PRACTICAL SYNOPSIS OF CUTANEOUS DISEASES, ACCORDING TO THE ARRANGEMENT OF DR. WILLAN, EXHIBITING A CONCISE VIEW OP THE DIAGNOSTIC SYMPTOMS AND THE METHOD OF TREATMENT. BY THOMAS pTEMAN, M.D. F.L.S. ?HTSICIAW TO THE FCBLIC DISPENSARY,, AHD TO THH FETOR IX6TITCTIOW SECOND AMERICAN EDITION. »Oa*rtartiCa: JAMES CR1SSY, NO. 177 CHESTNUT STREET J. Crissy and G. Goodman, printer*. ADVERTISEMENT. This edition is a reprint of the last, with the exception of the concluding observations, relative to Syphilitic Eruptions, which have been altogether omitted. The further my experience has extended on the subject of these and the resembling Eruptions, the more complete has been my conviction, that any attempt to give a definite character of them is premature. Some correction appears also to be required on the subject of Pompholyx, which, however, I am not yet enabled to make with sufficient accuracy. Although it is obvious that there is no such disease as the contagwus fever, accompanied with Bullae, described by authors under the appellation of Pemphigus; yet some cases, which have been communicated to me, demonstrate the occasional concurrence of severe and even fatal fever with such an eruption, and therefore the necessity of modifying the definition and history of Pompholyx. T. B. 14 Bloomsbury Square, Dec. 12th, 1816, PREFACE TO THE FIRST EDITION. To prevent any misapprehension in regard to the nature and object of this volume, it may be necessary to state, that it is not brought forward with any pretensions to supply the deficiencies which have been left in the valuable treatise of Dr. Willan, or to be considered as the completion of that original work. Its sole purpose is to present an abstract of the classification proposed by that respected author, together with a concise view of all the genera and species, which he intended that it should comprehend. The materials for the description of the first four Orders have been obtained principally from Dr. Willan's publication, of which the first part of this Synopsis may be regarded as an abridgment: some additional facts, however, have been supplied from subsequent observation. The remainder of the matter has been derived partly from personal experience and research, but principally from a constant intercourse with Dr. Willan, upon the subject of these VI PREFACE. diseases, during a period of ten years, while his colleague at the Public Dispensary, and from his own communications in his last illness, before be departed for Madeira, when he kindly undertook a cursory perusal of his unfinished MSS. for my information, during which I made notes relative to those points with which I was least acquainted. For it was, in fact, his wish that the profession should possess a sketch of the whole of his arrangement, even when the completion of his own treatise, though distant, was not without hope. Were I capable of following my learned preceptor through the literary and historical researches which enriched his publication, it would be altogether incompatible with my plan. I have, however, deemed it advisable to introduce into notes some brief illustrations and references, which, without interrupting the practical details, may satisfy the reader that the principles of the classification and nomenclature were not adopted without the sanction of reason and authority. I am far from maintaining that this arrangement of cutaneous diseases is altogether free from material imperfections; (for what artificial arrangement of natural objects has yet been devised, to which imperfections may not be imputed?) but I apprehend it will be impossible to study it carefully and practically, without deriving benefit from the exercise. I am aware, indeed, that there are many individuals, professing themselves PREFACE. VII to be practical men, who affect a contempt for all nosological disquisitions, and deem the discussions relating to nomenclature, in particular, very idle and frivolous, or, at the best, a sort of literary amusement, which is not conducive, in the smallest degree, to the improvement of the medical art. But this I conceive to be a mistaken view of the subject, originating perhaps from indolence, or from a want of habitual precision in the use of language. The inferences of slight and superficial observation may, indeed, be detailed without recourse to a very definite vocabulary; for, where little discrimination is exercised, very little nicety can be requisite in regard to the import of the language employed. But it is not by such means that the boundaries of science are extended. Among the manifest advantages of a copious and definite nomenclature, may be mentioned, in the first place, the necessity which it demands of an accurate investigation of phenomena, or, in other words, the habitual analytic turn which it tends to give to our inquiries, and therefore the general improvement of the talent of observation which it must ultimately produce. Secondly, it contributes to facilitate the means of discrimination, bymultiplying, as it were, the instruments of distinct conception ; for, from a deficiency of terms we are apt to think, and even to observe indistinctly. But, above all, a definite nomenclature supplies us with the means of com- VIII PREFACE. municating, with precision, the information which we acquire, and therefore contributes directly to the advancement of knowledge, or at least removes an other* wise insurmountable impediment to its progress. In this view, such a nomenclature, as far as regards the diseases of the skin, is obviously a great desideratum. For, while the language taught us by the fathers of medicine, relative to all other classes of diseases, is clear and intelligible, the names of cutaneous disorders have been used in various acceptations, and without much discrimination, from the days of Hippocrates, and still more vaguely since the revival of learning in modern times. From that period, indeed, the diseases of the skin have been generally designated by some few terms of universal import, which therefore carried no import at all. Hence the words leprosy, scurvy, herpes, scabies, dartres, and some other appellations, have become so indefinite, as to be merely synonyms of cutaneous disease. Even the more scientific inquirers, whose knowledge of diseases was not always equal to their learning, or whose learning fell short of their pathological skill, have interpreted the generic and specific appellations of the ancients in various senses. They have not only differed, for instance, in their acceptation of general terms, such as of the words pustule, phlyctama, exanthema, erythema, phyma, phlzyacium, &c.; but the particular appellations lichen, psora, Iwrpes, impe- PREFACE. IX tigo, porrigo, scabies, and many others, have been arbitrarily appropriated to very different genera of disease. The practical errors, which must necessarily have resulted from such a confusion in the use of terms, are very numerous, as every one must be satisfied, who has attempted to study the subject in books. It may be sufficient to allude to the gross misapplication of the remedies of the petechial or sea scurvy, which have been prescribed for the cure of inflammatory, scaly, and pustular diseases, merely because the epithet, scorbutic, has been vaguely assigned to them all; and to specify the single instance of the administration of tincture of cantharides in the scaly lepra, on the recommendation of Dr. Mead, who, however, seems to have spoken of the tubercular elephantiasis, or the non-squamous leuce; although it would be very difficult to ascertain his meaning. Most of the writers who have composed express treatises on cutaneous diseases, in modern times, have implicitly adopted the nomenclature of the ancients, without attempting to render it more definite, or to improve upon the diagnosis which they had pointed out. The essays of Mercurialis, Hafenreffer, Bonacursius, and Turner, were written after this manner; and even Lorry, in his able and elegant work, does not step far out of the ancient path. About the year 1780, however, an elaborate classification of the diseases of the skin 2 PREFACE. X was published by Prof. Plenck, of the university of Buda; and subsequently to the commencement of Dr. Willan's publication, a sort of arrangement has been proposed, in the splendid and pompous performances of M. Alibert, which however is altogether destitute of method. The arrangement of Plenck is founded upon the same principles as that of Dr Willan, namely, upon the external appearances of the eruptions: but, in filling up the scheme, he has deviated widely from the strict laws of classification, which naturalists have established. Nine of his fourteen classes very nearly correspond with the eight orders of Dr. Willan.* These are, 1. Maculae; 2. Pustulae; 3. Vesiculae; 4. Bullae; 5. Papulae; 6. Crustae; 7. Squamae; 8. Callositates; and 9. Excrescentiae. But the five remaining classes comprise, 10. Ulcera; 11. Vulnera, 12. Insecta cutanea; 13. Morbi Unguium;and 14. Morbi Capillorum, which are less judiciously devised. But such a classification must fail to answer its end, because it requires the different stages of the same disease to be considered as so many distinct maladies, and to be arranged in several classes. For example, the Crustae and the Ulcera cutanea are equally the result of Pustules, Vesicles, * It seems probable, indeed, that Dr. Willan was indebted to this work of Professor Plenck for the groundwork of his classification; since his definitions, as well as his terms, accord accurately with those of the Hungarian nosologist. PREFACE. XI and Bullae, and sometimes even of Scales: hence, while Smallpox and Scabies are arranged among the Pustules, and Lepra (by which he understands Elephantiasis) among the Papulae, the Crusts, which succeed them, are all brought together as species of one genus, in the class of Crustae. In like manner, particular symptoms are classed as distinct genera: thus the " ilugositas" and the " Rhagades" of the same Elephantiasis are found in the classes of Squamae and Ulcera respectively. In short, this Elephantiasis is divided into no less than four genera, and its parts arranged under four different classes; —an error, which renders the purposes of the classification almost nugatory. M. Alibert, with loud pretensions to superior skill, and much vaunting of the services which he has rendered this department of medicine, has, in fact, contributed nothing to the elucidation of the obscurity in which it is veiled. The merit of his publication belongs principally to the artists, whom he has had the good fortune to employ. For he has adopted the ancient confusion of terms, without a single definition to fix their acceptation; and he has not scrupled to borrow the nomenclature of the vulgar, in its most vague and indeterminate sense. He has moreover, thrown together his genera, without any attention to their affinity or dissimilarity, making an arbitrary whole of disjointed parts. Thus his arrangement commences with " Les Teignes" XII PREFACE. (Porrigo,) which are followed by " Les Pliques" (Plica or Trichiasis,) and by " Les Dartres" (which seems to be equivalent to our vulgar and indefinite term Scurvy;) —and he then passes to the discolorations, called " Ephelides," to some eruptions, which he chooses to call u Cancroides," but which are not intelligibly described —to the comprehensive Lepra,—to Frambcesia, —and to Ichthyosis. But the total defect of discrimination and of method is still more obvious in M. Alibert's distribution of the species. The Dartres, for instance, are said to be of seven kinds, —furfuraceous, scaly, crustaceous, phagedenic, pustular, vesicular, and erythemoid; so that, in fact, the appellation has an universal fitness to almost every form of cutaneous disease: it includes at least the Pityriasis, Psoriasis, Lepra, Impetigo, Ecthyma, Herpes, Acne, Sycosis, Lupus, and Erythema, of this classification. In like manner, the Lepra includes some forms of the scaly disease properly so called, together with Leuce or Vitiligo, the tubercular Elephantiasis, and the Barbadoes leg. Thus he unites, under the same generic name, diseases which have no affinity with each other. From these gross errors the classification of Dr. Willan appears to be entirely free; and the imperfections, which confessedly belong to it, are probably inseparable from the nature of the subject. The truth is, that the various genera of cutaneous disease, as charac- PREFACE. XIII terized by their external appearances, do not differ in the same essential degree, in which the diseases of organs of various structure differ from each other. The same exciting cause will produce different kinds of cutaneous disorder, in different individuals: thus, certain substances, which suddenly derange the organs of digestion, sometimes produce Urticaria, sometimes Erythema and Roseola, and sometimes even lepra and psoriasis; yet each of these shall retain its specific character, and follow its peculiar course: thus also certain external irritants will, in one case, excite the pustules of impetigo, and. in another, the vesicles of eczema. Again, the diseases which commence with one generic character, are liable occasionally to assume another, in the course of their progress:—thus, some of the papular eruptions become scaly, and still more frequently pustular, if their duration be long protracted; the lichen simplex and circumscripta, for instance, sometimes pass into psoriasis; the lichen agrius and prurigo formicans are occasionally converted into impetigo; and the prurigo mitis is changed to scabies. Moreover, it frequently happens, that the characteristic forms of eruptive diseases are not pure and unmixed, but with the more predominant appearance there is combined a partial eruption of another character: thus, with the papular strophulus, with the rashes of measles and scarlet fever, and with the pustular impetigo and scabies, there XIV PREFACE. is occasionally an intermixture of lymphatic vesicles. And lastly, the natural progress of many eruptions is to assume a considerable variety of aspect: so that it is only at some particular period of their course that their character is to be unequivocally decided. Thus in the commencement of scabies papuliformis and lymphatica, the eruption is of a vesicular character, although its final tendency is to the pustular form: and, on the contrary, in all the varieties of herpes, the general character of the eruption is purely vesicular; yet, as it advances in its progress, the inclosed lymph of the vesicles acquires a considerable degree of opacity, and might be deemed purulent by cursory observers. In like manner, the original pustular character of some of the forms of porrigo is frequently lost in the accumulating crusts, the confluent ulcerations, and the furfuraceous exfoliations, which ensue, and which conceal its true nature from those who have not seen, and are unacquainted with, the whole course of its advancement. These ciicuinstances constitute a series of natural impediments to every attempt at a methodical arrangement of cutaneous diseases. But it is more philosophical, as well as practically useful, to compromise these difficulties, by retaining in the same station the different appearances of a disease, in its different stages and circumstances, when our knowledge of the causes and remedies, as well as of the natural progress and termi- PREFACE. XV nation of it, is sufficient to establish its identity,—than to separate the varying symptoms of the same disorder, and to distribute the disjecta membra, not only under different genera, but into different classes of the system, after the manner of Prof. Plenck. Such was the method adopted by Dr. Willan; and, although it may sometimes diminish the facility of referring individual appearances to their place in the nosological system; yet it greatly simplifies the classification, as well as the practical indications to which it conduct* us. If, then, the adoption of the arrangement and nomenclature, of which a synopsis is here given, should lead to more clear and definite views of the various forms of cutaneous disease, and should enable practitioners to write and converse respecting them with perspicuity, by fixing the meaning of the terms which they employ, we may consider this as an important object gained: and it will at length, perhaps, be found, that, for the successful treatment of these diseases, the discovery of new medicines is less necessary'than a discriminate appropriation of those which we already possess. I am fully aware that it is very difficult to convey bywords, used in an acceptation that is not familiar, distinct notions of many of the minute changes of appearance in the skin; and that one great deficiency, which Dr. Willan's larger work was calculated to supply, by means of the engravings which accompanied it, will be XVI PREFACE. left unprovided for by this synopsis. Perhaps, however, this defect will be partially obviated by the plate prefixed to this volume, in which I have endeavoured to convey an idea of the fundamental principles of the classification, as well as to designate the characters of some of the more remarkable genera of cutaneous disease. T. B. 24, Bloomsbury Square, May 25, 1813. XVII EXPLANATION OF THE PLATE. The eight compartments of the plate exhibit the eight forms of cutaneous eruptions; and illustrate also some of the genera and species. Fig. 1. represents five varieties of papulae, as they are seen in (a) Strophulus confertus, (b) Lichen simplex, (c) Lichen pilaris, (d) Lichen lividus, and (e) Prurigo mitis. Fig. 2. shows the scales and circular patches of Lepra vulgaris. Fig. 3. exhibits two forms of exanthemata or rashes, viz. (f) the measles, and (g) the febrile nettle-rash. Fig. 4. shows the bullse, of Pompholyx diutinus; in different stages of their progress. Fig. 5. illustrates the four forms of pustules, distinguished in Def. 5; namely, the phlyzacia, as they appear in (h) Ecthyma vulgare, and in (i) Scabies purulenta upon the hands; —the psydracia, as they arise in (k) Impetigo, and afterwards form a scab; —the achores, (1) of Porrigo scutulata, on the scalp;—and the favi (m) as they appear on the scalp and other parts. Fig. 6. contains three genera of vesicles; namely, patches of (n) Herpes zoster, and (o) Herpes phlyctsenodes; (p) miliary vesicles; and (q) the vaccine vesicle. Fig. 7. exhibits different forms of tubercles; as in (r) Acne punctata, and(s) Acne indurata; in (t) Sycosis: and in (v) Molluscum. Fig. 8. contains specimens of Maculse; viz. (w) a Naevus compared to the stain of red wine; (x) a spider Naevus; and f y) a mole. 3 XVIII DEFINITIONS. 1. Papula (Pimple); a very small and acuminated elevation of the cuticle, with an inflamed base,, very seldom containing a fluid, or suppurating, and commonly terminating in scurf.* 2. Squama (Scale); a lamina of morbid cuticle, hard, thickened, whitish and opake. Scales, when they increase into irregular layers, are denominated crusts. 3. Exanthema (Rash); superficial red patches, variously figured, and diffused irregularly over the body, leaving interstices of a natural colour, and terminating in cuticular exfoliations. 4. Bulla (Bleb); a large portion of the cuticle de- * The term, papula, has been used in various acceptations by the older writers, but the nosologists have nearly agreed in restricting it to the sense here adopted. Sauvages defines it," phyma parvulum, desquamari solitum " (Nosol. Meth. class. 1. Synops. ord. ii. 6. See also Linnaei Gen. Morbor. class, xi. ord. 4.) In this sense also Celsus seems to have understood the term, although he uses it generally: for when he calls it a disease, in which " the skin is made rough and red by very minute pustules," he means obviously dry papulae; as by the word pustula he understands every elevation of the skin, including even wheals. (De Med. lib. v. cap. 28. § 15 and 18.) See below, p. 137. note. DEFINITIONS. XIX tached from the skin by the interposition of a transparent watery fluid. 5. Pustula (Pustule); an elevation of the cuticle, with an inflamed base, containing pus. Four varieties of pustules are denominated in this arrangement as follows: a. Phlyzacium; a pustule commonly of a large size, raised on a hard circular base, of a vivid red colour, and succeeded by a thick, hard, dark-coloured scab.* b. Psydracium;dL small pustule, often irregularly circumscribed, producing but a slight elevation of the cuticle, and terminating in a laminated scab.f Many of the psydracia usually appear together, and become * The derivation of this term, M arto tw $%w>, $fa>?w, sive $%vaaa, quod servere significat, et ebullire," (Gorraei Def. Med.) would render it sufficiently appropriate to elevated and inflamed pustules, if we had not possessed also the interpretation left by Celsus: " $%v£axiov autem paulo durior pustula est, subalbida: acuta; ex qua quod exprimitur, homidum est. Ex pustulis vero nonnunquam etiam ulcuscula fiunt, aut aridiora, aut humidiora, et modo tantum cum prurigine, modo etiam cum inflammatione aut dolore; exLtque aut pus, aut sanies, aut utrumque. Maximeque id evenit in aetate puerili raro in medio corpore; saepe in eminentibus partibus." (De Medicina, liv. v. cap. 28. § 15.) — See also Ecthyma, below, p. 171. t As the Phlyzacia were denominated from the heat of the eruption, so the Psydracia received their appellation from the opposite quality, u quasi 4>uxpa vSpaxia, id est, frigidse seu frigefactae guttulse," says Gorraeus.—The psydracia are enumerated among the eruptions peculiar to the head by Alexander and Paul, and some other Greek writers; but Galen and others mention them as common to other parts of the body. (See Alex. Trail. Op. lib. i. cap. 5. Paul. Mg'm. lib. iii. cap. 1. Actuarius, lib. vi. cap. 2.) See also Impetigo, below, p. 138. DEFINITIONS. XX confluent; and, after the discharge of pus, they pour out a thin watery humour, which frequently forms an irregular incrustation. c. Achor; and d. F(wm. These two pustules are considered by the majority of writers from the Greeks downwards, as varieties of the same genus, differing chiefly in magnitude.* The Jlchor may be defined a small acuminated pustule, containing a straw-coloured matter, which has the appearance and nearly the consistence of strained honey, and succeeded by a thin brown or yellowish scab. The Favus. or *qpw f is larger than the Achm, flatter, and not acuminated, and contains a more viscid matter; its base, which is often irregular, is slightly inflamed; and it is succeeded by a yellow, semitransparent, and sometimes cellular scab, like a honey-comb; whence it has obtained its name. 6. Vesicula ( Vesicle); a small orbicular elevation of the cuticle, containing lymph, which is sometimes clear and colourless, but often opaque, and whitish or pearlcoloured. It is succeeded either by scurf, or by a laminated scab. 7. Tuberculum (Tubercle); a small, hard, superficial tumour, circumscribed and permanent, or suppurating partially. 8. Macula (Spot); a permanent discoloration of some portion of the skin, often with a change of its texture. * See Aetius, tetrab. ii. serm. ii. cap. 68.—Alex. Trail, lib. i. cap. 8 & 9.—Paul. iEgin. De Re Med. lib. iii. cap. 3.—Oribas. De Loc. Affect, lib. iv. cap. 12. See also Porrigo, below, p. 151. DEFINITIONS. XXI The following terms are used in their ordinary acceptation ; viz. 9. Wheal; a rounded or longitudinal elevation of the cuticle, with a white summit, but not permanent, not containing a fluid, nor tending to suppuration. 10. Furfur (Scurf); small exfoliations of the cuticle, which occur after slight inflammation of the skin, a new cuticle being formed underneath during the exfoliation. 11. Scab;a hard substance, covering superficial ulcerations, and formed by a concretion of the fluid discharged from them. 12. Stigma; a minute red speck in the skin, without any elevation of the cuticle. When Stigmata coalesce, and assume a dark-red or livid colour, they are termed Petechial. XXII The Diseases of the Skin were arranged by Dr. Willan in eight orders, according to their external forms above defined, as in the following table. Page. PORRIGO 151 ECTHYMA 171 VARIOLA 178 SCABIES 179 VI. VESICULJE. VARICELLA 195 VACCINIA 202 HERPES 209 RUPIA 227 MILIARIA 229 ECZEMA 236 APHTHA 246 VII. TUBERCULA. PHYM& 255 verruca ibid. MOLLUSCUM 256 VITILIGO 258 ACNE 260 sycosis 275 lupus 279 elephantiasis 280 frambg2s1a 295 VIII. MACULAE. EPHEL1S 303 N.EVUS, SPILUS, ETC. 306 Order I. PAPULA. Page. STROPHULUS 1 LICHEN 6 PRURIGO 14 IL SQUA1VLE. LEPRA 24 PSORIASIS 34 PITYRIASIS 43 ICHTHYOSIS 47 HI. EXANTHEMATA. RUBEOLA 55 SCARLATINA 67 URTICARIA 84 ROSEOLA 92 PURPURA 99 ERYTHEMA 113 IV. BULLAE. ERYSIPELAS 119 PEMPHIGUS 129 POMPHOLYX 132 V. PUSTULiE. IMPETIGO 138 A PRACTICAL SYNOPSIS OP CUTANEOUS DISEASES. Older 1. PAPULiE. PAPULAE, or Pimples, (Def. 1.) appear to originate in an inflammation of the papillae of the skin, by which these are enlarged, elevated, and indurated, and made to assume more or less of a red colour. Sometimes even a slight effusion of lymph takes place, which gives a vesicular appearance to several of the papuke; but the fluid is re-absorbed without breaking the cuticle, and they terminate for the most part in scurf. The varieties of papulous eruptions are comprehended in this arrangement under three genera; namely, Strophulus, Lichen, and Prurigo. I. STROPHULUS. This genus comprises several papular affections, peculiar to infants, which are known by the common appellations of red gum, tooth-eruption, &c. They arise, in consequence of the extreme vascularity and irritability of the skin at that period of life, when the constitution 2 PAPULAE; is accidentally disturbed by irritation, either in the alimentary canal, the gums, or other parts. As they are not, however, very important objects of medical practice, but interesting only from their occasional resemblance to some of the exanthemata, I shall not dwell upon them at any length. The following varieties are mentioned by Dr. Willan. 1. Strophulus intertinctus, (Plate'I.) the red gum or gown, occurs chiefly within the two first months after birth, and is characterized by papulae of a vivid red colour, situated most commonly on the cheeks, forearms, and back of the hands, but sometimes universally diffused. They are usually distinct from each other; but are intermixed with red dots, or stigmata, (Def. 12.) and often with larger red patches, which have no elevation. Occasionally a few small vesicles appear on the hands and feet; but these soon desiccate, without breaking. This eruption is often obviously connected with a weak, irritable state of the alimentary canal, and consequent indigestion; w r hence it is frequently preceded by sickness of stomach, and sometimes by diarrhoea. But in its ordinary mild form it is not inconsistent with good health, and requires little medical treatment. Daily ablutions with tepid water, which remove sordes and promote an equable perspiration, are beneficial; and a proper attention should be enforced both to the kind and quantity of the aliment, and to the regularity of exercise afforded to the child. The cold bath, or even exposure to a stream of cold air, should be avoided during the occurrence of this eruption; and if, in consequence 3 STROPHULUS. of want of caution in this respect, the eruption shall have disappeared, and internal disorder have ensued, a warm bath affords the most speedy relief:—some slight cordial, as a few drops of the spiritus ammoniae compositus internally, and the stimulus of a blister externally, have also been found beneficial under these circumstances.* 2. Strophulus albidus (Plate II.) is merely a variety of the preceding species, and is occasionally intermixed with it; the papulas consisting of minute, hard, whitish specks, a little elevated, and sometimes surrounded by a slight redness, and appearing chiefly on the face, neck, and breast. 3. Strophulus confertus, (Plate III. Fig. 1.) which is sometimes called the rank red gum, and the tooth' rash, is distinguished principally by the more extensive crop of papulae which appears. These are chiefly seated on the cheeks and forehead, when they occur about the fourth or fifth month, and are smaller, more crowded, and less vivid in their colour, than in the first species. But in children seven or eight months old, they appear in large and irregular patches, on the outside of the hands, arms, and shoulders, and are hard and close set, so as to give to the whole surface a high red co- * See Underwood on the Diseases of Children, vol. i. p. 79, 5th edit, and Armstrong on the same subject, p. 84. These alternations of internal and superficial disorder, though not so frequently seen under modern management as under that of the older physicians, take place occasionally in Strophulus, as well as in the measles, and some other exanthemata. In such cases, diarrhoea, tormina, sickness, and sometimes a tendency to syncope or convulsions, ensue 1 PAPULJE: 4 lour. In about a fortnight they begin to fade and exfoliate, and gradually disappear. Sometimes, though rarely, a variety of the S. confertus appears on the legs, spreading upwards even to the loins and navel, producing a general redness of the cuticle, (not unlike intertrigo,) which cracks and separates in large pieces, occasioning much distress to the child. It is liable to recur at short intervals, for the space of two or three months. The S. confertus requires no specific medical treatment, as it appears to be one of the numerous symptoms of irritation arising from dentition, and recedes soon after the cutting of the first teeth.* It can only be alleviated by the general treatment proper for the state of teething, with great attention to cleanliness, and frequent tepid ablution with milk and water. 4. Strophulus volaticus (Plate III. Fig. 2.) is not a frequent complaint. It is characterized by small circular patches, or clusters of papulae, arising and exfoliating successively on different parts of the body, of a high red colour, and sometimes attended with slight fcverishness. Each patch turns brown in about four days and begins to exfoliate; and the whole series terminates in three or four weeks. * Dr. Bissct, a physician of the old school, but a man of observation, notices a circumstance respecting children affected with these eruptions, which I think I have seen confirmed in a few cases. After stating that " some children are more or less affected with it till they have got all their first teeth, in spite of every endeavour to repress it, and after that period it recedes spontaneously;" he adds, " but in that case they are apt to have carious teeth after the eruption disappears." See his Med. Essays and Obs. § xix. p. 274. STROPHULUS. 5 This eruption is usually connected with disorders of the stomach and bowels, and is alleviated by gentle laxatives; after which the decoction of cinchona, or a slight chalybeate,* is serviceable. No external application is necessary. 5. Strophulus candidus (Plate III. Fig. 3.) is distinguished by papulae of a larger size than those of the foregoing species, having no inflammation round their base, and a smooth and shining surface; whence they appear to be of a lighter colour than the adjoining cuticle. They are most frequently seen on the loins, shoulders, and upper part of the arms; but I have observed them also on the face and neck, when the S. confertus occupied the fore-arms: after continuing hard and elevated for about a week, they gradually disappear. This variety of Strophulus commonly succeeds some of the acute diseases, to which infants about a year old are liable. It has occurred also on the arms, when the face was occupied with porrigo larvalis: and in one case it appeared on the arms, thighs, and neck, at the age of three years and a half, during the cutting of the double teeth. * I shall take this opportunity of recommending to the attention of practitioners a chalybeate medicine, particularly adapted, from its tasteless quality, to the palates of children, and possessed of more efficacy than the vinum ferri; I mean a watery solution of tartrite of iron, lately introduced by an able and intelligent chemist, Mr. R. Phillips. See his Experimental Examination of thePharm. Londinensis, 1811. Its qualities have been well stated by Dr. Birkbcck. in the London Medical Review, No. xix. July 1812. PAPULAE: 6 II. LICHEN. The original acceptation of the term Lichen is not distinctly ascertained from the writings of Hippocrates, and therefore it has been variously interpreted by succeeding writers.* The majority have deemed it synonymous with the impetigo of the Latins: but, as Foes, De Goi ter, and other able commentators, have remarked, the impetigo described by the highest Roman authority, Celsus, is a very different disease; while the papula of the same author seems to accord more accurately with the lichen of Hippocrates f Whence Dr. Wil- * Hippocrates classes the with prurigo, psora, lepra, and alphos, without particularizing their characteristic forms. See his npoppyrtKov, lib, ii. and his book Uspt IlotOav, where he considers them as blemishes rather than diseases. It would seem, indeed, that the Greek writers after him looked upon the prurigo, lichen, psora, and lepra, as progressive degrees of the same affection; the first being a simple itching,—the second, itching combined with roughness of the skin, —the third, itching with branny exfoliations,—and the last, itching with actual scales. f See. Foes (EconomyHippocr.—De Gorter, Medicini Hippocrat. aph. xx. lib. iii. The latter observes, respecting this aphorism, '* In hoc loco, Hippocr. per Leichenas intelligit talem cutis faedationem, in qua summa cutis pustulis siccis admodum prurientibus exasperatur. —Sed quia humor totus fere volatilis est, non relinquit squamas ut lepra, neque furfures ut psora, sed siccam et asperam pustulosam cutim." It is to be recollected that pustula, among the ancients, signified any elevation of the cuticle; and therefore pustulse siccae are papulae. If the lichen, then, be viewed in its concluding stage, when it exhibits a slight furfuraceous roughness, it may be said to have some affinity with the scaly diseases mentioned above; and, in fact, it sometimes terminates in psoriasis. See Aetius, tetrab. ii. 7 LICHEN. lan decided on affixing the appellation to a papular affection of the following character: " An extensive eruption of papulae, affecting adults, connected with internal disorder, usually terminating in scurf, recurrent, not contagious." The varieties of this eruption are sevenr* 1. The Lichen simplex (Plate IV. Fig. 1.) is an eruption of red papulae, first appearing on the face or on the arms, and extending, in the course of three or four days, to the trunk and lower limbs. It is preceded for a few days by slight febrile irritation, which commonly ceases when the eruption appears. This is accompanied with an unpleasant sensation of tingling, especially in the night: it continues nearly stationary about a week, when its colour begins to fade, and the skin soon exhibits numerous scurfy exfoliations, which remain longest about the flexures of the joints. The duration of the complaint varies considerably, however, from ten days to three weeks. The disorder is subject to variety also in other respects. The papulae on the face, for instance, are large and rounded, and some of them form into small tubercles, resembling those of acne: on the breast and extremities they are more acuminated; and on the hands they are sometimes obscurely vesicular. In some cases, the eruption is partial, affecting the face, neck, or arms only; in some, it appears and disappears repeatedly, without leaving any scurf; and in others, successive serm. iv. cap. 16.—Actuar. lib. ii. cap. 11. —Celsus de Medicina, lib. v. cap. 28. PAPULA: 8 eruptions and exfoliations prolong the complaint for two or three months. The L. simplex is liable to return every summer in some individuals of irritable constitution. It appears occasionally, jn those who are subject to severe headache and plains in the stomach, as a sort of crisis to these complaints, which are immediately relieved. It is also sometimes a sequela of acute fevers.* This species of lichen is often mistaken for measles, scarlatina, and other exanthemata. But a strict attention to Definitions 1 and 3, and to the course of the symptoms, will enable the observer to avoid such errors. It is sometimes also mistaken for scabies (itch), from which it is not always so easily distinguished.! 2. Lichen pilaris (Plate V. Fig. 1.) is merely a modification of the preceding species, the papulae appearing only at the roots of the hairs of the skin. Like the former, it often alternates with complaints of the head or stomach, in irritable habits. It is not unfrequently connected with that derangement of these organs which is induced by intemperance in the use of * See Lorry de Morbis Cutaneis, cap. iii. p. 215. t See Scabies.—Prof. Lorry has stated the principal points of diagnosis with accuracy. Speaking of lichen, under the appellation of M Papulae," he says, " Primo a scabie differunt, quod papulae illae vulgo magis confertae sint et elatiores: 2do, quod rubicundae magis et minus aridae sint; Stio, quod saepe senatis febribus superveniant; 4to, quod latiores sint, et saepius recidivam patiantur quam vera et legitima scabies; 5to, quod in furfur abeant notabile; 6to, demum quod remediis sanentur a scabiei curatione alienis." Loc. cit. 9 LICHEN. spirits. The great irritability of the skin is manifest, from the facility with which the papulae are enlarged into temporary wheals by strong friction, which the itching and tingling compel the patient to resort to. 3. Lichen circumscriptus (Plate V. Fig 3.) is characterized by clusters or patches of papulae, which hav e a well defined margin, and are of an irregularly circular form.* Some of them are stationary for a week or two, and disappear; but others extend gradually, by new papulated borders, into large figured forms, which coalesce. As the borders extend, the central areae become even, but continue slightly red and scurfy. Sometimes, before the scurf is removed, a new crop of papulae arises, terminating like the former in exfoliations; and by these new eruptions the complaint is prolonged for several weeks. It may be excited either by internal or external causes of irritation. In adults it is occasionally produced by vaccination, and may be deemed a proof of the full affection of the constitution by the virus. Little medicinal treatment is necessary for these species of Lichen. It is sufficient that patients avoid heating themselves by much exercise or by stimulants, and take a light diet, with diluent drinks, and a gentle laxative occasionally. The diluted sulphuric acid is a grate- * This variety of Lichen was not noticed in the first edition of the Order of Papulae, published by Dr. Willan. It is the first of the two species of papulae described by Celsus:—Medium habet pnuxillum levius: tarde serpit; idque vitium maxime rotundum incipit, eaque ratione in orbem procedit." De Medicina. lib. v. cap. 28. See also Ingrassias dc Tumor, praet. Naturam. ract. I. cap. 1. 10 PAPULA: ful tonic to the stomach during the period of exfoliation; or a light chalybeate may be taken with advantage at the same period. All strong external applications are improper, especially preparations of mercury and of sulphur, which produce severe irritation. The ancients recommended that the parts should be besmeared every morning with saliva; and some demulcent lotion, as a substitute for this uncleanly expedient, prepared with the white of egg, or emulsion of almonds, will relieve the painful sensations of the patient. Lotions of limewater, or of liquor ammoniae acetatis, much diluted, occasionally also afford relief. 4. The Lichen agrius (Plate IV. Fig. 2.) is ushered in by febrile symptoms, which are commonly relieved on the appearance of the papulous eruption. The papulae occur in large patches, are of a high red colour, and have a degree of inflammation diffused round them to a considerable extent. They are accompanied by itching, heat, and a painful tingling, which are augmented to a sensation of smarting and scalding by the heat of the bed, washing with soap, drinking wine, or using violent exercise. The symptoms undergo a daily increase and remission: for they are all greatly diminished in the morning, and recur after dinner. Some small vesicles, filled with a straw-coloured fluid, are occasionally intermixed with the papulae*, but they are not permanent. The duration of the L. agrius is various: sometimes it continues for several weeks; and, in most instances, the eruption appears and disappears repeatedly before 11 LICHEN. the disease is removed. In both these cases, the cuticle of the parts affected becomes harsh, thickened, chappy, and exquisitely painful on being rubbed or handled. After repeated attacks, indeed, it is liable to terminate in a chronic pustular disease, the impetigo.* This tendency, and the diffuse redness connecting the papulae distinguish the L. agrius from the preceding species, which occasionally pass into psoriasis, as observed by the ancients. The L. agrius is sometimes repelled by exposure to cold, upon which an acute febrile disorder ensues, with vomiting, headache, and pains in the bowels, and continues for several days. Women are more liable to this species of Lichen than men, particularly after suffering long continued fatigue, with watching and anxiety: it sometimes occurs in spirit-drinkers. The treatment of this Lichen consists in administering, at first, some moderate laxatives, mercurial or saline, and afterwards, for some time, the diluted sulphuric acid, three times a day, in the infusion of roses, or decoction of cinchona. A simple cooling unguent, as the rose pomatum, or litharge plaster softened with oil * Celsus describes his second species of papula under the appellation of aypia, or fera; and has also pointed out its tendency to pass into impetigo:—" Difficilius sanescit; nisi sublata est, in impetiginem vertitur." (loc. cit.) His successors, the Greek writers, have also applied the same epithet to the severe form of Lichen. Galen speaks of Lichen simplex et ferus, ctirhHi x.tn etyp'oi ; (Isagoge, cap. 13. See also Paul. jEgin. de Re Med. lib. iv. cap. 3; and Oribas. ad Eunap. lib. iii. cap. 57.) and Aetius of rough and ofinflamed Lichens, xctt,the Edin. Med. and Surg. Journal for Jan. 1811, p. 41, and in the new Cyclopaedia of Dr, Rees, Art. Insects.) In warm climates, indeed, these insects are so abundant about the persons of the sick, that the utmost care is requisite to prevent the generation of larvae from the ova, which they deposit, not only in superficial wounds, but in the nostrils, mouth, gums, &c. Dr. Lempriere has recorded the case of an officer's lady, who had gone through an acute fever, but in whom " these maggots were produced, which burrowed and found their way by the nose through the os cribrif'orme, into the cavity of the cranium, and afterwards into the brain itself, to which she owed her death." (Obs. on the Diseases of the Army in Jamaica, vol. ii. p. 182.) The worms which were generated in the patches of lepra, observed by Prof. Murray, proved to be larvae of the common house-fly. " Incredibile fere est," he says, " quanta muscarum domesticarum copia continuo ad lectum advolarent aegrumque suctu suo torquerent, ut in clamorem usque nonnunquam erumperet," De Vermibus in Lepra obviis Obs. Auct. J. A. Murray, Gott- 1769 21 PRURIGO, The local pruriginous affections above mentioned have scarcely any affinity with the prurigo just described, except in the itching which accompanies them, not being in general papular diseases. The P. prcepuHi is occasioned by an altered or augmented secretion about the carona glandis, and is cured by frequent simple ablution of the parts, or by a saturine lotion. The P. pubis arises solely from the presence of morpiones, or pediculi pubis, which are readily destroyed by mercurial ointment. And the P. urethralis is commonly sympathetic of some disease about the neck of the bladder, or of calculi in that organ: in women, however, it sometimes occurs without any manifest cause, and is removable by the use of bougies, as recommended by Dr. Hunter. Two forms of local prurigo, namely, P. podicis, and pudendi muliebris, are more frequently the objects of medical treatment. Independently of ascarides, or haemorrhoids, which sometimes occasion a troublesome itching about the sphincter ani, the P. podicis occurs in sedentary persons, and those of advanced age, in connexion with an altered secretion from the part and sometimes with constitutional debility. This complaint is apt to extend to the scrotum, especially in old men, which becomes of a brown colour, and sometimes thick and scaly. The itching in these cases is extremely severe, especially at night, and often deprives the patient of a considerable portion of his sleep. A p 25.) In all such cases, the disease appears to have afforded only a nidus for the ova of these domestic insects, and to have been in no other way connected with their existence, either as cause or effect. See Scabies, 22 PAPULA: troublesome prurigo scroti is also occasionally produced by friction, from violent exercise, in hot weather; and sometimes it originates from the irritation of ascarides in the rectum. Lotions, whether warm or cold, with preparations of lead, zinc, lime-water, &c. have little efficacy in these affections. Those made with vinegar, or the acetate of ammonia, are productive of a temporary relief. But the mercurial ointments, especially the unguentum hydrargyri nitratis diluted, are the most successful applications.—Internally, small doses of calomel, with an antimonial, such as the pilula hydrargyri submuriatis of the New Pharmacopoeia, seem to be advantageous in correcting the morbid secretion; and the vegetable or mineral tonics should be administered in enfeebled habits. Great temperance should be inculcated in the case of P. podicis; since stimulant diet invariably aggravates the complaint. The P. pudendi muliebris is somewhat analogous to the preceding, but is occasionally a much more severe complaint. It is sometimes connected with ascarides in the rectum, and sometimes with leucorrhoea; but is most violent when it occurs soon after the cessation of the catamenia. The itching about the labia and os vaginae is constant and almost intolerable, demanding incessantly the relief of friction and of cooling applications, so as to compel the patients to shun society, and even sometimes to excite at the same time a degree of nymphomania. This condition is generally accompanied by some fulness and redness of the parts, sometimes by inflamed papulae, and sometimes by aphthae. Saturnine and 23 PRURIGO. saline lotions, lime-water, lime-water with calomel, vinegar, and oily liniments prepared with soda or potass, are beneficial, especially in the milder cases* but the most active remedy is a solution of the oxymuriate of mercury in lime-water, in the proportion of two grains, or a little more to the ounce. As in the cases before mentioned, however, the presence of rhagades or excoriations will require palliation, before it can be employed, Order II, SQUAMiE. SCALY DISEASES. Those opaque and thickened laminae of the cuticle, which are called Scales (Def. 2.) are commonly produced by some degree of inflammation of the true skin, over which they are formed, but occasionally, as in the slighter forms of pityriasis, the cuticle alone, or with the rete mucosum, appears to be in a morbid condition. If the definition be carefully attended to, scales will not be confounded with the scabs succeeding confluent pustules and vesicles, or superficial ulceration. The four genera of scaly diseases are, Lepra, Psoriasis, Pityriasis, and Ichthyosis. I. LEPRA. The term Lepra is here appropriated solely to the Leprosy of the Greeks, as described by the more accurate of those writers. It is characterized by " scaly patches, of different sizes, but having always nearly a circular form."* * The confusion which has every where prevailed in the use of the terms Lepra and Leprosy, seems to have originated principally with the translators of the Arabian writers after the revival of learning. The Greeks agreed in appropriating the appellation of tertpa to a scaly eruption (as its etymology dictated); most of them deemed it the highest degree of scaliness, exceeding in this respect the lichenes, psora, and alphos; and those who were most minute in their description stated, that " it af- 24 25 LEPRA, 1. Lepra vulgaris,* (Plate VII.) the ordinary species of the disease in this country, commences with small, round, reddish, and shining elevations of the skin, at first smooth, but within a day or two exhibiting thin white scales on their tops. These gradually, sometimes rapidly dilate to the size of half-a-crown, still retaining their oval or circular form, and are covered with shining scales, and encircled by a dry, red, and slightly elevated border. In some cases, these scales accumulate, so as to form thick prominent crusts. If the scales or crusts are removed, the skin appears red and shining, being very smooth, and free from the cuticular lines in the beginning, but marked, in the advanced stages, with long deep lines and reticulations, not always coinciding with those of the adjoining surface. fects the skin deeply, in circular patches, at the same time throwing off scales like those of large fishes." (See Paul. iEgin. de Re Med. lib. iv. cap. 2; —and Actuarius de Meth. Med. lib. ii. cap. 11:—also Aetius, tetrab. iv. serm. i. cap. 134$ and Galeu. Isagoge.) This was sufficiently clear: but those who translated the works of the Arabians into Latin, fell into the extraordinary mistake of applying the Greek term to a tubercular disease, which had been actually described by the Greeks under the appellation of elephantiasis; and they applied the barbarous term morplma, together with scabies and impetigo, to the scaly diseases of the Greeks above enumerated. Whence their followers, who detected the error, spoke of the Lepra Arabum as well as the Lepra Grsecorumj while the less accurate confounded every foul cutaneous disease under the term leprosy. The Arabians themselves do not employ the word Lepra; but have described these different diseases under appropriate appellations. See Elephantiasis below. * The " Dartre furfuracee arrondie" of Alibert, represented in plate 12 of his large work, livraison iii. 26 SQUAMiE: The Lepra most commonly commences on the extremities, where the bones lie nearest to the surface; especially below the elbow and the knee, and usually on both arms, or both legs at the same time. From these points it gradually extends, by the formation of new and distinct patches, along the arms or thighs, to the breast and shoulders, and to the loins and sides of the abdomen. In several cases, I have observed the eruption most copious and most permanent round the whole lower belly. The hands also become affected, and in many cases the hairy scalp; but the face is seldom the seat of large patches, although some scaliness occasionally appears about the outer angles of the eyes, and on the forehead and temples, extending from the roots of the hair. In the more severe cases, the nails of the fingers and toes are often much thickened, and become opaque and of a dirty yellowish hue, and are incurvated at the extremities: their surface is also irregular, from deep longitudinal furrows, or elevated ridges. When the eruption of Lepra is moderate in degree and extent, it is not attended with any uneasy sensations except a slight degree of itching when the patient is heated by exercise, or becomes warm in bed; and a little occasional tingling in certain states of the atmosphere.* When it is generally diffused, however, and there is a considerable degree of inflammation in the skin, it is accompanied with extreme soreness, pain, and stiffness; which I have sometimes seen so great as to render the motions of the joints impracticable, and to confine the patient to bed. Yet even under these circumstances, there is no constitutional disturbance; and * Hippocrates remarks that some Leprae itch before rain: lib. Ylfpt Xvu«i\ 27 LEPRA If no medicine be employed, the disease of the skin may continue for months, or even years, without any material derangement of the system. It is not easy to point out the causes of this disease, which appear, indeed, to be very various; for it is one of the most common affections of the skin, at least in this metropolis, and occurs at all periods, and under every circumstance of life.* It is certainly not communicable by contagion, nor does it appear to originate from confinement to certain kinds of diet, such as fish, dried or salted meat, &c.; since it is not endemic in districts where these are habitually used, and occurs frequently where they are almost unknown. But, like some other cutaneous affections of a more transient character, it is certainly produced occasionally by the influence of particular articles of food and drink, which operate through the idiosyncrasy of individuals. I have met with one gentleman, in whom spices or alcohol speedily produce it. The original attack in him occurred after eating some hot soup, containing spice, the first spoonful of which excited a violent tingling over the whole head, which was followed by the leprous * It is difficult, therefore, to account for the opinion expressed by the late Dr. Heberden, respecting the extreme rarity of Lepra in this country. " De vero scorbuto et lepra, nihil habeo quod dicam, cum alter rarissimus est in urbibus, altera in Anglia peneignotajunde factum est uthos morbosnunquam curaverim." (Comment, cap. 23.) And still more difficult to explain the statement of Dr. Cullin, whose definition of Lepra will include both the dry and humid tetters (psoriasis and impetigo) with the proper scaly Lepra; but who nevertheless affirms that he had never seen the disease. Nosol. Meth. class, iii. gen. 88, note.- 7 28 SQJJAMM: eruption, which soon extended to the h'mbs. In another case, in a young gentleman of nineteen, the disease commenced after taking copious draughts of cream: and vinegar, oatmeal, and other species of food, to which it has been ascribed, have probably given rise to it ocsionally: but these are all anomalies, and are only referrible to peculiar idiosyncrasy.* In some cases it has commenced after violent and continued exercise, by which the body had been much heated and fatigued. Dr. Willan has imputed the origin of Lepra to cold and moisture, and to certain dry sordes on the skin. It has seldom occurred to me, however, to witness the disease in bakers, laboratory-men, and others who work among dry powdery substances; while I have observed a considerable number of cases in young ladies, and in persons of both sexes in respectable ranks of life, by whom every attention to cleanliness was scrupulously paid. Where cold and moisture have excited the eruption of Lepra, the predisposition to it must have been peculiarly great. On the whole, the causes of this disease are involved in much obscurity There is obviously an hereditary predisposition to it in some individuals. 2. Lepra alphoides.f (Plate VIII. Fig. 1.) This is * Some poisonous substances taken into the stomach have produced an eruption of Lepra. The poison of copper is stated to have speedily excited it in several persons at the same time, in one of whom it continued for a month, but disappeared in the others in about ten days. See Med. Facts and Obs. vol. iii. p. 61. t The Greeks have described the Alphos as a milder disease, being more superficial, and less rough, than the Lepra: (see Ga- 29 LEPRA a less severe form of the disease than the preceding. It differs chiefly in the small size of the patches, which seldom extend beyond the diameter of a few lines, or become confluent, —in the minuteness and greater whiteness of the scales, —and in its limitation to the extremities. This variety of Lepra is most common in children. It is tedious and difficult of cure, like the former, and requires similar treatment. len, de Sympt Caus. lib. iii.—Aet. tetrab. iv. serm. i. cap. 134:) and the description of it given by Celsus accords with the appearances of the L. alphoides above stated. " Ax$oj vocatur, ubi color albus est, fere subasper, et non continuus, ut qusedam quasi guttae dispersse videantur. Interdum etiam latius, et cum. quibusdam intermissionibus, serpit." (De Medicina, lib. v. cap. 28.) Celsus no where employs the term Lepra. This scaly Alphos, which was deemed by Hippocrates a blemish rather than a disease (mpt naew, sect. 15.) was distinguished from another white affection of the skin, the teuce, which was not scaly, but consisted of smooth, shining patches, on which the hairs turned white and silky, and the skin itself, and even the muscular flesh underneath, lost its sensibility. The leuce was a disease of an incurable nature. (Hipp, npop/fytne. lib. ii.) Celsus, although pointing out this distinction, includes the leuce and the alphos under the same generic title, Vitiligo, (loc. cit.) It may be remarked that the Arabians distinguished these two affections by different generic appellations: calling the alphos, Albohak, and the leuce, Albaras, with the epithet white. Their translators have called the former morphsea, and included the leuce and elephantiasis under the appellation of Lepra. By retaining these distinctions in recollection, the accounts of the older writers may be read, while the confusion arising from their misapplication of names may be avoided. It appears probable that the /eucewas the leprosy of the. Jews, described in Leviticus, chap. xlii. See Greg. Horstii Obs. Med. SQJJAMJE: 30 It would be superfluous to enumerate the catalogue of useless medicines, which have been recommended from ancient times for the cure of Lepra: I shall, therefore, confine my attention to those of the beneficial agency of which I can speak from experience. It is necessary to premise, however, that there is no one remedy, nor any invariable plan of treatment, which will succeed in Lepra, under all the circumstances of its appearance in different instances; and that great errors are committed by prescribing for the name of the disease. The circumstances to which I allude more particularly are the different degrees of cutaneous excitement, or inflammatory action, which accompany the disease in different habits; and which, if carefully attended to, afford an important guide to the most successful application of remedies. In the less irritable conditions of the leprous eruption, in which no inflammatory tendency appears, such as the L. alphoides frequently, and the L. vulgaris occasionally, exhibits, a gently stimulant mode of treatment, at least externally, is requisite; though in all cases of Lepra the diet should be light and moderate, and heating liquors should be avoided; especially malt liquors and spirits; for every indulgence in these points will be felt in the aggravation of the symptoms. A frequent use of the warm bath, with which a moderate degree of friction may be combined, contributes to remove the scales, and to soften the skin; or, if the eruption be confined to the extremities, local ablution may be sufficient. These lib. vii. p. 330.—Leon. Fuchsii Paradox, lib. ii. cap. 16.-—Th. CampanellaeOrd, Medic, lib.vi. cap. 23.—Hensler, Von AbendV I'andischen Aussatz, p. 341. 31 LEPRA, cases are benefited by the use of the sulphur waters of Harrowgate, Leamington, Crofton, and other well known springs, both internally and externally, and by the warm sea-water bath. In fact, these gently stimulant ablutions are often sufficient, if persevered in during several weeks, to remove the modifications of Lepra of which I am now speaking. But if the scales adhere tenaciously, or are accumulated into thick crusts (see Def. 2.,) then some more active lotion must be conjoined with the warm ablution, or with the application of steam, in order to clear the surface. Lotions of diluted alcohol, of sulphurated potass, or the decoction of dulcamara, will aid the exfoliation; and the thick crusts may be softened and loosened by lotions containing a portion of the liquor potassae, or of the muriatic acid. When these are removed, the cuticle may be restored gradually to its healthy condition, by the unguentum picis, or the unguentum hydrargyri nitratis diluted with saturnine cerate, or simple ointment; or lotions containing a small proportion of the oxymuriate of mercury may be substituted. The ointments should be applied at night, and washed off in the morning with warm water, or a slight saponaceous lotion. In a few cases, the continued application of the tar ointment has effectually cleared the skin of the patches, and restored its texture, even when internal remedies had little influence; but this advantage has not always been permanent. The same inert cases will be accelerated in their progress towards a cure, by the use of those interna] remedies which tend to support the strength and to stimulate the cutaneous vessels. For this purpose the 32 SQJJAMiE: arsenical solution,* recommended by Dr. Fowler, is often extremely beneficial, in doses of four or five drops, which may be slowly increased to eight, and persevered in for a month or more.f Pitch, administered in the form of pdls, is productive of a similar good effect, where the cutaneous circulation is very inert; but both these medicines are liable to aggravate the eruption, where it is connected with much irritability of the skin. The solution of oxymuriate of mercury has appeared to have some efficacy in these inert states; and by thin and delicate girls, of relaxed habit, affected with the Lepra alphoides, the vinum ferri, or the tartrite before mentioned, has been taken with much advantage.J One of the most effectual remedies for Lepra, however, under all its varieties, is the decoction of the leaves and twigs of the solanum dulcamara, which was introduced to the notice of British practitioners by Dr. Crichton.|| * Preparations of this mineral have a direct tendency to stimulate the cutaneous circulation, and to inflame the skin; and are, therefore, altogether inadmissible in the irritative forms of Lepra. f This active medicine being now not only sanctioned by the profession in general, but by the Pharmacopoeia of the College, it will be enough to state, that, in these smaller doses, which experience has proved to be sufficient, it may be taken without any inconvenience. Another preparation, introduced by the late Dr. De Valangin, is kept at Apothecaries' Hall, under the name of solutio solventis mineralis, and is equally efficacious. | If in any case the tinct. lyttae prove useful in Lepra, it would probably be in these more inert instances. But it is to be observed that Dr. Mead, who originally recommended this medicine, was probably speaking, not of the scaly lepra, but of the leuce, or of the elephantiasis. See his Medicina Sacra, cap. ii. |J See his communication to Dr. Willan. (Treatise on Cutan. 33 LEPRA This medicine is at first administered in doses of two or three ounces thrice every day, which are gradually augmented, until a pint is at length consumed daily. When there is a degree of torpor in the superficial vessels, the same decoction, made with a larger proportion of the shrub, is advantageously employed as a lotion; but if there is any inflammatory disposition, this and every external stimulous must be prohibited. Where an irritable state of the disease exists, indeed, (and it is the most frequent,) nothing more stimulating than tepid water or thin gruel can be used for the purposes of ablution; and the arseniates, pitch, &c. above mentioned, must be excluded. The disease, under this condition, will be certainly aggravated by sea-bathing, by friction, by the external use of the strong sulphureous waters, or of any irritant, as I have frequently observed: but it will be alleviated by the internal employment of sulphur, with soda or nitre, or the hydrarg. sulphuratus niger with an antimonial, especially when conjoined with the decoction of dulcamara. The caustic potass, or liquor potassae of the L Pharmacopoeia, in the dose of twenty or thirty drops, alone, or in combination with the precipitated sulphur, is likewise beneficial ; and the tinctura veratri, given in such doses as not to disorder the bowels, has occasionally removed this state of the disease. When the skin is highly inflamed, thickened, and stiff, of a vivid red colour, intermixed with a yellowish hue, (where the cuticle is separating in large flakes,) the heat, pain, and itching, are often extremely trouble- Diseases, p. 145.) His formula has been adopted by the College in the late edition of the Pharmacopoeia. 34 SQTJAMLE: some, and the motion of the limbs is almost impracticable. The most effectual relief is obtained, in these cases, by gently besmearing the parts with cream, or a little fresh and well washed lard, or butter. 3. Lepra nigricans (Plate VIII. Fig. 2.) is a more rare variety of the disease, differing externally from the L. vulgaris chiefly in the dark and livid hue of its patches, which is most obvious in the margin, but even appears through the thin scales in the area of each patch.* The scales are more easily detached in this form of Lepra, and the surface remains longer tender, and is often excoriated, discharging bloody serum, till a new incrustation is formed. This variety of Lepra occurs in persons whose occupations expose them to the vicissitudes of the weather, and to a precarious diet, with fatigue and watching. It is cured by nutritive food, with moderate exercise, followed by the use of the bark, mineral acids, and seabathing. II. PSORIASIS. ) The Psoriasis, or scaly tetter ,f occurs under a considerable variety of forms, exhibiting, in common with * The melas of the ancients was deemed a superficial affection, resembling the alphos, except in its colour. " Maas colore ab hoc differt, curia niger est, et umbrae similis: caetera eadem sunt." (Celsus, loc. cit.) Possibly it included the pityriasis versicolor. See below, genus iii. of this order, spec. 3. t The scaly tetter was denominated psora by the Greeks, or sometimes rough and leprous psora. (See Aetius, tetr. iv. 1. 35 PSORIASIS. lepra, more or less toughness and scaliness of the cuticle, with a redness underneath. It differs, however, from lepra in several respects. Sometimes the eruption is diffuse and continuous, and sometimes in separate patches, of various sizes; but these are of an irregular figure,* without the elevated border, the inflamed margin, and the oval or circular outline of the leprous patches: the surface under the scales is likewise much more tender and irritable in general than in lepra; and the skin is often divided by rhagades or deep fissures. It is commonly accompanied by some constitutional disorder, and is liable to cease and leturn at certain seasons.f The causes of Psoriasis are nearly as obscure as those cap. 130, &c.) But the same generic term, with the epithet ulcerating, or pustular, •tfwpa kxxuSijs, was applied to the humid tetter, (impetigo,) and perhaps also to scabies. As the appellation psora has been appropriated to scabies by many of the modern writers, Dr. Willan adopted the term psoriasis (which was chiefly used to denote a scaly affection of the eyelids and of the scrotum by the ancients) for the name of the genus. * Paul of iEgina, who treats of lepra and psoriasis together, points out the irregular figure of the latter as a principal dia* tinction, that of the former being orbicular. " Acnpa per profunditatem corporum cutem depascitur oribculatiore modo, et squamas piscium squamis similes dimittit: *#wpa autem magis in superficie haeret, et varie Jigurata est, &c." lib. iv. cap. 2. " De Lepra et Psora." t Celsus seems to have had this tetter in view, when decrib' ing his second species of impetigo, and comparing it with lichen. " Alterum genus est pejus, et simile papulae fere, sed asperius rubicundiusque, figuras varias habens: squamulae ex cute deciduntj rosio major est; celerius ac latius procedit, certiorlbusque, quam prior, temporibus, et fit, et desinit: Rubra cog? nominatur." (lib. v. cap. 28.) SCLUAM^i: 36 of lepra. It is not contagious, with the exception perhaps of the first species, which Dr. Willan had observed to occur among children in the same school or family, at the same time; a circumstance, however, which I never witnessed. An hereditary predisposition to it is manifest in some individuals. Dr. Falconer has frequently traced it to sudden chills, from drinking cold water after being violently heated by exercise,—a cause to which lepra and other eruptive diseases are occasionally to be imputed.* Women, and especially those of a sanguineo-melancholic temperament, with a dry skin and languid circulation, are most liable to it: it affects them more particularly after lying-in, or during a state of chlorosis. And in children, it is not unfrequently produced by the many sources of irritation to which they are exposed It is also sometimes observed in both sexes, connected with arthritic complaints; and we have seen it occur under states of great mental anxiety, grief, or apprehension. In those who are predisposed to this eruption, slight occasional causes appear to excite it: such as being over-heated by exercise; the unseasonable employment of the cold bath; a copious use of acid fruits, vinegar, or crude vegetables; and some peculiar mixtures of food. The first two species of the eruption are sometimes the sequel of lichen. * See Memoirs of the Metl. Society of London, vol. iii.—In fact, Dr. Falconer, and even the nosologists down to our own time, include the lepra, scaly tetter, and pustular impetigo, in their description of lepra. See Vogel, de cogn. et curand. Homin. Affect, class, viii. § 699.—Sauvages, Nosol. Meth. class, x. ord. 5.—Linn. Gen. Morbor .class, x. ord. 4. Cullen, Nosol. class, iii. ord. 3. gen. 88. 37 PSORIASIS. Dr. Willan has given names to eleven varieties of Psoriasis, several of which are local, and require but a brief notice. 1. The Psoriasis guttata (Plate IX. Fig. 1.) is a sort of connecting link between this genus and lepra, the little patches being distinct and small, (seldom exceeding two or three lines in diameter,) but with an irregular circumference, and the other peculiar characters just described. They appear on almost every part of the body, and even on the face; but in the latter situation they exhibit only a redness and roughness, without scales. This eruption is most common in the spring, at which season it is liable to recur for several years. It is preceded by general pains, and slight feverishness. In children it often spreads rapidly over the body in two or three days; but in adults its progress is gradual and slow. 2. The Psoriasis diffusa* (Plate IX. Fig. 2. X,XII. Fig. 1.) presents a considerable variety of appearances. In most cases it consists of large patches, which are irregularly circumscribed, and exhibit a rough, red, and chopped superficies, with very slight scaliness interspersed. This surface is exceedingly tender and irritable, and is affected with a sensation of burning and intense itching, both of which are much augmented on approaching a fire, on becoming warm in bed, or even on * Good specimens of this affection are given in Alibert's 13th and 14th plates; the former exhibiting it on the neck and ear (" Dartre squammeuse humide,") —the latter in a patch on the cheek (" Dartre squammeuse orbiculaire.") Liv. iii-. SQUAMiE: 38 exposure to the direct rays of the sun; but they are relieved by the impression of cool air. Sometimes these extensive eruptions appear at once; but, in other instances, they are the result of numerous minute elevations of the cuticle, upon which small distinct scales, adhreing by a central point, are soon formed, and which become gradually united by the inflammation of the intervening cuticle. As the disorder proceeds, the redness increases, and the skin appears thickened and elevated, with deep intersecting lines or furrows, which contain a powdery substance, or very minute scurf. The heat and painful sensations are much aggravated by the least friction, which also produces excoriation, and multiplies the sore and painful rhagades.—This form of the disease is most frequent about the face and ears, and the back of the hand; the fingers are sometimes nearly surrounded with a loose scaly incrustation, and the nails crack and exfoliate: but it occasionally occurs on other parts of the body, either at the same time, or in succession. It commonly begins with some general indisposition; and a degree of erethism, with occasional sharp pains in the stomach, is sometimes kept up. during several weeks, by the constant irritation which it excites. Its duration is from one to four months, and sometimes much longer; and it is liable to return, in successive years, in the spring or autumn, and sometimes in both seasons. In other cases, the P. diffusa commences in separate patches, of an uncertain size and form, which become confluent, until they nearly cover the whole limb. Local instances also occur from local irritation; as in the 39 PSORIASIS. baker's itch, (Plate XI.) when the back of the hand is gradually covered with the rough scaly patches, interspersed with rhagades, and somewhat tumified; —and in the hands and wrists of washerwomen, from the irritation of soap. In the latter variety, (Plate X. Fig. 2.) a diffuse inflammation surrounds the hands, wrists, and fingers, and from the Whole of the affected surface the brittle cuticle separates in large irregular flakes in rapid succession. In infants, from two months to two years of age, this Psoriasis occasionally occurs in a severe degree, insomuch that Dr. Willan constituted the P. infantilis a distinct species. 3. In the Psoriasis gyrata (Plate XII.) the patches are in stripes of a tortuous or serpentine form, resembling worms or leeches, or sometimes bending into rings. It is apt to be confounded with the vesicular and pustular ring-worm (herpes and impetigo.) 4. The Psoriasis inveterata (Plate XIII. Fig. 2.) is the most severe modification of the complaint, beginning in separate irregular patches, which extend and become confluent, until at length they cover the whole surface of the body, except a part of the face or sometimes the palms of the hands and soles of the feet, with an universal scaliness, interspersed with deep furrows, and a harsh, stiff, and thickened state of the skin. The production of scales is so rapid, that large quantities are found every morning in the patient's bed. The nails become convex, thickened, and opake, and are frequently renewed; and, at an advanced period, especially SQUA1VL&: 40 in old people, extensive excoriations sometimes occur, with a discharge of their lymph, followed by a hard, dry cuticle, which separates in large pieces. In this extreme degree, it approaches very closely to the inveterate degree of lepra vulgaris in all respects; the only difference being in the form of the patches before they coalesce. It is sometimes the ultimate state of the Psoriasis diffusa; and occasionally a sequel of the prurigo senilis. The more local varieties of Psoriasis are the P. labialis, affecting the prolabium, especially of the under lip, the tender cuticle of which is thickened, cracks, and exfoliates, sometimes for a long period of time; —the P. palmaria? (Plate XIV.) an obstinate tetter, confined to the palm of the hand and wrist, which are rough, hot, and itchy, of a dirty hue, and cleft by deep furrows, which bleed when the fingers are stretched; —P. ophthalmica, when the scaliness occurs chiefly about the angles of the eyes, producing an itching, inflammation, and thickening of the eyelids, with a watery discharge;! —the P. pra3putii, which often accompanies the P. palmaria, is characterized by painful fissures and ing of the part, and is usually attended with pbymosis;— and the P. scrotalis, in which scaliness, heat, itching, and redness, are followed by a hard, brittle texture of the skin, and by painful chaps and excoriations. * Well represented in M. Alibert's 15th plate, under the title of « Dartre squammeuse centrifuge." t Galen distinguished the Psoriasis from the psorophthalmia a Psoriasis autem exterius est; psorophthalmia internam palpebram, superiorcm prsecipue afficit." Galen de Oculo, cap. 7, 41 PSORIASIS. The same general plan of treatment is applicable to the different modifications of Psoriasis, the period of its duration, and the degree of irritability, being carefully attended to. The popular practice, which hinges upon the old humoral hypothesis, consists chiefly in attempts to expel imaginary humours by evacuations, or to correct them by what are called antiscorbutics. But bleeding and repeated purging are injurious; and the vegetable juices, which an absurd notion of the scorbutic nature of the Psoriasis suggested, appear to he totally inefficacious. A more recent empiricism, which resorts to mercury in all affections of a chronic nature and of some obscurity, is not more successful: in fact, all these varieties of scaly tetter are ultimately aggravated by perseverance in a course of mercurials. In the commencement of the eruption, when it appears suddenly, and the constitution is obviously disordered, a moderate antiphlogistic treatment must be pursued. A gentle purgative should be administered, and the diet made light, by abstracting every thing stimulant. This regimen, indeed, is requisite throughout the course of the disease, which is immediately aggravated in sympathy with irritation of the stomach, whether by spices, fermented liquors, pickles, or vegetable acids; whence the disuse of these articles contributes materially to its cure. But if the constitutional disturbance has subsided,, the use of the fixed alkali, combined with sulphur lotum, or with an infusion of cinchona, together with tepid washing with simple water, or milk and water, will gradually remove the complaint. If the scaly patches SQUA1VLE: 42 have extended over a considerable part of the body, and have assumed a more inert and chronic character, it must be viewed in a similar light with the lepra, and the remedies recommended for the first and second species of that disease must be resorted to. The shooting and burning pain and itching, in the early and more inflammatory stages of Psoriasis, induce the patient to seek anxiously for relief from local external applications; but he is mortified to find that even the mildest substances prove irritants, and aggravate his distress. A decoction of bran, a little cream, or oil of almonds, sometimes produce ease; but any admixture, even of the oxide of zinc, or preparations of lead, with these liniments, is commonly detrimental. But the more local, and less inflammatory eruptions of Psoriasis are considerably alleviated by local expedients. The P. palmaria is deprived of its dryness and itching by exposure to the vapour of hot water, by the use of gloves made of oiled silk, and by the application of the unguentum hydrargyri nitratis, diluted with the ung. cetacei or cerae, according to the degree of irritation in the skin. Sea bathing, continued for many weeks, has been found an effectual remedy. The P. scrotalis and P. ophthalmica are also relieved by the same application, or the ung. hydrargyri praecipitati albi: but great care is requisite in the former case, to keep the parts clean by frequent ablution, and to prevent attrition. In the P of the lips, nothing acrid can be borne; and much of the cure depends upon securing the parts from irritation, even from heat and cold, by a constant covering of some mild ointment or plaster. In 43 PITYRIASIS. all these eases, some of the internal remedies above mentioned must be at the same time employed, according to the period and other circumstances of the disease. III. PITYRIASIS. The Pityriasis is a very superficial affection, characterized by irregular patches of thin scales, which re* peatedly exfoliate and recur, but which never form crusts, nor are accompanied with excoriations. It is not contagious.* It occurs under three or four varieties of form. 1. The Pityriasis capitis (Plate XV. Fig. 1.) which in infants is called dandriff, appears in a slight whitish scurf along the top of the forehead and temples, but in larger, flat, separate semi-transparent scales on the oc- * These negative characters distinguish this eruption, es? pecially when it affects the scalp, from the furfuraceous porrigo; a distinction which the last-mentioned circumstance rendered important and necessary. The ablest of the later Greek writers, Alexander and Paul, have described the disorder, as con? sisting of" slight scaly and branny exfoliations, without ulcera? tion." (See Alex. Trail, lib. i. cap. 4.—Paul. jEgin. lib. iii. 3.) Yet all the translators have rendered TLnvpiaats by the word porrigo; which according to Celsus, comprehended the ulcera? ting pustules, or achores, of the Greeks, (De Med. lib. vi. cap, 2.) The use of the term Pityriasis, therefore, to designate a dry and furfuraceous eruption, as distinct from the ulcerating porrigo, is sanctioned by authority, as well as by etymology, and pathological observation. 9 SQUA1VOE: 44 ciput. A similar affection occurs on the scalp of aged persons.* It is only necessary to enforce a regular ablution of the scalp with soap and water, or with an alkaline or weak spirituous lotion; for which purpose the hair must be removed, if it be not thin. If this be neglected, the affection may ultimately degenerate into porrigo. 2. The Pityriasis rubra occurs most frequently in advanced life, and is the result of a slight inflammation of the portions of the skin affected, somewhat resembling in this respect the psoriasis diffusa. The cuticle is at first only red and rough, but soon becomes mealy or scurfy, and exfoliates, leaving a similar red cuticle underneath, which undergoes the like process; the scaliness becoming greater, as the exfoliation is repeated. This complaint is attended with a dry and unperspiring surface, a troublesome itching, and a feeling of stiffness. There is also a general languor and restlessness. When the redness and scales disappear, the patches are left of a yellowish or sallow hue. But the whole process is liable to be repeated at short intervals, and the disease to be thus greatly prolonged. The P. rubia is removed by a combination of antimonials with the decoction of woods, and the warm sea-water bath. I have also seen it materially relieved by small doses of the tinctura veratri. Where the irritability of the skin is not very great, a gently restrin- * A good representation of Pityriasis on the occiput of an adult is given by Alibert, pi. 11, which he calls "Dartre furfuracee volante." 45 PITYRIASIS. gent lotion or ointment, containing a portion of borax or alum, and super-acetate of lead, may be applied to the parts affected with advantage. 3. The Pityriasis versicolor (Plate XI. Fig. 2.) is most remarkable for the chequered and variegated discoloration of the cuticle which it exhibits. It appears mostly about the breast and epigastrium, and sometimes on the arms and shoulders, in brown patches of different shades, variously branching and coalescing, and interspersed with portions of the natural hue.* In a few instances, it has extended over the whole back and abdomen, even to the thighs, and slightly affected the face. There is generally a slight scurfy roughness on the discoloured parts; but this is in some cases scarcely perceptible, and there is no elevation or distinct border to the patches. Dr. Willan states, that the P. versicolor " is not merely acuticular disease; for when the cuticle is abraded from any of the patches, the sallow colour remains, as before, in the skin, or rete mucosum. ,, This however, is not universal, for I have seen several instances of the eruption, in which the discoloured cuticle peeled off at intervals, in a thickened state, and a new cuticle was found underneath, of a red hue, as is usual under large exfoliations. ?These patches scarcely ever appear,like ephelides and freckles, on the face and hands, but chiefly on covered parts, as is remarked by Sennertus, who has given an accurate description of this eruption, under the appellation of " Maculae hepaticae," latinizing the popular German term, Leberflechte. He considers it as the Melas, or dark variety of Vitiligo. See his Pract. Med. lib. v. part, iii, § 1. cap. 7. SQUAMA: 46 The P. versicolor is usually of little moment; for it is rarely accompanied by internal disorder, or by any troublesome sensations, if we except a slight itching on growing warm in bed, after strong exercise, or drinking warm or strong liquors. In those instances, however, where the eruption is very extensive, the itching and irritation connected with it are sometimes extremely distressing, depriving the patients of their natural rest In these cases the digestive organs are also commonly disordered. But even when the eruption is not troublesome, great uneasiness is often occasioned by its appearance; since its brown and almost coppery hue frequently suggests, even to medical practitioners, the idea of a syphilitic symptom. But a little experience will soon enable the observer to recognise the eruption, independently of the total absence of any tendency to ulceration, however long its duration may be, and of every other concomitant symptom of syphilis. The causes of this Pityriasis are not well ascertained. It occurs most frequently in those who have resided in hot climates, especially in its troublesome form. In one young gentleman it began after a year's residence in the Greek islands: it is also not uncommon in military and sea-faring people. The most extensive eruption that I have seen occurred in a custom-house officer, after drinking spirits freely during a day of fasting in the boat on the Thames. Fruit, mushrooms, sudden alternations of heat and cold, violent exercise with flannel next to the skin, have been mentioned as probable causes of this eruption. Internal medicines have not appeared to have much 47 PITYRIASIS. influence on this eruption, as Dr. Willan has stated. The oxygeuated muriatic acid, however, I think, is possessed of some efficacy; and if the affection were of sufficient importance to induce the patient to persevere in swallowing medicine, the pitch pills* would probably be serviceable. By active external stimulants the disorder is often removed; as by lotions of strong spirit, containing the muriatic acid, or the caustic potass; one drachm of the former, or two or three of the liquor potassae, may be added to half a pint of distilled water. Sea-bathing is likewise beneficial, both as a remedy, and as a preventive of its recurrence. The more extensive and irritable eruptions of Pityriasis approximate somewhat in their character to the psoriasis, and are alleviated by the same treatment. 4. Pityriasis nigra. Subsequent to the period of his publication, Dr. Willan had observed a variety of Pityriasis in children born in India, and brought to this country, which commenced in a partially papulated state of the skin, and terminated in a black discoloration, with slight furfuraceous exfoliations. It sometimes affected half a limb, as the arm or leg; sometimes the fingers and toes.f IV. ICHTHYOSIS. The Ichthyosis, fish-skin disease, is characterized * See note, page 50. f M. Alibert has figured an eruption on the hand, which seems referable to this species, and whic h he denominates a "scorbutic ephelis." (See his plate 27, bis.) It appears to be the result of 48 SQJJAMiE: by a thickened, hard, rough, and in some cases almost horny texture of the integuments of the body, with some tendency to scaliness, but without the deciduous exfoliations, the distinct and partial patches, or the constitutional disorder, which belong to lepra and psoriasis. 1. Ichthyosis simplex. (Plates XVI, XVII.) In its commencement this disease exhibits merely a thickened, harsh and discoloured state of the cuticle, which ap* pears, at a little distance, as if it were soiled with mud. When further advanced, the thickness, hardness, and roughness become much greater, and of a warty character, and the colour is nearly black. The roughness, which is so great as to give a sensation to the finger passing over it, like the surface of a file, or the roughest shagreen, is occasioned by innumerable rugged lines and points, into which the surface is divided. These hard prominences, being apparently elevations of the common lozenges of the cuticle, necessarily differ in their form and arrangement in different parts of the body, according to the variations of the cuticular lines, as well as in different stages and cases of the complaint Some of them appear to be of uniform thickness from their roots upwards; while others have a short narrow neck, and broad irregular tops. The former occur where the skin, when healthy is soft and thin; the latter where it is coarser, as about the olecranon and patella, and thence along the outside of the arms and thighs. On some parts of the extremities, however especially about the ankles, and sometimes on the trunk of the body, these a degree of misery and filth, as little known in this country a*R the disease. 49 ICHTHYOSIS. excrescences are scaly, flat, and large, and occasionally imbricated, like the scales of carp. In other cases, they have appeared separate, being intersected by whitish furrows. " Th\k unsightly disease appears in large continuous patches, which sometimes cover the greater part of the body, except the flexures of the joints, the inner and upper part of the thighs, and the furrow along the spine. The face is seldom severely affected; but in one case, in a young lady, the face was the exclusive seat of the disorder, a large patch covering each cheek, and communicating across the nose. (Plate XVIII.) The mammas, in females, are sometimes encased in this rugged cuticle. The whole skin, indeed, is in an extremely dry and unperspirable condition, and in the palms of the hands and soles of the feet it is much thickened, and brittle. The disease often commences in childhood, and even in early infancy. This affection has been found to be very little under the control of medicine:* stimulating ointments and plasters have been industriously applied, with no material effect; and the disorder has been known to continue for several years, with occasional variations. Dr. Willan trusted to the following palliation by external management: " When a portion of the hard scaly coating is * For examples of Ichthyosis the reader may refer to Panarolus (Petecoste v. obs. 9.); Van der Wiel (obs. xxxv. cent. 2 )j Marcel. Donatus (Mirabil. lib. i. 3.; or Schenck, Obs. Medic. Rarior. p. 699, where the same case is related); and Philos. Transact, vol. xiv. no. 160—and vol. xlix. for 1755. See also the 37th plate of Alibert, in which the I. simplex is well represented. His appellation is " Ichthyose nacree." 50 SQJJAMM: removed," he says, " it is not soon produced agaiu. The easiest mode of removing the scales is to pick them off carefully with the nails from any part of the body, while it is immersed in hot water. The layer of cuticle, which remains after this operation, is harsh and dry; and the skin did not, in the cases I have noted, recover its usual texture and softness: but the formation of the scales was prevented by a frequent use of the warm bath, with moderate friction. 7 _ _ -. - t I have known the skin cleared of this harsh eruption by bathing in the sulphureous waters, and rubbing it with a flannel or rough cloth, after it had been softened by the bath; but the cuticle underneath did not recover its usual condition; it remained bright and shining, and the eruption recurred. Internally the use of pitch has in some instances been beneficial, having occasioned the rough cuticle to crack and fall off, and leave a sound soft skin underneath. This medicine, made into pills with flour, or any farinaceous powder, may be taken to a great extent, not only without injury, but with advan* tage to the general health; and affords one of the most effectual means of controlling the languid circulation, and the inert and arid condition of the skin.* Upon the same principle, the arsenical solution has been employed in ichthyosis: in one case, in a little girl affected * A lady took for a considerable time from three drachms to half an ounce of pitch daily, with the most salutary effect both on her skin and general health. She had commenced with four pills, of five grains each, three times a-day, and gradually augmented the dose.—It may be remarked, that the unpleasant pitchy flavour of the pills is materially diminished, if they are kept for some time after being made up. 51 ICHTHYOSIS. with a moderate degree of the disease on the scalp, shoulders, and arms, this medicine produced a complete change of the condition of the cuticle, which acquired its natural texture; but in two others no benefit was derived from it. The decoction of the inner bark of the elm has been said to be a specific for ichthyosis, by Plenck; but this originated in a misconception as to the use of the term.* 2. Ichthyosis cornea. Several cases of a rigid and horny state of the integuments, sometimes partial, but sometimes extending nearly over the whole body, have been recorded by authors,! and occasionally such a condition of the cuticle has been accompanied with the actual production of excrescences of a horny texture. These, however, are rare occurrences. The ordinary formation of horny excrescences in the human body, of which many examples have been described from the time of the Arabians downwards, is, however, unconnected with any general rigidity of the cuticle. These excrescences have been improperly calL * The definition of ichthyosis given by Plenck, as well as the description of" lepra ichthyosis," by Dr. Lettsom, on whose authority Plenck has mentioned this remedy, obviously refers to the lepra vulgaris. See Plenck, Doctrina de Morb. Cutan. p. 89. —Lettsom, Med. Memoirs of the Gen. Dispensary, sect. iii. p. 152. i t See Philos. Trans, no. 176, no. 297, and vol. xlviii. p. ii. p. 580.—Also Zacut. Lusitan. Prax. Hist. obs. 188.—Ephem. Acad. Nat. Cur. dec. i. p. 89. —Alibert has figured a singular case of " Ichthyose cornee," (plate 38) which resembles the case of the " porcupine man," described by Mr. Baker, Philos. Trans, vol. xlix. p. 1. 10 52 SQIJAMiE: ed horns; for they are purely of cuticular growth, having no connection with the bones or other parts beneath, and consisting of a laminated callous substance, contorted and irregular in form, and not unlike isinglass in appearance and texture.* They originate from two or three different diseased conditions of the cuticle; as from warts, encysted tumours, steatomata, &c. Morgag- Xii has mentioned the growth of a horn on the sinciput of an old man, the basis of which was a wart; and other authors have noticed the same factf In the most numerous instances, however, they have arisen from the cavity of encysted tumours, of very slow growth, which were lodged under the cuticle of the scalp, or over the spine, after the discharge of their contained fluid.J In * " Comua certe, quae hoc mererentur nomen,nunquam vidi;" says M. Lorry, " sed varias excrescentias in corpore et cute humana innascentes, et extra cutem forma singulari succrescentes, quis non vidit?" De Morbis Cutan. p. 520.—Yet our credulous countryman Turner, declines treating of horns, because, he affirms, " they are generally much deeper rooted than in the skin, arising from the cartilages or ligaments, or the bones themselves." On Diseases of the Skin, p. i. chap. xii. at the end. t Morgagni de Sedib. et Caus. Morbor. epist. lxv. art. 2.— Avicenna, who noticed the growth of horns on the joints, considered them as verrucous. Canon, iv. fen. 7. tract, iii. cap. 14. See also Lorry, p. 519.—Plenck de Morb. Cut. p. 98. | See two cases of this sort described by Mr. (now Sir Everard) Home in the Philosophical Transactions, vol. lxxxi. p. 1; and references to nine other cases of similar origin, in which the horny excrescences were from four or five to twelve inches long: one of them eleven inches in length, and two inches and a half in circumference, is preserved in the British Museum. See also Medical Facts and Observations, vol. iii. Eph. Acad. Nat. Curios, dec. i. an. i. obs. 30; and dec. iii. an. v. app.—Hist, de 53 ICHTHYOSIS. one case, a horn of this sort was the result of inflammation and discharge from a small steatomatous tumour of many years continuance.* Nearly the whole of these examples have occurred in women of advanced age. If these excrescences are sawed or broken off, they invariably sprout again. Excision, with the complete destruction of the cyst, or morbid secreting surface, is the only effectual remedy, when they have appeared, and a preventive during the growth of the primary tumour. la Soc. Roy. de Med. de Paris, for 1676, p. 316.—Bartholin. Hist. Anat. Rar. cent. i. 78. * See Memoirs of the Medical Society of London, vol. iv. app. p. 391. The reader will find other examples of horny excrescences in the works of Ingrassias, de Tumor, prset. Naturam, torn. i. p. 336; Fabric. Hildan. cent. ii. obs. 25, 26; and many more referred to by Haller, Elem. Physiol, torn. v. p. 30. note. Malpighi has figured similar excrescences, originating from a morbid growth of the nails. Opera Posthuma, p. 99. and tab. xix. fig. 3—6. 54 Order HI. EXANTHEMATA. RASHES. The term Exanthema, efflorescence, appears to have been used by the Greek writers in a very general sense, equivalent to that of our word eruption;* and it has been employed, in this acceptation, by many modern authors. The nosologists, however, have limited it to those eruptions which are accompanied with fever, and which have their regular periods of efflorescence and decline. In this arrangement, it is appropriated solely to those appearances which are usually called rashes; (see Def. 3.) namely, to patches of superficial redness of the skin, of various extent and intensity, occasioned by an unusual determination of blood into the cutaneous vessels, sometimes with partial extravasation. It has no reference, therefore, to the existence of fever or contagion, or to the duration and progress of the complaint. * Hippocrates applies the term to numerous eruptions, which he often classes together, as to lichen, lepra, leuce (Praedict. lib. ii. ad finem;) to miliary vesicles, and wheals (Epid. i. in the case of Silenus, some of which were prominent, like varij) and to eruptions resembling burns, flea-bites, bug-bites, &c, (Coac. Praenot, 441. 39. ed. Foes.—Epidem. lib. 7. p. 359. 28. &c.) He speaks also of fa apvxuSsa tt-wOiGpafa, or excoriations (Coac. Praenot. 444;) and applies the verb even to ulcers; — s!ou>0££t l%xca is xiq>a%qv (de Morbo Sacro, § iii. p. 88.) He has likewise fSw0ij stant oozing of blood from the mouth and nostrils, and at the same time considerable discharges of it from the bowels, and from the lungs by coughing; and in one, it was likewise ejected from the stomach by vomiting, for three or four days previous to death.f On the other * Several instances of sudden death, in this disease, from the occurrence of profuse haemorrhage, are mentioned by respectable authors. See Lister, Exercit. de Scorbuto, p. 96, &c.—Greg. Horst. lib. v. obs? 17. Two examples (one from pulmonary and the other from uterine haemorrhage) were communicated to me by my friend Mr. James Rumsey, of Amersham, one of which occurred in his own family. t Two of these cases were described in my Report of the Diseases treated at the Dispensary, Carey-street, in the spring of 1810. See Edin. Med. and Surg. Journal, vol. vi. p. 374. 105 PURPURA. hand, I lately saw a case of Purpura simplex, in which the petechias were confined to the legs, in a feeble woman, about forty years of age, who was suddenly relieved from the eruption and its attendant debility, after a severe catamenial flooding.* The causes of this disease are by no means clearly ascertained, nor its pathology well understood. It occurs at every period of life, and in both sexes; but most frequently in women, and in boys before the age of puberty, particularly in those who are of a delicate habit, who live in close and crowded situations, and on poor diet, or are employed in sedentary occupations, and subject to grief and anxiety of mind, fatigue, and watching.f It has likewise attacked those who were left in a state of debility by previous acute or chronic diseases. In one of the fatal instances above mentioned, it came on during a severe salivation, which had been accidentally induced by a few grains of mercury, given, as I was informed, in combination with opium, for the cure of rheumatism. It has sometimes occurred as a sequela of smallpox, and of measles; and sometimes in the third or fourth week of puerperal confinement.! The disease, however, appears occasionally, and in its severest and fatal form, where none of these circumstances existed: for instance, in young persons living in * See my Report for Jan. 1810, ibid. p. 124.—See also a case related by Wolff, in the Act. Acad. Natur. Curios, vol. iii. obs. 79. t See Dr. Willan's Reports on Dis. in London, p. 90. \ See Joerdens, in Act. Acad. N. Cur. vol. vii. obs. 110.— This is the Purpura symptomatica of Sauvages, class, iii. gen. vi. spec. .?. 106 EXANTHEMATA: the country, and previously enjoying good health, with all the necessaries and comforts of life. This circumstance tends greatly to obscure the pathology of the disease. For it not only renders the operation of these alleged causes extremely questionable, but it seems to establish an essential difference in the origin and nature of the disorder, from that of scurvy* to which the majority of writers have contented themselves with referring it. In scurvy, the tenderness of the superficial vessels appears to originate from deficiency of nutriment; and the disease is removed by resorting to wholesome and nutritious food, especially to fresh vegetables and to acids: while in many cases of Purpura, the same diet and medicine have been taken abundantly, without the smallest alleviation of the complaint. In the instance of the boy mentioned by Dr. Duncan, the remedies and regimen which would have infallibly cured the scorbutus, were liberally administered, without affording any relief; and in other cases, above alluded to, where a residence in the country, and the circumstances of the patients, necessarily placed them above all privation in these respects, the disease appeared in its severest degree. On the other hand, the rapidity of the attack, the acuteness of the pains in the internal cavities, the actual inflammatory symptoms that sometimes supervene, the * I mean the true scurvy, formerly prevalent among seamen in long voyages, and among people in other situations, when living upon putrid, salted, dried, or otherwise indigestible food, yielding imperfect nutriment. See Lind, Trotter, &c. on the Scurvy, and Vander Mye, de Morbis Bredanis. The symptoms are concisely detailed by Boerhaave in his 1151st aphorism. 107 PURPURA. occasional removal of the disease be spontaneous haemorrhage, the frequent relief derived from artificial discharges of Wood,* and from purging, all tend to excite a suspicion that some local visceral congestion or obstruction is the cause of the symptoms in different instances. This point can only be ascertained by a careful examination of the viscera, after death, in persons who have died with these symptoms. The ancient physicians directly referred some of them, especially the haemorrhagies from the nose, gums, and other parts, to morbid enlargement of the spleen.f In one case, in which an opportunity of dissection was afforded at the Public Dispensary, and which occurred in a boy under the inspection of my friend and colleague Dr. Laird, the spleen, which had been distinctly felt during life protruding itself downwards and forwards to near the spine of the ilium, was found enormously enlarged. In another instance, which occurred under my own care, in a boy thirteen years old, the abdominal viscera were found to be sound; but a large morbid growth, consisting of a fleshy tumour, with a hard cartilaginous nucleus, weighing about half a pound, was found in the situation of the thymus gland, firmly attached to the sternum, * See two cases of Purpura, related by an able and distinguished physician, Dr. Parry, of Bath, which were speedily cured by two bleedings from the arm. In both these cases, which occurred in a lady and an officer, the latter accustomed to free living, some degree of feverishness accompanied the symptoms of Purpura; and the blood drawn exhibited a tenacious, contracted coagulum, covered with a thick coat of lymph. See Edin. Med. and Surg. Journal, vol. v. p. 7. for Jan. 1809. f See Celsus de Med. lib. ii. rap 7 17 108 EXANTHEMATA: clavicle, pericardium, and surrounding parts * Cases not unfrequently occur, in which hepatic obstruction is connected with Purpura. A man, habituated to spiritdrinking, died in about a fortnight from the commencement of an eruption of petechias, which was soon followed by profuse and unceasing haemorrhage from the mouth and nostrils; but I had no opportunity of examining the body. The jaundiced hue of the skin and eyes, however, with the pain in his side, dry cough, and quick wiry pulse, left no doubt of the existence of considerable hepatic congestion. And, lastly, I attended a young woman, about the same time, labouring under the third species of the disease (P. urticans), with a sallow complexion, a considerable pain in the abdomen, and constipation, without fever. While she was taking acids and purgatives, which had scarcely acted upon the bowels, the pain on a sudden became extremely acute, the pulse frequent and hard, and the skin hot, with other symptoms denoting inflammation in the bowels, which were immediately relieved by a copious bleeding from the arm, followed by purgatives; after which the sallowness of the skin was gone, and the purple spots soon disappeared. These facts are not sufficient to afford any general inference, respecting the nature or requisite treatment of Purpura haernorrhagica; on the contrary, they tend to prove, that the general conclusions which are usually * This boy, though delicate, had enjoyed a moderate share of health, until ten or twelve days previous to his death, notwithstanding the diminution of the cavity of the thorax, occasioned by this tumour. See the Edin. Journal, vol. vi. just referred to. 109 PURPURA. deduced, and the simple indications* which are commonly laid down, have been too hastily adopted, and that no rule of practice can be universally applicable in all cases of the disease. In the slighter degrees of the Purpura, occurring in children who are ill fed and nursed, and who reside in close places, where they are little exercised; or in women shut up in similar situations, and debilitated by want of proper food, and by fatigue, watching, and anxiety, the use of tonics, with the mineral acids and wine, will doubtless be adequate to the cure of the disease, especially where exercise in the open air can be employed at the same time.f But when it occurs in adults, especially in those already enjoying the benefits of exercise in the air of the country, and who have suffered no privation in respect to diet; or when it appears in persons previously stout or even plethoric; when it is accompanied with a white and loaded tongue, a quick and somewhat sharp, though small, pulse, occasional chills and heats, and other symptoms of feverishness, * I am sorry to be under the necessity of differing from my respected friend and preceptor, on this subject; who would perhaps subsequently, have deemed the following statement, respecting the method of cure in the hemorrhagic purpura, too general. " The mode of treatment for this disease is simple, and may be comprised in a very few words. It is proper to recommend a generous diet, the use of wine, Peruvian bark and acids along with moderate exercise in the open air, and whatever may tend to produce cheerfulness and serenity of mind." See Reports on the Dis. of London, p. 93, for May 1797. f In enumerating the remedies, mentioned in the preceding note, Dr. Willan lays the most particular stress upon this point, and adds, that " without air, exercise, and an easy state of mind, the effect of medicines is very uncertain." On Cutan. Dis. p. 461, 110 EXANTHEMATA: however moderate; and if at the same time there are fixed internal pains, a dry cough, and an irregular state of the bowels; —symptoms which may be presumed to indicate the existence of some local congestion;—then the administration of tonic medicines, particularly of wine, cinchona, and other warmer tonics, will be found inefficacious, if not decidedly injurious. In such cases, free and repeated evacuations of the bowels, by medicines containing some portion of the submuriate of mercury, will be found most beneficial. The continuance or repetition of these evacuants, must, of course, be regulated by their effects on the symptoms of the complaint, or on the general constitution, and by the appearance of the excretions from the intestines.* If the pains are severe and fixed, and if the marks of febrile irritation are considerable, and the spontaneous haemorrhage not profuse, local or general blood-letting may, doubtless, be employed with great benefit, especially in robust adults. When the urgency of the haemorrhagic tendency has * While these sheets were in the press, I received a valuable communication from my friend, Dr. Harty, of Dublin, detailing the result of his experience in this obscure disease; and it afforded me great satisfaction to learn, that, after having witnessed the death of a patient, who was treated in the ordinary way, with nutritive diet and tonic medicines, he has been uniformly successful in the management of upwards of a dozen cases, since he relied solely upon the liberal administration of purgatives. He prescribed calomel with jalap, in active doses, daily, which appeared to be equally beneficial in the haemorrhagic, as in the simple purpura: the haemorrhages ceased, and the purple extravasations disappeared, after a few doses had been taken. This document being, in my estimation, too valuable to be lost, I transmitted it to Edinburgh, and it was published in the Medical and Surgical Journal, for April, 1813. 111 PURPURA. been diminished by these means, the constitution rallies, though not rapidly, with the assistance of the mineral acids, and the decoction of cinchona, or cascarilla, or some preparation of iron, together with moderate exercise, and nutricious diet. 3. The Purpura urticans (Plate XXIX.) is distinguished by this peculiarity, that it commences in the form of rounded and reddish elevations of the cuticle, resembling wheals, but which are not accompanied, like the wheals of urticaria, by any sensation of tingling or itching. These little tumours gradually dilate; but, within one or two days, they subside to the level of the surrounding cuticle, and at the same time their hue becomes darker, and at length livid. As these spots are not permanent, but appear in succession in different places, they are commonly seen of different hues; the fresh and elevated ones being of a brighter red, while the level spots exhibit different degrees of lividity, and become brown as they disappear. They are most common on the legs, where they are frequently mixed with petechiae; but they sometimes appear also on the arms, thighs, breast, &c. The duration of the complaint is various, from three to five weeks. It usually occurs in summer and autumn, and attacks those who are liable to fatigue, and live on poor diet; or, on the contrary, delicate young women, who live luxuriously, and take little exercise. Some oedema of the extremities usually accompanies it, and it is occasionally preceded by a stiffness and weight of the limbs. EXANTHEMATA: 112 The same rules of treatment apply to this, as to the preceding varieties of the disease. 4. Purpura senilis (Plate XXX.) I give this appellation to a variety of the complaint of which I have seen a few cases, occurring only in elderly women. It appears principally along the outside of the fore-arm, in successive dark purple blotches, of an irregular form and various magnitude. Each of these continues from a week to ten or twelve days, when the extravasated blood is absorbed. A constant series of these ecchymoses had appeared in one case during ten years, and in others for a shorter period; but in all, the skin of the arms was left of a brown colour. The health did not appear to suffer; nor did purgatives, bloodletting, (which was tried in one case, in consequence of the extraordinary hardness of the pulse,) tonics, or any other expedient, appear to exert any influence over the eruption. 5. Purpura contagiosa* is introduced for the purpose of noticing the eruption of petechiae, which occasionally accompanies typhoid fevers, where they occur in close situations: but as these are merely symptomatic, it would be superfluous to dilate upon the subject here. I may merely observe, in addition to the facts which I formerly communicated to Dr. Willan, respecting the occurrence of petechiae in patients admitted into the Fever-House,f that such an efflorescence is very rarely seen in that establishment. * Purpura maligna of Sauvages, spec. 3. f See his Treatise on Cutan. Dis. p. 468 and 469, nott. 113 ERYTHEMA, VI. ERYTHEMA. The Erythema, like the roseola, is commonly symptomatic, and occurs with much variety in its form: yet sometimes, like the same efflorescence, it is the most prominent symptom, and is, therefore, in like manner, liable to be mistaken for the idiopathic eruptive fevers. This term is often erroneously applied to eruptions, which, together with redness, exhibit distinct papular and vesicular elevations;* as, for example, to the Eczema produced by the irritation of mercury. In this arrangement, Erythema signifies " a nearly continuous redness of some portion of the skin, attended with disorder of the constitution, but not contagious." Dr. Willan has described six varieties, which will include all the ordinary forms of the efflorescence. In some of them, as will appear from their titles, the surface is more or less elevated at some period of its course, approximating to the papular or tubercular tumours: but * The word as used every where by Hippocrates, signifies simply redness; and is therefore correctly appropriated to this affection, which differs from erysipelas, inasmuch as it is a mere rash or efflorescence (Def. 3.) and is not accompanied by any swelling, vesication, or regular fever.—Modern authors have not agreed in their distinctions between these two terms. Dr. Cullen applies the word Erythema, to a slight affection of the skin, appearing without fever, or attended by a secondary fever of irritation; and Erysipelas, to an affection of the skin, when it is the result, or symptomatic, of fever; making no distinction as to the termination in bullae, &c. See his Nosol. Meth. gen. vii. spec. 2.; and First Lines, § 274.—Prof. Callisen deems Erythema only a lesser degree of erysipelas. See his Systema Chirurg. Hodiern. § 483. 114 EXANTHEMATA: these are obscurely formed, and soon subside, leaving the redness undiminished. 1. Erythema fugax consists of red patches, of an irregular form, and short duration, resembling the redness produced from pressure. These patches appear successively on the arms, neck, breast, and face, in various febrile diseases, and in bilious diarrhoea, generally denoting, as Hippocrates and the ancients have observed, a tedious and dangerous disease. They sometimes occur in chronic affections, especially those in which the primae viae are deranged; as in dyspepsia, hysteria, hemicrania, &c. 2. The Erythema leeve exhibits an uniformly smooth, shining surface, and chiefly appears on the lower extremities, in confluent patches, and is generally accompanied by anasarca. It affects young persons, who are sedentary, with slight fever, and terminates gradually, after an uncertain period, in extensive desquamation, as soon as the anasarca has disappeared. Exercise, with diuretics and corroborants contributes to shorten its duration in this class of patients. It occurs also in elderly persons, labouring under anasarca, (especially in those accustomed to excessive drinking,) and is liable to terminate in gangrenous ulcers. Indeed, under whatever circumstances anasarca occurs, so as to stretch the skin greatly, this Erythema is liable to be produced, and is often chequered with patches and streaks of a dark red or purple hue. Relief is afforded by the horizontal posture of the limbs, by the internal use of diuretics and 115 ERYTHEMA. bark, and also by a weak spirituous lotion applied to the surface. It sometimes occurs, without oedema, when the bowels have been much disordered, and occasionally, in women, at the menstrual periods. 3. Erythema marginatum (Plate XXXII. Fig. 2.) occurs in patches, which are bounded on one side by a hard, elevated, tortuous, red border, in some places obscurely papulated: but the redness has no regular boundary on the open side. The patches appear on the extremities and loins, in old people, and remain for an uncertain time, without producing any irritation in the skin. They are connected with some internal disorder, and their occurrence is to be deemed unfavourable. 4. The Erythema papulatam (Plate XXXI. Fig. 1.) occurs chiefly on the arms, neck, and breast, in extensive irregular patches, of a bright red hue, presenting not an inelegant painted appearance. For a day or two, before the colour becomes vivid, the surface is rough or imperfectly papulated. The redness afterwards continues for about a fortnight; and as the eruption declines, it assumes a blueish hue, especially in the central parts of the patches. I have seen this eruption attended with great disorder of the constitution; especially with a frequent, small pulse, total anorexia, and extreme depression of strength and spirits, and with acute pains and great tenderness of the limbs: but the general disorder is often trifling.* Light diet, with diaphoretics, and the * See Report of the Public Dispensary, Edin. Med. and Surg Journ. for Jan. 1812. 18 116 EXANTHEMATA: mineral acids, and an attention to the state of the bowels, comprise all that is necessary in the treatment of this disorder. 5. Erythema tuberculatum (Plate XXXI. Fig. 2.) resembles the last variety in the large irregular patches of red efflorescence, which it exhibits; but there are small slightly elevated tumours interspersed through the patches, which subside in about a week, leaving the Erythema, which becomes livid and disappears in about a week more. It commences with fever, and is accompanied with great languor, irritability, and restlessness, and succeeded by hectic. In the only three cases of this Erythema, which had occurred to Dr. Willan, the medicines employed did not appear to alleviate the symptoms, or to prevent the subsequent hectic. I have not seen any instance of it. 6. The Erythema nodosum, (Plate XXXII. Fig. 1.) which is a more common and milder complaint, seems to affect females only, and occurs on the fore part of the legs. It is preceded by slight febrile symptoms for a week or more, which generally abate when the Erythema appears. It shows itself in large oval patches, the long diameter of which is parallel with the tibia, and which slowly rise into hard and painful protuberances, and as regularly soften and subside, in the course of nine or ten days; the red colour turning blueish on the eighth or ninth day, as if the leg had been bruised. It has always gone through its course mildly, under the use of laxatives, followed by the mineral acids, and other tonics. 117 ERYTHEMA. Under the head of Erythema, Dr. Willan made mention of that form of intertrigo, which is produced in some persons, especially those of sanguine temperament and corpulent habit, by the attrition of contiguous surfaces.* It most frequently occurs beneath the breasts, round the axillae, in the groin, and at the upper part of the thighs. Sometimes it is accompanied by a glairy fetid secretion; and sometimes the surface is dry, and the redness terminates in a scurfy or scaly exfoliation. An erythematous appearance, analogous to the intertrigo, is occasioned by acrimonious discharges, as by those of fluor albus, dysentery, gonorrhoea, &c. and by the irritation of the urine and alvine discharges, in infants, when a sufficient attention is not paid to the proper changes of their linen. The heat and uneasiness attendant on this complaint are allayed by frequent tepid ablution, which removes the acrid secretion, where it occurs, and tends to pre- vent excoriation. If this takes place any simple ointment, or mild absorbent powder, will be applied with relief. * Sauvages includes this variety of intertrigo, and the chafing and inflammation produced by riding on horseback, tight shoes, the use of tools, and even that of bedridden persons, under Erythema, denominating the former Erythema intertrigo 5.) and the latter E. paratrimma (spec. 6.) 118 Order IV. BULLJE. In the original sketch of his arrangement, Dr. Willan conjoined in one order, the three following genera, Erysipelas, pemphigus and pompholyx, and those which now constitute the order of Vesicles: but he was led to separate them in consequence of a just criticism of Prof. Tilesius of Leipsic* The large and often irregular vesications, which are termed Bulke (Def. 4.) discharge a watery fluid when they break; and the excoriated surface sometimes becomes covered with a flat yellowish or blackish scab, which remains till a new cuticle is formed underneath; and sometimes is converted into an ulcer, which does not readily heal. * This criticism was contained in a paper on herpetic eruptions, " Uber die flechtenartigen Ausschl ge," published in a German periodical work, the Paradoxien of Dr. Martens, at Leipsic, 1802, ii band, i heft. Dr. Tilesius pointed out the improper application of Dr. Willan's definition of Bulla, " of a large size, and irregularly circumscribed," to the small, regular, and clustered vesicles of herpes; and he mentioned also the common inflamed base, upon which the herpetic clusters are seated, the scabby crust which invariably forms upon them, &c. as further grounds of separation. See p. 18 et seq. of the Paradoxien.-—The substance of the descriptive part of this paper was inserted by myself in the Medical and Physical Journal, for March 1804, vol. xi. p. 230, with an engraving of the herpes zoster. 119 ERYSIPELAS. I. ERYSIPELAS. The Erysipelas is a febrile disease, in which some part of the body is affected externally with heat, redness, swelling, and vesications. The tumour is soft, diffuse, and irregularly circumscribed, and not accompanied by throbbing or acute pain. The last mentioned circumstances distinguish the tumour of Erysipelas from that of Phlegmon;* and the presence of tumour, together with vesication, distinguishes the disease from Erythema. The disappearing of the redness on pressure, and its immediate return when the pressure is removed, are commonly mentioned among the characteristics of Erysipelas, by medical writers, from Galen downwards. This phoenomenon, however, belongs to Erysipelas in common with several of the Exanthemata; as with the efflorescence in scarlatina, in some varieties of roseola, and in erythema. The varieties of Erysipelas may be classed under four heads, namely, phlegmonous, cedematous, gangrenous, and erraticf 1. Erysipelas phelgmonodes. It is scarcely necessary to enter into a minute description of the well- * See Galen Meth. Med. cap. xiv. and Comment, in aph. 20, lib. vi; Also Aetius, tetrab. iv. serm. ii. cap. 59. t Galen speaks of Erysipelas phlegmonodes and asdematodes, in which he has been followed by Forest, Obs. Chirurg. lib. ii. 1. 3, & 4; by Plater, De Superfic. Corp. Dolore, cap. 17; and Frank, De curand. Horn. Morbis, lib. iii.—Mr. Pearson divides Erysipelas into three species, adding the gangrenous to the two just mentioned. See his principles of Surgery, chap, x BULLM 120 known appearance of acute Erysipelas.* This form of it most frequently occurs in the face, affecting usually one side of it only; sometimes it seizes one of the extremities ; and in both cases it is ushered in by a smart feverish attack. The colour is higher than in the other species, and the burning heat and tingling in the part are exceedingly distressing. The swelling generally appears on the second night, or third day of the fever; the vesications rise on the fourth and fifth, and break or subside on the fifth or sixth, when the redness changes to a yellowish hue, and the swelling and fever begin to diminish; —and on the eighth day both disappear; on the tenth, the new cuticle is commonly left exposed, the old one having separated, and the brownish or dark scab, which had formed where the fluid of the vesications had been discharged, having fallen off.—The progress of the disease, however, is more rapid, and its duration shorter, in young and sanguine habits, than in those more advanced in life: in the former, the tumefaction is sometimes fully formed on the second day, and the whole terminates on the sixth or seventh; while in the latter, it may be protracted to the tenth or twelfth, and the desquamation may not be completed before the fourteenth day. The vesications, in the latter instances, are often succeeded by a profuse discharge of acrimonious lymph, for several days, so that scabs do not form. Suppuration very rarely occurs in this species of Erysipelas, especially when it affects the face. * Dr. Cullen has given an excellent history of the disease First Lines. 1696. 121 ERYSIPELAS. 2. The Erysipelas cedematodes is less severe in its attack: the tumour is more gradual in its rise and extension, is of a paler red, or a yellowish brown colour, and is accompanied by less heat and local distress; its surface is smooth and shining; and if it be strongly pressed with the finger, a slight pit remains for a short time.* Vesications, which are smaller, less elevated, and more numerous than in the former species, appear on the third or fourth day from the commencement of the swelling; and are succeeded, in two or three days, by thin dark-coloured scabs, giving an appearance not unlike the confluent smallpox, from the edges of which a clear lymph exudes. The whole face is much enlarged, so that the form of the features is scarcely recognised, and the appearance is not unaptly compared by Dr. Willan to that of a bladder distended with water. This species of Erysipelas is attended with considerable danger when it affects the face, as above described; for the disorder of the functions increases with the advancement of the external disease. Vomiting, rigors, and delirium, followed by coma, takes place about the height of the disorder, and often terminate fatally on the seventh or eighth day; while in other cases, the symptoms continue undiminished, and death occurs at a later period; or a slow and tedious convalescence ensues. This form of Erysipelas most commonly affects per- * Mr. Pearson observes, that, 14 the part affected is almost wholly free from tension, and gives the sensation of an xdematose or emphysematose state except that there is no crepitation." He compares the sensation, on pressing a part in which a considerable formation of pus has taken place in Erysipelas, " to that which is excited by a quagmire or morass." loc. cit. 122 BULLAE sons of debilitated constitution, dropsical patients, and those who have long been subject to other chronic maladies, or live in habitual intemperance. It is not attended with danger, however, when it affects one of the extremities. In some unfavourable cases, matter is formed, which is apt to make its way through the cellular substance, producing irregular sinuses between the muscles, which it often materially injures, and prolonging the sufferings of the patient for many weeks. 3. The Erysipelas gangmnosum commences sometimes like the one and sometimes like the other of the foregoing species, and most commonly occurs in the face, neck, or shoulders. It is accompanied with symptoms of low fever, and with delirium, which is soon followed by coma, which remains through the subsequent course of the disease. The colour of the affected part is a dark red; and scattered phlyctaenae, with a livid base, appear upon the surface, which frequently terminate in gangrenous ulcerations. Even when it terminates favourably, suppuration and gangrene of the muscles, tendons and cellular substance, often take place, producing little caverns and sinuses, which contain an ill-conditioned pus, together with sloughs of the mortified parts, which are ultimately evacuated from the ulcers. It is always a tedious and precarious disease, and irregular in the period ot its termination. A peculiar variety of gangrenous Erysipelas occasionally occurs in infants, a few days after birth, especially in lying-in hospitals,* and is often fatal. Sometimes, * See Underwood on the Dis. of Children, vol. i. p. 31. (5th edit.) —and an ample account of it by Dr. Gartshore, in the Med. Communications, vol. ii. art. v. (1790)—with some references. 123 ERYSIPELAS. indeed, infants have been born with livid patches, vesications, and even gangrene already advanced * It most frequently commences about the umbilicus or the genitals, and extends upwards, or downwards, affecting the parts which it reaches with moderate swelling, and slight hardness; the skin puts on a dark red colour, and vesications with livid bases break out, terminating in sphacelus, which, if the child is not speedily cut off, nearly destroys some of the fingers, or toes, or even the genitals. In the milder cases, when the extremities alone are affected, suppurations take place rapidly about the joints of the hands and feet. The complaint, however, often terminates favourably in ten or twelve days. 4. In the Erysipelas erraticum the morbid patches appear, one after another, on different parts of the body; in some cases, those which appeared first remain till the whole eruption be completed; in others, the first patches decline as fresh ones appear. Sometimes the disease thus travels progressively from the face downwards to the extremities.f It commonly terminates fa* vourably, however, in a week or ten days. The exciting causes of Erysipelas are not always obvious: but it is commonly attributed to the action of cold air, after being heated; or to exposure to a strong * See a case related by Dr. Bromfield, in the same vol. art. iv. f Mr. Pearson mentions this progression of the disease, as belonging to the Erysipelas oedematodes; and adds, that each renewed accession of the complaint was less and less severe, as it receded to a greater distance from the part first affected. § 308. See also Frank, lib. iii. § 281. 19 BULLAE 124 heat, whether from the direct rays of the sun or from a fire; to intemperance; or to violent emotions of the mind, especially anger and grief. Erysipelas is likewise symptomatic of wounds and punctures, especially when the periosteum is injured, and of the local application of poisons, the stings of insects, &c* It has been the subject of some discussion, whether Erysipelas is not sometimes propagated by contagion. The disease has been noticed, in several hospitals, to prevail in certain wards, among patients admitted with different complaints; but has seldom been known to spread in private houses. Dr. Wells, indeed, has collected several examples of the apparent communication of Erysipelas by contagion, which occurred in private families.f But such cases are, at all events, extremely rare, and perhaps never happened in well-ventilated and cleanly houses. From the Royal Infirmary, at Edinburgh, this disease, like the puerperal fever, was banished by ventilation, white-washing, and other means of purification; and it has not occurred in any hospital of late years, since a better system has been adopted in these respects. Other diseases, not infectious in themselves, appear to become united with typhus, or contagious fever, under similar circumstances, and thus to be propagated in their double form; the dysentery,| for ex- * An erysipelatous affection, which has even proved fatal, has occasionally come on two or three days after inoculation, both variolous and vaccine, in children of irritable habits. See some cases in the Med. and Phys. Journal, for 1801. t See Transact, of a Soc. for the Improvement of Med. and Chirurg. Knowledge, vol. ii. art. xvii.(1800.) t See Dr. Harty's Observations on Dysentery. 125 ERYSIPELAS. ample, the peritonitis of women in child-bed, ulcerated sore-throat, &c. The simple phlegmonous Erysipelas, at all events, was never seen to spread like an infectious disease. The method of treatment must necessarily be widely different in the phlegmonous, from that which the other forms of the disease require. In the ordinary cases of this species of Erysipelas, the principal plan of cure consists in the administration of moderate purgatives, with a light vegetable diet, and in enjoining repose of body and mind, and a cool apartment. Saline and other diaphoretic medicines may be employed, as auxiliaries of secondary importance. Blood-letting, which has been much recommended as the principal remedy for the acute Erysipelas, is seldom requisite; and, unless there is considerable tendency to delirium or coma, can not be repeated with advantage, at least in London, and other large towns.* Local bleeding and blistering may be substituted, in such cases, but not upon, or very near the diseased surface. The administration of cinchona and opium, in this form of the complaint, is certainly unnecessary, and appears to be of very equivocal safety, notwithstanding the authority upon which it has been recommended. In the Erysipelas azdematodes, and erraticum, the two last-mentioned remedies are highly useful, in accelerating the decline of the disease, and relieving irritation, when the active symptoms of the first three or four days have been subdued by purgatives and diaphoretics; or, * See Pearson's Principles of Surgery, § 320. Bromfield's Chir. Obs. vol. i. p. 108;—also Prof. Callisen, Syst. Hodiern. $491- 126 BULLAE: if the functions of the sensorium were considerably disordered by a blister between the shoulders, or a topical bleeding in the same part. The strength should be supported, during the decline of the complaint, by a more cordial regimen, with a view to obviate the tendency to gangrene. In the Erysipelas gangrenosum, even in infants,* the bark is necessary, in considerable doses, through the whole course of the disease. Opium also, camphor, the mineral acids, with wine, and the general regimen adapted to gangrenous affections occurring under other circumstances, must be freely employed. The formation of sinuses, the separation of sphacelated parts, &c. will require surgical attention for some time. With respect to external applications in the early stages of Erysipelas, experience seems to have decided that they are generally unnecessary, if not prejudicial.! The application of powdery substances has commonly, According to my own observation, augmented the heat and irritation in the commencement; and afterwards, when the fluid of the vesications oozes out, such substances produce additional irritation, by forming with the concreting fluid, hard crusts upon the tender surface.! * n ora "er to allay the irritation, produced by the * " In tenellis infantibus observatum fuit Erysipelas a causa abscondita, saepissime lethali, nisi corticis usu occurratur malo." Callisen, § 493. —See also Underwood, and Garthshore, before quoted. ¦f" Externa remedia resolventia, emollientia, adstringentia, vel calida, vel frigida,—uti quoque pulveres varii, parum vel nihil in erysipelate prosunt; nec omnis noxae suspicionem, experientia teste, effugiunt." Callisen. J Mr. Pearson, § 331. 127 ERYSIPELAS. acrid discharge from the broken vesications, Dr. Willan recommends us to foment or wash the parts affected, from time to time, with milk, bran and water, thin gruel, or a decoction of elder flowers and poppy heads. In the early state of the inflammation, when the local heat and redness are great, moderate tepid washing, or the application of a cool but slightly stimulant lotion, such as the diluted liquor ammoniae acetatis, has appeared to me to afford considerable relief. The zona, zoster, or shingles, is considered as a variety of Erysipelas by the nosologists, as well as by several practical writers: but it is invariably an eruption of vesicles; (not of bullae,) and possesses all the other characteristics of herpes. See below, ord. vi. gen. 3. Sauvages under the head of (spec. 5) arranges the fatal epidemic disease, which prevailed extensively in the early and dark ages, as the sequel of war and famine, and which has received a variety of denominations ; such as ignis sacer, ignis S li Antonii, mal des ardens, ergot, kriebel krankheit, &c. &c. according to its various modifications and degrees of severity, or according to the supposed cause of it.* The erysipela- * Sagar has included the varieties of this disease under the genus Necrosis, of which he thus details the symptoms: u Est partis mors lenta, sine praevio tumore, mollitie, et dissolutione foetida, cum dolore ardente ordinario et stupore, quae sequitur exsiccatio partis, induratio, nigredo, et mumia: differt a gangraena in eo, quod lentius procedat, cum dolore rodente et stupore, et in mumiam abeatj gangroena contra mollescat, phlyctaenas elevet, putrescat, fceteat, atque cito decurrat." Syst. Morbor. cl. iii. ord. vii. gen. 42. He describes five species; and of the fourth epidemica, he says, " Apud Flandros regnavit haec Nccrossis 1749-50, spasmi urtuum cum doloribus vagisj post 2 128 BULLAE tous redness, however, followed by the dry gangrene, which often destroyed the limbs joint by joint, was only one of the forms or stages of that disease; as the contracted and palsied state of the limbs, to which the ancients gave the name of scelotyrbe,* constituted another. Instead of originating from eating rye affected with the ergot, as was supposed in France ;f or barley with which the raphanus was mixed, as was imagined in Sweden ;| the disease was, doubtless, the result of deficient nourishment —a severe land-scurvy, which was a great scourge of the ancient world, and often denominated The name of St. Anthony seems to have been first associated with an epidemic disease of this kind, which prevailed in Dauphine about the end of the twelfth century. An abbey, dedicated to that saint, had recently been founded at Vienne, in that province, where his bones were deposited; and it was a popular opinion, vel 3 septimanas stupor, fremitus obscurus, artus cum frigore glaciali, contracturis, et anaesthesia; tandem livor partis, nigredo, flavedo, phlyctaenae, et siccissima mumia." * See Plin. Nat. Hist. lib. xxv. cap. 3. f See an able history of the ergot, in the Mem. de la Soc. "Roy. de Medecine de Paris, torn. i. p. 260, by MM. Jussieu, Paulet, Saillant, and the Abbe Tessier.—See also the Philos. Trans.vol.lv. p. 118. An interesting account of the kriebel krankheit, which was endemic in Hessia and Westphalia during a season of dearth in 1597, is preserved by Greg. Horst. in Oper. lib. viii. obs. 22. torn. ii. | See Linnaeus, Amcenit. Academ. vol. v. § Several instances of pestilence mentioned by Livy appear to have been of this kind. Indeed the learned Heyne observes: " Nobis manifestum videtur, rie ullam quidem inter Romanos pestilentiam memorari, quae pro pestilentid proprie dicta haberi possit," Sec. (Opusc. Academ. iii. p. 113.) 129 PEMPHIGUS. in that and the succeeding century, that all the patients who were conveyed to this abbey were cured in the space of seven or nine days:* a circumstance, which the ample supply of food in those religious houses may probably satisfactorily explain. It would be foreign to my purpose to pursue the subject here. II. PEMPHIGUS There is probably no such fever, as that which has been described by a few continental physicians, under the titles of febris vesicularis, ampullosa, or bullosa, and to which Sauvages applied the term Pemphigus.] Subsequent nosologists have given definitions of the disease, upon the same authority, as an idiopathic, contagious, and malignant fever, in the course of which phlyctaenae or vesications, of the size of a filbert, with an inflamed base, appear in succession on different parts of the surface of the body, and sometimes in the mouth. J But Dr. Cullen justly expressed his doubts of the accuracy of the original writers. The case related * Mezeray, Abrege Chronologique. See the articles Ergot, and Ignis Sacer, in Dr. Rees's Cyclopaedia. t From rt£/*$ii) bulla, phlyctsena. See his Nosol. Method, class, iii. gen. 3. % Dr. Cullen defines Pemphigus, " Typhus contagiosa; primo, secundo, vel tertio morbi die, in variis partibus vesiculae, avellanae magnitudine, per plures dies manentes, tandem ichorem tenuem fundentes." Nosol. Meth. gen. xxxiv.— Linnaeus, who has designated the disease by the barbarous term Morta, characterizes it as " Febris diaria, malignissima, funestissima." Gen. Morbor. class, i. gen. 1. BULLAE: 130 by Seliger,* on which Sauvages founds his first species, Pemphigus major, is worthy of little attention, and was perhaps, as Dr. Willan suggests, a case of erysipelas, with some incidental variation. The account of the epidemic at Prague, mentioned by Thierry,! which is the prototype of the Pemphigus castrensis (spec. 2) of Sauvages, is not entitled to credit, as Dr. Cullen remarks, in some of its circumstances: the bullae are supposed by Dr. Willan to have been symptomatic of severe typhus, or of pestilential fever, in the same manner as Dr. Hodges described those appearances in the plague of 1666, and as they are occasionally seen, intermixed with petechiae and vibices, or with patches of erythema fugax (see page 113,) in typhoid fevers. Again, as to the Pemphigus Helveticus (spec. 3) of Sauvages, which is borrowed from the description of Dr. Langhans,J Dr. Cullen is of opinion that the disease was the cynanche maligna; and Dr. Frank viewed it in the same light, referring it to scarlatina anginosa.§ Dr. Willan, who * See Ephem. Acad. Nat. Cur. dec. i. ann. viii. obs. 56.—Also Delius, Amoenit. Medicae, referred to by Sauvages. t See his Medecine Experimentale, p. 134. Par. 1755. \ In the Acta Helvetica, vol. ii. p. 260. §" Quern helveticum alii dixerunt pemphigum, hie ad scarlatina? speciem ulcerosa? pertinere videtur." lib. iii. p. 263. Dr. Frank himself, however, is the author of a singular confusion in regard to the genus pemphigus. He divides it into two species; the first of which, P. amplior, includes the eruptions of bullae, which he deems in all cases symptomatic of gastric or nervous fevers, or of a chronic nature, without any fever; and the second, P. variolodes, which is the chicken-pox; and which he again subdivides into vesicularis (the true chicken or swine pox,) and solidescens (the acuminated, warty, dry, hornpock,) which is,, in fact, smallpox. 131 PEMPHIGUS. points out the unsatisfactory* nature of the history given by Langhans, independently of the contradictions which it contains, proposes a query, whether the disease was not rather endemic, than epidemic or contagious, and referable to some local cause, like the ergot, Mai des Ardens, &c. before alluded to. In a word, this conclusion seems to be deducible from an examination of these slight and imperfect histories of the subject, that the notion of an idiopathic contagious fever, terminating in a critical eruption of bullae, has been founded in error. All the cases of phlyctaenae, which have been related by authors, are therefore referable either to typhoid fevers, malignant dysentery, &c. in which they are accidental and symptomatic;* or to the following genus, pompholyx, in which they are unconnected with fever. Dr. Willan mentions a Pemphigus infantilis, of which he had seen a few cases in infants, generally soon after birth, and which he considered as analogous to the erysipelas, which occurs at the same period, and as originating from the same causes. It commonly affected weak and emaciated infants, with a dry shrivelled skin, and proved fatal in a few days, from the complicated distress arising from pain, loss of sleep, and violent fever. The vesications, which were at first small and transparent, became large, oblong, and of a purplish hue, and finally turbid, and were surrounded by a livid * Such was the Pemphigus Indicus (spec. 4) of Sauvages, taken from a single case mentioned by Bontius.—The swinepox, however, seems to have been described by mistake under the title of Pemphigus, by Mr. R. B. Blagden, in the Med. Facts and Observations, vol. i. p. 205. 20 132 BULLiE red border. After breakingfthey leftlilcerations, which spread beyond their original limits, and became extremely painful.* III. POMPHOLYX. To an eruption of bullae, appearing " without any inflammation around them, and without fever," and therefore differing most materially from the pemphigus described by nosologists, Dr. Willan applied the appellation of Pompholyx,f of which he has described three varieties. 1. The Pompholyx benignus exhibits a succession of transparent bullae, about the size of a pea, or sometimes of a hazel nut, which break in three or four days, discharge their lymph, and soon heal. They appear chiefly on the face, neck and extremities; and occur in * Consistently with the opinion that all these bullae are symptomatic, and that the existence of a peculiar eruptive fever, characterized by such vesications, is imaginary, this infantile disease should, I conceive, have been referred to Pompholyx, since it appears to differ from the Pompholyx benignus ©f infants, only in being connected with a severe and fatal marasmus, instead of the irritation of dentition. t Foesius observes (CEconom. Hippoc. ad voc. that Hippocrates uses that word to denote wheals, or those eminences which resemble the eruption produced by nettles, (lib. ii. Ilspi Ha6w) and that are the bubbles of air, which appear upon water: but that Galen explains the pomphi, as eminences of the cuticle, containing a fluid; in exegesi, lib. ii. de Mulier. —See also Gorraeus, Def. Med. 133 POMPHOLYX. boys in hot weather, in infants during dentition, and in young persons of irritable habit from eating acrid vegetable substances, or from swallowing a few grains of mercury. 2. The Pompholyx diutinus (Plate XXXIII.) is a tedious and painful disorder, and is usually preceded for some weeks by languor and lassitude, headache, sickness, and pains in the limbs. Numerous red pimple-like elevations of the cuticle appear, with a sensation of tingling, which are presently raised into transparent vesications, that become as large as a pea within twenty-four hours, and, if not broken, afterwards attain the size of a walnut. If they are rubbed off prematurely, the excoriated surface is sore and inflamed, and does not readily heal. The bullae continue to arise in succession on different parts of the body, and even re-appear on the parts first affected, in some cases for several weeks, so that the whole number of bullae is very great; and when the excoriations are thus multiplied, a slight febrile paroxysm occurs every night, and the patient suffers much from the irritation, and from want of sleep. This disease chiefly affects persons of debilitated habits, and is very severe in the aged. It seems to originate under different conditions of the body, but often after continued fatigue and anxiety, with low diet; sometimes from intemperance; and not unfreqeuntly it is connected with anasarca, or general dropsy, with scurvy, Purpura, and other states of the constitution, in which the powers of the cutaneous circulation are feeble. It has, in some instances, appeared after profuse sweating, during which cold liquors were copiously swallow- 134 BULLAE ed, in common with several other forms of chronic cutaneous disease. In the fevers in which it has been observed, it was obviously symptomatic; for it has not only occurred at various periods, and varied much in its duration, but has accompanied fevers of the continued, remittent, and intermittent type, as well as arthritic, and other secondary fevers.* It is sufficiently clear, from the statements of the writers just referred to, that the Pompholyx is never communicated by contagion; and that the fluid contained in the vesicles is not ichorous, but a bland lymph,! resembling that which is poured into the ventricles of the brain in hydrocephalus. In several of the persons, whose cases are recorded, the disease occurred more than once. The Pompholyx is most troublesome and obstinate in old persons, in whom the transparent bullae sometimes equal the size of a turkey's egg, while others of a smaller size are intermixed with them, which appear dark and livid. When broken, they * Many cases illustrative of these observations are on record; especially those related, under the appellation of Pemphigus, by- Mr. Gaitskcll and Mr. Upton, in the Memoirs of the Medical Society of London, vol. iv. art. i. and vol. iii. appendix; by Mr. Christie, in the Lond. Med. Journal, vol. x. p. 385 (for 1789;) by Dr. Stewart, in the Edin. Med. Commentaries, vol. vi. art. 3. p. 79; by Dr. Hall, in the Annals of Med. vol. iii. art. ix.; by Mr. Ring, in the Lond. Med. Journ. xi. p. 235; by Dr. Dickson, in the Trans, of the Royal Irish Academy, for 1787, and Lond. Med. J. vol. ix. p. 309; and by Bang, in the Acta. Reg. Soc. Med. Hauniensis; vol. i. p. 8, &c. See also Frank, De curand. Horn. Morbis, lib. iii. p. 263. Sennert. de Scorbuto, cap. v. § 59. t Mr. Gaitskell not only proved this by analysis, but by in oculating himself with it with perfect impunity. 135 POMPHOLYX. leave a black excoriated surface, which sometimes ulcerates. The warm bath, used every second day, was considered by Dr. Willan as the most active palliative, and the best remedy. I think I have seen the decoction of cinchona, with cordials and diuretics, of considerable advantage in these cases, especially when the eruption was combined with anasarca. In young persons, in whom the Pompholyx is seldom severe, these remedies are affirmed by Dr. Willan to be successful within two or three weeks; but the warm bath seems to increase both the tingling in the skin, and the number of the vesications, in these patients * 3. The Pompholyx solitarius is a rare form of the disease, which seems to affect only women. One large vesication usually appears in the night, after a sensation of tingling in the skin, and rapidly distends itself, so as to contain sometimes a tea cupful of lymph: within forty-eight hours it breaks, discharging its fluid, and leaving a superficial ulceration. Near this another bulla arises in a day or two, and goes through the same course; and it is sometimes followed, in like manner, * The warm bath sometimes aggravates the disease, even in the aged, as I lately had an opportunity of witnessing in an old lady of 80. In this case, however, the bulla?., of which eight or ten arose daily for several months, were surrounded by an extensive erythematous inflammation, and there was a considerable tendency to the febrile state. A single immersion in the warm bath excited a violent fever; and bark, sarsaparilla, and other tonics, produced a similar effect. She ultimately recovered, under a light and refrigerant diet and regimen. 136 BULLAE: by two or three others in succession; so that the whole duration shall be eight or ten days. Cinchona internally, and linseed poultices, followed by light dressings to the sores externally, were employed with advantage in three cases seen by Dr. Willan. 137 Order V. PUSTULJE. Pustules* originate from an inflammation of the skin, and the consequent partial effusion of purulent matter under the cuticle, by which the latter is elevated into small circumscribed tumours (Def. 5.) Sometimes several of these elevations arise upon a common inflamed surface; but most frequently the inflammation of the base of each is distinct and circumscribed. They often terminate in a scabby incrustation, varying in hardness according to the various tenacity of the contained fluid; and sometimes in superficial ulceration. The five genera of pustular diseases, comprehended in this order, have nothing in common in their character, * Although it seems obvious, that the origin of this term was deduced from the purulent contents of the eruption (quasi, pus fulit;) yet the best ancient authority sanctions the common indefinite and unlimited use of it. For Celsus applies it to every elevation of the cuticle, including even wheals and papulae," quae ex urtica, vel ex sudore nascuntur;" and he deems it synonymous with of the Greeks, which was in fact the general term for every species of eruption. (Celsus de Med. lib. v. cap. 28; § 15. —See above, page 55, note.) The Greek physicians appear to have comprehended both pustules and vesicles under the term qhvxfmvai, which their translators have rendered by the word, pustulse; and in this double sense the latter has also been generally used. Some discriminating writers, however, have correctly appropriated it to suppurating eruptions. <{ Pustularum nimirum conditio," says Prof. Arnemann, " exigit, ut in apice suppurentur vel in pus abeant." (Commentar. de Aphthis, Gott. 1787, § 2. See also Linn. Gen. Morb. class xi. ord. 4— Sagar, class i. ord. 2.) 138 PUSTULE: except the appearance of pustules in some stage of their progress: for some are contagious, and others not; some are acute, and others chronic. I. IMPETIGO. HUMID OR RUNNING TETTER. This eruption is characterized by the appearance of the small pustules, denominated Psydracia (Def. 5,&.) It is not accompanied by fever, not contagious, nor communicable by inoculation. It chiefly occurs on the extremities, and under the following forms.* 1. The Impetigo figarata (Plate XXXIV.) is the most common variety of the moist tetter. It appears in circumscribed patches, of various figure and magnitude, which are usually smaller and more circular on the upper, and larger, oval, and irregular, on the lower extremities. The patches consist at first of clusters of the yellow psydracious pustules, set close together and surrounded by a slight inflammatory border; the whole being somewhat raised, but the pustules not very prominent or acuminated. In a few days the pustules break, and discharge their fluid; the surface becomes red and * Celsus has described four species of Impetigo, the first of which is a pustular disease, terminating in excoriation, and corresponds with the affections described in the text. His other varieties seem to include some of the more violent forms of psoriasis, or lepra. See the 28th chapter of his 5th book, § 17. The ulcerated psora (4wpa fcsca&tyf) of the Greeks was apparently the same affection with the Impetigo of Celsus. 139 IMPETIGO. excoriated, shining as if it were stretched, but exhibiting numerous minute pores, from which a considerable ichorous discharge is poured out, accompanied with much troublesome itching, heat, and smarting. The discharge soon concretes partially into thin yellowish or greenish scabs; but still continues to ooze from under the scab, which it forms. In the course of three or four weeks, as the quantity of the discharge diminishes, the scabs dry and fall off, leaving the surface of the cuticle red, rough, and somewhat thickened, and at the same time extremely brittle, and liable to crack and to be excoriated; so that the ichorous discharge and scabbing are easily reproduced, and the disease is often thus much prolonged in its duration. Occasionally fresh crops of the psydracious pustules reappear, as at the commencement; and the whole course of the eruption is repeated. When the Impetigo figurata is beginning to heal, the patches undergo a process somewhat similar to that which takes place in the lepra vulgaris. The amendment commences at the centre of the patch, which first subsides, leaving the border elevated: at length this also disappears, but the cuticle, which was the seat of the patch, remains for some weeks red, shining, and tender. But though this is the most usual and regular, it is by no means the uniform progress of Impetigo. For this eruption, like scabies and eczema, varies so much in its phaenomena, as almost to bid defiance to arrangement. Sometimes the patches enlarge by the formation of successive pustular margins; an exterior circle of pustules arising, while the preceding border is drying, to be followed by others which go through the same 21 140 PUSTULjE: course until the patch attains a considerable extent. The area, in the mean time, becomes dry and rough, with a scaly or scabby incrustation in its centre.* Sometimes the papulae of the lichen agrius become pustular, or are intermixed with psydracia, as before mentioned, and the disease assumes all the characters of Impetigo. But the affinity of Impetigo with the vesicular diseases is manifested by a common variety of it in the upper extremities, in winch the psydracious pustules are intermixed with transparent vesicles, resembling the pustules in size and form. Where this intermixture occurs, the disease is much more troublesome, from the extreme irritation, itching, smarting, and heat, which accompany it; and much more tedious and difficult of cure. It takes place chiefly on the hand, about the knuckles and sides of the fingers, or on the wrist; and the space between the metacarpal bones of the forefinger and thumb is usually the seat of one of the blotches. The vesicles are slower in their progress than the psydracia: they remain many days transparent, but not much elevated, the cuticle over them being thick in that situation.—When they break, an acrid ichor is discharged, which produces inflamed points where it * This impetiginous ring-worm bears a considerable resemblance to the herpes circinatus, which spreads by a succession of vesicular borders. A severe form of this tetter occurs in hot climates, according to the testimony of physicians who have practised there. See Hilary on the Diseases of Barbadoes, p. 352. (2d edit). —Towne on the same, chap. 8.—-Winterbottom's Account of Sierra Leone, vol. ii. chap. 9. —Probably it is this form of Impetigo, which Bontius mentions, as a most distressing disease in India, where it is called by the natives courap. (De Med. Indorum, cap. 17.) 141 IMPETIGO. touches the cuticle, and these become vesicles or psydracia. Each vesicle, thus broken, is not disposed to heal; but the cuticle round its base now becomes inflamed and raised, and discharges a thin ichor, when in any degree irritated. The vesicles appear, in slow succession, at a little distance from each other and from the pustules; and at length an irregular blotch is produced, of a red, chopped, and thickened cuticle, interspersed with the rising eruptions, little humid ulcers, and chops or fissures.* The sense of burning and intense itching, accompanying especially the first rise of the vesicles, is extremely distressing, and is much aggravated by the irritation of almost every application that is resorted to. * This mixed form of the disease has misled the generality of writers to confound il with herpes, under which term it is commonly described. Such is the herpes of Dr. Cullen. " Phlyctaenae, vel ulcuscula plurima, gregalia, serpentia, dysepuleta." Nosol. gen. 147. And Prof. Callisen's brief description of herpes, in one of its varieties, is an accurate delineation of this Impetigo. " Herpes pustulosus, crustosus, serpigo, quem constituunt papulae pejores corrosivae, quae congestae aream circularem constituunt, acute pungentem, valde pruriginosam, deinde pars ilia tegitur crusta cuti firmiter adglutinata, a transudatione humoris tenuis et acris e cute porosaj ichor, si tangit alias partes, istas simili malo defaedat, unde late serpere solet hoc malum, tamen absque exulceratione." (Chirurg. Hodiern. § 612.) See also Wiseman's Chirurg. Treatises, i. chap. 17, on Herpes. Turner on the Dis. of the Skin, chap. v. where herpes and tetter are used as synonimous terms. —But it is to be recollected that, in this arrangement, herpes is appropriated to a purely vesicular disease, which has a short and nearly uniform course of ten or twelve days, the vesicles of each patch becoming confluent, and at length covered with a dry crust. Of this genus the shingles afford the most characteristic example, PUSTULE: 142 2. The Impetigo sparsa (Plate XXXV.) differs from Uie preceding rather in the form, than in the nature and progress of the eruption: for, with the exception of the indeterminate distribution of the pustules, which are not congregated in circumscribed clusters, but dispersed without any regular order along the extremities, and sometimes about the neck and shoulders, and even on the ears and scalp, the foregoing description.is applicable to both species of the disorder. The Impetigo sparsa more frequently occurs in the lower extremities, than the former; and is, in that situation, more troublesome and obstinate. In elderly people, especially of debilitated habits, the excoriations are liable to pass into deep, irregular ulcers, surrounded by a purplish colour, and often accompanied with oedema. These two forms of Impetigo are not always traced to any obvious exciting cause: but they are frequently preceded by some derangement of the digestive organs, languor, and headache. A predisposition to the disease appears to be connected with the sanguine temperament, with a thin soft skin, and a relaxed and bloated habit of body; or, with the sanguineo-melancholic temperament, a spare form, and a thin but harsh skin. Certain seasons appear to have great influence on the disease, in those who are predisposed to it. The I. sparsa, especially on the lower extremities, is apt to return with regularity at the latter end of autumn, and to harass the patient during the whole of the winter, but disappears in the warm weather; while the I. figurata, affecting the upper extremities, is liable to recur in the 143 IMPETIGO. spring; of both which I have witnessed several examples.* The accession of the eruption has, in other instances, been ascribed to violent exercise, intemperance, cold, and sudden depressing passions, especially fear and grief.f Local tetters are produced by the action of particular irritants on the cuticle, which soon disappear, when the source of irritation is withdrawn. The affection of the hands and fingers, in those who work among sugar, which is called the grocer's itch, is of this nature; and similar eruptions are produced on the hands of bricklayers, by the acrid stimulus of lime. It is worthy of remark, that both the grocer's and the bricklayers itch is, in some individuals, a pustular and in others a vesi- * In this and some of the preceding circumstances, the accuracy of the brief description of Celsus is manifest. The first form of Impetigo is thaty.*' quae similitudine scabiem repraesentat; nam et rubet, et durior est, et exulcerata est, et rodit, Distat autem ab ea, quae magis exulcerata est, et varis similes pustulas habet, videnturque esse in ea quasi bullulae quaedam, ex quibus interposito tempore quasi squamulae solvuntur; certioribusque hsec temporibus revertitur." t In two gentlemen, whom I lately had occasion to see, affected with Impetigo, the eruption was imputed to great alarm and agitation of mind. Some of the scaly eruptions also are now and then referred to fear and grief, as well as the tubercular elephantiasis. See Dr. Tho. Heberden's remarks on the elephantiasis, in Madeira (Med. Trans, vol. i. art. 2;) and those of Dr. Joannis on that of Martigues (Med. Obs. and Inquir. vol. i. art. 19.) Some time ago we witnessed the extraordinary influence of mental alarm on the cutaneous circulation, in a poor woman, who became a patient of the Public Dispensary. A sudden universal anasarca followed, in one night, the shock occasioned by the loss of a small sum of money, which was all she possessed. (See Edinb. Med. and. Surg. Journal, vol. v. p. 127. 144 PUSTULE cular eruption, referable to the eczema; but in neither case contagious, as the popular appellation might lead us to suppose. Local pustular patches are also the result of the application of the tartrite of antimony to the skin by friction, and in some cases of the application of blisters, and other stimulating plasters. These pustules are liable to extend considerably beyond the blistered or stimulated part, and sometimes continue to arise in succession for a fortnight or more; and many of them often assume the form of phlyzacia (Def. 5. a,) or of large protuberant pustules, with a hard elevated and inflamed base. Some of these even acquire the size of small biles, and suppurate deeply and slowly, with great pain, and considerable restlessness and feverish heat in the night. The Impetigo figurata and sparsa are sometimes confounded with two contagious diseases of the pustular order, porrigo and scabies. The appellation of ringworm, which is popularly given to the oval or circular patches of the first, has partly contributed to occasion this mistake. They differ, however, from the contagious circles of porrigo, inasmuch as they seldom affect children —occur principally on the extremities, —and do not continue to discharge a purulent and glutinous, but, after the first eruption, an ichorous humour, —nor do they form the thick, soft, and copious scabs of porrigo: not to mention the absence of contagion. The prevalence of transparent vesicles in the patches of Impetigo, may mislead an incautious or inexperienced observer into a suspicion that the disease is scabies: but the distribution of the eruption in patches,—the copious exudation of ichor, —the rough, reddened, and fissured 145 IMPETIGO. cuticle, —the magnitude and slow progress of the vesicles —and the heat and smarting which accompany the itching, in this form of Impetigo, will serve in general to determine the diagnosis. In the strictly purulent form of scabies, the pustules about the hands arise to a much greater magnitude and elevation, than the psydracia, they are filled with a thick yellow pus, and are more considerably inflamed round their base. In the incipient state of these two forms of Impetigo, it is useful to administer sulphur internally, in such quantities as not to induce purging; and, if there is much irritability or inflammation of the cuticle, a portion of nitre or crystals of tartar may be advantageously combined with it. The Impetigo sparsa commonly yields to these medicines, if diligent ablution with tepid water be at the same time employed. But when the disease is of long standing, it requires a treatment somewhat similar to that recommended for inveterate psoriasis; namely, the diet drinks, decoctions of sarsaparilla and cinchona, with the fixed alkalis, and antimonials. The mercurial alteratives, however, in this affection, are of essential assistance to this plan of cure; such as small doses of cinnabor, the hydrargyrus cum creta, or the pill of Dr. Plummer. The external applications adapted to these forms of Impetigo, especially to the figured species, are the mild desiccative unguents: for, in the majority of cases, the irritable surface of the tetter will not bear stimulants with impunity. When the discharge is considerable, the ointments prepared with the oxide of zinc, alone, or united with saturnine ointment, or with the white precipitated oxide of mercury, are the most efficacious, in 146 PUSTULJS: allaying the inflammatory condition of the excoriated surface, and in reducing the quantity of the discharge. When there is less of this irritability and exudation, the ointment of the nitrate of mercury, much diluted, as with five or six parts of simple ointment will be beneficial. From the too active employment of this unguent, and still more of that of the nitrico-oxide of mercury, by practitioners unacquainted with the character of the disorder, a great aggravation of the eruption and of the sufferings of the patient is sometimes occasionedi In some instances, indeed, the skin, under this impetiginous affection, is peculiarly sensible to the stimulus of mercury, whether employed internally or externally. I think I have observed this circumstance most frequently in a few cases, which were the sequelae of lichen. But the most irritable of all the varieties of Impetigo, are those in which vesicles abound; in some of which the zinc, and saturnine applications, and even simple lard, occasion an aggravation of the symptoms. In these cases, it is particularly necessary to keep the parts covered, with a view to avoid the effects of friction from the clothes, as well as of heat, and of cold; to wash the surface daily with some emollient fluid, sucli as milk and water, or an infusion of bran; to interdict the use of soap; and to besmear the parts with cream, or an emulsion of almonds. A lotion prepared by boiling mallow, digitalis, and poppy-heads has been found serviceable, where the parts were very painful. In many cases, however, the stiffness, which ensues upon the speedy drying of these lotions, renders it impossible to use them, and it is necessary to cover the part lightly 147 IMPETIGO. with dry lint only, or to interpose between it and the diseased surface a sprinkling of the oxide of zinc. In the drier, and less irritable forms of the Impetigo, the use of the waters of Harrowgate is the most effectual remedy, and likewise the best preventive of its returns: under the same circumstances, the warm sea-water bath, followed by a course of bathing in the open sea, is productive of great benefit. 3. Impetigo erysipelatous. This form of the disease, in its commencement, presents nearly the ordinary appearances of erysipelas; namely, a redness and puny swelling of the upper part of the face, with oedema of the eyelids; and is accompanied with slight febrile symptoms for the space of two or three days. But on a minute examination, the surface, instead of the smooth polish of erysipelas, is found to exhibit a slight inequality, as if it were obscurely papulated; and, in a day or two, the true character of the disease is manifested, by the eruption of numerous psydracious pustules, over the inflamed and tumid skin, instead of the large irregular bullae of erysipelas. These pustules first appear below the eyes, but soon cover the greater part of the face, and sometimes extend to the neck and breast: they are accompanied with a distressing sense of heat, smarting and itching. When they break, they discharge a hot and acrid fluid, which adds to the irritation and excoriation of the surface. In this painful condition the face remains for ten days or a fortnight, when the discharge begins to diminish, and to concrete into thin yellowish scabs. But on the interstices between the scabs, fresh pustules arise at intervals, with renewed heat and pain, 00 148 PUSTULE. and subsequently discharge, ulcerate, and form scabs, like the former. The disease continues thus severe and troublesome for an uncertain period, from one to two or three months; and ultimately leaves the cuticle in the same dry, red and brittle state, which remains after the other forms of Impetigo. The constitution is scarcely disturbed during the progress of this disease, and is much less disordered in the outset than in erysipelas. Its affinity with Impetigo has been further evinced, in some cases which I have seen, by the occurrence of the other forms of the eruption on the extremities, during its course; occasionally, indeed, extending over the whole surface, a capite ad calcem. In the commencement of the disease, purgative medicines, with the antiphlogistic regimen, afford great alleviation to the symptoms; but when the copious exudation and scabbing take place, the cinchona, in considerable doses, alone, or with the sarsaparilla, or mineral acids, is administered with the greatest benefit. The same local treatment is requisite, as in the other forms of the eruption; viz. tepid ablution, with emollient liquids; the application of the mildest ointments; and the use of sea-bathing, or of the sulphureous waters, in its decline. 4. Impetigo scabida. (Plate XXXVI.) In this more rare and severe form of the disease, one or more of the limbs becomes encased in a thick, yellowish, scabby crust, not unlike the bark of a tree, which is accompanied with a disagreeable heat and itching, and renders the motion of the affected limbs difficult and painful. This crust is the result of the concretion of an acrimo- 149 IMPETIGO. nious humour, which is discharged in great abundance from numerous psydracious pustules, as they successively form, break, and ulcerate over the surface of the limb. The concretion commences about the third or fourth week, when the discharge begins to abate, and invests the whole of the arm from the elbow to the wrist, or the leg from the knee to the ancle.* After some time longer, the scabby coating is divided by large cracks or fissures, from which a thin ichor exudes, and concretes into additional layers of scabs. If any portion of the scab be removed, the excoriated surface pours out its fluid again, and fills up the space with a new concretion. In the lower extremities, the disease is most severe and obstinate, is ultimately conjoined with anasarca, and often produces severe ulceration. The incrustation sometimes extends to the fingers and toes, and destroys the nails; and, as in other similar instances, the new ones are thick, notched, and irregular.f The I. scabida requires the same internal medicines, which have been recommended for the inveterate forms of the preceding varieties, especially the sulphureous waters. The chief peculiarity of its treatment consists in clearing the surface of its incrustation, and correcting the morbid action of the superficial vessels. The * Sauvages observes that this affection is called dartres encroutees by the French; but he describes it under the appellation of lepra herpetica. " Cognoscitur ex herpetibus crustaceis, squamosis, albis, hyeme majoribus, et suppurantibus; noctu intolerabiliter prurientibus: brachia ambo usque ad carpum, ambo femora tibiasque usque ad pedes, quandoque tegentibus; scalptu cruentatur haec lepra; poplites et cubiti vix flecti possunt: praecesserunt non raro tineae malignae." Class, x. gen. xxvii. spec. 7. t See lepra, above, p. 27. 150 PUSTULiE: thick scab can only be softened and gradually removed, by perseverance in the application of the steam of warm water to it, for a short time, daily. Those parts of the surface, which are thus cleared, must be covered with soft linen, after tepid ablution, twice a day; and some of the unguentum zinci, or a much diluted ointment of nitrate of mercury, with common cerate, (containing, for example, a fourth or fifth part of the mercurial,) or simply the oxide of zinc, or calamine in powder, must be interposed. 5. The Impetigo rodens is a rare, but intractable species of the disease, probably of a cancerous nature, in which the cellular membrane is affected, as well as the skin, and seems to shrink away, as the ulceration and discharge go on. The disorder commences with a cluster of pustules, sometimes intermixed with vesicles, which soon break, and discharge for a long period of time an acrid humour, from open pores or from under scabs; and the skin and cellular texture are slowly, but deeply and extensively, corroded, with extreme irritation and pain, which are only to be alleviated by large doses of opium. The disease commonly begins on the side of the chest or trunk of the body, and gradually extends itself. I have not seen any instance of this disease, which is said to have always terminated fatally, and to have been benefited by no medicine, either external or internal, which had been employed. 151 PORRIGO. II. PORRIGO. RINGWORM OF THE SCALP, SCALL'd HEAD, ETC. The Porrigo* is a contagious disease, principally characterized by an eruption of the pustules, denomiminated favi and achores (Def. 5, c, rf,) unaccompanied by fever. The several appearances which the disorder assumes are reducible to five or six specific forms.f 1. The Porrigo larvalis*\ (Plate XXXVII.) or Cmsta lactea of authors, is almost exclusively a disease of * This term is adopted, as a generic appellation, nearly in the same sense in which it was used by Celsus, who included the moist and ulcerating, as well as the dry and furfuraceous eruptions of the scalp, under this denomination. (De Med. liv. vi. cap. 3.) The word tinea is employed in the same generic sense by Sauvages; but being a term of no authority, and probably of Arabic origin, it is properly superseded by the classical appellation. Numerous writers, ancient and modern, have designated the varieties of the disease by distinct names; such as crusta lactea, alopecia, pityriasis, favi, achores, scabies, capitis, &c: but the most intelligent observers have pointed out the identity of the nature and causes of these various eruptions. See Sennert. de Morb. Infant, p. ii. cap. 4; and Pract. lib. v. p. iii. § ii. cap. 4.—- Heister, Chirurg. p. i. lib. 5. cap. x.—Tilingius, Lilium curiosum, cap. 17.—Vogel, de cognos. et cur. Horn. Morb. class, viii. § 713.—Stoll, Rat. Med. i. 49. t It must be remarked, however, that the first species appears to differ essentially from the rest; inasmuch as it arises independently of contagion, is perhaps never communicated by contact, and is connected principally with the period of lactation. In some respects it bears an affinity with impetigo. J The " teigne muqueuse" of Alibert, and pretty well delineated in his 5th plate.—Liv. i. PUSTULE: 152 infancy. It commonly appears first on the forehead and cheeks, in an eruption of numerous minute and whitish achores, which are crowded together, upon a red surface. These pustules soon break, and discharge a viscid fluid, which concretes into thin yellowish or greenish scabs. As the pustular patches spread, the discharge is renewed, and continues also from beneath the scabs, increasing their thickness and extent, until the forehead, cheeks, and even the whole face, become enveloped, as by a mask (whence the epithet larvalis,) the eyelids and nose alone remaining exempt from the incrustation.* The eruption is liable, however, to considerable variation in its course; the discharge being sometimes profuse, and the surface red and excoriated, —and at other times, scarcely perceptible, so that the surface remains covered with a dry and brown scab. When the scab ultimately falls off, and ceases to be renewed, a red, elevated, and tender cuticle, marked with deep lines, and exfoliating several times, is left behind; differing from that which succeeds to impetigo, inasmuch as it does not crack into deep fissures. Smaller patches of the disease not unfrequently appear about the neck and breast, and sometimes on the extremities: and the ears and scalp are usually affected in the course of its progress. In general the health of the child is not materially affected, especially when the eruption does not appear in the early period of lactation; but it is always accompanied with considerable itching and irritation, which, in young infants, often greatly * «Imo qujhidoque frontem occupant, ct totam faciem, excepts palpebris, larva tegunt." Plenck, p. 77. 153 PORRIGO. diminish the natural sleep, and disturb the digestion. Whence much debility sometimes ensues; the eyes and eyelids become inflamed, and purulent discharges take place from them and from the ears; the parotid and subsequently the mesenteric glands become inflamed; and marasmus, with diarrhoea and hectic, cut off the patient. Most commonly, however, the disease terminates favourably, though its duration is often long and uncertain. It sometimes suddenly puts on the appearance of cessation, and afterwards returns with severity. Sometimes it disappears spontaneously soon after weaning, or after the cutting of the first teeth; and sometimes it will continue from two or three months to a year and a half, or even longer. It is remarkable, however, that, whatever excoriation may be produced, no permanent deformity ensues. Dr. Strack has affirmed, that when the disease is about to terminate, the urine of the patient acquires the odour of the urine of cats; and that, when the usual odour remains unchanged, the disease will generally be of long continuance.* In the commencement of the Porrigo larvalis, while the discharge is copious and acrid, it is necessary to clear the surface two or three times a day by careful ablution with some tepid and mild fluid, as milk and water, thin gruel, or a decoction of bran; and to apply a mild ointment, such as the unguentum zinci, or a combination of this with a saturnine cerate. The latter will be useful to obviate excoriation, while the surface * See his Dis. de Crusta lactea infantum, et ejusdem specifico rernedio:-—also Lond. Med. Journal, vol. ii. p. 187. PUSTULiE: 154 remains red and tender, after the discharge has ceased. The removal of the disease is much accelerated by the use of alterative doses of mercurial purgatives, (especially where the biliary secretion is defective, the abdomen tumid, or the mesenteric glands enlarged,) which should be continued for three weeks or longer, according to circumstances. Small doses of the submuriate may be given twice a day, alone, or in combination with soda and a testaceous powder; or, if the bowels are very irritable, the hydrargyrus cum creta, or the cinereous oxide, may be substituted. But if the general health appear sound, the inflammatory condition of the skin, and the profuse exudation, may be alleviated by the internal use of soda, with precipitated sulphur, or with the testacea. When the state of irritation is removed, and the crusts are dry and falling off, the unguentum hydr. nitrati, much diluted, may be applied with advantage. And now some gentle tonic should be administered; such as the decoction of cinchona, or the chalybeates, (which are more readily taken by children,) especially the saturated solution of the tartrite, or the vinem ferri. I can not speak from experience respecting the medicine recommended as a specific by Dr. Strack; namely, a decoction of the leaves of the viola tricolor of Linnaeus, in milk.* In the course of the first week, this medicine is said to increase the eruption considerably; but at the same time the urine acquires the smell above * He prescribes a handful of the fresh, or half a drachm of the dried leaves, to be boiled in half a point of cow's milk, and the whole to he taken night and morning. 155 PORRIGO. mentioned, and, at the end of a fortnight, the crusts begin to fall off, and the skin underneath appears clean. Prof. Selle, however, has affirmed, that this plant is either noxious, in this complaint, or wholly inert* 2. Porrigo furfurans.] (Plate XXXVIII.) In this form of the disease, which commences with an eruption of small achores, the discharge from the pustules is small in quantity, and the excoriation slight; the humour, therefore, soon concretes, and separates in innumerable thin laminated scabs, or scale-like exfoliations. At irregular periods, the pustules re-appear, and the discharge being renewed, the eruption becomes moist; but it soon dries again and exfoliates. It is attended with a good deal of itching, and some soreness of the * Medicina Clinica, i. 185. t This is the tinea furfuracea of Sennertus, the tinea porriginosa of Astruc and Sauvages, the Porrigo furfuracea of Plenck, and the u teigne furfuracee" of Alibert. (Sennert. de Curat. Infant, p. ii. cap. 4.—Sauvages, Nos. Method, class, x. gen. xxix. spec. 6. Plenck, Doctr. de Morb. cut. class, vii. Alibert, plate 3, where it is well represented. It may be observed that the " T. amfantacee" of this writer (plate 4) appears to be a variety of P. furfurans.) It is, in fact, to a furfuraceous disease alone that the translators of the Greek physicians, and many modern Latin writers, apply the term porrigo, deeming it synonymous with the Greek rtitvpia&if. From the authority of Celsus, however, it is obvious that this is a misapplication of the term; and it is improper to comprehend the simple dandriff, and the contagious scall, under the same generic appellation. See Pityriasis, above, page 43, note. Plenck, though applying the term to both, marks the distinction, calling the contagious disease, porrigo furfuracea; seu vera, —and the other P. farinosa, seu spuria, which he considers as a mere accumulation of the secretion from the sebaceous glands. 23 156 PUSTULE: scalp, to which the disease is confined; and the hair, which partially falls off, becomes thin, less strong in its texture, and sometimes lighter in its colour. Occasion- ally the glands of the neck are swelled and painful. The P. furfurans occurs principally in adults, espe- cially in females, in whom it is not always easily dis- tinguished from the scaly diseases, pityriasis, psoriasis, or lepra, affecting the capillitium. The circumstances just enumerated, however, will serve to establish the diagnosis: as in those diseases, no pustules appear in the beginning,—there is no moisture or ulceration, — and the hair is not detached, nor changed in texture and colour; —neither are they communicable by contact. In the treatment of the P. furfurans, it is absolutely necessary to keep the scalp closely shaven. The branny scabs should then be removed by gentle washing, with some mild soap and water, twice a day; and an oilsilk cap should be worn, partly for the purpose of keeping the surface moist as well as warm, and partly for the convenience of retaining an ointment in contact with it. The nature of the ointments employed in this, as in the other species of Porrigo, must be varied, according to the period of the disease, and the irritability of the part affected. In the commencement of the eruption, when the surface is moist, tender, and somewhat inflamed, the zinc ointment should be applied; or, what has been said to be more beneficial, an ointment prepared with the cocculus Indicus, in the proportion of two drachms of the powdered berry to an ounce of lard. But when the scalp becomes dry and inirritable, in the progress of the complaint, it maybe washed with the common soft soap and water; or with a lather made 157 PORRIGO. by mixing equal portions of soft soap and unguentum sulphuris in warm water. More stimulant ointments will then be requisite, such as the unguentum hydrargyri nitrati, ung. hydrargyri initrico-oxydi, the tar and sulphur ointments, or the ung. acidi nitrosi of the Edinburgh pharmacopoeia. These, and other stimulant applications,* succeed in different individuals, in the inert state of the P. furfurans; but they must be intermitted, in case the inflammation and discharge return. 3. The Porrigo lupinosa is characterized by the formation of dry, circular scabs, of a yellowish-white colour, set deeply in the skin, with elevated edges and a central indentation or depression, sometimes containing a white scaly powder, and resembling, on the whole, the seeds of lupines.f These scabs are formed upon small separate clusters of achores, by the concretion of * A long catalogue of stimulants, of similar quality, may be collected from the writings of the Greeks, as remedies for the furfuraceous Porrigo: such as liniments of frankincense and vinegar, or the same gum with wine and oil; others prepared with oil of rue, litharge and vinegar; or with stavesacre and oil; lotions of the decoction of foenugreek, the roots of beet, and of the cucumis silvestris, &c. See Oribas. Synops. lib. viii. cap. 25. —Aetius, tctrab. ii. serm. ii. cap. 76. —Alex. Trail, lib. i. cap. 4. f From this resemblance, the same epithet was applied to the disease by Haly Abbas, who has distinguished six species. a Quinta est lupinosa, sicca, et, colore alba, lupino similis, a qua quasi cortices et squamae fluunt albae." (Theorice, lib. viii. cap. 18.) See also Guid. Cauliac. tract, vi. cap. 1. —Sennert. lib. v. p. i. cap. 32. It is the tinea lupina, of Astruc and Sauvages; and the Porrigo lupina, and scabies capitis lupina, of Plenck, (loc. cit.) The " teigne faveuse" of Alibert appears to be the Porrigo lupinosa. (plate 1.) 158 PUSTULE: the fluid, which exudes when they break; and they acquire, when seated on the scalp, the size of a sixpence. Frequently there is also a thin white incrustation, covering the intervening parts of the scalp, which commonly exfoliates; but if allowed to accumulate, through inattention to cleanliness, it forms an elevated crustaceous cap. The disease, however, is not exclusively confined to the head; but sometimes appears on the extremities, where the little white and indented scabs do not exceed two lines in diameter. This variety of Porrigo is liable to increase much, if neglected; and is usually tedious and of long duration. The first object in the management of the P. lupinosa, is to remove the crusts and little indented scabs, by a diligent application of soap and water, or other emollient applications. If the scalp be the seat of the disease, the previous removal of the hair will be necessary. If the scabs are not penetrable by these ablutions or by ointments, or if any thick intervening incrustation is present, a lotion of the liquor potassae,* or of the muriatic acid, in a diluted state, may be employed. When the surface is cleared, the ointment of cocculus Indicus may be applied to the red and shining cuticle; and afterwards the more stimulant unguents, as in the case of P. furfurans, with regular daily ablution, will complete the cure. * An alkaline lotion may be made with the proportion of a drachm of the aqua kali puri, two or three drachms of oil, and an ounce of water. —w Imprimis salia lixivia," says Prof. Selle, " ad crustam tarn firmam atque alias insolubilem emolliendam sunt apta." Medic. Clin. 187. 159 PORRIGO. 4. The Porrigo scutulata, (Plate XXXIX.) popularly termed the ringworm of the scalp, appears in distinct and even distant patches, of an irregular circular figure, upon the scalp, forehead and neck.* It commences with clusters of small light-yellow pustules, which soon break and form thin scabs over each patch, which, if neglected, become thick and hard by accumulation. If the scabs are removed, however, the surface of the patches is left red, and shining, but studded with slight elevated points, or papulae, in some of which minute globules of pus again appear, in a few days. By these repetitions of the eruption of achores, the incrustations become thicker, and the areas of the patches extend, often becoming confluent, if the progress of the disease be unimpeded, so as to affect the whole head. As the patches extend, the hair covering them becomes lighter in its colour, and sometimes breaks off short; and as the process of pustulation and scabbing is repeated, the roots of the hair are destroyed, and at length there remains uninjured only a narrow border of hair round the head. This very unmanageable form of Porrigo generally occurs in children of three or four years old and upwards, and often continues for several years. Whether the circles remain red, smooth and shining, or become dry and scurfy, the prospect of a cure is still distant: for the pustules will return, and the ulceration and scabbing will be repeated. It can only be considered as about to terminate, when the redness and exfoliations disap- * The " teigne granulee" of Alibert (plate 2) appears to be a variety of P. scutulata. 160 PUSTULE: pear together, and the hair begins to grow of its natural colour and texture. The disease seems to originate spontaneously in children of feeble and flabby habit, or in a state approaching to marasmus, who are ill-fed, uncleanly, and not sufficiently exercised: but it is principally propagated by contagion; i. e. by the actual conveyance of the matter from the diseased to the healthy, by the frequent contact of the heads of children, but more generally by the use of the same towels, combs, caps, and hats. Whence the multiplication of boarding-schools appears to have given rise to an increased prevalence of this disease, among the more cleanly classes of the community, at the present time. For such is the anxiety of parents to regain the lost years of education, that they too often send their children to these schools, when capable of communicating the infection, although supposed to be cured; against which no vigilance on the part of the superintendents can afford a sufficient security. The principles of local treatment already laid down, are particularly applicable in this species of Porrigo. While the patches are in an inflamed and irritable condition, it is necessary to limit the local applications to regular ablution, or sponging, with warm water, or some emollient fomentation.* Even the operation of shaving, * This mode of treatment was recommended by some of the ancients. Oribasius observes, that " if there is much heat or inflammation connected with the achores, this must be first alleviated by a. moist sedative." (Synops. lib. viii. cap. 27.) Aetius also observes, u Quod si incideris in achores inflammatos et dolentes, dolorem prius liquido medicamento concoctorio mollienteque ac leni mitigabis, Sec." (tetrab. ii. serm. ii. cap. 68.) And 161 PORRIGO. which is necessary to be repeated at intervals of eight or ten days, produces a temporary increase of irritation. At this time the patient should wear a light linen cap, which should be frequently changed; and all stimulant lotions and ointments, which tend only to aggravate the disease, should be proscribed. In the progress of the disorder, various changes take place, which require corresponding variations of the method of treatment. By degrees the inflammatory state is diminished, and a dry exfoliation and scabbing ensue: but again the pustular eruption breaks out, and the patches become again red and tender; or, in some cases, without much redness, there is an acrimonious, exudation, with considerable irritability of the scalp. In other instances, the surface becomes inert, and in some degree torpid, while a dry scaly scab constantly appears, and active stimulants are requisite to effect any change in the disorder. It is very obvious, as Dr. Willan used to remark, that the adoption of any one mode of practice, or of any single pretended specific, under these varying circumstances of the disease, must be unavailing, and often extremely injurious. In the more irritative states, the milder ointments, among the moderns, Heisterhas made a similar discrimination respecting the treatment of Porrigo. He recommends, in all instances, in the commencement of the disease, the use of mild, emollient applications; as cream with cerussa, oleum ovorum, " ung. de enula de cerussa, diapompholygos, aliudve simile saturninum," while moderate alteratives of calomel, antimony, &c. are given internally. He affirms that the application of mercurial and sulphur ointments, in the first instance, is exceedingly pernicious. Chirurg. part. i. lib. v. cap. 10. PUSTULiE: 162 such as those prepared with cocculus Indicus, with the submuriate of mercury, the oxide of zinc, the superacetate of lead, or with opium or tobacco, should be employed ; or sedative lotions, such as decoctions or infusion of poppy heads, or of tobacco, may be substituted. Where there is an acrimonious discharge, the zinc and saturnine ointments, with the milder mercurial ones, such as the ung. hydrargyri prsecipitati, or the ointment of calomel, or a lotion of lime-water with calomel, are advantageous. According to the different degrees of inertness, which ensue, various well-known stimulants must be resorted to, and may be diluted, or strengthened, and combined, according to the circumstances. The mercurial ointments, as the ung. hydrargyri praecipitati, hyd. nitricooxydi, and especially of the hydrargyrus nitratus, are often effectual remedies: and those prepared with sulphur, tar, hellebore, and turpentine, the unguentum elemi, &c. separately or in combination, occasionally succeed; as well as preparations of mustard,* stavesacre, black pepper,f capsicum, galls, rue, and other acrid vegetable substances.J Lotions containing the * See Sennert. loc. cit.—Underwood on the Dis. of Children, vol. ii. t There is an unguentum piperis nigri in the Dublin pharmacopoeia, of the efficacy of which Dr. Tuomy speaks highly. See his Essay on the Diseases of Dublin. | The ancients were accustomed to employ a similar collection of stimulants for the achores; among which were sulphur vivum, atramentum sutorium (sulphate of iron,) tar, burnt paper with oil, soap; oil of rue and of myrtle; resin, myrrh, and frankincense, with wine and vinegar, &c. Vinegar was deemed an efficacious remedy. " Acetum vero acerrimum ad achoras omni 163 PORRIGO. sulphates of zinc and copper, or the oxymuriate of mercury, in solution, are likewise occasionally beneficial. In the very dry and inert state of the patches, the more caustic substances are often extremely successful. Thus I have seen a lotion, containing from three to six grains of the nitrate of silver in an ounce of distilled water, effectually remove the disease in this condition. Touching the patches with the muriated tincture of iron, or with any of the mineral acids, slightly diluted, in some cases removes the morbid cuticle, and the new one assumes a healthy action.* The application of a blister, in like manner, sometimes effectually accomplishes the same end. But, in many instances, the effect of these renovations of the cuticle is merely temporary, and the disease returns in a week or two, upon the new surface. Professor Hamilton, of Edinburgh, who considers the ring-worm of the scalp, as " quite different from the scailed head," affirms, in a late publication, that he has seldom failed to cure the former, by the use of the unguentum ad scabiem of Banyer. For delicate children, he dilutes this ointment with an equal portion of simple cerate, and sometimes alternates the use of it with that of common basilicon.f tempore accommodation est." See Oribas. Synops. lib. viii. 27. Aet. tet. ii. serm. ii. cap. 68. * Mr. P. Fernandez mentioned to me an instance of speedy recovery, which followed a single application of the strong sulphuric acid, which was instantaneously washed off. A new and healthy cuticle succeeded. t See his < 4 Hints on the Management of Children."—The acrid ointment of Banyer consists of ceruss. j-fess, litharg. aur 24 164 PUSTUL/E: These various applications are enumerated, because not one of them is always successful, singly, even under circumstances apparently the same. They must be varied and combined; and the best criterion in the choice and combination of them is, the degree of existing irritation in the morbid parts, or in the general habit. The rude and severe employment of depilatories, which some practitioners have recommended, is to be deprecated, as often inflicting great injury lo the scalp, and retarding, rather than expediting, the progress to recovery. I have said nothing respecting the administration of internal medicine in the Porrigo scutulata; because it is often merely local, being communicated by contagion to children in other respects healthy. But in those in whom it appears in combination with cachectic symptoms, chalybeate medicines, or the decoction of cinchona and alteratives, must be prescribed, according to the particular indications; and the diet, clothing, and exercise of the patient, must be carefully regulated. 5. Porrigo decalvans. (Plate XL.) This singular variety of the disease presents no appearance whatever, except patches of simple baldness, of a more or Jess circular form, on which not a single hair remains, while that which surrounds the patches is as thick as usual. The surface of the scalp, within these areae, is smooth, alum. ust. mercur. sublim. seviporcin. fljij, terebinth. Ven. fcss. See his Pharmacopoeia Pauperum. I have used this ointment, somewhat diluted, in a few cases of this disease, since the first edition of this Synopsis was published; and I have found it, like other applications, sometimes successful, but frequently inert and useless. 165 PORRIGO. shining, and remarkably white.* It is probable, though not ascertained, that there may be an eruption of minute achores about the roots of the hair, in the first instance, which are not permanent, and do not discharge any fluid. The disease, however, has been seen to occur, in one or two instances, in a large assemblage of children, among whom the other forms of the Porrigo prevailed. But in other cases, and also in adults, it has appeared where no communication could be traced or conjectured. The arese gradually enlarge, and sometimes become confluent, producing extensive baldness, in which condition the scalp remains many weeks, especially if no curative measures are adopted. The hair, which begins to grow, is of a softer texture, and lighter colour, than the rest; and, in persons beyond the middle age, it is gray. If the scalp is cleared by constant shaving, and at the same time some stimulant liniment be steadily applied to it, this obstinate affection may be at length overcome, and the hair will regain its usual strength and colour. In fact, until this change takes place, the means of cure must not be intermitled.f Some of the more active * Celsus, and after him some other writers, have described this affection under the appellation of " Area." Under this generic term, he comprises two varieties, called by the Greeks Alopecia, and Ophiasis: the former of which spreads in irregular patches; and the latter in a serpentine form, round both sides of the head, from the occiput. De Medicina, lib. vi. cap. 4. t All that can be prescribed, respecting the treatment of this affection, has been expressed by Celsus with his usual terseness. " Quidam haec genera arearum scalpello exasperant: quidam illinunt adurentia ex oleo, maximeque chartam combustam: quidam resinam terebinthinam cum thapsia inducunt. Sed nihil 166 PUSTULE: ointments, mentioned under the preceding head, may be employed with friction; but liniments containing an essential oil dissolved in spirit, (for instance, two drachms of the oil of mace, in three or four ounces of alcohol,) or prepared with oil of tar, petroleum Barbadense, camphor, turpentine, &c. are more efficacious. 6. Porrigo favosa. (Plate XLI.). This species of the disorder consists of an eruption of the large, soft, straw-coloured pustules, denominated favi (Def. 5, d.)* These are not in general globular, with a regularly circular margin; but somewhat flattened, with an irregular edge, and surrounded by a slight inflammation. They occur on all parts of the body; sometimes on the scalp alone, and sometimes on the face, or on the trunk and extremities only; but most commonly they spread from the scalp, especially from behind the ears, to the face, or from the lips and chin to the scalp, and occasionally from the extremities to the trunk and head.f They are usually accompanied with considerable itching. Children from six months to four years of age are most liable to this eruption; but adults arc not unfrequently affected with it. melius est, quam novacula quotidie radere: quia, cum paulatim summa pellicula excisa est, adaperiuntur pilorum radiculae. Neque ante oportet desistere, quam frequentum pilum nasci apparuerit. Id autem, quod subinde raditur, illini atramento sutorio satis est." Loc. cit. * This has been called tinea favosa by Haly Abbas, Astruc. and Sauvages,—and scabies capitis favosa by Plenck. t Sauvages and several other writers have given a new title to the eruption, when it thus spreads from one part to another; such as tinea volatica, ignis volaticus, Sec. 167 PORRIGO. The pustules, especially on the scalp, appear at first distinct, though near together; but on the face and extremities they generally rjse in irregular clusters, becoming confluent when broken, and discharging a viscid matter, which gradually concretes into greenish, or yellowish, semi-transparent, scabs. The disease extends by the successive formation of new blotches, which sometimes cover the chin, or surround the mouth, and spread to the cheeks and nose; and, on the scalp, the ulceration ultimately extends, in a similar manner, over the whole head, with a constant discharge, by which the hair and moist scabs are matted together. Under the last-mentioned circumstances, pediculi are often gene* rated in great numbers, and aggravate the itching and irritation of the disease. On the face, too, a similar aggravation of the symptoms is occasioned, in children, by an incessant picking and scratching about the edges of the scabs, which the itching demands, and by which the skin is kept sore, and the ulceration extended; while the scabs are thickened into irregular masses, not unlike honeycomb, by the accumulating and concreting discharge. On the lower extremities considerable ulcerations sometimes form, especially about the heels and roots of the toes; and the ends of the toes are sometimes ulcerated, the pustules arising at their sides, and even under the nails. The ulcerating blotches seldom continue long, or extend far, before the lymphatic system exhibits marks of irritation, probably from the acrimony of the absorbed matter. When the scalp or face is the seat of the disease, the glands on the sides of the neck enlarge and harden, being at first perceived like a chain of little tu- 168 PUSTULE niours, lying loose under the skin; and the submaxillary and parotid glands are often affected in a similar manner. At length some of them inflame, the skin becomes discoloured, and they suppurate slowly, and with much pain and irritation. The eruption, in these situations, is likewise often accompanied by a discharge from behind the ears, or from the ears themselves, with a tumid upper lip, and inflammation of the eyes, or obstinate ulcerations of the edges of the eyelids. When the eruption appears on the trunk, although the pustules there are smaller and less confluent, and the scabs thinner and less permanent, the axillary glands are liable to be affected in the same way. The discharge from the ulcerated surfaces, especially on the scalp, when the crusts and coverings are removed, exhales an offensive rancid vapour, not only affecting the organs of smell and taste, but the eyes, of those who examine the diseased parts.* The acrimony of the discharge is also manifested by the appearance of inflammation, followed by pustules, ulceration, and scabbing, on any portion of the sound skin, which comes into frequent contact with the parts diseased: thus, in young children, the breast is inoculated by the chin, and the hands and arms by contact with the face. The arm and breast of the nurse are also liable to receive the eruption in the same manner; but it is not so readily communicated to adults as to children. The duration of this form of Porrigo is very uncertain ; but it is, on the whole, much more manageable * It has been supposed that the similarity of the odour of this discharge to that of garlic fporrumj gave rise to the appellation of Porrigo. 169 PORUIGO. than the P. scutulata and decalvans. Young infants often suffer severely from the pain and irritation of the eruption, and of the glandular affections which it induces; and those who are bred in large towns, and are ill feci and nursed, are thus sometimes reduced to a state of fatal marasmus. The Porrigo favosa requires the exhibition of the same alteratives internally, which have been recommended for the cure of the P. larvalis, in doses proportioned to the age and strength of the patients. The diet and exercise should also be regulated with care: all crude vegetables and fruits on the one hand, and stimulating substances, whether solid or fluid, on the other, should be avoided; and milk, puddings, and a little plain animal food or broths, should be alone recommended. If the patient be of a squalid habit, or the glandular affections severe, the bark and chalybeates, or the solution of muriate of barytes united with the former, will contribute materially to the restoration of health. There is commonly some degree of inflammation present, which contra-indicates the use of active stimulants externally. The unguentum zinci, or the ung. hydrargyri praecipitati, mixed with the former, or with a saturnine ointment, will be preferred as external applications, especially where the discharge is copious: and the ointment of the nitrate of mercury, diluted with about equal parts of simple cerate and of the ceratum plumbi superacetatis, is generally beneficial; but the proportion of the unguentum cerae must be varied according to the degree of inflammation. All stiff and rigid coverings, whether of oiled silk, or, according to a popular practice, of the leaves of cabbage, beet, &c. should be pro- 170 PUSTUUE: hibited; for they often excite a most severe irritation. I have witnessed, in several instances, an universal ulceration, with copious purulent discharge, and a highly inflammatory and painful state of the scalp, exciting even a considerable degree of symptomatic fever, produced by such applications. The substitution of a poultice, in these cases, removed this irritative condition in two or three days, and the disease was speedily subdued by the treatment above recommended. It may be mentioned, in conclusion, that an eruption of favi is sometimes seen on the face, (Plate XLII.) ears, neck, and occiput, in adults;* in whom it is preceded and accompanied by considerable derangement of the constitution, headache, pain of the stomach, loss of appetite, constipation, and some degree of fever. The pustules become confluent, discharge a viscid humour, and scab, as in the eruption just described; but they are surrounded by more extensive inflammation, and become harder and more prominent, somewhat resembling, in this respect, the ecthyma. Their course, however, is more rapid than that of the ecthyma, or of the tubercular sycosis, to which also the disease also bears some affinity. A cathartic, followed by the pilula hydrargyri submuriatis of the last pharmacopoeia, or Dr. Plummer's pill, and a vegetable tonic, will be found serviceable; and the mild external applications, above mentioned, must be employed, according to the degree of inflammation present. * Of this form of Porrigo favosa on the cheeks, the 16th plate of M. Alibert appears to be a representation. He calls it " Dartre crustacee flavescente." 171 ECTHYMA. A sudden eruption of Porrigo favosa, accompanied by fever, occasionally takes place also in children. A considerable alarm was excited by such an occurrence, in a family which I was requested to see, in which the disease was deemed to be some new or anomalous contagion. The first patient, aged five, was seized with severe fever, in which the pulse was at one time 140, and continued at 110 for several days: at the same time, clusters of favous pustules appeared behind the ears, which were speedily followed by others on the scalp, and about the apertures of the nostrils, which they plugged up as the scabs were formed. A few days after the commencement of this attack, a younger child, aged two years, was seized in a similar manner; but in her, the pustules appeared also about the chest, the glands of the neck swelled, and the abdomen became tumid. The contagion was immediately, though but locally, received by the mother and the nurse; the former of whom was inoculated about the mouth, by kissing the children; the latter in the palm of the hand. These children were somewhat squalid, and apparently ill nursed, especially in respect to cleanliness and exercise. III. ECTHYMA. The Ecthyma* is an eruption of the inflamed pustules, termed Phlyzacia (Def. 5. a.). They are usually * The term txBvfm seems to have been used by the Greeks in a general sense, and nearly synonymous with t&vQqpa, or eruption. Perhaps the more elevated and inflammatory eruptions were particularly called ccthymata; since, as Galen has observed, in 25 172 PUSTULE distinct, arising at a distance from each other, seldom very numerous, unaccompanied by fever, and not contagious. This eruption does not very frequently alone demand the assistance of medicine. It is commonly indicative of some state of distress, if that expression may be used, under which the constitution labours; and, although it is not attended by actual fever, yet a degree of general irritation or erethism, is often present with it It shows itself under three or four varieties, and is usually attributed to long continued exertion aud fatigue, to much watching, to imperfect nutriment, to the influence of cold, to a state of pregnancy, or to the debilitating effects of previous malignant fevers, especially of smallpox, measles, and scarlatina. It occurs most frequently on the extremities, but sometimes over the whole body, face and scalp. The diagnosis of this eruption from the contagious pustular diseases, as well as from some of the secondary appearances of syphilis, is of consider- his Commentary on the third book of the Epidemics of Hippocrates, the term is derived from txOvsw, " quod est tfrpfinv (Jmpelu erumpere) in iis quae sponte extuberant in cute." (§ 51.) See also Erotian de voc. apud Hippoc;—and Foes, CEconom. Hipp, ad voc. txOvnata. This view of the subject has led many authors, Fernel, Pare, Vidus Vidius, Sennert, Sebizius, Sec. to believe, that the terms ecthymata and exanthemata were used specifically, as the denominations of smallpox and measles. " Variolas vocant txQvimta, pustulas extumescentes, morbillos autem nominant, maculas in cute apparentes, &c." See a learned Treatise of Melchior Sebizius, D eVariol. et Morbil. Argent. 1742. These views sanction the appropriation of the term to the " pustulae extumescentes" of this genus. 173 ECTHYMA. able importance in practice, which renders it necessary to notice this genus. h The Ecthyma vulgare (Plate XLIII. Fig. 1.) is the slightest form of the disorder, and consists of a partial eruption of small hard pustules, on some part of the extremities, or on the neck and shoulders, which is completed in three or four days. In the course of a similar period, the pustules successively enlarge, and inflame highly at the base, while pus is formed in the apex; and in a day or two more they break, poui 1 out their pus, and afterwards a thinner fluid, which speedily concretes into brown scabs. In a week more, the soreness and inflammation subside, and the scabs soon afterwards fall off, leaving no mark behind. This eruption commonly supervenes on a state of languor, of some continuance, with loss of appetite, irregularity of the alvine evacuations, and pains in the stomach or limbs. Young persons are principally subject to it, and children are sometimes affected with it, especially in the spring or summer, after being overheated, or fatigued, or disturbing the digestive organs by improper food. The constitutional derangement is not immediately relieved on the appearance of the eruption, but ceases before its decline. The use of gentle purgatives in the early stage, and of the decoction of cinchona, after the maturation of the pustules, appears to comprehend all that is requisite in regard to medicine. 2. The Ecthyma infantile occurs in weakly infants, during the period of lactation, when an insufficient nu- PUSTULE: 174 triment is afforded them. The pustules are, in appearance, the same as those of the preceding species, and go through similar stages of progress, in the same time. But the disorder does not terminate here: fresh eruptions of phlyzacia continue to rise in succession, and to a much greater extent than in the E. vulgare, appearing not only over the extremities and trunk, but on the scalp, and even on the face; in which situation the pustules do not occur except in the fourth species of Ecthyma. Hence also the duration of the eruption is much greater*than in the preceding species, being sometimes protracted for several months. Yet the patients usually remain free from fever, and the pain and irritation seem to be inconsiderable, expept when a few of the. pustules become very large and hard, with a livid base, and ulcerate to some depth: in this case, also, a slight whitish depression is permanently left on the seat of the pustula. The principal means of cure will be found in changing the nurse: and the advantages of better aliment will be aided by proper clothing and exercise, as well as by moderate alteratives, and by the cinchona, or chalybeates. 3. Ecthyma luridum. (Plate XLIII. Fig. 2.) The most obvious peculiarity of this variety of the phlyzacious pustules is the dark red colour of their base, which is likewise hard and elevated. But they differ also from the two preceding varieties, in being of a larger size; and from the first, in the slow but long succession in which they arise, and in the extent of surface over which they spread, the face alone being exempt from 175 ECTHYMA. their occurrence. This form of the disease is most frequently seen in persons of an advanced age, who have injured their constitutions by hard labour, intemperance in the use of spirits, and night-watching; and it is most severe in the winter season. Under these circumstances, the pustules, as might be expected, are. slow in healing. They break in the course of eight or ten days, and discharge a curdly, sanious, or bloody matter: the ulcerated cavities, extending beyond the original boundary, soon become filled with hard, dark scabs, and remain surrounded by a deep seated hardness in the flesh, and dark inflamed borders, until the scabs are about to separate, —a period generally of several weeks, and sometimes of many months. The scabs are commonly firmly seated; but if removed by violence, they are not speedily reproduced; on the contrary, tedious ulcers, with callous edges and a sanious discharge, are often thus occasioned. The treatment of this Ecthyma must be chiefly directed to the amendment of the constitution, by means of good diet, by the occasional use of the warm bath, and by the bark, and vegetable decoctions, internally. A symptomatic Ecthyma, which bears a considerable analogy to the E. luridum, sometimes comes on during the cachectic state which follows the measles, and occasionally after the scarlet fever and smallpox. It is accompanied with a hectic fever, laborious respiration, and swellings of the glands; and is attended with extreme pain and soreness, sometimes with a tedious sloughing, in some of the larger pustules, which in children particularly, are productive of considerable distress. The phlyzacia arise in various parts of the extremities and 176 PUSTULE. trunk, and are highly inflamed at their bases, even after the scabbing takes place. The whole duration of the disease is often from one to two months; and the majority of patients struggle through it. Opiates and the warm bath afford essential relief to the distressing irritation occasioned by this affection; and a liberal use of the bark, where it can be so administered, both shortens and alleviates the disease. 4. Ecthyma cachecticum. (Plate XLIV.) An extensive eruption of phlyzacious pustules not unfrequently occurs, in connexion with a state of cachexia, apparently indicative of the operation of a morbid poison in the habit: for the phaenomena of the disease much resemble some of the secondary symptoms of syphilis, and it is often treated as syphilitic. The disorder usually commences with a febrile paroxysm, which is sometimes considerable. In the course of two or three days, numerous scattered pustules appear, with a hard inflamed base, sometimes first on the breast, but most commonly on the extremities: and these are multiplied day after day by a succession of similar pustules, which continue to rise and decline for the space of several weeks, until the skin is thickly studded with the eruption, under various phases. For, as the successive pustules go through their stages of inflammation, suppuration, scabbing, and desquamation, at similar periods after their rise, they are necessarily seen under all these conditions at the same time; the rising pustules exhibiting a bright red hue at the base, which changes to a purple or chocolate tinge, as the inflammation declines, and the little laminated scabs are formed 177 ECTHYMA, upon their tops: when these fall off, a dark stain is left upon the site of the pustules. In different cases the eruption varies in its distribution; it is sometimes confined to the extremities, where it is either generally diffused, or clustered in irregular patches; but it frequently extends also over the trunk, face and scalp. The pustules which occupy the breast and abdomen are generally less prominent than those on the face and arms, contain less matter, and terminate rather in scales than in scabs. The febrile symptoms are diminished, but not removed, on the appearance of the eruption; for a constant erethism or hectic continues during the progress of the disease. It is accompanied by great languor, and by much depression both of the spirits and muscular strength; by headache and pains of the limbs, which are described as rheumatic; and by restlessness and impaired digestion, with irregularity of the bowels. There is commonly also some degree of ophthalmia, affecting both the conjunctiva and the tarsi; and the fauces are the seat of a slow inflammation, which is commonly accompanied by superficial ulcerations. The duration of this disease seems to be from two to four months, in the course of which time, by the aid of the vegetable tonics, cinchona, sarsaparilla, serpentaria, &c. with antimonials, and the warm bath, the constitution gradually throws off the morbid condition which gives rise to it. The administration of mercury is not necessary to its cure, nor does it appear to accelerate recovery. The diagnosis between this disease and the syphilitic Ecthyma, is to be collected rather from the history of 178 PUSTULE: the disease, than from the prominent symptoms; unless, indeed, we are ready to concede to a recent writer, that this and similar affections are never the result of the true syphilitic poison.* Dr. Willan mentioned a topical variety of Ecthyma, occurring on the hands and fingers of workmen employed among metallic powders, which I have never seen. As it commences in a vesicular form, and though afterwards purulent, produces irregular patches of thin scabs, it should perhaps have been referred to eczema. IV. VARIOLA. SMALLPOX. In the completion of this arrangement, the smallpox should be the subject of investigation in this place; but I am induced, by several considerations, to omit the inquiry at present. While, on the one hand, the disease is universally known, and has been amply described by medical writers, from Rhazes downwards; it affords, on * See Part First of an " Essay on the Veneral Diseases, which have been confounded with Syphilis," by Richard Carmichael, President of the Royal College of Surgeons, Dublin. 1814. If I rightly comprehend this interesting but unfinished work, Mr. Carmichael maintains, that the true syphilitic ulcer is followed exclusively by one eruption, the scaly copper blotch, or Iepm venerea, described by Dr. Willan. It will now scarcely be doubted, indeed, that the above-mentioned Ecthyma, and some othereruptive diseases of an analogous character, are frequently, though erroneously, pronounced syphilitic; but we are not prepared, by the present state of the evidence, to limit the syphilitic eruptions thus narrowly. 179 SCABIES. the other, a topic too copious to be satisfactorily disposed of in a single chapter. It might, indeed, have been hoped that the general diffusion of vaccination would, ere now, have rendered a critical knowledge of the varieties of this pestilential malady less necessary to practitioners: and I still confidently anticipate the arrival of the period, when the just estimation of the value of Dr. Jenners discovery, by all ranks of people, will supersede the necessity of making smallpox an object of our study. At all events, the diagnosis of the disease, where it is sufficiently severe to demand the assistance of medicine, is seldom obscure, and one of the principal objects of this treatise is the discrimination of cutaneous symptoms. I am, besides, anxious to limit both the bulk and the price of this volume within moderate bounds. I shall, therefore, proceed to the remaining disease of the pustular order, which, common and vulgar as it is, occasionally baffles the best attempts both to distinguish and to cure it. V. SCABIES.* ITCH. This troublesome disease, which, from its affinity with three orders of eruptive appearances, pustules, ve- * The Greek terra Psora has been very generally, but incorrectly, adopted for the designation of this disease, in consequence of the example of some of the early translators, who considered Scabies (quasi scabrities) as synonymous with 4-opa, which, we have already seen, (page 6, note) was universally employed by 26 180 PUSTULE: sides, and papulae, almost bids defiance to any attempt to reduce it to an artificial classification, is not easily characterized in few words. An extreme latitude in the acceptation of the term has indeed been assumed by writers, from Celsus downwards; and no distinct or limited view of the disease has been given, until near our own times. Celsus has included other forms of pustular disease among the different species of Scabies; and some of the earlier writers, after the revival of learning, considered almost all the eruptions, to which the skin is liable, as modifications of this disease: even our countryman, Willis, to whom the contagious nature of true Scabies, as well as its specific remedy, was well known, has not sufficiently separated it from some other pustular and pruriginous affections.* The Scabies, or Itch, is an eruption of pustules, or of small vesicles, which are subsequently intermixed with, or terminate in pustules; it is accompanied by constant and importunate itching, but not with fever; the Greeks as denoting a scaly or scurfy disorder of the skin more rough than lichen, but less scaly than lepra. They did indeed occasionally use the term, in conjunction with the epithet i%xwtyf, or ulcerating, as applicable to a pustular disease, apparently the impetigo; but when used alone, it invariably implied the dry, scaly, or scurfy tetter, psoriasis. (See above, ord. ii. gen. 2.) Sir John Pringle, indeed, after noticing this inaccuracy, concludes that the itch was probably unknown, or at least uncommon, in ancient times. "The psora of the Greeks has generally been supposed to be the itch; but as this does not ap - pear by the description they give of it, I should conclude, &c." (On Diseases of the Army, part iii. chap. 5.) * See Celsus, lib. v. cap. 28; Plater, de Superfic. Corp. Dolorid. cap. 17; Hafenreffer, Nosodoch. lib. i. cap. 15; Willis, Pharmac. Rational, part i. § iii. cap. 6. 181 SCABIES. and is in all its varieties contagious. It appears occasionally on every part of the body, the face only excepted; but most abundantly about the wrists and fingers, the fossa of the nates, and the flexures of the joints.* Among the varieties which the disease assumes, four have been distinguished, with considerable accuracy, by the vulgar, who have, indeed, the most ample opportunities of becoming acquainted with its character; and to these they have given the epithets of rank, watery t pocky and scorbutic itch. Their subdivision was adopted by Dr. Willan, with the appropriate titles of Scabies papuliformis, lymphatica, purulenta and cachectica. The characteristics of these varieties, and the diagnosis between them and the papular, vesicular, and pustular eruptions, which they resemble, I shall endeavour to point out; but must admit, at the same time, that the practical discrimination, in many of these cases, is more difficult than in any other order of cutaneous disease. 1. The Scabies papuliformis, or rank itch, consists of an extensive eruption of minute itching vesicles, which are slightly inflamed and acuminated, resembling papulae when examined by the naked eye. They commonly arise first about the bend of the wrist and between the fingers, or in the epigastrium; on which parts, * " Scabies est pustularum purulentarum, vel, smiosarum, vel papularum siccarum, ex duriore et rubicundiore cute, eruptio,— pruritum, saeque quoque dolorem, creans, —interdum totum corpus, facie excepts*, invadens, —saepissime tamen solos artus externos, digitorum imprimis interstitia, occupans." Callisen. Syst. Chirurg. Hodiern. i. § 824. 182 PUSTULE: as well as about the axillae and nates, and in the flexures of the upper and lower limbs, they are at all periods most numerous, and often intermixed with a few phlyzacious pustules, containing a thick yellow matter. The itching is extremely troublesome in this form of Scabies, more especially when the patient becomes warm after getting into bed. The appearance of the disease is modified by the abrasion of the tops of the vesicles and pustules, and even of the rest of the skin, by the frequent scratching, which can not be withheld. Hence long red lines are here and there left, and the blood and humour concrete upon the vesicles into little brown or blackish scabs. These mixed appearances, partly belonging to the disease, and partly the result of abrasion by the nails, being in some measure common to the lichen and prurigo, where much scratching is also often employed, render the diagnosis of the Scabies papuliformis more difficult than it would be from the mere similarity in the form of the eruption. But, as the most effectual remedy for the Scabies is detrimental in the latter affections, the distinction is of great practical importance. With respect to the eruption itself, the unbroken elevations in Scabies papuliformis, when carefully examined, are found to be vesicular, and not papular; they are often intermixed, in particular situations, with pustules; and, when they break, are succeeded by scabs: whereas in lichen, the papulae terminate spontaneously in scurfy exfoliations. In Scabies, the eruption is unconnected with any constitutional or internal disorder, and the itching is severe: but in lichen, there is commonly some constitutional affection, and a tingling sensation, as well 183 SCABIES. as itching. The highly contagious nature of Scabies will in many cases, have already manifested itself, and remove all doubt; for the lichen is not thus communicable.* In prurigo, the papulae, where no friction has been applied, retain the usual colour of the skin, are commonly flatter, or less acuminated, and present no moisture or scab, except when their tops have been forcibly abraded; they are not particularly numerous in the parts above mentioned; and they remain long distinctly papular, without showing any contagious property. The eruption which I have called lichen urticatus (see page 13,) and which often occurs in weakly children, and exhibits a troublesome series of papulae, sometimes intermixed with minute vesicles, bears a close resemblance to scabies, especially when it has been of some continuance. But the first appearance of these spots in the shape of inflamed wheals, not unlike the inflammation produced by the bites of gnats —their subsequent papular or vesicular appearance, with little or no surrounding inflammation, —the intermixture of these two states of the eruption,—and the ultimate formation of a minute globular brown scab, which is set firmly in the apex of each elevation, will serve as diagnostic marks. 2. The Scabies lymphatica, or watery itch (Plate XLV.) is distinguished by an eruption of transparent vesicles, of a considerable size, and without any inflammation at their base. They arise in succession, with intense itching, chiefly round the wrists, between the * See the quotation from M. Lorry, supra, p. 8. note. 184 PUSTULE: fingers, on the back of the hands, and on the feet and toes: they often occur also about the axillae, the hams, the bend of the elbows, and fossa of the nates, where they are intermixed with pustules: but they do not frequently appear, like the papuliform species, over the breast and epigastrium, nor on the thighs and upper parts of the arms. In a day or two the vesicles break; and some of them heal, under the little scab that concretes upon them. But others inflame, and become pustules, which discharge at length a yellow matter, and extend into small ulcerated blotches, over which a dark scab is ultimately formed. —So that, during the progress of the eruption, all these appearances are intermixed with each other: the vesicles, and pustules, the excoriated blotches discharging pus, the minute dry scabs, and the larger ones succeeding the ulceration, may be observed at the same time. This circumstance constitutes one of the points of diagnosis between this and other vesicular diseases. Of these, however, the herpes and eczema, especially the latter, are alone liable to be confounded with Scabies lymphatica; for the acute form and short course of all the varieties of varicella render that eruption sufficiently distinct The herpes, likewise, differs materially from Scabies in the regularity of its course and termination, and in the arrangement of its vesicles in clusters, which are commonly not numerous, and appear on those parts which Scabies is not very apt to attack. The most difficult diagnosis relates to some of the varieties of eczema, which closely resemble this, and sometimes the former species of Scabies; so that it is not so much from the mere appearances of the eruption, 185 SCABIES. as from the consideration of the collateral circumstances, that a decision is to be obtained. The eczema can often be traced to distinct sources of irritation affecting the skin, such as exposure to the solar rays, or to great heat, —and to the application of acrid substances, such as lime, sugar, mercury, cantharides, &c. It sometimes becomes inflamed after the vesicles have discharged their lymph, but it does not produce the large phlyzacious pustules; and, although the itching is sometimes intense, yet there is commonly a tingling and smarting pain with eczema, that does not belong to Scabies; nor is it ever, like the latter ,communicated by contagion. 3. The Scabies purulenta, or pocky itch, (Plate XLVI. Fig. 1.) is, I believe, often mistaken by those, who confine their notion of the disease to the ordinary small and ichorous vesicles of the two former species. The eruption consists of distinct, prominent, yellow pustules, which have a moderate inflammation round their bases, and which maturate and break in two or three days, and then ulcerate, with increasing pain and inflammation. These pustules commonly appear first, and attain the largest size, on the hands and feet, especially about the knuckles and roots of the toes, between the fingers, and particularly between the forefinger and thumb, and round the wrists. In these situations, the pustules often exceed two lines in diameter, and assume a prominent globular form: whence, from their general resemblance to the large well maturated pustules of smallpox,* (and not from any allusion to syphilis, as * " Licet interdum majusculae sint, cum fundamento rubro, et pure impleantur, fere tanquam variolas." Heberden, Com. de Morb. Hist, et Curat, cap. 23. See the Plate, fig. 5. i. 186 PUSTULuE: some have erroneously supposed,) the popular term "pocky" has been applied to them. If the disease con- tinue a few weeks, the pustules begin to appear on the other parts of the body, which Scabies usually attacks, especially about the axillae, on the back and shoulders, and on the arms and thighs near the joints of the knee and elbow, in the fossa of the nates, and sometimes, though of a smaller size, even about the epigastrium. In several of these situations, where the pustules are largest and numerous, they coalesce, and form irregular blotches, which ulcerate to some extent, with hardness and elevation of the surface; but at length hard and dry scabs are formed, which adhere tenaciously for a considerable time. The majority of the cases of Scabies purulenta, which I have seen, have occurred in children, between the age of seven years and the period of puberty; and in them it not unfrequently assumes this form. The Scabies purulenta can not be easily mistaken for impetigo, when it occurs in patches, in consequence of the large size, the greater prominence, and comparatively small number of its pustules; not to mention the absence of the intense itching, and of contagion in the former.* From the porrigo favosa affecting the extremities, it will be distinguished its situation * Sauvages has described a variety of Scabies, which he terms htrpetica (spec. 4;) Herpes, in his language, as in that of many other writers, signifying the same with impetigo in the nomenclature of Dr. Willan. " Cog?ioscitur ex signis herpetis et scabiei simul concurrentibus, in amplos corymbos coeuntibus, papulis pruriginosis, rubris, quae squamas albas, farinaceas deponunt." But this termination in branny scurf, and the commencement in papulae, point out the eruption as a lichen, probably the L. circumscriptus. 187 SCABIES. about the fingers, axillae, fossa-natum, and flexures of the joints, and by the total absence of the eruption from the face, ears, and scalp; by the nature of the discharge; and by the thin, hard, and more permanent scab, which succeeds, instead of the soft, elevated semi-transparent scab, formed by the viscous humour of the favi. The only other disease, with which the Scabies purulenta has any affinity, is the ecthyma: but the hard, elevated, vivid red or livid base, which surrounds the pustules of ecthyma,—their slow progress both towards maturity and in the course of suppuration,—the deep ulceration, with a hard raised border, and the rounded, imbedded scab, which succeed,~as well as the distinct and separate distribution of them, —will afford the means of discrimination; to which the incessant itching, and the contagious property of Scabies, may be added. 4. Scabies cachectica. This variety of Scabies exhibits, in different parts of the body, all the appearances which belong to the three foregoing species. It is occasionally also combined with patches resembling lichen, psoriasis, or impetigo, especially in adults, or young persons approaching the term of puberty; whence it assumes an ambiguous character. In several instances, this form of Scabies has been obviously contagious in its double character; and after the scabious affection has disappeared, the impetiginous patches have remained, for some time, in a drier form, and yielded very slowly to medicine. For, although this form of Scabies does not so readily spread by contagion, it is much more obstinate under the use of remedies, than the preceding. 27 PUSTULE: 188 Another peculiarity of the S. cachectica, is, that it often originates, independently of contagion, in weakly children, and also in adults, when the constitution is suffering under some chronic malady, or debilitated by some previous acute disease:* and, however it is produced, it is liable to return at intervals, especially in the spring and autumnal seasons, after it has been to all appearance cured.f A severe degree of this ambiguous and combined form of Scabies is often seen in this country, in persons who have come from India: I have chiefly had occasion to observe it in children brought from that country. The eruption is exceedingly rank and extensive, sometimes even spreading to the face, and gives a more dark and sordid hue to the skin than the ordinary Scabies; and the intermixture of patches of an impetiginous character, where the pustules become confluent, is considerable. It is extremely contagious, and also obstinate in its resistance to the operation of remedies-! * Sir John Pringle observed, that, in military hospitals, the patients often became the subjects of itch after the crisis of fevers. Loc. cit. p. iii. cap. 8. t" Quaedam est etiam ejus species, quae quanquam in ipso corpore non genita sit, sed aliunde advecta, quanquam et consuetis remedis primo sanata fuerit, tamen non cessat redire semel vel bis quotannis." Heberden, Commentar. Perhaps the Scabies herpetica of Sauvages may include some of these cases of S. cachectica. \ Bontins, in his work De Medicina Indorum, lib. iii. cap. 17, has described this severe disease, under the appellation of u herpes, seu impetigo indica," as frequent among the inhabitants of India, by whom it is denominated courap, which is equivalent to our term itch. The cure of it, he says, is generally 189 SCABIES. Another violent form of Scabies is excited by the contact of dogs, cats, hogs, and other animals, affected with mange. (Plate XLVI. Fig. 2.) This also extends over the whole body, the pustules being very rank and numerous, and more inflamed and hard at the base than in the ordinary eruption; the general surface of the skin is also rough, and of a browner hue; and the excoriations and abrasions more extensive, in consequence of the more violent and irresistible application of the nails. The most ordinary cause of Scabies is contagion: the virus being communicated by the actual contact of those already affected with it, or of their clothes, bedding, &c. especially where there is much close intercourse. It seems to originate, however, in crowded, close, and uncleanly houses; and is, therefore, extremely prevalent in work-houses, jails, and hospitals, where the means of great cleanliness are not easily obtained, and is mostly seen among the families of the poor. When the contagion has been introduced, however, into families, where every attention to cleanliness is enforced, it will frequently spread to all the individuals, children, and adults, and continue, in spite of the utmost cleanliness, until the proper remedies are resorted to. Some writers have ascribed the origin of the itch, in all cases, to the presence of a minute insect, breeding and burrowing in the skin; while others have doubted much neglected there, in consequence of a prevalent notion, that it renders a person secure from all violent diseases; yet the itching is severe and incessant, and so much abrasion is produced by scratching, that the linen often adheres to the excoriated parts, so as not to be removed without drawing blood.— This is the Scabies indica of Sauvages, spec. 6. 190 PUSTULiE: the existence of such an insect.* Both these opinions appear to be incorrect; and probably that of Sauvages is right, who considers the insect as generated only in some cases of Scabies, and therefore speaks of a Scabies vermicularis, as a separate species.f The existence of such an insect, in some cases of Scabies, has been fully demonstrated; and, although never able to discover it in any patient myself, I have seen it, in one instance, when it had been taken from the diseased surface by another practitioner. In fact, it was described in the twelfth century by Abinzoar, and subsequently by Ingrassias of Naples, by Gabucinus, Laurence Joubert, and other writers of the fifteenth and sixteenth centuries, who are quoted by our countryman, Moufet.| These writers describe the insects as acari, that is, very minute and almost invisible animalcula, burrowing under the cuticle, and exciting small pustules, filled with a thin fluid, and intense itching. Moufet" states, that they do not reside in the vesicles or pustules, but near them; that they are not of the same genus with lice, which live exterior to the cuticle; — that they are similar to the acari, or mites, of cheese, wax, &c. but are called ivheal-worms in man; —and that when they are pressed between the nails, a small sound is heard. Most of these points have been subse- * Dr. Heberden never saw any of these insects; and he was informed both by Baker and Canton, who excelled in the use of the microscope, that they had never been able to detect them. Loc. cit. t Nosol. Method, loc. cit. spec. 11. | See his " Theatrum Insectorum," printed in 1634, cap. 24. ;t de Syronibus, Acaris, Tineisque Animalium." 191 {SCABIES. quently confirmed. The insects were accurately ascertained and figured (by the aid of the microscope) by Bonomo,* in 1683, whose> account was afterwards published by Dr. Mead,f Schwiebe, Baker, and others: and Linnaeus, De Geer, Wichmann, &c. have since that period illustrated the subject of these acari scabiei.J The latest authors particularly confirm the observation of Moufet, that the insects are not to be found in the pustules, but in the reddish streaks or furrows near them, or in the recent minute vesicles: but I must acknowledge my own want of success to discover them in any of these situations. I am disposed, therefore, to believe, that the breeding of these acari in the scabious skin is a rare and casual circumstance, like the individual instance of the production of a minute pulex in prurigo, observed by Dr. Willan; and that the contagious property of scabies exists in the fluid secreted in the pustules, and not in the transference of insects. Among the remedies appropriated to the cure of Scabies, sulphur has long been deemed, both by the vulgar and the erudite, to possess specific powers.§ The common people treated the disease with this substance alone, a century ago, administering it internally * See his Letter to Redi:—also Miscel. Nat. Curios, ann. x. dec. 2. f See Philosoph. Transact, vol. xxiii. for 1702. J SeeLinn." Exanthemata Viva," 1757; —and Amcenit. Acad, vol. iii. p. 333, and vol. v. p. 95. —Wichmann, Aetiologie der Kraetze, Hanover, 1786; also in the Lond. Med. Journal, vol. ix. p. 28.—De Geer, Memoires pour servir a - l'Hist. des Insectes. § See Willis, Pharmaceut. Rational, part ii. sect. iii. cap. 6. 192 PUSTULE: in milk, and applying it externally in butter.* In the less violent degrees of Scabies, and in the purulent species affecting the hands and wrists, perhaps no improvement can be made upon this practice. The latter species, when it occurs in children, is often readily removed by the internal use of this medicine, alone, or in combination with a neutral salt, independently of any external application.! And there are few cases of Scabies, which will not yield to the steady employment of the sulphur ointment, continued a sufficient time, and rubbed on the parts affected nightly with assiduity. Five or six applications are commonly sufficient for the cure of the disease: but sometimes it is necessary to persevere in the inunction for the space of a fortnight, or even longer; from which no detriment ensues to the constitution. The disgusting odour of the sulphur,} however, has * See Turner, De Morbis Cutaneis. t Writers in general agree in asserting the greater facility of curing the humid, than the dry forms of Scabies. But under the term Scabies sicca, it is obvious that they describe the prurigo, and even some scaly and furfuraceous eruptions, accompanied with itching, which are often more difficult of removal than any variety of true Scabies. See Sauvages and Sennert. (loc. cit.) and Vogel, de curand. Horn. Morb. \ Both the smell and sordid appearance of the sulphur ointment may be in a considerable degree obviated by the following combination: R Potassae subcarbonatis Aquae rosae Hydrarg. sulphurati rubri Olei essent. bergamot. j^ss Sulphuris-sublimati Adipis suillse aa Misce secundum artem. 193 SCABIES. led practitioners to resort to various other stimulating applications, some of which have been recommended from ancient times, for the cure of scabid and pruriginous eruptions. Among these, the root of the white hellebore is possessed of considerable efficacy, and may be applied in the form of ointment, or in that of decoction. In the latter form I have generally found it advisable to employ a stronger decoction, than that which is recommended in the pharmacopoeia of the college. Potass, in a state of deliquescence, was a favourite addition to these applications with Willis and his predecessors; and muriate of ammonia, and some other saline stimulants, have been more recently used, and not without benefit.* The strong sulphuric acid, which was long ago recommended by Crolius, mixed with lard, applied by external friction, has also been employed ;f and it certainly possessed the recommendations of being inodorous and comparatively cleanly. But independently of its corrosive action on the patient's clothing, it has appeared to me to be very uncertain in its effects. The muriate of mercury, and the white precipitated oxide, are both possessed of considerable efficacy in the relief of Scabies. The testimonies in favour of the latter are very numerous.} It seems particularly well * This salt, together with hellebore, is said to constitute a part of a celebrated nostrum for Scabies, called the Edinburgh Ointment. t See Hafenreffer de Cute, lib. i. cap. 14. The sulphuric acid was also recommended to be taken internally, as a remedy for Scabies, by Dr. Cothenius, who is said to have used it with success in the Prussian army, in 1756. SeeEdin. Med. Com. vol. i. p. 103. But subsequent experience has not confirmed his report. | See Willis, Vogel, Sauvages, Callisen, Heberden, &c. Prof. PUSTULE: 194 adapted to the impetiginous form of the disease, which is liable to be irritated by the more acrid applications. The muriate has probably derived some of its remedial character from its efficacy in the relief of prurigo, and other eruptions, accompanied by itching, with little inflammation ; but it is not altogether destitute of power in Scabies itself. A committee of French physicians reported the result of some experiments made with the root of the Plumbago Europcea, (pounded and mixed with boiling oil,) to the Medical Society of Paris; from which they inferred, that it cured Scabies more speedily than any other remedy. The third or fourth inunction with this substance, they affirm, is generally successful.* Several of the continental writers recommend in strong terms, the formula of an " Unguentum ad Scabiem," prescribed by Jasser, which directs equal parts of sulphate of zinc, flowers of sulphur and laurel berries, to be made into a liniment with oil.f From a few trials of this ointment, I am disposed to believe that it is possessed of considerable efficacy. Selle affirms, " Scabies £ contagio externo maximi ex parte per solum mere, praecip. albi usum tollitur." Med. Clin. 191. See also Fordyce, Fragmenta Chirurgica. * See Memoires de la Soc. Roy. de Medicine de Paris, torn, iii.j also Lond. Med, Journal, vol. v. t See Plenck, Doctr. de Morbis Cutaneis, p. 42; Callisen, Syst. Chirurg. Hodiern. 195 Order VI. VESICUL^E. The Order of Vesicles (see Definition 6) comprehends seven genera. I. VARICELLA. CHICKEN-POX, SWINE-POX, ETC. This disease is usually so slight as to require little medical assistance; but in consequence of the resemblance of the eruption, under some of its varieties, to the small-pox, it becomes important, as a point of diagnosis, to establish its character with accuracy. Although its appearances were described by writers on the smallpox three centuries ago, under the appellation of Crystalli,* and at a period not much later, it had even acquired popular names in Italy, France and Germany, and subsequently in England, f yet most of * Vidus Vidius (De Crystallis) and Ingrassias (De Tumor, praet. Nat. lib. i. cap. i.) describe these crystalli, as white shining pustules, containing lymph, nearly as large as lupine seeds, and attended with little fever: " suntque has minus periculosae (i. e. than smallpox,) et saepe citra notabilem febrem infantes prehendunt." t We have the testimony of many writers, in proof of the prior discrimination of the vulgar, in respect to this eruptive disease. Sennertus, who was a professor at Wittemberg, at the 28 196 VESlCUL^l: the systematic writers, down to the latter part of the eighteenth century, seem to have looked upon it as a variety of smallpox. D. Heberden, in the year 1767, pointed out the distinction with his accustomed perspicuity * Perhaps, however, as this learned physician, in his posthumous work, continues to designate the disease by the term Variola,f the employment of the same term by the systematic writers above alluded to, with the epithets volaticce, &c. can not be deemed ex- commencement of the seventeenth century, observes, in his treatise on smallpox and measles, that there are other varieties, " prseter communes variolas et morbillos," which are popularly known, in Germany, by the terms Schaffsblattern (sheep-pox, or vesicles) or Windbocten (wind-pox.) See his Med. Pract. lib. iv. cap. 12. And Riverius, who was professor at Montpellier at the same period, speaks of the eruption as familiarly known by the common people in France, by the appellation of Veirolette. See his Prax. Med. cap. ii. In Italy it was called Ravaglione. Ibid. —See also Diemerbroeck, De Variolis et Morbis, cap. 2.—Fuller, in his " Exanthematologia," published in 1730, describes the eruption, and acknowledges himself indebted to the nurses for the appellation. " I have adventured to think," he says, " this is that which among oar women goeth by the name of chicken-pox." p. 161. And it is mentioned familiarly, at Edinburgh, in 1733, as " the bastard or chicken-pox. See Edin. Med. Essays, vol. ii. art. 2. At Newcastle and in Cumberland, it is popularly known by the name of water-jags. See Dr. Wood, in the Med. and Phys. Journal, vol. xiii. p. 58, note. * See his paper in the Med. Transact, of the Coll. of Phys. vol. i. art. xvii. t " Variolar pusillsc" See his Comment, de Morbis, cap. 96. $ See Vogel, de cognoscend. et cur. Horn. Morb. § 128. (edit. 1772.) Burserius, Inst. Med vol. ii. cap. 9. § 305. Sauvages, however, actually makes it a species of variola, class, iii. gen. ii . spec. i. V. lymphatica. 197 VARICELLA. dence, that they actually considered the disease as generically the same with smallpox. The three principal varieties of chicken-pox were well known a century ago, and were distinguished in the north of England, and in some counties in Scotland, by the popular names of chicken-pox, swine-pox, and hives. Dr. Willan proposed to distinguish them, according to the different forms of the vesicles, by the epithets, lenticular, conoidal and globate.* 1. The lenticular Varicella (Plate XLVII —VIII.) appears on the first day of the eruption, in the form of small red protuberances, not exactly circular, but tending to an oblong figure, having a nearly flat and shining surface, in the centre of which a minute transparent vesicle is speedily formed. This on the second day, is filled with a whitish lymph, and is about the tenth of an inch in diameter. On the third day the vesicles have undergone no change, except that the lymph is strawcoloured. On the fourth day, those which have not been broken begin to subside, and are puckered at their edges. Few of them remain entire on the fifth day; but the orifices of several broken vesicles are closed, or adhere to the skin, so as to confine a little opaque lymph within the puckered margins. On the sixth day, small brown scabs appear universally in place of the vesicles. The scabs, on the seventh and eighth days, become yellowish and gradually dry from the circum- * See his treatise " On Vaccine Inoculation," published in 1806, sect. viL—Dr. Fuller, above quoted, described these three varieties under the appellations of chicken-pox, swine-pox, and crystalli, p. 161-3. VESICULjE 198 ference towards the centre. On the ninth and tenth days, they fall off, leaving for a time red marks on the skin, without depression. Sometimes, however, the duration of the disease is longer than the period just stated, as fresh vesicles arise during two or three successive days, and go through the same stages as the first* 2. In the conoidal Varicella, the vesicles rise suddenly, and have a somewhat hard and inflamed border: they are, on the first day of their appearance, acuminated, and contain a bright transparent lymph. On the second day, they appear somewhat more turgid, and are surrounded by more extensive inflammation; the lymph contained in many of them is of a light straw-colour. On the third day, the vesicles are shrivelled; those which have been broken, exhibit, at the top, slight gummy scabs, formed by a concretion of the exuding lymph. Some of the shrivelled vesicles, which remain entire, but have much inflammation round them evidently contain on this day purulent fluid: every vesicle of this kind leaves after scabbing, a durable cicatrix or pit. On the fourth day, thin dark-brown scabs appear intermixed with others, which are rounded, yellowish, and semitransparent. These scabs gradually dry and separate, and fall off in four or five days. A fresh eruption of vesicles usually takes place on the second and third day; and as each set has a similar course, the whole duration of the eruptive stage in this species of Varicella, is six days; the last formed scabs, therefore, are not separated till the eleventh or twelfth day. 3. In the swine-pox or hives (for in the south, the 199 VARICELLA. former appellation is applied both to the second and third species) the vesicles are large and globated, but their base is not exactly circular. There is an inflammation round them, and they contain a transparent lymph, which on the second day of the eruption, resembles milk-whey. On the third day, the vesicles subside, and become puckered and shrivelled, as in the two former species. They likewise appear yellowish, a small quantity of pus being mixed with the lymph. Some of them remain in the same state till the following morning; but, before the conclusion of the fourth day, the cuticle separates, and thin blackish scabs cover the bases of the vesicles. The scabs dry and fall 01T in four or five days. Some degree of fever generally precedes the eruption of Varicella for a couple of days, which occasionally continues to the third day of the eruption. This is sometimes very slight, so that it is only recollected, as having been previously indicated by fretfulness, after the eruption appeared.* M The eruption usually commences on the breast and back, appearing next on the face and scalp, and lastly on the extremities. It is attended, especially in children, with an incessant tingling or itching, which leads them to scratch off the tops of the vesicles; so that the characteristics of the disease are often destroyed at an early period. Many of the vesicles thus broken and irritated, but not removed, are presently surrounded by inflammation, and after- * Dr. Heberden observes, " These pocks come out in many without any illness or previous sign."—But Dr. Willan states, " I do not remember to have seen any case of Varicella without some disorder of the constitution." Loc. cit. 200 VESICULiE: wards become pustules, containing thick yellow matter. These continue three or four days, and finally leave pits in the skin." The eruption is sometimes preceded, for a few hours, by a general erythematous rash. It is usually fullest in the conoidal form of Varicella, in which the vesicles are sometimes coherent, or seated close together, but seldom confluent.* The incidental appearance of pustules, just mentioned, among the vesicles, sometimes occasions a doubt respecting the nature of the eruption. The following circumstances, however, if carefully attended to, will afford sufficient grounds of diagnosis. The " vesicle full of serum on the top of the pock," as Dr. Heberden expresses it, on the first day of the eruption;—the early abrasion of many of these vesicles; their irregular and oblong form; —the shrivelled or wrinkled state of those which remain entire, on the third and fourth day, and the radiating furrows of others, which have had their ruptured apices closed by a slight incrustation; —the general appearance of the small scabs on the fifth day, at which time the smallpox are not at the height of their suppuration,—sufficiently distinguish the eruption of Varicella, from the firm, durable, and slowly maturating pustules of smallpox. Dr. Willan also points out a circumstance, which is very characteristic ; viz. " that variolous pustules, on the first and second day of their eruption, are small, hard, globular, red, and painful: the sensation of them to the touch, on passing the finger over them, is similar to that which * See Dr. Willan's treatise. A case of confluent chicken-pox, illustrated by a coloured engraving, was published by Mr. Ring, in the Med. and Phys. Journal for 1805, vol. xiv. p. 141. 201 VARICELLA. one might conceive would be excited by the pressure of small round seeds under the cuticle. In the Varicella almost every vesicle has, on the first day, a hard inflamed margin; but the sensation communicated to the finger, in this case, is like that from a round seed, flattened by pressure." Dr. Willan remarks likewise, that, as the vesicles of the chicken-pox appear in succession, during three or four days, different vesicles will be at once in different states of progress: and if the whole eruption, on the face, breast and limbs, be examined on the fifth or sixth days, every gradation of the progress of the vesicles will appear at the same time. But this circumstance can not take place in the slow and regulated progress of the smallpox. When the globated vesicles of the hives appear, (and they are occasionally intermixed both with the lenticular and conoidal vesicles,) they afford a ready distinction from the smallpox, to the pustules of which they bear little resemblance. There is a variety of smallpox, which is occasionally produced by variolous inoculation, and which has usually appeared where vaccination had only partially influenced the constitution: this commonly dries up, on the sixth or seventh day, without maturation. But the small, hard, tubercular form of this eruption, is sufficiently distinct from every form of the vesicles of chicken-pox. It is unnecessary to say any thijjg respecting the treatment of Varicella; since nothing in general is requisite beyond an attention to the state of the bowels, and abstinence from animal diet for two or three days. 202 VESICULjE: From some experiments made, in his own family, by an eminent surgeon, and from others performed at the Smallpox Hospital, it appears, that Varicella is communicable by inoculation with the lymph of the vesicles; — that it may be introduced while the constitution is under the influence of vaccination, without impeding the progress of the latter, or being itself interrupted;—that smallpox, inoculated during the eruptive fever of Varicella, proceeds regularly in its course, without occasioning any deviation in that of the latter; —but that, when variolous and varicellous virus is inserted at the same time, the smallpox proceeds through its course, while that of the chicken-pox is in a great degree interrupted.* But the experiments have not been sufficiently numerous to warrant the accuracy of these general conclusions. II. VACCINIA. As the subject of Cow-pox has been amply treated of, in publications that are in every body's hands, it will be unnecessary for me to enter into a minute detail upon it here. It is now well known, that the characteristic of this eruption (the discovery of which, as a preventive of the pestilential smallpox, has conferred immortality on the name of Jenner) is a semi-transparent, pearl-coloured vesicle, with a circular or somewhat oval base, its upper surface, until the end of the eighth day, being more elevated at the margin than in the centre, and the margin itself being turgid, shining, *' See Dr. Wilkin's T tise on Vaccination, pp. 97 —103. 203 VACCINIA. and rounded so as often to extend a little over the line of the base.* This vesicle is filled with clear lymph, contained in numerous little cells, that communicate with each other. After the eighth or ninth day, from the insertion of the virus, it is surrounded by a bright red, circumscribed areola, which varies in its diameter, in different cases, from a quarter of an inch to two inches, and is usually attended with a considerable tumour and hardness of the adjoining cellular membrane. This areola declines on the eleventh and twelfth day; the surface of the vesicle then becomes brown in the centre; and the fluid in the cells gradually concretes into a hard rounded scab, of a reddish brown colour, which at length becomes black, contracted, and dry, but is not detached till after the twentieth day from the inoculation. It leaves a permanent circular cicatrix, about five lines in diameter, and a little depressed, the surface being marked with very minute pits or indentations, denoting the number of cells of which the vesicle had been composed.f A vesicle, possessing these characters, and passing through these regular gradations, whether accompanied by any obvious disorder of the constitution or not, effectually and permanently secures the individual from the danger, and almost universally from the contagion of smallpox.} * See the Plate, fig. 6. q. t See Dr. Willan's Treatise on Vaccination, p. 9. \ At the end of the sixteenth year from the promulgation of the discovery, this truth remains in full force: the very exceptions to it (and what result of human research is free from exceptions?) may be said, without a solecism, to corroborate it. 29 204 VESICULJE: It is requisite, therefore, that the vaccinator should attend to the irregular appearances, which are produced either by the insertion of matter, that is so far corrupted or deteriorated, as to be incapable of exciting the perfect disease, or by the inoculation of proper lymph, under certain circumstances of the habit, which interfere with its operation, and which will be mentioned presently. There is no uniform appearance, which is characteristic of imperfect vaccination: on the contrary, three varieties of irregularity have been noticed; namely, pustules,* ulcerations, and vesicles of an irregular form. The pustule, which is sometimes produced instead of the proper vaccine vesicle, is more like a common festering bile, occasioned by a thorn, or any other small extraneous body sticking in the skin, according to Dr. Jenner; and it throws out a premature efflorescence, which is seldom circumscribed.f It is, as Dr. Willan has stated, of a conoidal form, and raised upon a hard For,in the very small number of cases, (such as that of the son of Earl Grosvenor,) where an extensive eruption of smallpox has occurred subsequent to vaccination, the controlling influence of the cow-pox has been invariably and strikingly manifested, by the sudden interruption of the smallpox in the middle of its course, and the. rapid convalescence of the patient. * The pustules here mentioned occur on the inoculated part. Those pustules, which appeared over the body, in the first experiments with the vaccine virus made, in the Smallpox Hospital, by Dr. Woodville, and which puzzled the early vaccinators, were subsequently proved, and admitted by Dr. Woodville himself, to have been genuine smallpox, the result of the contagion of the place. t See Med. and Physical Journ. vol. xii. for Aug. 1804, p. 98 205 VACCINIA. inliamed base, with diffuse redness extending beyond it: it increases rapidly from the second to the sixth day, and is usually broken before the end of the latter, when an irregular,yellowish-brown scab succeeds* Ulceration, occupying the place of a regular vesicle, must be obviously incorrect; it probably originates from the pustules just mentioned, which, on account of the itching that is excited, are sometimes scratched off at a very early period; or, being prominent and tender, are readily injured and exasperated by the friction of the clothes, &c f With respect to the irregular vesicles, " which do not wholly secure the constitution from the smallpox," Dr. Willan has described and figured three sorts. " The first is a single pearl-coloured vesicle, set on a hard dark red base, slightly elevated. It is larger and more globate than the pustule above represented, but much less than the genuine vesicle: its top is flattened, or sometimes a little depressed, but the margin is not rounded or prominent.—The second appears to be cellular, like the genuine vesicle; but it is somewhat smaller, and more sessile, and has a sharp angulated edge. In the first the areola is usually diffuse, and of a dark rose-colour; in * This premature advancement was pointed out by Dr. Jenner as a characteristic of the irregular pock, in his Paper of Instructions for Vaccine Inoculation, at an early period of the practice. He also justly remarked, in respect to the " soft, amber-coloured" scab, left by these pustules, that " purulent matter can not form a scab so hard and compact as limpid matter." loc. cit. p. 99, note. In other words, that the scab succeeding a pustule is less hard and compact than the scab which forms on a vesicle. f Dr. Willan, loc. cit. 206 VESICUL22: the second, it is sometimes of a dilute scarlet colour, radiated, and very extensive, as from the sting of a wasp. The areola appears (earlier) round these vesicles, on the seventh or eighth day after inoculation, and continues more or less vivid for three days, during which time the scab is completely formed. The scab is smaller and less regular than that which succeeds the genuine vesicle; it also falls off much sooner, and, when separated, leaves a smaller cicatrix, which is sometimes angulated. The third irregular appearance is a vesicle without an areola."* There are two causes, as I have intimated above, for these imperfect inoculations; the one is the insertion of effete or corrupted virus, and the other the presence of certain cutaneous eruptions, acute and chronic. * It appears to me that Mr. Bryce, in his able and valuable work on the Inoculation of Cow-pox, has, without any sound reason, impugned these observations upon the " irregular vesicles," and considered the introduction of the terms as productive of " much injury to the true interests of vaccination," and as serving to screen ignorance or inattention in the operator:" and that his own reasoning, which amounts to nothing mere than a hypothetical explanation (and consequently an admission) of the fact, is irrelevant. He divides the whole " into constitutional and local;" but at the same time admits, that he knows no criterion by which they are to be distinguished, save the ultimate security against smallpox produced by the one, and not by the other. (Appendix, no. x. p. 114, edit. 2d.) Now this is surely to screen ignorance and inattention, by representing minute observation of appearances as unnecessary. However, he more than compensates for this error of logic, by the ingenious test of a double inoculation, at the interval of five or six days, which he has established, and which is sufficiently mechanical, to be employed without any unusual nicety of observation or tact. 207 VACCINIA. The lymph of the vaccine vesicle becomes altered in its qualities soon after the appearance of the inflamed areola; so that, if it be taken for the purposes of inoculation after the twelfth day, it frequently fails to produce any effect whatever; and in some cases it suddenly excites a pustule, or ulceration, in others an irregular vesicle, and in others erysipelas. If taken when scabs are formed over the vesicles, (as in the case of the pustules of smallpox,) the virus is occasionally so putrescent and acrid, that it excites the same violent and fatal disease, which arises from slight wounds received in dissecting putrid bodies. Again, the lymph, although taken from a perfect vesicle on the sixth, seventh, or eighth day, may be so injured before its application, by heat, exposure to the air, moisture, rust and other causes,* as to be rendered incapable of exciting the true disease. The most frequent cause of these imperfections, however, seems to be the presence of chronic cutaneous eruptions, or the concurrence of eruptive fevers, or even of other febrile diseases. The chronic cutaneous diseases, which sometimes impede the formation of the genuine vaccine vesicle, have been described by Dr. Jenner under the ordinary indefinite term herpes,f and tinea capitis. In the more accurate phraseology of Dr. Willan, they are herpes (including the shingles and vesicular ring-worm,) psoriasis and impetigo (the dry and humid tetter,) the lichen, and most frequently the varieties of porrigo, comprising the contagious eruptions *Dr. Willan, loc. cit. t See his letter to Dr. Marcet, Med. and Phys. Journ. for May, 1803; also the same Journal for Aug. 1804. 208 VESICULjE. denominated by authors crusta lactea, area, achores and favi Dr. Willan thinks that the itch and porrigo likewise have the same influence. Of the interference of the eruptive fevers, measles, scarlet fever, and chicken-pox, with the progress of the vaccine vesicle, when they occur soon after vaccination, numerous instances have been recorded. The suspension of its progress, indeed, would be expected, under such circumstances, from the known facts respecting the reciprocal action of these contagious fevers on each other. But the action of the vaccine virus is not only suspended by these fevers, so that the vesicle is very slow in its progress, and the areola not formed till after the fourteenth day or later, and sometimes not at all; but it is occasionally rendered altogether inefficient. Even typhus fever and the influenza have been observed to produce a similar interruption in the progress of vaccination. Finally, the vesicle, without an areola, takes place if the person inoculated have previously received the infection of smallpox, or if he be affected with some other contagious disease during the progress of vaccination.* Other irregularities may probably have occurred. Ai all events, though the constitution is sometimes fully secured from the infection of smallpox, even by the irregular vesicles, yet, as it is more commonly but imperfectly guarded by such vesicles, the propriety of Dr. .Tenner's caution is obvious; that, " when a deviation arises, of whatever kind it may be, common prudence points out the necessity of re-inoculation."f * Dr. Willan, loc. cit. t Paper of Instructions, before quoted 209 HERPES, III. HERPES * This appellation is here limited to a vesicular disease, which, in most of its forms, passes through a regular course of increase, maturation, and decline, and terminates in about ten, twelve, or fourteen days. The vesicles arise in distinct but irregular clusters, which commonly appear in quick succession, and they are set near together, upon an inflamed base, which extends a little way beyond the margin of each cluster. The eruption is preceded, when it is extensive, by considerable constitutional disorder, and is accompanied by a sensation of heat and tingling, sometimes by severe deep-seated pain, in the parts affected. The lymph of the vesicles, which is at first clear and colourless, becomes gradually milky and opaque, and ultimately concretes into scabs; but, in some cases, a copious discharge of it takes place, and tedious ulcerations ensue. The disorder is not contagious in any of its forms. The ancients, although they frequently mention Herpes, and give distinctive appellations to its varieties, have no where minutely described it: hence their fol- * Actuarius explains the origin of this term, as well as of the application of the word fire, to these hot and spreading eruptions. " Herpes dicitur eo quod videatur ipxtiv (quod est serpere per summam cutem,) modo hanc ejus partem, modo proximam occupans, quod semper, priore sanata, propinqua ejus vitiura excipiat; non secus quam ignis qui proxima quxque depascitur, ubi ea quae prius accensa erant, deficiente jam materia idonea, prius quoque extinguuntur." Mcth. Med. lib. ii. cap. 12.— From this creeping progress, the disease was called Formica by the Arabians. 210 VESICUL^E: lowers have not agreed in their acceptation of the term.* It has been principally confounded with erysipelas, on the one hand, and with eczema, impetigo,! an d other slowly spreading eruptions, on the other. But if the preceding character be well considered, the diagnosis between these affections and Herpes will be sufficiently obvious. From erysipelas it may be distinguished by the numerous, small, clustering vesicles, by the natural condition of the surface in the interstices between the clusters, and by the absence of redness and tumefaction before the vesicles appear: and from the chronic erup- * Although some of the ancients are more anxious to point out the nature of the morbid humour, to which the Herpes was to be imputed, than to describe its symptoms; yet most of them speak of small bullse, or phlyctsenae, as characteristic of the eruption. (See Galen de Tumoribus praet. Naturam; —Aetius, tetrab. iv. serm. ii. cap. 60; Paulus, lib. iv. cap. 20; —Actuarius, lib. ii. cap. 12.) Again, Scribonius Largus speaks of the most remarkable form of this vesicular disease (the zoster, or shingles,) as a species of Herpes. "Zona quam Graeci dicunt." See Scribon. de Compos. Medicam. cap. 13. In describing the appearances of this disease, under the appellation of Ignis sacer, Celsus has properly characterized it by the numerous and congregated eruption, the small and nearly equal size of the vesicles, and the situations which it most frequently occupies, 8cc. " Exasperatumque per pustulas continuas, quarum nulla altera major est, sed plurimae perexiguae: in his semper fere pus, et saepe rubor cum calore est: serpitque id nonnunquam sanescente eo quod primum vitiatum est; nonnunquam etiam exulcerato, ubi, ruptis pustulis, ulcus continuatur, humorque exit, qui esse inter saniem et pus videri potest. Fit maxime in pectore, aut lateribus, aut eminentibus partibus, praecipueque in plantis." Lib. v. cap. 28. § 4. t See Dr. Cullen's definition of Herpes. Nosol. Method, gen. 147. 211 HERPES. lions just alluded to, by the purely vesicular form of the cuticular elevations in the commencement, by the regularity of their progress, maturation, and scabbing, and by the limitation of their duration, in general, to a certain number of days. The ancient division of Herpes into three varieties, miliary, (**yxpw,) vesicular (fta#*n#»wtyjj) and eroding m ay by properly discarded: for there appears to be no essential distinction between the first two, which differ only in respect to the size of the vesicles; and the last is incorrectly classed with Herpes, being perhaps referable rather to pompholyx, or those larger bullae, which arise in bad habits of body, and are followed by ill-conditioned ulcerations of the skin.* The various appearances of Herpes may be comprehended under the six following heads. 1. Herpes phlyctanodes. (Plate XLLX.) This species of the eruption, including the miliary variety above mentioned, is commonly preceded by a slight febrile * Celsus has, in fact, made this distinction between the Herpes esthiomenos and the proper Herpes, ranking the latter under the head of Ignis sacer; a term which most of the translators of the Greek writings have incorrectly substituted for erysipelas. Whereas he speaks of the H. esthiomenos as a deep spreading ulcer, of a cancerous character. " Fit ex his ulcus quod IprUfttk ta9ioftBvov Graeci vocant, quia celeriter serpendo penetrandoque usque ossa, corpus vorat. Id ulcus inaequale est, coeno simile, inestque multus humor glutinosus, odor intolerabilis, majorque quam pro modo ulceris inflammatio. Utrumque (sail, dqpt9o$, by which most of the Greek writers designate the disease. Aet. tetrab. ii. serm. iv. cap. 13. The Latins denominated the tubercles vari. See Celsus, lib. vi. cap. 5.—-Plin. Hist. Nat. lib. xxiii.—Sennert having spoken of the affinity of vari with the pustules about the head, called psydracia by some writers, Sauvages made the eruption a species of the latter, Psydracia acne. Nosol. Meth. class i. ord. ii. gen. 9. See Jul, Pollux, Onomasticon, lib. iv. cap. 25. 261 ACNE. succession, they are generally seen at the same time in the various stages of growth and decline; and, in the more violent cases, are intermixed likewise with the marks or vestiges of those which have subsided. The eruption occurs almost exclusively in persons of the sanguine temperament, and in the early part of life, from the age of puberty* to thirty or thirty-five; but, in those of more exquisite temperament, even later. It is common to both sexes; but the most severe forms of it are seen in young men. There are four varieties of this eruption, which may be designated by the titles of Acne simplex, punctata, indurata and rosacea.f 1. The Acne simplex (Plate LXIL) is an eruption of small vari, which appear singly, and are not very numerous, nor accompanied by much inflammation, nor by any intermediate affection of the skin. When it has continued some time indeed, a little roughness of the face is produced, where the larger tubercles have disappeared in consequence of a slight cracking or dispo- * From this circumstance, both the Greek appellations appear to have originated; mw0os, from its occurring during the growth of the lanugo, or first beard, which the word also signifies;—and axvq, quasi axfit], from its appearance at the acme or full growth and evolution of the system. i( Ionthi, flores cum papulis circa faciem, vigoris signum," is the definition given by Julius Pollux (loc. cit.). And Cassius,in his 33d problem, explains, a Cur in facie vari prodeuntfere in ipso setatis flore vigoreque (quapropter et axpai, id est vigores, idiotarum vulgus eos nuncupat?") t Alibert has not figured any specimen of Acne, unless an illdefined plate (22d,) representing what he calls " Dartre pustuleuse miliaire," on the forehead, be intended for Acne simplex. TUBERCULA: 262 sition to exfoliate in the new cuticle; but these marks are not permanent. Many of the tubercles do not proceed to suppuration; but gradually rise, become moderately inflamed, and again slowly subside, in the course of eight or ten days, leaving a transient purplish red mark behind. But others go on to a partial suppuration, the whole process of which occupies from a fortnight to three weeks. The tubercles are first felt in the skin, like a small hard seed, about the size of a pin's head, and enlarge for three or four days, when they begin to inflame: about the sixth or seventh day they attain their greatest magnitude, and are then prominent, red, smooth and shining, and hard and painful to the touch. After two or three days more, a small speck of yellow matter appears on the apices of some of the tubercles; and, when these afterwards break, a thinner humour is secreted, which soon dries into a yellowish scab. The inflammation now gradually declines, the size and hardness of the tubercles diminish, and the small scab becomes loosened at the edges, and at length falls off* about the third week. The individual tubercles, which rise and suppurate in succession, pass through a similar course. This eruption recurs frequently, at short intervals, in some individuals, who have it partially; but in others, who are more strongly predisposed to it, it is more extensive, and never wholly disappears, but is, at uncertain periods, more or less troublesome. Such persons often enjoy good health, and can not refer the cutaneous complaint to any obvious exciting cause; whence Dr. Darwiu* has constituted it a distinct species, with * Dr. Darwin names the genus gutta rosea, of which, he says, 263 ACNE the epithet, " hereditary:" which, in fact, is to ascribe it solely to the temperament of the patient, or to consider the predisposition, arising from the great vascularity of the skin in sanguine habits, as adequate to give rise to the eruption, under ordinary stimulation. There appears, however, to be no clear distinction between the stomachic and hereditary cases of Acne, as Dr. Darwin supposes; for it is only where there is a strong constitutional predisposition, that substances which disorder the stomach excite the eruption of Acne; and in those who are so predisposed, the vari occasionally appear after eating heartily, or drinking, an unusual portion of wine or from any slight cause of indigestion; as well as after any inordinate excitement of the cutaneous circulation from violent exercise in hot weather, or in heated rooms, especially when followed by a copious draught of cold liquor. In some cases, a sort of critical eruption of vari has suddenly occurred, after severe indigestion, or continued pains in the stomach, which have been immediately relieved; and in such instances, there is occasionally also an eruption of lichenous papulae on the body and limbs. Being generally, however, a local disease, the Acne simplex is to be treated chiefly by external applications. there are three species:—I. The gutta rosea hepatica, connected with diseased liver in drunkards: 2. G. R. stomatica, which is occasioned by taking cold drink, eating cold raw turnips, Etc. when the body is much heated by exercise; and 3. The G. rosea hereditaria, or puncta rosea (the Acne simplex), which consists of smaller pimples, that are less liable to suppurate, and which seems to be hereditary, " or at least has no apparent cause like the others." SeeZoonomia, class, ii. 1. 4. 6.-—and class, iv. 1. 2. 13. and 14. 264 TUBERCULA: Except in females, indeed, this variety of the eruption seldom calls for the attention of medical men. Celsus observes that, in his time, the Roman ladies were so solicitous of maintaining their beauty, that he deemed it necessary to mention the remedies for this affection, which otherwise he considered as too trifling for the notice of the physician.* The ancients agree in recommending a number of stimulant applications, with the view of discussing the " thick humours" which were supposed to constitute the vari. Lotions and liniments containing vinegar and honey, sometimes combined with an emulsion of bitter almonds, and sometimes with turpentine, resin, myrrh, and other gums, or with alum, soap, and Cimolian earth, or the bruised roots of the lily, cyclamen, narcissus, &c. were the substances which they principally employed.f They were, doubtless, correct as to the principle; as a gentle stimulus to the skin is the most safe and effectual remedy. The apprehensions, which have been strongly expressed by the humoral pathologists, of producing internal disorder by the sudden repulsion, as it has been called, of these cutaneous eruptions, are not altogether hypothetical. Headache, and affections of the stomach and bowels, * " Peneineptiae sunt, curare varos, et lenticulas, et ephelidas: sed eripi tamen foesninis cura cultus sui non potest." De Med. lib. vi. cap. v. t See Celsus, loc. cit.—Oribas. Synops. lib. viii. cap. 34; and De Loc. Affect, lib. iv. cap. 51.—Aetius, tetrab. ii. serm. iv. cap. 13. —Paulus, lib. iii. cap. 25. —Actuarius, lib. iv. cap. 12. By the older modern writers, who were'chiefly their copyists, the same applications were prescribed. See Hafenreffer, Nosodochium, lib. ii. cap. 14. 265 ACNE. have sometimes been thus produced, which have ceased on the re-appearance of the eruption: but, on the whole, as far as my observation goes, this alternation of disease is less frequent and obvious in this form of Acne, than in the pustular and crustose eruptions of the face and head. The stimulant applications, which are most easily proportioned to the irritability of the tubercles, are lotions containing alcohol, which may be reduced or strengthened, according to circumstances, by the addition of any distilled water. It is not easy to describe the appearances of the eruption, which indicate any certain degree of strength in the lotion: but a little observation will teach this discrimination. If the tubercles are considerably inflamed, and a great number of them pustular, a dilute mixture will be requisite; containing, for example, equal parts of spiritus tenuior, and of rose or elder-flower water. The effect of a very acrid lotion, under such circumstances, is to multiply the pustules, to render many of them confluent, and to produce the formation of a crust of some extent, as well as to excite an inflammatory redness in the adjoining skin.* A slight increase of the inflammation, * It must be admitted, however, that the eruption is sometimes materially diminished, after the violent action of an irritating application has subsided. I lately saw a lady, who considered herself much benefited after a severe inflammation, and even excoriation, of the face, which had been produced by a poultice of bruised parsley. Dr. Darwin affirms that blistering the whole face, in small portions, successively, is the most effectual remedy for this Acne. (loc. cit.) But the " cura cultus sui" generally renders patients of this class unwilling to employ harsh remedies. TUBERCULA: 266 indeed, is sometimes occasioned by the first applications of a weak stimulus; but this is of short duration; and the skin soon bears an augmentation of the stimulant; until at length the pure spirit is borne with advantage, as the inflammatory disposition subsides. Under the latter circumstances, even a considerable additional stimulus is often useful; such as from half a grain to a grain or more of the muriate of mercury, in each ounce of the spirit; or a drachm or more of the liquor potassse, or of the muriatic acid, in six ounces. Acetous acid, as recommended by the ancients, and the liquor amnion iae acetatis, afford also an agreeable stimulant, in proper proportions. Sulphur yields a small portion of its substance to boiling water, poured upon it, and allowed to infuse for twelve or fourteen hours, a quart of water being added to about an ounce of broken sulphur. A lotion of this nature has been found advantageous, in slight cases of Acne simplex, and especially in removing the roughness and duskiness of the face connected with it.* 2. Acne punctata. (Plate LXII.) The eruption, in this variety of the disorder, consists of a number of black points, surrounded by a very slight raised border of cuticle. These are vulgarly considered as the extremities of small worms or grubs, because, when they are pressed out, a sort of wormlike appendage is found attached to them: but they are in fact only concreted mucus or * This lotion has been recommended by Dr. Clarke of Dublin, as containing a sufficient impregnation of sulphur for the cure of scabies in children. See Med. Facts and Observ. vol. viii. p. 275. 267 ACNE sebaceous matter, moulded in the ducts of the sebaceous glands into this vermicular form, the extremity of which is blackened by contact with the air* In consequence of the distention of the ducts, the glands themselves sometimes inflame, and form small tubercles with little black points on their surface, which partially suppurate, as in the foregoing species: but many of them remain stationary for a long period, without ever passing into the inflammatory state. Not unfrequently they are intermixed with a few tubercles, in which the puncta have not appeared. These concretions may be extracted, by pressing on both sides of the specks with the nails, until the hardened mucus is sufficiently elevated to be taken hold of. A blunt curved forceps may be employed with advantage for this purpose * When the puncta are removed, the disease becomes Acne simplex, and requires the same treatment with the preceding species. Dr. Underwood has recommended the use of a solution of carbonate of potass internally, in these cases ;f and Dr. Willan was in the habit of occasionally prescribing the oxymuriate acid. One or two tea-spoonfuls of this liquid, taken in a glass of water three times a day, for a considerable period, has sometimes appeared to benefit the health, and improve the colour and smoothness of the skin; but, on the whole, it is not easy to dis- * Such a forceps has been contrived by a surgeon's instrument maker, of the name of Hattersley, in South Molton-street. t See some observations relative to " crinones, or grubs," which he says, he had often found troublesome, especially in females, about the time of puberty. Treatise on the Dis. of Children, vol. ii. p. 167, 5th edit. 37 268 TUBERCULA: cover any sensible operation of this medicine, and its only effect is, perhaps, that of a tonic to the stomach. Medicines of this nature are more adapted to the subsequent species of the complaint, especially to the A. rosacea. S. Acne indurata. (Plate LXIII.) In this form of Acne, the tubercles are larger, as well as more indurated and permanent, than in A. simplex. They rise often in considerable numbers, of a conical, or oblong conoidal form, and are occasionally somewhat acuminated, as if tending to immediate suppuration, being at the same time of a bright roseate hue: yet many of them continue in a hard and elevated state for a great length of time, without any disposition to suppurate. Others, however, pass on very slowly to suppuration, the matter not being completely formed in them for several weeks, and then only a small part of the tubercles are removed by that process. Sometimes two or three coalesce, forming a large irregular tubercle, which occasionally suppurates at the separate apices, and sometimes only at the largest. In whatever mode they proceed, the vivid hue of the tubercles gradually becomes more purple or even livid, especially in those which show no tendency to suppurate. Slight crusts form upon the suppurating tubercles, which after some time fall off, leaving small scars, surrounded by hard tumours of the same dark red colour; and these sometimes suppurate again at uncertain periods, and sometimes slowly subside and disappear, leaving a purple or livid discoloration, and occasionally a slight depression, which is long in wearing off. 269 ACNE, The tubercles, even when they do not suppurate, but especially while they continue highly red, are always sore, and tender to the touch, so that washing, shaving, the friction of the clothes, &c. are somewhat painful. In its most severe form, this eruption nearly covers the face, breast, shoulders, and top of the back, but does not descend lower than an ordinary tippet in dress: yet this limitation of the disorder is independent of the exposure of those parts; for it occurs equally in men and women. In a few instances in young men, I have seen an extensive eruption of Acne indurata, affecting these covered parts, while the face remained nearly free from it. By the successive rise and progress of the tumours the whole surface, within the limits just mentioned, was spotted with the red and livid tubercles, intermixed with the purple discolorations and depressions, left by those which had subsided, and variegated with yellow suppurating points and small crusts, so that very little of the natural skin appeared. Sometimes the black puncta of the sebaceous ducts were likewise mixed with the vari and their sequelae. The general health does not commonly suffer, even under this aggravated form of the eruption.* If a fe- * Forestus, and several other physicians of the sixteenth century, assert that vari are the precursors of elephantiasis, and indicate its approach. Sennertus asserts the same of vari, that are accompanied with puffy swelling (inflatio) of the face, and hoarseness. But these assertions are obviously either the result of mere hypothesis, founded on the resemblance of the larger vari to the incipient tubercles of elephantiasis; or of practical error, in applying the appellation of vari to the early symptoms of the latter disease. See Forest. Obs. Chirurg. lib. v. obs. 7. Sennert. Med. Pract. lib. v. part. ii. cap. 23. 270 TUBERCULA: ver or other severe disease should take place, indeed, the tubercles often subside and disappear: so that their recurrence, under such circumstances, is to be deemed a sign of returning health. I have seen the erethism of a mercurial course, administered for other purposes, occasion the disappearance of this Acne, which returned with the restoration of flesh and strength, after the omission of the medicine. Many persons, however, who are affected with the eruption, are liable to disorders of the bowels and stomach, to haemorrhoids, and some to phthisis pulmonalis. Its first appearance, too, is commonly ascribed to some irregularity of diet, or to some cold substance swallowed when the person had been overheated, and was in a free perspiration. Hence the first eruption is not unfrequently sudden. The Acne indurata is often much alleviated, and sometimes entirely removed, by the steady use of external stimulants, combined with a proper regulation of the diet and exercise. The eruption will bear a more acrid stimulus, even from the beginning, than the inflamed Acne simplex. A spirituous lotion, at first a little diluted, and containing the oxymuriate of mercury, in the proportion of a grain or somewhat less to the ounce of the vehicle, is often extremely beneficial. Gowland's lotion, an empirical preparation, which is said to contain this mercurial salt in an emulsion of bitter almonds,* is popularly used; and where its * The hitter almond was a favourite application with all the ancient physicians in inflammatory cutaneous eruptions. Its emulsion is prescribed, as a vehicle of more active substances, in every tract which they have left on these subjects. ,Yet it is probably a mere agreeable mucilage. 271 ACNE strength happens to accord with the degree of irritability in the eruption, and it is not applied to the other varieties of it, it is doubtless beneficial. Many other stimulants, some of which have been already named, may be substituted, of course, with similar effect; but it is unnecessary to specify them. It will be proper to remark, that, in general, it is requisite to augment the activity of all these applications, in the progress of the treatment, partly in consequence of the diminished effect of an accustomed stimulus, and partly on account of the increasing inertness of the tubercles, as (he inflammatory state subsides, which must be determined by the appearances. Frequent purgatives, which are often resorted to in these cases, especially by unprofessional persons, among whom the dregs of the humoral pathology still remain, are of no advantage; but, on the contrary, often augment the disease, in feeble habits. The copious use of raw vegetables in diet, which the misapplication of the term " scurvy" has introduced, is likewise to be deprecated, as well as the free use of vegetable acids, especially in constitutions that are predisposed to indigestion. These substances not only afford little nutriment, under such circumstances, but tend to increase the indigestion: and it is a fact, which it may not be easy to explain, that, under many modifications of cutaneous inflammation, especially about the head, and face, that inflammation is immediately increased in sympathy with the offended stomach, when these substances are eaten.* It were totally superfluous to re- * See above, p. 16, note. TUBERCULA: 272 mind professional men of the very opposite nature of inflammatory and suppurating affections of the skin, to that of petechias and ecchymoses, the mere effusions of extravasated blood under the cuticle, which belong to the proper, or, as it has been called, the putrid scurvy. And this negative inference at least must be deduced from the fact, that it is almost impossible, that these two opposite states of disease should be benefited by the same remedies. The diet, in these cases of Acne, should be good, i. e. light, and nutritious, but not stimulating; consisting of animal food, with well-dressed vegetables, and the farinaceae; wine and fermented liquors being omitted, or taken with great moderation. Internally, medicines effect very little; but I have had an opportunity, in several severe cases of Acne tuberata, of witnessing the increased amendment of the disorder, under the external treatment already mentioned, when small doses of soda, sulphur, and antimony were at the same time administered; by which plan the skin has been totally cleared. 4. Acne rosacea? (Plate LXIV.) This form of Acne differs in several respects from the preceding species. In addition to an eruption of small suppurating tubercles, there is also a shining redness, and an irregular granulated appearance of the skin of that part of the face which is affected. The redness commonly appears first at the end of the nose, and afterwards spreads from both sides of the nose to the cheeks, the whole of * This is the gutta rosea or rosacea of authors; some of whom, however, (as Dr. Darwin, to whom I have already referred,) comprehend all the varieties of vari under that appellation. 273 ACNE which, however, it very seldom covers. In the commencement it is not uniformly vivid; but is paler in the morning, and readily increased to an intense red after dinner, or at any time if a glass of wine or spirits be taken, or the patient be heated by exercise, or by sitting near a fire. After some continuance in this state, the texture of the cuticle becomes gradually thickened, and its surface uneven or granulated, and variegated by reticulations of enlarged cutaneous veins, with smaller red lines stretching across the cheeks, and sometimes by the intermixture of small suppurating vari, which successively arise on different parts of the face. This species of Acne seldom occurs in early life, except where there is a great hereditary predisposition to it; in general it does not appear before the age of forty; but it may be produced in any person by the constant immoderate use of wine and spirituous liquors. The greater part of the face, even the forehead and chin, are often affected in these cases; but the nose especially becomes tumid, and of a fiery red colour; and, in advanced life, it sometimes enlarges to an enormous size: the nostrils being distended and patulous, or the alae fissured, as it were, and divided into several separate lobes.* At that period of life too, the colour of the Acne * Sennert mentions a case, in which the enlarged nose made such an approximation in magnitude to Strasburg steeple, as to impede the exercise of vision, and to require lopping. 4< Sumunt tubercula ista interdum incrementum, ut facies inaequalis et horrid a evadat, et nasus valde augeatur. Vixit superiori adhuc anno, non procul a Dresda, vir, cui hoc malo affecto, nasus ita incrementum sumsit, ut eum in legendo impediret; quod malum ipsum ed adegit, ut anno 1629 particulas quasdam de naso sibi amputari curaret," Pract. Med. lib. v. part. i. cap. 31, 274 TUBERCULA: rosacea becomes darker and more livid; and if suppuration take place in any of the tubercles, they ulcerate unfavourably, and do not readily assume a healing disposition. In young persons, however, who are hereditarily predisposed to this complaint, irregular red patches not unfrequently appear in the face, which are often smooth, and free from tubercles, and sometimes throw off slight exfoliations at intervals. These patches may be gradually extended, if great temperance both in food and drink be not observed, until the whole face assume a preternatural redness. As this eruption is chiefly sympathetic of some derangement of the chylopoetic viscera, or of a peculiar irritability of the stomach, little advantage can be expected from local applications: and, in fact, the stimulants, which are beneficial, under proper regulations, in most of the other forms of Acne, are generally prejudicial in this, and aggravate the complaint. The misapplication of the nostrum, before mentioned, to this variety of the eruption, is one among the numerous practical errors, which originate from the indiscriminate recommendations of empiricism. On the other hand, all strong sedatives or restringents, if they succeed in repressing the eruption, are liable to aggravate the internal disorder. The perfect cure of Acne rosacea is, in fact, seldom accomplished; for whether it originate in a strong hereditary predisposition, or from habitual intemperance, the difficulties in the way of correcting the habit of body, are almost insurmountable. The regulation of the diet, in both cases, is important: and when the stomach or liver is disordered, in the latter, the symptoms may be 275 SYCOSIS. sometimes palliated by the liquor potassae, or other antacids, which seem also to have some influence in lessening inflammatory action in the skin. The gentlest restringents should be used externally to the patches of reticulated veins; such as very dilute spirituous or acetous lotions, with or without a small proportion of the acetate of lead; or simple ointments combined with alum, acetate of lead, &c. in small quantities. The more purely local and primary the eruption appears to I e, the more active may be the astringency of the substances applied to it. VI. SYCOSIS. Although this eruption was not mentioned in the enumeration of tubercles, on the cover of Dr. Willan's publication, I believe he intended, after the example of the old writers, to introduce it in this place, in consequence of its affinity to acne. The Sycosis* consists of an eruption of inflamed but * This denomination has been given to the disease, from the granulated and prominent surface of the ulcerationwhich ensues, and which somewhat resembles the soft inside pulp of a fig (odxok.)" Est etiam ulcus, quod a fid similitudine ovxueis a Grsecis nominatur, quia caro in eo excrescit." Celsus, lib. vi. cap. 3. The later Greeks, however, apply the terms, ovxa, and oyxob *dxwS«s, (fid and fcose tumours,) to excrescences of the eyelids, as well as to the proper Sycosis of Celsus. See Aetius, tetrab. i. serm. ii. cap. 80 & 190; —also tetr. ii. serm. iii. cap. 43; —Paul. jEgin. lib. iii. cap. 22; —and Actuarius, lib. ii. cap. 7. Paul, however, describes the Sycosis of the face as an eruption of "round, red, somewhat hard, painful, and ulcerating tubercles." 38 276 TUBERCULA: not very hard tubercles, occurring on the bearded portion of the face and on the scalp, in adults, and usually clustering together, in irregular patches. Celsus has correctly stated, that some difference takes place in the appearance and progress of the eruption, when it is seated in the chin, and in the scalp; whence he divides it into two species.* h In the Sycosis menti, (Plate LXV.) the tubercles arise first on the under lip, or on the prominent part of the chin, in an irregularly circular cluster: but this is speedily followed by other clusters, and by distinct tubercles, which appear in succession along the lower part of the cheeks up to the ears, and under the jaw towards the neck, as far as the beard grows.f The tubercles are red and smooth, and of a conoidal form, and nearly equal to a pea in magnitude. Many of them continue in th;s condition for three or four weeks, or even longer, having attained their full size in seven or eight days; but others suppurate very slowly and par- (lib. iii. cap. 3.) And Aetius, in another place, mentions the eruption as " one of the affections of the chin, which," he says, " differ from acne, in the nature of the humour, which it discharges, and in its greater tendency to ulceration." (tetrab. ii. serm. iv. cap. 14.) * " Sub eo vero duae sunt species. Altera ulcus durum et rotundum est; altera humidum et inaequale. Ex duro exiguum quiddam et glutinosum exit; ex humido plus, et mali odoris. Fit utrumque in iis partibus quae pilis conteguntur: sed id quod callosum et rotundum est maxime* in barba; id vero, quod humidum, praecipue in capillo." loc. cit. f An indifferent representation of this disease is given by Alibert, plate 20, under the appellation of " dartre pustuleuse mentagra." 277 SYCOSIS. tially, discharging a small -quantity of thick matter, by which the hairs of the beard are matted together, so that shaving becomes impracticable, from the tender and irregular surface of the skin. This condition of the face, rendered rugged by tubercles from both ears round to the point of the chin, together with the partial ulceration and scabbiDg, and the matting together of the unshaven beard, occasions a considerable degree of deformity; and it is accompanied also with a very troublesome itching. This form of the Sycosis occurs, of course, chiefly in men; but women are not altogether exempt from it, though it is commonly slight, when it appears in them. Its duration is very uncertain: it is commonly removed in about a fortnight; but sometimes the slow suppuration goes on for many weeks; and sometimes the suppurating tubercles heal, and again begin to discharge. Occasionally the disease disappears for a season, and breaks out again. 2. The Sycosis capilitii* (Plate LXVI.) is seated chiefly about the margin of the hairy scalp, in the occiput, or round the forehead and temples, and near the external ear, which is also liable to be included in the eruption. The tubercles rise in clusters, which affect the circular form; they are softer and more acuminated, than those on the chin; and they all pass into suppuration in the course of eight or ten days, becoming con- * M. Alibert has figured a disease of the scalp, under the appellation of « pian ruboide," in plate 35, which resembles the Sycosis of the scalp, if it be not a case of neglected or mismanaged porrigo favosa. 278 TUBERCULA: fluent, and producing an elevated, unequal, ulcerated surface, which often appears granulated, so as to afford some resemblance to the internal pulp of a fig. The ulceration, as Celsus states, is generally humid; for there is a considerable discharge of a thin ichorous fluid, which emits an unpleasant rancid odour. The Sycosis, under its first-mentioned form, may be distinguished from acne indurata, by its seat being exclusively on the bearded part of the face, —by the softer, more numerous, and clustered tubercles, —and by the ulceration which they tend to produce. And under its second form, in which it is somewhat assimilated to the eruption of favous pustules, or porrigo favosa, affecting the (ace and the borders of the capilitium, it may be discriminated, by the tuberculated and elevated base of the suppurating tumours; not to mention the adult age of the patient, and the absence of contagion. The cure of Sycosis is generally much more easily accomplished than that of porrigo favosa; but the method of treatment required for it is not very different. When the tubercles are numerous, inflamed, and confluent, and especially when the suppuration is either beginning or considerably advanced, the most speedy benefit is derived from the application of poultices, at night, of linseed powder, bread and milk, or other simple ingredients. In the less severe forms, warm ablutions or fomentations may be substituted. When the inflammatory symptoms are reduced, and in cases where they are from the first moderate, the healing process is much promoted, and the discharge moderated and restrained, by the application of the unguentum hydrargyri nitrati, diluted with three or four parts of simple ointment, 279 LUPUS, or by the ung. hydrarg. praecipitat. united with an equal portion of the zinc ointment, or the cerate of acetate of lead. At the same time it is useful to prescribe antimonials, with alterative doses of mercury, followed by cinchona, or serpentaria, and the fixed alkalis, especially where there appears to be any affection of the digestive organs, which not unfrequently concurs with this eruption. VII. LUPUS. Of this disease I shall not treat at any length; for I can mention no medicine, which has been of any essential service in the cure of it, and it requires the constant assistance of the surgeon, in consequence of the spreading ulcerations, in which the original tubercles terminate* (Plate LXVII.) The term was intended by Dr. Willan to comprise, together with the " noli me tangere" affecting the nose and lips, other slow tubercular affections, especially about the face, commonly ending in ragged ulcerations of the cheeks, forehead, eyelids, and lips, and sometimes occurring in other parts of the body, where they gradually destroy the skin and muscular parts to a con- * Alibert has two admirable portraits of Lupus in the face in plates 19 bis, and 21 j the former of noli me tangere, which he calls * dartre rongeante scrophuleuse;" and the latter of a less malignant variety, which he terms " dartre pustuleuse couperose." His 19th plate is apparently an incipient Lupus of the ala nasi, under the appellation of " dartre rongeante idiopathique." 280 TUBERCULA: siderable depth. Sometimes the disease appears in the cheek circularly, or in the form of a sort of ring-worm, destroying the substance, and leaving a deep and deformed cicatrix: and I have seen a similar circular patch of the disease, dilating itself at length to the extent of a hand-breadth or more, upon the pectoral muscle. By surgical means, i. e. by the knife or the caustic, a separation has sometimes been made of the morbid from the sound parts, and the progress of the disease arrested. And in some cases, where the ulceration was very slow, and unaccompanied by much inflammation, the internal use of arsenic has been found beneficial; a circumstance which has probably given rise to the opinion, that cancer has been cured by that mineral. In three or four less severe cases of lupous tubercles in the face, which had made no progress towards ulceration, I have seen the solution of muriate of barytes, taken internally materially amend the complaint. VIII. ELEPHANTIASIS. As the Elephantiasis (Plate LXVIII.) is almost unknown in this country, and I have only seen two instances of the disease, I must speak of it principally as it is described in books; and should have omitted the subject altogether, had it not appeared to me that some comment on the mistakes of translators and their followers, as well as on the history of the disease in general, might contribute to put the matter in a clearer light, than that in which it now stands. 281 ELEPHANTIASIS. The Elephantiasis (as described by the Greeks*) is principally characterized by the appearance of shining tubercles, of different sizes, of a dusky red, or livid colour, on the face, ears, and extremities; together with a thickened and rugous state of the skin, a diminution or * The terms £fctas and ste$avtumf were applied to this tubercular disease by Aretaeus, and the succeeding Greek writers, partly perhaps on account of some resemblance of the diseased skin to that of the elephant; but principally from the formidable severity and duration of the disease. " For it is disgusting to the sight," says Aretaeus, " and in all respects terrible, like the beast of similar name." (De Diuturn. Morb. lib. ii. cap. 13.) And Aetius observes, " Elephantiasis quidem a magnitudine et diuturnitate nomen accepit." (tetrabibl. iv. serm. i. cap. 120." So also the poet: " Est leprae species, elephantiasisque vocatur, Quae cunctis morbis major sic esse videtur Ut major cunctis elephas animantibus exstat." Macek de Herbar. Virtut. The same disease was described by the Arabians, under the appellation of Juzam or Judam, and is still designated by similar terms in Arabia and Persia, viz. Dsjuddam, and Madsjuddam, according to Niebuhr. (Description de l'Arabie, torn. iii. p. 119.) The translators, however, of the works of the Arabian physicians into Latin committed an extraordinary blunder, in rendering this appellation by the Greek term lepra; by which they misled their brethren, (who henceforth called Elephantiasis, the Arabian leprosy,) and contributed to introduce much confusion both into medical and popular language in the use of the term. The Arabians have not employed the'word lepra; but have designated the varieties of scaly and tubercular diseases by appellations, in their own language, as distinct and definite as those of the Greeks. (See Avicenna, lib. iv. fen. 3. tract. 3.— Alsaharavius, tract. 31.—-Haly Abbas, Theorice, lib. viii. cE(p. 15. and Pract. cap. 14.—Avenzoar, lib. ii.) 282 TUBERCULA: total loss of its sensibility, and a falling off of all the hair except that of the scalp. The disease is described as very slow in its progress, sometimes continuing for several years, without materially deranging the functions of the patient During this continuance, however, great deformity is gradually produced. The alae of the nose become swelled and scabrous, and the nostrils dilate; the lips are tumid; the external ears, particularly the lobes, are enlarged and thickened, and beset with tubercles; the skin of the forehead and cheeks grows thick and tumid, and forms large and prominent rugae, especially over the eyes: the hair of the eye-brows, the beard, the pubes, axillae &c. falls off; the voice becomes hoarse and obscure; and the sensibility of the parts affected is obtuse, or totally abolished, so that pinching or puncturing them gives no uneasiness. This disfiguration of the countenance suggested the idea of the features of a satyr or a wild beast; whence the disease was by some called Satyriasis* and by others Leantiasis.] * The term satyriasis, or satyriesmos, was also deemed applicable to the disease, on account of the excessive libidinous disposition said to be. connected with it. See Aretaeus, loc. cit. and Aetius, tetrab. iv. serm. i. cap. 120. t The two Greek writers, just quoted, attribute this name to the laxity and wrinkles of the skin of the forehead, which resembles the prominent and flexible front of the lion. But the Arabian writers ascribe it to a different source. Haly Abbas says the countenance was called leonine, because the white of the eyes becomes livid, and the eyes of a round figure; and Avicenna observes that the epithet was applied to the disease, because it renders the countenance terrible to look at, and somewhat of the form of the lion's visage, loc. cit. These appellations prove 283 ELEPHANTIASIS. As the malady proceeds, the tubercles begin to crack, and at length to ulcerate: ulcerations also appear in the throat, and in/the nose, which sometimes destroy the palate and the cartilaginous septum: the nose falls; and the breath is intolerably offensive: the thickened and tuberculated skin of the extremities becomes divided by fissures, and ulcerates, or is corroded under dry sordid scabs, so that the fingers and toes gangrene, and separate, joint after joint.* Aretaeus and the ancients in general consider Elephantiasis as an universal cancer of the body, and speak of it with terror; they depict its hideous and loathsome character, its contagious qualities, and its unyielding and fatal tendency, in strong and metaphorical language, which, indeed, tends to throw some doubt on the fidelity of their description. The very appropriation of the name is poetical; and Aretaeus has absurdly enough prefixed to his description of the disease an account of the elephant, in order to point out the analogy between the formidable power of the beast, and of the disease. that the allusions were entirely metaphorical, and did not refer to any resemblance in the skin of patients to the hide of these beasts.—M. Alibert has figured two varieties of Elephantiasis; viz. in plate 32, under the title of" Lepre tuberculeuse," where it is incipient on the eye-brows; and in plate 34, affecting the nose and lips, where it is called " Lepre leontine." His " Lepre Elephantiasis," plate 33, is the Barbadoes leg. * Alsaharavius thus states the symptoms of the juzam, when fully formed:—" the colour of the skin is changed, the voice is lost, the hairs have entirely disappeared; the whole surface of the body is ulcerated, discharging a putrid sanies, with extreme foetor; the extremities begin to fall off, and the eyes weep profusely." Lib. Practice, tract. 31. cap. 1. 39 284 TUBERCULA: It is probable, that his terrors led him to adopt the popular opinion respecting the malady, without the correction of personal observation: for, although his account has been copied by subsequent writers,* and the same popular opinions have been constantly entertained, there is much reason to believe, that some of the prominent features of his portrait are incorrectly drawn. Notwithstanding the care with which the separation and seclusion of lepers have been enforced, in compliance with the ancient opinion, there is great reason to believe that Elephantiasis is not contagious. M. Vidal long ago controverted that opinion, having never observed an instance of its communication from a leprous man to his wife, or vice versa,f although cohabiting for * It is impossible to read the description of this disease, (as said to occur at Barbadoes) by the learned Dr. Hillary, without a conviction that that respectable physician had in his mind a history detailed by the eloquent Greek (Aretaeus,) and not the phaenomena of the disease, as he had himself seen it. See his Obs. on the Air and Dis. of the Island of Barbadoes, p. 322, 2d edit. t See his Recherches et Obs. sur la Lepre de Martigues, in the Mem. de la Soc. Roy. de Med. torn. i. p. 169. —Dr. Joannis, a physician at Aix, who investigated the disease in the lazarhouse at Martigues, in 1755, also asserts the rarity of its communication between married persons. See Lond. Med. Obs. and Inquiries, vol. i. p. 204.—Indeed, several able physicians, two centuries before, though bending under the authority of ancient opinion, yet acknowledged their astonishment at the daily commerce of lazars with the healthy, without any communication of the disease. See Fernel, de Morb. Occult, lib. i. c. 12. Forest. Obs. Chirurg. lib. iv. obs. 7: also the works of Fabricius, Plater, &c. Fernel, indeed, admits, that he never saw an instance which proved the existence of contagion. ELEPHANTIASIS. 285 a long series of years. Dr. T. Heberden daily observed many examples of the same fact in Madeira, and affirms that " he never heard of any one who contracted the distemper by contact of a leper." And Dr. Adams has more recently given his testimony to the same truth, remarking that none of the nurses in the lazar-house at Funchall have shown any symptoms of the disease; and that individual lazars have remained for years at home, without infecting any part of their family.* With respect to the libido inexplebilis, which is said to be one of the characteristics of Elephantiasis, the evidence is not so satisfactory. Its existence, however, is affirmed by most of the modern writers, with the exception of Dr. Adams. MM. Vidal and Joannis mention it among the symptoms of the disease at Martigues f Dr. Bancroft senior states its occurrence in the Elephantiasis of South America :f and Prof. Niebuhr asserts, that it appears in the Dsjuddam of Bagdat.§ But Dr. Adams observed, on the contrary, in the lazars of Madeira, an actual wasting of the generative organs in the men, who had been seized with the malady subsequent * See his Obs. on Morbid Poisons, 2d edit. chap. 18. t M. Vidal particularizes the case of Arnaud, a sailor, who had been afflicted with the tubercular Elephantiasis six months, when he died of a putrid fever. " II n'avoit cesse, presque jusqua sa mort, de ressentir les ardeurs d'un assez violent satyriasis." t" Lepers are notorious for their salacity and longevity." Nat. Hist, of Guiana, p. 385. § Loc. cit. The story related by Niebuhr, of a lazar gratifying this propensity by infecting a woman by means of linen sent out of the lazar-house, and thus obtaining her admission, appears, however, to be entitled to little credit 286 TUBERCULA: to the age of puberty, and a want of the usual evolution of them, in those who had been attacked previous to that period. Is the Elephantiasis in Madeira now less virulent than that of former times? has it undergone some change in its character? oris the ancient account of the disease incorrect? It is generally affirmed, that the Elephantiasis was extensively prevalent in Europe, in the middle ages, especially subsequent to the crusades; and it is certain, that every country abounded with hospitals, established for the exclusive relief of that disease, from the tenth to the sixteenth century;* and that an order of knighthood, dedicated to an imaginary St. Lazarus, was instituted, the members of which had the care of lepers, and the control of the lazarettoes, assigned to them, and ultimately accumulated immense wealth. From these facts, however, nothing satisfactory is to be collected, respecting the actual prevalence of Elephantiasis at those periods. For although it is obvious, from the nature of the examination instituted by the physicians of those lazarettoes, that the tubercular disease was the object of their inquiry, yet it is also evident that, in consequence of the general application of the term, leprosy, * The number of these establishments, however, has been greatly misrepresented, in consequence of an error of quotation from Matt. Paris, which has been echoed by several authors. That historian has been made to assert, that, in the thirteenth century, there were 19,000 lazarettoes in Christendom: whereas he only states that the Knights Hospitalers were then in possession of so many manors. " Habent Hospitalarii novemdecim millia maneriorum in Christiahitate," are his words. See his Histor. Angl.ad. ann. 1244; also I)u Can?.je, Gloss, voc. Lazari; Mezeray, Hist, de France. 287 ELEPHANTIASIS. to the Elephantiasis, to the leprosy of the Jews,* to the proper scaly lepra, and even to other cutaneous affections, which have no affinity with either of the diseases just mentioned, almost every person, afflicted with any severe eruption or ulceration of the skin, was deemed leprous, and was received into the lazarettoes. This fact, indeed, is acknowledged by many of the physicians to these hospitals in the sixteenth century and subsequently. Greg. Horst, who was one of the appointed examiner% ati»Ulm, towards the close of that century, and who has given a minute detail of his investigations, admits that, M where the tubercles of the face, the thick lips, acuminated ears, flattened nose, round eyes, (the essential symptoms of Elephantiasis,) are absent; yet if the patients are affected only with a dry and foul scabies, with pustular eruptions,, fissures, and branny exfoliations, which constitute the psora of the Greeks, —or * This appears to have been the leuce of the Greeks, the white haras of the Arabians, and the third species of vitiligo of Celsus. (See Hippocrat. n«ptrio9wi/. Avicen. loc. cit.—Cels. de Med. lib. v. cap. 28.) The two characteristic symptoms of the Hebrew leprosy, which are pointed out in the Mosaic account, are the ivhiteness of the hair of the parts affected, and the depression of the skin. " And if the hair of the plague is turned white, and the plague in sight be deeper than the skin of his flesh, it is a plague of leprosy, See." (Leviticus, chap, xiii.) Thus also Avicenna: " There is this difference been the white alguada (alphos) and the white baras; the hairs grow upon the skin affected with the former, and they are of a black or brown colour: but those which grow in the baras are always white, and at the same time the skin is more depressed or sunk than the rest of the surface of the body." (loc. cit.) And Celsus: " uvxtj habet quiddam simile alpho; sed magis albida est, et altius descendit; in eaque albi pili sunt, et lanugtni similes." TUBERCULA: 288 even with great itching, emaciation, ulceration, and exfoliations of thicker scales, which are the lepra of the Greeks, —nevertheless they are sent to the lazarettoes, if they are poor, for the means of subsistence. Hence it happens," he adds, w that, here and elsewhere, very few instances of real Elephantiasis are found in the lazarettoes, while many are there affected only with an obstinate psora or lepra Graecorum."* Forestus, who held a similar office at Alcmaer and Delft, in the same century, affirms that a very small proportion of the persons who wandered about the low countries, as lepers and beggars, were true lepers; but were merely affected with scabies, or some external defoedation of the skin. " Nay," he says, " not one in ten of them is truly a leper, or afflicted with the legitimate Elephantiasis."! Riedlin makes a similar observation respecting the patients admitted into the leper-hospital at Indeed there is little doubt, that every species of cachectic disease, accompanied with ulceration, gangrene, or any superficial derangement, was deemed leprous; and hence that, in the dark ages, when the desolation of repeated wars, and the imperfect state of agriculture, subjected Europe to almost constant scarcity of food, the numerous modifications of scurvy and ignis sacer, which were * See his Obs. Med. lib. vii. ob. xviii. epist. J. H. Hopfnero. t See his Obs. Chirurg. lib. iv. obs. vii. schol. | " Sicuti vero non nisi rarissime inveniuntur, quibus leprosi nomen meritd et revera attribui posset, uti quidem leprosi a pierisque auctoribus describuntur; sed plerumgue hisce domibus illi includuntur, qui scabie sicca, fceda, et diu jam instante, laborant, &c." D. V. Riedlin, Linnse Med. vol. iii. Ann. 1697. Mens. Maio. 289 ELEPHANTIASIS. epidemic during periods of famine, and endemic wherever there was a local dearth, were in all probability classed among the varieties of leprosy; more especially as the last stage of the ignis sacer was marked by the occurrence of ulceration and gangrene of the extremities, by which the parts were mutilated, or entirely separated.* Under the head of Elephantiasis, Dr. Winterbottom appears to have described the leuce, and not the Elephantiasis, of the Greeks; the baras, and not the juzam of the Arabians. The principal symptoms which he witnessed, were the pale colour of the skin (in black subjects) and its loss of sensibility, which are distinctly stated as the leading symptoms of leuce, by Celsus, and by the other Roman and Greek physicians, as well as of baras by the Arabians.! Some of the Greeks and Arabians, indeed, seem to consider the leuce or baras, as possessing an affinity with Elephantiasis, and sometimes terminating in it;J and, if they be not modifica- * It would be foreign to my purpose to enter into any detail here respecting the history and symptoms of the ignis sacer, which was correctly ascribed by Galen (de Succor. Bonit. et Vitio, cap. 1.—-De Natur. Humor, lib. ii. cap. 3, &c,) to the use ©f unsuitable food. It has been well described by Lucretius, lib. vi. In more recent times, it has been erroneously supposed to originate from various deleterious substances taken with the food, and not from actual deficiency of nutriment. See. above, p. 128. t See Celsus de Medicina, lib. v. cap. 28.—Aetius,tetrab. iv. serm. i. cap. 123.—Paul. iEginet. lib. iv. cap. 5.—Actuarius, Meth. Med. lib. ii. cap. 11. $ Avicenna applies the term baras, with the epithet black, to the rugged and scaly state of the skin in Elephantiasis: (lib. iv, fen. 3. tract 3. cap. i—and fen. 7. tract. 2. cap. 9.) and Alsaha- TUBERCULA: 290 tions of the same disease, it is probable that some of the symptoms of the one (leuce,) such as the insensibility, and change of the colour and strength of the hair, may have been transferred in description to the other. The numerous large tubercles of the nose, forehead, and ears, which are deemed characteristic of Elephantiasis, did not appear in the disease seen by Dr. Wiuterbottom. The swejlings or tuberosities of the joints of the hands and feet, which terminate in ulcerations, that occasion the fingers and toes to drop off, appear also to belong to the two diseases in common, and afford another proof of their affinjty. Nevertheless, as we have nowhere any account of the regular succession of the tubercular state (Elephantiasis or juzam) to that of mere discoloration and insensibility (leuce or baras,) we are not warranted in drawing the conclusion, that they are but degrees or stages of the same disease.* ravius expressly states, that when the disease arises from putrid phlegm, it commences with baras, or with white bohak, (alphos of the Greeks,) and becomes juzam in its advanced stage. Lib. Pract. tract. 31. cap. 1. See also Dr. Thomas Heberden's account of Elephantiasis in the Island of Madeira, (Med. Trans, of the Coll. of Physicians, vol i. p. 27.) * It is curious, that the Foolas, on the coast of Africa, employed the Arabian terms, but, if Dr. Winlerbottom was correctly informed, in an inverted sense. They divide the disease into three species, or rather degrees; 1. the damadyang, or mildest leuce, when the skin is merely discoloured and insensible in patches. 2. the didyam, (sometimes written sghidam, dsjuddam, and juzam,) when the joints of the fingers and toes are ulcerated and drop off, the lips are tumid, and the alac nasi swell and ulcerate; and 3. the baras, when these symptoms are increased, and, from ulcerations in the throat and nose, the voice becomes hoarse and guttural. See his Account of the Native Africans in Sierra Leon, vol. ii. chap. 4. 291 ELEPHANTIASIS. Accurate histories of the Elephantiasis, leuce, and other modifications of the formidable cutaneous diseases, that occur in hot climates, and especially where agriculture and the arts of civilization are imperfectly advanced, must be deemed still among the desiderata of the pathologist. By the surgeons of the present day the appellation of Elephantiasis is appropriated to a disease, altogether different from the malady originally so called by the Greeks; namely, to an enormously tumid condition of the leg, arising from a repeated effusion and collection of a lymphatic and gelatinous matter in the cellular membrane under the skin, in consequence of inflammation of the lymphatic glands and vessels. The skin itself is much thickened in the protracted stages of this extension, and its vessels become much enlarged; its surface grows dark, rough, and sometimes scaly.* This condition of the surface, together with the huge misshapen figure of the limb, bearing some resemblance to the leg of an elephant, suggested the application of the term.f As the effusion first takes place after a febrile *See Alibert's plate of "Lepre Elephantiasis," No 33, where this is well represented. t The appellation of elephant or elephant-disease, was, in fact, applied to this affection by the Arabians, confessedly from this resemblance: (See Haly Abbas, Theor. lib. viii. cap. 18; —Aven- lib. ii. cap 26; —Alsaharavius, Pract. tractat. xxviii. cap. 11, Sec.) hence the translators were puzzled, and misinterpreted juzam by the Greek term lepra. The translator of Haly Abbas was alone correct in rendering the Arabic names: having given the proper classical appellation of Elephantiasis to the tubercular juzam, he translates this name (denoting the elephant leg) by the term elephas. (loc. cit.:—-also Theorici, lib. viii. cap. 15; 40 TUBERCULA: 292 paroxysm, in which the inguinal glands of the side about to be affected are inflamed, and the limb is subsequently augmented in bulk by a repetition of these attacks. Dr. Hendy termed the malady, " the glandular disease of Barbadoes," in which island it is endemial.* In England it is often called, " the Barbadoes leg."f Except when these paroxysms occur, the functions and constitution of the patient are not materially injured, and they often live many years, incommoded only by carrying " such a troublesome load of leg. "J In this country the disease is only seen in its inveterate stage, after repeated attacks of the fever; an effusion having completely altered the organization of the integuments of the limb, and rendered it altogether incurable. In this state, the swelling is hard and firm, does and Practice, cap. 4.) For, as this disease had not been noticed by the Greek physicians, even by those of the Eastern empire, there was no classical term by which it could be rendered. * See his inaugural dissertation, and subsequent treatise on the subject, London, 1784: also Rollo's "Remarks on the Disease lately described by Dr. Hendy, Sec." 1785. t The disease is not exclusively confined to the leg; it sometimes appears on the arms, and even on the ears, breast, scrotum, 8cc. Hillary on the Diseases of Barbadoes, p. 313; —Hendy, part i. sect. 2. J See Hillary on the Climate and Dis. of Barbadoes. It is affirmed by Dr. Clark, however, and by Dr. Winterbottom, that the agility of the patients, who are affected with this unseemly deformity, at Cochin, and on the Gold Coast, is not impaired by it. (See Clark's Obs. on the Dis. in long Voyages to hot Climates; Winterbottom, loc. cit. p. 113.) Dr. Hendy observes that, in consequence of the gradual augmentation of the bulk, patients are not in general sensible of the weight, except where they are debilitated by indisposition. 293 ELEPHANTIASIS. not pit on pressure, and is entirely free from pain. The skin is thickened and much hardened; its blood-vessels are enlarged, particularly the external veins, and the lymphatics distended; and the cellular substance is flaccid, and sometimes thickened, and its cells much loaded with a gelatinous fluid. The muscles, tendons, ligaments, and bones, are generally in a sound state.—In this advanced stage, the disease is altogether irremediable; and indeed little success seems to have attended the practice employed in the earlier stages, which has been chiefly directed to alleviate the febrile paroxysms by laxatives and diaphoretics, and subsequently to strengthen the system by cinchona. Local bleeding has never been employed; for there are no leeches in Barbadoes, according to Dr. Hendy; but after the fever and inflammation have subsided, he strongly recommends the binding of the limb in a tight bandage, as the means of exciting absorption, and of reducing the swelling.* * While this sheet was in the hands of the compositor, I was favoured by Mr. J. Mason Good, a gentleman distinguished by his knowledge of the oriental languages, with some observations relative to the original Arabic appellations of these diseases, which while they confirm the views which I had entertained in general, throw additional light on the subject. " The leprosy of the Arabs," he says, " appears to have been called by themselves immemorially, and is still called juzam and juzamlyk, though vulgarly and more generally judam and judamlyk, from an Arabic root, which imports erosion, truncation, excision. The term juzam has passed from Arabia into India, and is the common name for the same disease, among the Cabirajas or Hindu physicians, who also occasionally denominate it jisadi kh&n, from its being supposed to infect the entire mass of blood, but more generally khora" 294 TUBERCULA." Tn conclusion, then, it will be seen that the terms Elephantiasis and lepra have been thus confounded. The word lepra (which should be confined to a scaly disease) has been erroneously applied to the proper Elephantiasis (a tubercular disease.) Elephantiasis again, which is so distinctly described by the Greek I learn also, from this communication, that the original Arabic term, which was used to denote the tumid leg, above mentioned, was dalfit, which is literally elephant disease; and further, that " dal fit is the common name for the swelled leg in the present day among the Arabians, who sometimes contract it to fil alone, literally elephas." But although the Arabians in general distinguished the juzam from other diseases; yet I have observed, that they sometimes mentioned the baras (leuce) as having an affinity with it, calling some forms of the juzam black baras. Mr. Good remarks, that "juzam itself has occasionally been employed in the same loose manner, and has been made to import leuce or vitiligo, as well as proper or black judam; though in the former case it is commonly distinguished by the epithet merd, i. e.pilis carens, as merdjuzam, bald-juzam. The proper and more usual name for this last disease, is beras or aberas, sometimes written alberas, though less correctly, as this last is beras with a mere prefix of the definite article " Mr. Good adds, " that one of the most celebrated remedies for this disease (juzam) employed by the Cabirajas, or Hindu physicians, is arsenic (Shuce, in India sane' hya) mixed in pills with black pepper," six parts of the latter being added to one of the former: the pills are ordered to be of the size of small pulse, and one of them is to be swallowed morning and evening, with some betel leaf. Since the publication of the former editions, I have had an opportunity of seeing two cases of Elephantiasis, which have been under treatment in London during the greater part of the present year (1814;) and in both, the arsenic had been fully tried, and proved to be entirely void of any remedial power. PRAMBGSSIA. 295 writers, has been transferred, by the Latin translators of the Arabian writers, to the local affection of the leg, (the elephas of these writers, the Barbadoes leg, and the glandular disease of Dr. Hendy,) and is commonly used in that acceptation by practitioners at present. But it has been also misapplied to the white disease of the skin, called by the Greeks, Romans, and Arabians, leuce, vitiligo, and baras (or beras) respectively; and thence, by an easy step, it has been again transferred, by some unlearned persons, even to the scaly lepra; while the term lepra has been often indiscriminately applied to all these affections. I trust the foregoing statements may contribute to elucidate this matter. IX. FRAMBCESIA. YAWS. The nature of this disease, which is indigenous in Africa, and has been thence conveyed to the West Indies and America, has been perfectly investigated by European practitioners; and as it is perhaps never seen in England, a very brief account of it here will be sufficient.* The eruption of the Yaws sometimes commences * M. Alibert has figured two diseases as examples of Frambcesia, under the titles of" pian ruboide," and " P. fungoide," which were seen at the hospital St. Louis at Paris; but they are obviously not Yaws. The first of them appears to be a neglected porrigo, or a sycosis of the scalp (plate 35;) and the other a species of wen (plate 36.) TUBERCULA: 296 without any precursory symptoms of ill health; but it is generally preceded by a slight febrile state, with languor, debility and pains of the joints, resembling those of rheumatism.* After several days, minute protuberances! appear on various parts of the skin, at first smaller than the head of a pin, but gradually enlarging, in some cases to the diameter of a sixpence, and in others even to a greater extent: they are most numerous, and of the largest size, in the face, groins, axillaa, * The earlier writers on this disease assert, that the general health is not impaired by this eruption during the first stages. But on the authority of Dr. Winterbottom, and of Dr. Dancer, I have stated that a febricula is the ordinary precursor of the Yaws. Dr. Winterbottom, indeed, observes that the successive eruptions, which occur, are also usually preceded by slight febrile paroxysms, sometimes by rigors. See his Account of the Nat. Africans of Sierra Leone, vol. ii. chap. 8; —and Dancer's Medical Assistant. t It is not easy to discover the precise character of this erup tion, from the varying language of authors. An anonymous writer, who gave the first explicit account of the disease, (see Edin. Med. Essays, vol. v. part ii. art. 76.) says they are at first " level or smooth with the skin," but soon " become protuberant like pimples ." Dr. Hillary, who has copied much from this writer, describes them as "pimples" though smooth and level with the skin, but soon becoming " protuberant pustules." (On the Dis. of Barbadoes, p. 339.) And Dr. Winterbottom, who has given, on the whole, the most perspicuous description of the disease, calls them "pustules" from their first appearance. Again, as to the contents of these eruptions, the anonymous author and Dr. Hillary say that no pus, nor any quantity of ichor is found in them, but speak of a little ichor as drying upon the surface; while Dr. Winterbottom says, they are " filled with an opake whitish fluid," and when they burst, " a thick viscid matter is discharged." 297 FRAMBCE3IA. and about the anus and pudenda. But the crop is not completed at once; new eruptions appear in different places, while some of the earlier ones dry off. When the cuticle is broken, a foul crust is formed on the surface, from under which, on the larger protuberances, red fungous excrescences often spring up, which attain different magnitudes, from that of a small raspberry to that of a large mulberry, which fruit they somewhat resemble from their granulated surfaces.* When the eruption is most copious, these tubercles are of the smallest size; and when fewer, they are largest. Their duration and progress are various in different constitutions, and at different periods of life. Children suffer less severely than adults, and are more speedily freed from the disease: in them, according to Dr. Winterbottom, the duration of the Yaws is from six to nine months; while, in adults, it is seldom cured in less than a year, and sometimes continues during two or three. The fungous tubercles attain their acme, according to the anonymous writer already quoted, more rapidly in the well-fed negroes, than in those who are ill-fed and thin; and they likewise acquire a larger size in the former than in the latter. They are not possessed of much sensibility, and are not the seat of any pain, except when they appear upon the soles of the feet, where they are confined and compressed by the hard and thickened cuticle: in that situation they render the act of walking extremely painful, or alto* * Hence both the popular appellation of Yaw, which in some African dialect signifies a raspberry, and the nosological title Frambcesia, from the French Framboise, which denotes the same fruit. See Sauvages, Nosol. Meth. class, x. ord. iv. gen. 23. TUBERCULA: 298 gether impracticable. They never suppurate kindly, Dr. Winterbottom says, but gradually discharge a sordid glutinous fluid, which forms an ugly scab round the edges of the excrescence, and covers the upper part of it, when much elevated, with white sloughs. When they appear on any part of the body covered with hair, this gradually changes in its colour from black to white, independently of the white incrustation from the discharge. They leave no depression of the skin.* The period during which the eruption is in progress, varies from a few weeks to several months. u When no more pustules are thrown out," Dr. Winterbottom observes, " and when those already upon the skin no * The anonymous writer in the Edin. Med. Essays, and after him Dr. Hillary, and others, have deemed the Frambcesia to be the Hebrew leprosy, described by Moses. (Leviticus, chap, xiii.) In some respects, and especially in the appearance of what is called " raw flesh," in the leprous spots, together with whiteness of the hair, the description of the leprosy of the Jews is applicable to the Yaws. But the leprosy is described by the great legislator as beginning in several ways, or appearing under several varieties of form, in only one of which this rising of" raw flesh" is mentioned: and the two circumstances, which all these varieties exhibited in common, were a depression of the skin, and whiteness of the hair. Now this change in the colour of the hair is common to the Frambcesia, and to the leuce, as stated; and it is conjoined, in the latter, with cutaneous depression. It seems pretty obvious, indeed, that the term leprosy was used, in the Scriptures, to denote several diseases of the skin, against which the law of exclusion was enforced, and others, to which it did not apply. An instance of the latter occurs in Gehazi, whom we find still in the employment of Elisha, and even conversing with the king, after the leprosy had been inflicted upon him, " and his seed for ever." (2 Kings, chap, v. and vi. and chap. viii. ver. 4.) 299 FRAMBCESIA. longer increase in size, the disease is supposed to have reached its acme. About this time it'happens, on some part of the body or other, that one of the pustules becomes much larger than the rest, equalling or surpassing the size of a half-crown piece: it assumes the appearance of an ulcer, and, instead of being elevated above the skin like others, it is considerably depressed; the surface is foul and sloughy, and pours out an ill-conditioned ichor, which spreads very much, by corroding the surrounding sound skin: this is what is called the master, or mother-yaw." When arrived at its acme, however, the eruption continues a considerable time without undergoing much alteration, often without very materially injuring the functions, and it seldom proves dangerous, except from the mischievous interference of ill-directed art.* The Frambcesia is propagated solely by the contagion of the matter, discharged from the eruption, when it is applied to the wounded or broken skin of another person, who has not previously undergone the disease.f * 44 All this time the patient is in good health, does not lose his appetite, and seems to have no other uneasiness, but what the nastiness of the sores occasions, &c." Edin. Med. Essays, vol. v. p. 789. The fact is stated by Hillary in the same words, p. 343. f The complaint is sometimes inoculated by flies, in those hot countries, where the skin both of the diseased and the healthy remains uncovered. Hence, Dr. Bancroft says, " none ever receive it whose skins are whole; for which reason the whites are rarely infected; but the backs of the negroes being often raw by whipping, and suffered to remain naked, they scarce ever escape it." Nat. Hist, of Guiana, p. 385. See also Winterbottom, pp. 141—3. 41 300 TUBERCULA: For, like the fehrile eruptions, the Frambcesia affects the same person only once during life; but, unlike them, it is not propagated by effluvia. In Africa it is usually undergone during childhood. The period which elapses between the reception of the contagion and the commencement of the disease, is nowhere mentioned: but in the case of a Dane, whom Dr. Adams saw at Madeira, the patient had been ten months absent from the West Indies, before he felt any indisposition.* With respect to the treatment of Frambcesia, nothing very satisfactory is to be collected from the writings of the practitioners to whom we are indebted for the history of the disease. The native Africans, according to Dr. Winterbottom, " never attempt to cure it, until it has nearly reached its height, when the fungi have acquired their full size, and no more pustules appear." And the practitioners in the West Indies soon learned, by experience, that active evacuations retard the natural progress of the disease; and that mercurials, although they suspended it, and cleared the skin of the eruption, yet left the patient still susceptible of, or rather still impregnated with, the virus, which speedily evinced its presence, by a reappearance of the symptoms more severe and tedious than before. In truth, the disease, it would seem, like the pustular and exanthematous fevers of our own climate, will only leave the constitution, after it has completed the various stages of its course, and removed the susceptibility of the individual to future infection; and no medicine, yet discovered, has had any influence in superseding this action, * See Memoirs of the Med. Soc. of London. 301 FRAMBCESIA. or in accelerating its progress. Unless, therefore, any urgent symptoms should require alleviation, (which seldom, if ever, happens,) it is advisable to dispense with the administration of medicine, and to be content with restricting the patient to a moderate and temperate regimen, during the first stage of the malady. When the eruptions begin to dry, or as soon as they cease to multiply and enlarge, the disease appears to require the same management as other slow and superficial ulcerations, accompanied with a cachectic state of the system; viz. a light, but nutritious diet, a dry and wholesome air, warm clothing, moderate exercise, and a course of tonic medicine, especially of sarsaparilla,.or cinchona, with the mineral acids, or with antimonials aud small doses of mercury, according to the circumstances of the individual habit. The effects of mercury, however, exhibited so as to excite salivation,* as the early West Indian practitioners recommend, seem to be of a very questionable nature, especially when it is unaccompanied by the vegetable decoctions; and it is certain that patients have, in some cases, soon recovered under the use of the latter, when the mercurials were omitted.f The native Africans employ decoctions of * This treatment is often followed by a train of harassing symptoms, called by the negroes, the bone-ache. u The unhappy sufferer is tormented with deep-seated pains in the bones, especially round the joints, which are occasionally aggravated to a violent degree: the periosteum becomes thickened, inflamed, and painful, and nodes are formed on the bones. When these symptoms have continued for some time, the bones are affected with caries, and even become soft and lose their form." t See Dr. Winterbottom's " Account, &c." ii. p. 158-9; and Schilling, de Frambcesia, quoted by him. TUBERCULA. 302 the bark of two or three trees, which are gently purgative, as well as tonic, and likewise wash the sores with them, after carefully removing the crusts.* The master-yaw sometimes remains large and troublesome, after the rest of the eruption has altogether disappeared. It requires to be treated with gentle escharotics, and soon assumes a healing appearance under these applications. Stronger caustics are requisite for the cure of the crab-yaws, or tedious excrescences, which occur on the soles of the feet. * In a very short but able account of this disease, which I lately saw in MS., the mercurial treatment was said not only to be unsuccessful, but to aggravate the affection of the skin; and much advantage was ascribed to strong decoctions of the woods, of vervain, wild senna, &c, when the scabs began to fall off; and to the frequent ablution of the diseased parts with warm water, and to the use of lime-water as a drink previously. These decoctions were also found to relieve " the small eruption, boneache, and joint-evil often consequent on the bad treatment, of mere nalliation," by mercurv. 803 Order FIB MACULAE. This order comprises those discolorations of the skin which are permanent, and most of which are the result of an alteration of the natural texture of the part. It comprehends, therefore, several varieties of connate and acquired disfigurations of the skin, some of which are not capable of being removed, and most of them are removable only by surgical means. The various Maculae, that have been described in medical and surgical writings, are included under the terms Ephelis, Njevus, Spilus, and moles, with other appellations applied to the more anomalous appearances. I. EPHELIS. The term Ephelis (Plate LXIX.) denotes not only the freckles, or little yellow r lenligines, which appear on persons of fair skin, and the larger brown patches, which likewise arise from exposure to the direct rays of the sun, as the name imports; but also those large dusky patches, which are very similar in appearance, but occur on other parts of the surface, which are constantly covered.* Lorry and some other writers have * " Nomen inditum arto tw rfiwv, non quod a tan turn vitia ilia in cute contrahuntur, sed quod a reliquiis inducta causis, similem asperitatem et colorem habeant." Gon ad Defin. ad MACULAE: 304 endeavoured to make distinctions between lentigines and Ephelides; but there does not appear to be any essential difference between them, and all the aneient writers have properly treated of them together.* The larger Ephelides, especially those which occur on the sides, abdomen, and other covered parts, sometimes differ little from the pityriasis versicolor, or actually degenerate into it; the cuticle becoming rough with minute furfuraceous scales. The brief description of the Ephelis given by Celsus is, indeed, equally applicable to both. " Nihil est nisi asperitas quaedem, et durities, mali coloris."f I have occasionally known the dingy hue of these maculae, as well as of the patches of pityriasis, give rise to a suspicion of syphilitic infection. But independently of the history of the previous symp- voc. t$tpMi —This acceptation of the term is sanctioned by the authority of Hippocrates, who gives the same appellation to the spots, which sometimes occur in pregnant women, and to those occasioned by the solar rays. " Quae utero gerunt in fascie maculam habent, quam t$tpM> vocant." —Lib. n«pt aopwv. Also Ilfpt ii. Sauvages has improperly classed with Ephelis the mottled and dusky red hue of the shins of those, who expose their legs constantly to strong fires in the winter; and also the livid patches of scurvy, which arise from extravasation of blood under the cuticle. Nosol. Meth. class, i. gen. iii. spec. 4 &<»6. —See also Plenck de Morb. Cut. class, i. spec. 2.: and Plater has, by an extraordinary mistake, called the pustules of scabies, Ephelides. De Superfic. Corp. Dolore, cap. 17. * See Oribas. de Loc. Affect. Cur. lib. iv. cap. 52, and Synops. viii. 33.—Aetius,tetr. ii. serm. iv. cap. 11.—Actuar. Meth. Med. iv. cap. 13. t De Medicina, lib. vi. cap. 5. —M. Alibert has thought the common freckle and the larger Ephelis worthy of two beautiful engravings; the former, in plate 26, is called " Ephelide lentiforme," and the latter, in plate 27, "Ephelide hepatique." 305 EPHELIS. toms, the paucity of these patches, their want of elevation or depression, their permanency, and their final evanescence, without any tendency to ulceration, or even to inflammation, will enable those, whom a habit of inspecting such appearances has not sufficiently instructed to discriminate them. Celsus apologizes, as has been already observed, for prescribing the treatment of Ephelides and freckles, and such trifling discolorations of the skin; and the same apology must still be urged: "eripi tamen foeminis cura cultus sui non potest." The uniform practice both of ancient and modern authors has been to apply some gentle astringent and discutient lotion or liniment to the parts affected.* From the time of Hippocrates, bitter almonds have been recommended as possessed of such discutient properties-! They have probably no active virtues, which are not possessed by the ptisan, decoctions of tares, and some other mucilaginous and detergent applications, recommended by the same authors. Some gentle restringent or stimulant is commonly advised, however, by these writers. Celsus employed resin, with a third part of fossil salt, and a little honey;— and Actuarius combined vinegar, honey, and bitter al- *In the remedies adapted to all these superficial and cuticular discolorations, according to Oribasius, " mediocri adstrictione et abstersione opus est." Synops. lib. viii. cap. 33. The same observation is stated from Crito, by Aetius, tetr. ii. serm. iv. cap. 11. See also Actuarius, Meth. Med. lib. iv. cap. 13. t Hippo. Tispi ywatxeutv, lib. ii. Oribasius says, " Amygdalae amarae sunt facultatis perspicue* attenuantis, ut ephelin expurgent." De Virtute Simplic. lib. ii. cap. i. 306 MACULAE: monds for the same purpose.* Wine was likewise recommended as a vehicle for these and other substances. The principle of these applications was correct; but it may be pursued in a more simple and effectual manner by lotions of alcohol, in its pure state, or diluted with some distilled water, if the skin be irritable; —by dabbing the spots two or three times a day with the diluted mineral acids, in the proportion of about a drachm of the strong sulphuric acid to a pint of water, or the same quantity of muriatic acid to half a pint;—or by using, in a similar manner, the liquor potassae diluted with about twenty times its quantity of water. II. NjEVUS, etc. The various congenital excrescences and discolorations of the skin, to which the appellations of Naevusf spilus, moles, &,c. have been applied, may be conveniently treated of together. They exhibit many peculiarities of form, magnitude, colour, and structure, and are seen on almost every part of the surface of the body in * Celsus, loc. cit.—Actuarius, loc. cit.—Dr. Withering recommends an infusion of horse-radish in milk, as a cosmetic. See his Botan. Arrang. of Brit. Plants. Of these cosmetic lotions, however, we may say, with Celsus, " pene ineptiae sunt." t In consequence of the old notion, that these spots were impressed upon the foetus by the emotions of the mother, the term Nsevus is commonly associated with the epithet malernus, and the appellation^of mutter ~mahl, mother-spots, fancy-marks, See. have been given to them in different languages. See Turner on Diseases of the Skin, chap. xii. 307 W3BVUS, ETC. different instances. Some of them are merely superficial, or stain-like spots, and appear to consist of a partial thickening of the rete mucosum, sometimes of a yellow or yellowish brown, sometimes of a blueish, livid, or nearly black colour. To these the term Spilus* has been more particularly appropriated. Others again exhibit various degrees of thickening, elevation, and altered structure of the skin itselff, and consist of clusters of enlarged and contorted veins, freely anastomosing, and forming little sacs of blood. These are sometimes spread more or less extensively over the surface, occasionally covering even the whole of an extremity, or one half of the trunk of the body; and sometimes they are elevated into prominences of various form and magnitude. Occasionally these marks are nearly of the usual colour of the skin; but most commonly they are of a purplish red colour, of varying degrees of intensity, such as the presence of a considerable collection of blood-vessels, situated near the surface, and covered with a thin cuticle, naturally occasions. The origin, which was anciently assigned to these marks by physicians, and to which they are still ascribed by the vulgar, (viz. the influence of the imagination of the mother upon the child in utero,) has occasioned * Srftfioj, macula. This discoloration seems to be included by Sauvages under his first species, Naevus sigillum, and by Plenck under N. lenticularis, spec. i. of his Arrangement. See Sauvages, Nos. Meth. class. 1. gen. 4.; Plenck, Doctrina de Morb. p. 37. t Sauvages comprehends all these excrescences under Naevus maternus, spec. 2; and Plenck under his four remaining species, N . Jlammeus, tuberculosa, cavernosas, and malignus, 42 MACULES: 308 their varieties to be compared with the different objects of desire or aversion, which were supposed to operate on the passions of the mother: whence the following Naevi have been described. The flat and purple stains were considered as the representative of claret, or of port wine (Plate LXXI. Fig. t.;) and sometimes of a slice of bacon, or other flesh. Sometimes the stains are regularly formed, like a leaf, with a very red border, and lines, like veins, across from a central rib, forming the Naevus foliaceus (Plate LXX. Fig. 1.:) and sometimes a small red centre with branching lines, like legs, has suggested the idea of a spider, or N. araneus* (Plate LXXI. Fig. 2.) But those Naevi which are prominent have most commonly been compared to different species of fruit, especially to cherries, currants, and grapes, when the surface is smooth and polished; or to mulberries, raspberries, and strawberries, when the surface is granulated: whence the Nasvus cerams, (Plate LXX. Fig. 2.) ribes, moms, mows, fragarius, &c.f (Plate LXXU.) Some of these excrescences are raised upon a neck or pedicle; while some are sessile upon a broad base. Some of them again, although vivid for some time after birth, gradually fade and disappear; some remain stationary through life, but commonly vary in intensity of colour at different seasons and under circumstances easily explained: and others begin to grow and extend, sometimes immediately after birth, and sometimes from * See the Plate fig. 8. x. t See Bierling Adversaria Curios, obs. ix.—Valentin. Prax. Med. Infallib. cap. 1. —Strobelberger de Curand. pueril. Affect, cap. 17.—Septalius de Naevis. 309 N.EVUS, ETC. incidental causes, at a subsequent period, and from small beginnings become large and formidable bloody tumours, readily bursting, and pouring out impetuous and alarming haemorrhages, which, if they do not prove suddenly fatal, materially injure the health by the frequent depletion of the system. Sometimes, however, after having increased to a certain degree, they cease to enlarge, and thenceforth continue stationary, or gradually diminish, till scarcely any vestige remains.* In some instances, however, these preternatural enlargements and anastamoses, which constitute the Nasvi, are not merely cutaneous. A similar morbid structure may take place in other parts; it sometimes occupies the whole substance of the cheek, according to Mr. Abernethy, and has occurred in the orbit of the eye; and Mr. John Bell affirms, that it affects indifferently all parts of the body, even the viscera.f ' . The origin of these connate deformities is equally inexplicable with that of other anomalous and monstrous productions of nature; but it would be insulting the understanding of the reader, to waste one word in refutation of the vulgar hypothesis, which ascribes them to the mental emotions of the mother, —an hypothesis * See Mr. Abernethy's Surgical Works, vol. ii. p. 224 et seq. t f The ordinary Naevi appear to consist of venous anastomoses only: but some of them, even when congenital, are of that species of morbid structure, which Mr. John Bell has denominated " aneurism by anastomosis," and which, he says, is made up of " a congeries of small and active arteries, absorbing veins, and intermediate cells," somewhat analogous to the structure of the placenta, or of the gills of a turkey-cock. See his Principles of Surgery, vol. i. discourse xi.;also Mr. Abernethy's Surg. Works, loc. cit. 310 MACULE: totally irreconcilable with the established principles of physiology, and with the demonstrable nature of the connection between the foetus and the parent, as well as with all sober observation. It is important, however, to know, that very slight causes of irritation, such as a trifling bruise, or a tight hat, will sometimes excite a mere stain-like speck, or a minute livid tubercle, into that diseased action, which occasions its growth. This growth is carried on by a kind of inflammatory action of the surrounding arteries; and the varying intensity of colour arises from the different degrees of activity in the circulation. Thus these marks are of a more vivid red in the spring and summer, not in sympathy with the ripening fruit, but from the more copious determination of blood to the skin, in consequence of the increase of the atmospheric temperature. The same increased determination to the surface is also produced temporarily, and, with it, a temporary augmentation of the florid colour of the Naevi, by other causes of excitement to the circulation; as by active exercise, by heated rooms, or the warmth of the bed, by drinking strong liquors, or high feeding, by emotions of the mind, and, in women, by the erethism of menstruation. These considerations will serve to suggest the proper means of treating the Nasvi and spili, where any treatment is advisable. When they are merely superficial without elevation, which would render them liable to accidental rupture, and without any tendency to enlarge and spread, there appears to be no good reason for interfering with them. The applications mentioned by the older writers, were doubtless as futile as they were 311 NiEVUS, ETC. disgusting; such as saliva, the meconium of infants, the lochial blood of women, the hand of a corpse, &c.: and the severe resource of the knife, even if the deformity of a scar were much less than that of the original mark, is scarcely to be recommended. But when the Naevi evince a tendency to enlarge, or are very prominent excrescences, and either troublesome from their situation,* or liable to be ruptured, some active treatment will then be required. Either their growth must be repressed by sedative applications, or the whole morbid congeries of vessels must be extirpated by the knife. All strong stimulants externally must be avoided, as they are liable to produce severe inflammation, and even constitutional disorder. The consideration of the mode in which these vascular excrescences grow, by a degree of inflammatory action in the surrounding vessels, suggested to Mr. Abernethy the propriety of maintaining a constant sedative influence upon those vessels, by the steady application of cold, by means of folded linen kept constantly wet. This practice has succeeded, in several instances, in repressing the growth of these unnatural structures, which have afterwards shrunk, and disappeared, or ceased to be objects of any importance. Pressure may, in some instances, be combined with this sedative application, and contribute to diminish the dilatation of the vessels: but in the majority of cases, pressure is the source of great irritation to these maculae, and can not be employed. The temporary enlargement of these * A cherry-nsevus on the lip, for instance, has prevented the act of sucking-, MACULAE: 312 prominent Naevi by every species of general excitement, would teach us to enjoin moderation in diet, exercise, &c. during the attempt to subdue them. The mode of extirpation is within the province of the surgeon; and the proper choice of the mode, under the different circumstances, is directed in surgical books. From the days of Fabricius Hildauus.* the propriety of radically removing every part of the diseased tissue of vessels has been inculcated: but Mr. John Bell has most satisfactorily stated the grounds of that precept, by explaining the structure of these excresences, as well as the source of the failure and danger, when they are only cut into, or opened by caustic. I shall therefore refer the reader to his " Discourse," already quoted. The varieties of spilus, or mere thickening and discoloration of the rete mucosum, are sometimes removable by stimulant and restringent applications. A combination of lime and soap is extolled by several writers: and lotions of strong spirit, with the liquor potassas, as recommended for the treatment of the ephelides and of pityriasis, certainly sometimes remove these maculae. With respect to those brown macula?, commonly called moles, I have little to observe: for no advantage is obtained by any kind of treatment. It is scarcely safe, indeed, to interfere with them: for when suppuration is induced in them, it is always tedious and painful, the matter emitting at the commencement an extremely fetid odour. When moles are irritated by accident, or rudely treated, so as to produce excoriation, they are liable, it is said, to become gangrenous, and thus to produce sudden fatality. Fab. Hild. Oper. cent. v. obs. 46 313 NAEVUS, ETC. Moles are not always congenital. I lately saw an instance in a lady of remarkably fair and delicate skin where a numerous crop of small moles appeared, in slow succession, upon the arms and neck. Congenital moles, indeed, are not always stationary; but they sometimes enlarge, gradually, for a time, and afterwards disappear. THE Ex\D. INDEX. Page. Acarus scabiei - - - - - 190 Achores - - - " " 152 Acne 260 simplex - - " - - 261 punctata ------ 266 indurata ----- 268 rosacea ----- 272 Albaras ----- 29 Albohak %b. Alopecia - - - " " - 165 Alphos - - * - - - 28. 259 Aphtha - - - - - 246 lactantium - - " • 247 . adultorum - - - " - 251 anginosa - - " - 253 Area 165 Baras. See Elephantiasis. Blister, followed by Eczema - - - - 240 Bulls 118 Chicken-pox - - - " " -295 lenticular - 297 conoidal ----- 298 globated - 299 Courap ' - 148 Cow-pox. See Vaccinia. Crusta lactea. See Porrigo larvalis. Crystalli. See Chicken-pox. Dandriff. See Pityriasis. Ecthyma - - - - * 171 vulgare - - " " * Jl infantile - " " luridum ----- 174 1 ¦¦ i cachecticum - - " - 176 43 316 INDEX Page. Eczema - - - - - 236 solare ..... 237 impetiginodes - 239 rubrum - 241 from mercury - 242 Elephantiasis ..... 280 Eohelis - - - - - - 203 Epinyctis - - - - - - 92. 255 Ergot - - - - - - 128 Erysipelas - - - - - - 119 phlegmonodes - - - ib. • oedematodes - - - - 121 ——— gangrenosum • - - - 122 erraticum .... 123 of infants - 122 Erythema - - - - - - 113 fugax - - - - 114 • laeve ib. marginatum - - - - - 115 ¦ — papulatum - ib. tuberculatum - - - - 116 ¦ nodosum - - - - - ib. Exanthema, what - - - - 54 Favus - - t - - - 151 Febris ampullosa. See Pemphigus. ¦iV' . bullosa. See the same. ¦. i- vesicularis. See the same. Fevers, eruptive, known to the ancients - - 61 Fici. See Sycosis Fish-skin Disease. See Ichthyosis. Formica. See Herpes. Frambcesia ...... 295 Freckle. See Ephelis. Furunculus ...... 255 Gum, red. See Strophulus. Gutta rosea. Sec Acne rosacea. Haemorrhcea peiechialis. See Purpura. Heat, prickly. See Lichen tropicus. Herodotus, described febrile eruption - - 63 Herpes - 209 . phlyctaenodes - - - - 211 -zoster - - - - - -213 . circinatus - . - - - 219 . ' labialis - 222 praeputialis ..... 223 Iris _ - - - - - - 225 Hives. See Chicken-pox. 317 INDEX. Page. Horns, nature and origin of - - - 51 Hydrargyria. See Eczema rubrum. Ichthyosis - - - - 47 simplex 48 • cornea - - - - 51 Ignis sacer - - - - - 127. 289 Sancti Anthonii - - - - - 127 Impetigo - - - - - 138 ¦¦¦ figurata - . - - - ib. sparsa - - - - 142 erysipelatodes » - - - 147 scabida - - - - 148 rodens - - - - - 150 Intertrigo - - - - - - 117 Ionthos. See Acne. Iris. See Herpes Iris. Itch. See Scabies. Itch, Baker's - - - - 39 ¦ Grocer's - 143. 240 Bricklayer's - - - - ib, ib. Itch insect - - - - - - 189 Judam. See Elephantiasis. Juzam. See the same. Kriebel Krankheit ----- 127 Lactucimen. See Aphtha. Larvae mistaken for pediculi - - - - 20 Lentigo. See Ephelis. Lepra - - - - - . 24 " vulgaris - - - - - - 25 alphoides ----- 28 ¦ 1 nigricans - - - - - 34 ¦ Arabum, a mistake - - - - 25 Leprosy of the middle ages - 286 Leuce, probably the Jewish Leprosy - - 29 differs from Lepra - - , 29. 258 Lice - - - - . . -20 Lichen - 6 " simplex . . _ 7 pilaris - 8 circumscripta ----- 9 ' agrius ----- 10 lividus - - - - - - 12 tropicus ib. urticatus - - . - - 13 Lupus ------ 279 Maculae - 303 1 hepaticse . . « „ 45 318 INDEX Page. Mai des Ardens - - - - - 131 Measles ------ 55 > antiquity of - - - - - 62 Mercurial rash. See Eczema Miliaria - 229 Molluscum 256 Morbilli. See Rubeola. Morphea - - - - - - 25. 29 Mother-spots. See Naevus. Muscles, rash produced by eating - - 86 Naevus - 303 Necrosis - - - - - - 127 Nettle-rash. See Urticaria. from eating shell-fish, &c. - - 86 Nirles. See Herpes phlyctenodes. Noli me tangere. See Lupus. Ophiasis - - - - - - 165 Papulae - - - 1 Pemphigus - - - - - - 129 —— probably no such disease - - ib. Petechias sine febre. See Purpura. Phlyzacia ------ 172 Phyma ' - - - - 255 Pimples. See Papule Pitch, internally - - - - - 31. 50 Pityriasis ------ 43 "' capitis - - - ib. rubra ----- 44 ¦ versicolor - - - - 45 nigra - - - - 47 Pompholyx - - - - - -132 ————— benignus - - - - ib. diutinus - - - - - 133 solitarius - - - - 135 Porrigo - - - - - - -151 —— larvalis - - - - - ib. furfurans - - - - - 155 ——— lupinosa - - - - 157 scutulata - - - - - 159 decalvans - - - - - 164 favosa - - - - - -166 Prurigo ------ 14 ¦ mitis - - - - - ib. formicans - - - - •>¦ 15 senilis - - - - - - 18 local varieties of - - - 21. 22 Psora. See Psoriasis 319 INDEX Page. Psora erroneously applied to Scabies - - 179 Psoriasis - - - - - 34 . guttata - - v- - 37" — diffusa - - - - ib. - gyrata ----- 39 > inveterata - - - - - ib. local varieties 40 Psydracia - - - - - - 138 Purpura ------ 99 simplex ----- 100 haemorrhagica - - - - 101 urticans - - - - - 111 senilis - - - - - 112 contagiosa - - - - ib. Pustules - - - - - - 137 four varieties of - xix Rashes ----- . 54 Ringworm, various - - - 140. 144. 220 of the Scalp. See Porrigo scutulata. Roseola - - - - - - 92 aestiva ----- 93 :— autumnalis - - - - - 94 annulata ib. infantilis - - - - - 95 variolosa - - - - - 96 vaccina - - - - 97 miliaris - - - - - ib. Rubeola - - - - - - 55 vulgaris - - - - - ib. - sine catarrho - - - 60 nigra - - - - - 61 Rupia ------- 227 simplex ib. prominens .... - 228 escharotica - - - - - ib. Scabies - - - - - - -179 papuliformis - - - - 181 lymphatica - - - - - 183 ¦ purulenta - - - - - 185 cachectica - - - - - 187 Scales, how produced 24 Scalled head. See Porrigo favosa. Scarlatina - - - 67 — simplex ----- 69 anglnosa - - - - - 70 maligna - - - - - 81 Scarlet fever. See Scarlatina, 320 INDEX Page, Scelotyrbe - - - - - - 128 Scurvy, a misapplied term - - - -16.271 Shingles. See Herpes zoster. Small-pox. See Variola. ¦ probably known to the ancients - - 61 Spilus — - - 307 Strophulus - 1 intertinctus - 2 ¦ ¦ ¦ albidus - 3 - confertus ib. volaticus - 4 ' candidus - - - - 5 Swine-pox. See Chicken-pox. Sycosis - 275 menti ----- 276 capillitii ----- 277 Tetter, dry or scaly. See Psoriasis. humid. See Impetigo Tinea. See Porrigo. Thrush. See Aphtha. Tooth rash. See Strophulus. Vaccinia - , 202 Vari. See Acne. Varicella ------ 195 Variola ------ 178 Verruca ... - 255 Vitiligo - 258 Urticaria - - - - - 84 « febrilis ----- 85 evanida - - - - - 88 perstans - - - - - 90 conferta - - - - ib. subcutanea - - • - 91 tuberosa - - - - ib. Water-jags. See Chicken-pox. Wheals ------ 84 Wheal-worms - - - - - - 19§ Yaws. See Frambcesia. Zona. See Herpes. Zoster. See the same.