminished its bulk, by giving exit to the infiltrated albuminous fluid. In the cases which have come under our inspection, there has been no evidence of disease of veins or lymphatics, or any enlargement of lymphatic glands ; but swelling in the course of the absorbents does frequently take place accompanied with enlargement of a gland. In its pathological aspect boucnemia presents the characters of a chronic cellulitis sometimes assuming an erysipelatous type. In gene- ral it is insidious in its origin, and being unattended with pain, has made some progress before it is observed; the first sign of its existence being a feeling of tightness and weight, with swelling. At other times it makes its beginning like a simple erysipelas, followed by oedema. A mild form of boucnemia occurring in Bermuda is called "the rose," from its erythematous character, and from its never reaching the full development of the disease as met with in Barbadoes and more southern countries. It is very slow in progress; remaining stationary for a while ; and every now and then awakening to fresh 348 HYPERTROPHIC AND ATROPHIC AFFECTIONS. activity and assuming a periodic character. These periodic attacks are accompanied by some febrile action, and have given rise to a popu- lar belief in the association of the disease with intermitting fever; one of the popular titles of the affection in Barbadoes being " fever and ague." In Barbadoes it has also been considered as due to inter- rupted function of the lymphatic system, and has been regarded as a lymphatic glandular disease. Excepting during the moments of its febrile exacerbations boucne- mia is unaccompanied by symptoms of constitutional disturbance, and is consistent with a good state of general health. It occurs for the most part at and after middle life, and is more common in the male than the female. The " rose" of Bermuda is most frequent in middle- aged females of sedentary habits, and especially in such as are the sub- jects of dyspepsia and gastric derangement. Sometimes the fever of bouc- nemia is attended with a more severe exacerbation of the cold, hot, and sweating stage, and sometimes with delirium. The local uneasiness may be a feeling of heat and throbbing, and sometimes only of itching. Diagnosis.—Boucnemia when fully developed is unlike any other affection of the skin; in an incipient stage it might be confounded with that oedematous condition of the integument and subcutaneous cellular tissue which goes by the name of " white leg," and which originates in inflammation of the veins; indeed there is some analogy between the two diseases, and boucnemia may in its essence be a " white leg" of endemic or sporadic origin. Cause.—Boucnemia must be referred to endemic or sporadic causes peculiar to hot climates, but occurring exceptionally in those of a milder temperature. It may be excited by checked perspiration or excessive exertion. Prognosis.—Our hopes of cure must be very limited ; the disease is very troublesome and annoying, but not in its nature of a fatal ten- dency. Nevertheless, by inducing debility and exhaustion, and inter- fering with progression, it would eventually undermine the health. Treatment.—Removal from the country, where the disease is endemic, is an important element of cure; but our experience of the disease does no more than warrant the suggestion of means founded upon general principles; for example, the iodide of potassium or ammonium, arsenic, mercury, with local pressure and position, the use of evaporating and saturnine lotions, frictions with an ointment of the biniodide of mercury; and sometimes a blister. We advised our patient, above referred to, to commence his treatment with a course of Zittmann's decoction. Some benefit might also be anticipated from a prolonged course of tonics with the bichloride of mercury. But any plan of treatment that may be determined upon must be continued steadily for a considerable length of time. Time in this, as in many other diseases, will be an important medicine in the cure. Ligature of the main artery of the limb has been practised in several instances with success.1 1 Vide Paper by Mr. Thos. Bryant, read at the Med.-Chirurg. Society, June, 26,1866. Also cases by Dr. Carnochan, Messrs. Statham, Butcher, and Alcock, and Dr. Fahrer. ATROPHIA CUTIS. 34£ Those prodigious enlargements of the scrotum that sometimes find their way from China into our hospitals in this country, have in several instances been submitted to the knife; and it is surprising how much the Chinese constitution will bear in the way of surgical operation. ATROPHIC AFFECTIONS. Atrophia cutis, affecting the entire body, is a very rare affection, in a partial form attacking a limited extent of surface, or occurring in cicatrix-like lines, it is not infrequent. In general atrophia cutis the skin becomes thinned and stretched, and seems as if it were too small for the body which it contains. The thinness and stretching are most remarkable at the apertures of the body and in the extremities; the eyelids look too smalljto cover the eyes; the nose is pinched; the ears curled up; the teeth exposed by the contraction of the lips; and the cheeks are drawn against the jaws so as to produce a cadaveric expression of countenance. The skin of the neck in like manner is stretched, and the fingers and toes are shrunken, pointed, white, and not unfrequently ulcerated at the tips. The process is so gradual that the ends of the last phalanges make their appearance beyond the skin without much previous pain. The bone crumbles and comes away, and after a while a fresh piece is protruded, until an entire phalange may be expelled through the opening. Often, also, the tendons contract, and the fingers are more or less bent. The pain accompanying these pathological phenomena is generally very trivial; there is always great coldness, with numbness; some degree of aching; then a little pus appears at the ends of the fingers; next a chronic ulceration of no apparent moment; and then the ragged end of the bone. These phenomena remind us very strongly of ele- phantiasis anaesthetica, and suggest the idea that this curious affection may be a remnant or vestige of the ancient leprosy. A remarkable case of atrophia cutis fell under our observation in 1849 ; the patient had for some time been under the care of Nathaniel Jarvis Highmore, of Bradford, Wiltshire, and that gentleman, in a letter introducing the patient, observes: " 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 circum- stances, the subject of great mental anxiety, weak, poorly, and com- plained 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 grasping it." Some months later she fell into a state 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 medi- cine. Dr. Highmore first saw her in 1846, at which time she was '350 hypertrophic and atrophic affections. 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 neck, was hard an'd con- tracted, and of a dark olive color. When this patient appeared before us she was extremely emaciated, 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 dead- ened, 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." Another example of atrophia cutis is at present under our observa- tion in the instance of an unmarried lady, aged thirty, who had a sudden seizure of rheumatism six years back, followed by extreme cachexia and debility, but without any organic disease or any suffi- cient explanation of the extreme state of exhaustion and weakness into which she fell. At the present time she has recovered her strength in some degree, but is still thin and weakly; her features are pinched, and the skin of the face is sprinkled over with small crimson blotches that suggest the idea of purpura. Closer examina- tion, however, shows that these blotches result from a state of atrophy of the papillary layer of the corium, and the substitution for that layer of a plexus of varicose capillaries. Her hands and feet are always cold, the fingers attenuated ; the lit- tle fingers of both hands bleached and shrunken for half their length, and hard and insensible to the touch. The ring fingers are beginning to undergo the same morbid process, and together with the little fin- gers show a tendency to ulceration at the extremity. The ulceration begins without any suffering; there is a sensation as if the skin were pricked, it is sore for a week or two, the skin ulcerates slightly, and, subsequently, heals slowly. Partial atrophia cutis is illustrated in the following case occurring in a young lady of twenty. She is small for her age, of weakly con- stitution, subject to cold hands and feet, and to circumscribed conges- tions on the fingers which have been regarded as chilblains. The little finger of one hand is bent from contraction of the fibrous tissue of the joints, much smaller than natural, and tapers at the extremity to an obtuse point. The skin of the finger is smooth, hard, and pale; the bones seem to have undergone partial absorption so as to reduce their bulk; and at the extremity is a slight superficial ulceration, apparently resulting from the pressure of the skin against the end of the phalanx. Atrophia cutis linearis.—Partial atrophia cutis more frequently assumes a linear character than the general form already described. Sometimes the linear atrophy results from the disorganization of a nerve, and the affection of the skin follows the line of distribution of ATROPHIA CUTIS LINEARIS. 351" the nerve; at other times it is the consequence of pressure, as of dis- tension, which occasions a partial disruption of the corium, or pressure of the opposed borders of the integument corresponding with the lines of motion of the skin. The latter causes give rise to the cicatrix-like lines which are seen after parturition, or the subsidence of obesity; but are also met with occasionally in situations where neither of those causes is present. We have met with several examples of linear atrophia cutis from disorganization of a nerve, and most frequently on the forehead, where the line has taken the course of one of the branches of the su- praorbital nerve. The first symptom is generally a faint white line, along the borders of which the normal redness of the skin is a little increased; by degrees the white line becomes more evident, broader, and depressed, and the distinction between it and the bordering sound skin more obvious. Later, the sensibility of the affected skin is lost, the skin is withered, and a reparative process, the absorption of the damaged skin, is commenced ; and as a result of the latter process, the adjoining parts of the healthy skin are drawn together, and nothing remains but a deep linear groove resembling the scar of a sword wound. Linear atrophia cutis from parturition is met with in the integu- ment of the abdomen, and results from a gradual yielding and disrup- tion of the fibrous tissue of the corium. It occurs also on the mammae from the enlargement of the glands during pregnancy and lactation. Similar linae atrophicae in the integument of the abdomen are produced by distension caused by accumulations of fluid in the ovaries, or peri- toneal cavity, from enlargement of the viscera, or from obesity. From the latter cause, and from the pressure induced by the movements of the body, they are not unfrequently seen on the thighs, on the hips, and around the shoulders. In their early development these atrophic lines are accompanied with erythema; at a later period they are smooth, and have a bluish and glistening appearance. If they be examined with the finger, they will be found to correspond with a fissure in the subcutaneous cellular and adipose tissue; and in fat persons this fissure of the tissue gives to the subcutaneous fat a lobulated character. Dr. Wilkes describes these linae atrophicae in the Guy's Hospital Reports for 1861, and they are well illustrated in a plate accompanying his description. His cases were those of young persons in whom the disease commenced at the age of thirteen, and was not referable to obesity ; and he makes the important practical observation, that the most common cause of these lines in women being pregnancy, we are apt to consider them under the name of lineae gravidarum, as one of the proofs of a foregone preg- nancy, whereas it is clear that they may be produced independently of that state. In one of our patients, where the lines were developed on the lower part of the abdomen, and were identical in character with the lineae gravidarum, the subject was a man. Diagnosis.—The obvious signs of atrophy already described dis- tinguish this affection from the generality of cutaneous diseases; but 352 HYPERTROPHIC AND ATROPHIC AFFECTIONS. from the atrophy which accompanies elephantiasis the distinction is not so easy. Indeed, we ourselves have sometimes doubted, whether these affections might not be classed with elephantiasis anaesthetica. A similar state of the skin is occasionally seen, which is associated with a tubercular infiltration resembling that of elephantiasis tuber- culosa ; and this latter we have not hesitated to group with elephanti- asis, under the designation of morphcea lardacea. Cause.—Of the predisposing cause of atrophia it is difficult to make a suggestion; the general form is usually associated with an extreme state of nervous debility; and the exciting cause of the partial or linear kind is sometimes traceable to violent muscular efforts, such as accompany spasmodic sneezings and spasmodic cough. Prognosis.—The general form of atrophia cutis is grave; the con- stant irritation which it keeps up tends to weaken and exhaust the constitution. The linear form of atrophy is not serious, and we have seen it undergo spontaneous cure. Treatment.—Atrophia cutis being more constitutional than local in its nature, that is as regards its general form, we must have recourse to tonics, and last, and often best among these, to arsenic. We repeat here what we have already said before, that arsenic is a special cu- taneous tonic, and therefore a very appropriate remedy where loss of nervous power of the skin is specially concerned. The local treatment must consist of moderate stimulant applications, such as the unguentum resinae, or ointments containing mildly stimu- lant balsams. We have also found camphor cerate and a weak solu- tion of nitrate of silver useful adj uvants.. In cases of linear atrophy we have pencilled the part with the acetum cantharidis with advantage, and have applied liniments containing chloroform. CHAPTER XIV. ALPHOUS AFFECTIONS. Alphos, the lepra alphos of the Greeks, is one of the three vitiligoid or spotted affections of Celsus. " It is called alphos," he says, " when it is white, rough, and dispersed, resembling drops sprinkled on the skin; sometimes the spots have greater breadth than mere drops, and are apt from time to time to enlarge their dimensions." Willan adopted the term " lepra" to distinguish this disease, and, at the same time, employed the word " psoriasis" for one of its forms, associating the two words by this means; but, as this association is attended with the inconvenience of attaching two independent terms to the same disease, we proposed, in an early edition of this book, to retain the word lepra, as typical of roughness and scaliness; and transfer the term psoriasis, the representative of itchiness, to the chronic and squamous stage of psora, that is, eczema, to which, we believe, it more correctly belongs. ALPHOS. 3*3 Our colleagues of Germany and France took a different view of the subject; Hebra and Hardy have preferred the term psoriasis, and reject that of lepra as appertaining to the ancient leprosy. The ques- tion therefore arises: Which is the more correct, and, at the same time, the most convenient title for the affection? Is it lepra? Is it psoriasis ? Or, Would it be better to discard both, and adopt some other and independent term ? We prefer the latter alternative, and propose to restore the specific term " alphos," by which the disease was known to the fathers of medicine. This term was given to the disease by the Greeks, was adopted by the Latins, and was only dis- turbed by the confusion of literature which occurred during the dark ages. Lepra alphos is undoubtedly the most correct appellation of the disease; but, as the genus lepra includes besides lepra melas and lepra leuce, it would contribute materially to the clearness of the sub- ject 'to reject the word lepra, as associated with alphos, and retain it as the representative of melas and leuce, the symbols of the true leprosy. Psoriasis, on the other hand, is decidedly incorrect as applied to lepra alphos, because psora and alphos are perfectly distinct diseases; and psoriasis is nothing more than a congener of psoria or eczema, and as such we have employed it. Therefore, with the significations now proposed, the three terms, alphos, lepra, and psoriasis, would represent: the first, the lepra alphos of the Greeks ; the second, the true leprosy ; and the third, the chronic and squamous stage of eczema. We main- tain that, whether these significations be accepted or not, they approach more closely to a correct definition of the diseases than the terms at present used in Germany and France; and we record our own senti- ment on the subject in the words of an able writer, Mason Good: " It will not be the present authors fault if the correction, so generally called for in the case before us, should be postponed to another age, or the error complained of be chargeable on future nosologists." ALPHOS. Syn. Lepra, Willan ; psoriasis, Hebra, Hardy, Devergie ; lepra alphos, Greeks ; vitiligo albida, Celsns ; boak, Hebrew ; lepidosis lepriasis, Mason Good ; dartre squammeuse ; dartre furfur ace" e arrondie ; dry tetter. Alphos (Plate XII.) is an eruption of white, round, and slightly- raised spots, varying in size from two lines to an inch or two- inches in diameter, symmetrically dispersed over the surface of the body, but met with especially on the elbows and knees; and sometimes forming continuous patches of irregular figure and considerable extent. The whiteness of alphos is due to a small mound or scale of morbid epidermis formed on the surface of the spot; its roundness and eleva- tion are the consequences of its origin from a tubercle, or from a cluster of tubercles; and the size of the spot is dependent on the presence of a single tubercle; of a cluster or of an aggregation of clusters of tubercles. It is remarkable for its persistence and tendency to recur- rence, but is not contagious. At its earliest appearance the pathological element of alphos is a 23 364 alphous affections. small flattened papule (alphos punctatus vel papulosus) which occupies the circumference of the mouth of a follicle; the papule is of a dull red color, and one line in diameter ;l and in a short time enlarges to the diameter of two, three, and four lines. Sometimes it retains the latter size permanently and constitutes the form of alphos termed guttatus; at other times the redness spreads from the base of the primary tubercle, a circle of pores around it are involved, and the tubercles developed at the apertures of these pores become fused into one continuous elevated border. The patch has now attained the diameter of five or six lines, is circular in figure, has a rounded border which sometimes exceeds in elevation the central or primary tubercle, and has a tendency to peripheral growth; this is the circinate form of alphos ;' in other words, alphos vulgaris. Alphos, therefore, may exist as a single tubercle; as a cluster of tubercles more or less completely fused into a single circular mass or patch, ranging in diameter from half an inch to two inches; or it may present an aggregated character, and constitute a widely-spread patch composed of independent tubercles, connected by a common erythe- matous base; the patch being irregular in its outline, and covering a large surface, sometimes an entire limb: this is alphos diffusus. These differences in degree of development of the eruption have reference to the constitution of the patient, to the tone of the skin, or to the energy of the disease; but their chief interest consists in their being the basis upon which are founded the varieties of the disorder. An arrest of development of the eruption at the papular stage constitutes an alphos punctatus vel papulosus; its advance to the condition of an isolated tubercle is the alphos guttatus; a cluster of tubercles, blended into a single homogeneous patch, of moderate size and circular form, is alphos circinatus vel vulgaris; while an aggregation of tubercles covering a large surface, without fusion of mass, and with an irregular boundary, is alphos diffusus. This eruption presents some variety in its degree of elevation; sometimes the elevation is very slight, as in alphos papulosus, and in a pityriasic form of the disease, occasionally met with; while in the ordinary forms the prominence of the tubercles reaches to about a line. The scale or crust also exhibits differences, both in thickness and whiteness; these properties of the scale being due to the activity of morbid cell-formation, and being greater in proportion to the degree of imperfection of the structure of the cells. The most morbid con- dition of the scale is evinced by a laminated and porous structure; the lesser degree of departure from the healthy standard, by the yellowish and horny foliation of ordinary epidermis. In alphos cir- cinatus, which creeps on gradually by its circumference, the scale becomes imbricated, and has a remarkable character, being dense and yellowish in the centre, and laminated and snowy towards the circum- ference, often assuming a frothy lightness of appearance with a silvery brilliancy. In alphos guttatus the scale forms a little white cap to 1 The prominent papule of cutis anserina measures half a line in diameter at the base when round, and three-quarters of a line by half a line, when elliptical in figure. alphos. 355 each of the tubercles; and the scales of alphas diffusus are an aggre- gation of crusts of this smaller kind, accumulated often in astonishing numbers. When alphos is in process of cure, the s(/-called retrograde meta- morphosis of the eruption, the scales looser, and fall off and cease to be reproduced; leaving a smooth, red, aid slightly raised surface which gradually subsides, and eventually Returns to the natural tint and texture of the skin, without a trace of its previous existence; in the guttated variety the little elevations or tubercles sink in mass to the level of the skin; in the diffused kind, they sink here and there in the midst of the irregular patch, and form so many clearings, which go on enlarging in dimensions until the patch is wholly removed. The mode of disappearance or dispersion of the circinate kind is, how- ever, more peculiar; the patch subsides in the centre, where the skin is restored to its normal state, while it runs on by the circumference, and so forms a ring of variable size; then the ring gives way, and the patch is reduced to one, two, or more segments of the original circle. When two rings join by their circumference they form a figure of 6 ; a cluster of three produces the outline of a trefoil, and when numer- ous rings are thus connected in the state of dispersion, they give rise to a variety of irregular serpentine figures, which have suggested the term alphos gyratus. Alphos has no constitutional symptoms, and scarcely any local symptoms. It is consistent with a perfect state of health of the indi- vidual ; but as the sufferers from alphos are not protected from other diseases, the eruption may be rendered irritable, and become inflamed from the presence of different disorders ; for example, gout or eczema. In gouty persons alphos will frequently become red, tumid, and exces- sively itchy; alphos erythematosus. And in eczematous subjects the eruption may become the seat of eczematous congestion, and assume the characters of the fissured, the ichorous, and the incrusted forms of eczema. These symptoms, however, must not be regarded as belonging to alphos itself, but as being the appurtenance of the dis- order with which it is complicated. Alphos generally gives rise to no inconvenience whatever beyond the vexation of its appearance, and some little itching arising from the more active circulation attending its development and growth, and from the accumulation of the scales upon the skin; the itching being apt to be increased by the reaction of alternations of temperature, and particularly by the heat of exercise. When alphos disappears from the skin, it not unfrequently leaves melasmic stains on the spots occupied by the patches; and at other times the skin around has become darkened, while the seat of the patches is bleached. This melasmic discoloration is usually attributed to the stimulant action upon the skin of the arsenic used in the treat- ment of the disease; and in many instances, no doubt, this explana- tion is correct. It is evidently so in the case of diffused melasma with bleached patches; but we have noted cases in which melasmic stains were present, and where no arsenic had ever been administered. In these latter examples the congestive energy of the skin had sup- 356 ALPHOUS AFFECTIONS. plied the place of the stimulus attributed in other instances to arseni- cal action. i The principal varieties of alphos are three in number, namely :— •> Alphos circinatus, Alphos guttatus, Alphos diffusus. To which may be added as accidental forms, alphos papulosus, alphos pityriasicus, and alphos gyratus ; and certain local forms; for exam- ple, alphos capitis, alphos faciei, alphos manuum, and alphos articu- lorum. Alphos circinatus vel vulgaris1 (Plate XII. A B), the lepra vulgaris of Willan; the psoriasis vulgaris of most modern authors, and the psoriasis ^nummularis, discoidea, circumscripta, and orbicularis of Hebra, is the common form of the disease. The patches are de- veloped in the semblance of circular disks, of an average diameter of one inch; they enlarge by the circumference, and in process of cure subside at the centre, and are converted into rings (a. annulatus). Alphos circinatus is the most strikingly-marked form of the disease; in it, the circular figure, the depressed centre, the raised border, and the laminated and porous scale are best exhibited. It is met with on the fleshy parts of the body, as of the trunk and limbs; while on the elbows and knees, where it is constantly present, it loses its circular figure, and becomes irregular and diffused. Alphos guttatus2 (Plate XII. C), the lepra alphoides of Willan, is rare as compared with alphos circinatus; it presents the tubercular type of the disease in a persistent form, has a thinner and less arti- ficially developed scale than the preceding, and no tendency to grow by the circumference and subside by the centre; on the contrary, its summit is always the most prominent part of the eruption, and the average diameter of its tubercle, two lines. Alphos guttatus is commonly intermingled with patches, composed of several tubercles, which approach in size the smaller disks of alphos circinatus; it is for the most part dispersed over the trunk of the body, and sometimes on the limbs. In a case of alphos guttatus now before us, there are about eighty tubercles and patches, scattered over a surface as large as the 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 clus- tered 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. If there be any eruption present on the elbows and knees, it presents the diffused character, as in alphos circinatus. 1 A good example of alphos circinatus, under the name of lepra vulgaris, will be found among our portraits of diseases of the skin, Plate XIII. T. 1 Portraits of diseases of the skin; Plate XV. A M, exhibits a good example of alphos guttatus, under the name of psoriasis guttata. ALPHOS GYRATUS". 357 Alphos diffusus1 (Plate XII. H I) is the lepra inveterata of Wil- lan, and is remarkable for the large size of its patches, often covering an entire limb, and in rare instances the whole body (universalis), and for an obstinacy of character which has gained for it the title of inve- teratus and agrius. Unlike alphos circinatus, it has no tendency to circularity of form, although bounded by a circumscribed border; while in structure it consists of a multitude of the typical tubercles of alphos closely assembled together, sometimes touching, and frequently blending by their bases. The scales of alphos diffusus often attain considerable thickness, they fall in a shower when the eruption is brushed by the hand, and may be collected in amazing quantity from the bed of the patient after a night's rest. This form of the disease is more frequently complicated with bleeding cracks and fissures, and also with eczema, than the other varieties. On the convexity of the elbows and knees, alphos commonly as- sumes the diffused form with a circumscribed border, although the general form as developed elsewhere may be circinate or guttate. Alphos papulosus, vel punctatus, is alphos arrested at its papu- lar stage, when it exists as a crop of papules developed at the aper- tures of the pores of the skin, each papule being surmounted by a white scale. Alphos pityriasicus, like alphos papulosus, is an imperfectly developed form of the eruption, in which the elevation and thickening of the skin are absent, and the squamae small and imperfect. Such cases must be regarded as presenting an aberration from the natural standard ; but they are not very uncommon. Alphos faciei commonly presents this character. Alphos gyratus, as we have already described, is an accidental combination of the rings of alphos circinatus, occurring during the dispersion of the eruption, and assuming a more or less complicated serpentine arrangement; the figures are never properly gyrated. Alphos capitis.—Alphos is not unfrequently met with on the hairy scalp, and covers the head more or less extensively, showing a red margin along the forehead, temples, and nape of the neck, some- times extending to the ears. It commonly presents the diffused form ; the scalp is thickened, very itchy, and throws off an abundance of white scales, but the hair is not altered. Alphos capitis rarely exists independently of the presence of the eruption on other parts, particu- larly on the elbows and knees; but the general eruption may be insignificant as compared with that of the head. Alphos faciei.—As a general rule, it may be said that alphos never occurs upon the face; but there are occasional exceptions, and the above designation is intended to record the exception. On the face the patches are usually flat and very little raised, and generally present the characters of alphos pityriasicus. They occur for the most part on the forehead and cheeks, and are always associated with eruption occurring on other parts of the body. 1 Portraits of diseases of the skin, Plates XIV. V. XVI. A 0, alphos diffusus is represented under the names of psoriasis vulgaris and psoriasis inveterata. 358 ALPHOUS AFFECTIONS. Alphos manuum indicates another exceptional seat of the erup- tion, the back of the hands. We have seen it also once or twice on the palm of the hands. In this, as in the generality of the varieties, the eruption is met with elsewhere, and notably on the elbows and knees. Alphos unguium illustrates a more common seat of the disease, namely, the matrix of the nail, where it destroys the normal secretion and growth of the horny tissue, and causes the separation of the nail from the derma, and its subsequent fall. We have a patient under our care, a young lady, who, besides general alphos, also suffers with alphos faciei, dorsi manuum, et unguium ; the existence of alphos of the nails must generally be regarded as a serious aggravation of the affection, and indicates an obstinate form of the disease. The nails of several of the fingers usually suffer, rarely the whole, the horny tissue is altered, it becomes opaque, discolored, and brittle, and at an early stage, a tubercle of alphos distinguished by a yellowish color and transparency may be seen spreading beneath the nail. Alphos articulorum reminds us of the special propensity of this eruption to attack the convex side of the elbows and knees. It is very rarely absent from these regions when it exists elsewhere, and not uncommonly it lingers on them when it has disappeared from the rest of the skin, or it is sometimes limited to these joints and has never appeared on any other part. Willan describes a lepra nigricans, which seems to be nothing more than a lividity of color of alphos circinatus, due to cachexia; it is also probable that some forms of centrifugal syphilitic tubercle have been included under this head. At the best, it is a mere alteration in the color of the eruption, without any difference of pathological structure, and we have therefore thought it well to omit it from consideration as a variety of the disease. A lepra syphilitica, the synonym of alphos syphiliticus, has also been described; but the term is incorrect; alphos is essentially distinct in its nature and manifestation from tubercular syphiloderma, to wdrich the above name has been applied. The error has arisen from a similarity of appearance; syphiloderma often presents a tubercular character, spreading by its circumference, subsiding in the centre, and covered by a thickened epidermis in the state of desquamation; but the antecedents and accompanying features of the disease are altogether different. Diagnosis.—Alphos is distinguished from other cutaneous diseases by its white, roof-like, porous, and often laminated scale, surmounting and more or less concealing a dull red tubercular base; and some- times when it has been scratched, marked around the circumference with a blackish concretion of desiccated blood. The only eruption with which it can be confounded is a tubercular and non-ulcerative form of syphiloderma. In a case of doubt we may be guided to the truth by the constitutional condition of the patient: if the eruption be syphilitic, there will have existed some foregone symptoms of that disease, and the patches on the elbows and knees, so characteristic of CAUSES OF ALPHOS. 359 alphos, will be absent. We shall also derive help from a remem- brance of the symmetrical distribution of alphos, and from a know- ledge of the duration of the disease. Syphiloderma is chronic, lasting for several months, but alphos exceeds every other known disease of the cutaneous tissues in chronicity. Forty-two out of one hundred cases of alphos, nearly one-half, have been in existence more than ten years; twenty-eight had lasted between ten and twenty years, and fourteen between twenty years are fifty-seven. Cause.—'Alphos is due to an innate tendency or diathesis; and the diathesis in many instances is hereditary. It occurs pretty equally in the male and in the female; and is met with at all periods of life, from the age of three to eighty years. In its origin it is most frequent at puberty, twenty-three in one hundred cases beginning between ten and sixteen; and it is remarkable, that in examples of hereditity, where the children are numerous, ranging from four to ten in a family, the number afflicted with this disease rarely exceeds two; in three families of ten each, the number of children attacked with alphos was three in one, and two in the others; while in three families of six and seven children, only one in each was the subject of the disease. In reference to predisposing causes, we have little evidence; four examples in one hundred cases were traceable to a consumptive stock; two to a gouty source; and one to the marriage of near rela- tions; while in the same number, the exciting causes, arranged in order of frequency, were as follows: rubeola, scarlatina, parturition, over-study, over-nursing, development of menses, bad or insufficient diet, rapid growth, exposure to cold while heated, climate, fever, anaemia, cessation of menses, overheating the body, sea-bathing, and debility caused by syphilis. It is curious, however, to note, that one case was cured by an attack of measles. Alphos is greatly influenced by seasons, being worst in the winter, and clearing away in the sum- mer ; it commonly begins to appear or increase in the autumn; but exceptional cases are occasionally met with, wherein the eruption is worst in the spring and summer. Prognosis.—The prognostics as to cure are most unsatisfactory. Alphos may disappear after a few years, but it is equally likely to last a lifetime; and no difference is perceivable whether the disease be independent or hereditary in its origin; the only thing that can be said in its favor being that it does not affect the health, but only the comfort of the patient. It is especially liable to recurrence, some- times clearing away completely in the summer and reappearing in the autumn and winter, but more frequently dispersing only partially, and lingering always in its favorite haunts, the elbows and the knees. Treatment effects no better results; the eruption is as liable to return after an apparently successful treatment as where no remedies have been employed; and this fact suggests an argument for moderation in our therapeutical management. The eruption will often disappear suddenly under the influence of an intercurrent disease, as in the example of rubeola already noted, or under the exhaustion occasioned by violent medicines; but in either case it is certain to return. With respect to its duration, we are enabled to form an opinion from a 360 ALPHOUS AFFECTIONS. knowledge of its stage and apparent activity; small in size, and itchy in an early stage; dense and thickly coated with scales in its most chronic form ; and orbicular or annular at its period of decline. Treatment.—In simple or uncomplicated alphos there is com- monly no question of regulating the digestive organs and general health; the specific treatment may be commenced immediately, and the one reliable internal remedy is arsenic. Where, however, there is any disturbance of the health, or any complication such as gout or eczema, the complication must be removed in the first instance, before the specific treatment is begun. It will usually be found that with the removal of the complication the eruption will be benefited, and the patient may be led to hope that the eruption is in process of cure; but the physician knows full well to what the improvement is due, and does not permit himself to be so easily deceived. The best form for the administration of arsenic is the liquor arse- * nicalisy or Fowler's solution. Other good forms are the liquor sodae arseniatis, or Pearson's solution; the liquor ammoniae arsenitis; the liquor arsenici chloridi, or solutio solventis mineralis of de Valangin, and the triple solution of Donovan, the liquor hydriodatis hydrargyri et arsenici. The dose of the alkaline solutions is two minims to five; of the acid solution, four minims to ten; and of Donovan's solution, ten minims to thirty, three times in the day. For many years we have been in the habit of prescribing Fowler's solution according to a formula which we call the ferro-arsenical mixture;1 and of this mixture the dose is one drachm three times a-day, and taken in the middle of a meal. The patient should be furnished with a minim measure, and after measuring the dose, he should drink it pure, out of the measure. The reasons for these instructions are, that where a medicine is to be taken for many months, and three times every day, it is important that it should be as agreeable in taste as possible, and also that it should be administered in the smallest dose practicable; again, a small quantity is less likely to nauseate the stomach than a larger one. Secondly, by taking the dose in the middle of the meal it is secured a more thorough admixture with the food, and it is less likely to be brought into direct contact with the mucous surface. We may add, that the experience of many years has convinced us that this is the best, and therefore the only method according to which this very important remedy should be used. In administering arsenic in any form we prefer to begin with a small dose, say two or three minims, to test the susceptibility of the patient to our remedy; and if we find no resulting inconvenience, we can raise it by degrees; but in few instances will it be found neces- sary to increase the dose beyond five minims. We believe that arsenic operates its healing effects by time rather than by quantity; at any rate, it is clear that in the treatment of alphos it must have time; and if we nauseate the stomach by too large doses given at first, we frustrate our own intentions, namely, of applying a chronic remedy to the cure of a chronic disease. If a stomach be intolerant Vide selected prescriptions, at the end of the volume. TREATMENT OF ALPHOS. 361 of arsenic, it is shown at the commencement of treatment, and then we must diminish our dose or suspend our treatment for a while; where there is no intolerance of the remedy, but where, after a time, say several weeks, it shows signs of disturbing the functions of the stomach or of the nervous system, a state usually referred to the cumulative effects of arsenic, we must again suspend our treatment for a week, or longer if necessary. We commonly anticipate this possibility by commanding our patient to desist immediately from the use of the mixture if it seem to disagree in any manner whatever. The importance of these remarks will be the better understood when it is remembered that the patient may require to continue the remedy steadily and daily for a period of three, six, or nine months, and even longer. Hence our care in the combination of the medicine, and in the regulation and administration of the dose. Possibly we may wish to make a change in our remedy; one form or combination of arsenic may suit the stomach better than another; or it may be desirable for the sake of change, for change is an import- ant feature in the use of medicines, and then we may select the acid solution of arsenic, the solutio solventis mineralis of De Valangin, of the same strength as the ferro-arsenical medicine, and administered in the same way, or with the addition of a little water to subdue the acid taste; but in every other respect after the same method, and with the same precautions. We have seen a case of alphos cleared by the acid solution, which had proved rebellious to the alkaline solution, but, as far as we know, it is not on the whole so reliable a remedy as Fowler's solution. Where there exists chronic disorder of the digestive organs; at or after the mid period of life; where there are signs of torpid liver and inactive nutrition; we may find an useful remedy in Donovan's solution. Hebra sums up the virtues of arsenic in a few words when he says that it is the best remedy for alphos, and the safest for the pro- longed use which this affection demands; but that it is no better than other remedies in respect of the power of preventing the recurrence of the disease. He has watched its administration for long periods, and has never seen any evils result from its use. Of the solutions, he gives a preference to Pearson's, and thinks lightly of Donovan's. He has administered the Asiatic pill1 in doses equal to a quarter of a grain of arsenic a-day, raising the dose by degrees to one grain; and has continued to employ it until the total quantity taken by the patient reached 160 grains. His favorite formula, however, is that of the pilulae arsenici cum opio,2 containing each one-sixteenth of a grain of arsenious acid combined with a quarter of a grain of opium ; of these he prescribes, night and morning, two, equivalent to a daily dose of a quarter of a grain of arsenic with one grain of opium; his patients have persevered with this dose for months with favorable results. We must, however, remark, with reference to the administration of solid arsenic, that the dose is less certain, and the remedy necessarily 1 Vide selected prescriptions, chap, xxviii. 2 Ibid. chap, xxviii. 362 ALPHOUS AFFECTIONS. weaker, than where a solution is taken; and we entirely disapprove of its exhibition in any other form than that of solution. Our colleague of Vienna has, moreover, done good service by passing in review the various remedies which, from time to time, have been recommended for alphos, and giving his experience of their virtues. He assembles in one group the vegetable remedies which have been employed for alphos, as for skin diseases in general, and throughout the entire globe, but without results sufficient to warrant any confidence in their merits. The list is so numerous, that after giving a place at its head to a few that still retain a linger- ing reputation, we shall arrange the rest in alphabetical order; they are as follows: Dulcamara, bardanum, ulmus campestris, sarsapa- rilla, saponaria, guaiacum, species lignorum, belladonna, carbonum decoctum, conium, eupatorium, flores pedemontanae, fumaria, inula hellenium, juniperus vulgaris, juniperus sabinae, ledum palustre, mezereum, millefolium, nicotiana, nux juglandica, folia et putamina, orobanche virginiana, phyllis amara, pulsatilla nigricans, rhus radi- cans, rhus toxicodendron, sassafras, scabiosa arvensis, solanum nigrum, trifolium fibrinum, and viola tricolor. More powerful, he observes, in their nature, but equally valueless, are: aethiops antimonialis, aethiops mineralis, alumen in decoctum sarsaparillae, anthrakokali, antimonium, antimonium tartarizatum, auri murias natronati, baryta muriatica, calx antimonii sulphureti, cupri ammonio-murias, ferruginea, graphites elutriatus, hydrargyri nitras, manganum nigrum, sodae chloras, sulphur auratum antimonii, sulphuretum potassae et sodae, and turpethum minerale. To which are added mineral and vegetable acids, including lemon juice and vinegar, hydrocyanic acid, liquor potassae, cucumbers, brittanica, and vipers'-flesh, as recommended by Galen. In no less disparaging terms Hebra treats of the medication of al- phos by purgatives. During their use, he observes, the disease may disappear spontaneously, or the eruption may be exhausted by a,rrest of nutrition of the skin; but even when any such favorable consequences follow their employment, the disease will return when the treatment is over. And he takes the opportunity on several occasions to remind us that recurrence is a normal phenomenon of the disease, and that, as a consequence, we must not damage the constitution of the patient by strong and violent remedies. His list of purgatives is as follows: Sulphate of soda, sulphate of magnesia, phosphate of soda, the waters of Seidschiitz, Piilna, Karlsbad, Marienbad, Kissengen, &c.; the vege- table purgatives, jalap, aloes, colocynth, gummi-guttae, colchicum, cro- ton oil, &c.; and the mineral purgative, calomel. In the same cate- gory he enumerates the diuretic remedies with the remark, that while all are useless for the purpose, some, such as cantharides, should be prohibited as dangerous; his list is»as follows: Aconite, bardanum, cantharides, digitalis, equisetum, galium aparine, juniperi baccae, ononis spinosa, petroselinum apium, rhamnus catharticus, scilla, tartaric-salts, uvae ursi, &c. The tincture of cantharides has been administered sometimes alone and sometimes in conjunction with Fowler's solution, and has been TREATMENT OF ALPHOS. 363 thought to be productive of benefit; we have seen some cases in which we believed that a better effect was produced than when the solution of arsenic was administered alone, and especially in cases of long standing in which arsenic has been taken by the patient for years. But we have never exceeded the dose of five minims three times a day. Rayer has carried the dose as high as fifty, and a hundred and fifty minims daily. But Hebra, who began with four minims, and ascended by degrees to thirty in the day, found that after he had ex- ceeded fifteen minims the dose, given three times a day, he produced disorder of the kidneys, with dark colored urine, albuminuria, and subsequently haematuria. Hebra did not succeed in obtaining any good results in the cure of alphos, and he suggests that the cures by cantharides, reported by Rayer, may have resulted from the concur- rent use of sulphur baths, an useful remedy, particularly when the sulphuret of lime is employed. The hydrargyrum corrosivum sublimatum, together with mercurials in general, Hebra thinks useless, and believes that supposed cures of this eruption by these means were in reality cures of syphilitic erup- tion. Iodine and the iodides, and cod-liver oil, he declares to be equally valueless. Among specifics for alphos Hebra was induced to make trial of a Brazilian plant, the hura braziliensis, which has obtained a reputation for the cure of leprosy and syphilis. This remedy is prepared in the form of an expressed juice called assacou, of which the dose is half a drachm daily; a tincture of the assacou, one drachm for the daily dose; and a decoction of the fresh bark, of the strength of one ounce to six ounces of water. It produces vomiting and diarrhoea to such an extent that the Brazilian physicians administer it every fourth day only, keeping the patient in bed in the meanwhile and on invalid diet; but although violent in its action the medicine occasions no after ill effects. Used for some weeks or months, the eruption disappears, but does not fail to return when the remedy is omitted; and its cura- tive influence is due, according to Hebra, to a suspension of nutrition of the skin, similar to that which causes the removal of alphos when it is brought about by active constitutional and depressing disease. Tar was once a favorite remedy for alphos, and is administered in capsules and pills. When liquor potassae is given, the dose is half a drachm three times a-day in some bitter infusion, in infusum dulcamarae, or in beer; and the dose of diluted nitric acid is one to two drachms in sweetened barley-water three times a-day, an hour before meals. Local Treatment.—While the constitutional treatment has for its object the alteration of a diathesis, the local treatment is intended to soften and remove the scales of morbid epidermis, and stimulate the tissues of the corium to a more healthy action. A convenient means of effecting this object is a solution of potash soap, with tar and alcohol. This should be applied at bedtime with a moderately stiff brush, and washed off in the morning with soap; or if a more active stimulus be needed, the solution may be laid on more thickly, and covered with a piece of linen, and kept bound to the 364 alphous affections. part like a plaster for a longer period. The scales soon yield to this treatment, and fresh scales are removed as frequently as they are produced; the corium is stimulated, the circulation becomes more active, the effused fluids are taken up from the tissues, the capillaries contract in size, and the corium returns by degrees to its usual state and normal function. Sometimes, however, before the healthy tone of the skin is restored, the part is irritated and inflamed by the application, and it becomes necessary to suspend its use for a while, and employ instead some soothing and healing remedy. With a like object we may employ an alcoholic solution of soap alone, or pine tar or juniper tar, either simple or combined with alcohol and potash soap, or in the more solid form of juniper-tar soap or petro- leum soap. Sometimes we have recourse to the less agreeable application of unguentum picis liquidae, the unguentum picis jvith unguentum sulphuris, or the ointments of the nitric oxide or ammo- nio-chloride of mercury. The mercurial ointments, diluted with simple pomatum (pars 1 ad 3), are very useful for removing fur- furaceous scales from the scalp, aided by the juniper-tar or carbolic acid soap; and the latter, followed by a lotion of bichloride of mercury in emulsion of bitter almonds, is the best suited for the face. When the eruption is excoriated, inflamed, and fissured, we must have recourse to the sedative action of a lotion of acetate of lead, or to the benzoated ointment of oxide of zinc. The eruption on the face and scalp yields more quickly to treatment than that on the rest of the body. Hebra classes the local remedies for the treatment of alphos under three heads, namely, water, soap, and stimulant applications, the latter including tar, naphthaline, sulphuret of calcium, and ointments of mercurial salts. Under the head of water, he designates the warm bath, steam bath, hot air bath, water dressing, and water packing. These applications require to be continued for a considerable time in order to soften the epidermis as completely as possible. The patient must remain in the warm bath (90-100° Fahr.) for one or two hours, and the softened scales must be rubbed off with the aid of soap. Warm mineral waters owe their reputation, he believes, rather to their softening agency than to their chemical contents; and he regards, as among the best, the baths of Loeche in Switzerland, in which the patients are made to soak for six or eight hours daily. On the same principle he thinks the perpetual bath invented by himself might be found of service. Water dressing and water packing besides being softening and macerating, must also, from the reaction which ensues after their use is suspended, be stimulating and discu- tient. The water packing should be conducted after the old method prescribed by Priessnitz, which Hebra describes as follows: an oil cloth or gutta percha sheet is to be placed upon the mattress of a bed ; upon this are laid crosswise two towels, folded to the width of belts; next comes a thick blanket of large size; then a sheet well wrung out of cold water. The patient is placed naked upon the sheet, with an urinal between the legs; and the sheet is folded smoothly and tightly around him ; then follows the blanket, and then treatment of alphos. 365 the belts, until the whole body is carefully packed up, and no part remains exposed to the air but the mouth, nose, and eyes. He lies in this state for three or four hours, being supplied with water to allay thirst and assist perspiration. After this interval he is un- packed, and quickly immersed in a bath of cold water, wherein he is well rubbed with sheets and cloths, and is made to move his limbs; he is next rinsed by means of a shower bath, or by a douche from a can, then rubbed dry and permitted to dress. When the process is over, he takes a walk in the open air. The first shock of wrapping in the wet sheet very soon gives way to an agreeable warmth, and the washing in the cold tub is pleasant and refreshing. The packing is to be performed twice in the day, at four or five in the morning, and again in the afternoon at four or five, a few hours after the mid-day meal; the diet shuold be simple and nourishing and the drink water. It is clear that this method can be effectually carried out only in a hydropathic institution, and the patient must give up his entire time to the cure, which may last several months. Soaps owe their therapeutical value to their well-known property of dissolving the horny tissues. The»most active are those composed of potash, such as the soft soap; and they may be medicated by the addition of tar, carbolic acid, sulphur, iodine, or other medicinal sub- stances. Hebra especially recommends a preparation which he terms spiritus saponatus kalinus, and which is composed of two parts of soft soap to one of alcohol. This is to be applied to the patches of alphos by means of a brush, and left to dry on, or it may be used as a poul- tice, in both cases to be washed away after a few hours or several days. By this process the scales are dissolved and washed away, and the patches decorticated even to the quick, and are then in a condition the most favorable to be acted on by other medical remedies. One of the methods adopted for the cure of this disease is termed Pfeuffer's soap cure, and is thus described by Hebra : The patient is placed in a blanket, and, for three days, six ounces of soft soap are to be well rubbed into the diseased skin by means of a flesh-brush or a piece of flannel, four ounces in the morning and two in the evening; while, for another period of three days, only one ounce is to be used night and morning at each friction ; the patient remaining in the same blanket for the six days. He is then thoroughly washed and placed in bed until the lost epidermis is restored ; and, if the scales be reproduced, the same process must be repeated. Hebra objects to this method as being too severe, and modifies it as follows: he takes from two to six ounces of soft soap, according to the age and sensitiveness of the patient, and extent of the disease, and rubs it into the eruption night and morning, keeping the patient in the meantime enveloped in a blan- ket. After the first general friction he selects a region of the body,' and rubs the soap into the squamous patches with a piece of woollen rag, until he removes the epidermis and causes bleedingof the con- gested derma; on the next occasion he takes another region, and so in succession until every spot has been subjected to friction and excoria- tion. After that the patient remains in his blanket until the epider- 366 ALPHOUS AFFECTIONS. mis desquamates in lamellae, upon which he is well washed in a bath and allowed to dress. But neither this process nor that of Pfeuffer removes the eruption completely, although it facilitates the use of curative remedies. The best curative agent in the external treatment of alphos, as far as the word "curative" can be applied to that disease, is tar. Hebra enumerates five varieties of tar: oleum empyreumaticum coniferum, or pine tar, the pix liquida of the British Pharmacopoeia ; the oleum juniperi pyrolignici, oleum cadinum, the huile de cade, a product of the juniperus oxycedrus; the oleum betulae, or oleum rusci, prepared from the bark of the birch tree; the oleum fagi, produced from the beech tree; and the oleum empyreumaticum ligni fossilis, the coal tar or gas tar. Tar may be employed in its native state, or in the form of hard and soft soap, ointment, liniment with oils or glycerine, or in alcoholic solution or tincture. It must be well rubbed into the denuded patches of alphos, with a stiff brush, and repeated twice a day, each time cleansing the surface from the previous application by means of a saponaceous ablution. After being brushed into the skin it should be allowed to dry, and, where the surface is extensive, the patient should remain covered by a blanket from two to six hours before he puts on his clothes, and should wear a woollen covering, as less liable to absorb and remove the remedy. Tar is apt to create some degree of inflammation of the skin; sometimes an erythema, with swelling,, stiffness, and pain; sometimes a papular eruption; and sometimes a vesiculous or bullous eruption, resembling erysipelas. After long use Hebra has observed a prominent state of the hair fol- licles, which he compares to the papules of acne, and terms tar acne. Tar generally removes the pruritus of the eruption, but now and then increases it very considerably. The indication for the cessation of the tar treatment is the subsidence of the fulness and congestion of the patches, and the arrest of desquamation, the spots become pale or brown in color, and the epidermis recovers its normal transparency and smoothness. Occasionally tar is absorbed into the circulation, and gives rise to constitutional disorder, a sense of tightness or weight in the head, quick pulse, nausea, sometimes vomiting, and sometimes diarrhoea. The vomited matters and feces are colored with a black fluid; and the urine has an olive-green tint, referable to the presence of the pigmentary principle of tar. These symptoms subside in a short period, and commonly terminate in diuresis; and their dispersion is facilitated by the use of mild diuretic fluids, such as barley-water with chlorate or bitartrate of potash. Sometimes nausea and vomit- ing take place in half an hour to three or four hours after the "application; and the urine becomes discolored in an equally short period. The solution of sulphuret of lime is applicable to cases in which an objection arises to tar, and especially to very chronic patches of small extent. As in the use of tar, the scales must, in the first place, be removed with soft soap, and the sulphuretted solution applied with more or less friction, according to the effect intended to be produced. STRUMOUS AFFECTIONS. 367 Hebra recommends that the patches should be rubbed with a piece of flannel saturated with the solution until the surface bleeds, or that the scales should be removed by pretty strong friction with pumice-stone. When the patches are desquamated and excoriated by these means, the bleeding surface should be dabbed with the sulphuretted solution; the patient must then be placed in a warm bath for an hour, after- wards the eruption may be washed and anointed with oil or any sim- ple unguent. Crusts are formed over the patches, and peel off at the end of a week. Hebra observes that the process is too painful to be used extensively, but is especially suitable to the removal of small chronic patches, which may often be cured at a single sitting if the process be effectually carried out. Naphthalin, a white crystalline product of the distillation of coal, with a strong smell of coal gas, has sometimes been used as a sub- stitute for tar, made into an ointment containing one drachm to the ounce, and rubbed into the skin ; the smell is quickly dissipated. We have found it a serviceable remedy. Lemery states, that by applying it night and morning as a dressing on linen, he succeeded in curing eight patients out of fourteen, in from five weeks to three months. It is a powerful stimulant, and may be used with friction, as in the case of tar, after the previous removal of the scales by soap. Mercurial ointments Hebra considers of value in mild forms of the affection, and especially in alphous eruptions on the scalp and face. The eruption must first be thoroughly washed with soft soap, and, after drying the skin, the ointment should be firmly rubbed into the patches, the process being practised twice in the day. The ointments to which he gives the preference are, the unguentum hydrargyri ammo- niati; the unguentum hydrargyri nitratis; and the unguentum hydrar- gyri iodidi viridis for milder purposes; and the unguentum hydrar- gyri iodidi rubri (gr. x-xx ad 3j) for more powerful effects. The mercurial ointments are brought in aid of tar and sulphuret of lime; and the red iodide ointment should be applied by means of a dressing, or well rubbed into the spots twice in the day, until it produces ex- coriation, or swelling and vesication. CHAPTER XV. STRUMOUS AFFECTIONS. Struma, scrofula, or scrofulosis, presents itself in the skin in two forms, either as simple scrofuloderma or as lupus. Scrofuloderma occurs either as tubercular swellings of the integument or ulceration, and lupus as an organic change in the tissues of the skin, followed sometimes by ulceration and sometimes by absorption. The former is a primary result of recently produced and crude scrofulous tissue; the latter a consequence of the identification of the scrofulous tissue with 308 STRUMOUS AFFECTIONS. the structure of the organ; the former is associated and in some degree dependent on inflammation and hypertrophy of lymphatic glands, subcutaneous abscess, or disease of bone; the latter is for the most part free .from these associations. Scrofuloderma.—The tubercular swellings of cutaneous scrofula are of small size, indolent, and of a purplish red or livid color ; they soften internally, break after a time, and give exit to a white curd- like matter and to an imperfect pus; often remain open or fistulous for a lengthened period ; and when they at last 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 pf 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 the 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 disturbed or displaced, a fresh exit of ill- formed pus or ichorous fluid takes place, and the opening continues for an indefinite time, without snowing any disposition to heal. When the healing is at last accomplished, an ugly scar is often left behind. Scrofuloderma is especially remarkable for its chronic character, arising out of the low vitality of the morbid tissues; the edges of the ulcers are thin, often undermined, and wanting in granulations, or studded with granulations that are pale, tumid, and flabby, and bleed upon slight injury. Moreover, there is commonly an absence of puru- lent secretion, the discharges being ichorous or sanious, and more or less intermingled with curd-like matter and small flakes of disor- ganized tissue. Sometimes there is only one opening through the skin, the edges of which have the appearance and hardness of a cica- trix ; at other times the diseased surface is honeycombed with aper- tures, from all of which there is an oozing of unhealthy and often fetid discharge. In scrofulous subjects, particularly in young persons, it is not un- common to find an inflammation of the matrix of the nail, scrofulo- derma unguale. The disease begins by inflammation and swelling of the skin immediately around the edges of the nail, the extremity of the finger swells considerably, and becomes vividly red; and the 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 sur- face, upon which a rugged, ill-formed, and imperfect nail is from time to time produced. The denuded derma, covered with fungous granu- lations, secretes more or less of an unhealthy pus, and the disease is kept up for a considerable length of time, often for many months. LUPUS EXEDENS. 369 LUPUS. By the term lupus we understand a strumous degeneration of the tissues of the skin, attended with more or less hypertrophy, with ab- sorption, and with ulceration; such morbid phenomena originating in a constitutional condition or diathesis. Hypertrophy of the tissues produces a special enlargement of the diseased part, constituting a circumscribed prominence or tubercle, and sometimes a general swell- ing. Absorption is manifested in the gradual disappearance of cer- tain of the tubercular elevations without ulceration. And ulceration may be superficial or deep, slow or rapid, and more or less exten- sively destructive. Moreover, lupus sometimes creeps more or less superficially over the surface of the skin, healing in the centre and leaving behind it a permanent cicatrix, and growing by the circum- ference. These, the prominent characters of the disease, have laid the foundation of its varieties; its ulcerative tendency has suggested the terms lupus exedens and lupus non exedens; its disposition to promi- nence and swelling, lupus tuberculosus and lupus hypertrophicus; and its proneness to peripheral growth, lupus serpiginosus. To the above essential forms, lupus exedens and lupus non exedens, have been added another variety of affection characterized by disorganization and atrophy of the papillary layer of the corium, but not necessarily due to a strumous source like the preceding, namely, lupus erythe- matosus. The three varieties are, therefore, as follows:— Lupus exedens, Lupus non exedens, Lupus erythematosus. LUPUS EXEDENS. Syn. Lupus vulgaris, Hebra ; herpes exedens; herpes esthiomenes ; esthiomena ; noli me tangere ; dartre rongeante ; esthiomene serpigineuse, Alibert. Lupus exedens,1 the most destructive of the three varieties, may- attack any region of the body, but is most commonly met with in the nose. On the latter it may begin in the mucous membrane, or in the skin; in the former case involving the nasal duct, and causing swell- ing of the lachrymal sac and a discharge of matter through the puncta lachrymalia ; in the latter case breaking out upon the tip, the columna, or the ala nasi. In its origin it is a dull red hemispheroidal papule of about one line in diameter, and remains for a long time in that condition; later, it unites with other similar papules, and constitutes a tubercle; the tubercle is smooth on the surface, desquamates from time to time, and spreads by degrees to the immediately surrounding skin. Sometimes a small accumulation of pus takes place at the sum- mit of the tubercle and forms a crust, and beneath this crust the sup- puration extends. At other times a crack occurs in the cuticle, an 1 Portraits of diseases of the skin, Plates XLVI. XLVIL E F. 21 370 STRUMOUS' AFFECTIONS. excoriation is produced, some exudation follows, and the exuded secretion dries up into a thin crust. When in either case the crust is removed, the surface beneath is found to be ulcerated, the ulcer being filled with granulations of various size, bathed in a purulent secretion. While pursuing this course to suppuration and ulceration the disease is slowly propagated to the immediately adjacent tissues, the skin becomes red and infiltrated, swollen and tense, suppurative points are produced at several spots, crusts are formed of various thickness according to the quantity of the secreted fluids, the crusts are loosened and rubbed off wholly or partially, and an extensive ulcerated surface is brought into view covered with granulations and excrescences; and in the case of the nose the alae are swollen and everted. In the successive phenomena now described we have the explanation of the specific terms which have been applied to the disease, and are usefully employed to distinguish its different stages; for example, lupus tuberculosus, lupus hypertrophicus, and lupus exulcerans. The progress of lupus is commonly very slow; it remains for a long time in one particular stage, and then becomes suddenly active. It would seem to run its course more quickly in the winter and spring than at other seasons of the year, and sometimes progresses with so much celerity and with such destructive force as to deserve another of its synonyms, namely, lupus vorax. Commonly, lupus exedens confines its destructive operations to the skin; but not unfrequently, when active in its progress, involves the deeper tissues; for example, all the soft parts of the lips, the eyelids, the nose, including its cartilages; sometimes also it attacks the peri- osteum, penetrates into the cavities of the nares and mouth, and destroys the vitality of the bones, giving rise to great suffering and terrible deformity. In a poor girl now before us the face has lost its normal figure completely, the lower eyelids are drawn down towards the middle line, exposing the red and tumid conjunctiva, while the nose and lips are gone, and their place supplied by a vertical slit opening into a cavernous opening, bounded above by the roof of the nares and behind by the posterior wall of the pharynx; all trace of palate or superior maxillary bones is lost, excepting at the sides. In another case, the face is simply a cicatrix; two oblique slits represent the place of the eyes; the apertures of the nostrils are entirely closed; and only a small circular opening remains at the side of the middle line, through which fluid nourishment can be introduced into what remains of the mouth. In a poor lady, thirty years of age, the ulcera- tion has crept from each cheek'across the face, destroying the nose totally, and producing such an amount of contraction as to draw the lower eyelids down upon the cheeks, shorten the upper lip, and 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 retreated from the teeth, leaving them unnaturally elongated. On the cheeks, and extending from the tem- LUPUS EXEDENS. 371 pies 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. On the body and limbs, lupus exedens presents a greater or less disposition to spread, it heals in the centre, leaving a thin white cicatrix, through which the subcutaneous tissues are often perceptible, and is bounded at the circumference by a slightly raised tubercular ridge; this is lupus serpiginosus. Sometimes, the central area over which the disease has passed is smooth; sometimes a few tubercular elevations are met with covered by white scales, and sometimes it is rendered rough and uneven by the mingling of tubercles, scales, and depressed cicatrices. The surrounding rim or border is more or less raised and uneven ; sometimes coated with white scales, and sometimes with yellowish, or grayish, or dark-colored crusts resulting from ulcera- tion ; lupus serpiginosus exulcerans. Lupus serpiginosus may be pre- sent on various parts of the body at the same time; sometimes occu- pying the greater part of a limb, and sometimes the back of the hand or of the foot. Occasionally, the morbid patch is perforated with numerous openings through which pus exudes, or is roughened by a multitude of granulations. On the feet, the serpiginous ulceration creeps downwards to the sole, and forward to the toes; and the morbid surfaces of the latter not unfrequently adhere, and the toes are united into a single mass. Hebra, who has observed lupus with especial care, gives the follow- ing masterly description of the origin and progress of the disease. After remarking on the extremely chronic nature of lupus and its disposition to remain for months, and often years without change, he says, it makes its appearance in the form of reddish-brown papulae of the size of millet seeds; the papulae are slightly prominent; some- times smooth, and sometimes covered over with a thin white scale; they increase very slowly in size, and when there are several congre- gated together, or when new papulae are produced in the interspaces of an already existing group, they are apt to become blended by their margin, and constitute a small tubercle of the size of a lentil, or horse bean, and sometimes by interstitial infiltration to attain the bulk of the segment of a hazel-nut, and even of a walnut. By a further increase of prominence and extension, and by additional infiltration, which gives to the morbid surface a puffed and tumid appearance, the disease acquires the character of a nodulated, hypertrophic, and tumid lupus: lupus tuberculosus hypertrophicus seu tumidus. The lupus may remain in either of the above described states for a longer or shorter period without any apparent change; or it may spread out and increase in extent; while around the circumference new papulae may be pro- duced which may blend with each other, forming tubercles; and the latter, uniting with the original blotch, may still further extend the limits of the disease. The next phenomena that occur in lupus are those of retrograde metamorphosis; either the tubercles and infiltration subside with or without an increase of desquamation ; or, more frequently, softening of 372 STRUMOUS AFFECTIONS. the morbid tissue is set up attended with suppuration. A pustule is produced at one or more points in the midst of a congested spot, or upon the summit of a tubercle or nodule ; and the suppurative pro- cess is repeated at intervening points, until a considerable extent of epidermis is raised by the purulent accumulation, and dries up into a thick and rugged crust. The crust varies in appearance, in thickness, and density, in accordance with the nature and quantity of the secre- tions which enter into its composition, whether they be pus alone, or pus mingled with serum, blood, or lymph, or with the glandular secre- tions of the skin; it varies also, in its degree of adhesivenes to the surface, being sometimes loose and broken, and sometimes firmly and closely attached. If the crust be removed, either by the accumulation beneath it of morbid fluids or designedly, the surface will be seen to present elevations and superficial excavations, the former in the shape of excrescences and exuberant growths, the latter in the form of exco- riations and ulcers. The exuberant growths vary in size from the bulk of a hemp seed to that of the segment of a walnut, and are them- selves composed of small granulations no larger than the head of a pin ; these vegetations are for the most part semi-globular in figure, of a brownish-red color, and are immersed in a purulent or serous secretion; they are soft and spongy in texture, and often excoriated by superficial ulceration. The ulcers present a concave yellowish or reddish-gray base, with either prominent and swollen, or flabby and indolent borders; and the epidermic desquamation from the rest of the surface consists of layers which vary in size from the breadth of a lentil to that of the palm of the hand, are thin in texture, and bounded by a rounded or angular border. These are the characters which especially distinguish the ulcerative lupus: lupus exulcerans, herpes phagedsenicus, esthiomenos, he. The unchecked progress of this kind of lupus ends in destruction of the skin, subcutaneous cellular tissue, fasciae, and cartilages, and often in the loss of a part or the whole of the nose, the eyelids, or the pinna of the ear. Sooner or later the ulceration ceases; the secreted fluids diminish in quantity and become thicker in consistence ; new skin is produced, and grows from the circumference to the centre; and by degrees the ulcers are covered with a thin, smooth, and delicate epidermic layer, through which the red hue of the subjacent corium is apparent. At a later period the redness of the new covering disappears, the epider- mal layer thickens, and the cicatrix contracts and alters its appear- ance, sometimes being marked by elevated lines which radiate from a centre towards the periphery, sometimes raised into prominent ridges, and presenting hollows and elevations, and finally resembling in every respect the cicatrices produced by burns, or scalds, or suppurating ulcers of whatever kind. After some years, these cicatrices lose their red tint, and become white, smooth, and shining, and by their con- traction give rise to serious deformity; such, for example, as ectropium, drawing down the tip of the nose, distorting or averting the lips and occasioning dribbling of the saliva, contracting the skin of the neck, and interfering with the movements of the head; and, finally, imped- ing and restricting the movements of the limbs. LUPUS NON EXEDENS. 373 While lupus vulgaris is running through its course and progress- ing towards cure, new papules and tubercles are very often developed along the periphery of the cicatrix. These papules and tubercles obey the same laws as those which governed their predecessors; they blend with each other, desquamate on the surface, suppurate, ulcerate, and eventually become closed up with new skin, and so increase the dimensions of the original cicatrix; while they also in their turn are followed by a further growth externally to themselves, and become involved in a wider spreading increase of the disease. In this way the appearance of the lupus is sensibly modified, and the resulting form is termed, lupus serpiginosus, esthiomenos obambulans.1 Lupus non exedens2 (Plate XIII.) is less destructive, and there- fore more lasting than lupus exedens; it is unattended with ulcera- tion, and its situation is somewhat different, beginning on the cheek, on the upper lip, or on the lobe of the ear, and occasionally on the ala nasi, and spreading, not in depth, like the former variety, but along the surface. It originates as a small tubercle of a reddish-yellow, or pale amber-color, and has the appearance of a drop of jelly effused beneath the cuticle. It is obvious that the papillary layer of the skin is destroyed, and converted into a tissue of low organization, a kind of hyaline or crude cell-tissue; there is no inflammation, no redness around the tubercle, and a few minute vessels may be seen straggling through it, or over its surface. This is the first beginning of lupus non exedens. and in this shape it may often be seen in the Very centre of the blooming cheek of a young girl; a few weeks later, two or three yellowish points may be observed around the original tubercle; these increase slowly, or, per- haps, the change is more quickly effected, and an uniform patch of slight elevation is formed by the blending of the tubercles, and the patch may go on increasing until it covers the greater part of the cheek. There is still the same reddish-yellow or pale amber tint of color ; still the same evidence of an apparently gelatinized tissue in place of the natural papillary surface of the derma; still the minute vessels straggling through the transparent tissue; still the absence of vascular congestion, either in the patch or around its circumfer- ence. We have before us one of those curious transformations due to lowered vitality of tissue; a highly organized structure, the papillary surface of the derma, converted into a non-vascular gela- tinous stratum, and in a state to be absorbed and removed like an effete material. But the vitality of the skin is unequal to the exer- tion of removing the disorganized tissue, and so it remains; occasion- ally, however, it is removed spontaneously, and then we have proof of the nature of the disease; the papillary layer of the derma is gone, the fibrous structure of the corium, with its cord-like bands, is brought into view, and remains as a cicatrix for ever after. Here then is a cicatrix, permanent for life, on a spot where there has been no lesion of continuity, not even an abrasion of the cuticle. 1 Atlas der Hantkrankbeiten. * Portraits of diseases of the skin, Plate XLV. A C. 374 STRUMOUS affections. But as in healthy so in morbid processes, nature is not always regular in her course. Sometimes a patch of large size is found which presents uniformly the structure already described; sometimes the morbid structure is removed by absorption at the centre of the patch, and the border stretches further and further upon the sound skin by its circumference; sometimes, the patch breaks up in parts, the tubercles subside here and there, clear spaces are formed in portions of the patch, and tubercles are scattered irregularly over the rest of the surface; sometimes the tubercular origin of the disease is manifest throughout its entire course, and sometimes it. is entirely lost. Lupus non exedens is accompanied with little pain, some- times none; sometimes there is a sense of pricking, and sometimes of itching. Commonly there is a slight degree of exfoliation of the cuticle, and sometimes, but rarely, the cuticle gives way along the prominent edge, and there results a little oozing of an ichorous fluid, and a consequent thin brown crust. The disease is very chronic in its nature, lasting for many years, and sometimes for life. It increases by extension to the surrounding healthy skin, but it is also capable of reproduction through the areolar spaces of the fibrous tissue of the corium; and when it has been removed by a caustic application, it is apt after a while to show itself anew in these spaces, and throw up fresh tubercles. Beginning by a single tubercle, or by a small cluster of tubercles, lupus non exedens will often spread over the whole of one side of the face and part of the other, including the nose in its course ; and the loss of tissue which it occasions and the permanent cicatrix which it leaves behind give rise to considerable deformity: the alae of the nose are drawn up as if by ulceration; the point of the nose is sharpened; the upper lip is shortened so as to bring the teeth into view; and the lower lids are pulled down so as to expose more of the globes of the eyes than natural. The surface of the cicatrix is frequently white and polished; crossed by white ridges and bands; slightly sunk below the level of the surrounding integument; the spaces between the white lines being smooth, thin, and glossy. 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. Occasionally we meet with blotches of lupus non exedens on other parts of the body than the face; for example, on the arms or on the trunk of the body ; and where the patches have been treated by poultice or water-dressing, it is not uncommon to find them com- plicated by a muco-purulent discharge, sometimes in considerable quantity, and without abrasion of the cuticle. But if the improper dressing be laid aside, the patch will recover its previous dry and tubercular character. Lupus erythematosus (erythema centrifugum, Biett) is an ery- thematous redness of the skin occurring in patches of small size, LUPUS ERYTHEMATOSUS. 375 usually on the face; lasting for a long period without change, and terminating in a dry, sordid, and atrophied surface, or in a white depressed cicatrix. Lupus erythematosus is sometimes seen associated with lupus non exedens as a sequel of that complaint. The disease is commonly met with on the nose, the cheeks, the upper lip, or the scalp; it appears as a patch of irregular figure but well-defined redness ; the centre of the patch being coated over with a dry sordid cuticle, slightly depressed, and the follicles filled with horny exuviae ; at a first glance the patch appears trifling; its sta- tionary habit and resistance of treatment excite suspicion that it is something more than common erythema; its disposition to occasion atrophy of the skin proves it to be more serious in its nature, and when it fortunately disappears spontaneously, the white cicatrix indi- cating the removal of the papillary layer of the derma, or on the scalp the destruction of the hair-follicles, declares its relation to the family of lupus. It is a chronic and very troublesome disease, and sometimes incurable. Associated with lupus erythematosus of the face we not unfre- quently meet with similar spots on the fingers ; in the latter situation they have the appearance of chilblains, and are commonly mistaken for them ; but their persistence through the summer as well as the winter, the white dry cuticle which covers their surface, the central depression, and frequently the atrophy of the portion of the skin attacked, indicate.their real nature. The erythematous spots or blotches are usually of a circular figure, of a purplish-red color, and slightly raised above the level of the surrounding 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, gradually dries up into a thin, yellowish, and horny layer, and desquamates from time to time. A common situa- tion of these blotches is the joints, and 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 fkin of the face, the special character of the disease is atrophy; and in a young girl now under our 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. Diagnosis.—Scrofuloderma may be mistaken for syphiloderma, and in forming our diagnosis we must be guided by the strumous constitution or descent, together with the age of the patient, and the ordinary signs of struma; for example, the clear anaemic skin, blue eyes, thick lips, and enlargement of lymphatic glands. The ex- perienced physician detects these signs at a glance, and is not likely to be deceived. Occasionally it is not easy to draw the line between simple scrofuloderma and lupus non exedens; and it is far from un- common to find the former merge into the latter at the expiration of several years; the period of abscess and ulceration belongs to scro 376 STRUMOUS AFFECTIONS. fuloderma; the tubercular and non-ulcerative period to lupus non exedens. The diseases likely to be mistaken for lupus exedens are tubercular and ulcerative syphiloderma and carcinoma; the resemblance between lupus exedens and some forms of syphilis is so close that one of the varieties of the latter has received the objectionable name of lupus syphiliticus. It is desirable to avoid confusion between these im- portant diseases, as the treatment suitable for the one would do injury to the other. Our diagnosis must be founded upon the general history of the case rather than upon seemingly distinctive appearances; the former is certain ground, the latter may be delusive, and the difficulty can only arise when the disease is limited to the point of the nose or the edge of the nostril. If there exist eruption in other parts of the body, if there be evidence of the previous existence of eruption else- where, or any of the concomitant signs of syphilis, we may easily decide the question; while the associated symptoms of lupus are, struma or strumous parentage, or the development of the disease at an early period of life. Cancer (epithelioma) commences in a sebi- parous gland, is slower in its progress, attended with less congestion and swelling than lupus, and presents a peculiarly transparent and hardened border around its circumference. Lupus non exedens, particularly of the face of young persons, whom it usually attacks, is unmistakable ; on the limbs and trunk of the body it may be taken for tubercular syphiloderma or alphos. Youth, the presence of a strumous diathesis, and the absence of sore throat and other signs of syphilis, decide the question in favor of lupus. We have seen lupus non exedens on the limbs, occurring in circular patches of about an inch in diameter, strangely like alphos in appearance; but the origin was different, a pustule or small abscess; and if a portion of the patch have undergone spontaneous cure, there will be the de- cisive evidence of a cicatrix in lupus and the absence of any morbid alteration of the skin in alphos. Lupus erythematosus is distinguished from all other affections of the skin by its maintenance of a circumscribed erythematous form; its obstinate persistence; the atrophy of the surface of the skin that ensues; its sordid appearance; and the presence of a permanent cica- trix in parts that have healed. It is comparatively a rare affection. Cause.—The cause of scrofuloderma and lupus is the strumous diathesis, whether hereditary or accidental. Prognosis.—Scrofuloderma and lupus are remarkable for their obstinacy, frequently resisting treatment, and lasting many years, or for life; and even when the sequel is favorable, leaving behind them indelible cicatrices, and often considerable deformity, as where the face and nose are attacked, and the latter more or less destroyed by absorption or ulceration. Treatment.—In strumous affections in general, great attention must be paid to diet. There is commonly weak nutritive power and defec- tive assimilation and sanguification; hence our patients are fair in complexion, pallid, flabby in tissue, and more or less anaemic. The diet should consist of one-half or two-thirds animal food. Animal treatment of scrofuloderma. 377 food should be taken at each meal, and with the addition at dinner and supper of beer, either ale or porter, according to the taste of the patient. In these disorders occurring in children, there is advan- tage also in mingling a few grains of phosphate of lime with each meal. The medicines especially applicable to strumous affections are cod- liver oil, iodine, iron, and nitric acid; and these specific anti-scrofulous remedies may be combined with ordinary tonics, namely, vegetable bitters, cinchona, or quinine. In children the superphosphate of iron is especially valuable, and both in children and adults the syrup of the iodide of iron will be found of great service. At the recommenda- tion of the late Mr. Peter Price we have employed the iodide of am- monium with good results, using it both internally and externally at the same time. For internal exhibition the dose is two or three grains, twice or three times a day, in any suitable vehicle, such as the com- pound fluid extract of sarsaparilla or syrup of orange peel. And for externa] 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. Donovan's solution has some- times been found serviceable in lupus, particularly in conjunction with cod-liver oil; and the bichloride of mercury in combination with cinchona. In all the forms of lupus it is important to regulate the functions of digestion and the secretions of the patient, and afterwards make our way through the ordinary tonics to the specific tonics; in other words, to put our patient in the best possible health, and, by every means in our power, conjointly with the local treatment. By this process we give our local treatment a better chance of a certain and speedy success. We must maintain and support the vital power of the patient as much as possible, for our contention is against a debili- tated constitution. The local treatment of scrofuloderma must be stimulant in various degrees, according to the form of the disease; while water-dressings and poultices must be looked upon with great suspicion, as generally doing much more harm than good, by increasing the local debility of tissues already seriously weakened. Scrofuloderma in an ulcerating and fistulous state may be treated with the unguentum resinae flavae, diluted to suit the sensations of the patient, or the unguentum picis liquidae, or the unguentum picis juniperi; the unguentum elemi is also an useful ointment; or, if we need milder applications, we may have recourse to the benzoated ointment of oxide of zinc, or unguen- tum calaminae. The liquor plumbi diacetatis, pencilled on the tender skin, is sometimes useful; and when the ulceration is healed, the juni- per-tar tincture, or balsam of Peru, will be found of service in strength- ening and hardening the skin. Where tuberculous growths are to be absorbed or enlarged glands to be reduced, the compound tincture of iodine or a saturated solution of iodine in glycerine may be painted on the part. In lupus exedens the morbid tissue of the ulcer must be destroyed, and the condensed and infiltrated tissues unloaded by means of a free application of nitrate of silver, the acid nitrate of mercury, or of a 378 strumous affections. solution of equal parts of potassa fusa and water. After the operation the part may be dressed with the unguentum resinae diluted one-half, or with the benzoated ointment of oxide of zinc. Caustics constitute a necessary part of the treatment of lupus, and the enumeration of these remedies forms a somewhat considerable catalogue. The caustics the best suited for the 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 sublimatum 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 quick- lime, 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 hun- dred parts of calomel. The chloride of gold and acid nitrate of mer- cury 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 sur- rounding 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 lamb- skin, or with a dressing of the benzoated ointment of oxide of zinc, ,or liquor plumbi, or calamine ointment. In lupus non exedens the patch of morbid tissue, or the tubercles both primary and secondary, must be destroyed by the application of the solution of caustic potash (equal parts); after the application no dressing is required: and when the crust falls, the caustic should be repeated until the disease is entirely removed. When the diseased surface is extensive and the caustic can only be applied to a part of the eruption, the remaining portion should be kept washed night and morning with the juniper-tar soap, and afterwards anointed with the benzoated ointment of oxide of zinc, or with glycerole containing one drachm of the oleum juniperi pyrolignici, or two grains of the bichlo- ride of mercury to the ounce. If any objection be felt to the caustic potash, the acid nitrate of mercury, nitric acid, or the chloride of zinc, may be employed instead. Lupus erythematosus is best treated in the same manner as lupus non exedens, with the caustic potash solution. Other remedies have been recommended, such as a concentrated solution of iodine in gly- cerine, the compound tincture of iodine of double strength, the iodide, biniodide, and chloriodide of mercury ointments, the iodide of lead ointment (5ij ad 3j), &c.; but we give the preference to the treatment above described. CARCINOMA. 379 CHAPTER XVI. CARCINOMATOUS AFFECTIONS. Carcinoma of the skin is apt to occur upon the face in the form of a small tubercle, and for the most part after the middle period of life. The tubercle is solitary, gives rise to little or no uneasiness, is slow in its progress, and persists for several years without attracting attention. When ulceration begins, the process is equally torpid, but occasionally, and in an irritable state of constitution, may take on a more rapid action, and give rise to considerable destruction. The tubercle at the beginning is round or lobulated, about one line in height and two in diameter; it is hard, semi-transparent, colorless or yellowish and sometimes bluish, and streaked by a straggling net- work of small veins. It grows by the increase of its circumference, the border being more or less lobulated, and the centre somewhat depressed, and reaches a diameter of four to six lines, and sometimes one to two inches. By degrees a thin scale is produced over the cen- tral depression, one or two fissures are formed in the centre of the mass, an oozing of a colorless or semi-purulent ichor takes place, and the scale is converted into a scab or crust, sometimes brownish in color, and sometimes, from an oozing of blood, almost black. At this period the tubercle is generally circular in figure, has a raised, lobulated, and semi-transparent border, streaked by venules, with a central dark-colored or black scab, that looks like the lid of a cavity or like an eschar. t Ulceration is now established, but proceeds slowly, and is very imperfect; it is a softening and breaking up of the centre that takes places, rather than absorption. The discharge increases, although still small in quantity; it is ichorous or semipurulent, and sometimes sanguinolent; it forms by concretion and desiccation a thicker and harder crust, and on the removal of the crust a deep hollow is found, which is bounded by a vertical edge, that is sometimes excavated at its base, and sometimes everted. The floor of the cavity is uneven; it is composed of red, tumid, and bleeding granulations, which sometimes assume a fungous character, and sometimes rise in the centre above the level of the surrounding surface. There is but little pain accompanying the progress of the disease; sometimes there is itching, which leads the patient to loosen the crust with his nail; sometimes there may be throbbing or darting, but commonly the local suffering is confined to a feeling of numbness, heaviness, or dull aching. These symptoms are increased if there be any derangement of digestion; and they are apt to be augmented by any constitutional disturbance of the economy, such as an attack of gout. When the disease takes on a more active character, it may 380 CARCINOMATOUS AFFECTIONS. become very painful, from involving deeper structures than the skin, and may destroy a surface of considerable extent. We have lately seen a case in which the greater part of the nose was destroyed; in another the external ear is almost entirely removed ; while in a third instance we have seen the whole of the lower lid and part of the in- tegument of the cheek swept completely away. Carcinoma cutis is a more frequent affection than might at first sight be imagined. In two thousand cases of cutaneous disease it occurred eleven times, in other words, somewhat more than one-half per cent., or one in every two hundred. In twenty cases it was more than twice as frequent in males than in females; in two-thirds of that number it occurred after the age of fifty, several of the patients being above sixty; and its general duration at the time of coming under treatment ranged between two and fifteen years. In all the twenty cases the disease manifested itself on the face or its immediate neighborhood; in nine, it appeared upon the cheek ; in eight, upon the nose; while in one case it was developed on the eye- brow near its outer extremity; in another, on the temple, and in a third, upon the mastoid process. When it is formed on the side of the bridge of the nose, it is apt to creep towards the angle of the eye; near the ear it moves backwards; and in an instance before us, has destroyed the whole of the pinna, with the exception of the upper rim. Commonly there is very little disturbance of the general health in this disease; sometimes we have noted cachexia, anaemia, debility, feeble heart, and on several occasions an unhealthy condition of the skin of the face, which was dry, tjiin, wrinkled, sordid, and seemingly withered. The form of carcinoma cutis now described has its origin in a sebi- parous gland; it is, in fact, an epithelial cancer, or epithelioma, origi- nating in one of these glands, conjoined with a propagation of the dis- ease to surrounding glands. This idea of the pathology of the disease serves to explain the extreme tardiness of its course at first, when one only, or a small group of glands are attacked, and its subsequent more rapid progress, when it takes in the circle of glands which imme- diately border its circumference. The glandular origin and seat of the complaint also serve to explain the limitation of the disease to the gland-bearing portion of the skin. True carcinoma cutis is a much more rare affection than epithe- lioma, and is associated with a morbid condition of the lymphatic glands; the tubercles of true carcinoma are hard, non-vascular, and produced apparently by infiltration of cancerous matter into the tissues of the corium. In advanced stages of the disease the skin is hardened and contracted in the interspaces of the tubercles, the sub- cutaneous cellular tissue is removed, and the integument is drawn tightly against the bones. This condition of the skin is sometimes seen in conjunction with cancer mammae. Diagnosis.—The carcinomatous tubercle might be mistaken for a wart or for a mole ; but a careful inspection discovers the disorganiza- tion of the mass, even before ulceration has commenced; in an ulce- TREATMENT OF CARCINOMA. 381 rated state the disease soon betrays its malignant nature. It might also be taken for an enlarged sebiparous gland, and its scab for a mass of concreted and discolored sebaceous substance. When the morbid action has sunk into the deeper tissues of the skin, the affected integu- ment is remarkable for its hardness. Cause.—Carcinoma, like alphos and scrofuloderma, takes its origin in a diathesis, and not in a blood-poison, like the zymotic and syphi- litic affections. Alphos and struma are hereditary; carcinoma is fre- quently the same, and, according to Weeden Cooke, is allied to tuberculosis, and apt to be met with among the relatives and descend- ants of consumptive persons. It is an indication of degeneration of the organic tissues, and is therefore very commonly associated with mal-assimilation, defective nutrition, and cachexia. Prognosis.—Carcinoma of the skin is more under our control than a similar affection of the deeper tissues, and, if taken early, may be effectually and radically removed. It is altogether superficial at first, and seemingly perfectly local, exhibiting no tendency to produce hypertrophy of neighboring lymphatic glands, nor any general dis- order of the constitution. An unfavorable sign is, hardening of the subcutaneous tissues and the implication of cartilage in the disease. Treatment.—The carcinomatous tubercle should be destroyed as early as possible by caustic, and the same remedy is equally appli- cable to its ulcerated condition. We sometimes use caustic potash, sometimes nitric acid, sometimes the acid nitrate of mercury, and sometimes the chloride of zinc; but we prefer the three former, in con- sequence of their being the least painful. A fragment of potassa fusa pressed into the centre of a tubercle of moderate size very soon dis- organizes it throughout; the disorganized mass dries into a crust; and when the crust falls, at the end of about twenty days, the skin will be found healed and the tubercle gone, leaving a very unim- portant cicatrix. If the tubercle be not wholly removed, the opera- tion must be repeated ; or if, at a later period, there should be any threatening of a return of the disease, then also the caustic should be reapplied. When the disease has the form of an ulcer, and particu- larly of any magnitude, it is better to apply a solution of equal parts of caustic potash and water by means of a sponge-brush. Formerly we gave a preference to the nitric acid, but we are now strongly in favor of the potassa fusa, on account of the rapidity of its action, the speedier cessation of pain, and the absence of the obscuration asso- ciated with the use of other caustics. The acid nitrate of mercury also requires the aid of the sponge-brush for its application. When nitric acid is selected, it should be mixed with sublimed sulphur to the consistence of paste, and applied somewhat thickly by means of a slip of wood ; the sulphur incorporates itself with the scab, and the latter falls off in about the same time as that produced by the potassa fusa. The chloride of zinc may be applied in its deliquescent state by the aid of a camel's-hair brush, and afterwards dressed with dry lint. The other caustics require no dressing, and no further local in- terference until the crust falls. 382 ZYMOTIC AFFECTIONS. The constitutional treatment of epithelioma, as of cancer in general, must have for its object to improve the tone of the patient, to invi- gorate nutrition, and to subdue cachexia. These ends are best attained by regulating the secretions and diet, and administering tonic reme- dies ; among which, the mineral acids, quinine and iron, and cod-liver oil, must occupy an important place. CHAPTER XVII. ZYMOTIC AFFECTIONS. Zymotic affections of the skin are eruptions originating from the presence in the blood of an organic poison, which operates on the blood like a ferment, hence the term zymotic, derived from Cv^, fer- mentum, or leaven, and tends to the production, in excessive quantity, of a poison similar to itself, and to the elimination of that poison by the surface membranes of the body, and especially by the glandular apparatus of the skin. The special eruptions coming under this head are:— Rubeola, Varicella, Scarlatina, Vaccinia, Variola, Equinia, Framboesia. The first four of these affections are the exanthematous or eruptive fevers ; vaccinia is an eruptive disease of cattle, analogous to variola, and transmissible to man; equinia is a disease of the equine family, and also transmissible to man; and framboesia is a disease of the na- tives of Africa, possessing a close resemblance in some of its features to the eruptive fevers. Arising from a similar cause, zymotic affections offer to our observa- tion certain symptoms which are common to the whole; for example, constitutional symptoms, due to the action of the poison in the blood and on the nervous system, symptoms having the character of fever; and heal symptoms, manifesting the operation of the poison on the surface tissues of the body, the skin and mucous membrane. The former series of symptoms belong to the consideration of fevers; the latter bring the zymotic affections into the family of cutaneous dis- orders ; and just as the history of fevers would be incomplete without embracing the eruptive fevers, the review of cutaneous diseases would be equally imperfect without the consideration of the phenomena pre- sented by the operation of the zymotic poison in the tissues of the skin. The poison of the zymotic affections, as of fevers in general, mani- fests its first and most powerful influence on the nervous system; the brain, the spinal cord with its branches, and the organic system of EXANTHEMATA. OOQ ooo nerves, are, as it were, intoxicated by the poison ; then a general ex- citement of the circulating system ensues, and the excitement of the circulating system is followed by an outburst of eruption, an exan- thema of the skin. The exanthema is manifested by redness, resulting from congestion of the vascular plexus of the skin, congestion of the vertical or folli- cular capillary plexus, giving rise to puncta and papulae, and conges- tion of the horizontal or papillary capillary plexus, producing suffu- sion. In rubeola or measles the congestion affects chiefly the follicular plexus, and, governed by a law of structure, appears in small oblong clusters or corymbi, which give to the skin a mottled appearance, corresponding with the mottling of the arms of children in cold weather. In scarlatina the congestion is more diffused, from a blend- ing of the two forms of congestion, and probably from a greater activity of circulation; it is no longer limited to the small insular corymbi which represent the extent of distribution of the ultimate ramuscules of a small artery or the range of influence of a nervous twig, but occurs in patches of large size, or is more or less uniform over the whole surface. Moreover, minute papulae, resulting from follicular congestion, which are common in scarlatina, are less frequent in rube- ola, and exhibit their highest degree »f development in variola. In variola the congestion is chiefly follicular, and produces papulae, which subsequently run through the vesicular and pustular stage, and ter- minate in dark brown and black scabs. The pathology of the zymotic eruptions is, therefore, an active con- gestion of the capillaries of the skin running on to the production of minute papulae, and of larger papulae which pass through the vesicular and the pustular stage. As far as pathology is concerned, rubeola and scarlatina are aborted forms of variola; rubeola representing the simple congestive form; scarlatina the congestive arid papular form ; and variola the congestive, papular, vesicular, and pustular forms. It follows from this view of these eruptions, that the exanthema of rubeola, usually flat, may be more or less papular; and papulae are often met with on the face, neck, hands, and legs, while they are absent elsewhere. Scarlatina, again, generally papular, particularly on the parts above indicated, may be more or less smooth. But rubeola and scarlatina never run on to the production of pustules, as is the case with variola. Rubeola and.scarlatina, having but the limited range of simple congestion and papulae, offer little variety of pathological structure; but the case is different with variola, which embraces all chief pathological forms of inflammation of the skin ; namely, redness, papulation, vesiculation, and pustulation. Variola may be arrested or aborted at each of these stages, and we may have instead of the perfect pustular development of the eruption, a series of aborted forms, that reach no further than the papular, the vesicular, or the incipient pustular stages. These aborted forms of variola are termed varioloid, and as their "abortion" is a frequent consequence of a previous attack of variola, or of vaccination, conditions which modify the violence of the variolous poison, they are so called "modified variola." Variola, or smallpox, besides representing the human disease known 334 ZYMOTIC AFFECTIONS. by that name, also includes vaccinia, or the smallpox of the cow ; than which, as offering a safeguard against the violence of variola, and a protection to the population, there is no affection in the whole category of zymotic diseases of more interest in regard to public health. If we turn to the classification of Willan, we shall see that the diseases collected into the group of zymotic affections are dispersed among four of his orders, namely, exanthemata, vesiculae, pustulae, and tubercula; exanthemata taking possession of rubeola and scarla- tina ; vesiculae, of varicella and vaccinia; pustulae, of variola, and tu- bercula of framboesia ; but it is clear that the mutual relations of these affections is such that it would be unphilosophical to continue so un- natural a separation. The eruptive or exanthematous fevers seem to have originated in the East, and were first described by the Arabian physicians; and from the East they were gradually propagated through the rest of the world. Of the nature of the poison or poisons which give rise to them we know very little. We assume that they are of organic crea- tion, and are derived from the same source as the poisons which pro- duce the continued fevers; but we do know that they are highly in- fectious and contagious, and are actively transmissible from an infected to a sound person, both through the medium of contact, namely, immediate or direct infection or contagion, or through the intervention of the atmosphere, namely, mediate and indirect infection, or simply infection. Moreover, there seems to be good reason for the belief that there are three separate and distinct poisons, although arguments are not wanting for supporting the theory that one and the same poison, under the influence of different atmospheric conditions, and in different states of the body, may have the power of giving rise to the differ- ences of character which distinguish the three diseases. Thus, when rubeola prevails as an epidemic, scarlatina is least frequent, and vice versa; and occasionally, as in the spring of 1864, we meet with an epidemic, in which rubeola and varicella appear to be intermingled, and the same patient may experience in succession an imperfect rubeola (rubeola notha) and a varicella. The exanthema of the eruptive fevers presents a curious difference of color, which has suggested the term rubeola, ruby or raspberry colored, and scarlatina or scarlet colored, important diagnostic cha- racters, depending possibly on a more sluggish circulation through the dilated cutaneous capillaries in the former, and a more active cir- culation through the latter; and, possibly, in some degree also upon a modification of the coloring principle of the blood by the poisonous ferment, such as occurs in association with the syphilitic poison. The physiological relationship of the skin and mucous membrane is amply illustrated by the exanthematic affections; the mucous mem- brane of the fauces is congested in all the three diseases, but most in scarlatina; in rubeola the congestion elects for its principal seat the con- junctiva, the Schneiderian membrane, and the mucous membrane of the trachea and bronchial tubes ; and the eruption of smallpox is met with in severe cases, also in the mucous membrane of the mouth, EXANTHEMATA. 385 fauces and trachea. In general terms, rubeola may be said to attack chiefly the mucous membrane of the air-passages; and scarlatina, the mucous glands and the mucous lining of the mouth and salivary glands. The exanthema, in its evolution on the skin, makes its first appear- ance on the face and neck, next on the trunk and upper extremities, and lastly reaches the lower limbs; and departs-in a similar order; while the eruption is always most abundantly developed on parts exposed habitually to the action of the air, such as the face and the hands. At its decline the redness loses its vivid hue and becomes dull, subsequently purplish, and not unfrequently leaves behind yellow- ish, brownish, and greenish stains which call to mind the tints of a bruise. Congestion of the vessels of the skin is necessarily attended with a certain amount of swelling, the skin is somewhat thickened, and the subcutaneous cellular tissue more or less infiltrated, sometimes to the extent of constituting oedema. Hence the features look swollen or puffed, the limbs are enlarged, and oedema may prevail in the latter to a greater or less extent. The sensations of the skin are a moderate degree of tingling and itching in the early stage of the eruption, sub- sequently heat, and when desquamation begins, a very troublesome degree of pruritus. Another phenomenon accompanying the decline of the exanthema- tous eruption is desquamation of the cuticle. The congestion of the skin causes a temporary suspension of the process of epidermal cell- formation ; the epidermis loses its vitality, and is separated from the newly-formed horny tissue produced beneath it, and when the skin resumes its normal functions, the old cuticle is cast off in the form of exuviae of considerable extent; in scarlatina, the entire cuticle of the hands or of the feet is sometimes cast in a single piece, and the new and tender cuticle, showing through its transparent wall the pink hue of the derma, is seen beneath. The period of desquamation is with good reason regarded as a time of active transmissibility of the dis- ease, for the cuticle is saturated with fluids produced during the most active period of the fermentation of the poison, and particles of exfo- liated cuticle become so many vehicles of contagion. In the normal course of the eruptive fevers, a full development of the exanthema is favorable to the safety of the patient; the disease would seem to expend its power upon the skin, and the action on the skin to divert the violence of the fever from the internal organs. Hence we regard with satisfaction a thorough development of the exan- thema, while we perceive with apprehension the disappearance or retrocession of the rash after it has once broken out, and we employ all our efforts to restore it. All the exanthemata may exhibit the fever without the eruption; but in this case the fever is commonly mild, and the absence of eruption indicates only a mitigated form of the disease. The zymotic fevers are to a certain extent protective of the consti- tution against a repetition of the disease, and persons who have once had rubeola, scarlatina, or variola, may be regarded as free from the 25 386 ZYMOTIC AFFECTIONS. danger of their recurrence; nevertheless, instances not unfrequently happen in which patients have suffered more than once from these affections; more commonly, perhaps, in the case of rubeola than in that of scarlatina or variola. As a general rule, the second attack is milder than the first; but this rule is not without its exception. Moreover, different epidemics of these fevers have generally their dis- tinguishing peculiarities, sometimes being more and sometimes less severe. And in each separate epidemic there is always great variety in the gravity of the disease, some cases being very serious and others very slight, without any apparent reason for such difference of char- acter. Sometimes an epidemic begins with moderation and closes with severity, and vice versa ; and, at the tail of an epidemic of variola, varioloid is more frequent than in the middle of its course. Hence the rise, the height, and the decline of an epidemic may present a con- siderable amount of variety. RUBEOLA. Syn. Measles; morbilli, Ali-abbas; febris morbillosa, Sydenham ; blactioz, Ingras- sias ; rubeolar, Sauvages ; phatnicismus; rougeole, Fran. ; masern, kindspecken, flecken, Germ. Rubeola, or measles, is an eruptive fever attended with constitu- tional symptoms of fever, with an eruption on the skin of a punctiform and mottled rash or exanthema of a dull red or raspberry color, and with congestion of the conjunctiva and mucous membrane of the nose and respiratory tubes. The 'constitutional symptoms are the ordinary series of febrile symptoms, ranging from a scarcely perceptible disorder of the system to the highest degree of severity. They are, lassitude, weariness, drowsiness, pains in the head, in the back, in the limbs, chills suc- ceeded by flushes of heat, sometimes rigors, sometimes convulsions, and moderate delirium at night; the skin is hot and dry, the pulse frequent but without force; the tongue white, thickly coated and moist, sprinkled with red papulae, and red at the tip and along the edges; there is soreness of throat, tightness and wheezing at the chest, hoarseness of voice, quick respiration, dry and frequent cough, thirst, loss of appetite, nausea, not unfrequently vomiting, constipation, and high colored and scanty urine depositing lithates on cooling. These symptoms progressively increase in severity for four or six days, and begin to subside when the exanthema is fully developed. The exanthema first makes its appearance in the mucous mem- brane; on the third day the conjunctiva is suffused, the eyelids are congested and swollen, there is a copious distillation from the eyes and nose, constituting coryza, and sometimes epistaxis. At the same time there is sneezing and cough, or catarrh, and the cough, dry at first, and sometimes paroxysmal, soon becomes moist and mucous, with considerable expectoration. The fauces are mottled with red and congested, but without much swelling; and the bearing is fre- quently dull, from the extension of the congestion to the Eustachian tubes. RUBEOLA. 387 The eruption on the skin first appears on the fourth day, sometimes on the third, and more rarely on the fifth. It is seen in the first instance on the forehead, then on the front of the neck, on the cheeks, and around the mouth, and reaches its height in twenty-four hours. On the fifth day it invades the trunk and upper extremities; on the sixth, the lower extremities, in each instance reaching its height in twenty-four hours; and on the sixth or seventh day appears on the back of the hands. The decline of the efflorescence follows a similar course; on the sixth day it fades upon the face; on the seventh, upon the trunk and upper extremities; on the eighth, upon the back of the hands and lower limb's; and on the ninth day the form of the patches is discoverable only by a pale yellowish discoloration, which slowly disappears. The exanthema of rubeola is a punctated rash, resulting from con- gestion of the capillary plexus of the follicles; the puncta are clus- tered into small oblong groups or corymbi, and are more or less blended in each corymbus by a moderate suffusion, resulting from congestion of the interfollicular capillary plexus. This arrangement gives a mottled appearance to the congested skin, which is pathogno- monic of rubeola. Here and there some of the pores of the follicles are raised into minute papulae, and on certain regions of the body, as on the face and limbs, these papulae are more strikingly apparent than on other parts. Indeed, on the face, it is not uncommon to find a genera] suffusion, roughened by papulae, the corymbose appearance being lost; and in general the mottled arrangement of the clusters is more constant on the trunk of the body than elsewhere. Added to the corymbose form of the exanthem, as diagnostic of rubeola, we have the dull red crimson color which has been compared to that of the raspberry; and at the decline of the eruption, the exfoliation of the cuticle in thin foliaceous plates and furfuraceous scales. The normal course of rubeola presents a four-day premonitory fever of moderate vehemence, a four-day exanthema, succeeded by a four-day decline, a subsequent exfoliation of the cuticle, and gradual return to health. It also brings to our notice an inflammatory con- gestion of the mucous membrane, beginning in the conjunctiva, the Schneiderian membrane, the Eustachian tubes, and the fauces, and running downwards along the trachea and bronchial tubes, accom- panied with cough, dry and irritable at first, and subsequently moist and mucous, the mucus at the height of the disorder being raised in roundish pellets, termed nummular expectoration. Later in the course of the disorder the mucous membrane of the alimentary canal participates in the congestion, and relieves itself at about the ninth or tenth day by diarrhoea. A review of the normal course of rubeola is suggestive of its com- plications, its possible dangers, and its subsequent evils denominated sequelae. The first and most important of these is the affection of the lungs; the catarrh, the hoarseness, and the cough usually subside on the seventh day ; but instead of subsiding, the bronchitis may increase and run on to pneumonia and permanent disease of the lungs; there may be purulent discharges from the eyelids, nasal and ear passages, 388 ZYMOTIC AFFECTIONS. and even ulceration. The mucous membrane of the mouth, of the fauces, of the salivary glands, may become inflamed, and proceed to ulceration and suppuration; the mucous lining of the larynx may become swollen and oedematous, and threaten suffocation. The diar- rhoea, which generally ceases spontaneously in a few days after the disappearance of the rash, may be prolonged, and become compli- cated by ulceration of the mucous glands, and even the mucous lining of the genito-urinary apparatus may suffer a similar disorganization. Moreover, as a secondary evil, the mesenteric and lymphatic glands may become enlarged and impervious, and lay the foundation of tabes and superficial abscesses; there may be tubercular deposits in the lungs and in the serous membranes, or there may be rheumatic inflam- mation of the joints. The period which elapses between exposure to contagion and the commencement of the fever, usually termed the period of incubation, varies between seven and fourteen days, and the term at which a patient may be supposed to be free from the danger of communicating the infection, three or four weeks. Rubeola is a disorder of childhood, rare in infants, but occasionally met with in the adult. It may happen a second or a third time, and without the modification which occurs in variola; indeed, it is more likely to be severe in the adult than in children. It makes its attack usually in the winter and early spring, at that period of the year when catarrhs and whooping-cough are*most frequent; and, as we have seen, the chief danger of the disease is the propagation of the catarrh and subsequent bronchitis and morbid orperation, to the structure of the lungs. The differences of manifestations of the symp- toms of rubeola constitute its varieties, which are as follows:— Rubeola vulgaris, Rubeola sine exanthemate, sine catarrho, " nigra. Rubeola vulgaris represents the common type of the eruption, consisting of constitutional and local symptoms, pursuing the course already described. The constitutional symptoms may be mild or severe, the local symptoms developed to a greater or less degree, and the disease may subside at the end of twelve or fourteen days, with a gradual return to health. On the other hand, if the patient be exposed to cold or neglected, the cough may increase, and the foundation be laid for a serious state of disease that may terminate fatally; or if his constitution be unhealthy, or the epidemic unusually severe, chronic disease may be established. With proper management, rubeola is commonly a mild disorder. Occasionally the symptoms are so slight as to render it doubtful if the .case be really one of rubeola; the exanthem is more or less fully developed, but the constitutional symptoms are almost absent. An epidemic of this very mild description prevailed in the spring of 1861, and the doubtful character of the disease suggested the term rubeola notha, or spurious rubeola, given to it by Dr. Babington. Rubeola sine catarrho is an example of a mild form of measles, in which its more serious symptom, that of the aft'ection of the mucous RUBEOLA VULGARIS. 389 membrane of the air-tubes, is absent. In this case, as in rubeola notha, the constitutional symptoms are very moderate, although the exan- them may be fully developed. Rubeola sine catarrho is apt to occur more frequently at the beginning or end of an epidemic than during its height, and is met with in one or more members of a family wherein $ the rest pass through the disease in the ordinary way. Persons who have experienced this mild form of the complaint are more than usually liable to a subsequent attack of the disease. Rubeola sine exanthemate, called by Sydenham "febris morbil- losa," is a rarer variation of measles than the preceding, and a similar example of aberration from a normal standard, the peculiarity in the present case being the existence of the fever without the exanthema. Cases of this kind are also met with more or less numerously in the course of a rubeolous epidemic. Rubeola nigra, or black measles, is a designation derived from the color of the exanthem; the circulation through the cutaneous capil- laries is slower than natural, those vessels are dilated, and the blood, robbing the tissues of their carbon, is converted into venous blood. The eruption, consequently, is purplish or livid in hue, and extrava- sations are apt to take place, which suggest the idea of purpura. Rubeola nigra is rare, and occurs for the most part in weakly and exhausted constitutions; the constitutional symptoms assume the cha- racter of typhus, and are sometimes complicated by effusions into the cellular tissue and into the serous cavities. Diagnosis.—In zymotic fevers, as in fevers in general, the medical man is attracted by the duiness, the listlessness, and drowsiness of the patient. If conjoined with these symptoms of depression of power of the nervous system, there be present coryza and catarrh, and the patient has not already had rubeola, suspicion becomes stronger, and is increased if a rubeolous epidemic is known to be in existence at the time. The fourth day of these symptoms is marked by the appear- ance of the rubeolous rash upon the face, and its dull red and rasp- berry-tinted color places the question beyond further doubt: the case is one of rubeola. Cause.—A special contagious principle or poison, sometimes spora- dic, more frequently conveyed from one person to another, either by the atmosphere or by actual contact. Rubeola is the most contagious of the zymotic affections, and prevails most abundantly during the damp and cold seasons of the year, when whooping-cough and catarrhs are frequent; catarrh being a predisposing cause. The period of isola- tion after recovery from the illness should be at least three weeks. The most remarkable epidemics of measles which have occurred in this country are those of London in 1671, 1674, 1763, and 1768, hav- ing Sydenham for their historian; and the epidemic of Plymouth in 1741, recorded by Huxham. Prognosis.—Rubeola is of favorable augury, and when it occurs divested of irregularity of course and complications, is a mild dis- order. It is serious only when neglected, and when there exists pre- vious disease, particularly of the lungs. 890 ZYMOTIC AFFECTIONS. Treatment.—As the issue of rubeola involves the safety of the lungs, the patient must be submitted to rigorous discipline, so far as the avoidance of chill is concerned. He must be kept in an apart- ment of equable temperature (about 60°), well ventilated, but pro- tected from draughts of cold air. If the feverish symptoms be slight, he may be permitted to be up; but even with moderate fever he would "be much better in bed, and kept as tranquil as possible both in body and mind; light should be excluded from the room, and sleep encouraged by every suitable means. We may also be guided in our precautions by the previous state of health of the patient, and by our knowledge of his constitutional power. Abundant care cannot be too strongly insisted on, provided that the apartment be not too hot, nor the bed coverings oppressive. The diet should be moderate and unstimulating, easy of digestion, and administered at regular intervals. It should consist of the usual invalid series: gruel, arrowroot, milk, beef tea, Liebig's beef tea, chicken broth, veal broth, jellies, farinaceous and egg puddings, panada, &c, selecting as much as possible those articles which are most acceptable to the taste and inclination of the patient, and care- fully avoiding excess in quantity. In case of nausea and sickness, cold bread and milk will often stay upon the stomach when other articles of diet fail ; or warm milk with soda water, barley water, or meat jelly. Thirst may be allayed with toast water, barley water, ice, and acidulated drinks; but care should be taken to avoid a large quan- tity at one time. Barley water with chlorate of potash, half a drachm or a drachm to the pint, is an admirable febrifuge drink; as also are, lemonade a little sweetened, tamarind water, raspberry vinegar with water, imperial drink; and where a tonic combination is desired, a weak bitter infusion acidulated with hydrochloric or nitromuriatic acid. When the powers of the constitution flag, the pulse becomes weak and quick, and the tongue dry and brown, we may have recourse to alcohol in addition to food, and may administer it in such form and quantity as the symptoms may determine. It will be necessary also to watch the operation of the bowels; a mild aperient may become requisite, but the bowels are easily excited, and we must bear in mind the natural tendency to diarrhoea which is evinced at the " turn" of the disease. We may prescribe, if need be, a rhubarb or senna draught, and if the secretion of the liver be sus- pended, a small dose of calomel or gray powder; or if the critical diarrhoea fail in its appearance at the decline of the disorder, a gentle aperient may be administered to supply its place. The treatment of rubeola might be summed up in two words, watch nature, were it not for a knowledge which experience has given us with regard to specific remedy, the carbonate of ammonia. As soon as rubeola is suspected or developed, and after a preliminary clearance of the alimentary canal by means of a mild purgative, five grains of carbonate of ammonia in solution in water, broth, or milk, may be administered every three hours; in severe cases it may be given oftener, every hour or every two hours; and when the symptoms subside, less frequently, namely, every four or every six hours, dimi- TREATMENT OF RUBEOLA. 391 nishing the frequency of the remedy by degrees, until health is restored. Dr. Charles Witt,1 who is a zealous advocate of the ammo- nia treatment, suggests that acids should be abstained from during its use. When the ammonia treatment is not adopted, the best remedy is the liquor ammoniae acetatis, 3ij, with or without nitric ether (3ss), and camphor mixture (oj); and where the bronchitis is troublesome, a few drops of ipecacuanha wine ("ix). Or the practitioner may pre- fer effervescent salines, with diaphoretics, with which may be com- bined, if necessary, saline aperients. The local treatment of rubeola is best provided for by keeping the body covered with bedclothes, and preserving a temperature agree- able to the sensations of the patient; but where there exist pruritus and uneasiness of the skin, and when desquamation has commenced the pruritus is often very troublesome, the skin should be anointed with some simple oleaginous substance, such as lard. The lard should be applied with gentle friction to the whole body, exposing as little of the skin as possible during the operation, and the inunction may be repeated every twelve hours, or oftener if the itching should return. During convalescence, the preservation of a wholesome temperature of the body, by means of warm clothing, is especially important, as neglect of proper precautions at this period is a common cause of the serious sequelae which sometimes follow measles. Indeed, the neces- sity of shielding the patient from exposure in zymotic diseases can- not be too strongly impressed upon the mind of the practitioner. The leading complications of rubeola are: retrocession or sudden disappearance of the exanthema, severe bronchitis, pneumonia, laryn- gitis and oedema of the glottis, inflammation and ulceration of the conjunctiva, inflammation of the ear tubes and vagina with muco- purulent discharge, ulceration of the mucous glands of the mouth, inflammation and enlargement of the salivary glands, chronic diar- rhoea, dysentery, and rheumatism of the joints. Retrocession of the eruption is to be treated by the application of stimulants to the skin, either stimulating liniments, such as ammonia, or cajeput, or mustard, spongiopiline saturated with a solution of mus- tard or the spiritus sinapis, mustard poultices, a mustard bath, or the ammonia bath. Bronchitis, pneumonia, and the sequelae involving the mucous membranes, the synovial membranes, and the glands, must be treated like independent inflammations of those organs, and in every instance the treatment must be combined with counter-irritation. It may be necessary to apply a blister for a longer or shorter period, and follow the blister with a poultice, or with inunction and cotton-wool; or we may prefer the counter-irritant action of the compound tincture of iodine, or of a saturated tincture. It may be necessary also to follow or combine this treatment with a tonic regimen; with the use of qui- nine, steel, or cod-liver oil; with the tepid or cold bath ; or with sea 1 " An Effectual and Simple Remedy for Scarlet Fever and Measles, with an Appendix of Cases." Third edition, 1SG2. 392 ZYMOTIC AFFECTIONS. bathing. In chronic bronchitis, change of air frequently acts like a charm; and in the absence of change we may derive advantage from the inhalation of the vapor of tar, carbolic acic, or iodine. In inflammation of the fauces, salivary glands, or larynx, a piece of spongiopiline or ordinary sponge squeezed out of hot water, and kept applied over the painful part, is the best remedy. Sometimes a poul- tice may be preferred ; while locally -the fauces may be soothed by the inhalation of steam, or by the use of a gargle. In the case of young children, the lotion must be applied by means of a syringe; and the best adapted to the purpose is a solution of chlorate of potash in barley water, or barley water accidulated with hydrochloric acid. Chronic muco-purulent discharges from the conjunctiva, ear-tubes, and vagina, are relieved by bathing the parts with warm soap and water, and subsequently employing a weakly astringent lotion, either Goulard, sulphate of zinc, or sulphate of alum ; or a moderately stimu- lating lotion, as of carbolic acid. Chronic diarrhoea should be treated by an occasional dose of calo- mel or gray powder, and judicious diet; while pains in the abdomen are to be relieved by a linseed meal poultice, by a water compress, or by a sedative injection. For rheumatism of the joints, the best remedy is a chloroform liniment, with a bandage of flannel. SCARLATINA. Syn. Scarlet fever; febris scarlatina; morbilli confluentes ; rubeola rossalia ; febris rubra, Heberden ; fcbris miliaris rubra et maligna; febris anginosa miliaris, Huxham ; scarlatine, Fran.; scharlachfieber, scharlachaufschlag, Germ. Scarlatina, or scarlet fever, is an eruptive fever, attended with constitutional symptoms, with an exanthema or rash of a scarlet color, partly papular and partly suffused, and with an inflammation of the fauces (angina) of greater or less severity. It is highly contagious, is developed between the second and tenth day after infection or con- tagion, has a normal course of nine or ten days, and terminates in desquamation of the epidermis. The constitutional symptoms are similar to those of rubeola: lassi- tude, weariness, drowsiness; pains in the head, back, and limbs; rigors, flushes of heat, nausea, and rapid pulse. To these, which are the symptoms, of invasion, there speedily follows a general febrile reaction; the eyes are bright and humid, but without lachrymation; the features are swollen; the tongue is white and moist in the middle, but red at the edges and tip, and studded all over with red papillae; the fauces are red and inflamed, the tonsils enlarged; the skin hot and dry ; there is a short and dry cough, thirst, constipation, and high- colored and scanty urine. Immediately preceding the outbreak of the rash there are fre- quently, restlessness, anxiety, sometimes convulsions, and sometimes delirium; these symptoms are relieved by the eruption. The fever is generally augmented towards the evening, and not unfrequently there is an exacerbation of its symptoms at the beginning of the de- cline of the eruption. SCARLATINA. 393 The exanthema, or rash, makes its appearance on the second day of the fever; the surface of the body is intensely hot and dry, more or less swollen, especially that of the face, hands, and feet; and there is a sense of tingling and itching of the skin. It is first apparent on the face, the neck, and chest; on the second day it reaches the trunk and upper extremities; and on the third day the lower extremities; on the third or fourth day it arrives at its height, and on the fifth begins to decline, following the same order as that of its invasion. The decline continues during the sixth and seventh day, and on the eighth and ninth is followed by desquamation and exfoliation of the epidermis. On close inspection of the exanthema it is found to be composed of minute puncta and papulae, blended by a superficial suffusion ; on the face and limbs the suffusion is uniform, but on the trunk the rash is more or less patchy, and is always more vivid on the loins, the nates, and around the joints, than elsewhere. Sometimes, and constantly in certain regions of the body, the exanthema is smooth, from the pre- sence of a moderate degree of oedema of the skin, this is the scarlatina plana vel laevigata; at other times, and in other situations, it is rough and papular, scarlatina papulosa vel milliformis ; and occasionally, but rarely, there may exist an intermingling of vesicles or pustules, scar- latina vesicularis, vel phlyctaenosa, vel pustuhsa. The rash is always brighter and more vivid in the evening, when the fever is highest, than at any other time of the day. Scarlatina makes its attack between the second and tenth day after exposure to contagion ; the exanthema begins on the second day of the fever, and lasts commonly for seven days, making the whole period of the active stages of the disease nine days. On the third day of the fever the exanthema extends to the eyes, nose, and mouth, causing congestion of the mucous membrane. Scarlatina, like rubeola, is remarkable for its extreme variation of intensity, being sometimes so mild as to be a mere trivial disorder, almost without constitutional symptoms of any kind, and at other times so severe as to be rapidly fatal. Where the exanthema is fully developed, the febrile symptoms are for the most part mild; but the most severe form of the disease is that which is accompanied with much congestion of the mucous membrane/ and particularly of the fauces. The varieties of scarlatina are founded on these differences of character: the more simple form, that in which the exanthema is fully developed and the mucous congestion moderate, is termed scar- latina simphx, while the scarlatina attended with a severe congestion of the mucous membrane of the fauces, is the scarlatina anginosa. Another form of the disease is termed scarlatina maligna, from the dangerous nature of the affection of the throat; while a fourth is dis- tinguished by general mildness, and by the absence of exanthema, scarlatina sine exanthemate. Other modifications are also occasionally met with; a child may pass through a mild form of the disorder, and in the midst of convalescence may be attacked with a severe form ; the former may present as its leading feature exanthema, the latter, angina. Dr. Sims has recorded such a case, and we have seen a similar 394 ZYMOTIC AFFECTIONS. • on.e.. Sometimes scarlatina is accompanied with acute pains in the joints or in the head, and sometimes with a troublesome cough. And occasionally there is met with a form of the affection, termed scarlatina Mens by Copland, in which the exanthem and angina may both be absent, and the disease manifested only by one of its sequelae, such as dropsy. In its most favorable form, scarlatina expends its violence chiefly on the skin and mucous membrane of the fauces, and then gradually subsides ; but when it is interrupted in its course, when the cutaneous rash is accidentally checked, in an unhealthy constitution or unfavor- able season, or when the prevailing epidemic assumes a severe cha- racter, several organs of the body are liable to be endangered by its violence; the most important of these, after the glandular structures of the throat, being the kidneys, the pericardium, the joints, and the mesenteric glands. The morbid phenomena which follow an attack of scarlatina are termed its sequelae, and are sometimes referable to the violence of the inflammation attacking the skin, as in the case of oedema of the sub- cutaneous tissue, and mortification of parts of the skin ; sometimes to a similar morbid action taking place in the mucous membrane and resulting in chronic conjunctivitis, chronic otitis, loss of hearing and suppuration from the ears, ulceration within the nares, ulceration of the mouth and lips, ulceration of the fauces and larynx, inflammation and suppuration of the salivary glands, chronic bronchitis, chronic diarrhoea, and gangrene of the vagina or rectum; sometimes to inflammation of the lymphatic system, such as enlargement of the lymphatic glands of the neck and mesenteric glands; sometimes to inflammation of the serous membranes, as of the pericardium, the peritoneum, or the synovial membranes, and sometimes to inflamma- tion of the kidneys, inducing anasarca and dropsy. Inflammation of the kidneys is possibly the most serious of the sequelae of scarlatina, and is commonly induced by too early exposure of the body to cold or damp after the decline of the fever. It is apt to occur between the tenth and twentieth day, sometimes earlier, is preceded by heaviness, headache, restlessness, and symptoms of con- stitutional disturbance; and these symptoms are quickly followed by oedema, commencing in the face and lower limbs, and extending by degrees to the body; the belly is swollen, and the urine, scanty in quantity, is commonly found to contain albumen, blood particles, and cell-detrita from the tubuli uriniferi. Anasarca sometimes results from simple anaemia, and happens in weakly and lymphatic children; in this aft'ection there are no special symptoms of constitutional disturbance, and the urine is very little altered in quantity; it is pale, and contains neither albumen, blood particles, nor epithelial cells. The varieties of scarlatina arranged in tabular order are as fol- lows :— Scarlatina simplex, Scarlatina maligna, " anginosa. " sine exanthemate. treatment of scarlatina. 395 Scarlatina simplex is the typical form of the disease, in which the constitutional and local symptoms are moderate, and run a regular course. As already remarked, the constitutional symptoms are some- times so slight as hardly to deserve the name of fever, while the exan- thema is fully developed. This is the most desirable combination for the patient, but nevertheless requires the same caution in management as the more severe forms. There is always congestion of the fauces, even in the mildest variety of scarlatina; and in scarlatina simplex there exists a moderate amount of swelling of the mucous membrane and sore throat. Scarlatina anginosa is distinguished by a predominance of sore throat, and a more severe type of the disease, more constitutional dis- turbance, more local suffering, and an irregular exanthema, deficient in amount of cutaneous congestion, and imperfect in its course. The fauces are inflamed from the beginning of the attack, and often before the constitutional symptoms are developed; by the second day after invasion the voice is hoarse, the throat feels rough, there is an accumulation of viscous mucus on its surface, deglutition is painful and difficult, and there is a sense of constriction and tightness, that extends from the throat itself to the surrounding part of the neck and to the muscles of the jaws. During the third and the fourth day, the redness, the swelling, and the constriction increase, the uvula and ton- sils are so much swelled as to block up the isthmus faucium almost entirely, patches of false membrane appear upon the inflamed surface, and the membrane covered by these patches is apt to pass into a state of superficial ulceration. The tongue is coated with white mucus, and studded over with papillae of a vivid red color. These symptoms are accompanied with nausea, rapid respiration, a quick feeble pulse, parching heat of skin (104°-108°), restlessness, great debility, headache, and often delirium. The exanthema is sometimes retarded to the third day of the con- stitutional symptoms, is irregular in the order of its appearance, and deficient in the amount of cutaneous congestion, showing a patchy redness over the greater part of the body, and a more uniform red- ness only around the joints. It sometimes disappears for a day, and returns, remains later than in scarlatina simplex, and is succeeded by a less perfect desquamation. The decline of the exanthema commonly takes place on the fifth or sixth day, and at the same time the mucous membrane of the fauces begins to improve, the swelling subsides, the sloughs separate, and the surface assumes a more healthy character. The restoration of the fauces, however, is a gradual process, and where ulceration has taken place and the powers of the constitution are low, it may be delayed for several weeks. Scarlatina maligna, or putrid sore throat, is a scarlatina angi- nosa, attended with extreme prostration of the nervous system, with extensive and deep ulceration of the fauces and adjacent parts, and with an imperfect and partial exanthema. It occurs under the influ- ence of an unhealthy state of constitution of the individual, or of un- healthy hygienic conditions, is highly dangerous, and commonly fatal. 396 zymotic affections. .This form of scarlatina is sometimes met with in the course of an ordinary epidemic, and sometimes prevails as the leading type of the epidemic. It is marked from the beginning by prostration of power, feeble pulse, restlessness, anxiety, and delirium. The fauces are not swollen, but are deeply and extensively ulcerated, the whole mouth is inflamed and aphthous, the tongue swollen and ulcerated, the pha- rynx and larynx more or less ulcerated, loaded with viscous phlegm, and the respiration quick and obstructed. The ulceration frequently becomes sloughing, the breath is excessively offensive, the eyes are red and sunken, an acrid discharge distils from the nose, the ears are affected with deafness, the tongue and lips are covered with a dark- brown or black sordes, and deglutition is painful and difficult. Some- times there is diarrhoea, sometimes haematuria, and the scene closes in coma. Scarlatina maligna often proves fatal on the second or third day; and after death extensive ulceration is found to have occurred in the fauces, larynx, trachea, lungs, oesophagus, and alimentary canal. The exanthema in scarlatina maligna is uncertain, irregular, and incomplete; it is late in appearance, often pale and indistinct, gene- rally purple or livid, sometimes patchy, sometimes accompanied with petechiae, and sometimes disappears in a few hours after its outbreak. Occasionally, after having wholly disappeared, it returns at the end of a week, and remains for two or three days, and sometimes it has been observed to return again at the end of another week. Scarlatina sine exanthemate is a variety occasionally met with in the course of an ordinary epidemic; the fever and angina are present, but there is no exanthema. This form of the disease some- times attacks the adult, or occurs in a child who has gone through the eruption in the ordinary manner; it is generally mild in its symptoms. Diagnosis.—The pathognomonic characters of scarlatina are, in the first place, the acute congestion of the fauces; secondly, the early development of the exanthem; and thirdly, the scarlet color, and diffused or patchy character of the rash. It is distinguished from rubeola by the absence of coryza and catarrh, and by the different color of the exanthem; and from variola, by the absence in the latter of angina and the development of the eruption in the form of isolated papulae. Rubeola is more contagious than scarlatina, and more likely to appear a second time; the desquamation of scarlatina is more laminated and less furfuraceous than that of rubeola, and the early symptoms of variola are accompanied with a severe pain in the loins, which is absent in the other exanthematic fevers. Cause.—The cause of scarlatina, as of rubeola and variola, is a spe- cific poison. Like rubeola, it is favored by a cold and humid state of the atmosphere, and is therefore more common in the spring and autumn than at other seasons of the year. It also resembles rubeola in being a disease of childhood, although occasionally attacking the adult. It is somewhat less contagious than rubeola, and less disposed to affect the same person a second time. As a rule, scarlatina, rubeola, and variola, when they have once run their course regularly, are not treatment of scarlatina. 397 subject to recurrence; this, however, is a rule with many exceptions, but less in the case of scarlatina and variola than that of rubeola. Patients under scarlatina are, at all periods of the fever, capable of communicating the contagion, but most so during the stage of desqua- mation, and after convalescence they require seclusion for a month or six weeks. Prognosis.—Scarlatina is always grave; if not in its immediate symptoms, it is so in the liability to disease of important internal or- gans, for example, the kidneys." Nevertheless, scarlatina simplex is sometimes so slight as to disarm apprehension ; not so the anginous form, which is always alarming. Sometimes the constitution of the patient is, as it were, overwhelmed with the poison, and death occurs in a few hours. Scarlatina is also rendered dangerous by retroces- sion, by the early evidence of weakness and prostration, by a livid appearance of the throat, and by complication with organic disease. It often deals severely with adults, especially with pregnant and recently-confined women ; and, according to the observation of Dr. Peter Hood, is generally more severe in children with dark eyes and complexion than with their brothers and sisters of blue eyes and fair complexion. Treatment.—On the bare suspicion of scarlatina, and certainly as soon as the disorder is declared, the patient should be put to bed; he should be kept quiet; the bed-clothes should be light, but sufficient; the apartment darkened, kept at a reasonable temperature, and pro- perly ventilated. Two points should be looked to with especial atten- tion, the avoidance of light, heat, bustle, noise and conversation, which are calculated to excite the nervous system of the patient; and the avoidance of draughts of cold air, which might check the development of the exanthema, or, when developed, might lead to its retrocession. The patient's head should be well raised on the pillow, and kept cool, and his body and feet warm. It will probably be necessary to keep the bed for three weeks, and the room for a week or ten days after- wards. A too early suspension of precautions should be rigorously prevented. The diet should consist of milk, tea, broths, farinaceous puddings, and cooling and refreshing drinks, such as toast-water, lemonade, tamarind-water, soda or seltzer-water, or a weak solution of chlorate of potash, acidulated with hydrochloric acid. The medicines likely to be required are, a mild purgative, to remove irritating ingesta or acrid secretions from the alimentary canal, and, a few hours later, a saline and diaphoretic mixture, composed of liquor ammoniae acetatis vel citratis, spiritus aetheris nitrici, and mistura camphorae, administered every four hours. The best purgatives for the purpose indicated are the compound jalap powder, senna, or rhu- barb. And care must be taken during the action of the bowels that the patient be not exposed to chill. In cool weather a woollen gown would be preferable to one of lighter material, and the bed-clothes must be accommodated accordingly. We must confess to a strong leaning in favor of the ammonia treat- ment, and, instead of salines, we would begin from the first with a 398 ZYMOTIC affections. solution of the carbonate of ammonia, two or three grains for a child under seven years of age, and four or five grains above this age, or for an adult; the dose should be dissolved in from two to four drachms of water, and administered every two, three, or four hours, according to the degree of severity of the fever; in very severe cases, every hour. The advocates of the ammonia treatment1 attribute to it the most happy properties: it calms irritability, tranquillizes the nervous system, induces*sleep, promotes the exanthema, subdues fever, heat, and delirium, and soothes the throat and alimentary canal. And to these virtues we may venture to add that it diminishes the quantity of viscous mucus secreted by the mucous membrane of the fauces. This treatment, however, is not intended to supersede the necessary daily attention to the secretions, and the use of tonics when they seem to be required. Dr. Peter Hood, in an excellent monograph on scarlatina, advocates a method of treatment which he has found in the highest degree suc- cessful. Attributing the nausea, which so constantly attends the inva- sion of scarlatina, to the presence of irritant matter in the stomach, he begins with an emetic composed of ipecacuanha and sulphate of zinc, the dose for a child of six years being ten grains of each, and follows the emetic with as much warm water as the child can be made to drink. After the action of the emetic has subsided, he administers a purgative of scammony and calomel {gr. vj) and by way of stimulating the emunctory action of the liver and alimentary canal, he continues the purgative every night, in modified doses, so as to secure one pro- per evacuation daily. With children who can swallow a pill he varies the remedy by prescribing gray powder with extract of hen- bane and the compound rhubarb pill; and when the tongue is clean be has recourse to simple rhubarb or castor-oil as a laxative, or any simple medicine ; but as long as the tongue remains coated, which he takes as an evidence of the presence of morbid secretions in the stomach and alimentary canal and morbid action of the liver, he adheres to the mercurial in one form or another. And he keeps up the proper action of the bowels by this means throughout the whole course of the disease. The alimentary canal being kept to its duty, his next remedy, the staff of his treatment, is quinine; the dose, one or two grains every four or six hours. He combines the quinine with eight or ten minims of dilute sulphuric acid and half a drachm of compound tincture of bark or orange-peel. He very justly observes that quinine alone, without the elimiuatory action of the bowels, would be in- jurious, but that the combined action of the two kinds of remedy, with proper attention to diet and regimen, is calculated to subdue all the more grave symptoms of the disease, and bring it to a favorable termination, and without the danger of the sequelae which render scarlatina so formidable. The reader will be struck with the solid 1 Vide " An Effectual and Simple Remedy for Scarlet Fever and Measles," by Dr. Charles Witt. treatment of scarlatina. 399 sense of this view of the "quinine treatment" of scarlatina, and will doubtless profit by Dr. Peter Hood's experience. Dr. Hood is careful to maintain a liquid diet for his patients; the chief support being milk, sopped bread, and beef tea. Solid food is prohibited until the tongue be clean, and have remained so for a few days; and bed is to be maintained until the desquamation is over. Wine he allows to adults, but does not think desirable for'child- ren, excepting in the malignant variety of the disease, and where prostration of power is apparent. Where there is restlessness and irritability, with a clean tongue and want of sleep, he prescribes Battley's solution of opium ("lv aet. 4); for dirty-water stools, he adds a few grains of aromatic confection, with tincture of cinnamon and cinnamon-water; and for irritability of heart's action at the close of the fever, he orders one grain of Dover's powder with half a grain of powder of conium, every four hours, followed in an hour by a draught of supercitrate of potash and sweet spirits of nitre. Burning heat of the skin is occasionally a very distressing symp- tom to the patient in scarlatina, and we are called upon to prescribe a remedy. Sponging with warm vinegar is sometimes used for this purpose; we have usually given the preference to sponging with a tepid solution of ammonia of moderate strength; but the remedy which is best of all suited to effect the object, is inunction with warm lard. The lard should be gently but well rubbed into the skin night and morning, beginning with the limbs, and passing thence to the trunk of the body, and at the same time avoiding thd? exposure of a larger surface than that immediately under the operation. The inunction may be made more pleasant by the use of benzoated lard; but common lard answers every purpose. This simple remedy not only relieves the heat and irritation of surface, but tranquillizes the whole nervous system, fixes the exanthema in the skin, assists desqua- mation, reduces the tendency to congestions of internal organs, and diminishes the liability to diffusion of contagion. At the decline of the disorder, when convalescence is established, the patient's, strength may be helped with mild tonics, such as the citrate of iron alone, or with quinine; a more generous diet, meat, and a little wine. He should be kept in bed as long as possible, and still longer to his room, and on resuming his ordinary dress should be warmly clothed in flannel, with a view to prevent secondary complications, which are often more dangerous than the original disease. The angina of scarlatina is generally the most difficult part of the treatment of the disorder; the swelling of the fauces renders degluti- tiou painful and difficult, and also impedes respiration; and the swelling of the salivary glands and adjacent parts impedes the open- ing of the jaws, and often seriously interrupts the circulation through the brain. This state of things has led to the suggestion of leeches behind the ears, or in the submaxillary region, and also to that of blisters ; but both these remedies are highly objectionable, and should be avoided if possible. Loss of blood, by adding to the extreme weakness of the patient, might be fatal in its effects, and the irritation 400 ZYMOTIC AFFECTIONS. of blisters might increase the inflammation of the fauces. We have found inunction with lard, and a covering of cotton wool, a good sub- stitute for both. Dr. Peter Hood recommends linseed poultices as hot as they can be borne, and repeated as often as they cool; while, for counter-irritation, we should prefer the compound tincture of iodine to the blister. The remedies applicable to the fauces directly, are gargles and the nitrate of silver either in the solid form or in strong solution. Nitrate of silver may be used at the outset of the congestion of the throat, with the view of changing the morbid inflammation into one of a more healthy character; and for this purpose the solid stick is more serviceable than a solution. If the latter be preferred, its strength must be from twenty to thirty grains to the ounce, and it should be applied by means of a piece of sponge firmly fastened to the ex- tremity of a handle. Not unfrequently, and always in young chil- dren, the patient is unable to use a gargle, and then it must be injected into the mouth by means of a syringe. For removing viscous mucus and sordes from the mouth and fauces, a small piece of sponge is the best instrument, and the sponge may be previously moistened with one of the solutions intended for rinsing the mouth. The solutions the best adapted for gargles are, sulphuric acid, the chloride of sodium, the hypochlorate of ammonia, the permanganate of potash, the chlorate of potash, and the chlorine solution developed by the combination of chlorate of potash and dilute nitric acid, one drachm of each to eight ounces of water, or by the mixture of chlorate of potash and strong hydrochloric acid. All these gargles have the ad- vantage of being innoxious or even beneficial when swallowed; and while acting the part of moderate stimulants to the mucous mem- brane, they also correct fetor. Dr. Peter Hood eschews the nitrate of silver, excepting in ulceration; and for a gargle generally pleasant to children, and soothing to the throat, recommends a pint of thick barley-water, with one ounce of lemon-juice and half an ounce of honey. As a curative remedy, the most important of all is the solid nitrate of silver, and this should be applied twice in the day, and efficiently. Occasionally it is found desirable to have recourse to steaming the throat by inhalation, and we have seen great comfort derived from the inhalation of the vapor of ammonia. In retrocession of the exanthema we may have recourse to the hot bath, and may very advantageously add a handful of mustard to the bath. We have already remarked that the chances of retrocession are very much diminished by the employment of inunction, and would suggest as a general stimulant of the skin, in the case of that event, a bath at 100°, containing an ounce of strong solution of ammonia to the gallon,' or where the bath was impracticable, sponging the skin with water of the temperature of 120°, containing one ounce of strong 1 See a paper by Mr. Grantbam, of Crayford, " On the Therapeutic Effects of Ammo- nia as a Dermic Agent in the Treatment of Disease."—Medical Gazette. TREATMENT OF SCARLATINA. 401 liquor ammoniae to the quart. After the bath or sponging, the inunc- tion with lard might be repeated very advantageously. Where the head is much affected, as with severe pain and delirium, it will be necessary to crop the hair closely, and apply ice to the scalp. A blister on the nape of the neck or behind the ear has also been recommended, and counter-irritation of the feet and lower limbs. When the pulse is strong and hard, leeches have been suggested. These are questions which must be left to the judgment of the practi- * tioner; but it is desirable in such cases to be assured that the cerebral congestion does not proceed from irritant matter in the alimentary canal. Dr. Peter Hood favors an emetic where that is the case, and regards the cerebral congestion as sympathetic; on the same principle, an active purge might be found useful. When the presence of anasarca indicates congestion of the kidneys, the treatment consists of counter-irritation of the skin and alimentary canal, and the use of diaphoretics and mild diuretics. The patient must be placed in a warm bath (90°-98°), containing ammonia, twice a day; inunction must be performed after the bath; a purgative of compound jalap powder with calomel, must be administered, and re- peated if necessary; the regions of the loins should be painted with compound tincture of iodine, saturated with iodine; and gentle diu- retics, such as the bitartrate of potash, citrate or acetate of potash, com- bined with the liquor ammoniae acetatis and digitalis, and saline ape- rients, should be exhibited internally. When the anasarca results merely from anaemia, the proper reme- dies are chalybeate tonics, such as the citrate or tartrate of iron, with quinine, or the tincture of the hydrochlorate of iron. In scarlatina maligna, the indications for treatment are the restora- tion and support of the vital powers, and the local relief of the fauces and the skin. For the maintenance of general power, the nourish- ment should be of the best kind ; for example, essence of meat, and port wine, administered alternately and frequently. Any gastric irri- tation from accumulated ingesta or acrid secretions, should be pre- vented by mild but efficient remedies. The best tonics are the liquor cinchonae with sulphuric acid, tincture of orange-peel with nitromuri- atic acid, hops, cascarilla, canella, &c. The liquor cinchonae may be administered very advantageously in port wine. Ammonia also is as applicable to the malignant form of scarlatina as to the simple kind, and the drink of chlorate of potash (5j ad Sxvj), recommended by Dr. Hunt, or the euchlorine mixture (potassae chloratis, acidi nitrici diluti, aa 3j, aquae 3viij).' The fauces and mouth should be gargled or syringed with the euchlorine solution, or with a simple solution of chlorate of potash, carbonate or hydrochlorate of ammonia, or common salt. These solutions may also be injected into the nostrils, to relieve the Schueiderian membrane, and reach the back part of the palate. 1 The formula recommended by Sir Thomas Watson is a very useful one. Potasaae chloratis 5ij, dissolved in §ij of hydrochloric acid, diluted with §ij of water, kept in a stoppered bottle and in a dark place. Of this mixture, 5ij may be added to one pint of water, and a dose of half an ounce or an ounce given every hour or two hour*. 26 402 ZYMOTIC AFFECTIONS. Considerable benefit also is derived in some cases from the inhalation of the vapor of vinegar or ammonia. For a hot and parched skin, the best treatment is sponging with warm vinegar, or a moderately strong lotion of ammonia (3j-3ij liquoris ammoniae ad aquam 3"viij), and afterwards applying the glycerine paste with gentle friction. Scarlatina sine exanthemate must be treated, in regard to its severity, according to the principles already laid down; in mild cases the warmth of bed and a flannel shirt may be sufficient to draw forth the exanthema, or if the nervous system or mucous membrane seem to be * suffering from its absence, the skin might be stimulated by the ammo- nia lotion used warm, the ammonia bath, or a hot bath with mustard, anointing the skin afterwards with warm lard, applied with moderate friction. The more serious of the complications of scarlatina manifest them- selves in the form of affections of the brain, the larynx, the lungs and pleura, the pericardium, the alimentary canal, the liver, the kidneys, the peritoneum, and the joints. Affection of the brain is shown by delirium and coma, and these symptoms may result from congestion of the brain, independent of much inflammation of the fauces; con- gestion from mechanical interference with the circulation where there is much swelling of the throat; and congestion from irritability. In all these instances the counter-irritation of a blister may be necessary, and in the two former a few leeches may be serviceable. In the last of the three we shall gain more advantage from the use of sedatives. In all the ammonia treatment is especially valuable. In the other local affections counter-irritation is an important remedy, and in ex- treme cases the use of a few leeches. When the mucous membrane of the larynx, besides being congested, is swollen from oedema, tra- cheotomy may become necessary. In congestions of the thoracic organs, our remedies are the same; in diarrhoea we may derive a great amount of relief from a large poultice, or from inunction and cotton wool, while the counter-irritation action of ammonia may, at all times and in every situation, be resorted to. In affections of the joints the lard inunction and cotton wool are very useful; and in ulceration of the fauces, the nitrate of silver either in solution, or fine powder puffed upon the sores. VARIOLA. Syn. Smallpox; febris variolosa; variole, petite verole, Fran.; blattern, pocken, Germ.; vajuola, Ital.; viruelas, Span. Variola is an acute inflammation of the tegumentary investment of the 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- gressive development, becoming, in quick succession, pimples (vari), conical vesicles, flattened and umbilicated vesicles, pustules, and hard brown scabs; the latter falling off from the eleventh to the twenty- fifth day, and leaving behind them small uneven pits, and permanent cicatrices. On the mucous membranes it produces great congestion VARIOLA. 403 of surface, and in some situations pustules, particularly in the respi- ratory passages. The fever of variola is of the remittent type, pre- ceding the eruption for two days, subsiding as soon as the eruption is developed, and returning when the eruption has reached its height, namely, on the eighth or ninth day. 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 proceed from contagion, or be the consequence of the voluntary introduction of the variolous virus into the system, constituting the two varieties termed natural smallpox and inoculated smallpox. In reference to distribution the eruption may be discrete, the pustules being distinct, and scattered over the surface of the body; it may be coherent or semi-confluent, the pustules being very numerous, and, in many situations, placed closely side by side, but still distinct; it may be confluent, the pustules being more numerous, and in several situa- tions so closely set, as to run one into the other, and form confluent blotches of various size and extent; or it may be corymbose or clus- tered, the clusters being three or four in number, and the rest of the skin occupied by a discrete eruption. As regards degree of severity, variola may be benignant or it may be malignant; or it may be modi- fied, the pustules being altered in their number, their size, and their course, either by the nature of the contagion or constitution of the patient; or by the previous invasion of smallpox, natural or inocu- lated, or by vaccination. Modified smallpox is a much milder affec- tion than the parent variola, and is termed varioloid. Another division of variola relates to its occurrence for the first time, or as a second attack, a distinction which is expressed by the terms primary smallpox and secondary or recurrent smallpox. Besides the pre- ceding, we sometimes have occasion to remark, during the prevalence of an epidemic of variola, the occurrence of the fever of smallpox without its eruption, a variety which has been termed variola sine varialis. These terms, expressive of diff'erences in the character of variola, are chiefly useful for the purposes of description, and as dis- tinguishing forms of the affection which are more or less grave in their course or in their termination. The varieties of smallpox may be comprehended at a glance by placing them in tabular order, thus— NATURAL VARIOLA. Variola discreta, Variola maligna, " semiconfluens, " benigna, " confluens, " sine variolis. " corymbosa, " anomala. MODIFIED VARIOLA. INOCULATED VARIOLA. The course of variola admits of consideration in five successive periods, this division being alike convenient in the treatment and % description of the disease. The periods of variola are those of in- 404 ZYMOTIC AFFECTIONS. cubation; invasion or primary fever; exanthemation or eruption; secondary or suppurative fever; and decline, including incrustation and decrustation. I. The period of incubation comprehends all that space of time which intervenes between the exposure of the body to infection or contagion, and the invasion of the disease. In very severe cases the period of incubation is short; in the milder forms, on the contrary, it may be longer. The limits commonly assigned to -this period are from five or six to twenty days, but Marson fixes it at twelve days.1 II. The period of invasion or primary fever 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,2 and in the limbs; the skin is hot, and either dry or moist; the conjunctivae suffused; the pulse and respiration quick- ened ; 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 prostra- tion. To these succeed, though various in degree in different indi- viduals, oppression of breathing, cough, lethargy, and sometimes coma. The tongue, at the commencement of the period, usually white, soon becomes red at the point, and subsequently over its entire surface. In children, convulsions not unfrequently ensue at this stage of the febrile symptoms. Throughout all the periods there is exacerbation of the febrile symptoms 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 forty-eight hours or two days, and its symptoms are remarkably lessened by the succession of the eruptive period. III. The period of eruption, or exanthemation, comprehending the full course of development of the exanthema to the complete matura- tion of the pustule, by Marson termed the stage of maturation, the " stadium floritionis" of Hebra, is often ushered in by a manifest exacerbation of the constitutional symptoms, which are suddenly and immediately 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 1 Vide article Smallpox, in Reynold's System of Medicine, vol. i., 1866, by James Fairness Marson. 1 Chomel regards the pain in the loins, which he refers to the kidneys, as pathog- nomonic. 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. Marson 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. VARIOLA. 405 the latter to the trunk, and from the trunk to the lower extremities, the entire body being pervaded in the space of twenty-four hours. The development of the eruption is indicated by the appearance of small red points,1 which soon become conical in form, and hard to the touch, and are disseminated over the surface in numbers proportionate to the subsequent pustules. Thus, in the discrete variety the spots are scattered and distinct; in the coherent kind they are numerous and clustered, like the patches of rubeola; while in confluent variola 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 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 seventh of in- vasion), the papular elevations, with their inflamed bases, go on pro- gressively 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. During the sixth, seventh, and eighth day the lactescent contents of the vesicles are converted into pus; the vesicles assume a progressively deeper tint of yellow, and lose their umbilicated form, becoming at first spheroidal and then somewhat flattened. Similar phenomena may be observed to be taking place at the same time in the mouth and pharynx; the mucous membrane is red, swol- len, and congested ; there is soreness of the throat, and painful deglu- tition ; the respiration is somewhat impeded in consequence of the extension of the inflammation to the larynx and trachea ; the voice is hoarse and weak; and there is frequently a hard, dry, and trouble- some 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 im- perfect, the eruption often 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 granulated. The incipient pustules constitute one continuous vesicle over the inflamed surface, the vesicle being raised by the effusion of liquor sanguinis or coagulable lymph beneath the epidermis. This fluid, at first transparent 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. Subsequently the opaque lymph is changed into pus, and, on the face, the raised epider- mis frequently begins to desiccate into a thin yellowish crust before the formation of pus is completed; the pus in this case is effused » 1 By some writers these points have been compared to the spots produced by the bite of the flea. 406 ZYMOTIC AFFECTIONS. beneath the crust, giving to it additional thickness, and a character- istic brownish hue. 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 confluent form extends to the mouth and pharynx, the mucous membrane is covered with pustules, deglutition is rendered exceedingly painful, and respi- ration 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 inflamma-, tion of the conj unctiva. 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 parts last observed to undergo the suppu- rative 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, with great tumefaction, and a dis- tressing sensation 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 eye- lids 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) salivation f the lining membrane of the alimentary canal sympathizes with the general irritation of the mucous surfaces, as may be inferred from the presence of diarrhoea. And the nervous system is greatly depressed, as is shown by listlessness and lethargy. The eruptive period occupies eight days; one corresponding with the various stage, four with the vesicular, and the remaining three with the pustular stage. IV. The period of secondary or suppurative fever, corresponding with the maturation or full development of the pustules, is reached on the eighth day of exanthemation, and continues until the eleventh day, during which time the pustules burst and give exit to a portion of their contents; to be followed by desiccation of the pustule or in- crustation, and, subsequently, by the fall of the crust or decrustation. In mild cases this stage is accompanied with moderate delirium; but in such as are severe 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 developed on the eighth or ninth day ; the symptoms are severe, and often accompanied by restlessness, a dangerous symptom, which increases towards night. 1 The eruption is always most confluent on those parts of the body where some ex- ternal source of irritation is added to that of the disease. Hence the eruptipn 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, 2,000 of these will occupy the face. J Marson observes, that " patients who have the face a good deal swelled for four days, who have pretty free salivation, and a very tender skin, nearly always do well." VARIOLA. 407 Desiccation of the pustules is indicated by subsidence of tumefaction of the skin, by the drying up of the pus and purulent discharge pro- duced during the preceding period, and by the conversion of these 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 (decrustation), 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 deep 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, and increase in depth as the swelling of the skin subsides. In the confluent variety, as has been already mentioned, the crust on the face commences before the conclusion of the suppurative pro- cess, 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 more or less disfigured with deep pits, and seamed with extensive cicatrices. The crusts of confluent smallpox are softened with the fluids poured out by the inflamed skin, and their fall is not completed till the twentieth or twenty-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 black discoloration of the scabs which form over the wounded parts. The desiccation of the pus and of the purulent discharges is accompa- nied with a nauseous and offensive odor. It is remarked by Simon, that the urinary secretion of variola under- goes changes having relation to the various stages of the disease. That, in the beginning, when the.fever assumes the character of synocha, the urine is diminished in quantity, and increased in specific gravity; its 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 spon- taneously, 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 con- 408 ZYMOTIC AFFECTIONS. tains a turbid, apparently purulent mucous sediment, of an unpleasant odor." "During the suppurative stage of variola, Becquerel observed that urine retained the synochal character as long as the symptoms con- tinued." And in cases in which this fever persisted until death, the state of the urine also remained the same. Sediments and frequently purulent mucus occur in the urine of this period. "During the period of desquamation the urine is either normal or anaemic." In the nervous form of variola, the urine is very changeable, and often dark. " In the putrid form the urine appears decomposed, ammo- niacal, and not unfrequently of a dark red color, from the presence of haematin."1 VARIOLA CORYMBOSA. The discrete, the semi-confluent and the confluent forms of variola are distinguished by the number of their pustules, and caeteris paribus are dangerous in proportion to the amount of eruption. The corym- bose variety of the disease, on the other hand, is remarkable, not for the number, but for the manner of distribution of the pustules; " they appear in clusters, or, it may be that only a single cluster is formed; while in other parts of the body the eruption is perhaps but sparsely scattered. It generally happens there are two or three patches, about the size of the palm of the hand, in different parts of the body, in which the pimples are as closely set as could be; and in the imme- diate neighborhood of each patch the skin is for some distance free from eruption, or nearly so, a few spots only of the disease being formed. There is a great tendency to symmetry in this form of the complaint; when a patch is formed on one arm or leg it often happens that a similar patch is formed on the same part of the corresponding limb on the opposite side. In some instances there are numerous corymbose patches in different parts of the body, about the size of a half-crown or five-shilling piece."* Variola corymbosa is rare; in thirty years, one hundred and four cases only were admitted into the London Smallpox Hospital, of which sixty-one died. Of the one hundred and four cases, seventy-four had been vaccinated, and twenty- nine were unvaccinated. " When these cases seem to be recovering," says Marson, " very frequently some dangerous complication arises to mar our fair hopes of a successful termination of the malady, and, gene- rally, under more favorable circumstances, there is a long and tedious convalescence." VARIOLA MALIGNA. Syn. Variola, hemorrhagica^ seu nigral. Variola maligna is distinguished from other forms of the disease by the manifestation of a morbid change in the blood, a change of com- position or dyscrasis. The blood is more fluid than natural, loses its power of coagulation, is deficient in fibrin, and resembles serum holding blood corpuscles and coloring matter in suspension. With 1 Simon, vol. ii. p. 282. 2 Marson, loco citato. VARIOLA SINE VARIOLIS. 409 these alterations in its plastic properties, the blood exudes through the capillary vessels, occasioning hemorrhages from the mucous mem- brane, from the conjunctiva, nose, mouth, air passages, alimentary canal, and the urinary and uterine cavities. It escapes into the tissue of the mucous membrane, as of the conjunctiva, and into that of the derma, producing ecchymoses; and it tinges the contents of the vesi- cles and pustules of the eruption, variolae haemorrhagicae, giving them a black color, variolae nigrae. With this serious change in the blood the powers of the constitution are excessively prostrated, the face is pale and shrunken, the expression of the countenance anxious, the respiration quick, the heart fluttering; and the patient may die before the eruption is developed. The eruption, when it appears, is of the confluent kind, but late in occurrence, and tardy in development, never reaching the state of true pustule, and very commonly termi- nating fatally on the fifth day; while the constitutional symptoms evince absence of power and debility. VARIOLA BENIGNA. Syn. Variola papulosa, verrucosa, cornea ; wart-pock ; horn-pock ; stone-pock. In the midst of an epidemic of variola, and in persons unprotected by vaccination, a modified eruption is sometimes met with which is remarkable for its mildness, for the brevity of its course, and for its arrest of development at an early period, possibly the papular stage, in this case giving rise to a hard and verrucous papule. Such a mis- carriage of the eruption is the common consequence of vaccination or variolation ; but, under favorable circumstances, it may also occur where no vaccination has been practised. The primary fever may be as severe as that of ordinary smallpox; but on the third or the fourth day of eruption the constitutional symptom suddenly subside, and the majority of the pustules retain their papular form, while others, which have run into the vesicular stage, shrink and dry up, and only a few become true pustules. In a case of this kind there is no secondary or suppurative fever, and no pits or marks are left upon the skin. VARIOLA SINE VARIOLIS. Syn. Febris variolosa. This form of variola is rare; it has, however, been 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. Rayer re- marks that he has never seen an instance of this variety of smallpox. VARIOLA ANOMALA. Syn. Variolce anomalai. Variola may be diverted from its normal course by a variety of circumstances'affecting the bodily condition of the patient. " We have 410 ZYMOTIC AFFECTIONS. seen it," says Marson, "in conjunction with scarlatina, measles, urti- caria, syphilis, bronchitis, pneumonia, phthisis, dysentery, &c. Preg- nancy may be mentioned as one of the anomalies; and another, the existence of smallpox on the foetus at birth, which must have gone through the stage of incubation, the primary fever, and early days of eruption before it was born." MODIFIED VARIOLA. Syn. Variola variolodes; varioloid; variola varicelloides. When vaccination was first introduced into practice by Jenner, it was expected that the new operation would become a complete pre- ventive of smallpox; or, at least, that it would exercise a controlling power over the constitution similar to that of smallpox, that is to say, that an attack of smallpox after vaccination would take place as rarely as an attack of smallpox after smallpox, or after smallpox inoculation. Experience, however, has proved, unfortunately, that this expectation is unfounded in regard to both these propositions, for smallpox does occur after vaccination, and much more frequently than after variola- tion or variola; nevertheless, vaccination, when properly performed, exercises a powerful controlling influence over variola; in many instances it protects the individual from an attack of the latter dis- ease.; and when it fails to prevent it entirely, mitigates, or modifies the severity of the disease. Recurrent smallpox, in other words, smallpox after a previous at- tack of smallpox is known to be rare; but cases of the kind do some- times happen. " The Smallpox Hospital," says Marson, " has been founded 119 years; but there is no record of a patient having been admitted there twice, each time suffering from smallpox." And the same author quotes as an example of recurrent variola the following striking illustration : " An Irishman, the son of a medical officer in the army, who had been vaccinated in infancy by his father, and had a large cicatrix remaining from the vaccination, and who was at- tended by his father for smallpox in early life, and bore decided pits of the disease; in 1844, at twenty-three years of age, was admitted into the Smallpox Hospital with severe confluent smallpox, of which he died." Again, at a time when half the population was inoculated and half vaccinated, the proportion of cases of smallpox admitted into hospital was one for the hundred after inoculation, as against fifty- three per cent, after vaccination. On the other hand, if we turn to the protective influence of vacci- nation, as shown by the experience of the London Smallpox Hospital, we find that, taking three classes of patients, the vaccinated, the un- vaccinated, and the inoculated, the vaccinated exceed the unvacci- nated in number; while of those who have been inoculated or have undergone variola the number is very few. Thus, of 5797 cases of smallpox the proportion of vaccinated wras 3094, or fifty-three per cent.; and of unvaccinated, 2654, or forty-five per cent.; while of those previously variolated the number was only 47, or less than one per cent. The same records inform us that the number of vaccinated MODIFIED VARIOLA 411 persons attacked with smallpox is progressively; that from 1835 to 1845 the proportion was forty-four per cent.; during the following decade, namely, 1855 to 1865, seventy-eight per cent.; and during the two years 1863-4, eighty-four per cent., that is, nearly double the number registered during the decade 1835-45. It is impossible, therefore, to resist the conclusion that smallpox occurs very frequently after vaccination, much more frequently, in fact, than could be desired by those who have at heart the interests of public health. It would appear, besides, that smallpox after vaccination not only occurs frequently, but is also frequently fatal. Thus, out of 4896 cases, the number of deaths was somewhat more than six and a half per cent.; and the question naturally arises, Were these persons pro- perly vaccinated? This question is answered by Marson, as follows: He arranges the 4896 cases in five principal groups, namely, patients having one perfect vaccine cicatrix, numbering 2001; two cicatrices, 1446 ; three, 518 ; four, 544; and a remainder of 370, said to have been vaccinated, but having no cicatrix ; and the proportion of deaths is found to correspond with the number of perfect cicatrices as confirma- tive of the degree of efficiency of the vaccination ; thus, in the case of one cicatrix, the number of deaths was 7.73 per cent.; two cicatrices, 4.70 per cent.; three cicatrices, 1.95 per cent.; and four cicatrices, only 0.55; while the absence of cicatrix was indicated by the figures 23.57 per cent. We are thus led to the conclusion that smallpox, although not altogether prevented by vaccination, is yet favorably modified by that operation. We may now inquire in what the modification or mitigation of smallpox consists, that constitutes the basis of modified variola. Modi- fied variola has been termed " varioloid," but Marson very reasonably objects to this term; it is not like variola, he observes, it is variola; variola diverted from its natural course through the influence of vac- cination. And that diversion sometimes brings it to the very confines of mildness, and suggests a comparison with the harmless vesicular exanthema of children, termed varicella. Hence Gregory employed the term variola varicelloides; but if modified variola be not vario- loid, it may be equally objected that neither is it varicelloid; and it is best to adhere as much as possible to the three simple terms, vari- ola, modified variola, and varicella. In the consideration of variola we have a certain fixity of standard; we have the same also in varicella; but in modified variola there is a wide range of variety, sometimes verging on variola and sometimes on varicella, which has given rise to considerable perplexity, and has been the occasion of attaching the term varicella to many forms of the eruption which in reality appertain, not to varicella, but to variola. To be sure of our diagnosis, the safest course would be to determine the special characters of varicella; and everything which is more than varicella we may consider to belong to modified variola; nevertheless, with all our care, we shall find the question of diagnosis in these cases not a little difficult and obscure. Varicella is an affection of children; it is a vesicle which rises from a red base and attains its full size, that of a small pea, within twelve hours ; it is preceded by constitutional 412 ZYMOTIC AFFECTIONS. fever of one day's duration, generally very slight and sometimes im- perceptible; a number of vesicles are produced on successive days for four days; the vesicles are remarkable on the first day for their tenuity and glass-like transparency; on the second and third, they become opalescent and milky; on the fourth day they begin to collapse, the cuticular dome hardens into a thin crust, which subsides upon the base of the vesicle; and two days later, the scab exfoliates, leaving a smooth surface without hardness and without depression. The whole course of the disease is accomplished in a week. Occasionally a slight areola is apparent on the second and third day; occasionally the con- tents of the vesicle become semi-purulent, especially on the face and hands, or where irritated by rubbing or scratching. The feverish symptoms subside immediately the first eruption appears; the tongue is clean, the appetite good, the circulation undisturbed, and there is no secondary fever. Such is varicella, its contagious principle being distinct from that of variola. The modifications of modified variola are chiefly exhibited in the cur- tailment of the disease. While natural variola has its three principal stages, namely, primary fever, eruption, and secondary fever, modified variola has only the two former, namely, primary fever and eruption. We have already seen, in the benignant form of natural variola, the reduction of the disease to these two stages, namely, primary fever and eruption, by natural causes; and in modified variola, we recog- nize a mitigation of the disease by the influence of vaccination to a similar mild type of the disorder. In modified variola the primary fever is very commonly as severe as that of natural smallpox, but usually less. The eruption, generally discrete, may also be confluent; it makes its appearance with the follicular puncta, the hard and granu- lar papules; but it may stop suddenly at the papular stage, or it may proceed onwards in its development and stop at the vesicular stage, or it may still run onwards and reach the pustular stage. When it was thought desirable to draw a strong line of distinction between variola, and that which was only seemingly variola, the forms just referred to were termed varicella, varicella papularis, varicella vesi- cularis, and varicella pustulosa. But with our present knowledge, we find it better to restrict both variola and varicella to their proper limits, and distinguish the intermediate forms, occurring after vacci- nation or variolation, as modified variola. It follows, therefore, that modified variola may be papular or vesicular, or it may be pustular. Variola variolodes papularis is po'st-vaccinal or post-variolous smallpox arrested at the papular stage; the primary fever may be severe or insignificant; it subsides with the development of the erup- tion, and the latter is composed of red puncta and papulae, the papulae being hard and more or less prominent, as in variola benigna. The papulae remain persistent for a few days and then decline; while here and there a few of the papulae may run on to the vesicular or pustular stage, especially on the face and hands, or when the eruption has been subjected to external irritation. The papular form of modified variola is identical with variola benigna in every respect, excepting the modifying cause, and has INOCULATED VARIOLA. 413 received similar synonyms; for example, variola cornea, varicella papularis, verrucosa, solidescens; horn-pock, wart-pock, and stone- pock ; and in order to determine the correct diagnosis of the disease, we must ascertain whether the patient has previously had the small- pox, or has been more or less successfully vaccinated. Variola variolodes vesicularis belongs to the vesicular stage of variola, and corresponds with varicella coniformis of Willan. As with variola variolodes papulosa, the primary fever may be as severe in this variety as in ordinary smallpox, but the eruption is arrested at the vesicular stage, and declines after five or six days' continuance. A few of the vesicles generally run on to the pustular stage, especially on the face. Variola variolodes pustulosa is a modified variola aborted at the pustular stage; sometimes the pustules retain the conical figure of the early vesicle; at other times the pustule expands into a globe of the size of a small pea; and in both these cases the contents of the vesicle are semi-purulent rather than purulent, while a more advanced form possesses the proper umbilication of variola, and retains that character to its close. The conical and the globular forms are usually milder in their character than the umbilicated variety, but this con- sequence is by no means certain ; the primary fever may be severe in all; the pustules are surrounded by an inflamed areola; and the fall of the scab is succeeded by a somewhat hardened base, a red congested mark, and frequently a permanent pit. The globular form of the eruption is the varicella globularis of Willan; the hives or swine-pox of popular language. 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 purpose has been effected, the inoculated particles dissolved in the fluids of the tissues are conveyed by imbibition into the system, and communicate to the whole mass of the blood a disposition to the'pro- duction 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 a tenderness of the integument around the vesicle, and some degree of pain on moving the arm; the vesicle begins to look 414 ZYMOTIC AFFECTIONS. 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 appa- rent 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 ordinary 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 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 may be developed. The eruptive period of inoculated smallpox is sometimes compli- cated with an erythematous inflammation of the skin, constituting variolous roseola. 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; and may have for their seat, the nervous system, the blood, the mucous membranes, the serous membranes, the eyeball, the tongue, or the cellular tissue. Instead of pursuing the milder course already described, the period of invasion is occasionally marked by symptoms of excessive severity, the accompanying lever runs high, the rigor which 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. There is sometimes delirium and coma, at other times convulsions; and death may occur before the eruptive stage is established. In cachectic states of the system 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. COMPLICATIONS OF VARIOLA. 415 The period of eruption, like the preceding, is liable to its accidents ; instead of the 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 twitch- ing of 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 abdomi- nal 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 ifi 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 otitis, deafness, ophthalmia, opacity of cornea, staphyloma, ulceration of cornea, oedema glottidis, haemoptysis, pul- monary 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, gangrene of the genital organs, 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 ordi- nary 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. Pathology.—On examination after death of those who have fallen victims to smallpox, several of the internal organs are found to pre- 416 ZYMOTIC AFFECTIONS. sent traces of congestion, particularly the brain, the lungs, and the alimentary mucous membrane. The tissue of the lungs is generally found congested and infiltrated, and the serous coat of the blood- vessels stained of a deep red color. Pustules are discovered upon the mucous membrane only when the patient chances to perish at the commencement of the suppurative stage. At a later 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 epider- mis. For the same reason, pustules on the mucous membranes never attain a size equal to those of the cutaneous surface, and rarely con- tain pus. When ruptured, the surfaces occupied by these pustules are found to be covered with loose laminae and shreds of false mem- brane. The situations in which pustules have been observed on mucous surfaces are, the extremities of the alimentary canal, where the epi- thelium is thick, namely, in the mouth, pharynx, oesophagus, and rectum ; Rostan detected them throughout the entire intestinal canal, on the respiratory mucous membrane, namely, in the larynx, trachea, and bronchi, and in the urinary bladder. The form of the pustule of smallpox is strikingly modified in reference to the seat of its development. Thus, on the face, where the pustules advance very rapidly to maturity, they are flat and non- umbilicated. On the palm 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 sole 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 presents a reddish or brownish tint, and sometimes, though rarely, is perforated 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 epidermis, forming the superficial boundary of the pustule, is the segment of a sphere, and continuous by its cir- cumference with the cuticle covering the adjoining skin. The trans- verse septum is a layer of false membrane, of a whitish color, which was deposited on the derma at an early stage of the pustule. Sub- sequently 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 com- municate with that already contained in the superficial chamber. In consequence of the peculiarity in the mode of its production, the layer of false membrane generally retains permanently the umbilicated form of the primitive pustule, and is thinner at the centre than towards its circumference: When the septum is removed, the deep chamber is brought into view, and the depressed and sometimes ulcerated base CAUSE OF VARIOLA. 417 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 of the umbilicated appearance of the pustule of variola during its early stages. Dr. Heming many years since attributed it to the perforation of the pustule by the efferent duct of a sebiparous gland. Velpeau, who believes that the principal seat of smallpox is the follicles of the derma, would, we apprehend, entertain the same opinion. Other writers believe it to be produced by the pores of the skin, and Rayer refers it to the attachment of the false membrane. We agree with Velpeau that the follicles of the skin are the primary seat of the vas- cular congestion, that this congestion gives rise to the production of the papules or vari, 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 com- pared 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; pains in the limbs are somewhat greater than in other exanthemata, and convul- sions in children more frequently. The prevalence of an epidemic of this disease, or the previous exposure of the individual to the influence of contagion, are of themselves calculated to raise suspicion in the mind of the practitioner before the true nature of the symptoms is confessed by the appearance of the eruption. When first developed, the eruption presents considerable resemblance to rubeola ; but from the latter it may be distinguished, as well by the nature of the pre- vious symptoms as by the more decidedly papular character of the eruption, and the rough or granular and gritty sensation which the incipient papulae communicate to the hand. It is utterly impossible to confound the mature pustules of smallpox with any of the pustular affections of the skin. Marson remarks that the diseases with which smallpox is most frequently confounded, are, measles, febrile lichen, varicella, and some forms of continued fever. Causes.—It is stated by Moore, in his " History of Smallpox," that the 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 Mahomet, 569. Pur- suing the track of armies, we find it raging in Egypt in 640, and sub- sequently 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 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 27 418 ZYMOTIC AFFECTIONS. 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 Iceland in 1707, when 16,000 persons were carried off by its ravages, more than a fourth part of the whole population of the island. It reached Green- land still later, appearing there for the first time in 1733, and spread- ing so fatally as almost to depopulate the country.1 Smallpox occurs at all periods of life, from the foetus in the womb to the most advanced old age. It is developed equally in the two sexes, in all seasons and in all climates. It may appear as a sporadic affection, or epidemically. In the latter form its invasion is most fre- quently observed in the summer or the autumn season. The cause of smallpox is a specific animal poison f the period when transmission is most likely to happen being the suppurative stage, and when developed epidemically, it is propagated in the direction 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. Sometimes the sub- sequent attack is as severe as the first, but usually the recurrent affec- tions 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 inten- tion of inoculation is to produce an attack of the disorder, at a period when the physical powers are sound and capable of resistipg its in- fluence; moreover, it is found that the inoculated disease is always more mild than the sporadic affection. Several serious objections, however, raise themselves against inoculation, and one of these so great as to have been deemed worthy of a restrictive Act of the Legis- lature. 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 important objection to the continuance of the practice is, that the smallpox engendered by inoculation may be communicated to others by conta- gion ; and, consequently, that one such case may become the source of a fatal and devastating epidemic. An instance of this kind is re- lated in the memoirs of Maria-Theresa of Austria, who, having inocu- lated a number of children, the smallpox was communicated by the latter to an entire village. 1 Sir Thomas Watson's Lectures, first edition, vol. ii. p. 657. 2 Several authors have imagined the cutaneous eruption of smallpox to depend npon the presence of minute animalcules ; but careful observation affords no ground for this supposition. PROGNOSIS OF VARIOLA. 419 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. Marson treats of the prognostics of smallpox under eight heads, namely, as governed by quantity of eruption, age of patient, concur- rent inflammation of the mucous membranes especially the larynx and air passages, hemorrhagic dyscrasis giving rise to the malignant and petechial forms of the disease, adynamic state of the nervous sys- tem conjoined with irregular habits of living, vaccination, pregnancy, and general conditions of favorable or unfavorable import. In 2654 cases of every kind, he found the death rate to be 37 per cent.; namely, in the discrete form, four per cent.; semi-confluent, eight per cent.; and confluent, fifty per cent. Of those unprotected by vaccination, death occurs in one of every three. Variola discreta " is hardly ever attended with danger to life, except in children who may be cutting teeth at the time, and may have con- vulsions or some affection of the brain." In variola semi-confluens the patients " usually do well," fatal cases being the consequence of the combination of dentition with cerebral irritation already alluded to, or some other kind of complication, such as erysipelas, gangrene, or a petechial or malignant dyscrasia. In variola confluens the dan- ger proceeds from excessive pustulation, and especially the multipli- cation of pustules on the head and face; while other unfavorable in- dications are, flatness, want of circumscription' and a central blackness of the pustule, asthenic and pemphigoid vesication, a too purple tint of areola, absence of areola with general congestion of the skin, white and paste-like appearance of the pustules on the face, and much inflam- mation of the mucous membrane of the mouth, tongue, fauces, nares, larynx, trachea, and bronchial tubes. Variola corymbosa is a " very fatal form of the disease," the death average being over forty per cent.; happily, however, it is rare, Marson having seen only 104 cases in thirty years, 29 in unvaccinated, and the remainder in vaccinated persons. The danger proceeds chiefly from a tedious convalescence and a proneness to dangerous complication. Variola maligna, accom- panied with prostration of nervous power, asthenia, and haemorrhagic dyscrasia, is sometimes fatal before the appearance of the eruption, and in the confluent form commonly on the fifth day. In these cases the contents of the pustule are blackened by the presence of blood (variolae nigrae), and hemorrhages take place from the mucous mem- brane, sometimes from the conjunctiva and ears, and sometimes from the nose, mouth, air passages, bowels, kidneys and uterus; in case of pregnancy, the foetus is expelled dead. Petechial variola falls into the same category, and is also of unfavorable prognosis; the petechiae being the most frequently met with in the axillae and groins. The anomalous forms of variola are also unfavorable in proportion to the magnitude of the irregularity or complication. 420 ZYMOTIC AFFECTIONS. The age the most favorable for smallpox ranges between ten and fifteen years; the rate of mortality in infants under five years being fifty per cent.; and that of adults above thirty and elderly persons over fifty per cent. Congestion of the mucous membrane of the air passages, early dis- tinguished by hoarseness of voice, may run on to inflammation of the lungs. The hemorrhagic dyscrasis, constituting the malignant and petechial forms of variola, is also a grave complication; so also is a giving way of the power of the nervous system, as indicated by early delirium, irritability, tremulousness, restlessness, and sleeplessness. Delirium on the tenth day is a bad sign, and the result generally fatal; grinding the teeth, in children, is also bad ; but the presence of a quiet, tranquil, cheerful and hopeful temper is of good augury, while apprehension and anxiety are the reverse. Smallpox is always favorably controlled by vaccination; the pri- mary fever may sometimes be severe, but it subsides completely as soon as the exanthem is developed. Pregnancy is always a serious complication of smallpox; in fatal cases abortion takes place the day before death, the foetus being dead; sometimes, however, the child is born alive, and both parent and off- spring survive. The general unfavorable conditions mentioned by Marson are : the occurrence of smallpox on ship-board; in small, confined, and ill- ventilated tenements; in hospitals, and especially in lying-in hos- pitals ; in plethoric persons, and such as have lived an irregular life; in drunkards, and those who are kept in too heated an atmosphere, and make use of exciting and stimulating food during the progress of the fever. In hospital, the space allotted to each patient should not be less than 2000 cubic feet. Marson also notes that smallpox " is particularly destructive to the dark-skinned races; the blacks who come to the Smallpox Hospital suffer more from the disease than the native inhabitants of Great Britain." And Dr. Bulkeley "mentions an instance in which a tribe of American Indians took smallpox, and they all died of it; every individual of the tribe was swept away." Treatment.—The uncomplicated form of smallpox requires the most simple plan of treatment, namely, confinement to bed in an apart- ment which is well ventilated, spare of furniture, curtains, and carpets, darkened and quiet, light bed coverings, diluents, cooling regimen, cool and equable temperature, frequent change of linen, and an atten- tion 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 ex- pectant ; very little is required of the practitioner during the fever treatment of variola. 421 of invasion beyond the maintenance of a cooling regimen, keeping the bowels gently open by saline purgatives, and sponging the skin with tepid water. The diet should consist of milk, bread and milk, barley-water, gruel, arrowroot, sago, tea; with cooling fruits, such as grapes, oranges, strawberries, roasted apple alone or pulped with milk, as suggested by Sydenham ; and refrigerant drinks, for example, toast and water, lemonade, orangeade, apple water, tamarind water, water sweetened with currant jelly or acidulated with raspberry vinegar, imperial, and water or barley-water, containing chlorate of potash (5j ad Ixvj). 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 to regulate the bowels, and opiates to relieve restlessness, sleeplessness, and nervous symp- toms. The diet may be improved by the addition of beef tea, chicken and veal tea, mutton broth ; and, if the powers of the system flag, wine may be administered and repeated according to its effect. The carbonate of ammonia treatment, so valuable in rubeola and scarlatina, is equally applicable to variola, for ammonia is, probably, 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 am- monia should be the same as that laid down under the head of treat- ment of scarlatina; and the general precautions taken, and the man- agement of the patient, should be the same. Our own experience of the carbonate of ammonia fully corroborates the value of Dr. Witt's suggestion ; and we 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 valuable of our remedial appliances. The indication for the use of aperients is a coated state of the tongue and a torpid condition of the bowels, and the remedies em- ployed may conform to the ordinary usage of the practitioner: sul- phate of magnesia with infusion of senna; infusion of rhubarb with sulphate of soda ; calomel; gray powder; or .castor oil; or if the in- tention be to maintain power in combination with aperient action we may unite sulphate of quinine with sulphate of magnesia. When the tongue is clean no aperient may be found necessary, excepting in instances of decided constipation. The opposite condition of bowels namely, diarrhoea, is rare; but where it exists, it may be necessary to have recourse to opiates with antacids and astringents; to injections 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 or six hours, puts an end to it completely During the prevalence of an epidemic a wine-glassful is taken daily as a prophylactic. Various trials of this remedy in this country have, however, failed to establish its reputed beneficial effects. 422 ZYMOTIC AFFECTIONS. of starch and laudanum; to sulphuric acid with the infusion of roses ; to hydrargyrum cum creta" with aromatic confection; and to a linseed meal poultice applied over the abdomen. 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; a mustard cataplasm to the epigastrium for pains in that region with violent vomiting; mineral acids with infusion of roses, for hemorrhages; and emollient appli- cations to the eyelids where the conjunctivae are painful and swollen. If the eruption be tardy in its appearance, the patient may be im- mersed 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. Sydenham recommended a small bleeding at the commence- ment of the secondary fever, and following it up with an opiate; but he cautions us against abstracting much blood. The safer practice is not to bleed ; and in this opinion the profession is 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, especially counter-irritation. Local bleeding by leeches or cupping might 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, lest too great debility follow its use. Counter-irritation is applicable when the removal of blood by bleeding would be admissible. Under the same circumstances, again, mild purgatives may be administered, when symptoms of gastro-intestinal irritation are absent. But purga- tives, it must be recollected, are calculated to excite and keep up irritation of the mucous membrane, and they may frequently be very judiciously superseded by emollient 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 mem- brane of the nose and behind the ears has been unsuccessful in remov- ing, ice may be applied to the head, or the cold water pillows recom- mended by the late Professor Davis for hydrocephalus, or, still better, the cold cushions of Dr. James Arnott.' For the pleuritis which sometimes attacks smallpox patients, accompanied with severe local pain and short and difficult respiration, the treatment is a blister or mustard sinapism with an opiate. Pneu- monia and bronchitis are also best relieved by similar local means, with the addition of salines and sedatives ; and the irritable cough of bronchitis is much soothed by the inhalation of the vapor of hot water, to which a few drops of chloric ether or creasote have been added. See Lancet, vol. ii. 1841-2, page 441. TREATMENT OF VARIOLA. 423 Erysipelas is to be treated in the same manner as when of idiopathic origin; and gangrene by the use of wine, tonics, and, locally, the application of the chloride of lime and dredging with pulvis cinchonae. In ulcer of the conjunctiva, or, ulcer of the cornea, it may be necessary, after cleansing the eyelids with a decoction of poppies, to touch the ulceration with a point of nitrate of silver; and in inflammation of the vulva, with mucopurulent discharge, the poppy-head decoction is especially valuable, followed by a lotion of liquor plumbi and lauda- num or one of tannin. When the nervous system is especially affected, as in that variety termed by Gregory nervous variola, the administration of tonics, such as bark and quinine with sulphuric acid, is called for; and similar means must be adopted when there is evidence 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 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. Dr. Marris Wil- son has pursued the practice of sponging the surface for several years, and he assures us with the best success. The belladonna treatment recommended for scarlatina is also appli- cable to smallpox. We 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 had become 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 the region of the eyes, nose, and lips. The secretions from the 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 linimeut composed of equal parts of olive oil and lime-water, 424 ZYMOTIC AFFECTIONS. 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. Sometimes also dredging with starch will be found serviceable. The importance of keeping the surface moist, and excluding the atmosphere, would seem to have suggested to Hebra, the eminent Der- matologist of Vienna, the application of an apparatus for maintaining a permanent warm bath. A butcher's apprentice, eighteen years of age, seized with confluent variola, was placed in the bath on the fifth day of invasion, the third of eruption; and retained there until the seventeenth day, when the crusts had fallen. Hebra expresses his satisfaction with the result, although, during his confinement in the bath, the patient was attacked with pleuro-pneumonia dextra, -never- theless, as far as the variola was concerned, the fever remained mode- rate, and the eruption passed favorably through its course. We should be sorry to prejudge this method of treatment; but we are disposed to regard it less favorably than the treatment by the carbonate of am- monia, with the local application of some material capable of forming a coating to the skin, 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 ectrotic methods of arresting the development of the erup- tion 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 the 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 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, contain- ing fifteen or twenty grains to the ounce; this application to a surface of any extent has been found to be dangerous, in consequence of giv- ing 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 TREATMENT OF VARIOLA. 425 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 fail- ure. In summing briefly the objections to the employment of nitrate of silver, they may be stated as follows: firstly, it creates pain; se- condly, it requires more time for its application than the practitioner can devote; and thirdly, it augments the febrility and nervous ex- haustion of the patient. Another ectrotic remedy has been warmly eulogized by Dr. Midi- vaine,1 of Ghent, It consists in the application of sulphur ointment, by means of light friction, to the entire surface of the 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 of the disease. _ The effects of the remedy, according to Dr. Midivaine, are, contraction and hardening of the papulae, diminution of tumefaction of the skin, and subsidence of the gastro-intestinal irritation. The appetite of the patients quickly returns, and they are speedily restored to health. A more important ectrotic remedy than either of the preceding is one which was made the subject of an essay,2 read before the Parisian 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 attentive consideration. Mercury administered internally has long been known to possess remarkable powers in modi- fying the influence of variola upon the system, but it was left to modern times to prove that this agent has also the property of neu- tralizing the variolous virus when applied externally. We pass over the well-known and unmeaning experiment of Von Wenzel, namely, the trituration of the variolous matter with calomel, and the subse- quent marvel that the virus should have lost its inoculating power, to the more rational experiments of Serres, afterwards so successfully pursued by Briquet. The mercury was employed by these gentlemen in the form of a plaster, the emplastrum vigo cum mercurio, of which the formula in the French Pharmacopoeia is as follows :— $.—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 mercurial 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 1 Bulletin de la Soc. Med. de Gand, 1840. 2 Lancet, vol. i. 1840-41, p. 694. 426 ZYMOTIC AFFECTIONS. 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 of the 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 of the 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 arising, mercurial ointment may be substituted with a fair prospect of benefit. We recently suggested this plan of treatment to a young practitioner who had several cases of smallpox under his care; he re- ported that within 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 shown that the erup- tion 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; the eruption never becomes purulent, nor the skin between the pustules inflamed and swollen. But, however powerless as a perfect ectrotic the mercurial application may be when used in the pustular stage, it would seem, from the evidence of Sir Joseph Oliffe, that the local inflammation is much modified and ameliorated. According to Briquet, " the mercury acts as an antiphlogistic, or re- solutive, in destroying or suppressing the local inflammatory process; or it exercises a specific action on the cause, whatever it be, which produces the variolous pustule." From his researches on other in- flammations of the skin, the latter of these propositions would appear the most correct. It is interesting to learn, that, in the progress of his experiments, Briquet ascertained that mercury possessed precisely the same in- fluence 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 TREATMENT OF VARIOLA. 427 commonly leaves behind it, and the formation of pits. In the instance of two sisters, in whom we employed similar means, all irritation and discomfort of the skin were prevented; but symptoms of salivation showed themselves in the course of a few days, the mouth was tender, and the salivary glands eularged and painful. If the same beneficial result could be obtained without the mercury, the discovery would be of much importance. We have not heard of any injurious effects following the use of the mercurial ectrotic, but 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 repercussion. 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. We cannot admit for a moment the doctrine of repercussion, 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 Piorry's objection 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 our 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 we believe it to be inferior in power to the mercurial ectrotic ; namely, the tinc- ture of iodine. 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 corroborated 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 the 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 inferior to the mercurial ectrotic. It should be pencilled on the eruption at as early a stage as possible, and repeated once or twice daily for several days. Piringer, however, recommends that, on the first day of the eruption the whole face, including the eyelids, should be painted ten times, with intervals of half an hour; if the patient be seen for the first time, on the second day, twelve applications will be required; while, on the third day, fourteen to sixteen will be necessary. 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 cleanliness, and of enabling the operator to see what is passing beneath, without requiring to disturb it. Another of its properties, namely, its con- tractility, 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 428 ZYMOTIC AFFECTIONS. has been made the subject of experiment in France, and favorably reported on by Dr. Aran, of the hospital Bon Secours.1 The appli- cation recommended by Dr. Graves, a few years since, of a solution of gutta percha in chloroform, did no good; and by confining the dis- charge, produced a most offensive condition of the patient.2 The ethereal solution of mastich and iodine3 of Dr. Thomas Smith Howe, of Margate, 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 existed 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 sugges- tion of John of Gaddesden, the rooms were hung with scarlet cloth, and the windows carefully blocked up. So recently as 1832, Dr. Picton,4 of New Orleans, asserts, that in his practice no instance of pitting after smallpox occurred when the light was shut out. Serres placed 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 pus- tule checked, and that when they were completely shut out, the pus- tule became shrivelled and quickly dried up. Moreover, Serres remarks that he never reaped such successful results, in the cure of smallpox, as he did at La Piti£, during one year that the patients were placed in a kind of cellar, which was very dark and ill venti- lated. The same principle has been more recently acted on by Le- grand, who proposed to the Academy of Medicine, in 1839, the plan of covering the surface of the body with gold leaf. After the experi- ments of Fourcault (page 62), this practice would appear somewhat hazardous. VARICELLA. Syn. Chicken-pox; glass-pox ; water-pox; chrystalli; varicella bullosa, Cross ; pemphigus variolodes vesiculosus, Frank; variolas pusillce, Heberden; variola crystallines., vola- ticoe, Morton; variola lymphaticce, Sauvages ; varicella vesicularis, lenticularis. Varicella5 is an eruption of isolated vesicles more or less nume- rously dispersed upon the skin; and accompanied with a slight degree of febrile disorder of the constitution. The fever precedes the erup- tion by a few hours, sometimes an entire day, and is greatest at night. The eruption is successive, appearing every morning for four or five days, and drying up into thin friable scabs, which desquamate in two or three days without leaving any trace of their previous existence, 1 Bulletin de Therapeutique, vol. xxxix. p. 369. 2 Marson, loco citato. 8 Vide Formulary of selected remedies. 4 American Journal of Medical Science. 5 According to Gregory, the term varicella was first employed by Vogel in 1764; it was named chrystalli and variolae chrystallinae by Ingrassias in 1553 ; and is men- tioned by Riverius in 1646, under its popular designation among the Italians of verolette. The first use of the term chickenpox is attributed to Morton in 1694; and Heberden, in 1767, has the credit of distinguishing it from variola under the title of variolae pusit Ice. VARICELLA. 429 making the full period of duration of the disease about a week. It is especially an eruption of children; takes its origin in contagion, and. like other zymotic affections, is not liable to recurrence. The chief interest of varicella resides in its relation to the other zymotic affections, and especially to variola; to the near approach which it makes to certain of the forms of modified variola, and to the consequent necessity of distinguishing between it and that disease. Like the zymotic affections in general, it has its period of incubation, its fever of invasion, its eruption, and its decline; and like variola, its eruption consists of a papule and vesicle; but unlike variola, the vesicle is unilocular; it subsides at the serous stage; it leaves no pit or cicatrix at its fall; and it is incapable of exciting a secondary or suppurative fever. The period of incubation, as determined by the interval between exposure to contagion and invasion ranges between four days and seventeen days, and may be generally stated at a week or a fortnight, during which time no symptoms are present indicating a failure of health. The period of invasion is limited to a few hours, probably to a single night, rarely reaching twenty-four. Its symptoms are those of fever of a mild description, for example, lassitude, headache, some- times sickness, sometimes cough; with heat of skin and increased quickness of pulse. The eruption commonly makes its appearance in the morning, and consists of semi-globular vesicles, remarkable for the thinness of their epidermis and transparency, dispersed over every part of the skin more or less numerously. There may be a hundred or more of these vesicles, and every morning an equal number for four or five days. In size they have been compared to a small kind of pea or vetch, the chick-pea; hence the term chicken-pox. They have no redness around the base, and look like drops of water sprinkled on the skin; hence their early name crystalli, and the popular expressions glass-pox and water-pox. On closer examination it will be found that the vesicle is preceded by a small red spot surrounding the aperture of a follicle ; the centre of the spot soon becomes swollen, constituting a papule; and in less than twelve hours the red spot and the papule are both submerged by the vesicle. These primary stages of the vesicle correspond with similar stages of variola ; but it is clear that varicella is more super- ficial than variola; the papule of varicella is less raised, its ruddy base is not hard to the touch, nor is the papule granular and gritty as in variola. The vesicle also is different both in figure and structure; it is globular in varicella, and depressed in the centre or umbilicated in variola; it is a mere blister with a single cavity in varicella, but multilocular in variola. Even the contents, though equally trans- parent, are different in the two forms of vesicle; for in varicella the lymph is serous and watery, while in variola it is plastic and viscous. " The vesicle of varicella of a day old, so remarkable for its crystal- like transparency, is opalescent or lactescent on the second and third day, and sometimes assumes the yellowish tinge of pus; on the third 430 ZYMOTIC AFFECTIONS. day a slight areola is formed around the vesicle; and on the third, the fourth, or the fifth day it darkens in the centre of its dome from desiccation and is soon converted into a thin, lightish-brown, granular and friable scab. Two days later, from the fifth to the seventh day of eruption, the scab falls off; leaving a smooth and slightly-reddened surface, uniform with the rest of the skin ; not unfrequently the vesicle is broken, when it reaches its full dimensions, and then a thin scab is formed by the desiccation of its base. The development and course of the eruption, and sometimes its outbreak, is accompanied with some degree of itching; and it is im- portant that the patient should be prevented from scratching, for irri- tation of the vesicle may induce inflammation and suppuration, and a pit like that of variola might be left behind. The pressure of the body against the bed-clothes and the movements in bed sometimes produce a similar result. The constitutional symptoms accompanying varicella are usually very slight; there is some peevishness, sometimes moderate fever at night, but none in the day; the pulse is scarcely affected; the tongue is clean, and appetite undisturbed ; but there is commonly some degree of catarrh, generally mild ; and a little debility follows convalescence. Diagnosis.—The pathognomonic characters of varicella are its transparent semi-globular vesicles, appearing in successive crops; the general distribution of the vesicles; the invasion of the eruption with fever; the limited duration of the disease; its occurrence in children ; and the absence of other signs of cutaneous disorder. And the erup- tions with which it is liable to be confounded are miliaria, herpes, and modified variola. The vesicles of miliaria very closely resemble those of varicella ; but in every other respect the disease differs completely, namely, as to successive crops, limitation of course, general distribu- tion, and specific fever. The miliary eruption is an accidental accom- paniment of fevers attended with much heat of skin, or clinical states associated with sweating, for example, the early stages of the eruptive fevers, continued fever, acute rheumatism, and childbed. In miliaria the skin is reddened and moist from heat; the vesicles are met with only on parts of the body, as on the sides of the trunk, the loins, arm- pits, and inner side of the thighs, or they may be limited by the extent of some heating article of dress, such as a woollen vest; they are not dispersed universally over the body and limbs as are the vesicles of varicella; and although, generally, somewhat smaller than the latter, they present considerable variety of size, and are sometimes clustered; moreover, they occur more frequently in the adult than in children, and especially in acute rheumatism and in parturient women. The vesicles of herpes are generally of a somewhat larger size than those of varicella; clustered; partial in their distribution; developed on a hard, thickened, and inflamed base; often accompanied by a hot, tingling, and pricking itching, and unattended with special constitu- tional symptoms. It is only on their first eruption that any difficulty of diagnosis could arise, the subsequent changes in the vesicles being totally different; those of varicella tending to desiccation and the for- TREATMENT OF VARICELLA. . 431 mation of a thin crust in three or four days; while the vesicles of herpes take three or four days to attain maturity. Moreover, varicella is an aff'ection of the vascular surface of the corium, while the morbid changes in herpes sink deeply into the corium, and terminate often in suppuration and sometimes in gangrene and sloughing. The diagnosis between varicella and the vesicular forms of modified variola, for with these alone can it be confounded, are the greater de- gree and longer duration of the fever of invasion of the latter; the bard and gritty papule; the hardened base, and the slow development of the vesicle; the special characteristics of varicella being the short duration of the primary fever, the softness and trifling prominence of its papule and the suddenness of development of the vesicle, which attains its full size within a day. If the modified variola be present in its papular or pustular form; if its vesicle be conical, umbilicated, or multilocular, then the distinction is so obvious as scarcely to involve the possibility of a doubt. Lastly, the fall of the crust of modified variola is commonly followed by a pit which is altogether absent in varicella. Cause.—The cause of varicella is a specific contagion; it is con- tagious and epidemic, but not communicable by inoculation of the fluid of the vesicle, and is uninfluenced by vaccination. The belief in the inoculability of varicella probably owes its origin to an error of diagnosis, the lymph having been obtained from a case of vesicular varioloid. Varicella is rare in the adult, but common in childhood; from a table of cases occurring in the Children's Hospital, and quoted by Dr. Gee,1 it would appear that of 727 cases the greatest number (623) occurred between the ages of six months and six years; 177 under one year; 137 between one year and two; 100 between three years and four; and 96 between four years and five; under three months the cases were only 23; and between nine and twelve years, 22. Prognosis.—Varicella is a very harmless affection; it is never dangerous, and has never been known to be fatal. Treatment.—The simplest antiphlogistic treatment, in respect of tranquillity, diet, and medicine, is all that is necessary. Our remedies may be expectant, and if any debility appear at the termination of the eruption, we may have recourse to bitters with nitromuriatic acid, quinine, or chalybeates, such as the syrup of the phosphate of iron. The indications for local treatment are, pruritus and abrasion of the corium; the former may be best relieved by sponging with a tepid solution of carbolic acid ("Ixl ad 3xvj), or by dusting the surface with calamine powder; fuller's earth powder; oxide of zinc with starch; or starch powder alone. These powders are also the best application where any abrasion or excoriation has occurred. The benzoated ointment of oxide of zinc with or without spirit of wine is also a valuable agent for producing a coating over the excoriated sur- face, and protecting it from exposure to the air or further irritation. 1 Article Varicella, in Reynold's System of Medicine. 432 ZYMOTIC AFFECTIONS. VACCINIA. Syn. Variola vaccina ; variolae vaccinae; cow pox; coio smallpox. Variola vaccina, the smallpox of cattle, is a contagious inflam- mation of the skin, prevalent among cattle, and occasionally commu- nicated to man. It is characterized by the development, upon an in- flamed base, 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 with 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 in- ferior animals, is a theorem that might, a priori, be predicted. It is perfectly consistent with our knowledge of the physiological laws and comparative structure of man and 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, in- deed, as a principle, in the first rudi mentsof our physiological 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 engendering in the latter animal an eruption that could not be distinguished from the true vaccinia. This disorder in the horse was, unquestionably, 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, con- founded 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 science at fhat period, an inference which its distinguished author subsequently relinquished, namely, that the variolae vaccinae had their origin in the horse, Jenner created an argument which, for many years, was industriously em- ployed as an objection to the philosophy of his 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 1 Transactions of the Provincial Medical Association, vol. viii. 1840, p. 1. VACCINIA. 433 has been seen in the valleys of England, it has likewise been observed upon the mountains of the Andes, on the elevated ranges of the Himalayas, in the plains of Lombardy, in the green pastures of Hol- land, 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 cow-pox, that we shall content ourselves with stating the facts which we conceive to be established relative to this disease, and the principal observations by which those facts are supported. The facts to which we allude are:— 1. The prevalence, at the same period, of the cow-pox among cattle, and the smallpox among men. 2. The transmission by contagion of the smallpox to cattle, and the consequent development of cow-pox in those animals. 3. The transmission by inoculation of the smallpox to cattle, and the consequent development of cow-pox in those animals. 4. The transmission by contagion of the cow-pox to man, and the consequent development of a pustule similar in character to the vac- cine pock of the cow. 5. The transmission by inoculation of the cow-pox to man, and the consequent development of a pustule similar in character to the vac- cine pock of the cow. 6. The transmission by inoculation of the cow-pox 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. Gibson,1 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." Macpherson, writing from Murshidabad 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 circumstances 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 preva- lence of variola, the cow-pox " 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 Ceeley2 in the following narrative: " On Friday, the twenty- 1 Transactions of the Medical and Physical Society of Bombay, vol. i. 2 Transactions of the Provincial Medical Association, vol. x. 1842, p. 211. 28 434 ZYMOTIC AFFECTIONS. 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 con- nected 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 erup- tion, 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 cottages across the close was, of course, continued after this event. On the following day the wearing apparel of the deceased, the bed-clothes, bedding, &c, 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 morn- ing for this purpose, and were driven from it every afternoon, to be transferred to a distant meadow to be watered and milked, where they remained through the night. Whenever the cows quitted the meadow in question in the afternoon, the infected articles above mentioned were again exposed on the hedges, and the flock of the bed spread out on the grass, and repeatedly turned, where it remained till the morn- ing, when the cows were readmitted." It appears, however, that the removal of the infected articles was not always accomplished so punc- tually as had been enjoined, for both the proprietor and the milkers affirm, that on one occasion, at least, they observed the bed-flock on the grass, and the cows amidst it, and licking it up. The proprietor positively declares, and the milkers corroborate his statement, "that the animals were in perfect health on their first entering this close, but within twelve or fourteen days of that event, five of the milch cows appeared to have heat and tenderness of the teats, upon which, imbedded in the skin, were distinctly 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 swol- len, and very tender, the constitutional symptoms were first observed, viz., sudden 'sinking,' or loss of milk, dribbling of saliva from the- VACCINIA. 435 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, dis- agreeable, 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, Ceeley observes, " Another circumstance, too, requires to be particularly noticed ; it is the fact of the occur- rence of the vaccine disease on a young sturk, which, of course, could not have been induced by those casualties which commonly propa- gate it among milch cows, but simply by the cause which originated 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 in- ferred 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 we 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 udder 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 cow-pox in those animals, is also established on abundant evidence, for the chief of which we are again indebted to the zealous perseverance of Mr. Ceeley, of Aylesbury. It is stated by Dr. Macmichael, in an essay read before the College of Physicians in 1828, that "vaccine matter having failed in Egypt, medical gentlemen were led to institute certain experiments by which it has been discovered that, by inocu- lating the cow with smallpox from the human body, fine active vac- cine virus is produced." M. Viborg. of Berlin, is reported to have 436 ZYMOTIC AFFECTIONS. inoculated cattle, and several other classes of domestic animals, with success. 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 of the 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 splendid." 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 of the 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 acme. On the eleventh, de- cline 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 of the 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 at 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 cow-pox. 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 constitu- tional 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 eruption so pro- duced bore all the characters of true smallpox. Thus, it would ap- pear, that, as the smallpox virus, when introduced into the system of the cow, is so modified by the vital laws which regulate the functions of the animal as to produce an eruption of cow-pox ; so, on the other hand, the virus of the cow, under like circumstances, is modified by the constitutional phenomena of the human organism, and is made to assume the characters of smallpox. VACCINIA. 437 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, and is transmitted to other members of the herd by the hands of the milkers. Occa- sionally 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 tissues, 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 sporadic form, or as the result of contagion communicated by the hands of milkers; the former of these varieties Ceeley terms natural, the latter casual. Natural variola vaccina makes its invasion with heat and tenderness of the teats and the udder, unaccompanied by constitutional symp- toms, 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 summit. The vesicles, increasing in size, become acuminated, ovoid, or globular, and are distended with an amber-tinted and viscid fluid. When ruptured they present de- pressed 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 central slough. When uninjured, or merely rup- tured, without the removal of the epidermis, the vesicles desiccate into thick, dark-brown crusts, which commence in the centre, and pro- ceed towards th,e circumference, appearing at first inlaid in the mar- ginal elevation, and subsequently 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 summit they become gradually depressed, assume a yellowish-white and pearly hue, and have a small central dot or linear impression. On the eighth or ninth day the central concavity increases in depth, while the margin becomes more elevated, tense, and shining, more pearly or silvery in its aspect, and the central depression acquires a bluish or slaty tint. At this period the pock is more than half an inch in diameter, and is surrounded by a narrow areola of a pale rose or light damask hue. Between the tenth and eleventh day the erup- tion 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 438 ZYMOTIC AFFECTIONS. central depressions have augmented in depth, their bluish, slaty color has acquired greater intensity, and the epidermis which invests them becomes distended with an abundance of lymph, and rises into a globu- lar 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 crusts in the manner described, ulcerated and sloughing surfaces are sometimes produced, which remain for weeks in an irritable state. Moreover, casual vaccine variola always pre- sents the eruption in every stage of its progress at the same moment, the elevations 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 succession in the rupture depends upon the diffusion of the virus by the rupture of the vesicles, either in consequence of the move- ments of the animal, or by the milker, and the consequent revaccina- tion of the neighboring unaffected skin. Ceeley has observed aa 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 sometimes, 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, intro- duced by Jenner, of transmitting the contagion artificially 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 originat- ing 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 ru- beola and scarlatina is protective of the individual against that conta- gion for the rest of life. The same circumstance is remarked 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 sug- gested 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 subsequent VACCINIA. 439 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 philosphic thought that spread happiness and security where gloomy anticipa- tions and uncertainty had previously prevailed. He had the talent to perceive in cow-pox 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 smallpox. This trust was rewarded by the complete success which attended the prosecution of his views. In the foregoing remarks we 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 mean3 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 recurrent 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 suspicion that vaccinia gradually loses its pro- tective influence over the system.2 With a view to meet the supposed declining influence of vaccinia, numerous propositions have been made, and modes of practice adopted, the principal of which are, revaccination, retro-vaccination, variolo-vaccination, and an immediate return to the variolae vaccinae of the cow. These various modes of re-establishing the protective powers of vaccinia we shall examine in their turn, after having, in the first place, traced the history of casual vaccinia, as observed and recorded by Ceeley, and described the eff'ects of ordinary vaccination with Jenner's lymph. 1 Jenner's first experiment was made on the 14th of May, 1796. 2 In a conversation which we recently had with Mr. Marson, he made the important practical observation that, after an imperfect vaccination, revaccination will often fail, while the person still remains open to the reception of the smallpox. 440 ZYMOTIC AFFECTIONS. CASUAL VARIOLA VACCINA IN MAN. The transmission of the cow-pock 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 sometimes escape altogether, while others who have been vaccinated or variolated will take the disease; and instances not unfrequently occur in which persons who regard themselves secure, in consequence of having previously suffered from casual vaccinia, are a second time affected. In all the three latter cases, however, and especially 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 back of the hands, the flexure of the joints, sides of the fingers, and the face. When the eruption appears in the latter situation the virus is conveyed by means of the hands moistened with the lymph of the ruptured vesicles. On the back 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 of the 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, Ceeley records the following interest- ing case:—l "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 eighteenth of the same month (ten days), having milked them in that period six times. On this day (the eighteenth) he felt the cervical absorbent glands and lymphatics stiff and tender, and on the twentieth found a pimple on the temporo-frontal region, which he could not resist scratching. On the day before that he observed on 1 Transactions of the Provincial Medical Association, vol. x. p. 216. VACCINATION. 441 his finger a red pimple, of the size of a pin's head; on the next day one on the thumb, very small. In neither situation was he aware of the pre-existence of any visible wound or abrasion of the cuticle. On the twenty-first he had headache, general uneasiness, and pains in back and limbs, with tenderness and pain in the course of the corres- ponding lymphatic vessels and absorbent glands, particularly of the axilla, which increased till the twenty-third, when nausea and vomit- ing 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 cor- responding 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 obtained from a vesicle on the temple, in 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 interruption of their natural course. "On the twenty-sixth and twenty-seventh, when the redness and elevation of the base of the vesicles had materially diminished, 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- tents of the vaccine vesicle, the vaccine lymph or virus, to the papil- lary surface, or to the vascular tissues of the derma of a sound per- son. This object is effected by means of an oblique puncture; by several oblique punctures ; by numerous superficial punctures, as in tattooing; by numerous superficial punctures, accompanied with a 442 ZYMOTIC AFFECTIONS. sudden lift of the point of the instrument so as to rip up the cuticle; by several parallel scratches, vertical or horizontal; or by numerous small scratches, either parallel or crossed.1 The punctures should be effected with a clean sharp lancet freshly dipped in the vaccine lymph; the punctures and scratches may be made either with the lancet or with a needle, in both instances also charged at the point with lymph; or the small parallel scratches and cross scratches may be made by a small rake or scarificator invented expressly for the purpose. In whatever way the operation be performed, the endeavor should be kept in view to introduce the lymph as thoroughly as possible into the wounds. Another and rarely practised mode of vaccinating is to make a small incision, and place within it a thread saturated with the lymph. And in persons who have resisted the contagion, it has been recommended to use a small blister. The blister is produced by re- taining upon the arm a piece of adhesive plaster, in the centre of which has been placed a fragment of emplastrurn 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 operation in the usual way; and it is worth bearing in mind in cases where the ordinary operation has more than once failed.2 The proper subjects for vaccination are infants, and as the purpose of vaccination is to protect them from smallpox, the operation should be performed early; earlier in cities and towns, where the dangers of smallpox are greatest, than in country districts; and especially early during the prevalence of a variolous epidemic. And we are led to this practice by the knowledge of the fact, " that one-fourth of the deaths from smallpox in England occur in children under the age of one year."3 Another very important consideration is the health of the child; if the child be weakly or ailing, or if it be suffering under some existing disease, the operation must be deferred. Dr. Seaton remarks, that the contra-indicating influences of vaccination are acute disease, diarrhoea, or any chronic affection, such as a disease of the skin, for example, eczema, and especially that local form of eczema to which infants are so commonly liable, namely, intertrigo. A healthy infant should be vaccinated between the fourth and sixth week; a delicate child between the second and third month; " but all except those whose state of health positively contra-indicates vac- cination, should be vaccinated by the age of three months. This early period of life is also particularly suitable for vaccination, as being usually free from the disturbing influence of teething." And under every circumstance tending to delay operation, the process should never be postponed beyond the sixth or seventh month.4 1 Vide article " Vaccination," by Dr. Edward Cator Seaton, in Reynold's System of Medicine. 1866. 2 Lancet, vol. ii. 1850, p. 642. 3 "Of 20,590 deaths from smallpox which occurred in England in the six years 1856-61, 5010 were children under one year of age." 4 The early period of vaccination, ranging between one month and three months, is strongly commended to our adoption on a principle of policy; but we know more VACCINATION. 443 But although from its intention vaccination must be practised in infancy, the operation may also be performed at every period of life. Thus children at any age who are found unprotected may be vacci- nated or revaccinated; and in case of the presence of smallpox in a house or in a family, every member of the family should undergo the operation as a mutual protection. At the smallpox hospital the nurses are vaccinated when they commence their duties, as are also servants and laborers employed about the house; and, as a conse- quence of this precaution, no instance of smallpox has taken place in a nurse for a great number of years. During an epidemic of small- pox it is as necessary to vaccinate adults as children; and there are special circumstances that render it advisable that persons should be vaccinated at puberty and at manhood. Vaccinators have their different methods of operation; and it is well that each should adhere to that process which yields him the greatest amount of success. Good vaccinators, says Dr. Seaton, expect "to raise a vesicle for every point of insertion." Marson remarks that, " with good lymph and the observance of all proper precautions, an experienced vaccinator should not fail of success in his attempts to vaccinate above once in one hundred and fifty times." And Seaton observes further, that " at several large stations where vacci- nation is well performed, and where accurate records are kept, I found the average of failures to infect at the first operation did not exceed one in one hundred and seventy cases." Dr. Seaton considers the best mode of vaccinating to be that by puncture; the lancet should be held at an angle of 45 degrees, and directed obliquely from above downwards, and pressed onwards until it enters the derma; the punc- ture produced in this manner is valvular; and the lymph inserted into it has no tendency to escape, but, on the contrary, is disposed to gravitate into its deepest recess. There is no fear, he says, of the expulsion of the lymph by hemorrhage; and when an ivory point is used, he directs that the finger should be pressed against the valvular flap as the point is withdrawn. Five such punctures, half an inch apart, must be made on the arm, or three on each arm. " It is a very good plan," he observes, "to make each puncture a double one," by which means "a finer and larger, often oval, compound vesicle is raised." But the same author remarks, that in less adroit hands the plan by puncture is not so successful as that of the cross scratch, the latter presenting the largest amount of abraded surface for absorption of the lymph. When the cross scratched surface is large, it will be sufficient to make two such patches on each arm; but when the patches are small, not exceeding the length of the punctures, there should be as many as of the latter. The larger patches should be placed three-quarters of an inch asunder; the smaller ones, half an inch. The small tattoo punctures, and the ripped or torn punctures, should be disposed in a similar manner to the scratches, in small plots; the number of plots being the same, so as to afford a similar than one, of whose judgment we entertain a high respect, who believe that a later period, namely, after the ninth month, is more efficient as a protection against small- pox. 444 ZYMOTIC AFFECTIONS. extent for absorption. Where separate long scratches are used, they should be drawn half an inch or an inch apart, and be three or four in number. In vaccination by puncture the lymph is introduced into the small wounds by the point of the lancet, or by the ivory point; but in the case of the superficial punctures and scratches, the lymph should be spread upon the abrasions with the flat surface of the lancet, and pressed as far as possible into the wounds, or insinuated into them with a small amount of friction. In the superficially punctured and scratched surfaces, the vesicles produced are frequently confluent and numerous, but of small size; while on the long scratches there are two or three larger vesicles, or one oblong vesicle of considerable bulk. On a patch of ripped punctures of the dimensions of a six- penny-piece, Seaton counted as many as eighteen or twenty vesicles. In a word, the principle of the operation is to bring the vaccine lymph into the most favorable and extensive contact with the vascular corium, and to deposit it there with the least possible chance of dis- turbance or removal. If the punctured or scratched surfaces bleed to such an extent as to obstruct the application of the lymph, the blood must be dabbed off before the lymph is plastered on the abra- sions. Wherever practicable, vaccination should be performed with fresh lymph taken directly from the vesicle; but where this advantage is not to be obtained, we must have recourse to lymph preserved by desiccation on ivory points, or between plates of glass, or to lymph inclosed in capillary glass tubes hermetically sealed. In distant parts of the world, where fresh lymph cannot be procured, and where, from the nature of the climate, lymph dried on points or between plates of glass would be liable to injury, it is sometimes necessary to make use of the dried vaccine crust. The crust is triturated with water to a consistence equal to that of fresh lymph, and in this state it has been used with moderate success. Lymph begins to be formed in the vesicle on the fifth day after vaccination, and is ready for use as soon as it appears; but the period the best suited for taking the lymph, both on account of the perfection of the vesicle and the abundance of its contents, is the eighth day, the day week of vacci- nation, and this lymph is called eighth day lymph. The lymph is pro- cured from the vesicle by piercing the dome of the vesicle with several punctures, and then awaiting its gradual exudation. The vaccine vesicle is a many-chambered cavity, and unless all the cham- bers be opened, the whole of the lymph cannot escape; that is the reason for employing several punctures, and the punctures should be made obliquely or almost horizontally, so as to slice off the upper portion of the dome. A double advantage is gained by this proceed- ing; there is a greater probability of the escape of the whole of the lymph, and freedom from the liability of its admixture with blood. When the lymph has exuded from its loculi, the tip of a clean and sharp lancet is to be moistened with the lymph, and the lancet charged with the lymph is to be employed for making the punctures and scratches, and for conveying a proper quantity of the lymph to the incisions and abrasions. It is of course desirable that every portion VACCINATION. 445 of the abraded derma should be moistened with the lymph. A good vesicle, says Dr. Seaton, of such a size as is produced by a single deep puncture, will produce enough lymph to vaccinate from four to six children, or to charge thoroughly six or eight ivory points. Where direct vaccination cannot be effected, the charged points must be moistened with water preparatory to being used; and when glasses are employed, a small drop of water should be placed on the dried film of lymph, the object being to bring the lymph as nearly as pos- sible to the degree of fluidity which it possesses in its fresh state. To be too dry or too moist would be equally objectionable. Lymph as it issues from the loculi of its vesicle is perfectly trans- parent, somewhat viscous, and wholly free from any tinge of blood. The vaccinator must assure himself that the lymph has the proper appearance and aspect, and must be ready to use the most careful judgment, both in the selection of the child from whom the lymph is taken, and of the most perfectly developed vesicle. The child should be healthy; "babies are much better lymph-givers than elder children or adults, and children of dark complexion, not too florid, with a thick, smooth, clear skin, yield the finest and most effective lymph."1 The lymph also must not be serous and watery, neither should it be opaque and purulent, but should possess the transparent, viscous character already mentioned. The most convenient spot for vaccination, and that usually selected for the purpose, is the rounded prominence of the shoulder over the middle of the deltoid muscle, and about an inch below the point of the acromion process. The operator grasps the arm with his left hand so as to make the skin tense, and with his right, armed with a sharp and clean lancet tipped with lymph, he makes the oblique and val- vular punctures, or the smaller punctures with and without ripping, or the long or short scratches, as may best consort with his usual and therefore most successful mode of practice, that practice of which, as we have stated, the failures should not number more than one in every one hundred and fifty vaccinations, and which for every puncture should produce a vesicle. The number of punctures is another very important consideration ; there should be five on one arm half an inch apart, or three on each arm ; for it is necessary, as shown by Marson, that not less than four good and perfect cicatrices should be left on the arm as evidence of the success of the operation and of the conse- quent safety of the child. And when other plans than that by punc- ture are chosen, the abraded spots should be equivalent in number. Again, after the operation, any exuded blood may be allowed to dry upon the wounds, and the part upon which the operation has been performed must be carefully protected against pressure or friction. Indeed this latter precaution is necessary to be enforced throughout the whole course of the subsequent phenomena, and until the crust has formed and has fallen spontaneously. For two days after the operation no change is perceivable in the appearance of the punctures; the seed is in the soil, and has not yet Dr. Seaton, loco citato. 446 ZYMOTIC AFFECTIONS. commenced to push forth the future plant. On the third day there is a small red papule at the seat of the puncture. On the fifth day the vesicle is formed, the cuticle of the papule is gently lifted up by the effusion beneath it of the vaccine lymph. The vesicle has a bluish white tint, is rounded at the border, and slightly indented or umbili- cated in the centre. The eighth day is the day of perfection of the vesiole; it is round, pearl colored, plump, swollen at the border, and umbilicated in the centre. While a slight redness around its base, the incipient areola, gives warrant for Jenner's expressive definition of its appearance at this period, namely, "the pearl upon the rose." This is the time of the mature fruit, for now the lymph is in its best state for removal and propagation. The development of the areola, which begins on the eighth day, constitutes a new phase in the phenomena of the vaccine vesicle. The areola assumes importance during the ninth and tenth days, reaching a breadth of one to three inches, and on the eleventh begins to fade, declining more and more during the succeeding days until it alto- gether disappears. The areola presents a vivid red color, sometimes bright, and sometimes roseate, and represents a true inflammation of the skin. The integument is hot, painful, itchy, swollen, hard, and infiltrated; and with these local symptoms there is more or less con- stitutional disturbance or feverishness; the child is restless and frac- tious ; its stomach and bowels may be deranged ; the skin is hot; and there is frequently enlargement of the axillary glands. These symptoms correspond with the secondary fever of variola, and are due to the same cause, namely, the maturation of the vesicle, and the transmission of the vaccine virus into the blood and throughout the system. As long as the pathological process is simply local, it pro- ceeds onwards by successive steps in a state of calm, without any excitement of the organism; and this is the period at which we obtain the lymph for the purpose of vaccination. But the constitu- tional feverishness which is set up coincidently with maturation of the vesicle explains why the lymph obtained at the latter period may be a source of evil rather than of good, and may be the means of arous- ing unhealthy action in the recipient, while it must necessarily fail in producing the normal results of successful vaccination. Vaccination, therefore, presents us with a regular succession of phenomena; an incubation of two days, a papulation of two days, a vesiculation of four days bringing us to the eighth day, then a crescent areolation of two days followed by dispersion of the redness, and a maturation and desiccation of the vesicle extending from the ninth to the fourteenth or fifteenth day. Desiccation begins in the umbilicated centre of the vesicle and gradually spreads to its border; the lymph becomes opaque and purulent; and the crust, which is at first brown, becomes deeper colored until it is almost black; it hardens and shrinks, and falls off between the twentieth and' twenty-fifth day, leaving behind it a deep circular pit sharply defined at its circum- ference, and marked on its floor by minor pits or foveolae correspond- ing with the loculi of the vesicle. The floor of the pit is often a little elevated in the centre, and sometimes from this centre there issue a VACCINATION. 447 number of radiating lines. This is the foveolated cicatrix of vaccina- tion, a mark which endures for life; the stamp of succes of the opera- tion ; and in the absence of which the individual is unvaccinated, and therefore unprotected.1 But the current of vaccination does not always run its course as smoothly as is here described; the vaccine vesicle may be retarded or accehrated in development; or the areolar inflammation may be attended with the production of a roseolous rash, a lichenous or vesiculous eruption, erythema, enlarged and painful axillary glands, erysipelas, ulceration, and sloughing. "The most simple and frequently seen form of retardation is a mere delay for a day or two in the course of the vesicle; by the eighth day it has not more size or development than ordinarily is met with on the sixth, and the areola does not form till the tenth day, or even later. Sometimes the delay is much longer; at the end of a week from the vaccination, when the child is brought for inspection, so little of result is seen that it is a question whether the vaccination have not altogether failed; some fresh lymph is in- serted on another spot; and as the vesicle of the new vaccination rises, that of the first vaccination is seen also to develop itself, and the two run their course at the same time. Lymph may thus lie dormant, as it were, without any apparent reason, it has been said, for even three weeks. I have not myself, however, seen a case of such dura- tion. But sometimes there is an obvious reason for the retardation, as when vaccine lymph has unwittingly been inserted in a child who happened to be incubating measles or scarlatina. When these appear, the vaccine vesicles, if any have been induced, will be arrested in their course, and no areola will be formed till the measles or scarla- tina have subsided. Retarded cow-pox is much more frequently seen when vaccination is performed with dry lymph than when it is done direct from the arm." However, " mere retardation of phenomena, if these phenomena be regular in their character, does not in any way interfere with the protective value of vaccination. When vaccination has been performed with effect on a child who is incubating small- pox, the vaccine vesicles proceed in the ordinary way till the small- pox manifests itself, and even after this, may undergo some further local development, the vaccinia and variola apparently going on together; but, unless before the smallpox appeared, the vaccination had already reached the stage of areola, its progress to that stage will be arrested, and it will have no effect in modifying the smallpox.2 In respect of acceleration, of course, Dr. Seaton observes, that "accelerated cow-pox is to be regarded with much more suspicion than retarded cow-pox, because spurious vaccination has generally an accelerated course. There may be, however, simple acceleration, a course some twelve or twenty-four hours in advance of the usual course; the vesicle on the eighth day being in the state in which it is 1 According to Marson, " a good vaccine cicatrix may be described as distinct, fove- ated, dotted, or indented, in some instances radiated, and having a well, or tolerably well, defined edge ; an indifferent cicatrix as indistinct, smooth, without indentation, and with an irregular and ill-defined edge." 2 Dr. Seaton, loco citato. 448 ZYMOTIC AFFECTIONS. usually seen on the ninth ; the areola, nevertheless, being regular, and the crust being subsequently duly formed. In such case the value of the vaccination is not impaired." Sometimes vaccination "runs an entirely irregular course, the varieties of irregularity being very considerable." In irregular and spurious cow-pox, the pathological process is imperfect and hurried, the papular stage is accompanied with irritation and itching; the vesicle is acuminated or conical; its contents being straw-colored or opaque; the areola reaches its acme on the fifth or sixth day, is faded on the eighth day; the scab is small, and decrustation is complete on the tenth day. Sometimes, nothing remains on the eighth day but a small thin scab in the act of desquamation; and, sometimes, the vesi- cles burst before the eighth day, and are succeeded by an irregular, suppurating, and incrusted ulceration. The irregular character of the vaccine phenomena Dr. Seaton believes to be due either to an injudi- cious selection of vesicle, or to an unhealthy condition of the child; in the latter case, not unfrequently associated with intertrigo or eczema. Irregularity is also the type of revaccination ; the vaccine vesicle may fail altogether, or it may be normal; it is more apt to fail in the child than in the adult; and in the adult a more perfect vesicle is met with than in the child; nevertheless, a perfectly developed vesicle in a child bearing the proper cicatrix of vaccination is occasionally ob- served. After revaccination in the adult, the papule or vesicle is formed earlier than usual; the areola is hard and variable in size, and the vesicle reaches its acme on the fifth or sixth day, to be succeeded on the eighth day by a scab. There is often a considerable amount of diffused local inflammation, and the constitutional symptoms are frequently severe. Severe constitutional symptoms are more common in revaccination than in primary vaccination; and are sometimes accompanied with ulceration and sloughing, and sometimes with phlegmonous inflammation, followed by pyaemia and death. Besides the general phenomena of vaccination heretofore described, the areolar, or constitutional period of the process, is sometimes accom- panied with local or general erythema, roseola, or with an eruption of papulae or vesicles. Sometimes the vesicles are limited by the boundary of the diffused areola, at other times they are produced like an independent eruption upon any part of the body. Occasionally they are small, and sometimes so large as to challenge comparison with the bullae of pemphigus. Ceeley observes, that he has seen a pemphigoid eruption frequently in vaccinated children, and occa- sionally on the cow and dog; and he regards it as a special vaccine eruption. The following are examples of the secondary eruption of vaccinia:— Green, a child eighteen months old, was vaccinated at the London Smallpox Hospital, on Monday, June 7, 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 VACCINATION. 449 the night. On the sixteenth day we 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 nearly free. In these situations it existed in its successive stages; there were small red spots, the earliest form of the aff'ection, and larger patches, of a roundish or irregular figure, of about the size' of a fourpenny piece, several of these latter patches being congregated here and there, so as to form clusters of considerable size. The mar- gins of the patches were of a dull-red color, arid 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, particu: larly on those patches where vesicles had existed. On the face the vesicles terminated in thin, brownish, and spongy laminae. We inocu- lated a healthy child with lymph taken from these vesicles, but with- out any result. In the early part of the year 1846, we had an opportunity, through the courtesy of Dr.\Tohn 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 extended to the neck and chest. On the latter there were more than one hundred vesicles, presenting the characteristic flattened and umbilicated 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 eczema from its birth; a cir- cumstance deserving the attention of the medical practitioner. The following case occurs in the " Archives de Medecine" for Sep- tember, 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 ordi- nary vaccinia. Dr. George Gregory communicated to the Royal Medical and Chi- rurgical Society the case of a child in whom petechiae appeared upon the skin four days after vaccination. The child was to all appearance in perfect health. The areola was occupied on the eighth day by an extensive ecchymosis, and the body was covered with petechial spots. By the sixteenth day, the petechiae had commenced to fade. Five children of the same family were vaccinated at the same time, and with the same lymph, and went regularly through the disease. Dr. Gregory regarded this case as one of petechial cow-pox, in which the influence of the vaccine virus in the production of an hemorrhagic state of the system was demonstrated. Petechial cow-pox is rare; Dr. 29 450 ZYMOTIC AFFECTIONS. Gregory had never before seen a similar case, and had only heard of two of the same kind. PROTECTIVE POWER OF VACCINATION. We now come to a question of the utmost importance, namely, the efficacy of vaccination as a protection against smallpox. But before we engage in this discussion, it may be necessary to define precisely the meaning which we attach to the term vaccination. Vaccination we 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 subject shall have passed regularly through the stages known as the natural course of the vaccine pock, and described in the preceding section. 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 per- fect, 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 above established, 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 have been directed to the fact of its being always obtained at the requisite period, and from a vesicle which has passed regularly through its course, in fact, from the true "pearl upon the rose." But as the atten- tion 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 unphi- losophical, to attribute this apparent falling off in the influence of the vaccine lymph to any but its true cause, the one just mentioned. On this topic we are much gratified by a recent conversation with Mr. Marson, the resident surgeon and vaccinator of the London Small- pox Hospital. He informed us that when, in 1835, he became attached to the hospital, he found in use a lymph which had been employed PROTECTIVE POWER OF VACCINATION. 451 there for nearly forty years, and which had become greatly enfeebled in its powers. Two years afterwards, namely, in March, 1837, he for- tunately 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 eighth day after the operation; Jenner says between the fifth and eighth day, which is too indefinite.1 If the vesicles appear incomplete on the eighth 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 pro- duces one which is irregular in its appearance or course, and is inca- pable of conferring safety on' the person vaccinated. It is true, that occasionally the fallen crust is sufficiently impregnated with the desic- cated lymph to possess the power of exciting the disease, and is some- times 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 vacci- nation. 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, we 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 subsequent conditions.2 When the vesicle passes regularly through its stages, the cicatrix which it leaves behind is strikingly characteristic, and may be de- pended 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 unprotected. 1 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 lymph is therefore seventh-day lymph. On this day he generally finds the lymph fit for removal. 2 It may not be out of place here to remind the. vaccinator of the importance of being very particular with regard to the purity of the instrument used in performing the operation, and indeed of the necessity for uicety and care throughout the entire process. We were lately called upon to give an 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 eseaped with life, the effects of inflammation of the ab- sorbents and suppuration of glands ; and there was every reason to fear that these serious consequences resulted from an impure lancet. 452 ZYMOTIC AFFECTIONS. In taking a review of vaccination, we have to consider its many and important-advantages, and balance these advantages against the small number and insignificance of its counter accidents. It has been proved over and over again that the properly vaccinated are safe in the midst of variola, while the unvaccinated inevitably take the dis- ease ; and Marson has shown that the deaths from variola are thirty- seven per cent, in the unvaccinated, and less than seven in the vacci- nated. What, then, are the considerations that can possibly raise an objection to this important operation ? They are simply an unfounded belief in the mind of the uninformed that disease may be conveyed from the vaccinated to the person to be vaccinated through the agency of the vaccine lymph. The physician and the physiologist know this alarm to be unfounded, and such a transmission to be impossible, and for the following reasons. The child from whom the lymph is taken is healthy, and the vesicle from which the lymph is obtained is per- fect in all its features. To produce a perfect vesicle is in itself an assurance of health; for neither a weakly child nor a diseased child can develop a complete vaccine vesicle. If the child be scrofulous, the vesicle will be wanting in those characters which the vaccinator would deem necessary for the purpose of vaccination. If the child be the subject of a syphilitic constitution, the vesicle will be altered in its appearance, and no longer a true vaccine vesicle. Therefore the rule of practice is simple enough, and it is imperative that only a perfect vesicle should be used for vaccination. But there is another disease which is more commonly associated with vaccination than scrofula or syphilis, namely, eczema. Scrofula is a disease of hereditary mal-nutrition; syphilis is a blood-poison ; but eczema is a disease of mal-assimilation that may be induced in a few hours by any cause capable of lowering the tone of the system, and consequently the vitality of the individual, and therefore may be produced by vaccination. If the reader will turn back to the page relating to the causes of infantile eczema, he will see how trifling a disturbance of nutrition may be the cause of eczema; a fright or a chill to the mother of the child; or a change of food of the child. Thus the attempt to bring up an infant by hand is frequently the cause of an eczema, and at a later period dentition. In the same category we may very safely place vaccination. It is not denied that vaccination is a pathological process, and is attended with some little feverishness and disturbance of function; and a child that would suffer from eczema as a consequence of an alteration of diet would be equally susceptible of eczema from the invasion of vaccinia; no more and no less. Viewed in its correct light as a disease of mal-assimi- lation and debility, the relation of eczema and vaccinia is simple enough, and infinitely more easy of explanation than the theory that sees in eczema a state of morbid humors communicable by inoculation. After the experience of many years of practical operation in able and efficient hands, it is clear that the liability of the transmission of dis- ease from one person to another by true vaccination' must be considered to be a thing wholly impossible. But we exclude from this consideration vaccination from imperfect REVACCINATION. 453 and abnormal, and possibly morbid sources. These latter, we believe, may be a means of communicating disease; thus, in the case of a syphilized child, the vesicle developed under the influence of the vaccine operation, might be a constitutional syphilitic sore, and there- fore susceptible of conveying syphilis by inoculation. And our atten- tion has been seriously drawn of late to the possibility of the inocu- lation of elephantiasis with the lymph of an imperfect vaccination. 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; re- vaccination is a second test; and a third is that described by Dr. Bryce of Edinburgh. Bryce's test 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. PROTECTIVE INFLUENCE OF VACCINIA. For several years past opinion has been divided relative to the pro- tective 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 seventy years that it has been transmitted through the human race, and has lost a portion of its protective quality. We shall not stop to inquire into the merits of these two questions, both warmly contested and supported by powerful advocates, but at once proceed to examine the propositions that have been made and acted upon for the purpose of supplying a remed}T 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. 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 develop- ment of contagion. In the abstract, these propositions are incontro- vertible, but they require the modification implied in the estimate of 454 ZYMOTIC AFFECTIONS. time, to render them applicable to the thousand peculiarities that occur in daily practice. Thus, in relation to the first, we have to inquire, For what length of time the susceptibility is destroyed ? and in relation to the second, At what period after contagion is the restora- tion of the organism so far effected, that a second attack of contagious disease may take place ? To both 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 investiga- tion. 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 con- tagion 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 true 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. Revaccination, or a repetition of vaccination, is in most instances a simple and harmless operation, and may be practised at any period of life. Very commonly, in persons previously vaccinated and bearing the proper cicatrix of successful operation it produces no results; at other times certain results are obtained which are sometimes partial, and sometimes complete; and in a few instances, serious inflamma- tion is set up in the vaccinated part, and either extends to the neigh- boring lymphatic glands, or spreads in the skin or deeper tissues in the form of erysipelas and gangrene. Marson points out as among the causes predisposing to a recurrence of smallpox, "exposure for a time to great change of climate either hot or cold," hence the importance 1 It is proper to mention in this place that some opinions are opposed to this belief. Dr. Robert Williams observes, "Vaccinia is a disease sui generis ," and further on he emarks, "It is likewise by no means proved, that the smallpox and the cow-pox are dentically diseases of the same species."—Vol. ii. p. 49. Elements of Medicine. REVACCINATION. 455 of revaccinating persons who are about leaving home for a change of climate, or have returned to England after a long residence in a dis- tant country, such as Australia, China, and the East Indies; and the same reasoning applies to the movement of troops. Marson also points out the important fact, that the majority of those attacked with small- pox after vaccination, are from eighteen to twenty-five years old, and this age is the one the most susceptible of recurrent variola. Hence, he considers it a " wise course to pursue, to recommend all person on reaching adult age, especially if about to change their place of resi- dence, to be examined as to their probable security against smallpox. If they have four or more good cicatrices from vaccination, they are tolerably safe; if, on the other hand, they have but one cicatrix, and that such as can hardly be seen, or no cicatrix at all, such persons had better be revaccinated as a matter of precaution. These remarks apply especially to persons on passing from one part of the world to another, more particularly if the climate be very different from the one where they have been living." Numerous cases have been adduced in which an attack of smallpox has followed vaccination.1 We care not to inquire if vaccination have been perfect in those cases, for instances are not wanting 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 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 (recurrent smallpox) to be only in the ratio of a half to one per cent., while the attacks of the former (smallpox after vacci- nation) are not less than five percent., 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 200,000 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 2000, 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 7958 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 gov- ernments are awakened to the great truth that the health and industry of the lower orders form the surest basis of national wealth and greatness, and where vaccination is 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.) 456 ZYMOTIC AFFECTIONS. only that which daily experience tends constantly to corroborate, namely, that man has still much to learn. There can be no ques- tion that instances of variolous constitutions exist in which all pre- ventive means that we can suggest would be utterly futile, but these are, happily, exceptional cases. 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 Vaccination Section of the Provincial Medical Association, is exceedingly interesting, as showing the relative frequency of success in vaccinating" after small- pox, and after vaccination :— Vaccinated after smallpox with success, . . . .32 " " modified,.....26 " " without effect, . . . .42 —100 Revaccinated with success,.......34 " " modified,.....25 " " 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 certain, 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 revaccina- tion. 8. That the total extinction of variola is to be effected by the uni- versal adoption of vaccination. V A riolo- vaccina tion. 457 variolation after vaccination. Inoculation after vaccination has been proposed as an additional security against the contagion of smallpox. To those who regard vac- cinia 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 vac- cination is but a repetition of revaccination, and is, consequently, incapable of bestowing any superior advantage. RETRO-VACCINATION. The process of retro-vaccination 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 dif- ferent order. The operation has, however, succeeded several times in the hands of 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 diff'erences were entirely lost after three removes- in the human sub- ject. From these experiments, we think it may justly be inferred, that for the purpose of improving the vaccine lymph, retro-vaccina- tion, or passing it again through the cow, is useless. variolo-vaccination. Inoculation with the variolo-vaccine 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, 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 illus- trated in the following successful case: " Emma Jaycock, aged four- teen, 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 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, 458 ZYMOTIC AFFECTIONS. 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 Excell, 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 complained 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 cuti- cle, renewed inflammation and induration, with circumscribed slough- ing 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, Ceeley remarks, "Nothing could be more satis- factory 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, distinct papulation was apparent on the second day; on the third it was not only visible but elevated and well-defined; on the fifth and ' sixth, vesiculation was abundantly obvious, and lymph was often taken on those days. On the seventh day vaccination was frequently performed, and points were often charged; on the eighth the vesicle commonly exhibited a bold, firm, and glistening aspect; between this period and the ninth day the areola generally commenced (but in young infants with tense and sanguine skins, it appeared early on the eighth); by the tenth day the vesicle was commonly in its greatest beauty and highest brilliancy, glistening with the lustre of silver or pearl, having the translucency and appearance of crystal, or shining with a pale blue tint, occasionally of a dull white or cream color, bold and elevated, 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 generally vivid areola existed, with more or less tension and induration of the integuments. At this time the lymph was fre- quently 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 part, reflected a blue or slate-colored lymph, from the con- gested or ecchymosed 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 moderately thick, the vesicles attained a considerable size, measuring often in their longest diameter six and a half or seven lines, and acquired a light brown centre, from commencing desiccation, VARIOLO-VACCINATION. 459 which was surrounded with an outer margin of dull white, or pale dirty yellow, soft and flaccid, and still possessing fluid contents. During this period the areola, of a dull red or damask hue, would revive and decline again and again, and even to the sixteenth or eighteenth day, the period to which complete desiccation was fre- quently protracted. The crust commonly partook of the form of the vesicle; it was often prominent and bold, varying in color from that of a chestnut to that of a tamarind stone. It fell generally about the twenty-third or twenty-fifth day, often later." "The cicatrices were of variable depth and extent. When the vesicles remained unbroken on a thick sanguine skin, they were deep, but on a thin skin, shallow; they were 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 skin, &c. Spontaneous bursting did not often occur, except in those subjects possessing the before-mentioned and well-known obnoxious constitutional endermic characteristics, upon whom we must always use active lymph with some risk. t " 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 infants, 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 un- equivocally visible, and often complained of; fever, vomiting, delirium, and diarrhoea, were not unfrequently witnessed at the commencement or during the progress of the secondary symptoms. In adults, of course, more complaint was made, headache, chilliness, anorexia, and sometimes thirst, on the fifth or sixth day; increased on the seventh day, with axillary tenderness; but on the ninth and tenth days much general febrile complaint, disinclination, and even inability, to leave the bed. But in several instances, amongst young 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 of the primary disturbance. If properly developed, small vesicles often gave rise to marked constitutional symptoms, and the most splendid vesicles were often seen with trivial, sometimes scarcely appreciable disturbance." " The secondary symptoms are often as active with three or four as with six or eight vesicles; acceleration of the pulse was frequently noticed, when no other symptoms appeared. Both primary and secondary symptoms very commonly showed a remitting type." 460 ZYMOTIC AFFECTIONS. With respect to cutaneous eruptions, Ceeley observed but one in the adult, and in children nothing approaching the varioloid charac- ter. " Roseola, strophulus, lichen, were the principal eruptions." Dr. Basile Thiele,1 of Kasan, has succeeded several times in inocu- lating the udder of cows. W.hen 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 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 the vario- lous 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 prin- cipally indebted for this supply are, Estlin, of Gloucester; Fox and Sweeting, of Dorsetshire; and Ceeley, of Buckinghamshire. It has also been obtained and employed in France by Saunoy. Whenever an attempt is made to inoculate man with the virus de- rived directly from the cow, or, on the other hand, to inoculate the cow with humanized vaccine lymph, or with smallpox, some difficulty is encountered. There would seem to exist an indisposition to the assimilation of virus derived from an animal of a different order; but when this lymph has once become assimilated, all difficulty is at an end. When inoculation is effected, a remarkable difference is per- ceived 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 herbivo- rous and a carnivorous (the human infant) or semi-carnivorous animal, we are unprepared to say. We 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 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 commences on any one of the days between the sixth and the tenth. Desiccation of the vesicle is also protracted; it contains fluid until the sixteenth or eighteenth day, and the crust remains adherent until the end of the fourth or fifth week. The areola is completed from the eleventh to the sixteenth day, and is sometimes covered with small supernu- 1 Bulletin de l'Acadgmie Roy. de Med., Jan. 1S41. RECURRENCE TO THE PRIMARY VACCINE VESICLE. 461 merary vesicles, and accompanied by a general eruption of papulae, vesicles, or bullae. When the vesicle is ruptured in unfavorable con- stitutions, 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 de- veloped," 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 sub- jects. By this process, also, in a very short time, most of the defects and some of the evils connected with the use of primary lymph may be dissipated, and the lymph rendered milder, and more suited to general purposes." " Children are the best, certainly, for the purpose; and such should be selected as possess a thick, smooth, clear skin, and have a dark complexion, and are not too florid, but still, plump, active, and healthy." By a steady and judicious selection of these, and simi- lar 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 transferred 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 successfully 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 us to be the only unobjectionable method of improving the current lymph, and correcting the deterioration which has arisen from neglect of the pre- cepts of Jenner. Lymph from this source must necessarily be pure, and its use should therefore be encouraged.1 Treatment.—Any morbid conditions arising accidentally from vaccination should be treated in accordance with the general princi- ples of medicine. 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 1 Dr. Lichtenstein, in a paper entitled, " On the sources from which matter preser- vative against the smallpox has been derived," in Hufeland's Journal for 1841, re- marks, that limpid lymph taken from the pustules produced by tartarized antimony, and inoculated in a person who has not been vaccinated, produces vesicles which cannot be distinguished from those of vaccinia. These vesicles appear to be equally protective against smallpox with the cow-pox, and the matter may be transmitted from person to person in the same manner. The author of the paper has inoculated and re-inoculated thirty-one persons with the matter procured 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 ! 462 ZYMOTIC AFFECTIONS. 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. EQUINIA. Syn. Equinia, Elliotson ; farcinoma ; farcin ; morve; rotzkrankheit; maliasmus, Fuchs ; glanders ; farcy. Equinia or glanders, a disease of the horse, is communicable to man as is vaccinia in the instance of the cow, but with less happy results. Equinia in the horse is a grave disease, and its consequences in man serious and frequently fatal. It is distinguished in the horse by a profuse semi-purulent, viscous, and fetid discharges from the nares, with ulceration of Schneiderian membrane, and swelling and induration of the submaxillary glands. The mode of conveyance of the disease to man is by contact with this morbid secretion, sometimes without abrasion of the cuticle, but more commonly. through an already existing wound or by puncture. In the former case the poison enters the stream of blood by absorption; in the latter, the wound becomes inflamed and painful, the inflammation assuming an erysipelatous character, the lymphatic vessels may be traced as red lines in the direction of the glands with which they communicate, and the latter are inflamed and tender. When the poison enters the blood without local lesion, a period of latency occurs, the period of incubation, lasting from one to fourteen days, but having an average duration of three days; after which certain constitutional symptoms are developed, consisting of lassitude, weariness, extreme muscular prostration, pains in the limbs, the joints, and the head, rigors, nausea, often vomiting, sometimes diarrhoea, and frequently delirium. When a local lesion exists, the injured part is tranquil for two or three days before inflammation begins, but at the same time with the local inflammation, phlegmona' occur in the limb as well as in distant parts of the frame, and abscesses of various size and depth are produced. The first effects of the poison, whatever its method of introduction into the system, would seem to be the development of phlegmona which are converted into abscesses, and may be deep or superficial, small or large, and sometimes very numerous. But after a few days, and after the occurrence of constitutional disorder, the abscesses become more superficial and numerous, and are associated with ery- sipelatous blotches, with small tubercles composed of a yellowish concrete substance, which subsequently softens into pus, and vesico- pustules containing a semi-purulent fluid, sometimes sanguinolent and purple, and sometimes pustular. The vesico-pustules or phlyc- tenae are variable in size, some being small and some large, and have an irregularly-formed base. With the successive progress of these local symptoms, namely, the phlegmona, the abscesses deep and superficial, the erysipelatous blotches, the yellow tubercles or knots in the skin, and the semi- equinia 463 purulent, often purplish phlyctenae, the constitutional symptoms augment in severity, the prostration increases, delirium occurs, and inflammation is set up in the mucous membrane of the nares, the larynx, and the bronchial tubes. Inflammation of the larynx and bronchial tubes is accompanied with a loud, sonorous, dry cough, and frequently a roaring respira- tion, hoarseness and loss of voice, rapid breathing, dyspnoea, restless- ness, anxious countenance, and an unusual excitement of manner. The affection of the mucous membrane of the nares resembles that of the skin, there is great congestion, with numerous small yellow tubercles, pustules, ulcers left by the pustules, and a profuse purulent and viscous discharge, the discharge being sometimes streaked with blood, and sometimes extremely fetid. The inflammation of the skin is very commonly associated with erysipelatous blotches, which appear on the eyelids, nose,»cheeks and scalp, and are accompanied by symptoms of congestion of the brain, sometimes drowsiness, and sometimes a low muttering delirium. In this state the patient falls into a state of coma, and dies on the twelfth or thirteenth day, soon after the development of the discharges from the nose. Veterinary writers describe two varieties of equinia, which they distinguish by the names glanders and farcy ; in the former, the force of the disease is manifested by the mucous membrane of the nares and fauces, and by the continuous submaxillary glands; while in the latter the lymphatic vessels and glands are chiefly and primarily attacked, and the inflammation runs on to suppuration and abscess. And each of the two varieties presents an acute and a chronic form; in the horse, glanders is most frequently chronic; while in man, it presents the characters already described, namely, those of acute glanders. Chronic glanders is more rare in man than the acute form, and may either make its invasion with chronic phenomena, or follow an exhausted farcy. When it begins as chronic glanders, it is preceded by the precursory constitutional symptoms already mentioned, namely, prostration of power, pains in the joints, cough, sore throat, and uneasiness of the nose. But when it follows farcy, these precursory symptoms may be absent, and its first indications may be a hoarse cough, soreness of throat, obstruction and tightness in the nose, pain and weight in the forehead, loss of voice, difficult respiration, and symptoms of congestion of the lungs, or pneumonia. Accompanying these symptoms are, pain in the nose, the discharge of purulent mucus streaked with blood when the nose is blown, and sometimes a fluent puriform discharge, denoting ulceration of the Schneiderian membrane. Sometimes also ulceration appears in the pharynx, but there is no en- largement or hardness of the submaxillary glands, and no eruption on the skin. The general symptoms of chronic glanders are, extreme prostration of power, articular and muscular pains, nausea, often diar- rhoea, emaciation, and asthenia ending in death. Sometimes chronic glanders takes on the acute type, and sometimes the patient recovers, the common duration of the disease being several months. 464 ZYMOTIC AFFECTIONS. Acute farcy is identical with acute glanders, excepting only in the absence of inflammation of the Schneiderian membrane and the occasional omission of cutaneous eruption ; but in place of these there exists inflammation of the lymphatic vessels and glands and subcuta- neous abscesses. The presence of a cutaneous pustular eruption indi- cates a more serious form of the disease, and such cases are equally fatal with acute glanders; the fatal issue occurring at the end of the second or the beginning of the third week. While in cases where the cutaneous eruption is absent the chances of recovery are greater, or the disease merges into the chronic type. Chronic farcy is distinguished from the preceding by a less in- tensity of symptoms and slower progress of the disease, and is some- times associated with the affection of the nares of chronic glanders. Its special characteristic is the formation of subcutaneous abscesses, which burst and give exit to a sanguinolent or semi-purulent fluid, and terminate in unhealthy and indolent ulcers. A common situation of one of these ulcers is the centre of the forehead, near the root of the nose, while others are dispersed often in considerable numbers, in the vicinity of the joints and on the limbs. The lymphatic vessels and glands are less affected than in the acute form of the disease, and their inflammation seems to be the effect rather than the cause of the ab- scesses. In chronic farcy, as in other forms of equinia, there is engendered, but to a greater degree, a state of cachexia. The patient is prostrate in power, his joints and limbs are painful, he is attacked with a hoarse and sonorous cough without expectoration, he loses his voice or speaks in a whisper, the complexion of his skin is yellow and discolored, he is emaciated, and gradually succumbs to asthenia. Some patients become the subject of pyasmia, and a smaller number recover. The disease is commonly protracted to ten or twelve months, and sometimes to two or three years. Cases of human equinia have been recorded by Travers, Elliotson, Rayer, Tardieu, and others, and one case came under our own notice many years ago. One of the cases narrated by Travers was that of a vet- erinary student, who had contracted the disease by puncture while mak- ing the post-mortem examination of a horse that had died of glanders. Pus taken from an abscess of this patient was used by Coleman to in- oculate an ass, and the ass speedily fell a victim to glanders. Two very interesting cases of the disease are narrated by Dr. Wilks in the Guy's Hospital Reports for 1861, and reference is also made by an ar- ticle by Dr. Hughes in an earlier volume of the same reports. Diagnosis.—The pathognomonic features of equinia are, after ex- posure to contagion, inflammation of the injured or wounded part, the inflammation assuming the characters of erysipelas ; inflammation of the lymphatic vessels leading from the injury, with swelling and ten- derness of their associated glands ; prostration of power ; pains in the joints ; eruption of pustules, vesicles, and erythematous blotches; ca- chexia ; inflammation of the air-passages and lungs, with, in the case of glanders, inflammation, muco-purulent discharge and ulceration of FRAMBOESIA. 465 the mucous lining of the nares and swelling of the submaxillary glands, without affection of the lymphatic system; and, in the case of farcy, special inflammation of the lymphatic vessels and glands, with subcu- taneous abscesses and without aff'ection of the nares. Without the special knowledge of the contagion of equinia, this disease might be mistaken for constitutional syphilis, to which it bears considerable re- semblance, for example, in the cachexia, the neuralgia, the kind of eruption, the congestion of fauces, and especially the ill-conditioned ulcers which follow the superficial abscesses of farcy, and which are very like rupial ulcers. We have seen a case of this kind, which, as far as its symptoms were concerned, must have been syphilis, had it not been farcy. Cause.—The cause of equinia in the human subject is a special poison derived by contact from the equine family, and communicated in general by absorption through an open sore or by puncture. Prognosis.—Equinia is always dangerous, and often fatal; in the acute form, whether glanders or farcy, accompanied with pustular eruption, it is generally fatal. Acute glanders, following upon a chronic form of the disease, is also very grave, as is the union of chronic glanders with farcy. Nevertheless, recovery after the acute forms of the affection sometimes takes place, but more frequently after the chronic forms. Treatment.—Iodide of potassium and mercury, so useful in syphi- lis, appear to exert no beneficial influence on equinia. The indica- tions for general treatment are obvious, to regulate the nutritive func- tions and support the powers of the constitution by generous diet and tonics. The specific remedies from which the grafcfcesit advantage has appeared to be derived is the combination of arsenic and strychnia. The catylitic medicines, namely, the hyposulphites, may also, we may infer, be found of advantage; and we should recommend the tincture of the perchloride of iron as used in erysipelas* For the eruption and for the inflammatory tracks of the lymphatics, the best remedies are a solution of nitrate of silver in nitric ether, twenty grains to the ounce; or the tinctura picis cum sapone. The nostrils, when affected with mucopurulent discharge, should be in- jected with a solution of chloride of zinc, two to six grains to the ounce, night and morning, care being taken to prevent the solution from being swallowed; the strong solution of table salt used in malignant sore throat might also prove useful, or a solution of chlorate of soda or carbolic acid. FRAMB(ESIA. Syn. Mycosis, Alibert; yaws ; pian. Frambcesia is an eruptive disease of zymotic origin, common in Africa, and conveyed by the negroes to the West Indies and America. It has almost entirely disappeared in some of the West India Islands, for example, Barbadoes; while in others, as Bermuda, it is unknown ; but in others again, as in Nevis and Jamaica, it exists very extensively. Dr. Bowerbank remarks that, when he first went to Jamaica in 1836, 30 466 ZYMOTIC AFFECTIONS. "there was not an estate or penn that had not its yaw-house or hos- pital, and which used to be well filled; but after the emancipation in 1837, these were all done away with ; and, now, many practitioners who have been in practice for years have not seen a dozen cases." Within the last few years, however, the disease would appear to be on the increase; and in the census of 1861, 1512 cases are reported, namely, 894 males, and 618 females. Framboesia sometimes begins as an eruption without premonitory symptoms, but more frequently is preceded with mild symptoms of fever, namely, weariness, lassitude, and pains in the limbs. And each successive development of eruption is accompanied with similar con- stitutional symptoms. But when the eruption has broken out, the constitutional symptoms disappear ; and, although the disease is com- monly prolonged for several months, there is no constitutional disor- der of any importance; such constitutional disorder, when it exists, being referable to the irritation caused by the local disease, and the drain from the ulcers. The eruption makes its appearance in the form of small spots, which are sometimes flat, sometimes raised in the shape of papules, and sometimes pustules ; their size ranging from that of the head of a pin to half an inch, or an inch in diameter. They are developed most commonly on the face, in the axillae, around the pudendum, and in the perineum, and appear in successive crops; some of the earlier pimples drying up, while others extend in dimensions. After a time, the papule, or spot, becomes covered by a crust formed of desiccated secretion; the crust covers a raw surface, and this surface throws up granulations; the granulations are red and fungous, moistened by a muco-purulent secretion, and suggest the idea of a raspberry ; hence the synonyms of the disease, yaw and framboesia. Sometimes the effort of the system is directed to the production of these granulations in prominent masses of considerable extent. At other times ill con- ditioned ulcers are produced; but the ulcers are always superficial, and heal up without leaving permanent scars.1 Framboesia is common in children ; and in them is both lighter in its attach, and of shorter duration, than in adults ; in children it com- monly lasts for three to six months ; but in adults from six to twelve months. In Africa it would seem to take the place of measles and scar- latina, which are unknown, and is looked upon as a necessary ailment of childhood. It is not supposed to be infectious, but its contagion is undetermined; according to some, it is capable of being communi- cated by the discharges of an ulcer; and, in the West Indies, is believed to be conveyed from one to another by flies; nevertheless, it is strictly limited to the negro population. Like measles, scarlatina, and variola, it occurs only once in a lifetime. But, unlike those dis- eases, is never fatal. 1 John Hunter makes some observations with regard to the phenomena of ulcers in the West Indies, which are suggestive of the cause of the granular vegetation of the ulcers of yaws. The granulations, he observes, "are luxuriant, though pale, and their surface glossy ;" and this state may be " imputed to the bad habit of body asso- ciated with remittent fever."—Observations on the Diseases of the Army in Jamaica. SYPHILODERMATA. 467 Cause.—The nature of the poison of framboesia is unknown ; the disease has been surmised to take its origin in syphilis, and has also been compared with leprosy. Dr. Angerstein of Nevis observes: " When yaws are neglected, they become constitutional; and in the case of careless, dirty negroes, present the appearance of leprosy." But there is good reason to believe that framboesia is perfectly dis- tinct, both from syphilis and the Greek elephantiasis. Treatment.—Like as in other zymotic diseases the physician must wait on nature; the efforts of European medical men to control the disease have generally proved unfortunate; while the negroes, by making use of mildly aperient bitter decoctions, have been more suc- cessful in their practice; they use the same decoctions for local applica- tion, and in Africa dress the sores with an ointment of carbonized herbs. CHAPTER XVIII. syphilitic affections. The diseases of the skin arising from the poison of syphilis or lues are the syphilitic eruptions or syphilodermata. 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; there- fore, 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 deplomb around the patient; he is unable to pursue his avo- cations 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 and weariness which evince the poisoned condition of the nerves, there is often neuralgia to an intense 468 SYPHILITIC AFFECTIONS. 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 dur- ing the night, and often, but not always, entirely absent by day. The pulse is quickened; 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 some- times constipated, sometimes relaxed ; the urine sometimes clear and limpid, at other times loaded with salts. The conjunctiva is injected 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, the so-called secondary syphilis, but they may not all be present, and those which exist may be complicated by local congestions of the mucous mem- branes. 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 poi- son 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 us consider one or two examples. A printer, aged fifty, six weeks after suspicious con- nection, was exposed, in the winter season, to a heated and impure atmosphere during the day, and cold and rain at night. At this time he became the subject of nocturnal headaches, attended with profuse fetid perspirations. One 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 mem- brane 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 us arose from the presence of an eruption on the forehead, which we recognized as syphilitic. The eruption SYPHILODERMATA. 469 had appeared with the first attack of bronchitis, and in her own mind she connected the disorders together. It occurred to us, 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. We treated this lady as we should have done an ordinary case of constitutional syphilis, and both affections got well together. Thus far as to resemblances to the exanthematic fevers; but there are also differences between the syphilitic fever and that of the exan- themata, so remarkable as to call for special consideration. The exan- thematous 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 happen, which present all the .symptoms of the most violent fever, and are attended with delirium; but such cases are occasional, they are the exception, and not the rule. The cause of the differences of character perceptible between the exanthematous and the syphilitic fever appears to us 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 vio- lent effort is made for its expulsion. The expulsive effort obeys rigidly certain laws of order and time, and the poison being once removed, 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 shall result in its removal. Hence the poison is slow in accu- mulating; its excitation of febrile symptoms seems rather a matter of accident than the consequence of an irresistible law; the patient enjoys less 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, an 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 simi- lar action. The poison of syphilis having once entered the system, the blood and tissues appear to become accustomed to its presence; it remains latent for years, or for life, and gives notice of its existence from time to time by a variety of symptoms. Nay, more, it is trans- ferable to offspring, not merely to one, but, possibly, to a series of generations. We have said that the occurrence of syphilitic fever seems rather the effect of accident than the result of an immutable law. We mean, 470 SYPHILITIC AFFECTIONS. that the poison itself appears to be insufficient to light up the* fever without the intervention of an accidental exciting cause, such as cold; and the exciting cause frequently determines the shape which the subse- quent symptoms assume. Sometimes the leading feature of the fever is sore throat, sometimes neuralgia or rheumatism, sometimes iritis, sometimes cutaneous eruption, and sometimes periosteal inflamma- tion ; 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 expressed by 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 conse- quence 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 hereditary and infantile syphilis. Hence the syphilodermata admit of a primary division into syphihdermata primitiva, or syphilitic eruptions proceeding from the first poison; and syphilodermata hsere- ditaria, 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 syphilodermata mitigata, to include those modi- fications of syphilitic eruption 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 hasreditaria, a first and a second period. To render this classification of syphilitic eruptions more clear, we have arranged them in the form of a table, as follows :— I. Syphilodermata Primitiva. First Period— 1. Syphiloderma erythematosum. Roseola syphilitica, Maculae syphiliticae, Erythema palmare. 2. Syphiloderma papulosum. Lichen syphiliticus, Lichen pustulosus. syphilodermata. 471 3. Syphiloderma tuberculosum. Tubercula syphilitica. Tubercula ulcerantia. 4. Syphiloderma vesiculosum pustulosum. Rupia syphilitica. 5. Syphiloderma pilare. Alopecia syphilitica. 6. Syphiloderma unguale. Onychia syphilitica. Second Period— 1. Syphiloderma erythematosum. Erythema palmare et plantare. 2. Syphiloderma tuberculosum. Tubercula mucosa, Tubercula ulcerantia, superficialia, Tubercula ulcerantia, profunda, Tubercula ulcerantia lupiformia, Tubercula gummata. 3. Syphiloderma ulcerosum. II. Syphilodermata Hereditaria. 1. Syphiloderma erythematosum. Erythema syphiliticum infantile. 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 accumulated poison; and is the common precursor of the other forms of eruption. The period at which it makes its appear- ance is between six and nine weeks after the development of the pri- mary disease. Like measles, which it closely resembles, it begins with general 1 Portraits of diseases of the skin, Plate XXIV. P. ■ 472 syphilitic affections. 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, especially the abdomen. 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 versicolor. 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 capillary system which is normally emptied by a separate venous trunk; per- haps, again, it includes the small district of skin the circulation of which may be governed by the ultimate divisions of one small nerv- ous twig. Occasionally the roseolous congestion is defined in its boundary, forming circular blotches of uniform redness, 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 dis- tribution of nervous influence. Again, the blotches may be irregular in figure, and of variable dimensions, roseola diffusa. Syphilitic roseola, therefore, may present itself to our examination under four varieties of form, namely, as a patchy and mottled redness, as circular blotches, as congested rings, and as irregular and diffused blotches. 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 or 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, roseola papulata. These differences, however, are mere diff'erences in degree of conges- tion ; 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 character of all syphilitic eruptions. The stain generally corresponds in figure with that of the eruption which preceded it, and is of a brown color of varying tint; deep, and almost approaching to black in per- SYPHILODERMATA. 473 sons 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 of the skin are termed 'maculae syphiliticae. Sometimes the roseolous congestion which precedes them is so slight that they appear to be independent of such an origin; but this is not the case; they are always the effect of a congestive action in the skin. Whether, therefore, the maculae syphi- liticae 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 we have had occasion to distinguish from the rest, under the name of melanopathia syphilitica,1 melasma syphiliticum. Erythema palmare.—Erythema palmare is sometimes associated with syphiloderma on other parts of the body, and sometimes purely local; it is also remarkable for its association with all the periods of the disease, with the latest as with the earliest, and for the variety of form which it assumes, varying in degree of redness, in amount of infiltration, in degree of desquamation, in character of limitation or circumscription, and in manner of increase. It sometimes appears as a single blotch in the centre of the palm, and sometimes as several; sometimes, and especially in the earlier periods, the desquamation is thin and superficial; at other times, the epidermis covering the inflamed spots becomes yellow and horny, cracks in the lines of motion of the skin, and exfoliates in thick layers. Sometimes the thickening of the derma is trifling, and the hyperaemia superficial; at other times the thickening extends more deeply, and the infiltrated corium evinces a disposition to crack. Sometimes the redness fades at the circumference; at other times the peripheral hyperaemia is more active than the central, and the border consequently somewhat raised. These are all phenomena common to the syphilodermata, but are the more striking for being seen in so limited a region as the palm of the hand or the sole of the foot. Taking a general survey 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 macuhe syphiliticae ; to the elevated group the small pimples of lichen, and the larger pimples or tubercles of tubercular syphilis. These differences are, however, more apparent than real, and may be re- garded 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- elevated and the elevated form of the syphilodermata. 1 Portraits of diseases of the skin, Plate XXXIV. M. 474 SYPHILITIC AFFECTIONS. 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 uncommon 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 we have given to the eruption, namely, lichen corym- bosus ;* 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;2 and at other times they are packed almost as closely as the pores which they represent, lichen confertus.3 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 by exposure to cold. In a few instances we have seen the eruption of syphilitic lichen developed into the form of rings, constituting a lichen syphiliticus annulatus ;4 and a lichen syphiliticus pustuhsus may be distinguished 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 in 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 contrasted 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, how- ever, 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 of the patches was undergoing a general exfoliation. In another case, one of lichen disseminatus, the eruption chiefly 1 Portraits of diseases of the skin, Plate XXVI. A H. * Ibid., Plate XXVIII. O. 3 Ibid., Plate XXV. A L. 4 Ibid., Plate XXVII. A N. SYPHILODERMATA. 475 occupied the back and arms, but numerous pimples were scattered over the rest of the body and face. The pimples were large and iso- lated, 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 accompanies 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 at the summit of 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 eud 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 remind- ing us of miniature crusts of conical 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 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 circumfer- ence 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 have 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. We 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 respect of color, form, density, and elevation; and they also differ in the manner of growth and arrangement. In point of color they are sometimes 476 SYPHILITIC AFFECTIONS. 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 they 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, tubercula urceolata), 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 result 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 yellow element of the blood upon the tissues of the skin, the color approaches towards the secondary 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 differences 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 secre- tions ; 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 common 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, we are 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 SYPHILODERMATA. 477 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" erup- tion ; the so-called copper color being, infact, a reddish-yellow brown. We 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 represents, in fact, a declining stage of the eruption, when the congestion is sub- siding, 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 cop- per color, it is clear that the term is objectionable when taken as a pathognomonic sign of a 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, we 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 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, we have often seen non-syphilitic eruptions possessing more of the dull and muddy hue, which is generally sup- posed to be characteristic of syphilis, than syphilitic eruptions them- selves. 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 we have named them tubercula corymbosa. 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 tuber- cula circumscripta} Others are scattered over one or several regions 1 Portraits of diseases of the skin, Plate XXX. A B. 478 SYPHILITIC AFFECTIONS. 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 figure 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 distin- guished as tubercula ulcerantia. Tubercula corymbosa. — In a well-marked case of tubercula corymbosa 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 iso- lated they measured two lines, and there were some which reached four lines in diameter. They were dispersed irregularly over thesur face 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 was 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 clustered 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 differences of appear- ance 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 the congestion was on the decline they lost their brightness of hue, and looked faded and shrunken, 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 exfo- liating cuticle, on their summit. When the tubercles subsided alto- gether, 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 alphos, and the broken laminae of desquamating epidermis suggest a motive for considering it to be a squamous aft'ection. 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 eruption of a dusky-red hue. On parts of the face, and particularly on the ex- posed portions of the neck, the eruption consisted of distinct rounded tubercles, of large size. On other parts of the face the tubercles had the form of oblong mounds, more or less curved, and again, in other situations, formed complete circles. On the forehead the tubercles • Ibid., Plate XXIX. N. SYPHILODERMATA. 479 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 simple 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 the corymbi more or less annular. In certain situations the tubercles were less fully formed, and appeared to be made up of a number of papula?, 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 cen- tre, fading away gradually to the circumference, and in some situations had the appearance of the 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 corym- bosa is general and acute; the eruption of tubercula circumscripta be- longs to a later period in the existence of the poison, and is, conse- quently, 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 as- semblage of tubercles, among which there is an obvious tendency to assume a circular arrangement, and they are distinctly circumscribed, the boundary being formed by a line of tubercles. The following is an illustration of 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 irreg- ular 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 480 syphilitic affections. 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 alphos in the state of retreat; even the scattered tubercles within the circles are met with in alphos. But there are certain strongly distinguishing characters, between alphos and the alphoid 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 alphos; and lastly and chiefly, the total absence of squamae. In old syphilitic tubercles, the epider- mis may frequently be seen in a state of exfoliation; but the thin, ragged films of exfoliating epidermis, peeling from their summits, are easily distinguished from the thick, circular, morbifically elaborated scales of true alphos. 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 of the diseased skin. If the large syphilitic patches (two inches in diameter) be examined carefully, and at various stages, with reference to their mode of de- velopment, they will be found to originate in simple tubercles, dis- posed 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 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 figure; 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 of the 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 SYPHILODERMATA. 481 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; 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 varicose capillary plexus, and numerous meander- ing venules, which may be seen on a close examination of the skin. Often, the tubercles seem to possess the power of disorganizing the structure of the skin completely, without suppuration and without ulceration; hence, when 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. The vascular congestion and shallow pits are both charac- teristic of the chronic form of syphilitic tubercular eruption of the skin. Tubercula disseminata.—The disseminated form of tubercular eruption is less acute and less 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 the clustered eruption, perfectly round, and but little elevated above the surface of the skin ; in their appearance and eleva- tion suggesting an appellation by which we once distinguished them, namely, tubercula lentiformia. In point of measured size, the medium diameter of the dissemiuated tubercles may be roughly stated 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 mea- suring 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 urowth of the tubercles. The developed tubercles 31" 482 syphilitic affections. presented every degree of complexion and decline; some were smooth, others wrinkled, others beginning to desquamate, while in others, desquamation had advanced some stages. In our observations on this case, we remarked that the tubercles were 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 gradually from the centre to the circumference, which merges insen- sibly into the surrounding skin. In point of elevation and form, they have very much the appearance of split lentils laid upon the skin, only that they are much broader. Their color varies from a bright coppery red, to a dull, dirty crimson. Their epidermal covering changes with their stage of growth; 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. The manner in which the exfoliation of cuticle commonly takes place from the surface of the tubercles is the following: the cuticle cracks in a circular direction, just within the boundary of the eleva- tion, and then separates gradually from the surface beneath; the cen- tral piece separating towards the centre of the convexity; the periphe- ral piece towards the sound skin, and forming a kind of frill around its margin. A crop of tubercles may 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; others, in which the edge of the central piece has been worn away, and has be- come 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 exfoliation 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 annulate form of erup- syphilodermata. 483 tion 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 (alphos) has been applied, and the resemblance is so great as to give a certain warrant to the error. The eruption is subacute and partial in its distribution, and appears to result from the agency of a modified or exhausted 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 forearm bv two spots, and gradually extended, first to the neck and hips, and then to her limbs. On the neck, the eruption presented every stage of pro- gressive development. There were papules scarcely a line in diame- ter; 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 circular 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 the 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 thin; and not, as in the case of alphos, epidermis altered in its anatomical structure, 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 dis- tributed 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 dia- meter. They consisted of a central, broad, and fleshy tubercle, sur- rounded 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 surface; the ring was marked by numerous transverse furrows, and was in a state of desquamation, the portions of desquamating epidermis corresponding 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 repre- sented the first stage of growth of the patch; another was a raised, flat, oval-shaped tubercle, half an inch in diameter, and appearing, 484 . SYPHILITIC affections. from the elevation of its border, to be slightly depressed in the centre ; the remaining two measured an inch, and an inch and a half in dia- meter, were oblong and oval in shape, and had each a broad and irregular central 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 alphos circinatus was very striking, and we have no doubt that they would have been called lepra or psoriasis syphilitica by any one who had seen them ; and yet their origin and mode of development was identical with that of tuber- cular syphilitic eruptions in general. They differed from alphos, however, in the absence of scales, an important point; and also in the presence of the central tubercle; the patches of alphos are depressed in the centre ; these were more elevated in the centre than at the cir- cumference. In another example there was no central tubercle, and the eruption had more of the character of alphos circinatus than the preceding cases. The patient was a medical student; he consulted us for an eruption, which he considered to be common alphos, and its appear- ance 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 smooth, and of a yellowish-brown color ; the ring itself raised, dull-red, and irregularly circular or oval in its figure. 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; and their surface presented certain differences of appearance: in some, it was uniform and smooth; in others, marked by numerous transverse wrinkles; and others, again, were either papulated on the surface, or looked as if formed by the aggre- gation and fusion of numerous tubercles. There was a slight con- densation of the cuticle covering some of the rings, and here and there an indication of epidermal exfoliation. Tubercula 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 might be anticipated from a knowledge of the varieties of constitution presented by mankind, and the varied conditions to which the poison must be subjected in its numberless mutations. Even ulceration is exhibited to us in a transition state, in that curious phenomenon wherein a tubercle disappears, or is removed by SYPHILODERMATA. 485 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 is of the superficial kind. SYPHILODERMA VESICULOSUM ET PUSTULOSUM. Rupia syphilitica.—The only eruption coming strictly under the denomination of vesicular and 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. We have ourselves fallen into the error of denominating a pustular eruption, produced under the impulse of constitutional syphilis, " impetigo syphilitica ;'n upon further reflection we think it would have been more correct to have regarded it as a lichen passing into the state of suppuration. Such cases are by no means rare, and a pustular lichen may fairly be admitted among the occasional phenomena of that eruption. We recollect an instance in which the greater part of the papules developed on the arms and legs of a syphilitic patient were gradually converted into pustules. Syphi- litic ecthyma seems to us to be also doubtful, but not so positively unlikely as the production of smaller pustules. Even in the instance of ecthyma it is necessary that we should be well assured that the case is not one of suppurating tubercle. Rupia (Plate VIII.) is characterized by the eruption of small, sero- 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 be- comes purulent or sanguinolent, and concretes and desiccates into dark greenish or blackish rough crusts. These crusts are 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 asthenic 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 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. 1 Portraits of diseases of the skin, Plate XXXI. Y. 486 SYPHILITIC AFFECTIONS. RUPIA SIMPLEX. Syn. Ecphlysis rhypia, Mason Good. Sordid blain. In rupia simplex (Plate VIII. L, M, N) the purulent bullae are cir- cular in form, flattened on the summit, and in diameter about equal to a sixpenny or shilling piece. When first developed they contain an opaline fluid, which soon becomes purulent, and gradually con- cretes 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 indi- cated by redness or lividity of the skin around the cicatrix, the red- ness enduring for a considerable period. The more frequent situation 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 bulla?. The pustules are of greater extent than in the simpler variety, and are followed by a troublesome ulcer of considerable depth. 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 concretes, and gradually desiccates into a thick and wrinkled crust of a brownish-black color. While the crust is proceeding towards com- pletion 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 figure 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 a week, and then becomes stationary. In this state it remains for a variable period, being at one time easily detached and at another firmly fixed. When detached, either spontaneously or by accident, it is found to conceal an ulcer of considerable depth, and of variable extent, being deep in proportion to the duration of the crust. The ulcer, when thus exposed, sometimes secretes a new crust, which grows thick by successive additions from beneath. At other times, and this is the more frequent course, the ulcer retains its open form, SYPHILODERMATA. 487 presenting a foul surface, thin, livid, or pale, and excavated edges, and an inflamed areola. The ulcer is difficult to heal, and after the for- mation of a cicatrix, leaves a livid and purplish stain, which continues for many months. This form of rupia occurs both on the upper and the lower limbs, but more frequently on the latter. The bullae are 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 bulla, instead of pursuing the tardy course described above, is developed quickly, and is filled with a viscous 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 a river 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 infection 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, became filled in the summit with a bright yellow pus. Two or three days later the centre of the pustule had become brown, and was beginning to desiccate into a yellowish-brown scab. The margin of the scab, where it was continuous with the epidermis, was still yel- low 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 preced- ing 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 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 pretty evenly limpet-shaped; while a few were broken into small fragments, and had a mulberry-like appearance. Upon the eye- brows 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 those most recently formed a red- dish-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, 1 Portraits of diseases of the skin, Plate XXXII. W. 488 SYPHILITIC AFFECTIONS. Plate VIII. 0), that particular form being partly the result of freedom from injury, and partly the consequence of the slow and gradual peri- pheric 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 prola- bium, there were two, of a circular and conical form, which curved downwards to the mouth, and weije 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, thin, and of the oyster-shell kind. 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 u lhealthy 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 fragments of undestroyed skin. A little later, when the ulceration reaches the deepest stratum of the corium, the tissues of the latter may be detected among the granulations, forming an open network ; 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 behind them ugly cicatrices, with more or less of a purplish hue of the skin, and often a deep brown 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 constitutional action present in these fevers, the formation of the epidermis and hair is temporarily suspended, the epidermis exfoliates as a consequence, and the hair falls. Where the fall of the hair is a chronic action, it probably depends upon insuffi- cient nutrition of the skin; a condition especially characteristic of 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 frequently ; but occasionally it is brought under our attention by the immediate inconvenience to which it gives rise. The hair does not fall off evenly, but comes out in patches, that have sometimes the appear- SYPHILODERMATA. 489 ance of area, but without the thinness and paleness of skin of the latter disease. We are often consulted for alopecia where syphilis is not suspected, and in these cases, we subject our patient to a careful scrutiny for the detection of any symptom which might indicate its dependence on the syphilitic poison. Sometimes we have succeeded in discovering such a symptom, however obscure, and then the treatment applicable to constitutional 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 fissure 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 trans- pire 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 us the hair was falling abundantly, it was parched and shrunken as if dead, and the scalp was dry and scurfy. Upon examination we found the stain of a syphilitic tubercle on the nape of his neck. SYPHILODERMA UNGUALE. Onychia syphilitica.—The matrix of the nails is not unfrequently affected with redness, swelling, suppuration, and often ulceration, under the inflammation of syphilis, and-the case is one of syphilitic onychia. Sometimes one finger or toe alone is invaded, at other times several may be attacked at the same moment. The skin immediately around the nail is considerably puffed and swollen, often the whole extremity of the 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 overlap the nail; the suppura- tion extends beneath it, and the nail is, in consequence, more or less loosened. This state of disease is extensively painful, but quickly 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 dis- colored 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 condi- tion of the nails is accompanied with erythema of the matrix, or of the skin immediately 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 constitutional 490 SYPHILITIC affections. symptoms of syphilis into secondary and tertiary is universally recog- nized. It does not, however, follow, that these are necessarily con- nected 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 grad- ually 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 observations 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 accord- ing as they present, in chief, the characters of erythema, of. tubercle, or ulcer. To the erythematous group belong erythem squamosum pal- mare et plantare. Under the head of syphiloderma tuberculosum are to be considered, tubercula mucosa, tubercula ulcerantia, superficial and deep, tubercula ulcerantia lupiformia, and tubercula gummata; while the syphihderma ulcerosum exhibits one of the destructive attributes of syphilis when the latter has gained long possession of the system. ERYTHEMA SQUAMOSUM PALMARE ET PLANTARE, SYPHILITICUM. Erythema squamosum palmare commences usually in the middle of the palm of the hand, in one of the grooves of flexion, as a reddish spot, over which the cuticle becomes hard and yellow, from destruc- tion of its vitality, and soon after cracks and exfoliates, leaving a red surface beneath, covered by a new epiderm. Sometimes this process begins 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 crackling, uncomfortable patches on the hand; at other times there may be several; for example, around the ball of the thumb, on the wrist, in the lines of flexion of the fingers. The exfoliating erythe- matous 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 once we met with a case in which its principal seat was the back of the hand. But whether it be partial or general in its attack 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 SYPHILODERMATA. 491 heals; sometimes 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 squamosum palmare centrifugum, and presents the annulate character already referred to under the head of syphilitic tubercles. In the case of centrifugal growth, the border is defined, the area presents the red, dry, cracked, and exfoliating 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 inflammatory process 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. We have delineated a case of this kind in our " portraits of diseases of the skin," under the name of erythema annulatum palmare.^ We had not at that time detected the syphilitic nature of the affection, and had only seen one or two cases; we have examined many since, and, with a slight alteration in the arrangement of the words, we have retained the name we then gave to it, namely, ery- thema squamosum palmare annulatum. The erythema squamosum 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 squamosum palmare of one hand, with syphi- litic tubercles on other parts of the body, the disease 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 had 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 squamosum palmare centrifugum,3 with a similar affection of the skin of the penis, the eruption occu- pied the whole of the palmar surface of the hand and fingers extend- ing 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 exfoliation of 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 i Plate XIX. K. 1 Portraits of diseases of the skin, Plate XXI. A. T. 492 SYPHILITIC AFFECTIONS. 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 epi- dermis ; while the area of the patches was red, furfuraceous, and ex- hibited a tendency to crack in the direction of the lines of motion of the skin. Erythema squamosum 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 we noted the period intervening between the primary disease and the affection of the skin of the palm of the hand, we 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 our seeing the patients, nine months, three years, six, nine, and ten years. Not unfrequently we meet with cases wherein the syphilitic infec- tion is recent, dating back to a few months, in which, simple erythema, like that which occurs in infants, is developed. In this case a copper colored redness spreads over the palm of the hands and palmar sur- face of the fingers, the integument is thickened, somewhat indurated or stiffened, and cracked in the lines of motion ; but there is no des- quamation such as happens in ordinary cases of erythema squamosum palmare, where the affection is of many years' duration. These cases yield to the iodide of potash, which the erythema squamosum does not. Erythema squamosum plantare syphiliticum is identical in its mode of origin and growth with erythema squamosum palmare syphi- liticum ; a good example of this eruption will be found among the " portraits of diseases of the skin," Plate XXII. A V. An erythematous syphiloderma, very much resembling lupus ery- thematosus, is met with in old standing cases of tertitary 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 we have termed it syphilo- derma erythematosum haereditarium. Thirdly, it occurs occasionally under circumstances of, and with appearances involving, so much obscurity, that we have thought it necessary, for the present, to transfer its consideration to the group whose name it bears, namely, lupus. At a future time, we hope to be able to unravel more completely the entanglement which envelops this very peculiar and very trouble- some and obstinate disease. SYPHILODERMATA. 493 SYPHILODERMA TUBERCULOSUM. 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 growths is favored by the secretions of the vulva. They are also occasionally found between the greater labium and the thigh, on the scrotum, in the femoro-scrotal groove, 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 we propose to make, under the name of syphilodermata mitigata. Mucous tubercles are far from uncommon on the inside of the labia majora, and in 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 the level of the surrounding integument, but occasionally they enlarge and are troublesome; and sometimes become the seat of superficial ulceration. Warts and vegetations, due to the exuberant growth of the papillae of the mucous membrane and skin, are another form which syphilis is apt to present in situations frequently or permanently moistened with secretions, such as the inner surface of the labia pudendi, the whole extent of the vulva, the perinaeum, the circum- ference of the anus; and, in men, the fossa coronae glandis and the anus. Tubercula ulcerantia.—Ulceration of tubercles may be either superficial or deep; and in either case it may be stationary or pro- gressive. Ulceration is one of the 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 corres- ponds with tertiary syphilis. When the ulceration is stationary, it commences at the summit of the tubercle, and extending its circum- ference by degrees, delves into the substance of the skin more or less deeply. When, however, it is progressive, it creeps on by the cir- cumference, and acquires the name of serpiginous, sometimes creeping over the surface to a considerable extent. At other times, the creep- ing 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 frequent 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. 494 SYPHILITIC AFFECTIONS. 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 at 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 at the opposite side it is uniform with the level of the surrounding skin. The centrifugal action of the ulcerative process is, perhaps, most 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. We once saw a man, par- tially bald, whose head was covered with these serpiginous wheals; they were coated with a thin, squamous scab, and curved around his temples 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 our " portraits of diseases of the skin," Plate XXIII. A Q, under the name of psoriasis gyrata syphilitica; properly, it is a syphiloderma annulatum ulcerans, or it may be termed tubercula annulata syphilitica ulcerantia, or tubercula ulce- rantia serpiginosa syphilitica; it is the syphilide pustuleuse serpigi- neuse of Alibert. TUBERCULA ULCERANTIA LUPIFORMIA. 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 ter- tiary state. In lupiform syphilis 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. The ulcerative action is 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 SYPHILODERMATA. 495 by several deep ulcerated pits, the affection resembles lupus still more closely. TUBERCULA GUMMATA. 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 in it 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 merge 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 by the other they continue to grow; hence the ulcer has more or less of a horse-shoe figure, 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 situation in which we have seen these ulcers in a state of progress, is the integument immediately in front of the ear; the following as 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 of 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 496 SYPHILITIC AFFECTIONS. 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 of the cicatrized skin. In this portion of the skin, and particu- larly in the neighborhood of the ulcer, are a number of enlarged venules. SYPHILODERMA ULCEROSUM. 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 substance. 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 we 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-, crowji. On the left leg near the ankle, was another unhealthy-looking sore, of considerable magnitude. The skin surrounding the sores was of a deep-red color, indurated, and apparently infiltrated; the edges of the phagedasnic sore were dry, black, and excavated perpendicu- larly, 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. SYPHILODERMA 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 poi- son, 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 there- fore not always hereditary ; it is transmitted when the poison is im- bibed 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, modi- fied and chastened by transmission through the blood of another indi- vidual. It is not impossible in the adult to have secondary syphilis, that is, constitutional syphilis, without any primary disease; we have met with such instances. In the transmission of the secondary poison, secondary disease is more frequent; thus, the newly contaminated wife, her husband being locally sound, is probably affected from the SYPHILODERMATA. 497 first with secondary or constitutional syphilis, and has no local dis- ease ; 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. SYPHILODERMA H^REDITARIUM ERYTHEMATOSUM. Syn. Syphiloderma erythematosum marginatum; erythema syphiliticum infantile; alphos syphiliticus 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 alphos in process of periphe- ral extension, and without scales; erythematous patches, of various extent and figure, also slightly raised above the surface; and excoria- tions and fissures around the apertures of the body, the seeming con- sequence or 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 those aper- tures ; aphthae and congestion of the mucous membrane of the mouth and fauces; a clogged state of the air-passages; tumefaction of the membrane of the trachea and larynx; and, not unfrequently, diar- rhoea. 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 ap- parent 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 copi- ously 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 de- velopment of what seemed to be a common but severe catarrh. Its mouth and lips were 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 we 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 emaci- ated ; and its skin dry. An inflamed state (erythema) of the feet wts 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 32 498 SYPHILITIC AFFECTIONS. cracks extended quite around the fingers, were of considerable depth, and bled a good deal. 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 excoria- tions at their outer angles. There were also excoriations around the apertures 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 side of the arms and legs.1 In a more advanced stage of the disease, the erythema having sub- sided 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 alphos 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 indicated swelling of the mucous membrane of the larynx; the child was, besides, restless and fractious; had been suffering from a somewhat 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. In hereditary syphilis, Mr. Hutchinson has pointed-out certain ap- pearances of the physiognomy, and certain alterations of the teeth, eyeballs, and bones, which may be taken as pathognomonic of the disease. " Our most valuable aids," he observes, "are the evidences of past disease, more especially of the inflammations which may have occurred in infancy. A sunken bridge of nose caused by the long continued swelling of the nasal mucous membrane when the bones were soft, a skin marked by little pits and linear scars, especially near the angles of the mouth, the relics of an ulcerating eruption; and a protuberant forehead, consequent upon infantile arachnitis, are among the points which go to make up what we recognize as an 1 A good example of this eruption will be found among the portraits of diseases of the skin, Plate XVIII. A W. SYPHILODERMATA. 499 heredito-syphilitic physiognomy. Added to them, we have very valuable aid furnished by the shape of the incisor teeth. In these patients, it is very common to find all the permanent incisor teeth dwarfed and malformed; sometimes the canines are affected also. These teeth are narrow and rounded and peg-like; their edges are jagged and notched. Owing to their smallness, their sides do not touch, and interspaces are left. It is, however, the upper central incisors which are the most reliable for purposes of diagnosis." " The characteristic malformation of the upper central incisors consists in a dwarfing of the tooth which is usually both narrow and short, and in the atrophy of the middle lobe. This atrophy leaves a single broad notch (vertical) in the edge of the tooth, and sometimes from this notch a shallow furrow passes upwards on both anterior and poste- rior surface nearly to the gum. This notching is usually symmetri- cal." " In addition to the peculiarities of physiognomy and the mal- formation of the teeth, the diagnosis may be much helped by observ- ing the state of the eyes and of the bones. If there be evidence of past iritis, or if there be clouds in the substance of the corneae, the results of past keratitis, or especially if the corneae be now attacked by this peculiar inflammation in its acute stage, very valuable evidence will have been obtained." " In a few cases, the existence of nodes on various long bones may help us to a diagnosis, and in others we may obtain aid from finding that the patient has become deaf without otorrhcea, or that he is partially amaurotic from chloroiditis."1 Diagnosis.—The detection of the syphilodermata is founded on the appearance of the eruption and the concomitant constitutional symptoms. The redness of the eruption is peculiar, a brownish or yellowish-red, a tint of color different from ordinary inflammation, and commonly designated by the vague expression " copper-color." The general complexion of the skin is dirty or muddy, and sometimes yellowish or greenish-brown. Then there is congestion of the fauces, sometimes ulceration of the tonsils, depression of spirits, profuse and fetid sweats at night, anaemic conjunctiva; oftentimes pain, sometimes neuralgic, and sometimes rheumatismal; occasionally affection of the eyeball, iris, cornea, or retina, and sometimes periostitis and nodes. The presence of all these signs and symptoms together would tend to decide the nature of the disease authoritatively; but they observe much irregularity, and some may be absent; hence the diagnosis of syphilitic eruptions offers considerable difficulty, and particularly, as we have already seen, from being identical in type with other erup- tions of the skin. Syphilitic roseola is very like common roseola; in both there is congestion of fauces and a muddy complexion of the skin, and both are attended with moderate febrile symptoms; but in syphilitic roseola there is usually ulceration of the tonsils, which is absent in common roseola. The diagnosis, therefore, requires the corroboration to be derived from- a knowledge of the pre-existence of syphilitic disease. Constitutional Syphilis, in Reynold's System of Medicine, 1866. 500 SYPHILITIC AFFECTIONS. This observation applies to the punctated and corymbous variety of the eruption, and also to the annulate kind. But the roseola maculosa presents the character of the syphilodermata in a more decided form; the redness is more characteristic, and it leaves behind it well-marked brown stains upon the skin. Syphiloderma papulosum may be mistaken for eczema papulosum or lichen ; but the papulae are generally larger and softer to the touch than in the latter complaints; they are frequently corymbous, and there is an absence of pruritus. When to these differences are added, the congested fauces and ulcerated tonsils and one or other of the constitutional symptoms of syphilis already indicated, there can no longer be any doubt. It may be well to note in this place that pru- ritus is a very important sign of difference between syphilitic and other eruptions, and as a general rule is absent in syphilis. Syphiloderma tuberculosum may be a mere exaggeration in size of the papulae of syphiloderma papulosum, in which case it is unlike every other eruption of the skin, or the tubercles may be large, and either prominent or flat, and suggest the idea of alphos. Indeed, as we have seen, one form of tuberculous syphilis has been termed lepra syphilitica and psoriasis syphilitica, a barbarous nomenclature, but sufficient to show the near approach in resemblance between the syphilitic eruption and alphos. The form in question grows by the circumference, like alphos circinatus, while it subsides and perhaps heals in the centre, and the prominent circumferential ridge produces and casts off a succession of epidermic scales. When, however, ulcera- tion manifests itself in the tubercles, all relation to alphos ceases, for the latter never ulcerates, although it may sometimes crack and bleed. The ulcerating forms of syphilitic tubercle bear some resemblance to lupus, both the non-exedent and the exedent variety; and this resemblance has been indicated by the old term herpes exedens, ap- plied indiscriminately to both. To distinguish between ulcerating tubercular syphilis and lupus, we must bear in mind the special cha- racters of the respective diseases. Syphiloderma vesiculosum vel bullosum reminds us of pemphigus; but the bullae are smaller, and their contents soon become purulent; their base commonly ulcerates, and the secretions dry up into the black, thick, and rugged crusts of rupia simplex, or the conical or oyster shell-figured crusts of rupia prominens. The base of the bulla of pemphigus rarely ulcerates. Syphiloderma pustulosum is altogether unlike impetigo, although it may be mistaken for ecthyma; but the hardened and inflamed base of ecthyma is absent, while the disposition to ulceration is greater. Syphiloderma ulcerosum is either superficial or deep in the corro- sion of the skin; both produce crusts from the desiccation of a morbid secretion; the former is extremely sensitive, but the latter, although more extensive, is less tender and painful, and is commonly associated with cachexia. As already observed, the superficially ulcerating forms of tubercular syphiloderma may be-mistaken for lupus, and particularly that variety which has been named herpes serpiginosus; the common synonym of lupus being herpes exedens. SYPHILODERMATA. 501 Squamous syphiloderma, as it occurs on the palm of the hands and sole of the feet, is commonly termed psoriasis palmaris et plantaris, and is confounded with true psoriasis, or eczema palmare. The diag- nosis is often difficult, as syphiloderma palmare belongs to the tertiary as well as to the secondary period of syphilis, and all the other symp- toms of syphilis may be absent. Our inquiry should rather take the direction of determining whether the disease may not be of eczemat- ous origin, by a search for concurrent symptoms. In syphiloderma palmare we must remember the excentric growth of the eruption, and the frequent presence of a raised margin all around, or at some point of the circumference. Syphiloderma infantile is so unlike all other affections to which the skin of infants is liable, that it can hardly be mistaken for anything else; and then the state of the mouth, the nose, the eyes, and the anus, is pathognomonic of infantile syphilis. • Cause.—The cause of syphiloderma is a specific poison, and its operation upon the skin probably associated with the function of elimi- nation. Its admission into the system is effected by absorption through the tissues of the skin, and without the necessary presence of abrasion ; and it may exist in a state of solution in the mucous secretions as well as in the pus of an ulcer. Having entered the tissues for a cer- tain depth, it may react on the surface, and produce the local lesion termed primary disease; or, like other poisons, it may pass directly into the blood, and saturate the entire system, producing a constitu- tional affection commonly termed secondary disease. And, in the next place, it may abide in the system in a latent form for a number of years, and manifest its presence from time to time by partial erup- tions, as we see illustrated in tertiary syphilis. These are some of the phenomena of this remarkable poison ; but it has many others. Like the vaccine poison, it is chastened and miti- gated by its continuance in the human system, and year after year becomes weaker in its influence, until its power upon the individual is entirely lost. It may remain still communicable to another person ; but, in its modified state, produces only a modified disease : hence another source of variety of syphilodermata. They are not only modi- fied in the individual by the long residence and naturalization of the virus, but they are modified also by their origin from a modified or secondary poison, in lieu of a primary poison. Similar modifications also take place in the transmission of the poi- son, primary or secondary, from the father to the mother, and from the mother to the offspring: or, as is believed by some, from the father to the ovum, and from the ovum to the mother. In spite, however, of the modifications which take place in the power of the virus, the ovum is commonly blighted by its reception, and abortion ensues. The syphilitic virus has all the sensitiveness of vaccine lymph, and is, doubtless, as much influenced by the age and purity of the secre- tion, which serves as its medium, as it is by the constitution of the recipient. Aconcentrated virus may be expected to produce a more powerful result than one which is weakened by dilution; and one which has already existed for some time in the system and has become 502 SYPHILITIC AFFECTIONS. assimilated, may be supposed to be milder in its effects than one that is quite recent. The belief seems to be gradually gaining ground that a perfect inoculation serves as a protection to the. individual as com- plete as a perfect vaccination operates against the repetition of small- pox. And the practice of syphilization has proved to us that the syphilitic virus may be repeated on the same individual until his tis- sues refuse any longer to be excited by it; and he is, doubtless, placed in the condition of being insusceptible to the operation of the poison in whatever way it may be presented. In estimating the protective power of the syphilitic virus, we must bear in mind the observation of Marson, that quantity of inoculation is one of the necessary condi- tions of success. The lymph must not only be pure, and taken from the vesicle at the proper period of development, but a quantity suffi- cient to produce at least four complete vesicles must be introduced into the tissues of the vaccinated person. With a pure syphilitic virus, we should expect as a result a hard chancre, indisposed to spread superficially or suppurate, and an active constitutional exanthematous fever. But in an impure or diluted state, the results would be very different; possibly, a superficial sore, soft, suppurating and spreading; an absence of subsequent constitutional exanthematous fever, and an irregular contamination of the system. Marson has shown that an imperfect vaccination, while it is wholly unprotective of the constitution, operates powerfully as an obstacle to a perfect subsequent vaccination. The same phenomena may possibly present themselves in syphilis ; an inoculation takes place from which nothing but local results follow; subsequently another inoculation takes place, but the results are imperfect; incomplete in the local pro- cesses and equally incomplete in the constitutional phenomena. It therefore happens that a variety of circumstances may modify the syphilitic poison; and these modifications must necessarily give rise to a considerable variety of results, both in respect of the primary or local and the general or constitutional disease. Under these circum- stances, the individual remains for ever unprotected ; he may be the subject of a spurious disease over and over again, and still be as liable to receive contagion at the last as at the first. In a case of this kind, we see at once in what manner syphilization might operate as a pro- tection and a cure. Prognosis.—The prognosis of syphilodermata is favorable; they are very amenable to treatment, and with the aid of judicious treat- ment always terminate satisfactorily. They are mudn more manage- able than syphilis of the mucous membranes. 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 poision, 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, kidneys, and skin; and our means of support must be derived from SYPHILODERMATA. 503 the catalogue of tonic remedies, amongst which one of 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 prac- tice. 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 proliferation; 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 needed in very severe cases of local congestion, as of the brain or lungs ; and, even in such cases, the quantity of blood requiring to be removed will be very small. The general inflammatory excitement attendant 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 sulphate of magne- sia, 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, and for the purpose of aiding the action of the mucous membranes and skin, ten grains of the compound ipe- cacuanha 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. We are not aware that any particular form of mercurial preparation is superior to another for this purpose. We select usually the protioduret, which we prescribe in doses of half a grain to a grain, in combination with extract of lettuce, or conium, twice or three times a day. This medicine agrees with the stomach usually very well; but if it produce nausea or colic, then we either exhibit the 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 thigh 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 consequence that the inunction should not attract the attention of the patient's family, we limited the frictions to the sole and inner side 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 of importance to pay attention to hygienic conditions and diet. Stimulants of all kinds, either in food or drink, are to be avoided, as is also exposure to cold and fatigue. And the intention of the treatment should never be lost 504 syphilitic affections. sight of, namely, to increase the natural functions 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 decoction of guaiacum; the decoction of saponaria; or the infusion of elder-flowers. We have no belief in the specific powers of sarsaparilla; but we cannot conceive a remedy better suited for the purpose of soothing the alimentary canal, and at the same time 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 a 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 particu- larly from the risk of being chilled. Medicinally; if the inflamma- tory 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, fol- lowed by a black draught, together with liquor ammoniae citratis and tartarized antimony; or effervescent salines, with antimony; and a Dover's powder at bedtime, until the inflammatory stage is subdued. Thirdly, mercury in small doses, with the compound 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 addi- tional importance, from its having been made the chief agent of treat- ment of constitutional syphilis by Langston Parker. Mr. Parker raises the vapor of the bath by means of a lamp, and he also intro- duces 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 emunc- tory property .of mercury, and the special emunctory action of the skin. In Germany, in addition to several curative processes founded on the limitation of diet, one method of treatment, which may be "briefly defined as a triple combination of starving, purging, and sweating, enjoys special favor, namely, the treatment by Zittmann's decoction. This treatment is as follows: On the first day the patient takes a full SYPHILODERMATA. 505 dose of calomel and the resinous extract of jalap. During the next four days he drinks daily two quarts of Zittmann's decoction; one quart of the strong decoction; taken warm, in the morning, and one quart of the weak, cold, at midday. 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 soaked in water; and if he be weakly, he takes of Zittmann'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 practical surgeon, whose practice we 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 will be found in the chapter devoted to "formulae" at the end of the volume. 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 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 char- acter 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 506 SYPHILITIC AFFECTIONS. it had previously possessed. That may not be the case with regard to the second, or even the third, outbreak of the secondary eruption; 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 possi- bly 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 the 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, induc- ing 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 affects the 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. We 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, than 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 attribute 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 we have distinguished as tubercula cir- cumscripta, 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." We 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 potas- sium, and this medicine frequently acts as a charm in such instances. We have in our mind at this moment the case of a gentleman, who one morning staggered feebly into our consulting room, supported by his physician and ordinary medical attendant. He introduced him- self as a lost and hopeless man; and he certainly presented a vivid picture of exhaustion and decay. He showed us several large, deep, and foul ulcers upon his legs, and he said that the surgeons of emi- nence whom he had consulted, even a few days before his visit to us, would insist upon his taking mercury, which he knew was destroying him. We prescribed for him the iodide of potassium; and in less than three months he called upon us, having just returned from the country, declaring that he never felt stronger or better in his life. SYPHILODERMATA. 507 We should have been very sorry to have mentioned this case, if we thought it could, by any possibility, be used as an argument against mercury. Mercury is an invaluable medicine, but one requiring to be used with judgment; to be watched in its eff'ects, and to be regu- lated according to those effects rather than upon any scheme of theo- retical results; indeed, mercury, like iodide of potassium, and every other medicine, must be exactly graduated, in dose, combination, and period of administration, to the special case of the patient. Each pa- tient, as he varies in physiognomy from his foregoers, 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 sarsapa- rilla 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 skin. After iodine has been taken for a time, it begins to excite an over- action in the various tissues of the body; firstly, in the mucous mem- brane ; then in the nervous system and brain ; and these actions may be regarded as evincing the poisonous properties of the medicine. The symptoms now referred to are first perceived in the mucous mem- branes, 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 of the 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 an irritant to the system, there is a feel- ing 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 salivation. By de- grees the congestion extends to the trachea and bronchial tubes, add- ing cough and bronchitis to the other symptoms. These indications of irritation of the mucous membrane generally precede those of dis- turbance of the nervous system, and give sufficient warning of a neces- sity 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 we saw severe palpitations of the heart. But, although we have used the medicine extensively, we have seen very little of its morbid eff'ects, probably from always exhibiting it with caution. Our mode of administering the iodide of potassium, is to prescribe five grains twice or three times a day, according to the power or con- stitution of the patient. If we begin with five grains three times a day, we 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 be 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, we require that the dose for 508 SYPHILITIC AFFECTIONS. recommencement should be that first prescribed. In this way we get the full eff'ects of the medicine rapidly, and avoid the risk of any mis- chievous effects from its use. We were first led to adopt this mode of employing the iodide of potassium from meeting with cases in which the medicine 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 us 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 without increase of dose becomes utterly useless. Sometimes we find it convenient to continue the five grain dose for a longer period than a week, and the same with the others; we endeavor to ascertain the period during which the action of the medicine is progressive, and have the dose increased immedi- ately that period is passed. Occasionally, we may find it desirable to make a change in the remedy, in which case we may have recourse to the bromide of potassium or iodide of ammonium; the dose of the former being similar to that of the iodide of potassium, that of the latter being somewhat less as being a more powerful preparation. Syphilitic eruptions of the skin, when general, require no other local treatment than the occasional use of the tepid soap-bath. When situated on the face, the diluted citrine ointment, or the nitric-oxide- of-mercury ointment, applied with gentle friction, are good remedies, and tend to hasten the dispersion of the hyperaemia, 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 combination 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 gen- eral system; but we have succeeded beyond our expectation, in several 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 very soon the fall of the hair, which accom- panies syphilis, is checked by means of the remedies employed for the relief of the other symptoms; the mercurial preparations or the com- pounds of mercury with iodine. The plan of treatment is, therefore, SYPHILODERMATA. 509 simple and obvious. Occasionally, however, alopecia is the only evi- dent symptom 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 we 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. The best local application for alopecia 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-lotion,1 introduced among the roots of the hair by means of a sponge, may be used in the morning before brushing. This lotion, besides aiding in the excitation of the scalp, 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 aids in 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 palm of the hands and sole of the feet, and their treatment is mercurial; either the protioduret or the bichloride. It is 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 cured, after every other remedy and mode of treat- ment had been tried in vain. Medical men suffering from this com- plaint have been startled at our audacity, when we have promised them a cure, in three weeks, of that which had baffled themselves for months, and more frequently for years; but our promise has rarely failed to be accomplished. We 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. We do not believe that any good results from continuing the medicine for many days beyond the period of cure ; we direct that it should be left off at the end of a week, after the skin is healed; and prefer, in case of relapse, to resume the remedy as before. 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 benzoated lard is a good application; or a lotion containing T7e?e, Selected Prescriptions. 510 SYPHILITIC AFFECTIONS. one part of glycerine to three of camphor mixture or rosewater; or better still the amylated glycerine. 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; while a 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 man- agement. When in an inflamed state, water-dressing, with Alison'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 ointment, or ben- zoated lard with camphor, or an ointment of Peruvian balsam, answer better than the lotions; and in two or three instances we have obtained the best results from covering the granulations with powder of char- coal or Peruvian bark. 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. The region in which they occur should be kept thoroughly washed with the juniper-tar soap, or carbolic acid soap; and, 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 our 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 alone, the infant drawing its nourishment from her breast being re- garded as part of herself. If the proportion of mercury thus conveyed to the infant be deemed insufficient, there can be no objection to give it independently to the latter. And in several instances we have given it to the infant only. We 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; and we were quite prepared, should any retardation in the cure of the infant occur, to exhibit the remedy to the mother also. In a word, we 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. We 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 of the mother may subsequently occur SYPHILODERMATA. 511 in consequence of transmission of the poison from the diseased child to the tissues of the parent. Such a theory we 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, full of germinal life, which we may conceive to be more sus- ceptible 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 benzoated lard. 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 or fuller's earth. For discharges from the meatus of the ears soap and water is the best remedy. Hereditary syphilis.—After the age of infancy, congenital sy- philis gradually merges into what may be termed hereditary syphilis. The infantile syphilis gets well, but several months or years afterwards it may break 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 dis- ease 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. We have had little experience of the hydrochloride of gold, but we apprehend that it is to the pre- sent form of syphilis that it would be especially applicable. Some of the forms of hereditary syphilis are remarkable for 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 512 SYPHILITIC AFFECTIONS. 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- lated to exhaust the powers and do mischief. In making these obser- vations, we have now in our memory several persevering " incurables," 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, because 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 in- cited to make a bold effort, which cannot but end unhappily, and the patient takes no step to urge him to such an attempt by impatient suggestions. In some instances of the lupoid tubercle we have found the iodide of potassium a serviceable remedy; in others, the bichloride of mer- cury has proved most useful. Sometimes the iodide of iron has brought about a healthy condition of the general system, which has been followed by improvement in the local disease; and, at other times, we have derived the best results from the triple solutiou of mercury, iodine, and arsenic, given alone, or in conjunction with cod- liver oil. When the arsenic, in the triple compound, has appeared to be objectionable, we have had recourse to the tonic properties of qui- nine as an adjunct to the iodide of mercury, and with a very satisfac- tory result. The following formula is an excellent substitute for Donovan's solution, agreeing well with the stomach, and possessing the advantage of being in a more condensed and convenient shape for deglutition:— ]£.—Hydrargyri biniodidi, gr. \. Micse panis, gr. j. t Quinse iodidi, 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 resumed after such an interval of time as may seem good in the judgment of the surgeon. Like food and hygienic conditions, medicines, 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 necessary rule to be borne in mind in the management of so obstinate a class of diseases as those of the skin. ELEPHANTIASIS GRAECORUM. 513 CHAPTER XIX. LEPROUS AFFECTIONS. Lepra, the leprosy, is a term employed by the ancient Greeks to distinguish a roughness or scaliness; a state of leprosity of the skin. The most complete example of scaliness known in modern times, and possibly also in ancient times, is remarkable for the whiteness of its scales; hence the recognition of color as an element of classification ; the disease in question became a scaly whiteness, or in technical lan- guage, a lepra alphos ; and the whiteness served to distinguish it from a black lepra, lepra melas; and from a shining white or glossy lepra, lepra leuce. The Latins set forth another feature of leprosy, a spotted character, the skin being spotted like that of a vitulus or calf; hence their term vitiligo; the white vitiligo, the black vitiligo, and the shining white or glossy vitiligo; vitiligo albida, nigricans and Candida; or in the language of Celsus, vitiligo alphos, vitiligo melas, and vitilgo leuce. But the Greeks were not long in discovering that the lepra melas, besides simple discoloration, manifested a thickening of the skin, and they very readily adopted a symbol suggested by the name of a dis- ease prevalent among the Arabians, and described by the Arabian physicians as the dal fil, the elephant disease. It is true that the dal fil was an aff'ection totally different from lepra, namely, the boucne- mia of the present day; but the comparison between the thickened skin1 of lepra melas and the hide of the elephant was sufficiently appo- site to warrant the application of the term elephantiasis to this disease. But elephantiasis by degrees acquired another signification; it not only expressed the thickening and discoloration of the skin, rendering the integument similar to that of the elephant; but it also indicated a more grave and serious disease, one which was not simply limited to the surface like lepra alphos, but was constitutional as well as local. Therefore, looking only at the surface, the Greek physician might pronounce the case to be a lepra, a lepra alphos, a lepra melas, or a lepra leuce; but looking deeper than the surface, he would proclaim the lepra melas and the lepra leuce to be an elephantiasis. We have an illustration of this mode of viewing the disease in the writings of Celsus, who not only distinguishes between the local signs comprised in his genus vitiligo; but, at the same time, transfers the constitutional disorder accompanying vitiligo melas and leuce to a different chapter of his work. In his third book, on the treatment of 1 " In most places the true skin was not less than a quarter of an inch thick."__ Report of post-mortem examination of a case of elephantiasis Graecorum, by Dr. John Davy, M. D., F. R. S. 33 514 LEPROUS AFFECTIONS. diseases by diet, chapter 25, he gives the following admirable outline of this affection: "The disease which the Greeks call elephantiasis is almost unknown in Italy, although very common in other regions of the world. The entire body is attacked, even to the bones. The surface of the body is thickly studded with maculae and tubercles, at first red, then becoming brown; the skin is remarkable for inequali- ties, in some parts thickened, in others thinner than natural; in some, hard; in others, soft; in many parts rugged, and apparently coated with scales. The body is emaciated ; the bones, the calves of the legs, and the feet, swollen. When the disease is of long standing, the fin- gers and toes become lost in the swelling; feverish symptoms are developed, and the patient .sinks overwhelmed with suffering." But for the local signs of the disease we must go to the fifth Book, on the treatment of disease by medicine, chapter 28, where, under the head of vitiligo, he observes: " There are three kinds of the affection. "It is called alphos when-it is white, rough, and dispersed, resem- bling drops sprinkled on the skin; the spots having sometimes greater breadth than mere drops; and from time to time enlarging their dimensions." Melas " differs from alphos in possessing a deeper tint of color, as though of a shadow thrown upon the spots; in other respects it is the same." Leuce, " at the first glance, somewhat resem- bles alphos; but is whiter, and implicates the skin more deeply ; the hairs growing on the part are white, and are like down." " All these affections spread ; some quickly, some slowly. Alphos and melas occur at all periods of the year, and terminate with equal irregularity. Leuce is difficult of removal. The former two admit of cure without much trouble, the latter (leuce) rarely ever gets well; for if a part of the disease disappear, the entire skin never returns to a healthy color. But whether a given example of the disease be or be not curable, is easily tested by experiment. For, if the skin be punctured or pricked with a needle, and blood flow, as it commonly does in the two former, there is hope of a remedy ; but if there issue a colorless humor, the case is incurable. Therefore, we may abstain from treating the latter." No reference is made to any constitutional disturbance accompanying these symbols of disease; but it would be unreasonable to suppose that there was an absence of general disor- der. We use the words symbols of disease, for the reason, that although lepra alphos is a substantive disease, melas and leuce are not so, but merely signs of lepra or elephantiasis; excepting, perhaps, so much of idiopathic melasma as may be erroneously mixed up with the description of melas; and so much of common leucasmos as may equally erroneously be confounded with leuce. The Arabian physicians distinguished lepra by the word juzam; and in addition, they had amongst them the dal fil, or elephant dis- ease, the elephanta. Hence, in the Greek literature, there came to be two diseases bearing the name elephantiasis ; the one being their own lepra melas and leuce, the elephantiasis Graecorum, the juzam of the Arabians; the other, the dal fil of the Arabians, or elephantiasis Ara- bum. Reviewing these terms with reference to their signification as ap- ELEPHANTIASIS GRJ3C0RUM. 515 plied to the known character of the diseases which they represent, we may express that signification as follows: lepra, roughness and des- quamation ; alphos, melas, leuce, and vitiligo, color, and distribution of color; elephantiasis, pathological structure and universality of morbid contamination ; juzam, mutilation ; and dal fil, bulk and texture. We may now inquire in what respect the leprosy of the Hebrews' corresponds with the leprosy of the Arabs and of the Greeks. The Hebrew terms assigned to that disease have especial reference to color and smoothness; and, like the alphos, the melas, and the leuce, are limited to superficial appearance. The distinctive Hebrew title of leprosy is Berat, signifying a bright spot; and, of the berat, there are three varieties, the boak, or dull white spot, corresponding with the lepra alphos of the Greeks; the berat cecha, or dark spot, agreeing with the lepra melas; and the berat lebena, bright or glossy white spot, or lepra leuce. The lepra melas and lepra leuce have an existence at the present day in a disease sufficiently well known to us, and pretty extensively distributed over the world's surface, the elephantiasis Grsecorum; and these characters are so distinct as to have suggested terms still in com- mon use, namely, the black and the white leprosy; and, as there is good reason for believing that the lepra melas and lepra leuce are identical with the tsorat of the Hebrews, namely, the berat cecha and the berat lebena, we are warranted, as we believe, in coming to the conclusion, that elephantiasis, lepra melas et leuce, and tsorat, are one and the same identical disease. In no other disease known at the pre- sent day are the peculiar black and white spots, described in the Book of Leviticus, present; and we are further led to believe that the disease is the same, from the importance which is attached to it in the sacred writings, and the proclamation therein of its contagious nature. In handling this question, we take the only facts that are presented to us; and especially that pathognomonic sign of the disease, the glossy white spot upon which the hairs are fallen; or, if they remain, are changed to white. Celsus lays before us little else than change of color, and drives us to an earlier page to study the constitutional symptoms of the disease. The book of Moses professes no medical dissertation ; it simply points to signs; and those signs, we venture to affirm, exist as unmistakably on the body of the leper at the pre- sent day as they did when the written law of Leviticus was proclaimed. Not only is there the white spot, but there is indicated also the atro- phy of the skin, the spreading character of the disease, and its ten- dency to ulceration. To our mind, the identity of elephantiasis Grae- corum and the leprosy of the Hebrews, if indeed the latter be not, as imagined by certain divines, a mere symbol of moral disease or sin, is a fact which cannot admit of the slightest doubt. Assuming, therefore, the elephantiasis or lepra Graecorum to be the same with the leprosy of the Hebrews, it is also the juzam, or leprosy of the Arabians, the leprosy of the middle ages, the leprosy of the crusades, and the elephantiasis and vitiligo of the Latins. It is a dis- ease of great interest, on account of its early existence and almost uni- 516 LEPROUS AFFECTIONS. versal distribution throughout the world, its extreme severity, its spontaneous disappearance in countries where it had prevailed as an epidemie, and its persistence in others with all its original and histo- rical 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, Hindostan, China, Japan, Australia, New Zealand, Africa, Tur- key, Greece, Italy, France, Spain, Britain, Germany, Russia, Scandi- navia, 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 the East, and confined to that region at the com- mencement of the Christian era, the disease spread rapidly through Greece and the south of Europe during the period ranging from the second to the seventh century, reached its culminating point during the Crusades of the eleventh and twelfth century, and began to decline from the fifteenth to the seventeenth century. The earliest records of the leprosy in Great Britain are those of the Welsh king, Hoel Dba, in the year 950; and from that date until the beginning of the sixteenth century, the disease was common in Eng- land ; and there is evidence also of its existence in Ireland. The Leper Hospital of Hugh Pudsey, at Sherburn, in Durham, was founded between 1180 and 1183, for the maintenance of sixty-five lepers; whereas in 1434 the foundation was reduced to fifteen per- sons, of which two should be lepers, "if such can be found ;" and, in 1585, by Act of Elizabeth, there being no lepers, the foundation was extended to thirty brethren, old, blind, and lame, and otherwise im- potent. At Bodmin, in Cornwall, a seal is preserved of the Hospital of St. Laurence de Ponteboy, which bears evidence of being engraved iq the latter part of the fifteenth century. "This seal shows that the hospital existed as an ecclesiastical foundation for some time anterior to the Reformation, and perhaps for a hundred years or more before its Elizabethan incorporation."2 And it is satisfactory to know that the revenues of the hospital are at present enjoyed by the Cornwall Infirmary at Truro, the governors of that institution having bound themselves, in 1810, to receive leper patients. 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 cen- turies later, the earliest Lazar-houses dating back to about 1150, and the disease was still traceable during the 17th 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 hos- 1 " High up the Nile, 'mid Egypt's central plains, Springs the dread Leprosy and there alone." Lucretius De Natura Rerum. Poetical version by John Mason Good, M.D. 2 Professor C. C. Babington,in Archseologia Cambrensis, for July, 1863. ELEPHANTIASIS GRAECORUM. 517 pital at Kingscase, near Ayr. Symptoms of decline of the disease in Scotland are perceived in an order for dismantling the Lazar-house at Greenside, Edinburgh, in 1652 ; but in the islands to the north of Scotland, the Orkneys, Shetland, and Faroe islands, the malady 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 the 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 Mal de la Crimee ; on the shores of the Caspian sea ; in the islands of the Indian Ocean; on the coasts of Africa, Arabia, Hindostan, and China; in Madeira; in the West Indies; in Canada; and notably in Iceland and on the coast of Nor- way. In Norway, the presence of leprosy has been so great and so fatal that a royal commission was appointed a few years back, to exa- mine into the nature of the disease, and determine the course to be taken to limit its progress, and, if possible, to effect its cure. The report of this commission, by Drs. Danielssen and Boeck, was printed by the Norwegian Government in 1848; it is accompanied with a fasciculus of excellent plates, and is by far the best treatise on elephan- tiasis in existence.2 The name elephanta or elephantiasis was given to this disease by the early Greek and Roman writers; 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 hercukus and morbus herachus. Other names, such as leontia, leontiasis ; satyria, used by Aristotle; satyriasis, satyriasmos, had reference to the deformity of countenance produced 1 Sir James Young Simpson 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 " Edin- burgh Medical and Surgical Journal,"for October, 1841 ; and January and April, 1842. 2 Traite" de la Spedalskhed, ou Elephantiasis des Grecs ; par D. C. Danielssen, MSdecin en chef des Hopitaux de Spedelques a Bergen; et Wilhelm Boeck, Profes- sor de la Faculty de Medecinea Christiania. Paris 1848. These authors have further illustrated the disease in their" Recueil d'observations sur les maladies de la peau ; troisieme livraison, 1862," which is especially devoted to elephantiasis anaesthotos. 3 De Natura Reruui; translated by the Rev. John Selby Watson. Lucretius was born ninety-five years before Christ. 518 LEPROUS AFFECTIONS. 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 rob- bery and violence. The latter circumstance caused them to be dis- tinguished 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, juzam, judam, juzamlyk, judamlyk, alzuzam, dsjuddam, madsjuddam, jecldem, muzd- jeddem, didyam, damadyand, dschiddam, sghiddam, judas, &c. 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 Mora, kushta (leprosy), mahakushta (great leprosy), ructa-kusta (tubercular), guleet-kusta (an- aesthetic), schvet-kusta (white leprosy), sunbahiree or soubharry (anaes- thetic), jugaru, jejani, burrabeemanee (great sickness), ructa-pitia (tuber- cular), ruggat-pittee, and mahaviadhi (tubercular); in China,fa-fung, fak-fung, fat-foong, ma-fung, and ta-ma-fung; in New Zealand, nge- rengere and tuwhenna; in Africa, kohan, koban, and kokobe • in the West Indies, kokobay ; in Morocco, ezdam ; in Turkey, miskine or 7nes- kin; in Constantinople, tzaraath ; in Greece it is popularly known as the lova,-1 in the Ionian Islands it is recognized as the lepra; in Crete it is called khalassi,2 komagra,3 and tzaraath ; in Dalmatia, mal de fiume, falcadine, and scherlievo ; in Italy; il male di san Lazaro, male di commochio, 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 skin; while in other countries it has been named mal noir, also from the dusky hue of the surface. 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 hreqf and licprower signify knotty or tubercular, the latter, found in the Northumberland dialect, evidently corresponds with the Norwegian word likpra.4 Sir James 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 Edin- burgh, was thence named Liberton, a corruption of Liper Town. The Scandinavian designation of the disease is spedalskhed, and in Sweden, speialskhan; in Norway it is also called arvesygen, or hereditary dis- ease, and likpra, that is, knotty or tubercular; in Denmark, besides spedalskhed, likwoerthing and likwosrthingsof; and in Iceland, holdsveiki, leinafalls-syki, likthrd and malaottosott. In some parts of South America it has received as an appellation, the term boasi. 1 Laffn, mutilation. 2 XaXa£asiv, to have pimples or tubercles, Hippocrates. 3 Possibly from Ktu/um, lethargy ; a.y%a, attack. * Drs. Danielssen and Boeck, loc cit. ELEPHANTIASIS GR^CORUM. 519 ELEPHANTIASIS vel LEPRA. Syn. Elephantiasis Gracorum; orientalis; legitima; alopeciata. Lepra elephantia; Grwcorum ; Arabum; alopeciata; medii ozvi. Black and white leprosy. Elephantiasis tuberculosa ; leontina ; satyria. Lepra leontina, satyria ; melas; rubra. Vitiligo melas; nigricans. Black leprosy ; red leprosy ; humid leprosy. Elephantiasis anjesthetica ; nodosa; mutilans. Lepra Hebrozorum; Judazorum ; leuce ; articulationum; mortificans; gangrenosa; rheumatica; phlegmatica. Vitiligo leuce; Candida. White leprosy; articular leprosy ; joint evil; dry leprosy. Elephantiasis is a chronic disease, involving, especially, the skin, the mucous membranes, the nerves, and the bones; lasting for many years; seldom if ever undergoing spontaneous cure; and terminating in loss of sensation, atrophy, ulceration, and necrosis. The disease is indigenous to particular countries; is met with most abundantly in the neighborhood of great rivers, lakes, and the sea-coast; is here- ditary; and possibly under certain circumstances, contagious. In its invasion, the disease makes its attack slowly, insidiously, and imperceptibly; the first evidence of its existence is an erythematous spot, sometimes a transient febricula, followed by an exanthema. In either case, the disease has already taken possession of the blood, and has probably been present in the system for several months, possibly for one or more years. We may therefore regard this presympto- matic period as a latent stage of the affection, to be followed by an exanthema or manifestation by the skin, and subsequently by ulcer- ation or atrophy. A careful investigation of the state of health of the patient during the latent period would probably discover an in- cipient cachexia, indicated by pallor, slight anaemia, yellowness and muddiness of complexion, some degree of debility, and a tendency to emaciation; but in the absence of suspicion, these slight symptoms would be unobserved; the individual seems and feels well, and similar symptoms might occur without being the forerunners of elephantiasis. Nevertheless, the symptoms above mentioned are sometimes suffi- ciently distinct to constitute a real state of disturbance of function; a sickening for an anticipated illness in fact, but without the direct ten- dency of the symptoms being discoverable. The latent stage is gene- rally" passed over without remark, but is, nevertheless, the most im- portant period of the affection, and the only period, according to our present knowledge, at which remedies may be expected to exert a curative influence over the disease. It is the period during which the poison accumulates in the blood, and eff'ects the morbid constitu- tion of the sanguineous fluid. The cutaneous development of elephantiasis has the general type of an exanthema, modified by the peculiar agencies of the disease. The exanthema makes it appearance as a congested or erythematous spot of circular figure, of a size of two to four lines in diameter, and most vascular in the centre, while it fades towards the circumference. There may be only a single spot, or the spots may be numerous; they may be isolated, or they may be aggregated in small or large clusters so as to form blotches, varying in dimensions from one to several inches in diameter. A single spot or blotch, or a partial dis- 520 leprous affections. tribution of spots or blotches, may appear upon the skin without any accompanying constitutional symptoms, or they may appear in suc- cession until they cover the greater part of the body equally without constitutional symptoms; but a sudden and general outburst of the eruption is usually associated with a smart attack of febrile aymp- toms, namely, chills, succeeded by heat of the skin, thirst, lassitude, somnolency, and incapacity for exertion of every kind. The spots and blotches of elephantiasis, at their first appearance, have a pinkish or purplish red color; after one or two weeks, the redness is deepened and assumes a brown or copper colored hue from the deposition of pigment in the rete mucosum; and still later the redness subsides, and a brownish-black or bronze-colored stain takes the place of the original red spot. The melasmic or pigmentary spots resemble the red or vascular spots in size and figure; and in the fact of being deepest in color in the centre, and fading towards the circum- ference. They are also, like the red spots, met with in clusters, form- ing blotches of considerable size, but variously tinted with pigment; and it is by no means uncommon to meet with cases in which the red and black spots, variously commingled, are distributed over the whole body of the patient. At an advanced period of the disease, it may also happen that the black pigment is removed, and a white and bleached spot left in its place. In these three variations of color, we find illustrated, the red, the black, and the white leprosy of authors; the two latter being the lepra melas and leuce, vitiligo nigricans and Candida, morphcea nigra and morphcea alba. The exanthema of elephantiasis may appear upon the skin as a single spot; for example, on the cheek; or, as a few spots and blotches scattered over the trunk of the body, as upon the back and chest; or, as a more abundant eruption, resembling a roseolous or rubeolous rash. In the latter case the likeness to rubeola may be increased by the presence of a smart exanthematous fever, and by a subsidence of the constitutional symptoms on the development of the eruption. The spots usually make their appearance without any local inconvenience; sometimes, however, there is a slight degree of itching or tingling, and, not unfrequently, a feeling of rawness or soreness, of extreme sensitiveness or aching pain. This state of hyperaesthesia accompanies the congestive period of the exanthema, and subsides by degrees until in the pigmentary period the sensation of the skin is lowered, a feel- ing of numbness takes possession of the part and runs on to anaes- thesia, more or less complete; while, in the achromatous stage, sensa- tion is entirely annulled. With the congestive period, moreover, it is not uncommon to find an increase in quantity of the sebaceous secretion of the skin {unctuositas elephantina, Plenck); and this also ceases during the pigmentary period; the epidermis becomes dry, sometimes it is parched, and sometimes cracks and breaks into fissures, and is removed by desquamation. With dryness and desquamation of the epidermis we commonly find a prominent and impacted state of the follicles, the latter are dis- tended with a dry epithelial sordes, the nails also loosen from their matrix and break off, and the hair of the affected parts of the skin ELEPHANTIASIS GR.EC0RUM. 521 falls out. This is especially the case with the eyebrows, and in a less degree with the eyelashes, the head, the face, and the trunk of the body. The loss of the hair from defective nutrition has suggested the term elephantiasis alopeciata, as* one of the synonyms of the disease. The hair is also apt to undergo another change; it becomes white with the loss of pigment which accompanies the achromatous stage of the disease, and, in its bleached condition, may be found occupying the smooth, white, anaesthetic spot of leuce. If the disease commence before puberty, the hair of the face is often undeveloped, and, in the female, menstruation is retarded and subsequently is deficient and irregular. Next to the vitiliginous or spotted appearance of the skin, and the remarkable tints of color of the spots, we are attracted to the other physical characters of the exanthema. In the first instance, there is no elevation of the spots above the surrounding surface; but, if we touch them with the finger, we discover that they are hard in the centre, and that the derma is not only congested but it is also thick- ened. If we pinch up a fold of skin, including one of the spots, the thickening is more obvious, and in a blotch or cluster of spots the uneven thickening is very perceptible. The thickening of the skin is owing partly to the increased bulk of the congested vascular plexus; but is chiefly due to exudation from the vascular plexus into the tissue of the corium. At first the thickening is only perceptible to the touch, but soon it becomes distinguishable by the eye. The interfolli- cular cutaneous tissue is puffed up above its ordinary level, while the apertures of the follicles look enlarged; and the skin has the coarse punctated appearance of the rind of an orange. This kind of eleva- tion may be met with wherever the spots and blotches occur; but, upon other parts, and particularly on the face and limbs, the promi- nence of the cutaneous tissue is apt to assume the form of small tuber- cles, corresponding in breadth with the size of the spots from which they arise. Before the tubercles rise above the level of the surface they may be felt as knots in the skin; and when they have risen, it is evident that they owe their origin to a thickening and infiltration of the cutaneous tissue, similar to that which occasions the broad blotches of coarse punctated skin. The tubercles necessarily follow the distribution of the exanthematous spots; in some situations being isolated; in others, congregated in small clusters. Having proceeded thus far with our description of elephantiasis, we are in a position to recognize those special symptoms or characters which constitute the distinction between the tubercular and the anaes- thetic form of the disease. In its first operations on the skin, the dis- ease attacks at the same moment the cutaneous tissues and the ulti- mate ramifications of the cutaneous nerves. In its future progress it exhibits an elective affinity for the surface tissues, on the one hand, or for the nerves, on the other; in the former case it produces tuber- cles and becomes tubercular; in the latter case it follows the nerves upwards to their source, and destroying their function as it proceeds, occasions amesthesia; while, in a considerable proportion of cases, as 522 LEPROUS AFFECTIONS. may be inferred from their physiological relations, the two forms of the disease are combined and constitute a mixed variety. The early pathological changes taking place in the skin are, vascu- lar congestion, pigmentation, and thickening, and each of these pro- cesses has its peculiarities of manifestation. In the process of con- gestion the capillary vessels are at first only moderately distended as in ordinary erythema ; but, after some persistence, the capillaries become more enlarged, and form a coarse vascular network in the tissue occupied by the spots. The same change takes place as the result of frequent repetitions of the exanthema, until a large surface, sometimes the entire forehead, the ears, the nose, or a portion of the trunk, is permanently reddened by the presence of a dilated capillary plexus, which spreads more or less extensively over the surface; it is this magnified plexus that gives the peculiar copper-red color to the skin which has suggested the term red leprosy. The redness of the early exanthema disappears by degrees ; but that of the dilated plexus persists until the anaesthesia of the skin breaks up the plexus, and a few meandering venules are all that remains of the vascularity in the bleached and atrophied spot of leuce. The pigmentation is first seen in the exanthematic spots, as a con- sequence of the debility of the skin and heightened circulation of the part. But the pigmentary change is not confined to the spots, it makes itself manifest on the face and upper part of the neck, on the hands, and on the feet. And from the hands and feet, it creeps upwards upon the limbs to the shoulders in the upper extremities, to the groins and hips in the lower. It is greatest on the hands and feet, and becomes less and less in its course upwards upon the limbs. The tints of color are, pale-brown, yellow-brown, red-brown, purple-brown, and black of various shades; sometimes having a leaden hue, and sometimes the metallic lustre of oxidized silver. But on the comple- tion of anaesthesia, the melanic pigment disappears, and gives place to a bleached and colorless spot. The thickening of the skin resulting from exudation in the cutane- ous tissue, is sometimes sensible only to the touch, sometimes it pro- duces a punctated coarseness of surface, which may be compared to the rind of an orange, sometimes a tumid and slightly elevated blotch, smooth and semi-transparent, and resembling gelatinized skin, and sometimes a more defined prominence, varying in breadth from one to three lines, which has received the name of tubercle. The tubercle may be felt in the skin before it rises above the surface, and rarely exceeds a line in elevation; it is generally discrete, but sornetimes occurs in aggregated clusters and forms a compound or nodulated tubercle of half an inch to an inch in diameter, and of considerable prominence. For some time after its appearance, the tubercle looks paler than the surrounding skin, by degrees it becomes red from the presence of a network of capillary vessels that occupies its surface ; and later still, it is transparent as though gelatinized, and a few small venules may be seen straggling over its surface. These changes mark a gradual metamorphosis of the tissue of the tubercle, from a state not widely divergent from the healthy structure, to the gelatinous ELEPHANTIASIS GRAECORUM. 523 condition of the crudest form of cell-tissue. The nodulated tubercular masses produced by the agglomeration of a cluster of tubercles, not unfrequently take on a suppurative change, and form small cutaneous abscessess which burst and heal, or in some instances terminate in ulceration. The proximate cause of the thickening and tuberculation of the skin, is the transudation of a viscous albuminous fluid, sometimes whitish and opaque, and sometimes transparent, into its tissues; and the general tendency to the transudation of the fluid portion of the blood from its vessels, is shown even at an early stage of the disease, by a puffiness and oedema of the hands and feet, and by a progressive thickening of certain parts of the skin, as of the forehead, the nose, the lips, the lower part of the cheeks, and the ears. At a later period the tendency to transudation of the serous element of the blood is evinced by the production of a bulla upon one of the extremities. The first bulla probably appears on the foot; this is followed after a while by a similar bulla on the hand; later, the other foot and the other hand suffer in a similar manner. After some days the bulla bursts and gives exit to an opalescent albuminous fluid, possibly it fills again a second and a third time, and then the excoriation heals. It may be mentioned, in limine, that although the tendency to exu- dation, infiltration, and oedema, exists in both forms of leprosy, it is greatest in the anaesthetic form, and its presence in a considerable degree is pathognomonic of the latter variety of the disease. The tubercles of the tubercular form of the affection are disposed to soften and become converted into abscesses, which burst and heal, or degene- rate into chronic ulcers. But in anaesthetic leprosy, although there are no tubercles, there constantly occur elevated spots and blotches occasioned by serous infiltration into the tissues of the derma. These spots and blotches are transparent, as though the tissue were gelatin- ized, and may be regarded as showing a disposition to that surface transudation which constitutes a bulla. In an advanced'stage of tubercular leprosy, where the skin of the greater part of the body has undergone exanthematous congestion and thickening, ulcers of considerable extent are apt to take place, and an extremity may be robbed of its integument from the hand to the shoulder, or from the foot to the hip. So in the anaesthetic variety of the disease, the excoriations left by the bullae, which heal readily at first, may after a time become stubborn ulcers, constantly discharging a serous fluid, and refusing to heal. But in the anaesthetic form of elephantiasis, the ulceration does not assume a superficial character and spread along the skin, it sinks more or less deeply into the sub- cutaneous tissues, and seems to have for its object the excretion of a viscous and colorless fluid in great abundance. Concurrently with the pathological processes now described as taking place in the skin, the mucous membrane undergoes similar changes. The conjunctiva is more or less reddened, and, at a later stage, thickened and opaque, or transparent and anaemic. The mucous membrane of the nose is congested and thickened, producing obstruc- tion of respiration, expanding the nostrils and altering the voice; 524 LEPROUS AFFECTIONS. sometimes secreting an abundance of opaque mucus, occasionally streaked with blood, and not unfrequently offensive. The mucous covering of the mouth is spotted like the skin, the soft palate and pillars of the fauces are thickened and tuberculatec* the mucous glands of the pharynx enlarged, and the mucous lining of the larynx thickened and nodulated. The voice is hoarse, and the throat dry, and the patient is occasionally troubled with a short mucous cough. At a later period, there may occur ulceration of the thickened mucous membrane of the nose, throat, and larynx; while the occurrence of chronic diarrhoea and dysentery leads to the inference, supported by post-mortem examination, that there prevails an enlargement of the mucous glands of the alimentary canal and superficial ulceration. The nervous system, like the surface tissues of the body, partici- pates in the general evil; and it is worthy of observation that, in certain cases, the surface tissues principally suffer, while all but the peripheral plexuses of nerves escape, constituting tubercular elephan- tiasis; but in others the skin and mucous membrane only suffer secondarily, the chief force of the disease being thrown upon the nervous tissue, constituting anaesthetic elephantiasis. And as we have already had occasion to remark, a blending of the two series of symp- toms constitutes the mixed form of the disease. In neither of the two principal forms can it be said, that the skin and mucous mem- brane on the one hand or the nervous system on the other entirely escape; but the distinction is founded on a predominance of one or other of the two kinds of affection, peripheral or neurotic. In the tubercular form of the disease we rarely hear of pains; the patient is well, all but the outward signs of the complaint; he eats and drinks and sleeps well, and at an early period can scarcely be brought to comprehend the necessity for treatment. But, in the neurotic or anaesthetic form, we are admonished of pains, and painful sensations, and mental suffering, from the very commencement. In the early stage of the disease the pains are superficial, pricking, ting- ling, and shooting, associated with abnormal sensations of heat and coldness, tightness, constriction, heaviness, and numbness. In parts of the skin there is excessive soreness, sometimes as if the cuticle had been removed by a scald, constituting hyperaesthesia; while in other parts there is anaesthesia; and, at a later period, total loss of sensation in the part previously so abnormally sensitive. The legs, from the ankle to the knee, are commonly the first to show signs of insensi- bility ; while, at the same time, very possibly, the soles of the feet are hot and tender. In the first instance the pains occupy the cutaneous nerves, and are elicited by the nerves of sensation in every part of the skin; by the filaments of the fifth nerve in the face; by the cutaneous branches of the spinal nerves on the neck and trunk; and by the cutaneous branches of the nervous cords in the limbs. As the disease advances the deeper nerves are implicated, and then erratic and fugitive pains are felt shooting through the limbs, lasting for a while and then ceas- ing, to be again reproduced without apparent cause or warning. The nerves the more especially the seat of these morbid phenomena, after ELEPHANTIASIS GRJECORUM. 525 the fifth pair, are the cutaneous, the trunk of the ulnar nerve, and the cutaneous branches of the radial nerve in the upper extremity; and the cutaneous branches of the crural, the peroneal, and the posterior tibial in the lower extremity. These nerves sometimes acquire so great a degree of sensitiveness, that a slight pinch of the skin is ex- quisitely painful; and a knock upon the limbs thrills through the whole system like an electric shock. We may produce these sensa- tions at will, by pressing the ulnar nerve against the inner condyle of the humerus; and we are at the same time made aware that the trunk of the nerve is increased in bulk, that it is twice or three times larger than in its normal state, and that it may be seen as well as felt through the skin. Moreover, that here and there may be found knots or ganglia on the cutaneous nerves, which are equally painful to the touch. The researches of Danielssen and Boeck into the pathology of elephantiasis, have shown that the morbid changes which take place in the nerves are identical with those occurring in the skin; that, in the first instance, there is an erythematous hyperaemia or neuran- thema of the nervous sheaths; that a transparent, viscous fluid is transuded into the sheaths, separating the nervous 'filaments, and compressing them so as to disorganize their contents and eventually obliterate their tubules; that coincident with these processes the nerves enlarge to several times their normal diameter, and eventually shrink into discolored atrophied cords and threads. And we perceive* in these phenomena an explanation of the alteration of function which the nerves undergo; in their congested state, more sensi- tive than natural, tortured with pains when compressed and displaced by the transuded fluid, and paralyzed and reduced to insensibility by a continuance of pressure and consequent exhaustion of vital power. The same authors have pointed out, that the erythematous hyper- aemia is a true neuranthema, developed in circular spots, like the spots on the skin, and occurring at irregular distances on the trunk of the nerve, so as to give it somewhat of a nodulated or ganglionated character. The cutaneous fibrils are evenly swollen, and the nerves next affected are those which receive cutaneous branches, tne first points of congestion corresponding with the union of those branches with the main trunk; moreover, that the enlargement is greatest where most cutaneous branches unite with the trunk of a nerve. The color also of the nerves corresponds with the coloration of the skin ; in the early stage of hyperaemia the inner surface of the nerv- ous sheaths and the nervous fibrils have a pink and roseate hue ; later a deep and dusky red ; and, later still, when the nerves have passed into their insensible and atrophied state, they have a reddish-brown color, and the peripheral ramifications may be discerned as brownish streaks in the tissue of the skin. The morbid affection of the nerves in elephantiasis begins at the periphery, and follows the course of the nerves upwards to the nerv- ous centres, the spinal marrow and the brain. It is greatest in the posterior columns of the spinal cord ; and consists, as in the nerves 526 LEPROUS AFFECTIONS. and skin, of vascular congestion, thickening of membranes and transu- dation, followed by hardening of the nervous substance, and eventually shrinking and atrophy. Danielssen and Boeck, in severe cases, found the dura mater and the arachnoidean spaces distended with serous fluid, thick deposits of a whitish albuminous substance accumulated on the surface of the spinal cord, particularly its posterior segment; adhesion of the pia mater and arachnoid, forming a layer as thick and dense as the dura mater,, and a want of normal adhesion between the arachnoid and the substance of the cord; the latter, in some in- stances, being so much indurated as to creak like cartilage during its section with a knife. They found also a pathological condition, similar to that already described, of the brain and of its membranes, - transudation, thickening, hardening, and diminished vascularity. Deposits of albuminous lymph are seen in the sulci of the hemis- pheres, in the hollows around the ropts of the nerves; and the sheath of the Casserian ganglion is sometimes so much distended as to give the appearance of a small tumor at the base of the cranium ; while the distension of sheath follows its principal branches for a short distance in the course of their distribution. With the morbid anatomy of anaesthetic elephantiasis thus dis- played before our view, we are enabled to comprehend more clearly the semeiology of the disease, the hyperaesthesia, the anaesthesia, % the neuralgia, the perverted sensation of heat and cold the loss of muscular power, the disordered assimilation, the defective nutrition the imperfect sanguification, the metamorphosis of the red particles of the blood into melanic pigment, the anaemia, the loss of vision, of smell, and lastly, the mental torpor and incapacity. We can also comprehend another singular phenomenon of the disease, namely, the painless elimination of a bone of the foot or hand, or the amputation of a part of a limb. To go back somewhat in our description of elephantiasis, it must be remarked that one of the most frequent and commonest of the symptoms of the disease, is a puffiness of the hands and* feet, from oedematous transudation into the subcutaneous cellular tissue. In advanced stages of anaesthetic leprosy, it also happens that pains are felt in the foot or in the hand, that the pains are succeeded by the development of a bulla, and that, as the result of the exudation on the skin, the pains subside and are relieved. This process is repeated, one while on a foot, then on a hand, and the excoriated surface heals readily. Later in the course of the disease, the excoriation fails to heal, and an ulcer remains, which pours out a transparent or semi- purulent fluid in considerable quantity. The discharges from the ulcer evidently act as a source of relief to the general system, but in time the ulcer closes, a want of the accustomed issue is felt by the economy, and a second ulcer opens to supply the place of that which had healed. These ulcers have callous edges, a smooth, ungranulating surface, and are insensible to irritation. At a still more advanced period of the disease a fluctuating spot may be discovered on a toe, or in the sole of the foot; it breaks and pours out a quantity of semi- purulent matter, and after the escape of this matter, continues to dis- ELEPHANTIASIS GR^CORUM. 527 charge an abundance of a transparent albuminous fluid. Such an ulcer will sometimes heal, and another form, but it may also happen that, failing to heal, it may sink deeply into the soft parts and reach even to the bone. It is not improbable that a congestion of the capillaries, similar to that which takes place in the skin and in the sheaths of the nerves, occurs also* in the periosteum of the bones, and is attended with similar pathological consequences, namely, effusion of albuminous fluid and separation of the periosteum, resulting in necrosis and ex- trusion of the bone through the ulcerated opening. When this morbid process takes place on a toe or a finger, the first or second phalanx is destroyed and removed, leaving the last phalanx and the nail growing at its extremity. The affected member is necessarily shortened, and not unfrequently pulled out of its normal position, and more or less distorted by muscular contraction. When the ulcer takes place in the sole of the foot, a tarsal bone may in the same manner be lost, and the morbid process may be repeated first in one foot or . hand, and then in the other, and continued in similar succession until the foot may be amputated at the ankle-joint, or the hand at the wrist, and all this may be accomplished without pain or suffering to the patient, in consequence of the obliteration of the nerves, and the anaesthetic state of the part. Generally the ulcer is preceded by some degree of aching, but the discharges from its cavity relieve the pain, Fig. K. Hand of a lady affected with anaesthetic leprosy. and contribute very importantly to the comfort of the patient. It is remarkable how complete and symmetrical these amputations gene- rally are, how perfect the healing process which accomplishes the cure, and it is singular in some instances to find the cartilage of a joint blending in a firm and solid union with the integument.1 1 The Leper establishment on the He Curiense at Seychelles, affords the following striking illustration of the mutilations effected by the anaesthetic form of elephanti- asis. Of thirty-one patients, the following examples were presented : loss of both hands, 11; loss of one hand, 1 ; loss of fingers and toes, 27 ; loss of all the fingers 523 LEPROUS AFFECTIONS. In the anaesthetic form of leprosy, the ulcerative process sometimes attacks the face; the periosteum of the nasal bones takes on the morbid action, and the bones are discharged through an ulcerous opening; sometimes ulceration occurs in the cornea, the humors are let out, and the eyeballs collapse; but more frequently a dense muco- purulent secretion concretes on the conjunctiva; the eyelids being kept permanently apart by contraction of the surrounding skin, ectro- pium is produced ; and the lower lip is drawn down so as to expose the gums, which are also covered with a dry squamous crust, while the saliva flows from the angles of the mouth, and the tears from the eyelids. Reverting to the beginning of elephantiasis and the period during which the poison is present in the system without giving rise to any manifestation of its existence, it is evident that this, the latent period of the disease, extends over many months, sometimes, not improbably, over years. The next period, the period of evolution or eruption, the exanthematous period, may be occasioned by the mere force of the dis- ease, or by some accidental cause producing a febrile erethism of the system; hence the evolution may be partial, perhaps limited to a single spot; it may be slow and progressive, or it may possess some degree of energy and show itself more extensively. Sometimes it is preceded by a true exanthematic fever, that may equal in intensity a rubeola or a syphiloderma. Like the exanthemata, the febrile symp- toms subside when the efflorescence has appeared on the surface, and the attack might be mistaken by those not familiar with leprosy, for a rubeola, a roseola, a scarlatina, or a secondary syphiloderma. It is curious also to note, that not only are the constitutional symp- toms relieved by the outbreak of the exanthema, but the fever having subsided, is not again renewed for several, sometimes for many, months or years. At other times the fever is repeated at shorter in- tervals, such as a month, and recurs with regularity, suggesting, with its accompanying symptoms, namely, chills followed by heat, an inter- mittent fever. The febrile period commonly lasts for a week, some- times for two or three weeks, and then suddenly subsides; occasion- ally it may be protracted to a longer time, and raise a suspicion of continued fever. The common symptoms of the febrile period are chills, succeeded by burning heat without perspiration; sometimes perspirations without sensible heat; somnolency during the day; rest- lessness at night; inaptitude for exertion ; mental dejection; headache; dry mouth and throat; thirst; and total loss of appetite. To these symptoms are sometimes added, fugitive shooting pains, unpleasant dreams, and nocturnal emissions. Associated with the infiltration of the subcutaneous cellular tissue of the feet and hands, and the tendency to infiltration and gelatinifica- tion of the blotches, is the existence of albuminuria. But this symp- tom does not seem to alter in any way the condition of the patient, it and toes, 6 ; loss of nearly all the fingers and toes, 6 ; loss of fingers only, 4 ; loss of toes only, 4; loss of sight, 4 ; falling in of the nose from destruction of the bones, 3; ulcers, 16; and tubercles of the face, only 3. In this same community were eighteen unaffected persons. ELEPHANTIASIS GR.ECORUM. 529 neither adds gravity to the disease nor increases the debility of the patient, and it appears and disappears without any apparent conse- quences; while post-mortem examination discovers no more serious alteration in the kidneys than is met with in other organs. Post-mortem examination of those who have succumbed to leprosy shows that the skin, the mucous membrane, the subserous tissues, the spleen, the liver, and the kidneys, are the structures the most injured by tubercular leprosy ; while in the anaesthetic form of the disease, the nervous system, the serous membranes, the muscular system, as also the liver, kidneys, and spleen, exhibit a morbid state ; the lymphatic system being slightly deranged in both. In the former, infiltration of tissue gives rise to an apparent hypertrophy; while the latter is associated with anaemia and atrophy. In tubercular elephantiasis, thickening and ulceration of the mucous membrane is met with in the conjunctiva, Schneiderian membrane, buccal membrane, membrane of the fauces, larynx, and pharynx; and the glands of the intestinal mucous membrane are enlarged and ulce- rated, producing chronic diarrhoea and dysentery. The spleen is en- larged, the liver fatty, with tubercular deposits covering its surface ; there are similar deposits in the subserous tissue of the uterus and broad ligaments; and the kidneys are flabby and congested. In an- aesthetic elephantiasis, besides the morbid appearances already noted in the nervous system, the mucous membrane of the stomach and alimentary canal is anaemic and pale; and there is a pervading atro- phy of tissue both in the organic and in the muscular system. As we have said, anaesthesia is present in both forms of the disease, but is greatest in the anaesthetic form; and in the latter is associated in a greater degree with loss of muscular power, defective nutrition, and declension of animal heat. The insensibility of the skin some- times precedes every other symptom, and is the first that attracts the attention of the patient to his state ;* and it is apt to run on until a lighted taper may be held to the skin without being felt. Strong caus- tics may be applied to ulcers; parts may be divided or incised; even amputation at a joint may be effected, without the slighest suffering or inconvenience being evinced. Loss of muscular power is first exhibited in the hands and in the feet; the fingers and wrists lose their strength ; the fingers are commonly taper and thin, and the interosseous spaces hollow from atrophy of their muscles. The weakness of the feet is shown by a loss of confidence in walking, and a fear of stumbling. Defective nutrition is declared by the emaciation of the whole frame, the yellowish and purplish hue of the skin, and a general appearance of cachexia. While the reduction of animal temperature is proved by the experiments of Danielssen and Boeck, who found the mercury in the thermometer stand at twenty degrees of Fahrenheit below the 1 One of our patients, had his attention first draw$ to his disease by the fall of boiling water on his arm, without occasioning sensation. And Dr. Nichobon, of the Leper Hospital at Tracadie, in New Brunswick, observes : " I have known one of tlin patients in the hospital burn her hand and arm severely at the stove without being aw;viv of the injurv until told of it by one of the patients." 31 530 LEPROUS AFFECTIONS. normal standard, when held in the hands; and nearly five degrees when placed in the mouth, arms, axillae, and groins. Elephantiasis is brought to a fatal termination by asthenia and apncea; and sometimes possibly by coma. Asthenia may be induced by chronic diarrhoea or dysentery, or by the progressive atrophy of the nervous system; apnoea, by thickening and ulceration of the mucous membrane of the larynx ; and coma, by suspension of function of the kidneys, or serous effusion into the cranial cavity. The aver- age duration of life in the two forms of the disease, as stated by Danielssen and Boeck, is for the anaesthetic kind upwards of eighteen years, and for the tubercular kind less than ten years. Of twenty- four cases of anaesthetic leprosy, twelve survived more than twenty years, and one thirty-one years; and of eighty-eight cases of tubercu- lar leprosy, fifty-four ranged in duration from six to eleven years, and one survived twenty-two years. The relative proportion of the two forms, of the disease, as deduced from the observation of 1468 cases was, tubercular, 758; anaesthetic, 488; and mixed, 222. Ngerengere and tuwhenna are the native names of a disease of New Zealand analogous to anaesthetic leprosy, and described by Dr. A. Thomson1 under the title of lepra gangraenosa. The disease begins in the lower limbs with desquamation of the cuticle, and spreads more or less extensively over the body. Sometimes the skin becomes cracked and fissured, and sometimes presents signs of considerable irritation. Many months later, and sometimes after an interval of several years, the skin of the face, and especially of the forehead, nose, and lips, becomes bloated and shining; the hair of the eyebrows, eyelids, whis- kers, and beard falls off; and the face and skin assume a pallid hue, mixed with a purple tinge. At a later period, a bleb or fissure forms in the joint of a phalanx of the hands or feet; ulceration follows, and sinks deeply into the part; the joint gives way, and the phalanx separates without pain. This process is repeated on other fingers and toes; then invades the metacarpus and carpus, the metatarsus and tarsus; and the hand or foot becomes separated without suffering to the patient. Dr. Thomson further reports that the general health of the patients is little disturbed, and that they seem cheerful and comfortable. The disease begins at puberty, or between that period and the age of thirty, and terminates fatally in from one to eight years; the fatal issue being determined by affection of the air passages or diarrhoea. The patients seen by Dr. Thomson were highly scrofulous. In this short narrative we find condensed the common history of elephantiasis anaesthetica. There is no ground for the term gangrae- nosa, applied to the disease by Dr. Thomson; the mode of separation of a member at the joint being identical with that which takes place in ordinary anaesthetic ltprosy (elephantiasis mutilans). The presence of anaesthesia in the progress of the disease appears to have been over- looked ; although it must necessarily have been present. 1 Brit, and For. Medico-Chirurg. Review, April, 1854. CASES OF ELEPHANTIASIS. 531 CASES OF ELEPHANTIASIS. About twenty-five cases of elephantiasis Graecorum have come under our own observation, of which we have preserved the notes of twenty- four. Twenty-two of these cases were those of Europeans, and one a native of Hindostan; the special source from which the cases were derived being: from the East Indies, including the islands of Ceylon (one) and Mauritius (five), twenty; one from China; and from the West Indies, three. Twenty were males, and four females ; the age of origin ranging between seven years and sixty-seven, and the duration of the disease ten years. These cases illustrate the three periods of the disease, namely, its latent period, its febrile period, and its persistent period, together with its chief varieties of manifestation, namely, neurotic or anaesthetic, cutaneous or tubercular, and mixed tubercular and anaesthetic. One of the cases fixes the attention on a remarkable resemblance between elephantiasis and syphilis, and suggests a comparison with the latter disease, and at the same time raises the question of the possibility of contagion by syphilitic inoculation; while others point to ordinary sexual connection, to vaccination, and lactation, as possible means of transmission. Case 1.—Elephantiasis tuberculosa; no pains; febrile attack stimulating rubeola ; vaccinated from a native child; latent period, two years; present duration, five years ; patient living and enjoying average health. A young gentleman (E. W. P.), aged sixteen, with fair hair and complexion, and somewhat more youthful in appearance than might be expected of his age, has been afflicted with the tubercular form of leprosy about five years. He was born in Ceylon, is the son of European parents, and one of six children, all of whom are healthy. His father and mother have always enjoyed good health, the father having resided in Ceylon for twenty years, the mother since her mar- riage. He was nursed by his mother, but vaccinated with lymph taken from a native child. Our patient was sent to England for his education at the age of nine; he had suffered from dysentery while in Ceylon, but had reco- vered, and was in good health on his arrival in this country. About two years after this period his mother remarked an alteration in the appearance of his countenance; it was pallid, had a yellowish-brown tint, and was somewhat spread out, as though the features were enlarged and flattened; he shunned amusements, was fond of sitting alone and secluding himself, became remarkably timid, and had fre- quent fits of crying. There was no alteration in the animal functions, and no suspicion of his being out of health, his peculiar habits being attributed to idiosyncrasy rather than to disease. In March, 1863, being then thirteen years and three months old, he was seized with an exanthematous fever, which was regarded as rubeola, and which con- fined him to his room for fourteen days. There was nothing unusual in the febrile symptoms; he was chilly and sleepy, had headache, thirst and loss of appetite, and being sent to bed, an exanthem ap- 532 LEPROUS AFFECTIONS. peared upon his body, chiefly, he thinks, on his legs. He does not remember if he had coryza and catarrh, but he was the only boy in the school seized with the disorder; and the spots which then broke out upon his skin became permanent, and have remained until the present time. His face and the uncovered parts of his neck are of a reddish-brown hue, contrasting strongly with his light hair and the normal fairness of the skin; the deepest shade of brown, with a yellow tinge, is apparent on the forehead, and a roseate and purplish tint plays about his nose and ears. His hands are deeper in color than his face, and are of a blackish-brown or bronze color. These are the three varieties of color commonly met with on the skin in this disease, namely, a brown, which is sometimes reddish (copper color), sometimes yellowish or tawny, and sometimes blackish or melasmic, or bronze- colored. On removing his clothes the brown tint was found rising up the arm to the shoulder, and from the foot to the groin, becom- ing lighter in its ascent, and leaving the trunk of the body of its normal fair complexion. The feet are of a livid brown color, and always cold. The skin of the face is of an uniform tint; there are no maculae; but there is an evident swelling or thickening of the integument, which has altered the natural appearance of the features. The brow is somewhat heavy, the alae of the nose spread out, and the ears promi- nent. The pores of the skin, also, are more apparent than usual, from hypertrophy of the intermediate skin. But a more striking character perceptible on the face is a crop of small tubercles, two lines in diame- ter, and one in elevation, sprinkled over the surface. About forty of these tubercles are dispersed upon the forehead, a cluster of fourteen being situated just above the root of the nose. A few of the tubercles are three lines, and three upwards of four lines in diameter. The smaller tubercles do not differ in tint of color from the surrounding skin; but the larger ones are semi-transparent, as though gelatinized, and traversed by three or four minute venules. There is also an inci- pient nodulation of the anterior border of the helix of the external ear. The eyebrows are scanty and thin ; there is a general baldness of appearance of the face; and the conjunctiva is pallid and traversed by large venules. There are no signs of disorder of the mucous mem- brane of the nose, mouth, or fauces; but the voice is weak and some- what altered from its natural tone: The tubercles on the face were originally maculae of a pale pink color, and were not elevated into their present shape until a year after the supposed rubeola. Similar spots were apparent on the lower limbs during the rubeolous fever, and are now to be seen on both lower and upper extremities, together with a faint roseolous rash on the front of the chest and abdomen. The circular maculae dispersed on the arms and legs have a reddish and yellowish-brown tint; they are slightly elevated by transudation into the tissue of the corium, and larger on the legs than on the arms; for the most part isolated, and having an average diameter of some- what more than two lines, they are here and there collected into cir- cular blotches, measuring nearly half an inch in diameter, and are CASES OF ELEPHANTIASIS. 533 variously elevated, according to the amount of oedematous infiltration. They are scantily dispersed over the scapula, are numerous at the point of the shoulder and the back of the upper arm, but most abund- ant on the forearm, and are absent on the hands, their place on the latter being occupied by the bronzing of color already mentioned, and by a puffy oedema of the back of the metacarpus, more particularly at the radial side. On the lower extremities there is a cluster of raised maculae over the buttock, a few on the upper part of the thigh, but many on the leg; and the instep, like the back of the hand, is puffed by oedematous infiltration. The maculae are numerous on the sole of the feet, and the integument near the root of the toes is some- what oedematous and benumbed. As we have already noted, there is no melasmic pigmentation of the skin of the trunk of the body; and the front of the chest and abdomen presents a faint roseolous mottling. Turning to the mucous membrane, we find the conjunctiva pale on the inside of the lids, but congested on the eyeballs. He has had a feeling of " stuffiness" of the nostrils for about two years, and is sub- ject to frequent attacks of catarrh. About six months back the mucus from the nose was streaked with blood. The mucous lining of the fauces is normal; and no change is visible in the neighborhood of the glottis to account for his change of voice. His tongue is clean and appetite good, but he suffers occasionally from what he calls bilious attacks. The abdominal organs are apparently healthy, and his general condition is normal. He has had no pains or aches of any kind, nor any indication of affection of the nervous system, beyond a feeling of numbness in the sole of the feet; a numbness that extends up the right leg to the hip, and a constant coldness of the feet. These are symptoms which have scarcely attracted his attention, but may be the beginning of neurotic disorder. He sleeps well, without dreams or discomfort; and although greatly depressed in spirits formerly and frequently weeping, he is now applying his mind cheerfully and hope- fully to the study of the classics preparatory to commencing a pro- fessional education. It cannot be questioned that this is a case of tubercular elephantiasis, for the skin and mucous membrane are almost solely attacked; there have been no neuralgic pains, and only a very trifling affection of the cutaneous nervous system. It must be noted also that the tubercles are not whitish, as they sometimes are in tubercular leprosy, but transparent and yellowish, the tissue of the skin having undergone a gelatinous metamorphosis, common in this affection, and met with also in tubercular syphilis and lupus non exedens and erythematosus. We Jiave remarked above that the semi-transparent tubercles are streaked on the surface by the straggling trunks of several minute veins. This case is also interesting as exhibiting the insidious and progressive character of the invasion of elephantiasis. With the exception of the rubeoloid attack nearly three years ago, he has suffered no febrile symptoms whatever. Case 2.—Elephantiasis tuberculosa; ten years'1 duration; neu- ralgic pains; cutaneous anaesthesia; partaking of the character of the 534 LEPROUS AFFECTIONS. mixed form, the tubercular being in excess; a brother died of mixed leprosy. A young man (G. L.), aged eighteen, the son of European parents, was born in Bombay, and resided in that city until April, 1865, when he was sent to England for his health. His father went to India from England at an early age, and held a civil appointment in that country; his mother was born in India of European parents. The father was twice married, and had children by both wives; seven by the first, four by the second. The mother was also married twice, and by her former husband had four children. She died at the age of thirty-two, of disease of the liver; and the father died at forty-nine, of disease of the thoracic organs, when our patient was one year old. Of the three sets of children, the two first families were healthy; and of the last, four in number, the eldest and the youngest became the subjects of elephantiasis; the two intermediate children, a brother and a sister, remaining sound. The eldest son died of mixed elephan- tiasis, at the age of twenty-three; the youngest is the patient whose case we are now recording. Our patient had good health as a child, and underwent the opera- tion of vaccination with success. At the age of seven or eight, while at school, and without previous illness, he first perceived a brown spot or blotch upon the left forearm; subsequently a similar spot appeared upon the outer side of the right leg; and after an interval, on the inner side of the left knee, and afterwards on the thigh. With the exception of the spot on the right leg, the right side of the body remained free until ten years later; the spots were more numerous on the lower limbs than on the arms, and occupied the region supplied by the cutaneous branches of the crural nerve in the leg, and the internal cutaneous nerve in the arm. Subsequently to these appear- ances on the limbs, numerous small spots of the size of a small wafer appeared upon the face and entire body. Having his attention drawn to the occurrence of spots upon the skin, he noticed that their color at the first appearance was a "beau- tiful pink;" that by degrees they assumed a purple tint, and subse- quently faded to a dirty brown. At the present time there are examples of these shades of color, excepting the early pink, on differ- ent parts of the body. There is a slightly elevated tumor of about an inch in diameter upon the left cheek, the surface of the tumor being mottled with pink and purple; and a swelling over the ball of the thumb has the same tints, resembling a large chilblain. A similar swelling on the inner side of the left calf is knotty, and involves the saphenous vein, and the femoral glands on that side are enlarged. The color of the principal spots may be compared to that of the mul- berry, and when chilled they have a leaden hue. The swelling of the blotches is a recent event, and did not occur until a year back, after he had become affected with chancre, and was salivated for its cure. During this treatment he,was feverish and ill and lost his appetite. He then had pains "in the flesh;" these pains were followed by redness and swelling, and by degrees the pain CASES OF ELEPHANTIASIS. 535 ceased. The attack of pains was periodical, occurring once a-month ; he lost them, however, during his voyage to England, and regained his appetite; but having become wet and chilled during the late in- clement weather of October, the pains have returned. They are not deep seated, but simply cutaneous, " pains of the flesh," as he terms them; and he remarks that they had increased in severity at each recurrence. During the prevalence of the pains in his flesh he has some degree of feverishness, which comes on in the evening, with chilliness; and while m bed is followed by burning heat; but he has no perspiration, and his skin is commonly dry. When suffering from these feverish attacks he loses his appetite. He has also been troubled since he left India with nocturnal emissions; they take place for two or three nights in succession, and after a similar interval, and sometimes occur twice in the course of the night. In the interval of the feverish periods and the cutaneous pains, his spirits are cheerful; he reads, he sees sights, and he enjoys himself. He sleeps well at night, and has no drowsiness during the day. He was taken from school at the age of fifteen, in consequence of the ill- ness under which he now suffers, and was put into a merchant's office, where he remained until his present visit to England. In general appearance he is short and thin; his head somewhat large for his body, and the face pale and tawny. The expression of his countenance is dull and dejected ; the skin is thickened and rough- ened by small whitish tubercles of about the size of a split pea, which have shown themselves during the last month, and the spaces between the tubercles mottled with a dirty brown tint. The only hair on his face, with the exception of the eyelashes, is that of his eyebrows, which are thin and scanty. • On close inspection the integument of the forehead is seen to be thickened and nodulated, particularly in the region of the eyebrows. The eyes are dull, the conjunctiva pale, the nose enlarged and nodu- lated, the cheeks are also thickened and nodulated, and the ears pre- sent the same character. The heavy brow gives a pensive thought- fulness to the face, and reminds us of the leonine countenance charac- teristic of leprosy. Numerous small whitish tubercles of the size of a split pea are dispersed over the whole face; and on the left cheek is a large prominence looking like a subcutaneous abscess,, mottled with red and purple. This prominence is affected with the periodical pains already described, but is not tender to the touch; on the contrary, it evinces a degree of anaesthesia, which is also met with in the similar swellings on his legs and arms. At a subsequent period this promi- nence formed matter and broke, and afterwards healed readily. It is evident that the manifestation of the disease has been accom- panied by an arrest of development of the body generally, and the check to development is especially shown by the non-production of hair, not only on the face, but upon the entire skin, with the excep- tion of the head and pubes. We have already remarked on the thin- ness of the eyebrows, which gives a bald appearance to the face; and 536 LEPROUS AFFECTIONS. he informs us that his brother lost the hair of the pubes previously to his death. Our patient's voice is puerile and weak, and somewhat hoarse, indi- cating thickening of the mucous lining of the larynx ; the columnar folds of the pharynx are red and swollen ; he has a sensation of tick- ling in the fauces, and an occasional slight cough, which raises a quantity of mucus. He complains of a bad taste in his mouth, the lips and tongue have a feeling of soreness, and the latter is pink towards the tip. The hoarseness has been evident for about a year; the affection of the mouth is recent. His most annoying symptom, however, is a sense of fulness and dryness of the nostrils, which commenced eight months back. This inconvenience has gone on increasing, and within the last week has been accompanied with the discharge of a small quantity of clotted blood. There is evidently considerable swelling and thickening of the lining membrane of the nostrils, and possibly some slight degree of ulceration ; but, with this exception, there is no excoriation of any part of the surface of the body, and no tendency to the formation of blisters on the skin. He sees and hears well, and his appetite is good, excepting on the invasion of feverish symptoms and pains. The pains are in kind shooting and aching, and are always followed by an increase of swell- ing and congestion of the inflamed blotches, of which there are four or five dispersed over the body. Some of these blotches, of longest duration, are beginning to show signs of anaesthesia; but the insensi- bility is superficial and moderate in degree, and there is slight anaes- thesia and loss of power of the left hand. The hands are mottled blue and brown, and somewhat swollen, while on the inside of the wrist and ball of the thumb of the left hand is a swollen tuberculous blotch. The soles of the feet are covered with small brown spots as large as lentils, and some of these spots have recently been developed into whitish tubercles. In summing up the special characters of tubercular elephantiasis, as presented by this case, we are struck with the chronicity of its nature, already ten years in existence, and so little progress made; then its first appearance as a single dark colored spot, followed slowly by other similar spots; next, the periodical attacks of fever of no great severity, preceding pains in a circumscribed patch of integu- ment; then the roseate blush, the tumefaction, the purplish tinge, and the deep brown stain. These symptoms repeated at longer or shorter intervals for years, and succeeded by a moderate amount of anaesthe- sia, but as yet no leucasmic change. Next, the signs or morbid action in the mucous membrane; the hoarseness of voice; the dryness and obstruction of the nares; the nodulated thickening of the integument of the forehead, cheeks, and ears; and the production of whitish tuber- cles. Moreover, the arrest of development and growth, and the absence of hair. Case 3.—Elephantiasis tuberculosa; four years' duration; no pains; extreme chilliness ; extreme mental dejection. A young gentleman (J. T.), aged twenty-one, born in Jamaica of CASES OF ELEPHANTIASIS. 537 European parents, was brought to us in 1850, affected with tubercular ' leprosy. He had been sent to England in 1846 for his education; he arrived in September ; the winter was severe, and he suffered very much from the cold. During the following year he first observed reddish-brown maculae on the legs below the knee; a year after they appeared on the face, and twelve months later spread to the trunk. With the development of maculae on the limbs and body, the face, the hands, , and the feet, became discolored ; the face had a deep reddish-brown hue: the hands were of a blackish-brown color, the discoloration extending up the arms to the shoulders, and becoming fainter in its ascent; the feet were also deeply colored a livid blackish-brown, and the color rose upwards to the top of the thighs, being deeper below the knee than above. With the completion of the maculation of the body, the skin of the face and especially of the forehead became coarse and thickened, tubercular elevations were produced along the eye- brows, upon the nose, lips, and chin, and upon the prominent ridges of the ears. The thickening of the integument of the brows gave a frowning and dejected expression to the countenance, the appearance of dejection being increased by the •presence of a leaden or purplish tinge. The skin was as though pricked over with depressed points, the mouth of the follicles; while the interfollicular portion was puffed and semi-transparent, and suggested the idea of the rind of an orange. The tubercles were firm to the touch, and somewhat more transparent than the surrounding skin. He had no whiskers or beard, and the hair bad fallen from the eyebrows. Close examination of the maculae showed that the lining of the fol- licles was more deeply tinted than the interfollicular spaces, a condi- tion that gave a spotted character to the maculae. The skin was shining as though from a greasy moisture; but nearer inspection showed that this appearance resulted from tumefaction of the corium; that the maculae were really drier than the rest of the skin, and defective in perspiration and sebaceous secretion, and that, as a con- sequence, the face was liable to be much irritated by the rays of the sun. The maculated portions of the skin were also deficient in sen- sation. The mucous membrane of the eyelids and mouth was paler than natural, the conjunctivae were suffused, the nares somewhat obstructed, and the voice was weak and husky, as though from thickening of the lining membrane of the larynx. He was much depressed in spirits, and incapable of applying him- self either to amusement or study; his manner was listless and melan- cholic, while the redness of the conjunctiva, combined with the heavy brow and severe expression of feature, gave an occasional gleam of savageness to his countenance. He was not troubled with pains of any kind, but his hands and feet were habitually cold, even in the summer time; indeed, he suffered more from cold during the summer than the winter, and his favorite haunt was the fireside. His hands, besides being deeply bronzed, were slightly puffed on the back ; the fingers were attenuated, there was a visible loss of substance of the 538 LEPROUS AFFECTIONS. interossei muscles of the metacarpal spaces, and loss of power of the fingers and wrists. The general health of the patient seemed good; he had a fair appe- tite, and the functions of the body were properly performed. He was behindhand in sexual development and instinct. We were unable to follow the history of this patient further in con- sequence of his leaving London. Case 4.—Elephantiasis tuberculosa ; no pains; extensive ulce- ration of the skin ; ulceration of the mucous membrane; incipient leucas- mos ; fatal issue in ten years. A young lady, the daughter of European parents, residing in the island of Mauritius, was brought to us in the summer of 1852, suffer- ing under tubercular leprosy. Her countenance was pale, broad, and bloated, of a yellowish-brown color, with a purplish, almost livid, blush on the nose, cheeks, and chin. The brow was heavy and frowning; the eye sunken, anaemic, and glistening; and the general expression of the features listless and melancholy. Her hands were thin, the fingers taper, and, with her feet, were deeper in tint of color than the face, the discoloration extending upwards upon the limbs. On the arms and legs were scattered a number of round ma- culae, about half an inch in diameter, and of various tints of color. They had come out successively, were flat and smooth on the surface, but hard to the touch, both the hardness and the color becoming grad- ually diffused in the surrounding skin. The most recent of the macu- lae had a delicate roseate tint; this became deeper with time, purplish and livid. In some the redness had entirely disappeared, and a deep brown stain remained behind ; and in three or four the centre of the macula was undergoing a process of bleaching (leuce), and formed a pale disk, surrounded by a halo of dark brown, fading at the circum- ference into the general tint of the neighboring skin. There was, besides, a feeling of numbness of the limbs, a loss of sensation in parts of the skin of the legs just above the ankle, and on the older maculae, more particularly those that had undergone the melasmic and the leu- casmic change, and an arrest of perspiratory secretion. The disease had probably existed in a latent state for some time before it was observed ; the first symptoms that were noticed were the exanthematous spots, which immediately followed a slight intermittent feverishness of a few days' duration. With the development of the spots the feverish symptoms subsided, but new spots were thrown out- from time to time without the recurrence of the febrile affection. The spots had first shown themselves two years before the time of our see- ing her; and at the latter period she had no constitutional symptoms of any kind, excepting some degree of paleness of mucous membrane approaching anaemia; coldness of extremities, inappreciable to her- self; and a certain listlessness, heaviness, sleepiness, and indisposition for exertion of every kind. After an absence of six years we again saw this young lady, and found that the disease had made serious progress. The face was covered with tubercles, her complexion was yellowish-brown, the frowning eyebrows had lost their hair, the conjunctivae were anaemic / CASES OF ELEPHANTIASIS. 539 and glassy, the eyelids were drawn widely open, the hair of her head was scanty, and presented a state of alopecia, the lobes of the ears were enlarged, her limbs thin and shrunken, and her hands and feet wasted, and fingers attenuated. She died two years later, at the age of seventeen. She suff'ered no pain, and seemed to have no idea of her repulsive state. During the latter months of her life her vision was weakened, she had ulceration of the larynx, ulceration of the integument of the arms extending from the shoulders to the wrists, the legs were oedematous, the urine albuminous, the feet ulcerated, thick ichorous and semipurulent matter oozed from large openings in the face, and her failing powers were ultimately exhausted by diar- rhoea and dysentery. Case 5.—Elephantiasis tuberculosa ; insidious invasion and progress ; fever of intermittent type; sharp exanthematous fever. A gentleman (B.), aged forty-three, a captain in the Indian army, who had resided in that country seventeen years, noticed while in Scinde, about the tenth year of his Indian service, a spotted discol- oration of the skin of his limbs, accompanied with a brown discolora- tion of his hands, feet, and face. He was otherwise in good health, and performed his military duties without inconvenience. Four years later he suffered from a successsion of feverish attacks, intermittent in their character, which progressively increased in severity for two years, and rendered it necessary that he should return to Europe for relief. He describes his symptoms at that period as being a constant state of fever, with exacerbations and rigors every other day. For these symptoms he was sent to Kissin- gen, and after a course of the waters, had an attack of his old symp- toms of greater severity than usual, accompanied with some cerebral disturbance, which he called a " determination of blood to the head." After a few days of this severe exanthematous fever, numerous fresh spots appeared on the body and limbs, while the spots on his forehead and face were raised into small tubercles. The fever then subsided somewhat suddenly, and he had had no return of the fever- ish symptoms up to the date of this report, namely, a year and a half. His application to us had reference to the maculae on the skin generally, and the maculae and tubercles on the face. He considered his health to be good, and looked upon the feverish attack at Kissingen as a bath crisis; his only present complaint was coldness of feet and hands, which was as troublesome in summer as in the winter season. His face, his hands, and his feet, at this period, were of a deep purplish-brown hue; the discoloration extended up his limbs for some distance, and half way down his neck; but the trunk of the body had not undergone the same melasmic change although it was sprinkled over with small round maculae and blotches of various size. Along and immediately above the eyebrows were twelve or fourteen prominences at each side, of about the size and elevation of a split pea ; in the lower part of the skin of the fore- head, and towards the inner end of the eyebrows, the tubercles were isolated ; along its outer half they were clustered and confluent. On close examination the tubercles appeared to be whitish and semi- 540 LEPROUS AFFECTIONS. transparent, and streaked by the ramifications of several small venules, the cuticle covering them being of a dark color like that of the sur- rounding skin. The hair of the eyebrows was thin and absent on the tubercles; while the dusky hue of the skin of the forehead, and the heavy frown of the rugous and hairless eyebrows, gave a strongly marked leonine character to the countenance. The hands were thin, the interosseous muscles of the metacarpus shrunken, particularly those of the first metacarpal space. The fingers had a leaden hue, and the skin was smooth and polished, shining with the metallic lustre of lead or oxidized silver. On the limbs some of the blotches were raised by infiltration and semi-transparent; others had undergone partial absorption, and were collapsed and wrinkled ; but all the older blotches were dry, from the absence of cuta- neous secretion, and less sensitive than the surrounding integument. Case 6.—Elephantiasis tuberculosa ; insidious invasion and progress ; no pains ; no fever ; death in six or seven years. A gentleman (Mr. O), in the judicial service of India, aged about sixty, who had resided in the East for upwards of twenty years, con- sulted us in 1857 for tubercular leprosy. The whole face including forehead, cheeks, nose, lips, chin, and ears, was studded with opaque tegumentary tubercles of about the size of a split pea, a few being larger. There were also a number of maculae dispersed over the limbs, and some on the body. He considered his bodily health to be good ; he had suffered no illness of any kind, and he consulted us only for the eruption, which had made its appearance two years before, and had somewhat in- creased. He was listless and dull in his manner, and seemed incredu- lous of any aberration of health, ascribing his want of energy to the exhaustion consequent on a residence in India for many years. We lost sight of this gentleman a few months after his first visit, and have since heard of his return to India and death ; the duration of the disease being six or seven years. Case.—Elephantiasis tuberculosa ; insidious invasion and pro- gress ; extreme dejection ; smart febrile attack ; leontiasis. A captain in the Indian army (Captain G.) who had served through the mutiny, first observed symptoms of tubercular leprosy in 1857, and came before us for consultation in 1860. At this period his face presented a deep melasmic discoloration, and was covered with tu- bercles, which gave a frowning and morose expression to his counte- nance. The conjunctiva was reddened by congestion; his feet and hands were dark brown and purplish in color, cold and swollen. The limbs and body were sprinkled over with maculae; his voice was husky, and his manner dejected, listless, and melancholy. He was sleepless and restless at night, and during the day would sit for hours in his chair without occupation, and without exhibiting any inclination for exertion. He had a severe febrile attack, resulting as usual in an increase of the exanthema and greater prominence of the tubercles while under our care, and presented a good example of the kind of countenance, CASES OF ELEPHANTIASIS. 541 sombre and frowning, which has been compared to that of the lion, and has gained for the disease the synonym, leontiasis. This gentleman left London after a few months, and we were unable to follow his case further. Case 8.—Elephantiasis tuberculosa; satyriasis; red leprosy, intermittent febrile attacks; neuralgic pains; anaesthesia; ulceration; death from chronic diarrhoea and dysentery; duration of disease fourteen years. A colonel (Colonel B.), aged about sixty, who had spent many years in the West Indies, became the subject of tubercular leprosy about ten years before he came under our notice in 1856, and died of ex- haustion from dysentery in 1859. The disease had existed altogether about fourteen years; and he believed it to have arisen from sleeping in an unclean bed in a negro's hut. The appearance of this gentleman was very remarkable, his coun- tenance resembling that of the satyr, as represented in the paintings of the old masters, and suggesting an explanation of the use of the term satyriasis, as applied to this disease. His features were large and of a deep red brown or copper-color (totvi*^ vovaoi} Hippocrates); the forehead deeply wrinkled and studded with tubercles, two of the tubercles at the upper angles of the forehead resembling young horns ; the brow was thickened, heavy, frowning, and deprived of hair; the eyes suffused with redness; the nose, lips, and chin sprinkled with tubercles; the cheeks hollow; and the ears tuberculated, projecting, and singularly elongated. His voice was hoarse and sonorous; his speech indistinct; he breathed noisily through the larynx and nose; was extremely deaf, and the mucous membrane of the fauces was covered with small tubercles, some in a state of ulceration. His hands were of a dark color and swollen, the discoloration ex- tending upwards to the shoulders; the trunk of his body was spotted with large yellowish-brown blotches, composed of an aggregation of maculae, the interspaces of the blotches being mottled with separate maculae. His arms and legs were similarly spotted, and the feet swollen, oedematous, and somewhat insensible. Moreover, on the heel of one foot was a large superficial ulcer, which was insensible to the touch or the application of caustic, and which poured out a copious glairy albuminous and semi-purulent secretion. During the four years he was under our observation he had repeated febrile attacks, accompanied with neuralgic pains of a fugitive cha- racter, and followed in each instance by an augmentation of the exan- them and an increase in the number of the tubercles. He died of asthenia, consequent upon chronic diarrhoea and dysen- tery. Case 9.—Elephantiasis an^esthetica following vaccination; in- sidious invasion; suspension of symptoms during pregnancy; neuralgia; vesication; leucasmos; anaesthesia ; death from illness folhwing a second pregnancy. A lady, aged twenty-six, the wife of an officer of the Indian Army, became affected with elephantiasis in 1861. She was born in Cal- cutta of European parents, and brought to England when two years 542 LEPROUS AFFECTIONS. old; she returned to India in 1853 ; was married in 1855; has been eight years married, and has now (1863) revisited England for medical treatment; the length of her residence in India being ten years. In 1861, being then in Oude, she was vaccinated from a native child, and shortly after the vaccination " a slight spot came on her cheek, and increased in size to the diameter of a shilling." It was hard to the touch, a little raised above the level of the surrounding skin, and of a dull red color, without pain or tenderness. The swelling was painted with iodine, and afterwards blistered several times, and the blister kept open; but although somewhat reduced in size, the promi- nence was not removed. About six months later, dull red flat spots appeared dispersed over the greater part of her body. Her hands and feet became swollen, and she had pains of some severity in her joints and feet. She reports that her general health is good, she has a good appetite, and digests well, but her pulse is weak, and menstruation scanty; she has had no family. The spots upon the skin vary in size from a quarter of an inch to an inch in diameter; some are mere erythematous blotches, these assume a dusky brown tint, then the brown color is discharged, and blotches of white (leuce) take their place. The first spot that appeared had a prominent character from the beginning, the elevation being occasioned by serous infiltration into the cutaneous tissue. Two or three other similar prominent blotches have formed subsequently. That on the face retains its brown color, while around it is a ring of white, and bounding the white a deep tint of brown, which fades away gradually into the surrounding skin. In this case are seen the dull red erythematous blotches charac- teristic of the disease; secondly, the brown blotches verging to black; thirdly, the bleached and colorless blotches; fourthly, the prominent blotches, caused by serous infiltration of the tissues of the skin; and, fifthly, the insensibility or anaesthetic element. Her hands and feet have a benumbed feeling, she picks up small objects with difficulty, and there is a degree of loss of power of the lower limbs. Her symptoms were much alleviated by her voyage to England; the hands and the feet were better and the right hand and left foot alone retained some degree of swelling, with occasional pains. An- other circumstance interposed to afford her relief, she became preg- nant, and was safely delivered of a fine healthy boy in January, 1864. She remained pretty well after her arrival in England until August, when she was attacked with neuralgic pains; the pains began in the right arm, and were somewhat severe, then they extended to the back of the right hand, afterwards to the back of the neck and feet, and then became diffused over the whole body. This attack of neuralgic pains was accompanied with rigors and general feverishness. It lasted a fortnight; on the two last days she had a severe pain in the right side, which was ascribed to the liver, and then the pains ceased entirely ; she felt well, but somewhat debilitated. She had previously been subject to frequent fits of sneezing, which had now abated; she CASES OF ELEPHANTIASIS. 543 had less thirst, the maculae were fainter, and the bulk of the limbs was somewhat reduced. In the early part of December, having been unusually well since the attack in August, she suffered pain in her right hand; after a few days a blister formed suddenly over the painful part, and broke • it refilled several times, and then the skin healed. On the 29th of. January, the lady was confined, and she remained without pain or uneasiness of any kind until the 25th of February, when a severe neuralgic pain occurred in the left foot; after a few days a blister suddenly appeared over the painful part; it broke, and after refilling a few times disappeared. A month later, she experi- enced neuralgic pains in the right hand and left foot at the same time • the ankles of both legs were painful and swollen, the legs up to the knee tender to the touch, and the soles of the feet oedematous and sen- sitive. These symptoms were succeeded by a blister on the hand and another on the left foot, followed as in previous instances by relief from pain. A similar attack of swelling and pain occurred in the left hand nearly three months later, namely, in June, and was at- tended with similar relief. At this period the hands were both somewhat swollen and stiff, sometimes cold, and sometimes benumbed; the fingers were taper in figure, and the skin stained of dark purplish-brown. But the diges- tive organs continued normal, her spirits were only occasionally de- pressed, and she regarded her health as good. The time had now arrived for her return to India with her husband, his furlough havino- expired. Since that event, we are informed that she was confined for the second time, and died at'the latter end of the year 1865 of some illness incidental to childbirth. Case 10.—Elephantiasis an^esthetica ; in a native of Hindostan; neuralgia; anaesthesia; ulceration; fever; albuminuria. A young lady, aged nineteen, a native of Hindostan, became the subject of anaesthetic leprosy at the age of fourteen. The disease made its appearance as an elevated oedematous semi-transparent blotch on the middle of each cheek. The blotches gradually increased in size, while other blotches were developed on the forehead, and on the prominent parts of the ears. These blotches were in the first instance sensitive, subsequently they lost their sensibility. At the same time with or soon after the appearance of the blotches on the face, raised blotches and flat maculae of a dull red color occurred upon the body and limbs, the hands and feet became somewhat swollen and oedema- tous, and of a darker color than the rest of the skin. Concurrently with the development of the maculae and blotches, she suffered from occasional attacks of pain in the lower limbs, the loins, and the chest. These pains were in some instances excited by cold winds, but after a time,4t was found that the skin of the legs and feet had lost its normal sensibility. Hot fomentations with mustard, in- tended to relieve the pains, occasioned blisters, without being felt by the patient, and one or two indolent and insensible ulcers were pro- duced, which healed with difficulty, and are apt to reopen from time to time. 5-14 LEPROUS AFFECTIONS. The mucous membrane participates in the general physical disor- der; the conjunctivae are streaked with enlarged venules; the mem- brane of the nares has lost its sensibility to strong odors; she has fre- quent attacks of sore throat, and her voice is weak and hoarse. Men- struation, likewise, is deficient and irregular; she is losing her hair; she is dull and listless, and indisposed to exertion or amusement. This young lady first came under our notice in May, 1865; in the subsequent autumn she was attacked with febrile symptoms, which were at first continuous, and afterwards intermittent; the febrile symptoms lasted about two months, and were accompanied with albuminuria. She was much reduced by this attack, was debilitated and thin, but her appetite returned and continues as good as usual. Case 11.—Elephantiasis an^esthetica ; apparently resulting from venereal infection by a leprous woman; insidious advance of the disease; neuralgia; smart fever; resemblance to syphilis ; severe mercurial treat- ment ; progressive anaesthesia. A young medical officer of the Indian Army (J. E. L.), aged twenty- three, born in Ferozepore, of English parents, always enjoyed good health, with the exception of an attack of intermittent fever in 1854 which lasted four months, until four years back, when his present illness commenced. His parents, with two brothers and one sister, have excellent health; from his infancy he was somewhat darker in complexion than his brothers and sister, but during the last few years, and especially during the last twelve months, has become swarthy, and at present is darker than a native, the swarthiness not being limited to the exposed parts of the body, the face and hands, but pervading the whole skin, and being greatest on the lower limbs, and especially on the legs and feet. His hair, originally somewhat curly, is black and straight, the eyebrows also black, and he has a small moustache and beard of the same color, but no whiskers. In the month of August, 1861, he had a soft, sloughing, venereal sore upon the corona glandis, for which he was treated very actively with mercury, and severely salivated. At the commencement of his treatment he took two grains of calomel every two hours, and con- tinued a modified mercurial course for four months, by which time the sore had healed. After the healing of the sore he had some con- gestion of the fauces, which yielded to a gargle, and passed away in a few days. On the 7th of March, 1863, having remained well since 1861, he again had a venereal sore, this time a hard chancre on the exterior of the prepuce; he treated the sore himself by local means, dusting it with calomel, and keeping it moist with black wash; it healed in three weeks, but has left a cicatrix of considerable size. On the 16th of April, nineteen days after the cure of the hard chancre, he had his attention called by some*companions with whom he was bathing, to a spotted state of his skin. The spots were circular in figure, of a reddish-brown color, and dispersed over the trunk of the body, some few being visible on the forehead. The spots gave him no uneasiness, and no further attention was paid to them. In the month of October following he experienced shooting pains CASES OF ELEPHANTIASIS. 545 in his limbs; they were occasional, not severe, and deep seated, seem- ing to him to be fixed in his bones. In December an additional symptom of his disease, namely, a puffy swelling of the hands, was first noticed; and this, like the spots, not by the patient himself, but accidentally by a companion. The swell- ing was unattended with pain. In January of the following year, 1864, the appearance of his face attracted the attention of his superior officer while on parade, and he was ordered to his quarters by the Deputy Inspector-General of Hos- pitals, under the impression that he was laboring under symptoms of secondary syphilis. He had no feeling of illness, and was not aware of any symptoms of disease, beyond the spotted appearance of the face already adverted to, and which at this time had been in existence for nine months, latterly somewhat more conspicuous than at first. Being now put upon the sick list for supposed secondary syphilis, he was ordered three grains of iodide of potassium in decoction of sarsa- parilla thrice daily. After a month, as no impression was made upon the spots, the dose was progressively increased to eight grains three times a day, and with a similar result; he besides took a warm bath, containing chlorate of potash, every night. Becoming tired of treatment, and experiencing no beneficial result from the medicine he had taken, and at the same time believing him- self to be in good health, he obtained permission to remove to another station, and went to Cawnpore in medical charge of a military detach- ment, a nineteen days' march. On the journey he experienced con- siderable dryness of throat, debility, palpitations of the heart, loss of appetite, feverishness and sleeplessness at night, shooting and aching pains in his bones, drowsiness by day, and extreme depression of spirits; and these symptoms increased in severity after his arrival at Cawnpore. Feeling at this time really ill, he demanded examination by a Medical Board, and appeared before the Board on the 1st of April, 1864. The maculation of his skin had rapidly increased after its first appearance, had spread over the whole body, and was accompanied with thickening of the integument. His conjunctivae were reddened, as were also the fauces, but he had no feeling of soreness of throat and no ulceration of the mucous membrane. The deep-seated pains in his limbs had also somewhat increased; he was feverish, restless and sleepless at night, and languid by day, particularly in the morn- ing; drowsy, and unequal to the exertion required by his duty; he had frequent attacks of palpitation and loss of appetite. To these symptoms were added, subsequently to this date, nocturnal emissions, sometimes occurring twice in the night. The "case" of the patient was thus reported by the Medical Board : " In April, 1863, he first noticed some copper-colored blotches on his face and extremities; these have gradually increased, and now cover his entire body. Last October he was attacked with rheumatism, chiefly affecting the extremities, from which he has suffered more or less ever since, and is now quite unfit for duty. I therefore recom- mend him for three months' leave, and that he be removed to the 35 546 LEPROUS AFFECTIONS. * General Hospital, Allahabad, for treatment. Treatment: hydrargyri bichloridi; potassae iodidi; iron tonics." He remained under treatment in the Allahabad Hospital from April until September, pursuing the prescribed treatment, varied at inter- vals with mercurial fumigations, nitromuriatic acid, quinine, and arsenic. He states that he felt more unwell at the end of this period than he did at first, and he again went before a Medical Board. The report of the Board, recapitulates the occurrence of primary syphilis, followed by secondary syphilis ; " on admission in April last his body was covered with a copper-colored eruption, the eruption being attended with considerable thickening of the skin in the part engaged ; he suffered a good deal from nocturnal pains, and at a later period from sore throat. His general health was also in a bad state, and during the past hot season he was much debilitated. Latterly he has suffered from nocturnal emissions and palpitation of the heart." " The eruption is very much better now, and he is in better health, but he still remains considerably debilitated and hypochondriacal, a state which the nocturnal emissions tend to keep up. As I believe that Mr.----requires a complete change of climate and a sea voyage for the recovery of his health, I recommend that he be permitted to proceed to England on medical certificate," &c. In November all medical treatment was given up; he sailed from India in January, and reached England on the 18th day of May. Arrived in London, he put himself under the care of an eminent hos- pital surgeon, who took the same view of his case as his medical advisers in India. He was fumigated with calomel until his gums became sore ; and making no progress, was seen in consultation by another surgeon distinguished for his knowledge of syphilis. He had now been three months in London; the diagnosis was still syphilis, and it was agreed in consultation that he should go to the sea side for awhile to regain his strength, and on his return to London that he should be thoroughly mercurialized. Having so recently had a sea voyage without any profit to his health, the patient preferred an inland place, and went to Malvern, where for a short time he was submitted to hydropathic treatment. Such was the state of the case on the 4th of September, 1864, when the patient addressed to us a letter, from which the following is an extract: " I have been suffering from constitutional secondary syphilis for the last two and a half years; my body is entirely covered with large copper-colored blotches, attended with considerable thickening of the skin, and my general constitution is extremely shattered." A few days afterwards he presented himself before us, and we perceived at once that he was suffering under elephantiasis. By a fortunate coincidence, Dr. Boeck, of Christiania, celebrated, in conjunction with Dr. Danielssen, for his researches on Elephantiasis Graecorum, was at this time a visitor to London, and we were glad of the opportunity of obtaining a corroboration of our diagnosis by so eminent an authority. He recognized the nature of the case imme- diately, and determined one symptom of the disease, namely, incipient anesthesia, which we had overlooked. CASES OF ELEPHANTIASIS. 547 This case is peculiarly instructive, and especially on account of its association with syphilis. It is an evidence of the independence of the leprous poison and the syphilitic poison, and it illustrates power- fully the resemblance which exists in the constitutional manifestation of the two diseases. It is interesting, also, as regards the origin of the complaint; the woman with whom the patient cohabited in 1861, and from whom he received his first syphilitic infection, being a leper; and it goes some way to fix the period of latency of the disease at two years. Let us review the leading symptoms: taking them in the order of time, the first that showed itself was the outbreak of maculae on the skin; then followed congestion of the mucous membrane of the fauces; thirdly, neuralgic pains; fourthly, nervous prostration; and fifthly, anaesthesia. The whole case, it must be remembered, is in its infancy and an unusually favorable opportunity is offered by it of observing the incipient symptoms of the disease, and watching their progressive development. These circumstances must also be borne in mind in judging of the universal acceptation of the case as one of syphilis by the medical men under whose observation it came. Our own opinion is, that there was no combination of constitutional syphilis with the disease in chief, and that the symptoms were from the first the ordinary symptoms of development of elephantiasis. And their resemblance to the constitutional symptoms of syphilis is, as we perceive, so close, that they must necessarily be taken for syphilis by every medical man who has not had the opportunity of separately observing and studying elephantiasis. We must here remark that our patient had received a medical education and training in the hospitals of India, in which many native patients were received; but he never saw an instance of elephantiasis, and no suspicion had ever crossed his mind, until we pronounced our diagnosis, that his own case was other than syphilis. This will explain also the opinion of the numerous medical officers by whom he was examined in India, and it serves to prove that, elephantiasis, however common on the coast, is by no means frequent in the interior of Hindostan. Recurring to the symptoms of elephantiasis as manifested by the present case, it will be convenient to take them in the following order, namely: the skin, the mucous membrane, the nervous system. The remarkable swarthiness of the skin was very striking. A photograph of a sister of the patient showed that the family tint of complexion was not deeper than is to be seen daily amongst ourselves, and yet the color of this young man was darker than that of a native Indian. He had always been darker than his brothers and sister, but the extreme swarthiness of his skin had only been developed during the last year or two. The swarthiness of color was most remarkable on his lower limbs, beginning in the thigh and increasing in depth downwards to the foot. Moreover, the left foot was deeper colored than the right, and the end of the great toes was somewhat bleached, showing a tendency to leuce. The hands were also deeper in color than the arms, and tbere was a certain leaden and metallic hue of the skin of the hands and also of the face. 548 LEPROUS AFFECTIONS. The maculae were dispersed chiefly on the forehead and on the trunk of the body, producing a mottling of the skin. They were \ circular in figure, of a size varying from a quarter of an inch to several inches in diameter, and of a reddish and yellowish-brown color, not strictly copper-colored, of which the predominant tint is red, but having a duskier and more melasmic hue. They were, in fact, the representatives of the melas of vitiligo and lepra. Some of the smaller and more recent maculae had a ruddy glow, marking their origin in erythematous congestion; while others, of longer standing, were more decidedly melasmic. A later period would probably be indicated by a total loss of color, a true leuce, and its accompanying anaesthesia. The next character evinced by the maculae is a certain degree of thickening of the integument from infiltration ; several of the maculae on the forehead were thickened to the extent of producing a slight degree of prominence, but there were no tubercles. There was also some degree of thickening of the integument of the dorsum of the hand ; and wherever the maculae were pinched up between the fingers a thickening of the integument could be detected. In association with the thickening of the integument is a dilated state of the pores of the skin, which gives it a coarse appearance; and when the infiltration is carried a little further, and the maculae become oedematous, the ele- vated surface has a degree of semi-transparency, that suggests a re- semblance to the outer covering of brawn. Sometimes the dilated follicles exude a greasy secretion, at other times they are dry. The general surface of the skin of our patient was dry, more particularly the head and the lower extremities. When, at our request, he took a Turkish bath, he found that, although the trunk of the body perspired profusely, there was no moisture on the wrists and hands, and none upon the legs below the knees; the thighs perspired slightly. The non-perspiring regions of the body were those which were also the most remarkable for swarthiness; and on the legs the pores were dry and prominent, and filled with cuticular exuviae, and there existed a slight degree of desquamation of the epidermis. The state of the skin in general is one of abnormal innervation and defective nutrition. Abnormal innervation is shown in the tendency to erythematous congestion which is generally accompanied with a heightened sensibility of the skin, and the lowered sensibility which follows in the melasmic, and especially in the leucasmic stage. Our patient complained of heat and tingling in the soles of the feet, while the legs above the ankle were shown by the needle, as used by Dr. Boeck, to be in a state bordering on anaesthesia. Defective nutrition of the skin was evinced by the suspension of perspiration on the legs and hands, by the dryness of the legs, by an unhealthy ulcer on the metatarso-phalangeal joint and heel of the left foot, and particularly by the loosening and casting of the nails of the feet. The root of the nail of both great toes could be lifted from its bed, and the body of the nail was in course of separation from its matrix. The ulcer had arisen from pressure during his march from Ferozepore to Cawnpore in March, 1864, and, in consequence of deficient vitality, exhibited no disposition to heal. CASES OF ELEPHANTIASIS. 549 The prominent blotches on the forehead gave a sombre character to his countenance, not as yet approaching the leonine expression of tubercular elephantiasis, but a heaviness that heightened the gloomy, listless, and melancholy expression of his face. There was no thick- ening of the lobes of the ears, and, although he had lost a considerable quantity of the hair from his head, it was still thick and abundant, and there was no loss of the eyebrows. In elephantiasis the mucous membrane very early participates in the surface congestion of the body; the conjunctiva in our patient soon became injected, as did the mucous lining of the nares, the fauces, and the larynx. In advanced stages of the disease the mucous membrane becomes thickened, and subsequently is apt to ulcerate; but at the early period of the present case the affection of mucous membrane had not advanced beyond congestion. The patient's appe- tite and digestion had remained good throughout the progress of the disease, with the exception of the acute period of the attack which he experienced during the march to Cawnpore. He remarks that he has a feeling of soreness in his nose, and the nostrils are always more or less stuffed. He has uneasy sensations in his palate, which he compares to some object projecting into the cavity of the mouth; he has a similar sensation sometimes in the fauces, with a sense of soreness extending to the ears, and some degree of hoarse ness of voice. He complains of having lost the vocal power of his larynx. Before this illness he was a good singer, with a powerful voice; now he cannot utter a note. He also speaks of a feeling of dryness in the throat and of a fetid state of the breath ; sometimes the odour of the breath has a sickly sweetness, like almonds, and at other times is, to his own appreciation, excessively offensive. Dr. Morell Mackenzie examined the patient's throat with the laryngoscope, and reported him to be " suffering from slight chronic congestion and fol- licular disease of the mucous membrane of the larynx, but with nothing of a specific character about the affection." The nervous sensibility of our patient, as is common in elephan- tiasis, partakes of the double character of hyperaesthesia and anaesthe- sia ; the former belonging to the period of invasion of a febrile state or exacerbation, the latter to the decline of such an attack; while the mental powers of the patient are depressed and lethargic. Thus, while the soles of the feet were hot and sensitive, the legs, as was first remarked by Dr. Boeck, were anaesthetic. At a later period the sen- sibility of the fingers and feet is reduced, and they are remarkable for their coldness; our patient declared that he could pick up a small object like a needle or pin with his fingers; but on the following day he'informed us that he had lost the power of his wrists, and could not unfasten the straps of his portmanteau without great difficulty; he also complained of inability in buttoning the collar of his shirt. The deep-seated pains which he referred to his bones were very little changed during the first two years of his illness. Since that period they have increased, and other abnormal nervous sensations have been added. The original pains occupied the limbs, particularly the legs, the cartilages of the ribs, and the region of the sternum; but 550 LEPROUS AFFECTIONS. latterly he has complained of a " peculiar throbbing nervousness of the whole body, a trembling nervous sensation, and frequent attacks of palpitations. These nervous feelings destroy his sleep, and his flesh is so tender that the slightest pinch is productive of pain. He has also had recently severe pains in his loins, and great general debility. Case 12.—Elephantiasis an^esthetica ; mistaken for secondary syphilis ; severe treatment with mercury and iodide of potassium; aggra- vation of the disease; anaesthesia; febrile attack ; apparent recovery. A physician, aged seventy, one of the chiefs of the Bengal Medical Establishment, having resided in India forty years, and, with the exception of some mild attacks of hepatic disorder, having enjoyed remarkably good health, was attacked with symptoms of anaesthetic leprosy in 1849, in the sixty seventh year of his age. He states that in the summer of 1850, while in Malta, he became aware of an occa- sional 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, when moving the foot, was attended with a prickling sensation and a feeling of tightness, as of a wire fastened around the part. In 1851, similar phenomena occurred in the left foot, and several erythematous 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 prick- ling sensation was more general, and the tightness on progression extended higher up the leg. While these changes were in progress, he began to experience a sensation of numbness on the side of the metacarpo-phalangeal joint of the middle finger, and observed a patch of redness on the next joint. In the month of January of the follow- ing 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 quickly 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, oedematous-looking blotches, which he described as blebs, suddenly made their appearance on the outer bor- der 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 numbness returned, but'disappeared on the eleventh day. In July there was a third febrile attack of the same kind, accompanied with a burning sensation, pain, and soreness of the outer border of the feet, increased numbness of the ring and little finger of the left hand, redness of the knuckles, pain on expo- sure to the slightest cold, and the development of a hard and inflamed swelling just above the inner condyle of each upper arm, in the situa- tion of the supra-condyloidean lymphatic gland. During the month CASES OF ELEPHANTIASIS. 551 of August the disease continued steadily progressing; raised spots were thrown out on the face; erythematous spots and blotches ap- peared on the abdomen and limbs, being preceded by itching and smarting. In September there was a still further increase of the dis- ease, the whole forehead was studded over with elevated spots; there were erythematous spots 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 witnessed a progres- sive advance of the disease in every way, with increased insensibility and lividity of the fingers and feet. In January, 1853, numerous large blotches made their appearance on the back of the thighs, and several of those already in existence threw out a broad erythematous 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 temperature of 104°, the face was flushed and spotted over with erythematous blotches of a vivid red color, the redness of the spots on other parts of the skin increased, and they became prominent from oedematous. infiltration, while those which were already promi- nent were 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 alas of the nose were remarkably distended, and hard knots could be perceived as well as felt under the skin, at the outer angle of the eye, upon the temple, and upon the ears. In flammation now appeared in the right hand, and the fingers became swollen and pafciful, like those of the left. The deranged sensations of cold and pain continued in the legs and feet, spots showed them- selves on the palm 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 our observation, his state being much aggravated, and the disease accelerated, as he be- lieved, by the treatment which had been pursued, and which consisted 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 tender- ness of gums, in addition to the bichloride of mercury and sarsaparilla. It was after this severe course of treatment, extending in time from August 13, 1852, to April 20, 1853, that we first saw him. The history of the patient, while under our care, was one of a pro- gressive advance of the disease, both in eruption and reduction of sensation, until the month of August, when a state of extreme dul- ness, heaviness, and lethargy came on, accompanied with febrile symp- 552 LEPROUS AFFECTIONS. toms, and continued for several weeks. From this attack he gradually recovered, and two months later, had regained strength, appetite, and power of applying his mind to reading. The oedematous spots and blotches on various parts of his body were becoming smaller; many of the brown-colored spots were fading; and there was a slight in- crease 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 influ- ence of cold, and he was obliged to continue the use of warm gloves to protect them. The nephew of this gentleman, himseM" 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 alone, and no'appearance of spots was visible, with the exception of a few upon the abdomen." The patient had no return of the symp- toms of leprosy, but died a few years afterwards of ordinary bronchitis. Case 13.—Elephantiasis an^esthetica ; insidious invasion and progress; absence of neuralgia ; anaesthesia; fair general health. A fine healthy-looking man (Mr. E ), a merchant of the Mauritius, where he had resided twenty-nine years, became aware, at the age of forty-seven, of the presence of elephantiasis. There is reason to be- lieve that the disease had already existed in a latent form, probably for some years, for his first notice of being affected was the discovery that his arm was insensible to the accidental aspersion of boiling water from the spout of a teakettle.' His wife is a remarkably fine woman, a native of Mauritius, and, with his children, five in number, enjoys perfect health. His medical man reports that when he first saw th^ case there was a croup of small, round, tubercular elevations, of a darkish-red color, sprinkled over the arms and neck ; and that subsequently the blotches increased in size and number, and made their appearance on the trunk and face. His general health " both then and since remained unaf- fected ;" but as the disease resisted treatment, and resembled in its manner of origin the leprosy of the country, it was thought desirable to send him to England, " where the disease with which he was men- aced is unknown." At his appearance before us the patient declared that he felt as strong as ever in his life, that he had no pain, and was not sensible of any inconvenience of any kind beyond the appearance of the promi- nent blotches, and a knowledge of the presence in his system of a seri- ous disease. His face presented a not unhealthy looking reddish-brown tint, his hands and feet were deeply bronzed; and there was an obvi- ous insensibility of the skin of the hands and arms. Case 14.—Elephantiasis an^esthetica ; eight or nine years' dura- tion; neuralgic pains ; anaemia; debility; atrophy. In February, 1866, we were consulted by a gentleman (Mr. B.), aged fifty, but having the appearance of sixty. He was tall and of large frame, thin and languid; walked somewhat feebly, and, drop- ping into a chair, gave utterance to a sigh of exhaustion. On his CASES OF ELEPHANTIASIS. 553 cheeks and forehead were several large, slightly raised, and brownish blotches, which at once centred our diagnosis on elephantiasis. His face and conjunctiva were pallid, the former having a delicate lilac tint; the backs of the hands were somewhat swollen, the wrists puffed, and the skin marked by a brownish blotch. Our first remark to him was, "You have resided in the East Indies." " No," he replied, " in China." On removing his clothes, which he was too listless to undertake himself, but accepted the assistance of a friend, we found the feet and ankles puffed and swollen like the hands. On the feet and legs were several brown patches; the cuticle of the legs was fissured and desquamating ; but the most remarkable symp- tom of the disease was emaciation of the legs, apparently from mus- cular atrophy. We pricked the skin of the legs a few inches above the ankle, without exciting sensation ; and, to our question if he felt pain, his answer was that his feet and legs were benumbed. On proceed- ing higher, we found brown marginate blotches on the thighs and on the trunk of the body ; these melasmic blotches were all insensible to the prick of a pin, and his skin and muscular system betokened inci- pient atrophy. Proceeding further with our inquiry, we found, in addition to the anaemic condition of the conjunctiva, obstruction of the nares, from which mucus, streaked with blood, was occasionally expelled. The lips were thick, but there were no tubercles in the skin of the fore- head, face, ears, or nose, and no evidence of congestion Of the buccal membrane or fauces, although the voice was weak and somewhat hoarse. In reference to his visceral system there seemed to be nothing abnormal; he passed urine seldom, and it had been analyzed, without any trace of disorder; he suff'ered slightly from haemorrhoids, but his digestion was fair; and, but for an addiction to alcoholic stimulants, which weakened his appetite, his general health might be stated as good. To the question of pains his evidence was less negative; he was much annoyed with shooting pains in his feet and legs; they were irregular and fugitive; began on the dorsum of the foot, and ran up the outer side of the legs, particularly the right, to the hip. He had not suff'ered pain in his hands or arms, and although his sleep at night was bad, the fault was not attributable to pains. The neuralgic pains were most troublesome in the evening, but not at night. Looking to the puffed and somewhat oedematous state of the feet and ankles, together with the emaciation of his legs, his weak powers of progression were explained; and we noticed that he failed in his attempts to fasten the button of the collar of his shirt, and that the motive power of the hands was as feeble as that of his feet. With all the insensibility of the skin and of the extremities, however, he had had no vesication of the cuticle, no deep-seated rheumatic pains, and no threatening of ulceration. Having determined thus far his pathological state, we in the next place proceeded to inquire into so much of his history as bore upon his malady. He had gone to Hong Kong in 1844, and resided there fourteen years, namely, until 1858. During his residence in China he 554 LEPROUS AFFECTIONS. had lived very freely, and in 1850 suffered from fever, for which he was mercurialized. For four years he had a Chinese mistress, but she was to all appearance well, and he had never had venereal disease of any kind. The disease made its first external appearance in 1858 in the form of a red and slightly raised blotch on each cheek, and has therefore very probably been nine or ten years in existence. The insensibility and numbness of the skin and limbs he noticed first in 1862. Lat- terly the tips of the fingers have become pale, and their numbness has increased. In the month of August, 1866, the following notice appeared in the obituary of the Times: " On the 4th inst., suddenly, W. A. B., late of Hong Kong, China, in the 50th year of his age." Case 15.—Mixed elephantiasis; tuberculosa and anaesthe- tic a ; loss of voice; distortion of limbs and joints ; uheration ; death after a course of ten years. The elder brother of the young gentleman whose medical history is reported in Case 2 was attacked with elephantiasis at the age of thirteen, and died at twenty-three, the duration of the disease being ten years. The exanthem was first noticed on the face in the form of spots; the features were pale and bloated; the eyebrows fell off; he had no whiskers or beard, and he subsequently lost the hair of the pubes; the nails also broke away from their matrices, and were not reproduced. The mucous membrane of the nares was severely affected, morbid secretions accumulated on its surface, the nasal bones and cartilages gave way, and the nose became flattened. His voice was weak and hoarse, he had difficulty in making himself heard, and was troubled with an occasional cough. His appetite also was defective. He had ulcers on various parts of the skin, and had lost a phalanx from the little finger of one of his hands, the rest of the fingers were bent in different directions, and the hands distorted. He was unable to use his hands, and was incapable of walking. His spirits were greatly depressed, he was subject to fits of extreme despondency, and suffered severely from neuralgia. The number of cases falling under our notice in 1865 was five, four males and one female; and in 1866 the number was similar, with the same proportion of males and females. The cases of 1865 and one of 1866 have been narrated, and we now proceed to subjoin a brief notice of those that remain. The youngest patient (G. E.) was a boy, born in Calcutta, twelve years and a half old, the son of European parents; his mother was born in Shandagore ; his father had resided in India fifteen years. Of three children, the present is alone affected with this disease. Between three.and four years back while in Bungpore, a marshy and unhealthy district, he was seized with intermittent fever with sore throat, and these attacks were re- peated from time to time until his voyage to England, two of the attacks occurring on board ship. He has now been in England nearly three years, and has experienced no further inconvenience from the fever. Four months back, it was observed that a number CASES OF ELEPHANTIASIS. 555 of yellow brown stains were apparent on several parts of his body, and shortly afterwards were followed by pimples on the face, and a tawny discoloration of the skin. The spots or stains vary in size from two to four lines in diameter, and are deepest in color in the centre, fading at the circumference; they are most abundant on the shoulders and shoulder blades, on the front of the neck, along the lower border of the pectoralis major, on the front of the upper arm, along the line of the ilium, and upon the back of the thigh down to the ham, the rest of the body is comparatively free; there are none on the front of the chest and abdomen, and none on the legs below the knees or on the feet. The papulae are most abundant on the face where there are three measuring fths of an inch in diameter, two mea- suring fths, while the rest have an average diameter of £th ; they are brownish and transparent, and seem to be composed of a gelatinous tissue, traversed by a few scattered venules. The papulae are also numer- ously scattered over the back of the upper arm, the whole circumfer- ence of the forearms, the buttock, where they are large and prominent, and the legs. There is also a slight degree of oedema of the hands, and a granular and somewhat congested condition of the tonsils. In other respects, the boy is in good general health, but seems to evince a little lethargy and dulness of manner. He has no anaesthesia, has had no neuralgic pains, and, as is apparent, the disease is in its first stage of development. He was sent to us for an opinion as to the treatment of an obstinate acne, to which the papulae were supposed to appertain. The next patient (C. K.) was a boy of sixteen, born in Gwalior, of English parents, his mother having been born in India; he has one brother and four sisters, all of whom are well. Previously to leav- ing India a year ago, he had intermittent fever with sore throat, but from this he has quite recovered, and he appears, with the exception of a slight degree of anaemia, to be in good health. He is somewhat dull in manner, indisposed to activity, but in other respects would be regarded as a robust healthy-looking boy. His application to us had reference to a circular spot three inches in diameter which had shown itself on the left side of the trunk of the body just below the scapula, and had been taken for a ringworm. The spot consisted of a circular band three-quarters of an inch in breadth, inclosing an area of about two inches in diameter. The color of the band was a bright red-brown or copper hue, dotted with puncta of a deeper tinge, corresponding with the apertures of the follicles, while the tint of the area was a faded yellow-brown. There was no infiltration, and consequently no prominence; the surface was smooth without desquamation, and the skin evinced insensibility when "pricked with a pin. Further examination discovered a second and similar spot on the ulnar side of the left forearm, three on the right leg between the knee and the ankle, and a knotty thickening of the lower segment of the prepuce, accompanied with a slight oedematous infiltration. The maculae on the leg were remarkable for their loss of sensibility, and presented a pityriasic desquamation of the epi- dermis. Up to the time of his visit to us he had not experienced 556 LEPROUS AFFECTIONS. pain, but a month later he had a severe aching and darting pain in the ulnar side of the left forearm, extending to the little and _ ring- finger of the same hand; the pains began at about four o'clock in the morning and prevented sleep, and were more or less troublesome during the day. This attack lasted five or six weeks, the pains gradually subsiding, but leaving behind them numbness and partial insensibility with a tendency to permanent flexion; no fresh spots were developed, and the older ones seemed to be fading. He had as yet no affection of the mucous membrane, and the tendency'of the symptoms was evidently towards the anaesthetic form of the disease. The third case was that of a young gentleman (T. C), aged eighteen, born at Connamore, on the Malabar coast, of English parents, the father having resided in India from the age of eighteen, and the mother since that of fourteen. His mother reports that he was a fine infant, that he took vaccination favorably,1 that he had measles as a child; but as he grew to the age of seven to nine he fell off in strength, and became weakly and delicate. At the age of ten he was sent to school in Ireland, where he was seen by a medical man for a cough ; the physician reported him free from disease of the lungs, but weakly. Between three and four years later he had an exanthematous fever, which was treated as scarlatina; it occurred in the summer, and during the holidays, and he was alone in the school, so that the exist- ence of an epidemic at the time is not determined. Four or six months later, that is, in the winter immediately following the scarla- tina, he began to experience tingling and pricking in the tips of the little and ring-finger of the right hand; the painful sensations then extended up the ulnar side of the forearm to just above the elbow; after a few weeks these unpleasant sensations ceased, and the affected skin, previously over sensitive, became benumbed and anaesthetic. After a few months, similar phenomena were observed in the legs; and quite recently they have commenced in the left hand and arm. He has had no acute pain, only the painful sensations already men- tioned. One year back large pimples appeared on his face; and at the present time the face, and particularly the cheeks and chin, is sprinkled over with numerous large reddish-brown and olive-colored tubercles, intermingled with several brawn-like and infiltrated blotches; altogether there are about fifty tubercles on the face, ranging in size from half to three-quarters of an inch in diameter, with an elevation of a quarter of an inch ; they are for the most part isolated, and have risen upon the disk of the maculae; but some are clustered and form an irregular mass. A few are situated in the eyebrows and one on the eyelid, while the tip of the nose is red and tumid. A number of large irregularly shaped ochre-colored blotches are dispersed upon the limbs; and although there is an absence of the usual oedema of the back of the hands, the right wrist is purplish and puffy. The right hand is somewhat deformed from the loss of sensibility and incipient contraction of the little and ring-finger, and especially by a 1 There is only one imperfect cicatrix of vaccination to be discovered ou one arm, and none on the other. CASES OF ELEPHANTIASIS. 557 state of atrophy of the muscles of the metacarpal space between the thumb and forefinger; while on the ulnar border of the hand are two bullae of recent origin, one collapsed and emptied of its contents, the other containing a small quantity of sanguinolent serum, and partially broken, exhibiting at its base a superficial asthenic ulcer like that of a broken chilblain. Bullae first made their appearance six months back, and there is evidence of the remains of a bullous eruption and the thin dry crusts of superficial ulceration in the neighborhood of the right elbow, the circumjacent skin being thin, purplish, and somewhat livid. In his countenance there is less of the melancholy, frowning, and leonine expression common in tubercular leprosy than usual; the eyebrows are thin, and he is beardless and whiskerless. The conjunc- tivae are unaffected, but there is some obstruction of the nasal pas- sages from swelling of the mucous membrane ; the fauces are red, and there is a deep redness of the palate. He is tall, moderately full in the face, but emaciated in body and limbs; eats and drinks well, but is drowsy during the day, and awakes in the morning with headache, whilst twice in the week he is much tormented with headache during the day. His mother wished to take him back to India, but although he has been eight years at school he is so little advanced in his studies that she determined to leave him longer: and she was naturally shocked on seeing him, after so long an absence, with his face deformed by tubercles and prominent brown blotches; but she had no suspi- cion of the nature of the disease, having never seen anything like it in India. She informed us, moreover, that her daughter, aged twelve, is suffering under enlargement of spleen, the sequela of malarious fever. The fourth case was that of a lady (Mrs. M.), aged fifty-five, who had resided in India from the age of eight, and for the last thirty years in Bombay close to the sea. The disease commenced at the age of forty, just fifteen years back, and began with disorder of the abdo- minal organs and swelling; the swelling lasted for a day and a half, and was followed by the appearance of pale brown maculae on the face, hands, lower extremities, and feet. At the present time she is infirm from weakness of the muscular system ; her face is of a tawny color, nodulated and flabby; the hair of the front of the head, the eye- brows, and eyelids gone; the corneae opaque, the nose flattened from sinking of the bones, the alae of the nose everted, the nares obstructed, the cavity of the mouth pale and mottled, and the soft palate contracted and pinched up. But the most striking feature of her appearance is the mutilation and distortion of her hands; the fingers are flexed backwards, and the little and ring-finger altogether distorted from their natural position,1 they are livid and cold. The arms are flabby, and the skin mottled with brown and purple ; the legs have a similar character, but are not so much affected as the hands; and the feet, which are purplish and cold, are less distorted. She complains much of suffering with chills and heats, and during the night with a raging burning heat of the whole body, which she compares to being baked. These symptoms are not constant; sometimes her suffering proceeds 1 Vide a rude sketch of the left hand at page 527. 558 LEPROUS AFFECTIONS. from a general tingling or prickling and itching; and when they are most severe, she is obliged to take forty minims of laudanum at bed- time. Conjoined with this hyperaesthesia of parts of the surface, there is also anaesthesia of other parts, and particularly of the hands and feet. Diagnosis.—The detection of elephantiasis must be based on the chief features of the aff'ection, and a recollection of resembling diseases with which it might accidentally be confounded. Its most positive characters are the alterations of the skin, namely, exanthematous congestion, maculation, pigmentation, infiltration, elevation in tuber- cles and blotches, hyperaesthesia, anaesthesia, the pallid and bloated features, the anaemia, the cachectic discoloration, and the fall of the eyebrows. To which may be added the expression in the countenance of sadness, melancholy, and gloom; the heaviness of the brow, the expansion of the nostrils, the nodulation and prominence of the ears, the redness of the eyes, the obstruction of the nose, and the hoarseness and weakness of the voice. The prominent signs of tubercular leprosy are the elevation of the integument, and chiefly of the face, into small prominences or tuber- cles, more particularly along the line of the eyebrows, upon the nose, chin, ears, and cheeks. Some of the tubercles are dispersed, some aggregated in clusters, forming tubercular masses; while the entire integument is more or less thickened, and tubercular nodules, not as yet obvious externally, may be felt in the skin. The alae of the nostrils are tuberculated and expanded, the voice is guttural from obstruction of the nares, and hoarse from thickening of the mucous lining of the larynx. Sometimes the heavy, nodulated, hairless brow, gives a frowning, lion-like expression to the countenance; hence the terms leontia and leonliasis ; and the leonine resemblance is increased by the expansion of the nostrils, the flattening of the nose, and a tubercular enlargement and spreading of the lips. At other times, when the skin has a deep-red hue from varicose distension of the capillaries, a dark-brown tint from melasmic pigmentation, when tubercular masses are produced at the upper angles of the forehead, and resembling budding horns, when the ears are enlarged and elon- gated, the chin lengthened and tuberculated, the face hairless, the lips large and prominent, and the voice hoarse and indistinct, a picture of one of the cases that came under our own observation, we are reminded of the satyr of the painter and of the poets, and are enabled to com- prehend another synonym of the disease, namely, satyriasis. The leading characters of the anaesthetic form of the disease are, the exanthematous and maculated state of the skin, the presence of prominent and transparent blotches on the face and forehead, or dis- persed over the body; the melancholy expression of countenance; the congested eyeball; the hoarse and weak voice, resulting from loss of power of the muscles of the larynx ; the anaesthesia of parts of the skin ; and especially the complaint of erratic and fugitive pains in the skin and in the limbs. Then there is the negative sign; the absence of tubercular thickening and its consequent deformity of feature and appearance. Possibly, beyond the dejected expression, DIAGNOSIS of elephantiasis. 559 the maculation, and a few blotches somewhat prominent and semi- transparent from infiltration, there may be nothing in the countenance of the patient to distinguish the disease. Next to the face, the hands present the most important signs in both forms of the disease. There is the melasmic pigmentation, the ema- ciation of the fingers and of the interosseous muscles, and especially the puffy infiltration of the dorsum and of the wrist; then there is more or less anaesthesia, and sometimes bleaching of the tips of the fingers or the occurrence of leucasmic spots, and not unfrequently alopecia of one or more of the nails, and contraction. The feet ex- hibit similar signs, the cutaneous anaesthesia being more conspicuous in them than in the hands, and, greatest of all, just above the ankles. On the trunk of the body and on the limbs the signs are for the most part alike in both forms of the aff'ection, bearing in mind a greater tendency to emaciation, to oedematous infiltration, and to anaesthesia in the neurotic than in the tubercular variety of the com- plaint. In anaesthetic leprosy, moreover, nodosities may be discovered here and there on the cutaneous nerves, and thickening of those nerv- ous trunks which, like the ulnar, approach most nearly to the surface; and leucasmic spots are more common than in the tubercular variety! The diseases with which elephantiasis is most apt to be confounded are, secondary syphilis, rubeola, roseola, and chloasma. The resem- blance to secondary syphilis is so striking that an error is certain, excepting on the part of those who have had the opportunity of seeing and observing leprosy; and the liability to error is the greater when the disease has followed or is complicated with syphilis. There is the exanthema, having frequently the yellow and brown-red tint that goes by the name of copper colored; the congestion of fauces, the cachectic and sordid skin, and the neuralgia," which is common to both; and it is only the history and circumstances of the case, and the lapse of time, that can determine with precision to which the dis- ease really belongs. An important element of diagnosis is obtained also from treatment; the remedies, namely, iodide of potassium and mercury, which act beneficially in syphilis, are injurious in elephan- tiasis ; the exanthema of the former they remove, the exanthema of the latter they increase and aggravate. We have met with an instance of elephantiasis in the commence- ment of which the patient was attacked with an exanthematic fever, to all appearance identical with rubeola; but the eruption which then appeared upon the skin has remained permanently, and there is good reason to believe that the exanthematic fever was not rubeola at all, but an exanthematic febrile attack of elephantiasis. Similar obser- vations have been recorded by others, and possibly admit of a parallel explanation. It may also be observed as a commentary on the diagnosis of ele- phantiasis, that there is probably no disorder in the whole category of diseases of the body so remarkable for variety of characters, a variety which entitles it to be considered as a pathological paradox; for exam- ple, it is black, red, tawny, and white, according to the constitution of the patient and the form or period of the disease; it is hyperaesthetic 560 LEPROUS AFFECTIONS. and anaesthetic; hypertrophic and atrophic, and it is moist and dry ; to which series of opposite characters may be added the broad line which separates the constitutional from the local affection, and which has led to so much perplexity ; which induced Celsus to treat of these conditions as different diseases, and which enabled Moses to select the cutaneous manifestation of the disease as a means of diagnosis of the leprosy of the Hebrews. In connection with the diagnosis of the true leprosy or elephantiasis Graecorum, it will be interesting to peruse the Scriptural account of the disease, contained in the thirteenth chapter of Leviticus, and so frequently referred to by medical writers. ' The following appears to us to be a correct interpretation of this important chapter, so far as it treats of the distinguishing signs 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 rising (saat, Heb., oia^, LXX.), a scab (saphat, Heb., arjuaai-a, LXX.), or a bright glossy spot (berat, Heb., xtvx?], LXX.); then he shall be brought unto the priest ; 3. And 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 involve the entire thickness of the skin; then the case is one of leprosy, and the disease is contagious. 4. If the bright spots 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 spots 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 some- what 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 dismissed by the priest as free from contagion, he shall be again admitted to examination ; 8. And if the priest find that the scab is still spreading, 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 a 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, }ret if it be all turned white [lepra alphos] he shall pronounce the patient free from contagion : 14. But if there be an open sore, then there is contagion ; DIAGNOSIS OF ELEPHANTIASIS. 561 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 boil (schechin, Heb., s\xos, LXX.), which is healed; 19. If there be a white rising, or a bright 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 lep- rosy 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 bright spot remain, and spread not, it is a carbuncle (mecutash, Heb., a hot burning, xataxavap.a nve,oi, LXX.), 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 of the carbuncle; wherefore, the priest shall pronounce it con- tagious. 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 (nega, Heb., afrj, LXX.), a plague; or a man, on the hairy part of his face; 30. The priest shall examine it, and if he find that the disease sink 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 (netek, Heb., e^avafia, LXX., 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 36 562 LEPROUS AFFECTIONS. deeper than the visible surface of the skin, then the priest shall pro- nounce the patient to be free from contagion: 35. But if after this the scall spread, 36. 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 bright spots or white bright spots, 39. The priest shall examine them; and if the bright spots be darkish white, it is a freckled spot (boak, Heb., ax^oj, LXX., 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 red- dish sore, it is a leprosy: 43. Then the priest shall examine it; and if there be a white red- dish 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 bright or glossy spot in the skin; 2d, the disease penetrating the entire thickness of the 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 alphos), 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, we are inclined to think that the Hebrews restricted the sig- nification, 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 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, we 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 sub- DIAGNOSIS OF ELEPHANTIASIS 563 iect, by an 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," (Sec. It would seem by these words as if depression of the affected skin were applied, a condition distinct from depth, and having refer- ence to the morbid alteration of the skin only in its effects as produc- ing a disorganization and thinning of the skin, which actually does take place in elephantiasis; 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. We 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 dther 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 as a generic term, and includes any spread- ing 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 snail 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 Willan, the boak or bohak of the Hebrews and Arabians, the alphos of the Greeks, a known non- contagious affection. If, in the next place, we inquire what are the forms of disease set down as varieties of contagious leprosy in the Levitical code, we shall find them to be ten in number, as follows:— 1. A bright spot (verse %. 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 bright 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. 3. A bright 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 11,13), 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 564 LEPROUS AFFECTIONS. boil (verse 18), the hair of the aff'ected skin being white (verse 20), is a contagious leprosy. 6. A bright 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 30), 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, occuring in a bald person and where the absence of hair excludes one feature of diagnosis, the red- dish 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 Graecorum; the bright white leprosy, true leprosy. 2. A spreading scab; probably an eczema. 3. The Tsorat, with funguous sore. 4. Fungous sore in conjunction with lepra alphos; the latter being the boak, Heb.; 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 be*ird ; superficial, but spreading. iO. A white, reddish, elevated sore, on a bald person. A Tsorat, or Berat lebena. Now, of the ten varieties of disease here designated under the gen- eric term leprosy, it would appear that only eight deserve to be con- sidered 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 spe- cific 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 remaining two varieties are, the second, a spreading scab, probably 1 It is worthy of remark that the word disease is used in this place (verse 36) in- stead of leprosy, although there can be no doubt, from the context, beginning with verse 29, that the disease leprosy is intended. CAUSE OF ELEPHANTIASIS. 565 an eczema; and ninth, a "dry scall," affecting the skin only superfi- cially, but exhibiting a tendency to spread. For the latter reason alone, namely, their progressive increase, they are classed with a con- tagious disease, as demanding, although not contagious in themselves, seclusion from healthy persons. Cause.—The cause of elephantiasis is very probably a malaria engendered by peculiar circumstances of soil and climate, the condi- tions the most favorable for its development being such as belong to an island or to the sea-coast. In early times, supposing elephantiasis Graecorum to have been the leprosy of the Hebrews, the disease existed abundantly in Egypt and Syria. At the present day it is most largely found in the islands and upon the sea-boards of the Indian Ocean, as also in Iceland and on the coast of Norway. In these instances the disease is endemic to the soil; but it may also be endemic to a race, as among the African negroes of the West Indies. Although constant in its selection of the sea-coast, the disease may also be met with in certain inland localities, as upon the mountainous ridges of Madagas- car, the table-land of the Deccan, and the sterile district of Zenjan, lying to the west of the Caspian Sea. It exists under the extreme heat of the tropics and under the extreme cold of the northern regions ; it is found in damp and swampy localities, and also in those which are dry and sterile; in low-lying districts; and amongst the spurs of a mountain range. It is impossible, therefore, to assign a special geo- graphical position or special conditions of soil or climate as essential to the production of the disease; and we can approach no nearer the truth than to remark, that it is most abundantly found on islands and peninsulas near the sea-coast. Neither is it an appurtenance of a par- ticular race, as of the Jews or of the Eastern people in general; nor dependent upon peculiarity of food. " In the island of Madagascar there are a number of different races, of all shades of color, from the pure negro to the Hovah, whose complexion is not darker than a native of Spain. These occupy widely varying climates. The cen- tral provinces, from their great elevation, possess a temperate climate, similar to that of the south of France. The climate of the plains is tropical, and towards the north excessively warm. The circumstances and mode of life of these races are as varied as their origin and the nature of the localities in which they reside. Yet leprosy affects all alike; the Hovah who lives in European fashion and in a temperate climate is not less exempt from the scourge than the African slave. It is found amongst the Betsemasarahas who eat pork, and amongst the Betanmenas who abhor it. It occurs where fish is an article of food, but it is also seen where no fish is to be had, and where rice and vegetables satisfy the simple wants of the population. It exists in town and country, at an elevation of 7000 feet above the level of the sea, along the coast line, and through all intermediate elevations."1 As a rule, the disease seems to be found chiefly among \he lower orders of the native races; in the east among the dark races, in the west 1 Tubercular Leprosy in Madagascar, by Dr. Andrew Davidson, medical missionary and physician to the Court of Madagascar. 1864. 566 LEPROUS AFFECTIONS. among the Africans. In Egypt it is most common among the Jews, while in Syria and Hindostan the Hebrew race is exempt. " In Jamaica," says Dr. Fiddes, "the Jewish inhabitants are probably afflicted most of all;" the disease attacks the poor and the affluent alike, and the proportion, as compared with the other inhabitants of the island, is one per cent, for the Jews, and one in five hundred for the dark races. The difference of manifestation of leprosy, constituting the tubercu- lar, the anaesthetic, and the mixed form, would seem to be due to cer- tain predisposing causes influencing the constitution of the individual, and possibly to race. Tubercular leprosy is more frequent than anes- thetic leprosy; it is also most common among the Chinese, among the negroes of the West Indies, and in Madagascar; while the anaes- thetic variety prevails on the eastern shores of Hindostan. The predisposing causes of elephantiasis differ in no wise from those of disease in general, and are such as tend to depress the powers of the constitution, whether in a moral or in a physical sense. The dis- ease would be likely to be more frequent among a people in bondage, as in the instance of the Hebrews in Egypt, or the negro slaves of the east and of the west, than in those that are permitted to enjoy their freedom. It is more common in the poor than in the wealthy, and is evidently fomented in its development by bad or insufficient food, exposure to cold or wet or extreme heat, defective clothing and habi- tation, absence of cleanliness, and excesses of every kind. Danielssen and Boeck point to the existence of spedalskhed amidst the gulfs and islands of the Norwegian coast, or, if it be found inland, it is in the line of rivers communicating with the sea. The climate of this region is cold, humid, and foggy; the soil clayey, marshy, and interspersed with stagnant pools; the drinking water loaded with calcareous salts, flat from the absence of carbonic acid, and in the summer season scanty and almost undrinktfble; the dwellings of the people are dirty, ill-ventilated, crowded, heated with smoky stoves, and often the joint residence of the owner, together with his dogs, pigs, and poultry. The people, young and old, are insufficiently clothed, and frequently sleep in wet coverings and on the damp ground ; while their chief diet is fish, generally stale or salted, and not unfrequently far advanced in decomposition. The cause of elephantiasis, admitted into the body through the agency of imbibition, probably by respiration, and also by the mu- cous and cutaneous surface of the body, produces a morbid change in the blood, which, for the want of a better expression, is termed dys- crasis ; and the morbid blood, operating upon the tissues of the sys- tem, induces in them those alterations of structure which constitute the disease. The entire body is permeated throughout by the mor- bid element, the solids and the fluids alike, and is brought into a con- dition by which' the morbid constitution may be communicated by impregnation and generation to offspring through successive genera- tions. The heredidity of leprosy is fully established, and obeys those laws which are common to heredidity in general; sometimes attacking every member of a family ; sometimes affecting one or two only; CAUSE OF ELEPHANTIASIS. 567 sometimes passing over one generation or two; and sometimes spread- ing collaterally, as well as in the direct line of succession. Heredi- tary transmission must, therefore, be regarded as a cause of the disease next in importance to idiopathic origin, and will serve to explain the prevalence of leprosy in countries which are not endemically favor- able to its development. A curious illustration of the hereditary transmission of leprosy is met with in the province of New Brunswick, in Lower Canada; the disease is supposed to have been brought into the country, half a century ago, by a French emigrant family, origin- ally from St. Malo in Normandy. " From what I can gather from the old inhabitants of Tracadie," says Dr. Benson, in a report to the Lieu- tenant-Governor of New Brunswick, in 1862, " the disease was first noticed about forty years since, in the case of one Benoit, daughter of Maria Bredeau; and, although no mention is made of the disease ex- isting previously in the family, it might easily have been so, as the Bredeaus came from St. Malo, in Normandy, when young, and might 1 either have been unacquainted with the fact, had it been so, or unwill- ing to admit it when discovered. Be that as it may, it has pursued her descendants with frightful pertinacity, and there is no case now in the hospital which does not claim some relationship to that unfortu- nate stock."1 • We learn from these observations that elephantiasis may be idio- pathic, and it may be hereditary; but besides these two sources of origin and dispersion, it may also, in a limited degree, be contagious. In twenty-five cases that have fallen under our own notice, contagion seemed probable in several, and the chief sources of contagion ap- peared to be lactation and syphilitic inoculation. With a contami- nated blood, contagion by these means would not be very remarkable; it is, in fact, more remarkable that this source of communication has not been more frequently observed. A young medical officer of the Indian Army, the son of English parents, had connection with a leprous woman, and contracted a sloughing chancre; two years later, and apparently in direct succession from the sore, he became the sub- ject of elephantiasis. Careful reflection on this and other cases, sug- gested to our mind the possibility that leprosy, under favoring circum- stances, might be contagious by inoculation, as well as being commu- nicable by that other form of contagion which belongs to heredidity. Dr. Eegnaud, of the Mauritius, adduces two instances of apparent contagion; and Dr. Bolton, of the same island, mentions the case of a boy of fourteen, afflicted with leprosy from the age of seven, the son of British parents, whose father ascribed the origin of the disease to vaccination. The physician of the Leper Hospital of the Seychelles, on the He Curieuse, a native of Great Britain, was " himself an un- mistakable leper." And the Governor of Mauritius, Sir Henry Barkley, observes: " My own experience in the West Indies furnishes in- stances similar, in which Europeans in constant communication with lepers have themselves become affected with the disease." And Dr. • Abstract of Replies to Interrogatories prepared by the Leprosy Committee of the Royal College of Physicians, 1864. 568 LEPROUS AFFECTIONS. Bolton makes the curious remark, that " a young ox brought up at the Leper Asylum died of the disease."1 Several medical men, who have had the opportunity of watching the disease closely, express their belief that leprosy may be conveyed to a sound person through the medium of the discharges of ulcers. The Chinese have a strong feeling as to the contagion of leprosy; and a woman afflicted with this disease seeks, by cohabitation with a healthy man, to relieve herself from its influence. Nevertheless, there exists a weak point in the theory of contagion, namely, that in all the instances adduced, the subject of the disease has been for a time, often a long period, an in- habitant of the country where the disease prevails endemically. But, however contagious it may be through the agency of inocu- lation, it is clearly non-contagious in the ordinary intercourse of life, and, in general, is neither communicable from a husband to a wife, or from the latter to the former. Nevertheless, instances do sometimes occur in which married persons are infected the one by the other. It is believed in many countries that the leprosy wears itself out in three or four generations; and this belief is so strong in China, that the lepers are divided into classes corresponding with the progressive re- moves of the disease. Marriage with a leper is interdicted by law, but the lepers may marry amongst themselves, each in his own respec- tive class; and the children of lepers of the fourth degree are con- sidered sound, and are free to marry with any one they please. A further illustration of the exhaustion of the disease is shown in the census of the Seychelles Leper Establishment on the He Curieuse; thus, of forty-nine persons all living together, lepers and their progeny, eighteen, ranging in age from two to twrenty-four years, were perfectly sound. Elephantiasis affects all ages; it has been seen at birth,2 at the age of two years,3 and we ourselves have recorded a case in which the disease made its first appearance at sixty-seven. When of hereditary origin, or proceeding from lactation, it may be developed at the age of seven or fourteen; or from idiopathic causes, or other sources of contagion, at any period of life. And numerous instances are recorded of its existence in persons of seventy and eighty years of age. Prognosis.—The prognostics of elephantiasis are far from being encouraging. The common history of the disease is, that beginning insidiously, and progressing slowly, it gradually saps the powers of the patient, and ends only with his life. Even the duration of the disease has been determined approximately, ten to fifteen years for the tubercular form; fifteen to twenty years for the anaesthetic form. "Patients have lived," says Dr. Bowerbank, of Jamaica, "for thirty years and more, after the first manifestation" of the disease. As yet, no specific remedy has been found deserving of the name, although several are upon their trial; and for the want of a proper understand- ing of the nature of the complaint, scarcely a principle of treatment has been established; for our little existing knowledge of a methodus 1 Abstract of the Replies to the Leprosy Committee. 2 Dr. Saturnin, medical superintendent of the Leper Hospital, Trinidad. 5 Dr. Abercrombie, Cape of Good Hope. PROGNOSIS OF ELEPHANTIASIS. 569 medendi, we are indebted to those honest laborers in the field of medical science, Danielssen and Boeck. It is assumed, rather than proved, that the disease may be combated more successfully at an early period of its course than at a more advanced period; when it sets in with fever, than when it is slow and progressive; and that the chances of cure will be greater when the malady is acquired, than where it is hereditary ; and doubtless greatest of all where it has been acquired from sources of contagion, than from idiopathic causes. When the disease is once developed, the instinctive suggestion is to send the patient away from the place where the morbid influence is endemic, and, by a change of hygienic conditions, to arrest the current of the morbid phenomena. Hence," removal from Hindostan to Britain is one of the first recommendations of the physicians of India, and a similar practice is followed in other regions. From Scio, we learn, that " rare cases of spontaneous cure, in a very early stage of the dis- ease, are said to have occurred by removal to a climate quite different from that where the disease originated, as Wallachia, Moldavia, or Bussia. A man, twenty-eight years of age, son of a leprous mother, and having four brothers younger than himself, all leprous, left this island on the earliest appearance of the disease for Constantinople, where he lived four years. Last spring he returned, apparently quite well, but, being obliged to resume his work in the fields, within three months he became again leprous." It is surprising how very few cases have been observed of spontaneous cure, even as an aberration from the ordinary law; here and there one; one or two only in the exten- sive experience of Danielssen and Boeck. And at this point it is necessary to be borne in mind that the disease is remarkable for its periods of rest, sometimes extending over several years, during which the morbid action is quiescent, and especially for a rest after muti- lation of the extremities. So that we must be cautious in regarding a mere respite from the operations of the disease as a state of cure. In anaesthetic leprosy, writes Dr. Fiddes, of Jamaica, the disease not unfrequently "expends itself," after which "the patient may live through the ordinary term of life, showing no trace of'the disease except the mutilation of the extremities, and the leprous expression of the countenance." He mentions the case of a negress, aged fifty-five, in whom " a period of fifteen years has elapsed since the cessation of the disease, and her health has continued good. Both feet have been removed through the metatarsus, and all the fingers and the thumb of both hands at the metacarpal joint. She earns a livelihood as a washerwoman." He also adduces as another instance a woman of eighty, who had suffered to an equal extent with the preceding, but nevertheless enjoyed good health. He has seen cases in which the nerves, having been enlarged, have returned to their natural size, and others- in which the normal sensibility of the mutilated extremity has been restored. Unfortunately, at the present time we must regard these instances of cure, or partial cure, as exceptional. Of a similar class is a case mentioned by Consul Skene, of Aleppo; the disease " had reached the first stage of ulceration, and an attack of smallpox accelerated the curative process." Time was not given to observe if 570 LEPROUS AFFECTIONS. the disease returned. And another case, reported by Governor Hamilton, of Antigua, carries us back to the days of ancient Greek medicine: "I have never met with a case of spontaneous cure but one, which was attributed to a popular remedy, namely, soup made of the common lizard." But it must be remembered, at the same time, that lizard soup is very wholesome and nutritious, and, like our own turtle soup at home, is one of the luxuries of the West Indies. The most sanguine prognosis, therefore, cannot go further than to declare that much may be accomplished by the medical art to check the development and progress of the disease, but little for its cure. Treatment.—The treatment practised by the early physicians in this disease appears to have been founded on the principles of 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 per- fection of this plan than in seeking further into the obscurity of experi- mental medicine. Aretaeus, who has left so excellent an account of elephantiasis in his writings, lays down as the proper plan of treat- ment, the practice of venesection, followed by the use of purgatives, diluents, baths, and inunction with fat, assisted by a plain, nutritious, 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 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. ^Etius 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 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 of, by a similar process of exuviation, the sordid covering of morbid secretions and scales which is apt to accumulate in these diseases. Paulus iEgineta, 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 TREATMENT OF ELEPHANTIASIS. 571 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 turpethum) 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 constitu- tion 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, con- sisting 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 per- spiration, 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 palpita- tions and faintings. The diluent remedies with which he proposes 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 recommends these drinks to be taken in quantities of eight pints in the day, and con- tinued for six weeks at a time; and he states, as the effect of the treat- ment, that the secretions of the bowels and kidneys are regulated and brought into a healthy condition. After the above preparatory course, of six weeks' duration, he directs the employment of stronger altera- tives and sudorifics, such as decoction of saponaria, sarsaparilla, squi- nanthus, contrayerva, serpentary, pimpernel, rapuntium, zedoary, sassafras, juniper, scolopendrium, holy thistle, pareira brava, and drinks of verjuice. He maintains a strict diet, and if nausea super- vene, 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 indicates, he bleeds, purges, or adds tonic extracts to the preceding decoctions, such as fumitory, holy thistle, smaller centaury, pimpernel, arum, and worm- 572 LEPROUS AFFECTIONS. wood. 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 purgatives, 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 fumigations, and, after his cure, the patient should carefully follow the prescribed rules of diet and exercise. In a case treated successfully by Baum&s there were taken three hundred baths in the course of a year; the chief remedies were de- mulcent, 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.. Dauielssen and Boeck have had little experience of these remedies, their atten- tion 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 bleed- ing state of the gums, and a scorbutic state of the surface membranes. Antimony, the primiXm mobiU of Paracelsus, had great weight with the older physicians, in the fourfold capacity of purgative, sudorific, diuretic, and alterative, but is of little value in elephantiasis. The preparations of iodine 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 inconveni- ence when the iodide of potassium, in doses of a grain or a grain and a half, was administered. In the latter case a 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; 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 ad- ministered to seven patients, in increasing doses, and for a long period, without utility; four of these patients suffering 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 TREATMENT OF ELEPHANTIASIS. 573 used. The arseniate of copper was also tried, and 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, chaoul moogra, veronica quinquefolia, 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 alphos having been mistaken for this disease. Danielssen and Boeck make the same remark with regard to tar, which has also, and with little pretence, 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 application 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 desirable than one near a river, lake, or the sea; for it is in the latter situations that elephan- tiasis is chiefly found. The plough and the new-turned earth would probably supply the double requisite of the best air and good exer- cise. In respect of baths, we have no need at the present day to inquire the nature*of the fluid of which the bath should consist. The plain water-bath is as good as that of milk, and better 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 the one of which the naturalist predicates, from the structure of his teeth and conforma- tion of his stomach, he was born to make use. 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 vege- table ; now, to consist alone of anti-scorbutic 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' 574 LEPROUS AFFECTIONS. 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 ele- phantiasis, is one that we would fain have omitted to notice, and we only mention now to condemn, namely, castration. Under the im- pression 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, we may now mention, that in 1844, Danielssen and Boeck pro- jected a course of treatment which was found more successful than any which had been pursued up to that time. Thus they observe: 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 conges- tions, partly by frequent bleedings, and partly by stimulating the mu- cous membrane of the alimentary canal. For the latter purpose we had recourse to sulphate of magnesia, arsenic, or the tincture of can- tharides. 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 destil- latae, two drachms); and where they were scattered generally over the body, we had recourse to caustic and sulphuretted baths, the caus- tic bath being composed of six or eight ounces of carbonate of potash, and an equal quantity of quicklime, mingled with the water; the sul- phuretted bath, of five or six ounces of sulphuret of potash. The patients were kept in a bath for a period varying from one to three- quarters of an hour; the head was repeatedly dipped, and after each dip was deluged with cold water; and the bath was repeated 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 a while. We also found caustic potash of service in those cases of tubercular deposition within the larynx which sometimes give rise to TREATMENT OF ELEPHANTIASIS. 5"5 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 application, 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 Danielssen adduces the two following cases: A tailor, in whom the disease was hereditary, suffered from elephantiasis in its compound form, tubercular and anaesthetic. He was treated by Danielssen, and got well. Twelve .months after he suffered a relapse, from cold, and the disease assumed the pure anaesthetic form. There were insensibility of the skin of the extremities, particularly the hands, and an increased and painful sen- sitiveness 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 iodide and bromide of potassium, and with decided benefit; the excessive sensitiveness of the fingers had subsided, and given place to insensi- bility, and he was unable to feel his needle. He was thin and emaci- ated, his cheeks were pale and flabby, and his skin dry and inelastic. Danielssen now saw him; he continued the iodide and bromide of potassium, ordered cupping along the vertebral column, and subse- quently, the application of the moxa. The patient improved rapidly, his fingers became straight and recovered their flexibility, the sensi- bility 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 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 sur- face were hard and bluish, the eyebrows 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 in- guinal glands. The disease had commenced three or four years pre- viously, by an eruption of reddish spots, which first broke out on the arms, 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 p and rain, and had often slept in his wet clothes. His progenitors and 576 LEPROUS AFFECTIONS. 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, subsequently, one grain twice a day, for the purpose, apparently, of hastening the healing of the ulcers, and removing a thickening which had been left in the cicatrices, together with the thickening and infil- tration of the integument of the legs. These objects were, in a great measure, gained, the thickening of the cicatrices and infiltration or the skin of the legs were removed, but the ulcers took to bleeding, periodical pains occurred in the legs, and pains in the teeth. After the cessation of the mercury, the ulcers improved rapidly. In Sep- tember 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, with 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 in- creased 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 the 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, be- tween the sixth and tenth vertebrae. In November the moxa was kept open by means of from sixteen to twenty peas, sensibility 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 discolora- tion ; 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 TREATMENT OF ELEPHANTIASIS. 577 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 process of healing, and their pro- gress was continued steadily. 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 immedi- ately 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 potassium, 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* We have no experience of this mode of administering the remedy, and should have preferred five grains three times a day. This, however, 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 capable 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 insensi- bility 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 success- fully directed against that symptom was bleeding and counter-irrita- tion ; 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, 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. He cautions us against the use of oils and fats, and strongly against mer- curial 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 37 578 LEPROUS AFFECTIONS. 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 simply innocuous to man. Danielssen and Boeck, discarding these empirical means, have determined the cause of the disease, be it miasm or poi- son, to be present in the blood. They have observed the alterations 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 has for its object to change the composition of the blood, alter and improve nutrition, and eliminate the poisonous ele- ments of the disease. In pursuing this principle they have the means to a favorable issue in their hands, and we 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 the anaesthetic form should be conducted on the same principle. Portions of the blood of the patient 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 well-selected 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 is to be rendered more energetic, to facilitate the requisite changes in nutrition. With this view, the alimentary canal, the liver, the kidneys, the skin, are all to be brought into more active play; to which end, saline aperients and diluents are the appropriate remedies. Elimina- tion, 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 stimulated by counter- irritants, and by the use of the moxa. Local symptoms, such as infil- tration 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 cor- responding parts of the spine. TREATMENT OF ELEPHANTIASIS. 579 Danielssen and Boeck regulate their treatment in accordance with the degree of severity and stage of the disease, and the power and condition of the patient; and, according to their latest' experience, they recommend, for the first twelve months, generous diet, regular exercise, warm sea-water baths twice or three times a-week, together with cod-liver oil and chalybeate remedies, and, where enlargement of the lymphatic glands raises a suspicion of struma, iodine and iron. The chalybeates to which they give the preference are the hydrated oxide of iron, three grains three times a-day; the saccharated carbon- ate, six grains three or four times a-day; and the solution of sesqui- chloride, two to sixteen minims every two hours. Cod-liver oil they prescribe in doses of half an ounce twice or three times a-day, and, in the case of scrofulous diathesis, two to six drachms of the syrup of the iodide of iron daily. In the absence of debility and emaciation, or when, under the above treatment, the system has acquired a better tone and condition, and when the cutaneous manifestation is the chief indication for relief, they prescribe the local abstraction of blood by means of cupping, a vapor bath three times a-week, and a four months' treatment with tartarized antimony. The dose of the tartarized antimony is a quarter of a grain every two hours for one or two weeks, to be increased gradually during the following month until it reaches three-quarters of a grain, and then reduced in a similar manner during the following ten weeks, until the period of four months is completed. If the treat- ment occasion nausea, the dose must be advanced more slowly, or qualified with syrup of poppies or tincture of opium; and if the patient prove intolerant of the remedy, nitrate of potash, in doses of seven grains and a half, should be substituted for the antimony, and taken for the same space of time. In children under eight years of age a leech should be substituted for cupping, warm baths for vapor baths, and smaller doses of antimony prescribed. Danielsson informs us that, in its early stages, the disease will some- times yield to the above treatment; the patient may recover his healthy condition, the spots fade away, and, if any anaesthesia have already occurred, the sensibility may return. In general, however, although the more pressing symptoms may be removed by the treatment, the disease continues to linger; in which case the cupping and the baths are to be repeated, unless the abstraction of blood be contraindicated by anaemia, when it will be proper to have recourse to chalybeates. But the antimonial treatment should be suspended for four months, and at the end of this interval be resumed as before, and for a like period. If the pains continue to be troublesome, and are succeeded by anaesthesia, electro-magnetism may be employed daily. And if they still remain severe, they must be assailed with subcutaneous in- jections of morphia and atropia. On the other hand, if the pains cease to occur for six months, the treatment may be suspended, and a cure anticipated. When, however, the spots have merged into blotches of large size; 1 Recueil d'observations sur les Maladies de la Peau, 3me livraison, 1862. 580 LEPROUS AFFECTIONS. when the discoloration of the surface has increased ; when cutaneous hyperaesthesia is developed; and the pains are deep-seated, violent and constant; and when, also, deformity of the joints has commenced, symptoms which indicate that the trunks of the nerves are involved, Danielssen prescribes immersion in a warm bath for two to seven hours daily for a period of six weeks, plain for the first fifteen days, and subsequently containing from one and a half to three ounces of nitric or nitro-muriatic acid. And he combines with this plan the antimonial treatment already described ; and if there be no anaemia, cupping on the back or the extremities twice in the week; in some instances inducing suppuration in the wounds caused by the scarifi- cator, by frictions with an ointment of tartarized antimony. In addition to these measures, Danielssen endeavors to remove thickening of the sheaths of the nerves by the subcutaneous injection of oxide of chromium, and neuralgic pains by the subcutaneous injec- tion of morphia and by the application of blisters of the compound tincture of iodine and nitrate of silver. When the chief trunks of the nerves have become enlarged and thickened, when anaesthesia is estab- lished in the skin, and when the fingers and joints are dislocated and distorted, then, he says, nothing remains to be done but to relieve pain, the most powerful agents for that purpose being the local abstraction of blood, and sometimes the current of a powerful galvanic battery. In our own limited experience of this remarkable disease, the indi- cations for the regulation of treatment would seem to be to sustain generally the powers of the constitution; to prevent the morbid changes in the blood resulting from the presence of the supposed malarious poison; to arrest, if possible, the confirmation of a diathesis; to combat febrile symptoms as they arise; and to treat on general principles other symptoms developed in the course of the affection. Thus in the latent period, we should have recourse to quinine, quassia, nitro-muriatic acid with bitter infusions, chalybeates, and, on the prin- ciple of catalysis, the hyposulphites, especially that of soda. We might also deem it desirable to administer arsenic or cod-liver oil, and stimulate the skin with warm bathing. During the febrile period our remedies must be of the class of antiphlogistics, especially the chlorate of potash, and warm baths. And during the persistent period, comprehending the onward course of the disease, an extension of the plan laid down for the latent period, with the addition of more decided tonics, such as the tincture of the sesquichloride of iron, iron with phosphoric acid, the citrate of iron and quinine, and iron with arsenic, with a continuance of the catalytic remedies and warm baths. For the relief of local pains we have seen much benefit result from the use of a liniment composed of linimentum saponis, with cajeput oil and chloroform. Assuming elephantiasis to be a mal-assimilation, a cachexia origi- nating in malaria, we should not a priori expect to derive much assist- ance from mercury and iodide of potassium, the great emunctory remedies so valuable in syphilis; and experience has proved that these medicines employed as emunctories have been more injurious than useful in this disease. Iodide of potassium is suggested not only TREATMENT OF ELEPHANTIASIS. 581 on account of its anti-syphilitic powers, but also as a remedy against the neuralgic pains, and an absorbent of the deposits accumulated in the tissues, constituting thickenings and tubercles. The opinion of Danielssen, however, on this point is far from being encouraging. "There is scarcely," he says, "a preparation of iodine that I have not tried, and I am bound to declare that of all our known remedies, iodine is the least suitable for elephantiasis. The remarkable reac- tionary powers of its salts, on which I have often expressed my opinion, has led me to give them repeated trials, but I must confess that I have never obtained any satisfactory results. Nevertheless, the fact that these medicines tend to produce a dyscrasis of the tubercles, has led me to hope that an elimination of the morbid elements of the disease might in the end be brought about; and I have therefore commenced the use of iodine by subcutaneous injection in cases where I had pre- viously, administered it internally." The persistent period of the disease is the proper time for the use of specific remedies, of which the most important are the asclepias gigantea of Hindostan, the hydrocotyle asiatica, the chaoulmoogra, and the veronica quinquefolia. 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 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 rpot of the mudar, have been found successful when aided by the applica- tion of topical stimulants. The formula he proposes is composed 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 asclepias, to be administered three times a day; and the local stimulant, a weak acid solution (four grains to the pint, with ten minims of hydrochloric acid) of the bichloride of mercury, applied with friction to the local affection. The asclepias gigantea was discovered by Playfair, who called it vegetable mercury, and regarded it as a 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 in healing the ulcers, and often succeeded in effectiftg 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 eruptions 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 rapidly pervades every part of the system, and produces a titil- lating 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 the eruption pustular. The 1 "Medico-Chirurgical Transactions," vol. x. 1819. 582 LEPROUS AFFECTIONS. 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 recommend it as a substitute for mer- cury. It will enable you to heal a chancre, but does not eradicate the poison. In the secondary symptoms, however, it is an admirable ally, superseding, by its certain efficacy, the exhibition of mezereon, sarsa- parilla, 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 employed, 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 principle 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 pill,"1 and the mudar powder is also used in Hindostan in the form of an ointment, in combination with lard or spermaceti cerate. Another vegetable remedy which has attained a high and appa- rently a deserved reputation in the East, the hydrocotyle asiatica, is a plant resembling in appearance and ordinary characters the common hydrocotyle of the staguant ponds of this country. The hydrocotyle asciatica is reputed to be specific in many diseases, particularly 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, on fifty cases of diseases 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, 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 recommended as an excellent stomachic and tonic. It appears to have a peculiar action on the capil- laries of the mucous surfaces, and on the skin; it causes at first a sen- sation 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 1 Vide selected formulae. TREATMENT OF ELEPHANTIASIS. 583 by an augmentation of appetite and transpiration, and a general improvement in the health." M. Boileau, a physician of Mauritius, published an account of this plant, as a remedy for leprosy, in 1852; and M. Jules Lepine of Pon- dicherry, in the Journal de Pharmacie et de Chimie for 1855, has given a further description of the plant, with a chemical analysis, pharma- cology, and list of the formulae used in the Government 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, hav- ing 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, browm 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 containing, 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 con- sequently destroyed by exposure to heat. For this reason decoction and extract-are inadmissible forms. The virtues of veronica quinquefolia, also an Indian remedy, have been advocated by Mr. William Prince, Dr. Beach, and Dr. Ogden, both as a cure for leprosy and as a general emunctory. The part of the plant employed is the root, and ten ounces are said to be sufficient to cure a leprosy; while, according to Dr. Ogden, twelve ounces in four doses will restore the blood of an adult to the purity of that of an infant. The chaoulmoogra odorata or petarkura is a tree of large size, indi- genous to the Sylhet district of Hindostan. It is described by Rox- burgh in his Flora Indica, and is placed by Lindley in the order Pan- giaceae, and distinguished by the name of gynocardia odorata. The medicinal part of the tree is its seed, which is small in size, and yields, according to Dr. F. J. Mouat,1 "a bland fixed oil, with a peculiar and slightly unpleasant smell and taste, with the faintest possible after- flavor of the bitter almond." This seed has been long known to the natives for its virtues in the treatment of leprosy, and is apt to be largely adulterated when sold in the form of oil. It may be exhibited 1 The Indian Annals of Medical Science, April, 1864. 584 LEPROUS AFFECTIONS. as a pulp of the decorticated seed made into pills, the dose being six to twenty grains three times a day, or six to twelve minims of the oil; and for external use the pulp of the seed may be beaten up with lard, or the oil may be simply applied with a camel's-hair brush. It is advisable to avoid salt meats, acids, spices, and sweets, during its use; but its action is encouraged by oily fliud, butter, &c; and it might probably be combined advantageously with ood-liver oil. When taken in excess it produces nausea and irritability of stomach. Dr. Mouat narrates three cases in which he employed the chaoul- moogra seed with very satisfactory results: one a bad case of ulcera- tive elephantiasis; a second, an equally bad case of scrofulous ulcera- tion ; and the third, one of constitutional syphilitic ulceration. In the case of ulcerative leprosy, the sores began to heal rapidly after the patient had taken the remedy for a fortnight. In the scrofulous case the remedy was more active in its operation; and the third, which was regarded as hopeless, was effectually cured in six weeks. Dr. Marshall, of Bombay, found nitric acid a valuable and success- ful 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 portion of the remainder much benefited. Dr. Powell, of Mauritius, derived great benefit in anaesthetic leprosy from the continued use of quassia in doses of ten grains twice a day; the ulcers became more healthy and healed, and the patient remained well, frequently for two or three years. Dr. Seeman, in his account of a mission to Viti, gives a narrative of a barbarous method of cure of leprosy practised by the Fijians. His account is founded on the statement of a Wesleyan minister, who knew the patient as a "fine healthy young fellow ;" he was "surprised to find him one day so much altered by the effects of leprosy. Some time after, he again met him in full health, and on inquiry learnt the treatment adopted to bring about this change." It must be premised that we have no evidence of the disease referred to being leprosy; and the improbability is increased by the brevity of the attack and the suddenness of the cure. But, to proceed, a small fire was made in a closed shed with the wood of a poisonous tree, the sinugaga or poison sinu, Excaecaria agallocha of Linnaeus; the patient was then rubbed with the leaves of the tree and bound hand and foot; next a cord was made fast to his ankles, and he was suspended head down- wards in the thick black smoke of the burning wood; there he was left for several hours and until he had fainted away. He was then scraped, and freely bled by means of incisions made through the skin, taken down, and laid upon a mat to "await the result"—"in some cases death, in many life and health."1 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 1 Report of Leprosy Committee. MORPHEA. 585 history of Europe, and especially of Great Britain, of which examples have not very long vanished from our land, the question 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 infallable 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 ! We repeat, that elephantiasis still exists amongst us in this country as a faint trace of its former self, and the observation of that trace, however faint, becomes a matter of interesting 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 insen- sibility, the metamorphosis of tissue, 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 Hebrews, and as it is to be found at this moment on the shores of Norway, the symptom which was called by the ancients morphcea. This symptom, or rather sign, has been handed down to us by our forefathers, and it is this which we shall now proceed to describe, preserving the name by which it was originally known, namely, MORPHCEA. Syn. Vitiligo; morphoza maculosa; morpheiv. MORPHCEA, derived from the Greek word po^, forma, signifying a visible appearance, and in application to its seat, a visible appear- ance or spot in the skin, is, as its name implies, a spot upon or in the skin, of irregular form, and either white, morphoza alba, or of a dark- brownish or blackish hue, morphcea nigra. Moreover, morphcea 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, morphcea alba lardacea, vel tuberosa; the other being distinguished by atrophy of the skin, and by a greater degree of insensibility, morphosa alba atrophica, vel ansesthetica. 586 LEPROUS AFFECTIONS. M0RPHC3A ALBA LARDACEA. Syn. Berat lebena, Heb.; lepra leuce; vitiligo Candida; morphcea maculosa alba ; white morphew. Morphcea alba lardacea, vel tuberosa, presents itself 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.integu- ment, being neither elevated nor depressed, but remarkable for its marble-like whiteness, smoothness, and polish. It is more or less dense and hard, and frequently roughened on the surface by a slight desquamation of yellowish dried-up cuticle. Its hardness and density serve to isolate it from the surrounding integument 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 surrounding it presents a delicate lilac blush; but in cases of long standing no such border exists. The smoothness, whiteness, and polish of the morbid integument all proceed from the same cause, namely, infiltration into the cutaneous tissue, or deposition within its cells, of a white semi-opaque 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 cuti- cle ; 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 whiteness 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 appearance 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 wanting in the usual downy hair of the body, 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 morphcea 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 dimensions of a crown-piece or the palm of the hand. The redness is altogether 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 M0RPH03A ALBA LARDACEA. 587 away altogether. The development of the erythematous spot is usually accompanied with a feeling of tingling, like that occasioned by pres- sure on a nerve. Sometimes this sensation is sufficiently powerful to attract the attention of the patient, and give him annoyance; at other times it is scarcely appreciable. The size and number of the patches are very various. We have seen a number clustered together about the neck, each no longer than a lentil. A common and usual size is that of a crown-piece or the palm of the hand; and we have seen one patch occupy the greater part of the thigh. The limb had the appearance of a piece of beauti- ful marble sculpture, highly polished. One felt tempted to touch it, it looked so white and smooth, to be convinced that it 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. We recollect expressing our astonishment in looking upon that limb; and, upon asking some question, the gentleman smiled, and said that it gave him no inconvenience, 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 supra-clavicular region of the neck, the chest just below the mammae, the front of the abdomen, and the thighs. We have a patient now 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 almost equally in- sensible. Our friend Mr. Samuel Wood, of Shrewsbury, writing to us 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 had 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 blood- vessels ramifying over several parts. The edge is slightly raised, and beyond this there is a slight blush. The size of the patch on the left side is four inches long by three broad. It has been slowly pro- gressing for about twelve months. There is little pain, but an occa- sional burning heat." Mr. C. Wilson Steel, of Lewisham, writing to us 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 perceived for the first time, a white spot on the back of the hand; subsequently, other spots appeared on different parts of the body, as on the abdomen, thighs, and arms; indeed, they are dispersed more or less abundantly over the entire surface. The face is free, with the exception 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 warn- 588 LEPROUS AFFECTIONS. ing of its occurrence. The spots do not attain any magnitude ; and the spread of the disease takes place by new spots, which when once formed, are permanent. They are distinguished from the surround- ing skin, not by any raised margin, by any chap, ulceration, scurfi- ness, 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 sensa- tion of pain, other than the premonitory numbness 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." 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 our experience does not enable us to say whether any other symptoms of elephantiasis follow upon this first step. We have observed several cases of morphcea 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 morphcea is often the immediate forerunner of that serious disease. MORPHCEA ALBA ATROPHICA. Syn. Berat lebena, Heb.; lepra leuce ; vitiligo Candida ; morphoza maculosa alba ; white morphew. Morphcea alba atrophica, vel anaesthetica, differs from morphcea 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 sur- rounds them, the same; but there is no deposition of morbid matter in the texture of the derma, and consequently no marble-like smooth- ness, polish and hardness; the lardaceous deposit is absent. In fact the two forms of morphcea alba bear the same relation to each other as do the two forms of elephantiasis ; morphcea lardacea belonging to the tuberculated, and morphcea atrophica to the anaesthetic type. From the absence of deposition in the tissue of the derma, and, as a consequence 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 finer than natural, and before the tint of color reaches the dead white of complete insensi- bility 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. MORPHCEA ALBA ATROPHICA. 589 Just as elephantiasisanaesthetica and elephantiasis tuberculosa, being merely varieties of the same disease, may coexist, so morphcea alba atrophica may be present with morphcea 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 our care, who has six or eight patches of morphcea 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 com- parison with the tawny skin into which they are, as it were, inlaid. Morphcea 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, on the abdomen, in the groins, and on the inner side of the arms and legs. Three or four times we 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 disease, the skin sometimes becomes shrivelled and dried up, like parchment; this is more particularly the case over a hard surface, as upon the head. The following is an example of morphcea alba of the forehead, occurring 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 us 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 dis- tance from the end of the streak. In March, 1855, he consulted us 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. This deposit rendered the surface smooth and polished, obliterating the linear markings of the skin, and destroying 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 590 LEPROUS AFFECTIONS. which dipped from point to point into the small spaces between the lobules of the morbid deposit. The 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 sub- sided 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 in- tegument, and the border of the sound skin presented the pale lilac blush which constitutes the ordinary limit of the patches of morphcea alba. We have thus brought under our eyes, as far as is possible in the living body, the actual process of the conversion of morphcea atrophica into morphcea tuberosa. Reaching the summit of the fore- head, 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 (morphcea alopeciata). The gently undulating course of this broad band suggested to the mind the idea of a river as represented on a map, 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 pre- sented the form of morphcea 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 of the 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 our 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 our 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. We 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. At his visit to us in 1851 we prescribed for him 'iodide of potash MORPHCEA NIGRA. 591 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 mild 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 oint- ment. 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 allowed his adviser the opportunity of regulating or modifying the treatment from time to time. In April, 1855, he returned to us, when we 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 with soap-liniment. As we have not seen him since, we are unable to report the success of this plan. MORPHCEA NIGRA. Syn. Berat cecha, Heb.; lepra melas, Gr.; vitiligo nigricans; black morphew. Morphcea nigra resembles in origin and general symptoms the two preceding forms, but differs from both in the conservation of the pig- ment-forming function of the skin, which is increased instead of being suspended as in morphoea alba. The persistence of this function iudicates 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 fey oedema. Patches of morphcea nigra were present in all the cases of elephantiasis which have come under our observation, but we have not seen it independently of that disease; sometimes the patches are round, and not more than a quarter of an inch in diameter; at other times they may be as large as a crown- piece or 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 portion. 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 the skin a greasy appearance, but later in the attack the patches are dry and devoid of secretion. 592 LEPROUS AFFECTIONS. MORPHCEA ALOPECIATA. Morphcea commonly produces a total disorganization and complete atrophy of the skin, and necessarily destroys the secreting functions of that organ; the perspiratory, sebiparous, chromatogenic, and tri- chogenetic 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 mor- phcea are smooth and bald, or the hair covering them is colorless or white; and when, as before related, the patch 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, we have shown that the pathognomonic characters of the disease are such as to point to exhaustion of nervous power as their source; and we 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. The specific characters of alopecia areata, and especially of mor- phoea alopeciata, are, loss of hair in a patch of circular, and some- times, 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 conse- quence of morbid alteration of structure of the nervous fibrils supply- ing the affected spot of skin. Alopecia areata 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 some- times 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 invete- rate, though we have seen the hair return in several instances. But setting aside all these varied appearances, the most characteristic form is that in which the spot is of considerable 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. AFFECTIONS OF THE PIGMENT SYSTEM. 593 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 nutri- tion, originating in defective innervation. In the adult this explana- tion 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 common seat of the disease in the adult is the chin, where the bald, white, circular spot contrasts strongly with the hair- bearing skin, and is particularly 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 and tonics. At other times we 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 morphcea 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, carbolic acid, tar, &c. For morphoea alopeciata of the scalp, plentiful friction with the hairbrush, in addition to the stimu- lants already enumerated, is indicated, together with the use of a stimulating lotion or pomatum. Where the scalp is denuded to a great extent, advantage is often gained by dipping the head in cold water, and exciting 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 we have had recourse to cod-liver oil, in addition to the preceding local and altera- tive 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 aff'ected skin, and the baldness becomes established permanently. CHAPTER XX. AFFECTIONS OF THE PIGMENT SYSTEM. The pigment system of the skin has its seat in the rete mucosum. The disorders of this system, or the disorders of chromatogenesis, may therefore be regarded as diseases of the rete mucosum ; and the rete mucosum being the formative layer of the epidermis, they may also be considered as diseases of the epidermis. The diseases treated of in previous chapters have been diseases of the derma, but this and the two following chapters will be devoted to the consideration of disor- ders aff'ecting the epidermis, its mucous and its horny layer, the action of the disease taking place in the rete mucosum, and the horny epi- 38 594 AFFECTIONS OF THE PIGMENT SYSTEM. dermis suffering derangement of structure to a greater or less extent as a consequence. The chromatogenous, or dyschromatous diseases, manifest their existence by a variation of color of the skin ; the more common change is that of a deepening in hue of the natural dark pigment of the rete mucosum, constituting melanopathia, melanoderma, or melasma; in the second place, the predominating morbid tint may be yellow, as in freckles, and the disorder one of xanthopathia; occasionally a blue pigment has been noted as being present in the skin, and the deranged function has been termed cyanopathia; and, lastly, there may be an achroma, or total absence of color and the skin may be perfectly white. This is the state which is termed leucopathia, leucoderma, or leucasmus. In a tabular scheme the dyschromatous affections may be arranged as follows:— Melanopathia, Cyanopathia, Xanthopathia, Leucopathia. MELANOPATHIA. Syn. Fuscedo cutis; nigredo cutis ; nigrities; melasma cutis; melanoderma. 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 extremes every shade of tint may be found in intermediate latitudes; and, indeed, by the alternation 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 con- siderable 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 hue. But it is scarcely necessary to remark that the phenomena involved in the functions of the skin are not wholly referable to external agen- cies. That which the stimulus of light and of the sun's rays is to the skin, under natural circumstances, the stimulus of morbid action may be in a disordered state of the system. Hence we occasionally meet 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, melasma MELANODERMA. 595 figuratum, or being more or less generally diffused over a large sur- face, melasma universum. Again, it is clear that especial organization must also contribute very largely to the differences of tint which are observed in the human race. _ The long winter of the colder climates, or protracted imprison- ment 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 num- ber of years would give rise to these results. It is to especial organi- zation that we must have recourse to explain the great difference in shade of color that exists among the inhabitants of the same island, and the diff'erences 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 altera- tion 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 par- tial in its distribution, and appears in the form of patches of various size. Again, patches of a darker color than the surrounding skin, but identical in every other respect, may be developed upon any part of the surface of the integument in individuals of every shade of com- plexion. Plenck seems to have been under the belief that the Tar- tars have naturally a mottled skin: "Cutis variegata nativa, in Tar- tarorum 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 preg- nant 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 of the 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 curi- osity and interest. Such was the case in the following narrative, communicated to us by Mr. Jackson, of High Wycombe, Bucking- hamshire. " 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 clavicles, downwards to about the middle of the thighs, of a negro blackness. " From the girl's statement I learned that, shortly after she became pregnant, the areola around each nipple looked very dark, but no fur- ther perceptible change took place until she quickened, when an evi- dent darkness of the whole breast was visible, extending upwards to 596 AFFECTIONS OF THE PIGMENT SYSTEM. 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 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 presentation of the hand and umbilicus; turning was resorted to, and the girl 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 meet- ing her, about a year afterwards, she assured me it had entirely disappeared." Melasma universum.—The following interesting case of general melanopathia was communicated to us 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 gypsy. The dark- ness of the skin, though general over the body, was most marked at the nape of the neck, and least so on the nose and upper lip. His hair is light-colored, and his eyes gray; these, his mother states, have un- dergone 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 somewhat resembled that which I have seen produced by the inhalation of arseniuretted hydrogen; but in the latter case the sclerotic coat of the eye was dis- colored; 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 sub- jected 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 pityriasis nigra. A blister was applied to the nape of the neck. After it had caused vesi- cation, it was obvious that the dark color of the skin resided 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 effect MELANODERMA. 597 the change going on, the boy ceased to attend the hospital after a few weeks." In a case of melasma universum which we had the opportunity of seeing, through the courtesy of Mr. Acret, of Torrington-square,' the blackness affected the entire skin, with the exception of the feet and the 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 became 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 fre- quently delirious. Previous to the illness, menstruation was regular and the menses copious ; but since her recovery, she has suff'ered from amenorrhoea, with much periodical pain, until the last three months. Her health at present is what she styles " good," that is, her strength is not impaired, but she is liable to headache, has an eczematous erup- tion 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 the body are, the back of the trunk and the back 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 of the eyeball is brilliantly white and anaemic. 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 correspond- ing with the apertures of follicles. The areola of the nipples ap- proached in depth of color to a negro blackness. Another case, communicated to us 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 on his cheeks, and thence extended over the entire body, being greatest on the front and sides of his breast, the inner side of his legs, and the hands. With the termination of this case we are not acquainted. Addison' called the attention of the profession a few years back to the association of melasma with disease of the suprarenal capsules, 1 On the Constitutional and Local Effects of Diseases of the Suprarenal Capsules, by Thomas Addison, M.D. 4to., 1855. 598 AFFECTIONS OF THE PIGMENT SYSTEM. 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, accom- panied with extreme weakness. After the cessation of the 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 pearly whiteness; 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 the urine, and Golding Bird, under whose care he was, con- sidered 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." 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 a dark olive-brown color; and black pigmentary patches were developed on the mucous membrane of the inside 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; tender- ness of epigastrium, constipation, clean 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 raucous membrane of the 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 pre- MELANODERMA. 599 ceded his death black patches of discoloration upon the mucous mem- brane 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 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, sick- ness of stomach, hiccough, and typhoid symptoms. Dr. Rees, under whose care he was during part of his illness, discovered "white cor- puscles" 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 melasma 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 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. Addison expresses his "belief that the urgency of the symptoms, and the quick or slow progress of the dis- ease, 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 pro- bability, 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. Ths subject, however, is in the infancy of its research, and we must accept Addison's observations as a valuable contribution to medicine, and as a basis for further investigation. It cannot be allowed that all cases of melasma are also examples of disease of the suprarenal cap- sules, any more than that every case of disease of the suprarenal cap- sules must be necessarily accompanied by the deposit of a dark pig- ment in the skin. Addison has very properly shown that melasma is only one of the symptoms, of a series of those which constitute the 600 AFFECTIONS OF THE PIGMENT SYSTEM. peculiar form of anaemia which he so forcibly describes. " For a long period," he writes, "I had, from time to time, met a very remarkable form of general anaemia, occurring without any discoverable cause whatever; cases 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 lead- ing and 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 integu- ment." And 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 our- selves, with a view of ascertaining how far they accord with Addison's description, it will be evident that our first case, that of Martha Wes- ton, must be looked upon merely as a physiological phenomenon. In the second case (John Daniels), Pereira speaks of the sclerotica as being remarkably white, but does not otherwise lead us to infer the existence of anaemia, or an}r constitutional disease; the discoloration had been in existence fifteen months when it came under his observa- tion. 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; we regret, however, that we are unable to report her present state; she had been two years undergoing a gradual MELANODERMA. 601 change of color, and, in compliance with Addison's views, ought by this time to be dead. According to Addison, disease of the capsulae suprarenales is attended with disturbance of the chromatogenous function of the skin, such disturbance tending to the production of an excess of black pigment. 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 condition 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 caus- ing 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 of the abdominal parietes." In taking this view of the suprarenal 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 semilunar 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 Addison refers. Admitting all this, we have, as an explanation of the phenomena indicated by Addison, namely, spontaneous or idiopathic anaemia, with melasma of the skin, and associated disease of the capsulae supra- renales—disease of the capsulae suprarenales, irritation or disease of the solar plexus, arrested haematogenesis, augmented chromatogenesis, exhaustion, death. In a word, the solar plexus is the actual source of all these successive phenomena, and the disease of the capsulae supra- renales only the exciting cause. A state of irritation or disease of the solar plexus will explain all those symptoms which we have difficulty to comprehend as proceeding from such apparently insignificant organs as the suprarenal capsules. 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 augmentation 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 objec- tion which we should otherwise be inclined to set up, namely, the diversity in the forms of the melasma, described by Addison. For, as the case at present stands, every black patch of discoloration of the skin becomes the foundation of a diagnosis of diseased suprarenal 602 AFFECTIONS OF THE PIGMENT SYSTEM. capsules, and prognosis of speedy death ; a line of argurnent which is clearly unfounded. But we cannot object, indeed we think it worthy of attentive consideration, to the diagnosis of irritation and probable disease of the solar plexus in these cases. We should strongly pro- test against a harmless chloasma being set down as a sign of a fatal cachexia ; but our experience is altogether in favor of considering it a consequence of irritation of the great centre of innervation of the assimi- lative organs. But Addison goes further than this, and suggests the inference that the suprarenal capsules are the especial 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 characteristic of renal capsular disease, depended rather upon an interruption to some special function than upon the nature of the organic change; for, with the exception of the manifestly recent san- guineous effusion into its tissue, the capsule itself did not appear to have undergone any considerable deterioration." With such an infer- ence we are indisposed to agree, and the physiology of the suprarenal capsules in no way inclines to such a conclusion. Melasma figuratum is a partial form of melanopathia, generally circumscribed, but not unfrequently associated with a diffused duski- ness of the skin, fuscedo cutis, of considerable extent. It is to this form of melasma that the term ephelis (ephelis umbrosa, Franck) has been given ; but as the word ephelis applies only to a cause, although to a cause that is far from uncommon, nevertheless, to one only of many causes, it is more consistent with a better knowledge of the nature of the disease, to adopt the term melasma or melanoderma in preference to ephelis. Plenck distinguishes seven varieties of Melas- ma, under the name of Ephelis; three belonging to the local group, namely, Solaris, ignealis, and a vesicatario; and four constitutional, namely, gravidarum, hepatica, dysmenorrhcealis, and haemorrhoidalis. Melasma figuratum is more frequently seen upon the face than else- where, but may be developed upon any part of the body. Its com- mon seat is the forehead; next in frequency it is met with on the back of the hands, on the trunk of the body, and on the limbs. On the face and back of the hands it occupies a position which is most exposed to alternations of temperature, to the action of the sun and of fire, common causes of the disease. The face also is the seat of mani- festation of many of the sympathies of the body, and the reflex phe- nomena of nervous irritation excited in the digestive and reproductive system are manifested, as in a mirror, on the forehead and upon the face. Melasma palpebrarum, or blepharal melasma, commonly pre- sents itself in a diffused form, more highly concentrated near the edges of the lids than elsewhere, and commonly associated with anaemia of conjunctiva, and a dark liquid transparency of the globe of the eye, which we have designated by the name of melasma oculi. In coun- tries where the charcoal brazier is much in use for warming the feet, a mottled form of melasma, ephelis ignealis, is met with on the inner side of the legs and thighs. . A similar mottling is sometimes produced MELANODERMA. 603 by varicose veins, and the lower extremities are especially liable to a yellow, black, or brown discoloration occurring in patches of variable extent, " maculae livido-atrae tibias, potissimum senum, absque evi- denti causa." Neither must we omit the melasmic blotches or ma- culae which sometimes follow blisters, the patches of alphos, ulcers of the legs, and, in particular, syphilitic eruptions and ulcerations. Looking to the constitutional origin of melasma, we see a reason why it should be more common in the female than in the male sex, and also why it should prove more obstinate in the former than in the latter. In twenty cases, seventeen were females, and only three males; the ages of these twenty ranged between twenty and forty - five, and the duration of the disease was: in ten, from two to five years, and in seven, from five to ten years. Melasma frontis often assumes a peculiarity of figure which is not met with elsewhere; it is most concentrated along the line of the hair, and fades towards the centre, or, it is absent in the centre and assumes the shape of an arch; sometimes there is a central patch as well as the arched segment at either side ; and occasionally the pigment takes the direction of the supraorbital nerves. A lady whom we know has a melasmic patch shaped like a horse-shoe on the middle of the fore- head ; the ends of the arch correspond with the inner extremity of the eyebrows, and two smaller curves proceed from these ends parallel with the eyebrows to about their middle. Melasma is sometimes confined to a single region of the skin, as of the forehead, but is also very commonly dispersed over several regions at the same time; for example, in the twenty cases already mentioned, melasma frontis was present in thirteen of the number, but was alone in three only, the femaining ten cases presenting the following combi- nations : melasma diffusum, five; faciei, three; faciei et colli, one; and labii superioris, one. In one case the melasma occupied the cheek and the conjunctiva, and in another the dorsum of the hand and the popliteal region ; while all presented examples of melasma oculi more or less perfectly defined. Moreover, two of the cases were asso- ciated with chloasma, a theme for future consideration. A partial melasma has been described under the name of pinta, as endemic on the western coast of Mexico. The affection is confined to the laboring classes, and is said to begin with symptoms of miasmatic fever, namely, shivering and nausea, followed by febricula, and lasting for some days. When the fever subsides, the skin is found spotted over with yellowish stains, particularly the face, chest, and limbs. The yellow stains become paler and paler until they are almost white, and then they gradually darken until they attain a negro-blackness, which remains permanently. The general surface of the skin desquamates, is more or less rough and inflamed, and sometimes falls into a state of ulceration; the perspirations are fetid, but the general health remains uninjured. Melasmic stains of the skin are sometimes congenital, in which case they receive the name of naevi pigmentosi; and sometimes they are associated with an abnormal growth of the hair of the part, naevipilosi. In a case at present before us (Oct. 1866), a boy three years of age, 604 AFFECTIONS OF THE PIGMENT SYSTEM. more than half of the right side of the face is deeply colored with pisrment, and covered with a strong growth of thick black hair. The surface of the skin is uneven, in some parts raised and corrugated, and irregular in the distribution of its pigment; the tints varying from deep red and yellow brown to deep black, the latter occurring in patches on the rest of the surface. The melasmic and pilous patch is continuous with the hairy scalp, but differs from the latter in the pre- sence of pigment as well as hair, and its boundary line descends upon the forehead to the inner third of the eyebrow and eyelids, and from the latter in a curve towards the ala of the nose and angle of the mouth, and thence backwards across the lower jaw to the nape of the neck; the discoloration and pilous growth involving the ear as well as the rest of the skin. The boy has, besides, several large pigmentary and pilous spots scattered upon his limbs. The mother of the child met with no shock during her pregnancy, and no hereditary tendency would seem to have prevailed. The special consideration of these marks belongs to the chapter devoted to the eleventh group, namely, of hypertrophic affections. Diagnosis.—The prominent feature of melanopathia, namely, color, is so obvious, and the existence of anaemia so striking, that errors of diagnosis in well-marked examples of the disease are not likely to occur; in doubtful cases it may be remembered that the cuticle is commonly unchanged in melasma, but is more or less broken up and foliaceous in chloasma. Cause.—Melanoderma obeys a double cause, namely, a heal cause, such as the heat of the sun or fire and the reaction of heat after ex- posure to cold, or local irritation such as that occasioned by varicose veins; and a constitutional cause, under the influence of which the red corpuscles of the blood are changed into pigment particles, creating melanaemia, and afterwards deposited by way of elimination in the cells of the rete mucosum.1 Looking to the predisposing cause: nervous debility was present in thirteen of the twenty cases already referred to, nutritive debility in four, and assimilative debility in three; while the remote predis- posing causes were as follows: pregnancy and uterine derangement, nine; nervous shock, six; and the following, one each: rapid growth, climate, rubeola, syphilis, and the heat of the sun after parturition. Melasma frontis succeeded pregnancy on two occasions in the same patient; and an additional predisposing cause seemed to contribute additional potency to the influence of the puerperal state in others; for example, the conjunction of rubeola and parturition, parturition and exposure to the sun, &c. Prognosis.—Grave or unimportant, according to the nature of the cause: if the irritation of the organic nerves be due to visceral disease, and proceed to an aggravated form of melanaemia and leucaemia, the case will prove fatal; if the disease be slight, or simply functional, 1 For further researches into the pathology of melasma, see our essay, entitled " Dyschromatoderma, or Discoloration of the Skin," in the British Medical Journal for 1863. MELANODERMA. 605 there is hope of cure. And cure may especially be predicted where the nervous irritation originates in deranged uterine function or in hysteria. Treatment.—The treatment of melanopathia must be governed by the nature of the cause of the disease; in a large proportion of cases it originates in nervous debility ; in a small number, in nutritive and assimilative debility. Our treatment must have for its object to renovate strength and nervous power. Tonics of all kinds are indi- cated, especially quinine and iron, and phosphoric acid and iron. In nutritive debility we may conjoin cod-liver oil with the tonics; and in assimilative debility regulate digestion and secretion before aiming at bestowing power. In the generality of these cases, particularly where all ordinary indications have been accomplished by the usual means, we have found the ferro-arsenical mixture of great value, of a strength sufficient to give two minims of Fowler's solution for the dose, three times a day. With this treatment it is also necessary to combine moral medicine and a generous diet. The local treatment requires moderate stimulation, by means of friction and ablution with the carbolic acid or juniper-tar soap and the use of cold water. The bichloride of mercury lotion, one or two grains to the ounce, is frequently of great service; so also are frictions with the unguentum picis liquidae and unguentum sulphuris, of each equal parts. We have in some instances employed with advantage a lotion of carbolic acid, a lotion of juniper tar with alcohol and soft soap, the unguentum creasoti, and the liquor carbonis detergens; and in obstinate cases have had recourse to the compound tincture of iodine pencilled on the surface, a saturated solution of iodine in gly- cerine, and a solution of potassa fusa, one part to eight of water. Melasma tinctum.—Persons who have taken nitrate of silver for a certain length of time are liable to be affected with a chemical altera- tion 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 a greenish-slate color. The discoloration takes place upon all parts of the surface of the body at the same time, but is most remarkable in those regions which are exposed habitually to the influence of light, as the face and hands; and in the latter situations it not unfrequently assumes 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 surface it is much deepened by those causes which, under other circumstances, would produce pallor; for the same reason the discoloration is more apparent upon persons naturally pale than in those who possess a fresh complexion. Once established, the dis- coloration 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 removal; hence, it becomes necessary to inquire what remedies might 606 AFFECTIONS OF THE PIGMENT SYSTEM. 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. XANTHOPATHIA. Syn. Xanthoderma ; xanthochroia ; flavedo cutis. Xanthopathia, or yellow discoloration of the skin, consists in the deposit in the cells of the rete mucosum of a yellow coloring princi- ple, and is the foundation of diffused pigmentary yellowness of the cutaneous surface, flavedo cutis, the yellow tints of cachexia cutis, the maculae luteae of newly-born infants, the circumscribed spots of lentigo, and, in combination with a small proportion of black, the yellow and reddish-brown of chloasma. Xanthoderma represents the yellow com- plexion of certain of the races of mankind, as does melanoderma that of the negro; and the xanthic element, like the melanic element, is doubtless derived from the coloring principle of the blood. We see this coloring principle developed in the varying tints of a bruise; and we have evidence of its presence in the economy in the coloration of the bile and of the urine. In a free state, namely, as a secretion of the sebiparous glands, we have another illustration of the xanthic coloring principle in stearrhcea flavescens; and in association also with the sebiparous apparatus, a subcuticular discoloration of the eyelids, which we have designated a yellow hypertrophy of the epithelium. The diseases which call for special consideration under the head of xanthopathia are: Lentigo and Chloasma. LENTIGO. Syn. Epichrosis lenticula, Mason Good ; phacia ; freckles ; sommersprossen, Germ. Lentigo is the small lentil-shaped and lentil-colored spot commonly met with on the face of children and young persons, in considerable numbers, and popularly termed freckles (lentigines). The spots are small, round, and yellow, of various size, rarely larger than the dia- meter of a split pea, and often considerably smaller. They are seated in the rete mucosum, and most abundantly distributed on parts of the body exposed to the influence of the light and heat of the sun; as the face, neck, and hands; and on the face they are most numerous around the eyelids, upon the forehead, and upon the cheeks. The color of the lenticular spots offers some variety, in accordance with the complexion of the individual; in red-haired persons they are saffron-colored, and in children of different complexions may be traced a series of tints, running through every shade of yellow, to light brown, and even green. .Plenck seems to have been most familiar with the CHLOASMA. 607 browner kinds; for he says, " lentigines sunt maculae fuscae, quae, colore, figura et magnitudine, lentes referunt." Lentigo is sometimes a congenital affection, appearing soon after birth, and continuing through life ; more commonly, however, it pre- vails during the ten years from ten to twenty, and is more frequent in persons of light complexion and light hair, than in those possessing a darker skin. There is, however, a form of lentigo, which occurs upon the covered parts of the skin, Untigines frigidae, or cold freckles, which are more common in adult life than in the young; these latter result from some derangement of the coloring principle of the skin, referable to internal causes, and except for their size, belong to the consideration of malasma rather than of xanthoderma. The exciting cause of lentigo is the operation of light and heat upon the skin, and in particular the sun's rays; but there doubtless exists a predisposing cause, in a weakness of structure of the skin, and a sen- sitiveness to irritant impressions. Cold freckles pbey a constitutional cause, are met with in men as well as in women, and are favored in their development by a weak state of the cutaneous tissues. Treatment.—The intention of treatment in lentigo should be to promote a healthy tone and healthy nutrition of the skin; to this end the parts should be washed once or twice a day with some mildly stimulating soap, such as that of juniper tar or carbolic acid, and cold water, and a moderately stimulant lotion subsequently applied, such as that of the bichloride of mercury in emulsion of bitter almonds (gr. j-ij ad 3j); a similar solution in spirit, with elder or rose-water ; or a lotion of borax and rose-water. Plenck recommends acetum armora- ciae; pasta amygdalarum amarum ; fel taurinum ; lac sulphuris ; aqua phagedaenica (yellow wash); and solution of sulphate of zinc. Fel taurinum is a favorite cosmetic remedy among the older physicians. Lenticulae, says Celsus, " are cured by galbanum and carbonate of soda, rubbed down with vinegar to the consistence of honey." The paste is to be rubbed upon the skin, left for some hours, and then washed off. CHLOASMA. Syn. Pityriasis versicolor, Willan; maculae hepaticce ; ephelis hepatica; hepatizon; leberftecke, Germ. Chloasma is a discoloration of the skin of a light yellowish or greenish-brown tint, having its seat in the rete mucosum, occurring in small patches, or blotches of considerable extent, distinctly circum- scribed, and developed symmetrically on the trunk of the body, the neck, and occasionally on the limbs.1 Chloasma is popularly named liver-spot, probably from its color, or possibly from some theory of its origin; but the color is subject to * certain variations, ranging from a reddish and yellowish tint to a light or even a dark brown or greenish hue; the latter tint having suggested the term chloasma. These differences of tint correspond 1 Vide Portraits of diseases of the skin, Plate XXXV. A. 608 AFFECTIONS OF THE PIGMENT SYSTEM. with the complexion of the patient, the color being light in fair, and deep in dark persons. The patches of which it is composed are some- times small and separate, like a cluster of islets or fleecy clouds, and at other times large and extensive, and bounded by a map like out- line. The common situation of the discoloration is the trunk of the body, beginning at the axillae, extending upwards upon the'shoulders and neck and downwards upon the flanks, or beginning at the groins and extending upwards upon the abdomen and downwards for a short distance upon the thighs. The patches are developed in a similar manner upon the back, and are also met with in the flexures of the elbows and of the hams, and sometimes upon the inner side of the arms and legs. Next to color and figure the most striking character of chloasma is pruritus, and that also is very variable. We have met with persons who have complained of intense suffering from itching, and we have found it convenient to designate such cases by the name of chloasma pruriginosum, while in the greater number the pruritus was trifling, and in some there was no itching at all. Another of the symptoms of chloasma is desquamation, and this forms no exception in variety to that which prevails in the other symptoms. Occasionally there has been no trace of desquamation or exfoliation, the predominating symptom being color only, and such cases we have distinguished as chloasma pigmentosum ; while in others the exfoliation and desquamation have been the first appearances to catch the eye, and we have felt the necessity of employing the term chloasma furfuraceum.. In. brief, we have sometimes seen chloasma presenting the charac- ters of an erythematous redness, and entitling itself to the denomina- tion of chloasma erythematosum, while at other times its characters were best distinguished by the terms pigmentosum, pruriginosum, and furfuraceum. It is evident that chloasma is not a mere alteration of color, like melasma and lentigo; but that it is associated very com- monly with a degree of hyperaemia of the skin, and when hyperaemia exists, there is more or less alteration of structure of the rete muco- sum, and a furfuraceous breaking up and desquamation of the epider- mis. It is this latter character that has occasioned the confusion between pityriasis and chloasma, and has gained for the latter the synonym of pityriasis versicolor, while a chloasma with a deeper tint of pigmentation has been termed pityriasis nigra. According to our views of the pathology of chloasma, the rete mucosum and epidermis present a degeneration of structure, in which the primary granules of the cells take on a morbid growth and possibly proliferation. This state of the cell-tissue we have termed granular degeneration; and when a portion of the morbid cell-tissue is placed in the field of the microscope, the granules may be seen in vast num- bers. By others these granules are regarded as mucedinous plants, and have received the names of microsporon furfur and epidermophy- ton. • The color of chloasma is supposed to be due not to animal pig- ment, but to the coloration of the supposititious plant, and the desqua- mation to result from the breaking up of the horny tissue of the CHLOASMA. 609 epidermis by the growth of the plant, and by the absorption of its moisture and that of the rete mucosum, for the purposes of nutrition of the parasite; in the language of this theory, the granules are spo- rules, and the sporules constitute the plant. Chloasma prevails somewhat more frequently among males than among females; the ages most favorable for its development ranging from fifteen to thirty, and its duration from one to ten years. It is therefore a chronic complaint, and is apt to recur from time to time for a considerable period. We have found it to be sometimes asso- ciated with melasma figuratum and melasma oculi, and sometimes with eczema; while in one instance it accompanied melasma oculi and alopecia areata. Diagnosis.—The pathognomonic characters of chloasma are its yellowish, brownish, and greenish patches, some small and others extensive; its principal seat, upon the trunk of the body and flexures of the joints ; its symmetrical position, either excentric or concentric ; pruritus, sometimes present and sometimes absent; and cuticular exfo- liation, also absent occasionally. Its color distinguishes it from ordi- nary pityriasis, as it does also from melasma. Cause.—The cause of chloasma is a debility of tissue, originating in nervous sympathy with the visceral organic system, and chiefly with the assimilative organs. In its pathological nature it is a hyperae- mia accompanied with a morbid alteration of the*epidermic cells, and an accumulation of pigment in the rete mucosum. But according to the supporters of the vegetable theory, it is a parasitic fungus, coming from without, growing in the rete mucosum at the expense of the juices of the cell-tissue, breaking up the horny epidermis into foliace- ous and furfuraceous scales, and itself constituting the chief bulk of the desquamating substance, the color of the chloasma being in fact the color of the fungus. According to the same theory, chloasma is contagious, a belief which does not accord with experience. The predisposing cause in thirty cases, was, assimilative debility in twenty-five, nutritive debility, in three, nervous debility in one only; and the remote predisposing causes were as follows: dyspepsia, alter- nation of seasons, variations of climate, pregnancy and menstrual dis- order, general nervous weakness, eczematous diathesis, affliction, haemorrhoids, rheumatism, leucorrhcea ,sedentary pursuits, alternation of cold and heat, and hereditary diathesis. Prognosis.—Chloasma is harmless, although disagreeable to the patient from its appearance, and sometimes annoying from insupporta- ble itching. It betrays no serious constitutional disturbance, is obsti- nate and recurrent, but eventually gets well. Treatment.—The treatment of chloasma must be directed to the digestive and assimilative organs and secretions; and the best reme- dies for this purpose are, sulphate of magnesia with quinine or a bit- ter infusion; or, nitromuriatic acid with bitters. In obstinate cases it may be desirable to have recourse to the ferro-arsenical mixture. The local treatment is one of stimulus of the skin, ablution with the juniper-tar or carbolic acid soap, the cold tub in the morning, and 3^ 610 AFFECTIONS OF THE PIGMENT SYSTEM. spongings with the bichloride of mercury lotion, two grains to the ounce; or with a lotion of sulphite of soda, an ounce to the pint. In very obstinate cases the solution of the pentesulphide of lime will be found useful, or friction with an ointment composed of equal parts of unguentum picis liquidaeand unguentum sulphuris: these latter reme- dies should be used at night and washed off with soap in the morning, and they are at the same time the most eff'ectual agents for the relief of pruritus. The unguentum creasoti is a useful application for the same purpose. CYANOPATHIA. Cyanoderma, or blue discoloration of the skin, is identical in. its mode of manifestation with melanoderma and xanthoderma ; but there is this difference between them, namely, that black and yellow are natural animal pigments, and are developed normally in the skin of the human family, their extremes being represented by the Negro and the Mongol; but blue pigment is an abnormal product resulting from morbid chemical combinations, and is consequently less frequent. Billard d'Angers has reported a case of cyanoderma of the forehead, face, front of the neck, chest, and abdomen, in a .young girl ; and he makes the curious observation that she blushed blue instead of red. Blue pigment has also been seen in the sebaceous secretion in stear- rhoea caeruleum, in ?he perspiratory secretion, and also in the urine. LEUCOPATHIA. Leucoderma vel leucasmus cutis is an absence of pigment in the skin, an achromatous condition of the rete mucosum, and presents itself sometimes as a general aff'ection, leucasmus universalis, and some- times as a partial aff'ection, leucasmus figuratus. LEUCASMUS UNIVERSALIS. Syn. Epichrosis alphosis, Mason Good ; achroma; alphosis; albinismus. General achroma of the skin is best illustrated in the albino, in whom there is a total absence of pigment, not only in the skin, but also in the hair and in the choroid coat of the eyeball. The absence of color is in this case physiological, and frequently hereditary ; but as far as the individual is concerned, it is a state of disease, for it inter- feres with his comfort in a serious degree; he is almost blind by day, and only sees as well as other men in the gloom of evening and at night. Albinoes are met with among all races of mankind, among the dark- complexioned nations of the south, as well as among the fair-haired inhabitants of the coldest regions of the earth. Their skin is of a milk-white color, the hair fair, sometimes silvery white, 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, the iris pinkish and sometimes bluish. There is intolerance of light, the LEUCODERMA. 611 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 con- stitutional power. Albinism is congenital; but sometimes accidental in its develop- ment, arising without any apparent cause, upon some part of the body, and thence extending to the entire surface. Instances of accidental general leucoderma have only been observed among the natives of Africa. An example of complete albinism in the negro, alphosis osthiopica, leucaethiopes, 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. LEUCASMUS' FIGURATUS. Syn. Epichrosis pcecilia, M.a,son Good; ephelis alba; cutis variegata; piebald skin. Partial leucasmus is the common form of pathological achroma, and occurs in patches, usually of a circular figure, and developed both on the trunk of the body and on the limbs. Leucasmus is not uncommon in the black races (pied negro), sometimes hereditary and sometimes accidental, and in the latter case is very possibly a simple arrest of pigment-formation, from disordered innervation and nutrition. But amongst those who possess normally a less degree of coloration the disorder of chromatogenesis is more general; for not only is there an absence of pigment on the parts affected with leucasmus, but an excess of pigment on surrounding parts or diffused over the rest of the body. We have constantly before us examples of pure melasma, but never cases of pure leucasmus, for leucasmus is always associated, in a greater or less degree, with melasma. In our " 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 (melasma), and subsequently lost the cutaneous pig- ment on various parts of the body (leucasmus). Several white patches made their appearance on the face ; one nipple was blanched, 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 accu- ' Plate XXXIII. H. 612 AFFECTIONS OF THE PIGMENT SYSTEM. mulated on the side of the trunk in blotches of deep black. He had been undergoing this change for seven years when be came first under our observation. A strange case of partial leucasmus is recorded also in the fifty-first volume of the " Philosophical Transactions." The dis- coloration of the skin said to be so common on the west coast of South America, amongst the spurs of the Cordillera mountains, and named carate, is a partial leucasmus in the black, and a melasma in the white races. Bonpland mentions having seen it on the banks of the Magdalena River in New Granada, and remarks that it has a tendency to make the blacks white, and the whites black ; it often produces a marbled appearance of the skin, is very common, but apparently independent of any disorder of the general health. The spots were most frequent on the arms, breast, and face, and presented various degrees of whiteness, and, in some instances, were of a crimson red color. If we may judge from so small a number as twelve cases, leucas- mus would seem to be more common in the male than in the female, and in the proportion of seven to five. Ten of these cases commenced between the ages of fifteen and forty, four out of the number occur- ring between fifteen and twenty, and four between twenty and thirty; one at the age of nine, and one at fifty-four. The duration of the dis- ease at the time of treatment ranged between one year and five, in six cases; between five years and ten, in three; and between ten years and twenty, in two; one having lasted twenty-seven years. Ten of the twelve cases now referred to were examples of leucas- mus figuratus, associated with melasma diffusum ; in one case the leu- casmic spots were small and elongated in form, resembling cicatrices, leucasmus macuhsus; and in another the bleaching was confined to the edge of the upper eyelid of one side, and implicated six or eight of the cilia, which were also white. / When leucasmus attacks the hairy parts of the body it is not un- common for the hairs growing upon the spot to be white. In one of the above cases a circular leucasmic spot occupied the summit of the forehead, and the hairs were completely bleached; in a man of forty, who had. spent four years in the Greek archipelago, the skin and hair of the axillae and pubes were snowy white, and the penis and scrotum mottled; and we have in remembrance a young lady who had one patch of leucasmus on the side of the scalp, from which there issued a solitary lock of white hair. On the other hand, the surface of the skin may be bleached without implicating the growing hair. Leucasmus very commonly begins at the extremities of the body, as the fingers and toes; next in frequency it appears on the lips, the face, and neck; in the neighborhood of the axillae and groins; on the abdomen, and on the scrotum and penis. On the scrotum it sometimes assumes the form of longitudinal streaks. In India it has been ob- served to be more common on the sea-coast thau elsewhere. There is usually no symmetry of arrangement of the blotches; they are defined by a sharp edge, and the skin immediately around them presents a deep tinge of black, which subsides by degrees into the LEUCODERMA. 613 general duskiness of the melasmic skin. The leucasmic skin is in no- wise altered in structure, but has the appearance of being less vas- cular and more delicate in texture than the adjacent parts, and is evi- dently less sensitive to the impression of stimulus. Diagnosis.—The pathognomonic characters of leucasmus are the whiteness or bleaching of the skin without alteration of structure; and, as we have seen, leucasmus being in its essence a derangement of pigment-formation, it is commonly associated with melasma to a greater or less degree. The white patches of elephantiasis and mor- phoea alba always indicate a morbid alteration of structure combined with the loss of color. Cause.—Leucasmus is a neurosis, and the result of weakened in- nervation of the skin, the excitant being commonly referable to the organs of assimilation or reproduction. Occasionally, and especially in India, it may depend upon the operation of a local irritant. Of the twelve cases mentioned* above, eight were examples of nervous de- bility, three of assimilative debility, and one of nutritive debility. And the remote predisposing causes were as follows: menstrual ir- regularity, excess of mental labor, climate of India, gastric disorder, sudden alternation of heat and cold, typhus fever, and smallpox. In some instances several of the above causes were successive. Prognosis.—Where this affection is in the main physiological, as it is in India, it is comparatively unimportant, excepting as a deform- ity. An Indian gentleman, suffering under the complaint, remarked that, in his case, the color had returned on most of the original patches, but that new spots were developed from time to time. Even in Euro- peans the disease is not inconsistent with a moderate state of health of the body; and it only becomes serious from its neurotic sympathies. Treatment.—Regulate digestion and secretion, give vigor to as- similation and tone to innervation, and, at the same time, apply a healthy stimulus to the skin. These are the general indications for the treatment of leucasmus, as they are those for the management of all the dyschromata. To this end a regular and nutritious diet and healthful hygienic conditions materially conduce. Next tonics; digestive tonics, blood tonics, nerve tonics, and, at the proper time and in proper doses, the ferro-arsenical mixture. The local treatment should consist of cold ablutions daily, the use of soap and friction to the skin, and stimulant applications to the affected part, such as lotions of the bichloride of mercury, carbolic acid, acetum lyttae, compound tincture of iodine, iodide of potassium combined with soft soap, sulphurous acid, and frictions with a compound ointment of sulphur and tar. 614 PHYTODERMIC AFFECTIONS. CHAPTER XXI. PHYTODERMIC AFFECTIONS. The Phytodermic or Dermatophyte Affections are diseases involving the structure of the rete mucosum and epidermis, and they present the character in common of developing a morbid tissue resembling that of a fungus plant or mucedo; hence these diseases have also received the name of nosophyta. The seat of the morbid tissue is the rete mucosum and hair; and in the rete mucosum it gradually rises to the surface by the detrition of the horny epidermis and by the exfoliation of the lining membrane of the follicles, until it is found to pervade the whole thickness of the epidermic structure. The morbid or phytiform tissue is composed of globular nucleated granules, and these granules have the properties of proliferation and growth; by proliferation they increase in number without change of figure; by growth they become elongated into diaphragmated cylin- drical shafts, and have the power of throwing off shoots from point to point, and assuming a branched or phytiform character; the medium of growth being the division of their nuclei. In botanical language these elements are termed: the nucleated granules, sporules, or seeds; the cylindrical and ramified shafts, mycelium; and as they resemble in every respect mucedinous fungi, they have been classed with those vegetables, under the names of Microsporon, Trichophyton, and Achorion. The miorosporon and the trichophyton are composed almost wholly of sporules, with little or no mycelium; the achorion is more complicated in structure, and consists of sporules or seeds, sporidia or seed vessels, and mycelium. The difference between them seems to be one of nourishment: on the trunk of the body, where the follicles are small and only scantily supplied with capilla- ries, the microsporon is found; in the substance of the hair, also poor in nutritive fluids, the sporular trichophyton exists; but in the highly vascular hair-follicles the achorion finds the supply of nutri- tion suitable for its greater growth and development. And what is this phytiform growth? Is it, as we maintain, an alteration of structure of the elementary components or granules of the cell tissue of the rete mucosum ? or, is it an independent organism, a plant originating from a sporule or seed, conveyed accidentally to the skin, fixing itself in the skin, drawing nourishment from the skin, and growing in the soft cell-tissue of the rete mucosum, at the expense of the nutritive fluids of the skin, just as a lichen or a fern may grow upon the bark of a tree ? Is it a parasite figuratively as a blood-corpuscle or an epithelial cell may be a parasite, or is it a parasite actually ? The latter is the theory maintained by many, and that theory is embodied in the expression, " parasitic diseases of the skin;" and that no mistake should arise, the parasitic plants are nosophyta. 615 arranged by the side of the parasitic animals, the acarus scabiei and entozoon folliculorum. The question is important, not so much in a practical point of view as in its relation to physiology. We maintain that we have seen the cells of the rete mucosum passing through those stages of growth which have converted their nuclei into granules, the so-called sporules; we maintain that the granular condition is the normal foetal structure of the young epidermal cell, and that the morbid con- dition in question is an arrest of development of those cells at their foetal stage, and the cause of their consequent modification of destiny no longer to rise through those higher stages of animalization which culminate in the production of horn, but doomed in their crude con- dition to the lowest function which belongs to immature organic matter, namely, poliferation. We can find no better word to express this degradation of structure than the term " granular degeneration." To return, however, to the disease before us, this phytiform tissue is an undoubted fact; its seat is also admitted ; we have now only to say that it constitutes the pathological element of four separate diseases, as follows:— Favus, Sycosis, Trichonosis, Chloasma. In favus, the phytiform tissue was first observed, and the fungus is termed achorion Schoenleinii;1 in trichonosis and sycosis the sporular form of the fungus is met with under the name of tricho- phyton tonsurans; while in chloasma the fungus is also sporular, and is named from that circumstance, and from giving rise to a fur- furaceous condition of the epidermis, microsporon furfur, and epi- dermophyton. These diseases, therefore, having a common pathological element, admit of being grouped together, and consitute a veritable epiderminosis. Besides their common pathological element, the epiderminotic affec- tions have several other points of resemblance; namely, their seat in and around the follicles of the skin, their destruction of the epidermis and hair, and their epidemic and possibly their contagious nature. If the phytiform substance be a real plant, and the granules real sporules, the contagion of these diseases should be positive and unquestionable, which we cannot admit to be the case; and we are not helped in this matter by experiment; for the proliferous granules of aborted cells would retain their proliferous properties under favorable conditions, such as inoculation, and might continue the form of growth which belonged to them, without giving sanction to the belief that that was their normal mode of transmission. A strong objection to the mode of contagion admitted by the phy- 1 Achor is a name given to a small follicular pustule of the scalp. The term is at present disused, in consequence of the difficulty of identifying with exactness the pustule intended to be defined. The Greek word *%<»? signifies scurf or dandruff, a^usov meaning " chaff." The term would therefore seem to have been applied rather to the thin scale left by a pustule than to the pustule itself. Achorion is a derivative of achor, and Schoenlein tlie name of one of the early observers of the dermatophyta, which were discovered by Reinak in 183li. 616 * UNGUAL AFFECTIONS. topathologists is involved in the fact that the disease begins, not upon, but under, the horny epidermis; and to reach the bed in which it grows, the sporule must have the power of perforating the horny cuticle, a process which we believe ourselves warranted in declaring a physiological impossibility, while another argument against the con- tagion theory is the symmetry of development of one of the diseases, namely, chloasma. Contagion by seed implies the growth of the plant wherever the seed falls; and in the case of the scalp and face, there is nothing opposed to this view in the mode of distribution of the morbid patches; but the symmetrical disposition of the patches of chloasma obeys another and a vital law, one appertaining to the indi- vidual, and indicative of an action of the nervous system; it is, in fact, a neurosis. Favus and sycosis being diseases of the hair-follicles chiefly, and trichonosis being a disease of the hair chiefly, their description will be found in the chapter devoted to the hair and hair-follicles. Chloasma is remarkable, principally, for the altered pigmentation by which it is accompanied, and is therefore treated of in the chapter on chroma- togenous affections, although as an epiderminosis it also occupies the follicles of the skin, and the interfollicular rete mucosum. The reader will find the present subject more fully discussed in a paper " on the phytopathology of the skin and nosophytodermata ; the so-called parasitic affections of the skin," published in the British and Foreign Medico-Chirurgical Review for January, 1864. CHAPTER, XXII. UNGUAL AFFECTIONS. The disorders of the nails are referable to alterations in the dispo- sition of the skin around the margin,of the nail; in the development, growth, color, and texture of the nails themselves; and to inflamma- tion, suppuration, and ulceration of the matrix and adjoining 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 with a thin film. This 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 sore- ness and tenderness of the skin. These little ragged bands of cuticle are called agnails, on account of the pain and suffering which they not unfrequently occasion. At other times, instead of growing for- ward, the cuticular margin of the follicle recedes, and exposes the root DEFORMITAS UNGUIUM. 617 of the nail. This affection is rare, but has received the name officus unguium. Rayer remarks that he has observed it among curriers; we have seen it a few times 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 shed from time to time, with and without apparent cause; in their irregular shape, their occurrence in greater number than natural, and 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), we 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 alopecia ungualis. 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 arrest of nutrition, as in elephantiasis Graecorum. Faulty shape of the 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 at the sides, arctura unguis, too prominent, too flat, or too much arched or curved. 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 direction of the concavity being longi- tudinal, or horizontal; and sometimes it is re- markable for its curve over the end of the Fis- L- 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 development, we find the nail occupying an abnormal situation. The most remarkable illustration of the latter phenomenon is the production of a nail-like growth at the extremity of amputated fingers; even on the stumps of the first and second phalanges, where no rudiment of the original matrix can have existed. Abnormal growth of the nails is illustrated, sometimes by de- ficient growth, sometimes by growth in excess, and sometimes by unnatural growth. We 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 or extent; the nails sometimes attain an enormous size in boucnemia; and an instance 618 UNGUAL AFFECTIONS. of extraordinary growth of the nails is recorded by Saillant, as occur- ring 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 acquire an extravagant size. We have in our possession several toe-nails of this kind, measuring two and three inches in length. Rohout, 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 mea- sured 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 Unguibus Monstrosis," 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 aff'ecting the matrix of the nails, as in eczema and alphos ; and it also results from injury, as in ecchymosis beneath the nail, the con- sequence of a bruise, ecchymoma unguis. Not unfrequently the nail is speckled with small roundish white spots, selene unguis, figuratively named by the ancient writers, fiores unguium ; and, by the moderns, less elegantly termed mendacia, or lies. These spots are more common 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 thethreefold form of increased thickness, altered density, and altered smoothness, constituting the state of disease known as degeneratio unguium. Or the matrix of the nail may be the subject of inflammation, suppu- ration, and ulceration, constituting onychia. We may now proceed to the consideration of these two forms of disease. degeneratio unguium. Syn. Defozdatio unguium ; scabrities unguium. The nails sometimes acquire an excessive degree of thickness, and the increase of bulk is accompanied with a yellow and dirty discolor- ation, 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 its matrix, and a dry, whitish, broken sub- stance collected in large quantity beneath it. Two such cases are now before us, in which the greater part of the fingers of both hands are affected in this manner. In another case, also under our observation at the present time, the nails are reduced to a mere film, and so soft and brittle in texture, that they split and break with the slightest pressure, mollities un- guium; the texture of the nail is healthy, but its quantity deficient, 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 1 Saillant, Memoire sur la maladie de la femme dite aux ongles. Paris, 1776, 8vo. ONYCHIA. 619 Fig. M. subject of much annoyance to the lady who is the sufferer from the affection.; the ends of the nails are always ragged and broken, they catch in her clothes and in almost everything she touches; and when torn, they occasion bleeding and soreness of the matrix. Sometimes the nails are brittle from a morbid alteration of tex- ture, being converted into a white earthy matter which breaks up into shapeless granules on the ap- plication of a slight degree of pressure. Another change in the nails, for which we have been several times consulted, is a fibrous state of those organs, which appear to be made up of a thick stra- tum of fibres, closely packed together, but becoming loosened here and there, so that separate fibres are met with on the surface. The surface of the nail is necessarily rough, ragged, discolored, and marked by numerous dark, longitudinal lines; and, besides being very unsightly, adheres like a burr to any rough ma- terial 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. The state of the nail, like the preceding, is unsightly, 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. ONYCHIA. A. B. C Forefinger, middle, and ring- finger, showing the broken and dis- figured state of the nail, in degeneratio unguium ; flssura unguium. Onychia is an inflammation of the matrix of the nail, sometimes confined to that structure only, but more frequently involving the immediately surround- ing soft parts. The inflammation is succeeded by suppuration and ulceration to a greater or less extent, the production of granulations of large size and un- healthy texture, of a fungous character, and an ichorous, sanious, and fetid discharge. The inflammation is sometimes superficial, some- times 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 occasionally 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 of the nail in destruction. It may occur along the edge of the nail, or at its root; and it may be either acute or chronic in respect of its progress. 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 have been produced and kept up by the pressure of the 620 UNGUAL AFFECTIONS. 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 occasioned 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 thinned by scraping until reduced to a 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 forward, 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 still further to the pressure; then suppuration takes place, next ulceration, the production of fungous granulations and an unhealthy discharge. The medical management of this case consists in the withdrawal of the cause by rest and position; then the removal of the offending border of the nail; and the general relief of the in- flammation by scraping the whole surface of the nail, until it become 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 special treatment, but usually gets well when the general eczema is relieved. Scrofulous onychia commonly attacks the nail follicle, and the in- flammation spreads to the whole of the skin immediately bordering the nail; by degrees the entire end of the finger is inflamed and en- larged, and the nail looks as if it were sunk in a deep hollow, sur- rounded by a tumid border of a deep red or purplish hue. The finger has the appearance which is commonly denominated clubbed, and, as the disease 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 syphilitic 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 different 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. Malignant onychia sometimes extends so deeply as to affect the periosteum and bone; and is often many months under treatment. TREATMENT OF ONYCHIA. 621 N Onychia is not unfrequently accompanied with irritative fever, the consequence of severe pain and loss of sleep, and the constitutional disorder tends materially to the aggravation of the local disease. 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 are, direct violence or injury, continued irri- tation from in-growing nail, and the constitutional and specific affec- tions, eczema, scrofula, and syphilis. The cause of onychia maligna must be referred to some general derangement of the constitution, probably mal-assimilation and cachexia. Treatment.—In degeneratio unguium, we have derived advantage from the local application of. iodide of potassium and chloride of zinc in solution. The treatment of onychia must be local and constitutional; local to subdue the congestion of the inflamed part, to relieve the pressure, to give early exit to pus, and to stimulate to a healthy healing pro- cess; and constitutional, to remove internal causes of irritation, and maintain and support the powers of the system against the morbid influence of the local disease. The general principles of local treatment are, position, maintenance of an uniform temperature, and exclusion of air by a dressing of basili- con ointment. If foreign bodies are present, they must be removed in the first instance; and if the evil be kept up by the nail, either in consequence of its thickness and density or of its pressure upon the inflamed part, the nail must be scraped, and the offending parts gently cut away. It must be remembered that by scraping, the nail may be reduced to the thinness and softness of cuticle, and that in this way one of the chief difficulties in the treatment of onychia, and one of the chief causes of its virulence, may be swept away. We may thin the nail so as to reach the bed of the pus, and liberate the matter with ease; and the same operation practised along the middle line permits of the folding of the nail, and at once relieves the pressure of the edges on the lateral walls. It is useful in some instances to introduce a piece of dry lint between the tumid lateral wall of the matrix and the border of the nail. Exuberant granulations must be kept down by the application of a strong solution of nitrate of silver or sulphate of copper, and the part must be dressed with a desiccative or mildly stimulative ointment, such as the benzoated ointment of oxide of zinc, the unguentum resinae flavae, or an ointment of Peruvian balsam. The constitutional treatment of onychia must be regulated accord- ing to the indications presented by the general system. If the evil in the constitution be the eczematous or strumous diathesis, if it be syphilitic or cachectic, the treatment must be adapted to those states of the organism. Under all circumstances, digestion and secretion 622 AFFECTIONS OF THE HAIR SYSTEM. should be regulated, and we should keep up the powers of the systemr by nutritious diet and by tonic medicines, to enable it to resist the attack of disease, and to furnish the mSans of restoration of the dis- organized parts to a healthy status. The remedies the most likely to be needed are, quinine and iron, iodide of iron, the mineral acids with vegetable bitters, and cod-liver oil. CHAPTER XXIII. AFFECTIONS OF THE HAIR SYSTEM. The hair system is composed of two parts, the hair itself, and the follicle in which the hair is implanted; and the diseases of these organs are represented by their aberration from the normal standard of structure and function. In the case of the hair, the aberration may be one of quantity, length, color, direction, and texture; and in the case of the follicles, there may be excess, or diminution, or alteration of secretion, or an organic change of structure. The disorders of the hair having reference to quantity and color are, hirsuties, hairiness, or excess of hair; alopecia, or deficiency of hair; trichonosis decolor, or discoloration of hair; and canities, or whiteness of hair. The disorders of texture, remarkable especially for brittleness of structure, are fragilitas crinium, and trichonosis tonsu- rans or ringworm. And the disorders of the follicles are, simple alteration of secretion, and an organic change in the structure of the follicle constituting favus, kerion or scalled head, and sycosis. In a tabular scheme the diseases of the hair system may be arranged under four heads, as follows:— 1. Diseases of quantity. Hirsuties, Alopecia areata, Alopecia vulgaris, " calva, vel calvities. 2. Diseases of cohr and direction. Trichonosis decolor, Canities, Trichiasis. 3. Diseases of texture. Fragilitas crinium, Trichonosis tonsurans, Plica polonica. 4. Diseases of follicles. Morbi sebacei, Kerion, Favus, Sycosis. HIRSUTIES. 623 ^ DISEASES OF QUANTITY. HIRSUTIES. Syn. Trichosis hirsuties, Mason Good ; trichoma ; 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. Judg- ing 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 beard grows one line (French) in the course of a week, let us call it one line and a haif (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 and 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 frequently met with at our country fairs ; and Rayer quotes the following instance of remarkable development of this production: " I once saw a Piedmontese, aged twenty-eight, strongly built, having the chest broad and large, and the muscles of an athlete ; the arm was above twenty-one inches, and the calf of the leg nearly two feet in 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 pur- pose, 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 eff'ects produced upon the system by the habit of removal of the hair. We have known persons who always experience headache after having the hair cut; and man3r 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 observations2 on the advantages and dangers of cutting the hair; and he especially details the case of a young lady cured of mania by that operation. The hair is often 1 Miiller's Archiv., 1850. 2 Journal General de Medecine, vol. iv. p. 280. 621 AFFECTIONS OF THE HAIR SYSTEM. found of unusual length in phthisis, and long black eyelashes are con- sidered pathognomonic of strumous disease. This is an interesting 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. When it is recollected that every part of the skin, with the excep- tion of the palm of the hands and sole of the feet, is organized for the production of hair, it will cease to be a 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 pilous naevi or moles. In naevi of this kind there is no hyper- trophy 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 enlargement 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. 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 we saw a lad, about twelve years of age, of healthy aspect and constitution, who presented an unusual growth of long, harsh, and black hair upon the outer side of the arms, extend- ing from the back of the hand to the shoulder. The integument upon which the hair grew was of a brownish color, and contrasted 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 terminating imperceptibly in the ordi- nary color of the cutaneous surface. The skin, in other respects, was uniform with the rest of the integument; 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 only differing from eye- lashes in being longer and finer. Examined with a lens, the hair might be seen extending deeply, in an oblique direction, into the integument. They were furnished with a>bulb, and were 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; while Bioha't, 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 HIRSUTIES. 625 the gall-bladder he once found about a dozen hairs, evidently im- planted by the roots in the tissue of the mucous membrane. Vil- lerme' states, that hairs have been found on the tongue, pharynx, in the rectum, uterus, and vagina, growing from 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 recover- ing from an attack of fever a considerable growth of hair took place on the side 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 of the head, was harsh, but smooth, and thickly planted in the skin. Rayer records a parallel case; and Boyer was wont, in his lectures, to speak of a man who suffered from an inflamed tumor in the thigh, which subsequently became covered with numerous long hairs. Rayer mentions another case, occurring in a medical student, who had several hairy patches on the skin, induced, apparently, by frequent bathing in the summer season, and exposure to the scorching rays of the sun. Augmented growth of hair in abnormal situations, arising from con- stitutional conditions, is illustrated in numerous instances which have from time to time been recorded. In some of these the unusual growth appears to have resulted from general disorder of the system ; in others it was the consequence of a particular modification of the economy. Of the former kind is the case of a young lady, narrated by Ollivier ;* she was remarkable for the whiteness of her skin, and for a fine head of jet-black hair; while recovering her strength after a chronic gastro-enteritis, she perceived one day that the entire surface of her skin, both of 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 surmounted by a short hair, which grew rapidly ; so that at the end of a month every part of the body, with the exception of her face, the palm of the hands, and sole of the feet, was covered with a short hairy coat. The indi- vidual 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 dark complexion. In young women it is frequently associated with disturbed menstrual function. This fact is observed by Hippocrates; but we have seen several instances in which no such disturbance ex- isted, 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 mam- 1 Dictionnaire de Medecine, article Poil. 10 626 AFFECTIONS OF THE HAIR SYSTEM. mae, absorption of the subcutaneous adipose tissue, harshness of voice, masculinity of deportment and of action. A similar condition is re- marked 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 ob- servable on the faces of many 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 propagation cease, loses many of her peculiar properties, and may be said, except from mere structure of parts, to be of no sex, even receding from the original character of the animal, and approach- ing in appearance towards the male, or perhaps more properly towards the hermaphrodite." The physician is appealed to for the relief of hirsuties chiefly in the case of women, and the common seat of the excess of hairiness is the upper lip, the chin, the maxillary and submaxillary region, the chest, the arms, and sometimes the entire body. The age of the patients may range from childhood to twenty-five or thirty, and sometimes to a later period; and the causes which will be found the most common in the production of this state are, nervous and nutritive debility. In seven cases now before us, nervous debility, anxiety, and affliction, are the remote predisposing cause in four; deferred and arrested menstru- ation in two ; and defective nutrition of the skin in the remaining one, a girl of ten years of age, in whom the skin is dry, discolored, brown, and unperspiring. In one of the cases, menstruation was protracted until the age of sixteen, the place of that function being taken seem- ingly by one of abnormal hair-for mation; but when the menstrual function was fully established, the hair ceased to grow, and gradually fell off, until it entirely disappeared. It is remarkable, and worthy of note, that some cases of alopecia are preceded by a superabundance of hair, and the inference is sug- gested that the skin may become exhausted by excessive function. We throw out the idea for the reader's reflection. The treatment of hirsuties must be directed to the removal of the remote predisposing cause and of the debility engendered by that cause. After the general functions of the body have been regulated, we have derived advantage from small doses (two or three mimims) of Fowler's solution, the local use of the juniper tar soap, and active ablutions with cold water. Depilatories should be discountenanced as much as possible, and especially plucking out the exuberant hairs with tweezers, as remedies calculated to injure the skin, to increase the evil, and frequently to add to the existing deformity a papular eruption induced by irritation of the hair-follicles. The use of the razor in aggravated cases is more rational, and sometimes necessary. We have occasion to note a variety of irrational attempts to remove the growing hair, such as the use of nitrate of silver, nitric acid, caus- tic potash, &c, but the most remarkable that we have met with was, in the first instance, singing the chin, and that failing, piercing the ALOPECIA VULGARIS. 627 follicle with a red-hot needle; the needle having been heated in the candle and coated with carbon, left a permanent black spot at the seat of the puncture, like that produced by tattooing, and the hair con- tinued to grow. ALOPECIA VULGARIS. Syn. Athrix simplex, Mason Good; trichorrhoza; xerasia; de fluvium capillorum; die Dunhaarigkeit, Germ. Alopecia, derived from ajiurt^, a fox, because foxes were often seen to be more or less divested of hair when suffering under the mange, is used at present as the generic designation for thinning of the hair and baldness, and offers threp varieties: namely, simple thinning of the hair, or alopecia vulgaris; total loss of the hair of limited extent, alopecia areata, or simply, areae ; and total loss of the hair of the scalp, and sometimes of the entire body, the result of disease, and not of old age, alopecia calva, or calvities. The latter form of calvities may be further distinguished as calvities juvenis, in contradistinction to the baldness of old age, calvities senilis. Trichorrhoea, or 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 partings, and more obvious in woman than in man from the manner of wearing the hair. Defluvium capillorum, in a small degree, is a common physiological phenomenon occurring once in the year, generally in the autumn sea- son, 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 of health of the individual, and most complete and serious where the general health has undergone deteri- oration. The change is often rapid; in the course of 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 being large and dilated ; and at other times there may be extensive concretions of desiccated sebaceous substance. The hair also exhibits a variety of appearances, 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 of the 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 prodigous quantittes, and if the roots be examined they will be found thinner than the shaft, showing the eff'ects 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 628 affections of the hair system. 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 length. Females are more liable to alopecia than are males; their suscep- tibilities are greater, and they are more open to the influence of disturbing causes. In one hundred cases, sixty-three were females, and thirty-seven males; but this great difference is not the consequence of constitution alone, being partly referable to the greater importance of a healthy head of hair to females than to males, and to the greater care which is usually given by them to personal appearance. The age at which alopecia is most frequent is between twenty and thirty; yn the one hundred cases already referred to, sixty-three were of this age; while between fourteen and twenty years the number was twenty. Of the same number, namely, one hundred, eighteen cases had existed at the time of application for treatment, between five and ten years; seven, between ten and twenty years; while two had lasted twenty- two and twenty-six years respectively. alopecia areata. Syn. Porrigo decalvans; alopecia circumscripta; area, Celsus; area diffluens; area serpens ; tyria ; ophiasis. Alopecia areata, or area, is a total loss of the hair in a circum- scribed and circular patch, and sometimes in the form of an elongated band, which has been compared to the trail of a serpent; hence the term ophiasis. The fall of the hair in area takes place suddenly, generally unobserved by the patient; and the first intimation he re- ceives of its existence is the sudden discovery of a bald spot. The denuded portion of the scalp is remarkable in appearance; it is white and polished, evidently less vascular than the surrounding skin, less sensitive, thinner, depressed towards the centre, and entirely divested of hair. The case is not one of simple shedding of the hair, as in alopecia vulgaris; it is.in reality arrested formation of hair; the forma- tive function has ceased, and hair is no longer produced, nor is it capable of production until a more healthy condition of the skin be restored, until it recover its normal vascularity and sensibility, and with those conditions, its healthy nutrition. Pathologically, we must regard area as a suspended innervation, as a kind of paresis of inner- vation ; and the other features of the disease follow upon this exhaust- ed state of the nerves of the part; circulation is weakened, nutrition is suspended, and the function of hair production and secretion is at an end. In area we are impressed with the conviction that the morbid phenomena must begin with a nerve, that the disease is, in fact, a neurosis, and that the more obvious and appreciable signs of the disease are simply its symptoms. In further support of this view, we have the fact of area being more frequently unilateral than bilateral; and where it assumes the ribbon form, it commonly follows the course ALOPECIA AREATA. 629 of the nerve. But area is not limited to the scalp ; it is met with also in the beard, the whiskers, and the eyebrows, and occasionally also on the body and limbs. The patch or disk of area is commonly single; more frequently, however, there are two, sometimes three or four, and occasionally as many as twenty on the scalp. Their ordinary size is half an inch to one inch in diameter; sometimes, however, they form a patch of larger dimensions and irregular figure, especially on the occiput; occasion- ally two or three disks are linked together, and form a continuous band, as in the case of ophiasis; and sometimes the morbid action, beginning with a few isolated disks, is quickly propagated to the entire scalp, constituting calvities; and even to the entire body. Area is more common in the female*than in the male sex, but occurs at all periods of life, from the age of two years to sixty, the range of greatest frequency being from five to forty years. As may be inferred from its pathological nature, it is always slow in its progress, lasting several months, and more frequently years. Of eighty cases, nine had lasted between five and ten years at the time of application for treatment, five had resisted treatment between ten and fifteen years, and two had been in existence between fifteen and twenty years. In reference to cause, fifty-seven of this number were dependent on nutri- tive debility, eleven on nervous debility, nine on assimilative debility, while three owed their origin to local debility. The remote predis- posing causes in these cases, arranged in their order of frequency, were as follows : scarlatina, rubeola, whooping-cough, organic disease, anxiety, fatigue, affliction, pregnancy and parturition, rapid growth, anaemia, neuralgia and nervous shock, deficient food, climate and seasons, congenital weakness, deranged menstruation, fever, and ecze- matous diathesis. The local injuries that had resulted in area were: accidental avulsion of the hair, stinging by bees, and a bruised wound. Area commonly exists independently of any other form of disorder of the skin, but is occasionally combined with other affections; for example, with alopecia vulgaris, pityriasis capitis, eczema, canities, trichonosis tonsurans, and alphos. We have also seen it associated with melasma oculi. The return of hair upon the bald patches of area is always slow, but sometimes more rapid than could be supposed from a view of the nature of the disease. Nevertheless, the restoration of the hair is greatly influenced by the predisposing cause; after pregnancy the hair has reappeared in from one to three months, this may be regarded as a case of accidental lowered vitality ; but when the constitutional powers of the patient are exhausted, a longer time will be required. It is also worthy of remark, that, on its reproduction, the hair is usually white or fair, like that of an infant; but as it obtains increased power of growth, the natural tint of the adult is gradually restored. Celsus gives us the following account of area: " There are two kinds of this affection; the common characters of both being atrophy of the superficial portion of the skin and loss of hair. If the diseased skin be made to bleed, the blood is watery and fetid; and the aft'ec- 630 AFFECTIONS OF THE HAIR SYSTEM. tion spreads, sometimes quickly, and sometimes slowly. The worst form is that which condenses the skin, destroys the fat, and renders the surface totally smooth. That which is called alopecia, spreads irregularly and without assuming any particular form. It occurs both on the scalp and in the beard. That form, which, from its resemblance to a serpent's trail, is named ophiasis, begins at the occiput, never exceeds the breadth of two fingers, and creeps onwards by two heads towards the ears, sometimes to the forehead, where the two heads unite over the middle of the forehead. The first of these forms may occur at any period of life; the latter commonly shows itself in children; the former scarcely ever gets well without treatment; the latter not unfrequently undergoes spontaneous cure." * ALOPECIA CALVA. Syn. Aihrix calvities, Mason Good ; calvities. Alopecia calva, or calvities, requires to be distinguished by the addition of the word "juvenis," to avoid its confusion with calvities senilis, the natural consequence of old age. Calvities juvenis is a total absence of hair, not limited, as in area, to a few patches, but extending to the entire head, sometimes to the eyebrows, the eyelids, and face, as well as to the head, and sometimes to the entire body. The relation of this form of baldness to area is shown by the fact of its often beginning as area, and in some instances alternating with that form of the affection. One of our patients, aged twenty-four, had area in childhood; the hair returned to its normal state, but in a recent attack not a hair of the body has been spared; and another, now suffering from area, had an attack of calvities capitis ten years before. 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 appearance until the end of the first year, and sometimes as late as the second and third year. We have seen only a few instances of congenital absence of the hair of the head, but we have met with cases of deficiency in other regions more frequently, as upon the chin and pubes. " Congenital absence, and ulterior defective development of the hair," says Rayer, " are phenomena of considerable rarity, which I have, nevertheless, had opportunities of observing. Such was the case of the man Beauvais, who was a patient in the Hospital de la Charite', in 1827. The skin of this man's cranium appeared completely naked; although, on examining it narrowly, it was found to be beset with a quantity of very fine, white, and silky hair, similar to the down that covers the scalp of infants; here and there, upon the temples, there were a few black specks, occasioned by the stumps of several hairs which the patient had shaved off. The eyebrows were merely indicated by a few fine and very short hairs; the free edges of the eyelids 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 Beau- vais only clipped it off every three weeks; a few straggling hairs were ALOPECIA CALVA. 631 observed on the breast and pubic region, as in young people on the approach of puberty; there were scarcely any under the axillae ; they were rather more abundant on the inner part of the legs; the voice had the pitch and intonation of that of a full-grown and well-consti- tuted 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." In twelve cases of calvities juvenis, five affect the head alone, four the eyebrows, the eyelids, and the face, together with the head, and three the entire body. The ages of these patients range from five years to forty-one ; five being under twenty, two between twenty and twenty-five, four between thirty and thirty-five, and the remaining case, forty-one. The sexes are evenly divided; and the duration of the disease ranges between four months and eleven years, in five the duration is under one year, and in three it exceeds five years. The predisposing cause in eleven of the twelve cases is nutritive debility, that of the remaining case, nervous debility, the consequeuce of anxiety, and accompanied with melasma oculi. The remote pre- disposing causes are, congenital debility, scarlatina, rubeola, partu- rition and pregnancy, neuralgia, mental anxiety, and the climate-of India. The evidence of defective nutrition of the skin is more obvious in calvities juvenis than it is in area ; the scalp is always pale, remarka- ble for its thinness, and somewhat insensible. The thinness of the scalp approaches often to a state of atrophy, the skin is more or less transparent, the venous plexus of the scalp is visible through it, and is nearer the surface than natural; and the sutures of the cranium may be traced with ease; moreover, a strong stimulant application pro- duces less effect than it would upon a healthy head. Again, when the hair begins to appear, it is apt to be white at first, and upon attaining a fuller and hardier growth, to resume its natural color. There is evidence also of the defective nutritive power being in some instances rooted deeper than the surface ; in one case the cranium was imperfectly developed, and the child was feeble in intelligence. Other indications of degradation of nutrition were perceptible in a gentleman aged thirty-two, in whom there existed also scabrities unguium, while in another case the disease had been preceded by trichonosis tonsurans. The exhausting consequences of scarlatina and rubeola were shown in three of the cases, and that of intense neuralgia following scarlatina in one. The influence of the uterine sympathies on the organism is exhibited in one of the patients, aged forty-one, who was attacked with area and calvities toti corporis at thirty-three, after her first parturition, and again during her second pregnancy, the hair having returned in the mean time. Calvities senilis, the natural consequence of age, is a change taking place gradually in the follicles, by which the formative struc- ture, from exhausted 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 con- 632 AFFECTIONS OF THE HAIR SYSTEM. fined to old persons; it is daily observed at an earlier period of life, as at forty, thirty, and sometimes in persons still younger. Occasion- ally it results from mental anxieties and severe afflictions, but at other times comes on without apparent exciting cause. 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 poste- riorly 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 circula- tion through the textures of the scalp of the upper part of the head; and in correspondence with this inference, we remark the exceeding paleness of the cranial region. But the same cause may be supposed to have existence also in women, unless we admit that a larger quan- tity 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. We are the more induced to suppose that this may be the case, from observing the infrequency of baldness on the pubes, where a thick cushion of fat is interposed between the hard parts and the sur- face, and the vessels are enabled to make their passage through a soft and yielding medium to their distribution in the papillary layer of the skin. The integument of the scalp of old persons who have been bald for some time is remarkable for its extreme smoothness. Bichat observes, that he 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 contrary, 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 import- ant difference between the baldness of the aged and that which suc- ceeds 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 folli- cle 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. ALOPECIA CALVA. 033 Causes.—The proximate causes of baldness are, defective develop- ment of the formative organ, defective circulation in the formative organ, and defective nutrition of the formative organ. The remote causes are, hereditary peculiarity, the termination of acute diseases, certain diseases of the skin, certain general affections, syphilis, mer- cury, coffee taken in excess, late hours, extremes in venery, old age, &c. 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 con- sequently to defective nutrition of the hair. Lemery1 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 portion of the body to the impoverishment of the rest, as in some local diseases. We 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 only the hair of the scalp, but also that of the eyebrows and beard is apt to fall. This change is particularly observable in young women possessed of extremely long hair. Instances in which alopecia is attributable 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 " Dictionnaire de Mede- cine," expresses a different opinion as relates to the operation of mer- cury. 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, comparatively rare. We are disposed to believe that the dif- ference between the sexes in this respect lies in the greater proportion of subcutaneous 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. 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 we are in the habit of recommending the washing of the head every morning with cold water, drying it by friction with a rough towel, 1 Mem. de l'Acad. des Sciences, prem. mem. vol. ii. p. 39. 2 Hippocrates remarks, "Quibus tabe laborantibus, capilli de capite defluunt, hi, alvi lluxu superveniente, moriuntur." 631: AFFECTIONS OF THE HAIR SYSTEM. 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 l<3ng hair contra-indi- cates the use of the cold bath, stimulating applications with plentiful brushing must be relied on. From two to four drachms of the ungu- entum stimulans,' 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. We may also avail ourselves of the stimulating properties of certain soaps, as of that of juniper-tar, petroleum, sulphur, and especially of carbolic acid. In addition to the trichogeneous pomatum, it is sometimes con- venient to be in possession of an agreeable stimulating lotion for the hair. The wash may be used either alone or alternately with the pomatum. The best trichogenous wash, according to our experience, is the ammoniated spirit lotion, 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 advantaneous results; such as mustard, horse-radish, walnut-leaves, the pomades of Dupuytren and Gibert. The pomatum ascribed to Dupuytren appears to us 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 advocates the use of leeches, slight scarification or acupuncture 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, euphorbia, pomegranate, nasturtium, stavesacre, foenugreek, rose- mary, sage, Peruvian balsam, tar, frankincense, mastich, myrrh, and ladanum. Ladanum is warmly praised by Dioscorides and Galen, and occupies a place in most of the local applications for baldness. It would not, however, in all cases, be judicious to limit the 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. Our practice in area, after regulating the secretions, and, if neces- sary, administering ordinary digestive tonics, is to prescribe our ferro- arsenical mixture internally; and the use locally of some moderately stimulating pomatum, liniment, or lotion such as, the diluted pomatum stimulans, chloroform pomade or liniment, ammoniacal liniment, acetum cantharidis, or the compound tincture of iodine. With these remedies the cure is simply a question of time, the result cannot be otherwise than successful. " Some physicians," writes Celsus, " stimu- late the area by punctures with the lancet; some rub in caustics, and some employ turpentine. But there is no remedy better than daily Vide " selected formulae" at the end of the volume. TRICHONOSIS DECOLOR. 635 shaving with a razor; for, as soon as the superficial pellicle of the skin is removed, the roots of the hairs are opened. Frequently the mere rubbing in of writing ink after shaving is all that is necessary." But he fails to inform us that the writing ink of his day was simply composed of vegetable carbon and mucilage, like the Indian ink of the present time. 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 the operation being to confine the nutritive fluids to the formative structure, until the latter 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 strengthening the hair. Fallopius upon this subject ob- serves, "II y a quarante ans que nous portons la barbe longue, en signe de notre deshonneur 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." DISEASES OF COLOR OF THE HAIR. Alteration of the color of the hair arises from disorder of the chromatogenous function of the formative organ, and is very com- monly 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, trichonosis decolor, from that which surrounds it. Less fre- quently, sudden alterations of color have been observed, while blanch- ing of the hair or canities, trichonosis cana, is the natural effect of the torpor of function which accompanies advancing age. Trichonosis decolor.—Two instances of reproduction of hair of different color to the original, after recovery from severe illness, are recorded by Alibert; in one of these, a head of bright red hair replaced one of dark brown, and in the other, hair of a deep black color took the place of brown. In the case of baldness from hyper- catharsis, mentioned in a preceding 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. Isoard, in a paper entitled, " Observation relative a une famille dont chaque individu presente plusieurs anomalies remarquables," in the "Journal Complementaire du Dictionnaire des Sciences Medicales," amongst other extraordinary physiological and pathological anoma- lies observed in the members of this family, remarks, that one of the daughters, seventeen years of age, and deaf and dumb from birth, each time that she is attacked by a fever peculiar to her constitution, un- 636 AFFECTIONS OF THE HAIR SYSTEM. ' dergoes 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 a narrative of a case in which the hair of a female was changed from brown to fair during her con* finement, which otherwise presented no remarkable feature. M. Vil- lerme'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 situations first affected, and of brown hair over the rest of the head. The wool and the brown hair became white, and partly fell off after they had reached the length of three or four 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 appear- ance, 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. Villerme observes, that he has more than once seen the hair, particularly in phthisical patients, after having become white and fallen off, succeeded by a crop of new hair of a darker color even than the original hair of the patient. The late Dr. Chaumenton presented this phenomenon in a marked degree. Dr. Bruley, of Fontainebleau, communicated to the Society of Medi- cine 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 seen to be quite black, with a few white hairs interspersed. On exami- nation 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 comments on this case, Dr. Bruley observes: " It is certain that disease may give rise to a change in a short period, that, according to Haller, requires a long period to accomplish natu- rally." Trichonosis versicolor.—But the most remarkable variation of color that has ever fallen under our notice is one which presents an alternation of black, or rather dark brown and white, from one end to the other of the shaft, and affecting every hair of the head, a parti- colored hair. The terms " banded" hair, " ringed" hair, rise to the mind as we survey it with a lens, whilst its general effect may be expressed by the term "speckled." It is an example of a kind of hair not infrequent in the animal kingdom, as in the ichneumon, and, in a magnified form, in the quills of the porcupine; but we have never before heard or read of such a condition occurring in man. Our specimen is taken from the head of a boy seven years and a half old, Journal GenSrale de Medecine, vol. lxix. p. 213 TRICHONOSIS cana. 637 in good health, and active. The change in the hair has been observed for about two years, and is latterly on the increase. The length of the white and brown segments is pretty uniform, about g'^th of an inch, but the dark are, in general, nearly double the length of the white. Sometimes the transition from brown to white is abrupt; sometimes the segments are elliptical, sometimes conical; not unfre- quently the pigmented segment begins abruptly, and terminates in a rounded cone; and occasionally the segments are white and brown longitudinally. These variations relate only to the pigment, as the cylinder of the hairs is uniform like ordinary hair; although, from the manner of distribution of the pigment, some look varicose and some spiral. This peculiar structure of hair must necessarily result from peri- odicity of function of the hair-pulp; one while producing pigment, another while ceasing to produce it; sometimes producing it actively] and sometimes languidly. But the cause of these alternations it may be difficult to determine, and we can scarcely do more than attribute them to a law of periodicity like that which governs sleep, or hun- ger, or menstruation. It is known that the hair grows more slowly during sleep than during the waking hours; and, it may be, that not only is the energy of hair formation suspended for a while, but also that of pigmentation; or, it may be, that the presence or absence of pigmentation may be attributable to other kinds of functional peri- odicity. Our treatment of a case of this kind must turn upon our capability of influencing the periodicity of the function of hair formation; and if this periodicity be a consequence of diminished vital power or tone, we may, by invigorating the vitality of the skin, increase the pigment- producing function, and make permanent that which, in the absence of power, is only intermittent. trichonosis cana, vel canities. Syn. Trichosis poliosis, Mason Good ; der Graukopf, Germ. ; Blanching of the hair. Under the term trichonosis cana, or canities, we propose to consider whiteness of the hair, whether its production be congenital, or depend- ent 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 diff'erences; 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; we have seen 638 affections of the hair system. two examples in young children where the phenomenon presented itself in the form of round patches; both were of the snow-white kind ; in one the patch was situated on the side of the head; in the other it occupied one side of the forehead. The skin upon which the hair grew was remarkable for its whiteness, and contrasted strongly with the 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 uni- formly white, although different in appearance from that of old age, and approaching very slightly the tint of fair hair. We have before alluded to the whiteness of the hair of Albinoes, both of the European and African race. Rayer, in the Atlas accompanying his work on diseases of the skin, gives a delineation, copied from a picture in the museum of the Jardin dii 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 more striking, by pre- senting a roundish islet of deep black near its middle. On the same plate is a figure, representing the head of an Albino negress, copied from Buffon; the skin of the face and the wool upon the head are entirely, and completely white. Schenkius details the case of a young man whose beard grew white from its first appearance. Accidental canities and senile canities present varieties in extent: sometimes the whiteness is partial, being intermingled with the ordinary hair over the entire head, and producing, according to its proportion, the relative shades of 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 then cespreads gradu- ally over the rest of the head. Blanching of the hair occurs first upon the scalp; it proceeds, in the next place, to that 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 com- mon 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 sometimes commences at the root, and the colored part is gradually carried onwards, further and further from the integument. The kinds of hair most liable to the invasion 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. We have at present under our 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 pale, thin, and excitable; and bas a superadded cause of TRICHONOSIS cana. 639 nervous exhaustion in a large clitoris. At her birth she posessed 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 since 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 the appearance of that of an elderly person. There is besides some tenderness of the scalp, and a furfuraceous 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 inherit in the organization of the individual. Accidental canities is the consequence of diminished power of the cutaneous nervous system, as evinced, either by alteration of the pigment de- posited in the formative cells of the hair, or by the entire absence of the coloring principle. Morbid canities is more common in the female than in the male; of eleven cases of which the register is now before us, nine are female and two male. The ages range between fifteen and forty, three being under fifteen, and three under thirty. Three only are associated with other derangements of the hair, namely, alopecia; two having alope- cia of the head, and one alopecia of the beard. The governing cause of the morbid condition of the hair is nutri- tive debility in seven cases, assimilative debility in three, and nervous debility in the remaining one; the remote predisposing causes being as follows; over-rapid growth of the body, headache, cold climate, parturition, and deranged menstruation. 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 blanch- ing of the hair, there are numerous recorded instances. In some of 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 remark- able influence over the internal structure of the hair; often, in a short period, grief eff'ects changes 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 acquaint- ance became almost entirely blanched on receiving some distressing news." The bair 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 Languedoc, 610 AFFECTIONS OF THE HAIR SYSTEM. the other a Spaniard,.were so violently aff'ected, 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. Cassan, in a paper in the "Archives Gene'rales de Me*decine," 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 evi- dence 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 the 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. 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." The poets make frequent reference to this remarkable and sudden effect of violent mental emotion :— " 0 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." We have met with several undoubted instances of blanching of the hair within the space of a few hours, and have recorded them in our treatise on Healthy Skin; and our researches into this subject, started in a sceptical spirit, and with doubt as to the possibility of such an occurrence, have resulted in a conviction that sudden blanch- ing of the hair, although rare, is nevertheless an established fact. After some diseases of the scalp, it sometimes happens that the .' Journal Ge"nerale de Medecine, vol. iv. p. 2S0. TRICHIASIS. 641 newly-formed hair remains permanently white; the same change is occasionally observed upon cicatrices left by wounds. The principle of treatment of canities is to remove the causes of debility existing in the constitution by tonics, especially chalybeates and phosphoric acid, and, where defective nutritive power prevails, by means of the ferro-arsenical mixture, and to stimulate the scalp locally by.abundant brushing, and by the use of some mildly stimu- lating lotion, such as the ammonia lotion advised in cases of alopecia. DISEASES OF DIRECTION OF THE HAIR. Abnormal direction of hair is termed trichiasis: and of this kind of disorder there exist two principal varieties, the one being due to morbid direction of the eyelashes, trichiasis ciliorum, the other to inter- lacement and clotting of the hair, the consequence of neglect. Trichiasis ciliorum is an irregularity in the growth and direction of the eyelashes. The cilia grow inwards towards the surface of the eyeball, and, rubbing against the conjunctiva, give rise to chronic inflammation of that membrane. The treatment of this aff'ection is the removal of the misdirected lashes by means of the ciliary forceps, and the prevention of their future growth by the application of nitrate of silver. Trichiasis coacta, or felting, is a derangement of the hair arising from neglect, and has no claim to consideration as a disease. It is a state of inextricable interlacement of the hair, and is sometimes met with in the course of protracted illness, and more particularly in women, whose long hair favors the disorder. Of a kin to this affec- tion is the matting of the hair which takes place in plica polonica. diseases of texture of the hair. Passing onward from diseases of quantity, color, and direction, to disorders of texture, we are reminded of the physiological qualities of the hair, the most remarkable of these qualities being toughness and elasticity. These properties are obviously due to the perfection of elaboration of the cell-tissue of which the hair is constructed ; the soft mucous shells of the rete mucosum are, by virtue of the power of elaboration which belongs to cell life, converted into the horny tissue of the cuticle, and, at the same time, the analogous cells of the pulp of the hair are transformed into the still more horny, dense, and fibrous structure of the hair. But if we suppose a deficiency of vital power in these formative cells, the result must be imperfect elaboration, and the production of a tissue which is wanting in the properties that nor- mally belong to it; that, in the case of the hair, it may be neither tough nor elastic, but, on the other hand, may be brittle and fragile. Such a morbid condition of the hair does, in fact, occur, and a state of fragility of the hair sometimes presents itself to our notice, and demands our attention. Fragilitas crinium is met with in two well-marked forms; one, in which the hair of the head, or of the beard, breaks upon the most 41 642 affections of the hair system. moderate traction, as in. the act of combing and brushing; and another in which a certain amount of toughness remains, which resists com- plete rupture, but makes itself evident as a partial break or bruise of the shaft of the hair. In the latter case an individual hair may present a series of bruised spots, occurring at short intervals throughout its entire length, and giving it a jointed appearance. On close examina- tion the cuticle of the hair is found to be broken through, together with the exterior of the fibrous portion, leaving the central part of the fibrous portion intact; the broken ends of the fibrous structure stand out like the hairs of a brush, and, as remarked by Dr. Hermann Beigel, who has also observed this condition of the hair, the broken spot is larger than the rest of the diameter of the hair, and resembles two outspread brushes meeting each other by their ends. Furthermore, these bruised and broken spots are generally white or grayish in color, and resemble particles of scurf dispersed among the hair. It is this unpleasant appearance that first attracts the attention of the patient, and induces him to seek counsel for its relief. Like other defects of structure, fragilitas crinium originates in nutri- tive debility, and calls for the same method of treatment as that which is applicable to canities. A physician, who lately consulted us for this state of hair, informed us that it began while he was pursuing his studies in Edinburgh ; that he recovered during a short residence in Australia, but that it reappeared on his return to Scotland. trichonosis tonsurans. Syn. Common ringworm ; trichonosis furfuracea, tonsurans ; tinea capitis, nummularis, tondens, Mahon ; porrigo scutulata, Willan ; porrigo circinata, Mason Good ; porrigo furfurans, tonsoria; squarra tondens; herpes tonsurans, Cazenave ; pityriasis decalvans, Gibert; alopecia porriginosa, Sauvages ; phyto -alopecia, Gruby ; trichophyton tonsu- rans ; trichomyces tonsurans, Malmsten. Trichonosis tonsurans, or tinea, or common ringworm (Plates XIV. XV.), is a disease of the hair, of the epidermal lining of the hair- follicles, and of the adjacent interfollicular epidermis. The hair and the epidermis are altered in structure ; the hair is thin, shrivelled, dis- colored, faded, bent, and brittle, breaking off close to the skin, as though it had been eaten through by the grub of the clothes-moth or tinea, or, had been rudely shorn, hence the term tonsurans; and the epidermis is dry; laminated, and furfuraceous, forming a thick uneven layer on the surface, and distending the follicles by its accumulation. The disease presents some variety of appearance, having reference to distribution and degree. It commonly occurs in round patches, varying in size from half an inch to two inches or more in diameter. This is its aggregated form ; at other times it is dispersed over the scalp in small spots, each involving from two to ten or twelve hairs. The varieties in degree are manifested by the force of the disease being expended chiefly on the inter-follicular epidermis, the epidermal lining of the follicle, or the hairs. Other varieties result from its situation on the scalp or on the body or limbs, and also from the presence of TRICHONOSIS TONSURANS. 643 inflammation in various degrees, and giving rise to simple congestion or suppuration. Trichonosis tonsurans or tinea capitis, is the common and typical form of ordinary ringworm of the scalp; it occurs in the shape of round or oval-shaped patches, slightly raised, covered with a thick stratiform layer of furfuraceous scales, sometimes papillated from the prominence of the follicles, and more or less denuded of hair, any hairs that remain on the patch being of a yellowish-gray color, dry, shrivelled, bent, and withered: sometimes several small bundles are matted together, and lie entangled with the furfuraceous base; but more frequently the hairs are broken off close to the surface of the patch. This is the porrigo scutulata of Willan, the term porrigo being synonymous with » furfuraceous, and scutulata significant of the resemblance of the patch to a scutum, or shield. When the disease is recent, the papillae are very conspicuous; they 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.1 The pa- pillae are inclined obliquely in the direction of the hair, are somewhat imbricated, and from the summit of each there issue one or two hairs surrounded by a whitish film, formed by the accreted sebaceous and epithelial 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 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 may generally be perceived. The scuta of trichonosis tonsurans commonly appear on the summit of the head ; sometimes there is but a single patch, sometimes three or four; or there may be one or two large scuta, and many small ones scattered over the surface. Occasionally, in slighter attacks, the patches may all be of the smaller kind referred to under the head 1 MM. Mahon call the papillfe asperities; and compare the appearance of the mor- bid surfaoe to the skin of a plucked fowl. 644 AFFECTIONS OF THE HAIR SYSTEM. of trichonosis dispersa ; while in a chronic case the disease may spread over the entire scalp, trichonosis diffusa, and leave no more than a fringe of hair around its circumference. Trichonosis tonsurans may be complicated by inflammation of the diseased patch; and the inflammation may be erythematous, exuda- tive, or pustular. Simple erythema may occasion thickening of the integument. The exudation, when it occurs, is muco-purulent, and agglutinates the furfuraceous scales and morbid hair into a mass; and the pustules, when they burst, produce a similar result. The dis- ease is usually accompanied with itching, sometimes considerable; and with more or less enlargement and tenderness of the auricular, occipital, and cervical lymphatic glands. Trichonosis pityriasica.—In the common, aggregated, or scuti-» form variety of trichonosis tonsurans, the surface of the skin, repre- sented by the epidermis, and the follicle and hair, or the deeper por- tion of the skin, are equally aff'ected, and the diagnosis of the case is very simple ; but in milder cases the epidermis alone may be attacked, and the hair and follicles more or less completely escape ; this consti- tutes a pityriasic form of trichonosis. The pityriasic patches may occur at the beginning or at the end of an attack of.the ordinary dis- ease ; they may be present on parts of the scalp, in association with the scutulate form, or they may occur on one member of a family of children, while others of the same family are suffering from the ordi- nary form of the disease. Trichonosis annulata.—When trichonosis attacks the body and limbs, it assumes a superficial and centrifugal character; it spreads by the circumference, while the erythema subsides in the centre, and thus forms a ring of varying dimensions, sometimes half an inch, and sometimes many inches in diameter. The border of the ring may be simply a raised erythematous ridge; more frequently it presents a row of papulae, and sometimes a range of minute pustules. The trichonosis or tinea annulata may therefore be erythematosa, vel papulosa, vel pustulosa, while the central area remains more or less pityriasica. The spreading character of trichonosis annulata is supposed to be due to the absence of the deep follicles and large hair-pulps of the scalp; and this, no doubt, is in some degree the fact; but instances are not rare in which the same centrifugal progression is seen upon the scalp, where the rings are more prominent than on the rest of the skin, and where they are frequently accompanied with a double and even a treble row of pustules. In trichonosis annulata it is not uncommon to find the circumfer- ential ring to have become the point of departure of a second ring, and the second ring of a third; while the area of the ring is com- monly of a yellowish color, slightly furfuraceous, and sometimes papular. And occasionally, when several rings occur in the same region, their segments are apt to become intersected, and irregular forms arise, which have received the name of trichonosis gyrata. Trichonosis annulata may be associated on the same person with trichonosis tonsurans, or it may exist where no other form of tricho- pathology of trichonosis. 645 nosis is present. It is the form in which the disease is met with in adults who have associated with children affected with ringworm; and it frequently attacks one member of a family, while another may have the commoner trichonosis tonsurans. The rings of this disease are usually solitary; sometimes several are dispersed over different parts of the body; but they are never numerous. The relative frequency of the three varieties of trichonosis, namely, tonsurans, annulata, and pityriasica, in seventy cases was: fifty, ton- surans; fifteen, annulata; and five, pityriasica. The proportion of males to females was forty-two to twenty-eight; the age of origin, two years to fourteen ; and the period of duration as follows: under one month, nineteen; between one month and six months, thirty-four; between six months and one year, nine; and between one year and four years, eight. The annulate forms are found at the extremes of age, beyond the limits of the tonsurant variety; in one instance, at three months, in another at six months; and at the opposite extremity, at the ages of sixteen, nineteen, twenty-six, and forty-six. In two of the seventy cases the tonsurant and annulate forms were present to- gether in the same person, while in one the annulate form had assumed the pustular character. There were also in these seventy cases three examples of complication with eczema and two with pityriasis. Pathology.—The seat of disease in common ringworm is the hair, the epidermal lining of the hair follicles, and the interfollicular epi- dermis. When examined with the microscope, the dry, discolored, and fria- ble hairs of this disease are found to be more than twice their natural size, and a great change is perceptible in their structure. The aver- age diameter of human hair is ?*D of an inch, while a number of hairs growing from the morbid patches of common ringworm measured between 2-jj and T^ 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 unaffected; the chief pathological changes are found in the fibrous portion, and particularly in its external part. 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 xdnv °f an inch, and they are somewhat flattened from mutual pressure. The cohesion subsisting between the granules 646 AFFECTIONS OF THE HAIR SYSTEM. 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 nucleated granules. The undulated and swollen character of the fibres gives to the entire shaft an appear- / ance 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 (40), we 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 enlargement 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, we found corpuscles perfectly resembling favus-corpuscles, and we make no doubt that these corpuscles undergo the same changes of growth and development. There is, however, this difference be- tween the two affections, namely, that in common ringworm 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 circum- stances, that favus is so rare in comparison with ringworm, and that the latter does not occasionally assume the characters of the former. Gruby, who has made the granules of common ringworm the sub- ject of examination, -as well as the abnormal cell-tissue of favus, regards them in the light of vegetable formations, and places them in the same category as parasitic mucedinous plants, under the name of microsporon Audouini. The granules are, of course, sporules; but where the parent plant is that produces them, he fails to inform us. Malmsten, of Stockholm, seems to adopt the views of Gruby; he gives the disease a new name, trichophyton tonsurans, and illustrates his paper with an engraving of the appearance of one of the morbid hairs when seen with the microscope. For ourselves, we are as little inclined to yield the point in this disease as in favus; on the contrary, the absence of the cellated shafts is an additional ground of argument against the vegetable theory. It DIAGNOSIS OF TRICHONOSIS. 647 is perfectly consistent with the pathology of abnormal nutrition, that the hair-granules should become enlarged and increase in number by proliferation, and thus be the cause of the subsequent changes taking place in the hair. But the hypothesis of vegetable growth within the substance of 3. 44 690 AFFECTIONS OF THE SEBIPAROUS SYSTEM. now describing the manner in which horny bodies of larger growth, the so-called cornua humana, are produced. We shall have occasion to recur to the subject again. True encysted tumors, or tumors with a closed cyst, are, with the exception just named, identical in structure with the preceding. They occur most frequently in the scalp, but are met with also on the trunk of the body. They are globular in form, prominent, resembling marbles under the skin ; hard at first, but at a later period, when their contents are broken up, soft and tense. They vary in size, from that of a pea to a marble, and sometimes acquire the dimensions of a small orange. Not unfrequently there are two or three, and occasionally as many as ten or twenty on the head; and the tendency to their formation would appear to be sometimes here- ditary. When they have been a long time in existence they cause, by their pressure, the obliteration of the hair-follicles, and the skin covering them becomes bald. In their early stage encysted tumors are hard, from the compact nature of their contents; but when they have grown to a considerable size, or when the cyst has been inflamed, their contents are apt to become softened and altered in quality, sometimes quite fluid, and often fetid. Hence, according to the nature of their contents, they have received the name of atheroma when filled with a substance like meal porridge or bread sauce ; and meliceris, when the contents resem- ble a semi fluid wax. Occasionally they are filled with an albuminous fluid containing crystals of stearine, and sometimes, amidst their softened contents, are found a considerable number of hairs. The outer layer of the accumulation of the encysted tumors forms a boundary to the mass, and at the same time takes the place of an epithelium to the cyst; it is commonly, dense and horny in its texture, while the cyst is remarkable for its tenuity. The operation for the removal of the tumor turns upon this point of structure; the cyst should be punctured; the horny epithelium should be seized with the forceps, and held firm, while the thin cellular tissue which holds the cyst in its place should be pressed back until the horny layer with the attenuated cyst is liberated from its attachment, and comes out as an unbroken shell, representing the precise form of the cyst, and inclosing the morbid matter of the tumor. Celsus gives us the following account of encysted tumors : " They are very small at the beginning, enlarge slowly and by degrees, and are inclosed in a special tunic or cyst; some are hard and resisting; some, soft and yielding; in some, the covering skin is bare; in others, the hair is not aff'ected ; and they are generally unaccompanied with pain. Their contents, although they may be predicted, cannot be ascertained with certainty, until they are brought to light. Geuerally, however, those that are hard and resisting are filled with a calcareous looking substance, or condensed and matted hair; while those that are soft are found to contain a substance like honey or pap, or some- thing similar to the scrapings of cartilage ; or a fleshy looking sangui- nolent mass; or matters differing in color and appearance; atheroma contains a pap-like pulp; in meliceris, the contents are more liquid, CORNUA HUMANA. 691 and flow out on pressure." In reference to the treatment of these tumors, he observes : " The hair having been removed with the razor, an incision is to be made through the middle of the tumor; the cyst is to be preserved intact; the cyst is quickly discovered, white and dense; it is to be separated from the skin and surrounding parts with the handle of the scalpel, and gradually turned out whole, without dislodging its contents. Where an adhesion subsists between the inferior part of the cyst and a muscle, it is better to cut away the upper part of the cyst than injure the muscle; and, in this latter case. where a portion of the cyst is left behind, the wound should be treated so as to promote suppuration ; but where it has been entirely removed, the edges of the wound should be brought together and retained in contact by appropriate means, and subsequently dressed with some agglutinating application." Cornua humana.—We have shown, in preceding paragraphs, that the substance of the comedo and the accumulations of the open en- cysted tumor are in part horny in their nature, and that when exposed to the atmosphere they dry up into a hard mass, scarcely distinguishable from horn, and thus give rise to the so-called cornua humana. We must now apply the same reasoning to the true encysted tumors. The cysts of these tumors and the skin covering them are apt to become inflamed ; the latter ulcerates, and the follicular substance is exposed ; it dries up into a horny mass, and fresh portions are from time to time extruded, as they accumulate by fresh secretion at the base, until we find produced those extraordinary growths that resemble a ram's horn in shape, and are several inches in length. In 1843 we removed one of these horns from the thigh of a woman, aged fifty-seven, the servant of a medical friend, the late Mr. Barkli- more. Her account of the progress of the growth was as follows: At the age of five-and-twenty, after 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 with the 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 awkward blows which it sustained, and in the month of October applied to her master for relief. At this period the growth had acquired considera- ble size ; it was situated on the upper and front part of the thigh, and presented the appearance and characters of horn. It was semi-trans- parent, 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 curved beak of a bird, of large size, and had a broad and extensive base. Around the base 692 AFFECTIONS OF THE SEBIPAROUS SYSTEM. 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 sur- face of the horn, and gave the idea of a degeneration of the integu- ment into the horny structure. On examining the horn after removal, we found its base to be formed by the deep stratum of the corium, so that it was obviously a cutaneous formation. The base was oval in shape, and measured in long diameter 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 vertical thickness of the horn ; for, in consequence of its mode of growth, its long diameter lay parallel with the surface of the skin. The sebaceous accumulation must originally have formed a promi- nent 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, surrounded 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 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. The epithelial scales are somewhat larger than those of the epidermis, and possess nuclei, a circumstance which confirms the analogy between the inflected follicles of the skin and those larger inflections lined by mucous membrane. The flattened cells measured in long diameter from 7^ to 3^ of an inch ; and in short diameter from iVoo t0 aso! the average of these measurements being 5 J-c for the long, and g£5 for the short diameter. The nuclei are, for the most part, oval in shape, the long diameter measuring ^^^, the short 33'^ of an inch. We made no chemical analysis of the horn in the present case, but this has been done repeatedly on the Continent. M. Dublanc has published an analysis of human horn in the " Journal de Pharmacie,"1 and another analysis was made of a horn, which is deposited in the Dupuytren Museum.1 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. » March, 1830. 2 Cruveilhier, Anatomie Pathol ogi que, liv. 24, vol. 2 ; and Journ. de Med. Prat, de Eourdeaux, 1835. CORNUA HUMANA. 693 Since the occurrence of the above case, we have met with many instances of horn in the human subject; one was on the shoulder, two at the root of the nose, and one on the penis. The latter measures in its dried Fls- p- state one inch in length. We also pos- sess, 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 measures, in its dried state, somewhat more than four inches and a half in length, and two inches and three-quarters in its great- est 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 improvements 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 Medicine of France, by M. Lozes, the com- mittee appointed to inquire into the subject collected seventy-one observations of horny growths from the skin, of which thir.ty-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.1 In pursuing this inquiry, we succeeded in collecting ninety cases, of which forty-four were females, and thirty-nine males; of the remainder the sex is not mentioned. Of this number, forty-eight were seated on the head, four on the face, four on the nose, eleven on the thigh, three on the leg and foot, six on the back, five on the glans penis, and nine on the trunk of the body. The greater frequency of the disorder among females than males is admitted by all authors, but this fact is most conspicuously shown in the instance of the 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 re- maining 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 ;2 three were young persons,3 and three were infants/ 1 Memoires de 1'AcadSmie Royale de Medecine, Juin, 1830. 1 Gastellier, Hist, de la Soc. Roy. de Med., vol. i. p. 311. 1776. s Aldrovandus et Bartholin us. * Amatus. Out. 1, Cur. 1. Zacutus Lusitanus, Prax. Med. Adin. lib. iii. obs. 83. Joseph Lanzoni, Nat. Cur. Ephein. Germ. anu. 4, 1673. 694 AFFECTIONS OF THE SEBIPAROUS SYSTEM. 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 general 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.1 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 Home2 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 tumour,3 and Soemmering,4 Gastellier,5 and Caldani,6 notice the same fact. Some curious speculations were excited in the minds of the older physicians by the observation of cases of horny growths. Rhodius7 met with a Benedictine monk who had a pair of horns, and was ad- dicted to rumination, and Fabricius,8 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 urjon his head. The most remarkable case of human horn on record is that of a Mexican porter named Paul Rodriguez.9 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. Voigtel10 cites the case of an old woman who had a horn with three branches growing from her forehead; and Dubois11 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 Home12 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. Gregory13 mentions a horn which was removed from the temple of a woman in Edinburgh, and measured seven inches. Chariere,14 of Barnstaple, saw one growing 1 Loc. citat. 2 Philosophical Transactions, vol. lxxxi. p. 95. 1791. 3 Epistolis. 4 Archives Generales de Med., vol. xiii. 1827. 5 Loco citato. 6 Diet, de Med. ; Art. Cornee. i Bartholinus, de unicorn, aphor. 8 De ventriculo. Also, Bartholinus, de unicorn, aphor. 9 New York Medical Repository for 1820. 10 Handbuch citat, " Diciionnaire de Medecine ; Art. Cornee. 12 Loco citato. u Sir E. Home's paper; loco citato. 14 Eodem loco. CORNUA HUMANA. 695 from the napeofa 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;! and Bartholin,3 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 appearance, was extirpated by Faget; the portion removed, with the two portions previously cut. off, amounting 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 pre- sented to the King of France, the other is stated to have been nine inches long, and two inches in circumference. The periods of shed- ding were three, four, and four years and a half. There is an engrav- ing of this woman in 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 Mu- seum. The authors who have given their attention to this curious subject are more numerous than might be expected. Bartholinus and Borel- lus have each collected numerous cases. Vicq d'Azyr1 treats of the subject in his essay on "Animal Concretions," in 1780; Franc,4 in an essay "de Cornutis," in Heidelberg; Sir Everard Home, in the Philo- sophical Transactions for 1791; Alibert, in his " Pre'cis Thdorique et Pratique des Maladies de la Peau ;" Rudolphi,* in a paper read before the Academy of Sciences of Berlin, in 1815 ; Dauxais, in a thesis pub- lished in Paris in 1820 ; Breschet, in the article " Cornee," in the " Dic- tionnaire de Medecine;" Cruveilhier, in his "Anatomie Pathologique." The latter author devotes the whole of his twenty-fourth fasciculus to > Eodem loco. * Epistolis. s Hist, de la Soc. Roy. de Med., p. 1S4. 1780-81. 4 Tract. Philolog. Med. de Cornutis. 6 Vol. ii. 696 AFFECTIONS OF THE SEBIPAROUS SYSTEM. horny growths. And Sir Astley Cooper and Travers, in their Surgi- cal Essays.' The following case is strikingly illustrative of the mode of growth and appearance of a horn when developed on the face. Louise Ma- rino, 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 im- bedded 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 80th 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 sur- face, 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.2 A similar case to this, in so far as seat and mode of appearance are concerned, has just come under our notice. Finding the horn imper- fectly adherent to its base, we displaced it with the 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,3 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 treatment of encysted tumors is simply local, and consists in the removal of the contents of the cysts and the destruction of the thin membrane which constitutes the cyst, and which is incor- porated with its epithelial layer. In the case of encysted tumor with open mouth, the latter may be dilated or enlarged by incision, the accumulation may be removed, and the surface of the cyst pencilled with a solution of potassa fusa (partes aequales) or rubbed with the solid nitrate of silver. The encysted tumor without aperture, or true encysted tumor, requires to be incised to an extent corresponding with the breadth of the tumor. The incision brings into view the contents of the cyst, and with them the firm, horny, capsule-like outer layer which is adherent to the surface of the cyst. This horny layer should be seized and held firmly with the forceps, and the vascular tissues pressed back with the handle of the scalpel, until the shell is drawn out entire and unbroken. The tearing away of the horny layer is a sufficient stimulant of the cyst, and no other treatment is required ; the blood that fills up the vacuity after the mass is withdrawn should be left to coagulate and cement the edges of the incision, and serve the purpose of an adhesive bond. Horny growths are to be softened with water-dressing or poultice, 1 Part 2. 2 II Filiatre, Sebezio, February, 1842. 3 Lancet, vol. ii. 1850, p. 342. TUBERCULA sebacea. 697 and then removed; painting the surface of the cyst with the strong potash solution, or rubbing it with nitrate of silver; operation with the knife is wholly unnecessary. TUBERCULA SEBACEA. Syn. Tubercula miliaria; exormia milium, Mason Good; grutum; milium, Plenck; follicular elevations, Rayer ; pearly tubercles ; der gries, Germ. There is another form of enlargement connected with the secretion of the sebiparous follicle which is not an aff'ection of the gland like the sebiparous tumor, but a mere accumulation of the cell-element of the sebaceous secretion in the upper stratum of the corium, and pos- sibly one of the ramifications of the gland, but without any opening communicating with the exterior. It is not unlikely that in its origin it may be an aborted follicle. The accumulation is small in quantity, pearl-like in whiteness, pearly tubercle, round in its figure, prominent, and of about the size of a millet-seed; hence the terms grutum and milium assigned to it by Plenck, and miliary tubercles by ourselves. The sebaceous miliary tubercle is commonly met with in clusters on the face of young persons, and most frequently upon the eyelids. We have sometimes seen instances in which the face was disfigured by the small tubercles, sprinkled by hundreds through the skin. Occasionally, examples occur in which calcareous matter, phosphate and carbonate of lime, are deposited in the epithelial cells composing this accumulation, and the tubercles become entitled to the denomina- tion of cahareous miliary tubercles. Meckel found a number of these concretions in the skin of the gluteal region; Voigtel1 records an instance as occurring on the forehead and root of the nose; and Yogel2 has described another affecting the scrotum. The integument 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 maturity, the little tubercles wasted and became dry, and were followed from time to time by successive crops. At the period of detailing the case they were one hundred and fifty in number, seated in the corium. The contents of the tumors were a white greasy and softish substance, like atheroma, chemically composed 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 with a small encysted tumor of the eyelid, and showed the seat of the calcareous matter to be the epithelial scales of which the tumor consisted. In- stead of presenting their natural transparency, the scales " were thick- ened and hard, and contained granular, earthy molecules, which could be removed by immersion in weak muriatic acid." Gulliver ascer- tained the earthy matter to be phosphate of lime, with a trace of the 1 Handbuch der Pathologischen Anatomie. 8 Algemeine Zeitung l'ur Chirurge inuere Heilkunde und ihrer Hiilfswissenschaft^n, July, 1841. 698 AFFECTIONS OF THE SEBIPAROUS SYSTEM. carbonate of the same earth.1 Dalrymple informed us that he had, since the publication of the preceding, seen a second instance of the same disease. Other forms of follicular tubercle are occasionally met with on the edges of the eyelids, of which the contents are a serous fluid, forming a serous cyst, which, depending from the upper eyelid, may become an obstacle to vision. Sometimes they are as small as the millet-seed, and sometimes enlarge to the size of a grape. , Another of these serous sacs is remarkable for the transparency and extreme toughness of its cyst, and, from some fancied resemblance, has been termed grando, or hailstone, and also chalazion. The integument covering it is extremely attenuated and semi-transparent, and small vessels may be seen meandering over its surface. Celsus observes: " In the eye- lids above the eyelashes there is apt to occur a small tubercle, which the Greeks name krithe, from its resemblance to a grain of barley. It is slow in maturating. Certain other little tumors, not unlike hordeolum, also make their appearance in the eyelids; they are some- what different in form, and movable, so as to admit of being rolled with the point of the finger under the skin; hence the Greeks call them chalazia." Treatment.—In sebaceous tubercles the principle of treatment is to induce healthy action in the skin by moderate local stimulants, such as the juniper-tar soap, and the bichloride of mercury lotion in emulsion of bitter almonds, and to release the accumulations in the cysts by puncture. The pearly tubercles on the face may be punc- tured, and the contents squeezed out; so also may the calcareous and the serous cysts; and where they have attained a size of any import- ance, the cavity of the cyst may be touched with a point of nitrate of silver.. ACNE. Syn. Ionthos ; varus; whelk; stone-pock; couperose, Fran.; hautfinne, kupferfinne im Gesicht, Germ. Retention of sebaceous secretion within the follicle, occurring in the languid and torpid skin of young persons, is apt to act as an irritant, and give rise to congestion and inflammation of the skin immediately surrounding it; this is the disease which is termed acne, apparently a perversion of acme, or more correctly ax^ot; axp.^,flos setatis, points especially to the period of life when the disease prevails; ionthos to its association with the growth of the hair at puberty, and varus to its deformity, "quia varum corpus facit et inaequale," as Celsus observes. Acne (Plate XIV.)2 has received several specific names having reference to its ordinary periods. In its earliest stage, when only a slight elevation without redness, but hard to the touch and dotted in the centre with the black point of a comedo, it is termed acne punctata; ' Medico-Chirurgical Transactions, vol. xxvi. 1843, p. 238. " For a good example of acne presenting at one view all its various forms, see " por- traits of diseases of the skin," Plate XXMX. I. ACNE. 699 when the progress of congestion and inflammation has raised the slight prominence into a well-marked conical pimple of a red color, the term acne coniformis becomes applicable ; in a third stage the summit of the cone is converted into a well-marked pustule, acne pustulosa ; in a fourth, pustulation is imperfect, and the skin becomes tuberculated by thickening and infiltration of its tissue ; this is acne tuberculata ; while in a fifth, the skin is indurated and deeply scarred, acne indurata. Sometimes the whole of these forms are present in the same person, but more frequently the punctated, the coniform, and the pustular form are united, while the tubercular and the indurated form consti- tute a chronic stage of the disease. In the two latter the skin becomes purple, and often livid, and the disease is usually accompanied with small cutaneous abscesses. The relative frequency of the four principal forms of acne, as shown in the analysis of one hundred cases, gives, for acne coniformis, the number sixty-five; twenty-five for acne punctata ; six for acne tuber- culata, and four for acne pustulosa. Of these one hundred cases, sixty were females and forty males, showing a greater prevalence of the disease in the former than in the latter sex. The situations in which acne is met with are, the face, and.particu- larly the forehead, cheeks, and chin; the back, from the shoulders to the hips, and the front of the chest, especially the sternal groove. In the one hundred cases already mentioned, the eruption was developed on the face chiefly, in seventy-eight; on the back and face in fifteen, and on the chest in seven. The ages of the patients ranged between ten years and thirty, the latter age being exceeded in three instances only. Between ten and fifteen the number of cases was twenty-eight, more than a quarter of the whole; between fifteen and twenty it was forty-eight, or very nearly one-half of the whole ; while the remaining twenty-one, some- what less than a quarter, fell between twenty and thirty years of age. The chronic and slow nature of the disease is shown by the duration, estimated at the time of application for treatment. In this particular, the disease had lasted between one year and five years in more than one-half, namely, fifty-eight; while in twenty-three, nearly one-quar- ter, it had endured between five years and ten. Nine of the cases had been in existence between ten years and fifteen, while two exceeded the latter period. Diagnosis.—Acne is a disease of the follicles, a disease of inflam- mation, accompanied with accumulation of sebaceous substance, a dis- ease of youth, and a disease of chronic duration. In these respects it is distinct from every other form of eruption, and not to be con- founded with gutta rosacea, called in error acne rosacea, which is a disease of mature life, chiefly confined to women; and although attacking the follicles of the face, not dependent on accumulation of sebaceous secretion. Cause.—Acne is essentially a disease of debility, and especially of nutritive debility. In one hundred cases we found only two that we could designate as dependent on assimilative debility, and one only 700 AFFECTIONS OF THE SEBIPAROUS SYSTEM. on nervous debility. The remote predisposing causes made evident by these one hundred cases were as follows: rapid and over-growth, twenty-five ; congenital weakness, twelve ; anaemia, eleven ; deficient and improper diet, seven ; errors of air, exercise, and general hygiene, six; and under five each, the following: nervous debility, mental application and study, scarlatina, fever, deranged menstruation, ecze- matous diathesis, rubeola, dyspepsia, rheumatism, chill, syphilis, vari- ola, vaccination, strumous diathesis, hemorrhage, abscess, depressing climate, and climate of India. Prognosis.—Although chronic, acne is perfectly curable, the ten- dency of age is to induce spontaneous cure, but cure may be hastened by medical means, as may be inferred from the examination of the long list of depressing influences involved in the remote predisposing causes. Treatment.—The treatment of acne is indicated by the nature of its predisposing causes, both proximate and remote. The diet of the patient must be nutritious and generous; the regimen, in reference to air, exercise, and amusement, must be equally liberal, and we must aid the weakened energies of the vital powers by suitable tonics; in one series of cases by bitters and mineral acids, and in another by chalybeates. But when the functions of digestion and secretion are properly performed, and the indication is special and not general, and betokens debility of nutritive power rather than faulty assimilation, we may have recourse to the ferro-arsenical mixture, in doses con- taining two or three minims of Fowler's solution, three times a day. The local treatment must have for its object to restore power to a weakened tissue, and renovate a languid and torpid condition of the skin. The best remedy for this purpose is the compound hypochloride of sulphur ointment, which should be rubbed into the eruption at bed- time, and washed off in the morning with soap and cold water. Another valuable remedy applicable to acne is the bichloride of mer- cury in solution in spirits of wine, or in an emulsion of bitter almonds, in the proportion of one or two grains to the ounce. This solution may be dabbed on the eruption night and morning, after ablution with soap and moderate friction with a towel. Sometimes we shall find the saturated solution of pentesulphide of calcium serviceable, and sometimes an ointment of the iodide of sulphur, as recommended by Hebra. Celsus appears to have considered acne as unworthy the attention of the physician. " It is almost absurd," he says, " to treat vari, lenti- culae and ephelidae; but a care of personal appearance is a part of the nature of women." Hence, he condescends to inform us that " vari are best removed by applying to them equal parts of resin and pow- dered alum, mixed together with honey; the skin is to be anointed with this application, and after the lapse of some hours, say in the morning, the remedy should be washed off and the surface lightly smeared with oil." DISORDERS OF STRUCTURE. 701 CHAPTER, XXV. AFFECTIONS OF THE SUDORIPAROUS SYSTEM. The sudoriparous system represents the aqueous element of the follicular secretion of the skin, as does the hair system the corneous element, and the sebiparous system the oily element. The sudoripa- rous glands are far too minute to afford the opportunity of tracing with accuracy any pathological change that may be taking place in their structure; nevertheless, analogy, as well as observation, leads us to believe that the glands are liable to certain organic alterations; we have noted in connection with idrosis palmaris a state of hyperaemia of those organs; and, in an instance of anidrosis, we detected atrophy of the glandular tissue ; while a state of suppurative inflammation of the glands has been described by Verneuil and Bazin under the name of hydro-adenitis. Hence, diseases of the sudoriparous system may be divided into two groups, structural and functional; the functional affections being manifested by derangement of its peculiar secretion, thus the secretion may be augmented or diminished in quantity, or it may be altered in its physical or chemical qualities. In a tabular form the diseases of the sudoriparous system may be enumerated as follows:— DISORDERS OF STRUCTURE. Hyperaemia, Atrophia, Hydro-adenitis. DISORDERS OF FUNCTION. Idrosis, Osmidrosis. Anidrosis, Chromidrosis, Haemidrosis. Hyperemia and atrophia of the sudoriparous glands call for no further notice at present than that which we have already given to them. Hydro-adenitis was first described by Verneuil, in 1854, as a state of phlegmon of the sudoriparous glands, making its appearance in the form of a crop of minute inflammatory tumors, beginning in the substance of the skin, rising gradually to the surface, and terminating by the expulsion of a small quantity of pus. They have been most frequently seen in the axilla, around the nipple, and in the circumfer- ence of the anus; and occasionally on the face, ear, limbs, and genital organs; but they may also occur on every part of the body where sudoriparous glands exist. AY hen fully developed they reach the size of a small pea, and are more like boils than any other form of aft'ec- 702 affections of the sudoriparous system. tion of the skin, but differ from boils in their deep origin, in the absence of elevation and pointing, and also in the absence of core; they burst upon the surface frankly, and, having burst, their course is at an end. The causes which are supposed to favor this affection are, external irritation of the skin from neglect of cleanliness, friction, sweating, and the contact of morbid secretions; while the constitu- tional causes, according to Bazin, are, struma, arthritic dyscrasia, and syphilis. The treatment applicable to its cure consists in regulating the general health ; the local application of unguentum conii or tinc- ture of iodine, according to the state of sensibility and activity of the eruption ; and in the advanced stage, liberation of the pus by puncture. Idrosis, also termed ephidrosis, hyperidrosis, and sudatoria, is an augmentation in quantity of the perspiratory secretion, accompanied with some degree of vascular congestion of the skin, by a sense of heat, tingling, or itching, and sometimes by pricking and lancinating pains. When of accidental origin and slight in its nature, it is termed idrosis or sudatoria simplex ; but when it prevails as an epidemic or contagious disorder, as did the sweating sickness of the sixteenth cen- tury, it is distinguished as idrosis vel sudatoria maligna. Idrosis simplex is apt to prevail in the summer time, or as a clinical affection excited by the heat of bed-coverings and heat of apartment in the winter as well as in the summer season. The per- spiration is most abundant on those parts of the body which are rich in follicular glands, for example, the head and face, the armpits, the perineum and groins, the palms and soles, and certain regions of the trunk; and on the more sensitive skin of the sides of the body, the inner side of the arms and thighs, and the front of the abdomen and chest, is apt to be accompanied with an eruption of miliary vesicles, or sudamina, constituting the form of idrosis known as sudatoria miliaris. The fits of perspiration are sometimes preceded by a feeling of chilli- ness of surface, and sometimes by a flush of heat, the coldness suc- ceeding the flow of the secretion; and are repeated once or twice in the twenty-four hours, sometimes oftener, and chiefly in the night season. They are frequently accompanied with a sensation of faint- ness and sinking at the epigastrium, sometimes with nausea and derangement of the digestive functions, and sometimes with fever- ishness. When idrosis occurs as an acute affection it terminates in one or two weeks, or, if it be associated with any form of illness which tends to maintain an unnaturally heated state of the skin, it may continue for a longer period. It has been known to exist for years, and in the latter form, ephidrosis chronica, is unaccompanied with miliary vesicles. During the excessively hot weather of August, 1856, we had occa- sion 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 epigastrium ; a profuse cold perspiration imme- diately bedewed the whole surface of the skin, and continued for a space of time, varying between a quarter and half an hour. In some IDROSIS simplex. 703 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. We saw about ten cases, one beinc followed by vomiting and slight fever. Dupont has published the account of a curious case of 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 inde- pendent of any other aft'ection, 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 perspira- tions were so prodigious" that basins were set beneath her " to receive the trickling humor." Ephidrosis partialis is more common than the general form ; some- times it is confined to the 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 We have at present under treatment a young lady, whose hands are the seat of this disagreeable aff'ection ; under the influence of slight nervous excitement, the hollow of the palm fills with secre- tion, and the perspiratory fluid drips from her fingers as she stretches them out. A gentleman whom we attended lately for severe gastric disorder, called on us one morning, with rills of perspiration running down one side of his forehead and face, the opposite side being dry ; and an eminent actor recounted to us the following anecdote of him- self: When a young man, starring in America, he had one night, in the summer time, been playing in 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 ex- 1 Rayer, Translation, page 920. The extract of aconite here referred to is much inferior in strength to the English alcoholic extract, of which the dose is £ to h a grain. 2 Rayer, loc. cit. 701 AFFECTIONS OF THE SUDORIPAROUS SYSTEM. hibited the care-worn lines and withered seams 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 con- sequence, he suffered bitterly in his health. Chronic idrosis is sometimes hereditary, as in a gentleman whose mother is similarly aff'ected; it began in his case at the age of nine, and has lasted fifteen years; he has two brothers and two sisters; the brothers are similarly troubled, but the sisters have escaped. The secretion is constant in this case, and the cuticle of the palms and palmar surface of the fingers is thick and sodden. In another gentle- man the hands have a bright red tint, as though they were stained, and the perspiratory ducts and glands may be seen through the cuti- cle as vascular points. In the first-mentioned case, the palms of the hands only are affected ; in the second, the palms and the soles; while in a third, the soles alone are the seat of the disorder. The latter gentleman is twenty-one; the disease has existed for two years, and is worst ir> the summer time. The soles are burning hot and red, and so tender as to make walking extremely painful. 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.—The malignant form of idrosis appears to cor- respond with the sweating sickness of the sixteenth century, a disor- der which is no longer met with in England, but which would seem, by the numerous reports made to the Acade'mie de Me'decine, to be still prevalent in France. The disease is infectious and contagious, and occurs epidemically. The following brief notice of the disorder is an abstract of the description given by Rayer. Malignant idrosis is commonly associated with inflammation of the stomach and intestines, inflammation of the lungs, inflammation of the bladder, or inflammation of the cerebro-spinal axis. When the diges- tive organs are especially effected, the disease is characterized from the commencement, or at an early period, by a severe constriction at the epigastrium, spasm of the diaphraghm affecting respiration, dis- tressing anxiety, deeply drawn sighs, feeling of weight in the chest, with a sense and alarm of suffocation, and in some cases, vertigo, vio- lent 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 sanguino- lent 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- idrosis maligna. 705 four or forty-eight hours, or the disease may run on for two or three weeks. The following cases of idrosis were observed by Marrotte, in the Hotel Dieu, at Paris, at the close of an epidemic of typhus fever, which raged in that city in 1842. Honored in whose wards the pa- tients lay, had never before seen cases of this disease; and 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 sufficiently pressing to induce him to relinquish his duties. Suddenly, in the middle of the day, he was seized with pain in the head and great prostration, which forced him to take to his bed; but he had no rigors, 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 crepitation throughout the whole extent of the bronchi. This combination of symptoms persisted in all their force for ten or twelve days; at the expiration of that period the patient felt improved. His amendment seemed in some degree to have been effected by a change in the position of nis bed to a better ventilated situation. Under the influence of this change of position the perspi- rations 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. Vesicles are dispersed about the neck and trunk, some being filled with a milky serum, and surrounded by a slight areola; others being transparent. The return of appetite is more tardy. 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 45 706 AFFECTIONS OF THE SUDORIPAROUS SYSTEM. drowsiness. Since his admission the fever has become increased and continued; his skin is covered with a constant perspiration ; h'e 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 expectora- tion, 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 di- minished* 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 convales- cent. In a third case, the patient was a young man, twenty-four years of age; he had, for some time, suff'ered 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 re- mained 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 continual; his abdomen was distended ; and he suff'ered from thirst. For several days he remained in this state, answering with difficulty the questions that were put to him. He had retention of urine, and 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, how- ever, 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 convales- cent from the latter disease, but he appears more debilitated. Marrotte remarks with regard to these cases, on the exacerbation which took place at the close of the fifth or sixth day; the continuous perspirations which existed at that period both day and night; the TREATMENT OF IDROSIS. 707 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 per- spirations ; 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 pathognomonic. Contrasting the disease with typhus fever, he recalls the negative characters of sudatoria. There was no diarrhoea in the commence- ment; there was 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.—Idrosis must be regarded as a disease of debility, especially of nervous debility, and treated upon those general princi- ples that are applicable to a similar state, irrespective of the local affection ; for example, nutritious and generous diet, and tonic remedies, particularly sulphuric acid in combination with quinine, cinchona, or salicine, or the citrate of iron and quinine. In chronic cases we have had recourse to the ferro-arsenical mixture with much advantage. Locally, the skin should be washed with the juniper-tar soap, and sponged from time to time with a lotion containing one part of liquor ammoniae to three of water. In idrosis of the hands and feet an oint- ment of equal parts of unguentum picis liquidae and unguentum sulphuris is of much service, with constant ablutions with the carbolic acid and juniper-tar soap. The use of a strong solution of sulphate of alumina and chloride of sodium has been found useful in some instances, as also have a solution of tannic acid, a solution of acetate of alumina, and a sulphur vapor bath. We have sometimes applied, with considerable benefit, a liquid paste of precipitated chalk. A gentleman informed us that he had relieved himself of this discom- fort by the use of a brine foot-bath every night. Panarolus, remark- ing 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." Dr. Druitt has lately drawn attention to the fact that a part of the body bathed or sponged with water as hot as it can be borne, say for sponging 130°, and so treated until the skin tingles with the heat, will remain for some hours afterwards hot, dry, and unperspiring. And he suggests this application in cases of excessive perspiration whether induced by the heat of the weather or by pathological causes, as in partial perspirations, or resulting from organic disease, as in the night sweats of phthisis. Cold bathing, he observes, is followed by warmth and a speedy return of the perspiration; tepid sponging is 708 AFFECTIONS OF THE SUDORIPAROUS SYSTEM. succeeded by a sense of clamminess and chill, and warm spongings increase the perspiration. To produce the desired effect the water must be hot, almost to scalding. Anidrosis, or simple deficiency of perspiratory secretion, may depend on torpor, or defective nutrition or innervation of the sudori- parous glands, and the glands may, after a time, dwindle into a state of atrophy. Sometimes it is congenital from defective development of the glandular organs. The disorder is not simply an inconvenience, for its destroys the balance of excretion, and more labor is thrown upon the mucous membrane and the kidneys than they are competent to bear. 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 Transactions1 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." We have occasionally met with persons whose skin has failed to perspire in the high temperature of a Turkish bath ; and in that very serious disorganization of structure which accompanies elephantiasis Grraecorum, exhausted function of the sudoriparous system is a common symptom. The treatment of anidrosis should have for its object to induce more healthy innervation and nutrition of the skin, with the view to restore the normal function of the organ. For this purpose moderate stimulation by frictions, by the juniper-tar soap, by the habitual use of the cold affusion bath on first rising in the morning, and by daily muscular exercise, will be found to be the best remedies. 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 indepen- dently of increase in quantity. The most apparent alteration in physical properties is that which relates to odor, osmidrosis. The perspiration frequently assumes an acid smell, probably from con- taining a larger proportion than usual of acetic acid, or a rancid odor from excess of butyric acid, or a combination of both, constituting a fetid and disagreeable odor, which has been aptly compared by Rayer to the smell of " rotten straw." The same author remarks, " I had a woman under my care in the Hopital de la Charite, affected with chronic peritonitis, and who, some time before her death, exhaled a very decided odor of musk : the pupil who called my attention to this circumstance had observed the smell for several days while dressing a blister, but thought it owing to a bag of musk put purposely into the bed to overpower oth.er bad smells.2 The woman, however, 1 Abridgment, vol. iii. 2 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 osmidrosis. 709 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. Speranza1 relates a similar case. SchmicTt has inserted in the Ephemerides Naturae Curiosarum 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. We were once consulted by a valet de chambre, who could never keep a place in consequence of the unpleasant odor (odor hircinus) 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 offensive 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 Pathology we find it stated, that the odor of sweat in scrofula re- sembles 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 scro- fula, 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 free ammonia. In cases of gouty and urinary concretions, the quantity of phosphate of lime appears to be increased."2 Dr. Piutti, of Elgersburg, has made some analyses of morbid sweat, 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 hedge- hogs, hares, serpents, and crocodiles. The odor of civet is the production of the civet* cat alone, the viverra zibetha, aud viverra civetta of Linnaeus, though we meet with faiut 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 agreeable kind, aud of very high excellence; for the musk scent of the cerambix moschatus, the apis 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 fragrant, but peculiar to itself." Vol. v. p 551. Second edition. 1 Observation d'odeur aromatique exhalee par la peau de l'avant-bras. Archives Generates de Medecine. Vol. xxx. p. 399. * Simon's Animal Chemistry, vol. ii. p. 10S. 710 AFFECTIONS OF THE SUDORIPAROUS SYSTEM. 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 our opinion, believes it to be a constitu- ent 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 ... 933.0 ... 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 asthenic 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 (uridrosis), bilin and biliphaein, uro-erythein, and fat. " The following substances enter into, aud have been detected in the sweat: quinine, sulphur, mercury, iodine, iodide of potassium, assafoetida, garlic, saffron, olive oil, rhubarb, indigo, Prussian blue, and copper."1 Treatment.—Assuming that this annoying aff'ection arises from some error of secretion, induced by lowered vitality of the system or deranged organic functions, the aim of treatment should be. to restore strength and health by every available means. When no other indi- cation presents itself, the ferro-arsenical mixture may be of service, by invigorating the nutrition of the skin. We have administered the bisulphide of soda with the view of setting up a catalytic action, and we have thought with good results. The local treatment applica- ble to this disorder is, frequent ablution with the carbolic acid soap, and inunctions with creasote ointment, together with neutralizing remedies, such as a solution of carbonic acid, chlorine, or permanganate of potash. Chromidrpsis, or colored sweat, the ephidrosis discolor of Mason Good, originates, like osmidrosis, in some chemical alteration of the perspiratory fluid, or in the development in the system of some color- ing principle which is eliminated by the skin. Cases of black perspi- rations2 have been frequently recorded; and possibly the disease described in the preceding chapter under the name of stearrhoea nigricans, may by some be taken as an example of this affection. Blue perspirations3 have also been noticed, and have been regarded 1 Simon, quoted from Stark's General Pathology, p. 1127 ; and Baumgartner, Ele- ments of Physiology and Therapeutics, p. 486. 2 Bartholinus, Acta. Hafn. 1. Obs. 70.—Ephemerid. Nat. Cur. Dec. 1. Ann. 2. Obs. 19. 3 Conradi. Blue perspiration of one half the scrotum, Anat., p. 292.—Lemery, His- toire de I'Academie des Sciences, 1701. Fontenelle, sur les sueurs bleues; Journal H.EMIDROSIS. 711 as resulting from the presence in the perspiratory secretion of Prus- sian blue. Green perspiration1 was seen in the case of a young lady who had accidentally taken copper with her food; yellow perspiration,2 possibly deriving its pigment from the biliary secretion, has also been noted; as also have those of a saffron and ruby color. In a case of green perspiration recorded by Mr. Pritchard,3 of Leamington, the cause was ascertained to be the accidental exhibition of copper with the food, the food having been prepared in a copper vessel plated with tin, from which a portion of the tin had been rubbed away. The subject of the affection was a young lady of four- teen, who " had for some months evinced much general debility." She was then "seized with an attack of rheumatic fever, which yielded to remedies slowly and unsatisfactorily. After some days, during which the perspiration was considerable, my attention was called to a collec- tion of light green perspiration between the toes, and underneath the nails of the young lady's feet, while the same appearance was observa- ble in a fainter degree on the upper, but more especially the under surface of the foot." The treatment of these cases must be similar in principle to that already indicated for osmidrosis. HAEMIDROSIS. Ephidrosis cruenta, Mason Good ; menidrosis; bloody 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 call for separate consid- eration. Landerer4 observed a red perspiration which flowed from the axilla of a patient laboring under fever. Voigtel, also, noticed an instance of sanguineous perspiration.5 Du Gard has recorded the case of a child only 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 de Chimie-Medicale, vol i. p. 330. Billard, Frorieps Notizen, No. 32. Dr. Bleifuss in Wurtemburg Med. 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 coloriDg matter of unknown nature. Dr. Semnola has recorded two cases of blue urine. The coloring principle of blue perspiration is probably of a similar nature. Dr. Maker, of Colmar (1858), records the case of a delicate anaemic girl of nineteen, in whom for many months together, the face, and particularly the eyelids, assumed a blue color from the exudation of a secretion that could be wiped completely away with a cloth moistened in oil. She was dyspeptic, and a sufferer from leucorrhcea, and occasionally the saliva was blue. Analysis showed the pigment to be Prussian blue. 1 Borellus, Hist. et. Obs. Med. Phys. Cent. 2. Observatio 54.—Paullini Cent. 1. Observatio 38. John Peter Franck, de curandis hominum morbis. Landerer men- tions an instance of green milk, secreted by the peripheral lobules of the mammary gland in a pregnant woman. i Ephemerid. Nat. Cur. Dec. 1. Ann. 6 et. 7. Obs. 78. 3 London Medical Gazette, vol. ii. p. 211. 1833. 4 Buchner's Repertorium, 2d Series, vol. v. p. 234, quoted by Simon. 5-Stark's General Pathology, p. 1131. 712 AFFECTIONS OF THE SUDORIPAROUS SYSTEM. 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 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, menidrosis. We once saw a young lady, in whom a discharge of this nature took place once 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 fore- head, and one on the chin. And more recently we 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 we sponged away the blood the skin looked congested and erythematous. 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; pre- sently after, at the umbilicus and corner of the eye; several times by sweat; and at last it burst out from the middle of her breast; after- wards 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."2 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." It is said also to have occurred in some instances in new-born infants,5 probably from the additional force given to the circulation, in conse- quence of a full inflation of the lungs, accompanied with violent cry- ing." The treatment of haemidrosis must be regulated by the nature of the cause. Deranged menstruation or hysteria will demand a specific method of management, so also will the hemorrhagic diathesis, if the bleedings be regarded as having relation to such a cause. 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 Paulina, cent. 3. Obs. 46. Ephemerid. Nat. Dec. 2. Ann. 6. Appendix, pp. 4, 45, 55. 4 Bartholinus, Epistola, i. p. 718. 5 Ephemeridse Naturae Curios. Dec. 2. Ann. 10, Obs. 65. TRAUMATIC AFFECTIONS. 713 CHAPTER XXVI. TRAUMATIC AFFECTIONS. Traumatic affections of the skin are such as result from the presence of parasitic animals, upon, in, or under the skin; and the effects of excessive heat and cold. Of the parasitic animals which infest the human integument, the chief are: the entozoon folliculo- rum, the acarus, the pediculus, the pulex, the cimex, the filaria medi- nensis, and the oestrus. The entozoon folliculorum is found in the sebiferous follicles, in the midst of the sebaceous matter which forms its food. The acarus scabiei lives within the scarf 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, makes only a temporary sojourn on the skin, for the purpose of supplying its wants, and is simply a transient annoyance; the pedi- culus also resides upon the skin, clinging to its surface, pediculus corporis; or to the hairs, close to their exit from the follicles, pedicu- lus capitis, and pediculus pubis. The pulex and cimex, the flea, and bed-bug, belong rather to the covering 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 subcuta- neous 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. The oestrus or gadfly, which is known as a persecutor of the horse ana1 ox, and deposits its ova within the skin, that they may be licked up and swallowed by the animal, and undergo their developmental metamorphosis in the stomach of the creature, sometimes attacks the human skin in a similar manner. The occurrence is rare in this country, but far from uncommon in hot climates, and especially in the vicinity of rivers.1 Lastly, the effects of heat and cold, the one caus- ing burns and scalds, the other gelatio or frostbite and chilblains, require no further illustration than that which they obtain under their respective heads. The diseases originating from these causes are, scabies, the in- flammation of the skin caused by the acarus scabiei; malis, 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 act- ing destructively on the skin; the latter head also includes that com- mon cause of suffering in the winter season, namely, pernio, or chil- blain. We have already treated of scabies in the chapter on Ecze- i Howship communicated some cases of this kind to the Medico-Chirurgical Society in 1832. 714 TRAUMATIC AFFECTIONS. matous Affections ; and to the natural history of the acarus scabiei we devote a future chapter. The entozoon folliculorum, as it gives rise to no morbid phenomena, but is rather an aid than an impediment to the functions of the skin, will also be considered separately, with the description of the acarus. MALIS vel MALIASMUS. Die Insektengeschwulstesucht. The term malis, the ^oxij and pauaapbs 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 nour- ishment from the human skin are the entozoon folliculorum, acarus scabiei, acarus autumnalis, pediculus, 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 six following heads, namely, malis acari, malis pediculi, malis pulicis, malis cimicis, malis filariae, and malis cestri. MALIS ACARI. Crinones ; die Mitesser. The acarus, or mite, is very abundantly dispersed throughout na- ture, existing apparently wherever nourishment is to be found, and representing, among terrestrial and air breathing animals, the infuso- ria 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 con- verting 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 mat- ters of various kinds are to be met with, either in the form of excre- tions from the skin, or the juices of the skin itself; hence it is, that in this locality we find the,, acarus revelling in abundance, sheltered among the lower animals by the hairy coverings, and provided with 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 us all; but be- sides these common examples, we have discovered the acarus on the skin of the pheasant, in the mouse, and in the horse; in the latter MALIS, OR CUTANEOUS VERMINATION. 715 constituting the cutaneous disease termed the mange.1 From these observations it may be inferred,that every animal has its acarus ; and, judging from the great variety of figure which the few examples we have had the opportunity of observing have presented, we should be ready to conclude that each genus or even species of animal had its peculiar acarus, modified in configuration and structure to suit the special circumstances of its existence. Thus the meal-mite and the cheese-mite, imbedded in their aliment, 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 ; it is furnished with a coat of plate and four strong arms in front, spines set backwards on its 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 additionally pro- vided with a pair of. strong perforating organs, constituting a haus- tellum, 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 occa- sional parasite, and not organized for habitation in or on the skin, is merely supplied with hooks to grapple with the surface while he is taking in his supply of food. Fig. Q. Fig. S. Fig. R. Fig. Q —The itch animalcule, acarus scabiei, viewed upon the back, showing its figure and the ar- rangement of its spines and filaments. Fig. E.—The male itch, animalcule, viewed upon the under surface, showing its legs and lobulated feet. Fig. S.—The foot and last joints of the leg of the itch animalcule. Fig. T.—Ova of the itch animalcule. The acarus scabiei and acarus autumnalis are the only two acari at present known which attack the human skin, at least in this country ; 1 The acarus equi will be found described by us 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. 716 TRAUMATIC AFFECTIONS. 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, we may mention that some specimens of acari were sent us 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 the body of 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, ^th of an inch in length, by 7V of an inch in breadth; consequently, somewhat more than three times the size of the acarus scabiei and acarus autumn- Fig- u- alis. It is oval in figure, and furnished with eight legs, two of which are set forward and six laterally ; therefore the creature is not organized for burrow- ing. The legs are long, seven-jointed, and armed with a double tarsal hook, which would enable the animal to ad- here firmly to the skin; its head is supplied with maxillae and*palpi, or rather chelae, which are five-jointed ; and from between the chelae is pro- jected a long lancet-shaped haustellum. The Stockholm acarus, viewed on its un- Judging from the organization of this der surface, and magnified 38 diameters. acarUS, We should Conclude that its presence on the skin of man was the result of accident, that it drew its subsistence habitually from some other source, but that it was quite capable of piercing the cuticle, and obtaining its aliment from the juices of the human body, and in this way of giving rise to considerable irritation. Probably it is to this species that Rayer refers, when he observes that " symptoms similar to those produced by pediculi may be occasioned by acarides, an in- sect very closely allied to the ixodes, but capable, according to Bory St. Yincent, of forming a new class, characterized by a small sucker, accompanied with two feelers consisting of four joints. 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." 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^th of an inch in length, by the TKo^h °f an mGa iQ breadth ; the average size of the acarus scabiei being T^th of an inch in length, by T^th of an inch in breadth; consequently the acarus autumnalis is narrower than the acarus scabiei, and flattened instead of being globular. It is of a reddish color, and provided with six legs and two chelae. The chelae MALIS, OR CUTANEOUS VERMINATION. 717 are four-jointed, scarcely reach beyond the level of the maxillae, and are furnished at the extremity with strong nippers. The six legs spring from the thorax, are long, seven- jointed, and terminated by a short tarsus, Fig- V. with a pair of ample recurved hooks. The haustellum is concealed. The acarus autumnalis is most trouble- some in the autumn season, and commonly during harvest, and is met with abundantly on a chalky soil. It makes its attack chiefly on the legs of those who venture into the fields during the harvest season, and from ,11 n i •. n .i The acarus autumnalis, viewed the legs finds its way to every part of the on its under gnrfcco> and magni. body, causing more or less irritation accord- fied 70 diameters. ing to the susceptibility of the individual. Its bite is followed by redness and some degree of swelling, the amount of both depending more upon the cutaneous sensibility of the person than upon the real injury done to the skin; sometimes the bite is fol- lowed by a small, glossy, red blotch, white and raised in the centre, like a wheal of urticaria, 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 ex- panse of erythema may be the consequence. If the inflamed spot be examined with care, a minute 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 wine, carbolic acid in lotion or soap, a lotion of ammonia, containing a drachm of the ses- quicarbonate to eight ounces of elder-flower water; a lotion of equal parts of sal-volatile and distilled water, the liquor ammoniae acetatis, distilled vinegar, the bichloride of mercury in emulsion of bitter almonds, the elder-flower ointment, or an ointment consisting of sim- ple cerate with camphor. MALIS PEDICULI. Morbus pedicularis ; phtheiriasis; die Laussucht. Three kinds of pediculi infest the human body, the pediculus capi- tis, pediculus corporis, and pediculus pubis. The pediculus capitis is found chiefly in children, but is not absent in the adult; the pedicu- lus 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 ; the itching which it creates is said to be referable to the movements of the animal on the skin more than to the sting with which it is sup- 718 TRAUMATIC AFFECTIONS. posed to be armed; they are named pediculi, says Isidore, " quod magis pedum motu lsedant, quarn 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 carry- ing on the calculation, he estimates that the two females conjointly might produce eighteen thousand in two months." Linnaeus gives the louse the credit of saving full-fed children from coughs, epilepsy, &c. 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 met with in prisons and workhouses, and in those abodes of the poor where cleanliness and nastiness meet; less fre- quently 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 pungent 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 phtheiriasis 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 pustules, and then the skin presents the characters of a 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 con- clude, 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. We have seen them teeming on the bodies of persons, laboring under malignant disease, in whom the powers of life were scarcely sufficient to preserve the body from decompo- sition ; and probably to this circumstance, to the exhalation of efflu- via agreeable to their instincts, their presence in such excessive num- bers might be attributed. Stories are on record 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 Alc- manes and Pherecydes Syrus, mentioned by Aristotle, are accounted." MALIS, or cutaneous VERMINATION. 719 Riolanus says : " Felicitatem Syllae pityriasis terminavit; eodem mor- bo Pherecides, Pythagorae preceptor, et Alcman perierunt." Of the latter, Q. Serenus has these verses:— " Sed quis non paveat Pherecydis fata tragoedi, Qui nimio sudore fluens, animalia tetra Eduxit, turpi miserum quae morte tulerunt ? Sylla quoque iufelix tali languore peresus Corruit, et foedo 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 reason 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 the'se 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 pediculi 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, enlarging towards their extremities like the claw of a lobster or crab, and the body is furnished 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 plactulse, petalae, andpesso- latae (probably from its flatness), ,a«d mfifipiones. Although termed pediculus pubis, it is also fouud^n^oSher parts of the trunk of the body where there is hair, in ,the alulae, 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 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^ 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 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 the animal sets up a degree of irri- tation which pervades the skin more or less extensively, giving rise 720 TRAUMATIC AFFECTIONS. to an eruption of lichen. On the borders of the eyelids it is apt to create considerable inflammation ; thus, as Celsus observes, " there is a disorder which the Greeks term phtheiriasis, which results from the presence of pediculi between the eyelashes. This complaint origi- nates in a bad habit of body, and runs on to the production of an acrid discharge from the eyelids and ulceration of the eyes, and endangers the sight." 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 ointment, scented with some pungent odor, such as lavender or cam- phor ; the red precipitate ointment;1 calomel ointment; sulphur oint- ment, lotion, or fumigation; a lotion of the bichloride of mercury; calomel in powder; and carbolic acid in lotion and soap. Several simples have also retained a reputation in this complaint, namely, the seeds, of the stavesacre in infusion or ointment; the lesser cen- taurea in decoction; the powdered seeds of the parsley; wormwood seeds; seeds of veratrum, lycopodium, rue, &c. 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- 1 The Scottish bard Burns seems to have been acquainted with the destructive properties of the " mercurial rozet" for this purpose, as well as of " fell red smeddum," which we take to mean red lead ; he suggests their use in one of his famous sonnets, in the following verse :— " My sooth! right bauld ye set your nose out, As plump and gray as ony grozet; Oh 1 for some rank mercurial rozet, Or fell red smeddum ; I'd gie ye sic a hearty dose o't, Wad dress your droddum." MALIS, OR CUTANEOUS VERMINATION. 721 ally, we have seen the petechiae of flea bites purplish in color, and 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 fra- grant 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.1 The carbolic acid in lotion or soap will be found to be the best medical remedy. The pulex penetrans, or chiggre, burrows beneath the skin, com- monly 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 suc- ceeded 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 some- times the insect 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 be 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. A lotion of chloride of zinc would be found an effectual remedy for destroying the ova and young. MALIS CIMICIS. The cimex lectdarius 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 cover- ing the skin more or less extensively with inflamed and irritable bumps. The cimex has received its specific name of lectuarius or 1 "While wormwood hath seed, get a handful or twaine, To save against March, to make flea to refraine ; Where chamber is sweeped, and wormwood is strown, No ilea, for his life, dare abide to be known."—Jusser. 46 722 traumatic affections. 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 obtain 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 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 near 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 mindererus spirit, the liquor ammoniae acetatis, a lotion of carbonate of ammonia or sal volatile, or eau de Cologne. MALIS F1LARLE. 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 par- ticular 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 occasion 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 1 Medinensis, from the prevalence of the worm in the country of Medina, in Arabia- Irk medina of Avicenna ; vermis medinensis ; nervus medinensis ; vena medinensis ; vena civilis ; fyoMovri* of the Greeks ; dracunculus; Guinea worm. Some of the older physicians, as Galen and 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. 723 India. We have seen two such cases in young military officers; both were out of health, and, in one of the two, we succeeded in per- forming the feat in which the natives of India are so expert, namely, of extracting 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, 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, pro- truded 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 us with a small phlegmon on the side of the foot, more than two inches from the former abscess, and complained of its excessive painfulness. We recommended hina to apply a poul- tice ; and a day or two later, perceived a fluctuating point, which we punctured, and a small white loop about an inch long was projected from the puncture, with a very small quantity, of sanious pus. We 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 we wound upon a narrow slip of card; we then placed his foot under a stream of cold water, and, winding as we pro- ceeded, gradually and slowly drew out about six inches more. We 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 por- tion 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 us there was a good deal of pain extending up the limb ; he was unable to walk, and during the pro- gress of the case this pain increased ; the skin was oedematous and shining, the ankle swollen and erythematous, and the pain extended, in the course of the nerves of the limb, as high as the groin. Once we were obliged to desist from any further tracfion on the worm for several days, on account of the severity of the symptoms, which excited some irritative fever, and completely destroyed his rest at night, while the foot was so tender that he was unable to bear the pressure of the bed- clothes. Our attention was attracted from the first, before we had discovered the cause of his suffering, to the extraordinary dispropor- tion 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. Looking at the smooth and shining skin covering the worm, we perceived a tortuous and slightly elevated ridge, which no doubt corresponded with the burrow of the animal beneath, and which led us to give credence to the patient's suggestion that the cause might be the guinea-worm; and having never seen a similar case, we watched it with attention; the result we have already stated. 724 TRAUMATIC AFFECTIONS. 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 out with difficulty, or resisted further traction, the pain was excessive, and 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 us 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, inflam- mation is set up, and the inflammation is followed by a scanty suppu- ration. 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 transparent; 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 walls 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 a part of the flesh itself, and to be immovable. After days of careful and laborious winding of this creature, we were agreeably surprised, on the last day, to find it come out without diffi- culty, even to the end, perseverance and gradual encroachment had finally exhausted its vitality and powers of muscular resistance. After the extraction of the worm all pain ceased immediately, and MALIS, OR CUTANEOUS VERMINATION. 725 the sinuous ulcer in which the creature had lain imbedded speedily rf healed. In the second case that came under our 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 accident, for a week or more, we counselled our 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 us 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. We were not surprised at this report, for it appeared to us 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 filariae 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 filariae, all minute and all of the same size. Why these young filariae 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 they belong to a different species? MALIS C3STRI. The deposit of ova by the oestrus or gad-fly in the human skin, an occurrence so common in cattle and the horse, has been noted by several observers in South America, and, among others, by the dis- tinguished naturalist Humboldt and Mr. Howship. In our own coun- try the fact has been recorded by Dr. Duncan in the instance of a young girl who had been tending cattle in Perthshire; and by Dr. Spence, of Shetland, where the phenomenon is far from being uncom- mon. The patients are persons exposed to the air in grazing dis- tricts, and who often lie down to sleep upon the ground. The sting of the insect is generally unnoticed by the patient; and it is not until after the expiration of some weeks that the first symptom is perceived. This symptom is a burning pain at some point in the skin, attended with the elevation of a small hard knot; in a day or two the pain and the knot change their place, and a bluish line is discernible, marking the interval of the two points; sometimes other changes of position occur, or the little knot travels for a considerable distance along the skin. The skin covering the knot is unaltered in appearance, but after awhile a small pinhole is discovered over the convexity of the knot; and some irritation is created, which leads to the skin being pinched and pressed; and if the opening be sufficiently large, the larva of the oestrus, the bot, may be squeezed out. Left to itself, the 726 TRAUMATIC AFFECTIONS. opening would enlarge sufficiently for the escape of the larva, but it is more commonly expelled by pressure with the fingers of the patient. Dr. Duncan remarks that his patient was infested with three of these larvae, and that one, which he pressed out, measured half an inch in length. When, however, their presence could be determined, the patient would be saved some pain and annoyance by the making of a puncture with a lancet over the knot. In hot climates they often give rise to considerable pain and inconvenience, and sometimes severe inflammation. 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 constituting the degree of burn, noted from the earliest period of their history, and recognized universally at the present day. Daniel Tur- ner 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. 3. " Into those which penetrate still deeper, burning not only the skin, but flesh and other parts subjacent, into a coal or crust." Dupuytren has enlarged and improved on this division of burns; he makes six degrees of severity, which he classifies as follows :— 1. " Erythema, or superficial inflammation of the skin without vesi- cles. 2. "Inflammation of the skin, with separation of the cuticle, and the production of vesicles filled with serum. 8. '' 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." AMBUSTI0 — BURNS AND SCALDS. 727 For our present purpose, and with especial reference to the skin, it may be convenient to classify burns into three groups, namelv: 1. Erythematous burn; 2. Vesicated burn; and 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, a certain 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 des- quamation 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 re- sult from the momentary action of hot water or steam, or from long subjection to the heat of a fire. The erythematous burn produced by insolation or the heat of the sun's rays is commonly called ephelis Solaris; 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 repeatedly ; the color of the skin changes to a reddish-brown, which is more or less per- manent ; 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 resulting from the heat of the charcoal brazier, or chauff- rette, which they use for warmth 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 pigment; and by long continuance of the habit, the mot- tling assumes a deep brown tint. The constitutional symptoms of erythematous burn are insignificant or absent altogether, if the burn be slight, of small extent, or the individual insusceptible ; but under the influence of opposite condi- tions, particularly if the burn be extensive, the action of the heart may be accelerated, and there may be more or less 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." 728 TRAUMATIC AFFECTIONS. 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 epidermis is removed at the time of the burn, and then the local action is more severe, and results in suppu- ration. 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 derrna is acutely sensitive, and becomes quickly covered with a gelatinous 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, returns 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 super- ficial 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 ner- vous system being greater, and the chances of internal congestion more probable; moreover, the danger is increased as the subject of the accident may be more excitable and delicate. We 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, rep- resenting the dead portion of the papillary layer of the skin; the vesicles covering these patches are filled with a brownish, lactescent, 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 the special organ of 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 removed from the living tissues, is established. When the ulceration finally heals, it AMBUSTIO — BURNS AND SCALDS. 729 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 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 con- tinued 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 in- sensible; and being shrunk by the heat, draws the skin around it into puckers and folds, the latter presenting the erythematous and vesi- cated 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 off, 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 deformity, on account of the contraction which ensues and the adhe- sion of parts accidentally drawn together. It is well remarked by Dupuytren, 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. Eoche, Sanson, and Begin, report the case of a young man who, 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 sensa- tion of pain. The constitutional symptoms of gangrenous burn differ from those accompanying the erythematous and vesicated burn, chiefly by the addition of certain secondary phenomena, which accompany the sepa- 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 to the constitution; the secondary symptoms those which are concerned in the reparation of the injury. The primary symptoms are, cerebral, spinal, and sympathetic irri- tation, congestion 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, 730 TRAUMATIC AFFECTIONS. particularly in children and persons of sensitive temperament. Du- puytren was of opinion that 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 exces de douleur. At other times, the pain, by exciting violently the brain and nervous system, may cause an immediate and instantaneous congestion of the whole of the internal organs of the body, the brain, the lungs and heart, the alimentary canal, with its cavi- ties and glands. This state, in fact, is met with in persons who have been rescued dead from a conflagration, or, although living at the mo- ment, have died immediately afterwards; the brain, heart, lungs, and mucous membrane have been found gorged with blood, extravasation has occurred in many places, particularly in the mucous membrane, and blood has been effused by exhalation into the cavities of the mucous and serous membranes. This kind of congestion is termed primary, from its occurrence at the time of the injury, and to dis- tinguish it from those phenomena which are the consequence of reac- tion, 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 said, 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 internal 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 of general fever; the 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, frequent- ly complicated with cerebral and pulmonary congestion. The limits of this period are the third to the ninth day. After suppuration is established, serious internal lesions may result from the absorption of pus, pyaemia; and during this period the internal.congestions which have already taken place may undergo further morbid changes, and result in ulceration, perforation of the duodenum, destruction of tis- sues, and other dangerous consequences; while the period of exhaus- tion, from a long-continued drain on the powers of the constitution, AMBUSTIO — BURNS AND SCALDS. 731 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. Mr. Grantham, has published a remarkable case of burn, in which several of the points of difficulty and danger here laid down are illus- trated.1 The patient was a boy, 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 thick- ness 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 period 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 contain fluids of any kind. This state continued for four days, and was succeeded for twenty-five days by a low form of fever. The fever then abated, and he improved gradually 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 aftes 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 fluids, 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 continuance of the typhoid fever he was nourished with beef-tea, mutton broth, and port wine; and as the typhoid symptoms abated, was plentifully supplied with milk, taking on an average six pints in the twenty-four hours*. The local treatment consisted in the use 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 vear, to one inch; it now remained "in a passive state for the space of a year and a half" before it finally healed. • i Facts and Observations in Medicine and Surgery: the gleanings of ten years of active general practice, &c. Churchill. 1844. 732 TRAUMATIC AFFECTIONS. During the whole process, Grantham remarks that there was a greater or less " tendency to congestion of the brain," which was re- lieved by small general bleedings, occasional saline aperients, and 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 burn is a question, into the answer to which a number of considerations enter, namely, extent, both in breadth and depth; seat, whether upon the trunk of the body, the face, neck, or limbs; age of the patient, his constitution and tem- perament ; 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 in- stantaneous in its application to the skin, -such as lightning, the explosion of gas or gunpowder, or prolonged. Again, the question of prognosis 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 sur- rounding 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 axis, and the joints dislocated. Again, there is the deformity which sometimes results from hypertrophy of the white fibrous tissue producing kelis traumatica. 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 camphorae 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 AMBUSTIO — BURNS AND SCALDS. 733 the dredger; a layer of wadding or cotton wool should be placed next, and then a bandage, lightly but firmly applied to prevent frac- tion. Another popular and admirable dressing is a paste of common whiting of the consistence of a thick cream, and applied with a soft brush. The purpose of the local applications is threefold ; namely, to cool the heated skin ; to exclude the atmospheric air, which i's always an irritant 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, the latter may be covered with a lini- ment of olive and white of egg (pars 1 ad 2), or with the benzoated ointment 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 the flour 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 a lint, spread with the benzoated ointment of oxide of zinc, and afterwards some cotton wool, and a light bandage. In the third and fourth degree of burn, where a portion of the skin has been killed by the heat, and the cutis is excoriated to a greater or less extent, while, in the circumference, the injured part presents the erythematous and vesicated forms of the injury, 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 bv the heat, or of preventing parts which were merely weakened, from falling 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, after the application of the simple liniment to the skin. It was upon this principle that Grantham, in the case above narrated, bathed the edges of the injured part with spirits of turpentine. Whenever 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 off, and the part excoriated ; and the burn being completely exposed to view, the flour dredger should be immediately brought into play. It has been recommended, immediately when 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 objec- tion 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 inno- 734 TRAUMATIC AFFECTIONS. cent; but are neither so pleasant nor so convenient as the flour dredg- ing. Again, when the shock to the system has produced a chilled state of the surface, the moist and cold applications would be objec- tionable, as tending to aggravate that state. Fabricius and Senner- tus 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 the 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; it was applied by means of a piece of linen rag; the rag being left on the skin, and saturated twice or thrice a day with 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 cover- ing to the burn, and leaving it undisturbed, a principle which we advocate in the treatment of eczema, we may mention the experience of a house-surgeon of a London hospital, emulous of distinguishing himself during his week of service. We 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 hos- pital 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, tl;e whole surface of his body in fact, he lived. Accident has given us here a lesson, an example, for imitation. 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 an useful auxiliary in lotions of the chloride of lime (3j ad Sviij); in the elemi ointment, or in the yellow basilicon, the unguentum resinae. 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 calaminare from first to last, which is anodyne, digests, incarns, and cicatriseth to admiration;" AMBUSTIO — BURNS AND SCALDS. 735 and he further lauds the uses of the oxide of zinc, under the mag- nificent 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 antiphlo- gistic regimen ; we may be required to abstract blood generally and locally, and contend with the various congestions as they show them- selves. In Grantham's case, it will be seen that he had to combat in succession, typhus fever, bronchitis with sanguineous expectoration, erysipelas, and symptoms of congestion of the brain. In the suppu- rative stage of the injury, where the powers of the constitution are exhausted by a long-continued drain, it will be found necessary to have recourse to a generous diet and tonics. Hebra has suggested for the treatment of burns and scalds, as also for certain eruptions of the skin, a perpetual warm bath ; and depo- sited at the International Exhibition 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 escharo- tica," 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-oven ; he was placed in the bath apparatus, and left there for twenty-eight days, or 672 hours, until the sores were perfectly healed ; the burn in this case had de- stroyed 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 apparatus, and left it only when all symptoms of the disease had disappeared." On a relapse taking place some months afterwards, the boy was again placed in the bath at his own repeatedly expressed desire. Hebra'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; more- over, 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 position 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 surfaee." If it be desired to keep the face continually 736 TRAUMATIC AFFECTIONS. 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 lid, 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 insensi- bility, and may proceed to the extent of actual freezing of the aff'ected part. 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 diminished 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, consecutive 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, constitut- ing chilblain, to positive freezing and death of a part of the body. In the one case there is mere suspension of vitality, in the other a state of complete death. So long as the 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 immo- bility ; but when the temperature undergoes a degree of elevation, however slight, such as that which occasions a thaw, then a new series of phenomena are presented by the congelated part, phenomena which are comprehended by the term reaction. Sensation 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 nerves. Circulation 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 state of inflammation of GELATIO — FROSTBITE. 737 the 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 long continued as to destroy the life of the part, that part retains the insensibility, the cold- ness, and the paleness of death ; while the living tissues alone take on the characters just mentioned, namely, the redness, the heat, the swell- ing, 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 con- tracted 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 com- mon 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, chilblains, 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 a moderate 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 sufferer. In the morn- ing, or after a few days, the chilblain has a bluish and livid appear- ance, resulting from the establishment of a permanent congestion of the part, dilatation of the capillaries, and retardation of the circula- tion ; 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 child from walking without pain, and exciting fresh attacks of itching every time an alternation of temperature from cold to warm occurs. As already observed, chilblains may seize upon the lobes of the ears, upon the ears themselves, and also upon the nose, or the more promi- nent parts of the face. The vesicated chilblain, or broken chilblain, is either an aggra- vation of the preceding, or the result of a more severe 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 pur plish, livid tint, and the cuticle gradually separates by effusion beneath 47 738 TRAUMATIC AFFECTIONS. 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 gangrene and a consequent 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 arlected 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 frost- bite or gangrenous chilblain is often associated with symptoms of general prostration and congestion of the vital organs, particularly of the brain, and sometimes terminates fatally. Treatment.—The treatment of gelatio and chilblain is intended to restore the innervation and circulation of the part, and to effect this restoration gradually. If reaction occur rapidly, and an active circula- tion be set up in the tissues lowered in their vitality by the effects of 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 cool 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 friction; 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 strong stimulants; and all with the view of bringing back the normal circulation of the part, and restoring its tone, avoid- ing 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 addition of laudanum, camphor, or chloroform; or it may be rendered more stimulating by the addition of cajeput or ammonia. If turpentine be objected to, a liniment of camphor, ammonia, and laudanum (two parts of camphor liniment to one of liquor ammoniae and one of laudanum) may be preferred. Sir Henry Halford was wont to prescribe soap liniment with tinctura lyttae, six parts of the former to one of the latter; a remedy originally advised by Mr.War- ACARUS SCABIEI. 739 drop.1 Dr. Turnbull recommended a concentrated tincture of cay- enne pepper 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 solution (,lj 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 ammoniae, 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 oint- ment of oxide of zinc; the calamine ointment; or some more stimu- lating remedy, such as an ointment of Peruvian balsam (3j ad Ij), the unguentum elemi, or resinae. In the broken state of chilblains, Dr. Balfour prescribes, with great success, an ointment composed of equal parts of unguentum resinae 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 XXVII. HISTORY AND DESCRIPTION OF THE ITCH-ANIMALCULE, AND ENTOZOON FOLLICULORUM. ACARUS SCABIEI. Syn. Acarus siro, acarus exulcerans, Linnaeus ; sarcoptes hominis, Latreille ; acaridion, Aristotle ; syro, sciro, siro, sirones, pedicellus, Rom. ; pedicello, pedicellus, Ital. ; scirro, Turin ; ciron, brigant, Gascon ; ocao, oucou, oucam, Portug. ; seuren, reitliesen, Germ. ; scaborm, kridorm, Dan. ; klamask, Swed. ; okok, Greenland ; assoalat, assoab, Arab. ; wheale-worm. 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 com- monly 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 ' " Of the treatment of chilblains ;" in a paper entitled " An Account of some Dis- eases of the Toes and Fingers," published in the fifth volume of the Medico-Chi- rurgical Transactions for 1814. 740 history of the itch-animalcule. animalium," that Aristotle was acquainted with these syrones, a statement which he precedes by a reproof to Thomas a Veiga for mak- ing an assertion to the contrary. For, says he, "Syronem antiquitate ignotum fuisse Tho. a Veiga falso memorat, nam ipsum axa^biov Aris- toteles vocat." (5 Histor. Animal., cap. 32.) That the itch-animalcule was weW 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, dnd *oi ov^* t^rtnv, quia tractim sub cute repunt." And again he observes, " to yet ^dxo^fy, teste Polluce et Suida, exiguum ilium dicitur, quoad ab exiguitate non possumus xil^ai, id est, dividere." The Arabians were also acquainted with the animalcule at an early period, for we find Abinzoar, in the twelfth century, thus speaking of them: "Syrones Assoalal et Assoab dicti, sunt pedicelli subter manuum crurumque et pedum cutem serpentes et pustulas ibidem excitantes aqua plenas: tam 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 null us 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 Roman physicians were well acquainted with it. Scaliger, in his letter to Cardanus in 1557, remarks that the acarus is globular in form, and so minute as to be scarcely perceptible. The Turinians, he observes, call it scirro; the Paduans, pedicelh; 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.2 Gabucinus observes, "Ad nostra temporaquoddam supplicii genus indomita foeditate pervenit; in manibusexilisquidam pedicellus, lente minor, sub cute serpit." Ingrassias, after referring to the statement of Abinzoar, observes, "Excoriata cute ubi minimus ille jonthus varulusve, cujusdam suda- minis instar apparet, exeunt animalcula viva, tam parvuncula ut vix possint videri." Jobertus very aptly compares them with moles, but unfortunately invalidates his testimony by supposing them to be the hidden cause of trichonosis tonsurans, for, says he, "nascuntur saepe in capite et pilorum radices exedunt, quos Graeci ■re,i%oi3e,atov$, t^txoa^xtas, o^rdy, te.t*x°P°e,°vi, tineas peculiari nomine appellant." Aldrovandus, also, in 1596, draws attention to the minute size of the pedicelh or sciro, its resort in burrows beneath the epidermis, and 1 Moufet, Theatrum Insectorum, p. 266. 2 Exercitatio 194; de Subtilibus ; num. 7, 1557. OBSERVATIONS OF MOUFET — HAUPTMANN. 741 its excitation of vesicles. He remarks that we need sharp eyes and a good light in order to perceive it. Moufet, in the 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-animal- cule 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 reference to their size and form, he observes, "Syronibus nulla expressa forma (ut recte Scaliger notavit) preterquam globi: vix oculis capitur mag- nitudo 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 higro 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 cuticula sulcos peragat. Hoc obiter est observandum, syrones istos non in ipsis pustulis sed prope habitare." He, moreover, rebuts the notion of their being allied to pediculi, and defends Aristotle against such an insinuation. " Neque syrones isti sunt de pediculorum genere ut Johannes Langius ex Aris- totele videtur asserere: nam illi extra cutem vivunt, hi vero non : neque revera Aristoteles ullo quod sciam scripto inter pediculos acaros numeravit." His inference respecting their origin, 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 pustula collecto: quo absumpto, vel exsiccato, brevi omnes inte- reunt. Unde colligimus, quemadmodum ex sero putrefacto exorian- tur, sic eodem vicissim sustentantur." Moufet falls into the pardon- able error, since repeated by several modern authors, especially by Linnaeus, of confounding the acarus scabiei with the acarus domesticus. Thus, he remarks, that the syrones are produced in decayed cheese and wax, and when found in these substances, as well as in leaves and Published in his work on Morbid Poisons, 4to., 1807, p. 293. 746 HISTORY OF THE ITCH-ANIMALCULE. 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 unifor- mity, and have each a red line; whereas in itch the vesicles are variable in size. 5. The natives of Maderia 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 dis- tinct from that of the itch. 7. John Hunter could never discover the itch-animalcule.1 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 objec- tions above cited is unfounded. The figures appended to Adams' papers are so excellent, that we are 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 textures also. The year 1812 witnessed the performance of a remarkable scene in the memoirs of the acarus scabiei. Gales, Pharmacien of Saint Louis, tempted by a prize offered by an unbeliever in the existence of the animalcule, 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 Musee Royale was called to perpetuate the juggle. He has recorded the figure of the common meal mite ! (acarus farinae.) It is needless to say, that the statements put forth by Gales 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 never could have seen the animalcule. M. Patrix played pantaloon to GaleVs clown. •' The discovery of the treachery of Gale's was not, however, made for a certain number of years, when, with some difficulty, Raspail 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, Renucci, in the year 1834, exhibited the veritable ani- malcule in the clinical theatre of Alibert, and demonstrated the method of discovering its lurking place in the epidermis.2 1 See quotation from John Hunter, stating that he had " frequently seen them picked out of the skin, and examined them with a microscope," p. 859. 2 Some account of Renucci's mode of procedure will be found in the Gazette des OBSERVATIONS OF RENUCCI — ALBIN GRAS. 747 The subject was next taken up by Albin Gras, a student of St. Louis, who has shown himself well qualified for the undertaking. He published a small treatise1 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 Gras' experiments with medicinal agents on its powers of vitality. After giving a description of the animalcule, inferior, however, to that of Raspail, the author remarks, " If we observe the mode of progres- sion 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 opera- tion, for, being directed posteriorly, all return on the part of the ani- mal is rendered impossible." " In examining several sarcoptes with the microscope, we frequently perceive them to lay several small, white, oblong, and transparent eggs, the eggs, according to 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 then fixing itself upon the epidermis, and raising the posterior part of its body." In 1834, Raspail published his " Memoir comparatif sur l'histoire naturelle de l'insecte de la Gale," in which he details the history of modern discovery in France relative to the itch-animalcule, a narrative replete with misadventures, that the perusal of Moufet might have effectually prevented. In 1831 he had seen and delineated the acarus 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 indicated by a white point. His description of the animalcule is the following. It is white, scarcely half a millimetre in diameter, head and feet red- dish and transparent, and it is invested by a covering which is hard, dense, and resisting. Its abdomen is flat and smooth; the dorsum pre- sents three prominences, one, of very large size, in the middle; one, next in size, over the abdomen ; and one near the head. Along the lateral 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 anterior legs from the space between the carapax and plastrum in front, between which they appear capable of retraction. The head is Hupitnux, and Gazette Medicale for 1834. The animalcule was subsequently exhi- bited in London by Mr. Holthouse, who had the opportunity of witnessing Renucei's demonstrations in Paris. 1 Recherches sur 1'Acarus, ou Sarcopte de la Gale de l'homme. Par Albin Gras. Paris, Octobre 11, 1634. 748 HISTORY OF THE ITCH-ANIMALCULE. provided with two large eyes, placed laterally; it is surmounted by four antennae, which are disposed in two rows between the eyes; the trunk is folded beneath the head. The anterior legs have four joints, and a haunch-piece at the base of each ; they are terminated by a stiff ambulacrum, 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 cara- pax, and is bounded by two short parallel hairs on each side. The carapax and plastrum are horny in texture; the former being sur- mounted 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 appears tohavebeen known to the author; while he praises the figures of De 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 dis- eases of children; Pallas, de infestis viventibus, 1760; Sauvages, Maladies de la Peau; Miscellanea Curiosa, 1692 ; Annates des Sciences d''Observation, vol. ii. p. 446, vol. iii. p. 298, 1830 ; Lancette Francaise Aout, 1831 ; Bulletin de Therapeutique, vol. vii.; Journal des Con- naissances Medicales, Septembre 15, 1834. And for the comparative history 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:1 Os proboscide carens, haustello vagina bivalvi, cylindrical, palpis duobus compressis, aequalibus, haustelli longitudine. Oculi duo ad latera capitis. Pedes octo. Tentacula duo, articulata, pediformia. In the first edition of the Fauna Suecica,2 Linnaeus describes the animalcule under the specific designation of " acarus humanus subcu- taneus." In the second edition,3 he considers the acarus humanus subcutaneus as belonging to the game species as the flour-mite and cheese-mite; and in the "Systema Naturae," 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 exulcerans." The specific characters of the two species he thus indicates :4— " Acarus siro.—A. lateribus sublobatis, pedibus quatuor posticis longissimis, femoribus capiteque ferrugineis ; abdomine setoso. 1 Systema Naturae, 1767. 2 Entomologia Faunae Suecicse. Viller's edition, 1789. No. 1194. 3 Anno 1761. No. 1979. * Fauna Suecica. Editio altera, auctior, 1761, Nos. 1975, 1976. observations of linn^us—fabricius. 749 "3- A. humanus subcutaneus.—Habitat sub cute hominis scabiem caussans ubi vesiculam excitavit, parum recedit corporis rugis secutus, quiescit iterum et titillationem excitat; nudis oculis sub cuticula deli- tcscens observaturab adsueto acu facile eximitur, ungui impositus vix movetur, si vero oris calido halitu affletur agilis in ungue cursitat. D<-scriptio.—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 exulcerans.—A. pedibus longissimis setaceis ; anticis duo- bus brevibus. Habitat in scabie ferina, cujus caussa est." In the "Entomologia Faunae Suecicae" of Linnaeus, edited by Vil- lers,1 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 Fauna Suecica, ed. 1, acarum farinae et scabiei separaverat Linnaeus, postea conjunxit, sed DD. Geoff., Fab., De Geer, pro diversis speciebus rite* habuerunt; ergo vere dis- tincti. Obs. 2. Scabiei certe hie acarus caussa est." In the 13th edition2 of the " Systema Naturae," 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 rufe- scentibus; posterioribus quatuor seta longissima. Habitat in ulceri- bus scabiosorum, cutis rugas sequendo penetrans, titillationem exci- tans ; utrurn causa, an potius, symptoma mali ? Sirone multo minor." Of the acarus exulcerans, Linnaeus remarks, " Habitat in ulceribus / scabie ferina leborantium. An satis distinctus ab A. scabiei?" In the " Amoenitates Academicae"3 the following passages, which are deserving of notice, occur. The first conveys the best idea of the seat and appearance beneath the cuticle of the acarus that we have met with in any writer; the latter puts forth the unfortunate observa- tion which led Linnaeus into error with regard to the classification of the itch-animalcule. Speaking of the 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 Scepissime habitant, adsperserit, infans in ea parte primo et toto tandem corpore scabie laboravit." 1 Ann0 17S9. 2 Edited by Gmelin, anno 1788, vol. v. 3 Miracula Insectorum ; by G. E. Avelin; Upsal, 1752. Anioenitat. Acad., vol. iii. p. 333. 750 HISTORY OF THE ITCH-ANIM ALCULE. In Sweden, remarks Linnaeus, the itch-animalcule is named Klamask. Schaeffer also describes the animalcule in his " Elementa Ento- mologiae," in 1776. Baron de Geer was thoroughly well acquainted with the itch- animalcule, and has left an admirable description ,of the creature, as well as two excellent figures.1 The latter, however, are not equal to the description. He points out the error of Linnaeus with regard to classification, 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, pedi- bus rufescentibus brevibus ; posticis quatuor seta longissima, plantis quatuor anticis fistulatis capitulo terminatis." The capitulum in this definition he speaks of as being " en forme de vessie ;" and in refer- ence to scabies he observes, " Ces mittes sont meme 1'unique cause de cette vilaine maladie." Fabricius,2 in his " Systema Entomologicae," 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 filifbrmes." 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 asserva- tis, cutem hominis rugas secutus penetrat, vesiculum et titillationem excitat. Caussam, nee symptoma morbi esse evincunt observata analogia cum Gallis contagium cura." And of the latter: "Habitat in scabie ferina." In the " Fauna Groenlandica,"3 the same author observes, with regard to acarus siro : " Habitat in vesicula scabiei Grcenlandorum, qui ilium 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 " Entomologia Systemica, emendata,"4 Fabricius adopts the opinion of De Geer with regard to the identity of the acarus siro with the acarus domesticus, or cheese and meal mite, and admits the itch- animalcule as a distinct species, with the 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 exulcerans, and quotes a passage from Linnaeus to the same effect. Muller, in his " ProdromusZoologiae Danicae,"5 adopting the early classification of Linnaeus, treats of the itch-animalcule under the designa- 1 Memoire pour servir a l'histoire des insectes. Vol. vii. 1778, p. 94. pi. 5. figs. 12-14. ' Johannes Christ. Fabricius. Ed. 1775, p. 813. 3 Anno 1780, p. 221. • Anno 1794, vol. iv. 5 Otho Fredericus Muller. Anno 1776. observations of linnjeus—FABRICIUS. 751 tion of acarus siro. In Denmark, he observes, the creature is called Krid-orm, Ring-orm, and Meel-mid. The latter term, which, trans- lated, 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 ; we have extracted as many as twenty from their retreat at a single sitting. We have placed them on a slide of glass, and seen them run ; and after the business of the day has been over, we have examined them with the microscope, and found them still active, living for several hours after our examination. We 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. 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 microscope brings into view a head not unlike that of a tortoise, and a pair of large and strong legs on each side of the head. These organs are encased in a moderately thick layer of chytine, and have consequently the reddish-brown tint of the case 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, but broader in the female than in the male. 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 projecting 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, we measured ten specimens, and found them vary between T£T and TV of an inch 752 HISTORY OF THE ITCH-ANIMALCULE. in length, and between -5^3 and v\ in breadth. The following were the measurements of seven of this number:— Length.......ii? jh ih ?& s's Vt Vt Breadth.......T|? T£j TiT T±y TJ5 T^ff 5'? 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 of the animal, but chiefly transversely, and resembling a coat of plate armor. The connecting membrane of these plates permits of a certain degree of movement between them. The dorsum of the creature is convex, but uneven, and exhibits upon its borders a ten- dency to division into a thoracic and an abdominal segment, the former being somewhat broader than the latter, especially in the male. Anteriorly, the dorsal case terminates in a sharp border, which is scalloped, and forms a jutting roof of protection to the head and four anterior legs. Posteriorly, the case is somewhat deeply cleft, form- ing 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 lateral enlargement towards the root of the head is the most'suitable place for eyes; but we have not 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 head, and becoming broad towards the root of the latter. It is bounded later- ally by a double pair of palpi and mandibles, the latter being termi- nated by strong chelae; while at the bottom of the oral fissure is the buccal opening, and, according to Bourguignon, the respiratory aper- ture. The head is capable of elongation or retraction beneath the dorsal plate or carapax. The legs are eight in number, four being anterior, and four poste- rior ; 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 HISTORY OF THE ITCH-ANIMALCULE. 753 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 termination 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, in virtue of their thickness, of a deep color. These are the red lines of Gras, Easpail, and others. The posterior 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, two at each side; they are conical in form, composed of three segments, and each leg is connected to the body by means of a trian- gular and flattened hip-piece. Each posterior leg is terminated by a long, membranous, hair-like organ, and the posterior part in the male by a tarsus and pente-lobate foot. We 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 pos- terior margin of the abdomen. These four filaments, with the four hair-like organs of the posterior legs, and the four directed backwards from the lateral part of the thoracic segment, form the twelve hair- like filaments which are observed along the posterior margin of the animal. These filaments, together with the hairs, spines, and tubercles situated on the dorsum, fix the animal in its cuniculus while using its head as a lever to force up the epidermis in front. We have not been able to distinguish any distinctive sexual organs. In a sketch before us is drawn a conical projection in this region, but we have not seen that appearance repeated. The ova we have seen, but the internal organization of the animalcule is obscured by the large collection of adipose cells which form its superficial stratum. The above description of the animalcule, founded on our own re- searches, was published in the first edition of this book in 1842; a little later we succeeded in observing the tubular tarsus and pente- lobate foot on the posterior pair of legs; and were led to infer, from our examination of the mange-animalcule of the horse (1843), that the structure in question was an attribute of the male, and was intended as a means of more rapid progression when in pursuit of the female, and also as a means of clasping the female during coitus. The male of the mange animalcule is furnished with a pair of powerful suckers to hold the female, and the prehensile foot is found on the third pair 48 754 HISTORY OF THE ITCH-ANIMALCULE. of legs, which are largely developed, while the fourth pair are small and aborted. Whereas in the female the fourth pair of legs are the largest, and provided with a tubular foot and ambulacrum ; and the third pair is smaller and wanting in that appendage, being provided instead with a pair of enormously long hairs. The natural history of the acarus scabiei has since this period been enriched by the labors of Hebra, Eichstedt, Bourguignon, Lanque- tin, Gustav Simon, Gudden ; and more recently by Fuchs, Bamberger, Gumpert, Kohn, Bernhardt, Gerlach, Worms, Leydig, Rudolph Bergh, Karl Seggel, Fiirstenberg, &c. The distinction of the sexes is now well established; the migratory habits of the male; the retirement and seclusion of the impregnated female in the cuniculus during the deposit of her ova; the hatching of the ova; the production of larvae having only six legs; the moult and metamorphosis of the larvae; the instincts of the young previously to assuming the habits of the male on the one hand, and those of the impregnated female on the other; and the habits of activity of the animalcules during the first two hours of the warmth of bed. The wants of the acarus, says Bourguignon, are three in number; warmth, air to breathe, and the animal juices of the skin. His favor- ite temperature ranges between 75° and 95°; and below 50° he dies; the burrowing female, while depositing her ova, perforates the vault of epidermis immediately above her for the sake of air for herself and for her ova ; while the strong forceps of the mandibles are brought into play to procure a flow of juices fitted for nutrition. The acarus does not breathe by means of spiracles and lateral tracheae like certain insects, but by means of an opening situated near the buccal aperture through which he inspires the air, globule by globule, and passes it onwards through the oesophagus into the tissues of the body. The impregnated females dig long burrows in the epidermis, depositing their ova as they move onwards, and never reappearing on the skin; the larvae and young females avail themselves of broken surfaces, or burrow for a short distance in the cuticle; and the males hide them- selves under any protecting edge during the day, and ramble actively over the surface at night, when they are stimulated by the warmth of bed. The males course along the skin with extraordinary speed, and are able, according to Bourguignon, to run from the hand to the shoulder in the space of ten minutes. This author thinks it possible that a scabies might be engendered by the males alone, or by the un- impregnated females alone, in which case all the irritation of itch might be present, without the cuniculi of the impregnated females, which are considered pathognomonic of the disease. In his study of the ovology of the acarus, Bourguignon observed that the female laid four eggs at a time, sometimes in pairs, sometimes in single line; and these ova are seen in the cuticle, separated every here and there, or bordered by small black fecal masses. The newly deposited ovum is a thin membranous film, filled with a colorless fluid, holding in suspension an abundance of minute dark granules; in forty-eight hours the granules are partially dissolved, and small cells take their place, the undissolved granules being dispersed among the HISTORY OF THE ITCH-ANIMALCULE. 755 cells, and some being apparently included within them. During the following two days, the cells accumulate in small groups, and being surrounded by an enveloping membrane from larger cells; and the mass of compound cells, contracted on itself, leaves a space between its periphery and the membrane of the ovum. Again the compound cells accumulate in masses, and assume a rude shape, the fashioning of the future larva; five of these masses at one extremity represent the head and four anterior legs, two behind, the posterior legs; on the tenth day the larva is complete, and on the eleventh, bursts its enveloping mem- brane, endowed with marvellous activity, but provided with only six legs. On the eighteenth day it again casts its skin, and is found pro- vided with a fourth pair of legs, and capable of entering upon social life and assuming its proper sexual function. The male acarus was first described by Kraemer and Eichstedt in 1845; and five years later by Lanquetin and Bourguignon. He is smaller than the female, has a distinct genital apparatus, and is fur- nished with a tubular tarsus and sucker foot on the fourth pair of legs, Bourguignon's description of the acarus is as follows :— General Characters.—Tortoise-shaped; head, two palpi, adherent, lateral, hooked; false palpi; four mandibles, superimposed in pairs, bidactyl, the two superior armed with hooklets; legs, four anterior, jointed, with ambulacrum terminated by a sucker ; respiration by buccal aperture, not by stigmata or tracheae. Female.—Four posterior legs, jointed, each terminating in a long hair; epimeres of posterior legs separated ; numerous horny append- ages on dorsum ; subject to metamorphosis; size, one-third of a milli- metre. Male.—Sexual organs distinct; ambulacrum with sucker, termi- nating the central pair of posterior legs; epimeres of posterior legs united; horny appendages on dorsum in small number; size, one-fifth of a millimetre. Larvae.—Hexapod, without distinct sexual organs. STEATOZOON FOLLICULORUM. Syn. Acarus folliculorum, Gustav Simon ; entozoon folliculorum steatozoon folliculorum, Wilson ; demodex folliculorum, Owen. In the course of some researches directed to the investigation of the cause of acne, Gustav Simon, of Berlin, discovered an animalcule in the sebaceous substance with which the hair-follicles are so com- monly filled, particularly on the face, and gave it the designation, acarus folliculorum.1 Simon's researches have hitherto been directed principally to the cutaneous follicles of the nose, where he finds the 1 Muller's Archiv. 1842, 218. Ueber eine in den kranken und nonnalen Haarsacken des Menschen lebende Milbe. Researches into the structure and development of a newly-discovered parasitic animalcule of the human skin, the entozoon folliculorum ; by Erasmus Wilson ; communicated to the Royal Society, December, 1842 ; published m the Philosophical Transactions for 1844. Subsequently we termed the animalcule steatozoon, "the animal of the oily product of the skin." 756 HISTORY AND DESCRIPTION OF THE parasite with astonishing frequency, even in cases where the skin pre- sents all the characters of ordinary health. Of living persons, he de- tected the animal in three out of the men, in the sebaceous matter squeezed out by pressure from the follicles ; but in the dead he disco- vered them in almost every individual examined; the only exceptions out of ten bodies being two newly-born children. The mode of exa- mination in the case of the dead was by means of thin sections of the skin. The animalcules imbedded in the sebaceous matter are found in the hair-follicles near the outlet, their long axis corresponding with that of the follicle, and their heads directed inwards; in four in- stances, 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 re- tain their vitality for a considerable length of time; they were found moving after a confinement of eight and twelve hours between two plates of glass, and in one body they were 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 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 tooth-like processes. The proboscis, which is capable of elongation and retrac- tion, resembles a long tube, upon which lies a triangular organ, hav- ing its narrow base directed towards the root of the proboscis, and extending by its apex almost to the extremity of that organ. 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 leg 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 of the 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 corresponding with the second pair of legs. The abdomen is marked by a number of transverse lines produced by a series of grooves or contractions, 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. STEATOZOON FOLLICULORUM. 757 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 characteristic transverse lines. In a third form the abdomen is very short and acutely pointed. The thorax is broad, and there are no transverse lines on the abdo- men. 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 of the animal kingdom does the parasite belong ? asks Simon; and this question he refers to an eminent entomologist of Berlin, who returned 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 palpi. The different forms in which the creature has been seen are stages of development. In the early stage of the mite the presence of three pairs of legs is a common character. The length- ened form here principally described is the second stage of develop- ment, 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 which they possessed on first breaking from the egg, even although an addi- tional pair of legs have to be developed. On the other hand, Hartig has observed and described in the mite of the pine-gall {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. ' These acari have only three pairs of legs in their embryo state. 758 HISTORY AND DESCRIPTION OF THE 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 T^n 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 con- jecture, 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 animalcule, 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 externally to it. Further researches may serve to establish this question; in the mean time, however, I will designate this animal, from its habitat in the hair-follicles, acarus folli- culorum. About six times have I seen, both in the comedones of living per- 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 of the 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 it. This observation, with the fact of the non-resemblance of the heart-shaped body to any known human structure, gives force 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 movements, 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. 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 1 The trichomonas vaginalis, with which we are 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 j A Glycyrion AMYLATUM. R.—Glycerinae purificatae.......?viij. Pulveris amyli ........ ?j. Rub the starch in a mortar with a portion of the glycerine until perfectly smooth, and add the remainder of the gtycerine. Heat gradually to a temperature of 240O,' and keep constantly stirred. The preparation is a jelly-like transparent paste, to be used alone or as a vehicle for other remedies. Glycyrion iodatum. • Dr. Gage, U.S. fy.—Glycerinae purificatae ....... gjj. Potassii iodidi, Iodinii . Misce. aaoJ< A powerful stimulant, applicable to lupus vulgaris and erythematosus. LOTIONS. Lotio hellebori albi, P.L. R.—Pulveris radicis hellebori albi Aquae fontanae Boil down to ^xvj., strain, and add Spiritus vini rectificati . For scabies. Lotio sodje hyposulphitis. R.—Sodae hyposulphitis Acidi carbolici Aquae lavandulae spicatae Aquae destillatae Misce. For chloasma. 5xxxij. 3iv. 3ss. Hi- §viss. 1 The term glycyrion was suggested by Dr. Frederic Farre as a designation of compounds of glycerine and appears to us to be so admirably suited to the purpose, that we have not hesitated to adopt it. 774 FORMULARY OF SELECTED REMEDIES. Lotio hydrargyri bichloridi. R.—Amygdalarum amarum ...... no. xx. Aquae destillatae ........ §vj. Contunde et tere simul dein cola et adde Hydrargyri bichloridi ....... gr. xvj. Spiritus vini rectificati . . . . . . . £"ij. Misce, ut fiat lotio. For acne and gutta rosacea. Lotio capillaria stimulans. R.—Olei amygdalae dulcis.......§j. Liquoris ammoniae fortius . . . . . . ,^j. Spiritus rosmarini . . . . . . . . %iV. Aquae mellis ......... §ij. Misce, fiat lotio. For alopecia. Bateman's formula. R.—Olei macis.........§ss. Spiritus vini rectificati ....... §viij. Misce, fiat lotio. For alopecia areata. Lotio capillaria refrigerans. R.—Olei amygdalae dulcis ....... §ss. Sodae biboratis ........ 9j. Aquae riorum aurantii ....... §iss. Aquas destillatae ........ §vj. Misce, fiat lotio. . For alopecia. SPIRITS and TINCTURES. Spiritus saponatus kalinus. Hebra's formula. R.—Saponis mollis........§ij. Alcoholis ......... ^j. Misce, et cola. For alphos. Spiritus saponatus iodidus. R.—Saponis mollis, Alcoholis . . . . . . . . . aa §j. Potassii iodidi . . . . . . . . 3ij. Misce. For scrofulodermata and strumous swellings. Tinctura ^etherialis iodinii et mastiches. Dr. Thomas Smith Rowe's formula. R.—Spiritus vini rectificati ....... j^v. iEtheris sulphurici ....... 3iij. Misce: et adjice, Gummi mastiches ........ gr. xxv. Solve et cola, dein adde> Iodinii..........P)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 mastic h creates a varnish-like film on the skin, which detains the iodine, and facilitates it 3 absorption. FORMULARY OF SELECTED REMEDIES. 775 Tinctura crotonis tiglii. R.—Seminum contusorum.......gj. Spiritus vini rectificati.......giv. Macera per dies quatuordecim et cola. A valuable cutaneous stimulant in chronic irritation and thickening, as also in languid innervation. Tinctura capsici, fortior. Turnbull's formula. R.—Capsici..........?j_ Spiritus vini rectificati . . . . . . . 5iij. Macerate for a week, and strain. For erythematous chilblains ; to be applied with gentle friction by means of a piece of sponge. Decoctum Zittmanni. » Strong. R.—Radicis sarsae concisae ....... §xij. Aquae fontanae........libris lxxii. Digest for twenty-four hours ; then add, tied up in a piece of linen— Sacchari albi, Aluminis ......... aa 3vj. Calomelanos ......... 5iv. Antimonii sulphureti .......3j. Simmer down to twelve quarts ; towards the close of the simmering add— Seminum anisi, contus : Seminum fceniculi, contus : ...... aa^ss. Foliorum sennae ........ §iij. Radicis glycyrrhizae, concisae ...... §iss. Press and strain, and, after standing until cool, decant the clear liquid, and bottle twelve quarts. Weak. To the dregs of the strong decoction add— Radicis sarsae concisae .......§vj. Aquae fontanae........libris lxxii. Simmer down to twelve quarts, and towards the close of the simmering add— Corticis fructus citri, contusi, Cardamomum minorum, contus : Radicis glycyrrhizae, concisae ...... aa 5nj- Squeeze and strain, and, after standing until cool, decant the clear liquid, and bot- tle twelve quarts. One bottle of the stronger decoction is to be taken warm, before twelve o'clock in the day; and one bottle of the weaker decoction cold, between twelve o'clock and bedtime. It has been suggested that the mercurial and antimonial salts contained in the linen bag are useless, as undergoing no solution in the liquid. This may be the case, but we have fancied that the remedy answered better when prepared in accordance with the old formula than in a mutilated form. The treatment is com- menced with an active purge of calomel (gr. iv) and colocynth (gr. viij); and if the action of the bowels be sluggish, the purgative should be repeated in the evening of the fourth day. CAUSTICS. ACID CAUSTICS. The concentrated nitric or sulphuric acid may be made into a paste by admixture with sulphur sublimatum ; a wooden or glass spatula must be used for the purpose, and the caustic applied with an instrument of similar material. Rivallie produces a solidified nitric acid by the combination of the latter with scraped lint. Maisonnecve prefers asbestos to scraped lint as the solidifying material. 776 FORMULARY OF SELECTED REMEDIES. «. A " caustique noir" is formed by the admixture of concentrated sulphuric acid with saffron, and is extolled by Velpeau and Maisonnectve. The acid nitrate of mercury ; hydrargyri nitratis liquor acidus, of the British Phar- macopeia, must also be enumerated amongst the acid caustics. For carcinoma and lupus. ALKALINE CAUSTICS. Potassa caustica cum calce. Vienna paste. R.—Potassae causticae ........ 5v. ^ Calcis hydratis ........ 3VJ- Tere bene simul, ut fiat pulvis. To be mixed with rectified spirits of wine to the consistence of a thick paste, when required for use. Filho's caustic. The potassa cum calce, consisting of two parts of caustic potash to one of lime, in * solid stick, is also an admirable caustic. For carcinoma and lupus. Soda caustica cum calce. Dr. Morell Mackenzie's caustic. R.—Sodae causticae, Calcis hydratis. partes aequales, Tere simul, ut fiat pulvis. To be mixed with water to a proper consistence. Chloride of zinc Caustic. Canquoin's paste. R.—Zinci chloridi, Farinae tritici . . . . . . . . aazj. Aquae guttarum . . . • . . . . . v-x. Mix into a paste of-convenient consistence. This caustic requires the previous removal of the epidermis; and when applied upon a cancerous tumor in a layer a quarter of an inch in thickness, destroys the tissues beneath it to the depth of an inch in forty-eight hours. For lupus it should be diluted to the extent of one part of chloride of zinc to two or three of flour, and is then both slower in its operation, and less painful. Chloride of zinc with antimony. Canquoin's formula. R.—Zinci chloridi, Antimonii chloridi.......aa 3j. Farinae tritici ........ 3is's. Aquae guttarum ......... v-x. Mix to a paste of the consistence of soft wax. For carcinoma and lupus. Chloride of bromine caustic. Llandolfi's paste. The chloride of bromine is either used alone, made into a paste with liquorice pow- der, or according to the following formula :— R.—Bromini chloridi ........ 3iij. Zinci chloridi ........ t\\ Antimonii chloridi . . . . . . ■ 3j. Auri chloridi Misce. 3J- These substances are sometimes used in equal proportion ; and in either case are mixed with wheaten flour to the consistence of a paste. FORMULARY OF SELECTED REMEDIES. 777 Arsenical caustic. Ma nee's formula. R.—Acidi arseniosi . . . . . . . . 3j. Hydrargyri sulphureti (cinnabar) . . . . . gj. Spongiae ustae........gss. Misce, ut fiat pulvis. To be made into a paste of a convenient consistence with water. Dupuytren's formula. R.—Acidi arseniosi . . . . . " . . gr. ii. Calomelanos ......... 3j~3iij. Misce. To be made into a paste with water like the preceding. For lupus and carcinoma. Arsenical caustics are open to the objection of causing constitutional disorder from absorption ; the danger of absorption would seem to be proportioned to the extent of surface brought into contact with the arsenic ; and the effects of absorption may be arrested by the application to the part of the hydrated peroxide of iron. Other caustics applicable to the treatment of lupus and cancerous ulceration are : the terchloride of antimony, alumen exsiccatum, and the ferri sulphas exsiccata recom- mended by Sir James Simpson. BATHS. Ammonia bath. Grantham's formula. R.—Liquoris ammoniae fortioris......gij. Aquae calidae 100° . . . . . . . • Cong. ij. An admirable cutaneous stimulant and derivative, used in a hip-bath. Brick bath. Mr. Grantham describes a form of vapor bath, under the above name, which he finds very valuable in country practice, and which, from its domestic nature and facility of application, must be regarded as an important remedy. The patient is seated on a stool and enveloped in a blanket; under the blanket is placed a pan or pail contain- ing-two gallons of hot water ; and the water is kept hot, and raised into steam, by the addition of a brick heated in the fire to redness. Moreover, the simple vapor bath is converted into a sulphur vapor bath, by mixing two ounces of sublimed sulphur with the water, previously to dropping in the brick. BENZOATED OINTMENTS. The prevention of rancidity of fats and oils, used in the preparation of ointments, is a modern discovery, of immeasurable importance, in local cutaneous medicine. The hint was given to us more than a quarter of a century ago by Dr. Jones Quain, who himself derived the information from the pharmaceutical school of Paris. His pro- posal was, the addition of benzoic acid to lard ; but the result of our experiments with this substance was unsuccessful. At a later period, namely, in 1854, Dr. Alexander Ure mentioned to Mr. Hills the adaptation of gum benjamin to this desirable purpose ; and a few days later, the first specimen of pimple benzoated ointment, and the ben- zoated ointment of oxide of zinc, were submitted to us for examination and trial. We found them both excellent, and have used them ever since with increasing satisfac- tion ; while the formula for their preparation was published by the firm of "John Bell & Co." in the Pharmaceutical Journal for November, 1854. When we first commenced the treatment of diseases of the skin, water-dressing had just been introduced, aud suddenly became the surgical fashion of the day, while a general outcry was raised against ointments, "greasy applications," as they were con- temptuously called. Finding that in practice it was impossible to contrive any sub- stitute for ointments in the treatment of these diseases, aud being unable to discover any cause for the objections raised against them by our contemporaries, we set our- 778 FORMULARY OF SELECTED REMEDIES. selves to inquire into the possible reasons of their disrepute. This was soon ascer- tained ; they were ill-prepared, long kept, and in many instances so rancid as to act as irritants and aggravators of the disease. On the other hand, when properly pre- pared and perfectly fresh, ointments are all that can be desired as a local application. Again, it is to be remembered that a cutaneous eruption, by virtue of the inflamma- tory 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 impurity 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 of prevent- ing decomposition 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 con- dition of some importance where an application is required to be kept on the skin duriug the period required for cure. The benzoated ointment of oxide of zinc, 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 dis- ease. Once properly applied, it will loosen the crusts and prevent further crusts 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 advantages which no other local appli- cation possesses ; and we cannot but arrive at the conclusion that it is a most valu- able 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 oxidization, and it retains the ordi- nary moisture of the skin, acting 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. We make it a prominent part of our directions, that the morbid part should not be washed after the application 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. 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 caliminare 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 zincwas 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 all the former compounds by its greater den- sity, slight buff color, and far greater purity." Again, the eye test and public preju- dice did their best to deteriorate this substance ; and, but for the efforts of Mr. Red- wood, might have succeeded. The buff color was thought to indicate impurity, which is not the case; but happily au experienced manufacturer, Mr. Hubbuck, stepped in and supplied an equally pure white oxide; so that we have now two oxides of equal FORMULARY OF SELECTED REMEDIES. 779 purity, and only differing, to all appearance, in their tint of color. We 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 oils," he says, " when in contact or mixed with metallic oxides, soon turn rancid, a circum- stance which gave dispensing chemists a great deal of trouble with seemingly quite Bimple 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-observed 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 ben- zoated 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 readily 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 subse- , quently acts on the zinc How far this greater susceptibility to weak acids may ren- der it 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." Although of British origin, the unguentum benzoatum has not as yet been adopted by any British Pharmacopoeia; but the United States of America have had the wis- dom to introduce it into their Pharmacopoeia of 1863, under the name of " unguentum benzoini," and have given as their formula for preparing it one part of gum benzoin to sixteen of lard, with an exposure to heat in a water bath of two hours. 780 GLOSSARY OF DERMATOLOGICAL TERMS. CHAPTER XXIX. GLOSSARY OF DERMATOLOGICAL TERMS. Achor; a%aif>, scurf, dandruff, or dandriff; axv?ov> meaning "chaff." According to Willan achor is " a small acuminated pustule, containing a straw-colored matter, which has the appearance and nearly the consistence of strained honey, and is succeeded by a thin brown or yellowish scab;" but, looking to the derivation of the term, it would seem to be applicable to the scab rather than to the mature stage of the pustule; in the former sense it is, according to the same author, a constituent of porrigo. Willan's definition of achor corresponds with the pustule of kerion; the term, however, has fallen into disuse. Achorion, derived from "achor;" is the name of the dermatophyte of favus, achorion Schoenleinii. Achroma ; a^pa/xo;, Hippocrates; colorless; an absence of pigment in the skin. Acne ; ax/xn, flos aetatis; a disease of puberty, associated with the development of the hair, and affecting the follicles of the face, breast, and back. Dr. Greenhill remarks that the word " acne" owes its origin to a typographical error occurring in iEtius. The proper term is ax^u, or rather the plural of acme, namely ax/tat. Acrochordon; axpo^o^ajv, Hippocrates, Celsus; axpov, a point or end; xofa, a cord; an elongated wart with a narrow neck; a pedunculated wart. Acrodynia ; axpov, the extremity, otiuvn, pain; a term applied by Alibert to an epidemic erythema of the hands and feet, attended with burning heat and pain. Acrotjca; one of the orders of the class eccritica of Mason Good, embracing "diseases of the external surface." Mason Good derives the term from ay.pi;, summus, and anemic, summitas, and groups under it ten genera, namely, ephidrosis, exanthesis, exormia, lepidosis, ecphlysis, ecpyesis, malis, ecphyma, trichosis, and epichrosis. Agnail; from the Saxon word ange, angry; the term is applied to the shreds of epi- dermis which separate from the skin covering the root of the nail, and which, on being torn, give rise to a painful state of the finger. Agria; aypios, angry, fierce, raging, violent; e. g., lichen agrius, a form of eruption remarkable for the violence of its itching; and, at the same time, the severest degree of the disease. Albinismus ; albus ; white; albinism ; a bleached state of the skin. Allosteatodes; a\\o<;, a^rtarahit; altered sebaceous secretion; a term embracing the morbid changes of the sebum or sebaceous substance. Alopecia; aXoomma, Aristotle, Galen; from a\wTrn%, a fox; a state of baldness, resem- bling the loss of hair, as seen in a fox suffering from the mange. The term alopecia ungualis is applied to the loss of the nails. Alphos; aX$?, from *\$nw, the dull white leprosy; white, like barley-meal; alphos being akin to albus. Alphos is the Boak of the Hebrews and Arabians ; the lepra alphos of the Greeks; the vitiligo alphos of Celsus; and the lepra of Willan. Its non-contagiousness, as compared with the true leprosy, is testified by the Greek translation of the Bible; Leviticus, chapter 13, verse 39, as follows, aXo? es-ti E^avSst ev rm topf*art T»f g-ctfuoq avrov, xadapot ss-riv; "it is a freckled spot that groweth iu the skin; he is clean." Alphosis; a\tn;, whiteness; alphosis is one of the species of Mason Good's genus,' epichrosis; which he terms albino-skin; the equivalent of albinismus and leuco- derma. Ambusta ; participle of the verb amburere, to burn; blisters caused by burn or scald. ANiEMLa:; avai/uua, want of blood; the title of Hebra's second class of cutaneous diseases. Anesthesia ; from a, want or absence of; acrflna-i?, sensation. The term a«-0«crja, is used by Aretaeus. GLOSSARY OF DERM ATOL OGIC AL TERMS. 731 Angeiectasia ; ayyti*, vessels; EXTan?, extension; extension of hypertrophy of the capil- laries and minute vessels of the skin; hence augiectasia capillaris, a term applicable to several forms of vascular naevus. Angina; from «y^<», to strangle; hence the Latin word ango, having the same signifi- cation. Anidrosis ; from a, ityawj, perspiration; i$fo<», to perspire ; absence of perspiration. Anthrax; av6pa£, Hippocrates; a coal or carbuncle; possibly significative of its coal-black color, or of its resemblance to the precious stone termed "carbuncle." It is also expressive of a burning coal, " carbo, in quo avdet, id est floret ignis." Aphtha; atyBtt, a, the leg; the form of hypertrophy of the lower extremity, called by the Arabians dal fil, the elephant leg; by the Greeks, elephantiasis Arabum; and, by ourselves, the Barbadoes or Cochin leg, from the frequency of its occurrence in those countries. Bulla; bulla, a bubble; such as is formed on the surface of water by the fall of rain or by boiling. The diminutive of bulla is bullula Bullae; the title of Willan's fourth order; including as genera, erysipelas, pemphigus, and pompholyx. * 782 GLOSSARY OF DERMATOLOGICAL TERMS. Cacochroia ; xaxoxpota, Galen; a bad color or complexion; Hippocrates uses the term xaxoxpoot; sallowness and pallor with discoloration of the skin. Cacochymia ; xa.xoxyy.ia, Galen; bad juices; a morbid condition of the skin, due to an unhealthy state of its fluids. Cacotrophia; xaxorpo^oq, ill-fed, from xzxorpoyem, to nourish badly; an ill-nourished state of the skin. Theophrastus, a.c. 322, uses the term as expressive of "bad food." Callus ; hardness of the cuticle, as produced by pressure and friction; a corn. The term callosity is used in the same sense. Calvities; baldness; from calvus, bald. Cancrois ; from xapxivo?, cancer; a synonym of kelis. Canities ; canus, hoary, gray-haired; whiteness or grayness of hair. Carate ; probably from the Portuguese word car&o, complexion; a partial leucasmus endemic on the western coast of South America, and especially in New Granada and Peru. Carbunculus ; Galen, Celsus ; diminutive of carbo, a coal or burning coal; synonymous with' anthrax. The name of an aggravated form of boil, distinguishing probably its black appearance and burning nature. Carcinoma; xapxivmy,*,xapxivo?; Hippocrates; an eating sore, a cancer. Chalazion , £aXo£i<>v, from ^aXa^a, hail; a small, hard, and transparent encysted tumor of the eyelids, resembling in appearance a hailstone. Chaps ; clefts, gaps, or chinks in the skin; such as occur on the back of the hands and wrists in cold weather, erythema a gelu; also in psoriasis and alphos. Chelois ; ^»iXij, a crab's claw ; a term applied to kelis from the resemblance of one of its varieties to the bifid claw of the crab. Chicken-pox ; from the word chiches, chick-pease; a small pulse less than a pea; a diminutive pock. In French the word chiches has a similar signification, the cicer of the Latins. The Spanish word chico, and the Italian chichino, signify, little, petty. Chilblain ; a blain or blister caused by the cold; the chilblain presents three stages, erythematous, vesicular, and gangrenous. Chloasma; xKoaiTfJtaf t^at which is green; Hippocrates. A stain of the skin of a green- ish hue ; the pityriasis versicolor of Willan; chloasma pigmentosum^ Chromatogenebis ; p^po^a, color ; yevtm, generation. The production of color. Chromidrosis ; ^p^a, color; iJpiw?, perspiration. Colored perspiration; the ephidrosis discolor of Mason Good. Chrystalli ; crystalli ; a synonym of varicella, from the crystal transparency of the vesicles ; variolae chrystallinse, Ingrassias. Cingulum ; a girdle; the Latin name for herpes zoster, so called from encircling a certain extent of the circumference of the body. Cirones, sirones, and cyrones ; synonyms of acari; applied to the acari scabiei. Clavus; a round knob or stud; a term applied to a corn. Celsus writes, "clavus non- nunquam etiam alibi, sed in pedibus tamen maxime nascitur." Cnidosis ; xn&vo-ti, Hippocrates; an itching like that caused by the nettle, xviSV KviJ» is derived from xvasiv, to itch ; another term for the nettle is xvn^n, hence the word xviktjuo?, a synonym of pruritus. Cnidosis is a designation of urticaria. Comedones ; from comedo, to eat up, to devour like grubs, a term applied to the so-called grubs of the skin; the little cylindrical accumulations of sebaceous matter in the sebiferous follicles. Couperose ; a French synonym of gutta rosacea; a face cut up or disfigured with roseate blotches. Crinones ; a synonym of comedones; probably from crinis, a hair, in consequence of their hair-like figure when expressed from the follicles. Crusta lactea; milk-crust; the name given to the incrusted stage of eczema pustu- losum or impetiginosum, as it occurs upon the face of infants during the period of lactation. Cyano-derma ; xvaveog, blue. A blue discoloration of the skin. Cyanopathia; xuavEs;, blue; itaAa^, disease ; the blue disease, morbus cceruleus. Cyanosis ; a synonym of cyanopathia or morbus cceruleus. GLOSSARY OF DERMATOLOGICAL TERMS. 733 Dandruff or dandriff; derived from two Saxon words signifying "itch" and "foul." An itching foulness or scurfiness, commonly of the head, as in pityriasis and psoriasis capitis. Dartre; the French equivalent of the English word tetter; apparently derived from ttptn, to skin or flay; hence SNtp-roc, skinned or flayed; therefore, an abrasion or ex- coriation, or skinning as in desquamation. Dartre is the popular appellation of all the more common affections of the skin, as is tetter in English; but the term has also been adopted by some French authors as a scientific denomination of a group of cutaneous diseases, including eczema, alphos, lichen, and pityriasis. Hence also, the expression "dartrous diathesis," a tendency to the production of dartres. Dermapostasis ; Stp/xa, the skin; amos-Tatrtt;, a standing away from; a swelling or en- largement. Dermatalgia; aXyof, pain; pain of the skin. Dermatolysis; te?f*a, the skin; Xuj-i?, loosening, looseness; Xueiv, to make loose. Loose- ness of skin, the skin hanging in folds; Alibert describes five varieties of derma- tolysis : palpebralis, facialis, collaris, abdominalis, et genitalium. Dermatonosis ; voa-o?, disease; disease of the skin. Dermatophyton; xi/a-i?, Galen; cx$Xvt», to burst forth; the fifth genus of the class " eccritica" of Mason Good; "blains," that is "orbicular elevations of the cuticle containing a watery fluid;" a vesicular eruption confined in its action to the surface, in contra- distinction to emphlysis, which is connected with "internal and febrile affection." Ecphlysis includes four species, namely, pompholyx, herpes, rhypia or rupia, and eczema. Ecphyma; e«ac, an elephant; the elephant disease, from the resemblance of the skin to the elephant's hide, or from the progress of the disease as implicating the whole body. This term was probably suggested to the Greeks by the Arab word, da ool fil, the elephant disease; and applied to the affection already known to them by the terms lepra leuce and lepra melas. The Arabians recognized by dal fil a different disease, namely, boucnemia tropica, the Barbadoes leg. Hence we distinguish as separate diseases the elephan- tiasis Graecorum, or lepra, and elephantiasis Arabum, or boucnemia. Emphlysis ; e^Xuo-i?, Hippocrates; ev, in; a-ts, a coloring. A surface stain. Mason Good distinguishes it as a genus, a " macular stain," and includes under it seven species, namely, leucasmus, spilus, lenticula, ephelis, aurigo or orange stain, paecilia or pie-bald stain, and alphosis or albino-skin. Epiderminosis ; S7rifcp/xis, Hippocrates; voo-o?, disease; disease of the epidermis. Epidermophyton ; a, Hippocrates; sweat eruption; in Latin termed sudamina and aestates. Hydroa febrile is a synonym of herpes labialis, Franck. Hydroadenitis : vbup, water; aUv, a gland; a term given by Bazin and Verneuil to minute inflammatory tumors in the skin, sometimes ending in suppuration, and sup- posed to have their origin in inflammation of the sudatory glands. Hyperemia; virtp, super ; aiya, blood; excess of blood contained in the bloodvessels, as in inflammation; the title of Hebra's first class, consisting of erythema, active and passive. Hyperesthesia; uttep, super; aio-Sua-i?, sensation; excessive sensibility. Hyperidrosis ; vm?, super; iJpaxnj, perspiration; excessive perspiration. Hyperplasis, Hyperplasia ; vmp, super; wXao-if, conformation; excessive conformation; accumulation of similar structure. Hypertrophia ; vitep, super; rpo», nourishment; excessive nutrition as shown in ex- cessive growth or enlargement. Hypertrophiae, is the title of the sixth group of Hebra's classification, its sub-divisions being, hypertrophy of epidermis, pigment, corium, follicles, and appendages of the skin, namely, hairs and nails. Ichthyosis ; ixBva, Hippocrates; the drietl rough skin of a fish, from i^fiu?, a fish; the fish-skin disease. Idrosis; i^piaa-tg, a perspiring; ityoeiv, to sweat or perspire. The sweating disease or sickness. Ignis ; fire ; ignis sacer, Celsus, Pliny. The ignis 6acer of Celsus is a chronic tubercular affection, suppurating and forming ulcers, and spreading by the circumference; probably strumous or syphilitic. Ignis sancti Anthonii is a synonym of erysipelas; ignis Persicus, of anthrax; while herpes zoster has been termed zona ignea, from the burning pain which attends it. Impetigo ; Celsus, Pliny; ab impetu agens ; breaking out with violence or impetuosity; a pustular eczema. Intertrigo ; ob interterendo, a rubbing together; a chafe-gall, or gall from chafing; a fret; a term applied to one of the varieties of erythema; when accompanied with a muco-purulent secretion, it is an eczema mucosum. Ionthos ; jovflo?, the root of a hair. Hippocrates applies this term to an eruption on the face associated with the first growth of the beard; to the same eruption the term ax{A.ui, or acne, has also been given. Greenhill connects the word with avflo?, a flower, because the eruption occurs at about the flower of life; and Mason Good derives the term from «ov, violet, on account of the occasional purple hue of the eruption, and treats it as a genus containing two species, varus and corymbifer. Itch: an uneasiness or irritation of the skin, which demands the aid of rubbing or scratching for its relief. The psora of the Greeks; scabies of the Latins. Strictly, the itch or scabies is an eczema excited by the presence of the acarus humanus in the cuticle. Juzam, judam; from an Arabic root, signifying erosion, truncation, excision; Mason Good. The Arabian term for elephautkisis Graecorum, and particularly the anaes- thetic form of the disease. Of a similar origin are the terms, Judas, juzamlyk, judamlyk, alzuzam, djudam, dsjnddam, djouzam, madsjuddam, jeddem, muzjeddem, didyam, damadyand, dschiddam, sghiddam, &c, the Mahommedan and Persian jezam, and the Moorish ezdam. Kelis, keloides, kelois, chelois ; x»x», a tumor; eiJo;, resemblance ; tumor-like; pro- bably from p^iXx, a sea-bank or mole. A cutaneous tumor, commonly ridge-like in form, produced by hypertrophy of the white fibrous tissue of the corium. Another signification of kelis is, macula, a mark, spot, stain or blemish. GLOSSARY OF DERMATOLOGICAL TERMS. 787 Kerion; Celsus; xnpiov, a honeycomb; from x»po?, wax. A suppurative inflammation of the follicles of the scalp; the follicles filled with yellow pus, and pouring out a viscous secretion resembling honey, suggest the idea of a honeycomb. The separate pustule of kerion corresponds with Willan's definition of achor. Kibe ; kerb, a cut; a broken chilblain. Knesmos; xvuo-jUoj, Hippocrates; from xvaeiv, to scratch, to itch: hence also xms-jc, a scratching, and xma-ya, a comb. An itching, particularly that produced by the nettle. , Kvna-fxovn, is one of the synonyms of psora, and Turner treats of pruritus under the head of knesmos. Krithe; xpi9»i, xpiflai, barley, hordeolum. "In the eyelids above the eyelashes there is apt to occur a small tubercle, which the Greeks name xpiBn, from its resemblance to a grain of barley," Celsus. Lanugo ; from its resemblance to wool, lana. The downy hairs of the body, the first and temporary hairs of the infant, and the fine hairs of the face of puberty. Lenticula; Celsus; diminutive of lens; a lentil, a freckle. Freckles frequently cor- respond both in color and size with the lentil; according to Plenck, "lentigines sunt maculae fuscae, quae, colore, figura et magnitudine, lentes referunt." Lentigo; Pliny; the same as lenticula. Dioscorides calls lentigo, faxog; hence phacia, a freckled skin. Leonita, leontiasis; Xeovteio?, lion-like; a term applied to elephantiasis tuberculosa, in consequence of a leonine expression of countenance being common in that disease ; the da el ased, or lion disease of the Arabians. Lepidosis ; XE7n?, or xetto?, a scale; vos-o?, disease ; the scaly or squamous disease. Lepi- dosis is the fourth genus of the order acrotica, class eccritica of Mason Good; the species being four in number, namely, pityriasis, lepriasis, psoriasis, and ichthyasis. Lepra; xtm;, or xeiro;, a scale; xettsiv, to scale; XE7rpoj, scaly; Xnrpa; Herodotus, Hippo- crates ; the leprosy. The Greeks admitted three forms of lepra, namely, alphos, melas, and leuce, and adopted the term elephantiasis as embracing melas and leuce. Willan retained the term lepra in connection with alphos; but modern opinion is in favor of its association with the elephantiasis Graecorum solely. Lepriasis; Mason Good; "XETrpoy, scaber vel asper ex squammulis decedentibus ; with a termination appropriated, by a sort of common consent, to the squammose tribe of diseases." Lepidosis lepriasis is the equivalent of alphos. LeuC-ethiopes ; Xeuxo?, white; aiQio^, an Ethiopian. A white negro; or negro, spotted white. Leucasmus; Xevxaa-fxot, Xwxavs-u;; a whitening, or growing white. Leuce; Xeuxh, Herodotus, Hippocrates, Celsus; xsuxoc, light, white. The white leprosy; the lepra leuce or elephantiasis of the Greeks; that variety in which the skin is bleached white, or contradistinguished from the lepra melas, or black leprosy. From leuce is- derived the leuta of Montserrat. Leucoderma ; xtvxohpfxa-rog, with a white skin ; white discoloration of the skin. Leucopathia ; xtuxor, white ; waSoj, disease. The white disease, resulting from the loss or absence of pigment in the skin. The same as albinismus. Lichen; xei^uv, a tree moss, especially of the olive; Theophrastus. As a cutaneous eruption, the term was employed by the Greeks, in the plural; Xei^>ive?, xai xenpai, xcil Xevxa\ Hippocrates; to the same author is attributed the definition, aei^iv est summae cutis vitium ut -^upa et Xnrpa cum asperitate et laevi pruritu ; and according to Galen, summte cutis asperitas cum multa prurigine, squamis et furfuribus. At present we limit its use to an eruption of " dry" pimples. Lues ; Xui.v, solvere, dissolvere. A synonym of syphilis. Lupus a wolf, from its eating or destroying quality. A scrofulous tubercular eruption, presenting three forms, erythematous, non exedens, and exedens; the latter is also termed lupus vorax, and announces a destructive form of ulcer. Macul e • macula, a spot or stain. The title of Willan's eighth order, which includes ephelis ntevus, spilus, &c The use of the term is also shown in its application to maculae hepaticae, maculae syphiliticae, &c. Madarosis ; (xaUpoxns, calvities, baldness. Malis maxiasmus; akxXfxa, skin. Black discoloration of the skin. ' Melanopathia ; fxsXa;, black; ttaBoq, pain or disease. The disease of blackness; an excess of pigment deposited in the skin. Melanosis ; fxeXavaia-i;, fxuXava-i/;, a becoming black ; the opposite of leucasmus. Another derivation is y.tXa<;, black ; voc-oi;, sickness or disease ; the disease of blackness result- ing from the deposit of black pigment in any of the tissues of the body. Melas ; y.txa<;, Celsus. The black leprosy, just as leuce expresses the white leprosy ; the former being lepra or elephantiasis Graecorum, with the deposition of black pigment in the rete mucosum; the latter the same disease with the abstraction or absence of pigment. Melasma, melasmus ; fxtXao-fxa, fxeXaa-fxoi;, Hippocrates ; blackness; a black spot; darken- ing of the skin by the deposit in the rete mucosum of an excess of pigment. Meliceris ; ,uEXix>fpi?, Hippocrates, Celsus; from ^eXi, honey ; x»5o?, wax, or honeycomb; ic*EX(x»p(tt, jusXixEpov, have the same meaning. A virulent eruption on the head resem- bling a honeycomb; the disease kerion, a suppurative inflammation of the follicles of the scalp ; the tinea favosa of the Romans. The term has been misapplied to an encysted tumor^ of the scalp containing a substance resembling wax, and of the con- sistence of honey. Melitagra ; h*eXi, honey; aypa, seizure, attack. An exudative disease emitting a dis- charge like honey ; one of the symptoms of eczema pustulosum vel impetiginodes of the face. Mendacia ; lies, falsities, deceits ; mendacia unguium ; white opaque spots in the nails, resulting from faulty structure ; by the Greeks they were termed xeux«i. Menidrosis ; fxnvtt;, menses ; fx»v, a month ; ityona-ti;, perspiration. A sanguineous oozing from the skin vicarious of the menstrual discharge. Mentagra ; a hybrid word, composed of mentum, the chin, and aypa seizure or attack. A disease of the chin synonymous with sycosis. Mentagrophyton ; mpntagra; 9 Mycosis ; fxvxoq, a fungus; a term applied by Alibert to framboesia; molluscum con- tagiosum he terms mycosis fungoides; jc*ux»j, Hippocrates, is a fleshy excrescence. Myrmecia; fxv?y.t>xia, Celsus. Warts on the palm and sole of the hands and feet; from (j.vpfA.n^t an ant; sessile warts, as distinguished from acrochordones or pedunculate warts; probably compared with ants from their appearance when numerously clustered. Myrmeciasmos ; fAvp(xnxia?/A.o;, a breaking out of warts or wart eruption; ^up^nxaor,?, signifying full of warts. Nevus ; a natu, as in nativus; or, a genere, to beget, as in gneevus. A natural mark, freckle, spot, excrescence. Hence, naevi materni, vasculosi, pilosi, pigmentosi, &c. Narcosis; vapxuTi;, Hippocrates; a benumbing; hence, narcosis folliculorum, arrest of function or torpor of follicles. Nega ; Hebrew ; Leviticus, chapter xiii. ver. 29; a;ov, a nerve ; a nervous affection. Nigredo ; blackness; hence, nigredo cutis, blackness or swarthiness of skin. Nigrities ; Celsus ; the same as nigredo. Nirles ; herpes phlyctaenodes; olophlyctis miliaris of Alibert. Noli me tangere; touch me not; term of dread applied to lupus exedens. Nome ; corroding sores, which by creeping on corrode and consume the body; from vefA-ttv, to spread ; hence, -voptn, a pasture; and vo/tai iXxxv, Dioscorides, eating sores or ulcers. Nosophyta ; yoXwtTic, Theocritus; an entire and complete phlyctis or vesicle. Alibert uses the term to represent the small bulla of herpes. Onychia ; ow£, a nail; disease of the matrix of the nail. Ophiasis; o^ias-ij, Celsus: a bald place on the head; of serpentine form; from 0i?, a serpent; a variety of alopecia areata. Osmidrosis : or^n, odor; i5pw«j, perspiration; fetid perspiration; the ephidrosis olens of Mason Good: odor hircinus. Pachydermia ; naxuSipfAia, Hippocrates; thickness of skin; from naxvu thick; fopa, the skin. • Pachylosis; the same in signification as pachydermia, but not founded on ho good authority. Panaris : Panaritium : probably derived from wavoj, panus; an abscess close to the nail; a paronychia or whitlow. Panus; wavo?, Celsus; hence the Latin, panis; bread, cake, anything round like a ball or loaf of bread; a superficial subcutaneous abscess. Papule ; Celsus ; pimples. Willan's first order, comprising: strophulus, lichen, and prurigo. Paratrimma ; maparp^ya, Dioscorides ; napar^*,, to rub together ; erythema caused by friction in riding or walking. Paronychia; itapa, about; axoj, a lentil; hence a lentil-shaped spot; a freckle, axo? Trpoo-onrm, lens faciei. Dioscorides, a physician of the first or second century, was called Phacas, from possessing a freckled face; Galen, Paulus iEgineta. In Latin, lenticula and lentigo. Phenicismus ; GivixE(o?, red; Hippocrates applies the term oa-ig, canities. WThiteness or hoariness of hair. Phlebectasia; XE^, xs£o?, a vein; sxrao-ii, extension; increment of the venules of the skin, the same as hypertrophia venarum. Phlyctena ; XwtTaiva, Hippocrates, Celsus. A rising of the skin, whether vesicle, pimple, or pustule; yxvxrts has the same signification, from qxveiv, to bubble or boil up ; XuxTaivi»s-if is an eruption of phlyctaenae ; and XuxTaiva>J»j, corresponds with the word phlyctenous. Phlyctenosis ; XuxTif, Hippocrates; the same in signification as phlyctaena. Phlyzacion ; 0£ipiao-i?, Celsus; ia?ti;, and which results from the presence of pediculi between the eyelashes." Phygethlon ; upEof, purple; purpura, porphyriacus, purpureus. The Greek synonym of purpura; wopvpa signifies a brighter tint of red than the mere crimson or purple, $0IVt£. Porrigo; Celsus; a porro; quia, ut porrum in tunicae involucra, ita cutis, velut in squamas resolvitur. Scurfiness or scaliness, especially of the head; dandriff; the equivalent of pityriasis. Mason Good derives the word, incorrectly as we believe, from "porrigere" to spread about; and Willan tells us that "it has been supposed GLOSSARY OF DERMATOLOGICA L TERMS. 791 that the similarity of the odor of this discharge to that of garlic (porrum) gave rise to the appellation of porrigo." Porrigophyton ; porrigo ; utov, a plant. The plant of porrigo; a term introduced by Gruby. Pruna ; Avicenna; perurere to burn all over. A burning or live coal; the designation of a kind of furunculus or anthrax; possibly its name may have been suggested by some resemblance to a ripe plum. Prurigo ; prurire, to itch ; an itching disorder of the skin. Pruritus ; the state of itching. Pseudoplasma ; 4EU^>?> false, irXatr/xa, formation; faulty structure; pseudoplasmata is Hebra's ninth class,comprising cancer and tubercle. Psora; 4-aipct, Hippocrates; -Jaieiv, ^»eiv, to rub; -Itepiaeiv, to have the psora or itch. A Bynonym of eczema among the Greeks; restricted at present to scabies. Theo- phrastus terms the lichen of the fig-tree, psora; while others give the name to the lichen of the olive. Mason Good maintains the derivation of psora from the Hebrew term tsora, " to smite malignantly or with a disease," "from the Hebrew tsorat they obtained their psora, as our own language has since the word sore." Psoriasis ; ^.tupiao-is, from -^oopa; itch or mange. Dry scall, or scaly tetter, Mason Good. Psydracia ; J,utyaxlov, Dioscorides; diminutive of -^ufyaf, a blister on the tip of the tongue ; a lie blister, from ^.u&eiv, to lie. A blister; -\-vxpa. vlpaxia, frigidae guttulae, cold or non-inflammatory bli ters or pustules. Pterygium; mepvyiov, Celsus; >mipv%, a wing. Pterygium unguis, a growth of cuticle over the nail. Purpura ; purpureus, purple; the same as porphyra and porphyreos. The purple eruption. Pustul.e ; Celsus; pustula; a push, pock, blister, little wheal or blain ; in modern medi- cine limited to a small vesicle or pock containing pus. Willan's fifth order, com- prising impetigo, porrigo, ecthyma, variola, and scabies. Willan describes four varieties of pustule, which he names; phryzacium, psydracium, achor, and favus. Pyrophlyctis ; trvp, fire; Xi>*TK, a vesicle; a fiery or hot vesicle, the term applied by Alibert to the pustula maligna. Radesyge ; a Scandinavian term for tertiary syphiloderma; derived from rada, bad, and syge, sickness or disease. Rhagades; payaq, rent or chink, Hippocrates ; payn, payout, paying, torn or rent. Cracks, chaps, and fissures of the skin. Rhypia; pvrrot;, sordes; the more correct latinity of rupia, according to Mason Good, who includes the disease in his genus ecphlysis, thus: ecphlysis rhypia. Ringworm ; a circular eruption or tetter; in the popular sense it is applied indiscri- minately to every circular or annulate eruption; scientifically, it is limited to tricho- nosis or tinea tonsurans, a disease in which the hair breaks close to the skin, and suggests the idea of being eaten off as by the tinea or moth-worm. Rosa ; rosa anglicana; rosa Sennerti; a synonym of erysipelas. Mal de la rosa is a synonym of pellagra. Rosalia ; a synonym of scarlatina; and according to Mason Good a more correct ex- pression for that exanthem than the term " scarlatina;" the latter he designates enanthesis rosalia. By some authors it is written rossalia and rossania. Roseola ; the rose rash. Rougeole; the French synonym of rubeola; but originally applied both to rubeola and scarlatina, the two diseases being confounded by early writers. Rubeola ; Rubiola ; rubere, to blush, to redden; rubia, the madder used for dyeing. The measles. Rupia; pvrro;, dirt, filth; Hippocrates applies the term pvnov, to whey, probably from its want of'clearness. A syphilitic ulcer covered with a foul crust. Saat ; Hebrew; Leviticus, chapter xiii. v. 2; ovXn, LXX. ; a rising, 0. T.; a prominence of the skin ; swelling or tubercle. Saphat; Hebrew; Leviticus, chapter xiii. v. 2; ^yas-ta, LXX.; a scab, 0. T.; a disease of the skin accompanied with the formation of a scab or crust. Sarcoptes ; the name given by Latreille to the acarus scabiei; Mayne writes the word sarcocopta; from e-apl, flesh, xjttu,,to pierce. Satyria, Satyriasis, Satyriasmos; ertTveiat, o-aTuxant, trarv^ia^fxo;, Hippocrates; from e-ctrvpoc, the satyr; synonyms of elephantiasis Gnucorum, from the resemblance of a 792 GLOSSARY OF DERMATOLOGICAL TERMS. leper to a satyr; the face red, the forehead surmounted by small tumors like young horns, the nostrils expanded and flattened, the lips large, the chin projected, the ears lengthened, and the legs crooked and deformed. Sauroderma ; ravta, a lizard; hpya, the skin. Lizard skin. Sauriosis ; the lizard skin disease. Scabies; Celsus; from scabere, to scratch; a-xanrw, fut. sec. of a-xa^uv, fodere, to dig, as with -the nails in scratching. The Latin representative of psora and eczema, at present limited to the eruption excited by the acarus scabiei, the itch. Scabrities ; scabritia, roughness, ruggedness; as in the case of scabrities unguium. Scall; a term of doubtful meaning; one while used in the sense of a "scale," and applied to a squamous disease such as alphos and psoriasis; another while to in- crusted eruptions of the scalp and face, such as eczema impetiginodes, favus, and kerion, and sometimes synonymously with "tetter." We think the second of these significations the more correct, which rests on its derivation from a Saxon word mean- ing "a separation or discontinuity of skin," and consequent exudation. From scall we obtain the terms "scalled" and " scaldhead." Mason Good prefers the deriva- tion from the Saxon sceala or scala, a scale. Scarlatina; scarlaltino; Italian, scarlet cloth. "A barbarous and unclassical term," says Mason Good, a vernacular from the Levant " that has unaccountably crept into the nomenclature of medicine, upon the proscription of the original and more classical name of rosalia." Schechin ; Hebrew; Leviticus, chapter xiii. v. 18; eXxo?, LXX.; a boil, 0. T. The Greek word is the source of the Latin " ulcus," and our own term, ulcer. Scleroderma ; o-xXupo?, hard ; hp/xa, skin. Hardness of the skin. Scleroma ; s-xXnpot;, hard. Hardness of texture. Scorbutics ; the scurvy, the porphyra or purpura; "as a term," says Mason Good, "it is neither Greek nor Latin, nor any language whatever, but an intolerable barbarism, derived, as is commonly supposed, from the German compound scharpocke, literally aggregate-pox, cluster-pox, but more likely from scharf-pocke, violent or vehement pox, or schcrf-pocke scUrf or scurvy pox, to which the inventor has endeavored to give a sort of Latin termination. , Scrofuloderma ; a term compounded of scrofula and derma, signifying scrofula of the skin or cutaneous scrofula. Scrofulosis ; a morbid state appertaining to, and of the nature of scrofula. Seborrhea ; a term composed of sevum or sebum, tallow, and psav, to flow; a flow or flux of sebaceous substance. Selene unguium; triXmn, the moon; implying roundness and whiteness; hence atXrmov, the bald crown of the head. The small, round white spots sometimes seen in the nails, especially of children, and termed mendacia. Semeion ; Celsus; c-d^siov, a mark, a spot; having the same signification as stigma. "Vari and lenticulae," says Celsus, "are very well known, but there is a rarer kind, which the Greeks call o?j a twisting of the bowels; colic; in the Latin tormina, implying the association of the eruption named strophulus with a disordered state of the bowels. The term «-Tpoof, is used by Hippocrates, also by Aretaeus. A papular eruption or lichen occurring in infants. Struma; Celsus ; arptu/ua, stratum, "quod gutturi substrata sit;" a swelling in the neck or armpits, limited at present to scrofula. Sty; Stigh; stithe, stihan, stian; stihan, a Saxon word signifying arising, springing up, ascent. To sty, as used by Spenser, means to soar, to ascend— "To climb aloft and others to excel, That was ambition and desire to sty." Sudamina; sudor, sweat; a vesicular eruption associated with excessive perspiration. The vesicles equalling in size the millet seed, are also termed miliaria, or miliary eruption. Sudatoria ; the same in derivation as the preceding. The sweating sickness. Sycosis; a-mao-is, Hippocrates, Celsus ; a-vxov, a fig; a rough, fig-like excrescence on the flesh, especially of the eyelids. An inflammation of the hair follicles of the face, attended with papulation, pustulation, and sometimes with fungous granulation, sycosis fungosa vel ficosa. Occurring on the chin it is termed mentagra. Syphilis; o-»4>Xof, defect; from o-j<}>Xoeiv, to maim or cripple; but, according to Mason Good, the term was probably "invented by Frascatorio, about the close of the 15th century, from the Greek o-u and iXEia>(xivov eXxo?, malignant ulcer. Thrausma ; Boavi-fxa, a breaking, or breaking out; a Greek word used in the translation of the 13th chapter of Leviticus, chap. xiii. v. 30. A dry scall; O.T. Thymion ; Bvfxtov, Hippocrates, Celsus ; Bvyoc, thyme. A warty excrescence, so called from its resemblance to a bunch of, thyme-blossom, Galen; it is also used syno- nymously with a-vxov, ficus. A large wart. 794 GLOSSARY OF DERM A TOLOGIC AL TERMS. Tinea; the moth-worm; "quod teneat et eous-que insideat, quoad erodat." Tinea capitis, the old term for trichonosis. The ringworm. Erosion of the nails is termed tinea unguium. Trichiasis ; rpix'ta-a;, Hippocrates ; 0sj£, a hair. A disease of the eyelids produced by inversion of the eyelashes; the same term was given by the Greeks to eczema fissum of the nipples of nursing mothers. Trichogenous ; Bh%, a hair; ytvofxat, to beget; a term applied to remedies intended to aid the reproduction of hair. Trichomyces ; 6pt%, a hair; fxvxn;, a fungus; the fungus of the hair. Trichonosis ton- surans is termed by Malmsten, trichomyces tonsurans. Trichonosis; 0pi£, a hair; voa-o?, disease; disease of the hair. Mason Good employs the term trichosis in the same sense, pilare malum, on the authority of Actuarius ; but Tpip^iDo-i?, like rptxovfxa, means hairiness, or growth of hair. Trichosis is the ninth genus of the order Acrotica of Mason Good, and contains eight species, namely, setosa, plica, hirsuties, distrix, poliosis, athrix, area, decolor. The chief varieties of trichonosis are, tonsurans, pityriasica, and annulata. Trichophyton ; 0^, a hair; utov, a plant; the plant or vegetable fungus of the hair. Tiuchorrhcea ; rpixopovng; tpi^o^ueiv, to shed or lose the hair. Defluvium or defluum capillorum ; the fall of the hair. Tsorat; a Hebrew word, signifying "venom or malignity," and used to intensify the two forms of leprosy comprehended by the Hebrew terms berat lebena and berat cecha; the former of these being the lepra leuce, the latter the lepra melas of the Greeks; the vitiligo Candida and vitiligo nigricans of Celsus. Tyloma ; rvXoofxa, a callosity. Tylosis ; tux *ne human skin. Yellowness of skin. Xanthoderma; the same as xanthochroia. Xanthopathia ; morbid yellowness of the skin. Xerasia ; ^npaa-ia; ^njioqy dry, parched. A disease of the scalp distinguished by dryness. Xeroderma; £»pec, dry; Je^mo, skin. A dry and parched skin. Yaw, an African word signifying a raspberry ; the framboesia ; pian of the French. Zona; £®v>j, a belt or girdle ; £ Moles ..... . 326, 624 Noli me tangere Mollities unguium . . 618 Nosophyta * Molluscum areolare . 328 contagiosum . 93, 679 Odor hircinus parvum .... . 679 Ointments pisiforme . 679 Olliffe, treatment of variola sebaceum . 679 Olophlyctis . sessile .... . 679 labialis . simplex .... . 328 miliaris . subglobulosum . 679 Onychia Morbilli..... . 386 maligna . benigni .... . 388 scrofulosa confluentes . 392 syphilitica 48S erethrici .... . 388 Ophiasis 595 Morbus heracleus . . 517 Oribata geniculata herculeus . 517 Osmidrosis Maculosus . 308 Oxide of silver stain pedicularis . 717 pilaris .... . 653 Pachylosis pulicaris .... . 308 Pacinian corpuscles Morgagni, on acaru scabiei . . 743 Panaris .... Morphew .... . 585 Papillae of the derma Morphoea .... . . 585 Papillary layer of the derma alba anaesthetica . 592 Papula, definition . e alopeciata . 585 Papulae, Willan's first order atrophica . . . . 588 epidermicae 94 lardacea .... . 586 flavae epithelii 94 maculosa . 585 Papulous eruptions nigra .... . 591 Parker, Langston, on syphilis tuberosa .... . 585 Paterson, cases of molluscum Morpiones .... . 719 Pathology of the skin . Morve ..... . 462 Pearly tubercles Mother's marks 303, 326 Pediculus capitis Moufet, on the acarus scabiei . 741 corporis . Mower's mite . 716 ferox Mucous membrane • . 30 pubis Mudar or Muddar . 581 Pellagra Muller, on the acarus scabiei . 750 Pemphigus 76 Muscles of the hair . 19 acutus Muscular fibre of skin . 18 apyretieus Mycosis .... . 465 benignus chronieus Naevi materni . 326 confertus pigmentosi 326, 603 confluens pilosi . ■ • . 3S 6, 603, 624 congenitus vasculosi . 303 contagiosus Naevus . • • • • . 302 diutinus . » araneus .... . 304 foliaceus arteriosus • . • . 303 gangrenosus flauameus . 304 infantilis hypertrophicus maternus . 326 iris . 303, 326 ozaenodes pigmentosus . . 326 pruriginosus 265 804 INDEX. PAGE Pemphigus pyreticus .... 273 simultaneus . . 273 solitarius . 275 successivus . 273 variolodes . 428 vulgaris . . 273 Pemphix . . . 272 Pereira, case of melanodern la . 596 Pernio .... . 736 Perspiration . 32, 58 chemical composition of . 62 colored . . 710 disorders of . 702 morbid . 63, 702 Perspiratory glands . 30 tubes 32 Petechia . 311 Petechias . 311 mendaces . 308 post-vaccine . . 450 sine febre . 308 Petechial scurvy . . 308 Phacia .... . 606 Phaenicismus . 386 Phaenigmus petechialis . . 308 Phlebectasia . . 305 Phlyctaenae 74 Phlyzacia . . . ■ . 278 Phtheiriasis . . 717 Phyma .... . 282 anthrax . . 285 furunculus . 282 hordeolum . 285 sycosis . . 667 Physiology of the skin . . 53 Phyto-alopecia . 642 Phytodermic affections . . 614 Pian .... . 465 Picton, treatment of variola . 428 Piebald skin . . 611 Pigment, chemistry of . . 29 cells 27, 29 Pigmentary diseases 87, 593 naevi . 603 Pilous naevi . 603, 624 Pimply diseases . 171 Pinta .... . 603 Pityriasis . 164 capitis . 164 deealvans . 642 foliacea . . 168 rubra 168 nigra 164 rubra If 4, 165 versicolor 164 vulgaris . 164 Plenck, classification 101 Plica, polonica 649 caudiformis 649 multiformis 649 Pompholyx . 272 solitarius 275 Porcupine disease . 323 Pores of the sudoriferous ducts 31 Porphyra , 308 haemorrhagica 313 nautica .... 314 senilis .... 314 simplex .... 311 Porrigo..... 138, ( asbestina 138 Porrigo circinata deealvans favosa furfuracea furfurans granulata larvalis . lupinoso . scutulata tonsoria . Porrigophyta Prickly heat . Johnson's observations Winterbottom Pruna . Prurigo . formicans mitis senilis vulgaris . Pruritus ani pr;pputii . pudendi . scroti urethras . Psora humida . lepra porrigo . sicca Psoriasis circumscripta discoidea eczematosa figurata . furfuracea infantilis leprodes . nummularis orbicularis palmaris ' squamosa rubi Psorophthalmia Psydracia Pterygium unguis Pulex irritans penetrans Puncture in erysipelas Purpura apyreta . cachectica chronica . haemorrhagica nautica . pathology of pemphigoides senilis simplex . urticans . Pustula, definition Aleppensis gangraenosa maligna . Pustulae Pustular eruptions Pustule, definition of Pyrophlyctis endemica Rainbow ringworm Raphania maistica INDEX. | PAGE Raspail, on the ac arus scabiei . . 747 Rayer, classificatk >n . . .104 Red-gown, or red- Rum rash . . .174 Remedies for the s kin . . . .115 constitutional . 119 local .....116 Renucci, on the ac arus scabiei . . 746 Rete Malpighianui n . . . .17 Rete mucosum .....17 Retro-vaccination .....457 Revaccination .....453 Ringworm, commc n . . .642 crusted . .....654 honeycomb .....654 rainbow . .....217 vesicular .....266 Rosa .....227 Rosalia, vide rube 3la . . . . 386 Roseola .....246 rcstiva .....248 annulata .....252 arthritica .....256 Jiutumnalis .....256 choleriea .....256 corymbosa .....248 febris continu » . • . .256 infantilis •. 248 maculosa .....256 miliaris . .....257 orbicularis .....472 papulata .....472 punctata ■ • • . .253 rheumatica .....256 syphilitica .....471 vaccina . .....256 variolosa .....256 versicolor .....472 Rose-rash .....246 Rosy-drop .....192 Rougeole .....386 Rubeola . 386 maligna, vide rubeola nigra . ' . 389 nigra .....589 notha . 273, 388 rossalia . .....392 sine catarrho .....388 sine exanthem ate . . . . 389 vulgaris . .....388 Rumex gigantea . 581 Rupia .....485 escharotica . 280 prominens . 486 simplex . . 486 syphilitica .....485 St. Anthony's fire * . .227 Saracenia purpures t .... 421 Sarcoptes hominis . 739 Satyria . . 517 Satyriasis . 517 Satyriasmos . . 517 Sauriosis . 322 spinosa . . 323 squamosa .323 Sauriderma . . 322 spinosum . 322 squamosum . 322 Savian corpuscles 22 Scabies _ . . 123, 131, 195 caehectioa . 195 crustosa . . 199 Scabies humida lymphatica Norwegica papuliformis . purulenta sicca Scabrities unguium Scalds . Sealiger, on the acarus scabiei Seall, crusted humid papulous running . Seabed head Scalp, disease of the alopecia . alphos canities . eczema capitis erysipelas favus narcosis folliculorum pityriasis capitis psoriasis capitis stearrhoea tinea capitis . trichonosis plica tonsurans Scarf skin Scarlatina anginosa benigna . erethrica gravior, vide maligna laevigata latens maligna . milliformis mitior, vide anginosa nervosa . papulosa phlyctaanosa . plana pustulosa putrida . septiea simplex . sine angina, vide simplex sine eruptione sine exanthemate torpida . treatment of . vesicularis Scarlet fever . Schaeffer, on the acarus Sclerosis dermatos Scorbutic eruption Scorbutus Scrofula Scrofuloderma Scrofuloderma unguale Scrofulosis Scrofulous tubercles Scrofulous ulcers . Scurf-skin Scurvy . Sebaceous accumulations flux secretion alteration of augmentation of 806 INDEX. PAGE PAGE Sebaceous secretion, composition of . 58 Sycosis contagiosa .... 668 diminution of . . 674 erythematosa . . 668 retention of ' . 677 ficosa . 608 tubercles, miliary . . 697 fungosa . . 668 tumors, encysted . 689 papulosa. . 668 small . 697 pustulosa . 668 Sebiferous ducts . 34 tuberculosa . 668 Sebiparous glands . 34 Syphilis erythematous 471, 490 system, diseases of . . 671 hereditary . 496 Seborrhcea .... 651, 673 infantile . 496 Selene unguis . 618 lupiform . 494 Sensibility of the skin . . 54 papular . . 473 Serous cysts .... . 698 pustular . . 485 Serres, Bretonneau, and Velpeau, treat- secondary . 471 ment of variola . 424 tertiary . . 489 Sessile warts . 329 treatment of . . 502 Shingles .... . 261 tubercular 475, 493 Simon, acarus folliculorum . . 755 Syphilitic affections . 467 Skin, sensibility of . 54 Syphilitic eruptions . 471 absorbing power of . 55 ecthyma . . 485 anatomy of . . 17 fever . 467 pathology of . . 64 lepra . 483 physiology of . . 53 lichen . 474 Smallpox .... . 402 maculae . . 473 inoculated . 413 papulae . . 474 modified . 410 pustules . . "485 spurious . 409 roseola . . 471 pathology of . . 415 rupia . 485 Soft corns .... . 333 tubercles 475, 493 Spargosis .... . 346 Syphiloderma . 467 Spasmus periphericus . 19 erythematosun L 471, 497 Spedalskhed .... . 518 haereditarium . 470 Spiloplaxia indica . 518 papulosum . 474 Spilus..... . 326 pilare . 488 Sporisorium maydis . 225 pustulosum . 585 Squama, definition . 68 tuberculosum 475, 493 Squamae .... 77, 352 ulcerosum . 496 Squamous diseases . 352 unguale . . 489 Squarra tondens . 642 vegetations . 493 Stearrhcea .... . 673 vesiculosum . 485 capitis .... . 651 warts . 493 coerulea .... . 676 Syphilodermata . 467 flavescens . 674 classified table of . 470 nigricans . 675 hereditaria . 470 simplex * 651, 673 mitigata . . 470 Steatozoon folliculorum . 755 Syphilodermata primitiva . 471 Stigmata .... . 311 Stimulant remedies . 118 Tactile corpuscles . . 20 Stone-pock .... 409, 698 Tar remedies . . 770 Strophulus .... 72, 174 ! Teleangiectasia . 303 albidus .... . 174 ! Terminthus . . 283 candidus .... . 174 Tertiary syphilis . 489 confertus . 174 Tetter, branny . 164 intertinctus . . . , . 174 crusted . . 189 volaticus . . - . . 174 dry. . 353 Struma ..... . 367 humid . 125 Strumous affections . 367 Therapeutics of the skin . 115 Sty, or Stigh .... . 285 Thomson, Hale, on molluseur a . 688 Sudamina .... 269 Tilesius, case'of molluscum . 682 Sudatoria .... 702 Tinea amiantacea . . 138 maligna . . . 704 capitis . 642 miliaris .... . 702 favosa . 654 partialis .... . 705 furfuracea 138, 145 simplex .... . 702 . granulata 138, 145 Sudoriparous glands . 30 lupinosa . . 654 system, disorders of 95, 701 maligna . . 554 Sulphur remedies . . 766 mucosa . . 138 Sunburn .... 602, 727 nummularis . 642 Swine-pox .... . 413 tondens . . 642 Sycosis..... coniformis . 615, 667 ; Tooth-rash . . 174 . 668 Touch . . 54 INDEX. 807 Traumatic affections Trichiasis ciliorum £ PAGE 1, 713 641 Urticaria ab ingestis conferta . PAGE . 241 • 241 coacta . 641 evanida . • 241 Trichogenous remedies . 773 febrilis . 240 Trichoma 623 perstans . 241 Trichomonas vaginalis . 758 subcutanea . 242 Trichomyces tonsurans . 642 tuberosa . 242 Trichonosis . 615 annulata 644 Vaccination . . 441 cana 637 tests . 453 decolor . 635 Vaccinella . 449 erythematosa . 644 Vaccinia . 432 furfuracea . 642 Vallecula unguis . 50 gyrata . 644 Varicella 428 hirsuties . 623 bullosa . 428 papulosa . 644 cellulosa . . 413 pathology of . 91 coniformis . 413 pityriasica 644 globularis . 413 plica 649 lenticularis 428 poliosis . 637 papularis 413 pustulosa 644 pustular . . 413 tonsurans 642 verrucosa . 413 versicolor 636 vesicularis 428 Trichophyton tonsurans . 61 5, 642 Varicose venules . . 305 Trichorrhcea . 627 Variola 402 Tsorat .... . 563 anomala 409 Tubercles, cupped . . 476 benigna . 409 miliary . . 697 coherens 403 pearly 697 confluens 403 syphilitic . 475 cornea 409 Tubercula 79 corymbosa . 40 2, 408 miliaria . 607 discreta . 403 mucosa . 493 inoculated 413 sebacea . 697 inserta 413 syphilitica 475 Variola maligna 408 annulata . 482 ne-rvous . 419 circumscripta . 479 papulosa . 409 corymbosa 478 pathology of . 415 disseminata 481 secondary 410 gummata . 495 semiconfluens . 403 lupiformia 494 sine variola 409 mucosa 493 vaccina . 432 ulcerantia 48 4, 494 varicelloides . 410 urceolata 476 variolodes 41 0, 412 Tuberculum, definition . 69 verrucosa . r 409 malignum 380 Variole anomalae . 409 Tumores encystici . 689 crystallinae 428 gummati 495 haemorrhagicae 408 cebaeei . 689 lymphaticae 428 serosi 698 nigrae 408 Tumors, atheromatous . 689 pusillae . 428 encysted . 9 3, 689 vaccinae . 432 erectile . 303 verninosae 409 follicular 697 verrucosa? 409 gummated 495 volaticae . 428 melicerous 689 Variolation 413 sebiparous 679 Varioloid . . 410 Turkish bath 55 Variolo-vaccination 457 Turner, classification 99 Varus 698 Tuwhenna 530 Vascular affections 302 Tylosis .... 331 naevus 303 Tyria..... 592, 628 Veins, dermal hypertrophy 21 305 Ulceration . 82 Vellarine 583 Unctuositas elephantina 520 Velpeau, treatment of ei ysipe las . 238 Ungual affections . 616 Veronica quinquefolia . 583 Ungues adunci 617 Verruca 329 Uredo . 239 acrochordon 32 8, 67 d, 681 Uridrosis 710 confluens 330 Uritis . • • • 728 digitata . 330 Urticaria 239 filiformis 330 808 INDEX. PAGE PAGE Verruca lobosa ..... 330 Willan, classification . . 101,114 sessilis 329 Williams, treatment of erysipelas . 234 Vesicula, definition 69 Witt, treatment of scarlatina 397 Vesiculas 73 258 Vesicular eruptions 258 Xanthelasma 671 Vibices 311 laminosum 672 Vienna paste . 776 palpebrarum . 672 Vigo plaster in variola 425 papulosum 671 Vitiligo 513 585 planum . 671 albida 353 Xanthochroia 606 alphos 353 Xanthoderma 606 Candida . 519 586 Xanthopathia 606 leuce 519 Xerasia ■ . 627 melas 519 Xeroderma 317 nigricans 519 591 Xeroderma ichthyoides 320 Vitiligoidea . 672 sauroides simplex . .322 319 Wart-pock 409 Yaws 465 Warts . 329 Washerwoman's itch 141 Zinc ointment, benzoated 771, 777 Water-pox , 428 Zittmann's decoction . 775 Weber's experiments 54 treatment of syphilis 504 Wen 689 Zona .... 26J Whealworm . 716, 739 herpetica 264 Whelk . 698 ignea 261 White blisters 275 Zoster .... 261 Whitlow 621 Zymotic affections 382 Wichmann, on the acari s sea biei 744 THE END. HENRY C. LE^'S (LATE LEA * BLANCHARD'S) CLASSIFIED OA.TAI_,OQ TTE OF MEDICAL AND SUKGICAL PUBLICATIONS, In asking the attention of the profession to the works contained in the following pages, the publisher would state that no pains are spared to secure a continuance of the confidence earned for the publications of the house by their careful selection and accuracy and finish of execution. The printed prices are those at which books can generally be supplied by booksellers throughout the United States, who can readily procure for their customers any works not kept in stock. Where access to bookstores is not convenient, books will be sent by mail post-paid on receipt of the price, but no risks are assumed either on the money or the books, and no publications but my own are supplied. Gentlemen will therefore in most cases find it more convenient to deal with the nearest bookseller. An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- warded by mail, postpaid, on receipt of ten cents. HENRY C. LEA. Nos. 706 and 708 Sansom St., Philadelphia, November, 1868. ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. THREE MEDICAL JOURNALS, containing over 2000 LARGE PAGES, Tree of Postage, for SIX D0LLAKS Per Annum, TERMS FOR 1869—IN ADVANCE: The American Journal of the Medical Sciences, and 1 Five Dollars per annum, The Medical News and Library, both free of postage, j in advance. OR., Six Dollars per annum in advance. The American Journal of the Medical Sciences, published quar-, quarterly (1150 pages per annum), with The Medical News and Library, monthly (384 pp. per annum), and Rankino's Abstract op the Medical Sciences, published half- yearly (600 pages per annum), all free of postage. SEP ABATE SUBSCRIPTIONS TO The American Journal of the Medical Sciences, subject to postage when not paid for in advance, Five Dollars. The Medical News and Library, free of postage, in advance, One Dollar. Rwring's Half-Yearly Abstract, Two Dollars and a Half per annum in advance. Single numbers One Dollar and a Half. Tr thus offering at a price unprecedentedly low, this vast amount of valuable nrartioal matter, the publisher felt that he could only be saved from loss by an PvtPnt of circulation hitherto unknown in the annals of medical journalism. It is t Wfore with much gratification that he is enabled to state that the marked appa- lltion of the profession, as evinced in the steady increase of the subscription list, omises to reader the enterprise a permanent one. He is happy to acknowledge the 2 Henry C. Lea's Publications—{Am. Journ. Med. Sciences). valuable aid rendered by subscribers who have kindly made known among their friends the advantages thus offered, and he confidently anticipates a continuance of the same friendly interest, which, by enlarging the circulation of these periodicals, will enable him to maintain them at the unexampled rate at which they are now supplied. Ar- rangements have been made in London by which " Ranking's Abstract1' will be issued here almost simultaneously with its appearance in England: and, with the cooperation of the profession, the publisher trusts to succeed in his endeavor to lay on the table of every reading practitioner in the United States a monthly, a quarterly, and a half- yearly periodical at the comparatively trifling cost of Six Dollars per annum. These periodicals are universally known for their high professional standing in their several spheres. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M.D., is published Quarterly, on the first of January, April, July, ands October. Each number contains nearly three hundred large octavo pages, appropriately illustrated, wherever necessary. It has now been issued regularly for over forty years, during nearly the whole of which time it has been under the control of the present editor. Throughout this long period, it has maintained its position in the highest rank of medical periodicals both at home and abroad, and has received the cordial support of the entire profession in this country. Among its Collaborators will be found a large number of the most distinguished names of the profession in every section of the United States, rendering the department devoted to ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to all practitioners. Thus, during 1868, contributions have appeared in its pages from more than one hundred gentlemen of the highest standing in the profession throughout the United States* Following this is the "Review Department," containing extended and impartial reviews of all important new works, together with numerous elaborate "Analy- tical and Bibliographical Notices" of nearly all the publications of the day. This is followed by the " Quarterly Summary op Improvements and Discoveries in the Medical Sciences," classified aud arranged under different heads, presenting a very complete digest of all that is new and interesting to the physician, abroad as well as at home. Thus, during the year 1868, the "Journal" furnished to its subscribers One Hundred and Twenty-two Original Communications, Eighty-six Reviews and Biblio- graphical Notices, and Two Hundred and Forty-nine articles in the Quarterly Sum- maries, making a total of over Four Hundred and Fifty articles emanating from the best professional minds in America and Europe. To old subscribers, many of whom have been on the list for twenty or thirty years, the publisher feels that no promises for the future are necessary; but gentlemen who may now propose for the first time to subscribe may rest assured that no exertion will be spared to maintain the "Journal" in the high position which it has so long occu- pied as a national exponent of scientific medicine, and as a medium of intercommu- nication between the profession of Europe and America—in the words of the " London Medical Times" (Sept. 5th, 1868) "almost the only one that circulates everywhere, all over the Union and in Europe"—to render it, in fact, necessary to every practitioner who desires to keep on a level with the progress of his science. The subscription price of the "American Journal of the Medical Sciences " has never been raised, during its long career. It is still Five Dollars per annum; and when paid in advance, the subscriber receives in addition the "Medical News and Library " making in all about 1500 large octavo pages per annum, free of postage. II. THE MEDICAL NEWS AND LIBRARY is a monthly periodical of Thirty-two large octavo pages, making 384 pages per annum. Its "News Department" presents the current information of the day, with Clinical Lectures and Hospital Gleanings; while the "Library Department" is de- voted to publishing standard works on the various branches of medical science, paged * Communications are invited from gentlemen in all parts of the country All elaborate articles inserted by the Editor are paid for by the Publisher. Henry C. Lea's Publications—(Am. Journ. Med. Sciences). 3 separately, so that they can be removed and bound on completion. In this manner subscribers have received, without expense, such works as " Watson's Practice," "Todd and Bowman's Physiology," "West on Children," "Malgaigne's Surgery," &c. Arc. The work now appearing in its pages, Dr. Hudson's valuable "Lectures on the Study of Fever," will be completed in the number for December, 1868. With January, LS69, another work of similar practical value will be begun, rendering this a very eligible period for the commencement of new subscriptions. As stated above, the subscription price of the "Medical News and Library" is One Dollar per annum in advance; and it is furnished without charge to all advauce paying subscribers to the "American Journal of the Medical Sciences." III. RANKING'S ABSTRACT OF THE MEDICAL SCIENCES is issued in half-yearly volumes, which will be delivered to subscribers about the first of February, and first of August. Each volume contains about 300 closely printed octavo pages, making about six hundred pages per annum. "Ranring's Abstract" has now been published in England regularly for more than twenty years, and has acquired the highest reputation for the ability and industry with which the essence of medical literature is condensed into its pages. It pur- ports to be "A Digest of British and Continental Medicine, and of the progress of Medicine and the Collateral Sciences," and it presents an abstract of all that is impor- tant or interesting in European Medical Literature. Each article is carefully con- densed, so as to present its substance in the smallest possible compass, thus affording space for the very large amount of information laid before its readers. The volumes of 1868, for instance, have thus contaiued forty-two articles on general questions in medicine. ONE HUNDRED AND TWENTY-NINE articles on special questions in medicine. seventeen articles on forensic medicine. eighty-eight articles on therapeutics. foiity-one articles on general questions in surgery. one hundred and fifty six articles on special questions in surgery. one hundred and twelve articles on midwifery and diseases of women and children. six articles in appendix. Making in all nearly six hundred articles in a single year. Each volume, moreover, is systematically arranged, with an elaborate Table of Contents and a very full Index, thus facilitating the researches of the reader in pursuit of particular subjects, and enabling him to refer without loss of time to the vast amount of information con- tained in its pages. The subscription price of the "Abstract," mailed free of postage, is Two Dollars and a Half per annum, payable in advance. Single volumes, $1 50 each. 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He trusts especially, that the subscribers to the "American Medical-Journal" will call the attention of their acquaintances to the advantages thus offered, aud that he will be sustained in the endeavor to permanently establish medical periodical literature on a footing of cheapness never heretofore attempted. * * Gentlemen desiring to avail themselves of the advantages thus offered will do welf to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1869. &$* The safest mode of remittance is by postal money order, drawn to the order of theundersigned. Where money order post-offices are not accessible, remittances for the "Journal" may be made at the risk of the publisher, by forwarding in registered Utters. Address, letter HENRY C. LEA, Nos. 706 and 708 Sansom St., Philadelphia, Pa. Henry C. Lea's Publications—(Dictionaries). T)UNGLISON [ROBLEY), 31. D., ~^ Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Con- taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirioal, and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes; so as to constitute a French as well as English Medical Lexicon. Thoroughly Revised, and very greatly Modified and Augmented In one very large and handsome royal octavo volume of 1048 double-columned pages, in small type; strongly done up in extra cloth, $6 00 ; leather, raised bands, $6 75. The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. The mechanical exe- cution of this edition will be found greatly superior to that of previous impressions. By enlarging the size of the volume to a royal octavo, and by the employment of a small but clear type, on extra fine paper, the additions have been incorporated without materially increasing the bulk of the volume, and the matter of two or three ordinary octavos has been compressed into the space of one not unhandy for consultation and reference. It is undoubtedly the most complete and useful medical dictionary hitherto published in this country. —Chicago Med. Examiner, February, 1^65. What we take to be decidedly the best medical dic- tionary in the English language. The present edition is brought fully up to the advanced state of science. It would be a work of supererogation to bestow a word of praise upon this Lexicon. We can only wonder at the labor expended, for whenever we refer to its pages for information we are seldom disap- pointed in finding all we desire, whether it be in ac- oentuation, etymology, or definition of terms.—New York Medical Journal, November, 1865. It would be mere waste of words in us to express our admiration of a work which is so universally and deservedly appreciated. The most admirable work of its kind in the English language. As a book of reference it is invaluable to the medical practi- tioner and in every instance that we have turned over its pages for information we have been charmed by the clearness of language and the accuracy of detail with which each abounds. We can most cor- dially and confidently commend it to our readers.— Glasgow Medical Journal, January, 1866. A work to which there is no equal in the English language.—Edinburgh Medical Journal. It is something more than a dictionary, and some; thing less than an encyclopaedia. This edition of the well-known work is a great improvement on its pre- decessors. The book is one of the very few of which it maybe said with truth that every medical man should possess it.—London Medical Times, Aug. 26, 1865. Few works of the class exhibit a grander monument of patient research and of scientific lore. The extent of the sale of this lexicon is sufficient to testify to its usefulness, and to the great service conferred by Dr. Robley Dunglison on the profession, and indeed on others, by its issue.—London Lancet, May 13, 1865. The old edition, which is now superseded by the new, has been universally looked upon by the medi- cal profession as a work of immense research and great value. The new has increased usefulness; for medicine, in all its branches, has been making such progress that many new terms and subjects have re- cently been introduced : all of which may be found fully defined in the present edition. We know of no other dictionary in the Eugltsh language that can bear a comparison with it in point of completeness of subjects and accuracy of statement.—N. Y. Drug- gists' Circular, 1865. For many years Dunglison's Dictionary has been the standard book of reference with most practition- ttrs in this country, and we can certainly commend this work to the renewed confidence and regard of u j.r readers.—Cincinnati Lancet, April, 1865. For many a long year "Dunglison " has been at our elbow, a constant companion and friend, and we greet him in his replenished and improved form with especial satisfaction.—Pacific Med. and Surg. Jour- nal, June 27, 1865. This is, perhaps, the book of all others which the physician or surgeon should have on his shelves. It is more needed at the present day than a few years back.—Canada Med. Journal, July, 1865. It deservedly stands at the head, and cannot be surpassed in excellence.—Buffalo Med. and Surg. Journal, April, 1865. We can sincerely commend Dr. Dunglison's work as most thorough, scientific, and accurate. We have tested it by searching its pages for new terms, which have abounded so much of late in medical nomen- clature, and our search has been successful in every instance. We have been particularly struck with the fulness of the synonymy and the accuracy of the de- rivation of words. It is as necessary a work to every enlightened physician as Worcester's English Dic- tionary is to every one who would keep up his know- ledge of the English tongue to the standard of the present day. It is, to our mind, the most complete work of the kind with which we are acquainted.— Boston Med. and Surg. Journal, June 22, 1865. We are free to confess that we know of no medical dictionary more complete; no one better, if so well adapted for the use of the student; no one that may be consulted with more satisfaction by the medical practitioner.—Am. Jour. Med. Sciences, April, 1865. The value of the present edition has been greatly enhanced by the introduction of new subjects and terms, and a more complete etymology and accentua- tion, which renders the work not only satisfactory and desirable, but indispensable to the physician.— Chicago Med. Journal, April, 1865. No intelligent member of the profession can or will be without it.—St. Louis Med. and Surg. Journal, April, 1865. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references.—London Medical Gazette. TTOBLYN {RICHARD D.), M.D. A DICTIONARY OF THE TEPvMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition, revised, with numerous additions, by Isaac Hays, M. D., Editor of the "American Journal of the Medical Sciences." In one large royal 12uio. volume of over 500 double-columned pages; extra eloth, $1 50 ; leather, $2. 00. It is the best book of definitions we have, and ought always to be upon the student's table.—Southern tied, and Surg. Journal. Henry C. Lea's Publications—(Manuals). 5 JSfElLb {JOHN), M.D., and OMITH {FRANCIS G.), 31. D., Prof, of the Institutes of Medicine in the Univ. of Penna. AX ANALYTICAL COMPENDIUM OF THE VARIOUS LRAXCHES 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, extra cloth, $4; strongly bound in leather, with raised bands, $4 75. The Compend of Drs Neilland Smith is incompara- bly the most valuable work of its class ever published in this country. Attempts have been made in various quarters to squeeze Anatomy, Physiology, Surgery, the Practice of Medicine, Obstetrics, Materia Medica, aud Chemistry into a single manual; but the opera- tion has signally failed in the hands of all up to the advent of "Neill and Smith's" volume, which is quite a miracle of success. The outlines of the whole are admirably drawn and illustrated, and the authors are emiuently entitled to the grateful consideration of the student of every class.—N. 0. Med. and Surg. Journal. This popular favorite with the student is so well known that it requires no more at the hands of a medical editor than-the annunciation of a new and improved edition. There is no sort of comparison ^between this work and any other on a similar plan, and for a similar object.—Nash. Journ. of Medicine. There are but few students or practitioners of me- dicine unacquainted with the former editions of this unassuming though highly instructive work. The whole science of medicine appears to have been sifted, as the gold-bearing sands of El Dorado, and the pre- cious facts treasured up in this little volume. A com- plete portable library so condensed that the student may make it his constant pocket companion.— West- ern Lancet. To compress the whole science of medicine in less than 1,000 pages is an impossibility, but we think that the book before us approaches as near to it as is pos- sible. Altogether, it is the best of its class, and has met with a deserved success. As an elementary text- book for students, it has been useful, and will con- tinue to be employed in the examination of private classes, whilst it will often be referred to by the country practitioner.— Va. Med. Journal. As a handbook for students it is invaluable, con- taining in the most condensed form the established facts and principles of medicine and its collateral sciences.—N. H. Journal of Medicine. In the rapid course of lectures, where work for the students is heavy, and review necessary for an exa- mination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and sound- est doctrines and the latest improvements and dis- coveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recom- mend it to all last course students, but there is a class to whom we very sincerely commend this cheap book 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 ex- actly now what it was when they left it off. — Tlie Stethoscope. JTARTSHORNE {HENRY), 31. D., Professor of Hygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. In one large royal 12mo. volume of nearly 1000 closely printed pages, with about 300 illustrations on wood. (Nearly Ready.) The ability of the author, and his practical skill in condensation, give assurance that this work will prove valuable not only to the student preparing for examination, but also to the prac- titioner desirous of obtaining within a moderate compass, a view of the existing condition of the various departments of science connected with medicine. J UDLOW {J.L.), 31. 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 of 816 large pages, extra cloth, $3 25; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- able for the office examination of students, and for those preparing for graduation. We know of no better companion for the student during the hours spent in the lecture-room, or to re- fresh, at a glance, his memory of the various topics trammed into his head by the various professors to whom he is compelled to listen.— Western Lancet. As it embraces the whole range of medical studies it is necessarily volumiuous, containing 816 large duodecimo pages. After a somewhat careful exami- nation of its contents, we have formed a much more favorable opinion of it than we are wont to re?ard Mich works. Although well adapted to meet the wants of the student in preparing for his final examination, it might be profitably consulted by the practitioner also, who is most apt to become rusty in the very kind of details here given, and who, amid the hurry of his daily routine, is but too prone to neglect the study of more elaborate works. The possession of a volume of this kind might serve as an inducement for him to seize the moment of excited curiosity to inform him- self on any subject, and which is otherwise too often allowed to pass unimproved.—St. Louis Med. and Surg. Journal. 'AXXER {TH031AS HAWKES), 31 D., A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- NOSIS. Third American, from the second enlarged and revised English edition. To whkh is added The Code of Ethics of the American Medical Association. In one hanu- uome volume 12mo. {Preparing for early publication■) 6 Henry C. Lea's Publications—{Anatomy). QRA Y {HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawing by H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dis-ee- tions jointly by the Author and Dtt. Carter. Second American, from the second revised and improved London edition. In one magnificent imperial octavo volume, of over 800 pages, with 388 large and elaborate engravings on wood. Price in extra cloth, $6 00; leather, raised bands, $7 00. The author has endeavored in this work to cover a more extended range of subjects than is cus- tomary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Notwithstanding its exceedingly low price, the work will be found, in every detail of mechanical execution, one of the handsomest that has yet been offered to the American profession; while the careful scrutiny of a competent anatomist has relieved it of whatever typographical errors existed in the English edition. Thus it is that book after book makes the labor of l and with scarce a reference to the printed text. The the student easier than before, and since we have | surgical application of the various regions is also pre- seen Ulanchard & Lea's new edition of Gray's Ana- ; sented with force and clearness, impressing upon the tomy, certainly the finest work of the kind now ex- tant, we would fain hope that the bugbear of medical students will lose half its horrors, and this necessary foundation of physiological science will be much fa- cilitated and advanced.—N. O. Med. News. The various points illustrated are marked directly on the structure; that i6, whether it be muscle, pro- cess, artery, nerve, valve, etc. etc.—we say each point is distinctly marked by lettered engravings, so that the student perceives at once each point described as readily as if pointed out on the subject by the de- monstrator. Most of the illustrations are thus ren- student at each step of his research all the important relations of the structure demonstrated.—Cincinnati Lancet. This is, we believe, the handsomest book on Aua- tomy as yet published in our language, and bids fair to become in a short time the standard text-book of our colleges and studies. Students and practitioners will alike appreciate this book. We predict for it a bright career, and are fully prepared to endorse the statement of the London Lancet, that "We are not acquainted with any work in any language which can take equal rank with the one before us." Paper, printing, binding, all are excellent, and we feel that dered exceedingly satisfactory, and to the physician I a grateful profession will not allow the publishers to they serve to refresh the memory with great readiness; go unrewarded.—Nashville Med. and Surg. Journal. OMITH {HENR YH.), M.D., and JJORNER { WILLIAM E.), 31.D., Prof, of Surgery in the Univ. of Penna., Ac. Late Prof of Anatomy in the Univ. ofPenna., &c- 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. $4 50. The plan of this Atlas, which renders it so pecu- I the kind that has yet appeared; and we must add, Marly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up " tistical execution, have been already pointed out. We is so creditable to the country as to be flattering to must congratulate the student upon the completion our national pride.—American Medical Journal. of this Atlas, as it is the most convenient work of I H VRNER {WILLIAM E.), M.D., SPECIAL ANATOMY AND HISTOLOGY. Eighth edition, exten- sively revised and modified. In two large octavo volumes of over 1000 pages, with more than 300 wood-cuts; extra cloth, $6 00. VHARPEY ( WILLIAM), M.D., and Q UAIN {JONES $■ RICHARD). HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidv, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00. The very low price of this standard work, and its completeness in all departments of the subject, should command for it a place in the library of all anatomical students. ALLEN {J. M.), M.D. THE PRACTICAL ANATOMIST; or, The Student's Guide in the Dissecting Room. With 266 illustrations. In one very handsome royal 12mo. volume, of over 600 pages; extra cloth, $2 08. One of the most useful works upon the subject ever written.—Medical Examiner Henry C. Lea's Publications—(Anatomy). Wilson {Erasmus), f.r.s. A SYSTEM OF HUMAN ANATOMY, 'General and Special. A new and revised American, from the last and enlarged English edition. Edited by W. H. Go- bkecht, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. Illustrated with three hundred and ninety-seven engravings on woo'd. In one large and handsome octavo volume, of over 600 large pages; extra cloth, S4 00; leather, $5 00. The publisher trusts that the well-earned reputation of this long-established favorite 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 in- troducing everything which increased experience in its use has suggested as desirable to render it a complete text-book for those seeking to obtain or .to renew an acquaintance with Human Ana- tomy. 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 author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appropriate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. DF THE SAME AUTHOR. THE' DISSECTOR'S MANUAL; or, Practical and Surgical Ana- tomy. Third American, from the last revised and enlarged English edition. Modified and rearranged by William Hunt, M. D., late Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, of 582 pages, with 154 illustrations; extra cloth, $2 00. TTODGES, {RICHARD 31.), 31. D., -*--*■ Late Demonstrator of Anatomy in the Medical Department of Harvard University. PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In one neat royal 12mo. volume, half-bound, $2 00. (Just Issued.) The object of this work is to present to the anatomical student a clear and concise description of that which he is expected to observe in an ordinary course of dissections. The author has endeavored to omit unnecessary details, and to present the subject in the form which many years' experience has shown him to be the most convenient and intelligible to the student. In the revision of the present edition, he has sedulously labored to render the volume more worthy of the favor with which it has heretofore been received. 31 ACLISE {JOSEPH). SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best style and beautifully colored, containing 190 figures, many of them the size of life; together with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. Price $14 00. As no complete work of the kind has heretofore been published in the English language, the present volume will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascer- tain the exact relative positions of the various portions of the human frame towards each other and to the surface, as well as their abnormal deviations. The importance of such a work to the student, in the absence of anatomical material, and to practitioners, either for consultation in emergencies or to refresh their recollections of the dissecting room, is evident. Notwithstanding the large size, beauty and finish of the very numerous illustrations, it will be observed that the- price is so low as to place it within the reach of all members of the profession. We know of no work on surgical anatomy which , refreshed by those clear and distinct dissections', can compete with it.— Lancet. which every one must appreciate who has a particle The work of Maclise on surgical anatomy is of the highest value. In some respects it is the best publi- cation of its kind we have seen, and is worthy of a place in the library of any medical man, while the student could scarcely make a better investment than thig.__The Western Journal of Medicine and Surgery. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given. While the operator is shown every vessel and nerve where nn operation is contemplated, the exact anatomist is of enthusiasm. The English medical press has quite exhausted the words of praise, in recommending this admirable treatise. Those who have any curiosiry to gratify, in reference to the perfectibility of the lithographic art in delineating the complex mechan- ism of the human body, are invited to examine our specimen copy. If anything will induce surgeons and students to patronize a book of such rare value aud everyday importance to them, it will be a survey of the artistical skill exhibited in these fac-similes of nature.—Boston Med. and Surg. Journal. DEASLEE {E. R.), M.D., J. Professor of Anatomy and Physiology in Dartmouth Med. College, N. H. HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; for the use of medical students. With four hundred and thirty-four illustra- tions. In one handsome octavo volume of over 600 pages, extra cloth. $3 75. 8 Henry C. Lea*s Publications—(Physiology). JlfARSHALL {JOHN), F. R. S. Professor of Surgery in University College, London, &c. OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. With Additions hy Francis Guhnev Ssiith, M. D., Professor of the Institutes of Medi- cine in the University of Pennsylvania, Sec. With numerous illustrations. In one large and handsome octavo volume, of 1026 pages, extra cloth, $6 50; leather, raised bands, $7 50. (Now Ready.) We may now congratulate him on having com- pleted the latest as well as the best summary of mod- ern physiological science, both human and compara- tive, with which we are acquainted. To speak of this work in the terms ordinarily used on such occa- sions would not be agreeable to ourselves, and would fail to do justice to its author. To write such a book requires a varied and wide range of knowledge, con. siderable power of analysis, correct judgment, skill in arrangement, and conscientious spirit. It must have entailed great labor, but now that the task has been fulfilled, the book will prove not only invaluable to the student of medicine and surgery, but service- able to all candidates in natural science examinations, to teachers in schools, and to the lover of nature gene- rally. In conclusion, we can only express the con- viction that the merits of the work will command for it that success which the ability and vast labor dis- played in its production so well deserve.—London Lancet, Feb. 22, 1868. If the possession of knowledge, and peculiar apti- tude and skill in expounding it, qualify a man to write an educational work, Mr. Marshall's treatise might be reviewed favorably without even opening the covers. There are few, if any, more accomplished anatomists and physiologists than the distinguished professor of surgery at University College ; and he has long enjoyed the highest reputation as a teacher of physiology, possessing remarkable powers of clear exposition and graphic illustration. It is only re- markable that Mr. Marshall has allowed so long a time to elapse before producing a text-book after his own heart. The plan of this book diners in many respects from that of existing educational books; the science of human physiology being treated.in wider and more constant reference to chemistry, physics, and comparative anatomy and physiology. There can be no question, we think, that this is the most satisfactory, philosophic, and fruitful mode of teaching physiology. We have rarely the pleasure of being able to recommend a text-booft so unreserv. edly as this.— British Med. Journal, Jan. 25, 186S. QARPENTER { WILLIA31 B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- cations 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 additions, by Francis Gurnet Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, &c. In one very large and beautiful octavo volume, of about 900 large pages, handsomely printed; extra cloth, $5 50 ; leather, raised bands, $6 50. We doubt not it is destined to retain a strong hold on public favor, and remain the favorite text-hook in our colleges.—Virginia Medical Journal. The highest compliment that can be extended to this great work of Dr. Carpenter is to call attention to this, another new edition, which the favorable regard of the profession has called for. Carpenter is the standard authority on physiology, and no physi- cian or medical student will regard his library as complete without a copy of it.—Cincinnati Med. Ob- server. With Dr. Smith, we confidently believe "that the present will more than sustain the enviable reputa- tion already attained by former editions, of being one of the fullest and most complete treatises on the subject in the English language." We know of none from the pages of which a satisfactory knowledge of the physiology of the human organism can be as well obtained, none better adapted for the use of such as take up the study of physiology in its reference to the institutes and practice of medicine.—Am. Jour. Med. Sciences. We have so often spoken in terms of high com- mendation of Dr. Carpenter's elaborate work on hu- man physiology that, in announcing a new edition, it is unnecessary to add anything to what has hereto- fore been said, and especially is this the case since every intelligent physician is as well aware of the character and merits of the work as we ourselves are. —St. Louis Med. and Surg. Journal. The above is the title of what is emphatically the great work on physiology; and we are conscious that it would he a useless effort to attempt to add any- thing to the reputation of this invaluable work, and can only say to all with whom our opinion has any influence, that it is our authority.—Atlanta Med. Journal. T>Y THE SAME AUTHOR. ---- PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- can, from the Fourth and Pievised London Edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations. Pp. 752. Extra cloth, $5 00. As a complete and condensed treatise on its extended and important subject, this work becomes a necessity to students of natural science, while the very low price at which it is offered places it within the reach of all. DY THE SAME AUTHOR. THE MICROSCOPE AND ITS REVELATIONS. Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very hand- some octavo volume, of 724 pages, extra cloth, $5 25. K IRKES {WILLIAM SENHOUSE), 31.D., A MANUAL OF PHYSIOLOGY. A new American from the third and improved London edition With two hundred illustrations. In one large and hand- some royal 12mo. volume. Pp. 586. Extra cloth, $2 25 ; leather, $2 75. It is at once convenient in size, comprehensive in design, and concise in statement, and altogether well adapted for the purpose designed.—St. Louis Med. and Surg. Journal. The physiological reader will find it a mast excel- lent guide in the study of physiology in its most ad- vanced and perfect form. The author has shown himself capable of giving details sufficiently ample in a condensed and concentrated shape, on a science in which it is necessary at once to be correct and not lengthened.—Edinburgh Med. and Surg. Journal. Henry C. Lea's Publications—(Physiology). 9 J)ALTON {J. c.), 31. D., -"-' Professor of Physiology in the College of Physicians and Surgeons, New York, &c. A TREATISE ON HUMAN PHYSIOLOGY, Designed for the use of Students and Practitioners of Medicine. Fourth edition, revised, with nearly three hun- dred illustrations on wood. In one very beautiful octavo volume, of about 700 pages, extra cloth, $5 25 ; leather, $6 25. (Just Issued.) From Vie Preface to the Nmo F.dition. "The progress made by Physiology and the kindred Sciences during the last few years has re- quired, for the present edition of this work, a thorough and extensive revision. This progress has not consisted in any very striking single discoveries, nor in a decided revolution in any of the departments of Physiology; but it has been marked by great activity of investigation in a multitude of different directions, the combined results of which have not failed to impress a new character on many of the features of physiological knowledge. ... In the revision and correction of the present edition, the author has endeavored to incorporate all such improve- ments in physiological knowledge with the mass of the text in such a manner as not essentially to alter the structure and plan of the work, so far as they have been found adapted to the wants and convenience of the reader. . . . Several new illustrations are introduced, some of them as additions, others as improvements or corrections of the old. Although all parts of the book have received more or less complete revision, the greatest number of additions and changes were required in the Second Section, on the Physiology of the Nervous System." The advent of the first edition of Prof. Dalton's Physiology, about eight years ago, marked a new era in the study of physiology to the American student. Under Dalton's skilful management, physiological science threw off the long, loose, ungainly garments of probability and surmise, in which it had been ar- rayed by most artists, and came among us smiling and attractive, in the beautifully tinted and closely fitting dress of a demonstrated science. It was a stroke of genius, as well as a result of erudition and talent, that led Prof. Dalton to present to the world a work on physiology at once brief, pointed, and com- prehensive, and which exhibited plainly in letter and drawings the basis upon which the conclusions ar- rived at rested. It is no disparagement of the many excellent works on physiology, published prior to that of Dalton, to say that none of them, either in plan of arrangement or clearness of execution, could be compared with his for the use of students or gene- ral practitioners of medicine. For this purpose his book has no equal in the English language.—Western Journal of Medicine, Nov. 1867. A capital text-book in every way. We are, there- fore, glad to see it in its fourth edition. It has already been examined at full length in these columns, so that we need not now further advert to it beyond remark- ing that both revision and enlargement have been most judicious.— London Med. Times and Gazette, Oct. 19, 1867. No better proof of the value of this admirable work could be produced than the fact that it has al- ready reached a fourth edition in the short space of eight yeais. Possessing in an eminent degree the merits of clearness and condensation, and being fully brought up to the present level of Physiology, it is undoubtedly one of the most reliable text-books upon this science that could be placed in the hands of the medical student.—Am. Journal Med. Sciences, Oct. 1867. Prof. Dalton's work has such a well-established reputation that it does not stand in need of any re- commendation. Ever since its first appearance it has become the highest authority in the English language; and that it is able to maintain the enviable position which it has taken, the rapid exhaustion of the dif- ferent successive editions is sufficient evidence. The present edition, which is the fourth, has been tho- roughly revised, and enlarged by the incorporation of all the many important advances which have lately beeu made in this rapidly progressing science. —N. Y. Med. Record, Oct. 15, 1867. As it stands, we esteem it the very best of the phy- siological text-books for the student, and the most concise reference and guide-book for the practitioner. —N. Y. Med. Journal, Oct. 1867. The present edition of this now standard work fully sustains the high reputation of its accomplished au- thor. It is not merely a reprint, but has been faith- fully revised, and enriched by such additions as the progress of physiology has rendered desirable. Taken as a whole, it is unquestionably the most reliable and useful treatise on the subject that has been issued from the American press.—Chicago Med. Journal, Sept. 1S67. D UNGLISQN {ROBLEY), 31. D., Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and extensively modified and enlarged, with five hundred and thirty-two illustrations In two large and handsomely printed octavo volumes of about loOO pages, extra cloth. $7 00. T EH31ANN {C. G.) ^ PHYSIOLOGICAL CHEMISTRY Translated from the second edi- tion by George E Day, M. D., F. R. S., Ac, edited by R. E. Rogers, M. D .Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations sele edfr'om Funke's Atlas Jf Physiological Chemistry, and an Appendix of plate. Com- plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two hundred illustrations, extra cloth. $6 00.__ ^ATfvTTAlToF CHEMICAL PHYSIOLOGY. Translated from the n nn with Notes and Additions, by J Cheston Morris, M. D., with an Introductory ^Con ViUl Force, by Professor'Samuel Jackson, M. D., of the University of Pennsyl- 1,-say on illustrations on wood. In one very handsome octavo volume of 336 pages vanta. " *o oi extra cloth. v>* ■"•___________________ mODD (ROBERT B.), 31. D. F.R.S., and gOWMAN (TV), F.R.S. TTIR PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF M AN With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume of 950 pages, extra cloth. Price $1 75. 10 Henry C. Lea's Publications—(Chemistry). J1RANDE ( WM. T.), D. C.L., and JAYLOR {ALFRED S.), 31. D., F.R.S. CHEMISTRY. Second American edition, thoroughly revised by Dr. Taylor. In one handsome 8vo. volume of 764 pages, extra cloth, $5 00 ; leather, $6 00. (Just Issued.) From Dr. Taylor's Preface. "The revision of the second edition, in consequence of the death of my lamented colleague, has devolved entirely upon myself. Every chapter, and indeed every page, has been revised, and numerous additions made in all parts of the volume. These additions have been restricted chiefly to subjects having some practical interest, and they have been made as'concise as possible, in order to keep the book within those limits which may retain for it the character of a Student's Manual "—Londo?i, June 29, 1867. A book'that has already so established a reputa- tion, as has Brande and Taylor's Chemistry, can hardly need a notice, save to mention the additions and improvements of the edition. Doubtless the work will long remain a favorite text-book in the Behools, as well as a convenient book of reference for all.— N. Y. Medical Gazette, Oct. 12, 1867. For this reason we hail with delight the republica- tion, in a form which will meet with general approval aud command public attention, of this really valua- ble standard work on chemistry—more particularly as it has been adapted with such care to the wants of the general public. The well known scholarship of its authors, and their extensive researches for many years in experimental chemistry, have been long ap- preciated in the scientific world, but in this work they have been careful to give the largest possible amount of information with the most sparing use of technical terms and phraseology, so as to furnish the reader, "whether a student of medicine, or a man of the world, with a plain introduction to the science and practice of chemistry."—Journal of Applied Chem- istry, Oct. 1867. This second American edition of an excellent trea- tise on chemical science is not a mere republication from the English press, but is a revision and en- largement of the original, under the supervision of the surviving author, Dr. Taylor. The favorable opinion expressed on the publication of the former edition of this work is fully sustained by the present revision, in which Dr. T. has increased the size of the volume, by an addition of sixty-eight pages.—Am. Journ. Med. Sciences, Oct. 1867. The Handbook in Chemistry of the Student.— For clearness of language, accuracy of description, extent of information, and freedom from pedantry and mysticism, no other text-book comes into com- petition with it.—The Lancet. The authors set out with the definite purpose of writing a book which shall be intelligible to any educated man. Thus conceived, and worked out in the most sturdy, common-sense method, this book gives in the clearest and most summary method possible all the facts and doctrines of chemistry.— Medical Times. T>0 W3IAN {JOHN E.), M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fourth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. &2 25. The fourth edition of this invaluable text-book of Medical Chemistry was published in England in Octo- ber of the last year. The Editor has brought down the Handbook to' that date, introducing, as far as was compatible with the necessary conciseness of such a work, all the valuable discoveries in the. science which have come to light since the previous edition was printed. The work is indispensable to every student of medicine or enlightened practitioner. It is printed in clear type, and the illustrations are numerous and intelligible.—Boston Med. and Surg. Journal. B Y THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Fourth American, from the fifth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., extra cloth. $2 25. (Just Issued.) It is by far the best adapted for the Chemical student of any that has yet fallen in our way.—British and Foreign Medico-Chirurgical Review. The best introductory work on the subject with which we are acquainted.—Edinburgh Monthly Jour. One of the most complete manuals that has for a long time been given to the medical student.— Atlie.nmum. We regard it as realizing almost everything to be desired in an introduction to Practical'Chemistry. pRAHAM {THOMAS), F.R.S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applications of the 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! $5 50. Part II., completing the work from p. 431 to end, with Index, Title Matter, Ac, may be had separate, cloth backs and paper sides. Price $3 00. ■ From Prof. E. N. Horsford, Harvard College. It has, in its earlier and less perfect editions, been familiar to me, and the excellence of its plan and the clearness and completeness of its discussions, have long been my admiration. No Teader of English works on this science can afford to be without this edition of Prof. Graham's Elements.—Silliman's Journal, March, I808. From Prof. Wolcott Gibbs, N. Y. Free Academy. The work is an admirable one in all respects, ana its republication here cannot fail to exert a positive influence upon the progress of science in this country. Henry C. Lea's Publications—(Chemistry, Pharmacy.dec). 11 po WNES {GEORGE), Ph. D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. Edited by Robert Bridges, In one large royal 12mo. volume, of 600 pages, extra cloth, 82 00 ; leather, £2 50. M. D. We know of no treatise in the language so well calculated to aid the student in becoming familiar with the numerous facts in the intrinsic science on which it treats, or one better calculated as a text- book for those attending Chemical lectures. * * * * The best text-book on Chemistry that has issued from our press.—American Medical Journal. We again most cheerfully recommend it as the best text-book for students in attendance upon Chem- ical lectures that we have yet examined.—III. and Ind. Med. and Surg. Journal. A first-rate work upon a first-rate subject.—St. Louis Med. and Surg. Journal. No manual of Chemistry which we have met comes so near meeting the wants of the beginner.— Western Journal of Medicine and Surgery. We know of none within the same limits which has higher claims to our confidence as a college class- book, both for accuracy of detail and scientific ar- rangement.—Augusta Medical Journal. We know of no text-book on chemistry that we would sooner recommend to the student than this edition of Prof. Fownes' work.—Montreal Medical Chronicle. A new and revised edition of one of the best elemen- tary works on chemistry accessible to the American and English student.—N. Y. Journal of Medical and Collateral Science. We unhesitatingly recommend it to medical stu- dents.— N. W. Med. and Surg. Journal. This is a most excellent text-book for class instruc- tion in chemistry, whether for schools or colleges.— Silliman's Journal. ABEL AND BLOXAM'S HANDBOOK OF CHEMIS- TRY, Theoretical, Practical, aiyj Technical. In one vol*. 8vo. of 662 pages, extra cloth, $4' 50. GARDNER'S MEDICAL CHEMISTRY. 1 vol. 12mo., with wood-cuts; pp. 396, extra cloth, $1 00. KNAPP'S TECHNOLOGY ; or Chemistry Applied to the Arts, and to Manufactures. With American additions, by Prof. Walter R. Johnson. In two very handsome octavo volumes, with 500 wood engravings, extra cloth, $6 00. pARRISH {ED WARD), Professor of Materia Medica in the Philadelphia College of Pharmacy. , A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 pages, with several hundred illustrations, extra cloth. $5 00. The immense amount of practical information condensed in this volume may be estimated from the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- ences ; under Emplastrum, 36; Extracts, 159; Lozenges, 25; Mixtures, 55 131; Tinctures, 138 ; Unguentum, 57, &c. Pills, 56; Syrups, We have examined this large, volume with a good deal of care, and find that the author has completely exhausted the subject upon which he treats ; a more complete work, we think, it would be impossible to find. To the student of pharmacy the work is indis- pensable ; indeed, so far as we know, it is the only one of its kind in existence, and even to the physician or medical student who can spare five dollars to pur- chase it, we feel sure the practical information lie will obtain will more than compensate him for the outlay.—Canada Med. Journal, Nov. 1864. The medical student and the practising physician will find the volume of inestimable worth for study and reference.—-Saw Francisco Med. Press, July, 1864. When we say that this book is in some respects the best which has been published on the subject in the English language for a great many years, we do not wish it to be understood as very extravagant praise In truth, it is not so much the best as the only book.—The London Chemical News. An attempt to furnish anything like an analysis of Parrish's very valuable and elaborate Treatise on pfaltical Phlrmacy would require more space than we have at our disposal. Tins, however, ,s^not so much a matter of regret, \flatsmuch0^/'^e ^a JfPPpharmace"tic substances or appliances which has not been clearly and carefully discussed in this vol- ume. Want of space prevents our enlarging further on this valuable work, and we must conclude by a simple expression of our hearty appreciation of its merits.—Dublin Quarterly Jour, of Medical Science, August, 1861. We have in this able aud elaborate work a fair ex- position of pharmaceutical science as it exists in the United States ; and it shows that our transatlantic friends have given the subject most elaborate con- sideration, and have brought their art to a degree of perfection which, we believe, is scarcely to be sur- passed anywhere. The book is, of course, of more direct value to the medicine maker than to the physi- cian ; yet Mr. Paruish has not failed to introduce matter in which the prescriber is quite as much interested as the compounder of remedies. In con- clusion, we can only express our high opinion of the value of this work as a guide to the pharmaceutist, and in many respects to the physician, not only in America, but in other parts of the world.—British Med. Journal, Nov. 12th, 1864. The former editions have been sufficiently long before the medical public to render the merits of the work well known. It is certainly one of the most complete aud valuable works on practical pharmacy to which the student, the practitioner, or the apothe- cary can have access.—Chicago Medical Examiner, March, 1864. D FWGLISON {ROBLEY), 31.D., - Professor of Institute* of Medicine in Jefferson M,-dical College, Philadelphia. ^NFPxaL THERAPEUTICS AND MATERIA MEDICA; adapted / \i^ii.nl Text-Book. With Indexes of Remedies and of Diseases and their Remedies. Q°rvrh edition revised and improved. With one hundred and ninety-three illustrations^ In fwo large and handsomely printed octavo vols, of about 1100 pages, extra cloth. $6 50. VFW REMEDIES, WITH FORMULA FOR THEIR PREPARA- TION AND ADMINISTRATION. Seventh edition, with extensive additions. In one very large octavo volume of 770 pages, extra cloth. $4 00. 12 Henry C. Lea's Publications—(3Iat.3Ied.and Therapeutics). CfTILLE {ALFRED), M.D., *-J Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Third edition, revised and enlarged. In two large and handsome octavo volumes of about 1700 pages, extra cloth, $10 ; leather, $12. (Now Ready.) That two large editions of a work of such magnitude should be exhausted in a few years, is sufficient evidence that it has supplied a want generally felt by the profession, and the unani- mous commendation bestowed upon it by the medical press, abroad as well as at home, shows that the author has successfully accomplished his object in presenting to the profession a system- atic treatise suited to the wants of the practising physician, and unincumbered with details interesting only to the naturalist or the dealer. Notwithstanding its enlargement, the present edition has been kept at the former very moderate price. From the Preface to the Third Edition. Although the second edition of this work had for many months been out of print, the author preferred to delay a new issue of it, rather than omit anything which appeared to be substantially valuable among the recent advances of the science and art of Therapeutics. The subjects now treated of for the first time, are : Chromic Acid ; Permanganate op Potassa ; The Sulphites of Soda, etc. ; Carbolic Acid; Nitrous Oxide; Rhigolene: and Calabar Bean. The article on Bromine has been prepared entirely anew; and that on Electricity very materially enlarged by an account of the most recent improvements in electrical apparatus, and in the appli- cation of this agent to the cure of disease. The additions which have been mentioned,.with much new matter besides, which* will be found under the more important titles, occupy nearly one hundred pages. April, 1868. A few notices of former editions are subjoined. hardly find a work written in a style more clear and simple, conveying forcibly the facts taught, and yet free from turg'idity and redundancy. There is a fas- We have placed first on the list Dr. Stille's great work on Therapeutics. When the first edition of this work made its appearance nearly five years ago, we expressed our high sense of its value as containing a full and philosophical account of the existing state of Therapeutics. From the opinion expressed at that time we have nothing to retract; we have, on the contrary, to state that the introduction of numerous additions has rendered the work even more complete than formerly. We can cordially recommend to those of our readers who are interested in Therapeutics a careful perusal of Dr. Stille's work.—Edinburgh Med. Journal, 1865. An admirable digest of our present knowledge of Materia Medica and Therapeutics.—Am. Journ. Med. Sciences, July, 1860. Dr. Stille's splendid work on therapeutics and ma- teria medica.—London Med. Times, April 8, 1865. We think this work will do much to obviate the reluctance to a thorough investigation of this branch of scientific study, for in the whole range of medical literature treasured in the English tongue, we shall cination in its pages that will Insure to it a wide po- pularity and attentive perusal, and a degree of use- fulness not often attained through the influence of a single work. The author has much enhanced the practical utility of his book by passing briefly over the physical, botanical, and commercial history of medicines, and directing attention chiefly to their physiological action, and their application for the amelioration or cure of disease.—Chicago Med. Jour- nal, March, 1860. It has held from its appearance in 1860, the place it so well deserves, that of the best treatise on Thera- peutics in the English language. A considerable amount of new matter has been added to this edition without increasing its bulk, and its general appear- ance is .all that could be desired of a work which should find a place in the hand library of every stu- dent and physician.—Boston Med. and Surg. Jour- nal, Dec. 15, 1864. riRIFFITH {ROBERT E.), M.D. A UNIVERSAL FORMULARY, Containing the Methods .of Pre- paring and Administering Officinal and other Medicines. Thts whole adapted to Physicians and Pharmaceutists. 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 of 650 pages, double-columns. Extra cloth, $4 00; leather, $5 00. In this volume, the Formulary proper occupies over 400 double-column pages, and contains about 5000 formulas, among which, besides those strictly medical, will be found numerous valuable receipts for the preparation of essences, perfumes, inks, soaps, varnishes, &c. Ac. • In addition to this, the work contains a vast amount of information indispensable for daily reference by the prac- tising physician and apothecary, embracing Tables of Weights and Measures, Specific Gravity, Temperature for Pharmaceutical Operations, Hydrometrical Equivalents, Specific Gravities of some of the Preparations of the Pharmacopoeias, Relation between different Thermnmetrical Scales, Explanation of Abbreviations used in Formula?, Vocabulary of Words used in Prescriptions, Ob- servations on the Management of the Sick Room, Doses of Medicines, Rules for the Administration of Medicines, Management of Convalescence and Relapses, Dietetic Preparations not included in the Formulary, List of Incompatibles, Posologioal Table, Table of Pharmaceutical Names which differ in the Pharmacopoeias, Officinal Preparations and Directions, and Poisons. Three complete and extended Indexes render the work especially adapted for immediate consul- tation. One, of Diseasks and their Rkmedies, presents under the head of each disease the remedial agents which have been usefully exhibited in it, with reference to the formulae containing them__while another of Pharmaceutical and Botanical Names, and a very thorough General Index afford the means of obtaining at once any information desired. The Formulary itself is arranged alphabetically, under the heads of the leading constituents of the prescriptions. This is one of the most useful books for the prac- We know of none in our language, or any other, so tisinz physician which has been issued from the press comprehensive iu its details.—London Lancet. of late vears. containing a vast variety of formulas, . . oi laio yf„*j" „„„?„„. uj,nini«trafinn of merii. 0ne of the most complete works of the kind in any for the sale and convenient autninisiration oi tneui- , T, ,. , . .r . r , J [in me » o ciples, with the quantities slated in full, without We are not cognizant of the existence of a parallel signs or abbreviations.—Memphis Med. Recorder. work.— London Med. Gazette. ___ Henry C. Lea's Publications—(3Iat. Med. and Therapeutics). 13 ^KREIRA {JONATHAN), M.D., F.R.S. and L.S. I MmJtEfKJA MET)IrA AXD THERAPEUTICS; being an Abridg- thf P • • ^ Dr" Perelra's Elements of Materia Medica, arranged in conformity with Dri . 'sn£h:lrmacoPnel'1. and adapted to the use of Medical Practitioners, Chemists and tugpsts, Medical and Pharmaceutical Students, Ac. By F. J. Farre, M D Senior n0ci^'C^ *^St- Bartholomew's Hospital, and London Editor of the British Pharmacopoeia; Phi™ •* ?°""T Bentley, M.R.C.S., Professor of Materia Medica and Botany to the ^narmaceutical Society of Great Britain; and by Robert Wap.ington, F.R S Chemical nntrai°c*t0. «Society 0f APotheci1ries- With numerous additions and references to the united btates Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the university of Pennsylvania. In one large and handsome octavo volume of 1040 closely printed pages, with 236 illustrations, extra cloth, $7 00; leather, raised bands, $8 0#. The task of the American editor has evidently been no sinecure, for not only has he given to us all that Is contained in the abridgment useful for our pur- poses, but by a careful and judicious embodiment of over a hundred new remedies has increased the size of the former work fully one-third, besides adding many new illustrations, some of which are original. We unhesitatingly say that by so doing he has pro- portionately increased the value, not only of the con- densed edition, but has extended the applicability of the great original, and has placed his medical coun- trymen under lasting obligations to him. The Ame- rican physician now has all that is needed in the shape of a complete treatise on materia medica, and the medical student has a text-book which, for prac- tical utility and intrinsic worth, stands unparalleled. Although of considerable size, it is none too large for the purposes for which it has been intended, and every medical man should, in justice to himself, spare a place for it upon his book-shelf, resting assured that the more he consults it the better he will be satisfied of its excellence.—N. Y. Med. Record, Nov. 15, 1866. It will fill a place which no other work can occupy In the library of the physician, student, and apothe- cary.—Boston Med. and Surg. Journal, Nov. 8, 1866. Of the many works on Materia Medica which have appeared since the issuing of the British Pharmaco- TJLLIS {BENJA31IN), M.D. 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. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- tion, carefully revised and much improved by Albert H. Smith, M. D. In one volume 8vo. of 376 pages, extra cloth, $3 00. (Now Ready.) We endorse the favorable opinion which the book has so long established for itself, and take this occa- sion to commend it to our readers as one of the con- venient handbooks of the office and library.—din- poeia, none will be more acceptable to the student and practitioner than the present. Pereira's Materia Medica had long ago asserted for itself the position of being the most complete work on the subject in the English language. But its very completeness stood in the way of its success. Except in the way of refer- ence, or to those who made a special study of Materia Medica, Dr. Pereira's work was too full, and its pe- rusal required an amount of time which few had at their disposal. Dr. Farre has very judiciously availed himself of the opportunity of the publication of the new Pharmacopoeia, by bringing out an abridged edi- tion of the great work. This edition of Pereira is by no means a mere abridged re-issue, but contains ma- ny improvements, both in the descriptive and thera- peutical departments. We can recommend it as a very excellent and reliable text-book.—Edinburgh Med Journal, February, 1866. The reader cannot fail to be impressed, at a glance, with the exceeding value of this work as a compend of nearly all useful knowledge on the materia medica. We are greatly indebted to Professor Wood for his adaptation of it to our meridian. Without his emen- dations and additions it would lose much of its value to the American student.. With them it is an Ameri- can book. — Pacific Medical and Surgical Journal December, 1866. cinnati Lancet, Feb. 1861. The work has long been before the profession, and its merits are well known. The present edition con- tains many valuable additions, and will be found to be an exceedingly convenient and useful volume for reference by the medical practitioner. — Chicago Medical Examiner, March, 1861. The work is now so well known, and has been so frequently noticed in this Journal as the successive editions appeared, that it is sufficient, on the present occasion, to state that the editor has introduced into the eleventh edition a large amount of new matter, derived from the current medical and pharmaceutical works, as well as a number of valuable prescriptions furnished from private sources. A very comprehen- sive and extremely useful index has also been sup- plied, which facilitates reference to the particular article the prescriber may wish to administer; and the languag^of the Formulary has been made to cor- respond with the nomenclature of the new national Pharmacopoeia.—Am. Jour. Med. Sciences, Jan. 1864. OARSON {JOSEPH), M.D ,«„.,,„ , . , v-/ Professor of Materia Medica and Pharmacy in the University of Pennsylvania, &c. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. With three Lectures on the Modus Operandi of Medicines. Fourth and revised edition, extra cloth, $3 00. (Now Ready.)___________________ CARPENTER'S PRIZE ESSAY ON THE PSE OF Alcoholic Liquors in Health and Disease. New edition, with a Preface by D. F. Condie, M D., and explanations of scientific words. In one neat 12mo. volume, pp. 178, extra cloth. 60 cents. De JONGH ON THE THREE KINDS OF COD-LIVER Oil, with their Chemical and Therapeutic Pro- perties. 1 vol. 12mo., cloth. 75 cents. MAYNE'S DISPENSATORY AND THERAPEUTICAL Remembrancer. With every Practical Formula contained in the three British Pharmacopoeias. Editod. with the addition of the Formulae of the U. S. Pharmacopoeia, by R. E. Griffith, M. D. In one 12nio. volume, 300 pp., extra cloth. 75 cents. ROYTF'S MATERIA MEDICA AND THERAPEU- '"■<•* of the Pharma- and of the With many now medicines. Edited M D. tics- including the Preparations of th copceias of London, Edi..burgh, Dubhn, FF^^'VT^ height „!„„. S£SriSAojr. large octavo volume of about 700 ■nflfffts. extra, clotn.

OKITANSKY {CARL), 31.D., Curator of the Imperial Pathological Museum, and'Professor at the University of Vienna. A MANUAL OF PATHOLOGICAL ANATOMY. Translated 1-y W. E. Swaine, Edward Sieveking, C H. Moore, and Q. E. Day. Four volumes octavo, bound in two, of about 1200 pages, extra cloth. $7 50. GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidt, M. D. In one volume, very large imperial quarto, with 320 copper-plate figures, plain and colored, extra cloth. $1 00. SIMON'S GENERAL PATHOLOGY, as conducive to the Establishment of Rational Principles for the Prevention and Cure of Disease. In one octavo volume of 212 pages, extra cloth. $1 2.3. jyiLLIAMS {CHARLES J. B.), M.D., Professor of Clinical Medicine in University College, London. PRINCIPLES OF MEDICINE. An Elementary Yiew of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the preservation of health. A new American, from the third and revised London edition. In one octavo volume of about 500 pages, extra cloth. $3 50. The unequivocal favor with which this work has been received by the profession, both in Europe and America, is one among the many gratifying evidences which might be adduced as going to show that there is a steady progress taking place in the science as well as in the art of medicine.—St. Louis Med. and Surg. Journal. No work has ever achieved or maintained a more deserved reputation.— Virginia Med. and Surg. Journal. One of the best works on the subject of which it treats in our language. It has already commended itself to the high regard of the profession; and we may well say that we know of no single volume that will afford the source of so thorough a drilling in the principles of practice as this. Students and practitioners should make themselves intimately familiar with its teachings— they will find their labor and study most amply repaid.—Cincinnati Med. Observer. There is no work in medical literature which can fill the place of this one. It is the Primer of the young practitioner, the Koran of the scientific one.— Stethoscope. A text-book to which no other in our language is comparable.—Charleston Med. Journal. The lengthened analysis we have given of Dr. Wil- liams's Principles of Medicine will, we trust, clearly prove to our readers his perfect competency for the task he has undertaken—that of imparting to the student, as well as to the more experienced practi- tioner, a knowledge of those general principles of pathology on which alone a correct practice can be founded. The absolute necessity of such a work must be evident to all who pretend to more than mere empiricism. We must conclude by again ex- pressing our high sense of the immense benefit which Dr. Williams has conferred on medicine by the pub- lication of this work. We are certain that in the present state of our knowledge his Principles of Medi- cine could not possibly be surpassed. While we regret the loss which many of the rising generation of practitioners have sustained by his resignation of the Chair at University College, it is comforting to feel that his writings must long continue to exert a powerful influence on the practice of that profession for the improvement of which he has so assiduously and successfully labored, and in which he holds so distinguished a position.—London Jour, of Medicine Henry C. Lea's Publications—(Practice of 3Iedicine). 15 PLINT {A LKTIN), 31. D., Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y. A JtPEATISE 0X THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Third edition, revised and enlarged. In one large and closely printed octavo volume of 1002 pages ; handsome extra cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (Just Ready.) From the Preface to tlu>. Third Edition. Since the publication, in December, 1866, of the second edition of this treatise, much time has' been devoted to its revision. Recognizing in the favor with which it has been received a pro- portionate obligation to strive constantly to increase its worthiness, the author has introduced in the present edition additions, derived from his clinical studies, and from the latest contributions in medical literature, which, it is believed, will enhance considerably the practical utility of the work. A slight modification in the typographical arrangement has accommodated these additions without materially increasing the bulk of the volume. New York, October, 1868. At the very low price affixed, the profession will find this to be one of the cheapest volumes within their reach. A few notices of former editions are subjoined. We are happy in being able once more to commend this work to the students and practitioners of medicine who seek for accurate information conveyed in lan- guage at once clear, precise, and expressive.—Amer. Journ. Med. Sciences, April, 1867. Dr. Flint, who has been known in this country for many years, both as an author and teacher, who has discovered truth, and pointed it out clearly and dis- tinctly to others, investigated the symptoms and na- tural history of disease and recorded its language and facts, and devoted a life of incessant study and thought to the doubtful or obscure in his profession, has at length, in his ripe scholarship, given this work to the profession as a crowning gift. If we have spoken highly of its value to the profession and world ; if we have said, all considered, it is the very best work npon medical practice in any language; if we have spoken of its excellences in detail, and given points of special value, we have yet failed to express in any degree our present estimate of its value as a guide in the practice of medicine. It does notcontain too much or too little ; it is not positive where doubt should be expressed, or hesitate where truth is known. It is philosophical and speculative where philosophy and speculation are all that can at present be obtained, but nothing is admitted to the elevation of established truth, without the most thorough investigation. It is truly remarkable with what even hand this work has been written, and how it all shows the most care- ful thought and untiring study. We conclude that, though it may yet be susceptible of improvement, it still constitutes the very best which human knowledge can at present produce. "When knowledge is in- creased," the work will doubtless be again revised; meanwhile we shall accept it as the rule of practice. —Buffalo Med. and Surg. Journal, Feb. 1867. Dr. Flint's book is the only one on the practice of medicine that can benefit the young practitioner.— Nashville Med. Journal, Aug. 1866. We consider the book, in all its essentials, as the best adapted to the student of any of our numerous text-books on this subject.—i^.Y Med. Journ., Jan. 67. Its terse conciseness fully redeems it from being ranked among heavy and common-place works, while the unmistakable way in which Dr. Flint gives his own views is quite refreshing, and far from common. It is a book of enormous research ; the writer is evi- dently a man of observation and large experience; his views are practically sound and theoretically moderate, and we have no hesitation in commending his magnum opus to our readers.—Dublin Medical Press and Circidar, May 16, 1866. In the plan of the work and the treatment of indi- vidual subjects there is afreshness and an originality which make it worthy of the study of practitioners as well as students. It is, indeed, an admirable book, and highly creditable to American medicine. For clearness and conciseness in style, for careful reason- ing upon what is known, for lucid distinction between what we know and what we do not know, between what nature does in disease and what the physician can do and should, for richness in good clinical ob- servation, for independence of statement and opinion on great points of practice, and for general sagacity and good judgment, the work is most meritorious. It is singularly rich in good qualities, and free from faults.—London Lancet, June 23, 1866. In following out such a plan Dr. Flint has suc- ceeded most admirably, and gives to his readers a work that is not only very readable, interesting, and concise, but in every respect calculated to meet the requirements of professional men of every class. The student has presented to him, in the plainest possible manner, the symptoms of disease, the prin- ciples which should guide him in its treatment, and the difficulties which have to be surmounted in order to arrive at a correct diagnosis. The practitioner, besides having such aids, has offered to him the con- clusion which the experience of the professor has enabled him to arrive at in reference to the relative merits of different therapeutical agents, and different methods of treatment. This new work will add not a little to the well-earned reputation of Prof. Flint as a medical teacher.—N. Y. Med. Record, April 2, 1866. R LJXGLISON, FORBES, TWEED IE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature nnd Treatment of Diseases, Materia Medica and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. Ac. In four large super-royal octavo volumes, o 13254 double-columned pages, strongly and handsomely bound in leather, $15 ; extra cloth, $11. * * This work contains no less than four hundred and eighteen distinct treatises, contributed by sfxty-eight distinguished physicians. " .__m„ietB work on practical medicine exL^t "°at Z^nlnTZ^-Buffalo Medical and Surgical Journal. „„..,« For reference, it is above all price to every practi- Haner—Western Lancet. One'of the most valuable medical publications of TMRTOW'S MANUAL OF THE PRACTICE OF MPniCIXE With Additions 1 K 1 vol. Svo., PP. *00, cloth With Additions by D. F. Coxdie, 50. 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 ad- vantageous light.—Medical Examiner. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. From the third and enlarged English edi- tion. In one handsome octavo volume of about 500 pages, extra cloth. $3 50. 16 Henry C. Lea's Publications—(Practice of 3Iedicine). TTARTSHORNE {HENRY), M.D., J-J- Professor of Hygiene in the University of Pennsylvania. ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book for Students and Practitioners. In one handsome royal 12tno. volume of 418 pages, clearly printed on small type, cloth, $2 38; half bound, $2 63. (Just Issued.) \ The very cordial reception with which this work has met shows that the author has fully suc- ceeded in his attempt to condense within a convenient compass the essential points of scientific and practical medicine, so as to meet the wants not only of the student, but also of the practi- tioner who desires to acquaint himself with the results of recent advances in medical science. nearly than any similar manual lately before us the standard at which all such books should aim — of teaching much, and suggesting more. To the student As a strikingly terse, full, and comprehensive em- bodiment in a condensed form of the essentials in medical science and art, we hazard nothing in saying that it is incomparably in advance of any work of the kind of the past, and will stand long in the future without a rival. A mere glance will, we think, im- press others with the correctness of our estimate. Nor do we believe there will be found many who, after the most cursory examination, will fail to possess it. How one could be able to crowd so much that is valu- able, especially to the student and young practitioner, within the limits of so small a book, and yet embrace and present all that is important in a well-arranged, clear form, convenient, satisfactory for reference, with so full a table of contents, and extended general index, with nearly three hundred formulas and recipes, is a marvel.— Western Journal of Medicine, Aug. 1867. The little book before us has this quality, and we can therefore say that all students will find it an in- valuable guide in their pursuit of clinical medicine. Dr. Hartshorne speaks of it as "an unambitious effort to make useful the experience of twenty years of pri- vate and hospital medical practice, with its attendant study and reflection." That the effort will prove suc- cessful we have no doubt, and in his study, and at the bedside, the student will find Dr. Hartshorne a safe and accomplished companion. We speak thus highly of the volume, because it approaches more we can heartily recommend the work of our transat- lantic colleague, and the busy practitioner, we are sure, will find in it the means of solving many a doubt, and will rise from the perusal of its pages, having gained clearer views to guide him in his daily struggle with disease.—Dub. Med. Press, Oct. 2, 1867. Pocket handbooks of medicine are not desirable, even when they are as carefully and elaborately com- piled as this, the latest, most complete, and most ac- curate which we have seen.—British Med. Journal, Sept. 21, 1867. This work of Dr. Hartshorne must not be confound- ed with the medical manuals so generally to be found in the hands of students, serving them at best but as blind guides, better adapted to lead them astray than to any useful and reliable knowledge. The work be- fore us presents a careful synopsis of the essential elements of the theory of diseased action, its causes, phenomena! and results, and of the art of healing, as recognized by the most authoritative of our profes- sional writers and teachers. A very careful and can- did examination of the volume has convinced us that it will be generally recognized as one of the best man- uals for the use of the student that has yet appeared. —American Journal Med. Sciences, Oct. 1867. TX7ATSON {THOMAS), 31. D., ice LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC Delivered at King's College, London. A new American, from the last revised 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 octavo, of over 1200 closely printed pages in small type; extra cloth, $6 50; strongly bound in leather, with raised bands, $7 50. Believing this to be a work which should lie on the table of every physician, and be in the hands of every student, every effort has been made to condense the vast amount of matter which it con- tains within a convenient compass, and at a very reasonable price, to place it within reach of all. In its present enlarged form, the work contains the matter of at least three ordinary octavos, rendering it one of the cheapest works now offered to the American profession, while its mechani- cal execution makes it an exceedingly attractive volume. DICKSON'S ELEMENTS OF MEDICINE ; a Compen- dious View of Pathology and Therapeutics, or the History and Treatment of Diseases. Second edi- tion, revised. 1 vol. 8vo. of 750 pages, extra cloth. $1 00. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER Death in Medical Cases. Published under the authority of the London Society for Medical Obser- vation. From the second London edition. 1 vol. royal 12mo., extra cloth. $1 00. LAYCOCK'S LECTURES ON THE PRINCIPLES and Methods of Medical Observation and Re- search. For the use of advanced students and junior practitioners. In one very neat royal 12mo. volume, extra cloth. $1 00. B ARCLAY {A. W.), M. D. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. Third American from the second and revised London edition. In one neat octavo volume of 451 pages, extra cloth. !t>3 50. A work of immense practical utility.—London I The book should be in the hands of every practical ■ted. Times and Gazette. man.—Dublin Med. Press. PULLER {HENRY WILLIA31), M. D., -*- Physician to St. George's Hospital, London. ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised English edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. (Just Issued.) Dr. Fuller's work on diseases of the chest was so | accordingly we have what might be with perfect jus- favorably received, that to many who did not know | tice styled an entirely new work from his peu, the the extent of his engagements, it was a matter of won- j portion of the work treating of the heart aud great der that it should be allowed to remain three years vessels being excluded. Nevertheless, this volume is out of print. Determined, however, to improve it, of almost equal size with the first.— London Medical Dr. Fuller would not consent to a mere reprint, and Tvnes and Gazette, July 2C, 1867. Henry C. Lea's Publications—(Practice of 3Iedicine). 17 ]?LINT {A USTIN), M. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, extra cloth, $4 50. (Just Issued.) Premising this observation of the necessity of each student and practitioner making himself acquainted with auscultation and percussion, we may state our honest opinion that Dr. Flint's treatise is one of the most trustworthy guides which he can consult. The style is clear and distinct, and is also concise, being free from that tendency to over-refinement and unne- cessary minuteness which characterizes many works on the same subject.—Dublin Medical Press, Feb. 6, 1867. In the invaluable work before us, we have a book of facts of nearly 600 pages, admirably arranged, clear, thorough, and lucid on all points, without pro- lixity; exhausting every point and topic touched ; a monument of patient and long-continued observation, which does credit to its author, and reflects honor on American medicine.—Atlanta Med. and Surg. Jour- nal, Feb. 1867. The chapter on Phthisis is replete with interest; and his remarks on the diagnosis, especially in the early stages, are remarkable for their acumen and great practical value. Dr. Flint's style is clear and elegant, and the tone of freshness and originality which pervades his whole work lend an additional force to its thoroughly practical character, which cannot fail to obtain for it a place as a standard work on diseases of the respiratory system.—London Lancet, Jan. 19, 1867. This is an admirable book. Excellent in detail and execution, nothing better could be desired by the practitioner. Dr. Flint enriches his subject with much solid and not a little original observation.— Banking's Abstract, Jan. 1867. B Y THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY,- AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume of nearly 500 pages, with a plate ; extra cloth, S3 50. We question the fact of any recent American author In our profession being more extensively known, or more deservedly esteemed in this country than Dr. Flint. We willingly acknowledge his success, more particularly in the volumeon diseases of the heart, in making an extended personal clinical study available for purposes of illustration, in connection with cases which have been reported by other trustworthy ob- servers.—Brit, and For. Med.-Chir. Review. (1HA3IBERS {T. K.), M. D., ^y Consulting Physician to St. Mary's Hospital, London, U3ISTEAD {FREEMAN J), •*-■* Professor of Venereal Diseases in the 0 (1ULLERIER {A.), and V-^ Surgeon to the Hbpital du Midi. -*--' Professor of Venereal Diseases in the College of Physicians and Surgeons, N. Y. AN ATLAS OF VENEREAL DISEASKS. Translated and Edited by Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life; strongly bound in extra cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at $•'! per part. (Just Ready.) As the successor of Ricord in the great Venereal Hospital of Paris, M. Cullerier has enjoyed special advnntages for the present undertaking, and his series of illustrations, though only recently finished, is already recognized as the most complete and comprehensive that has yet appeared on this subject. In reproducing these plates every care has been had to preserve their artistic finish and nccuracy, and they are confidently presented as equal to anything that has yet been produced in this country. The reputation of Dr. Bumstead as a writer and syphilographer is too well known to require other guarantee for the fidelity of the translation or the value of the additions introduced. Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, thus placing it within the reach of all who are interested in this department of prac- tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. *#* A specimen of the plates and text sent free by mail, on receipt of 25 cents. This is a very handsome edition in English of a well-known and highly valued French publication. That Dr. Bumstead, the author of by far the best and most popular treatise on venereal diseases in the English language, should think it proper to translate' Tllis is probaDly the handsomest work of its class and edit this one, speaks more highly in its favor than anything that can be said. It is a judgment ex ca- thedra. The translation is an excellent one. The plates in the first Part represent blennorrhagia and its complications, swelled testicle, and gonorrhceal ophthalmia. They are admirably and artistically ex- ecuted. Indeed they are superior to any illustrations of the kind hitherto executed in this country. The notes added by Dr. Bumstead enhance the value of the work. The whole getting-up of this publication is of rare excellence, and most creditable to all con- cerned.— Am. Journ. of Med. Sciences, April, 1S6S. A magnificent work, in the best style of artistic illustration.—Chicago Med. Journal, April, 186S. We desire now especially to call the attention of the profession to the appearance of this magnificent work. The plates in chromo-hthography are most admirably executed, and compare very favorably in distinctness and brilliancy with the ong.nals, as we know from personal examination. Theappearance of the work in parts places it within the reach of all, and when completed it will be a most valuable accession to our literature.—N. Y. Med. Journal, April, 1SUS. ever published in this country.—Boston Med. and Surg. Journal, April 15, 1868. The two parts thus published are illustrated by plates, than which none superior have been issued from the press; in fact, in this country, no more magnificent work has ever been published. Infinite credit is due the publisher and translator that they should have placed before the profession, in such a style, so valuable a production.—St. Louis Med. Re- porter, May, 1868. This is one of the most elegantly published and valuable works that have been reprinted and edited in this country, relating to the loathsome, though im- portant, class of venereal diseases. The author and editor are alike men of experience and eminent abi- lity and we freely commend the product of their labors to the general patronage of the profession.— Chicago Med.'Examiner, May, 1S68. L allemand and wilson. 'a prvcticvl treatise on the causes, symptoms, antt> TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and A H hv Henry J MoDougall. Fifth American edition. To which is added-----ON T NFASES OF THE VESICULjE SEMINALES, and their associated organs. With * 1 ference to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. specia re^ ^rILg0N jj.d. In one neat octavo volume, of about 400 pp., extra cloth, $2 75. // ILL {BERKELEY), Surgeon to the Lock Hospital, London. ox syphilis and local contagious DISORDERS. In one handsome octavo volume. (Nearly Ready.) 20 Henry C. Lea's Publications—(Diseases of the Skin). WILSON {ERAS31 US), F. R. S., ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $5. (Now Ready.) A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN," consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. From the Preface to the Sixth English Edition. The present edition has been carefully revised, in many parts rewritten, and our attention has been specially directed to the practical application and improvements of treatment. And, in conclusion, we venture to remark that if an acute and friendly critic should discover any differ- ence between our present opinions and those announced in former editions, we have only to ob« serve that science and knowledge are progressive, and that we have done our best to move onward with the times. The industry and care with which the author has revised the present edition are shown by the fact that the volume has been enlarged by more than a hundred pages. In its present improved form it will therefore doubtless retain the position which it has acquired as a standard and classical authority, while at the same time it has additional claims on the attention of the profession as the latest and most complete work on the subject in the English language. We can safely recommend it to the profession as the best work on the subject now in existence in the English language.—Medical Times and Gazette. Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases; it includes almost every fact or opinion of importance connected with the anatomy and pathology of the skin.—British and Foreign Medical Review. These plates are very accurate, and are executed with an elegance and taste which are highly creditable to the artistic skill of the American artist whoexecuted them.—St. Louis Med. Journal. The drawings are very perfect, and the finish and coloring artistic and correct; the volume is an indis- pensable companion to the book it illustrates and completes.—Charleston Medical Journal. Such a work as the one before us is a most capital and acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his book on diseases of the skin has long been re- garded as one of the best text-books extant on the subject. The present edition is carefully prepared, and brought up in its revision to the present time. In this edition we have also included the beautiful series of plates illustrative of the text, and in the last edi- tion published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great fidelity the various groups of diseases treated of in the body of the work.—Cin- cinnati Lancet, June, 1863. No one treating skin diseases should be without a copy of this standard work.— Canada Lancet. August, 1863. J)Y THE SAME AUTHOR. — THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- eases op the skin. Intone very handsome royal 12mo. volume. $3 50. (Lately Issued.) T>Y THE SAME AUTHOR. ---- HEALTHY SKIN; a Popular Treatise on the Skin and Hair, their Preservation and Management. One vol. 12mo., pp. 291, with illustrations, cloth. $1 00. lyELIGAN {J.MOORE), M.D.,M.R.I.A., A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M.D. In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. (Just Issued.) Of the remainder of the work we have nothing be- This instructive little volume appears once more. yond unqualified commendation to offer. It is so far Since the death of its distinguished author, the study the most complete one of its size that has appeared, of skin diseases has been considerably advanced, and and for the student there can be none which can com- the results of these investigations have been added pare with it .in practical value. All the late disco- by the present editor to the original work of Dr. Neli- veries in Dermatology have been duly noticed, and gan. This, however, has not so far increased its bulk their value justly estimated; in a word, the work is as to destroy its reputation as the most convenient fully up to the times, and is thoroughly stocked with manual of diseases of the skin that can be procured most valuable information.—New York Med. Record,: by the student.—Chicago Med. Journal, Dec. 1866. Jan. 15, 1867. | >Y THE SAME AUTHOR. ---- ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of disease. Extra cloth, $5 50. inclined to consider it a very superior work, com- bining accurate verbal description wjth sound views of the pathology and treatment of eruptive diseases. —Glasgow Med. Journal. A compend which will very much aid the practi- tioner in this difficult branch of diagnosis. Taken with the beautiful plates of the Atlas, which are re- markable for their accuracy and beauty of coloring, it constitutes a very valuable addition to the library of a practical man.—Buffalo Med. Journal. B The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheless, Dr. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong While looking over the "Atlas" we have been induced to examine also the "Practical Treatise," and we are TJILLIER {THOMAS), M.D., -LI Physician to the Skin Department of University College Hospital, &c. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. ~"In one neat royal 12mo. volume of about 300 pages, with two plates; extra cloth, $2 25. (Just Issued.) .__ Henry C. Lea's Publications—(Diseases of Children). 21 (JONDIE {D. FRANCIS), 31. D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. t-ixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, extra cloth, $5 25 ; leather, $6 25. (Now Ready.) From the Author's Preface. In preparing for the press this sixth edition of his treatise on the Diseases of Children, the great aim of the author has been to present a complete and faithful exposition of the pathology and therapeutics of the maladies incident to the earlier stages of existence. The entire work has undergone a careful and thorough revision ; while in the different sections has been incorporated every important observation in reference to the diseases of which they treat, that has been re- corded since the appearance of the last edition. Every effort has been made, and every available source of information sought after, to render the treatise a reliable and useful guide to the actual Btate of medical knowledge in reference to all those diseases which either exclusively or most usu- ally occur between birth and puberty—diseases which form, in some degree, a class apart from those of the adult—and demand for their cure a particular plan of treatment. Dr. Condie has been one of those who have per- formed such a service satisfactorily, and, as a result, his popular, comprehensive, and practical work has received that high compliment of approval on the part of his brethren, which several editions incontes- tably set forth; The present edition, which is the sixth, is fully up to the times in the discussion of all those points in the pathology and treatment of infan- tile diseases which have been brought forward by the German and French teachers. As a whole, however, the work is the best American one that we have, and in its special adaptation to American practitioners it certainly has no equal.—New York Med. Record, March 2, 1868. No other treatise on this subject is better adapted to the American physician. Dr. Condie has long stood before his countrymen as one peculiarly pre-eminent in this department of medicine. His work has been so long a standard for practitioners and medical stu- dents that we do no more now than refer to the fact that it has reached its sixth edition. We are glad once more to refresh the impressions of our earlier days by wandering through its pages, and at the same time to be able to recommend it to the youngest mem- bers of the profession, as well as to those who have the older editions on their shelves.—St. Louis Med. Reporter, Feb. 15, 1868. The work of Dr. Condie is unquestionably a very able one. It is practical in its character, as its title imports; but the practical precepts recommended in it are based, as all practice should be, upon a familiar knowledge of disease. The opportunities of Dr. Con- die for the practical study of the diseases of children have been great, and his work is a proof that they have not been thrown away. He has read much, but ob- served more ; and we think that we may safely say that the American student cannot find, in his own language, a better book upon the subject of which it treats.—Am. Journal Medical Sciences. We pronounced the first edition to be the best work on the diseases of children iu the English language, and, notwithstanding all that has been published, we still regard it in that light.—Medical Examiner. WITH {J. LE WIS), 31. D., *-J Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N Y. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. In one large octavo volume of about 650 pages. (Nearly Ready.) The object of the author has been to present within a moderate compass a complete but concise account of the pathology and therapeutics of the diseases incident to infancy and childhood, as viewed from the standpoint of the most advanced condition of medical science. The unusual opportunities which he has enjoyed of clinical observation in public and private practice cannot fail to render the work one of great practical value. WEST {CHARLES), 31. D., ' ' Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF INFANCY AND CHILD- HOOD. Fourth American from the fifth revised and enlarged English edition. In one large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $4 50; leather, $5 50. (Just issued.) affording the reader much pleasure, evenindependen Of all the English writers on the diseases of chil- dren, there is no one so entirely satisfactory to us as Dr. West. For years we have held his opinion as judicial, and have regarded him as one of the highest living authorities in the difficult department of medi- cal science in which he is most widely known. His writings are characterized by a sound, practical com- mon sense, at the same time that they bear the marks of the most laborious study and investigation. We commend it to all as a most reliable adviser on many occasions when many treatises on the same^ubjects will utterly fail to help uSj It is Wr}"*™**™* copious general index, and a special index to theifor- Zl* scattered throughout; the, work.-2»«fo» Med. and Surg. Journal, April 26, 18bb. Dr. west's volume is, in our opinion, incomparably With*'. t0° the'i)P"r°authority upon the maladies of children KCtitio'ner can consult "'^maUer truly" b, UsHU not" 'one ,..*t should be mu\Vo^d-Vv Wes •„ composition possesses a pecu- !^'!?'er,„. beauty and clearness of expression, thus liar charm, beauty of that which arises from the acquisition of valuable truths.—Cincinnati Jour, of Medicine, March, 1866. We have long regarded it as the most scientific and practical book on disease* of children which has yet appeared in this country—Buffalo Medical Journal. Dr. West's book is the best that has ever been written in the English language on the diseases of infancy and childhood.—Columbus Review of Med. and Surgery- There is no part of the volume, no subject on which it treats which does not exhibit the keen perception, die clear judgment, and the sound reasoning of the author. It will be found a most useful guide to the young practitioner, directing him in his management of children's diseases in the clearest possible manner, and enlightening him on many a dubious pathological point, while the older one will find in it many a sug- gestion and practical hint of great value —Brit. Am. Med Journal. I) F WEES { WILLIAM P.), 31. D., L de Professor of Midwifery, &>:, in the University of Pennsylvania, &c. TREATISE OX THE PHYSICAL AND MEDICAL TREAT- AiFVT OF CHILDREN. Eleventh edition, with the author's last improvements and cor- rections. In one octavo volume of 548 pages. $2 80. 22 Henry C. Lea's Publications—(Diseases of Women). /THOMAS {T. GAILLARD),3I.D., ■*- Professor of Obstetrics, &c in the College of Physicians and Surgeons, N. Y., Ac. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. In one large and handsome octavo volume of over 600 pages, with 219 illustrations, extra cloth, $5; leather, $6. (Now Ready.) From the Preface. " This work was undertaken with the conviction that a treatise, such as that which the Author has aimed to prepare, was needed as a text-book for the American student, and as a book of reference for the busy practitioner. " No department of medicine has made greater advances within the last few years than Gyne- cology ; yet the record of its progress is, for the most part, to be found only in special monographs, journals, transactions of societies, &c, and is thus inaccessible to the mass of the profession in this country. It has, therefore, seemed to the author that a volume which should, within a limited space, present the latest aspect of the subject in a systematic form, could scarcely fail to prove useful, while his position for the last thirteen years as a teacher in this department has encouraged him, in the hope that his familiarity with the needs of the student may, to some extent, have fitted him to undertake the task." The best text-book for students, and a perfect va.de mecum to the gynecologist.—N. Y. Journal of Obstet- rics, May, 1868. We have recently been almost flooded by works from American sources on the allied subjects of ob- stetrics and gynecology. Nor has quantity alone been the most noticeable feature connected with them, for their quality has invariably been of the highest. Dr. Thomas's work is no exception to this rule ; it is pre- eminently sound and practical, evincing much re- search and great clinical experience. It is further illustrated by upwards of two hundred engravings, some of them of great value.—London Med. Times and Gaz., April 25, 1868. The book of Prof. Thomas is well calculated to do away with this latter objection, and to accomplish more towards the establishment of a rational system of uterine therapeutics than any other work of its size in any language. We have rarely read any trea- tise upon a medical topic that has given us better satisfaction, or impressed us with the fitness of an au- thor for the proper performance of a most responsible task. It is perhaps unnecessary for us to commeud the work most heartily to every one who is or may be liable to treat uterine diseases.—N. York Medical Re- cord, April 15, 1868. A work which will certainly add to the reputation of its author, and come into general use in this coun- try as a text-book. The style is exceedingly clear and'concise, and the views expressed eminently prac- tical and scientific.—Quarterly Journ. of Psychol. Medicine, April, 1868. The work is concise and practical, avoiding the dis- cussion of unsettled questions, but giving a judicious resume of known facts.—Chicago Med. Journal, April, 1868. We are led to believe that it is the best work that has yet appeared on the diseases of women. There is about it a precision and accuracy, a fulness and completeness, a clearness and simplicity, to be found in no other book on the same subject within our knowledge ; its views on uterine pathology are, to our mind, more consonant with reason and common sense than any other we have seen. Enjoying fine opportunities in an extensive field of observation, Dr. Thomas, as an author, has fully sustained his high reputation as a teacher. We have no hesitation in strongly recommending it to the profession as the best exposition yet published of the subjects of which it treats.—Atlanta Med. and Surg. Journal, April, '6S. In no work with which we are acquainted, is there to be found so full and complete an exhibit of the im- proved means of diagnosis of the obscure subjects of gynecology, or of their more enlightened therapy. Did our space permit, we should be glad to go into an extended review of the work before us, giving not merely an outline of the subjects treated of, but full extracts from the text itself. As it is, we can only recommend our readers to buy it, feeling convinced they will be amply repaid for the outlay.—Leaven- worth Medical Herald, May, 1868. Indeed, we do not know a better study in briefer space, not for medical students merely, but for prac- titioners, who may really wish to have light upon an obscure pathway, to be trained in the thorough in- vestigation of diseases peculiar to women, than is herein to be found.— Western Journal of Medicine, May, 1868. It is a masterly rtsumt of what is known, by an experienced and honest observer. The Profession is indebted to Prof. Thomas for thus tabulating the much that has been accepted as valuable and reliable in gynecology, but this is not by any means all the merit of the work ; we have his ample experience, given in his opinions on pathology and treatment, which carry conviction by the confidence we feel that they are the candid opinions of an honest and compe- tent observer.—Humboldt Med. Archives, April, 186S. flHURCHILL {FLEETWOOD), 31. D., 31. R. I. A. ON THE DISEASES OF WOMEN; including those of Pregnancy and Childbed. A new American edition, revised by the Author. With Notes and Additions, by D. Francis Condie, M. D., author of " A Practical Treatise on the Diseases of-Chil- dren." With numerous illustrations. In one large and handsome octavo volume of 768 pages, extra cloth, $4 00; leather, $5 00. TOY THE SAME AUTHOR. ---- ESSAYS ON THE PUERPERAL FEYER, AND OTHER DIS- EASES PECULIAR TO WOMEN. Selected from the writings of British Authors previ- ous to the close of the Eighteenth Century. In one neat octavo volume of about 450 pages, extra cloth. $2 50. BROWN ON SOME DISEASES OF WOMEN AD- MITTING OF SURGICAL TREATMENT. With handsome illustrations. One volume Svo., extra cloth, pp. 276. *1 60. ASHWELL'S PRACTICAL TREATISE ON THE DIS- EASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Thi id American, from the Third and revised Lon- don edition. In one octavo volume, extra cloth, of 528 pages. $3 50. RIGBY ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. DEWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's last improvements and correc- tions. In one octavo volume of 536 pages, with plates, extra cloth, $3 00. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES. Translated by C. D. Meigs, M. D. Se- cond edition. In one vol. Svo, extra cloth, with numerous wood-cuts. pp. 720. $3 75. BENNETT'S PRACTICAL TREATISE ON INFLAM- MATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Sixth American, from the fourth aud re- vised English edition. 1 vol. 8vo., of about 500 pages, extra cloth. $3 75. Henry C. Lea's Publications—(Diseases of Women). 23 JJODGE (HUGH E). M.D. Ementus Professor of Obstetrics, &c, in Vie University of Pennsylvan ia. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. Second edition, revised and enlarged. In one beautifully printed octavo volume of 531 pages, extra cloth. $4 50. (Now Ready ) " n® Preparation of this edition the author has spared no pains to improve it with the results of his observation and study during the interval which has elapsed since the first appearance of the work. Considerable additions have thus been made to it, which have been partially accom- modated by an enlargement in the size of the page, to avoid increasing unduly the bulk of the volume. From Prop. W. H. Btford, of the Rush Medical College, Chicago. The book bears the impress of a master hand, and must, as its predecessor, prove acceptable to the pro- fession. In diseases of women Dr. Hodge has estab- lished a school of treatment that has become world- wide in fame. Professor Hodge's work is truly an original one from beginning to end, consequently no one can pe- ruse its pages without learning something new. The book, which is by no means a large one, is divided into two grand sections, so to speak : first, that treating of the nervous sympathies of the uterus, and, secondly, that which speaks of the mechanical treatment of dis- placements of that organ. He is disposed, as a non- believer in the frequency of inflammations of the uterus, to take strong ground against many of the highest authorities in this branch of medicine, and the arguments which he offers in support of his posi- tion are, to say the least, well put. Numerous wood- cuts adorn this portion of the work, and add incalcu- lably to the proper appreciation of the variously shaped instruments referred to by our author. As a contribution to the study of women's diseases, it is of great value, and is abundantly able to stand on its own merits.—AT. Y. Medical Record, Sept. 15, 1S68. In this point of view, the treatise of Professor Hodge will be indispensable to every student in its department. The large, fair type and general perfec- tion of workmanship will render it doubly welcome. —Pacific Med. and Surg. Journal, Oct. 1868. Jl/'EST {CHARLES), M.D. LECTURES ON THE DISEASES OF WOMEN. Third American, from the Third London edition. In one neat octavo volume of about 550 pages, extra cloth. $3 75 ; leather, $4 75. (Now Ready.) The reputation which this volume has acquired as a standard book of reference in its depart- ment, renders it only necessary to say that the present edition has received a careful revision at the hands of the author, resulting in a considerable increase of size. A few notices of previous editions are subjoined. The manner of the author is excellent, his descrip- tions graphic and perspicuous, and his treatment up to the level of the time—clear, precise, definite, and marked by strong common sense. — Chicago Med. Journal, Dec. 1S61. We cannot too highly recommend this, the second edition of Dr. West's excellent lectures on the dis- eases of females. We know of no other book on this subject from which we have derived as much pleasure and instruction. Every page gives evidence of the honest, earnest, and diligent searcher after truth. He is not the mere compiler of other men's ideas, but his lectures are the result often years' patient investiga- tion in one of the widest fields for women's diseases— St. Bartholomew's Hospital. As a teacher, Dr. West is simple and earnest in his language, clear and com- prehensive in his perceptions, and logical in his de- ductions.—Cincinnati Lancet, Jan. 1862. We return the author our grateful thanks for the vast amount of instruction he has afforded us. His valuable treatise needs no eulogy on our part. His graphic diction and truthful pictures of disease all speak for themselves.— Medico-Chirurg. Review. Most justly esteemed a standard work. .... It bears evidence of having been carefully revised, and is well worthy of the fame it has already obtained. —Dub. Med. Quar. Jour. jDF THE SAME AUTHOR. ---- AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCERATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. nrFTr"? (CHARLES D.), 31. D., Ill Late Professor of Obstetrics, Ac. in Jefferson Medical College, Philadelphia. WOMAN: HER DISEASES AND THEIR REMEDIES. A Series ;Ta„(„', to his Class. Fourth and Improved edition. In one large and beautifully printed octavo volume ofover 700 pages, extra cloth, $5 00; leather, $6 00. r»Y THE SAME AUTHOR. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED ■pFVl-IR In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume of 365 pages, extra cloth. $2 00. rUPSON {SIR JAMES U), 31.D. CIJXICAL LECTURES ON THE DISEASES OF WOMEN. With ^ numerous illustrations. In one octavo volume of over 500 pages. Second edition, preparing. As a writer, Dr. West stands, in our opinion, se- cond only to Watson, the "Macaulay of Medicine;" he possesses that happy faculty of clothing instruc- tion in easy garments; combining pleasure with profit, he leads his pupils, in spite of the ancient pro- verb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a candid, safe, and valuable guide.—N. A. Med.-Chirurg Review. 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 every page.—N. Y. Journal of Medicine. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language, and that it stamps Dr. West as the facile princeps of British obstetric authors.—Edinburgh Med. Journal. We gladly recommend his lectures as in the highest degree instructive to all who are interested in ob- stetric practice.—London. Lancet. We know of no treatise of the kind so complete, and yet so compact.—Chicago Med. Journal. s 24 Henry C. Lea's Publications—(Midwifery). JJODGE {HUGH L.), M.D., Emeritus Professor of Midwifery, &c. in the University of Pennsylvania, &c. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- trated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. (Lately published.) The work of Dr. Hodge is something more than a simple presentation of his particular views in the de- partment of Obstetrics ; it is something more than an ordinary treatise on midwifery ; it is, in fact, a cyclo- psedia of midwifery. He has aimed to embody in a single volume the whole science and art of Obstetrics. An elaborate text is combined with accurate and va- ried pictorial illustrations, so that no fact or principle is left unstated or unexplained.—Am. Med. Times, Sept. 3, 1864. We should like to analyze the remainder of this excellent work, but already has this review extended beyond our limited space. We cannot conclude this notice without referring to the excellent finish of the work. In typography it is not to be excelled; the paper is superior to what is usually afforded by our American cousins, quite equal to the best of English books. The engravings and lithographs are most beautifully executed. The work recommends itself for its originality, and is in every way a most valu- able addition to those on the subject of obstetrics.— Canada Med. Journal, Oct. 1864. It is very large, profusely and elegantly illustrated, and is fitted to take its place near the works of great obstetricians. Of the American works on the subject it is decidedly the best.— Edinb. Med. Jour., Dec. '64. *=*# Specimens of the plates and letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. We have examined Professor Hodge's work with great satisfaction ; every topic is elaborated most fully. The views of the author are coyipr^hensive, and concisely stated. The rules of pi ;m:i i< •■ are judi- cious, and will enable the practitioner to meet every emergency naI edition is already so extensively and favorably known to the profession that no recom- mendation is necessary; it is sufficient to say, the present edition is very much extended, improved, aud perfected Whilst the great practical talents and unlimited experience of the author render it a most valuable acquisition to the practitioner, it is so con- densed as to constitute a most eligible and excellent text-book for the student.—Southern Med. and Surg. Journal, July, 1867. It is to the student that our author has more par- ticularly addressed himself; but to the practitioner we believe it would be equally serviceable as a book of reference No work that we have met with so thoroughly details everything that falls to the lot of the accoucheur to perform. Every detail, no matter how minute or how trivial, has found a place.— Canada Medical Journal, July, 1867. This very excellent work on the science and art of obstetrics should be in the hands of every student and practitioner. The rapidity with which the very large editions have been exhausted is the best test of its true merit Besides, it is the production of an Ame- rican who has probably had more experience in this branch than any other living practitioner of the conn- try.—St. Louis Med. and Surg. Journal, Sept. 1867. He has also carefully endeavored to be minute and clear in his details, with as little reiteration as possi- ble, and beautifully combines the relations of science to art, as far as the different classifications will admit. —Detroit Review of Med. and Pharm., Aug. 1867. We now take leave of Dr. Meigs. There are many other and interesting points in his book on which we would fain dwell, but are constrained to bring our ob- servations to a close. We again heartily express our approbation of the labors of Dr. Meigs, extending over many years, and culminating in the work before us, full of practical hints for the inexperienced, and even for those whose experience has been considerable.— Glasgow Medical Journal, Sept. 1867. JDA3ISBOTHAM {FRANCIS H.), 31.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- CINE 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 of Obstetrics, Ac, 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. $7 00. To the physician's library it is indispensable, while We will only add that the student will learn from It all he need to know, and the practitioner will find it, as a book of reference, surpassed by none other.— Stethoscope. The character and merits of Dr. Ramsbotham's work are so well known and thoroughly established, that comment is unnecessary and praise superfluous. The illusi rations, which are numerous and accurate, are executed in the highest style of art. We can Dot too highly recommend the work to our readers.—St. Louis Med. and Surg. Journal. to the student, as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med. and Surg. Journal. When we call to mind the toil we underwent in acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which this work will afford him.—Am. Jour, of the Med. Sciences. ft BUR CHILL {FLEETWOOD), 31. D., 31. R.I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additions by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- dren," &c. With one hundred and ninety-four illustrations. In one very handsome octavo volume of nearly 700 large pages. Extra cloth, $4 00; leather, $5 00. In adapting this standard favorite to the wants of the profession in the United States, the editor has endeavored to insert everything that his experience has shown him would be desirable for the American student, including a large number of illustrations. With the sanction of the author, he has added in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses " recently issued by Dr. Churchill, believing that the details there presented can hardly fail to'prove of advantage to the junior practitioner. The result of all these additions is that the work now contains fully one-half more matter than the last American edition, with nearly one- half more illustrations; so that, notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. These additions render the work still more com- plete and acceptable than ever; and with the excel- lent style in which the publishers have presented this edition of Churchill, we can commend it to the professiou with great cordiality and pleasure.—Cin- cinnati Lancet. I"evv works on this branch of medical science are ual t0 it, certainly none excel it, whether in regard t theory or practice, and in one respect it is superior to all others, viz., in its statistical information, and :. -..gfore, on these grounds a most valuable work for the obvsi'cian, student, or lecturer, all of whom will find in it the information which they are seeking.— Brit. Am- Journal. The present treatise Is very much enlarged and pliiied beyond the previous editions but nothing has been added which could be well dispensed with. An examination of the table of contents shows how thoroughly the author has gone over the ground, and the care he has taken in the text to present the sub- jects in all their bearings, will render this new edition even more necessary to the obstetric student than were either of the former editions at the date of their appearance. No treatise on obstetrics with which we are acquainted can compare favorably with this, in respect to the amount of material which has been gathered from every source.—Boston Med. and Surg. Journal. There is no better text-book for students, or work of reference and study for the practising physician than this. It should adorn and enrich every medical library.—Chicago Med. Journal. 26 Henry C. Lea's Publications—(Surgery). QROSS {SAMUEL D.), M.D., Professor of Surgery in the Jefferson Medical College of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Thirteen Hundred Engravings. Fourth edition, carefully revised, and improved. In two large and beautifully printed royal octavo volumes of 2200 pages, strongly bound in leather, with raised bands. $15 00. The continued favor, shown by the exhaustion of successive large editions of this great work. proves that it has successfully supplied a want felt by American practitioners and students. Though but little over six years have elapsed since its first publication, it has already reached its fourth edition, while the care of the author in its revision and correction has kept it in a constantly im- proved shape. By the use of a close, though very legible type, an unusually large amount of matter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. It must long remain the most comprehensive work on this important part of medicine.—Boston Medical and Surgical Journal, March 23, 1865. We have compared it with most of our standard works, such as those of Erichsen, Miller, Fergusson, Syme, and others, and we must, in justice to our author, award it the pre-eminence. As a work, com- plete in almost every detail, no matter how minute or trifling, and embracing every subject known in the principles and practice of surgery, we believe it stands without a rival. Dr. Gross, in his preface, re- marks "my aim has been to embrace the whole do- main of surgery, and to allot to every subject its legitimate claim to notice;" and, we assure our readers, he has kept his word. It is a work which we can most confidently recommend to our brethren, for its utility is becoming the more evident the longer it is upon the shelves of our library.—Canada Med. Journal, September, 1865. The first two editions of Professor Gross' System of Surgery are so well known to the profession, and so highly prized, that it would be idle for us to speak in praise of this work. — Chicago Medical Journal, September, 1865. We gladly indorse the favorable recommendation of the work, both as regards matter and style, which we made when noticing its first appearance.—British and Foreign Medico-Chirurgical Review, Oct. 1865. The most complete work that has yet issued from the press on the science and practice of surgery.— London Lancet. This system of surgery is, we predict, destined to take a commanding position in our surgical litera- ture, and be the crowning glory of the author's well earned fame. As an authority on general surgical subjects, this work is long to occupy a pre-eminent place, not only at home, but abroad. We have no hesitation in pronouncing it without a rival in our language, and equal to the best systems of surgery in any language.—N. Y. Med. Journal. Not only by far the best text-book on the subject, as a whole, within the reach of American students, but one which will be much more than ever likely to be. resorted to and regarded as a high authority abroad.—Am. Journal Med. Sciences, Jan. 1865. The work contains everything, minor and major, operative and diagnostic, including mensuration and examination, venereal diseases, and uterine manipu- lations and operations. It is a complete Thesaurus of inodera aurgery, where the student and practi- Z>Y THE SAME AUTHOR. ---- A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second edition, revised and much enlarged, with one hundred and eighty-four illustrations. In one large and very handsome octavo volume, of over nine hundred pages, extra cloth. $4 00. tioner shall not seek in vain for what they desire.— San Francisco Med. Press, Jan. 1S65. Open it where we may, we find sound practical in- formation conveyed in plain language. This book is no mere provincial or even national system of sur- gery, but a work which, while very largely indebted to the past, has a strong claim on the gratitude of the future of surgical science.—Edinburgh Med. Journal, Jan. 1S65. A glance at the work is sufficient to show that the author and publisher have spared no labor in making it the most complete "System of Surgery" ever pub- lished in any country.—St. Louis Med. and Surg. Journal, April, 1865. The third opportunity is now offered during our editorial life to review, or rather to indorse and re- commend this great American work on Surgery. Upon this last edition a great amount of labor has been expended, though to all others except the authoi the work was regarded in its previous editions as so full and complete as to be hardly capable of improve- ment. Every chapter has been revised; the text aug- mented by nearly two hundred pages, and a con- siderable number of wood-cuts Have been introduced. Many portions have been entirely re-written, and the additions made to the text are principally of a prac tical character. This comprehensive treatise upon surgery has undergone revisions and enlargements, keeping pace with the progress of the art and science of surgery, so that whoever is in possession of this work may consult its pages upon any topic embraced within the scope of its department, and rest satisfied that its teaching is fully up to the present standard of surgical knowledge. It is also so comprehensive that it may truthfully be said to embrace all that is actually known, that is rearlly of any value in the diagnosis and treatment of surgical diseases and acci- dents. Wherever illustration will add clearness to the subject, or make better or more lasting impression, it is not wanting; in this respect the work is eminently superior.—Buffalo Med. Journal, Dec. 1864. A system of surgery which we think unrivalled in our language, and which will indelibly associate his name with surgical science. And what, in our opin- ion, enhances the value of the work is that, while the practising surgeon will find all that he requires in it, it is at the same time one of the most valuable trea- tises which can be put into the hands of the student seeking to know the principles and practice of this branch of the profession which he designs subse- quently to follow.—The Brit. Am. Journ., Montreal. Whoever will peruse the vast amount of valuable practical information it contains will, we think, agree with us, that there is no work in the English Ian- B guage which can make any just pretensions to be its equal.—N. Y. Journal of Medicine. Y THE SAME AUTHOR. ---- A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In one handsome octavo volume, extra cloth, with illustrations pp. 468. $2 75. Henry C. Lea's Publications—(Surgery). 27 fiRlCHSEN {JOHN), Professor of Surgery in University College, London. THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- gical Injuries, Diseases, and Operations. New and improved American, from the Second enlarged and carefully revised London edition. Illustrated with over four hundred wood engravings. In one large and handsome octavo volume of 1000 ciosely printed pages j extra doth, $6; leather, raised bands, $7. We are bound to state, and we do so without wish- i as one of the very best, if not the best text-book of lng to draw invidious comparisons, that the work of surgery with which we were acquainted, permits us Mr. Erichsen, in most respects, surpasses any that to give it but a passing notice totally unworthy of its has preceded it. Mr. Erichsen's is a practical work, merits. It may be confidently asserted, that no work combining a due proportion of the "Science and Art on the science and art of surgery has ever received of Surgery." Having derived no little instruction more universal commendation or occupied a higher from it, in* many important branches of surgery, we position as a general text-book on surgery, than this can have no hesitation in recommending it as a valu- treatise of Professor Erichsen.—Savannah Journal of able book alike to the practitioner and the student, i Medicine. -Dublin Quarterly. / i In fuiness 0f practical detail and perspicuity of Gives a very admirable practical view of the sci- ! style, convenience of arrangement and soundness of ence and art of surgery.—Edinburgh Med. and Surg. Journal. We recommend it as the best compendium of sur- gery in our language.—London Lancet. It is, we think, the most valuable practical work on surgery in existence, both for young and old prac- titioners.—Nashville Med. and Surg. Journal. The limited time we have to review this improved edition of a work, the first issue of -which we prized discrimination, as well as fairness and completeness of discussion, it is better suited to the wants of both student and practitioner than any of its predecessors. —Am. Journal of Med. Sciences. After careful and frequent perusals of Erichsen's surgery, we are at a loss fully to express our admira- tion of it. The author's style is eminently didactic, and characterized by a most admirable directness, clearness, and compactness.—Ohio Med. and Surg. Journal. B Y THE SAME AUTHOR. (Ready in June.) ON RAILWAY, AND OTHER INJURIES OF THE NERYOUS SYSTEM. In small octavo volume.- Extra cloth, $1 00. We welcome this as perhaps the most practically useful treatise written for many a day.—Medical Times. It will serve as a most useful aud trustworthy guide to the profession in general, many of whom may be consulted in such cases; and it will, no doubt, take its place as a text-book on the subject of which it treats.—Medical Press. /[TILLER {JAMES), llL Late Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with two hundred and forty illustrations on wood, extra cloth. $3 75. B Y THE SAME A UTHOR. ---- THE PRACTICE OF SURGERY. Fourth American, from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra cloth. $3 75? It is seldom that two volumes have ever made so I acquired. The author is an eminently sensible, prac- nrnfonnd ar, imnression in so short a time as the | tical, and well-informed man, who knows exactly pnitounu an lmpiessiuu Surgery by Mr. I what he is talking about and exactly how to talk it.— Mm'er.Tr to richly'meritedTh'repulaUof tlfey'have | Kentucky Medical Recorder. TJIRRIE { WILLIAM), F. R. S. E.. 1 Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by T H Neill M D., Professor of Surgery in the Penna. Medical College, Surgeon to the john i ^ , • ^ ^ jn one yery nan(jsome octavo volume of 780 pages, with 316 illustrations, extra cloth. $3 75. s- ARGENT {F. W.), M.D. -P, *vd\GING AND OTHER OPERATIONS OF MINOR SUR- (JJN liA~ ^ edition with an additional chapter on Military Surgery. One handsome royal GER1 • J>ew e ' , 400 pages with 184 wood-cuts. Extra cloth, $1 75. 12mo. volume, "* " j ° „„,7«nient and valuable to all mem- Exceedingly conjenie_ Medical Examiner, bers of the profession. May, 1862. mannal of Minor Surgery we have J^B%a\oMTaical Journal. ________ We cordially commend this volume as one which the medical student should most closely study; and to the surgeon in practice it must prove itself instruct- ive on many points which he may have forgotten.— Brit. Am. Journal, May. 1S02. Tn*lGNE'S OPERATIVE SURGERY. MAlXJAll7,lllstrations on wood. In one meroUSvolume, extra cloth, of nearly 600 pp. * octavo With nu- ne handsome .50. SKEY'S OPERATIVE SURGERY. In one very hand- some octavo volume, extra cloth, of over 650 pages, with about 100 wood-cats. $3 25. 28 Henry C. Lea's Publications—(Surgery). jyRUITT {ROBERT), 31.R. C.S., 6?c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition. Illus- trated with four hundred and thirty-two wood-engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages. Extra cloth, $4 00; leather, $5 00. Besides the careful revision of the author, this work has had the advantage of very thorough editing on the part of a competent surgeon to adapt it more completely to the wants of the Ameri- can student and practitioner. Many illustrations have been introduced, and every care has been taken to render the mechanical execution unexceptionable. At the very low price affixed, it will therefore be found one of the most attractive and useful volumes accessible to the American practitioner. All that the surgical student or practitioner could theoretical surgical opinions, no work tha't we are at desire.—Dublin Quarterly Journal. present acquainted with can at all compare with it. It is a most admirable book. We do not know > If « * compendium of surgical theory (if we may use when we have examined one with more pleasure.— , the wo.rd' and Practice in itself and well deserves Boston Med. and Surg. Journal. I the estimate placed upon it.—Brit. Am. Journal. In Mr. Druitt's book, though containing only some T,hus enlarged and improved, it will continue to seven hundred pages, both the principles and the , rallk am,on« °ur bDest ^f1:}0?** °n elementary sur- practice of surgery are treated, and so clearly and gery.—Columbus Rev. of Med. and Surg. perspicuously, as to elucidate every important topic. | We must close this brief notice of an admirable The fact that twelve editions have already been called ' work by recommending it to the earnest attention of for, in these days of active competition, would of every medical student.—Charleston Medical Journal itself show it to possess marked superiority. We and Review. have examined the book most thoroughly, and can Bay that this success is well merited. His book, moreover, possesses the inestimable advantages of having the subjects perfectly well arranged and clas- sified, and of being written in a style at once clear and succinct.—Am. Journal of Med. Sciences. A text-book which the general voice of the profes- sion in both England and America has commended as one of the most admirable "manuals," or, "vude mecurn," as its English title runs, which can be placed in the hands of the student. The merits of Druitt's Surgery are too well known to every one to Whether we view Druitt's Surgery as a guide to need any further eulogium from us.—Nashville Mtd. operative procedures, or as representing the latest Journal. TTA3IILTON {FRANK H.), M.D., Professor of Fractures and Dislocations, &c. in Bellevue Hosp. Med. College, New York. A PRACTICAL TREATISE ON FRACTURES ANI) DISLOCA- TIONS. Third edition, thoroughly revised. In one large and handsome octavo volume of 777 pages, with 294 illustrations, extra cloth, $5 75. (Just Issued.) The demand which has so speedily exhausted two large editions of this work shows that the author has succeeded in supplying a want, felt by the profession at large, of an exhaustive treatise on a frequent and troublesome class of accidents. The unanimous voice of the profession, abroad as well as at home, has pronounced it the most complete work to which the surgeon can refer for information respecting all details of the subject. In the preparation of this new edition, the author has sedulously endeavored to render it worthy a continuance of the favor which has been accorded to it, and the experience of the recent war has afforded a large amount of material which he has sought to turn to the best practical account. In fulness of detail, simplicity of arrangement, and American professor of surgery; and his book adds accuracy of description, this work stands unrivalled, jone more to the list of excellent practical works which So far as we kuow, no other work on the subject in have emanated from his country, notices of which the English language can be compared with it. While j have appeared from time to time in our columns du- congratulating our trans-Atlantic brethren on the ring the last few months.—London Lancet, Dec. 15, European reputation which Dr. Hamilton, along with j 1866. many other American surgeons, has attained, we also These additions make the work much more valua- may be proud that, in the mother tongue, a classical ( ble, and it must be accepted as the most complete work has been produced which need not fear com pa-; monograph on the subject, certainly in our own, If rison with the standard treatises of any other nation. '• not even in any other language.— American Journal —Edinburgh Med. Journal, Dec. 1866. Med. Sciences, Jan. 1867. The credit of giving to the profession the only com I , Tbis 'l* <■}*? m<>st complete treatise on the subject in plete practical treatise on fractures and dislocations the English language.- Ranking s Abstract, Jan. 1867. in our language during the present century, belongs! A mirror of all that is valuable in modern surgery. to the author of the work before us, a distinguished ■ Richmond Med. Journal, Nov. 1666. BRODIE'S CLINICAL LECTURES ON SURGERY. 1 vol. 8vo., 350 pp.; cloth, $1 25. HARWELL'S TREATISE ON DISEASES OF THE JOINTS. With illustrations. 1 vol. Svo., of about 500 pages ; extra cloth, $3 00. BOOPER'S LECTURES ON THE PRINCIPLES AND Practice op Surgery. In one very large octavo volume, extra cloth, of 750 pages. $2 00. GIBSON'S INSTITUTES AND PRACTICE OF SUR- obry. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo vol- umes, about 1000 pages, leather, raised bands. $6 50 JONES' PRINCITLES AND PRACTICE OF OPH- THALMIC MEDICINE AND SURGERY. With one hundred and seventeen illustrations. Third and revised American, with Additions from the second London edition In one haudsome octavo volume of 455 pages, extra cloth. $3 25. MACKENZIE'S PRACTICAL TREATISE ON DIS- EASES AND INJURIES OF THE EYE. From the fourth revised and enlarged London edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &e. &c. In one very large and handsome octavo volume of 1027 pages, extra cloth, with plates and numerous woodcuts. $6 50. Henry C. Lea's Publications—(Surgery). 29 T0TNPBE {JOSEPH), F.R.S., rn-rr-p, Ural Surgeon to and Lecturer on Surgery at St. Mary's Hospital. 1HE DISEASES OF\THE EAR: their Nature, Diagnosis, and Treat- Plen!;' With one hundred engravings on wood. Second American edition^ In one very ndsomely printed octavo volume of 440 pages; extra cloth, $4. The appearance of a volume of Mr. Toynbee's, tbere- [_ fi. !LT-. Ch. the subject of aural disease is treated in tne most scientific manner, and our knowledge in respect to it placed fully on a par with that which we possess respecting most other organs of the body, is a matter for sincere congratulation. We may rea- sonably hope that henceforth the subject of this trea- tise will cease to be among the opprobria of medical science.—London Medical Review. The work, as was stated at the outset o' our notice, is a model of its kind, and every page and paragraph of it are worthy of the most thorough study. Con- sidered all in all—as an original work, well written, philosophically elaborated, and happily illustrated with cases and drawings—it is by far the ablest mo- nograph that has ever appeared on the anatomy and diseases of the ear, and one of the most valuable con- tributions to the art and science of surgery in the nineteenth century.—N. Am. Med.-Chirurg. Review. TA URENCE {JOHN Z.), F. R. C. S., and liTOON {ROBERT C), "^ Editor of the OpJUhalmic Review, &c. House Surgeon to the Southwark Oph- thalmic Hospital, &c. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. With numerous illustrations. In one very handsome octavo volume, extra cloth. $2 50. {Just Issued.) No book on ophthalmic surgery was more needed. Designed, as it is, for the wants of the busy practi- tioner, it is the neplus ultra, of perfection. It epito- mizes all the diseases incidental to the eye in a clear and masterly manner, not only enabling the practi- tioner readily to diagnose each variety of disease, but affording him the more imponant assistance of proper treatment. Altogether this is a work which ought certainly to be in the hands of every general practi- tioner.—Dublin Med. Press and Circular, Sept. 12, '66 We cordially recommend this book to the notice of our readers, as containing an excellent outline of modern ophthalmic surgery.—British Med. Journal, October 13, 1866. Not only, as its modest title suggests, a "Handy- Book" of Ophthalmic Surgery, but an excellent and well-digested risurni of all that is of practical value in the specialty.—New York Medical Journal, No- vember, 1866. This object the authors have accomplished in a highly satisfactory manner, and we know no work we can more highly recommend to the "busy practi- tioner" who wishes to make himself acquainted with the recent improvements in ophthalmic science. Such a work as this was much wanted at this time, and this want Messrs. Laurence and Moon have now well supplied.—Am. Journal Med. Sciences, Jan. 1867. TAWSON {GEORGE), F. R. C. S., Engl. ■U Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorfields, &c. INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- diate and Remote Effects. With about one hundred illustrations. In one very hand- some octavo volume, extra cloth, $3 50. (Now Ready.) ' This work will be found eminently fitted for the general practitioner. In cases of functional or structural diseases of the eye. the physician who has not made ophthalmic surgery a special Study can, in most instances, refer a patient to some competent practitioner. Cases of injury, however, supervene suddenly and usually require prompt assistance, and a work devoted espe- eially to them cannot but prove essentially useful to those who may at any moment be called upon to treat such accidents. The present volume, as the work of a gentleman of large experience, may be considered as eminently worthy of confidence for reference in all such emergencies. It is an admirable practical book in the highest and best sense of the phrase. Copiously illustrated by excellent woodcuts, and with well-selected well- described cases, it is written in plain, simple lan- guage, and in a style the transparent clearness and frankness, so to speak, of which, add greatly to its value and usefulness. Only a master ot his subject .ould so write ; every topic is handled wita«l ease •ecision, and straightforwardness, that show_ the skilful and highly educated surgeon writing ftom fulness of practical knowledge. We predict for Mr. Lawson's work a great and well-merited success. We are confident that the profession, and especially, as we have said, our country brethren, will feel grateful to him for having given them in it a guide and counsellor fully up to the most advanced state of Ophthalmic Surgery, and of whom they can make a trusty and familiar friend.—London Medical Times and Gazette, May 18, 18t>7. T Suraeon and Professor'of Clinical Surgery to University College Hospital. LFCTURES ON DISEASES OE THE URINARY ORGANS. With illustrations on wood. In one neat octavo volume. (Preparing for early publication.) JUTORLAND {W. IE), M.D. mWASFS OF THE URINARY ORGANS; a Compendium of their Dlbli-A.o , , an(l Treatment. With illustrations. In one large and handsome ocSvoiume of ao^ut 600 pages, extra cloth. $3 50. ■ „r» <-an recommend Dr. Morland's 1 of every medical or surgical practitioner.—Brit, and Taken asawhole,we^_abieadd.t.ontotheUbrarv | Fm. Med.-Chir. Review, April, 1859. compendium as a very ue __-----__---------- HURTING (T.B.), F.R.S, / 1 UJ^-LJ ^ London Hospital, Pre*ide7it of the Hnnterian Society, &-c. ■ PRACTICAL TREATISE ON DISEASES OF THE TESTIS, pFRMATIC CORD, AND SCROTUM. Second American, from the second and enlarged .. _Ji;0h «dition. In English edition. tioBB. PP-420' one handsome octavo volume, extra cloth, with numerous illustra- $2 00. 30 Henry C. Lea's Publications—(Surgery). y^TALES {PHILIP S.), M. D., Surgeon U. S. N MECHANICAL THERAPEUTICS: a Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations: embracing Minor Surgery, Band- aging, Orthopraxy, and the Treatment of Fractures and Dislocations. With six hundred and forty-two illustrations on wood. In one large and handsome octavo volume of about 700 pages : extra cloth, $5 75; leather, $6 75. (Just Issued.) A Naval Medical Board directed to examine and report upon the merits of this volume, officially states that " it should in our opinion become a standard work in the hands of every naval sur- geon;" and its adoption for use in both the Army and Navy of the United States is sufficient guarantee of its adaptation to the needs of every-day practice. The title of this book will give a reasonably good idea of its scope, but its merits can only be appreci- ated by a careful perusal of its text. No one who un- dertakes such a task will have any reason to com- plain that the author has not performed his duty, and has not taken every pains to present every subject in a clear, common-sense, and practical light. It is a unique specimen of literature in its way, in that, treating upon such a variety of subjects, it is as a whole so completely up to the wants of the student and the general practitioner. We have never seen any work of its kind that can compete with it in real utility and extensive adaptability. Dr. Wales per- fectly understands what may naturally be required of him in the premises, and in the work before us has bridged over a very wide gap which has always here- tofore existed between the first rudiments of surgery and practical surgery proper. He has emphatically given us a comprehensive work for the beginner; and when we say of his labors, that in their particular sphere they leave nothing to be desired, we assert a great deal to recommend the book to the attention of those specially concerned. In conclusion, we would state, at the risk of reiteration, that this is the most comprehensive book on the subject that we have seen ; is the best that can be placed in the hands of the stu- dent in need of a first book on surgery, and the most useful that can be named for such general practition- ers who, without any special pretensions to surgery, are occasionally liable to treat surgical cases.—N. Y. Med. Record, March 2, 1868. It is certainly the most complete and thorough work of its kind in the English language. Students and young practitioners of surgery will find it invaluable. It will prove especially useful to inexperienced coun- try practitioners, who are continually required to take charge of surgical cases, under circumstances precluding them from the aid of experienced surgeons. —Pacific Med. and Surg. Journal, Feb. 1868. This is a most complete and elegant work of 673 pages, and is certainly well deserving of the com- mendation of every American surgeon. This work, besides its usefulness as a reference for practitioners, is most admirably adapted as a text-book for students. Its 642 illustrations in wood-cuts, represent every man- ner of surgical appliance, together with a minute de- scription of each, the name of its inventor, and its prac- tical utility in mechanical surgery. There is, perhaps, no work in the English language so complete in the description and detail of surgical apparatus and ap- pliances as this one. The entire work entitles the au- thor to great credit for his clear^and distinct style as a writer, as well as for his accuracy of observation and great research in the field of surgery. We ear- nestly recommend every member of the profession to add a copy of it to his library, with the assurance that he will find some useful suggestion in the treat- ment of almost every surgical case that may come under his observation.—Humboldt Med. Archives, Feb. 1868. • It is the completestbook on these subjects we know of, and it cannot fail to be exceedingly useful to the busy practitioner, especially to the bu~y country phy- sician who has thrown upon bis care something of surgery in its various details, with all manner of gene- ral practice, and, therefore, may often wish to refresh himself as to the most convenient and elegant modes of dressings and manipulations.—Cincinnati Lancet and Observer, Jan. 1868. We have examined Dr. Wales' book with much care, and believe that his labor will greatly benefit the practitioner of surgery. It seems to us especially beneficial to the country medical practitioner who is surgeon, physician, and obstetrician, as occasion re- quires. We commend the work to our readers as a most useful one.—Nashville Med. and Surg. Journal, Jan. 1868. The title of the above work is sufficiently indica- tive of its contents. We have not seen for a Jong time (in the English language) a treatise equal to this in extent, nor one which is better adapted to the wants of the general student and practitioner. It is not to the surgeon alone that this book belongs; the physician has frequent opportunities to fill an emer- gency by such knowledge as is here given. Every practitioner should make purchase of such a book- it will last him his lifetime.—St. Louis Med. Re- porter, Feb. 1868. A useful book is always a necessary one, and that this book is eminently one of that character, needs but a glance at its pages to show. It certainly de- serves a place in the library of every physician.— Leavenworth Med. Herald, Feb. 1868. The book seems to be complete in every respect, and is a welcome addition to our shelves.—Boston Med. and Surg. Journal, Jan. 9, 1868. In our opinion it is a good book, and one which every student and practitioner needs in his library. Especially would its value be appreciated by the sur- geon whose field of practice is anywise remote from the larger cities.—Chicago Med. Journal, Jan. 1868. This volume will be a useful acquisition to a large number of the working members of the medical pro- fession in this country. Practitioners will find mate- rial aid and encouragement in its pages which they could nowhere else obtain, to the same extent, in so convenient a form.— Am. Journal Med. Sciences, Jan. 1868. He must be a blockhead indeed who, after study- ing this portion of the book before us, fails to adapt himself to the emergency of any case, for we find here described pretty much every contrivance ever devised, and we can hardly conceive of that combi- nation of circumstances which would deprive us of all these means of assistance, and the absence of one or more of the usual aids would only stimulate the ingenuity to devise some other plan of relief.— New York Med. Journal, May, 1S68. ASHTON (T. /.) ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, from the fourth and enlarged London edition. With handsome illustrations. In one very beautifully printed octavo volume of about 300 pages. $3 25. (Just Issued.). We can recommend this volume of Mr. Ashton's in the strongest terms, as containing all the latest details of the pathology and treatment of diseases connected with the rectum.—Canada Med. Journ., March, 1866. One of the most valuable special treatises that the phvsician and surgeon* can have in his library.— Chicago Medical Examiner, Jan. 1866. The short period which has elapsed since the ap- pearance of the former American reprint, and the numerous editions published in England, are the best arguments we can offer of the merits, and of the use- lessness of any commendation on our part of a book already so favorably known to our readers.— Boston Med. and Surg. Journal, Jan. 25, 1866. Henry C. Lea's Publications—(3Iedical Jurisprudence, &c). 31 rpAYLOR {ALFRED S.), 31.D., Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Sixth American, from the eighth and revised London edition. With Notes and References to American Decisions, by Cle- ment B. Penrose, of the Philadelphia Bar. In one large octavo volume of 776 pages, extra cloth, $4 50 ; leather, $5 50. (Just Issued.) Considerable additions have been made by the editor to this edition, comprising some important sections from the author's larger work, " The Principles and Practice of Medical Jurisprudence," as well as references to American law and practice. The notes of the former editor, Dr. Harts- horne, have likewise been retained, and the whole is presented as fully worthy to maintain the distinguished position which the work has acquired as a leading text-book and authority on the subject. A new edition of a work acknowledged as a stand- ard authority everywhere within the range of the Euglish language Considering the new matter intro- duced, on trichiniasis and other subjects, and the plates representing the crystals of poisons, etc., it may fairly be regarded as the most compact, comprehen- sive, and practical work on medical jurisprudence which has issued from the press, and the one best fitted for students.—Pacific Med. and Surg. Journal, Feb. 1S67. The sixth edition of this popular work comes to us in charge of a new editor, Mr. Penrose, of the Phila- delphia bar, who has done much to render it useful, not only to the medical practitioners of this country, but to those of bis own profession. Wisely retaining the references of the former American editor, Dr. Hartshorne, he has added many valuable notes of his own. The reputation of Dr. Taylor's work is so well established, that it needs no recommendation. He is now the highest living authority on all matters con- nected with forensic medicine, and every successive edition of his valuable work gives fresh assurance to his many admirers that he will continue to maintain his well-earned position. No one should, in fact, be without a text-book on the subject, as he does not know but that his next case may create for him an emergency for its use. To those who are not the for- tunate possessors of a reliable, readable, interesting, aud thoroughly practical work upon the subject, we would earnestly recommend this, as forming the best groundwork for all their future studies of the more elaborate treatises.—New York Medical Record, Feb. 15, 1867. The present edition of this valuable manual is a great improvement on those which have preceded it. Some admirable instruction on the subjectof evidence and the duties and responsibilities of medica* wit- nesses has been added by the distinguished author, and some fifty cuts, illustrating chiefly the crystalline forms and microscopic structure of substances used as poisons, inserted. The American editor has also introduced several chapters from Dr. Taylor's larger work, "The Principles and Practice of Medical Juris- prudence," relating to trichiniasis, sexual malforma- tion, insanity as affecting civil responsibility, suicidal mania, and life insurance, &c, which add considerably to its value. Besides this, he has introduced nume- rous references to cases which have occurred in this country. It makes thus by far the best guide-book in this department of medicine for students and the general practitioner in our language.—Boston Med. and Surg. Journal, Dec. 27, 1866. Taylor's Medical Jurisprudence has been the text- book in our colleges for years, and the present edi- tion, with the valuable additions made by the Ameri- can editor, render it the most standard work of the day, on the peculiar province of medicine on which it treats. The American editor, Dr. Hartshorne, has done his duty to the text, and, upon the whole, we cannot but consider this volume the best and richest treatise on medical jurisprudence in our language.— Brit. Am. Med. Journal. w INSLOW {FORBES), M.D., D.C.L., frc. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised English edition. In one handsome octavo volume of nearly 600 pages, extra cloth. $4 25. (Just Issued.) Of the merits of Dr. Winslow's treatise the profes- sion has sufficiently judged. It has taken its place in the front rank of the works upon the special depart- ment of practical medicine to which it pertains.— Cincinnati Journal of Medicine, March, 186b. It is an interesting volume that will amply repay for a careful perusal by all intelligent readers.- Chicago Med. Examiner, Feb. 1866. A work which, like the present, will largely aid the pZctitiler in recognizing and arresting.hefirs insidious advances of cerebral a°d "^J^nest one of immense practical value, ^d demands earnest attention and diligent study on the pait ofa'lwj have embraced the medical P'ofi**»on. ^nd have thereby undertaken.J^™™^"^^ welfare ^nd happmess^r th fore close this are largely involved W notice of Dr. W^VS^ clasLa/work by expressing our conviction that it is long since so important and beautifully written a volume has issued from the British medical press. The details of the manage- ment of confirmed cases of insanity more nearly in- terest those who have made mental diseases their special study; but Dr. Winslow's masterly exposi- tion of the early symptoms, and his graphic descrip tions of the insidious advances of incipient insanity, together with his judicious observations on the treat- ment of disorders of the mind, should, we repeat, be carefully studied by all who have undertaken the responsibilities of medical practice.—Dublin Medical Press. It is the most interesting as well as valuable book that we have seen for a long time. It is truly fasci- nating.—Am. Jour. Med. Sciences. Dr. Winslow's work will undoubtedly occupy an unique position in the medico-psychological litera- ture of this country.—London Med. Review. ESSAYS ON THE WAGER OF TEA {HENRY C.) ^ qttpfH^TITION AND FORCE bV .w Vnw WAGER OF BATTLE, THE ORDEAL, AND TORTURE. In one hand- ^omT'voTume royal l2mo., of 406 pages ; extra cloth, $2 50. mstant uuu"' "nicn the progress ot humane and defeats, uy gtm marke(j. This work fills up j This is a D00jj 0f extraordinary research. Ii„n has been au HflcIltion and detail the wise has entered into his subject con amore; ai with the fu Iest eX£™pe qUoted above. As a book of remarks which we have q ^ ^ ^ ^ ^ ^^ ^iminster Review, Oct. 1867. Viiiue- lt- ;„ sDiteof himself, as it appears—he : outlying points of obsolete law, "Superstition aud When—na" rci,aracterin the historv of legalized Force" is one of the most remarkable books we have sketches a scene > betrays so artistic a feeling, and met with.—London Athenasum, Nov. 3, 1S66. „no**ni Mr. Lea and a more striking record of the cruel superstitions of our un- happy Middle Ages could not possibly have been com- piled. ... As a work of curious inquiry on certain 32 Henry C. Lea's Publications. INDEX TO CATALOGUE. Abel and Bloxam's Handbook of Chemistry Allen's Dissector and Practical Anatomist American Journal of the Medical Sciences Abstract, Half-Yearly, of the Med Sciences Anatomical Atlas, by Smith and Horner Ashton on the Rectum and Anus Ashwell on Diseases of Females Brinton on the Stomach Barclay's Medical Diagnosis . Barlow's Practice of Medicine Barwell on the Joints . Bennet (Henry) on Diseases of the Uterus Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Brande & Taylor's Chemistry Brodie's Clinical Lectures on Surgery . Brown on the Surgical Diseases of Women Buckler on Bronchitis .... Bucknill and Tuke on Insanity Budd on Diseases of the Liver Bumstead on Venereal .... Bumstead and Cullerier's Atlas of Venereal Carpenter's Human Physiology . Carpenter's Comparative Physiology Carpenter on the Microscope Carpenter on the Use and Abuse of Alcohol Carson's Synopsis of Materia Medica . Chambers on the Indigestions Ghristison and Griffith's Dispensatory Churchill's System of Midwifery . Churchill on Diseases of Females Churchill on Puerperal Fever Clymer on Fevers...... Colombat de l'Isere on Females, by Meigs Condie on Diseases of Children . Cooper's (B. B.) Lectures on Surgery . Cullerier's Atlas of Venereal Diseases Curling on Diseases of the Testis . Cyclopedia of Practical Medicine . Dalton's Human Physiology . De Jongh on Cod-Liver Oil . De wees's System of Midwifery Dewees on Diseases of Females . Dewees on Diseases of Children . Dickson's Practice of Medicine Druitt's Modern Surgery Dunglison's Medical Dictionary . Dunglison's Human Physiology . Dunglison on New Remedies Dunglison's Therapeutics and Materia Med Ellis's Medical Formulary, by Smith . Erichsen's System of Surgery Erichsen on Nervous Injuries Flint on Respiratory Organs . Flint on the Heart..... Flint's Practice of Medicine . Fownes's Elementary Chemistry . Fulleron the Lungs, &c. Gardner's Medical Chemistry Gibson's Surgery..... Gluge's Pathological Histology, by Leidy Graham's Elements of Chemistry . Gray's Anatomy..... Griffith's (R. E.) Universal Formulary . Griffith's (J. W.) Manual on the Blood, &c. Gross on Urinary Organs Gross on Foreign Bodies in Air-Passages Gross's Principles and Practice of Surgery Gross's Pathological'Anatomy Hartshorne's Essentials of Medicine . Hartshorne's Conspectus of the Medical Sciences Habershon on Alimentary Canal . Hamilton on Dislocations and Fractures Harrison on the Nervous Systeni . Hoblyn's Medical Dictionary Hodge on Women..... Hodge's Obstetrics..... Hodge's Practical Dissections Holland's Medical Notes and Reflections Horner's Anatomy and Histology Hudson on Fevers, .... Hughes on Auscultation and Percussion Hill on Syphilis..... Hillier's Handbook of Skin Diseases Jones's (T. W.) Ophthalmic Medicine and Surg PAOE 11 6 1 3 6 30 22 17 16 15 28 22 10 10 10 28 22 18 18 18 19 19 idged Jones and Sieveking's Pathological Anatomy Jones (C. Handfield) on Nervous Disorders Kirkes' Physiology .... Knapp's Chemical Technology Lea's Superstition and Force Lallemand and Wilson on Spermatorrhoea La Roche on Yellow Fever . La Roche on Pneumonia, &c. Laurence and Moon's Ophthalmic Surgery Lawson on the Eye .... Laycock on Medical Observation . Lehmann's Physiological Chemistry, 2 vols Lehmann's Chemical Physiology . Ludlow's Manual of Examinations Lyons on Fever..... Maclise's Surgical Anatomy . Malgaigne's Operative Surgery, by Brittan Marshall's Physiology . . . Markwick's Examination of Urine Mayne's Dispensatory and Formulary Mackenzie on Diseases of the Eye Medical News and Library . Meigs's Obstetrics, the Science and the Art Meigs's Lectures on Diseases of Women Meigs on Puerperal Fever Miller's System of Obstetrics Miller's Practice of Surgery . Miller's Principles of Surgery Montgomery on Pregnancy . Morland on Urinary Organs . Morland on Uraemia .... Neill and Smith's Compendium of Med. Science Neligan's Atlas of Diseases of the Sjkin Neligan on Diseases of the Skin . Prize Essays on Consumption Parrish's Practical Pharmacy Peaslee's Human Histology . Pirrie's System of Surgery . Pereira's Mat. Medica and Therapeutics, ab Quain and Sharpey's Anatomy, by Leidy Ranking's Abstract .... Roberts on Urinary Diseases . Ramsbotham on Parturition . Reese on Blood and Urine Rigby on Female Diseases Rigby's Midwifery..... Rokitansky's Pathological Anatomy Royle's Materia Medica and Therapeutics Salter on Asthma..... Sargent's Minor Surgery Sharpey and Quain's Anatomy, by Leidy Simon's General Pathology . Simpson on Females .... Skey's Operative Surgery Slade on Diphtheria .... Smith (J. L.) on Children Smith (H. H.) and Horner's Anatomical Atlas Smith (Edward) on Consumption . Solly on Anatomy and Diseases of the Brain Still6's Therapeutics .... Tanner's Manual of Clinical Medicine . Tanner on Pregnancy .... Taylor's Medical Jurisprudence . Thomas on Diseases of Females . Thompson on Urinary Organs Todd and Bowman's Physiological Anatomy Todd on Acute Diseases . . . . Toynbee on the Ear .... Wales on Surgical Operations Walshe on the Heart .... Watson's Practice of Physic . West on Diseases of Females West on Diseases of Children West on Ulceration of Os Uteri . What to Observe in Medical Cases Williams's Principles of Medicine Wilson's Human Anatomy . Wilson's Dissector..... Wilson on Diseases of the Skin . Wilson's Plates on Diseases of the Skin Wilson's Handbook of Cutaneous Medicine Wilson on Healthy Skin Wilson on Spermatorrhoea Winslow on Brain and Mind PAOE 14 * I " ■ &■*£'$#*:■ i ■'•• * 1