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i   \ 
MANUAL
DISEASES  OF  THE   SKIN,
FROM THE FRENCH OF
MM.  OAZENAVE  AND SCHEDEL,
      »«0
WITH NOTES AND ADDITIONS
      THOMAS H.  BURGESS,  M.D.,
SVBXiXOJt TO THE BLENHEIM STREET DISPENSARY FOK DISEASES OF THE SKIN, BTC.
         SECOND AMERICAN  EDITION,
BNLAKGED AND CORRECTED FROM THE LAST FRENCH EDITION,
            WITH ADDITIONAL NOTES,
          H. D. BULKLEY,  M.D.,
PHYSICIAN OF THE NEW YORK HOSPITAL ; FELLOW OF THE COLLEGE OF PHYSICIANS
  AHD SURGEONS, NEW YORK; LECTURER ON DISEASES OF THE SKIN, ETC., ETC.^



           JMnxs. Medical ttitlltf&t*
             NEW  YORK:
PUBLISHED BY SAMUEL S. k WILLIAM WOOD,
         261 PEARL STREET.
1852. 
WR
          Entjc&ed, according to Act of Congress, in the year 1851, by

                    SAMUEL S. & WILLIAM  WOOD.

to  the Clerk's Office of the District Court for the Southern District of New York.
a. CKAIOHEAD, PRINTER AND STEREOTYPES,
     112 PULTON STREET, NEW YORK. 
PREFACE
TO  THE  ENGLISH  EDITION.
  A Manual of Diseases of  the Skin, in  a  convenient form and at a
moderate price, has been long wanted by students, and the junior members
of the profession.  To supply this desideratum, I have rendered into English
the  excellent practical compendium of MM. Cazenave and Schedel, a work
which contains the substance of M. Biett's views and experience in cutane-
ous pathology, and which has passed through several editions in France.
  M. Biett, during his life, enjoyed the highest reputation as an authority on
diseases of the skin; and  the only record that  we possess of his extensive
experience  is contained  in  the present manual  of MM. Cazenave and
Schedel, with which I have been long familiar.  It  was my text-book during
the  two seasons of my  attendance at the Hospital of St. Louis, under M,
Biett, and since that period I have had increased opportunities in this country
of testing its value as a practical guide in the treatment of cutaneous affec-
tions.  I can conscientiously say that I know of no other work of a  similar
kind, either  in the English or any other language, which  is preferable to
that of MM. Cazenave and Schedel, nor one which would  answer  our
present purpose so well.   The clenr and methodical manner in which  the
diseases are  arranged, and the concise and simple style of the work, contrast
favorably  with  the  vague and obscure descriptions generally found in
treatises on diseases  of the skin.
  M. Cazenave now  fills the office  occupied  for so long a period by M.
Biett, at the Hospital of St.  Louis;  and this will contribute to  make  his
manual acceptable to English students who visit that excellent institution.
  From the complete manner in which the different subjects are  treated. 
PREFACE TO THE ENGLISH EDITION.
little remained to the translator in the way of  addition.   He has thought it
expedient, however, to  add an  article on  " Glanders  and Farcy," diseases
which  were omitted in the original treatise, and to embody in the form of
additions or notes some practical  facts worthy of notice.  The  different
parts thus added will be found included within brackets, [ ], or distinguished
by the initial " B."
                                                  T. H. BURGESS.

  29  Margaret street, Cavendish square.
         October 15, 1842. 
PREFACE
TO  THE   FIRST  AMERICAN  EDITION.
   The Manual of MM. Cazenave and Schedel on Diseases of the Skin is
too well and too favorably known, both at home and abroad, to require any
additional testimony to its value as a practical guide in the study of these
affections.   First introduced to the notice of the American profession by a
translation of the first edition of the original, published in Paris in 1828 (of
which same translation  a second edition  was afterwards published), the
book itself has now reached a third edition, the translation of which, by Dr.
T. H. Burgess, is now republished.
   Embodying, as it does, the results of the long experience and accurate
observations of M. Biett, so favorably known for his zeal and industry in the
pursuit of this branch of our profession, and drawn up by pupils of this able
teacher, who enjoyed the advantages of the same extensive field in which he
himself studied, it may be safely  recommended to both practitioners  and
students, as combining faithful and graphic descriptions of these diseases,
and sound principles for their treatment.
   Having myself adopted it as a text-book in the  study of  them at the
Hospital of St. Louis  (well known  to be specially  devoted to these  dis-
eases in Paris), and having also since used it in several successive courses of
lectures  on the subject in this city, I  need  hardly say that I fully coincide
with Dr. Burgess in his opinion as to its merits.
  The present edition has  been carefully compared with the  original, and
numerous  omissions  supplied  of passages which the  translator thought
proper to omit, but which it is thought, both  in justice to the authors and to
render the work more complete, ought to be restored.  Some errors also
have been corrected, which doubtless escaped his observation.
  Notes have been added, consisting  mostly of the  Editor's experience in
the treatment of these  diseases during the last eleven or twelve years, both
in dispensary and  private practice, with references to  other works, and to
the experience of those entitled to confidence.  These notes are designated
by the initials of his name.                                  H. D. B.
43 Bleecker street, New York.
    November 1, 1845. 
PREFACE
TO  THE   SECOND  AMERICAN  EDITION.
   The truly practical character of the work of MM. Cazenave and Schedel
was the  reason for  its original selection for republication in this country
from among other works on Cutaneous Diseases.   The sale of one edition,
and the numerous calls for another, have justified the anticipation that it would
prove acceptable to the American profession.   M. Cazenave still  retains the
place of physician of the Hospital of St. Louis, which, with his private practice,
affords him  advantages for  the study of this  branch of pathology unsur-
passed elsewhere, and gives him a deservedly high rank as authority on this
subject.
   Since the translation of the third edition of the work by Dr.  Burgess, a
fourth edition of the  original has appeared, in which two entire articles have
been  rewritten, and  other parts altered and improved, a proof both of  the
progress which  is constantly being made in this braneh of medicine, and of
the zealous devotion of our authors to the subject.   These articles, one on
Scabies and one on Pellagra, and also the greater part of one on Elephan-
tiasis Graecorum, have  been translated for the present edition, in which
most of the alterations and  additions in other parts of the work  have been
incorporated.  Extracts have also been introduced from the valuable Clinical
Lectures which M. Cazenave has since that time been delivering at the Hos-
pital of St. Louis, as they are reported in the Gazette des Hopitaux.   Errors
have been corrected which escaped notice in the former edition.
   Six additional years, during which the Editor has both studied and lectured
upon these diseases,  have furnished him with materials from his own experi-
ence, and from that of others, the  more important of which he has inter-
woven with the notes and references in the former edition; and he  trusts
that he has  been enabled, in this way, to enhance the value of  the  work
both to the  student  and the practitioner, without materially increasino- its
size.
   His additions, as heretofore, are marked with the initials of his name
                                                           H.  D. B.
   43 Bleecker street, New York.
       November 10, 1851. 
CONTENTS.
Original Preface,
Preface to the first American Edition,
Preface to the second American Edition
Introduction,
 Exanthemata,
     Erythema,
     Erysipelas,
     Roseola,
     Measles,
     Scarlatina,
     Urticaria,

 Vesicul^;,
     Miliaria,
     Varicella,
     Eczema,
     Herpes,
     ------ phlyctenodes,
     ------ labialis,
     ------ preputialis,
     ------ zoster or zona
     ------ circinatus,
     ------ iris,
     Scabies,

BULL.E,
     Pemphigus,
     Rupia,

PUSTUL.E,
    Variola,
    Vaccinia,
    Ecthyma,
    Impetigo,
    '       larvalis,
    ------ granulata,
    Acne,
    Mentagra,
    Porrigo,
    ------favosa,
Page 
fiii
CONTENTS.
Page
PesTUL.K continued.
     Porrigo  scutulata,
     Glanders and Farcy,

PAPUL.K,
     Lichen,
     Prurigo,

SqUAMjB,
     Lepra,
     Psoriasis,
     Pityriasis,
     Ichthyosis,   .

TtfBERCULA,
     Elephantiasis Graecorum,
     Frambcesia,
     Molluscum,

Macolje,
     Changes of color,
         Slate colored skin,
         Lentigo,
         Ephelides,
         Nsevi,

     Loss OF COLOR,
         Albinismus,
         Vitiligo,
Lupus,
Pellagra,
Aleppo Evil,
Syphilitic eruptions,
Purpura,
Elephantiasis Arabum,
Cheloidea,
Biett's Formulary,
Index, 
INTRODUCTION.
   There is no class of diseases which have been, and are still, so much
 neglected as diseases of the skin; yet there are none so easily recognised,
 for their characteristic phenomena are appreciable by the eye, while they are
 at the same time extremely frequent.  Perhaps, however, these two circum-
 stances may account for the confusion which has prevailed in the history of
 cutaneous affections;  here, as in many other branches of medicine, the mul-
 titude of facts has merely served to encumber the science, without enriching
 it; and what other results could we expect, when the different stages of the
 same affection have  been described as diseases essentially different from
 each other, and the various facts on which the science  rests have been col-
 lected without order, or any view  to  classification.  Want  of classification
 in the first instance,  and  at  a later period imperfect  classifications, have
 greatly contributed to envelope in obscurity the history of cutaneous affec-
 tions'; still, between the end of the  sixteenth and  the commencement  of
 the nineteenth century, several writers have endeavored to reduce the study
 of these diseases to some order, and, by grouping together the different
 forms, have succeeded in' throwing much light  on this important branch  of
 pathology.
   The various classifications may be reduced to three.  The first was in-
 troduced by Mercurialis (DeMorb. Cut. 1576), partially adopted  by Turner,
 (Traite  des Mai. de  la Peau, 1743), again brought  forward  in  1806 by
 Alibert.   The basis  of  this classification is the seat of the disease; two
 principal groups being admitted for the head and the rest of the  body. The
 treatise of Mercurialis  is divided into two parts; the first is  composed of a
 chapter on general considerations,  and of ten others devoted to affections of
 the head.  The second part, which commences thus, " post  vitia capitis se-
 quuntur vilia totiuscorporis" contains  six chapters.  Turner only partially
 adopted the method of Mercurialis; after  a general description of cutaneous
 diseases, he devotes the second part of his work to  those affections which
 are confined to particular parts of the body.  M. Alibert adopted the same
 method, and called cutaneous affections of the head teignes, while he  deno-
 minated dartres those which attacked other  parts of the body; he  added,
 however, several  species and varieties, founded on the form  of the eruption,
 product of the inflammation,  &c.  Thus, when the eruption was  attended
 with a scaly desquamation, he classed it under the dartre squammeuse, and
 then added the terms humid, orbicular, &c, according as it was accompanied
 by discharge, or presented  a circular  appearance.  Whenever the disease
 was attended with scabs, he ranged it under a genus which he denominated
dartre crustaeee.   Alibert likewise made a great number of sections under
 which he placed certain diseases that  did  not  admit of being classed with
the rest.   Thus, besides  his five species  of teignes, and seven  species of
 dartres,, Alibert  described  ephelides, pliques, cancroides, lepres,  pians, ich-
 thyoses, sijphilides, scrofules, and psorides.   This plan was much too vast  a
 one, and cannot be followed as a useful  guide in the study of cutaneous
diseases.
                                     2 
14                        INTRODUCTION.
   In the first  place, the method of M. Alibert  is subject to the objection
already advanced against the classifications of Mercurialis and Turner, viz.
that of separating  from each other diseases  which are identical,  merely
because  they are situated  in  different parts of the body.  Again, in ar-
ranging  his species according to  the products of inflammation, he has
brought together affections which  have little  analogy, and separated some
which were closely allied.  For  example,  under the genus  dartre squam-
meuse, we have  inflammatory eruptions  essentially different in their ele-
mentary characters, march, symptoms, and mode of treatment.  How can
we have a correct idea of the dartre squammeuse lichenoide and dartre squam-
meuse humide, while we arrange them under the same  order,  and clothe
them with the same characters 1  The dartre squammeuse humide, if taken
by itself, merely represents a certain period  of an inflammatory  cutaneous
affection, the elementary characters  of which may have been various, and
which may have terminated in diseases  essentially necessary to  be distin-
guished from each other.  On the other hand, Alibert describes, under dif-
ferent species, several affections which are  identical; thus, the  dartre fur-
furacSe arrondie  and the dartre  squammeuse lichenoide possess the same
elementary characters, follow the same course, require the same  treatment;
in a word, merely differ in the form of the  spots, the one being, at the very
utmost, but a variety of the other.
   These deficiencies could not fail  to strike M. Alibert, who abandoned his
method for another, which, so far from being an improvement, has no claim
whatever to the title of " classification."   In  his arbre des dermatoses we
find no trace of method or arrangement; branches shoot forth at the will of
the writer, and nothing more.
   The next classification which we have to notice is that of Plenck (1789),
which was subsequently improved in so happy a manner by Willan. Plenck
was  the  first who  rejected  all topographical distinctions, and arranged
cutaneous diseases  according to their external  characters.  Still he com-
mitted the error of mixing up  the products  of inflammation  with the  true
anatomical characters of the disease.  Thus, besides  vesicles, pustules, &c,
we have species based upon the existence of incrustations, ulcers, &c,  as  if
the latter were not a mere consequence of the former, and  as if it were  a
trifling error to divide one and the same disease into  two or three different
affections, according as it presented itself with pustules, scabs, or  ulcers.
"^Willan adopted the basis of Plenck's method, and on it established a  clas-
sification which  in the present state of our knowledge cannot be  surpassed
in clearness and precision.  He rejected all the products of inflammation,
and took the characters of his  orders from the elementary  lesions of the
skin, which he divided into eight orders.   The order squama, it is true,  is
founded rather  on a product of inflammation  than  on elementary lesions,
but its characters are well marked, and belong exclusively to the diseases
which are placed under it.

                  Classification of Willan (1798).
    Order I.   PAPULAE.                   1. Rubeola,
         1. Strophulus,                      -2.  Scarlatina,
         2. Lichen,                          3.  Urticaria,
         3. Prurigo.                        4.  Roseola,
    Order II. SQUAMjE.                  5.  Purpura,
         1. Lepra,                          6.  Erythema.
         2. Psoriasis,                   Order IV. BULLAE.
         3. Pityriasis,                        1. Erysipelas,
         4. Ichthyosis.                       2. Pemphigus,
    Order HI. EXANTHEMATA.          3. Pompholyx. 
INTRODUCTION.
15
      Order V. PUSTULE.'     .       Oeder VII. TUBERCULA.
          1. Impetigo,                        1. Phyma,
          2. Porrigo,                          2. Verruca,
          3. Ecthyma,                        3. Molluscum,
          4. Variola,                          4. Vitiligo,
          5. Scabies.                          5. Acne,
      Order VI. VESICUL^.                6. Sycosis,
          1. Varicella,                       7. Lupus,           I
        •  2. Vaccinia,                        8. Elephantiasis,
          3. Herpes,                          9. Frambcesia.
          4- Rupia,                      Order VIII. MACULAE.
          5. Miliaria,                         1. Ephelis,
          6. Eczema.                         2. Nsevus,
          7. Aphtha.                         3. Spilus.
   Willan's classification, taken on the whole, is a most perfect one; for the
 errors  of arrangement  which he committed  were not the results of his
 method, but errors in  its application.   Thus he  places purpura among the
 exanthemata;  erysipelas with the bulla ;  scabies among  the puslulcc ;  acne,
 sycosis, among the tubercula.  Independently  of these faults,  however, we
 find certain others which are not so easily got over.   For example, we have
 variola and tinea arranged under  the same order, although they present a
 very wide  difference in  their  nature and progress.   Besides, it is by  no
 means easy to apply artificial distinctions to  disease; there  is but a slight
 difference between a vesicle and a pustule; the bullae of rupia often bear a
 close resemblance to  the phlyzacious  pustule of ecthyma.  Finally, there
 are  several cutaneous diseases  which cannot  be arranged  under any  of
 Willan's eight orders; purpura, for example, bears  as little  affinity to the
 exanthemata, as it does to the  vesiculse or squamae :  and  lupus is not always
 a tubercular affection.   Notwithstanding  these imperfections, the classifica-
 tion of Willan is clear and precise, because it is based  on the elementary
 characters of the disease, which are invariable, and may be  detected at every
 stage of the affection.   The third method, or that of Joseph Frank (1821),
 would be a most attractive one, if it were applicable to the  study of diseases
 of the skin.  Following the example of Retz  (1790), and Derien  (1804),
 Frank divides  cutaneous affections into acute and chronic.  At  first  sight
 this seems a very natural division, but  a little  reflection shows  that  it is
 totally impracticable;  in fact, how can we divide a  work into two parts, in
 one of which is found the history of a disease during its  acute stage, and in
 the other the history  of the same malady during its chronic stage, unless,
 indeed, we admit with  Frank that  a given disease is always  acute  or
 chronic  This may be true for a  certain number, but certainly  not  for the
 majority, and hence the distinction laid down  by Frank cannot form the
 basis of a general classification.
   Such are  the three principal  methods of classification that have been
 applied  to cutaneous diseases.  None of them, as we have seen, are com-
 pletely  above  reproach,  but their imperfections are intimately connected
 with the nature of the  subject to which they are applied.  The signs  of cuta-
 neous disease are, it is true, appreciable  by the sight, but we are not  yet suf-
ficiently  acquainted  with the structure  of the  tissues  in which  they are
seated, to lay down precise and lasting distinctions.  It seems clear that a
perfect classification of cutaneous diseases should be founded on the special
seat of  each elementary lesion, but we  can never arrive at this degree of
perfection until our knowledge  of the intimate structure of  the skin  is more
advanced than at present.   Mr.  Plumbe, who has attempted the classification
oT these diseases according to  their causes, has  rather increased the diffi-
culties already existing in this branch of pathology. 
16                        INTRODUCTION.
Classification of Wilson.*
'Congestive
Effusive
Inflammation
Specific .  .



Non-specific


{Asthenic

Sthenic .  ,
Hypertrophy of the Papillae
 DISEASES OF THE DERMA.
                             ( Rubeola.
                              Scarlatina.
                              Variola.
                              Varicella.
                              Vaccinia.
                             'Erysipelas.
                              Urticaria.
                              Roseola.
                             __ Erythema.
                             5 Pemphigus.
                             \ Rupia.
                             C Herpes.
                             < Eczema.
                             ( Sudamina.

Suppurative......J Syma.'
                             C Strophulus.
Depositive    ......< Lichen.
                             I Prurigo.
                             C Lepra.i
Squamous.......< Psoriasis.
                             ( Pityriasis.
From Parasitic animalcules .   Scabies.
                             ( Verruca.
                             I Tylosis.
                             \ Clavus.
                             l^Pachulosis.
Disorders of the Vascular Tissues......] ^as^lar nam.

Disordered  Sensibility..........j ^Sf^^

                   Augmentation of pigment

                   Diminution of pigment
  Disordered
Chromatogenous •
   functions
Alteration of pigment
Chemical coloration
S Melanopathia.
\ Pigmentary nsevi.
S Albinismus.
\ Leucopathia.
  {Ephelis.
  Lentigo.
  Chloasma.
  Melasma.
  Oxide of silver stain.
       II. DISEASES OF THE SUDORIPAROUS GLANDS.
Augmentation of secretion........Idrosis.
Diminution of secretion.........Anidrosis.
                                               C Osmidrosis.
Alteration of secretion..........■? Chromidrosis.
                                               £ Haemidrosis.

  * Mr. Wilson gives to this arrangement, the name of Natural System of classification.
We have introduced it here for the convenience of reference, and also of comparison with
other plans.                                                    H. d. B. 
INTRODUCTION.
17
Retention of secretion
'Duct open
Duct closed
         III. DISEASES OF THE SEBIPAROUS GLANDS.
Augmentation of secretion......Stearrhcea simplex.
Diminution of secretion.......Xero-derma.
                                         C Stearrhcea flavescens.
                                         < Stearrhcea nigricans.
                                         ( Ichthyosis.
                                           {Comedones.
                                           Small sebaceous tumors.
                                           Sebaceous accumulations.
                                           Cornua.
                                           {Sebaceous miliary tubercles.
                                           Calcareous miliary tubercles.
                                           Serous cysts.
                                           Encysted tumors.
Inflammation of glands and adjacent textures < £che\


     IV. DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
Augmented formation   .......Pilous naevi.
Diminished formation........Hlopecia.
                                         ( Calvities.

Abnormal direction    ........\ Feml™*'
Alteration of color.........Canities.
                                         \ Trichosis Furfuracea.
                                         \ Trichosis Plica.
                                          {Narcosis Folliculorum.
                                          Stearrhcea Folliculorum.
                                          lnrlammatio Folliculorum.
                                          Favus.

  Of the methods just mentioned we  have adopted that of Willan, which
possesses the greatest claim  to our attention ; at the  same time we have
availed ourselves of the numerous  and  important modifications introduced
by M. Biett.   We have classed cutaneous diseases, as will be  seen in the
following table, according to their elementary characters, arranging under
distinct  heads some which we were unable  to comprise under the eight
principal orders.

                      Classification of Biett.
Diseases of the Hairs
Order I. EXANTHEMATA.
    Erythema,
    Erysipelas,
    Roseola,
    Rubeola,
    Scarlatina,
    Urticaria.
Order II. VESICUL^E.
    Miliaria,
    Varicella,
    Eczema,
    Herpes,
    Scabies.
Order III. BULLAE.
    Pemphigus,
    Rupia.
Order IV. PUSTULE.
    Variola,
    Vaccinia,
    Ecthyma,
    Impetigo,
    Acne,
    Mentagra,
    Porrigo.
    (Equinia, or Glanders).*
Order V. PAPULAE.
Added by Translator, who has writtena chapter on this disease. H. D. B." 
18
INTRODUCTION.
         Lichen,                            3. Frambaesia.
         Porrigo.                      Order VIII. MACULAE.
    Order VI. SQUAMAE.                 Coloraliones.
         Lepra,                             Fuscedo Cutis,
         Psoriasis,                          Ephelides,
         Pityriasis,                          Naevi.
         Ichthyosis.                         Decolorationes.
    Order VII. TUBERCULA.             Albinismus,
         1. Elephantiasis Graecorum,         Vitiligo.
         2. Molluscum,

                        Additional Orders.
    Order IX. LUPUS.           Order XIII. PURPURA.
    Order X. PELLAGRA.       Order XIV. ELEPHANTIASIS
    Order XL MALUM                             ARABUM.
         ALEPPORUM.           Order XV.  CHELOIDEA.
    Order XII. SYPHILID A.

  From the preceding table  it may be seen  that cutaneous  disorders are
capable of being reduced to a certain  number of elementary lesions; the
latter exist constantly in all eruptions classed under each order, and may be
discovered at all periods of the disease,  if we search for them  attentively.
Each elementary lesion has its special character, each possesses, as a symp-
tom, its peculiar value.
  Exanthemata.—This term  is  applied to patches of a reddish color,
varying in intensity,  size, and  form,  disappearing under  pressure  of the
finger, and terminating in delitescence, resolution,  or desquamation.
  Vesicul^:.—A vesicle is a slight elevation of the  epidermis, containing a
serous  and transparent fluid, which, however, is occasionally opaque or
sero-purulent.   The vesicle  may terminate in absorption of the fluid, slight
desquamation, excoriation, or the formation of small, thin incrustations.
  Btjll.2E.—Generally speaking, bullae  differ from vesiculae merely in  size;
they are  small,  superficial tumors, caused by effusion of serum  underneath
the epidermis.
  Ptjstulje.—This term should be strictly confined to circumscribed collec-
tions of  pus on the surface of the inflamed mucous  layer.   The contents
of the pustules, in drying, produce scabs, and they may be followed by
chronic induration, or by red, inflamed surfaces, or sometimes by slight exco-
riation.
  Papulae.—These are small  elevations, which  are solid, resisting,  and
never contain any trace of fluid; they may, likewise, give rise to ulceration,
but generally terminate in resolution or furfuraceous desquamation.
  Squamje.—The term squamae is applied to the scales of thickened, dry,
whitish, friable, and degenerated epidermis, which  cover minute papular ele-
vations of the skin; they are easily detached, and  may be reproduced for an
indefinite length of time by  successive desquamations.
  Tubercula.—These are small, hard tumors, more or less prominent, cir-
cumscribed in  form, and persistent; they may become ulcerated  at the
summit or suppurate partially.   In this definition  we consider tubercles as
elementary lesions, and not those which appear after abscesses.
  Maculae are permanent changes of color in certain points of  the skin, or
in the whole of the cutaneous envelope, but unattended with any general
derangement of the health.
  Under these  eight orders we  have arranged the great majority of  cuta-
neous diseases; we have, however, made a few changes in the classification
of the species/  Thus, in our opinion, pemphigus  and pompholix constitute 
•
INTRODUCTION.
19
one and the same disease;  acne is clearly not a tubercular affection, so we
have placed it under the pustulae, to which it  really belongs.  Erysipelas
is an exanthematous disease, and scabies a  vesicular one;  we have, there-
fore, transposed them  to  their respective orders;  the diseases  arranged
under the last seven orders do not  admit  of being classed with any of the
rest, and hence, we have thought it right to consider them apart.  We have
designedly omitted anthrax, burns, cyanosis, and several  other affections
which are quite foreign to our subject.  The plan of this work did not admit
of their being described;  and we would, at all  events, have been unwilling
to encumber it with an account of diseases which, as they are  seated in»the
subcutaneous cellular tissue, are as little adapted for a complete treatise as
for a manual of cutaneous diseases.
  The characteristic symptoms of diseases of the skin may  be mixed up
together, and we often  find many  different elementary lesions  coexisting,
especially in acute cases.   They are often attended by general symptoms,
particularly those  of more or  less severe irritation of the mucous mem-
brane of the air-passages, and  especially of the intestinal canal.  But many
cutaneous diseases are chronic, and  last for months or years without exciting
any derangement whatever of the general  health.  The color of cutaneous
eruptions and their termination may be considerably  modified by the  age or
constitution of the patient, the coexistence  of internal inflammation, and
several  other circumstances connected with  the  health of the individual.
Thus the  accession of  some febrile disorder  often has the effect of mitigat-
ing, or even dispersing altogether, a chronic disease of  the  skin  which  may
have existed for months; but when  the febrile symptoms disappear the cuta-
neous affection returns.   In cases of this kind it  is said, " that the eruption
has gone  in—has  fallen on some  internal organ;" but the  inflammation
of the internal parts has existed long before  the  disappearance of the cuta-
neous  disease,  and  the latter returns slowly—long after  the complete re-
storation of the internal parts to  a  state of  health.   Without meaning  to
decide the question of retrocession, at least  for diseases of the skin, we
may affirm that  things  occur in the way which  we have just  mentioned,
and that the examples of  true retrocession are rare.
   Causes.—The causes of cutaneous disease  are very diversified, and at the
same time  involved in considerable  obscurity.   They occur at  all ages, and
spare neither sex.   Some  forms, however, as the  various species of porrigo,
the variety of impetigo called crusla lactea, and the exanthemata, are almost
peculiar  to children,  while acne prevails  more at the period of puberty.
Generally speaking, diseases of the  skin are  more frequent amongst young
and  adult persons than during old age.  The  lymphatic temperament is a,
predisposing cause of cutaneous disease.   The influence  of profession  or
trade is sometimes very remarkable; thus workmen who handle acrid sub-
stances, or are compelled to expose their hands frequently to  intense heat,
are very subject to different cutaneous  diseases of these parts.
  Hereditary tendency is a predisposing cause of much importance; nothing
is more common than to find parents and children subject at the same time
to diseases of the skin.  But it by no means follows that the  same disease
must be handed down from father to child: thus the parent may have had a
scaly affection of the skin,  and the children  be attacked by a pustular  or
vesicular one ; but sometimes, as in the case of ichthyosis, the disease is iden-
tically the same in  both generations.   Amongst the most  powerful  of in-
dividual predisposing causes is that  peculiar idiosyncrasy under  which
certain persons are attacked by diseases of the skin from causes of apparently
the most trivial nature:  indeed, in many persons of this class we are unable
to trace any probable cause whatever.  The great extent of the skin, and
number of capillary vessels  and nerves distributed to it, point  out the inti- 
 20                        INTRODUCTION.           •

 mate sympathy which exists between  the  skin and the internal organs, and
 explain how readily functional or organic diseases  of the  viscera affect the
 tegumentary system.*
   The trades which seem to predispose most readily to  cutaneous diseases
 are those which give rise to constant excitement of the skin;  hence masons,
 workmen, farriers,  &c, are very subject  to these disorders.   The influence
 of trade is  particularly marked in causing relapse, and especially when the
 skin is exposed to the action of heat or acrid substances.  But there  is no
 relation between the cleanliness of a trade and its tendency to guarantee the
 workman from diseases of the skin, or vice versa.   Thus, nightmen, scaven-
 gers, coal-heavers,  &c, are  not peculiarly subject  to cutaneous affections,
 while the exercise  of  a trade which requires cleanliness and repose  is far
 from acting as a preservative.
   Season has likewise a well-marked  influence  on the development of
 diseases of the skin, which are much more frequent during spring than any
 other period of the year.  The same remark applies to climate.   Cutaneous
 affections are much more severe in warm than in temperate climates.  In
 Greece, Palestine, Egypt, and India, they present appearances and assume a
 degree of severity  unknown in  the climates of the north.  Constant heat
 and moisture  of the atmosphere also promote the  existence of many cu-
 taneous diseases.   The parts of Europe in which skin diseases most abound
 are Britariy, Picardy,  Flanders, Holland, certain districts  in  England and
 Scotland, the  borders of Holstein and Norway, and the  Crimea.  They are
 most common in capitals or large towns, and chiefly prevail in the dirty and
 ill-ventilated districts of crowded cities.   The influence of light, in the pro-
 duction of some cutaneous  disorders, is well  known.   During  spring the
 rays of the sun instantaneously produce  freckles.   Larrey  mentions a case
 in which indelible spots were produced by the action of the  electric spark.
 In a word, the influence of heat, light, and electricity, is greater, and deserves
 much more attention than has been generally bestowed upon it.
   The close  sympathetic connexion  which  exists between  the skin and
 stomach is manifested in the clearest manner by the effects which occasion-
 ally follow the ingestion of certain alimentary substances.  But these effects
 seem to depend rather on idiosyncrasy than on the nature of the  substances
 ingested.  Muscles, oysters and other shell  fish, lobsters, shrimps, mush-
 rooms, honey, almonds, strawberries, raspberries,  cucumbers, and vinegar,
 are the substances which most frequently produce  the effects now alluded
 to; the same results, but more rarely, have been known to follow the use of
 meal, apples, rice, and  even the least irritating eatables.
'  In  many  cases the influence  of this  sympathy is  slight, in others it is
 s'trong.  In some warm countries, for example, the  habitual use  of certain
 kinds of meat, particularly pork, contributed greatly to the spread of tuber-
 cular lepra and the  Elephantiasis  Arabum, and  hence the  experience of
 Moses and Mahomet induced them to forbid the use of  pork  to Jews and
 Mussulmans.  The  restrictive laws concerning this  article of  diet were evi-
 dently founded on the rules of public health; and  even  as late as  1779,
 Baron Larrey  witnessed the injurious effects  of pork  and  salt food on the
 French soldiers in Egypt, the continued use of these  articles  giving rise to
 more or less inconvenience, while a large  number were attacked with leprous
 eruptions, appearing first on the face, and afterwards on the extremities.  In
 Scotland the use of oatmeal is commonly supposed to produce a number of

  * This resemblance in form in hereditary diseases of the skin is stated in stronger terms than
 the above by our authors in the last edition of their work.  They say that, although it does not
 present in every instance the same characteristics  as that with which the  parents were for-
 merly afTected, it still exhibits, in the greatest number of cases, an analogous  form.  They
 mention ichthyosis as the most remarkable instance.—H. D. B. 
INTRODUCTION.                        21
 cutaneous diseases.   In Lombardy, pellagra is attributed mainly to the use
 of Indian corn, which, although.it may not be the exciting cause, is doubtless
 a predisposing one.   The action on the skin of solid or liquid  matters em-
 ployed for food is well known, but this  is  peculiarly true of wine, coffee,
 salt, pepper, &c, when taken in excess.  On the other hand, disease may be
 engendered by total abstinence from these stimulants: thus, the gutta  rosea
 of water drinkers is cured by the  use  of stimulant fluids.   Gangrenous
 affections are sometimes produced by the use of putrid meat, and by the flesh
 of animals which have died with epidemic  diseases; and it is  well known
 that eruptions, resembling  roseola and urticaria, are occasionally excited by
 copaiva,  belladonna, &c.
   Many other facts, which prove the  intimate connexion existing between
 the skin and stomach, are  mentioned  by  authors, and  Lorry in particular
 dwells upon  this point.   Excesses of diet may  certainly act  as  exciting
 causes of diseases of the skin, but it is certain  that at Paris, as elsewhere,
 bad food, poverty, and filth, are the most frequent causes of these affections.
   The copious  perspiration  produced  by exercise, and the  consequent
 excitement of the skin, show how powerfully it is influenced by the motions of
 the body.   Hence long continued  fatigue  is a powerful predisposing cause.
 On the other hand Lorry affirms that want of  exercise never gives rise to
 any cutaneous malady, and that exercise  at all  violent, immediately after a
 meal, is injurious to the beauty of the skin.  The want of rest  likewise has
 much influence as an exciting cause, producing herpes, acne, erysipelas; and
 the same remark applies to grief, strong moral impressions, &c.
   The humoral pathologists attributed great influence in the production of
 cutaneous disorders  to various derangements  of secretion and  excretion.
 The skin was regarded as  the natural emunctory of every kind of humor
 which did not pass off in the usual way.   The  existence of any disease in
 the skin  was considered as a proof that some  morbid humor required to be
 carried off, and the morbid condition of the integument as a salutary effort
 of nature to  relieve the  economy.    Again,  experience  has proved  that
 diseases  of the skin often  followed the suppression  of some  habitual  dis-
 charge, and that evacuants  were useful remedies in their treatment.   This
 further strengthened the doctrine  of  the  humorists, and when retention of
 humors  failed  to explain  the  presence of disease,  they had  recourse  to
 acridity,  thus  creating a vicious circle, from  which it  was impossible  to
 escape.  We regard the suppression of habitual evacuations as an occasional
 cause of cutaneous disease, and we think that this  cause should not  be
 neglected; but we are far from giving it the same weight as the humorists.
 We would apply the  same  remark to acridity of the blood, bile, or lymph,.
 milk, &c, which, in the opinion of some authors, are influential causes  of
 cutaneous disease.  Stimulant applications to the skin often give rise  to
 disease of the part.  Thus,  erysipelas  or  erythema may follow exposure to
 the sun's rays; and prurigo occasionally follows  sea-bathing, and is  often
 produced by neglect of cleanliness.  Frictions with irritant ointments,  par-
 ticularly  the citrine, may produce vesicular eruptions ; eczema often attacks
 the hands of persons who  handle  pulverized substances, or  expose these
 parts to heat; a blister, an issue, or simple puncture of the skin, especially
 on the scalp, may prove the exciting  cause of erysipelas, or of some other
 cutaneous affection.   Many cutaneous diseases arise from  contagion ;  here
the disease produced is always identical with the one whence it has arisen;
as examples, we may mention  small-pox, measles, scarlatina, itch, porrigo,
 and syphilis; amongst external occasional  causes we  must  reckon  that  pe-
culiar state of the atmosphere called " the prevailing medical constitution."
  External violence, sudden cold,  suppression of  habitual evacuations, and
neglect of regimen, are daily causes of cutaneous disease.  Strong mental 
 22                        INTRODUCTION.

 emotions, and grief in particular,  exercise a remarkable  influence.   The
 pupils of M. Biett must have heard him mention several examples of this,
 and especially the case of a young person who was attacked, within a period
 of twelve hours,  with very severe lichen agrms, after  having received some
 unpleasant news.
   Cutaneous diseases, as we have already mentioned,  frequently arise under
 the influence of a peculiar individual disposition, through which the disease
 is determined towards the skin rather than to any other part of the  body.
 This predisposition is sometimes  absurdly denominated dartrous,  a word
 which  only means a great predisposition to cutaneous diseases;  but it
 cannot be denied that  certain constitutional affections create this tendency.
   Scurvy, scrofula, rheumatism,  gout, and especially syphilis, are examples
 of such exciting  causes.  In England, scurvy was  for a long time regarded
 as the most frequent of these causes,  an error which has been more recently
 corrected.  Syphilis is, above all, worthy of attention, as an occasional cause
 of cutaneous disease, and that dreadful malady, lupus, is almost always con-
 nected with a scrofulous taint of the  constitution.  The obscure connexions
 sometimes existing between certain diseases, such  as  gout, rheumatism, he-
 morrhoids, &c, and affections of the skin, have  been  for  a long time  ob-
 served.   Erythema, erysipelas, and  purpura frequently accompany plethora,
 with derangement of the  menstrual function, in females.   Roseola  and
 urticaria often coexist with fever.   Finally, pellagra, and some other cuta-
 neous disorders,  seem closely connected with irritation of  the  stomach and
 bowels.  The latter connexion certainly exists, but we must not exaggerate
 its influence; diseases of the skin may arise from sympathy with the gastro-
 intestinal mucous membrane, but .this is very rare; in the majority of cases
 this membrane is perfectly healthy, and it is towards it that we  commonly
 direct our treatment; while,  on the  other hand,  a cutaneous disease  will
 disappear on the occurrence of intestinal inflammation, and  return when the
 latter has been dissipated.
    A general deterioration of health, arising from age, poverty, and privations
 of every kind,  is often an exciting  cause of certain  forms  of ecthyma,
 rupia, and  chronic pemphigus.  In Egypt and other  southern  climates, the
 disease  called Elephantiasis Graecorum, or tubercular lepra,  seems to depend
 on these causes.   Even in  our own times we have seen the same affections
 produced by the same causes; and similar causes seem to have exercised
 great influence during the  middle  ages upon the propagation in Europe- of
 the lepra brought from Palestine.
    The cases to which we allude occurred in the practice of M. Biett,  One
 was that of a young Portuguese student, who, while flying from the satel-
 lites of Don Miguel, was compelled to hide himself in a cave near Coinibra,
 where he underwent the severest privations; he was attacked by tubercular
 lepra, and when  we saw him his  case was hopeless.   The other occurred in
 the person  of a young German, on  his way to the United States; he had
 walked with several of his countrymen from  Nassau to Havre, but their
 resources had failed  them on their  arrival at this  latter  town, and they
 passed the winter in the greatest poverty, exposed to  cold, and lying on the
 bare ground.  He was seized with  elephantiasis of the scrotum, and died in
 the hospital of St. Louis, whither he had been sent from Havre.
    M. Biett also saw a case  of porrigo favosa, covering nearly the whole
 body, and produced  by long confinement with privation in a low, damp
 prison.
    Experience shows  that  diseases of  the skin may be caused by what we
' call, for want of a better  name, critical influences;  nature thus sets up a
 salutary derivation towards the  skin.   As to the cause of the special form
 which cutaneous disease may assume, we are completely ignorant; we  can- 
INTRODUCTION.
23
not tell  why  the exciting  cause should  in  one case produce a pustule, in
another a vesicle, in a third a papule, yet it  is to this obscure point all our
efforts should be directed, for on it probably depends the secret of the pre-
cise seat of cutaneous diseases*
  Diagnosis.—The differential diagnosis  of diseases of the skin  is one of
the most important  points  connected with their history.  Without it, how
can we form an opinion  respecting them, or  decide upon the proper course
of treatment ?   Calling an eruption scabies, when it is lichen, or  prurigo, or
eczema, has often caused great uneasiness in a family; while declaring an
eruption to be syphilitic, when it is of an entirely different character, or over-
looking that disease when it really exists, has given rise to serious evils.
  In diagnosis consists the entire study of diseases of the skin.  We  shall,
therefore, endeavor to lay down  some general rules to guide us in attaining
this important knowledge.*  The chief point is to determime the elementary
lesion ; this done,  we  have merely to compare the  disease with the few
which  possess the  same elementary characters.  In cases where the ele-
mentary lesion remains unaltered, we have simply to ascertain whether it be
a papule, vesicle, scale, &c,  and this generally is a very easy task.   Our next
step is to determine the species, and in  this we are aided by the form, seat,
progress, &c, of the eruption.
  For example, a  patient  has  on the inner side  of  the arm,  between the
fingers, &c, a number of  small collections  of serum, distinct, acuminated,
transparent at the  point,  and  accompanied  by itching, &c.   On carefully
examining, we find that the elevations contain no pus, that they are not solid
and resisting, that they are  not papular eminences covered by a scale, nor an
injection of the skin which  disappears under pressure; the  disease is  there-
fore vesicular.   We have, then, to find  out to what species of vesicular affec-
tion it belongs, and in carrying still further this  process  of exclusion, we
soon  reach a positive  diagnosis.  It is neither miliaria nor varicella;  for
these are accompanied by constitutional symptoms, and besides, the vesicles in
the former of these diseases are globular and very numerous, and in the lat-
ter they are larger and  more inflamed; it is not  herpes, for the vesicles in
this are collected together in groups, while in the present case they are scat-
tered.   It  must, therefore, be either  eczema  or scabies; but the vesicles of
eczema are  flattened, while here they  are acuminated; in eczema they are
usually more or less grouped, while here they are distinct; it must therefore
be scabies.
  The example which we have just given is a simple one;  but the diagnosis
is sometimes more  difficult, even when the elementary character of the dis-
ease remains in part; thus scabies, which is generally detected with readi-
ness, may sometimes present some difficulties of diagnosis, especially  when
the vesicles have been destroyed by scratching;  but  in such cases we are
assisted by various secondary indications, such as  the seat of the eruption,
the appearance  of  its accidental variety, the precursory and accompanying
symptoms.
  But a mere knowledge of the elementary character  of a cutaneous disease
is not  sufficient for  its diagnosis;  this character may have disappeared, and
given place to the secondary or consecutive lesions.   The  fluid of a vesicle
may, for example, dry off and leave a small incrustation; a  pustule may be
converted into a scab, and the latter give way to an ulcer; hence it is neces-
sary that we should study these secondary lesions,  and know to what pri-
mary characters they correspond. Incrustations may succeed vesicles, vesico-

  * The authors add here, in their last edition, that it is in diagnosis the classification of Wil-
lan exhibits its very great advantages ; for, they say, even if a natural classification  of these
diseases should at some future time be formed, that of Willan will always be retained for the
purpose of diagnosis.                                                D. D. B. 
24
INTRODUCTION.
pustules, and papules; scabs occur in most pustular diseases, and ulceration
may be a consequence of rupia, ecthyma, &c.
  In  cases  like the  foregoing, we must first ascertain the nature  of the
secondary lesion, then determine its  corresponding  primary element, and
finally pursue the course just pointed out.  For example, a .patient comes to
us with  a disease of the skin,  characterized by thick, rough, yellow scabs,
which cover a large portion of the extremities, especially the legs, and when
they fall off, expose  superficial excoriations; the latter discharge purulent
secretion, which dries up, and forms fresh scabs, these being the most cha-
racteristic features of the disease.  Now it is easy enough to  tell at once
that  this is  a pustular affection, but not so  easy  to  determine its  species.
The  disease is evidently  neither  variola nor vaccinia;  the pustules of
ecthyma are large, isolated, and frequently covered by black, tenacious scabs,
which  end  in ulceration; it is neither acne  nor  mentagra, the  pustules of
which rarely ever give rise to scabs, and are especially followed by chronic
indurations.   The only affections, then, that remain are impetigo and porrigo,
and we have merely to compare the character of these two species in order to
decide.  It is unnecessary to enumerate here the signs by  which we know
that the disease is not porrigo; it is therefore impetigo,  and  as the scabs are
scattered irregularly  over the limb, it is impetigo sparsa.
  In  the preceding  cases we  have supposed that there were no remains of
the distinct elementary lesion,  while, in the  great majority of cases, on the
contrary, some  may  always be  found  perfectly unchanged in the neighbor-
hood of the affected part.
  In some cases different elementary lesions occur in the same subject; but
even here we always find some predominant form, of which the rest  are but
complications.  However, it  may happen that we  cannot ascertain at once
the true nature of the disease.  This occurs in certain chronic affections,
where the elementary character gradually disappears, and seems confounded
in a different order of phenomena.  Even here a sudden exacerbation of the
disease, or a return to health, may develope its primary character.  The gene-
ral remarks which we have just made do not apply to those  orders which are
not characterized by  special  elementary  lesions; but the latter are distin-
guished by phenomena which we cannot mistake; or  even, when they assume,
as in syphilis, the elementary forms of other cutaneous diseases, they present
certain  special  appearances, which leave no doubt  about  their  nature.
Finally, we must neglect nothing which  can assist us in our diagnosis of
cutaneous diseases.   Beside the elementary characters, there are many sicns,
as the seat, form, and color of the eruption, its  progress, condition of the
patient, &c, which strike the practised observer, and  enable him often to dis-
pense with details.
  Prognosis.—The prognosis of diseases of the skin is intimately dependent
on their differential diagnosis.   They are rarely dangerous enough to com-
promise life, if we except the exanthemata.  The prognosis of tubercular
lepra, elephantiasis, and lupus,  is, however, always unfavorable.  Scaly dis-
eases are probably more intractable than pustular  or  vesicular; but "in all
cases our opinion should be guarded, for trifling cutaneous affections are
often extremely obstinate of cure.
  The general  state  of the patient's health, and  the influence which it ex-
ercises on the  disease, require our utmost  attention.   In  some cases the
cutaneous disorder is a salutary effort of nature, and we should avoid inter-
fering with it, or proceed cautiously and slowly when it is  necessary to get
rid of it; the practitioner must, however,  be guided  by  an attentive study of
the patient's constitution, the state of the viscera,  and the history  of the
case.   We do not belong to that class  of practitioners who attribute so
much importance to the sudden disappearance of cutaneous disease.  We 
INTRODUCTION.
25
know that  many times even chronic affections of the skin gradually  disap-
pear under the influence of some visceral irritation, and return  slowly  as the
patient is restored to health.  The vulgar will tell you, in such cases, " that
the disease went in upon some important viscus, and came out again;" but the
internal inflammation therein felt  preceded the disappearance of the erup-
tion, and the reappearance of the  latter was slow, and long after complete
recovery had taken place.  We regard  equally as an  unfounded prejudice,
what certain authors  say respecting  the  retrocession of itch, and the num-
berless  ills which  they pretend that the unseasonable cure of this disease
inflicts upon mankind.  Such reveries we leave  to Hahnemann and his cre-
dulous fojlowers;  while we recognise the  prudence of precautionary mea-
sures in the treatment of cutaneous affections of long duration, to which the
system has become, as it were, accustomed, and the sudden removal of which
would not be  without danger.
   Treatment.—Diseases of the »kin have been long submitted to a particular
line  of treatment: viz. the use of bitters, and  of remedies containing sulphur,
which seems  to have excluded all others;  within the  last few years, how-
ever, several remedies of great value have been discovered, but careful ob-
servations were wanted to determine their real value, and the cases to  which
they were applicable; in supplying  the  latter knowledge, M.  Biett has ren-
dered a most important service.  He was the only physician in Europe who
had  made a complete series of experiments on the treatment of. cutaneous
diseases, with different remedies; and  it is  a matter both of surprise and
regret that  many  of the  results  which  he has  obtained  should  have been
published by persons who conceal the source whence their  knowledge was
derived.
  The remedies employed in the  treatment of diseases of the skin may be
divided  into local and general.  Of  the former,  which are almost always
used, either alone, or at  the same time with general treatment, emollient
remedies (among which we reckon baths)  are those with which we should,
generally speaking,  commence.  They  often cure the disease without the
assistance  of any  other  means.   To mention the great variety of local
remedies employed would occupy  too much of our time; the principal are
decoctions of bran, barley, emollient flowers or roots, solutions of gelatine,
potato  flour,  poultices of ground rice, local  or  general baths, milk, &c.
Fatty substances are often employed in the form of ointment or pomatum,
but  we  should be very careful how we use them; they  should  always  be
perfectly fresh, and  even then are  subject to become  rancid; hence the
cerates  are preferable.   Lorry thinks that fatty matter acts by causing the
accumulation  of insensible perspiration on  the surface  of  the skin, and thus
producing the effect of a kind of local bath.
  Among local soothing remedies Ave would place certain preparations of
lead, hydrocyanic acid, cherry-laurel  water, and the cyanuret  of  potassium,
which often act like a charm in appeasing  itching.  Heberden recommends
local stimulants in cases where  the itching is very  severe,  but Bateman
justly remarks that this treatment  only applies to cases  in which the epi-
dermis  remains intact;  otherwise  emollient and soothing  remedies are
preferable.*
  The temperature of emollient applications, such as  baths, poultices, em-
brocations, &c, should not  exceed 90° F.  But when there is much heat,
pain, and itching, great benefit may be derived from water cooled down  to
  [* The studenrwill derive much assistance from a good magnifying glass, while observing
the progress of the eruption during the early period of the disease,  (t will also materially faci-
litate the diagnosis in difficult cases, by giving the observer a more correct idea of the element-
ary lesion, than he could obtain with the naked eye.J 
26
INTRODUCTION.
 36° F.   The linseed meal so often employed for poultices is  seldom fresh,
 and frequently causes  irritation, or even pustular eruptions*
    Finally, amongst local means we must not forget leeches.   These should
 never  be applied on  the diseased skin, but  in the  neighborhood, unless,
 indeed, the quantity of blood abstracted is such as will compensate for the
 irritation  produced by their  bites.  Successive applications of leeches  will
 generally be required.
   Local excitants are of various kinds, and often very useful;  they seem to
 modify the vitality of  the skin.   They comprise vapor baths  and douches,
 alkaline baths, sulphureous baths of every kind, lotions, or ointments contain-
 ing mercury, sulphur, iodine, &c.  When speaking  of the particular treat-
 ment  of each  disease, we  shall consider  these preparations more  fully.
 When an increased degree of irritation  is required,  great benefit  may be
 derived from blisters applied after Pare's plan.   Should it be  necessary to
 change the state of the diseased surface completely, or check the progress of
 some destructive  malady,  we have recourse to  caustic.   Acids in various
 states of dilution, and especially the hydrochloric, may be  employed, or  the
 nitrate  of silver passed lightly over  the surface; in some cases a single
 application is sufficient,  in others we must frequently use the caustic before a
 lasting effect is obtained.
   In cases of lupus more powerful caustics are required; the arsenical paste
 of Come is one of the  most efficacious, but it requires  a practised hand for
 its use ; we have also the binitrate of  mercury,  either alone  or dissolved in
 concentrated nitric acid; or the chloride of zinc may be employed with advan-
 tage instead of them.
   Before speaking of constitutional treatment  we may ask, is it always  ne-
 cessary to have recourse to general remedies ?  May we not obtain a cure
 by local means alone ?
   In some rare cases,  where the cutaneous disease is  slight and  limited in
 extent,  local means  may  suffice; but, generally speaking, a constitutional
 treatment is necessary,  for cutaneous diseases are almost always connected
 with some derangement of the general health, against which local remedies
 are powerless.
   The constitutional means employed in the treatment of diseases of the skin
 are  extremely  various.    They comprise bloodletting,  purgatives, alkalies,
 acids, antimonials, preparations of sulphur,  sudorifics, and, finally, the tinc-
 ture of cantharides and preparations of arsenic  or mercury, which evidently
 act in a direct manner on the skin.
   General bloodletting is required, not  only in various acute diseases of
 the skin, but in many others, where, at first sight, excitants might appear to
 be requisite.   Even in  chronic affections of the skin, it is  very  useful in
 young and robust patients.
   Purgatives are frequently employed in the treatment of cutaneous diseases.
 When the alimentary canal is  in  a healthy state, they are very beneficial in
 effecting a slow and long-continued derivation; hence we should  generally
 employ them in small doses, and suspend their use from time to time.  The
 remedies in common use are calomel, the  soluble sulphates  of magnesia and
 potass,  jalap, aloes, gamboge, cream of tartar, &c.
   Alkalies and acids, when properly diluted, are very useful in allaying itch-
ing ; they also  act directly on the skin.   Hydrochloric acid is the  one most
commonly employed.

 * Hence, our authors say (edit. 1847), that they have for a long time substituted potato starch
for flaxseed, and have, for  several years past, in many cases, discontinued the use of moist
and even of emollient applications, and have sprinkled the affected surfaces with dry starch or
powdered rice, with the best results.—H. D. B. 
INTRODUCTION.
27
   Antimonials were much in vogue amongst the  earlier  practitioners, who
 placed far greater  reliance on them than they deserve.
   Preparations of  sulphur are by many regarded as specific in diseases of
 the skin.   They  are, in truth, highly efficacious, but we must confess that
 they sometimes fail, and occasionally aggravate the disease.   But their use,
 whether locally or  internally, requires more experience and tact than is gene-
 rally supposed, and it is a great mistake  to employ them indiscriminately,
 as too  many practitioners do.  Sulphureous waters are either natural or arti-
 ficial ;  they may be used  in baths,  douches,  or in vapor.   Sometimes they
 are employed alone, at other  times diluted with gelatine  or other emollient
 substance.*
   Sudorifics comprise antimonial  remedies, of which we have spoken already;
 the remainder, such as sarsaparilla, guaiacum, &c, are now rarely used, except
 in cutaneous syphilitic disorders.   Dulcamara, saponaria,  rhus  radicans, and
 daphne mezereon have been highly  extolled by some English physicians.
   M. Biett has obtained the greatest benefit from the use of tincture of can-
 tharides and the preparations of arsenic.  The English have long since been
 in the habit of employing them, and in France the experiments of M. Biett
 prove,  in the clearest manner,  their efficacy.  Yet notwithstanding this evi-
 dence, the remedies now alluded to  have been attacked in the most extraordi-
 nary manner.   They deteriorate, it  is said, the health, and give rise  to disor-
 ders which break  forth after the lapse of time with great  violence.  These
 attacks are  completely unfounded,  and have become  futile,  in face  of the
 numerous facts which constantly prove their absurdity.
   The  powerful remedies of which  we speak may, when carelessly or igno-
 rantly  administered, produce certain  accidents, "but the same  remark will
 apply  to many other medicinal  substances, as corrosive  sublimate, tartar
 emetic, quinine, &c.  We must  be familiar with their use, and  carefully
 watch our patients  while  taking  them.   Besides, we  have seen them em-
 ployed  in a great  number of diseases of the skin with  the  following  results
 in a majority of cases:—1st. Complete and lasting cure of the most obsti-
 nate affections.  2d. Occasionally slight derangement of the health, requiring
 the remedy to be suspended for a  few days  only.  3d.  We have never met
 with those dangerous accidents so  much talked of by a set of  designing per-
 sons, who have no facts to support  their  opinions.   We are, therefore, pre-
 pared to assert,  and experience is there to support us, that  arsenic, when
 properly administered,  is an heroic  remedy in the  treatment of cutaneous
 disease; and we furthermore can affirm, that we have seen  patients, months
 and  years  after having undergone a course of this medjcine,  who  never
 experienced the  slightest inconvenience from it.

  [* The vapor of a combination of sulphur and iodine will often be found very useful as a
 local  application in some of the  tubercular and squamous diseases: especially in lepra vul.
garis. See Lepra.] 
 
DISEASES  OF  THE  SKIN.
                   EXANTHEMATA.

  The exanthematous diseases are inflammations of the skin,
characterized  by redness, which disappears  for a  moment
under  pressure  of  the  finger, and usually accompanied  by
constitutional symptoms.
  Erythema, erysipelas, roseola, measles, scarlatina, and urti-
caria, belong to  this class.   The exanthemata may spread
over the whole of the cutaneous surface, but in general some
are confined to certain  limits, while others are diffused, and
cover a great  part  of the body.   The special seat of  these
diseases appears to  be the superficial layers of the cutis vera,
and  especially  the  vascular  layer.  In some severe  cases,
however, the inflammation not only extends to the different
layers of the skin, but also to the subcutaneous cellular tissue.
With the  exception of urticaria, erythema, and chronic or
intermittent erysipelas,  these affections generally pursue  an
acute course.  Their duration varies from one to three weeks.
Urticaria and one of the varieties of erythema may be pro-
longed for several months, and even for years.
  The exanthematous diseases  are generally  preceded by a
certain degree of languor, by rigors, thirst, and anorexia; but
each disease has its own peculiar characters.  Thus,  each
form presents  redness  of the skin, which  disappears  under
pressure of the finger,  and  immediately returns on removal
of the pressure;  but this redness is much less in roseola than
in erythema and erysipelas, and  may be either temporary or
persistent in the different forms of urticaria; in which latter
affection, it is sometimes diffuse, and sometimes circumscribed;
hence the cause of  the irregularly formed  patches by which
it is  so often characterized.  Erysipelas is accompanied in
particular with pain, heat and swelling; and urticaria, on the
other hand, is attended with a smart itching.
                            3 
30
DISEASES OF THE SKIN.
  The exanthemata are frequently complicated with  gastro-
intestinal  inflammation,  and with  cerebral and  pulmonary
diseases.  It is owing to one or other of these  complications
that  they  sometimes  terminate  fatally.   They  generally
terminate by  resolution.   The  epidermis  becomes  furfura-
ceous, and falls off, or else  scaly lamellae form  of various
shape  and  extent.   In scarlatina,  the cuticle desquamates
repeatedly;  and erysipelas may be followed by suppuration
and gangrene.   Post mortem examinations of persons  dead
of these diseases do not throw much  light on their  nature
and causation.   A  brownish  red tint is sometimes observed
in the vascular network of the skin, especially if that tissue
had been highly injected during the progress of the disease.
Serum, and even a small  quantity of blood is often found
effused  in the cutaneous tissue.   In phlegmonous erysipelas,
pus is infiltrated into the subcutaneous cellular membrane.
  Measles and scarlatina are propagated by contagion, the
nature of which is  entirely unknown, and rarely ever occur
more than once in the same  individual during life.  The
rest of this class of affections may result from more direct
causes, but  in  general they depend on a peculiar condition
of the system, not  clearly  understood.  Generally speaking,
however, they  accompany inflammation of the mucous mem-
branes, and especially  an  unhealthy state of  the  digestive
organs.  Erythema  appeared  in Paris in 1829, in an epidemic
form.
  Diagnosis.—No  other class of cutaneous  affections is
characterized  by that  peculiar redness, disappearing under
pressure, which is diagnostic of the exanthematous diseases.
This of itself is  sufficient to  distinguish it from purpura and
ecchymosis.  In  the negro,  the color of the  inflamed  skin,
instead of being red, is even darker than natural.   Several
papular, vesicular,  and bullous eruptions  may be  compli-
cated with the exanthemata.  It was in  consequence of the
frequenc}'' of these complications that Willan placed ery-
sipelas  amongst  the bullae.  The prognosis  and  treatment
of the exanthematous diseases should be  regulated according
to  the  seat and extent  of the inflammation,  the age and
constitution of the  patient; and, above all, according to the
severity of  the accompanying lesion.   A  mild and simple
plan  of treatment  will, in  many  cases, be  sufficient.  In
some instances, however, the disease must be  attacked with
more energetic measures.   It  is impossible, as may easily
be  imagined, to lay down any precise line of  treatment for
a class of diseases  which appear under  such various forms
and degrees of intensity.  The period of convalescence is 
ERYTHEMA.
31
generally long, during which, several diseases, especially hoop-
ing cough, anasarca,  and chronic diarrhoea may supervene.
Hence the importance of attention to the general  health for
a long time after the cutaneous affection has disappeared.


                     ERYTHEMA.

Syn.—Inflammatory Blush; Tooth Rash; Gum ; Intertrigo;
          Macules Volaticce ;  Dartre erythemoide.

  Erythema  is  a  non-contagious  exanthematous  affection,
characterized  by  slight  superficial red patches,  irregularly
circumscribed,  and of variable form and extent.   Although
it may appear on every part of the body, it is most  frequently
seen  on  the face, the chest, and the limbs.   It is generally
confined to one or other of these regions, but it  sometimes
spreads over the whole body.  Erythema usually  follows  an
acute  course, and its duration varies from a week to a fort-
night. In a few rare instances  it assumes an intermittent,
and sometimes even an essentially chronic character.  When
it accompanies  ague, or supervenes during the paroxysms of
inflammatory fever, its duration will be  longer or shorter,
according to that of the diseases with which it coexists.
  Symptoms.—Erythema  is seldom preceded by febrile symp-
toms.  It appears in the  form of  patches,  of variable extent,
and of a light superficial red color, very different from the
deep  and intense hue of  erysipelas.  The redness  disappears
for a  moment  upon pressure of the finger.  There is little or
no heat or pain.   The spots are most commonly irregular in
shape, but are sometimes well defined.  They are often limited
in extent, and scattered over different parts of the body; and
in other cases, on  the contrary, they nearly cover an entire
limb,  half of the  chest, or, what is still more rare, a large part
of the surface of  the body.   Generally unattended by any
elevation, they  are sometimes accompanied  with  either  an
indolent  or a painful and  circumscribed degree  of tume-
faction, which  invests the eruption with a peculiar aspect,
and constitutes two distinct varieties of erythema.
  One of these  varieties   (Erythema papulatum, Willan) oc-
curs most frequently in  females  and in young men, on the
neck, the chest, the arms, the back of the forearm, and the
back of the hand.   The patches are small, seldom  exceeding
the size of a fourpenny-piece; they are irregularly rounded
and  slightly prominent,  like papulae.  The red color  soon
changes  into a  violet hue, especially in  the  centre of  the 
32
DISEASES OF THE SKIN.
patches.  In the  course of thirty-six or forty-eight hours,  the
tumefaction  diminishes,  and  nothing  remains  but  the  red
color, which gradually declines, and disappears altogether in
the  course of  a week" or  two.  In other  cases, however,  the
patches remain longer, and are much more prominent.   {Ery-
thema tuberculatum, Willan.)*
   Erythema nodosum occurs most frequently in children, in
females, and in young  persons of both sexes, of a soft and
lymphatic  temperament.   It generally appears on the  extre-
mities, and particularly on the anterior part of the leg.   Slight
constitutional  disturbance, depression,  loss of appetite,  fre-
quently precede or accompany this eruption.  The red patches
are  of an oval form,  slightly raised  towards the  centre,  and
their diameter varies  from a few  lines to an inch.  On pass-
ing  the hand over these patches,  they are found to  be elevat-
ed a little above the  level of the  skin;  the tumefaction  gra-
dually  increases, and  in  a few days  from  their  first appear-
ance, small red,  painful  tumors appear, which seem  inclined
to  suppurate,   but  they  immediately  diminish in  size;  the
original red color is replaced by a purplish stain ;  they soften,
and disappear  gradually in the course of twelve or fifteen days.
If the fingers  are passed  lightly over the surface of the skin,
when the tumors begin to subside, a suspicious sense of fluc-
tuation  is readily perceived,  and yet  there is no pus present.f

  * The large, dull red, flattened elevations  of this form are sometimes arranged
in patches from one to two inches in  diameter, forming entire circles or segments
of circles, with the centre sound, and not unfrequently appear in those advanced in
life, who are suffering from gastric or intestinal derangements, especially in females ;
and in such cases,  might be mistaken at first sight for tubercular syphilis.  These
patches are sometimes alone, and in  other cases, the distinct form  will be seen
scattered over the face, chest, arms, &c, at the same time.          H. D. B.
   t Erythema nodosum is sometimes found associated with rheumatism, and is
doubtless  more or less connected with a pathological condition of the system,
analogous to that  now recognised as characterizing that disease; but we see no
reason for supposing any direct relation between the two diseases, as has been
recently maintained by Dr. Begbie.—{Dublin Med. Press, June, 1850.)
                                                         H. D. B.
   Chronic Erythema.—Of this there are two  forms:—1st. That  produced by
external irritation, as  in  those whose occupation exposes them to irritating sub-
stances of different kinds, as masons, miners, those exposed to intense heat, also
grocers, &c.
   2d. That connected with  internal  causes, and generally symptomatic  of  some
derangement of the digestive organs.   The second form may cover large surfaces,
as the entire limbs, or may  be entirely local.   Of the latter variety, one of the
most common and most troublesome  is Erythema nasi, often called  Erysipelas of
the nose,  which is characterized by redness of the extremity of the nose, or of the
alae, and frequently of the neighboring parts of the cheek.  It appears in both
sexes, and is often connected with derangement of the  digestive organs, and in
females, with menstrual disorders.  Some of the follicles may become inflamed,
and increase in size, and the  disease thus pass into Acne rosacea, under which head
it is described by some  writers.  It  is also  sometimes produced by the habitual 
ERYTHEMA.
33
   Causes.—Erythema frequently results from  the  action of
different external causes on the surface of the skin.   Thus,
for example, in children  and persons of a full habit of body, it
is produced by the  constant attrition of two  contiguous
surfaces.    In  these cases,  it usually  occurs beneath the
breasts, in  the axillae and groins, and at  the upper part  of the
thighs.   (Intertrigo.   Sauvages.)  Under the same circum-
stances it  may  appear on the buttocks and  on the internal
surface of  the  thighs, from hard  riding or walking.  It may
also result  from the action of the sun and from cold, from the
contact of acrid or  irritating  matter, fluor albus,  gonorrhoea!
discharge,  urine, and even  from  faecal matter.  It appears
sometimes on  the  upper  lip,  resulting  from  the  action of
an irritating fluid  which  is discharged from the nostrils in
coryza.  Erythema  is  often  merely symptomatic of some
other affections; thus, for instance, it frequently  supervenes
during  the  periods  of  dentition,  menstruation, and  at the
climacteric period,  and  after  taking irritating  food, balsam
copaiba, &c.   Idiopathic erythema usually terminates by
resolution  in the course of a  few hours, or in  a day or two.
Slight desquamation occasionally  takes  place,  and  in  E.
intertriga  a sero-purulent exudation of a disagreeable odor is
established on  the diseased  parts.  Erythema  may assume
an intermittent or a periodic  form, and it frequently  super-
venes  during  the  convalescence  of  some  severe disease.
When it is symptomatic of an acute affection, it quickly dis-
appears  on  the  cessation of  the  paroxysms of the disease,
without  any perceptible desquamation; hence  the  name  E.
fugax.   This is the case when it occurs  with intermittent
fever; but at other  times, it  may  continue seven or eight
days, and  occasionally  a  much  longer  time, and  terminate
with slight  desquamation.  It may occur in cases of ana-
sarca, giving rise to several confluent patches, scattered here
and there  over a smooth and shining surface.  (E.  Iceve.)
It precedes and accompanies a great number of eruptive dis-
eases,  presenting different  forms, as it is  associated with
different eruptions.
   Diagnosis.—Erythema  may be  confounded,  not  only with
the  other  exanthemata, but  with eruptive disorders  of  an
entirely different nature and order from itself.  The follow-
ing  are those  from which it  is  most  difficult  to be   distin-
guished.   1. Erysipelas. Many  authors allege that  erythema


stooping required by some occupations, and is sometimes connected with a gouty
diathesis, a case of which kind is recorded by Dr.  R. J. Graves, in the Dublin
Journal, November, 1840.                               H. D. B. 
34
DISEASES OF THE  SKIN.
is but a mild form  of erysipelas.  There are, however, very
distinctive  characters  between  these diseases.   Erythema
can only be mistaken for  erysipelas when it is more diffused
than usual,  and when  the patches lose  their circumscribed
appearance ; even then they may be distinguished  by the
superficial redness  of the skin, by the absence of the tume-
faction and sharp burning pain which invariably  accompany
erysipelas, and by its mild progress and favorable termination.
Erythema nodosum was supposed to be a variety of phleg-
monous erysipelas.   The circumscribed nature of the tumors
of the former, which invariably terminates by resolution, and
the absence of those severe febrile  symptoms  which con-
stantly  attend  the  progress of the latter  disease, establish
a well  marked distinction  between  both these affections.
2.  Roseola,  In this eruption the red stain is also superficial,
but it has a  peculiar rosy  tint, which distinguishes it at once.
Erythema nodosum, the only variety that can be confounded
with the  irregularly-circular  patches  of  roseola,  may be
distinguished by the difference of the color, which is always
more diffused,  and  by the tumefaction which accompanies it.
3.  Measles  and  Scarlatina. These  diseases may be  distin-
guished from   erythema,  the  one by  its  irregularly-shaped
semilunar patches, and the other by the raspberry color and
large patches which are characteristic  of it.  Besides, these
eruptions are contagious,  and  are accompanied by a certain
train of symptoms peculiar  to themselves.  4. Erythema
papulatum   has  been mistaken  for urticaria.  The  greater
elevation of the patches, the absence of  the violet color, the
disagreeable smart itching, and the  irregular  and  often
fleeting course  of the  latter, will readily distinguish it from
erythema.   This variety  has  also been  confounded with
lichen  urticatus; but in the latter, the  papulae  are smaller,
more rounded,  and  solid:  the color is much  paler, and they
are  always  accompanied  with  pruritus,  which is often very
severe.  5.  Syphilitic patches may at first sight  be mistaken
for those of erythema;  but their duration and coppery color,
and other venereal symptoms, which are  generally present,
will indicate their real nature.   6.  Erythema has even been
confounded with tubercular lepra!  Very lately  a patient
laboring under this frightful disease was sent to the Hospital
of  St.  Louis.   There  were no  tubercles present, and the
eruption was mistaken by the former attendant for erythema.
The faint red   color, and especially  the insensibility of the
patches, easily  distinguished the one from the   other.   The
prognosis of erythema is never unfavorable.
   Treatment.—Idiopathic erythema  soon disappears on re- 
ERYTHEMA.
35
moving  the causes which  have  produced  it.   Mild  lotions,
tepid baths, and attention to cleanliness, constitute the whole
of the treatment required.   When  the eruption is  produced
by  the friction of  contiguous surfaces, either  in  infants or
adults, these parts should be powdered with  some absorbent
substance, and they should be prevented, as much as possible,
from rubbing together.  When erythema  is  symptomatic of
some  other  disease, the  treatment  ought  to  be  regulated
according to the measures necessary for that affection.   The
erythematic  blush or redness which  frequently  appears in
females at the climacteric period,  or when  the menses  are
suppressed,  requires  bleeding, diluents, regimen,  and  other
antiphlogistic  remedies.   Erythema nodosum,  although  the
severest  form  of the disease, seldom  requires  any  special
treatment.   Baths, mild  aperients,  and  the abstraction of a
small quantity of blood, with rest of  the affected part,  are
the  only  remedial  measures  required.  As  this affection
appears most frequently in scrofulous and lymphatic individu-
als, it may  often be advantageous to administer a course of
tonics after the eruption has disappeared.*
   M. Biett  has described  a very remarkable variety of  this
disease  under the name of Erythema centrifugum.  It is of
very rare occurrence, and  appears most frequently in young
people,, especially  in  females,  whose  health  is  otherwise
excellent.   It  attacks the  face chiefly.   It generally  appears
in  the form of round red patches, slightly elevated, and  about
the size  of  a shilling :f  these patches generally begin by a
small red spot, slightly papular,  which gradually increases in

  * In E. intertrigo, the parts should be frequently bathed with  some emollient
lotion, and a weak solution of acetate of lead, or alum., or of the nitrate of silver
will often be of service.  When  the discharge is foetid, Dr. A. T. Thompson
recommends frequent bathing with a lotion  of the chloro-sodaic solution, 3ij  or §j
to 5V water.  Weak creasote ointment may also be used in some cases.
  Dr. Ranking says that he has found equal parts of finely-powdered magnesia,
or flour, and the nitrate of bismuth, an invaluable application in the intertrigo of
children, and also in the  sore nipple of nurses, and superficial burns.—{Half-
yearly Abstract of Med. Science, Vol. I.)
  In E. papulatum and E. nodosum, mild mercurials are often indicated, with
laxatives, antacids, and tepid baths, and frequently tonics afterwards, with attention
to diet, which should be nourishing, but not stimulating. Among tonics, the sul-
phate of quina, with mineral acids, is one of the best.
  Chronic  Erythema must be treated by laxatives and alteratives, mineral acids,
and sometimes alkalies, with particular attention to diet, aided by bathing, either
the simple warm bath, or the alkaline or sulphur bath.  It is usually very obsti-
nate in its resistance to remedies.
  The treatment of E. nasi must be governed by its causes, so far as these can
be  ascertained.  Local  applications may be used of a gently astringent or stimu-
lating character.                                          "• D. B.
  t In the  original, the size is compared to that of a piece of thirty sous, which
 corresponds very nearly with that of a Spanish quarter of a dollar.   H. D. B. 
36
DISEASES OF THE  SKIN.
circumference, and sometimes spreads over the greater part
of the face.  The edges of the patches are prominent, and
the  centre, which retains  its natural color,  is  depressed.
There is a considerable degree of heat and redness, but no
pain or itching, and each patch leaves a slight depression on
the  skin.   The  causes of  this variety  are  unknown.  It
sometimes  coexists with dysmenorrhoea; it is an  essentially
chronic affection, although its appearance would indicate the
reverse.
  An epidemic  variety of this disease  appeared in Paris in
1828 and 1829, which  has  been  described under the name
of  Acrodynia,  the  principal features  of  which  were  an
erythematous eruption on the hands and  feet, accompanied
with a thickening and exfoliation of the.  epidermis.  It was
preceded, for several weeks, by uneasiness,  headache, nausea,
dull pains in the limbs, and obstinate diarrhoea.   The soles of
the feet and the hands then became numb, and the patient
experienced a kind of  prickling and .shooting  sensation in
those parts, which generally increased towards night.  These
symptoms were  usually accompanied with a perversion  or
diminution in the sensibility  of the affected  parts.  Some-
times the slightest  touch  produced  the most intense pain;
and in other cases,  on the  contrary, the  sensibility of the
skin was so torpid that the patients dropped their shoes with-
out perceiving it, and the pavement appeared as soft  as if
their feet were covered with cotton.  In a few instances the
sense of touch was  almost entirely  destroyed, and in others
the  smoothest surfaces appeared rough and  uneven  when
touched.  This  morbid condition,  which  occasionally pro-
duced contraction, palsy, and wasting  of the limb, often
existed without any apparent inflammation; but in general it
was either preceded  or accompanied with a certain degree
of  erythema,  attended  with  the following symptoms: the
palms of the hands were generally  of a crimson  red color,
which disappeared for a moment upon pressure  with the
fingers.  Some of the spots  were covered with a hard, thick,
yellowish envelope ;  others again were denuded, and appeared
depressed, and possessed a higher degree of sensibility.  An
inflammatory patch, about half an inch in extent, covered the
radial and ulnar edges of the arm.   Deep erythematous red
patches  were often  visible  on the  backs of the hands  and
about the  joints.  The feet presented the same appearances,
only that their plantar surfaces were generally  covered with
a thicker and harder envelope, especially about the heels and
toes.  This envelope terminated  abruptly  at the edge of the
foot on either side, and was circumscribed by a row of pretty 
ERYSIPELAS.
37
large erythematous patches, of a deep red color.   The dorsal
aspect was generally free from inflammation.   Erythematous
patches were at the same time often present in other regions,
especially on the scrotum, in  the  thigh, and in the arm-pits,
but without any thickening of the epidermis.   In some cases
the skin  presented  a remarkable  black color  (pytiriasis
nigra), and in others it was covered with a variety of distinct
eruptions.  This  affection  generally appeared  without .any
fever,  and often  without any derangement  of the digestive
organs.   Obstinate ophthalmia, and cedema of the face and
extremities, frequently supervened during the progress of the
eruption.
  The progress and duration of  these epidemic forms of ery-
thema, were variable and indefinite.  The eruption generally
continued for several months, and then disappeared gradually.
It sometimes subsided in the course of a few weeks.   Persons
of all  ages, and both sexes, were  attacked, but  it  occurred
in men of advanced years, among the poor, more than in any
other class of individuals, and among males more than among
females.   Antiphlogistic remedies  are those best adapted for
these varieties.   Leeches  to the hands  and feet, outside the
inflamed  margin,  simple  baths at first,  and  subsequently
alkaline and  vapor baths, and regimen, were all the remedial
measures required.

                     ERYSIPELAS.
  Syn.—Febris erysipelatosa ;  Rosa Volatica ;  Ignis sacer ;
                Rose ; St. Anthony's Fire.

  Erysipelas is an inflammatory disease of the skin, not con-
tagious, characterized by a  deep  red color of the  parts, with
pain and swelling, the latter of which frequently  extends  to
the subtegumentary  tissues.  It may attack any part of the
body, or even spread over the whole cutaneous surface, but
appears  most  frequently  on  the face  and  limbs.  The
erysipelatous inflammation  may be confined to the skin, or it
may extend  to the  cellular  tissue beneath, which  is often
deeply involved.  We shall describe three  varieties of this
disease.—E.  verum, E. phlegmonodes,  E. gangrenosum—
which  are usually preceded for a few days by general symp-
toms :  lassitude,  depression, slight or severe shivering fits,
hard and  quick pulse, epigastric pain, nausea, anorexia, and
constipation.  About the second or third day after the inva-
sion of these  febrile symptoms, the disease begins to appear.
It is sometimes, however, later in showing itself.
  Symptoms.—1.  Erysipelas verum.  The inflammation does 
38
DISEASES OF THE  SKIN.
not extend deeper than  the skin in this  variety, which is
generally attended with the following symptoms:—A degree
of pain, sometimes very  intense, is  perceived by  the  patient
on some part of the skin; the  part  soon assumes a deep red
color, which spreads more or less, and the inflamed surface is
much swollen, and its edges are raised.   The redness disap-
pears for  a moment, on  pressure with the finger, which is,
however, usually extremely painful.
  The eruption is accompanied with a sharp burning heat,
and  those febrile symptoms already enumerated.   The epi-
dermis becomes raised by the effusion of a yellow  serous fluid
between it and the cutis vera, and bullae of considerable size
are thus  frequently produced.  The bullae generally appear
about the third or fourth day; they burst within twenty-four
or forty-eight hours  after their appearance, and  pour out  a
thick, viscid fluid, which  terminates  in the formation of slight
incrustations  of various extent and form.  The constitutional
symptoms  usually  correspond  with  the  progress  of  the
cutaneous affection;  but they are sometimes slight, while the
erysipelatous affection is limited in extent, and the  reverse.
Towards  the fifth  or sixth  day  the redness fades into a
yellowish tint, the tumefaction subsides, and the epidermis is
folded upon itself in wrinkles.  At length  the  morbid color
disappears altogether, and the cuticle desquamates over the
dried surface.  This  is the ordinary  and most favorable ter-
mination  of  erysipelas verum.  When, however, the bullae
are numerous, the skin is covered with small brownish crusts,
which may  continue for some time.  Instead of running its
course on the  parts  where it was developed, erysipelas may
spread gradually to different parts of the body, according as
it disappears from its primitive seat.   In  other  instances it
spreads over  a surface of considerable extent, without disap-
pearing from the region where it was first  developed,  and
thus it has, in some rare cases, spread over the whole body.
M. Renauldin has related a  case of this  kind in  a woman
fifty years of age, who was,  however, speedily cured.   We
have seen a similar case at  the  Hotel Dieu, in which the
erysipelas, originating about a seton in  the neck,  spread thus
over the body and limbs, extending also to the cellular tissue,
and giving rise to large purulent formations, and soon proving
fatal.  There is a peculiar variety of  erysipelas (E. erraticum),
which flies  from one part to  another, leaving no  other traces
behind it than that of a slight desquamation.  We have seen
a case in which the eruption  appeared first on the left side of
the face, where it pursued the regular course; then broke out
on  the  other side  in  the  same manner; it subsequently 
ERYSIPELAS.
39
     returned to the part first affected, and so on three  different
«    times.  It  is to this form of the  disease that the chronic
     erysipelas  of  certain authors must doubtless be referred, of
     which Frank speaks.   When it assumes this  character, its
     duration is lengthened, desquamation  not taking place until
     the  end of two or three weeks.  Erysipelas  is  sometimes
     accompanied  with  oedema, especially when it attacks  the
     lower extremities, in persons of a soft and lymphatic habit.
     In these cases the  redness is pale, and sometimes  scarcely
     visible.  The skin  is smooth and  shining,  and retains  the
     impression of the finger for a considerable time.  (E. GEde-
     matodes.)  When oedema accompanies or precedes erysipelas,
     the termination of the latter is generally favorable ; but when
     it is consecutive of that disease, it is more dangerous ;  as, for
     instance, when it supervenes on anasarca, or from  the scari-
     fications necessary  to  give exit to the serous fluid, it may
     terminate  even in gangrene;  and,  in the event of this taking
     place, the inflamed skin  assumes a  livid or  bluish color.
     The  epidermis is raised in the form of [[large irregular phlyc-
     tenae, containing a  dirty brownish-colored serum, and death
     soon  ensues,  especially in  those  patients who have been
     already  exhausted  by previous disease.  When erysipelas
     results from  anasarca, it  most  frequently occurs on  the
     genital organs, and  on the lower extremities.
       2.   Erysipelas Phlegmonodes.—The  symptoms  of  this
     variety are much more intense than  those of  the preceding.
     The  inflammation extends much deeper, involving not only
     the  skin,  but  the   whole  thickness of the  subtegumentary
     tissues.  It may attack  any part  of the  body;  but most
     frequently occurs on the limbs; it is sometimes confined to a
     particular  portion, and at other times, spreads over a whole
     limb.   The  intensity of  the   symptoms, however,  varies
     according to the depth of the inflammation, and the anatomi-
     cal structure  of the parts  affected.  Even when the cellular
     tissue is not deeply inflamed, there is a high degree of pain,
     tumefaction,  and fever  present.  The skin  is  exceedingly
     painful on pressure,  and slowly  resumes its morbid color.   It
     may, in some  rare  instances, terminate by resolution, about
     the fifth or sixth day; but in general the pain  becomes dart-
     ing, the redness diminishes, and  a number of purulent deposits
     are formed, which,  on being opened,  discharge healthy pus,
     mingled with  flakes  of gangrenous cellular tissue.  When the
     cellular  tissue is deeply inflamed, or when the erysipelatous
     inflammation  spreads over a whole limb, the disease runs its
     course with  great  rapidity,  and  the subcutaneous  tissues
     appear to be inflamed at the  same time, or even  before  the 
40
DISEASES OF THE  SKIN.
skin itself.   The pain is intense in these cases ;  the  slightest
movement  makes the patient scream with agony;  the skin is    •
red, tender, and in a state of exquisite sensibility.  The pulse
is quick and hard, and the disease is  often accompanied with
delirium, insatiable thirst, parched tongue, and copious perspi-
rations.  This variety scarcely ever terminates by  resolu-
tion ; it usually  ends in  suppuration, between  the fifth  and
seventh  days,  sometimes   sooner,  the suppuration  being
accompanied by wandering  chills.  The redness and heat of
the skin  subside, but the swelling increases, and the limb has
a sort of doughy feel.  When the abscesses are  opened, they
discharge pus and  the debris of the  subcutaneous tissues, as
before  mentioned.   The disease continues  for a  considerable
time, and the patient, already exhausted by slow  fever and
suppuration, is run down by colliquative diarrhoea.
  Phlegmonous erysipelas may sometimes  appear in  a still
more severe  form ; as for example,  when  it occurs on  the
hands and  feet, where the swelling of the parts  is prevented
by  the   aponeurotic  sheaths.   The febrile symptoms  are
extremely  intense  in  these  cases.   Violet-colored patches
appear on the inflamed surface about the third or fourth day.
The skin loses its  sensibility,  and  the  patches  are  covered
with phlyctense, which extend rapidly.  Eschars form, which
are  gradually detached, and  the disease  terminates after
copious  suppuration.  Should  this severe  termination take
place while the  inflammation is diffused, the  whole  system
becomes  involved, symptoms  of severe  gastro-intestinal  dis-
turbance set in, and  delirium, drowsiness, wandering dreams,
and great change of the features immediately precede death.
  3. Erysipelas  Gangrenosum.—This  variety  often occurs
in those situations where the aponeurotic sheaths prevent the
parts from swelling, producing as it were a  kind  of strangula-
tion.  It is also  frequently  the  result of the scarifications
necessary to give exit to the serous fluid in  cases of anasarca.
It  chiefly attacks individuals who have been  debilitated  by
long-continued  disease,  or  whose constitutions have been
otherwise broken down.  Although the  local  symptoms  are
often comparatively mild,  in general,  however,  phlvctenae
form rapidly, and the inflammation of the skin soon terminates
in gangrene.  We have seen a case at the hospital  of  St.
Louis, in which the skin of  both breasts of a  female, imme-
diately  after delivery, was  quickly  destroyed.  The  nipple
and the areola around it escaped.   We have also seen a case
of an old man, whose left foot was attacked  with  phlegmonous
erysipelas, which had been at  first mistaken for gout.  The
skin was hot, the thirst great, and the  pulse frequent.  The 
ERYSIPELAS.
41
pain of the foot became very severe.  In the course of thirty-
six  hours from its first appearance, the inflamed surface was
covered  with  blackish  phlyctenae,  typhoid symptoms super-
vened, and the patient died on the fourth day.  On making a
post-mortem examination, the femoral artery was found to be
obliterated, and ossified to a considerable extent.   In  another
case, nearly analogous,  the patient recovered under the use of
charcoal applied externally.
  There are certain local varieties of erysipelas worthy atten-
tion, which we shall now briefly describe.
  1. Erysipelas  of the face is  by far the most  common of
them.  It generally commences  on the nose, the  cheeks, or
the eyelids, and gradually spreads over the face. The features
are greatly distorted, and  the eyelids are intensely  swollen.
It is accompanied with  general  symptoms, quick  pulse,  hot
skin, violent headache,  sleeplessness, wanderings,  and  slight
delirium, during the night.   These symptoms are  sometimes
very intense,  in  other cases they are scarcely perceptible.
The disease is at its height about the fourth  or fifth day,  and
resolution takes place on the  eighth.
  2. Erysipelas of the scalp  is rarely confined to that region;
it is frequently a  continuation of that of  the face.  In some
instances it is the result of punctures, contusions, minor ope-
rations, &c.   It is,  however, occasionally developed on  the
scalp, and does not extend beyond that  region during its pro-
gress.  MM.  Chomel  and Blache have related several cases
of this kind.   (Diet, de Med.  2d. edit.  art. Erysipelas.)   In
this variety the redness is so slight that it  may easily be mis-
taken for some other affection, but it is invariably attended
with cedematous swelling and great sensibility of the inflamed
skin.  It terminates frequently  in  suppuration,  and the sub-
cutaneous cellular  tissue often  becomes gangrenous  without
affecting the skin in the slightest.   This is  explained by  the
anatomical  disposition  of the vessels, which, as  Dupuytren
remarked, ramify in large branches on the internal surface of
the cutis vera, instead of in the tissue beneath it, as obtains in
the extremities.  This variety  is  more frequently attended
with cerebral symptoms, which  are  often  very  severe, than
any of the others.
  3. Erysipelas  of the  umbilical region is very frequent in
new-born infants  at the Foundling and other hospitals.  It has
been attributed to  rough usage  of the cord, and to the con-
fined air  of these  establishments.   It sometimes spreads to the
hypogastric  region,  and even to the genital organs, which
often become gangrenous;  death is then the inevitable result.
Although erysipelas appears most frequently in infants around 
42
DISEASES  OF THE  SKIN.
the umbilicus, it also  occurs now and then  on the face  and
limbs.  The new-born infant is more liable to this  than to
any other  exanthematous disease.   It rarely terminates  by
resolution or desquamation. Its most frequent terminations are
suppuration and gangrene, against which,  according to M.
Baron, no treatment will be of any  avail.   M. Baron  has ob-
served, that in cases where the  disease terminates fatally, it is
almost invariably  accompanied with  peritonitis.   (Diet,  de
Med. he. cit.)
   4. Erysipelas of the limbs is  often  very limited.   In other
cases it spreads over  an entire limb, and terminates by reso-
lution, with the exception of a circumscribed spot  or  two,
which generally suppurate.
   The most dangerous complications of erysipelas are cere-
bral and  gastro-intestinal inflammation.   The erysipelatous
inflammation usually  disappears suddenly in  these  cases,  and
at the same time the symptoms  of the organic lesion become
more marked.   In some instances, however,  it  does not  dis-
appear.   Swelling of  the  parts  is a frequent complication of
erysipelas of the face.
   Erysipelas, may terminate in resolution, desquamation,  sup-
puration,  gangrene,  and  death.   The first is fortunately the
most common.   Erysipelas of the  face is often preceded by
epistaxis.
   Autopsy.—A brownish  tint replaces the deep red color of
the  skin  after death.  The  epidermis peels off with much
facility.  The subtegumentary tissue is often  friable, infiltrated
with pus and shreddy.  M. Ribes has  observed the cutaneous
veins to be red and  inflamed, and to contain pus.   M.  Cru-
veilhier and Dr.  Copland corroborate this statement.
   Causes.—Erysipelas attacks persons of every age  and sex,
and  appears at  all seasons,   It occurs, however,  most  fre-
quently during the spring  and  autumn, and  in persons  of a
fine delicate skin, and sometimes spreads in an epidemic form,
especially through hospitals.  It is not contagious, although
Lorry was  unprepared fully to adopt the negative side of the
question.*  Local  irritants, exposure  to the sun,  punctures,

  * Dr. George Gregory considers it  both miasmatic and contagious.  He saya
that:—1st. It may commence in a hospital without the  suspicion of importation.
2d. That being so generated, from bed to bed, it may (spread by contagion.  3d.
That the miasma  generating erysipelas is identical with that which in lying-in
hospitals generates puerperal peritonitis, which  in foundling hospitals and work-
house nurseries gives rise to pudendal gangrene  and umbilical ulceration, which in
any hospital generates hospital gangrene, which  in hospitals differently circum-
stanced is found to occasion a malignant form of cynanche, both mucous and cel-
lular, with otitis, glossitis, an asthenic form of  laryngitis, and sometimes the most
aggravated type of typhus gravior.—{Led. on Eruptive Fevers, Amer. Edit., New
York, 1851, p.  210.)—H. D. B. 
ERYSIPELAS.
43
a contused wound, a minor operation, &c, often excite  this
disease.  The application of cold  may produce erysipelatous
inflammation in the form of chilblains.   It is, however, in all
these cases, often associated with  a peculiar state of the con-
stitution,  of  which we know little.  It may also arise  from
intemperance, from the use of putrid or highly-seasoned food,
and from  surfeit.   It occasionally  appears in a periodic form,
as for example, at the menstrual periods, when the discharge
is suppressed, or on the suppression of any other habitual dis-
charge.   Strong mental emotions and  gastric irritation fre-
quently produce erysipelas.  When the  disease  appears in
persons who have been long confined in prisons, hospitals, or
in any ill-ventilated places,  it is generally the result of chronic
derangement of the digestive organs.  It often supervenes
during inflammation of the serous membranes, or of some of
the internal  organ's; its appearance  is then, sometimes, con-
sidered salutary.   The relation that exists between erysipelas,
gout, and rheumatism, in certain constitutions, has been often
pointed out by writers on these diseases.
  Diagnosis.—The peculiar characters  of erysipelas are so
well marked that it is difficult to mistake it for any other affec-
tion.   In  cases of erysipelas of the scalp, a careful  examina-
tion  is sometimes necessary, especially  when it coexists with
some other severe  disease,  the symptoms of which are likely
to attract or draw off the physician's attention.*
  Prognosis.—Erysipelas  is only  dangerous when it is exten-
sively diffused or complicated with inflammation of the brain
or of the intestinal  canal.   When  the  erratic  variety of the
disease continues beyond a certain time, danger may also be
apprehended.  If it  supervenes during  the progress of ana-
sarca, pleurisy, pneumonia, and  gastritis, the  prognosis  is
generally  unfavourable.   Its sudden disappearance indicates a
metastasis to some of the internal or vital organs, and is in-
variably a bad omen.  The prognosis of phlegmonous  ery-
sipelas is  usually more serious,  and becomes  the  more so in
proportion to its extent.   Gangrenous erysipelas is  always
dangerous, especially when accompanied with  typhoid symp-
toms.  There are some  cases, however, in which the appear-
ance  of erysipelas seems to be  a  salutary turn or crisis of a
pre-existing disease ; as, for instance, when it occurs in gout,
rheumatism,  &c.;  but it is  in some of the chronic and rebel-
lious  diseases of the skin, as lupus, and certain old scaly erup-

  * The edges of the inflamed spot are as red as its centre, and slightly elevated
and festooned, the skin a line beyond this edge appearing to be normal; while a
line within it is as inflamed as in the centre of the affected part.  This festooned
edge, M. Velpeau considers as the pathognomonic sign of erysipelas.—H. D. B. 
44
DISEASES  OF THE SKIN.
tions, that the beneficial  results of its  development, whether
natural or excited, are most marked.
   Treatment.—When erysipelas is not  complicated with any
disease, or when  it is confined within a small compass, very
simple measures  will  suffice.   Regimen, diluents, quiet, and
the horizontal position,  are all that is required.   Goulard's
lotion is very beneficial in the variety called chilblains. When
the disease spreads, and  is accompanied with general symp-
toms, we  must have recourse to bleeding, especially if the
patient is young and plethoric, and  a general  reaction of the
system has taken place.   Venesection is also highly necessary
during  the inflammatory fever which  precedes the develop-
ment of the eruption.  Bleeding from the  arm is more effica-
cious than from the foot, as a  larger quantity of blood can be
obtained in a given time ; but when the pulse falls, and at the
same time the eruption preserves its intense character, local
bleeding is preferable when the face or the scalp  is  the part
affected.   Both  local  and general bleeding may  often  be
employed together with advantage ;  but the inflamed surfaces
should always be carefully avoided in opening the veins or
applying leeches. To these measures may be added acidulated
drinks, laxatives,  and regimen.   Erysipelas of the head always
requires the  most  energetic  and  decided measures.  Phle-
botomy ought to  be repeated according to the persistence and
urgency of the symptoms.   There is,  however, an exception
to this rule: for example, when the disease appears  in persons
of weak and broken-down constitutions, no matter how severe
the symptoms may be, great caution is  necessary in  extracting
blood from the system.   Emetics are  often very useful, espe-
cially in old persons, and where the digestive organs  are free
from inflammation, and  the tongue is  coated,  with  a  bitter
taste in  the  mouth, &c.   Purgatives sometimes  act  very
beneficially on the intestinal canal by derivation ; laxatives, or
mild purgatives, will generally suffice.*

  * In erysipelas, as it has prevailed of late years  in this country, and especially
in cities, the lancet is  rarely called for ; and, in some cases, supporting and even
stimulating means are required from the commencement.  This is especially true
of the disease as seen in hospitals and other public institutions.  In rural districts,
bloodletting  is more frequently beneficial, but even  here has often to be soon fol-
lowed by supporting measures.   The nature of the particular epidemic prevailing
at the time must be carefully studied.
   Mr. G. Hamilton Bell, of Edinburgh, has lately  recommended the internal use
of the muriated tincture of iron in this disease. He has used it in every case of
erysipelas which he has treated for upwards of a quarter of a  century without  a
single instance of failure, and says that it not only  removes the disease, but gene-
rally renders the patient more healthy and robust than before the attack.  He be-
lieves the capillaries in erysipelas to be in an atonic state.  After free action  on
the bowels, he gives fifteen drops of this article in water every two hours, in mild 
ERYSIPELAS.
45
  Local  applications are  seldom  useful in the treatrnpnt of
erysipelas.   Cold lotions should in particular be avoided ;  and
also poultices.   Blisters  may be  employed advantageously in
fixing to one spot the erratic variety of the disease,  or in repro-
ducing the  eruption  after  it has  suddenly disappeared.  Dr.
Higginbottom has cured erysipelas of the face, by touching a
small surface here and there with  the nitrate  of silver.   This
remedy has  also been employed to circumscribe  the  disease,
and prevent it from spreading.  MM. Biett and Velpeau have
adopted the same practice with success.   The application of
mercurial ointment  to the erysipelatous  surface has been much
recommended by writers in this  and in  other countries.  A
very strong mercurial  ointment should  always be employed,
otherwise it will be inefficacious.   It ought  to be rubbed in
gently with  the hand every two hours,  and for eight or ten
minutes at a time, provided that the friction  does not excite
much pain.   The parts are then to be covered with  dry linen.
Lard has been used by MM. Velpeau an# Lisfranc with some
success in cases of slight inflammation of the skin ;  but mer-
curial ointment has a peculiar antiphlogistic action in these
cases which simple  lard has not.  When lard is used, it should
be  as fresh  as possible.
   A layer of  larded cotton laid on a  piece of thin oiled silk,
and very loosely bound  on the affected surface,  with a  fine
compress over  it,  is a  very simple,  and often an efficacious
topical application.*   In phlegmonous  erysipelas, both local
and general bleeding should be resorted to the moment the
disease appears.   Emollient  local baths  may also  be em-
ployed and continued for some time, as much with  the view
of  encouraging the  bleeding as of diminishing the inflamma-
tion.
   If these measures fail, and  the  disease  still advances, we

cases, until the disease is completely removed.  Inl more  severe cases he gives
twenty-five drops every two hours, night and  day, however high the fever and de-
lirium. The only local applications he finds necessary are hair-powder and cotton
wadding.  The bowels require attention throughout the treatment.
  His brother,  Dr.  Charles  Bell,  unhesitatingly expresses the  same favorable
opinion respecting it, after an experience of many years in its use, and has  derived
equal benefit from it in infantile erysipelas, and in  the form consequent upon ex-
ternal injury.  He gives it to young infants in doses of two drops, every two
hours, in a teaspoonful of sugared water.  Both writers give cases in illustration.
—{Monthly Jour. Med. Science, June, 1851.)—H. D. B.
  * M. Velpeau speaks very favorably of the sulphate of iron as a  topical remedy
in this disease, either in solution or as an ointment—the former of  the strength of
Jj to fvj water, and the latter 3iiss  to §j—3x lard, to be applied every second
or third hour.  Internal remedies must also be used, if indicated by the symptoms.
The following lotion, extensively used in  the New York hospital, is found both
agreeable to the patients, and useful  in allaying the local inflammation:—fy. liq.
ammon. acet. § iij ; spir. vin. § j; aqu. fontan. § xij. m. f. lot.—H. D. B.
                              4 
46
DISEASBS OF THE SKIN.
must have recourse to free  incisions  of the  inflamed parts
down to the sheaths,  with the view of relieving the painful
tension  of the  aponeuroses, of giving exit to the confined
matter,  and of circumscribing the  gangrene.  Compression
by means of a bandage is not only a useless but even a dan-
gerous remedy in phlegmonous erysipelas.   It  may produce
gangrene.  In E. oedematodes of the legs, however, it is often
very useful.  Tonics  may be  employed with advantage  in
the early stages of this variety.   Sulphur fumigations have
been recommended in certain varieties of erysipelas.  In gan-
grenous erysipelas we ought early to have recourse to tonics,
some of which should  even be applied  to the diseased surface.
Acidulated drinks,  quinine, compresses  wet with aromatic
decoctions;  and at a later period quinine powders, camphor,
and  a solution of chloride  of lime, in the proportion of a
drachm to a quart of water,  as topical applications, are indis-
pensably necessary.   M. Biett has  employed charcoal poul-
tices  in  gangrenou% erysipelas with  great success,  and  we
have witnessed their very favorable action in some cases.

                       ROSEOLA.

Syn.—Effiorescentia erysipelatosa;  Rosalia ; Rosacia ; Ru-
   beola spuria; Rash ; Rose  rash ;  Anomalous  rosy erup-
   tion.

   Roseola is a mild, transient, non-contagious, exanthema-
tous eruption, characterized by deep  rose-colored patches of
various size  and form, without elevation, and generally pre-
ceded and accompanied by febrile symptoms.  It may attack
the whole surface  of  the body at once, or, as often happens,
be confined to  certain regions, as the trunk, the limbs, &c.
It is  always an acute affection, and its duration varies in
general from twenty-four hours to a week.
   Symptoms.—1. Roseola infantilis occurs in young infants
whose stomach and bowels are out of order,  or during den-
tition.  It appears in  the form of an  eruption  of  numerous,
deep, rosy-red patches of a nearly circular  shape, and from a
fourth to a  half of an inch in diameter.  They are closely
crowded together, yet perfectly distinct, and disappear in the
course of twenty-four or thirty-six hours.   In some instances
they  alternately vanish and  reappear for several days.
   2.  Roseola cestiva  is the most severe form  of  this erup-
tion.   It is usually preceded by  pretty smart  febrile  symp-
toms.  When  it attacks children,  slight delirium and even
convulsions often supervene.  The eruption usually appears
between the third and seventh days  on the face and neck, 
ROSEOLA.
47
whence it spreads, in the space of twenty-four or forty-eight
hours, over the rest of the body.  The  spots are of a deep
red color, more irregular in shape  than those of measles, and
their original color soon passes into a bright rosy hue. There
is also present a considerable degree  of itching and pain, and
often difficulty in swallowing.  The  progress of this affection
is very irregular ; there is sometimes entire absence of febrile
symptoms.  It lasts about three or four days, and then disap-
pears without any evident desquamation;  but it sometimes
disappears for a time, returns after a short interval, and then
vanishes  altogether.   It  sometimes appears  epidemically
during  hot  summers.  Children and females  appear  to be
most subject to it.
  3. Roseola autumnalis appears  during the autumn in chil-
dren ;  the patches are larger than  those  of  the  preceding
variety; they are seated on the upper extremities, and there
is scarcely any fever.
  4. Roseola  annulata appears in the form of distinct rosy
rings, in the centre of which the skin retains its natural color.
The rings are at first small, but gradually increase, and two
or three  may frequently be  seen  encircling each  other.   It
is principally observed upon the abdomen and lumbar regions,
on the buttocks and along the  thighs.   The  duration  of this
variety is,  when accompanied by  fever,  short,  but it fre-
quently assumes a chronic form, when it is  generally compli-
cated with some derangement  of  the digestive organs.  We
have seen two cases in which  it coexisted with chronic peri-
carditis.
  Causes.—Roseola appears at all  ages, and in both sexes ;
but occurs more frequently in children and in females, and in
summer and autumn, than at other seasons.  The same indi-
vidual  may have  repeated attacks  of it. It sometimes appears
in an  epidemic form, especially  in very warm seasons.   It
may precede the  eruption of small-pox, both natural and in-
oculated, and appears on the ninth or tenth day of the vacci-
nation  of some children.  Dentition, cold  drinks  when  the
body is heated, severe exercise, and gastro-intestinal irritation
in children,  are frequent causes of this affection.
  Diagnosis.—Roseola has frequently been confounded with
measles and scarlatina.  The spots of roseola are nearly cir-
cular, and are always circumscribed ; they are of a deep rose-
color, larger than those  of measles,  and smaller  than those
of scarlatina.*  The patches of measles are small, irregularly

  * In the edition of 1847 the patches are said to be larger than those of scarla-
tina, without any mention of their size compared with those of measles.—H. D. B. 
48
DISEASES OF THE SKIN.
semilunar, and of a bright red color; those of scarlatina are
large and diffused, and  of a raspberry tint.   Both these dis-
eases are  contagious,  and their  symptoms are peculiar  to
themselves.  The most experienced physician, however,  may
mistake  them  when  they  first  begin to  appear.  Roseola
annulata is distinguished from herpes iris by the absence  of
vesicles, and the large size of its rings.   Roseola is always a
mild affection.
   Treatment.—-Roseola does not require any particular treat-
ment.   Rest and antiphlogistic regimen are all that is neces-
sary.  \^hen it  is symptomatic of another disease, it is towards
the latter  that the  attention  should be  chiefly directed.
No treatment is required when it appears after vaccination.*


                       MEASLES.

       Syn.—Rubeola ; Morbilli ; Febris morbillosa.
  Measles  is a contagious  exanthematous disease accom-
panied from the beginning with coryza, lachrymation, cough,
and fever.   It  is characterized externally by small red spots,
slightly elevated and distinct at first, but soon becoming con-
fluent, assuming an irregular  semilunar form,  and leaving
small intervals  between  them  where the  skin is perfectly
sound.
  The progress of this disease is always  acute; eight or ten
days is about the extent of its duration;  but some few of the
symptoms frequently continue for a longer period.   The erup-
tion itself does not last longer than three or four days.
  Symptoms.—The invasion of measles is indicated  in  most
cases by a state of general languor of the  system, lassitude,
especially in the lower extremities, rigors, followed  by heat  of
skin, bleeding from the nose, and vomiting.  These symptoms
invariably  precede the appearance of the  disease for some
days, and  are then followed by  the  phenomena peculiar  to
measles—frequent pulse, heat of skin, sneezing, coryza, flow
of tears, discharge from  the nose of clear mucus,  frequent
dry  cough, slight  pain,  thirst, anorexia,  nausea, white  and
moist tongue, constipation,  red and scanty urine,  headache,
drowsiness, and sometimes  convulsions when infants are at-
tacked.
  These symptoms are developed within the first forty-eight

  * The evident connexion in most cases between roseola and gastric and  intes-
tinal disorder, leads to the necessity for means for the removal of this.  When it
lingers, or has a tendency to frequent returns, tonics, tepid baths, and a nourishing
diet, with laxatives, will often be found necessary.—H. D. B. 
MEASLES.
49
hours; their intensity, as also that of the fever, increases to
the third or fourth day ; when they are succeeded by  intense
heat of skin, perspirations, greatjsensibility of the conjunctivae
and  eyelids, coryza,  hoMjseness,  harassing  cough,  dyspnoea,
redness of the tongue, and occasionally vomiting and slight
delirium.   At this period,  the palate  and uvula are covered
with small red points, which soon become confluent.
  About the  fourth or fifth day, small,  circular, red spots,
slightly elevated like papulae, appear on the forehead, chin,
nose  and  cheeks.  Soon  after, the neck, chest, body,  and
limbs, are covered successively with a similar eruption.   The
spots gradually increase in size; they become slightly promi-
nent, and are not unlike flea-bites in appearance.  Sometimes
a small vesicle may be seen in their  centre.  They now in-
crease in  number, and uniting together, form  patches of an
irregular, semilunar appearance, leaving spaces  between them
in which the skin preserves its natural color.  In some cases,
and especially about the .hands and face, a sensation of rough-
ness  is given to the  finger when passed over the eruption.
The redness of the spots in general attains its greatest inten-
sity about twenty-four  hours after  their  appearance,  and
the eruption itself usually terminates in thirty-six hours from
that period.  About this time the face is greatly swollen, and
in some instances the tumefaction of the eyelids is so great as
to impede vision.   On the sixth day, the redness  begins to
subside on the face, and increases on other parts of the body.
About the seventh day, the eruption begins to disappear alto-
gether, and on  the ninth,  slight yellow patches indicate the
places which it  occupied.  The disappearance of the  disease,
which follows the same order as that of its development, is  suc-
ceeded by desquamation of the cuticle, generally accompanied
by a smart itching.  This desquamation, however, is never so
great  as  that which  succeeds  scarlatina.   The  heat, thirst,
coryza, cough, and other symptoms,  instead of subsiding as
the eruption advances, are considerably increased ; the expec-
toration  is abundant and thick; the  sputa have a peculiar
character, being round and nummulated, very analogous to
the sputa  of  patients with phthisis;  but the pulse becomes
slower.  These  phenomena, however, generally cease as soon
as the eruption disappears.  The  cough continues longer than
any of the other symptoms mentioned, haemorrhage from the
nose  sometimes supervenes at the termination of the  disease,
and  frequently  a  slight  diarrhoea ensues,  which appears to
hasten the convalescence.
   This is the natural course of  measles; but in some cases
the eruption  is scarcely apparent, .whilst in others it is unna- 
50
DISEASES OF THE  SKIN.
turally developed.   Sometimes the  red  color of the patches
is very intense, while, on  the  contrary, it is scarcely visible
in other instances.
  Measles  may be  complicated wj|fr a variety of diseases.
It may coexist with variola in the  same individual, but the
progress of one  of  these eruptions is,  under such  circum-
stances,  generally arrested  by that of the  other.  Hunter
mentions some curious cases bearing upon this point.   It is
rarely  accompanied by petechias;  but as M. Biett has  fre-
quently observed, the patches may assume the color and form
of purpura simplex,  and will no longer disappear under pres-
sure of  the finger.   The  complications  which  especially
demand  our  attention are the  cerebral  affections which
frequently terminate in effusion of serum into the  ventricles,
and pulmonary and  gastro-intestinal inflammation.  It  is in
these  instances that those symptoms called ataxic and ady-
namic  are developed.
  Croup is a  very  dangerous complication of measles;  but,
fortunately, not a very common one.  In short, a  variety of
eruptions of the vesicular, bullous, and pustular classes, may
accompany measles.
  Independent of the complications now mentioned, several
other  diseases may  arise  during  convalescence;  as for ex-
ample,  we not unfrequently  meet  with  obstinate  chronic
ophthalmia, inflammation of the mucous membrane of the air
passages,  otitis,  accompanied  with deafness,  and  chronic
inflammation of the lymphatic glands and vessels.  In indivi-
duals  predisposed to phthisis,  the  development of tubercles
appears to  be favored by the continuance of the catarrh con-
sequent upon  measles.   The convalescence of this affection
may also be retarded, as in cases of scarlatina, by  the occur-
rence of acute dropsy; a contingency, however, much more
frequently  occurring in the latter than in the former disease.
  In  the majority of cases,  measles follows a pretty regular
course, and terminates  favorably; but sometimes the patients
sink,  and then death is to be attributed to one of the compli-
cations of  the disease,  as in those fatal terminations signs of
inflammation,  or of organic congestion, are invariably  disco-
vered on making a post mortem examination, most frequently
of the  brain, the lungs,  or the stomach.
   Causes.—It is  pretty generally admitted that the measles
is the result of an unknown  morbid poison, which may be
transmitted by contact or by infection, and generally occurs
but once, in the same individual, during life.
  There are,  however, some well  attested cases  on record
of relapse  of  measles.   TJje arguments put forth  by writers, 
MEASLES.
51
with  the view to  prove that inoculation  of the blood  of  a
patient affected with measles into a healthy individual  may
transmit that disease, are by no means conclusive.*
 _ Measles is not indigenous to any country ;  it almost inva-
riably prevails in an epidemic  form.   In some of these epi-
demics,  and in  certain cases,  coryza and irritation  of the
pulmonary  mucous membrane are the only symptoms deve-
loped ; and again, in a few rare instances, measles shows  itself
without any of these phenomena.  In the latter cases,  how-
ever,  the patients  are  not protected from a second  attack.
No age is exempt from the  disease, but young subjects are
those most frequently attacked.  Infants have been borri with
the disease.  It occurs, however, more frequently after  than
before the first dentition.   It  prevails more during the  winter,
and particularly at the  beginning of spring, than at any other
season.
   The eruption generally appears  between  the tenth  and
fourteenth day from the period of infection.
   Diagnosis.—The characters  and progress' of the disease,
and the nature of its symptoms, are  always sufficient  to dis-
tinguish measles from scarlatina.  In measles, the symptoms
of  invasion precede the  eruption  three or four days; the
patches are smaller, of a bright red color, irregularly semi-
lunar, and the skin  between them is  perfectly healthy.  In
scarlatina, the eruption appears more suddenly, the patches
are larger, irregular, and of a raspberry tint.   The eruption
of scarlatina never disappears in the uniform manner  of that
of measles; and small irregular patches are  observed about
the end of the fifth day, which may easily be confounded
with  those  of the latter disease.   There  are,  indeed,  some
cases in which the diagnosis is really very difficult,  as, for
example, in those instances where large patches of an uniform
red color cover different parts  of the body,  and where the
symptoms of irritation of the mucous membranes  resemble
those commonly attendant  upon  scarlatina.   In such  cases
the prevailing epidemic  should be taken  into consideration,
and  the leading symptoms of  the disease;  the fact of the
patient  having already had the  measles should  not deter the
physician from making a careful examination, for it is ascer-
tained  that the same individual may be affected  twice with
this eruption.f
  * Measles has been communicated by inoculation with the blood in several well
authenticated instances.   In Hungary, in 1842, Dr. Ratona also inoculated 1122
persons with a drop of fluid from a vesicle, or from the tears of patients, and failed:
in only seven per cent, of those on whom it was tried.—Brit, ty For. Med. Re-
view, July, 1845, p. 211.                                 H- D- B-
  t To the above diagnostic marks between measles and scarlatina, we may add : , 
52
DISEASES OF THE SKIN.
  With regard to roseola, the size and deep red color of the
patches,  their  rounded  form,  and  its non-contagious cha-
racter, readily distinguish it at a certain period; but when the
ordinary symptoms  of measles do  not  appear  at  the  com-
mencement, it may be mistaken for that eruption.  In short,
the different cutaneous affections with which  measles may be
complicated,  have their own peculiar characters;  but it  is
necessary to remark, that  their progress  is sometimes very
insidious, and requires considerable attention.
  Prognosis.—Measles is not in general a severe disease, but
may become so in many  cases.  It is particularly dangerous
when 'attacking  pregnant women, or those  lately  confined
and  also individuals  exhausted by previous  disease, and in
feeble  children,   of  lymphatic  temperament,  who  are pre-
disposed  to  bronchial irritation.  In  forming the prognosis,
account should be taken of the general character of the form
of the disease then prevailing, of the degree of intensity of the
accompanying lesions, and the nature of the organs affected.
  The appearance of petechiae, a premature eruption, its sud-
den disappearance, followed by a considerable degree of fever
and oppression, are unfavorable signs.
  Treatment.—The  ordinary treatment  of measles  consists
in regimen, repose,  a moderately cool temperature, diluents
and  mucilaginous drinks, the  inhalation of  some  emollient
vapor, and care to protect the eyes from too strong  light.
  Emetics will be found very efficacious, if  administered at
the commencement,  with  the view of relieving  the sickness
of the stomach, but  especially  with the view  of  encouraging
the eruption.   In some instances, the administration of a few
grains of ipecacuanha will bring out the eruption more rapidly
and more freely.
  When measles is  complicated with croup, emetics will be
indispensable.  The  constipation which continues during the
first day or two, produces no inconvenience; and if it persists
when the disease is  further advanced, it may  be removed  by
simple injections.
  If the eruption does not  come out freely, or if it  suddenly
disappears, diaphoretics should be administered immediately.
The patient is to  be put into a warm bath, containing mustard,
or, still better, into a vapor bath, if it can be conveniently
done.  But when it  is very slow in appearing, and the fever

the difference in the periods  of incubation,  that of measles being two  weeks,
that of scarlet fever one week; the difference in the accompanying symptoms of
each, and also in the secondary affections peculiar to each.
  Dr. Gregory says that the color of measles is brightest on the parts exposed, and
in scarlet fever brightest on the parts covered.                  H. D. B. 
                         MEASLES.                      53

is at the  same  time increasing, we have reason  to fear
the development of some internal disease; and in the event of
this, it will be necessary to take decided preventive measures
at once.   We shall now pass in review the therapeutic mea-
sures which will best  contribute to this end.
   General and local bloodletting first command our attention.
In having recourse to these  remedies, it will be necessary to
distinguish clearly the symptoms which naturally accompany
the disease, from those which  depend upon  internal inflam-
mation, involving, to  a certain  extent, the  life of the patient.
As,  for  instance, during the  eruption of measles,  there is
frequently a good deal of  functional disturbance,  thoracic
pain, severe cough, prostration, and on stethoscopic examina-
tion,  a  sub-crepitant rale,  of  more or  less intensity, is
frequently discovered; nevertheless,  these alarming  symp-
toms almost invariably disappear spontaneously, as the disease
subsides.  But if they continue, recourse must be  had,  and
that  promptly, to general and local  bloodletting,  and  the
quantity  of blood to  be drawn must  be proportioned  to  the
strength of the patient and the  urgency of the symptoms.
   When  evident signs of pneumonia are present before the
appearance of the eruption,  or where  there are symptoms of
gastro-intestinal inflammation,  or coma, stertorous breathing,
accompanied with a high degree of fever,  the disease should
not  be left to nature; blood  should  be  drawn  freely.   In
young children,  the  application  of leeches to the  temples,
behind the ears, at the epigastrium, or anus, may be substituted
with advantage  for phlebotomy.   In  adults and  young sub-
jects, it  is frequently  useful to employ, at the  same time,
general and local bleeding.  It often happens,  when blood is
drawn under these circumstances, that the eruption appears
immediately,  and the symptoms become  less  urgent.  The
period at which  bleeding  should  be resorted to is highly  im-
portant ; the remedy  will  be  efficacious, in  proportion as it is
employed early, and at the commencement of the accompany-
ing  inflammation.  When the different vital  organs have
been already for some time the  seat of congestion, instead of
being useful, it  may  even hasten  a fatal  termination.   In
short, the employment of bloodletting is a point of the highest
importance; it is to be regarded as a remedy which has  for
its object the prevention or subjugation of these inflammatory
diseases  which, instead of averting the measles, invariably
aggravate that disease.
   Purgatives, perhaps, have  been too  much extolled in  the
treatment of measles.  The  gastro-intestinal irritation with
which it  is so frequently complicated, indicates the necessity 
54                DISEASES OF  THE SKIN.
              •
of being cautious in employing  these remedies.  They may,
however,  produce  considerable  beneficial  effect in  cases
where meningitis, pneumonia, sore throat, and croup occur;
they should be employed  conjointly with bloodletting.    The
purgatives which we have found most efficacious are manna,
senna, calomel, and castor-oil.
  About the ninth or tenth day, when the diarrhoea generally
commences, gentle cathartics and laxatives may be employed
with advantage; but when the disease is subsiding, they are
particularly  required.
  Blisters and sinapisms  should be employed with reserve ;
they are sometimes beneficial in reproducing the eruption or
hastening its progress.
  The application of cold water, when the skin is dry and
hot, has been much praised by English  practitioners.  When
speaking of  the treatment of scarlatina we shall recur to this
remedy,  which is  not, perhaps,  so applicable to measles, in
consequence of the frequency of its complication with pulmo-
nary inflammation, a circumstance already  observed  by M.
Guersent.
  Tonics, such as wine, bark, quinine,  camphor, are only in-
dicated when  the pulse is small and feeble, the skin cold, and
the eruption pale or livid. They  should never be adminis-
tered in cases where the skin  is dry and burning, notwith-
standing the appearance of adynamic symptoms.
  During convalescence tepid baths may be employed, but
great precaution is necessary to guard  against cold or chills.
If the cough continues, laxatives, opiates, a blister to the chest,
or on  the inside of each  arm, should be prescribed.   Some-
times slight febrile symptoms supervene, and hygienic  mea-
sures become necessary.  In conclusion, in  cases of obsti-
nate diarrhoea, opiates, emollients, strict regimen, a blister in
each groin,  or in the ileo-coecal region, are the remedial mea-
sures most likely to prove beneficial.  The prophylactic treat-
ment consists solely in isolation.   Since it is not positively
ascertained when  the contagion ceases, it is prudent to con-
tinue this precautionary  measure until  after the twentieth
day.

                     SCARLATINA.

Syn.—Febris scarlatina; Angina erysipelatosa;  Rosalia ;
   Purpurea scarlatina ;  Febris anginosa ;  Morbilli  confiu-
   entes.

   Scarlatina  is  another contagious exanthematous disease,
 appearing in  the form of minute  red  spots, which soon run 
SCARLATINA.
55
together, and  form broad, irregularly-shaped  patches, of a
raspberry color, which in  their turn  become  united, and
spread over a large extent of surface, sometimes  over  the
whole body.  The eruption appears between  the  third and
sixth day after exposure  to contagion,  and is preceded and
accompanied by general  febrile symptoms, and  irritation of
the mucous membrane of the mouth, larynx, &c.
   Symptoms.—Scarlatina presents great variety in the cha-
racter of its symptoms, being sometimes a very slight disease,
and at other times a severe one; and often accompanied by
serious  complications, which place  it sometimes beyond  the
reach of even the most appropriate  treatment.
   1. Scarlatina simplex generally sets  in  suddenly, towards
evening, with  symptoms of extreme  depression, rigors, nausea,
vomiting, and pains in  the back,  loins,  and limbs.   The
pulse is greatly accelerated, beating from  120 to 140  pulsa-
tions  in a minute,  and respiration  is hurried and irregular.
The body is hot, whilst the feet  are cold; and in some rare
cases convulsions supervene about this period.  The follow-
ing day, sometimes earlier, the eruption  appears ; first, on the
neck and face, whence it  spreads over the  whole body in the
space of twenty-four hours.
   The  eruption  consists of a great number of  small  red
points, which are so close  together  that the entire surface of
the skin is of a bright red color, and feels rough to the  touch.
It is also accompanied with intense heat, and a distressing
burning sensation; and the parts upon which the  body  has
been  lying ai*e of a bright scarlet  or raspberry  color.  The
color is equally vivid in the bends of the joints.  The tongue,
the pharynx, the soft palate, the internal surfaces of the eye-
lids, the nostrils, and the cheeks, present  the same brilliant
hue, and deglutition is painful and difficult.  The tongue is
often red only at its apex and edges, whilst the middle  and
back  part are covered with a whitish fur,  through which the
inflamed papillae project, giving the part the appearance of a
ripe strawberry.  The eruption is  usually accompanied  by
more or less  excitement;  sometimes there is delirium  and
coma.   The  febrile  symptoms sometimes subside on  the
appearance of the eruption, but they  commonly  continue,
as well as the thirst, heat, nausea, constipation, and difficulty
in  swallowing.   The  raspberry  tint is always  most vivid
towards the evening, especially about the third or fourth day.
It begins to subside about the fifth, and generally  disappears
on the  seventh, at which period desquamation  commences.
The foregoing symptoms disappear with the eruption.  The
redness  of  the tongue,  however,   continues, and  copious 
56
DISEASES OF THE SKIN.
perspirations or diarrhoea often supervene.  The urine fre-
quently deposits an abundant thick sediment.   The process
of desquamation, which may either be of the furfuraceous or
lamellated kind, is invariably attended with an insupportable
pruritus, and is often prolonged even for thirty or forty days,
and may be renewed several times.   This is the mildest form
of scarlatina, the duration of which is from eight to ten days.
  2. Scarlatina anginosa  derives  its  name from the much
more  severe affection of the  throat which  accompanies it.
All  the  precursory symptoms  are  much more  aggravated in
this variety  than in scarlatina simplex.  The patient com-
plains from the onset of stiffness of the muscles of the neck
and lower jaw; the mucous membrane of the pharynx is of a
bright red color.  After the second day the tonsils become
greatly swollen, fche .voice is hoarse, deglutition is painful and
difficult, and sometimes the liquids attempted to be swallowed
are  returned by the  nostrils.  Respiration is painful, and
there  is  a sensation  of  suffocating constriction  about the
throat.   The pulse  is also very frequent, the skin very hot,
and there  is restlessness, headache, coma, slight delirium,
epistaxis, nausea, and sometimes vomiting.
  The eruption presents  nearly the same appearance  as in
scarlatina simplex;  but it does not always  appear on the
second day, and often not until  the third, nor  does it spread
so extensively.  It  appears  in  the form of  broad  scarlet
patches,  irregularly  shaped,  and   scattered over different
regions of the body, especially on those parts  on which the
body rests.   The pillars of the  soft palate, thfe tonsils, and
pharynx, are in many cases  covered  with thick mucus, or
with flocculi of greyish-white pultaceous matter, which some-
times  remain adherent for several  days, and in other  cases
are  renewed  every  twenty-four hours.  These pultaceous
exudations are sometimes rendered dark-colored by extrava-
sated  blood; the tongue  often cracks, as well as the  lips,
which are  covered with black crusts formed by dried blood.
The tonsils, uvula, and posterior fauces are also occasionally
slightly ulcerated.  The eruption frequently disappears in the
course of twenty-four hours, and reappears on other parts of
the body at different intervals.  The symptoms are not more
severe in these cases, but their duration is longer, and desqua-
mation is less regularly accomplished.   The affection  of the
throat is the most obstinate symptom in  this variety  of the
disease.
  3. Scarlatina maligna  is a still  more intense form  of the
disease  than either of the  foregoing,  from  which it  differs
merely in degree, and scarlatina, which is  mild at first, may 
SCARLATINA.
57
early assume a malignant character.   The symptoms at first
are  the  same  as those already  enumerated,  but  become
greatly aggravated on the first or second day.   The eruption
usually appears within twenty-four hours, but is often later in
showing  itself.  There  is great depression, excessive thirst,
dryness,  and burning heat of skin,  anxiety, oppression, and
vomiting;  the pulse is full and frequent.  The symptoms be-
come still more severe in the course of a few hours; delirium
supervenes, the tongue becomes dry,  and the pulse feeble, the
eyes  injected, the  face of a dark  crimson color, and  the
breath foetid, and the tonsils and parts about them are covered
with a  blackish exudation.   When infants are attacked,
typhoid symptoms supervene.  There is coma, and stertorous
breathing, tumefaction about the neck,  and the head is bent
backwards on the body, and  the pulse  very  weak and very
rapid.   To  these sometimes  succeed haemorrhage from  the
noseband bowels, an eruption of petechiae, cold extremities, and
death.  All these symptoms follow in rapid succession, and
death often occurs without  the disappearance or even  the
fading of the eruption, and the burning heat of  the skin even
persists  to the  moment of  dissolution.  This  variety  may
terminate in death in a few hours,  or not until the end of the
third or  fourth  day, or even later.  When the disease  does
not thus terminate, gastro-intestinal inflammation  supervenes,
and  extensive  suppuration  takes  place  in the  numerous
eschars which form on different parts of the body.
   Scarlatina may be complicated with a variety of inflam-
matory cutaneous diseases.   Miliaria, for example, is a  very
frequent complication.  The eruption appears  on the chest,
neck, shoulders, temples, and  scalp, and  quickly vanishes
again, either by absorption, or by  the discharge of the fluid
of the vesicles.  It is  rarely  complicated with erysipelas,
measles,  or variola.  Inflammation of  the  mouth, posterior
na^es, and  pharynx,  are  the most dangerous,  and,  unfortu-
nately, the  most frequent complications of S.  anginosa and
S. maligna.  The greater part of the epidemics of gangrenous
anginas  described by Fothergill, Huxham, &c, were probably
instances of diphtheritis; and it is a rational supposition that
before the labors of M. Bretonneau, many cases of this dis-
ease were  regarded as gangrenous angina.  Croup  is  an
exceedingly rare complication ;  M. Biett and M.  Bretonneau
have never seen it, and M.  Guersent has  seen but a single
case of the kind.  Inflammation of the brain, thoracic viscera,
or of the mucous membrane of the  stomach and bowels,
almost always supervenes in the intense forms of the disease.
All  the  large viscera are often affected  simultaneously, in 
58                DISEASES OF THE SKIN.

which  case the  disease soon  proves  fatal.    The  partial
gangrene which occurs in some  cases  indicates a state of
great exhaustion in  the  circulation.   Amongst  the other
sequelae of scarlatina, we may  mention  abscesses  in the
tonsils, bronchitis, ophthalmia, otitis,  and deafness;  inflam-
mation of the parotid and testes in adults, or of the submaxil-
lary and inguinal glands in children.  But those which are
most to be feared during the convalescence of this disease,
are acute anasarca, and effusion into  the different splanchnic
cavities.  Anasarca usually appears about eight or ten days
after the eruption has  subsided, and may be partial or general.
It occurs much more frequently, and is much more severe, in
children than in adults, and oftener in the winter than in the
summer season.   The precursory symptoms are depression of
the spirits, languor, sleeplessness,  and want of appetite, with
frequent and  hard pulse,  hot  skin, and  scanty and turbid
urine.   The  oedema  commences  at  the eyelids, thence  it
spreads to the face, the lower extremities, and sometimes over
the  whole body.  It continues for  eight  or  ten  days, and
when confined to the  subcutaneous cellular tissue, is not dan-
gerous.  It may be complicated with  pain in the bowels and
diarrhoea.  In some rare cases, rapid  effusion  into the serous
cavities takes place, and death soon follows.
  Autopsy.—External appearances.   In general the  skin  is
studded with large livid  red  patches, which  do not  extend
deeper than the epidermis.  In other instances there is not
the slightest trace of any  eruption; but in  all  cases putrefac-
tion takes places rapidly in the tegumentary tissues.
  Internal appearances.—The mouth,  the pharynx, the larynx,
and even the trachea, are red, and  covered with a  grayish
white  pultaceous matter.   The  substance  of  the brain, and
the  vessels which ramify on it, are often highly injected.
The lungs are sometimes  sound, sometimes  engorged with
blood,  and friable; and in other instances  the parenchyma-
tous tissue is dense, of a bright  red  color,  and is torn with
difficulty.  The mucous membranes of the stomach and bow-
els  generally present  a slight red color, and  occasionally  a
peculiar violet hue;  but in a great many cases  they  are free
from every morbid alteration, even when diarrhoea has been
a prominent symptom.
   Causes.—Scarlatina is the result of an unknown contagious
principle, and occurs more frequently in children and young
persons than in any other class of individuals.   It is a disease
of frequent occurrence at the Children's Hospital, Paris, whilst
it rarely appears in the Foundling Hospital.  Its appearance
is confined to no particular season, but  it sometimes  prevails 
SCARLATINA.
59
in an epidemic  form in autumn, when  there is much rain,
succeeded  by great heat.   All  damp situations and  places
where there is not a free circulation of air, predispose to this
disease.  It appears to be most contagious during the  period
of desquamation.   It  never attacks  the same  individual a
second time.  Willan never met with  an instance of its return
in two  thousand cases.*  In some epidemics,  the constitu-
tional  symptoms occasionally occur without the eruption, or
the eruption without the constitutional symptoms.
  Diagnosis.—Scarlatina cannot be confounded with measles,
if we recollect that in the former the eruption appears ordi-
narily in the space of twenty-four  hours after the first symp-
toms.   The raspberry color of the eruption, the sore-throat,
and  the peculiar character of the  phenomena which  accom-
pany scarlatina, will readily distinguish  it from that disease.
Roseola is sometimes attended with decided sore throat;  but
the patches are  much broader, and the color is more vivid in
scarlatina.  Besides, the duration of  the former is short and
irregular, whilst that of the latter is prolonged, often for a
considerable time.
  Prognosis.—Scarlatina simplex is not a dangerous disease.
The prognosis of the other varieties is much more unfavora-
ble,  especially when they occur in  pregnant  women, or in
those newly confined, and when they are  accompanied with
other severe diseases.
   Treatment.—The treatment of the  mild forms of scarlatina
may be confined to dietetic and slight antiphlogistic measures.
A moderately cool temperature, refreshing mucilaginous drinks,
acidulated with lemon juice or hydrochloric or any other acid,
and  slightly detergent emollient gargles, are the only reme-
dies required.   The constipation which always exists at  the
commencement, should  be obviated  by simple  injections or
laxatives.  It is sometimes necessary to prescribe emetics at
an  early period;  however, in general, they produce gastric
irritation.   S. anginosa and S. maligna require more ener-
getic measures  than the foregoing,  espcially  when  compli-
cated with organic disease.  Bloodletting may  be necessary
under these circumstances. The repeated application of leeches
to the  neck, especially  when the  cervical and submaxillary
glands  are much  swollen,  and  when the pain  is intense, is
attended  with the  most beneficial results.  Leeches  to  the
epigastrium  are  also  serviceable  in  those cases which  are
accompanied with obstinate vomiting and violent pain of that

  * Second attacks of the disease do occur, though probably much less frequently
than is generally supposed.                              H. D. B. 
60
DISEASES OF THE SKIN.
region.  Venesection may be advantageously employed when
the disease assumes a severe character in strong and vigor-
ous  persons.   In this  case,  free bloodletting  at the begin-
ning  will diminish  the  intensity of the  symptoms.   In the
early stage  of S. maligna, it will prevent,  to a certain degree,
the organic congestion likely to occur in that variety; but at
a more advanced period of the disease it  will be useless, and
even injurious.   Leeches may be applied to the neck, or over
the mastoid processes, if symptoms of cerebral congestion
occur, and in that case must be applied early.
   When scarlatina is accompanied  with inflammation of any
vital  organ, early and copious bleeding is indispensable.  In
malignant sore throat, acidulated and alum gargles are  very
beneficial;  but in angina  membranacea it is necessary to
endeavor at once to modify the inflammation, by touching the
parts with hydrochloric acid, or with  nitrate  of silver.  M.
Biett was in the habit of using equal parts of honey and lemon-
juice  with much success.  A moment  should  not be lost in
having recourse to  prompt  and decisive  measures  in the
severer forms of this  disease.   Laxatives and purgatives, con-
joined with bloodletting,  should be freely employed  when
there are symptoms of cerebral or pulmonary congestion pre-
sent.   Their use is  also indicated when the  inflammation of
the throat is intense.  The physician  should not be guided
too much by  the  appearance  of the  tongue.  The scarlet
red color of that organ is but a  symptom of the disease.  If
there is much  gastric irritation present, injections should be
administered.*
   Emetics,  generally speaking, are only  indicated when the
pharynx becomes obstructed with pultaceous  matter, which
occurs chiefly in children.   Tepid  baths  are very beneficial
at the decline  of the eruption, or when it has  suddenly  dis-
appeared.   Cold affusion is. a powerful auxiliary  in the treat-
ment of scarlatina.   It reduces  at once the burning heat of
skin, and also the frequency of the pulse.  When it is attend-
ed with these happy results, the patient often enjoys a  calm
and refreshing sleep.   In some instances,  however, it is of no
avail, but it is never a dangerous remedy, as  has  been  sup-
posed.  In mild cases, it will be sufficient  to sponge the  parts
—the forehead,  temples, face, and arms—with  cold water, or

  * The remarks respecting bloodletting in erysipelas, in this  country (page 44),
are applicable to the use of this agent in scarlet fever.   It is very rarely called for
in this disease, and as it has prevailed for several years past, would do more harm
than good in the great majority of cases.  Caution is necessary even in the appli-
cation of leeches.  Active purgatives must also be used with discretion, and care-
fully avoided in many cases.                              H. D. B. 
•
                          SCARLATINA.                       61

vinegar and water.   The employment  of sinapisms,  blisters,
&c, should be confined to those cases in which it is necessary
to establish counter-irritation.   The application of a blister
to the neck, when the  throat is highly inflamed, merely  in-
creases the irritation of the  skin, without alleviating the  in-
ternal inflammation—it has even produced gangrene  in some
instances.   During the period of convalescence, the patient
requires great attention.   Dietetic measures, the frequent use
of the tepid bath, and mild laxatives, to guard against consti-
pation, constitute the principal treatment required during this
period.
   The patient should guard against exposure to cold and errors
of diet, which are frequent causes of anasarca.  Should that dis-
ease, however, appear during convalescence, the patient must be
kept quiet, and take light food  and warm  diaphoretic drinks;.
and if there is much fever, diarrhoea, or gastric disturbance,
leeches must be applied to the anus, or to the epigastric region;
it may also be arrested in a great measure by the use of the
vapor bath.*   The extract of belladonna  has been used  with
much successas a prophylactic remedy in scarlatina, and may
be used whenever the disease prevails epidemically.
   The tincture is the most convenient form for its use,  and
the one  which seems  to  be most efficacious.   Of this,  six
drops may be given  daily to children  from eight to ten  years
of age, and the quantity increased or diminished according to
the age.  This remedy ought  to  be continued for ten or twelve
days.   It seems to modify the disease, and in some instances
it gives immunity from it altogether.  The sulphuret  of  anti-
mony and  calomel in combination, have been employed  with
a similar view, with advantage.  The  dose for a child from

  * Warm baths, attention to diet, a free state of the bowels, and protection from
atmospheric changes, constitute the most important points in the preventive treat-
ment of the form of dropsy following  scarlet fever.  Dr. Golding Bird says that.
he can scarcely recollect a case of dropsy occurring after scarlet fever, when the
warm bath was daily used as exfoliation of the skin commenced, and  continued
until a perspiring, healthy surface was obtained.—{Urinary Deposits—Phil, edit.,
1851, p. 263.)
  When effusion has once taken place, the indications are to relieve the congestion
of the kidneys, which is found to constitute an important feature in the  pathology
of the disease; to remove the accumulated fluid, promote the action of the  skin,
and, in some  cases, to support the system—for it is far from being always in-
flammatory in its nature.  Not unfrequently, and especially in children of the
poorer classes, iodide of potassium, in  some bitter infusion, and also quinine, will
be found useful; and where the system is much debilitated, or the patient is of a
strumous diathesis, preparations of iron will prove of essential service.
  For a more full account of the treatment of the dropsy following scarlet fever,
and also of its pathology, we would take the liberty to refer our readers to Lec-
tures on Eruptive Fevers,  by Dr. George Gregory, Amer. Edit., appendix,  page
355-7.                                                 H.D.B.
                               5 
62                DISEASES  OF THE SKIN.

two to four years of age, will be about the sixteenth or eighth
of a  grain of calomel to the same quantity of antimony,
mixed with a little sugar or magnesia,  which should be re-
peated three of four times a day.

                     URTICARIA.

Sym.—Essera; Aspretudo; Febris urticata ; Exanthema urti-
  catum ;  Purpura urticata ; Papules cuticulares ; Cnidosis.
  Nettle rash.

  Urticaria is a non-contagious exanthematous affection, cha-
racterized by irregularly-shaped patches or wheals of various
sizes,  sometimes paler, sometimes redder than the surrounding
skin, in general extremely transient, and always accompanied
with  a very  annoying itching.   Urticaria is sometimes an
acute affection, but in the majority of cases it assumes a chro-
nic form, and its duration varies from two or three days to as
many  months and years.  The patches sometimes disappear
almost immediately after their formation: more frequently in
the course of twenty-four hours, and in  some rare instances
they have continued for a week or fortnight.
   Causes.—Nettle rash attacks  individuals of all  ages, and
both sexes, but children and young persons of either sex, of a
nervous and sanguineous temperament, appear to  be more
subject to it than any others.  It prevails more during spring
and summer than in autumn and winter; yet it is sometimes
produced  by cold.   Urticaria is one of the few cutaneous
eruptions  which can be traced distinctly to its source.   It  is
well known to result from handling the  leaves of the urtica
dioica; but this is only local, and usually of short duration. The
most  certain and most active cause is  the ingestion of cer-
tain kinds of food, especially shell-fish of different  kinds, as
lobster, shrimp, crab, muscle, and smoked, dried and  salted
fish.   The effect in these  cases has been attributed to more
or less putrefaction of these substances; but of  several who
partake of them, often  a single  individual only is affected.
There must  therefore  be some peculiar predisposition,  and
this is sometimes so marked that certain persons cannot par-
take  of these articles  of food without  invariably  suffering
from  urticaria.   Bitter almonds, mushrooms, cucumbers, salad,
and  even oatmeal, vinegar,  honey, and certain medicines,
such  as turpentine, balsam copaiba,  valerian, also  produce
this disease.  Indeed, some individuals are so susceptible that
the slightest pinching or  rubbing of the skin is  immediately
followed by the eruption of a prominent itching wheal.   It
sometimes results from derangement of the digestive organs, 
URTICARIA.
63
rheumatism, fever, &c.  It may also be developed by denti-
tion, and by mental emotions.   It  may coexist with other
diseases  of the skin of an entirely  different- character,  and
especially with lichen  simplex.  The course of this eruption
is  very  irregular;  sometimes  attended with  constitutional
symptoms, and at other times without them;  sometimes  dis-
appearing and returning several different times, and by these
irregular returns prolonging its  duration for weeks and even
years.   Urticaria has  been  divided into  several varieties,
according to the  nature and progress of the symptoms.  We
shall describe the three following.
   1. Urticaria febrilis.—This  is  the most   common  and
striking  form of the disease.   It is preceded for a day or two
by slight febrile  symptoms, and pain at the  epigastrium; a
hot itching sensation in the skin then ensues, after which the
eruption begins to  appear over the whole  of the body, but
especially on the shoulders, loins, the inner surface  of the arms
and thighs, and around the  knees, in the form of red  or pale,
raised blotches,  sometimes  circular, but  more  commonly
irregular in their shape, surrounded with a bright red or scarlet
border;  they are hard round  the  edges,  and  of  variable
extent.  Sometimes these  wheals are very  numerous, and
coalesce in many places, and give the limb a swollen and bright
red appearance.  (Urticaria  conferta.  Willan.)   An almost
insupportable smarting and itching sensation accompanies the
eruption, which  prevents the patient from sleeping, and is
greatly aggravated by the heat of the bed.   This pruritus is
much  more severe.in  some parts than in  others, especially
about  the scrotum.  The eruption does not continue through-
out the  disease, which lasts seven or eight days.  The wheals
appear and disappear  several times, on different parts of the
body.    They usually  return in the  evening,  accompanied
with a  slight acceleration of the pulse, and are often repro-
duced by the patient scratching the parts.  They sometimes
disappear in a few minutes, in other instances they continue
for several hours.  In cases of less frequent occurrence,  they
remain one, two, or three weeks. (Urticariaperstans. Willan.)
Depression of spirits, anorexia, fever, and more or  less gastric
disturbance, continue  during the course of the attack.   At
length the symptoms gradually decline, the eruption  follows,
 and nothing remains but  a slight itching ; but when the erup-
 tion has been violent, slight desquamation of the cuticle takes
place.                                              .
    This  form sometimes  presents all the symptoms of inter-
 mittent  fever, coming on  in regular paroxysms, and com-
 pletely disappearing with the fever, and returning with it the 
64
DISEASES OF THE SKIN.
following day. It often then appears to depend on some patho-
logical condition of the liver.   We  have several  times  ob-
served the blotches assume  a distinct jaundice color.*   The
itching is insupportable in these cases.
  To this variety of  urticaria  belongs  that  produced by the
different articles of food before  mentioned. The patient, soon
after partaking of some of these, experiences pain  at  the pit
of the stomach, vertigo, nausea, and  general depression ;  the
skin becomes hot, and the eruption breaks out.  The symp-
toms are nearly the same as those already enumerated, only
that in the latter  instance vomiting and diarrhoea frequently
supervene.   The eruption  is  more diffused,  and the wheals
become confluent, producing considerable stiffness and tume-
faction of the parts  affected.   When they  are  complicated
with erythematous patches,  as  sometimes is the case, desqua-
mation frequently occurs.   The disease generally subsides in
the course of a day or two;  in  some rare instances  it has ter-
minated fatally;  but  this event is more  to  be  attributed to
the pernicious effects of the exciting cause, than to the vio-
lence of the disease when established. The eruption in these
cases may appear within a few hours, or not until the next
day.
  2. Urticaria evanida is a chronic form of the disease.  The
eruption appears at  irregular  intervals,  sometimes  on  one
part, sometimes on another, and is sometimes confined to one
part alone.  It is unattended with fever, and generally disap-
pears in the course of a few hours. The wheals resemble the
marks produced on the skin by flagellation ; they are not sur-
rounded with an inflammatory border, and are  only accom-
panied with a smart itching.   This variety continues  for
several months, sometimes  for  years,  M. Biett has seen it
last seven  years.  This form occurs  more frequently  in
females, and in persons with great susceptibility of skin.  It
generally depends on chronic  derangement  of  the  digestive
organs, especially  of the stomach;  but  it also attacks  the
most healthy subjects.   Urticaria subcutanea is a very rare
variety, and is characterized by violent acute pricking pain,
as  if a needle were  thrust  into the  skin.  Slight  red spots,
scarcely elevated, are scattered here  and there, but there is
no  regular  eruption.  Deep mental  emotions,  and sudden
change of temperature, seem to be its chief  exciting causes.
It is very difficult to  overcome.
  3.  Urticaria tuberosa.—This is also a rare  variety, and

  * Dr. Graves {Clinical Lectures, Philad. Ed.,  p. 122) gives cases of the con-
nexion between urticaria and jaundice.—H. D. B. 
URTICARIA.
65
exhibits characters of great severity.   Instead  of slightly-
prominent blotches, we find broad,  hard,  deep-seated, and
painful tuberosities, which impede motion.  It appears chiefly
about the extremities and lumbar regions towards evening
and  at night, and  disappears entirely the  next day, leaving
the patient fatigued, weak, and greatly depressed.  We have
seen it at the hospital of St. Louis accompany a quotidian
intermittent.  It had lasted for four years in this case, and the
eruption  appearing about the face, throat, and chest,  occa-
sioned great  swelling and puffiness of the features, accompa-
nied with so much dyspnoea and irregular action of the  heart,
that the   patient became blue in the face, and would  have
perished, but that we had recourse to copious venesection.  It
was at  length cured by M.  Biett  with Fowler's  solution.
This variety generally  occurs  in intemperate persons.  It
usually lasts  several months.
   Diagnosis.—The' form and elevation of the blotches,  the
itching, and the fugitive character of the eruption, will rea-
dily distinguish urticaria from the rest of the exanthematous
eruptions.  In lichen urticatus,  which  may be mistaken for
urticaria, the papulse are rounder, less prominent, less exten-
sive, harder under  the finger, and of a deeper color.   They
never disappear  suddenly;  and, moreover, we may always
detect, in the vicinity of the spots, a number of true papulae,
which will distinguish it at  once.   Urticaria  tuberosa  may
be always  distinguished from   erythema  nodosum  by  the
regular and continuous course of the latter disease.   Finally,
the different varieties of urticaria are often complicated with
erythema, roseola, and sometimes with impetigo and lichen.
   Prognosis.—The eruption itself is usually without danger;
but  is always a troublesome and  distressing affection, on
account  of the great itching which accompanies it, and its
obstinate  duration.  Urticaria tuberosa may sometimes  prove
a serious  disease.
   Treatment.—When  urticaria  is  the  result  of  direct and
evident  causes, it  requires scarcely any treatment.  If the
eruption should not disappear quickly, acidulated local  appli-
cations,  diluents, and  a few  tepid baths are all that  are
required.   To allay the smarting and itching, acetate of lead
lotions, a solution of carbonate of potass, or alkaline baths,
will be found most efficacious.  Mild  purgatives  are  often
useful; but when the eruption is  produced by some irritating
food, vomiting should  be immediately excited, if it  has  not
already taken place, after  which  strong  acidulated drinks
ought to be administered  (half a  drachm of sulphuric acid to 
66
DISEASES  OF  THE SKIN.
a pint of barley water or  sugar water), and, every half hour,
from thirty to forty drops of ether on a small piece of sugar.
   When it assumes a chronic form, great attention  must be
paid to  diet, with the view of ascertaining and avoiding the
particular kind of food which excites the disease.  It is some-
times necessary to change the habits of the patient altogether.
General bleeding, or the application  of leeches  to the anus,
in  young plethoric  subjects,  and in females with menstrual
irregularities, will often be attended with  advantage.  In  ob-
stinate  cases alkaline or vapor baths, or the  vapor  douche,
will  be  found very efficacious.   Acidulated drinks and mild
laxatives should  be  conjoined with  the  foregoing remedies.
When urticaria   assumes  an  intermittent character, bark or
quinine  must be  prescribed,  and, if these  fail, .much  benefit
may be derived from  Fowler's solution, in small and  repeated
doses.*

  *  In no disease affecting the skin is the connexion with disorder of the digestive
organs usually so easily traced as in urticaria. We see the acute form of the dis-
ease directly and speedily produced by certain ingesta, and are warranted  in the
inference that, in the subacute and chronic forms, the eruption, with the excessive
irritation of the skin by which it is accompanied, may be referred to some derange-
ment of either the primary or secondary process  of digestion, and doubt not that
more extended research will lead to the detection of evidences of these disorders in
the excretions, especially the urine.  In one case, in which that fluid was examined
by Dr. Maclagan, he  found a deficiency of urea and  of uric acid, and attributed
the great irritation of the skin which existed to the retention in the system of solid
matters which ought to be eliminated from it. {Monthly Jour. Med. Science, Aug.
1846.)  In this case, colchicum (the tincture of the seeds) was found to triple the
quantity of urea, and to increase the quantity of uric acid tenfold, after its use for
a fortnight.  The irritation  of the  skin gradually diminished, and finally disap-
peared entirely under the internal use of colchicum.
  Acidity will often be found to prevail in urticaria, both in the acute and chronic
form;  and hence, in the acute,  antacids and antacid laxatives are  generally
required ; while  in the chronic, the moderate and long-continued use of alkalies,
especially when  combined with diuretics, will sometimes succeed when acids have
failed. Liquor potassse, in combination with sweet spirits of nitre, and the extract
or  tincture of hyoscyamu3,  wtll sometimes  afford relief, either alone, or with  a
bitter infusion or tincture, as of gentian or cinchona.   In  some cases tonics are
more especially indicated, and chalybeates will then  often be  found of service.
Mr. Kerr has recommended {Monthly Jour. Med. Science, May, 1848) the in-
ternal use of thepersesquinitrate'of iron  (pernitrate ?) in the ordinary doses, as very
successful in several cases of urticaria.   Warm salt water baths are often useful in
chronic cases.—H. D.  B. 
VESICULjE-
  The diseases which belong to  this order are characterized
by small elevations of the cuticle, formed by the collection of
a transparent serous fluid.   These  cuticular  elevations are
called vesicles.  In general, the fluid contained in these vesi-
cles readily loses its transparency, and assumes an opaline or
yellowish tint.  The serosity may  be reabsorbed  into the
system, but it #is more  frequently effused upon the surface,
where  it forms at first whitish scales, and subsequently thin
yellow and lamellated incrustations.
  The description of the vesicular affections naturally follows
that of the exanthematous diseases, in which  the inflammation
merely produces injection of the  capillary vessels; whilst, in
all cases of vesicles and bullae, the inflammatory process is fol-
lowed by effusion.  In  certain exanthematous affections, as
measles, scarlatina, and erysipelas, nothing  is more  common
than to meet  with partial elevations of the epidermis on the
inflamed surfaces, containing a transparent fluid;  in short,
true vesicles.   It  is very probable  that in these particular
cases the local irritation is  more  intense where the vesicles
appear  than  elsewhere,  and that the  serous  effusion is the
natural result of this excess  of inflammation.
  The very small size of some vesicles, as those of sudamina
and  of  eczema, has led to the supposition that they occupy
the extremity of the vessels  through  which  perspiration  is
excreted.  Late anatomical  researches, as well as some recent
clinical observations, seem  to confirm this view of  the sub-
ject.
  The  vesiculae,  like  the  pustular diseases,  are  naturally
divided into two classes—those  with an inflamed base,  and
those unaccompanied with inflammation.  (Phlysacia and Psy-
dracia.)   Sometimes red, hard,  elevated, and circumscribed
spots  precede the  formation of vesicles for a  day or two.
Again, on the contrary, the  vesicles  appear  abruptly, and the
serous  effusions apparently  takes  place as soon  as  the skin
becomes infected with the morbid virus.   Varicella, vaccinia, 
68                DISEASES  OF THE SKIN.
herpes,  and the itch, belong to the first variety.  The suda-
mina, eczema, and some of the bullae, which differ from the
vesiculae  merely in  their  size,  form the  second  division.
The vesiculae, considered independently of  the diseases with
which they may be complicated, invariably pursue an acute
course.   The  duration  of the vesicles is always brief, but
some of these affections continue longer  than others, as,  for
example,  the progress of varicella, sudamina,  and,  generally
speaking,  of herpes, is essentially acute; whilst, on the other
hand, eczema and  the  itch, although they sometimes may
follow an  opposite course, are  usually chronic affections.
  Symptoms.—-These diseases are  sometimes preceded  by
general febrile symptoms, but they  frequently appear almost
imperceptibly, and without any  accompanying phenomena,
except  a slight degree of itching.  Occasionally they appear
on  a red  and inflamed surface, but they are as often present
without the slightest traces of inflammation.   At  one time
they are  small,  pointed, or globose; again, they are large,
projecting, and irregular, or considerally flattened.   In some
cases, they appear in a scattered form, in others  they are
agglomerated, forming large patches  containing a multitude
of  small  silvery  whitish points.  This appearance .is par-
ticularly striking in certain cases of sudamina, in which the
eruption presents the appearance of minute  drops of dew
scattered  over the surface.  The vesiculae  not  unfrequently
assume  an irregularly circumscribed form.  Frequently, as
in  cases 'of  herpes,  for example,  they  form  semicircular
patches, or even perfect rings.
  The serum of the vesicles is usually transparent at its first
formation; so much so, that it resembles drops of water scat-
tered over the surface  of the skin.   By degrees this fluid
becomes opaque; it is sometimes reabsorbed, but most fre-
quently it dries into thin, scaly, and friable crusts.  Sometimes
these scaly incrustations leave behind them a  dry  but  red
surface  when they fall off;  at other times,  fresh incrustations
are formed on the same spot, by the drying up of the fluid
which exudes from the  inflamed  surfaces.  When  vesicular
eruptions  succeed each  other, those parts of the skin where
they were situated become  thickened, and  are rough to the
touch.  When the disease assumes a chronic form, the incrus-
tations  are whiter,  thinner, and  very nearly approach  the
true squamae.  The slightly  thickened and lamellated form of
the crusts of the vesicular eruptions  demand  especial atten-
tion, as  they furnish the best means of distinguishing vesicles
from certain other cutaneous  affections.   The laminated or
squamous  form of the  crusts is particularly evident in eczema. 
VESICULiE.
69
In general, the vesicles gradually disappear without leaving
any traces behind; they  are  sometimes succeeded by  small
scars, as seen in varicella; they may terminate in genuine
cicatrices.   The vesicles of herpes are succeeded by a  slight
ulceration, terminating in a more or less marked cicatrix.
  Seat.—Vesicular eruptions  may attack every  part of the
cutaneous surface; they frequently cover the whole body, as,
for instance, varicella, miliaria, and sometimes eczema.   Even
the itch, in some  cases, simultaneously affects the whole of
the cuticular surface.  Generally speaking, however, eczema,
herpes,  and the itch,  are  confined  to certain regions clearly
circumscribed.  Besides, the itch usually attacks the  hands
and fingers, and the folds of the joints where the skin is thin
and delicate.  Herpes,  on the other hand, attacks the  trunk
and face.
  Causes.—The itch is the only  one amongst the vesicular
eruptions  that is  decidedly contagious.  Some writers have
asserted that varicella is also produced by contagion, and that
it may  be propagated by inoculation; but there is not suf-
ficient evidence to prove  the correctness of this statement.
They attribute this affection to a certain varioloid contagion,
modified by the constitution of the individual.  It generally
assumes an epidemic  character, and prevails most frequently
in the early months of the year.  Eczema also prevails at this
season  more than  at any  other.  Everything  that  tends to
excite the circulation and the functions of the skin may  occa-
sionally produce some of the vesicular eruptions, as sudamina,
eczema, and herpes.   Eczema  may sometimes  depend on
external causes, such  as irritation applied directly to the skin,
a burn,  or the application of a blister.
  Diagnosis.—The presence of vesicles, independently  of the
characteristic  symptoms of each variety of these affections,
will always be sufficient to prevent any mistake in the  diag-
nosis.   There are  some vesicular eruptions which  at  first
sight may appear to be easily confounded with pustular erup-
tions, but the diagnosis  can readily be cleared up, by bearing
in mind that the former invariably commence with  vesicles,
which, on losing their transparency, never contain any  other
than a  sero-purulent fluid.  Moreover, some of the  vesicles
preserve their transparency all -along.  The scaly crusts which
the vesicles leave  behind them afford a still more  valuable
means of ascertaining the  nature of the primary affection.
The sero-purulent  fluid of vesicles invariably  terminates in
thin, laminated, scaly incrustations ; whilst pustular eruptions
usually  terminate in collections of true pus,  accompanied by
a considerable degree of inflammation, and, instead of thin 
70
DISEASES OF THE  SKIN.
crusts, they give rise to thick, rough scabs adhering  firmly
to the surface of the skin.
  Prognosis.—The vesicular eruptions,  generally  speaking,
are not dangerous; they never terminate fatally ; nevertheless
they should  not be regarded too lightly.   Chronic eczema, in
particular, may lead one astray  in the prognosis, as to its pro-
bable duration.  It requires some tact and observation to be
able to give a correct opinion on this point.
   Treatment.—When these affections assume an  acute form,
an  antiphlogistic treatment will be necessary.  When they
are chronic, they require particular remedies, and frequently
active treatment; which, however, they are often enabled to
resist for a considerable period.

                       MILIARIA,
Syn.—Sudamina; Febris miliaris; Purpura alba;  Purpura
         rubra; Papules sudoris ; Millet-seed rash.

  Miliaria  is characterized by an eruption of vesicles  which
seldom exceed the size of a millet-seed.  These vesicles spread
in considerable numbers over a large surface, and are gene-
rally symptomatic of some more serious disease.
   The miliary eruption  frequently forms a very important
phenomenon in the progress, and  symptoms of the disease;
as,  for example, in the epidemic miliary fever; at other times
it is of little value as a means of diagnosis, and the  physician
cannot form any decided opinion  from its presence.  Thus,
miliary  eruptions often precede variola and measles, and are
present in the last  stages  of  typhoid fevers, and in other
diseases  in  which the serous  membranes are more or less
involved.   It is in the last-named cases that the name of suda-
mina is particularly applicable,  whilst that of miliaria belongs
especially to the severe affection so well described by Syden-
ham under the name of miliary fever.
   Causes.—The miliary epidemic generally attacks  adults of
a lymphatic or sanguineo-lymphatic temperament.   Women
are more subject to it than men.   The existence of miliaria
as  a distinct  fever,  belonging  to the same class as variola,
measles  and scarlatina,  has been  often doubted by writers,
especially by Willan and Bateman.   These authors  also attri-
bute the appearance of Sudamina, in cases of puerperal and
typhoid fevers, to  the hot stimulating treatment to which the
patients  were subjected.  The miliary fever of Sydenham,
and the  miliary sweat of other writers, deserve, in our opi-
nion, a special  place among the skin diseases.  If a stimu-
lating treatment may be considered as the accidental cause 
MILIARIA.
71
of the eruption in some instances, we have had, on the other
hand, frequent opportunities of observing that the most rigid
antiphlogistic  measures could not prevent  its development.
This  observation applies in particular to the  sudamina of
puerperal fever, scarlatina, and typhoid fever.
  The eruption  generally follows irritation of  the skin or
copious  perspirations.  It prevails mostly during dry, warm
weather  in the summer season.  Miliaria accompanies many
gastro-intestinal  affections, and generally appears during a
paroxysm.  It frequently attends  puerperal fever, especially
when several of the  serous membranes are involved.  It is
also developed in meningitis, in certain cases of rheumatism,
and not  unfrequently in scarlatina and measles.  In general,
miliaria  may be considered, as we have before  observed/to be
symptomatic  of some other important affection ; but  there
are  cases in  which  it assumes  an  idiopathic form, as,  for
example, when it appears in healthy subjects  after violent
exercise  in warm weather ; in these instances  it is generally
accompanied with copious perspirations.  The eruption is then
attended with a disagreeable  sensation of heat and itching.
The number of vesicles is sometimes  very considerable, but
they are ephemeral, and disappear in the space of twenty-four
hours.
   Progress and Symptoms.—The miliary eruption is preceded
and accompanied by  peculiar symptoms, which invest it with
a special character;  these are, a remarkable  degree  of  de-
pression accompanied with fever, perspiration,  and a tendency
to  fainting.   The patient complains of a painful constriction
of the thorax, respiration becomes difficult, the pulse is  soft,
and often assumes a  very remarkable  intermittent character.
These premonitory symptoms appear three, four, and even
eight days before the eruption ; and the disease is generally
prolonged by  successive  eruptions  for one  or two weeks.
Miliaria has this peculiarity,  that the violence of the early
symptoms, and the oppression of which the patient complains
so much, receive but little alleviation from the appearance of
the eruption.
   The vesicles appear principally on the trunk, and especially
on the thorax and neck, either behind or before; after these,
the limbs are the parts most  frequently affected.  It seldom
appears  on the face.   The eruption is almost invariably con-
fined to  a certain circumscribed spot; it rarely spreads over
the body.
   The miliary vesicles usually appear in  patches of more or
less extent, or else  they are  grouped together.   Sometimes
they become  confluent, and then constitute  genuine bullae, 
72                DISEASES  OF THE SKIN.

which, although small, form  a  striking contrast with the rest
of the eruption.  They vary much in number ;  a considerable
part of the  body may be covered with  them, or  they  may
only be scattered here and there, over certain  regions.   The
vesicles are  at first small, prominent, and so transparent, that
the  fluid which they contain appears  as if it  was scattered
over the skin, like so many drops of clear water or of perspi-
ration.  At  a more  advanced  stage they become globular,
and the fluid assumes a milky color and loses its transparency.
Sometimes the seat of the  vesicles assumes a deep erythema-
tous red color, which may be  seen through them.  (Miliaria
rubra.)  When the  limpid serum is replaced by the milky
fluid already mentioned, the vesicles which cover  this red
surface  present  a singular  pearly appearance.   (Miliaria
alba)  This  is very remarkable in scarlatina,  where a great
number of vesicles are spread over large surfaces of a deep
raspberry  color.
  If the vesicles are  not interfered with, they  will terminate
invariably by resolution,  and will never leave scars behind
them.  They frequently occasion considerable exfoliation  of
the  epidermis, which, however, is often confined to the exact
spots occupied by the vesicles.
  In epidemic miliaria, the danger does  not subside with the
appearance  of the eruption;  symptoms of inflammation  of
the mucous  membrane  of the  air-passages  and bowels fre-
quently continue with considerable intensity, and are gene-
rally accompanied with important lesions of  the brain and
lungs.   The  real  danger in  this affection  consists  in the
diseases which accompany iff, of which the eruption  may  be
regarded as  symptomatic.  However, the appearance of the
vesicles should  not be considered as  altogether without
importance,  for many cases  occur in which their absence  or
sudden  disappearance  are followed by fatal terminations.
These untoward results do  not always depend  on physical
causes, as cold, shiverings, injudicious regimen, &c, but they
may even be suddenly produced by strong mental emotions.
When this eruption accompanies other  diseases, its physical
characters do not change,  but  its duration is  very variable ;
it does not, generally speaking, continue longer than twenty-
four hours, nor does  it, during its course, seem to affect the
original disease in the slightest degree.  The  miliary vesicles,
as  already observed, always terminate  by resolution.   The
idiopathic form terminates in sweating or miliary fever about
the third or  fourth week.
  Diagnosis. — Eczema  is  the only affection  with which
miliaria could be confounded.   The rapid progress and short 
                        MILIARIA.                      73

duration of the latter, form, however, an important difference
between them. Besides, in eczema the vesicles are confluent,
and a  multitude  of  them may be seen crowded  and agglo-
merated together in  a small circumscribed space; whilst in
miliaria the vesicles  are almost always  isolated, and  much
larger than the vesicles of eczema.
  Is there any difference between the vesicles of miliaria and
those  of sudamina ?   M. Barbie says, tha,t " miliaria usually
commences in small red spots, sometimes very numerous, and
invariably accompanied with itching, and even severe smart-
ing.   That  the shape of  the vesicle is conical, and that the
fluid they contain is  opaque and purulent.  That sudamina,
on the contrary, are   never  preceded  by redness  or itching,
but appear suddenly, and are of a globular form."  These
characteristics are not sufficient to form a distinction.   Both
names belong to one  and the same vesicular affection.
  The precursory symptoms of miliaria may sometimes lead
the physician to believe that variola, scarlatina, or measles is
about to be developed.  It is  by comparing the premonitory
symptoms of those diseases  with those of the one under con-
sideration that this error can be avoided.  The vomiting and
pains of the limbs, so marked during the invasion of variola,
are never present;   neither do  we meet with  the coryza,
ophthalmia, and bronchial catarrh of  measles, nor the  sore-
throat  of  scarlatina.  The  pathognomonic  symptoms  of
miliaria are the extreme depression with tendency to sweat-
ing and syncope, remarkable constriction of the chest; and,
above all, a peculiar state of the pulse, which is soft, frequent,
and intermitting.
  Prognosis.—Epidemic miliaria is the only dangerous form
of the disease-.  The vesicular eruption does not of itself pre-
sent any danger  as  a complication  of other  diseases; it
merely announces a state  of  general constitutional excite-
ment, and further than this it is of little importance.
   Treatment.—The  vesicular eruption does not  require any
particular treatment.  It is  the original disease that the phy-
sician should attack; and, in the majority of cases, a cooling
and antiphlogistic plan of treatment will be found  most effica-
cious,  as cold acidulated drinks and  aperients.   The treat-
ment of miliary fever is the  same;   but when  any of the
viscera become  involved, more active measures  must  be
resorted to.  Mild diaphoretics—the preparations of antimony,
&c, have been employed with much benefit. 
74
DISEASES OF THE SKIN.
                      VARICELLA.

Syn.—Variola spuria; Pemphigus Varioloides;  the Chicken-
                   pox ; the Swine-pox.

  Varicella is a non-contagious disease,* characterized by an
eruption of vesicles, at first transparent,  but  finally becoming
opaque, which are preceded  and accompanied with febrile
symptoms, and dry up  between the fifth  and eighth day.
Formerly  varicella was considered to be merely a variety of
small-pox  ; but Heberden proved it to be a distinct affection,
differing from variola in its causes,  symptoms, and duration.
With the  introduction of vaccination new difficulties arose,
from the  appearance of a new species  of varioloid disease,
bearing a close resemblance  to varicella.   The  disputes
respecting the nature of varicella continue to the present day,
but it still appears to us right to retain it amongst the vesi-
cular affections, and to describe it as  a distinct affection from
variola.
  There  are  two varieties of  varicella.   In the first  the
vesicles are small, but slightly elevated, and contain a color-
less fluid (Chicken-pox).   In the other the vesicles are large,
globular, soft,  and broader in the  circumference than at  the
base.  The fluid is  at first transparent, but finally assumes
a milky appearance (Swine-pox).  Both  varieties may appear
at different periods with the  same symptoms, whether they
occur previous to or after variola or vaccination.   It is  erro-
neous to suppose that they cannot prevail epidemically with-
out variola.  We have frequently seen varicellous epidemics
without observing a single case of variola, especially in board-
ing-schools. In general the disease only attacks persons once
during their lives.  It is, however, in some instances deve-
loped  several  times in  the  same individual.   It is  chiefly
observed  in young persons, although adults are not  exempt
from its attacks.
  Symptoms.—Varicella is preceded for a day or two by gene-
ral  indisposition, languor, thirst, anorexia, and  constipation.
There is frequently nausea, vomiting, pain at the epigastrium,
hot  skin,  flushed face, quick  pulse,  and a tendency to per-
spiration.    These symptoms may be more or less severe,  but
they generally continue for two or three days after the appear-

  * Our authors, in the edition of their work in  1847, still state this to be a non-
contagious disease ; but we feel no hesitation in regarding it  as decidedly conta-
gious, and this we believe to be the opinion of practitioners generally.—H. D. B. 
                        VARICELLA.                      75

ance of  the  eruption, which generally  commences on  the
trunk,  more rarely on the face, and  continues to appear in
fresh places for several successive days.
  1. Varicella  lenticularis, or  chicken-pox, first appears in
small,  red, irregularly rounded elevations, at  the centre of
which  minute transparent vesicles are  quickly formed.  These
vesicles increase gradually for two or three days.  Some are
acuminated,  others  flattened.  About the second or third
day, the  serous fluid has a milky  appearance; there is much
itching,  and  the  vesicles become shriveled and faded.  On
the fourth  day they are surrounded with  red areolae.  Desic-
cation commences on the fifth,  and on the sixth they are suc-
ceeded by small, brownish, scaly incrustations.   These thin
scabs  dry  from the circumference towards the  centre,  and
fall off towards the ninth or tenth day.   As the vesicles appear
in succession for two or three days, the different stages of the
eruption may be seen at  once in the same individual, and the
duration of the disease may  thus be  prolonged until the ele-
venth  or twelfth day.
   2. Varicella globata, or swine-pox,  is preceded  by the same
symptoms, and developed in  a  similar  manner.  The  red
spots  are  quickly replaced  by large vesicles, containing a
transparent fluid,  which becomes opaque about the second
day of the eruption.   The vesicles have then attained their
greatest  size ; they are soft and  flabby to the touch, of a pearly
white  color,  la-rger in circumference than at the base,  and
surrounded with an  inflammatory areola.  About the third
day the  vesicles  are  faded and wrinkled, the contained fluid
is thicker, and has become of a yellowish color.   As the itching
is generally pretty smart, the patients, particularly when chil-
dren,  tear the  vesicles, in consequence of which the inflam-
mation  is increased, and  a  thick  yellow pus formed.  This
accident occurs most frequently on the face. The scabs which
replace  those  pustules continue for some time, and leave
small  pits or scars.  This occurrence may also happen in the
former variety.  The vesicles  are  replaced about the fourth
day by  small,  laminated, brownish crusts. These desiccate
from  the circumference  towards the centre,  and fall off in
about  four or  five days, leaving  small red spots, which  gra-
dually disappear.
   Diagnosis.—It  is  very  easy to  distinguish varicella from
well-marked small-pox,  of the distinct  kind,  by the regular
progress and gradual development of the  variolous pustule ;
but it is not so easily  distinguished from modified  variola.
 However, in the latter disease the precursory symptoms  are
very  severe,  amongst which pain in the loins  is especially 
76                 DISEASES  OF THE SKIN.

remarkable,  which never occurs  in  varicella.  In  modified
variola the pustules are small, circular, and generally depress-
ed  in  the centre.  Frequently  after the  desiccation  of the
scaly  crusts, small  tubercles appear,  which  subside  very
slowly.  In varicella the  vesicles are  at first  transparent, but
subsequently contain a sero-purulent  fluid.  They are never
succeeded by small tubercles, as in modified  small-pox.   We
may add, that varicella is not, in our  opinion,  a contagious
disease,  whilst  modified  small-pox may be  transmitted  by
inoculation,  and may even in some instances excite a severe
form of variola.*
  Treatment.—The  treatment  of  varicella  is very  simple.
The patient should be kept in  bed, in  a room of  moderate
temperature.  Regimen,  cooling and refreshing drinks,  and
a mild aperient now and then, are all the remedial  measures
necessary even  in the severest form of the disease.

                         ECZEMA.

Syn.—Crusta lactea;  Dartre ; Squammeuse humide.  Humid
                   Tetter; Running Scall.

  The term eczema was  first adopted by Willan to  designate
one of the  vesicular  eruptions.  This  affection  is charac-
terized by an eruption of small vesicles on various parts  of
the skin, closely crowded together, and frequently occupying
broad  irregularly-defined patches.
  Eczema may appear under different forms, according  to
the condition on  which it depends.  It was, no doubt, owing
to this circumstance, that Willan divided  it into three varie-
ties—E. solare,  E. impetiginodes, and E. rubrum.   M. Biett
has been in the habit, for many  years, of describing it in his
clinical lectures under two forms, the acute and  chronic,  and
we shall adopt his method.
  Acute Eczema.—Under this division we  shall class,  1st,
Eczema simplex,  which, from the mild course it pursues, con-

  * In addition to the above diagnostic marks of varicella may be mentioned, that
the vesicles are often irregular in their shape, and sometimes oblong; that the fluid
in them  is contained in a single cavity ; that the eruption usually appears on the
trunk first, and is also more rapid in its progress than varioloid, being scabbed over
on the fifth to the sixth day ; that it is successive in its development, and is followed
by thin brownish scabs, instead  of tubercular indurations—also that it appears
almost exclusively in children, and that previous vaccination has no effect on it.
  At the same time, it is proper to add, that there is high authority for  regarding
both varioloid and varicella as identical in nature with variola.  This  was the opi-
nion of the late Dr. Thompson, of Edinburgh, and also of some continental writers,
and of some in  our own country—but I do not consider it advisable to burden a
work so elementary as the present with even an abstract of  the arguments on the
subject.                                                H. D. B. 
ECZEMA.
77
stitutes a perfectly distinct variety, but very different from the
chronic eczema, which succeeds the acute form of disease.
2d, Eczema rubrum; 3d, Eczema impetiginodes.
   1.  Eczema simplex.—This variety appears in the form of
minute vesicles, crowded together on different parts of the
skin, and is unattended with inflammation.  It appears with-
out the slightest precursory symptoms;  the  patient  feels  a
slight itching sensation, and is surprised to find it produced
by an eruption  of more or less extent.  The vesicles are very
numerous,  set close together, transparent, small, indolent, and
present a shining  appearance; the fluid which they contain
becomes turbid and opaque;  it is  soon after  absorbed, the
vesicle desquamates, or else it bursts, and forms a small, thin,
scaly disc, which soon becomes detached.   This variety never
terminates in the  inflamed patches, serous exudation, or in
the reappearance  of the  thin crusts observed in the other
forms.   It  never leaves the slightest trace behind.   It follows
a  mild course,  and is  usually prolonged by successive erup-
tions, and generally lasts for one, two, or three weeks, some-
times even longer than this.  Eczema simplex may become
general,  but is more  frequently confined to  certain regions.
Amongst other places,  it is observed frequently on the  arm
and  fore-arm, and between the fingers, where it  sometimes
fixes itself, and very much resembles itch.   It is never accom-
panied with any other  symptom than  that of itching, which
is  often  very  troublesome, especially when  the  eruption  is
general.
   This variety of eczema most frequently attacks young people,
and  females in particular.  It is often produced  by friction,
and  the application of irritating lotions and ointments.   We
frequently  see it in individuals whose business  compels them
to remain long exposed to intense heat, near stoves, furnaces,
&c.   Finally, it occasionally occurs without  any  appreciable
cause; thus, for instance, it frequently appears between the
fingers of  women during child-bed.  It is a mild  affection,
unaccompanied with febrile symptoms; it is  sometimes com-
plicated  with lichen, and frequently with itch; resulting, in
the latter instance, from the use of the ointments used to cure
it.  In the majority of cases, eczema appears  in a much more
acute  form than the foregoing,  and presents two other per-
fectly  distinct varieties.
   2.  Eczema rubrum.—In this variety the eruption is accom-
panied with considerable heat and tension, the skin is inflam-
ed, and assumes a bright red color; if it is closely examined,
it  will be found to be  prickly, and  covered with small, pro-
minent,  silvery-looking points, which at a  more  advanced 
78
DISEASES OF THE SKIN.
period become  true vesicles, and when fully developed,  are
about the size and form of a pin's head, transparent, and sur-
rounded with a  well-marked  inflammatory areola.
  About the sixth or eighth day, sometimes earlier, the red-
ness diminishes, the fluid becomes absorbed, the vesicles die
away, and the disease terminates in a slight exfoliation, pro-
duced  by the  debris  of the  vesicles.  If the eruption be
examined at this period, it will be found still to present cer-
tain well-marked characters.  It presents  a reddish  surface,
which lasts for  some days after the vesicles have disappeared
—scattered over with small round spots, surrounded with  a
whitish border,  with ragged  edges, which indicate the line of
demarcation between the elevation of the epidermis that forms
the vesicle, and the areola that surrounds its base.
  Eezema rubrum  does  not always terminate in so mild  a
manner.  Instead of subsiding, the inflammation may persist,''
or even become augmented: the vessels  become confluent,
burst, and give exit to  the  fluid, which was  at  first  trans-
parent, but is now  perfectly opaque.   This fluid flows over
an already irritated and  inflamed surface, and produces slight
excoriations,  whence  issues a serous effusion more or  less
abundant. However, this serosity soon diminishes.  It becomes
thickened, concretes, and forms thin, soft, and sometimes very
broad incrustations, which  are frequently renewed, and in
disappearing leave an inflamed surface behind.  The serous
exudation gradually ceases,  the crusts become drier and more
adherent, and are not renewed so often.  The diseased skin
by degrees resumes its natural condition, proceeding from the
circumference  to the centre, and the disease itself terminates
in two or three weeks.   It  frequently  happens that in place
of  declining, these symptoms continue for a much longer
period,  become more intense at intervals,  and the eczema
then becomes chronic—a very  remarkable  condition which
we shall have to speak of by-and-by.
   3. Eczema impetiginodes.—Whether in  this variety the
vesicles assume the usual form of those of eczema rubrum at
the beginning, as is most usually the case, or that the progress
of the inflammation is so rapid that its results do not appear
to  us until they are in  an  advanced stage, it often  happens
that we have two distinct diseases (a vesicular and a pustular)
combined and existing together.
   In eczema impetiginodes  the  inflammation  is much more
acute, the skin is swollen under the eruption, the  vesicular
fluid  loses  its  transparency, and becomes purulent.   These
agglomerated purulent vesicles frequently run into one another,
and soon burst.   The  fluid concretes, and instead of pro- 
                         ECZEMA.                       79
  9

ducing laminated crusts  like eczema rubrum,  soft,  yellow
scabs, composed of one or more layers, are developed.   These
scabs fall off, and give exit to a reddish serosity; they are repro-
duced, and pursue the same course, until at length the inflam-
mation diminishes, and the purulent vesicles are not redeve-
loped so often, or in  such numbers.  The scabs gradually
become thinner, the surface  beneath them is not so  red, and
at length the skin resumes  its natural color and condition.
This eruption may continue  for two or three weeks;  it may
be confined to a single region; it sometimes assumes a gene-
ral character, when it is accompanied with febrile  symptoms,
and becomes much more severe.
  We may often observe different degrees  of inflammation
in the same individual, especially when the eruption  is gene-
ral, or quite extensive.  Thus we may observe  the  vesicles,
at first transparent, passing into the pustular state; sometimes
half the  vesicle may be opaque;  and a yellowish color, and
greater thickening of the other half, indicates the transition
that is taking place.  In cases where this variety is  confined
to a particular part, vesicles of E. rubrum may be seen in the
vicinity of the vesiculo-purulent eruption, and they  are also
often observed in the centre of  the eruption.   Finally,  E.
impetiginodes, in  place  of  terminating  in twenty or thirty
days, may pass  into the chronic state; but then it does not
differ from chronic eczema, which  succeeds E.  rubrum, and
in this stage it  only  produces  true  vesicles,  the  pustular
vesicles becoming much more rare.  E. impetiginodes is not,
therefore, a form of E. rubrum complicated with the pustules
of impetigo,  but  an  eruption of  vesicles, transparent  at the
beginning, and passing into the condition of pustular vesicles
instead of  true pustules.  Otherwise, the  disease would be a
genuine  form of impetigo, for at a certain period almost all
the vesicles  become pustular, and nevertheless we shall see,
when treating of the  diagnosis,  that there are  well-marked
distinctions between these two affections.
  The inflammation is sometimes so active, that the disease
may be complicated with the pustules of impetigo, and even
with  the  larger pustules  of ecthyma.   These  contain pus
almost at the moment of their formation, their base is larger,
and the fluid thicker and yellower than that of the others.
  Acute eczema  is generally  accompanied with pretty  severe
febrile symptoms.  Sometimes,  when  confined  to a certain
extent, it  seems as if it was  to be a very  severe disease, and
yet it will pursue a regular course, and terminate speedily,
without occasioning any other disturbance than a slight acce-
leration of the pulse. 
80                DISEASES  OF THE SKIN.
   Chronic eczema.—Whatever may have been the symptoms
 by which it is ushered in, eczema frequently passes into the
 chronic  state.  The skin  being constantly  irritated by the
 ichorous discharge, and by frequent eruptions, becomes deeply
 inflamed and  excoriated, and fissures  form about the joints.
 There is a continual and copious discharge of serosity, which
 is constantly  saturating the linen; and in withdrawing the
 latter, care  should be taken not  to tear the vesicles, and pro-
 duce rents, which often give issue to  a considerable flow of
 blood.  They leave behind a red, soft, and  swollen surface,
 which often retains their impression.  The eruption may con-
 tinue for many months without much diminution in the serous
 discharge.
   On other occasions, the exudation begins to decline after a
•certain period.   It becomes thick, forms  lamellae,  incrus-
 tations, and small, thin, soft, yellow, slightly adherent scabs,
•extending  considerably, the bases  of which  are dry,  but
 inflamed.   These  laminated crusts  form  more  slowly,  are
 more dry, and the patient seems  upon the point of convales-
cence, when, without any apparent cause, the inflammation
 is greatly increased.  The  skin  becomes  red again, and is
 covered with  a  new crop of vesicles, which  soon burst, and
 the disease pursues the  same course as before.  It may thus
 be protracted  for years with similar exacerbations, occurring
 at certain intervals.
   Again,  there  are other cases in which  there  is not  the
 slightest exudation.  The scaly incrustations are  drier, more
 adherent, and  not  so yellow.  The skin is thickened, and is
 marked with  deep  fissures.  The  crusts,  which  are  easily
 detached,  exhibit a  slightly inflamed surface on  falling  off.
 Sometimes,  however, especially  in cases of general chronic
 eczema,  the  skin remains  of a bright red  color even  for
 months, and is covered here and there with  dry,  thin, flaky
 crusts.  It is also cracked, and there is no perceptible exuda-
 tion of serum.  In this state eczema resembles, and has been
 confounded with, psoriasis, inasmuch as the incrustations  are
 not  now produced by the concretion of an exhaled fluid,  but
 seem rather to  be, as in the true scaly diseases,  lamellae of
 the epidermis.  The appearance of vesicles  will  explain  the
 real nature of the eruption.  M. Biett  has pointed out, in his
 clinical lectures, many cases in which  eczema became a true
 scaly disease.  The vesicular character becomes more evident
 as the malady approaches its termination. In some instances,
 particularly when eczema is confined to the limbs,  it only
 occupies one  or two small spots, around which  the  skin is
 smooth, tense, and shining;  this form is covered with whitish 
ECZEMA.
81
lamellae,  as thin as the epidermis.   No vesicles  appear  on
these polished  surfaces, and the diagnosis is  very  difficult, if
a new eruption, or a knowledge of the preceding one, and
sometimes even the presence of vesicles scattered round the
circumference, does not  throw light  on the nature of the
disease.
  Chronic eczema, although  at the beginning confined to a
small space, may become extended  over  a large extent of
surface.   In some  rare  cases, it has been observed at the
commencement to occupy a  space  not larger than a crown-
piece, and yet  it gradually spread, until it covered the whole
limb.
•  Chronic eczema  is invariably accompanied with intense
itching, more distressing than the severest pain.  The patient
in vain struggles against it, but he cannot, however, resist
the urgent desire to scratch himself, and thus increases  his
sufferings.
  These itching sensations are particularly intolerable when
eczema is confined to certain parts, as  the inner part of the
thighs, for instance.   It is then often  accompanied in women
with a chronic discharge, and extends to the anus  and vulva,
and  sometimes to  the vagina, where it produces  an intense
degree of itching, which places the patient in a pitiable con-
dition.
  After  a certain period, the itching begins to subside, the
serous exudation gradually ceases, the scaly incrustations dry
up, and the skin is  less  inflamed.   The  seat of the  eruption
contracts,  the process of healing begins at the circumference,
the  lamdlae become thinner  and  smaller, they cease  to
appear, the skin is still a little more red than natural, but this
color soon disappears altogether. Finally, the  disease  becomes
reduced to a small, dry, red  surface, which is  covered with
extremely  thin  laminated  crusts.   The surrounding skin is
smooth,  tense, and  firm, and only slowly resumes  its natural
state.  The redness, as already stated, always  continues  for
a certain time  after the  disappearance of the eruption.
  The duration of  chronic eczema is very variable; it may
continue for months, and even years.
  Seat.—There is no part of the skin which may not be the
seat of  eczema;  but there  are certain parts on which  it
appears more frequently than on others ; e. g. round the beard
where the follicles  are  numerous;  the  pubes, the  groins, the
scrotum, and the axillae.  It may be  confined to one particular
region, as  the  breast, the scalp, or the  ears, and constitute
some important local varieties.
  It generally attacks  several regions at once;  indeed,  we 
82
DISEASES OF THE SKIN.
 have seen it cover the entire cutaneous envelope, both in an
 acute  and  chronic  form.  M.  Biett  is of opinion  that  the
 anatomical seat of this  affection is not in the sebaceous fol-
 licles  but  in the vascular membrane.   (Diet, de  Med. 2d
 edit., art. Eczema.)*
   Causes.—Eczema  is  not  contagious; however, in certain
 rare instances, it appears to have passed from one individual
 to another by the prolonged contact of two mucous  surfaces.
 M. Biett has observed many cases where  eczenia was trans-
 mitted by coition. It frequently attacks adults ; women seem
 to be  more  subject to  it than  men.   It  generally  appears
 during  the  spring  and  summer.   The spring equinox, the
 summer solstice,  and sudden changes of  temperature, are
 marked by  exacerbations of chronic  eczema.  It generally
 appears without any known  cause ; but it is occasionally the
 result  of some direct agent, as  the action of intense heat,
 exposure to  the  rays  of the  sun, &c.  It sometimes follows
 the application of a blister, and the eruption may then extend
 over the whole arm or thigh.  Eczema is frequently produced
 by dry frictions, and  especially  by inunction  with irritating
 ointments.   It is thus that  the  variety called mercurial is
 developed,  and which does not differ either in its  symptoms
 or progress from  the others, f   It is  often observed on the
 fingers of sugar refiners, or after a burn, and may be produced
 by any excess, particularly by the abuse of spirituous liquors.
 Whatever  may  be  the  influence of direct causes  on the
 development of acute eczema,  it is evident that  there is a
 peculiar disposition of the economy to which is to  be attri-
 buted its passage into a chronic state, and its prolonged dura-
 tion in that form.  Certain local varieties  are produced and
 kept up by the causes which affect the parts they occupy.
 As, for example,  chronic leucorrhoea will prolong eczema for
 an indefinite period.   The handling of metallic and  pulveru-
 lent substances is a frequent cause of eczema of the hands.
 It is one  of these varieties which has received the  name of
 bakers' itch.  But  this affection  is produced sometimes with
 papulae, sometimes  with vesicles.   Another proof  of the
 worthlessness of a classification which mistakes causes for
 effects.
  Diagnosis.—Eczema,  in each of its varieties, may be con-

  * In the last edition of their work, our authors regard the extremity of the sudo-
 riferous ducts as the anatomical seat of eczema.—H. D. B.
  t Rayer describes the vesicular eruption produced by mercury as a distinct
 affection, under the name of Hydrargyria, and as caused by the internal as well as
 the external use of that article.  This corresponds  with my experience respecting
it. -H. D. B.                                            *   * 
ECZEMA.
83
founded with other diseases perfectly distinct from it, and its
diagnosis  is,  therefore,  of the highest importance.  Eczema
simplex has  frequently been mistaken for itch, to which, at
first sight, it has a strong resemblance.  Both are developed
without inflammation ; they occupy generally certain  parts
or  localities,  as  the wrist, the  sides of the  fingers;  they
produce a smart itching : but the vesicles of itch are pointed,
while those of eczema are flatter :  the vesicles of eczema are
always  grouped,  while in  itch they are  usually isolated and
perfectly distinct from each other, presenting a single vesicle,
or  two, or three  only on  a surface of some extent, as the
inner sides of the fingers  for example, which is never the
case in eczema.  The itching of eczema is a kind of smarting
sensation very different from that of scabies.  In the former
there is real pain, whilst in the latter the sensation is  more
agreeable  than otherwise.  Finally, the  itch is  essentially
contagious, and eczema, generally speaking, is not.
   Eczema rubrum may sometimes be confounded  with milia-
ria, but in the latter affection the vesicles are  never confluent
as  in  the  former, in which  a vast number may suddenly
appear on  the surface.  The vesicles are more voluminous in
miliaria than in eczema; besides, the febrile symptoms which
usually attend symptomatic miliaria, and which indicate some.
latent severe disease, will suffice to distinguish the one from
the other.   That variety  of miliaria which follows severe
exercise in  the  heat of  summer has a  considerable resem-
blance to eczema ; but the  vesicles  are more scattered, there
are copious  perspirations,  and  the  eruption  disappears sud-
denly in the  former instance.
   Eczema impetiginodes presents several well-marked cha-
racters to  distinguish it from impetigo.  The vesicular affec-
tion  invariably occupies large surfaces; impetigo,  on  the
contrary, is confined within a narrow compass. The pustules
of impetigo  are never transparent at the beginning; they
have a larger base, and contain a thicker fluid.  The pustular
vesicles of E.  impetiginodes are always vesicular at their
origin,  and  never contain true pus, but a  yellowish sero-
purulent fluid.  Besides, their different terminations indicate
still more clearly the distinction  between these vesicles and
the pustules  of impetigo.  In the latter the pustules constantly
terminate in thick, rough, uneven, yellowish scabs, whilst the
pustular vesicles  of eczema merely form thin solt incrusta-
 tions, more broad than prominent; and, moreover, we always
 find in this affection vesicles  of E. rubrum  around the erup-
 tion, which never occurs in impetigo.   The  traces or  marks
 which these two  affections leave after them on the skin also 
84
DISEASES OF THE  SKIN.
present distinctive characters.   Those of impetigo have a
bright  red color; and occasionally that eruption  is followed
by slight cicatrices.   This never takes place in E. impeti-
ginodes, which leaves merely slight red spots.
  E. impetiginodes might be confounded with the itch, when
the vesicles of the latter are accompanied with pustules; but,
leaving the pustules out of the question, which, in the majority
of cases, are merely complications, attention should be direct-
ed to the numerous vesicles; and the characters which have
been already mentioned as distinguishing the  itch from  E.
simplex, will facilitate the diagnosis.
  The  diagnosis of chronic eczema is often much more diffi-
cult than  that  of any of the foregoing varieties.  Amongst
the eruptions  with  which it might  be confounded we may
mention lichen, two varieties  of which are sometimes mis-
taken for eczema.
  Lichen agrius, like eczema, is accompanied with a  serous
exudation, terminating in the formation of crusts; but  these
are thicker,  yellower, and not  so  large as those of eczema,
and are not unlike  scabs.  The surface of the skin left  by
them does not present  a red,  smooth, shining, and slightly
excoriated surface,  as in eczema,  but is  fretted with  small
prominent spots or  papulae, which  may be detected by the
eye or  by  the finger, if passed over the eruption.
  In other instances lichen, like  chronic eczema, may develope
thin dry laminated  crusts, without any serous exudation or
local inflammation; but in these cases the skin is more thick-
ened and rough than in eczema, so  that it is often difficult to
raise it between the fingers.  Besides, in lichen we  generally
find papulae  scattered  here and  there near  the eruptions,
which  may  easily be recognised by their  hardness  and slow
progress, exactly as  vesicles are developed in  eczema, near
the eruption,  which can  readily be  distinguished  from the
elements of lichen.   Those varieties  of lichen and eczema
which  attack  the hands require the greatest care in  distin-
guishing the one from the other.
   Some varieties of chronic  eczema have a  great  resem-
blance to psoriasis;  but the presence of vesicles in the neigh-
borhood of the eruption, and their reappearance in the former
affection,  is  sufficient to  distinguish them.   Moreover  the
scales  are always  thinner, more  dry and friable, although
softer.   They are also almost  always accompanied  with a
discharge, which never occurs  in psoriasis.  After they  fall
off, the skin does not present, as in psoriasis, a smooth, red, and
elevated,  but  a fissured surface.  However,  in  certain rare
cases of chronic eczema, the eruption may become general, 
ECZEMA.
85
and the skin  may assume a red tint, at the same time that it
is  covered with whitish  laminated scales.  The diagnosis is,
in this instance, difficult, especially if the early phases of the
disease  have not been  observed, and if there is no exudation
present.   It can, however, be distinguished from psoriasis by
these signs:—the skin is neither  elevated nor hypertrophied,
as observed in the  latter disease, and the cracks  or fissures
are the result of the muscular movements with which they
correspond, and never spread over the surface, in every direc-
tion, as in psoriasis inveterata.   But we again repeat, that it
requires the greatest care  and  attention to form a correct
diagnosis.
   Prognosis.—Eczema is, generally speaking, a slight disease,
especially  its  acute form; but when  it spreads over a  large
surface and  becomes  chronic, it is an exceedingly trouble-
some and obstinate affection.  The prognosis is not favorable
when it persists for several years, and when new eruptions
form at the time the disease appeared to be  dying  away.
Without  endangering  the life of  the patient, it  embitters  his
existence, when it is prolonged in this indefinite manner.
   It may coexist with lichen, and particularly with  the itch.
It is frequently complicated with  the pustules of impetigo and
ecthyma.  In some rare instances it  becomes converted into
a still severer disease.   It assumes the bullous form of  Pom-
pholix.   M. Biett has related some  instances  of this  kind.
We  have a case of a similar nature at present in the hospital.
   Treatment.—The treatment of  eczema simplex usually con-
sists in the employment of refreshing drinks, lemonade slightly
acidulated, tepid baths,  and regimen.  These measures are
generally sufficient to dispel the eruption in a very short time.
But  when the disease is of long standing, and  accompanied
with  smart itching, particularly  when it is diffused  over the
skin, it will be necessary to administer laxatives occasionally,
and  alkaline baths containing from four to eight  ounces of the
subcarbonate  of potassa or of soda, according  to the age  of
the patient and the state of the eruption.
   E. rubrum and E.  impetiginodes  require no other treat-
ment than that  necessary  for acute inflammation. When
they are local and circumscribed, diluent drinks and regimen
will suffice.  But when  the disease occupies a large surface,
and  is accompanied with quick  pulse, and  especially when
the patient is young and vigorous, it is necessary to  have
recourse to general or local  bleeding.  The lancet will be
required in some cases after leeches have been employed  in
the vicinity of the eruption.  Tf  the disease is diffused, vene-
section  may be  repeated with  advantage.  In a word, the 
86
DISEASES OF THE  SKIN.
only remedies  which  acute  eczema requires are  regimen,
simple  or emollient baths,  local baths of bran water or of
marshmallows; poultices of potato flour, and some emollient
application, when the vesicles burst and leave a red, raw,  and
painful  surface exposed.   The  preparations of sulphur, so
injurious in the treatment of all the dartrous diseases, should
be carefully avoided.   With regard to the  mercurial plan of
treatment, we have frequently seen patients at the Hospital
of St.  Louis in whom  E.  rubrum was increased  and kept
up  by  this injudicious method.   It often  became  converted
into E. impetiginodes, and  even complicated with the erup-
tion of impetigo  and ecthyma, and  was thus prolonged for
months.  On the other  hand,  acute  eczema, which  may be
diffused over the whole cutaneous surface, and appears to be
a severe disease, yields  in twelve or  fifteen days to  the anti-
phlogistic treatment above mentioned.   In every  case  the
first object should be to endeavor to remove the cause of the
disease, if possible.  Thus, for instance,  the  patient should
guard  against everything that would irritate  the parts,  and
should desist  from his  usual  employment,  if it is  found to
excite the eruption. We have frequently observed, and amongst
other  instances, in the case of a laborer working  in a labo-
ratory, the eruption of E. simplex reproduced as often, and as
soon as the individual resumed his work.
  Chronic  eczema, before it  assumes  a  severe  character,
generally yields to the following treatment:  Acidulated drinks,
as,  for example,  a scruple  to  half a drachm of sulphuric or
nitric  acid to a pint of  barley water; the nitric is more  effi-
cacious than the sulphuric acid; they are particularly bene-
ficial in those cases where  a  copious serous exudation  and a
smart  itching  exist.   The patient  should commence with
small doses, and take a  little cold water  after each dose, until
the stomach becomes accustomed to the  acidulated drinks.
The temperature of the baths ought not to exceed 88 to 90
deg. Fahr.   The patient should remain in the bath about an
hour.  It may be rendered emollient by  mucilage,  gelatine,
&c.  The quantity of gelatine necessary for a simple bath is
from half a pound to a pound.
   Laxatives are frequently required.  They may be admi-
nistered alone, or alternately  with acidulated drinks.  Thus,
for example, in any bitter infusion,  the sulphate of soda,  or
still better, the sulphate of  magnesia in  the proportion  of half
an  ounce to the pint, may  be  administered  in divided  doses;
also about two drachms of the acidulated tartrate of potassa in
whey, will be found very efficacious.
   The alkalies may be advantageously employed externally 
ECZEMA.
87
 as well as  internally.*   They are particularly useful exter-
 nally when the emollient  applications  and remedies fail  to
 remove the itching.   In these cases,  local baths, containing
 from  half an  ounce to two ounces  of the subcarbonate  of
 potash, or of soda, will sensibly diminish the  irritation.   The
 patient to take the bath before going to bed.  Fifteen to thirty
 grains of bicarbonate of soda daily, dissolved in water, or  in
 some bitter infusion, may  be  given  internally.  When the
 eruption  resists  these  remedies  and  continues to  spread,
 recourse  must be  had to more active measures, such  as  pur-
 gatives, sulphureous waters,  baths, and  the  vapor douche.
 Calomel may be administered in about four-grain doses every
 morning  before eating for a week or two.  It should then be
 changed for Plummer's pill, or aloes, or jalap, in the usual pur-
 gative doses, attention  being at the  same time paid to the
 digestive  functions.   Seidlitz water might be  advantageously
 prescribed in doses of one or two glasses every morning.
   The sulphureous waters may be administered internally or
 externally.   They are  only useful when  the  disease  is  of a
 long standing, especially when it is  confined to the lower
 extremities,  and is free from all  irritation.   The waters  of
 Bareges, Enghien, and Cauteretz, are most frequently employed;
 they can  be made artificially by adding to a simple  bath two
 or three ounces of sulphuret of potash, the quantity  of which
 may be varied according  to the  degree of excitement to be
 produced.   In every instance  simple  baths should  be admi-
 nistered alternately with the sulphur baths.  When sulphur is
 to be given internally, it should be mixed  with two parts  of
 barley  water or  milk.  By these means, the quantity of the
 mineral water may  be  gradually increased, until it  can be
 taken pure.f
   Local or general, simple or emollient baths, as before stated,
 are  the only measures  that  will  be  expedient  at  the  com-

  * The continued use of liquor potassae, in doses gradually increasing  from ten
drops to thirty, and even fifty drops, three times a day, is frequently useful  in this
as well as in some other chronic affections of the skin. Dr. A. T. Thompson
recommends  carrying the dose as high as one hundred drops, three  times daily,
but I  seldom  exceed twenty-five drops at a dose.   It may be taken in infusion of
hops or some other mild bitter, or in small beer, as recommended by Sir B. Brodie,
or in milk and  water, or clove or ginger tea—I have more frequently given it  in
some  preparation of the rumex acutus, or of sarsaparilla, or  of taraxacum, often
in combination with sweet spirits of nitre.                       H- J*- °-
  tOur own country is rich in sulphur waters of the most valuable  kind.  The
sulphur springs  of Virginia are favorably known, and our own State abounds  in
springs of this nature, of which those of Avon (Livingston county) have a long
established reputation  for their  efficacy in these diseases, and  those of Sharon
(Schoharie County) and of  Richfield (Otsego County) are much resorted  to for
this purpose.                                             "• ^" "• 
88
DISEASES OF THE  SKIN.
mencement, and whenever the inflammation becomes more
active.  In the latter event, whatever  may  have been  the
previous remedies employed, the application of leeches in the
neighborhood of the eruption will be attended with  advan-
tage.
  Vapor baths are occasionally very useful in cases of chro-
nic eczema, but the temperature should not be too high.  The
vapor douche is often of the greatest benefit when the disease
is  local.  When the eruption  is  confined or reduced  to a
small compass, the cure may be hastened by the  application
of ah ointment composed of the protochloride of mercury and
lard.  But it is  only in  exceptional  cases, as it were, that
unctuous  applications should  be used  in  the treatment of
eczema, and it is rare that their application can be continued
long.  In the course of the treatment it will  be often neces-
sary to  employ lead lotions in order to allay the  itching, or
else an emulsion of bitter almonds, dulcamara, or henbane.
  Sometimes a severe form of chronic  eczema will resist all
these measures,  and it will then become imperative to  have
recourse to a more  active and  vigorous  plan of treatment,
provided  always that the digestive organs are not suffering
from chronic  disease.  It is in  those  cases of rebellious
eczema that Biett's treatment succeeds in a manner truly sur-
prising.  With  the aid  of tincture of cantharides, which  is
particularly suitable  for females, and, still better, some of the
arsenical preparations, M. Biett has frequently overcome with
astonishing celerity the most inveterate cases of eczema.
  The tincture of cantharides should be given at first in doses
of three, afterwards  of five minims every morning, in a little
tisan, and every six or eight days  the dose may be increased
gradually from five  minims up to twenty  or thirty, without
inconvenience, taking care at  the  same  time  to omit the
remedy for a certain period now and  then, and always  to
recommence with the smallest dose.
  Among the preparations of arsenic, the best are, Fowler's
solution, Pearson's solution, and the solution of  the arsenite
of ammonia.   The base of the first is the arsenite of potassa.
It  is administered at the  commencement  in doses  of  three
minims in some inert fluid, every morning.   After five or six
days, it may be increased from two to three drops.   M. Biett
could never exceed fifteen drops a day, after repeated trials.
   Pearson's solution is milder and  more easily managed; it is
more suitable for females, irritable subjects, and is  the  only
preparation of arsenic that should be administered to  children.
Its base is the arsenite of soda in the proportion of the eighth
of  a grain to a drachm.   It may be given in doses from a 
ECZEMA.
89
 scruple to a drachm.   M. Biett introduced into practice, in
 1818, the solution of the arsenite of ammonia; a very useful
 remedy.  These  three preparations may be often  substituted
 with advantage  fof each other.  Pearson's solution may suc-
 ceed where  Fowler's  had failed, and  vice versa.   The admi-
 nistration of the arsenical preparations requires great caution
 and  attention.  If symptoms of irritation  of the  digestive
 organs appear, the remedy should be suspended; but the slight
 uneasiness  caused  by the medicine during the first few days
 of its administration,  and which will soon disappear,  should
 not be mistaken for that condition.  Besides, it is often useful
 to discontinue its use  for a few days and then  resume it, as is
 also necessary with cantharides.*
   Frequently  in  cases  when  the  eruption  is limited  and
 assumes the scaly  form, when  the  skin  is dry and chapped,
 and slightly hypertrophied,  as we sometimes  observe  on  the
 hands, gently stimulating local remedies must be employed.  In
 these  cases, ointments, of the proto-ioduret, or deuto-ioduret,
 or proto-nitrate of mercury, will be  found very  efficacious.
 A little camphor may be added to  allay the itching.   These
 mercurial preparations  have been employed externally with
 the  greatest benefit, but as internal remedies their utility is
 doubtful,  and sometimes they  are decidedly injurious.  It is
 in these cases that the sulphur baths,  both local and general,
 may be employed with advantage.   The beneficial effects of
 the  vapor douche have been well proved in these  instances.
 Caustic should never be employed in the  treatment of eczema,
 in which it has indeed been strangely abused;  the  application
 of stimulating ointments is by far more advantageous.!

   * Iodide of arsenic, first introduced into use  by the late Dr. A. T. Thompson,
 and the liquor arsenici et hydrargyri iodidi, introduced by Mr.  Donovan of Dublin,
 and hence called " Donovan's liquor," may also  be  used with benefit in appro-
 priate cases.                                              H. D. B.
  t Mr. Phillips has found warm water a most efficacious application in chronic
 eczema, dipping the bandages in it, and covering the  whole with oiled silk, so as
 to form  a constant tepid bath.  Dr.  Ranking applies fresh  cream, with liquor
 plumbi, instead of water, and considers the oiled silk the most important part of the
 plan.—{Half-yearly Abstract of Med. Science, Jan. 1845.)
  Dr. Burgess mentions a lotion composed of bicyanuret of mercury, two grains,
 and distilled water one ounce, as the most beneficial application in the inveterate
 forms of eczema.—{Eruptions of the head, face, and \ands,  Lond., 1849, p. 34.)
   Dr J.  H. Bennett regards chronic eczema of the scalp,  chin, and pubi3 as,
 sooner or later, an almost entirely local disease, and local applications as constituting
the chief part of the treatment.  He uses a solution of 3ij. sub. carb. soda, to Oiss
 water, which, he says, must not be used as a lotion merely, but that lint saturated
 with it should be kept over the affected  part, and the whole covered with oiled
silk, to prevent evaporation.  He considers keeping the surface moist a necessary
part of the treatment.—{Monthly Jour. J* Retrospect,  Edinb.,  Aug., 1849, p. 963.)
Gibert recommends the use of calamine ointment (lapis calaminaris), in partial 
90
DISEASES OF THE SKIN.
      Before concluding the subject of eczema,  we  shall briefly
    describe one or two forms in which the disease is confined to
    certain parts, and presents some important peculiarities.
      Chronic eczema of the mammce is, more frequently than any
    other  variety of  the disease, confined  within a  very limited
    compass.   It surrounds  the  nipple, and produces deep chaps.
    It requires  active treatment, and is  always  very  rebellious;
    we  have seen it continue for years.
      Eczema of the scrotum, and of the inner and upper parts of
    the  thighs in women, is also very rebellious.  It is the  same
    as  that  which surrounds the anus.   The  vapor  and  sulphur
    douche,  and  fumigations, together with  brisk purgatives, are
    the most effectual remedies.  In  robust individuals, who are
    otherwise  in good health,  purgatives  may  be  freely  admi-
    nistered.*
      Eczema of the ear is also  very rebellious, and as it  is some-
    times accompanied  with considerable hypertrophy, it may be
    necessary to put  a  piece of prepared sponge in the  external
    meatus, in order to  prevent  occlusion.f
      Eczema of the scalp  may appear with certain phenomena,
    which are the more important from their  liability to be con-
    founded  with some  varieties of  porrigo.   Thus  we often  see
    in persons attacked with this form of eczema  a copious serous
    exudation,  which mats  the  hair together.   This  fluid  soon


    eczema, and prefers the impure to the prepared  calamine, which is the kind in
    Turner's cerate.  A solution of alum, 3j. or 3ij. to a pint of water, is frequently
    very useful in chronic cases attended with moderate discharge  and great itching,
    particularly when local.  Also  a lotion of bichloride of mercury, half a grain to
    an ounce of water, especially  in cases of long standing.  M.  Trousseau speaks
    highly of  entire baths of  this article, and says that  he  never saw any harm
    from them, even in children.  He uses §  ss of the bichloride for a bath.  Others
    use the solution of this article as a lotion, of the strength of 3 ss to 3 ij to a  pint
    of water.  A weak solution of nitrate of silver, 1 or 2 grains to an ounce of water,
    will also allay the irritation in some cases.
      I have derived great benefit from the use of oiled silk, in this as well as in other
    chronic affections of the skin, and also of very thin sheet India rubber, worn over
    the affected part, when the  skin is dry and torpid.   When there is much irrita-
    bility of the skin, they cannot be borne.
      Chronic eczema of the hands (one of the forms of the salt rheum in popular lan-
i   guage) must be treated on the same general principles as the disease occurring on
    other parts—and care must be taken to keep the hands at rest as much as possible, and
    to avoid exposing them to alternations of moisture and dryness, and heat and cold.
    The nature of the local applications must be made to depend upon the duration of
    the disease, its condition at the time, and  the irritability of the skin in  each parti-
    cular case.                                                H. D. B.
      * Gibert speaks highly of the following ointment in chronic eczema of the geni-
    tals :—J£ Yellow subsulphate of mercury, 9j; laudanum, gtts. xij; lard, § j.
                                                             H. D. B.
      t Rayer considers the putting a piece of sponge in the external meatus, in eczema
    of the ear, as more likely to be attended with inconvenience than benefit, and this
    seems to be the most reasonable.                              H. D. B. 
ECZEMA.
91
dries or concretes, and forming into scales, surrounds the hair
in  tutts,  which  are  thus  entangled  with  each other;  and
whether it is owing to a natural desquamation, or to this  inter-
lacement,  these crusts soon become detached.   This pheno-
menon is not so visible in females, but it will generally be dis-
covered  if the  hair  be  examined  close to  the  roots.   The
presence  of -these white  shining scales in the middle of the
hair  has  a very  singular  and remarkable appearance,  espe-
cially  in persons of  dark  complexions.   In some  cases the
serous exudation  is not so  abundant;  it forms small, whitish,
dry, furfuraceous scaly incrustations,  which freely  fall off on
the  slightest friction, and  reappear with  wonderful  celerity.
These two varieties, which do  not at all injure  the bulbs of
the hair, sometimes merely require for their  treatment acidu-
lated drinks and emollient  lotions at the commencement, and
when more advanced,  alkaline  lotions  and  gentle  laxatives.
It is sometimes sufficient when children are attacked, to wash
the head with  soap  ana water, and  to comb it frequently.   In
other  cases, however, they resist all these means, and render
it necessary to resort  to the more active remedies before men-
tioned.*
  * Mr. Erichsen says that almost all the cases of eczema of the scalp which he
has seen above the age of 17 or 18 years have been in females; and that, in these
cases, it is almost invariably connected with some derangement of the menstrual
function.   {Lond. Med. Gaz., Jan. 1846, p. 67.)  He has found the same true in
many cases of eczema affecting the ears.  Hence the necessity of means directed
to the removal of such disorder when it  exists.  When there is amenorrhcea, he
uses the tinct. of cantharides, either alone, or combined with liquor potassae, or
Fowler's solution.  The local remedies required are the same as in disease of other
parts.
  Acute eczema of the scalp is said to be rapidly cured by the cold water douche,
employed daily, in the morning or at mid-day (not at bed-time), and continued
from 5 to 20 minutes each time—water as cold as can be borne to be kept applied
more or less constantly during the day.—{Monthly Jour, ty Retrosp., Sept. 1848,
p. 191.)
  In chronic eczema of the face in adults, Dr. Neligan prefers the  ioduretted
iodide of potassium and arsenic, a combination of arsenical solution, iodide of potas-
sium, and iodine.   Locally, he uses an ointment of iodide of sulphur, 10 or 12 grains
to § j white wax ointment, with 8 to 15 minims of chloroform ; and an alkaline
lotion combined with glycerine, substituting a wash  of carbonate of soda for soap
in all cases.  In young persons, he uses an ointment containing 10 grains of tannin,
and § ss of glycerine, to § j  of white wax ointment, with 4 minims of chloroform,
using alkaline lotions  at the same  time.—{Dublin Quart. Journ., May, 1851,

  In children, eczema of the scalp is often a very troublesome and very obstinate
affection,  not unfrequently  continuing during the whole period of first dentition.
The  itching is often excessive.  In  the acute stage, emollient applications on y
should be used, or simple warm water, with which the head should be  frequently
and freely washed. Attention must  also  be paid to the stomach and bowels and
to the gums, and great caution exercised with regard to local applications which
shall suddenly arrest  the discharge; and when  stimulating or astringent appli-
cations are used, it is most prudent to commence with those of the mildest form, 
92                 DISEASES OF THE SKIN.
                         HERPES.

            Syn.—Dartre; Olophlyctide ; Tetter.

  The  term herpes was  employed for a long period in as
vague a  sense as  that of dartre.   It  was  applied to many
eruptions  of a  perfectly  different  nature,  until  at length
Willan adopted it exclusively for the following distinct genus.
  This genus is characterized  by  an eruption  of  vesicles,
forming in groups upon an inflamed base, perfectly circum-
scribed, and separated from each other by intervals of sound
skin.   The form and seat of these  groups constitute  several
well-marked varieties, which may  be described separately.
The different species of herpes usually follow an acute course.
They  generally  last for a week, but  in some  instances they
may be prolonged to two or three weeks.  There are, never-
theless, cases in  which the  disease  may continue for months.
Herpes is rarely, if ever,  accompanied  with  dangerous symp-
toms.   The most usual phenomena are, slight indisposition,
depression, anorexia, and rarely fever.   In some few instances,
herpes  is produced  by some direct agent, but in by far the
majority  of cases  it manifests itself without  any appreciable
cause;  and even  when  there is a direct evident cause, such
as cold air, which usually occasions herpes labialis, there is at
the same time a peculiar state of the economy, of which the
eruption is symptomatic.   The formation of vesicles in groups
upon an  inflamed  base,  is always  sufficient  to  distinguish
herpes from other vesicular affections.  It is, generally speak-
ing, a mild disease, pursues a regular course, and requires but
simple  treatment.  Moreover, herpes may  exist  simultane-
ously with other diseases, either of the skin or of some internal
organ.

and to apply them to only a part of the scalp at a time.  Ointment of oxide of
zinc, diluted citrine ointment, creasote ointment, may  be used with caution when
there is much discharge, and the  bowels  are open. Weak lotions of carbonate
or sulphuret of potash will sometimes assist in allaying the itching and improving
the  condition of the surface.  Decoction of wheat bran is one of the most con-
venient and most efficacious of  the emollient applications.  Infusion of elder
flowers is also good for the same purpose.
  In some cases of eczema of the scalp and ears in scrofulous children, tonics are
very useful; and when the mucous membrane of the stomach and bowels will bear
it, I have seen the most decided benefit %om the iodide of iron.
  In eczema of children, whether  general or local, the diet is of the first impor-
tance ; and if nursing, particular  attention must be paid to the diet of the nurse.
The tepid bath assists very  much in allaying the irritation, especially during
dentition.                                               H. D. B. 
                         HERPES.                      93


                  Herpes Phlyctenodes,
  Under the common denomination of herpes phlyctenodes,
are classed those varieties of herpes which have no determi-
nate form, and no particular seat.   Herpes phlyctenodes is
generally  characterized  by an  eruption  of small vesicles,
which  may be developed on any part of the body, and fre-
quently on  several parts  at the  same time.  They become
agglomerated, and  spread over  a  surface  which varies  in
extent from that of a crown to that of the palm of the hand.
We commonly observe in the same  instance very minute
vesicles, and others the size of a large  pea; but  the smaller
vesicles are always much  more numerous than the larger
ones.  This  variety  is most frequently  developed on  the
upper  parts of the body, as  the  cheeks, the neck, the chest,
and the arms : it rarely  appears on the lower extremities.
Generally speaking, H. phlyctenodes is confined to one  or
two vesicular groups, and disappears  about the  seventh  or
eighth day.   However,  in  cases where  it appears succes-
sively  on  several different parts,  or  when several clusters
become almost united together, it may be prolonged beyond
this period, but rarely beyond the second  week.  In some
rare instances it has  assumed  a  decidedly  chronic form.
There is at present, in our ward at  the Hospital of St. Louis,
a patient  who has had for  six  months  a  patch of  herpes,
about  the size of the palm of the hand, on the inside of the
thigh,  which has resisted the most energetic treatment, and
especially the application of blisters.  The eruption is not on
any other  part of the  body.  When herpes  phlyctenodes
appears in  several groups, the latter  are  generally pretty
distant from each other; but however close they may be, the
skin between them remains perfectly sound.
   Symptoms.—Each group, composed of six or eight vesicles,
is developed in the following manner.   A number of almost
imperceptible red spots appear on  the part about to become
the seat of  the eruption, and are crowded together within a
comparatively small space.  The next day  the part appears
red, inflamed, and covered  with prominent vesicles, firm to
the touch, and the  size of which varies from that of a millet
seed to that of a small pea.  The redness generally extends
several lines  beyond  each cluster of  vesicles.   The small
vesicles are by far the most numerous; they are hard, globu-
lar, and transparent the first day,  but the next day, or even
before it, the  transparency is replaced by  an opaque or milky
tint.   An  itching  sensation,  often very painful, frequently
                            7 
f
94                DISEASES OF  THE SKIN.

accompanies the development of each group.  The vesicles
begin to fade about the third or fourth day, and by the seventh
or eighth  they have generally  disappeared.  Some of them
contain a purulent  fluid, others are transformed into brownish
incrustations.   They  soon desquamate; but slight  ulcera-
tions  are  occasionally observed here  and there.  The  red
color remains for  some days after the disappearance of the
eruption,  and then  gradually  subsides.   This  affection is
seldom accompanied with any  important symptoms.  Indis-
position, and sometimes anorexia and  slight  febrile disturb-
ance, are  the only phenomena which accompany it when
confined to  certain limits: moreover,  these  symptoms  only
appear with the eruption, and  vanish as soon as the latter is
developed.  With  regard  to the local symptoms, which  con-
sist in a smarting and sometimes very  acute  burning  sensa-
tion, as in H. zoster, they accompany  the  eruption through
all its stages, and even continue after it has subsided.
  Causes.—Herpes  phlyctenodes  generally  attacks  young
subjects.   In warm climates it  is frequently produced by the
rays of the sun.  Excess in diet, anxiety, grief, and  other
causes of  a similar nature, often seem to excite this disease;
but in general the causes on which  it depends are entirely
unknown,  or at least very difficult to be detected.
  Diagnosis.—The characters  peculiar to H. phlyctenodes,
as for example, clusters of numerous  vesicles  situate on a red
and inflamed surface, the extent of which varies from  that of
a crown to that of the palm of  the hand, are sufficient to dis-
tinguish this variety  from other affections, whether vesicular
or bullous.  Pemphigus is the disease  with which it is most
likely to be confounded; but  they can  be distinguished from
each other easily by observing, that in herpes  we find clusters
of vesicles separated  from each other, whilst in pemphigus
the  bullae are isolated, and not in clusters.  Sometimes,  it  is
true, we find red patches in pemphigus, where the bullae have
been closer than usual; but by recollecting that the latter are
bullae, and not vesicles, we can  seldom go  wrong.   Again,
some of the vesicles may  be transformed into bullae, but they
are very few, and  are scattered here  and there.
  Herpes phlyctenodes cannot be confounded with eczema,
unless in rare  instances, where the  vesicles of the latter
appear in groups.  Even  then  they may be distinguished by
the  following characters:  the  vesicles of eczema are  less
elevated,  and redder;  it is difficult to perceive the transpa-
rency ; andl finally,  when they are  grouped together,  they
become confluent, whilst those of  herpes remain isolated 
HERPES.
95
With regard to the other varieties of herpes, they only differ
from this in their seat and form.
  Treatment.—Herpes phlyctenodes is rather a mild disease,
and requires merely diluent and acidulated mixtures, regimen,
mucilaginous  lotions  and  tepid baths.  Bleeding  is seldom
required, and seems to be of little avail when it is employed.


                     Herpes  Labialis.

  This variety is characterized by small clusters of vesicles,
more  or  less  numerous  and  distinct, scattered  irregularly
around the mouth. Most commonly herpes labialis occupies a
certain defined surface on either  lip.  It always appears on
the  external  aspect,  and  generally  at the  junction of the
mucous membrane with the  skin.  However, in some cases
it is  altogether confined to the external  mucous membrane
of the  lip, whilst in others it is only to be seen on the  skin
immediately above the point of junction.  Sometimes the
clusters extend as far  as  the  cheeks, the chin, and the alae
of the  nose ;  and in rare instances they have been observed
in the pharynx.
   Herpes labialis is sometimes preceded for  several hours
by a slight  redness ; on other occasions the eruption appears
suddenly.   The  surface on which it is developed is swollen,
and is attended with an acrid burning heat.'  It then becomes
red, shining, and painful to the touch, and some vesicles begin
to point here  and there.  The tumefaction of the lip extends
beyond the vesicles, which are rapidly developed, and many
of them run into one another.   They are of various sizes, but
the largest does not exceed that of a small  pea, and are filled
with  transparent  fluid.   The irritating heat  gradually  sub-
sides, as soon  as the  eruption is developed; the transparent
fluid of the vesicles becomes  opaque; and  in  the course
of three or four days it assumes a yellowish tint, and finally
becomes sero-purulent.  By this time the redness  and swell-
ing  have  almost  disappeared.   Brownish  crusts are  now
formed, which fall off about the seventh or eighth  day of the
eruption ; when they disappear too early, they are replaced by
others, which continue much  longer.  After the eruption sub-
sides, it leaves behind a small red surface, which soon fades.
Its appearance is almost always preceded by a state ot  gene-
ral  indisposition, which continues for twenty-four or torty-
 eight hours.                         „        .    , ,     ,1
   Causes.—Herpes labialis is very  often produced by  cold
 air,  as, for instance, a person  leaving a  heated  room and
 going  into a cold damp  atmosphere, is very liable to  be 
96
DISEASES  OF THE SKIN.
attacked.   It  frequently  accompanies  coryza,  sore-throat,
stomatitis;  and in those cases it sometimes penetrates to the
inner surface of the  lips, and  even to the roof of the  palate
and tonsils.  The  contact of  acrid  and  irritating food  may
also produce   the  eruption.   It  frequently  supervenes on
intermittent fever.   It may be  complicated with inflammation
of some  of the internal organs,  but especially with that of
the lungs.
  Diagnosis.—The  arrangement of the  vesicles in  clusters,
their regular progress, the large size of some  of them, which
finally contain  a sero-purulent fluid, will suffice to distinguish
herpes  labialis from eczema of the lips.   It cannot  be  con-
founded  with  psoriasis of the  lips, if the dry  scales  and
striated furrows of the latter be borne in mind.
   Treatment.—Herpes labialis is such a slight affection, that it
hardly requires any treatment.  However, when it is accom-
panied  with the  acrid heat and  painful  tension of  the  skin
already  mentioned, cold lotions, containing a few  grains of
sulphate of zinc, or sulphate of copper, and a few drops of the
acetate  of  lead, will be  of much  service.   No remedies can
prevent the disease  running its  course.   In  every  instance
vicissitudes of heat and  cold should be carefully avoided.*

                      Herpes Preputialis.

   Herpes preputialis is known by the appearance of  one or
more small groups of vesicles on either the  internal or exter-
nal  surface of  the  prepuce.   It  first  appears  in the form of
several  red spots  or  patches,  more  or less inflamed,  rarely
exceeding  the  size of a shilling, and  generally much smaller.
These  patches are soon covered with small globose vesicles,
which differ slightly from  each other,  according to their situ-

  [* However mild this variety of  herpes may be in its nature and progress, it is
nevertheless frequently  ushered in  by an exceedingly smart feverish attack.   I
have more than once observed cases in which the eruption  was preceded by a train
of acute inflammatory symptoms, commencing with rigors, and terminating in the
course of twenty-four hours in the development of vesicles on the lips, and  on the
prepuce at the same time.  The severity of the symptoms would apparently in-
dicate the advent of some more important affection than that of a slight vesicular
eruption.  In herpes labialis the vesicles are often tedious and slow in disappearing.
As soon as each vesicle ripens, it  should be transfixed with a fine pointed needle,
so as to allow the contained fluid to escape, without exposing the surface.  By
this method the process of desquamation will be materially promoted, and the
duration of the eruption considerably shortened.                       B.]
  Dr. Neligan says that " if a strong spirituous lotion be constantly applied to the
parts on which herpes labialis is to appear before the vesicles are developed, the
further progress of the vesicles may generally be prevented," and  that nothing
answers so well as Cologne water.—{Dublin Quar. Journ., May, 1851.) 
HERPES.
97
ation.  Those clusters situated on the  external surface  are
slightly inflamed ; the vesicles, which are transparent and dis-
tinct, follow the ordinary course of herpes, with the exception
of their being reabsorbed;  the vesicles then break down, and
a  slight  desquamation  ensues.    Sometimes,  however,  the
serosity becomes opaque at the expiration of a few days, and
small scaly incrustations are formed over the seat of the dis-
ease, which terminates  about the  seventh or  eighth  day,
frequently earlier.   The inflammation  is much more  active
when  the  vesicles  form on the internal  surface of  the  pre-
puce ; they increase rapidly  in size, and unite in groups of
two or three vesicles to each.   They are extremely thin, and
so transparent that the red color of the skin beneath may be
seen through them.  The  fluid soon becomes sero-purulent,
small crusts are formed, which are gradually detached,  either
naturally or accidentally,  and expose  to view one or  two
excoriated  spots,  which  can easily be  distinguished  from
syphilitic  ulceration.  The skin  soon resumes its natural
color when the scabs fall off.
   A slight itching at the  beginning of the eruption,  and a
slight smarting when excoriations are  present, are  the  only
symptoms which  accompany H. preputialis.   This variety
pursues an acute course, and  very rarely lasts long.  H. pre-
putialis may assume a chronic form, and in this condition, as
M. Biett  has well observed, the accompanying symptoms are
much more important and severe.   The eruptions are fre-
quently reproduced, the inflammation is deep seated, the pre-
puce becomes rough and  difficult to draw back, the slightest
movement  cracks  and tears  it.   The orifice contracts for a
certain period; it  often remains  close to the mouth  of the
urethra, and yet the opening of the  prepuce does not corres-
pond  exactly  with the meatus   urinarius, the oozing from
which is constantly irritating the diseased parts.  The edge
of the prepuce becomes puckered, as if it was  folded upon
itself.  In  some cases  the contraction  is less marked, the
meatus is free, but the edge  of the  prepuce  is in  the same
condition.  It  becomes hard,  like cartilage, and forms  a  kind
of ring, which it is difficult to move.  The exertions required
to uncover a part of the gland frequently produce extremely
painful abrasions all round this ring.
   Causes.—This variety of herpes  seldom attacks  any but
adults.  The rubbing of  the clothes, certain chronic  dis-
charges, the irritation produced by the secretion of the seba-
ceous glands under  the prepuce, if allowed to  accumulate,
may produce  the  eruption.  It,  however, more frequently
appears  without any known  cause.  The contraction of the 
98
DISEASES OF THE  SKIN.
urethra, which may be present at the same time, has no other
relation with herpes than that of its coexistence.
  Diagnosis.—The seat of this variety of herpes has fre-
quently thrown  much obscurity  on the diagnosis, and it has
more than  once been mistaken for primary syphilis.  If the
peculiar characters of  H.  preputialis are borne in mind, it
appears to us almost impossible to confound it  with syphilitic
ulceration.   In the first  place, it  is a vesicular disease, and
all the  characters of  the genus herpes  are so marked, that it
cannot for  a moment be -mistaken by any careful observer.
No one could  mistake the thin, flattened, scaly crusts for the
thick elevated scabs  of syphilis.   The excoriations are quite
superficial,  and even  throughout, and appear  in  groups, like
the vesicles which  preceded  them.   The  syphilitic ulcera-
tions, on the other hand, are remarkable for their depth, their
hard  elevated  edges, and  the whitish  hard  pellicle  which
covers  them.  Nevertheless, a vesicle  of H.  preputialis has
frequently  been  mistaken  at  the  commencement  for  a
syphilitic sore.  In these cases, cauterization,  and even mer-
curial   frictions,  have often been employed to destroy  the
supposed  disease.   Under  the  influence  of  this erroneous
treatment, herpes passes  into  the chronic state, and from a
simple affection it becomes  a rebellious and obstinate disease,
which lasts for years,  and ultimately becomes complicated
with phymosis.  Fortunately, it is always easy to avoid this
error.   It is sufficient to know  that  the  venereal sore never
commences  with  a  vesicle,  but  with  a  redness  and  true
ulcerative inflammation.*
  Treatment.—Injections between the prepuce and gland of
the decoction of marsh mallows, a few  local emollient baths,
and lemonade, are the  only measures required in a majority
of cases.   However,  in  some  instances, it becomes chronic,
and resists the  most energetic  treatment.  M.  Biett  has
related many remarkable  cases of  this nature in his lectures,
and we have seen many others.  It will then be necessary to
have recourse to emollient and alkaline lotions alternately;
laxatives, soothing ointments,  and  vapor,  alkaline, and sul-

  [* Notwithstanding these  striking and distinctive characters, it is often very
difficult to distinguish at once herpes preputialis from a syphilitic sore, especially
when the vesicles have formed on the inner surface of the prepuce, when they have
burst, and when no perfect vesicles are present to assist the diagnosis. As soon
as the cuticular envelope breaks or falls off, the abraded surface beneath is irritated
and  prevented from healing by friction against the penis, with which  it is con-
stantly in contact.  The parts should be kept separate by a piece of dry lint inter-
posed between them ; and after one or two applications of a sulphate of zinc lotion,
containing three or four grains to the ounce, the nature of the sore, if vesicular,
will  readily be detected.                                       B.] 
HERPES.
99
phureous baths.   The frequent contraction  of the mouth of
the prepuce is the most  rebellious and troublesome symptom.
M. Biett has recommended, and we have several times used
with  success, the  introduction of prepared sponge in this
event.  As a last resource, the operation for phymosis may
be performed.*
   Three important varieties of the genus herpes still remain
to be described.  They  appear at first to be distinct species,
but on closer examination they will be found  not  to  differ
from  H phlyctenodes except in their more determinate  form.
However,  as they  are of frequent occurrence, and  as  there
still seems to be  some  doubt as to their  nature, we  shall
describe them separately.  H. zoster or zona, H circinatus,
and H. iris, are the varieties  alluded to.  Herpes iris occurs
much less frequently than others.   It was classed among the
exanthemata by Willan, and has  a great  resemblance to a
variety of roseola already described.

            Herpes Zoster, Zona, or the Shingles.
   It  is surprising how herpes  zoster could ever have been
described  as a  species of  erysipelas, with  which it has no
symptoms  in common.  Yet  as it has been  so regarded and
described  by  writers  on skin diseases, we  shall dwell  for a
moment on the probable  cause of that  error.   It arises, no
doubt, from the  fact that certain forms  of erysipelas are com-
plicated with bullae, but there is a vast difference between the
detached, circumscribed, and frequently  enlarged elevations
of the epidermis in erysipelas, and the small vesicles arranged
in groups,  and rarely exceeding the size of  a pea, which con-
stitute H. zona.  This, together with the regular progress of
the  latter,  the same  as  in  H. phlyctenodes, is sufficient  to
establish the relationship of these two affections, and to dis-
tinguish H. zona from erysipelas.
   Herpes  zona is known  by the presence of irregular patches,
of variable size, and of a bright red  color, covered with
agglomerated vesicles, which appear in the form of a zone on
the body or the limbs.   The zone usually commences at  a
certain point of the  median line, and  extends  around  to  a
point  on the  opposite side, without ever going beyond that
line.   It appears most frequently on the trunk,  in the  shape
of a semicircle or belt.   It not unfrequently commences on
the trunk  and terminates on the limbs.   Thus, it often begins
   * M. Cazenave cautions against the application of caustic in this form of herpes.
He says that  cauterization transforms a superficial inflammation into a deep one,
and increases the trouble, however slight the application  which may be made.—
{Gaz. des Hop. Sept. 24, 1850.)                           H.  D. B. 
100
DISEASES OF THE SKIN.
at the middle of the inferior posterior  lumbar region,  and
passes obliquely round to the external and anterior iliac region,
arrives at the groin, and terminates  on the inner side of the
thigh; or again, it commences on the upper part of the back,
reaches first the posterior, then the anterior part of the shoul-
der, and terminates on  the internal aspect of the arm, some-
times as low down as the elbow.   Two other lines are occa-
sionally observed issuing  from this zone, one  of which  pro-
ceeds along the arm, and the other along the lower extremity.
Its most frequent  situation  is round the base  of the  thorax.
It is seldom seen on the limbs alone.  We have most fre-
quently  seen it on the right side; while others have  met
with it oftener on the left.  It is probable that it affects either
side  indifferently, and that  the differences in  its seat which
have been noticed are only accidental.  It is sometimes situat-
ed on the neck  and face, and even extends into the mouth on
one side.  We have often observed it on the right side of the
scalp.   It never exists on two sides at  the same time.   Cases
of herpes reported as having encircled the whole body,  must
be referred to H. phlyctenodes.  In all cases these  zones are
formed,  not by  a  regular continuation  of vesicles,  but  by
isolated groups which pursue the same course, and their inter-
stices are perfectly sound.  Sometimes these groups approach
near each other, at others they are widely separate.
  The disease  lasts from one to three  or four  weeks.  It
never assumes a chronic form, and it is evident from the pas-
sage so  often quoted from Borserius (Inst. Med. vol. ii. p. 29),
to establish the existence of this condition, that the name of
chronic zona has been  given  to the painful ulcerated spots
frequently remaining after herpes zoster.
  Symptoms.—Herpes zona first  appears in the form of bright
red,  irregularly-shaped patches, pretty close to one another,
which are  developed successively, at variable   intervals, and
thus encircle one half of  the body.  The patches sometimes
commence at both ends of the  zone at the same time,  and
become connected by the development of intermediate patches.
Generally  those which  begin  and terminate in this  manner
are larger, and have an irregularly-rounded form, whilst the
patches that are between these  are smaller.   In  some rare
cases, their development  is accompanied all through  with a
painful  burning sensation.  If they  are carefully examined,
a number of small prominent silvery-white looking spots may
be  detected, which soon increase  in volume,  and  finally
become distinct transparent vesicles, about the size of small
pearls.   They are fully developed  in three or four days from
the first appearance, and seldom exceed the size of a large pea. 
HERPES.
101
They are, however, occasionally larger.  At this stage, the
skin on which the vesicles form is of a bright red color,  and
the redness extends for some lines beyond the  seat of the
vesicles.  As  new groups form, they follow the same course
as those which preceded them.   About  the fourth or  fifth
day from the  appearance of the eruption, the  redness dimi-
nishes, the vesicles subside and fall off, and the skin beneath
is wrinkled.  The fluid, which was at first transparent, becomes
opaque, in some instances blackish, and several  of the vesicles
contain  pus;  finally  small, thin, brown,  scaly incrustations
are formed, which disappear in the course of a few days.
Other groups of vesicles appear and follow the same course,
and after the lapse  of ten or twelve days no traces of the dis-
ease remain but the red stains, which slowly disappear. It some-
times happens, however, especially when the eruption is situat-
ed on the back, that slight excoriations, and even ulcerations,
are produced by the  rubbing of the parts against the bed
during  sleep, which prolongs the disease considerably.
   Such is the ordinary course of H. zona, the form, duration,
and progress  of which may, however, frequently vary: as,
for instance, the absorption of  the fluid may occur about the
fifth or sixth day, and the eruption itself disappear by desqua-
mation on the seventh or eighth day.  In other cases,  espe-
cially in persons enfeebled by age or privation,  the  vesicles
acquire  considerable size, burst, and produce  extensive and
painful ulcerations, followed by  well-marked  cicatrixes.  In
rare cases, particularly in very old cachectic people, gangrene
of the skin sometimes occurs on those parts where the vesicles
were formed.   We have seen many cases of  this disease at
the hospital of St. Louis, but have never seen it accompanied
with  any of those severe febrile, and especially gastric symp-
toms, with which  it has been erroneously associated.   The
only phenomena which we have observed as commonly accom-
panying H. zona, are slight indisposition, heat  of skin, some-
times a slight increase of pulse, a painful feeling of tension in
the seat  and  neighborhood of the eruption, and in cases of
ulceration, severe pain, which continues up to the period of
convalescence.  M.  Biett never  observed  any  of the  dan-
gerous  symptoms  alluded to,  in upwards of five  hundred
examples which had come under his notig^f itant, IMfctLlCill Oil
   Causes.—Herpes zoster chiefly attacks young persons with
 a fine delicate skin; men are more subject to it than  women.
 It attacks old people,  and appears  more frequently in  the
 autumn than in the spring or winter.  It occasionally succeeds
 small-pox, and assumes, in some instances, an almost periodic 
V
102               DISEASES  OF THE  SKIN.

character.   It may also put on an epidemic form.   Formerly
it was supposed to be hereditary.
  Diagnosis.—This affection can hardly be confounded with
any  other;  its vesicular  character and the presence  of  the
zone  will prevent any mistake from occurring.  Sometimes
when the zone is beginning to appear, or when it  is incom-
plete, and a few patches  only are to be seen in  the median
line, it may be mistaken for herpes phlyctenodes;  but it is
often merely necessary to examine  the opposite side of the
body in those cases, in order to discover other groups of vesi-
cles, and small  red patches  may  be  observed between these
clusters, indicative of the formation of new groups.   Besides,
their being confounded would not occasion any inconvenience
in the treatment, as  they are both fundamentally the same.
  Prognosis.—Herpes zona is, generally  speaking, a mild
affection.   The only instances in which it assumes a severe
character,  are  when it attacks persons  of an advanced age;
it then may terminate in ulceration and gangrene of the skin,
but even in those rare cases it scarcely ever terminates fatally.
The appearance of the eruption has  often a salutary effect in
checking the progress of some other more  severe disease,
which may coexist  with  it.  Guilbrand  relates several inte-
resting cases of this nature.   We have not met with any of a
similar kind.
  Treatment.—The affection, in the majority of cases, requires
but very simple treatment; regimen, repose, diluent drinks,
lemonade, &c, are all that is required, without any necessity
for either local or general bleeding.
  A very important point in the management of herpes is to
prevent the premature rupture of the vesicles; and for this
purpose we have been in  the habit, for several years, of hav-
ing the affected surfaces  sprinkled several times a day with
starch, and  tRen covered with  brown paper wnich has been
oiled, directing the patient, at the same time,  to keep as quiet
as possible.
  Simple  baths  are  beneficial  in  cases where the inflam-
mation is active, and the  constitution irritable.  Local appli-
cations  are, for the  most part, useless.   Those which have
been  most strongly recommended are lead,  or other astrin-
gent lotions.*   The  ulcerations may  be dressed  with  mild

  * M. Cazenave recommends elsewhere {Bull. G'ener. de Th'erap., Sept. 1847,)
smearing the patches with a little oil, and then  sprinkling them with dry starch,
which forms a kind of covering that protects the vesicles  from  any mechanical
cause of ulceration.
  M. Briquet has used collodion with success as  an external application in herpes
zoster, and says that it not only arrests the progress of the disease, but puts an end 
HERPES.
103
opiate  ointments.  If the disease appears  in  an  individual
whose  constitution is broken down  by old age, or by some
previous  disease,  tonics should  be  administered, and  the
strength recruited by nourishing diet.   If gangrene supervene,
recourse  must be had to tonics and stimulating local appli-
cations.  It is sometimes difficult to remove the pain, which
remains after "the eruption has  disappeared.  Frictions, ano-
dyne applications,  and  blisters, are frequently  required to
allay this irritation.  M.M.  Serres and Velpeau have lately
recommended the ectrotic method, as very  efficacious in H.
zona.   This is certainly one of those cases in which it has
the best chance of succeeding, for it is not so much to subdue
inflammation, as to allay the sensibility of the diseased parts,
that it is  required.   However, it is generally of little avail in
a  disease, the treatment of  which  is  usually  so  slight  and
simple as is required in herpes zoster.

                     Herpes  Circinatus.

   Herpes circinatus  is a very frequent variety, and appears
in the form of rings.  It is characterized by the appearance
of extremely small  globular  vesicles arranged in the form of
circles, the centre of which is free, and the border red.  This
circular border  is  often pretty broad,  compared with  the
centre,  especially when the rings are small, and the redness
extends beyond the vesicles the same distance  on either side.
   Symptoms.—The eruption is preceded by  a redness  of
various degrees  of intensity on the parts where  the  vesicles  •
are about to  form.   The red color  is usually confined to a
surface  not  exceeding  the  circumference  of  a shilling  ; it
sometimes,  however,  occupies a space  about  two  inches in
diameter.  The  redness  is paler in  the  centre of the small
rings.   In the centre of the larger ones, the  skin preserves its
natural  color.  The rings are often perfectly round, and occa-
sionally of an oval form.  The red  circular border  is soon
covered with  a number  of  small vesicles, set close together,
and  of a  globular shape.   The  transparent  fluid becomes
opaque, the vesicles burst,  and form  small thin incrustations,
which soon become detached.  The eruption generally termi-

at  once to the severe pain which accompanies it.—{Gaz.  des H6p., Oct. 1,
1850.)
  Oxide of zinc ointment forms a very good dressing when the vesicles break, and
stramonium ointment, or opiated cerate, affords relief when there is much irritation
—also an ointment of oxide of zinc and stramonium ointment, in the proportion of
3j to §j.  Warm and moist applications, as a general rule, should be avoided.
  A plaster of belladonna is a convenient, and often a very effectual application
for the removal of the neuralgic pains which sometimes follow herpes zoster, and
which occasionally harass the patient for weeks, and even months.   H. D.  B. 
104
DISEASES OF  THE SKIN.
nates about the eighth or  tenth  day, when the only trace
remaining of its existence is a slight degree of redness, which
gradually disappears.   This  is  the  usual  progress of the
disease;  but in some cases the centre of the ring  becomes
inflamed, and produces a slight desquamation, but no vesicles
appear.   Sometimes the vesicles do not terminate by desqua-
mation, but the contained fluid is absorbed, and they fall off
by an  almost insensible exfoliation.   This occurs principally
when the rings  are small, and  in  these cases the vesicles are
often so minute, that it requires  close examination to detect
them.  A good magnifying glass  will be found very service-
able in  these cases.  In  other instances, the rings  are very
large, and the vesicles more developed, but the latter rarely
ever exceed the size of a millet  seed.   When the rings  are
few, not diffused,  and developed simultaneously,  the eruption
rarely continues  longer than  the tenth day.  But in cases
where the  rings  appear in  numbers  one after the other, the
disease may be prolonged for two  or three  weeks.  In indi-
viduals of a fine delicate skin, the redness often continues for a
considerable period after  the disappearance of the  eruption.
Although it may  appear on any part of the body, its most
frequent seat is on the arms, shoulders,  chest, and especially
the neck and face.   We frequently  see boys, and particularly
girls, of  a fair and delicate skin, with herpetic rings about the
size of a sixpence on the cheek and skin.*
   Causes.—Herpes circinatus most frequently attacks children,
young persons and females.  It affects particularly fair people
with  a fine, transparent  skin.  Sometimes  it appears to  be
produced by cold. It may be developed on the face by stimu-
lating or irritating lotions.  No special cause can be assigned
for it.
   Diagnosis.—The peculiar  and well-marked  character of
this variety would apparently  obviate any error with regard
to diagnosis.   However, a small herpetic ring, the vesicles of
which  are slightly exfoliated,  situated on  a perfectly round
and red surface, may often  be  mistaken for a patch of lepra
without  scales ;  but the depression  in  the centre  and the
prominent  border of the one,  and the even  surface and the
debris  of  vesicles on  the  other,  will prevent  this mistake


  * There is another variety of herpes circinatus, which has been long known in
England, but only observed within a  few years in France. This affection, first seen
by  one of us in one  of the colleges in Paris, and since in a large number of
children, has been described by him  (M. A.  Cazenave) under the name of herpes
tonsurans; it affects chiefly the  hairy  scalp.  We shall  refer to it again, when
speaking of the diagnosis of porrigo.   This variety is contagious.—{Edition of
1847.)—H. D. B. 
HERPES.
105
        occurring to any careful observer.  Besides, it rarely happens
        that there is only one patch of lepra to be seen, and probably
        others may be found  on  different parts of  the body more
        strikingly developed.  The fact  that  the same name, that of
        ring-worm,  has been applied to both herpes  circinatus ton-
        surans  and to porrigo  scutulata, and that  they  are  both
        contagious,  may lead to  difficulty  in  the diagnosis  between
        them.  However, one (H. circinatus) is a vesicular affection,
        and merely  produces scaly crusts, is  of short duration, is not
        contagious,  and never causes loss of hair.  The other (porrigo
        scutulata) is a contagious pustular affection, the progress of
        which is long and indefinite.   It produces scabs, which gradu-
        ally increase in thickness.   It only appears on the scalp, and
        the hair falls off when the rings are  developed.  It is more
        difficult to distinguish it from lichen circumscriptus, the rings
        of which are  very  much larger  than those of herpes;  but
        vesicles are the elements of the latter, whilst the former are
        characterized by papulae.
           Treatment.—The  treatment of H. circinatus  is nearly the
        same as that of the other varieties, except that alkaline lotions
        may be advantageously employed in this form.   The frequent
        application   of saliva  will  often  allay  the  smarting which
        accompanies the eruption on the face, and also the inflamma-
        tion which  attends it.  Astringent lotions, composed of alum
        or sulphate  of  zinc, may also be used with advantage.  When
        it affects several parts of the body at the same time,  laxatives
        and alkaline baths should be administered.*

                                Herpes Iris.

          Herpes Iris  is an extremely rare form of this disease, which
        appears in  small  vesicular  groups,  perfectly rounded,  and
        forming four erythematic rings  of different shades  of color.
        The  patients   often  compare  them  to  small  cockades.
        Bateman  was  the first  to describe  this variety correctly, and
        also to place it in the genus herpes.
          Symptoms.—It appears  first  in small patches, which are
        soon  replaced by rings of different shades  of color.  About
        the second day a vesicle forms in the  centre, which is speedily

          * Herpes tonsurans is always very obstinate in its resistance to remedies, and not
        unfrequently lasts for a year or longer. The means which we have found the most suc-
        cessful are:  1.  Frictions, every evening, with a little of the following ointment—
        ^ tannin, grs. xv ;  lard, 3 v; water, q.s.; 2. In the morning, lotions with a solution
•       of subcarbonate of soda in distilled water ( 3 ss to a pint); 3. Alkaline baths.
          It is also proper very carefully to guard the children affected against direct
        contact with others, if not to isolate them entirely.  Cazenave and Schedel, edition
        1847.)—H. D. B. 
106
DISEASES OF  THE SKIN.
surrounded by many others of a smaller size.  In the course
of two or three days the central vesicle is flattened; the fluid
it contains becomes opaque and of a yellowish hue ;  the rings
are more developed, they now form four distinct circles, which
successively surround the central vesicles, so as to form a disc
about the size of a shilling.   The first and central ring is of a
reddish brown tint, the next a whitish yellow, the  third and
narrowest a  deep  red,  and the  fourth or external  circle
presents a pale rose color, which is lost insensibly in the color
of the surrounding  skin.   These  rings are often very nume-
rous, but the  various colors are not always so well marked.
The third is  the narrowest; each may be entirely covered
with vesicles, but they are  generally more numerous  on the
first.   They terminate about the fifth or  sixth day  by the
absorption of  the fluid, and  by slight  desquamation.  Some-
times the vesicles burst and  form small thin lamellae, which
soon fall off.   Herpes  iris  may appear on any  part  of the
body, but its most frequent situations are the face, the hands,
the instep, the fingers, the neck, &c.
   Causes.—Herpes  iris  most frequently  affects  children,
females, and persons of a fair skin, without any appreciable
cause.  It may coexist with other forms of herpes.
  Diagnosis.—The only disease   with  which  it  can  be
confounded is roseola annularis.  The  latter, however, differs
from the former, by the larger size of the rings, which some-
times exceed the circumference of a crown-piece, and by the
absence of vesicles.  Herpes iris may especially be confounded
with this form of  roseola, in cases where  the  vesicles have
burst and disappeared;  but generally, on closer examination,
the debris of vesicles will be detected, which will  prevent this
mistake.
   Treatment.—This  affection is  so  mild,  that  it  scarcely
requires any  particular treatment.  The remedies  suited to
herpes  circinatus will  also  answer in  this case, if any  be
required.  Herpes iris is  so rare, that M. Biett had  seen but
very few examples,  amongst  the  vast  multitude of cases of
skin diseases which came  under his observation at the hospital
of St. Louis during  a long  series  of years.  We  have seen a
beautiful example of this  affection in his wards, in which the
ring was situated in the middle of the forehead.*

  * In the edition of their work in 1847 the authors say, that they have since seen
several cases of this singular variety.  We have met with a few cases of it.
  The different forms of herpes  are frequently connected with disorder of some
portion of the digestive apparatus,*and sometimes require an emetic, followed by a
gentle purgative of an antacid character, and diluents, with mild farinaceous diet 
SCABIES.
107
                        SCABIES.

 Syn.—Psora; Gale  (French); Scabbia  (Italian) ;  Krcetze
                      (German); Itch.

  Scabies or itch is a cutaneous affection caused by an insect,
the acarus scabiei,  and characterized by  smart  itching, with
the formation  of  vesicles more or less  distinct  from each
other, acuminated, transparent at their summits, larger at their
base, which is of a rose color, and from which extends gene-
rally a furrow, sometimes straight, and at other times crooked,
at the extremity of which  the insect is found.   Its  favorite
seat is the intervals between the fingers and the  wrists.
  The  itch was known to the ancients;  but, in Greece arid
among  the  Romans, under the name of •j'wpa and of scabies,
were confounded several other diseases than those produced by
the presence of the insect, their names having  been derived
from  the external characters.
  Avenzohar, a native of Spain, is  the first  physician who
expressly mentioned the insect  of itch, he  doubtless  having
often  witnessed its extraction.  But  he  did  not point out the
connection  between the insect and the disease, having treated
of the itch itself in another part of his work.
  From Avenzohar, who wrote  in  1179, to  Moufet, whose
work  appeared in London in 1634 (insectorum sive mini-
morum  animalium theatrum), no mention is made by authors of
the acarus scabiei.  Moufet gives a  very good description of
it, and of the furrows which it makes.  Hauptmann described
it, and gave a drawing of it twenty years afterwards.   Since
that time it has been  described successively by Hafenreffer
(1660), Ludovici  (1678), Morgagni and Etmuller (1692), and
by Bonomi and Cestoni (1683).
   Linnaeus tended rather to  mislead than to throw light on
the subject by speaking of the acarus scabiei  as though it
were  the same as  the  acarus farinae, describing it under the
name of acarus exulcerans.   His errors, however, have been
corrected by Geoffroy, Gmelin, de Geer, Fabricius, Wichmann
and Latreille.

for a few days—at other times, active mercurial purgatives, followed by alkalies
and diuretics, with the warm bath, are required.
  When chronic, mild mercurial alteratives, with  laxatives and alkalies, as rhubarb
and magnesia, or rhubarb and soda, with mild tonics and bathing, either the simple
warm water, or alkaline, or warm salt water baths, are  useful.
  Liquor potasses, as mentioned under the head of eczema, will often prove of
service.—H. D. B. 
108
DISEASES OF THE  SKIN.
  The existence of the insect  was still a matter of doubt in
France, when, in 1812, M. Gales, formerly  an apothecary of
the Hospital of St. Louis,  instituted  experiments on more
than three hundred persons affected with itch, and exhibited
to a large body of physicians, and even to a Committee of the
Institute, more than three hundred insects, of  which he even
described  the  habits, and  of which a drawing was  made.
The insect exhibited by M.  Gales, however, proved to  be the
cheese  mite, and no insect could be found in the vesicles, as
stated by him.  Incredulity succeeded this exposure, and con-
tinued to prevail until 1834, when M. Renucci  then a pupil
at the Hospital of  St. Louis, pointed out the manner of find-
ing the acarus, showing that it  must be sought for not in the
vesicles themselves, but by  the side of them, and at a short
distance from  them.  It is sometimes  found about a quarter
of a line from an isolated vesicle, presenting a small white
point under the epidermis, from which  it can be raised  by the
point of a needle; at other times, it is found at the extremity of
the small  furrow,  which is  one or two lines in length, and
even longer, extending from the vesicle.
  Since  that period, M. Raspail has given a very good
description of the  insect, with  excellent drawings of it, and
M. Albin Gras has studied the action of certain articles on it
to ascertain  what will  destroy  it the soonest.   He  found
that it lived three hours in  pure water; two hours in olive
oil; one hour in a solution of sugar of lead ; three quarters of
an  hour in lime water; twenty minutes in vinegar, alcohol,
and an alkaline solution; twelve minutes in  a solution of sul-
phuret of potassa; nine minutes in spirits of turpentine ; from
four to six  minutes in a concentrated  solution of hydriodate
of potassa.   It survived one hour in the flour of  sulphur, and
sixteen hours in the  vapor  of  sulphur under a  watch glass.
The solution  of the  hydriodate of potassa is therefore  the
most  powerful agent which can be  used externally with
safety.  M. Albin Gras  has extracted them alive from a
patient who  had  taken three  sulphur baths, while  he has
frequently  found them destroyed  after a single  friction with
the ointment of Helmerich.
   Scabies is never caused by inoculation with the fluid from
the vesicles, nor by that from any other of  the eruptions  pro-
duced by the insect, but only by the insect itself.
   The  acarus scabiei is a small, round, greyish body, some-
times  in  motion,  and at  other  times at rest.   With good
sight, and  especially  with a magnifying glass, the  head and
fore legs of the insect  can be easily  distinguished.   Under
the microscope, it presents an oval body, the back somewhat 
SCABIES.
109
convex, on which  are  marked  numerous  fine curved  lines,
parallel with each other, and of unequal length in the different
groups.  Under the abdomen are eight legs, four of which are
in front, and have at their extremities a  sucker  of trumpet
shape, with  hairs at  their base.  The four hind  claws  are
without suckers, and  terminate  with a hair of greater or less
length.  The head  is  covered with  fine  hairs,  and has a
trumpet-shaped  protuberance, shorter  than those  on the fore
legs, with a hair longer  than itself on each  side of it.*
   Causes.—It is settled that the  acarus is the sole  cause of
itch.   It can be communicated even  from a dead  body, as
long as the insect is alive.
   Scabies  is  never epidemic ;  and  is  only endemic among
uncivilized  nations, and in countries where the habits of the
people are  filthy.
   Youth, the sanguineous temperament, the male sex, handling
of woollen  substances,  the  seasons  of spring  and summer,
tropical  climates, neglect  of  cleanliness,  are  predisposing
causes of the disease.  It occurs more frequently  in children
and youth, doubtless because there are more  of  these  ages
than of any other.
   It  is much more  frequent   among  males than  among
females, probably because the former are more exposed to it.
Those of lymphatic and sanguineous temperament are much
more frequently affected  with  it  than  those of  the bilious
temperament, in which  it  is of rare occurrence ; because this
temperament itself is  comparatively  less frequently met with.
  Seat.—Scabies affects  especially the hands,  the spaces
between the fingers,  and  the front part of the wrist, and the
limbs in the line of flexion.  It is never seen on the face.  It
is not unfrequently  found on the feet.
  Progress and Symptoms.—The period of incubation of itch,
or the period at which it appears after exposure to  direct con-
tagion, varies from several  days to  several weeks, and  even
months.
  In children it usually shows itself at  the end of four or five
days;  but  the time is longer in  feeble  and delicate children,
while it is much shorter, even only  two days, in very strong
and robust  children.
  In  adults  the  time  varies, as  before mentioned,  and  is
always shorter in spring and summer than in winter.  It also
lingers, even extending  to several months, in old persons and

  * For a scientific and much more minute description of the acarus scabiei, see
Wilson on Diseases of the Skin, second edition, 1847.           H. D. B.
                            8 
110
DISEASES OF THE  SKIN.
those laboring under  chronic disease.  The  vitality of the
dermoid system  appears to be the principal  cause  of these
remarkable differences.
  Itching over  different parts of the  body,  and especially
between the fingers, and on the front part of the wrists, with very
slight chills, and  a general irritation of a peculiar kind, usually
precedes the eruption of vesicles, and  increases  with  their
appearance.  This itching, with the development of vesicular,
erythematous, papular,  and  pustular eruptions,  in  different
degrees,  are  the symptoms  of itch which discover them-
selves.
  The itcjiing sensibly increases towards evening, particularly
when in bed, and also under the influence of all causes which
increase  the  cutaneous circulation, as  heat, exercise, stimu-
lating drinks, &c.   Small, more  or less papular elevations
soon begin to appear,  of a  pinkish tint in young and vigorous
persons, on the top of which  a small transparent vesicle soon
forms.  From this vesicle, when opened by the  nails of the
patient, a very  small  quantity  of clear  fluid, like water,
escapes, and forms, in drying up, a  small, rough, friable, and
slightly adherent scab.
  The vesicles  are accompanied by small  furrows,  made by
the insect in  his progress under the epidermis, which  resemble
the fine scratches that the  point of a pin would make drawn
lightly over the epidermis..  These furrows  have one extremity
■corresponding with  the vesicle,  and another marked  by  a
small, round  swelling, where the insect is found. The appear-
ances of these furrows vary with their duration, and with the
age and occupation of the patient.  It is only at the .end of
the furrow, opposite the vesicle, that the insect is to be found,
from which  it may be extracted with the point of a fine
needle.  The furrows are  usually found on the hands, in the
intervals between the fingers, the wrists, the axillae, the inside
of  the thighs, on the feet,  even on the soles, on the pelvis,
scrotum,  and sometimes about the  knees.  Sometimes  it  is
very difficult to find the  insect, and occasionally impossible,
and always requires some practice.
   The vesicles  left to themselves  rarely,  if ever, become
pustular; but when irritated  by the  nails, especially in young
and vigorous patients, and in those accustomed to the use of
stimulants, they  may  assume  a  pustular character;   and
pustules of impetigo and  ecthyma will then be found among
the original vesicular eruption.
   Scabies varies in  its progress and development with the
 age, constitution, temperament, and health of  the patient, and
with the  season of the year,  climate, &c.   In the young  and 
SCABIES.
Ill
robust,  and those in full health,  it spreads rapidly over the
surface, and the whole body is sometimes more or less covered
with different kinds  of eruptions, without any decided cha-
racteristics, mingled  with  brownish  scales, with more or less
redness of the whole skin; and to these are sometimes  added
large pustules of ecthyma and boils.  But whatever may be
the extent of the eruption, it is never attended with those
dangerous results which have been attributed to it.
   Terminations.—Itch  never terminates spontaneously, but
may last for years, and even for the whole life,  as is  the case
in  some countries;  but in these cases, the  skin becomes
accustomed to the presence of the disease, and it causes but
a moderate degree  of irritation.
   We admit but one kind of itch, that produced  by the acarus
scabiei, and consider the vesicular  form of eruption as the
only one belonging properly to it.
   Diagnosis.—Strictly speaking,  the  existence of itch  can
only be conclusively proved by the presence of the insect;
and the certainty of this  is established Ijy finding it, and by
the marks it leaves.  The vesicle is sufficiently  characteristic
in a great  majority of cases to establish the diagnosis.
   The eruptions most likely to be confounded with scabies are
eczema simplex and prurigo.  But the vesicles  of eczema are
flattened, while those of scabies are acuminated, and rest on a
reddish base, which is  never the case  with those of eczema.
In  eczema, also,  they are  grouped,  and often  run together,
while in scabies they are always  less confluent, and usually
distinct.  The sensation produced  by eczema  is a  kind of
general smarting, a  burning kind of itching; the  itching of
scabies is not of  that character, and  has well marked exacer-
bations.   Also, eczema is not contagious, at least very rarely
so.*  Some individuals have a vesicular eruption every year
after having been cured of  itch:  this is  not  scabies,  but
eczema; generally  eczema simplex.  This is  doubtless owing
to some modification of the innervation of the skin originally
produced by the  scabies.
   The  elementary form of prurigo  is papular,  and its usual
seat is  the back, the shoulders, and the line of extension of
the limbs.   The papulae,  which are almost  always  torn  by
scratching, have their tops covered with a little clot of dried
blood,  of  a black or dark color, which differs  entirely from

  * Eczema frequently appears on the face ; scabies never does. Eczema has a
tendency to disappear and  return  again, and particularly  to return at different
seasons of the year ; this is never the case with scabies.  Still there are some cases
in which  the  diagnosis is attended with extreme  difficulty, and perhaps is not
possible, though probably such cases are of rare occurrence.—H. D. B. 
112
DISEASES OF THE SKIN.
the small, yellowish, friable scale  which covers the vesicles
of scabies when they are torn.  The itching is more severe
and burning in prurigo, which is, besides, never contagious.
  Lichen  simplex might also be mistaken  for scabies; but it
is  characterized by papules, and those are  usually very near
together, which is rarely the case with the vesicles of itch;
the papules of lichen are of the same color as the skin, while
the papules which precede the vesicles of itch are of a reddish
color, as is also true of the vesicles themselves at their  base.
When lichen  affects the hands (which is the  form most  apt
to be mistaken for  itch), it occupies the dorsal surface, and
not the spaces  between  the fingers as  itch  does, and  also
covers the external surfaces of the limbs, and the itching is
less severe than that of scabies.  In  lichen urticatus, the itch-
ing is very severe, but the eruption always continues papular.
None of the varieties of lichen are contagious.
  All these different eruptions may coexist with scabies, and
thus obscure the diagnosis, which must then be founded on
the presence of the'insect, or of the furrows which it makes.
  Scabies may occur at the same time with syphilis, scrofula,
and  pellagra,  without  their being influenced  at all by each
other.   In some very rare cases, scurvy may impart a livid
tinge to the eruptions of scabies, and  when these  are nume-
rous, they may soon become covered with brownish scabs.
   Treatment.—Scabies is only cured by the extraction or the
destruction of the insect which causes it.   The duration  of
the disease,  under a  treatment capable of destroying  the
acarus  without increasing the irritation of the skin, varies
from  six to twelve  days; its complications may prolong  the
cure several months.
   A great variety  of remedies have been recommended for
the cure of itch; we can only mention those  most used, and
which have proved most beneficial.  Mercurial  preparations,
besides almost  always developing other eruptions, may cause
swelling of the salivary glands, salivation, and even  glossitis,
and should be renounced entirely.
   The  liniment of  Jadelot is  often useful, although it  gives
rise  to  eczematous eruptions, the  mean duration of which is
fifteen  days;  the same is true of the  lotions  of Dupuytren,
which consist of four ounces of sulphuret of potash, dissolved
in a pint and  a half of water, with the addition of half an
ounce of sulphuric acid; the affected parts  to be washed with
it twice daily.   This wash causes painful smarting, especially
in irritable persons, and the mean duration of treatment is
sixteen days.
   Of the great variety of ointments  used we have long given 
SCABIES.
113
the preference to that of  Helmerick, a modification of which
Biett  employed almost  exclusively.  It is  known under  the
name of sulphuro-alkaline ointment, and is composed of two
parts  of  sublimed  sulphur, one  part of  subcarbonate  of
potash,  and eight parts of lard.  The mean duration of treat-
ment is  twelve days ; but it has the disadvantage of discoloring
the clothes so that they cannot be restored.
   More recently agents have been used to  destroy the acarus,
and in this way cure the  disease more speedily.   Dr. Hebra,
of Vienna, found that a solution of common salt,  of corrosive
sublimate, of arsenic, of the sulphates of iron, and copper, and
zinc, or a decoction of the leaves of tobacco, or  hyosciamus,
or  belladonna,  or  hellebore, either black or white,  would
destroy the insect in from two to twenty hours.   He prefers
Wilkinson's  Ointment,  modified as follows :—prepared chalk
§ iv. ; sulphur  and  tar  aa 1 vj.;  soft soap  and lard aa § xvj.
M. Hebra considers the addition of the chalk of great import-
ance in acting mechanically to break up the furrows.
   The  remedies used,  of whatever kind,  should be applied
directly to the  parts occupied by the insect, as  they do not
act by  absorption.   Dr. Hebra  has  the frictions  made upon
the extremities, where,  according to his  view, the acarus
almost  exclusively  locates  itself,  and  in occasional cases on
parts to which he suspects  it may have extended itself; and we
have ourselves, for  a long time past, limited the application of
topical  remedies to certain  parts  in  preference.  PihoreVs
plan of treatment consisted in making, twice a day, frictions
in the palms  of the  hands, with pulverized sulphuret of lime,
mixed with a very small quantity of olive oil.
   The  problem to  be resolved  in  the rational treatment of
scabies  is to  cure quickly, with few or no complications, at
as trifling an expense as  possible, and without injuring  the
clothes.  In the endeavor  to accomplish this object, one of us,
after a great  number of trials of different remedies on a large
scale, has selected  the two following formulae as  those which
have yielded the most satisfactory results *—
   1. Alcoholic Aromatic Lotions :
           Essence of peppermint.
                "   of rosemary.
                "   of lavender.
                "    of lemon aa 4 to 6 drops.
           Alcohol,.....3 iss.
           Weak infusion of thyme,   3 quarts.
   The mean duration of  this treatment is  eight days ; it is a
desirable plan in private practice,  and  causes no serious com-
plications, but is too expensive 'for hospital  use. 
114
DISEASES  OF  THE  SKIN.
   2.  Ioduretted Lotions.
                Iodide of sulphur.
                Iodide of potassum aa 3 iss.
                Water,   ....     1  quart.
   The mean duration of this plan is six days.
   Whatever the  lotion  employed, it is necessary  not only to
wet the affected parts, but to prolong its application, so as to
produce that kind of maceration which is required to destroy
the insect.
   Baths are useful auxiliaries to the treatment, and one should
be taken at least  every  two days.  Sulphur vapor baths are
too fatiguing for  the patient, and  the mean  duration of treat-
ment is too long ; but they often are useful aids to other means.
   Accidental  complications  must be  treated by  appropriate
means when they  occur.   As these are most usually produced
by the  agents used to destroy the  acarus,  nothing  more is
required than to suspend the use of such  articles for  the time.
   Patients  must also be kept by themselves,  and their clothes
disinfected  ; and  after the treatment  is finished, warm  baths
should be taken.*

  * M. Bazin, physician of St. Louis Hospital, Paris, claims to have improved the
treatment of itch so as to have shortened its duration to four days.  The modifica-
tion of treatment consists in having the patient rubbed from head to foot, and over
the whole surface of the body, with the particular ointment which may be used,
instead of confining the application to the wrists and elbows only.  He says that
friction has very great  advantages over lotions and baths, and if it is only made
upon parts covered with pimples and furrows that are visible, it will not cure those
in whom the furrows are out of sight, and the acari in these will escape the action
of the ointment.  The treatment is to be  commenced and  concluded with a warm
bath, the frictions to be made every six hours for forty-eight hours.  He uses the
ointment  of Helmerick, and also the following:—]£ flowers of sulphur, §ss.  ;
common salt 3j. ; lard § ij.—{L Abeille Med., Nov. 3, 1850.)
  Dr.  J. H. Bennett, of Edinburgh, reports cases of scabies cured by inunction with
lard alone, the parts being also kept covered with oiled silk, and thinks that the
efficacy of sulphur ointment depends almost entirely upon the unctuous matter,
which causes the death of the acarus by stopping up its respiratory pores.—{Monthly
Journal Med.  Sc. Jan., 1850.)  Olive oil has also been used with similar results.
Frequent lotions through the day, with a solution of chloride of lime (§ j. to a pint
of water), are preferred by one writer to all other means.
   Emery gives the following recipe  for  an  ointment used at the St. Louis Hos-
pital :—1£ brown soap, § j. ; table salt, ^ ss.; alcohol, 3 j. ; vinegar 3 ij. ; chloride
of lime, 3 ss.   He says that it causes no irritation, does not soil the clothes, has no
unpleasant smell, cures in a short time, and is cheap.—{Bulletin G'ener de Thirap.,
Mai.,  1836.)
  The combination of sulphur with soap, of a kind and quality to suit the taste and
the means of the patient, forms a convenient and effectual  mode of applying that
remedy.   I have  combined it with the  common soft soap in dispensary practice
with good effect.
  M.  Bazin says, that to put the clothes which the patient has been wearing into a
hot oven is more sure to destroy the acarus than to wash them.       H. D. B. 
BULLAE.
                        ----*----                      »


  The diseases which belong to this order are characterized
by  elevations of the epidermis,  sometimes of considerable
magnitude, caused by the effusion of serum or a sero-purulent
fluid.  These tumors  are called bullae or blebs ; they are of a
round  form, have a broad base, and vary in size from a pea
to that of a goose-egg, which distinguishes them from the
vesiculce, the latter never appearing so large.
  The eruptions which come  under this denomination are
two, pemphigus and rupia.   Rupia has been classed by  Bate-
man amongst the vesiculae;  but we agree with M. Biett, that
it may be very appropriately placed under the head of bullae.
Analogous phenomena  are  sometimes observed in diseases
foreign to this order, but their development  is purely  acci-
dental.   They are simple complications, the elementary  cha-
racters of which are essentially different from those of the
diseases under consideration.  Thus, in herpes zona, some  of
the vesicles running together form genuine small bullae; but
the vesicles properly so called are much more numerous, and
besides, all their characters are very distinct  from those  of
the bullae.   The development of bullae in  erysipelas is also
entirely accidental, that affection being also characterized by
well-marked symptoms.  Although  the diseases belonging  to
this  order may  assume an  acute  form,  they  are  more fre-
quently chronic.   They appear successively on every part of
the body;  they spread over a large surface, but rarely over
the entire skin at the same time.   They are generally  con-
fined to the extremities, most frequently to the  lower.  Their
duration varfes  from a  fortnight  to several months.  Some-
times they continue for an indefinite period.
  Symptoms.—The invasion of these affections is frequently
preceded by a certain degree of redness of the  skin, but  in
many  instances this phenomenon  does not occur, and  the
bullae or blebs appear suddenly without any precursory symp-
toms whatever.  The cuticular elevations  are small  at  first,
but they gradually enlarge during the first twenty-four hours, 
116
DISEASES OF THE  SKIN.
  until they attain  a considerable size.  The bullae are tense
  when they first appear;  but as soon as the fluid thickens they
  become  flaccid, as if only half filled.  In all cases they burst
  sooner  or later, the serum becomes effused on the skin,  and
  they are succeeded  by incrustations of variable  thickness.
  The bullae which are developed on the  face are in general
  very small,  they burst  early, and are succeeded  by crusts
  analogous to those of impetigo.   In some cases the bullae  are
  succeeded by ulcerations, sometimes superficial, but more  fre-
  quently deep-seated, as in rupia.
    Causes.—The causes  of these affections  are very  uncer-
  tain. They  appear most frequently in persons of a broken-
  down constitution.
    Diagnosis.—These  diseases are  generally  easily  recog-
 nised.  The  vesiculae, which alone  could be mistaken  for
 them, may be  distinguished  by their  smallness.  The diag-
 nosis is  more difficult when  the bullae have burst,  and  are
 succeeded by thickish crusts.  However, the peculiar cha-
 racters  of each will  enable  them to be  distinguished at a
 glance, especially  as  the bullae invariably leave marks after
 them.  We have to depend chiefly on negative characters in
 these cases, in which  considerable experience is necessary to
 form a correct diagnosis.
   Prognosis.—The bullae  are sometimes dangerous, espe-
 cially when they  occur  in aged  persons, or in those of a
 broken-down  constitution. In these  cases they frequently
 accompany a chronic  disease of  some  internal organ, par-
 ticularly  of the liver.
   Treatment.—These  affections occasionally require an anti-
 phlogistic plan of treatment.  Sometimes they require tonics,
 the preparations of iron, &c.; and lastly, particular attention
 should be paid for a considerable time after the disappearance
 of the disease  to the patient's hygie'ne.

                      PEMPHIGUS.

 Syn.—Febris  bullosa ; febris vesicularis;  hydatis;   Pom-
                pholix; Phlyctena ; Bulla.

  A  cutaneous affection has been described  unTler the  name
 of Pemphigus, characterized by the appearance, upon one  or
 more  regions of the body, of large bullae, two inches or  more
in  diameter,  containing at first  limpid  serum, which  soon
becomes  reddish.  They are isolated, but numerous, and pro-
longed by successive eruptions, always terminating in slightly
thickened  crusts and  superficial excoriations.  Willan  and
Bateman have denied the  existence of pemphigus as an acute 
PEMPHIGUS.
117
affection, but admit and describe its appearance in a chronic
form under the name of pompholix,  "an eruption of bullae
without surrounding inflammation and without fever."   Gili-
bert has,  however, in his excellent monograph, established
the identity of pemphigus as a distinct affection, and M. Biett
had long entertained a similar opinion.   It may appear, there-
fore, in two forms, the acute and chronic.   Acute pemphigus
may be confined to a single region, but is generally so diffused
as to occupy nearly the entire surface of the body.   In these
instances  the bullae  are  almost always separate from  each
other; we very rarely find them confluent.
  Symptoms.—Sometimes the precursory  symptoms are of a
mild character, and  consist  merely  in slight  indisposition,
accompanied with a smart itching  of the skin, and  slight
acceleration of the pulse.  In other cases the skin is dry and
burning, there is much thirst, quick  pulse,  anorexia, and
rigors.  This state continues twenty-four to forty-eight hours,
and sometimes even  three  days.  The eruption then  com-
mences in  the form of small red circular patches, which gra-
dually increase, and become covered with  bullae.  The  latter
are produced by the  effusion of serum  under  the epidermis,
over  the  whole or part of the inflamed base.   Sometimes
these red  patches become  immediately covered  with bullae,
on  other occasions they are not developed for several hours.
In some instances the bullae cover all  the inflamed surface,
and  are then small, transparent, isolated tumors, varying in
size from  that of a pea to that of a  filbert, and  of a nearly
rounded form.  In other cases, on the contrary, the epidermis
is  not raised over the whole of the inflamed surface,  but
merely  at the centre, and  a  little way  round it.  Thus we
sometimes  observe in a spot the size of  a shilling  a single
bleb, not larger than a pea, whilst in others, on the contrary,
an  areola of one  or  two lines only  surrounds  the  isolated
tumor.  There  are also cases  in which  we  find red patches
here and there without any bullae; but on passing the finger
along the surface, a slight elevation is perceived, and the epi-
dermis is easily detached by friction, in consequence of the
subcuticular serous exudation.  The red color of the areola
is very bright for the first four days ;  the color of  the patches
that do not contain bullae is much paler ; in the interstices the
skin remains perfectly sound.   This redness has been denied
altogether by some writers.   Sometimes several of the bullae
unite and form a tumor, the size of a goose-egg.
  When the bullae have attained their full growth, they begin
to fade, and the serous fluid becomes opaque.   They some-
times burst within twenty-four or forty-eight hours.  They 
118
DISEASES OF THE SKIN.
are replaced by small, thin, brownish incrustations, which
begin to form before the redness disappears, or by small, dry,
whitish lamellae.
  The eruption of acute pemphigus may present itself in two
entirely distinct forms:  the bullae may appear successively,
or may all come out at the same time,  resembling in  this
respect the eruptive fevers.
  The febrile symptoms  which accompany this  disease are
sometimes so very  slight, that the patient does not require  to
keep his bed.  On other occasions they are exceedingly severe.
We have  seen a patient at the hospital of St. Louis in whom
this affection was accompanied with severe gastro-intestinal
irritation, pulmonary catarrh,  ophthalmia, and inflammation
of the urethra.  The tongue was  swollen, and the lips were
covered with  sordes.   All these symptoms, together with the
eruption,  disappeared in the course of a month.   The dura-
tion of acute pemphigus is ordinarily short, from one to three
weeks.  It sometimes affects children, when  the symptoms
are the same as the foregoing.  The Pemphigus infantilis,  or
P. gangrenosus of nosologists, seems  to us to belong more
properly  to  rupia  escharotica.   M.  Krauss  has,  however,
established pretty clearly, in his Thesis "De Pemphigo Neo-
natorum," the existence of this disease; and we have recently
seen a case, with M. Trousseau, in which the soles of the feet
of an infant  were  covered with bullae  containing a sero-
purulent fluid, and surrounded with  a violet-colored areola.
The infant  was  otherwise perfectly  healthy.   It frequently
appears in lying-in  hospitals, when it has often been mistaken
for a syphilitic affection.*
  Pompholix  solitarius of Willan appears to be a variety  of
acute  pemphigus.  The  appearance of the bullae  is preceded
by a  pricking sensation;  their course is  rapid,  and several
ounces of serum are  speedily effused under  the epidermis.
The bulla (only one appears at a time) opens in the course of
forty-eight hours, and leaves a slight excoriation.  One  or
two  days afterwards another bleb forms  near the first,  and
pursues the same course.   They frequently reappear twice  or
thrice in  this manner, so that  the disease may be prolonged
for eight or ten days.  This variety may also exist in a chro-
nic form.  It is, however, an exceedingly rare  affection.
   Chronic pemphigus (Pompholix diutinus of Willan)  is  a

  * Our authors say, in the edition of their work in 1847, that they have met with
several cases of this disease, respecting the true character of which they were for
a long time in doubt, and that recent observations have led them to coincide with
Prof. P. Dubois in regarding the pemphigus of new-born children as a rare and
serious form of congenital syphilis.                          H. D. B. 
PEMPHIGUS.
119
more common disease than the acute form, and appears more
frequently in adults and in old  men  than  in women.   This
affection often spreads over the whole body; at other times it
is  confined  to a  small  surface.  Febrile  symptoms never
supervene, as in the acute form, unless the eruption becomes
very much extended and prolonged.   A few days before the
bullae appear, the  patient feels a slight degree of lassitude,
languor, and  pains in  the  limbs.  A number of small red
spots, accompanied with slight  itching, then supervene.  In
the centre of each little patch the epidermis becomes elevated.
The base of this  cuticular  elevation gradually extends  so as
to form in  the course of a few hours an irregularly-shaped
bulla, the size of a filbert, or even of a walnut.  At the end of
two or three days the bullae  are as large as an egg, and some-
times larger.  Owing either to  their distended state, or the
movements  of the patient, some of these burst, and the serum
is  effused over the skin.  The epidermis shrivels and is cor-
rugated, or else it becomes partly  detached, folds upon itself,
and exposes  an  inflamed  and  slightly  excoriated  surface,
around which the  skin becomes puckered, and upon which
there takes place a slight exfoliation.
   Towards  the  third or fourth  day,  according as they lose
their transparency, and  as  the serum becomes reddish, the
bullae  which  have not  burst shrivel up.   The epidermis
assumes a whitish tint first,  then becomes opaque, and finally
terminates in small, flat, brownish  incrustations.  New bullae
form close to the old ones, and pursue the same course, so
that we may observe at the same  time bullae filled and dis-
tended  with semi-transparent serum, laminated  crusts, and
irregularly formed red patches, slightly excoriated, and  of
variable size.  Moreover, the skin of the  patient, in whom
all these various phases of the disease, from the formation of
the bullae to  their complete disappearance, are developed, pre-
sents a very peculiar and remarkable appearance.  Such is
the ordinary course of chronic pemphigus, which may thus be
prolonged for months.
  In some  rare cases, pemphigus  spreads over  the whole
surface of the skin  at  the same time.  The  bullae  then
coalesce, the contained fluid thickens, and becomes purulent;
and presently the whole body is covered with yellow crusts,
which  have been mistaken for  those of  impetigo.  These
crusts are not thick, and present certain peculiarities both in
their form and in their extent, which denote that they  have
proceeded from  bullae.   Some  of these incrustations,  ex-
tremely  thin, seem to  be  convex at the  centre, and  are
shrivelled and wrinkled at the circumference.  This variety 
120
DISEASES OF  THE  SKIN.
 usually appears on the face, which is not a common situation
 of pemphigus.  The  first bullae  are in some  cases  preceded
 by red, circular  spots, as in the  acute form,  which will not
 occur  with  the  succeeding  eruptions,  and  sometimes the
 reverse of this takes place;  while, in other cases, successive
 eruptions may have erythematous borders.*
   The disease is  sometimes confined to a certain point.   We
 have seen in  M. Biett's ward  a man, thirty years  of age, who
 had been  from  his infancy  affected with pemphigus, some-
 times in one part, sometimes  in another, which  produced  a
 purple-red  color  on  the lower part of the limbs, not unlike
 that which appears in individuals affected with indolent ulcer-
 ations of  those parts.  It was continually developed  in this
 situation for several years, and the bullae varied from the size
 of a  small  almond to that of a  large nut: they  sometimes
 attained the size of the palm of the  hand, when the epidermis
 would  peel off, and expose a  large  unhealthy-looking excori-
 ated  surface,  which  would  seem difficult  to  heal;  but they
 would  entirely heal in a day  or  two,  when new  bullae would
 form, and pursue the same course as the former.
   In some  severe  cases the patient  is confined  to  bed, but
 there  is rarely  any fever.   Pemphigus  may coexist  with
 many different eruptions, and most frequently with herpes and
prurigo.   In  the latter  (Pompholix pruriginosus of Willan)
 the patient experiences severe itching.   Chronic pemphigus
 may  be complicated with various chronic  diseases  of the


  * The more common form in which pemphigus is met with, is probably one
 which forms the connecting link between the acute and chronic forms, and which
 Corrigan {Cyclop. Prac. Med.) proposes  to call sub-acute.  This variety  he
 describes as corresponding with the acute  form in being attended by fever; and
 agreeing with the chronic in presenting, not  simultaneous, but successive eruptions
 of bullae.  He says, " the accessions of  febrile symptoms are irregular, and with
 each accession a new crop of bullae appears, the whole attack usually running its
 course within a few weeks."  This corresponds with my experience in this disease,
 which is far from  being of frequent occurrence amongst us.
  M. Cazenave speaks of a variety of pemphigus, in another place, which is inter-
 mediate between  the form in which the bulla? appear successively,  and that in
 which they are continuous ;  a form which constitutes a confluent eruption, appear-
 ing sometimes  at  intervals, and sometimes continuously, attacking the whole sur-
 face of the body.   The bulla? are flattened, and contain an opaque serum, which
 hardly raises the epidermis, and soon hardens into yellowish, scabby lamellae. The
 eruptions succeed  each other so  rapidly that the epidermis not being in a condition
 to form new bullae, the disease is reduced to the secretion of  a liquid, which dries
 under the form of large scales.  The patient exhales from every part of the surface
 a dead and sickening odor, and is soon attacked with oedema, diarrhoea, serous effu-
 sions, or chronic enteritis, and often dies.
  In some rare cases of pemphigus, several bullae partially run together so as to
 detach the epidermis over a large extent, and when the fluid is discharged from
 them, present the appearance  of a part denuded by a blister.—{Gaz. des Hop.,
 Oct. 1850.)                                               H. D. B. 
^HH
                        PEMPHIGUS.                      121

viscera.   It is evident, from the foregoing history, that the
duration of pemphigus is by no means determinate.   It varies
from one, two, or three weeks, to as many months and years,
or it  may be prolonged  to an  indefinite period.   It  often
appears in summer and disappears towards the end of autumn.
Pemphigus  usually terminates favorably; but it sometimes
proves  fatal, which  is generally the result of some severe
complication.  It often, for example, supervenes on general
or local  dropsy, or on chronic inflammation of the  digestive
organs.
   Autopsy.—We have had many   opportunities of making
post mortem examinations, at the Hospital of St.  Louis, of
persons  who died with this affection,  and have never  met
with  those  blebs or bullae which have been  alleged to exist
on the  mucous  membranes, and particularly on that of the
pharynx.  We have generally, on the contrary, found these
membranes pale,  and an effusion of  serum in the chest.   We
have also frequently observed the fatty liver in those cases ;
and M. Biett has likewise met with this lesion coexisting
with pemphigus.
   Causes.—Pemphigus may attack  persons of all  ages, but
especially adults  and old  people; both sexes are liable to it,
but  males  much  more than females.   Some persons  are
attacked frequently  during  life, at  different  intervals.  In
other cases  chronic  pemphigus  may be prolonged by succes-
sive eruptions for an indefinite period.  In some instances it
appears  to  be endemic, or, at least, it attacks a number of
individuals  at the same time.   Acute  pemphigus frequently
appears  during   the summer,  in  persons who have  been
exposed  to the sun's rays  for some  time.  Dentition, change
of  food, and excess, appear to promote the  disease.   This
variety  attacks  young persons only.  Chronic  pemphigus
affects old people, and  particularly persons of a broken-down
constitution.   Poor  and scanty food, over-exertion, low  and
damp dwellings, evidently predispose to the disease.   It has
been observed to follow an attack of rheumatism or inflam-
mation of the bowels.*
   Diagnosis.—The  presence of isolated bullae, and the  thin

  * Cazenave speaks particularly of cold and moisture, and especially when con-
nected with immersion for  some time in water, as one of the causes of acute pem-
phigus ; also, Working in damp places, keeping the arms immersed in cold water, &c.
  Chronic  pemphigus, he says, occurs more frequently in women than in men, the
contrary of which is true with respect to acute pemphigus.  It is also caused by
moral emotions, and is sometimes connected with menstrual derangement, espe-
cially suppression of the catamenial discharge ; and often takes the place of haemor-
rhages of different kinds.   It also  occurs in those who have discontinued the bad
habit of being bled from time to time.                        H. D. B. 
122
DISEASES OF THE  SKIN.
laminated crusts which cover  the  whole or part of the dis-
eased surface,  will always prevent  pemphigus  from being
confounded with other cutaneous affections.   It is distinguish-
able from rupia simplex on account of the bullae of the latter
being exceedingly few, and terminating in ulcerations, and in
thick prominent  scabs.  In ecthyma  the  epidermis is some-
times raised  to a certain  extent by a collection of pus, and
thus forms a kind of bulla; but in this case the fluid is puru-
lent and not serous;  the  apex of the cuticular elevation is
brownish; and, besides, pustules of  ecthyma  at an  earlier
stage will be found on some  other  part of the  body.   In
herpes the vesicles are always collected in groups upon a red
and inflamed  surface,  whilst  the  bullae  of pemphigus  are
isolated, and  are generally free from surrounding inflamma-
tion.  However,  in some rare instances  the bullae of acute
pemphigus are  small  and  agglomerated, here and there, and
the  disease   has  a  considerable resemblance  to clusters  of
herpes phlyctenodes;  but  then, on the other hand, isolated
bullae,  with  their  distinctive  characters,  are always  dis-
cernible ;  and,  besides, these  groups are formed by an agglo-
meration  of  bullae,  which, although small, are always  more
voluminous than the vesicles which constitute those of herpes.
  Those bullae  which  appear during the progress of erysipelas
are merely accidental, and the actual  presence of that disease
will distinguish them from  those of pemphigus.  In some
cases the incrustations  of pemphigus may  be  mistaken  for
those of impetigo, but  if they form a sort of general  envelope,
as  before observed,  they can scarcely  be mistaken;   for
impetigo is usually  confined  to a limited  surface, and rarely
ever extends  over the  whole body.   Besides, the crusts of the
pustular  diseases are  rough, thick, and indented; whilst  the
others  are thin, frequently elevated at the centre, and some-
times wrinkled.   In general they assume the form and size of
the bullae to which  they succeed.   The red patches remain-
ing after pemphigus, present certain peculiarities which are
easily perceived by persons accustomed to see  this  eruption.
They are of  a dark red color;  separated from each other, of
an  irregular  form, of  variable size, and occasionally giving
rise to slight  cuticular exfoliation.
  Prognosis.—The prognosis of acute pemphigus, if unat-
tended with  any serious  complication, is always favorable.
That of chronic pemphigus varies  according to the  consti-
tution of the patient;  it is less  favorable in proportion as  the
eruption is more  extended and  frequently  developed, and the
patient  enfeebled by  age, by poverty, or by dissipation.   It
may be stated,  generally, that pemphigus is always indicative 
PEMPHIGUS.
123
of a  bad state of  constitution.   Its  severity usually  cor-
responds with  that of the  chronic  diseases  with  which it
coexists.  We  are acquainted with no facts in support of the
opinion  which  has been advanced, that it sometimes  appears
as a favorable crisis in the course of some dangerous diseases,
as pneumonia and malignant fever.
   Treatment.—Acute pemphigus is a mild disease, and requires
but simple treatment.  However, if  inflammatory symptoms
should appear,  and if  the eruption  is diffused,  the warm bath,
bleeding,  or leeches  to  the  anus may be  employed  with
advantage.  In chronic pemphigus the treatment should also
be  antiphlogistic  at the commencement, but  care should  be
taken not to push it too far;  warm baths,  acidulated  drinks,
and at a more  advanced period, alkaline baths, are the  most
appropriate remedial  measures  at  this period.  At the same
time, if  there be much pain, emollient applications and opiates
ought to  be employed, especially if there is  much  insom-
nolency, diarrhoea, or dull pain in the abdomen.*
   If an obstinate  cough, bloody  sputa,  and other  severe
symptoms supervene,  bleeding must be had recourse to.   But
it is necessary  to  bear in mind that chronic pemphigus is not
a purely inflammatory affection, and if, notwithstanding the
administration of the  remedies already indicated, the eruption
should  continue to reappear, the strength of the patient  must
be recruited with tonics,  nourishing food, &c.   The decoc-
tion of bark, with half a drachm of sulphuric  acid to the pint,
or  the  preparations of iron,  will  be found very efficacious.
These  remedies are often required in young  subjects as well
as  in the old,  where they will be found equally efficacious.
They should be regulated according to the  constitution and
condition of the patient.f


  * In the last edition of their work, our authors say that warm baths are but sel-
dom useful in chronic pemphigus, and that in some cases they should not be taken.
                                                      H. D. B.
  t Pemphigus will often be found connected with inflammation or irritation of
some portion of the mucous surfaces, and must be treated  accordingly.  In the
cases of the subacute kind which I have seen, this  connection has been very evi-
dent.  In  this, as well as in the chronic form, strict attention to diet has been
necessary, both in effecting and in establishing the cure.  Tonics are also  neces-
sary after  the febrile symptoms have disappeared.
  When pemphigus follows the cessation of periodical haemorrhages, M. Cazenave
advises {Gaz. des H p., Oct., 1850) to give  tonics, instead  of abstracting blood,
as might seem to some the more rational course.  In some cases, the whole atten-
tion must  be directed to the general condition of the patient, and the complications.
   M. Trousseau says that he does not regard pemphigus as a disease of the skin ;
but that its local manifestations require to be treated, because reaction may  take
 place.
   He says that general pemphigus in adults is  almost always fatal, because the 
124
DISEASES  OF THE SKIN.
                           RUPIA.

                    Syn.— Ulcus atonicum.

   Rupia is characterized by isolated, flattened bullae, of varia-
ble size, filled  with a fluid frequently serous, frequently puru-
lent, sometimes  blackish, which are succeeded by thick scabs
and ulcerations  of more or less extent.   This affection has a
great analogy  to ecthyma, of which in many cases it appears
to  be  a variety, as indicated  by Bateman  and Biett.  The
lower extremities are more frequently affected than  any other
parts.   It  may,  however,  appear  on the  loins, the buttocks,
the upper extremities, and elsewhere.   Rupia generally pro-
duces  but few bullae, which are  widely separated from  each
other.   It pursues  a chronic course, and its duration varies
from a fortnight to several months.  There are three varieties
of rupia described by writers, which differ from each  other,
however, more in  degree than in kind.
   1. Rupia simplex.—This form chiefly attacks persons who
are ill-fed,  ill-clothed, and  who have suffered from privation
of  every  kind.   It often appears amongst  the sequelae  of
small-pox, measles, and scarlatina.  It appears in the form  of
bullae,  about the size of a shilling, round, flattened, and  deve-
loped without  any previous inflammation.   These bullae con-
tain at  first  a  serous  fluid,  which  subsequently  becomes
opaque and purulent.  They soon shrink, the fluid concretes,
and forms rough, brownish crusts, thicker at the centre than
at the  circumference, where they are attached  to the epider-
mis, which is  slightly elevated  at that point.  A slight ulcer-
ation of the  skin  exists  beneath the  scabs.   These fall  off
in a few days, and cicatrization speedily ensues; but in some


cause is fatal, and  that pemphigus is the expression of a more grave cachexia than
any other cachexia.
  Tonics and stimulants are required internally, and sometimes quinine. Locally
he recommends baths of corrosive sublimate, or alkaline baths.  {L'Abeille. Med.,
Avr. 1848, p. 82.)
  As a general rule,  the bulla should not be opened, and warm and moist appli-
cations to them should be avoided.  Should they burst,  either spontaneously or by
accident, some soothing application must be made to allay the irritation, and espe-
cially to protect the excoriated surfaces from the air.
  Our authors add in their last edition that liquid and even fatty topical appli-
cations are not of  much use, and that they have for a long time simply sprinkled
the affected surfaces with a mixture of powdered starch and tannin.
  The free application of nitrate of silver to the surface, after detaching the cuticle
with scissors, is said by  Mr. Cottingham to have succeeded in one case, after a
variety of other applications had failed. {Lond. Lancet  (Amer.  Rep.),  Mar.
1850.)    ti                                            H. D. B. , 
RUPIA.
125
cases circular-shaped ulcers are established, which continue
for several days, and are incessantly renewed.  A livid red
color remains after cicatrization has been completed.   Rupia
simplex frequently accompanies those cases of ecthyma where
there is considerable suppuration, and in which the epidermis
is  raised to a certain extent, by thin liquid pus, forming ge-
nuine bullae.   The largest of these are  soon covered with a
thick crust, raised  at the centre, and depressed at the edges,
which are continuous with the raised epidermis.
   2.  Rupia prominens.   The second  variety  differs from
rupia simplex by the larger size of the bullae, the greater depth
of the ulceration, and the thickness of  the crusts.   It has a
close resemblance to that form of chronic ecthyma described
by Willan under the name of Ecthyma cachecticum, and most
frequently attacks individuals of a broken-down constitution.
Its usual seat is  the lower extremities.  It often occupies but
a  single spot, in other cases several patches; but the bullae
are  always isolated and distinct.   This  variety commences
with a circumscribed inflammation of the  skin, on which the
bullae are  subsequently  developed.  The latter  sometimes
form rapidly, and are filled with a serous fluid, but, in general,
the epidermis is raised gradually, not with a citron-coloured
serum, but with  a  thick, blackish  fluid.   In some  instances
resolution may occur, and the inflammation disappear, with-
out  the  formation of scabs.  In  general the  serous fluid
concretes speedily, and forms rough, dark-colored scabs, the
thickness and extent of which, although at first considerable,
goes  on gradually increasing.   The circumference  of  this
scab  is surrounded by an inflammatory  areola, some lines
broad, upon  which the  epidermis is again raised;   a new
incrustation is formed, and adds to the extent of the former,
at  the same time  raising that concretion  above it.   The red
areola is again developed slowly round the circumference, the
epidermis rises,  and by these successive additions the primi-
tive  scab becomes  greatly enlarged and thickened; and finally
it ceases to extend, after a certain period varying from two
days to a week.   The scab is now broad and conical, and the
superadded layers may be  seen distinctly round the circum-
ference.  It is of a reddish-brown color, and is not unlike in
appearance to a  small oyster-shell. In other cases it is conical,
and resembles the  shells of certain  mollusca which adhere to
rocks. This scab continues sometimes for a long time, and if
it be easily detached in some  cases, it is with much  difficulty
in  others.  The  exposed surface  is more or less ulcerated,
according to the duration  of the scab.   Sometimes  a new
scab  quickly  forms;  at  other  times,  a round, unhealthy-
                            9 
126
DISEASES OF THE  SKIN.
 looking ulceration of considerable depth is  established, which
 it is very difficult to heal, especially in old subjects.  Its edges
 are of a livid red color, and tumefied ;  the surface is pale, and
 bleeds on  the  slightest  pressure,  and its circumference  is
 sometimes  larger  than that of a crown-piece.  After a certain
 period, cicatrization takes  place, and a purple patch remains,
 which slowly disappears.
   3. Rupia escharotica.—The third  variety appears to be
 the same affection as that described  by other writers under
 the name  of pemphigus gangrenosus.  This  variety only
 affects infants,  from the period of birth up to that of the first
 dentition.   A cachectic state of  body, resulting from  bad
 nourishment, exposure to cold, or some anterior disease, seem
 to be  the exciting causes.  The loins, the lower  extremities,
 the neck, the upper part of  the chest, the abdomen,  and the
 scrotum, are  the  usual seats  of this disease.  It commences
 with slightly prominent livid  patches, upon which the epider-
 mis is soon raised here and  there  by an effusion of serum.
 These elevations increase, and form large  flattened and irre-
 gularly-shaped bullae.   The latter  are surrounded with a red
 or violet-colored  areola.  The  serum thickens, and assumes
 a blackish tint.  The bullae  soon break, and ulcerated surfaces
 appear beneath, spreading  both in depth and in width; their
 edges are red and inflamed, and they are covered with foetid,
 unhealthy pus.  When these  disappear, new  bullae form, and
 pursue the  same course.  The infant suffers from acute pain,
 much fever, and insomnolency.  When  the disease assumes
 an intense  form, death may ensue in the course of one or two
' weeks.  When it does  not terminate fatally, the ulcerations
 are very long in healing.
   Diagnosis.—Pemphigus  and ecthyma  are the diseases most
 frequently  confounded  with  rupia.  The  latter,  however,
 differs from pemphigus in  this  respect, that the bullae rarely
 contain a transparent serous fluid, but rather a sanious liquid;
 and  besides,  the form of  the  scab, which is  thick,  rough,
 surrounded from the beginning with an  inflammatory areola,
 on which the epidermis  is  raised, and its oyster-shell  appear-
 ance,  together with the consecutive ulcerations of rupia, are
 sufficient to distinguish it from pemphigus.  Ecthyma, as we
 have observed,  has a considerable resemblance to  rupia ; they
 are frequently seen existing close  by each other in the same
 individual.   The  first  variety of rupia does  not resemble
 ecthyma so much as the others.  The resemblance only exists
 when the cuticle is  raised by a quantity of pus into the form
 of a  true  bulla.  We  have,  for instance, frequently  seen  at
 the hospital of St. Louis an ecthymatous  eruption, in which a 
RUPIA.
127
 great  number of pustules were set  close together, the epi-
 dermis was raised in several places to the extent of a shilling,
 genuine bullae, filled  with  purulent   fluid, were  developed,
 which terminated in the characteristic scabs of rupia.  These
 scabs, however, only formed on the largest of the accidental
 bullae.   In  admitting the great analogy that exists between
 these two diseases, it is necessary to observe, that the peculiar
 character of the scab, and the deep and rebellious ulcerations
 of rupia, establish a distinction between them, frequently very
 well marked,  and sufficient to admit a separate description of
 each, which are otherwise produced by the same causes.
   Prognosis.—If we except R. escharotica,  rupia is not a
 severe  disease. The age of the patient, the state of his health,
 and the extent of  the ulcerations, will be our guides in form-
 ing an  opinion as to the duration of the eruption.
   Treatment.—The treatment of rupia ordinarily consists  in
 restoring the  health of the patient, which  is generally debili-
 tated, by good  nourishing  food ;  tepid and alkaline  baths,
 when the ulcers are cicatrizing slowly ; or, still better in those
 instances, emollient applications, or lotions of wine with honey
 or aromatics;  or, finally, slight cauterizations with the nitrate
 of silver.  This  treatment will not be sufficient in the large
 round ulcerations which succeed Rupia prominens.  Although
 the emollients  will  appease the  pain, they will not reduce the
 surrounding inflammation, nor hasten the cicatrization. Adhe-
 sive straps,  so  useful in rebellious ulcers, are needed here.   It
 will then be necessary to modify the condition  of the diseased
 surface, and caustics will produce this result better than any
 other remedies.  It will sometimes  be necessary to cauterize
 the ulcerated surface deeply with the nitrate of silver, or still
 better, to wash it with nitric or hydrochloric acid, diluted with
 water.   And in cases where these remedies will not produce
 cicatrization, the parts  should be cauterized with the concen-
 trated acids, or with the acid nitrate  of mercury.  An oint-
 ment of the proto-ioduret, or the deuto-ioduret of mercury, is
 often very  efficacious.   In  all  cases, repose,  and  the  hori-
 zontal position when the  disease is seated on  the  legs, are
 indispensably  necessary.   In R.  escharotica it is necessary to
 continue the emollients at least as long as the fever continues.
 Quinine mixtures, wine, &c„ so frequently administered in
 these cases, do not appear to be very efficacious.  It is, there-
 fore, from amongst  the  anodyne and  emollient remedies that
 we should select the external applications.*

  * Nourishing diet, fresh air, and warm baths constitute the basis of the treatment
of most cases of rupia.  Warm salt water baths are frequently very useful.  The 
128
DISEASES  OF THE SKIN.
hydriodate of potash internally often acts very favorably—in other cases, quinine,
or some preparation of iron, will answer better.
  As a local application, Rayer speaks very highly of cream  of tartar, sprinkled
on the ulcers.  Wilson cured an unhealthy ulcer on the arm by injecting  a  strong
solution of alum under its edges.  When on the lower extremities, bandaging is of
great importance.
  In the early stage  the bullae may be opened, and their contents discharged, the
surfaces then dressed with simple cerate, or some narcotic ointment, or with cloths
wet with some slightly stimulant or astringent lotion.                 H. D. B. 
PUSTULE.
  The diseases ranged under this order are characterized by
small  circumscribed  cuticular  elevations, formed by  the
effusion of a  purulent  fluid between  the cuticle and cutis
vera.  These  small tumors are called pustules.  The cutane-
ous diseases which are characterized by a pustular eruption,
are  variola,  vaccinia,  ecthyma,  impetigo,  acne, sycosis,
porrigo, and glanders.*  Some of these affections, as variola,
and  sometimes ecthyma, appear  at  the same time over the
whole  cutaneous  surface;  whilst  others, as vaccinia  and
impetigo, are partial; and others again, as acne, sycosis,  and
porrigo, are confined  to certain defined limits, as is also the
case with vaccinia, which is only  developed  where the con-
tagious virus  has  been actually applied;  but no part  of the
body is exempt from an eruption of pustules.
  The progress of these diseases  may be acute  or chronic,
but each pustule terminates  individually in from two days to
a week.  The essentially acute pustular affections are variola
and vaccinia.   Ecthyma is most frequently acute, but it may
sometimes become chronic.   The  duration of these diseases
is from one to three weeks.  The chronic  pustular  affections
are porrigo, sycosis, impetigo, and acne.  Their  duration is
uncertain,  and they  are  often  prolonged for an  indefinite
period.   Most of  them, however, especially  impetigo, may
assume an acute form.
  The pustules of these diseases  present  some  peculiarities
which are worthy attention.   They are generally phlyzacious
in the  essentially  acute  affections,  and psydracious in  the
chronic varieties.   The larger, or phlyzacious pustules, have
an inflamed base, as  their name indicates.   The absence of
surrounding inflammation characterizes the psydracious pus-
tules, which are  also smaller than the former.   Porrigo, as
we  shall presently see, is characterized by distinct pustules,
called favi; and finally another order of pustules, the aclwres,
* Added by translator.  H. D. B. 
130               DISEASES OF THE SKIN.

characterize two eruptions of the head and face, which have
been  described  as varieties of porrigo.   The  pustules are
almost always of an umbilicated form in variola and vaccinia,
and  even frequently in ecthyma.   A small cicatrix, more or
less distinct, usually remains after  variola and vaccinia.  In
those varieties which pursue an indefinite course, the pustules
are often scattered irregularly  over  a  surface  of  variable
extent; sometimes  they are united in clusters, with determi-
nate characters.
  The scabs which succeed the pustules have certain pecu-
liarities, according to the nature of the disease, which require
considerable attention.  In porrigo they  are yellow, circular,
and have a depression in the  centre, which remains for a con-
siderable time.  After once disappearing they are not repro-
duced, unless by the formation of new favous pustules.  In
impetigo, the scabs, which are generally thick  and rough, are
produced by the concretion of the sero-purulent fluid, which
is effused over the inflamed surface.  They  are of a yellowish
green  or  brown color, and  are  often  replaced by others,
developed in  the same way. The scabs which succeed the
pustules of sycosis  and acne  are less  characteristic, and do
not continue so long.   In these cases there  is  often a cei$ain
degree of chronic inflammation where the pustules  appear,
which produces  those  hard  indurations  commonly  called
tubercles.
  The chronic  pustular  eruptions  rarely  leave cicatrices
behind; but the skin generally remains red  for some time
after  their disappearance.  These  diseases may be compli-
cated with each other, each pursuing its own peculiar course.
This  remark applies also to  variola and vaccinia, although
it has been argued that these affections never coexist in the
same individual.  The pustular diseases  are also often com-
plicated with exanthematous  and vesicular affections.  Vari-
ola is often accompanied with severe inflammation of some of
the internal organs, which rarely occurs in any  of the other
varieties.
   Causes.—Variola and vaccinia and the  two forms of equinia
or glanders are only produced by contagion.   Porrigo favosa,
and P. scutulata, although they may  appear  spontaneously,
are generally  propagated by contagion.  The other pustular
diseases depend  chiefly on some unknown internal cause.
   Diagnosis.—The  presence of small elevations filled with
pus, is sufficient to distinguish the pustular affections from all
other cutaneous diseases.   The vesiculae, it is true, contain at
a certain period of their formation  a thick sero-purulent fluid;
but it is altogether consecutive of the transparent serous fluid, 
VARIOLA.
131
whilst the pustular eruptions contain true pus from the begin-
ning ; besides, the physical character of this fluid, which is
thick and yellow, will readily distinguish it from the opaque-
colored serum which the vesicles contain just  before  their
disappearance.   There  are, no doubt, cases in  which  their
distinctive characters are not so well marked, as for example
in vaccinia, where a pustule succeeds a perfect  vesicle; but
in general the distinction is easily established.   The coppery
color of syphilitic pustules, together with other peculiarities,
is sufficient to distinguish true pustular eruptions from  those
resulting from syphilis.
   Prognosis.—With the exception of  variola,  the  pustular
diseases, although very  troublesome, never terminate fatally.
The  prognosis  is  not so favorable when  the  disease has
existed for a long time, and has resisted a variety of curative
remedies.
   Treatment.—In the acute varieties, the treatment should
be decidedly antiphlogistic; but it is difficult to lay down in a
general manner that which should be adopted  when  these
eruptions assume a chronic  form.   Sometimes  very simple
measures will suffice, but in general recourse must be had to
more energetic remedies, with the view of modifying or  alter-
ing the condition of the  skin.

                        VARIOLA.

            Syn.—Small-pox.—Febris variolosa.
   Variola is a contagious inflammatory disease, characterized
by an eruption of tolerably  large phlyzacious pustules, most
frequently umbilicated,  and  always ushered in  by consider-
able  constitutional  disturbance.  It is divided  into natural
and inoculated, according as it is communicated by exposure
to the variolous  infection, or results from the insertion of the
virus in some part of the system;  and into two species, the
distinct and confluent, implying  that in the former the pustules
are  perfectly  distinct from  each other, and that in the  latter
they coalesce.   It is also called coherent,  when  the pustules,
without running together, only touch by their edges.   But
these last divisions are very arbitrary; for the  eruption  is
often confluent  on one part, as on the face, while it is dis-
tinct on other parts.  There is also a great variety of  inter-
mediate shades  between the mildest form of distinct variola
and the most severe form of the confluent.
   It  is also divided into primary and secondary, an attack of
the latter being almost always milder than of the former.
   Symptoms.—1. Variola discreta.   The course or progress 
132
DISEASES OF THE SKIN.
of small-pox, whether discrete or confluent, has been divided
into, five periods—incubation, invasion, eruption, suppuration,
desiccation.   The period of incubation extends from the date
of the exposure to, and reception of, the contagion, to that at
which the morbid symptoms begin to appear; and lasts  from
six to twenty days.   It is marked by no visible  symptom, the
general health remaining apparently good.  The violence of
the disease has been  supposed to be the greater  in proportion
to the shortness of this period.   The invasion of the distinct
form of the disease usually commences with general constitu-
tional disturbance, rigors, depression,  lassitude,  pains  in the
limbs, and especially in the back, hot skin, quick pulse, head-
ache, thirst,  nausea, and  often vomiting, pain in the epigas-
trium.   These symptoms continue for three or four days, and
are then accompanied with cough, a tendency to perspiration
and  sleep, in adults ; and in  children, drowsiness, and  some-
times coma  and even convulsions.   The  tongue is  intensely
red, and the  pulse  greatly  accelerated.   In the  confluent
form, these  symptoms are still  more  severe.  The lips and
tongue are  dry, and covered  with  black sordes, and there is
great prostration.  There  is sometimes  diarrhoea, but  more
frequently obstinate constipation.
   The eruption appears about the  third or fourth day, first
on the  face;  on the  hands in some rare  cases.   It  then
spreads to  the neck, arms, and  the rest of the body, in the
course of twenty-four  hours.  Sometimes it  is preceded by
an erythematous or roseolous rash, and manifests  itself by
small red spots not unlike small  papulae.   During the period
of eruption, the skin is hot and shining; there is a general
exacerbation of the symptoms at the  commencement of this
process, and they generally subside  when it is completed.   A
period of  four or five days intervenes between the process of
eruption and that of suppuration, during which  the  small red
spots increase in volume, and present a peculiar cupped  or
umbilicated  depression in the  centre.  On  examining  the
skin, about the second day  of  the eruption, a multitude  of
small pointed  elevations may be seen, with red and inflamed
bases, more  of a vesicular than of a papular character, although
nothing  flows from  them when punctured.   They  are,  in
point of fact, the result  of  an  effusion of semi-transparent
coagulable  lymph, that  subsequently concretes, and forms  a
circular disc, which is  attached to the cutis vera.  At this
period most of these  elevations are  acuminated;  but  some
are already  depressed in the centre.   After the  third day, the
central depression becomes more and more marked, up to the
period of suppuration.   At this stage the pustules  are of a 
VARIOLA.
133
whitish color, and are  surrounded with a light  red  areola.
The pulse  is now  full  and regular;  very often  there  are
several pustules  on the  surface of  the tongue, and sometimes
in the  pharynx;  there is also some difficulty in swallowing,
and often slight cough.  When the disease is  distinct else-
where, it may be confluent on the face, in the event of which
the latter becomes red  and swollen as if from erysipelas: the
central depression is rarely seen.   At the same time, whitish
pustules  with central depression  cover the limbs; but they
are usually less confluent  on the body.  The  tongue is also
covered  with pustules,  which  often extend to  the pharynx.
The eyelids also become the seat of the eruption, and a pain-
ful acute form of ophthalmia, often ending in the destruction
of  vision, supervenes.   Coryza and cough, in a large propor-
tion of cases, indicate a similar eruption in the nasal passages
and the trachea.
   Suppuration begins between the fifth and  seventh days
after the appearance of the eruption, and terminates in three
or four  days.  It is  accompanied  with  a renewal  of the
febrile symptoms, and with a general swelling of the integu-
ments, more marked about the face and hands than elsewhere.
As the secretion of pus increases, the pustules  lose their um-
bilicated  appearance, assume a spherical shape,  and  acquire
a yellow and in some instances a blackish color.   Suppuration
generally commences  on the face first; reaching  the hands
and feet last, where the thickness of the epidermis keeps them
from opening the longest.  A small-pox pustule opened at the
period of maturity, contains a small quantity of  yellow  pus,
and at the base may be perceived a whitish umbilicated disc,
presenting a perfect  resemblance to the appearance of the
pustule  previously to  the commencement  of suppuration.
The pustules do not remain  long in a state of suppuration.
They  burst in the course of a day or two, and are replaced by
dark-colored crusts or scabs.   The process of suppuration is
usually  accompanied  with much fever,  tumefaction of the
hands and face, and ptyalism.  The swelling of the face usually
commences about' the'fifth or sixth day of the eruption, at the
same time with  the secondary fever.  The eyelids, lips, and
nose generally  swell before the other parts, and the eyelids
are sometimes  closed  for  several days.  The hands  swell
about the same  time as the face, and the swelling  of both
 diminishes about the eleventh or twelfth day of the eruption,
 when the suppuration is finished.
    Ptyalism sometimes occurs at the time of the eruption, but
 generally not until from three to seven days afterwards, and
 varies in severity in different cases. 
134
DISEASES OF THE  SKIN.
  Besides the secondary fever, severe diarrhoea, difficulty of
breathing, and coma often occur during the period of suppu-
ration.
  Desiccation commonly  commences  at  the  face, and  this
r%ion is frequently covered with an uninterrupted incrusta-
tion, when the  pustules are only forming  on  the limbs.   In
variola discreta the pustules burst, and the pus escapes and
concretes into  a small, slightly-thickened  scab,  which  pre-
serves the form of the pustule.  In  variola confluens, the
scabs form on the face  about the eighth or ninth day of the
disease ;  the features are masked by a thick brownish incrus-
tation, which falls off from the fifth to  the fifteenth  day  from
the date of its  formation,  and is  replaced by furfuraceous
scaly  crusts, which are  frequently renewed.  During  this
period the patient emits a  peculiar faint and  disagreeable
odor, and the linen is  soiled by  the  exudation of pus  from
various parts of the body.  There is a  considerable degree of
itching present,  which  induces the patient to scratch  himself,
until  deep and  painful excoriations  sometimes supervene.
When the scabs are completely detached, deep red stains are
visible  beneath, which disappear slowly, and according as
this red color diminishes, the cicatrices, or pits, become more
and more apparent, and usually continue for the remainder of
life.   Such is the ordinary course of variola.   The progress
of this disease is, however, subject to some irregularities, and
as a general  rule, it commences and terminates on the  face
earlier than on any other part of the body.
   Small-pox is greatly  modified by being  inoculated.  When
inoculation has been performed, a slight degree of  redness is
discovered on the third day around the puncture  by which
the virus was  inserted in  the  skin.  A slight circumscribed
induration may also be detected in this point on this day, and
especially on the following day, by passing the fingers over it.
The redness is much deeper on the fifth day, and on the sixth
the  epidermis  appears raised by the effusion of serous  fluid
under it, and at the same time a depression is visible in the
centre.   On the seventh, the superficial lymphatic vessels
in the neighborhood of the puncture  appear inflamed, the
movements of the arm become painful, and before the tenth
day the  usual symptoms of infection are manifested.   The
initiatory phenomena are nearly the same as those  of natural
 small-pox.   Desiccation  commences  about  the  twelfth  or
 fifteenth  day from the  period of inoculation;  crusts or scabs
 form, and fall  off about the twentieth or twenty-fifth day,
 leaving an indelible cicatrix behind.  Variola, especially when
 confluent, may be attended by many serious symptoms. 
VARIOLA.
135
  The invasion may be attended by violent chills, burning
heat of skin, and also by severe pain in  the head and in the
epigastric region.   There may be also obstinate nausea and
vomiting, and severe pains in the loins and sides, and also in
the limbs.
  Deep stupor, or violent delirium, and convulsions, may also
be present, and the case may prove fatal before the  eruption
is developed.
  The progress of variola may also be  complicated with a
number of diseases, especially with congestion of the different
internal organs, or with haemorrhage; as haemoptysis, epistaxis,
haematuria.   Congestion of the brain, but particularly of the
lungs, is  a frequent occurrence; hence we so often meet with
bronchitis, pulmonary  apoplexy, pneumonia,  pleurisy,  and
oedema of the lungs during the period of the eruption of small-
pox.  In  some cases the congestion is confined to the  skin,
which  is indicated  by the  presence  of petechias.  Severe
ophthalmia is also very common about this time.   Croup is
fortunately much more rare.
  Death  occurs more frequently during the period of sup-
puration than at any other stage of the  eruption;  but gene-
rally, in such cases,  free  suppuration does  not take place.
The disease advances with frightful rapidity, and dissolution
may supervene in the course  of a few hours, or even in a few
minutes,  without any appreciable  cause.  Death  has  been
attributed in these cases to suffocation produced by the burst-
ing of  the pustules into the larynx.   Salivation may be  very
troublesome  at  this  period  of the eruption,  and  may be
accompanied  by cough, and by  considerable difficulty in
swallowing.   Diarrhoea, especially when it occurs in children,
is far from being a bad omen  at the period of suppuration,
unless very severe.
  During the period of desquamation the  complications are of
a much  milder character.  This stage is often complicated
with pustules of ecthyma,  small subcutaneous phlegmonous
tubercles, and with the bullae  of rupia.  Amongst the sequelae
of small-pox, we may mention gastro-intestinal inflammation,
bronchitis, chronic ophthalmia, deafness,  blindness, and  even
the  development of pulmonary tubercles.  These  complica-
tions occur in young and vigorous subjects, as well as in per-
sons broken  down by  age  or dissipation,  and  the causes
which  influence their development  are by no means clearly
understood.
  Post-mortem Appearances.—The most common pathological
lesions observed in subjects  dead  of small-pox, are various
engorgements of the  cerebral and  thoracic organs,  pustules 
136
DISEASES OF THE SKIN.
in the mouth, pharynx, oesophagus, and even in the larynx and
trachea.   The stomach and the intestines, with the exception
of the rectum,  are  rarely affected.  It is  necessary  to  be
careful not to mistake morbid enlargement of the follicles for
variolous pustules of the intestinal mucous membrane; espe-
cially as the enlarged follicles, when opened,  present a similar
depression in the centre, like the pustules  of variola.  When
death occurs before suppuration is well established,  variolous
pustules are easily found on the different parts of the mucous
membrane already mentioned.  The epithelium is afterwards
detached,  and  small circular spots, red in  the  centre, and
without elevation, are all that will be seen.  We have  never
observed,  amongst the numerous variolous  bodies  we have
had the opportunity of examining  after death, pustules fully
distended  with pus on the mucous membranes ; and it appears
to us that the extreme  thinness of  the  epithelium  of  the
larynx and trachea would prevent,  by its early rupture, any
great  accumulation of pus under that membrane, and  there-
fore these instances  of sudden  death above  mentioned could
not be owing to this  cause.
   The internal surface of the stomach frequently presents an
injected,  dotted appearance; that  of  the intestines is more
rarely injected.   The heart is  generally flaccid and gorged
with black blood, as also are the lungs.   The aorta is stained,
either in  patches or  continuously,  for some distance.   The
pustules of the skin, which  were  violet-colored during life,
become pale after death, and  on examining  their  anatomical
structure from without inwards, before losing  their umbilicated
form,  the  following appearances may be  observed: 1.  The
cuticle preserves its natural  consistence, and may  easily  be
raised, leaving beneath a smooth whitish surface, with raised
edges and depressed centre.   2. A small umbilicated disc,
formed  by a whitish exudation from the inflamed surface,
occupies the place assigned by  anatomists to the corps mu-
queux, and seems to  be continuous  with the subtegumentary
tissue, when first  developed; at a  later  period, however,  it
becomes easily detached.  3. Beneath this  disc the surface
will be  found red, and frequently  moistened with  pus; and
when examined at a more  advanced period of the disease,
there will be'a  thick and yellow pus.
   Causes.—Variola  always appears under the influence of a
specific contagion, which may be  transmitted  mediately as
well as  immediately, and through the medium of the  atmo-
sphere.  It spares no age nor sex;  even the  foetus in utero is
not exempt from the infection.   It  frequently appears epide-
mically during summer and autumn, but it may occur in  all 
VARIOLA.
137
seasons and  in  every climate.  Some  individuals  have the
power of resisting its influence, even when placed in the most
favorable  circumstances for catching the disease;  but these
cases are rare, and such individuals most frequently take it
at some other period.   In general it does not affect the same
individual more  than once during life; but there are innume-
rable instances  on record in which it occurred twice, and
even thrice,  with  the same degree of intensity as at  first, in
the same  person.  Numerous curious and well authenticated
cases of this kind may be found in the work of Dr. Thompson
(Historical Sketches and Enquiries, fyc), and among  others,
that of a lady who, after having had variola in her youth, had
the  disease  six times  while  nursing  her six  children  suc-
cessively, who were inoculated with the virus.*
   Varioloid.—When  small-pox occurs  in persons who have
been vaccinated or inoculated, it is accompanied with  special
characters ; it is greatly modified, but more so in the  former
than in the latter instance, and has been  described under the
name of varioloid.  We have here an additional proof that
the  anti-variolous  power of vaccination is greater than that
of variola itself.   This  variety differs from variola proper, by
the  extreme  irregularity and rapidity  of its  course,  by  the
absence  of secondary fever, by its mild character in most
cases, and by its  favorable termination.  In some instances,
however,  it assumes  a  severer form than distinct small-pox.
In these cases, however, the pustules, though but few in num-
ber, pass through the stages of those of variola, which is not
the case  with the pustules of varioloid.   The same individual
may be affected several times with this variety.  The period
which has elapsed between the  time  of vaccination or of a
previous attack  of small-pox seems to exert no influence on
the progress  of  varioloid, which is sometimes seen in  persons
who have been carefully vaccinated only a few weeks before,
and, at other times, very slight after a vaccination of  twenty
years  previous.    The  same is also true with regard to its
occurrence after variola.  We have seen it in individuals who
never had the small-pox, and have been vaccinated  without
success.   The  virus of a pustule of modified small-pox may
produce variola discreta in persons who have not had the dis-
ease, or who have not  been vaccinated ; but  the  disease  is
generally very mild.  The premonitory symptoms are some-
times  very slight; in other instances they are very  severe,

  * For numerous instances of the recurrence of small-pox, and statistics of its fre-
quency, see  Gregory  on Eruptive Fevers—First Amer. Edit.—1851—Appendixi
p. 346.                                             H. D. B. 
138               DISEASES OF THE  SKIN.

without being followed by an eruption any more abundant.
The eruption may be preceded by slight erythematous patches,
scattered  irregularly over  the body, and is sometimes  very
slight; at other times, from twenty to a hundred pustules appear
on different parts of the body; and sometimes it covers nearly
the whole body.  It usually commences on the face, but it is
often developed simultaneously on different parts of the body;
it sometimes commences  on the limbs, and very frequently
spreads successively  over  different  parts.   A  number of
small,  hard, red, elevated  spots first appear, somewhat like
red papulae in appearance.   Many  of them disappear without
undergoing any transformation ;  others  become vesicular or
pustular  in the  course of twenty-four hours.   The  vesicles
are small, acuminated,  and filled with  a whitish  fluid ;  they
are frequently transformed into  umbilicated pustules, but in
general they burst in  two or three days, and are replaced
by thin,  round,  slightly-adherent  scabs.  The vesicles are
sometimes surrounded  with a red areola, which  gives  them
the appearance of those of vaccinia.  The pustules are small,
round, and never attain the size  of the pustules of variola
under  any circumstances.   They  are  soft and flaccid,  as if
their growth had been prematurely arrested.  They are some-
times acuminated, sometimes depressed in the centre.   The
contained fluid is absorbed between  the first and fourth day, and
either thin, flat, round,  brownish incrustations form, and soon
fall off; or else hard, brownish, shining scabs, imbedded in the
skin, are developed, and continue beyond the twentieth day.
It is  in consequence of the irregular progress of the eruption,
or from frequent successive eruptions, that papular elevations,
vesicles, pustules, scales, and scabs  are seen on the same  indi-
vidual at  the  same moment.   The  scabs are  sometimes
replaced on the face by warty elevations, which  are slow in
disappearing.  The duration of this  mild  affection  varies
from six  to twelve  days  and more.   It always  terminates
favorably, and in some  rare cases it leaves a few  slight scars
behind.
  Diagnosis.—The diagnosis  of  small-pox is  not difficult.
The presence of the umbilicated pustules, which are generally
preceded  by fever and general symptoms, together with the
peculiar progress of  the eruption, are sufficient to distinguish
variola, not only from other pustular affections, but from every
cutaneous  disease.   Varicella is more  frequently taken for
small-pox than  any other  affection.  It is the distinct  form
of variola, and the varioloid, that  are generally  confounded
with varicella;  but these errors  are  not unfrequently owing
to the preconceived views  and opinions of the observer.   As, 
VARIOLA.
139
for example, those who deny the possibility of a second infec-
tion, or that variola can  be developed after vaccination or
inoculation, will not admit  the identity of  the disease ; and
hence they give it the  name of varicella.   In comparing the
progress of the varioloid disease with; hat  of varicella, they
are undoubtedly very similar in many points of view.  Under
the head of varicella we have pointed out fully those charac-
ters which perfectly distinguish the one from the other.  The
diagnosis of the various affections with which variola is com-
plicated is often very difficult.  The progress of these diseases
is frequently so rapid that death may ensue before the mani-
festation of a single symptom indicating danger.
  Prognosis.—The prognosis  of small-pox is not unfavora-
ble when the eruption is  mild  and its progress  regular; but
it should be very guarded when  the disease is  confluent, in
consequence of the dangerous complications which commonly
occur during the course  of that  form of variola.  It will be
unfavorable when the disease occurs in children at the period
of dentition ; in strong and plethoric adults ; in persons debili-
tated and worn out, either by age, dissipation, or some  former
complaint; in  pregnant women, or in those newly delivered ;
and in young  females  who  have  a great horror  of the anti-
cosmetic powers  of this  fearful   malady.   When the  pre-
cursory symptoms  disappear  suddenly,, or  continue  with
violence  after the  eruption has  appeared, danger is  to be
apprehended.   When  the eruption is abundant, when it  is
mingled with petechias, and the pustules  filled with blood, the
prognosis will also be unfavorable.   When  the eruption does
not advance, and when the pustules remain indolent, white,
and flattened, it will not be very favorable; but  the  nature
and intensity of the general symptoms  should be carefully
taken into account  before  pronouncing  an  unfavorable
issue.   The condition  of the  cerebral and thoracic  organs
should  never  be  lost  sight of.  They require  the greatest
attention.
   Treatment.—When  variola pursues a regular course, and
is not complicated with any internal disease, rest,  a cool tem-
perature, regimen,  and  diluents  are  the only measures
required.  Emetics are in general unnecessary.   If there  is
constipation present, it can be obviated by simple injections
of warm water, &c, or by  mild  laxatives.   The pediluvium,
or the application of warm cataplasms to the feet,  when there
is intense headache ; mild cooling gargles, when the throat  is
sore, and painful;  and emollient lotions  to  the  eyelids when
the pustules are producing irritation, are the  only remedies
required in simple  small-pox.   When the eruption is slow in 
140
DISEASES OF THE  SKIN.
appearing, and when there is no organic disease present, an
emetic or sudorifics, as the acetate of ammonia, may be admi-
nistered ;  a warm, and  even a vapor bath,  may often be
employed with advantage.
  When variola appears  with symptoms of greater severity,
and especially at the period of invasion, when there are symp-
toms of cerebral or gastro-intestinal irritation present, vene-
section or local bleeding may be resorted to with the greatest
advantage.  General bloodletting has long had its advocates
in the treatment of variola:  while many  think  that  it > may
even  be injurious.  It is too true that it does  not always
prevent a fatal result; and when several  times  repeated for
the  sake of cutting short the eruption, the result has been
unfavorable, and often very serious.   If not used until con-
gestion has taken place in different internal organs,  it may
hasten death.   Local bleeding  should be practised at the
anus, epigastrium, neck, temples, or mastoid processes, accord-
ing to the nature of the symptoms.  When there is acute local
pain, a number of leeches should be applied without hesitation
to the part.  General  bleeding is always indicated when  the
patient is strong and vigorous, when the eruption is confluent,
and when symptoms of organic disease supervene ; but bleed-
ing should never be had recourse to during the period of sup-
puration, when the patient's strength is exhausted.  When
the  internal congestion advances slowly and insidiously,  and
the  pulse sinks, blisters to the legs  and purgatives are often
more  efficacious than bleeding;  but if the latter remedy is
decidedly indicated, local bleeding  should  be  employed.   As
a general rule, when venesection  is  indicated, it should be
performed freely, so as  to produce an  evident  and decided
effect on the system.  But we should always bear  in mind
that bleeding is far from acting so favorably in the inflamma-
tory complications of  variola as in simple phlegmasia of the
same organs.
  Mild  purgatives  are frequently of great  service  at  the
period of suppuration, in checking the insidious inflammatory
and congested state of the brain and lungs, which commonly
obtains in the more dangerous forms of variola.   It has been
proposed, with the view  of lessening the deformity which so
frequently  arises  from small-pox, to  rub the surface of the
body roughly with a coarse towel, as  soon as the eruption is
completed ; also to cauterize the pustules on the face, both to
prevent cerebral congestion and to prevent scars.  But these
advantages are  more imaginary than real, as we have often
seen this plan of treatment followed by effects the very oppo-
site of what was expected. But when ophthalmia supervenes, 
VACCINIA.
141
the pustules on the eyelids should always be cauterized imme-
diately with the nitrate of silver, either in the form of  oint-
ment, in  solution,  or in the  solid form.   The best means of
preventing cicatrices from forming on the face, consists in
opening  carefully  each pustule, pressing  the matter gently
out, and preventing  the scabs from remaining long, by the
application of emollient fomentations.  Different plasters  have
been recommended of late years, and especially the Emplas-
trum de Vigo; but they do little  good in mild cases, and may
do harm in the severe ones.*    The application of cold water
to the body should never be employed.
  Emetics, and also acetate of ammonia, together with the use
of temporary blisters, sinapisms, and  warm baths, are espe-
cially serviceable in these cases, when  the eruption is arrested
by  cold  during winter, when its  progress  is  slow, and when
there is general prostration and sinking of  the pulse.
   Tonics are often very useful after the period of suppuration,
when the patient's strength is exhausted ; but these remedies,
together with opiates, which  are very beneficial  in checking
the diarrhoea and in producing sleep, should be administered
with much  caution and watchfulness.  Towards the termi-
nation  of the disease,  warm  baths, administered with the
necessary precautions, will favor desquamation, and obviate,
in a great measure, the tendency which exists to the develop-
ment of boils, subcutaneous abscesses, pustules  of ecthyma,
&c.  A few mild laxatives are often required after the disease
has completely subsided.  The various affections with which
variola may  be  complicated,  require each a separate  and
appropriate treatment, the details of which would be out of
place in a work of this kind.

                        VACCINIA.

                  Syn.—Cow-pox ; Grease.
   Vaccinia  is more a vesicular than a pustular disease  ; but
as it is so nearly allied to variola, we shall, perhaps, be excused
for describing it  in this place.
  Vaccinia is a contagious eruptive disorder, developed spon-
taneously in the udder of  the cow, and when communicated
to man it has the effect of preventing, or at least of modifying,
the eruption of small-pox.  It is  characterized by the appear-
ance of  one or  more silvery-looking, large, flat, multilocular

  * Mercurial ointment, sulphur ointment, gold leaf, and almond oil, have all been
recommended as local applications for this purpose. For results, see Braithwaite's
Retrospect of Pract. Med. and Surgery, No. 3, p. 51.  More recentlypdhe tincture
of iodine and collodion have both been recommended for this purpose.—H. D. B.
10 
142
DISEASES OF THE SKIN.
pustules, depressed in  the  centre, surrounded with an ery-
thematous areola,  producing  a  brownish  scab, which  is
detached  about the  twenty-fifth day, and  leaves  behind a
peculiar cicatrix.
   Causes.—Dairy-women are often infected,  from milking
cows with this eruption on their teats.   Genuine vaccinia is
sometimes  developed on the hands of ostlers  who  have the
care  of horses with  the grease; but  the eruption is most
commonly produced  by vaccination  with the  virus  of the
cow,  or with  that which is produced in the human  subject
from the original source.  The latter is generally preferred,
because  it induces  a milder  form  of the eruption,  and  is
equally as certain in its. action as the former.*   The vaccine
virus possesses its greatest activity about the  fourth or fifth
day from the appearance of the pustule, or the eighth or ninth
day from the period of  vaccination.   The upper third of the
arm,  over  the insertion of the  deltoid muscle,  is  the  part
usually selected for  vaccination—an  exceedingly   simple
operation, which may be performed in the following manner:
The surgeon should take hold of the posterior part of the arm
to be  operated  upon with his left hand, and draw the skin
tightly backwards, and with the  other hand  he  should  intro-
duce the point of a lancet, charged with the virus, a few lines
into the skin in an oblique direction.   It should be allowed  to
remain in that  position for  a few  seconds, and when with-
drawn, the puncture  should be compressed for a moment  or
so, in order to prevent it from bleeding.   To ensure  success,
several punctures are frequently made at the same time; but
a single well-developed  vesicle  is  sufficient to impregnate the
system with the infection.  Some patients are very insuscep-
tible of the vaccine contagion, and require to  be vaccinated
several different times before they become infected.  Children
under six weeks of age  should never be vaccinated unless  in
case of urgent necessity.
  Symptoms.—The progress of the eruption  of vaccinia  is
marked by four different periods.   1.  The first continues for
three to four  days from the date of  inoculation;  but it  is
sometimes  prolonged  up  to  the fifteenth,  twentieth, and
twenty-fifth day, during which the puncture  undergoes no
further change than  that produced by the red areola  which
surrounds it  almost  from the  beginning.  2. In the  second

  * Gregory says  {Led. on Erupt. Fevers,  first Amer. Edit., New York, 1851,
p. 259), that " lymph recently derived from  the cow possesses so much intensity,
and fixes itself with  so much more of a poisonous character upon the skin than
lymph long*habituated to the human constitution, that a single incision made with
it is equivalent to six or eight made with lymph of minor energy."—H. D. B. 
VACCINIA.
143
stage, which commences generally about the third or fourth
day, and terminates on the eighth or ninth, a small, hard, red
spot is  perceived, which is raised and distended on the fifth
day by  a serous exudation.   On the sixth it becomes  a per-
fectly formed umbilicated vesicle of a whitish color, and round
or oval  form.  When the  puncture is large, the vesicle gra-
dually increases, and preserves its umbilicated appearance to
the end of the eighth or ninth day.  This is the proper period
for obtaining the virus.  3. The third period commences on
the eighth or ninth day, when the vesicle has acquired its full
development, and is surrounded with a  bright red  areola,
varying in size from three or  four lines  to two inches, the
development  of which is  accompanied  with  considerable
tumefaction of the  skin, and  of  the  subcutaneous  tissue.
This erythematous ring is often the seat of small vesicles.
These characters are well  marked on the tenth day,  when
febrile symptoms, engorgement  of the lymphatics of the arm,
and a  roseolous or erythematous rash, often supervene.  4.
The fourth period commences on the tenth day.   The areola
begins  to fade, the serous fluid  becomes purulent, desiccation
commences  at  the  centre, the  tumefaction subsides, and the
vesicle  is speedily transformed into a hard, dark brown, circu-
lar scab, which becomes blackish, and falls off from the twen-
tieth  to the twenty-fifth day from the date of vaccination.
When  it is  detached, a depressed, circular, and  honeycomb-
looking cicatrix remains, with several depressions at its base,
indicating the number of the cells of the vesicle.  The mark
of this  cicatrix is indelible.*   Accidental eruptions  of the
same character may be produced  by the application  of the
vaccine matter to other parts  by the  nails which have been
charged with  it by scratching the place  of  its  insertion.
General vaccine eruptions over the body sometimes follow the
insertion of vaccine virus,  the  matter taken from which will
communicate the genuine disease.
   Such is  the  regular progress and  form of vaccinia, and
these are the characters which  it should  present in order to
fulfil the intended object.  When the eruption does not pursue
the  course above described,  it is  called false cow-pox, and
never prevents the occurrence  of variola.  It often happens
that, instead of a vesicle, a true pustule is formed.   The inflam-
matory  symptoms appear on the same day, or on that follow-

  * It may be considered as fully established, that the vaccine scar may and does
wear out in the progress of life, and that, in the words of Dr. Gregory {Lectures
on Eruptive Fevers, first American edition, New York, 1851, p. 250)," the total
absence of cicatrix is not decisive against the present or prior existence of vaccine
energy in the system."                                  H.  D. B. 
144
DISEASES OF THE SKIN.
ing vaccination.   The  puncture is surrounded with  a deep
red areola, the pustule increases rapidly, and is raised at the
centre.   On the fourth or fifth day it is replaced by a brown
scab, which does not remain long, and never leaves a cicatrix
behind.  The eruption may  also assume a purely vesicular
character,  but in neither case will it prevail against variola.*
  Willan has described three varieties of false cow-pox:   1.
In the first, the vesicle  is perfectly formed, but the areola does
not  appear, neither does the inflammatory blush, commonly
observed about the ninth or tenth day.  2. In the second, the
vesicle is pearly-colored, much smaller than that of true vac-
cinia ; it is flat,  the circumference is not round, nor does it
extend beyond  the base, which is hard, inflamed,  slightly
raised, and encircled with a deep-red areola.  3. In the third
variety,  the  vesicle is  also small,  it  is  acuminated, and the
areola, which is sometimes of a  pale-red color,  is much
extended or spread.  In the  two latter instances, the areola
appears  about the seventh  or eighth day, and disappears on
the tenth.   The  scab  and  cicatrix which follow are smaller
and more irregular than those of vaccinia proper.  It is the
opinion of some, that even if the vaccine vesicle does pursue
a  regular  course, the  formation of purulent  matter by the
ninth day, and also a small and brittle scab, should lessen our
confidence in its protective  power.  The same effect is also
thought  to result from rubbing or scratching the vesicle so  as
to interfere with its regular progress, and  also from opening it
too frequently for the purpose of taking lymph.
   The production of false cow-pox is attributed to the follow-
ing causes :  1.  From inoculating with  vaccine virus indi-
viduals who have been already vaccinated, or who have had
small-pox.  2. From  inoculating with the  virus  of a false
vesicle,  or from  genuine vaccine matter taken at too late a
period from the vesicle.  3. From the complication of scarla-
tina, measles, gastro-enteritis, or from the existence  of some
chronic  cutaneous disease, as prurigo, eczema, porrigo, lepra,
&c.  But at the present  day we seldom meet with false cow-
pox ; in the great majority of cases, it either fails entirely, or
goes through its regular course.   Hence, the two  most im-
portant  questions  now are, why genuine cow-pox is not per-
fectly protective, and  after what length of time it  loses  its
 anti-variolous power.

  * Gregory says {Op. Cit., p. 259) that the body of the child is sometimes covered
from the  ninth to the twelfth day, and even later, with a papular eruption of a
lichenous  character,  which he attributes chiefly  to the peculiar delicacy of the
child's skin, and the fulness of its habit, and which, he says, is not essential to the
success of the process, but proves its efficacy.                  H. D. B. 
VACCINIA.
145
  Dr. Bryce of Edinburgh advanced the opinion that vacci-
nation produced  two effects in man: the  local,  which  is
incapable of protecting the system  against variola, and the
general,  which affords such  protection,  and  consists  of- a
certain  amount of  febrile disturbance.  For the purpose  of
deciding  whether  the system  had undergone this change,
which is alone capable of affording the desired protection, he
proposed the  plan of vaccinating  the  person a second  time,
four, five, or six days after the  first vaccination; and if the
constitution is under  the vaccine influence,  the vesicles  of
the second  vaccination will mature at the same time as the
others.*
   Diagnosis.—The pathognomonic characters of this  erup-
tion have been so fully described already, it is unnecessary to
repeat them  here;  indeed, vaccinia  can hardly be mistaken
for any other cutaneous  affection, by persons who are at  all
familiar with  that eruption.
   Treatment.—Cow-pox  is a very  simple  affection, and  is
hardly   ever  accompanied with  any other phenomena  than
the local symptoms of the eruption.   In some rare instances
it excites slight  febrile  disturbance,  and  an erythematous
rash; but even in  these cases, it requires no other treatment
than mild regimen, diluents, and some cooling drinks.   The
part should be protected from rubbing against the clothes.  In
cases where the vaccine eruption supervenes on the hands of
ostlers  having the  care of horses with the grease, the follow-
ing  remedies may   be  necessary:  acidulated lemonade,
emollient local  baths, sometimes poultices  to  diminish the
swelling, a few tepid baths, and mild laxatives.  If the erup-
 tion does not appear in  the regular  form,  and pursue the
natural   course,  the  patient should  be  vaccinated  anew.
 However, even  when it appears in  a regular  and healthy
form, the body is often not protected from  an attack of small-
pox ; but if the latter should supervene, it generally  assumes a
mild character.
   [The authors  here enter into an elaborate account of the
 results  of revaccination, so extensively practised within the
 last ten years, in several of the  continental countries.   They
 refer especially  to the  edict of  the  Prussian  government,
 enforcing revaccination amongst the troops of  that country ;
 also to  the  experimental researches  of  Heim  (Historische
 Kritische Darstellung der Pockenseuchen), and  express  them-
 selves  thus concerning the merits and necessity of revacci-
 nation  : that the periods defined by Heim and Gregory, when
* This has been long known under the name of Bryce's test.
H. D. B. 
146
DISEASES OF  THE  SKIN.
the vaccine virus loses its  anti-variolous power, and conse-
quently  when  re-vaccination  becomes  necessary,  are not
fully established.   According to the former writer, the period
of.exemption is seventeen years, according to the latter four-
teen  years.   That  they  have  frequently observed modified
small-pox in  persons  newly  vaccinated,  distinctly  resulting
from  variolous contagion, and  which had been  described  as
cow-pox: also that they have seen the mildest form of modi-
fied cow-pox in individuals who had been  vaccinated twenty-
five  years  previously,  evidently  showing that  the vaccine
virus  had not lost any of  its  modifying  power during that
long period.   Hence, they conclude that as variola is equally
modified a few days and  twenty-five years after vaccination,
the precise period at which the  anti-variolous power of vacci-
nation ceases  to  exist  cannot  be  rationally  decided.   They
are by no means  so sanguine  as the German writers in  favor
of revaccination, and of  the prophylactic advantages  to  be
derived from  it;  but with the view of regenerating the cow-
pox  virus,  they recommend the  method  of  M. Wanner,  of
Rambouillet, which  consists in inoculating  the  udder of the
cow  with  virus  taken from   the  human subject,  although
aware  that this  plan had  been  adopted formerly without
success.]*

  * There  are  several interesting points  connected with this subject which  the
nature of the present work as a manual excludes from investigation, and to which
we will only allude.
  The value and necessity of revaccination may be considered as fully established
by the results of its trial in the Prussian, Hanoverian, and other Continental  armies.
  It has been practised in the Prussian army since 1833, and the result is that  the
small-pox has been almost entirely extirpated.  In Wirtemberg, but one  case of
variola  occurred in five years among 14,384 revaccinated soldiers, and three only
among 29,664 revaccinated civilians.
  The extent of protective power of vaccination can never be definitely fixed, at
the same time that we can approximate near enough to the truth for practical pur-
poses.   The ratio of cases of small-pox after vaccination is low before ten years of
age.  The maximum of susceptibility is from fifteen to twenty-five years of age—
(Dr. Gregory places this maximum from  twenty to twenty-five)—after this period
it gradually diminishes. Tomasini thinks that its protective power only lasts  ten
or twelve years.
  Facts prove that small-pox in the unvaccinated is five times more  fatal  than in
those who have been vaccinated—and in  the words of the late Dr. Forry {Boyl-
ston Prize Essay on Vaccination, N. York Journ. Med., Sept., 1844), " When
perfect, vaccination is as complete a protection as any other prophylactic  known
to man," for when perfect, variola does  not  occur more frequently  after it than
small-pox after small-pox.
  Among the  causes  which  modify the protective power of vaccination,  Dr.
Gregory (op. cit.) mentions puberty, change of climate, a severe attack of fever,
and an epidemic constitution of the season.
  The  following are  some of  the most  important conclusions embodied in  the
report of the committee on vaccination of the  French Academy of Sciences, made
February 25th, 1845:— 
ECTHYMA.
147
                          ECTHYMA.

 Syn.—Phlyzacia; Agria; Scabies fera; Furunculi atonici.

  Ecthyma  is  a disease of the  skin, characterized by large
round phlyzacious pustules, almost always distinct, and seated
upon a hard inflamed base.   These pustules are  succeeded
by  thick, dark-colored  scabs, which sometimes leave  slight
superficial  cicatrices behind them,  or  more frequently,  red
stains, which disappear  after a certain time.  This eruption
may appear on every part of the body, more especially on the
neck,  the shoulders,  the  buttocks, the  extremities, and  the
chest.   The pustules are seldom developed on the  face or on
the  scalp.  Although they are  generally distinct  from each
other, they  may, however, spread over a large  surface, even
over the whole body, but  they are usually  confined to some
particular region.
   Causes.—Ecthyma  is  frequently  produced   by  distinctly
 apparent causes :  it is  also  sometimes developed  spontane-
ously.   In the  first instance,  it is offen the result of irritating
 applications to the skin;  thus, for instance, the characteristic
pustules of ecthyma are frequently produced by friction with
 tartar emetic ointment.   The pustules are  usually set close
together, the epidermis is always elevated  for a considerable
extent by a sero-purulent fluid,  and this elevation is in gene-

  1.  Small-pox rarely attacks those who have  been vaccinated before the age of
ten  or twelve, from which age,  until thirty or  thirty-five, they are particularly
 liable to small-pox.
  2.  Vaccine matter taken directly  from the  cow causes local symptoms of
 greater intensity ; its effects are also more certain than those of old vaccine matter ;
 but after being transmitted  for a few weeks through the human subject, the local
 intensity disappears.
  3. It is prudent to regenerate vaccine matter  as frequently as possible, to pre-
 serve its protective power, and the only mode of  doing this deserving of confidence
 is to procure it from the cow.
  4.  Revaccination is the only known method of distinguishing those vaccinated
 persons that remain protected, from those that do not.
  5.  The success of revaccination is not a certain proof that the person in whom
 it succeeds was liable to contract small-pox;  it merely  establishes a  tolerably
 strong presumption that he was more or less liable to take it.
  6.  In  ordinary periods, revaccination should  be practised after fourteen years,
 but sooner during an epidemic.
  M. Chomel says," if anything can lead to the extirpation of small-pox, it is revac-
 cination upon the most extensive scale" (L'Abeille Med., Fev. 15,1851) ; and we
 might add the strongest testimony from various sources in favor  of the importance
 and indeed, we may say, the necessity of  this practice.  But we must  refer our
 readers to other works for facts and items on the subject, and among these, to the
 valuable essay on  the subject by the lamented Dr. Forry {New York Journal
 Med. and Surg., Sept., 1844), and to Dr. Gregory's Lectures on the Eruptive
 Fevers, Amer. Edit., N. York,  1851; appendix, p. 370.            H. D. B. 
148
DISEASES OF THE SKIN.
   ral  umbilicated.   They continue for  several days,  and are
   then succeeded by scabs, which begin to form in the centre ;
   the  accompanying inflammation is sometimes pretty severe,
   but  it does not occasion any inconvenience, inasmuch as it is
   often desirable to establish this condition as a curative  mea-
   sure.  It must not, however, be allowed  to become intense
   without  having recourse to emollients.
     Idiopathic ecthyma is often the result of  handling  pulveru-
   lent and metallic substances; hence it is so frequently seen in
   grocers  and masons.  Ecthyma  is also developed spontane-
   ously,  and in general  appears to be symptomatic  of  some
   peculiar condition of the economy.  It attacks  all ages, and
%  appears in every season, but it most frequently appears during
   the  spring  and  summer in  young  persons  and in adults.
   Women are sometimes affected  with it during pregnancy.
   It appears to result in the majority of  cases from great  exer-
 -  tion, fatigue, bad food, want of cleanliness, and intense mental
   emotions.  It is likewise developed in the advanced stages of
   certain chronic affections of the skin, as lichen, prurigo, and
   especially scabies;  or  during the convalescence of  some  of
   the  acute  diseases,  as scarlatina,  measles,  and  variola.
   Finally, chronic inflammation of some of the internal organs
   may  have  considerable   influence on  the  production of
   ecthyma, and in some rare  cases an eruption of ecthymatous
   pustules  has appeared during the crisis of  gastro-enteritis.
   Ecthyma may be altogether partial, and confined to one par-
   ticular spot, when its duration varies from one to two weeks ;
   or it may be general, appearing on every part of the body at
   the same time, usually  by successive eruptions, and continue
   for weeks and even months.
     Symptoms.—When the  disease  is  partial, the  eruption
   appears at once;  but it more commonly shows itself in suc-
   cessive crops. It usually commences with the evolution of red,
   inflamed, circumscribed spots, which  attain a  considerable
   size  in the course of a few days.  Their apices  soon  contain
   pus,  whilst their bases are hard, circumscribed, and of a deep
   red  color.   The  fluid  dries up in three or four days;  and
   pretty  thick scabs are formed, leaving dark  red stains behind
   when  they  fall off.   The pustules are in  general  distinct;
   they sometimes form irregular groups, and  vary in size  from
   that  of a pea to that of a shilling, and beyond.  The eruption
   is occasionally accompanied with very severe pain.   In some
   instances suppuration takes place  rapidly;  in others slowly,
   not  for several  days.   Sometimes the  pus forms in  small
   quantity, and occupies the apex of the pustule alone, the base
   of which is  broad, hard,  and  inflamed.  The epidermis  is 
ECTHYMA.
149
often  raised considerably, so as to form a bulla.  The puru-
lent fluid seems then to be confined beneath by a thin circular
layer  of transparent serous fluid.  This appearance  presents
especially when the pustules are formed on the hands  and
feet.  Some of the pustules terminate by resolution, and slight
whitish incrustations appear successively on the surface; but
generally they are succeeded by thick, adherent scabs, which
on falling off leave a deep-red patch, and in some rare instan-
ces a cicatrix.  When the eruption is successively developed
for a  considerable period, the red patches become very nume-
rous  and confounded together, giving  a  peculiar appearance
to the diseased surface, which is only to be seen in ecthyma.
Sometimes  to  these pustules succeed  deep ulcerations,  par-
ticularly those on the lower extremities, and which follow
scarlatina and small-pox.   They are  then  greatly  inflamed
round the base, the scabs are thick, and the ulcerated surface
is in  general dull, sanious, bloody, painful, and always unheal-
thy looking.                                       .
   Ecthyma frequently occurs in weak, ill-fed, cachectic  chil-
dren, especially during the convalescence of gastro-enteritis,
when accompanied with distended abdomen.   The size of the
pustules is generally  irregular  in  these  cases,  and a  small
pimple may often  be  seen close by a large pustule.  They
are of a circular form,  and their color is more or  less  red,
according  as the child  is more or less feeble and debilitated.
The  large pustules frequently suppurate,  and, after a length-
ened period, terminate  in a small cicatrix; but often,  after
threatening suppuration, they gradually diminish, and termi-
nate  by desquamation.                               .
   In old,  debilitated  persons,  much  addicted  to  drink,  a
variety of ecthyma is often observed, the ecthyma cachecticum
 of Willan, having much resemblance  to  rupia.   It generally
forms on the limbs, but every part of the body is subject to
 it.   The skin is inflamed,  and more swollen than in  the  com-
 mon forms of the disease.   It assumes a deep-red color, and
in  about six or eight days the cuticle  is raised  over the pus-
tule,  is  blackish, and infiltrated with  blood.  It soon bursts,
 and forms a thick, dark scab, raised at the centre; the edges
 are hard, callous, and more or less inflamed.   The scabs are
 very  adherent,  and do not become  detached for several
 weeks—sometimes for  months.   If  they  fall accidentally, an
 unhealthy  ulceration ensues, and the scab is with  difficulty
 removed.   Sometimes  febrile symptoms precede or accom-
 pany the eruption, but they generally  disappear with the dis-
 ease.  Sometimes  engorgement of the  lymphatic ganglions
 accompanies  this  affection, which it  will be  necessary to 
150
DISEASES OF THE SKIN.
reduce by  emollient applications, and  sometimes by local
bleeding.  Suppuration and desiccation  are the usual termi-
nations  of ecthyma.  Resolution and ulceration are much
more rare.
  Diagnosis.—The pustules of ecthyma are generally easily
recognized by their size, their inflamed base, and their mode
of development.   These characters are  sufficient to  prevent
them  from being confounded  with those of acne, impetigo,
sycosis,  and porrigo.  However,  when  the  pustules  of acne
and sycosis are accompanied with a hard, red base,  as  they
often are, they might be mistaken for the phlyzacious pustules
of ecthyma, if the induration more than the inflamed base of
the former, and other peculiarities, which are always to be
detected, did not obviate  this error.  The  umbilicated pus-
tules  of variola,  and the  multilocular  pustules  of vaccinia,
together with their contagious nature, will prevent their being
confounded with ecthyma.
  It is more difficult to distinguish  the  eruption of ecthyma
from that of syphilis, especially as the latter sometimes  pre-
sents  the same physical characters  as the former.   In these
cases, the copper-colored areola, the history of the case, and
the accompanying symptoms, form the basis of our diagnosis.
Ecthyma cannot be confounded with scabies, if we recollect
that the  one is a  vesicular and the  other a pustular  disease;
and if a  few pustules should appear  amongst the  vesicles, the
respective  characters of  scabies and ecthyma  will enable
them  to be distinguished  at a glance.   Besides which, the
small  vesicles intermingled with the pustules, will remove
all doubt.
  Ecthyma may be distinguished from furunculi, by bearing
in mind, that in the former, the inflammation proceeds  from
without inwards, whilst in furunculi it commences in the  sub-
cutaneous  cellular tissue, which becomes  mortified to a  cer-
tain extent.  It then proceeds outwards, and forms an opening,
by which the dead  tissue is expelled.  Finally, rupia resem-
bles ecthyma so much, that these two affections often appear
to be merely varieties of  the  same  disease. Ecthyma luri-
dum,  in which the epidermis, raised by dark-colored  blood, is
succeeded  by a very thick scab, covering an ulcerated surface,
is much more difficult to  distinguish  from rupia  than  the
simpler varieties  of that disease, the phlyzacious pustules of
E. simplex resting on a hard and inflamed base, and  followed
by irregularly-shaped scabs and superficial excoriations, dif-
fering enough from elevations of the epidermis  by a  sero-
purulent fluid which constitute bullae, and succeeded by  pro-
minent  scabs resembling the shell of an oyster, and covering 
IMPETIGO.                       151
ulcerations which  are often  deep, to distinguish  that  form of
ecthyma from rupia.
   Prognosis.—Ecthyma is  not a dangerous affection.   The
prognosis varies according to  the extent of the disease,  the
age and condition of the patient, and the nature of the accom-
panying lesions.
   Treatment.—When the eruption is mild, partial, and follows
a regular course, it merely requires diluents, simple or emol-
lient baths,  attention to diet.   If it assumes a  severe  form,
and  is  accompanied  with much inflammation,  a  moderate
bleeding, or the application  of leeches,  may be resorted to
with advantage.   When the disease is of long standing,  and
the constitution of the patient is  deteriorated, hygienic mea-
sures should form the principal part of the treatment.   The
patient  should take moderate exercise,  and nourishing food,
together with simple or slightly stimulating baths, as the alka-
line  or salt-water bath.   Mild laxatives are very beneficial.
Spirituous liquors, and excesses of all kinds, should be parti-
cularly  avoided.   Tonics, as quinine, iron, &c,  are some-
times required.  Emollient applications ought to  be employed
when the ulcers are  inflamed,  and  difficult to  heal.  It is
sometimes necessary, on the other hand, to excite the surface
with nitrate  of silver,  or some stimulating lotions.   Muriatic
acid, diluted with  water,  is   very efficacious in  altering  the
condition of the  parts, which under this  treatment assume a
more healthy aspect, and soon cicatrize.*

                         IMPETIGO.

Syn.—Dartre  crustacee ;  Lepre  humide ;   Crusted  Tetter;
                  Running Tetter; Cowrap.

   Impetigo  is a  non-contagious disease of the skin, charac-
terized by an  eruption  of psydracious  pustules, most  com-
monly grouped in clusters, and forming thick, yellowish, rough

  * In the chronic form of ecthyma particularly, the secretions must be carefully
regulated,  for which purpose moderate doses of some mercurial  preparation  will
often be found necessary. In the cachectic form, the mineral acids, as the  sul-
phuric, in the form of elixir vitriol, from ten to thirty drops three  times daily, and
continued for some time, will often prove very effectual.  Opium may be combined
with it if it produces irritation, and may  also be given alone, or in the form of
Dover's powder when  there is great restlessness.  The hydriodate of potash  will
prove valuable in some cases, and the iodide of iron also, when the mucous mem-
brane of the alimentary canal will bear it.  When occurring in infants, the diges-
tive organs require constant attention—the diet  in these cases must be  nutritious
and easy of digestion,  without being stimulating.  Vegetable bitters, quinine,  and
preparations of iron will often be required, when the system is properly prepared
for their use. Fresh air and  cleanliness are also important auxiliaries, and often
essential to the cure.                                       H. D. B. 
152              DISEASES OF THE SKIN.
incrustations.  When the pustules  of impetigo are grouped
together, forming  circumscribed  patches  of  different  forms
and  extent, they constitute the variety described  by Willan
as impetigo figurata.  When they are scattered,  and  do not
assume  any particular order, they form the impetigo  sparsa
of the same author.   Each may assume the acute or chronic
form.  There are many intermediate varieties between them,
which have characters peculiar to themselves.
  Impetigo figurata occurs most  frequently on the face, and
especially on the cheeks; it is, however, often  met with on
the extremities,  and even on the body, and  usually attacks
children during  dentition, young  persons of both  sexes, of a
lymphatic or sanguineous temperament, with a fresh color,
and  fine delicate skin.  It appears .most frequently in  spring,
and  some  individuals are periodically affected with  it for
years.  Its development is not accompanied  with any other
symptoms  than  those of headache  and slight  indisposition.
When  I. figurata  is developed  on the face,  it  frequently
appears in  the form of small, distinct, red, and slightly raised
patches, which  are soon covered with  small  pustules, nearly
confluent.  These patches may remain isolated, or else become
united by the formation of pustules  in their interstices.   The
eruption is often much more extended, and the  inflammation
more intense.  Thus, for instance, both cheeks,  and even the
chin, may be affected at the same time.   A certain degree of
constitutional disturbance exists in these cases, and the erup-
tion is  frequently  preceded and  accompanied by a kind of
erysipelatous inflammation.
   The eruption  is pustular from  the beginning, and the pus-
tules are small,  confluent, and very slightly raised above the
level of the skin. They burst between thirty-six and seventy-
two hours from their formation, and  discharge  a purulent
fluid.  The heat,  itching, and  tension  are  then increased.
The  fluid  is abundantly discharged  by  numerous  small
orifices; it soon dries up, and forms thickish, yellow, friable,
semi-transparent incrustations, which have some resemblance
to  the  gummy  exudations of certain  trees,  or to layers  of
concrete honey.  The discharge continues, the scabs increase
in thickness,  and it is in this condition that the patient gene-
rally applies to the  physician.   The  scabs  form on a red,
inflamed, and irregularly-rounded patch, whence exudes a sero-
purulent fluid in variable quantity.   There still remain a few
isolated psydracious  pustules around the  periphery of these
inflamed surfaces, and  on  others  the discharged fluid  is
scarcely concreted.  When  the  disease is not prolonged by
 successive eruptions, it  remains  in this  incrusted condition 
IMPETIGO.
153
from two to four weeks.   The itching and heat then subside,
the exudation diminishes,  and the scabs are gradually but
irregularly detached, leaving a red and tender surface behind.
An ichorous fluid may be discharged from  minute pores,
which sometimes exist  underneath, and give rise to the for-
mation of new scabs, which are thinner.  Finally, when the
incrustations  have altogether disappeared, the skin remains
red, shining, and tender for a considerable time, during which
the slightest irritation will  reproduce the disease.
   This variety may  first appear on a small detached surface,
and ultimately spread round the circumference by the succes-
sive development of psydracious pustules.  Desiccation com-
mences in these cases at the centre.   I. figurata is sometimes
prolonged for weeks, and even  for years, by the  successive
development of the eruptions,  and is then chronic in its dura-
tion, while the fresh pustules  keep up.an acute state.   The
chief  causes which  prolong the disease in  this manner are
intemperance, high  living, irritating  applications,  as caustic,
for example, and the injudicious employment of the prepara-
tions of sulphur.   The skin may become deeply inflamed and
indurated in these cases ; but it never presents that peculiar
roughness   which  is observed in those  varieties  of  chronic
impetigo figurata that  are confined to the extremities.  This
variety sometimes occupies but a very limited surface on the
face ;  it is  confined to the eyelids, on  the middle of which
prominent conical incrustations are  formed.   It produces  a
state of chronic ophthalmia, which is  often very troublesome.
In other  instances  the eruption  appears  on the  upper lip,
exactly like a pair of moustaches.
   Impetigo figurata  may also  appear  on the extremities, and
even on the trunk.  When it affects the lower extremities,
 the inflamed  patches are in general large, and of an irregu-
 larly-oval form, whilst on the upper extremities they are more
 circular and  less extended.   The pustules are developed in
 the same manner as on the face, and  are speedily replaced by
 thick yellowish-green  or brown  scabs.   When  these are
 detached,   they are  succeeded  by others  produced by the
 desiccation of the  sero-purulent fluid, discharged by the
 inflamed  surface.   I.  figurata  may assume  a chronic  form.
 It then appears only from time to time  on  small portions  of
 the inflamed patches, near their circumference; and the suc-
 cessive eruptions and  large  crops  of pustules of the acute
 variety are never  present.   The cuticle is inflamed  to  a
 certain depth, and it acquires  a remarkable  degree of  thick-
 ness.   In  the same person may  be  seen scabby patches, of
 different sizes and forms.  Sometimes a large incrustation  is 
154
DISEASES OF THE  SKIN.
seated on the inner side of the thigh, whilst in other cases the
same product is  developed on the outer  side, or on the leg,
and even on the abdomen.   In some cases the pustules never
appear, and the disease is recognised merely by the peculiar
form of the patches, and the presence of the scabs.  When in
the progress of cure the heat and itching diminish, the dis-
charge becomes less abundant, and the scabs less  thick ; the
edges commence drying up,  and  the  surface ceases gradually
to be covered with scabs ;  but  the natural color of the  skin
returns very slowly.
  Impetigo sparsa differs  from the preceding variety merely
in the  irregular  and  scattered  distribution of the pustules;
otherwise it pursues the same course, and produces the  same
kind of thick, rough, and greenish-yellow scabs.  This variety
appears most frequently during autumn, continues the whole
of the winter, and disappears on  the return of warm weather.
It has  a greater  tendency than I. figurata to pass into the
chronic state.   Although I. sparsa may present  itself on any
part of the body, it  most frequently attacks the extremities,
especially the legs and the bends of the joints. Sometimes it is
confined to a single region, in other cases it covers the whole
limb.   The pustules  are scattered, are* accompanied with a
smart itching,  and soon burst.   Yellow  incrustations  are
formed by the partial  desiccation of th*e sero-purulent  fluid.
They are rough,  thick, friable, and very different from the
laminated incrustations of eczema;  they cover the whole  of
the diseased surface, but some scattered pustules are always
to be seen.   When, the scabs fall, either naturally or from the
treatment  adopted, an inflamed  surface  remains, with occa-
sional superficial excoriations. A sero-purulent fluid exudes
from this surface, speedily saturates  the  dressings,  lint, &c. ;
and, by its partial desiccation, reproduces the scabs.  In some
cases, and especially in persons  advanced in years, and of a
debilitated constitution, the scabs acquire a considerable degree
of thickness, and  a deep  brownish yellow color, not  unlike
the bark of a tree, hence the name impetigo scabida.   These
incrustations sometimes encase  the  whole  limb, the  move-
ments of which become painful and difficult, and are  accom-
panied with heat and a distressing itching.   The crusts soon
fall off, and are  speedily  replaced  by others.  When the
disease  is intense, and occupies  the lower extremities, it  is
sometimes  complicated with anasarca, and  extensive ulcera-
tions. When it extends  to the toes, the nails are often destroyed,
and when regenerated, are thick  and rough, like those seen  in
some cases of lepra and psoriasis.
   Although  impetigo  is  not generally accompanied with 
IMPETIGO.                     155
febrile symptoms, it sometimes, however, assumes  an inflam-
matory character.   In  these  cases it is accompanied with
much  constitutional  disturbance,  fever,  burning  itching,
and  erysipelatous  inflammation.   (Impetigo erysipelatodes,
Willan.)  M. Biett used to describe another variety, which is
rarely met  with, and which is  sometimes  confounded with
impetigo  erysipelatodes,  and  sometimes  with an ulcerated
syphilitic  eruption,  the impetigo rodens of authors.*  It seems
to destroy the tissues in which it is  developed.  The duration
of the disease varies from three to four weeks, or it may even
be prolonged indefinitely.
   Causes.—Impetigo often  results from the application of
irritating  substances to  the skin,  as from  handling brown
sugar, lime, metallic filings,  &c.  It appears  in all seasons,
but  especially during  spring  and  autumn,  and  principally
affects children during dentition, females at the critical period,
and  persons of a lymphatic or  sanguineous temperament with
a fine delicate skin.  Excess in diet, violent  exercise, strong
mental  emotions, as grief, fear,  &c, sometimes produce  the
disease.   It is often complicated with other diseases of  the
skin, especially with lichen.
   Diagnosis.—The presence  of psydracious  pustules,  in
clusters, or  scattered, which are succeeded  by thick, rough,
and  yellowish scabs, is  sufficient to  distinguish impetigo from
the vesicular or vesiculo-pustular eruptions of eczema, which,
on the contrary, are succeeded by thin, laminated scaly crusts,
with a few vesicles scattered here and there.  When impetigo
figurata appears on the  chin, it requires some attention to dis-
tinguish it from  sycosis.  In impetigo the pustules  are small,
yellow,  and  set close together.  The  exudation is considerable,
the  incrustations are thick, yellowish-green, and semi-trans-
parent ; besides, there are no indurations or  tubercles.  The
pustules of  sycosis, on the other hand,  are  larger, isolated,
more raised, and less yellow than those of impetigo; the exu-
dation is by no means so copious, the  scabs  are drier, of a
deeper color, and are only reproduced by a new eruption, not
by a cutaneous discharge.
  Impetigo  of the hairy scalp may be  mistaken  for porrigo.
The peculiar pustules  of porrigo  favosa, imbedded in the
epidermis, and terminating in yellow umbilicated  scabs, and
also  those of porrigo scutulata, which, owing to their being
agglomerated, still  more resemble impetigo, are  sufficient  to

  * Houghton  says  {Cycl. Prac. Med. Art.  Noli me tangere),  that the term
Impetigo rodens has  been derived from cases of complication of  impetigo with
lupus, it being not uncommon to find pustules of that disease in the neighbourhood
of lupoid patches.—H. D. B. 
156
DISEASES OF THE  SKIN.
distinguish them;  besides, those varieties of porrigo are con-
tagious, and cause the hair to fall, symptoms which  are  not
characteristic of the impetiginous eruptions.   When itch is
complicated with impetigo,  it requires but little attention to
detect the vesicles.  It should be borne in mind that the pus-
tules, which in the majority of instances  are  merely compli-
cations, are either psydracious pustules of impetigo, or phlyza-
cious pustules of ecthyma.
  The  thick  scabs  which  appear on the face  during  the
syphilitic eruption have  been mistaken for impetigo.  But a
physician who could commit such an error must be entirely
unacquainted  with the differential diagnosis of the diseases of
the  skin.  The large,  thick, blackish,  and  very adherent
incrustations,  seated on a violet-colored surface, and sur-
rounded with  several indelible cicatrices, which terminate in
deep ulcerations, a certain rounded form of the eruption taken
as a whole, and a peculiar aspect, which  once  seen can never
be mistaken, are sufficient  to prevent the occurrence of so
serious an error.
  Prognosis.—Impetigo  is not a dangerous disease, but it is
nevertheless exceedingly troublesome  and often  very repul-
sive.  The physician should be on his guard not to promise a
speedy cure, a circumstance which rarely occurs.  The dis-
ease is very obstinate in  persons advanced in  years and with
a broken  down constitution; and, on the other hand, it is
more manageable in  young and robust subjects, especially if it
assumes an acute form.
  Treatment.—The  preparations of sulphur have been  too
generally  recommended  in  impetigo.  Their  indiscriminate
employment is often decidedly injurious, especially in the early
stage.   When the disease is limited, and the local symptoms
mild, emollient lotions of marshmallows, decoction of poppy
heads, bran, or almond emulsions, are the best applications
that can be used; refreshing acidulated drinks should at  the
same time be administered to the patients.  But if the disease
spreads, and covers the greater part of the face, general and
local bleeding will often be required, and should be regulated
according to the strength of the  patient.   Bleeding from  the
foot and the application of leeches to the mastoid processes,
or to the arms, will generally suffice.   When the face is  the
seat of  the  disease, venesection  may   be  advantageously
employed during its  progress, as well  as  at the  commence-
ment, especially when it has been aggravated by the use of
injudicious remedies.  In addition to  the lotions just men-
tioned, mild laxatives may be administered with advantage.
  Baths, at a temperature between 88° and 90° Fahr., are often 
IMPETIGO.
157
useful even when the face  is affected, in diminishing  the
general irritation.  If they are employed at a higher tempera-
ture, they will probably produce cerebral congestion.   When
the inflammation subsides, emollient lotions with a little alum
in them will be found very beneficial.   Towards the termina-
tion of the disease, when  it seems to be slow of disappearing,
baths and the vapor douche are very useful in altering the
condition of the  skin to healthy  action.  It is  sometimes
necessary to have recourse to more energetic measures than
the foregoing, and in these cases purgatives,  as calomel, the
sulphates of soda and potash, jalap, and  castor-oil, are then
indicated.  The patient may take at the same time acidulated
drinks,  in the proportion of from  fifteen minims  to  half  a
drachm  of sulphuric acid to the pint.  Tepid and alkaline,
local  and general baths, and alkaline applications, are also
beneficial ifl these instances.  The alkaline  lotions may be
alternated with acidulated applications  occasionally.  It is
very desirable to remove  as much as possible of the incrusta-
tions from the  diseased  surfaces,  and this is most readily
accomplished  by the frequent and  prolonged employment of
tepid baths.
   It is when impetigo assumes a chronic character that  the
sulphureous  preparations are  really useful.  The  sulphur
waters, either in baths or  administered internally, either with
or  without milk, are then most  frequently employed.   The
salt-water bath has sometimes effected a radical cure of  this
form of the disease. The vapor bath, and particularly the vapor
douche, is often very efficacious  if applied  to  the patches of
impetigo figurata when they have passed into a chronic state.
The douche should be continued  from  ten to twenty minutes,
and should be kept a certain distance from the patient.   These
measures, judiciously employed,  usually overcome the most
rebellious forms of impetigo ; they-are most frequently required
for old and feeble patients. They may, however, be enforced in
young and robust subjects, if the nature  of the disease seems
to require them.           0
   There are some cases in which all  these measures seem to
fail; in this event  the diseased surface may be cauterized with
the diluted acids.  Hydrochloric  acid  is generally  preferred,
as it is supposed not  to produce cicatrices ; but this is not cor-
rect, and any other acid will  fulfil the  same end  by altering
the condition of the skin.  A weak solution of nitrate of silver,
or some dilute acid, maybe applied with a feather passed over
the surface, and water should be  poured upon it immediately
afterwards, in  case  the  acid  be too strong.   Much care
and attention are required in  using these remedies.   The pro-
                            11 
158
DISEASES OF  THE SKIN.
tonitrate of mercury,  in  the form  of an ointment, has often
been applied with success.   The oxide of zinc and acetate of
lead ointments are also useful.*  When the disease is limited,
a blister applied to the diseased parts has often proved benefi-
cial in altering the vitality of the skin.f  If all these  remedies
should fail, we must have recourse to the arsenical prepara-
tions, as Pearson's or  Fowler's solutions, which  are generally
followed by the most surprising effects.  Pearson's solution is,
in the  majority of cases, sufficient to produce a  perfect cure.
   A description  of  the achores, which are merely  varieties
of impetigo, although falsely classed by Willan amongst the
porrigos, naturally follows the  foregoing.  They are charac-
terized by  small, superficial, confluent pustules,  having no
regular order, and  seated  on  an  inflamed base.  After the
lapse of a few days they burst, and a fluid escapes, which con-
cretes  and  forms large brown scabs, composed  of  several
layers  placed  over  each other, and very different  from the
thick incrustations which succeed the favi.  These two varie-
ties have been described under the names of porrigo larvalis
and porrigo granulata, until M. Biett assigned to them their
proper place.
   Impetigo  larvalis is  characterized by an eruption of super-
ficial pustules  of a  whitish  yellow color, more or less con-
fluent, and arranged in groups.   These pustules are succeeded.
by yellow and greenish scabs, sometimes thin and laminated,
sometimes  thick and  rough, which have  the greatest resem-
blance to those of eczema impetiginodes and impetigo figurata.
This disease is seen  most frequently in young subjects, espe-
cially infants.  It may appear on any part of the body; but
the hairy scalp, the ears, and the lips, are its favorite situations.
The face is sometimes  almost  completely  covered with thick
crusts  in the  form  of a mask, hence the name  of larvalis.
There are several varieties of impetigo larvalis, resulting alto-
gether from the degree of the existing inflammation, and the
thickness and extent  of the crusts.  In very young  infants
the disease  consists solely in the formation of small  pustules,
which spread over the  scalp, temples, &c, producing  incrus-
tations of variable size, but generally thin, which have been
described by writers  under the name of crusta  lactea.  In
these cases  the disease is ordinarily exceedingly  mild, but it is
often pretty severe when it appears on  the  face  or scalp, or

   * Also ointments of creasote (gtts. xx to xl to §j lard), of  ioduret of sulphur
(3j to  3 ss to  §j) and of tar and sulphur.        *            H. D. B.
   + In  the last edition of this work, the whole of the preceding remarks respect-
ing local applications are left out, and we feel that these means  are of but equivo-
cal benefit, while they doubtless sometimes do harm.             H. D. B. 
IMPETIGO.
159
on both  at the same time, as well as on  other parts of the
body.
  Symptoms.—When the disease is about to appear on the face,
it usually commences with the formation of a few small pus-
tules on the forehead and cheeks, grouped  together,  and hav-
ing an inflamed  base.  They are  accompanied  with  smart
itching,  and soon burst either  spontaneously  or by  being
scratched with the nails.   A viscid yellowish fluid escapes,
which forms thin soft incrustations of a greenish yellow color.
The exudation continues, new crusts form, the first increasing
in thickness ; and in some parts they are thick, soft, and round,
whilst in others they are thin and  laminated.  On falling off,
a  red inflamed surface remains,  on which new scabs are
formed, but the exudation is often so considerable that it does
not  concrete.   The surface of the cuticle then  becomes
exposed, from which an acrid viscid fluid exudes by innume-
rable small orifices.  When the  disease is diffused, the itching
and  even  the  pain  are very severe, and the face, with the
exception  of the nose  and eyelids, which are almost always
exempt, is concealed as if with a mask.
   In  other cases  the pustules are  larger,  and are developed
behind the ears, round  the mouth, upon the chin, &c, termi-
nating in thick yellowish green crusts.  In some instances the
mouth is surrounded with large and thick  yellowish incrusta-
tions, which are of a deep  brown color in some parts where
the fluid  is mixed with blood.  The movements of the lips are
exceedingly painful in these cases.   In other instances, again,
these large incrustations form  only behind the ears.   They
emit a nauseous odor.   The  lymphatic ganglions sometimes
inflame, and even suppurate,  and the eyelids may become the
seat of chronic inflammation.  Coryza and a copious discharge
of mucus by the nares, frequently occurs.   When the disease
begins to  decline, the  exudation  gradually  diminishes, the
scabs are  not  formed  so  frequently, they  become  thin and
white, their bases are paler, and they are soon succeeded by a
slight desquamation, which is not  long in disappearing.  A
light rosy tint only remains on some portions of the diseased
surface, which  in its turn also fades away.   Such is  the man-
ner in which this variety usually terminates.
   In some cases,  however,  deep  chaps are  established, and in
others, when all the  symptoms  seem to have disappeared,  a
new eruption suddenly breaks out, and the disease commences
anew.  Cicatrices never form spontaneously, and those which
have  been mentioned by writers were  merely the  result of
scratching the diseased  surface.   When this variety occurs
on the hairy scalp, the pustules  are set close together, of a 
160
DISEASES OF THE  SKIN.
yellowish  white color, and  sometimes occupy the posterior
part of the head only, whilst in other instances the disease
appears on every part covered with hair.   These pustules are
very small, and are mixed with vesicles, some of which are
purulent  and  others transparent,  and  are  accompanied
with smart itching; they soon burst, or, as more frequently
happens, they are torn, and  throw out a  thick viscid fluid,
which  mats  the hair together, and forms  irregularly-shaped
scabs of a brownish yellow color.   The scabs are either scat-
tered or confluent, and  spread  over  a  surface of variable
extent; the exudation continues, and if the hair is long and
not properly  attended to, the scalp becomes covered here and
there with a  thick brownish  crust, which dries and cracks into
several friable pieces.
   When these incrustations are  thick and extended, and if
the patient has injudiciously applied linen cloths to the head,
the latter  become saturated with the fluid, and adhere to the
parts for months together.   A foetid  and disgusting smell is
given off  when they are at length  removed, and  the  hair
abounds with  lice, which aggravate the  pruritus.  On the
other hand, when  the scabs are carefully raised by means of
emollient  lotions, the surface beneath is but slightly  inflamed
and slightly  excoriated,  from which  exudes,  through a vast
number of pores, a nauseous viscid  fluid.   Sometimes the
subcutaneous cellular tissue  becomes inflamed, and  small
crrcumscribed collections of matter form, which frequently
have to be opened.  When  the  disease is of long standing,
and the incrustations firmly  adherent,  the  hair sometimes
falls off from some of the diseased parts; but this is merely a
temporary baldness, and  very different  from  that  which
follows porrigo  favosa and  porrigo  scutulata.  The bulbs of
the  hair are  not destroyed, they are  only inflamed, and  new
hair soon grows again, as if the parts were never affected.  In
addition to the localities already enumerated, this disease may
extend to the  trunk, and even to the limbs.   In these cases
the pustules appear to be smaller, more  scattered, and  the
scabs thinner.   The duration of the disease is very variable;
it is, however, always obstinate, and  generally  continues for
several months.
   Causes.—Impetigo larvalis is not a contagious disease ; it
chiefly attacks children, during the periods of dentition.  The
causes of this eruption are very obscure ; it appears in strong
well-fed children as well as  in those of an opposite condition.
 Want  of cleanliness very  often produces  it.  Adults  are
pretty often  affected  with this disease.
   Diagnosis.—The  characters  mentioned elsewhere as be- 
IMPETIGO.
161
longing to porrigo favosa and porrigo scutulata, are so strik-
ing,  that these diseases  can  scarcely  be confounded with
impetigo larvalis.  It is more difficult to distinguish I. larvalis
from  some other varieties of the same  genus, in which  the
order of development and the form of the scabs are precisely
the same.  The peculiar seat of the  disease, and its degree of
severity, are the only data we have for  guiding us in  the
diagnosis.
  Prognosis.—Generally speaking, there is little or no consti-
tutional  disturbance during this disease.  Gastro-intestinal
irritation, and diarrhoea, however, sometimes  supervene, and
the infant wastes.   In general  the prognosis  is not  unfavor-
able,  and the  eruption is troublesome in proportion "as it is
accompanied or followed by any severe  visceral  disease.   If
it continues for a lengthened  period, and has been  attended
with  a copious exudation, it will become more unmanageable,
especially  when it attacks very young, delicate, and weakly
children of the poorer classes.
   Treatment.—In most cases, lotions of tepid milk and water,
or an infusion of marshmallows, which  will both allay  the
troublesome itching and prevent  the scabs from  increasing,
form  the whole of the treatment necessary; and when infants
at the breast are attacked, the nurse should be desired to wash
the diseased surfaces with her own milk.  When  there  is
mnch itching and irritation, tepid emollient baths should be
administered.   It will also be desirable to change the infant's
nurse, if possible, or at least to diminish  the quantity of milk,
and give in its  stead a little gruel or barley-water.  Bleeding
is not advisable, unless the child is  two or three  years old;
and  when  there is much inflammation  present, one or two
leeches applied behind each  ear will generally be sufficient.
The  same treatment will answer when young persons and
adults are  affected, only that general bleeding may be prac-
tised  with  advantage when there is much local irritation, or
leeches behind the ears, or over the mastoid processes.
  When the scalp is affected,  the hair should be cut close,
and emollient poultices of bread and milk, or of potatoe-flour,
and   an  infusion of  marshmallows  ought to be  constantly
applied.  When the  eruption is of long standing, and diffused,
we should endeavor  to alter the condition of the skin with
alkaline  and sulphureous lotions, and  two  or three slight
inunctions with ointments of a similar  nature, daily.  Mild
laxatives are sometimes  beneficial.   In  very young infants
the syrup of chicory has proved exceedingly successful.  In
children and  adults, from  two  to  four grains  of  calomel
administered every morning, and two  drachms  to  half an 
162
DISEASES  OF  THE SKIN.
     ounce of the sulphate of soda in a pint  of barley-water, have
     often  produced a speedy improvement in the  progress of the
     disease.
       The sulphur douche is also  occasionally useful, and when
     the disease spreads to the trunk and limbs, and is of an obsti-
     nate character, sulphur baths alternated  with tepid emollient
     baths, should  be  prescribed.   The application  of  blisters  to
     the arms,  as recommended by some writers, generally pro-
     duces much  irritation of  the  skin.   In some rare instances,
     the eruption of impetigo larvalis  seems to  establish a certain
     degree of derivation, by means of which some severe internal
     disease is removed.   Under  these  circumstances,  and espe-
     cially when the increase of the serous exudation coincides with
     the decline of the original disease, great care and caution are
     necessary  in  proceeding   with  the  treatment.   It  is  often
     desirable to confine the curative measures to simple palliatives
     and attention  to cleanliness.*


       * In infants and young children, the secretions from the bowels require attention,
     and when disordered, may be regulated by small doses of calomel, or of hydr. c.
     creta, followed by castor oil or some other laxative.   I have also derived benefit
     in many cases from the continued use for some time of small doses of rhubarb and
     bicarbonate of soda, either with or  without  minute  portions of ipecac, together
     with the warm bath, and a diet which must be regulated in conformity with the
     state of the digestive organs and the  constitution of the patient.  In protracted
     cases vegetable bitters will also do good—as will also some preparations of iron, of
     which the iodide answers best in some cases.
       Phillips {Load. Med. Gaz., March, 1840)  speaks highly of the internal use  of
'  _  nitric acid in these cases, combined with sulphate of magnesia, and given in barley-
     water.   The state of the gums must always be watched.
       Any other  local  treatment than emollients must be abstained from in the early
     and acute stage of the disease.  When this has passed, topical remedies of a more
     or less stimulating nature may often be used with advantage, if  properly suited to
     the irritability of the scalp in each case, and care is taken to keep the bowels in an
     open state—of these, the dilute citrine ointment, ointments  of creasote, and  of
     ioduret of sulphur, are among the best.  Phillips is partial  to the use of a lotion of
     dilute nitric acid in some emollient decoction.  An oiled silk cap is useful to pro-
     tect the parts from changes of temperature and to promote the favorable action of
     topical remedies, as well as for the purpose of cleanliness.  In  some cases, how-
     ever, it cannot be borne, on account of ita increasing the heat and irritability of the
     parts.
       Astringent lotions are sometimes very useful.  M. Cazenave recommends else-
     where the following :—fy infus. red roses, § vj. ;  sulph. zinc, 12 grs. ; laudanum,
     3 ss.  He has the part wiped gently after each lotion, and then sprinkled with a
     little dry starch.   If this does not  answer,  he uses the following:—B> infus. red
     roses, 1 pint;  tannin, 45 grs.
       In acute impetigo of the face, Dr. Neligan advises leeches behind the ears, mild
     saline cathartics, and a wash of 3 ss. carb. soda, and  §  ss. of glycerine to a pint of
     elder flower water, and an ointment of 3 ss. of bicarb,  soda, and 3 j. of glycerine to
     § j. spermaceti cerate.
       When chronic, he gives minute doses of iodide of mercury internally, and applies
     locally an ointment of sulphate of iron, 2 to 5 grs. of the  dried sulphate to § j. of
     cerate, using at the same time the above alkaline wash.  In cases where this is too
     stimulating, he says that the best application is a lotion  of acetate of zinc 12 grs., 
IMPETIGO.
163
  Impetigo  granulata  is  characterized by the presence  of
small, isolated, greyish scabs, of an irregular form, on the pos-
terior part, or on the centre of the hairy scalp.   These  scabs
resemble the debris sometimes observed on the thick incrusta-
tions of porrigo scutulata, and also certain forms of  impetigo
larvalis, of  which J. granulata is but a variety.  They suc-
ceed small pustules, which are usually  scattered irregularly
over the scalp.  Children  and young persons are more sub-
ject to this disease than persons advanced in years.   It occa-
sionally attacks adults.   Its usual seat is the posterior part of
the scalp, but it may spread over the whole of it.
  Symptoms.—Impetigo granulata is known by the appear-
ance  of a number  of  whitish-yellow pustules,  accompanied
with pretty  smart  inflammation and considerable  itching.
They are traversed in  the centre by a single hair, and burst
in  from two to four days, when a  copious  exudation takes
place.   Rough, brownish scabs  are then  soon formed,  in
which the hairs are  matted together.  After a certain period,
when these  scabs dry, they present certain peculiarities which
distinguish  this variety.   They are  hard, uneven,  and em-
bossed, and  assume a brownish or dark  grey color.   Small,
dry, friable, irregularly-formed  incrustations become detached
and remain scattered through the hair, which projects from
them.   The hairs are  never destroyed, but when the disease
spreads they are found  united in groups  by the agglomeration
of  the scabs.   A disagreeable nauseous odor is given off, and
quantities of lice are seen in the midst of these  scabs  and in
the hair.   This  odor  never exists except in  very  filthy
patients.  In  more  cleanly persons,  the  scabs  frequently do
not present their distinctive characters, and resemble very
much those  of  I. sparsa.  The  duration of this variety  is
very variable ; it rarely exceeds a few months.   When left to
itself, it often persists for a longer period; but if appropriate
measures be had recourse to, and in  many cases attention to
cleanliness  is all  that  is  required,  it will terminate  in  the
course of a  few weeks.
   Causes.—Impetigo granulata is not contagious.   Poverty,
filth, and privation of every kind,  are its predisposing causes.
It is not met with so frequently as the other varieties,  a fact
which is  readily explained by the  instability of its  peculiar
characters,  depending for the  most part on a particular con-
dition of the eruption.


glycerine 3 ij., and distilled water §viij., which, he says, is especially useful in
chronic impetigo of the scalp.—{Dublin Quart. Journ., May, 1851, p. 335.)
                                                  H.  D. B. 
164
DISEASES OF THE SKIN.',
   Diagnosis.—The diagnosis is  not  difficult  when rough,
brown, or dark-grey scabs, resembling small pieces of  dirty
plaster, can be seen on the scalp.  There are cases, however,
in which porrigo scutulata appears with similar incrustations,
and many of  the characters  of I. granulata appear  also to
belong to porrigo scutulata.   The first, however, never pre-
sents  those large, thick, and  continuous incrustations which
accompany  porrigo in  this stage of its course.  Besides,  if the
scabs  are removed, the circular form of the patches, and the
nature of the pustules of the last-named affection, will readily
distinguish  it  from the other.  Impetigo granulata is never
contagious,  and never permanently destroys  the  hair.  The
color of the scabs and  their  cupped appearance in porrigo
favosa, independent of other characters, are always sufficient
to prevent any mistake on this point.  It will be more difficult
to  distinguish  I.  granulata  on its first  appearance from  I.
larvalis and other varieties of the same order, for the pustules
and scabs are almost the same.
   Prognosis.—This affection, generally speaking, is not very
severe.  It  is often rebellious and obstinate, although less so
than the other varieties.
   Treatment.—Our first  exertions  should  be  directed  to
removing the scabs, cutting the hair, and exposing thoroughly
the diseased surface.   Lotions and emollient applications are
the only remedies that can be conveniently used at the  com-
mencement, but the patient should  at the same time take
diluents and laxatives.  It is often necessary to continue for.
a considerable period the emollient applications.*   When the
inflammation of the scalp diminishes,  alkaline preparations
will be found very beneficial. Lotions and the sulphur douche,
&c, may often  be employed with advantage; in short, the
treatment of impetigo larvalis will  answer likewise  in this
variety.

                         ACNE.
 Syn.—Varus; Gutta rosea,  or rosacea; Bacchia rosacea ;
                       Copper-nose.
   The name  acne has been applied to  this disease  by the
ancients,  because  it  attacks  both  sexes  at  the period of
puberty.   It is a chronic pustular affection, characterized by
small isolated pustules, with  a hard, deep-red  base, leaving
behind small, red, circumscribed, hard  tumors,  very indolent

  * A poultice of bread and milk, or water, or of ground flaxseed, sprinkled over
with sulphur, will often remove the scabs more speedily than a common poultice.
                                                  H. D. B. 
ACNE.
165
and slow in disappearing, the seat of which appears to be the
sebaceous follicles of the  skin.  It appears most  frequently
from the age of puberty to thirty-five or forty, but in general
it is most severe  in young  subjects.   Both sexes are equally
subject to it.  The parts  most commonly  affected are the
temples,  cheeks, nose, and forehead.   It also appears on the
neck,  shoulders,  and front of the chest; but the  back and
upper part of the trunk is, perhaps, the most frequent seat of
the disease.  Acne occurs  on the back in a number of indi-
viduals without appearing  on  the forehead, cheeks, &c.; and
on the other hand, when it appears on  the face, the  back  is
rarely  attacked.  The limbs are never affected unless in those
instances where the disease spreads over the body, when the
backs  of the  arms are sometimes studded with  pustules.
   Willan admits  three varieties of acne, each having certain
characters of its  own.  It is, however, impossible to  draw
well-marked  lines of demarcation between them; for the same
individual may be affected with  them  all at the same, or at
different  periods.  These  varieties  are acne simplex, acne
indurata, and acne rosacea.  Acne punctata, described by the
same author  as a  distinct variety, is merely a complication of
the two first, and  the tumors consist in a collection of morbid
matter in the sebaceous follicles.   These follicles  open in a
blackish point, and the whole  appearance gives to the disease
a peculiar character.  Biett  has described another variety,
acne sebacea, which is now admitted by most writers.
  Acne  has been  regarded by Willan and  Bateman  as  a
tubercular disease.  The  circumscribed indurations of the
skin which have  received the name  of tubercles,  anq^ which
are so frequently met with in this disease, are merely the ter-
minations of the pustule, and not an elementary  lesion.  The
pustules of acne appear to be the result of inflammation of the
sebaceous follicles,  which  is  produced and kept  up by the
accumulation of the matter secreted by these follicles.
  Symptoms.—1. Acne  simplex chiefly affects young people
about the age of puberty.  It appears on the sides of the face,
or on the forehead;  and  is  often seen  on young girls at the
time of the first appearance of the  menses.  Young and robust
individuals,  in the  enjoyment of perfect health,  are  often
affected  with this  variety, covering  more or  less of the
shoulders and upper part  of  the  chest.  The pustules ordi-
narily  appear one after another in the form of small inflamed
spots,  which  soon  become pustular,  their base  being sur-
rounded with a red areola.   They  pursue their course singly,
without  any  general symptoms, and usually without pain or
local irritation.   Indeed, an eruption  of considerable extent 
166
DISEASES OF THE  SKIN.
frequently exists on the back of the patient without his being
aware of it.  When the disease appears on  the  forehead in
young girls, the pustules are developed simultaneously and in
variable number; the face is  sometimes covered over with
them.  In  general, when there are many present, the skin
appears oily and shining, and  suppuration takes place about
the eighth day.   The pus is  formed in  small quantity, and
produces very thin  scales, which soon fall off, and are often
scarcely perceptible.  In other instances, the suppuration  is
more abundant, especially when the disease is  seated  on the
back, and thick scabs form, which  are soon rubbed off  by the
friction of the clothes.   Even  when the pustules are set close
together, they never  form those  broad, thick incrustations
sometimes  seen in  sycosis.   A  slightly-elevated  red spot
remains after the fall of the scab, which gradually disappears.
In some  instances  the  redness  and tumefaction continues ;
and, if other pustules are developed  at the same time, the
disease may present all  the characters  of acne indurata. The
pustules  of acne simplex are often intermingled with small,
prominent, blackish  points,  formed by the sebaceous  matter
in the follicles ;  hence the name acne punctata.
   2. In acne indurata the inflammation extends through the
follicles.   Suppuration proceeds more slowly, and slight indu-
rations of  the  subcutaneous  cellular tissue, of more or less
extent,  are formed  by the union of  four  or  five inflamed
follicles.   These tumors  are  sometimes as large  as a filbert.
This variety generally appears on the face, but it is  also often
met with on the back, and we  have frequently seen it  at the
hospita] of St.  Louis occupying the whole of the posterior
part of the body.  It often appears in this  region in young
men.  Sometimes  it appears in  robust and  healthy indi-
viduals;  in other instances, in boys addicted to onanism, and
also in persons  subject to irritation of the bowels.  Individuals
whose business  compels  them to remain long in a stooping posi-
tion, and who are  much exposed to  heat, are very subject to
this variety  of acne.   It may assume a mild character,  in
which event a few inflammatory points appear on the temples
and cheeks; a  pustule  gradually  rises here and there, and
suppuration  is   not  completed for two  or three weeks,  or
longer.  New  pustules  form  and  suppurate  in  the  same
manner as the  first, the bases of which remain red and hard,
and terminate  in  chronic  indurations of the cellular  tissue
beneath.   The  eruption may thus be confined to a limited
extent.
   But in other cases  it is much  more intense, and the fea-
tures are greatly distorted.   The  face is then studded with 
ACNE.                       167
livid red  indurated  tumors ; they are most numerous along
the margin of the lower jaw, on the temples, on  the side of
the  face  and  nose.  A  number of pustules  are scattered
between these indurations, and also over other parts of  the
face.  Red patches and slight scabs are sometimes met with.
The skin covering the face is red all over, but this redness is
greater on some parts than on others.
   Instead of these symptoms, however, a multitude of black
points often appear on the nose,  the cheeks, and in the inter-
vals between the pustules  and the indurated  tumors.  The
skin is then  shining and unctuous, the cellular tissue is hyper-
trophied,  and  the  deformity  extreme.   Nevertheless,  the
patient's general health is not impaired;  he merely complains
occasionally of headache  and an unpleasant itching about the
face.  When  this variety is confined to  the back, it may
assume a mild character, or else be attended with all  the
symptoms just mentioned, with the exception of those of  the
face.  The duration of the eruption is  in this case also very
protracted.   It disappears very slowly, and is liable to return
again   The pustules of acne indurata frequently leave nume-
rous indelible oblong cicatrices, crowded together on the back,
as if produced by repeated eruptions.
   3. Acne rosacea  differs  from  the  preceding  variety  in
appearing generally in persons  of advanced years, and being
accompanied with a certain degree of erythematic redness of
the face.
   It frequently occurs  in females at the critical period,  in
drunkards, bon-vivants, and in studious persons; also in indi-
viduals subject to haemorrhoids;  and it often  results  from
hereditary predisposition.   In the latter event we often find,
after exposure to  the  heat of the  sun, or from excess in diet,
or  violent  exercise,  a number of irregularly circumscribed
red spots on the face, sometimes confined to the  cheeks, some-
times extending over the whole of that region, which gives it
a  very peculiar appearance.  The deep-red color, however,
is  evanescent.  Several scattered pustules are developed  at
the same time.
   In elderly people, the nose is the most frequent seat of this
affection.   Its  point  assumes  a  violet-red color, after the
slightest excess in diet, or often after a  moderate and simple
meal.  By and  by this redness becomes habitual, and imparts
a very peculiar expression to the countenance.   Pustules form
here and there, but  suppuration does not take place, or else
it is very incomplete, and  the redness is deeper in the neigh-
borhood of the  pustules.   The disease is sometimes confined
to  the nose, which, in the course of a short time, acquires 
168
DISEASES OF THE SKIN.
considerable  size.  The veins become  varicose, and form
bluish irregular lines, which contrast with the intense red  or
violet color of the diseased surfaces.  The appearance of the
nose, however, is more frequently altered than its size.   The
eruption spreads to the jaws, the forehead, the chin, &c.  The
red color is not equally bright in  all parts; it is most strongly
marked in the neighborhood of the  pustules.   Suppuration is
always slow and incomplete, more or less induration remains,
and  the skin continues injected.   When the disease continues
for some time, the tegumentary covering of the face becomes
rough and coarse ; and even when it subsides, the parts seldom
or never resume their natural  condition.
   Acne rosacea is very often connected with some  chronic
gastro-intestinal affection,  or  with  disease of the liver, &c.
The redness  is more evident in the evening  and  after dinner
than at any other period.   Finally,  the disease may disappear
and  return, in the same individual, with various degrees of
intensity.  The pustules are very numerous, and the yellow
color of their apices contrasts strongly with  the violet hue of
the  surrounding skin.  The features are in  all cases altered
considerably,  and the appearance of the patient is often very
repulsive.  In addition to the causes already mentioned, men-
tal excitement, cold drinks, irritating local  applications, cos-
metics, and everything that tends to produce a determination
of blood to the head, will produce this disease in  persons pre-
disposed to it.
   Acne sebacea, first described by Biett, is a purely follicular
disease, in which the surrounding skin is scarcely ever invol-
ved.  The face is the principal  seat of this affection, but it
may extend to the whole tegumentary envelope.  When the
follicular inflammation is  confined to a limited  surface, the
skin does not lose its natural color, but is  greasy and unc-
tuous  in the neighborhood of the eruption.   The local irri-
tation, however, soon increases, as  also the morbid secretion,
which becomes effused on  the skin, and forms a sort of squa-
mous incrustation of various extent.
   During the first few days this scaly formation is soft, slightly
adherent, and may  be  easily raised;  but  it  soon  acquires
greater  consistence, and  cannot be detached  without pro-
ducing a certain degree of pain.  The  skin beneath  is red
and irritable, and the follicular ducts examined with a glass,
appear dilated, and   sometimes obstructed,  by the thickened
sebaceous  matter.   The crust is occasionally detached spon-
taneously,  especially in summer, when  the  skin is moistened
with a free and  copious perspiration.  In other instances it
remains firmly adherent  for months;  particularly  when  it 
ACNE.
169
        appears on the nose.  After a certain period the incrustations
        become black, and present a very singular appearance, which
        may explain the mistakes that have been committed  with
        regard to the nature of this affection.
           The  follicular inflammation  rarely ever  extends  to the
        cutaneous tissue.  Even  in its  most severe form we never
        find any of those elementary lesions already described.  How-
        ever, it may become so intense as to alter the appearance of
        the  sebaceous matter to that  of the  sero-purulent fluid of
        eczema.   We  have seen, in M. Biett's wards, several patients
        with  these incrustations on the forehead, having a very  close
        resemblance to  those of eczema impetiginodes.  The   skin
        evidently presented the same appearance as it does in simple
        inflammation of the follicles.
           The  duration of this  disease is  very variable;  we  have
        occasionally observed it decline in the course of a few weeks,
        and we have also  seen it continue for years*.   It occurs  most
        frequently during the periods  of adolescence  and puberty;
        never in infancy  or  old age.   Persons of a sanguineous or
        lymphatic temperament appear to be more predisposed to  it
        than  others; or, at least, it is never seen except in persons of
        a fine, delicate, white, unctuous skin.  It frequently appears
       . in young women immediately after child-bed.  M. Biett had
        a patient under his  care for a  considerable time, a country-
        woman, aged 28, in whom the follicles of the entire skin  were
        inflamed. The eruption terminated in thick, permanent incrus-
        tations.   This patient was suffering at the same time  from
        general articular rheumatism.
           In  some cases, certain conditions of the atmosphere  may
        contribute towards the development of follicular inflammation.
        Thus, for example, M. Biett relates the case of a merchant of
        Nantes, a patient of his own,  whose face  became  rapidly
t       inflamed  after exposure to a sharp north wind for  several
        hours.  The face  was tense  and swollen for two days; the
        skin  then became bathed with  an abundant oily secretion,
        which was soon changed into thick brownish adherent crusts,
        covering the whole of the upper part of the face  like a mask.
        How far this  variety is  influenced by food  is not yet ascer-
        tained.
           Diagnosis.—The diagnosis of acne is rarely difficult.   The
        pustules of ecthyma, and the tubercles of syphilis, have  been
        sometimes confounded with this eruption;  but the pustules of
        acne are small, slowly developed, and are seated on a hard base,
        whilst those of ecthyma are large, superficial, never accom-
        panied  with  chronic  indurations,  and  terminate  in  thick,
        elevated scabs.  The peculiar appearance of the syphilitic pus- 
170
DISEASES OF THE  SKIN.
tules, which are surrounded with a copper-colored areola, and
the broad, flat, and shining tubercles, deeply tinted with  the
same  color, will suffice to distinguish syphilis from  acne;  in
addition to which we  have the  accompanying symptoms of
that disease.  Besides, the syphilitic  tubercles are invariably
ulcerated at the  summit, especially about the alas of the nose
and the commissures of the lips; and, moreover, the pharynx
and soft palate generally present additional unequivocal symp-
toms.   The cicatrices of acne  indurata are  oblong,  whilst
those of syphilis are small, round, and depressed.  The former
are also  covered with swollen  follicles, and the skin  around
them has an oily appearance.
  During the early stage of lupus, when  a few  scattered
tubercles only appear  on the  cheeks and nose,  there may  be
some  difficulty in distinguishing that disease from acne;  but
pustules never appear in  the former disease, which invariably
commences with tubercles.  They are never surrounded with
that erythematic  hue which always accompanies acne when
confined  to  those parts.  They are larger, flattened, and of a
rosy-red  color, and are followed and accompanied with de-
squamation, and a certain degree of puffiness  of the subcu-
taneous cellular tissue.
  Acne sebacea  has  sometimes been confounded with noli
me tangere by careless observers, and cauterization  and exci-
sion have even been  proposed for its cure.   We have seen
two cases in which the  patients were in the greatest alarm
from this serious error, and the disease terminated favorably,
in  the course of a few  weeks,  with the simplest  remedies.
When the inflamed follicles are  numerous and diffused over
a large surface, and the sebaceous incrustations are  at the
same  time  firm, thick, of a dark color, and in the form of
imbricated scales, the disease may be confounded with some
forms  of ichthyosis;   however,  this mistake  can  be  easily
avoided  by bearing in  mind that  the scales  of the latter
disease are deeply implanted by one  of their edges in the skin,
that they are dry and very adherent, and cannot be detached
without being torn, which is  never the case with the  incrus-
tations of acne.  It is necessary to recollect  these distinc-
tions, as mistakes of this kind have occurred more than once.
  Prognosis.—The  prognosis  will  vary according  to  the
variety of the disease present.  Acne simplex, for example,
is a mild affection, and  never  continues long.  It  generally
disappears  as the period of manhood approaches.  Acne indu-
rata is much more troublesome,  especially when the eruption
is diffused  and intense.  It  often  resists  every method of
treatment.   Finally, acne rosacea is very rebellious  and  is 
ACNE.
171
often incurable.   The prognosis should be  further guided  by
the length of time the eruption has existed, and by the  age
and constitution of the patient.
   Treatment.—The treatment of acne varies, not only accor-
ding to the variety of the eruption that exists, but  according
to the constitution of the patient and the causes and duration
of the disease.
   Acne  simplex requires scarcely any treatment  when  the
pustules are few; but, if the eruption is  extensive, both local
and  general measures will be required.  The diet  should be
restricted.   The  patient should abstain from  wine,  spirits,
and  coffee;  and take in  their stead whey, or an infusion of
succory.*   If the patient is young and vigorous, bleeding may
be necessary, especially when the disease affects young females
at the first appearance of the menses; and even then it  will
be useful to  promote this discharge by local baths, the appli-
cation of leeches to  the  upper and  inner part of each  thigh,
or by directing warm vapor  to the external  organs of genera-
tion.   Emollient applications, as an emulsion of bitter almonds,
a  decoction  of bran or of quince seeds, and tepid milk, will be
found very serviceable.   When the chronic indurations remain
after this  treatment, they must be combated by other mea-
sures,  which will be  noticed  in the following paragraph.
   Acne  indurata generally  requires both  local and general
bleeding, even if the patient is not strong or vigorous.  It
should be repeated several times if necessary; and at the same
time the diet should  be  restricted, and refreshing drinks pre-
scribed, f  Active measures  are now required to hasten the
resolution of the tubercles, and  to convert the  eruption from
a  chronic  into an acute form.   Lotions containing distilled
rose water, with a little sage  and lavender,  and  alcohol in the
proportion of a third, a  fourth,  and even a  half, according to
the state of the  eruption, may also be employed with advan-
tage.  Five  or six grains of corrosive sublimate in half a pint
of distilled  water,  with an  ounce of  rectified  spirit, form
another useful lotion in this variety of acne.   Gowland's lotion,
which is nearly the same as  this remedy, with the exception
of an emulsion  of bitter  almonds, which the former contains,
is  also very  serviceable.

  [* If the root of the common succory is cut into small  pieces, dried,  and
roasted, it resembles coffee, and  is sometimes a good substitute for it.  It allays
heat and irritation.]
  t Our authors have subsequently so far modified  their opinion respecting the
abstraction of blood in acne indurata as to say that either general or local bleed-
ing is often necessary, but say nothing of its repetition.  We suspect that general
bleeding is rarely required in this form  of disease.  The application of leeches may
sometimes do  good.                                      H. D. B. 
172
DISEASES OF THE SKIN.
  Frictions on the pustules and indurated parts, with an oint-
ment composed of from a scruple to a drachm of the proto-
chloruret  of mercury  to an ounce  of lard, is also frequently
attended with success.  But  by far the best remedy to pro-
mote the resolution of the induration is the iodide of sulphur,
in the proportion of  fifteen to twenty-four grains to an ounce
of lard.  We have seen this remedy attended with the greatest
success in  M. Biett's  wards, and  have had severe cases of
acne indurata under our own care, in which frictions with the
iodide of sulphur had the  most surprising effect in dispelling
the  tumors.  Baths,  and especially the vapor douche, applied
to the face for ten  or twelve minutes, are useful adjuvants,
and  if  administered judiciously, will obviate the  necessity
of having  recourse  to  cauterization, either with the nitrate
of silver or with hydrochloric  acid.   Moreover,  it  is very
difficult to confine the application  of the caustic to the
exact spot  for which it  is intended;  and if it penetrates too
deeply,  it  will produce painful ulcerations, and often deep
cicatrices.
  When the  eruption  is confined within a narrow compass,
the  successive application of blisters may  be advantageously
had recourse to, with the view of altering  the vitality of the
skin.  We have seen at the Hospital of St. Louis this method
attended with the greatest success.   If new eruptions super-
vene  during the treatment, and if there is great  tendency to
cerebral congestion,  repeated  bleedings and aperients should
be prescribed  according to circumstances.  The latter ought
to be suspended when there is much inflammation,  when the
indurations are painful, and  the pustules numerous.  On the
other hand, they should  be continued when the tubercles are
hard, indolent, and of large size.
  Drastic purgatives should be carefully avoided, as  being not
only useless, but frequently injurious.  Mild laxatives may, in
some cases, assist the operation of the  other  remedies, espe-
cially when the patient  is strong, the intestinal canal healthy,
and when there is a  decided  tendency of blood to the head.*
Sulphureous waters, administered  both  internally and exter-
nally, are often very useful.   They  do  not seem to produce
much beneficial  effect when mixed in  the baths.   Simple
baths, at a temperature of 88° or 90°  Fahr., are more effectual.
The patient should  take two or three every week.   The cold
sulphur douche has  been employed with success by M. Biett,

  *  In their  last edition, our  authors say that purgatives, and more particularly
laxatives, are useful auxiliaries in a great many cases.             H. D. B. 
ACNE.
173
when the eruption  disappears, .especially if it  was  accompa-
nied with the small black points before mentioned.
  Acne  rosacea requires a somewhat different plan of treat-
ment from that of the other varieties.   In this case the bleed-
ing  should  be  local, and  not general, in  the   majority of
instances.  As, for example, leeches ought to be applied in
the  neighborhood  of the disease, behind the ears, to the alas
of the nose, &c.; but when females are affected at the first
menstrual period,  the abstraction  of blood will   be  attended
with benefit.   This variety is very rebellious, and the topical
applications so  useful in acne indurata,  are  almost  useless^
they even become  injurious in  this form of the disease.  The
treatment of  acne  rosacea consists for  the most  part in
hygienic measures.  The  patient  should  avoid  excesses of
every kind ; he should lead  a  sober and regular life,  and live
on   light food, fresh  vegetables,  succulent  fruit,  &c.   He
should also avoid fatiguing exercise, both  of mind and body,
mental excitement, and  remaining long  in  heated apartments.
Immersion of the limbs  in warm water, containing two ounces
of nitro-muriatic  acid  to  eight or ten quarts of water, is a
useful auxiliary.   When the tubercles are  indolent, the vapor
bath should be applied to the face, and at the same time gentle
friction  or discutient lotions may be employed.
  Acne  sebacea can easily  be overcome when  the eruption is
limited.   M.  Biett has often seen follicular inflammation give
way in  a very few  weeks to the  vapor  douche, applied for
fifteen or  twenty  minutes  each time  to  the diseased parts.
The incrustations  speedily  soften,  and are  easily  detached.
Those which  reappear  are in general  thinner, less firm, and
often fall off spontaneously.   Narcotic lotions, rendered styptic
after a short time by the addition of alum  or of some vegeta-
ble acid, will contribute to hasten the cure.*

  * The state of the digestive  organs requires particular attention  in all of the
first three  forms of acne,  as does also the state of  the menstrual function in
females.
  Laxatives and alkalies, with regulated diet and the warm bath, will frequently
do much towards palliating, if not entirely relieving, the form of acne simplex,
which is often so annoying to  the young of both sexes.  A combination of rhu-
barb, soda, and ipecac, in small doses two or three times a day,  may be used for
this  purpose;  to which may sometimes be added with advantage half a grain
or more of quinine at a dose—and in some cases aloes may be substituted for
the rhubarb.  Sometimes blue pill or a small proportion of calomel may form
part of a pill which may be substituted for this at bedtime, two  or three times a
week.
  Dr. A. T. Thompson was partial to a combination of sulphate of zinc and liquor
potassae, 24 grains of the former to 3 xij of the latter, of which  thirty drops are
to be taken twice daily, in a wine glass of water, the bowels being regulated at
the same time.
  Dr. Naligan recommends as  the best preventive treatment in acne simplex,
                              12 
174
DISEASES OF  THE SKIN.
                  MENTAGRA, OR  SYCOSIS.

Syn.—Varus   mentagra;   Mentagra;   Dartre  pustuleuse;
                              Chin welk.

Mentagra  is characterized  by successive  eruptions of  small
acuminated  pustules, closely resembling those  of  acne,  scat-
tered upon the chin, and other parts occupied by the beard, the

vnashing the  face with carbonate of soda instead  of soap, and the application,
immediately after the face is washed, of a lotion, consisting of  3 ij  oil  of lemon
and  3 ss oil  of rosemary in a pint  of rectified spirit.   He says that the pustules
should be opened as soon as formed, and the curdy matter pressed out.   {Dublin
Quarterly Journal, May,' 1851.)
  M. Campardon says {Rev. Med. Chir. de Paris,  Avr , 1847)  that the  cure  is
remarkably promoted in  this form of acne by anointing  the affected parts every
evening before retiring with an  ointment of hydriodate of potash,  and habitually
using as a wash for the  toilet, lime water diluted one fourth.
  In A. rosacea, Alibert thought very highly  of sulphur, both internally  and
externally. I have derived  benefit  from  the  use of sulphuret  of potash in  this
form, as well  as in  A. simplex.   It may be given in pills, combined with quinine
and  ipecac, and sometimes with aloes, or rhubarb  and  ipecac,  or in solution with
rhubarb and ipecac, or the fluid extracts of taraxacum, or of rumex acutus, or of
sarsapariila.  It is in this form  of the disease  that  the  alterative effects of mer-
cury sometimes  produce a very favorable change ;  but, unfortunately, this improve-
ment is too often only temporary.   But little can be expected in  a certain class  of
cases without an entire change  in the habits of the patient, and they  are generally
of a nature which renders such a change almost hopeless.
  Dr. Neligan advises the application of leeches behind the ears two or three times
a week, at bedtime, in acne rosacea, when there  is much inflammation  present,
and  the daily use of some mild saline cathartic mineral water, an  hour or  two
before breakfast.  When the inflammation is subdued, if it exists, he commences
the use of iodide of potassium in decoction of elm bark, adding, in very obstinate
cases, an eighth of a grain of iodine  to each  dose.  Locally, he applies at night
an ointment of white precipitate, twelve grains to § j  spermaceti cerate, with  three
minims of oil of bitter  almonds,  and has it  washed off in  the morning with a
lotion  of carbonate of soda (3 ss to § viij of water).  When the ?kin of the face
is hard and dry, and inclined to crack and bleed, he adds  to this wash 3 ij to §  ss of
glycerine.  The diet  must be  carefully attended  to, and exposure  of the face to
fire  or harsh  winds avoided.  {Dublin Quarterly Journal, May,  1851, p. 330.)
   M. Campardon says that there is in this form of acne  a producing cause, which
must be destroyed to prevent relapses, and when all the functions  are restored  to
their natural  state, he recommends to give, every day fasting,  one tenth of a grain
of tartar  emetic, mixed  with  two  or  three grains of the powder of dulcamara,
which, he says, even in this small dose, acts very decidedly on the face.  The face
to be washed several times a day with diluted lime-water, and compresses wet  with
this kept on the affected parts, cold in summer and  warm  in  winter.  Sometimes
he substitutes Gowland's wash for this.  When  the redness of the skin begins to
decline, he uses ointments of iodide of potassium and  of iodide  of lead.   {Op.
 Cit.)
   Dr. Neligan considers acne indurata as " in nearly every instance  apparently an
 aggravated form of acne rosacea," and  recommends the same general plan of
 treatment, using an ointment  of  iodide of sulphur (grains xv to 3ss to 3jj lard),
 preceded  by the alkaline wash  before each application of the ointment.   {Op.  Cit.)
   M.  Campardon  says that the application every  night to the  tubercles of an  oint-
 ment of chloride of silver (twelve to fifteen  grs.  to "% ss of lard and 3 ij of white 
                     MENTAGRA,  OR  SYCOSIS.                  175


submaxillary region, and the lateral parts of the face.  Mentagra
is  an essentially  pustular affection.   It  has, however, been
mistaken by Willan,  Bateman, and  Plumbe, who  supposed
that tubercles were  the elements  of  the  disease, whilst  they
are merely consecutive, and do not  exist  in all cases;  and
moreover  the eruption  is pustular  from  its earliest appear-
ance.
   Symptoms.—Sycosis  most  frequently  occurs   in   adults,
sometimes in persons of advanced age.   It  is generally  pre-
ceded for several  months, or even  for years, by minor erup-
tions on the upper lip, on the chin,  or submaxillary region,
which  quickly  disappear.   The  pustules  shrink,  and  are
speedily replaced by  thin  scabs, which dry  and  fall off in  a
few days.   At a more advanced period, the eruption becomes
more abundant, and  then  it first  attracts the patient's atten-
tion.   It often appears immediately after a debauch.
   The  pustular eruption is generally preceded by redness,
heat, and  a painful degree of tension about the chin.   Small
red points soon make their appearance, which become pustu-
lar between the first and third days.   The pustules are acumi-
nated and usually  distinct; but when they are numerous  and


wax), hastens their resolution in  a remarkable manner.   He gives at  the same
time depurative decoctions of different kinds.
  M.  Cazenave recommends in his clinical  lectures at St. Louis Hospital {Gaz.
des Hop., Oct., 1850), ammoniacal lotions, the action of which, he says, is prin-
cipally chemical, by their alkaline properties forming with the fatty matter con-
tained in the follicles a  soluble soap with an  ammoniacal base.   The forms of
ammonia which he uses  are the hydrochlorate and the acetate, the strength of  the
solution of which he varies very much, adapting it to the state of the eruption and
the irritability of the skin in different cases.   Our authors also say, in the last edi-
tion  of their work,  that they have met with the most constant success from  the
continued use of weak solutions of ammonia.  He also continues to speak favora-
bly of the use of sulphur baths.
  I have  used with good success in acne indurata the dilute nitric acid with a bit-
ter  tincture, in the following manner:—$. Acid. nitr. dilut. Sj;j;   tine, gentian
comp. § iv.  M.  A teaspoonful  to be taken three times daily, freely diluted with
water, and in a way not to injure the teeth.
  Lotions of sulphur, as of a solution of sulphuret of potash (3j or 3 ij to  a pint
of water) have been found beneficial in acne sebacea.   The following is a pleasant
and efficacious lotion in that as well as in some other varieties of acne:— B;. Sul-
phuret potass., zinci sulphat. aa. 3j; aq. rosar. § iv. M.: the strength of which may
be increased or diminished to suit  the particular case.
  Local applications must be varied to suit the form of the disease, and its stage,
and the irritability of the skin in individual cases.  The free and continued use of
emollient lotions is grateful and beneficial in all the forms.  Astringent, sedative,
alkaline, and sulphureous lotions of varied degrees of strength, all have their advo-
cates, and all do good in  certain cases, and can sometimes be alternated with
advantage.  Copland {Diet. Pract. Med.) praises very highly as a wash  a  solu-
tion of bi-borate of soda, in an emollient decoction.   Iodide of sulphure ointment
is very valuable for the removal  of the indurations in A. indurata, and is also
useful in modifying the state of the skin in the other forms, for which latter purpose
creasote ointment is also useful in  some cases.                    H. D. B. 
176               DISEASES OF THE SKIN.

grouped together,  the upper lip and a great portion  of the
chin are covered  with small prominent  tumors, containing
a yellowish fluid, and traversed through the centre by a single
hair.   They remain  in this condition for six or seven days,
giving to the countenance a very peculiar appearance,  and at
length  burst, and  terminate  in slightly-thickened,  brownish
crusts ; but there is never any exudation, as in impetigo. The
scabs fall off imperceptibly, and the disease subsides altogether
in the course of ten  or fifteen days, if a new eruption does
not break out.
   It usually appears  in the form  of successive partial erup-
tions.  The skin becomes inflamed, either in isolated patches,
or over an  extended  surface.   When the eruption is general
and extensive, the subcutaneous cellular tissue, as well as  the
skin, is deeply inflamed. There is considerable heat and pain,
and even the scabs are in some cases  thickened and  matted
in the middle  of the hair.   The  extent of the eruption is
variable; it is  sometimes confined  to  the upper lip,  to one
side  of the  chin, to the side  of the face, or  it may appear at
once in all  these regions.   Frequently a number of pustules
form, and disappear, and are  replaced by others at  different
intervals.   In these  cases the skin is rough, the epidermis is
elevated  in the form of small whitish exfoliations,  in  the
centre  of which new pustules are occasionally developed.
   There  is another  rather peculiar variety of the complaint,
which  appears  in  old people, and  in persons whose  constitu-
tions have  been  deteriorated by  dissipation  or disease,  but
who are apparently strong  and  healthy,  characterized by
chronic tubercular indurations of the skin.  These tumors  are
of variable form  and size.   They are  sometimes almost  as
large as  a cherry.  In other instances, even after the deve-
lopment  of  the  eruption,  the inflammation   continues  to
increase  in intensity, and pustules, scabs, scales, and  tubercles
cover the lower part of the face, which is swollen and puffy.
They appear on every part of the face  where the hair  grows,
and pustules frequently form on those tubercular indurations ;
but  Mr. Plumbe  was not correct in saying that  the latter
contain pus. The  cellular tissue is  sometimes deeply involved,
especially  when the  inflammation is intense.
   When the disease  has continued  for some time,  the bulbs
of the hair  generally become affected, and the beard often
falls off to a considerable extent;  but it generally  reappears
when  the  disease  subsides,  and soon resumes its original
strength and color.  The indurations gradually disappear after
the eruption has ceased. The parts which have been affected
continue of a reddish or violet  color, and  slight  epidermic 
MENTAGRA, OR SYCOSIS.
177
exfoliation often takes place for some time.   The duration of
the disease is very variable.  In some cases it  resists  every
kind of treatment, and continues  for an indefinite length of
time.  It is also very apt to reappear, particularly in persons
fond of good living.
   Causes.—Mentagra chiefly attacks young people of  a san-
guineous and bilious temperament, and those who have much
beard.  It generally appears during spring and  autumn ;  and
persons  who are exposed  to strong  heat,  as  cooks, smiths,
founders, &c, are particularly liable to be attacked.  Women
are rarely ever affected.  The poor, who neglect cleanliness,
and indulge  in excess of different kinds, often  suffer from it.
The better classes, and persons  of cleanly habits, are, how-
ever, also liable to it.   This disease has  been often attributed
to the use of a dirty razor,  but seemingly without much foun-
dation.  Nevertheless  M.  Foville  has   seen  several of the
inmates  of the lunatic asylum at Rouen attacked successively
with mentagra  after  being shaven with the same razor.  It
is evident that the action of the razor will aggravate  the  irri-
tation of the parts when once the eruption is formed.*
   Diagnosis.—The differential diagnosis of mentagra is very
important.  Various eruptions appear on the chin, which may
be  mistaken  for it; as, for example, ecthyma,  impetigo figu-
rata, and syphilitic tubercles.  In  ecthyma the pustules are
larger,  and  the  bases  more  inflamed  than   in  mentagra.
Ecthyma is  never accompanied with the circumscribed indu-
rations of  the  skin  and   cellular  tissue ; and  its scabs are
broader,  thicker,  and more adherent.   The  pustules of
impetigo figurata are  disposed in  groups, and are but slightly
prominent,  whilst  those of mentagra are distinct  and acu-
minated.   The pustules of impetigo burst about the third or
fourth day, and give issue to a considerable quantity of fluid,
which  is promptly converted,  by desiccation, into  broad,
triick, yellow scabs.   Those  of mentagra burst between the
fifth and seventh  days, and are  succeeded by dark brown,
dry, and thin crusts.  Besides,  the tubercular  indurations  of
mentagra are never observed in impetigo.  These  characters
may be very difficult to recognise when  the eruption  is exten-
sive, the  inflammation severe, and the pustules  more or less

  [* M. Gruby has recently presented a memoir to the Academy of Sciences,
Paris, on a new species of cryptogame, which occupies the roots of the beard, and
forms a species of contagious mentagra. The disease generally occupies the chin,
lips, or cheeks ; the affected parts are covered with greyish  and yellow  scabs,
formed by the epidermic cells, under which is the root of the hair, surrounded com-
pletely by a sheath of cryptogamia  ; the latter are not elevated above the surface
of the epidermis.—B.] 
178
DISEASES OF THE SKIN.
agglomerated. It will then be judicious to suspend our opinion
until the disease is more advanced.
  Syphilitic pustules are distinguished from those of mentagra
by  the  absence of heat,  pain,  and tension.  They are  but
slightly  elevated, are situated on a copper-colored  or  violet
base, and are developed slowly ; while  the  pustules of men-
tagra are acuminated, and rest on a bright red base; besides,
syphilitic pustules rarely occur on the lower part of the face
only, but commonly appear  on the alae of the  nose, on the
forehead, and  at the  commissures of  the  lips.  Syphilitic
tubercles, which appear only to  affect the superficial layers of
the cutis vera, differ from the chronic indurations of menta-
gra, which are conical, and deeply seated in the skin, by their
shining  and  dull coppery color;  besides, there are always
some  local  or  constitutional symptoms present which  will
readily distinguish them.  Sycosis  can  hardly be confounded
with furuncles.
  Prognosis.—Mentagra  never terminates  unfavorably ; but
the physician should always be guarded in giving an opinion
as to when the  disease will disappear, or else he will often be
deceived.  The more  frequent  and successive  the  eruption,
the longer the duration of the complaint.
   Treatment.—The  first  indication in the treatment of men-
tagra is  to remove  the causes which excite the disease; as
for instance, when it  affects intemperate persons,  or  those
who are exposed  to strong heat,  the  patient should  guard
against  these exciting causes.  The razor should not be used
for a certain time, as it increases the irritation, and the  beard
may be  cut  with a pair of scissors.   When the  inflammation
is severe, the application of leeches  behind the ears, or on the
submaxillary region;  and  when  the  patient  is  vigorous,
general  bleeding, together with emollient  fomentations,  and
poultices of potatoe-flour, or crumb of bread, cooling drinks,
and attention to diet, are  the most  useful measures  that  can
be  adopted.  The use of local bloodletting, and especially of
emollients, should not be confined to cases which are strictly
acute;  but these means will often be of great service, even in
chronic  cases,  with induration of the  skin, when there is
inflammation  at  all  active.  Laxatives, as  the  acetate of
potass, calomel, sulphates  of potass,  of soda, and of magnesia,
are beneficial when there  is no  gastro-intestinal   irritation
present.  They should be continued for some time.
   When the disease is  of long  standing, the tubercles  large,
and the cellular tissue involved, we must  have recourse to
friction  with ointments of the  ammoniacal protochloruret of
mercury, or of the deutoxide or subsulphate of mercury.  To 
PORRIGO.
179
these may be added,  with advantage, the vapor bath, or vapor
douche.   We have  frequently seen cases  at the hospital of
St. Louis, in which these remedies had the most  happy effects
in  dispelling  the  tubercular indurations.   If  the eruption
recommences, the  friction  should  be suspended for  a  short
period, if it is abundant; but if only a few pustules appear, it
may be continued.
   Cauterization with nitrate of silver, or the strong acids, is
not  a  desirable  remedial   measure.  It  should  never  be
employed unless in cases where  the  disease  has assumed an
inveterate chronic character.  When all these  remedies  fail,
we have often succeeded with tonics, the preparations of iron
especially.  M. Biett has administered the  muriate of gold in
doses of a one third, and afterwards a  half of  a grain  each,
rubbed  into the tongue, with remarkable  success.   The  mer-
curial  preparations, and particularly Larrey's  syrup,   have
sometimes effected a perfect cure.*


                          PORRIGO.

   Willan and Bateman have confounded several  cutaneous
diseases of different kinds under  this head, and  thereby  have
added  much to the  difficulty of  studying and  distinguishing
the various disorders to which the  scalp is liable.   They  have
described  six varieties :  P.  larvalis, P. furfurans, P.   lupi-
nosa, P. scutulata, P.  decalvans,  and P. favosa, some  con-
tagious and some not, under the title of porriginous eruptions.
Four  of these  are  impetiginous,  or  squamous  affections.


   * The treatment may often be commenced with advantage by the exhibition of
free mercurial cathartics every second or third night for a few times, which may
be followed up for some time by alterative laxatives.
   The vapor of warm water will be  found to  have a soothing effect, even  in the
acute  stage, and  is  particularly serviceable in aiding to remove the indurations
remaining after that stage has passed. In conjunction with  this, and after using it
fifteen to twenty minutes two or three times a day, ointments of iodide of potassium,
or of iodide of lead, or of sulphur, and calomel ointment may be applied. The use
of these must always be discontinued when any irritation is produced.
   The application of a strong solution of nitrate of silver is sometimes productive
of good results, and collodion  will, doubtless, be found useful in  some cases of this
disease, as it is in the analogous disease of acne.  Blisters are recommended by
some writers.                                                 «
   Willis says that the hair whose root is affected must always  be extracted, and
that he has seen more than one case of mentagra yield to few means beyond tepid
bathing, and the extraction of loose and dead hairs, which h«l long resisted consti-
tutional means of every kind.
   The internal use of iodide of potassium or of iron, will abo often materially aid
in the removal of the indurations, especially in patients of strumous diathesis.
                                                       H. D. B. 
180
DISEASES OF THE  SKIN.
 Their porrigo favosa is a variety of impetigo ; and the same
 is true of their P. larvalis.  Their P. furfurans is, in some
 cases, a pityriasis  capitis,  and in other  cases a  chronic
 eczema, the thin scabs of  which are  formed by the drying up
 of  a fluid which slowly exudes  from the scalp : and their
 P. decalvans is a partial  alopcscia, which is often a sequel of
 different forms of disease.   P. scutulata, or  ring-worm,  and
 P. favosa, the P. lupinosa of  Willan, are different from all
 the  others, as M. Biett first pointed out,  by their peculiarly-
 formed pustules,  and their  contagious  nature.  They  are
 essentially fundamental diseases, and  the whole of the porri-
 ginous eruptions of Willan may be  reduced to these two, P.
favosa and P. scutulata.
   The  elementary lesions of this order are favous pustules,
 which exclusively belong to it.  They are small,  perfectly
 rounded, and imbedded in  the epidermis ; they contain yellow-
 ish straw-colored matter,  which soon  concretes, presenting a
 depression at  the  centre, which may be  detected in  the
 nascent  pustule with the aid of a magnifying glass.  In the
 course of a few  days, this  yellow matter is converted  into
 thickish   cellular  slightly prominent  scabs,  which  go on
 increasing for  some time, and which are  sometimes pitted or
 umbilicated  in the centre, and at other times lose this charac-
 ter,  and are of a greyish  yellow color, thick, and often very
 hard.
   These diseases are therefore distinguished from all others
 by an eruption of favous and contagious pustules, generally
 developed on the  hairy scalp, but which may appear on other
 parts of the body.  Children  are more  subject to them than
 adults; but  they often appear in full-grown persons, and are
 generally the result of some  peculiar disordered condition *of
 the economy.   They are sometimes produced by uncleanli-
 ness, poverty,  bad  nourishment,  and intense grief.  They
 may also be  propagated by contagion.   The  seat  of  the
 favous pustules has  been alleged by many  dermatologists to
 reside in the corps   reticulaire.  Duncan places it  in  the
 bulbs of the hair, in consequence of the latter being so easily
 removed when the pustules are new.   Still, it is evident that
 the bulb is only secondarily affected ; and  the true seat of the
 favous pustules appears to be at the extremity of the piliferous
 duct.  We  shall now describe  these   two  varieties  indivi-
 dually. 
PORRIGO FAVOSA.                  181
                  PORRIGO  FAVOSA.

  Syn.—Tinea; Favus; Porrigo lupinosa ; Tinea favosa;
                       Tinea rugosa.
   This is the most frequent variety, and is characterized by
an eruption of very small, flat, deep-seated  umbilicated pus-
tules, which soon concrete, and form small, bright yellow and
very adherent scabs, which retain the umbilicated appearance
of the pustules.  The scabs gradually increase, always pre-
serving the depression in the centre, unless they coexist with
other incrustations, when the disease is not so easily detected;
and they are highly contagious.
   The  hairy  scalp is the  special seat of this affection, but it
may appear on the forehead, the temples, the chin, and eye-
• brows.   It generally  begins on the scalp, and spreads thence
to  the  other mentioned parts.   We have frequently seen it,
at the Hospital of St. Louis, on the shoulders, on the  scapulae,
on the elbows, forearm, and on the knees, the upper part of
the  legs, thighs, and  on the scrotum.   It sometimes appears
on the back and abdomen, and  on the  hands, in which latter
instance it is generally the result of contagion.
   Symptoms.—Porrigo favosa commences with an eruption of
extremely  small yellow pustules, hardly  perceptible  the first
day, looking  like small yellow  points ; they  are always on a
level with the skin, and seem  to be set or imbedded in  the
epidermis.   They  are scarcely formed when the yellowish
fluid begins to concrete, and a slight  depression appears in
the  centre, which gradually increases,  and  is very distinct
about the fifth or sixth day.   The  pustules are generally dis-
tinct at the beginning ; sometimes, however, they are clustered
together, and become confluent, forming  a continuous scabby
surface,  of some extent.  Their appearance is always accom-
panied  with  smart itching.   When distinct, they are usually
seated on  an elevated and  slightly inflamed base, and each
pustule is generally  traversed  by  a single hair.  The scabs
slowly  increase,  preserving their  circular form,   and   the
central depression, which becomes more and more  marked;
they thus reach the extent of several lines,  and M. Biett has
seen them more than  an inch in diameter.
   When the pustules are set close  together, they often unite,
and form large incrustations on the surface  ; and the honey-
comb depressions corresponding to the  primitive pustules,  are
easily  distinguished.  Sometimes the whole head is covered
with a kind  of scabby cap; again, some detached  pustules 
182
DISEASES OF THE  SKIN.
appear here and  there, terminating  in  slight  desquamation.
If the scabs are removed at this period by means of poultices
or any kind of washes, slight erosions are seen beneath, which
do not become covered with new crusts ; for the formation of
these, new pustules are necessary.  When the disease is left
to itself, the scabs  continue  for months and  years;  they
become thick, whitish, and brittle, and split in various direc-
tions.  It often happens, that while  they are thus disappear-
ing from  one part, new pustules are forming in other places,
which pursue the same  course.   The  hair of the  affected
parts may be easily  pulled out by the  roots from  the  com-
mencement  of the disease.  If it is, however, of long stand-
ing, the hair falls off  spontaneously, and leaves behind  bald,
smooth, shining patches.  When the hair grows again,  it
is generally thin,  woolly, weaker, and of a lighter color than
the original.
   This affection  is never  accompanied by febrile symptoms,
but a  troublesome and  annoying itching is  often  present
during its progress, which is aggravated  by want of  cleanli-
ness.   A number of lice are often seen under the scabs, caus-
ing the patients to scratch themselves, and by this  means in-
crease  the inflammation.  In  these cases there is a strong
disagreeable odor, similar to that of cat's urine, given off from
the head.  After the head is cleansed from the scabs, the odor
becomes sickening.   The  excoriations on the surface, which
often reach to the hair-bulbs and thus produce baldness, are
not covered with the  regular cup-shaped favous pustules, but
a reddish and fetid  sanies oozes out,  which  concretes into
irregularly-shaped  scabs.   Fresh pustules,  however,  soon
appear, which give rise to fresh favous  scabs.  Small subcu-
taneous abscesses may sometimes appear, accompanied Vvith
sympathetic engorgement of the lymphatic glands of the  neck.
It is rarely complicated with internal organic disease.   It has
been remarked, that  the growth  of those persons who have
been affected with porrigo is often arrested, and  the develop-
ment of the mental as well as of the physical powers, is slow
and imperfect.   The  duration of  the disease is very variable
and uncertain; and  the hair, when reproduced, is  rarely the
same as the original, either in color or consistence.
   Causes.—Porrigo is  an essentially contagious disease.  In
some instances, however,  it is impossible to  transmit  it by
contagion.  It  appears  at  every season of  the   year, and
attacks  both  sexes  and  all ages;  but children and young
persons  much the  most frequently.  Individuals  of a soft,
lymphatic, and scrofulous  constitution,  are eminently predis-
posed to it, although it sometimes occurs in healthy and vigor- 
PORRIGO FAVOSA.
183
ous subjects.   The other exciting causes have been described
in the general observations at the head of this chapter.
  Diagnosis.—The peculiar appearance of the pustules and
incrustations of porrigo favosa will prevent it from  being con-
founded with any other pustular eruption of the scalp.  When
the scabs are in abundance, they are  of a yellowish white
color, dry, and sometimes crumble into powder.  The disease
then resembles impetigo  granulata;  but there are  always
some favous pustules present, which will clear up the diag-
nosis, and the hair invariably falls off in the former affection,
a  circumstance which never  occurs  in impetigo  granulata.
It has been mistaken for other diseases; and we have seen it,
when extensively diffused, confounded even with  lepra ; but
the  most superficial acquaintance  with the  characters of
favus would have prevented  any mistake of this kind.
   Prognosis.—The prognosis of this affection  is unfavorable
with  regard to  its duration, which  is often prolonged for a
considerable period  by the development of  new eruptions as
soon as the original have disappeared, and also  on  account of
the baldness which it occasions.
   Treatment.—The treatment of porrigo favosa is altogether
local, although in some cases it may be necessary to recruit
the patient's  strength with bitters, tonics, &c,  and  to ad-
minister a few mild laxatives.
   The first step to be taken is to cleanse the  scalp thoroughly,
to clip the hairs close with a  pair of scissors, or to shave them
off, and to remove the incrustations by the  frequent applica-
tion of tepid emollient fomentations, which may be alternated
with  soap  washes.  These  measures,  simple  as  they may
appear,  are highly efficacious in  the treatment of  favus, and
many cures which have been attributed to other remedies,
belong in reality to them.  They are not alone, however, in
general sufficient to remove  the disease.  Recourse  must be
had to  more energetic  measures, with the  view  of altering
the condition  or vitality of the skin from disease  to health.
The presence of  the hair does not seem to be so injurious as
some  writers allege; nor is the disease arrested as soon as it
is removed.    On the contrary, the scabs continue  frequently
for years  on parts devoid of hair:  neither is the  removal of
the hair from the diseased  parts with a pair of small forceps
so painful an operation as some people suppose; for the skin
about the  roots is soft  and  tumid, and the  hair is easily
detached.   Alkaline  preparations are  very  advantageous in
these cases; they modify the condition of the skin as well as
promote the removal of the hair.
  In addition  to the foregoing remedies, alkaline and sulphur 
184               DISEASES OF  THE SKIN.
ointments, and acidulated lotions, will be found to be the most
effectual measures  that  we can employ in porrigo favosa.
The alkaline preparation should vary according to the cir-
cumstances of the case ;  for example, when it is desirable to
remove the  hair at once, and at the same  time  to  stimulate
the scalp, the subcarbonate of potass or soda, in the propor-
tion of one  or two drachms to an ounce  of lard, should be
rubbed over the diseased parts for five or ten minutes every
day.  Alkaline lotions in the proportion of two drachms of
the alkali to a pint of water may be used at the same time.
After a certain period, the hair will begin  to fall off.  Before
having recourse to these  remedies the hair should be cut, the
incrustations removed as much  as  possible, and the scalp
cleansed in the manner already directed.
   We have  often employed the sulphuret of potass, in the
proportion of one or two drachms to a pint of distilled water,
at the hospital of St. Louis, with much  advantage, and also
Barlow's lotion.  The chloride  of  lime has been frequently
used  with  success  in these  cases.  Mild  sulphur  douches
repeated every day, will fulfil the object in view still better.
Great patience is necessary during the treatment,  and care
should be  taken that these measures are followed out exactly.
Dilute nitric  and muriatic acids have in some cases  been
employed  with success, but these may be  advantageously
replaced by a lotion composed of one drachm of dilute sul-
phuric acid to a pint of distilled water.
   Solutions of sulphate  of  zinc, of copper, of the  nitrate of
silver, or of the deuto-chloruret of mercury, have been some-
times used with much benefit, to which may be added two or
three ounces of alcohol to a pint of water.  Ointments com-
posed of  two drachms of sublimed sulphur, with  the same
quantity of white soap, to an ounce of lard, and of calomel, or
the oxide of manganese  in  the  same proportions, have  been
often recommended.   But  amongst all other remedies,  the
ioduret of sulphur  ointment, first employed by  Biett in  the
treatment of porrigo favosa, merits our greatest confidence.
We have seen it in  the course of a few weeks alter the condi-
tion of the  skin in old cases, prevent  the  formation  of new
pustules, and cause the hair to be reproduced with its original
characters and appearance.  The ointment should be rubbed
gently  over  the  parts  affected  every night and  morning.
During the use of  all these different means, the  scabs should
be removed as soon as they form, by means of the continued
use of emollient and alkaline lotions.  Baths are  always useful
in these cases, especially when the  disease appears upon  the
trunk or limbs.   Sulphur baths  are very efficacious in  some 
•
                          PORRIGO  FAVOSA.                       185


instances.   The  utmost  cleanliness  should  be  observed  all
along, and  the fluid which exudes  from the excoriations should
not, if possible,  be allowed to touch the sound skin.*
   In obstinate cases, cauterization with the  nitrate of silver or
some diluted acid, has been attended  with success.    After the
scabs are removed,  and the scalp well washed, the acid should
be passed  quickly over  the surface with a  feather, and water
poured immediately on the parts,  to prevent  the action of the
caustic extending too deeply.    In the treatment of P. favosa,

   * The list  of local applications recommended in porrigo  is of discouraging
length, and affords sufficient proof, if any were needed, of  the great obstinacy of
the disease.
   I have derived the most benefit from ointments of creasote and of iodide of sul-
phur, the former, 20 to 30 minims to ^j  of lard ; and the latter 9j to 3ss to §j ;
and am in the habit  of directing their application morning and evening, and to have
the head thoroughly washed before each fresh application with an alkaline wash,
such as carbonate of potash or of soda.   The oiled silk cap should be constantly
worn, unless  it causes too much irritation.  An ointment of sulphur and carbonate
of soda proved successful in a case lately under treatment, which was not, however,
of very long  standing.  Wilson  has used the iodide of sulphur with success in the
form of a liniment,  3 ss to §j olive oil, gently rubbed over the scalp night and
morning,  after having previously washed the part with warm water.—{London
Lancet, Feb. 1840.)  In  his  work on  diseases  of the skin (Phil, edit, 1847, p.
396), he says, that he has been most successful  in favus with iodine, either in the
form of vapor, applied twice a  day, or  tincture of iodine,  brushed upon the scalp
three times a day, in the morning and evening after each ablation.  Next to iodine,
he prefers a spirituous solution of bichloride of mercury, pencilled on the patches,
with which, he says, he has frequently  succeeded in checking the disease at once.
   Dr. J. H. Bennett, of Edinburgh, recommends the internal use of cod-liver oil, and
 also its application  with  a soft brush or dossil of lint to  the whole scalp, morning
 and night, after the crusts have been softened and removed by poultices, and the
 head shaved, and then covering the head with an oiled silk cap, the head to  be
 occasionally  washed gently with soft  soap  and a sponge, when any accumulation
 takes place.—{Treatise on Cod-Liver Oil, Edin., 1848.)
   For an interesting lecture on Favus, by Prof. B., taken from the Monthly Jour.
 of Med. Science for July, 1850, see Braithwaite's  Retrospect (Amer. Rep.) for
 Jan., 1851, p. 238.
   Dr. Neligan gives iodide of arsenic in this disease, which, he says, may be given
 with safety to the  youngest child.  Dose  for an adult from 1-10 to -J of a grain,'
 very gradually increased ; for a child six years  old, 1-15  of  a grain ; and for a
 younger child, 1-18 to 1-20 of a grain.   Locally, he uses  poultices and alkaline
 washes and ointment to remove scabs, and  afterwards the iodide of lead ointment.
 —{Dublin Quar. Jour. Med., Aug., 1848.)
   All the different applications mentioned in the text  have had their advocates,
 and each may be useful at times.  But I have thought alterative and mildly stimu-
 lant topical remedies more effectual than the powerfully irritating ones.  It is fre-
 quently necessary to change the application, and sometimes to  resort to emollients
 and sedatives for some time.
   According to my experience, internal  treatment often aids materially in effecting
 as well as in perpetuating the cure, especially in  patients of strumous diathesis, in
 whom the disease  occurs by far the most  frequently.   Mercurial alteratives and
 laxatives in such cases may be used, when any derangement of the digestive organs
 exists, followed by tonics, and aided by generous diet, exercise in the open air, warm
 Bait water bathing, &c.   In many cases the iodide of iron will prove of decided
 service.  Whatever  course is pursued, patience and perseverance must form leading
 points in it.—H. D. B. 
186
DISEASES OF THE SKIN.
we must bear in mind that no one remedy is  always success-
ful, and that great perseverance  is indispensable on the part
of  both  physician  and patient.   Cleanliness  must always  be
strictly attended to,   [We have lately seen creasote succeed
when many other means had failed.   The diseased parts are
to be touched with a camel's-hair pencil dipped in creasote,
and dressings of an  ointment composed of a scruple of creasote
to an ounce  of lard should afterwards be applied.—B.]


                PORRIGO SCUTULATA.

             Syn.—Tinea annularis ; Ringworm.
   This is  a chronic contagious disease of the scalp, charac-
terized by favous pustules arranged in annular-shaped clusters,
the centre of which  is  not so  crowded with pustules  as the
circumference.   These are  succeeded by scabs  which are
thin and small at first, but subsequently becoming  thick and
raised, and running  into  each  other, form  incrustations of
considerable extent.   The special seat  of this disease  is the
scalp, but it frequently exists  at the  same time on the fore-
head and neck.   When it appears on any other parts  of the
body, which  seldom happens, it is the  result of direct con-
tact.*
   Symptoms.—Porrigo scutulata commences with  red, cir-
cular, and furfuraceous  patches, upon which, after a variable
period of time, sometimes several weeks, very  small yellow
pustules  are  seen,  which are   both  less  elevated  and less
imbedded in  the  skin than those of  porrigo favosa.  These
pustules  are more  numerous towards the circumference of
the spot than at its eentre.  The evolution  both  of the red
patches  and of the  pustules  is accompanied with  smart,
intense itching.  The pustules very closely resemble those of
porrigo favosa, but the yellow color  is not so bright.   They
are commonly traversed by a hair, and have the same cupped
appearance as the pustules of that  variety.   The  contained
fluid soon dries up, and forms  scabs, which  are thin at first,
but increase  in thickness, though  they never become  very
thick ; and when they fall off a large furfuraceous patch, with
an uneven surface, is left, on which new favous pustules  do
not appear for a long time.

  * In the last edition of their work, our authors substitute  for the latter part of
this paragraph the following description of porrigo scutulata :—" it is developed
on the huiry scalp, which is its special seat, in the form  of isolated, distinct,  and
circular patches ; sometimes there is but  one patch."  Other alterations in  this
chapter are also made, which are embodied in the text.—H.  D. B. 
PORRIGO SCUTULATA.
187
  The hair falls off from these  patches from the commence-
ment, but is  not  completely destroyed.   There  is not, as  in
favus, permanent baldness.
  When these circular  patches are numerous, either from
their  spontaneous development, or from their inoculation of
different parts  by the patients  scratching,  they may  extend
and run together.   The union of the patches then presents a
peculiar aspect, a kind of furfuraceous covering, over  which
are scattered small points with  favous  pustules, and the cir-
cumference is  distinctly made up of quarters and halves of
circles.
   Causes.—This  disease  often  appears   spontaneously  in
children,  and  persons  of a lymphatic  habit,  and  who  are
badly clothed and fed;  but the  most frequent  cause is con-
tagion.  The use of the  same  comb,  towel, cap, &c, fre-
quently spreads the disease amongst children in schools, when
the strong  and vigorous  are affected as well as the weak and
delicate.   It is occasionally seen in adults.
   Diagnosis.—The diagnosis of  porrigo scutulata  is occa-
sionally attended  with  some  difficulty;  however, porrigo
favosa is the disease with  which it  is most likely to be con-
founded.   It is distinguished from all  other eruptions  by the
nature of  the  pustules, the color and form of the scabs, the
baldness which it  produces, and by its contagious character.
The elementary lesions of both  varieties of porrigo are small,
yellow, umbilicated,  and deeply-seated  pustules; but in  P.
scutulata they  are agglomerated and disposed in the form of
rings; whilst in P. favosa they remain distinct, and do not retain
any regular shape or form ; besides, even when the incrusta-
tion of the latter spreads like the former over the scalp, they
do not show the peculiar  honeycomb  appearance of porrigo
favosa.
   Impetigo figurata has been mistaken for this  disease when
situated on the hairy scalp; and on  the other hand,  P. scutu-
lata, when developed on the limbs, has been confounded with
I. figurata.  The pustules of the latter, however, are superfi-
cial, slightly prominent, and rest on an inflamed base, whilst
those  of the former are deep-seated, imbedded,  as it were, in
the epidermis, and unattended with inflammation around their
base;  and  the fluid they contain is  concreted almost as soon
as it is formed.  The fluid of the impetiginous pustules slowly
thickens, and is not converted into a true scab for some days.
Moreover, the incrustations of impetigo are much thicker, and
after disappearing are reformed by  the sero-purulent  exuda-
tion, whilst fresh pustules are necessary to produce new crusts
in P. scutulata.  The impetiginous patches  are generally con- 
188
DISEASES OF THE  SKIN,
 fined within certain limits, and are distinct, and the incrusta-
 tions are thicker in the centre than at the circumference.
 The latter disease never produces baldness, and is not conta-
 gious.  These characters are sufficient to distinguish  two
 diseases, a correct diagnosis of which is of the highest impor-
 tance.
   Porrigo scutulata may always be distinguished from herpes
 circinatus, and the patches  of  lepra which  appear on the
 scalp, by observing the progress  of these affections, and the
 manner in which they are developed.
   Great confusion still exists in the diagnosis between porrigo
 scutulata and an eruption  of the scalp  {ringworm), which
 we  have regarded  as  belonging  to  herpes  circinatus,  and
 have called herpes  tonsurans.   The  English have  not re-
 stricted  the term porrigo to the true favous pustular erup-
 tions to any  great extent, partly because they were in the
 habit  of applying this  term to every kind of eruption of the
 scalp, and partly because porrigo favosa  (p. lupinosa, Willan)
 is of  rare occurrence in that country;  besides, that porrigo
 scutulata presents itself under such forms there that we doubt
 whether the  disease known  among us  under that name is
 really the porrigo scutulata  of Willan and Bateman.   Some
 English writers describe the contagious ringworm, or porrigo
 scutulata, as a furfuraceous disease, circular in its form, while
 others describe it as a  pustular affection.  Plumbe says that
 porrigo scutulata is first furfuraceous and then pustular ;  and
 his description evidently applies to the  porrigo scutulata of
 France, patches of which we have  seen remain for a long time
 in a furfuraceous state, and then  have favous pustules on dif-
 ferent points of their surface.   But there is another contagious
 form  of the disease  of the scalp, circular in its form, without
favi,  and without pustules of any kind, which was, until very
 recently, unknown  among us, to  which  one  of us gave the
 name of herpes tonsurans, in consequence of its  well esta-
 blished vesicular character at the commencement, and  the
 simultaneous appearance of several spots of  herpes circina-
 tus in the neighborhood, on the neck, and on the forehead.
   This confusion has arisen from the vague manner in which
 the term porrigo is used in England, and from the continued
 improper application of it in that country to ringworm, which
 is not a pustular  affection.   .
   In our opinion, the porrigo scutulata of English authors gene-
 rally, contagious ringworm, is not only not our porrigo scutu-
 lata, but it is  not a porrigo at all, but an eruption of a furfura-
 ceous character.  Further observation will decide whether it is a 
PORRIGO  SCUTULATA.
189
pityriasis, or a form  of herpes ; but it is certain that it is not
a pustular disease.
   Prognosis.—Although this variety is  not so  difficult to  be
managed as P. favosa, still it often resists every mode of treat-
ment.   Baldness is not as frequent  an  occurrence  as in  the
former variety; jaor  are the bulbs of the  hair  so  much dis-
eased.
   Treatment.—The  treatment which this affection requires is
exactly the  same as  that already described under the head of
porrigo favosa,  to which we refer the reader.*


  *  No  allusion  has been made by our authors in either of the editions of their
manual to the  form of disease of the scalp known by English writers under the
name of  " ringworm of the  scalp" until the brief notice in the edition of 1847,
which we have embodied in the text of the present translation ; and what is there
said will do but little towards removing the confusion which exists in the minds of
practitioners, and, to a certain extent, in the works of authors on the subject.  One
reason for  this is probably its former rare  occurrence  in  France, while porrigo
favosa, the true favus, is of very frequent occurrence in that country, directly the
reverse with respect to these two forms of disease  of  the scalp  being true in
Great Britain.  The disease to which we refer is the porrigo scutulata of some
writers, the P. farfurans of others, the trichosis furfuracea of Wilson, the herpes
tondante of Mahon, who  seems to  have been the first French writer to notice it.
As our authors say, it is not a porrigo at all; that is, it differs entirely in its ele-
mentary  form, as well as in its progress, from the eruptions characterized by the
yellow, cup-shaped, &c, pustules, known under the name of favi, a form to which
the term  porrigo should be  restricted.
  The disease to which we allude is characterized by furfuraceous patches, varying
in size from a quarter or a third of an inch to an inch or more in diameter, usually
nearly or quite  circular in shape, attended with very little  morbid sensation, per-
haps a slight degree of itching, in which the hair breaks off at irregular though
very short distances  from  the surface of  the scalp, often giving the parts a moth-
eaten appearance ; and sometimes spreading by a succession of circles over greater
or less portions  of the scalp, which extend from their  centres towards the circum-
ference.  The first thing observed is often a mere scurfiness of the skin, either
around single  hairs  or in small patches around several hairs ; which  patches will
often reach the size of one  fourth or one third of an inch in diameter before being
discovered, the hair  immediately  adjoining  them being natural  in color and
unbroken.  Small vesicular rings, like those of herpes circinatus, often appear on
the neck  and face at the same time, and sometimes on those parts in the nurses and
mothers of the children.
  It  is a form of disease of the scalp  quite common in this country, usually occur-
ring  between the ages of two or three and eight or ten years, and often causes no
little embarrassment to practitioners.  It is always cured, and never leaves perma-
nent baldness ; but often lasts for weeks and months, and even years.
  Different views are entertained respecting its pathology, and also as to its con-
tagiousness ; some believing  that it is caused by a vegetable growth within  the
body of the hair, while others regard it as a  peculiar disease of the hair itself.
  One of our  authors, M.  Cazenave, in his recent work on Diseases of the  hairy
scalp {Traite des Mai. du  Cuir Chevelu, Paris, 1850), has given an extended and
minute description of this form of disease, which he first recognised in one of  the
large schools in Paris in 1840, and which is now quite common in  France, under
the name of herpes tonsurant.  He  regards it  as a form of  herpes circinatus
peculiar to the scalp, and describes it as characterized by " patches differing from
each other in size, but exactly  circular, dry, of a greyish color, and remarkable for
a peculiar kind of alopecia,  in which the hair is, as it were, shaved off, but so near
                                   13 
190                   DISEASES  OF THE  SKIN.
                 GLANDERS  AND  FARCY.*

                            Syn.—Equinia.

   [As glanders and  farcy are fundamentally the same disease,
resulting from a common cause, and differing from  each other

the skin as to appear, at first sight, as if the spot were entirely bare."   He says
that in their  very commencement the spots  are red, and covered  with very fine
vesicles, which are very ephemeral, and always terminate by resolution.
  Mr. Erasmus Wilson also describes the disease particularly, under  the name of
trichosis furfuracea {Diseases of the  Skin, Phila. edit., 1847), and we may also
refer to a clinical lecture published in the New York " Annalist," Aug. 15,  1848,
for a further account of it.
  According  to Mr. Wilson.it is necessary to use both  internal remedies for the
improvement  of  the general health, and local  applications of a moderately stimu-
lating nature  to excite a new action in the affected part.
   A favorite  and often successful  application at the commencement is the strong
acetic acid, with which the parts are touched  by means of a quill or brush, for
several successive days.  A solution of sulphate of copper rubbed over the patches
three times daily, of a strength proportional to the sensibility of the parts affected,
is also often useful ; the friction to be continued  until considerable smarting is felt.
The average  strength required  is about  15 grs. to § j. water.  Stimulating and
alterative  ointments  of  different kinds may be used  in  different cases, alternated
with alkaline lotions.
   Mr. Wilson regards keeping  the scalp  constantly moistened with some oleagi-
nous matter an important adjuvant to the  cure.  A remedy frequently  used by him
is liquor ammoniae and olive oil, graduating the quantity of alkali according to the
amount of stimulation  which he  wishes to  produce.  After the  tenderness has
abated which follows the use of  acetic acid, he recommends the daily application
of the citrine  ointment, more or less diluted, or of an ointment of sulphate  of zinc,
 3j. to 5j. lard.
   Irritating applications will frequently give rise to an eruption of vesicles or pus-
tules  over  the patches, an accident which it  is important to avoid, and upon the
occurrence of which emollient or sedative  applications must be made, the rule being
always to avoid the use of any means which will inflame the scalp, or give rise to
any discharge from the surface.   Time, patience, and perseverance  are important
requisites on the part of all interested.
   M. Cazenave insists (op. cit.)  upon the rejection of all kinds of irritating applica-
tions.  The  topical  means which he has found the most successful have  been an
ointment composed of two parts of citrine ointment and  one part of tar; and more
especially an  ointment containing tannin, in  the proportion of 15 to  30 grains to
§ j. of lard.   More recently, he has also used with advantage an ointment of sul-
phuret of lime, in the proportion of 3j. or 3 ij. to § j. of lard.
   The constitutional means must be such as the condition of the patient at the time
may  indicate ; alteratives, laxatives,  and tonics, if required.  Warm baths will
often prove valuable adjuvants.  Especial care must also be taken to prevent the
spread of the  disease by contact with others.                        H.  D.  B.
   * Our authors, in the edition of their work  in 1847, have  themselves introduced
an article on equinia, describing  the disease under the two  forms  of E. mitis and
E. glandulosa, the former  being the vesiculo-pustular disease found about the heels
of horses, and  long since recognised as one  of the sources of vaccine virus;
and the latter, the peculiar affection known within but  a  comparatively tew years,
and which has its seat within the nasal fossae of that  animal, and  which is fami-
liarly known under the name of glanders.  We have not thought it proper, how-
ever, to substitute a translation of this for the original article furnished by Dr. Bur- 
GLANDERS AND FARCY.
191
only by situation, I propose to describe and classify them with
the pustular diseases  to which glanders decidedly belongs.
The tubercular nature of the eruption in farcy, would appa-
rently indicate the propriety of placing that variety amongst
the tubercular diseases;  but it would  involve a pathological
contradiction to describe two affections so intimately allied as
glanders and farcy are, apart, and  in distinct classes of cuta-
neous eruptions.
   Glanders and  Farcy in  the  Lower Animals.—These
diseases have been observed  in the  quadrumana, to which
class of animals they were formerly supposed to belong exclu-
sively, in many different parts of the world.  They have been
found to exist in  France, in Italy, Germany, England, Syria,
Egypt,  Asia Minor, Arabia,  and  in  America.   They were
known  to the ancients ;  but we possess few documents—and
even those are scanty and imperfect—of their progress and
development; and we are wholly ignorant of the place whence
they derive their origin.  It is  marvellous the discrepancy of
opinion that obtains amongst veterinary writers on this sub-
ject ; and, instead of throwing any light on the question, they
seem to involve it more  than ever  in a  chaos of vague and
fanciful speculation.   " We cannot avoid," says M. Hamont,
director of the Veterinary School  at Abon-Zabel in Egypt,
" being  astonished at the confusion which prevails in veteri-
nary works on the origin and causes of glanders and farcy.
These diseases having been accurately observed only in some
parts of Europe, and  in climates  and under  circumstances
nearly analogous, their exact etiology cannot  be established
without all the conditions attached  to their development in the
different countries in  which they exist having been carefully
observed and studied."
   My attention has been  particularly  directed  to  these dis-
eases since  Dr.  Elliotson's memoir appeared.  I have had
frequent opportunities of observing glanders  in the horse, and
I am bound to say that M. Hamont's statement is founded on
fact.  We look in vain in veterinary works  for unity or pre-
cision in the various accounts  of the  origin, causes, and ele-
mentary nature  of glanders and  farcy.  The  pathological
conditions are either wholly overlooked, or else imperfectly
described,  in  the  anxiety  to  announce some  nostrum for a
disease  which is hitherto incurable, and must continue so until

gess in the work from which the first American edition was reprinted.  Both have
drawn freely from the  labors of Dr. Elliotson in  England, and Dr. Rayer in
France ; and Dr. B. himself, as well as  our own  authors, writes from personal
observation of the disease.  We therefore allow his chapter on this subject to remain
untouched.                                          H.  D. B. 
192
DISEASES OF THE  SKIN.
a more precise mode of observation be  adopted.  The result
of M. Hamont's researches (which have recently been  laid
before the Academy of Medicine, in the form of a memoir)
leads him to believe that glanders is a disease of privation or
poverty  (misere),  and  only attacks  impoverished  animals,
whose constitutions are broken down  by over-work and bad
feeding, or those of a deteriorated breed; and that the blood-
horse in Egypt scarcely ever  falls a victim  to the  disease,
whilst it is very common amongst the  horses  of the  poor in
that country.  He denies  the accuracy of  the  commonly
received opinion, namely, that moisture  and cold, narrow and
ill-ventilated  stables,  are the  causes  of glanders and farcy,
and  states  that he  frequently observed  them to be developed
spontaneously in dry, large, and  airy  stables.  M. Hamont
considers tubercular lepra of man to  be identical with the
farcy of the horse, and  that the former disease is confined to
the poorer classes of society, and never attacks the rich and
well-fed, exactly as the latter is developed in an ill-fed  and
low breed of  horses.
  " Tubercular lepra," says M. H., " appears in man on the
arms, the body, and the nose;  ulcers sometimes form within
the nose, and secrete a disgusting sanious matter; and in this
condition it  has a striking resemblance to glanders in the
horse."
  Glanders m3y appear in the horse  in different  forms.  It
may exist in a simple  form or combined with farcy.  Either
of these  varieties may appear and run  through their course
separately,  or, as commonly happens, one appears  first,  and
after a certain period the other is superinduced.  For example,
the disease may begin with farcy buds and terminate in glan-
ders, and vice versa.   Finally, they may assume an acute or
chronic character.
  The following are a  few of  the  principal symptoms of
glanders in the horse :—Intense inflammation of the pituitary
membrane attended by erosions, which soon pass into chancre-
like sores;  swelling of the  lips  and nose ; rapid extension of
the ulceration giving rise to a purulent discharge, which often
passes into a purplish or bloody  and horribly foetid  sanies ;
subsequently, gangrene  of  the  membrane of the nose,  with
increased  discharge,  sometimes  with  slight haemorrhage;
swelling  and  pain  of the sublingual glands; inflammation of
the conjunctivae and eyelids, quickly passing into a livid and
swollen state, with an offensive sanious discharge, and fever
of a putrid  or  malignant  character;  respiration  becomes
laborious and hurried, and the superficial blood-vessels con- 
glanders and  farcy.
193
gested, the animal dying in a few days, or after a longer or
shorter interval.
  When farcy supervenes during the progress of the disease,
it is then  called farcy glanders, and commonly presents the
following additional  appearances:—Small glandular  tumors
about the legs, lips, face, neck, and other parts of the  body ;
these tumors vary in size and in the rapidity of their progress
to ulceration.  They sometimes create little  inconvenience,
particularly in a chronic state;  but  at  other  times they are
large, painful, numerous, and rapid in their course.  They are
at first hard; soon become soft, burst, and  degenerate into
foul  ulcers, with abrupt edges, and of a pale, glossy appear-
ance.   Lines  of  communication  are   ordinarily observed
between these tumors or ulcers, especially when seated  on the
inside of the limbs ;  these lines are  inflamed  or enlarged
absorbents.  Such are the principal features of glanders and
farcy in the horse.


        GLANDERS AND FARCY IN THE HUMAN SUBJECT.

   History.—From the commencement of the present century
it was  known that wounds resulting  from  the  posthumous
examination of glandered horses were of a dangerous charac-
ter.   It was also known, that, in consequence of such wounds,
several veterinary surgeons were attacked  with malignant
inflammation, pains in the joints, mortification, terminating in
some instances fatally.  But all these results were attributed
merely to a septic poison, analogous to that produced  by
other putrid matters, and not to the specific action of a parti-
 cular virus.  However,  about  that period (1811) M.  Lorin
 discovered and proved the transmission  of farcy from horse to
 man.  (Observation sur la Communication du Farcin des Che-
 veaux aux Hommes.  Jour, de Med. Veterinaire, Feb.,  1812.)
   Although this  is the first case  on record of the disease in
 man, it by no means follows that the human race was  never
 afflicted with glanders before this time.   On the contrary, we
 have good reason to  suppose that  mankind was afflicted for-
 merly as well  as now with both varieties of the complaint,
 but  that it  escaped  the  less  scrutinizing  observation of our
 forefathers.  It  was not  till  1821,  however, that the first
 detailed case of  acute glanders in a man  was published.   It
 is recorded by  Shilling, a veterinary  surgeon  at Berlin.—
 (See Rust's Magazine fur die  Gesammte  Heilkunde, vol  ix.)
 The subject of  this case was  a stable-boy at  a veterinary
 college,  who became unwell soon after washing the nostrils of
 a glandered horse.  A pustular eruption broke out on the skin, 
194               DISEASES  OF THE SKIN.

pimples appeared on the nose, which speedily became gan-
grenous ; the boy died; and at the examination of the body
after death, small purulent  spots were found on the  frontal
bone, and pus in the muscles of the extremities.   In another
case, appended  to  that of Shilling, and which is related by
Weisses, there were observed delirium,  pustular  eruption on
the skin, and a secretion of  yellow purulent matter  from  the
nostrils.  This  patient had  been taking care of  a glandered
horse,  and  died on the thirteenth day from the commence-
ment of the attack.  Soon after these cases were published in
Germany, Mr. Muscroft recorded, in the nineteenth volume
of the Edinburgh Journal, the case of a jockey who  wounded
himself in the hand while trimming  a glandered horse, and
died with all the symptoms of glanders.  Here also the resem-
blance  of the disease in the  horse with that observed in man
is  strikingly exact.  In 1822, Thomas Tarozzi, in Italy, trans-
lated the case  of  Shilling into the Annali Universali, and
gave a description of a pestilential disease which was deve-
loped in a stable where a glandered horse died ; out of thirty-
five persons who visited that stable eleven were attacked with
a malignant complaint, characterized, from  its invasion to its
termination, by fever and an  eruption of boils and gangrenous
pimples.  At the close  of 1823, two new cases of the disease
in the  human  subject were  published in the Edinburgh
Journal;  and  another was  published in the same year in
Germany, by  Seidler, in Rust's  Magazin. In 1826, Mr.
Travers threw some additional light on the history of glanders
in man, in his work on " Constitutional Irritation."  In 1829,
Arnold Grub  defended an inaugural dissertation  at Berlin, in
which  he relates a remarkable case  of the transmission of
glanders from the horse to  man.   The same year  another
thesis on the  same subject was defended by Kriseg.  It was
also in 1829 that Mr. Andrew Brown published a well-marked
case of acute glanders in man, in the London Medical Gazette,
vol. iv. p. 134.
   However, notwithstanding their extreme importance, these
facts were  as yet little known, when Dr. Elliotson published
a  memoir entitled " Glanders in the Human Subject," in the
sixteenth volume of the Med.  Chir. Transactions for 1830,
which  at once  attracted  the  attention of observers  to this
interesting and  important question.  This memoir  contains
three well-authenticated and convincing cases of the disease
in man ; and from its  publication, only twelve years since, we
date the commencement of  our inquiries into the disease, in
so far as the human being is concerned, for up to that period
doubts were still entertained by many persons as to the iden- 
GLANDERS  AND FARCY.               195
tity of the two  diseases.  In  the  same year  (1830) M. A.
Nauman, Professor  of Veterinary Medicine  at Utrecht, also
reported two interesting cases (Wee-Artsenijkundig Magazin;
Groningen, 1830); in addition to which, M. Alexander, Pro-
fessor at  the  same University, has added two new instances
in the course of the year 1836.—(De la Diathese purulente, et
de la Morve aigue communiquee a I'homme; Archives Gene-
rales, Dec. 1836.)   In 1833, Dr. Elliotson published  another
case of the disease, with a colored drawing.  Mr. Youatt saw
this case with Dr. E.  It was the first case of the kind he had
seen ;  and up to that period would  not,  according to  the
statements of Dr. Elliotson, admit the transmissibility of glan-
ders from horse to man.  He has  since, however, announced
his belief in that opinion.  In 1834,  M.  Hertwig observed
seven  cases  of  farcy and glanders in  the  human  subject;
amongst these, three were  evidently and  distinctly those of
well-marked  simple glanders.  It is also evident that certain
cases  observed  and published by  M.  Brera, in 1833, and
described by him under the  name of Typhus  carbonneux
in the Encyclographie Medic, belonged properly to the disease
under consideration. M. Felix Vogely, of Lyons, in a  memoir,
entitled, " Some Facts tending to establish the Transmission
of the Farcy of Horses to Man," has cited five  examples.—
(Journ. deMed. Veterinaire, Jan. 1835.)  From 1830 to 1837
a variety of papers have  been published  on this subject by
MM. Hardwicke, Wolff, Prinz, Berndt, and Eck.
   M.  Rayer communicated to the members of  the French
Academy,  February 14, 1837, the remarkable  case of the
man Prost, who died under his care, of acute glanders.  This
interesting communication  immediately  gave  rise  to  an
animated  discussion in the Academy, in which MM. Rayer,
Dupuy, and Velpeau, supported the opinion of the identity of
the disease of the horse and of the human being; while they
were opposed by MM. Bartlemy and  Bouley.   The  latter
opinion appeared to prevail at the time, but the publication of
a very elaborate and very valuable  memoir  by M. Rayer,
inserted in the Memoirs of the Academy for the  same year,
removed all further doubt on  that  question.   In  addition to
the case  (Prost's) published,  M. Rayer gave a great  number
of observations, the results  of his own researches  into  the
nature of the disease.  He confined his description of glanders
and of farcy to the acute forms of these complaints. He gives.
a graphic description of the progress of  the disease in  the
human subject.   The inoculations, and their results, of man
with the morbid  virus taken from the  horse, and the reverse,
have  been elaborately discussed.   Indeed,  the existence of 
196
DISEASES OF THE SKIN.
glanders in the human being could be no longer doubtful even
to the  most incredulous, after  perusing the important and
interesting memoir of M.  Rayer.   During the year  1838,
MM. Brugieres and Vigla recorded a case of the same malady,
which occurred under M. Breschet, at the  Hotel Dieu, Paris :
and about the same period M. Deville on  the one  hand, and
MM. Husson  and Nivet on the other, published  additional
facts, which immediately produced a new discussion  in the
Academy  as to the possibility of the transmission of glanders
from man to the horse, and  vice versa.  M. Bartlemy, who
again took an  active part  in the  debate, seemed wedded  to
his former opinion, in which  no  other member now coincided.
New  cases were  published soon  after   by  MM.  Nonat,
Legroux,  Andral, Lions, Petit,  and Renaud; and M. Vigla,
in an interesting thesis (January,  1839), has taken up with
much  talent,  and  confirmed by  observations of his own,
several interesting points in the history of this dire disease.
   Mr. Leblanc, of Alfort, has demonstrated, in two important
memoirs of this  subject—the first entitled  " On the different
Kinds of Glanders and Farcy considered as Varieties  of one
and the same general Affection;" and the other, "Experi-
mental Researches on  the Effects  of the  Inoculation  of the
Horse  and Ass  with  glandered pus and  mucus,  and with
morbid humors of a different nature;"  Paris, 1839—First,
that all forms of glanders and farcy are contagious, but differ
in intensity according to  the  constitution  of the animal and
other  obvious  circumstances ;   and secondly,  that  pus   or
mucus  taken from glandered men  or horses, no matter from
which, will produce glanders or  farcy in healthy animals of a
similar kind if  inoculated  with them,  whilst pus or other
matter not taken from  glandered or  farcied animals will not
produce either glanders or farcy.
   In the London Medical Gazette for April, 1840, there is  an
account of a knacker who died at St. Bartholomew's Hospital
of glanders, and the nurse who  attended him took the disease,
and died also—this is  the first instance on  record of glanders
being transmitted from one human being to another ; and M.
Gibert of Paris, relates a case, in  the RCvue Me'dicale  for
November, 1840, of a man named Pagout,  who died of acute
glanders after having suffered dreadfully for some days.
   Several  cases  of glanders have  been  published in the
English journals since that date,  proving the identity,  if
any  proof were wanting, of glanders  in  the horse and  in
man.
   Symptoms.—The symptoms of acute  glanders in man are
essentially typhoid.  The disease  usually  commences with 
GLANDERS AND FARCY.
197
general constitutional  disturbance;  headache,  depression of
spirits, prostration of strength, stiffness  and constant pain of
the joints, aggravated by motion, irritability of the stomach,
and excessive thirst.  The patient complains  of great heat
about  the nose  and windpipe, accompanied with a copious
viscid  discharge, and with pain in the head, back, and limbs,
and constriction about the chest.   After a certain period, the
nose and surrounding parts  become  swollen, hot, excoriated,
and  of a bright red or livid color :  one or  both eyes are
inflamed,  or completely closed ;  a profuse tenacious mucus,
at first of a deep yellow, but afterwards of a  bloody or dark
sanious appearance, exudes from the nostrils, and occasion-
ally from the eyes; hard, round, phlyzacious pustules appear
on different  parts of the body ; the temperature of the skin is
increased; the pulse is rapid, soft, and  weak or undulating;
respiration quick, weak, and shallow.  The tongue dry, rough,
and reddish  brown; the body is  bathed in copious and offen-
sive perspiration, the thirst unquenchable, the stools are slimy,
and  horribly foetid;  the voice is weak, and the mind wan-
dering.  In  the course of a few days  these symptoms become
still more aggravated;  diffused  abscesses appear in various
parts  of the body, especially about  the  joints.   The fever
assumes a more  malignant character; the disease extends to
the air-passages  and lungs ; fresh abscesses form and suppu-
rate ; the nose and surrounding parts  become gangrenous; the
perspiration  is more profuse and sour;  finally, a  state of
general collapse  ensues, and  death  is  ushered in by  a  low
muttering delirium ; the foetor from the discharges, and from
the whole body,  towards  the close  of the disease, is insup-
portable.
   When the disease  is complicated with farcy, constituting
the variety called farcy glanders, we may observe the follow-
ing additional symptoms :—Small tumors on different parts of
the body, but more numerous on  one side  than on the other,
having a glossy red appearance, which soon changes to a dark
brown.  They also  affect  the head,  or even  the face,  and
chiefly on one side;  they are  sometimes exceedingly painful,
they crack on the  surface, and a thin acrid  sanies exudes.
They vary in size, and are generally accompanied with pus-
tules in  different parts of the body; the fauces are injected
with blood,  and  of a purplish hue.  The inflammation of the
lymphatic vessels and  ganglions is  generally accompanied
with diffuse  inflammation of the subcutaneous cellular tissue.
If the disease be inoculated, as it commonly is, a true pustule
sometimes forms-in  the vicinity of the puncture, to which
succeeds an  ill-conditioned ulcer, with raised edges  and of a 
198
DISEASES OF  THE SKIN.
greyish aspect.   An inflamed red line, or cord, produced  by
the  swollen  and inflamed  lymphatics, is  then observed along
the limb, and the lymphatic glands of other parts of the body
become  sympathetically affected.   Simple  farcy may  thus
slowly, but steadily, proceed to the destruction of life, or acute
glanders may supervene and hasten  that event.*
   Morbid Appearances.—Abscesses are generally found in the
lungs, which are engorged  with  dark blood; the  bronchi are
congested, livid, and partially filled with a dark frothy mucus ;
the nostrils and frontal  sinuses  contain a brownish glutinous
matter, and the lining membrane is ulcerated  and studded with
small tubercles, which are  generally ulcerated.   The mucous
membranes of the stomach and bowels are softened, discolored,
and sometimes studded with tubercular indurations, similar to
those on the nose.   When  glanders is complicated with acute
farcy, the following additional appearances may be seen: An
eruption  of pustules and bullae, in various stages of develop-
ment on different parts of the  body, especially on  the face,
limbs, trunk, and  genitals.   The eruption sometimes  resem-
bles varicella and ecthyma, and, when the  bullae are large,
rupia and the yaws.
   The  pustules, according to M. Rayer, do not contain true
pus until a late  period of their progress, and then but in small
quantity.  In the  nascent state they resemble firm  reddish
papulae, in which condition they  neither contain pus nor fibri-
nous deposit.   At a later period  they contain a plastic matter,
which does not  flow like pus.  When examined by the micro-
scope, this matter  does  not present pus  globules; but blood
globules are seen  in  a state of morbid  alteration,  some  of
which preserve their  peculiar  form and  yellowish  color.
Under this plastic deposit the cutis  presents small red spots,
and  is  depressed  and excoriated, but  the  deposit  itself  is
neither circular nor depressed in the centre  like the disc  of
variola; neither are the pustules umbilicated  like those  of
small-pox.   The  farcinous  pustules, when  more advanced,
penetrate into  the  substance of the cutis vera, the  tissue of
which is partly destroyed.   Abscesses are  invariably found
in the subcutaneous and intermuscular cellular tissues  in the
human subject, in various parts of the  body ; they are not so fre-

  * Dr. Elliotson describes four different  forms of glanders as appearing in  the
human subject:—1st. That of simple acute glanders ; the disease attacking  the
nasal cavities and adjoining parts. 2d. That of acute farcy glanders; appear-
ing in different parts  in  the form of small  tumors, followed by  foul ulcers, suppu-
ration, &c.  3d. These varieties may exist separately, or may be both produced
at the same time, or  the one may precede the  other.  4th. Each of these may
also occur  in a chronic form,  and in this form, also, may exist separately or be
conjoined.—(Copland—Diet. Prac. Med.,  art. Glanders.)         H.  D. B. 
GLANDERS  AND FARCY.
199
quently met with in the quadrumana.  The veins are more or
less inflamed.   Depositions of purulent matter are found in the
lungs, the tissue of which is considerably softened, and there
is an effusion  of  a sero-sanguineous fluid in the pleura and
pericardium.  M.  Rayer mentions a case in which a small
abscess  was found in the brain, and an effusion of sanguineous
serum in the arachnoid.
   Causes.—Glanders and farcy originate in the quadrumana.
They are never developed spontaneously in  the  human  sub-
ject, and when they do occur in man, they have been trans-
mitted to him from the lower animals; but they may  be pro-
pagated from  one human being  to another.   It  is to  be
regretted that  the etiology of these affections in the quadru-
mana is still involved in so much obscurity, for it is clear that
our knowledge  of  their nature, so far as the human being is
concerned, must be of little  avail, whilst their remote causes
in the animals  in which they originate  are  matters of mere
conjecture.
 . Glanders  and farcy are  essentially  contagious  diseases,
whether developed in man or in the quadrumana.   They are,
moreover, decidedly infectious as  well  as contagious in the
latter class of animals, i. e. the contagious  principle may  be
transmitted  through the medium of the atmosphere, as  well as
by actual contact from one animal to another.  I  have  known
several  instances in which there was no  possibility of contact
with glanderous matter, and yet the disease was developed in
healthy  horses.   A gentleman of fortune, in the  west  of Ire-
land, had had his stud of horses infected with glanders.  Ever)'
particle of  woodwork in  the stables, including  stalls, rack,
manger, &c, was taken down  or replaced with new materials.
The plastering  on the walls was completely removed, and the
pavement ripped up, and all was replaced with entirely  new
work ; but  the  first horses that  were again put into those
stables became  infected, and they were ultimately razed to the
ground.  It  would  even appear that  the contagious principle
remains for  a lengthened period, sometimes for years,  in any
stable or shed where glanders or  farcy may  happen to have
been developed.
  Although  it is by no means proved that these affections may
be transmitted to the human being through the medium of the
atmosphere,  still their history  shows that the effluvia of glan-
dered bodies is capable of exciting a malignant disease, if not
real glanders, in man, when  exposed to its  influence.  The
cases related by Terozzi, for example, support this view.  Dr.
C. Williams  also relates a case, in which a girl, sleeping over
a stable  where a glandered horse was kept, became affected 
200
DISEASES OF THE  SKIN.
with a disease very analogous to glanders, although she did
not  come  in contact with  glanderous matter.    There. is
another case in the Bull, de VAcad, de Medicine, November,
1841, in which  it  is stated that  a  dresser at the Hospital
Necker, who had the care of a glanderous patient, contracted
the disease, not by inoculation, but the same way that small-
pox or scarlatina is contracted ;  in other words, by infection.
However, as the dresser assisted at the autopsy of his patient
before the disease was manifested in  himself, this case is open
to  objection.   A  similar  case  is related  in the  Medical
Gazette, as already mentioned, in  which the nurse took the
disease from the patient she was attending, and died of it.  If
these examples prove nothing else, they show at all events
that glanders may be communicated  from one human being
to another.  M. Hamont's researches go to prove  that the old
notion of glanders being always  the  result of damp, narrow,
and ill-ventilated stables, is  erroneous.  He maintains, 1.  That
the  original  causes of glanders  and  farcy  do not  exist in
stables.   2.  That the habitation exerts but a very secondary
influence  towards  their development.   3.  That  an insuffi-
ciency, or a bad quality of food, may excite both glanders and
farcy in degenerated animals;  and lastly,  that  they never
appear spontaneously in the blood-horse when well fed and
taken care of.
   The matter of a glandered sore will produce farcy, and
that of a farcy-bud will produce glanders, a convincing proof
of the identity of these diseases.
   Diagnosis.—Farcy may be mistaken at the commencement
of its progress for the diffused  inflammation consequent upon
dissection wounds.   They are both characterized  by inflam-
mation of the lymphatics and absorbents, by  purulent deposits
in similar tissues, and are ushered in  and accompanied by the
same* train  of typhoid symptoms.  The cause alone distin-
guishes  these two series of  pathological phenomena.  Farcied
or  glandered matter, or an atmosphere contaminated with
their effluvia, are necessary to engender farcy ; but the mat-
ter  of a fresh and healthy subject is as  likely—some  think
more so—to produce dissecting  wound inflammation as that
of one in a  state of decomposition.  A fresh human brain is
more dangerous to examine than a subject  dead of cholera.
At a later  period, when the eruption is fully developed, and
when gangrenous bullae and diffused abscesses  are mixed with
the pustules, the  diagnosis  will not be so difficult.  Besides,
the peculiar characters of the pustules, and the nature of the con-
tained fluid already indicated, together with  the history  of the
complaint, will at once distinguish farcy from all other diseases 
GLANDERS AND  FARCY.
201
arising from the introduction of other morbid or putrid matter
into  the system.  The same characteristic phenomena will
distinguish it from phlebitis, and from the different pustular,
bullous, or even tubercular eruptions, which it may resemble
in its various phases.
  Prognosis.—The prognosis of the acute varieties of glan-
ders is  highly unfavorable.   In the chronic state, life may be
prolonged for a certain period, but in such a  condition that
death would  be preferable to it.   In the horse, however, this
form  is not so unfavorable, for the animal may still continue
to work, with farcy  buds of considerable size  along the legs,
without the  health being seriously  injured, and the  tumors
may ultimately disappear.  Although cases of "cure" have
been recorded, I doubt very  much if they were cases of real
glanders, for, as far as our present knowledge goes, glanders
still appears to be an incurable disease.
   Treatment.—The  treatment of glanders, like the  remote
causes of that disease, is vague and uncertain,  and as  yet  no
remedies have  been discovered that  can  prevail against  it.*
The prophylactic measures are, however, more evident.   As
we know  that  the  disease,  when once  generated,  may  be
transmitted by inoculation, every precaution should be taken
to obviate  that event.   For example, persons going about or
handling glandered animals, whether brute or  human, should
frequently  wash their  hands,  and perhaps  their faces as well,
in a strong solution of alum; the slightest cut or scratch  on
any part of the skin  that is exposed should be covered and
protected,  and the attendants should wear long gloves.
   Various antiseptic,  stimulating, and tonic remedies have
been  recommended  during  the progress  of the disease, with
the view of arresting it, and  at the same  time  supporting the
patient's strength when typhoid symptoms supervene.  These
are pyroligneous acid, creasote, camphor, chlorate  of  potash,
warm turpentine, the  sulphates  of copper and iron, quinine,
&c,  but  their administration has been attended  with little
benefit.  However,  Dr. Elliotson  relates  a  case in which
chronic glanders  in  the  human  subject  was cured in a few
weeks, by the constant injection  of a solution  of creasote up
the nostrils.  The abscesses  should  be  opened by free inci-
sions.   The inflamed lymphatic glands  have been  extirpated
in some cases of chronic  farcy.
   Fumigations with  the vapor of a  combination  of sulphur
and iodine, as recommended  in lepra, will be found useful in

  * Dr. Lee states {Cycl. Prac. Med., Amer. ed., art. Glanders, note) that seve-
ral cases have recovered under the use of creasote and turpentine.    H. D. B. 
202
DISEASES OF  THE  SKIN.
allaying the pain of the ulcerated tumors, and in altering the
vitality of the inflamed and enlarged glands before they sup-
purate, especially  when situated on the lower extremities.
Local bleedings, emollient poultices, and subsequently alkaline
poultices, have been prescribed with a similar view, but have
not been attended with much success.  In case of inoculation
in the thigh, or in any part of the body where a cupping-glass
may  be applied,  it should  be  instantly employed,  and  the
wound should be deeply  cauterized immediately afterwards.
B.]*                                           y

  * For further details, see Cycl. Prac. Med., Amer. ed., art. Glanders, by Dr.
Dunglison, and Copland's Diet. Prac. Med.,  Amer. ed., by Dr. Lee, who has
added numerous references to different works on the subject.        H. D. B. 
PAPULA.
  The diseases  belonging  to  this order are characterized by
small, firm, and solid elevations  of the skin, called papula.
They are slightly prominent, never  contain  either pus or
serum, and are always attended with more or less and some-
times very severe itching.  Sometimes they are merely the
result of a morbid enlargement of the cutaneous papillae ;  and
sometimes elevations of the skin  itself.
  These diseases generally assume a chronic  form, and their
duration varies  from a week or  two to several  months,  and
even years, as in prurigo, for  example.   There is no region of
the body on which they are not occasionally developed.  They
are sometimes confined to a single region, but most frequently
they affect localities very remote from each other at the same
time.   When the eruption appears on the limbs, it is usually
on the outer aspect, and in the line of extension.  When it
affects the trunk, it generally appears on the back.
  Symptoms.—The papular diseases are always preceded by
pretty severe itching, and are  slowly developed.  A number of
small, slightly prominent points first appear, usually of the color
of the skin, but often of a red or whitish tint.  They gradually
enlarge, and on passing the fingers along the skin, small, round,
hard, prominent elevations are distinctly felt. They are gene-
rally distinct, and are much smaller in lichen than in prurigo.
These affections are rarely accompanied by febrile symptoms.
They terminate  in  resolution, more frequently in slight  de-
squamation, and occasionally  in a slight degree of ulceration,
which supervenes at the summit of each papule, changing the
aspect and  condition of the disease;  hence the name lichen
agrius.   A reddish-yellow discoloration of the skin of  the
affected parts  generally remains for a long period, even  for
years after the disappearance  of the eruption.
  Causes.—These  affections  are  not contagious,  and  are
usually developed without any appreciable cause.  Sometimes
they are evidently produced by poverty and want of cleanli-
ness, as often is the case in prurigo.
  Diagnosis.—The diagnosis  of the  papular affections is  not 
204
DISEASES OF THE  SKIN.
in general difficult.  They may sometimes resemble certain
forms of scabies and eczema, but, with the slightest attention,
the elementary  character  of the eruption will  readily be
detected.
  Prognosis.—The prognosis is  not unfavorable, except that
the disease  may  be prolonged for a considerable time, and
alter the vitality of the  skin ;  and the insupportable itching
with which  it is accompanied may produce evil results, as  in
prurigo of the pubes, for example.
  Treatment.—Sometimes the  papular diseases yield  to the
simplest remedies;  they are, however, most frequently obsti-
nate and rebellious, even under the most energetic treatment.
There are  two genera in this order, lichen and prurigo.


                        LICHEN.

Syn.—Papula; Papulae sicece; Scabies sicca;  Scabies agria;
                Dartre furfur acee volante.

  The term lichen was regarded formerly as a synonym  of
impetigo, but Willan and Biett have  applied it exclusively to
a papular  affection, characterized by minute, hard elevations,
which are sometimes slightly red, but  more frequently of the
color of the skin.;  almost  always agglomerated and accom-
panied with  severe pruritus.   It sometimes  assumes an acute
but more  frequently a chronic character.   All parts of the
body may  be affected ; sometimes it is general, but more com-
monly confined to one or more regions—the  hands, forearms,
neck, and  face, being its most  frequent  seats.   It appears in
two very different forms; lichen simplex, and lichen agrius.
  Lichen simplex appears in the form of an eruption of very
small agglomerated papulae, rarely larger than a millet seed.
When the disease assumes an acute  form,  they are red,
inflamed, and accompanied with heat and distressing itching.
In about  three or four days the redness diminishes, a slight
furfuraceous desquamation is established, and the disease ter-
minates before the second week,  unless a fresh eruption takes
place.   The  papulae are neither red  nor inflamed  in the
chronic form; on  the contrary, they are generally the color
of the skin.  They are preceded by  a slight itching, and are
hard, prominent,  and firm to the touch; imparting  to the
fingers a  kind of prickly sensation.   These papulae remain
stationary for an indefinite period ; a new eruption may break
out when  the former declines, and thus prolong the disease
even for some months.  This variety is always accompanied
by a considerable degree of thickening of the  skin, and fre- 
LICHEN.
205
quently  by  a pretty  severe exfoliation.   Lichen  simplex
usually appears on the face and  trunk in the acute form.  In
the chronic  state, it commonly affects the limbs and dorsal
aspect of the hands.
  Symptoms.—Unless when it is diffused and very acute, this
affection is never preceded or accompanied by febrile  symp-
toms.   Formication and  itching  are its  only  precursors.
Various  terms have been  applied to the disease, according to
certain differences in its seat, form, and aspect.  1. When the
papulae are developed at the roots of the hair, which is a very
obstinate form, it is called lichen pilaris.   2. When it occurs
on the limbs of old, debilitated subjects, the papulae are not
prominent, but are frequently mixed  with  spots  of purpura
haemorrhagica, and the eruption assumes a violet tint—hence
the name  lichen  lividus.   3.  Sometimes the papulae appear
collected  in  regularly-formed circular groups with  defined
margins—lichen  circumscriptus.   These  patches extend by
the  development of fresh papulas round the margin,  whilst
the centres  heal with slight exfoliation.   They are  rarely
isolated,  but are  more or less numerous, and then run together
at their  borders.  4. M.  Biett  has  described a  very  rare
variety under  the name  of lichen gyratus.  We have seen
several cases of this kind  at the  Hospital of St Louis.   The
papulae formed a sort of elongated band, extending from  the
anterior  part of the chest to the inner surface of the arm,
twisting  on itself and following the course of the ulnar nerve,
until it reached the little finger.  Independently of these forms,
which are  merely modifications of lichen, there are two other
much more important varieties of that disease, namely, lichen
urticatus, and lichen strophulus.
  Lichen urticatus.—In this variety the papulae are numerous,
and much  larger than in any other form of  the disease; they
are inflamed, elevated, and confluent like the stings of nettles.
They appear  suddenly, and are  attended with a painful, dis-
tressing pruritus.  It most  frequently attacks children, females,
and  persons of a fine delicate skin, in the  spring  and during
the heat  of summer.  It usually attacks the face and neck, but
may appear on the  extremities.   The eruption is irregular,
transitory, and often reappears  soon  aften it has  subsided.
This  affection terminates by resolution,  or by  slight  fur-
furaceous desquamation.*

  * This form of eruption is a common and very troublesome one in the spring
and  during the summer, and  is characterized  by large, inflamed, and  elevated
papulae, which resemble very much the bites of bugs, and of some insects.   The
inflammation, however, subsides in  a day or two, and leaves small, elevated papula;,
which itch very much, and when seen by the physician, are very frequently exco-
riated by the nails of the patient.   The thighs are a frequent seat of it, as well as
                            14 
206
DISEASES  OF THE SKIN.
   Lichen  strophulus, commonly called red  gum, white  gum,
and tooth rash, generally attacks children  at the breast.   It
always assumes an acute  form; the  papulae are sometimes
redder, sometimes paler than  the  surrounding skin, and are
accompanied with severe itching, which is always aggravated
by the heat of the bed, and is subject to severe exacerbations.
This variety presents  considerable diversity in its color and
form, and these various  appearances are often  seen coexist-
ing in the same infant.   When the papulae are red or inflamed,
prominent and mixed with erythematous patches, the eruption
is  called  strophulus  intertinctus.  When  they are  small,
numerous, set  close together, and  confluent, they constitute
the modification called S. confertus:  again, when they are
disposed  in circular  clusters, and diffused  over  different
regions, the disease is called $. volaticus.  MM. Guersent and
Blache have recorded a remarkable  case, in which the papulae
were much elevated, and seated  in the centre  of petechial
spots.  When the papulae are white, small, limited in number,
and surrounded with a slight inflammatory areola, the disease
is designated S. albidus ; when they are larger, more project-
ing, and without any inflammatory  blush, it is called S. candi-
dus.  Lichen strophulus generally appears without any appre-
ciable cause.   It  accompanies  the  process  of dentition, and
sometimes seems connected with internal disease.  Its  dura-
tion varies from one to three or four weeks.   It  is an  ephe-
meral disease,  and  is never dangerous.   The  only treatment
it requires are a few tepid baths for the infant, and some cool-
ing and refreshing drinks for the nurse.  The physician should
always endeavor to ascertain if it is produced or kept  up by
an internal organic lesion.*
   Lichen  agrius  may  appear  spontaneously,   or it  may
succeed  to lichen simplex.  When it appears spontaneously,
the  papulae  are very  small,  red, acuminated, inflamed, and
developed on an erythematous surface of limited extent, which
is generally attended with heat and painful tension.  Instead

the other parts mentioned above.  The itching is sometimes so severe, even with a
comparatively moderate amount of eruption, as to interrupt very much the sleep of
the patient.                                            H. D. B.
  * Though perhaps never dangerous, strophulus in our  climate, and especially
during the spring and summer months, is  often a source of much suffering. It is
often connected with deranged secretions, and especially with acidity—requiring the
use of small doses of some mercurial and alkaline laxatives, as rhubarb and soda,
or rhubarb and magnesia. At the same time, particular attention must be paid to
the diet of the mother or nurse, or to that of the child itself, if weaned.  The gums
must also be carefully watched, and lanced, if necessary.  The tepid bath is often
very grateful and serviceable.  In some cases, small portions of sulphate of quinine
are useful, and at other times, the mineral acids, with  vegetable  bitters, in doses
proportioned to the  age  of the child.  In children with very irritable skin, the use
of flannel sometimes produces, and at other times keeps up the eruption. H. D. B. 
LICHEN.
207
 of subsiding on the fourth or fifth day, they continue increas-
 ing ; slight ulcerations  form on their apices, whence  issues a
 sero-purulent fluid, which concretes, and forms yellowish pro-
 minent crusts,  soft and slightly adherent.  These incrustations
 fall off, and are then replaced by thin, scaly scabs. Sometimes
 the redness  diminishes, the  inflammation disappears,  slight
 desquamation ensues,  and the disease  terminates  about the
 twelfth or fifteenth  day.  But frequently the discharge con-
 tinues, and new crusts are formed, by which the disease  is
 prolonged considerably.  The itching which  accompanies  it
 is  often  so  intense  that  the patient seeks  the hardest sub-
 stance to rub himself with, and this invariably aggravates the
 pruritus.  It may continue in this manner for several weeks,
 or it may pass  into the chronic state, when the scaly incrus-
 tations disappear, and are  succeeded  by slight exfoliation :
 and the skin is often considerably hypertrophied.   This form
 may last for months.
    Lichen simplex may, as  already mentioned, pass  into the
 state of lichen  agrius, in which event it is accompanied with
 heat and smarting, instead of pruritus.  The papulae are con-
 fluent, and are  surrounded with  a small reddish areola; they
 soon  become red themselves, and  the  eruption pursues the
 same course as idiopathic lichen agrius.   But sometimes the
 inflammation is less  severe and of shorter duration, and does
 not extend over the whole seat of  the eruption; and in such
 cases, it may produce a favorable change in the disease. This
 variety often appears on the face; it is seldom general, and
 occurs most  frequently  in  young  persons, and in adults  of
 strong  and vigorous constitutions.*
   Causes.—Lichen is not confined to any  period of life, or to
 either sex.   It  is  met  with most  frequently  in spring and
 summer.   It  is  frequently produced by extreme  heat; the
 direct rays of the sun, for example, may develope the eruption
 on the  face.   It is very common  in tropical countries, hence
 the name Lichen tropicus.  It sometimes is produced by  grief,
 and by the  intemperate use  of  ardent spirits.   There are
 certain local varieties  depending on distinct local causes;
 as,  for instance, the disease is  frequently seen on the hands
 of grocers, and persons who are much in the habit of handling
 pulverulent substances.   It occurs on the  arms of cooks and

  *  In addition to these varieties, Rayer describes four others, deriving their cha-
 racteristics from their seat, and which may be mentioned, because the disease is
 often confined to one  or more of these parts:—1st. Lichen of the face ; 2nd. L. of
 the  extremities; 3d. L. of  the genital organs and of the margin of the anus;
4th. L. of the hairy scalp. Chronic lichen of the hands is one of the forms of the
eruption popularly known under the name of salt rheum ; the other, comprising
with this nearly all the cases thus called, being chronic eczema of those parts.
                                                  H. D. B. 
208
DISEASES OF THE  SKIN.
blacksmiths, from exposure  to  heat, and is not unfrequently
a  consequence  of  gastric   derangement,  especially   in
infants.
  Diagnosis.—The diagnosis of lichen is often very difficult.
Lichen simplex may, in particular, be confounded with eczema,
scabies, and prurigo.   The solid, firm, cuticular elevations of
lichen, which for the most part appear on the external sur-
faces of the limbs,  together  with  the  severe  itching, will
readily distinguish it from eczema,  which is characterized by
transparent vesicles, generally situated on  the abdomen and
on the internal aspect of the arms, accompanied merely with
a slight  prickly  sensation.  The  itch, independently of its
vesicular character, so different from that of lichen, generally
appears on the limbs, in the line of flexion, in  the folds of the
joints, and between the fingers. The former is  a  contagious
.disease, and its vesicles are distinct, whilst the papulae of the
latter affection  are  crowded   together and confluent.   The
papulae  of prurigo, like those of lichen, are developed on the
external aspect and line  of extension of the limbs;  but they
-are  broader, flatter, and  their  summit is generally  torn, and
covered with a small blackish  crust, formed by a minute clot
of blood.   The itching is generally slight  in  lichen simplex,
•whilst it is burning and intense in  prurigo..
  Lichen  circumscripta may be confounded  with  herpes
circinatus ; but herpes is  seated  on a more  inflamed base,
whilst the former retains the natural color  of  the skin.   The
patches of lichen are papular at the centre, as well  as at the
circumference.  The centre of herpes generally remains free;
besides, the other is  not a vesicular disease.   The remains of
the vesicles of herpes present a large number of small, round
points, surrounded by a  small,  whitish border, formed by the
epidermis  which constituted  the   base  of the vesicle, and
which is detached.   The surface of lichen is rough to the
touch.   The  same marks will serve  to distinguish it from
eczema, with which it is very frequently confounded, and
which never presents itself under this form of small circular
patches.
  Lichen urticatus,  in consequence of the large  size of the
.papulae,  may  sometimes  be mistaken  for erythema papu-
latum,  or syphilitic  lichen.    The  patches  of  erythema,
however, are  much larger, less red, and  not so  prominent.
They are never  accompanied with  that intolerable  itch-
ing  which usually attends  this  variety  of lichen.   The
erythematous eruption  is  not  reproduced,  like lichen,  soon
after it has disappeared.   The  papulae of syphilitic lichen are
of a coppery color; they are  not inflamed, like those of L.
urticatus, nor accompanied with that continual pruritus. The 
LICHEN.
209
syphilitic  papulae are not fugitive, and they pursue a  more
tedious course than the former.  Besides, there are generally
other venereal symptoms present, as iritis, for example, which
will clear  up the diagnosis.
  Lichen  agrius, in its different stages, may simulate impetigo,
acute and chronic eczema, and psoriasis.   The confluent and
ulcerated  papulae  resemble  acute  eczema ;  but there are
always a  few papulae to be seen scattered round the morbid
parts, which will at once  distinguish them.  Lichen may be
distinguished from impetigo by its small, thin,  soft, slightly
adherent scabs, which are generally surrounded with inflamed
papulae; whilst the elementary lesion  of the latter—an  erup-
tion of pustules—is never observed in any  form of lichen.  It
is much more difficult to distinguish it from chronic eczema ;
the itching,  the thickening of the  skin, and the  presence  of
some papulae,  are the  only distinguishing marks of lichen.
The squamous crusts of psoriasis are always thicker than the
furfuraceous desquamation of chronic lichen agrius.  Unless
in psoriasis  inveterata, these scabs  are succeeded by red and
tumefied  patches ; but even then its characters are so well
marked that it cannot be mistaken.
  Prognosis.—Lichen is never a severe disease;  but its
obstinate  nature,  its  frequent eruptions,  and  the annoying
pruritus which  accompanies it,  make it  a very  troublesome
complaint.  Lichen simplex is  especially  a slight affection,
and rarely continues longer  than two or three weeks.  Lichen
agrius, on the other hand, is more  rebellious and unmanage-
able.  In  lichen inveteratus  the skin  is dry, rough, and fur-
rowed with  deep wrinkles, especially about the joints.   The
exhalant  functions of the  skin  where the  eruption is  seated
are wholly suspended.   M. Biett had  observed it retain this
dry character even in the vapor-bath.  Lichen may be com-
plicated with vesicles, with the pustules of impetigo, and even
with those of ecthyma.   Although it may continue for a long
period, it always  terminates favorably, by resolution or de-
squamation ; and  it  is  never  converted  into  psoriasis  or
impetigo,  as Willan alleged.
   Treatment.—Acute lichen simplex  requires no other  treat-
ment than diluents and tepid baths, or sometimes cold  baths,
which are  often the only kind  of service in L. urticatus.
When it  assumes  a chronic form,  acidulated lemonade, mild
laxatives, and  alkaline  or sulphureous baths, are necessary.
Tepid local  baths, rendered emollient with the decoction of
bran, and afterwards alkaline baths,  containing the subcar-
bonate of potass, in  the  proportion of half an ounce  or an
ounce to four or five pounds of  water.   These remedies will
in general suffice; but in some obstinate  cases, friction with 
210
DISEASES  OF THE  SKIN.
the calomel  and  camphor  ointment, or the  proto-ioduret of
mercury, may be advantageously employed.
   In lichen agrius, if the patient  be young and vigorous, vene-
section,  and  local  bleeding  by  leeches round the diseased
parts, will often  be very seviceable, if practised at the  com-
mencement.   Diluents,  emollient  applications,  and  severe
dietetic  regimen, and at  a later period  dilute  nitric  or  sul-
phuric acid,  should be given in barley-water, mild purgatives
being  at the same  time administered.   Sulphur or  alkaline
baths  are very useful when  the inflammation  is  subsiding;
they aggravate the disease when employed at the  commence-
ment.   In  very  obstinate cases, the  arsenical  preparations
have been found of great  service ; Pearson's  solution  is  the
most appropriate  for  this disease.  In these  cases, and even
in  the chronic form of lichen  simplex,  M.  Biett  has  used
Asiatic pills  with success, the patient  taking one daily for  a
month or longer.   In chronic  lichen agrius, friction with an
ointment composed  of  fifteen  to twenty grains of the deuto-
ioduret of mercury to an ounce of lard, is often attended with
much benefit.*

  * Lichen, in all its forms, is most frequently connected with some disorder  of
nutrition, and, in  many cases, especially of  the acute forms, symptoms of gastric
or of intestinal derangement, or of both, are very evident. In such cases, the removal
of the disease must of course depend upon the removal of this disorder as a cause. In
many cases it will not be discovered on a superficial examination, and will be  con-
nected with some part of the secondary process of digestion, instead of the primary,
and its removal depends not upon emetics and cathartics alone, but on a judicious
course of alterative remedies, adapted to the particular case, as indicated by the
character of the different secretions, and aided by long-continued attention to diet
and hygiene.  In fulfilling the indication in different cases, acids may be required
in one  case, and alkalies in another, and perhaps tonics, either with or without
these in  another; and with the particular  remedy indicated, the general regimen
and diet must be made to correspond.  The indication for the one or the other of
these remedies must be sought for in the character of the excretions, especially  of
the urine, from the examination of which, both chemically  and microscopically,
much valuable information  may often be obtained.  Diuretics are often  very
important auxiliaries in the treatment of lichen, both acute and chronic, and  may
be combined with any other  of the means  recommended.  In cases which resist
these remedies, and when there is no contra-indication, preparations of sulphur, or
of mercury, or of arsenic, will sometimes be required, which will  be assisted  in
their action by some form of sarsaparilla, or the extract or infusion of taraxacum,
or of the yellow dock.   The chronic forms of lichen are among the most intrac-
table of cutaneous diseases, and when neglected or improperly treated, last for
years, embittering life by the constant irritation which they produce.
  To relieve the  itching, which often constitutes the most troublesome symptom,
and sometimes becomes a truly distressing .one, a great variety of local means are
recommended ; but their success is so uncertain  that they sometimes afford no
relief at all, and,  at other times, produce only temporary benefit.  Among those
which I have found most useful, are camphor mixture, either alone or in combina-
tion with acetate  of lead, 5 grs. to § j of the mixture ; a dilute solution of chloride
of soda, or of lime ; a lotion  of muriate of ammonia, with vinegar and water, say
fj muriate  of ammonia,  %iv vinegar, and Oj water; pyroligneous acid, 3j or
more to Oj water.  Sometimes a weak solution of nitrate of silver affords relief,
especially when there is a discharge.   More recently the known anaesthetic effect 
PRURIGO.
211
                          PRURIGO.
      Syn.—Pruritus;  Cresmos ;  Scabies papuliformis.

   This  disease  is  characterized by  an eruption  of papulae,
larger than those of lichen, of the natural color of  the skin,
and commonly situated on the  external surface of the limbs,
and in  the  line of extension.   It is  an essentially chronic
affection, lasting for months, and  even years, and is accom-
panied with a burning and intolerable itching.   It  generally
occurs about  the neck  and shoulders, but sometimes extends
to the face, trunk, and  limbs, and assumes a severe character.
It is occasionally confined to a single spot.   Willan  describes
three  varieties—Prurigo mitis, Prurigo formicans,  and Pru-
rigo  senilis—which  are  admitted  by most  dermatologists.
The first two differ from each other merely in degree: there is
no fundamental distinction  between them.   The last variety
has some peculiar characters.
   Symptoms.—Prurigo mitis appears  in the form of minute,
slightly prominent papulae, perceptible to  the   touch,  and
accompanied  with  a distressing pruritus.  This is  the mildest
form.    P. formicans  throws  up larger,  more  prominent,
and at the  same  time  flattened papulae, accompanied with a
still more intolerable itching than  the former, always  aggra-
vated  towards evening, and  by the  heat  of the bed;  and
which has been compared to the sensation that might be pro-
duced by innumerable  ants gnawing the skin, or to that of
hot needles piercing it.  The papulae are distinct, of the same
color  as the  skin,  if not  torn  by the  nails,  and  are  almost
invariably seated on the  back  and  external  aspect  of the
limbs.   There may be but few of them, and the itching  is

of chloroform has  led to its employment for this purpose, in the form of both oint-
ment and wash.  M. Cazenave recommends a wash of the strength of 15 minims
to 5 iv °f distilled water, to be put into a bottle which will hold double the quan-
tity, for the purpose of shaking it up for use.  {Gaz. des Hop., Dec, 1850.)  The
ointment may be used of the strength of 30 to 60 minims to §j of lard or sperma-
ceti cerate.  He has also employed with success the extract of aconite internally
for the same purpose, giving from one to two grains, in divided doses, during the
day.  Sometimes one application will succeed after another one  has been used
with benefit for a time, and then lost its effect.
  When chronic and local, ointments of different kinds may be used—of these,
besides those mentioned in the text, one first introduced into use in this city by Dr.
Crane, now of Brooklyn (L. I), consisting of  nitrate of bismuth, 3 ij,  citrine oint-
ment §j, and lard  Ijss, is very often effectual—also, a modification  of it which
may be made by substituting stramonium ointment for the lard.  Other ointments
deserving a trial are, one  of sulphur and carbonate of potash, or soda, 3 J or 3 ij
of the former, and  3 ss or 3 j of the latter to §j °f lard ;  and creasote ointment,
gtts. xx to xl to  ^j lard.  The stramonium ointment  also frequently affords
decided relief—H. D. B. 
212
DISEASES OF  THE SKIN.
sometimes not so excessive. But in other cases, and especially
in young subjects, they are not very numerous.   The itching
is then so  severe  that the patients, in endeavoring to  find
relief, tear them open with  their nails, and a drop or two of
blood oozes  out, and forms  thin, black scabs, which, though
accidental, are pathognomonic.   Sometimes this thin  black
scab falls off and leaves an elevation, which is  scarcely  per-
ceptible, and, in  some  cases, the papule  even  entirely  dis-
appears.
   The papulae which have not been torn disappear by absorp-
tion, or by slight desquamation, and  the disease terminates in
two or three weeks.  More  frequently, however, the papulae
continue for a long  period, and the  disease is prolonged for
months by the development of a new eruption.   In old people
and in weakly children, prurigo often continues for two or three
years, sometimes for an indefinite period.  It becomes gene-
ral, the papulae are large, hard, and prominent.   The eruption,
which is  accompanied with considerable  thickening of the
skin, is  attended with occasional exacerbations, during which
the papulae  become confluent.   The  skin is tumefied  and
inflamed; a  number of vesicles, pustules, and boils are deve-
loped ; and abscesses, accompanied with febrile symptoms, and
those of gastric irritation, frequently supervene.   It  is in
severe and rebellious cases of this kind that the patient is  tor-
mented with that distressing and insupportable burning pruri-
tus, even  a  true  description  of which appears  exaggerated
and unfounded.   When the papulae are numerous and are  fre-
quently reproduced on the same parts, the cutaneous tissue is
profoundly altered, and a  number of small, slight cicatrices
may be observed with the naked eye over the  diseased  sur-
faces.
   Causes.—Prurigo occurs at all ages, but  most frequently in
children and old people, and at all  seasons, but most during
spring and  summer.  The exciting causes  are low and damp
situations,  bad nourishment,  infected beds, poverty, want of
cleanliness, the use of salt  food,  shell-fish,  privation,  and
strong mental emotions.  But it appears in all  conditions of
life.*
   Diagnosis.—The diseases with which prurigo may in  par-
ticular  be  confounded  are lichen and some of the vesicular
eruptions.   It is distinguished from  lichen by the larger  size

'  * It also  appears in those who have indulged in luxurious living, especially
when of full habit and past middle age ; and is not unfrequently connected with
derangements of the menstrual function, of which  some striking instances are
given by Alibert.  Dr. Graves says {Clin. Led., Phila. ed., 1842) that P. senilis
is generally accompanied by derangement of some of the important secretions of
the body, but particularly of the urine.                      H. D.  B. 
PRURIGO.
213
of the papulae, by the black incrustations, and by the intense
burning itching.   Scabies is the disease with which it is most
likely to be confounded.   The papulae  of prurigo are flattish
and  of the same color as the skin, whilst the vesicles  of the
itch  are acuminated and  rose-colored.   The vesicles of the
latter  terminate  in thin  yellow scabs,  and appear in exactly
opposite situations to those in which the papulae are developed,
viz. on the abdomen, the  internal surfaces  of the arms  and
thighs, and in the line of flexion.   The itching of scabies
is much less  severe.  Prurigo is not contagious.*   Prurigo
may  coexist  with lichen,  scabies,  and eczema,  and may be
complicated with the pustules  of impetigo  and  ecthyma.   It
terminates by resolution, or by furfuraceous desquamation.
  Prognosis.—Prurigo  is  never  a dangerous disease.   It is,
however, obstinate,  unmanageable, and exceedingly harass-
ing  to the patient,  and  very liable to return.  It is  often
incurable  in  persons of debilitated constitutions, who  have
suffered much from privation and from frequent repetitions of
the disease.f
   Treatment.—The treatment of the mild forms—P. mitis and
P. formicans—consists in alkaline drinks, two drachms  of the
subcarbonate of potass to the pint,  and simple baths.  M.
Biett  was in  the  habit  of ordering one part of the alkali to
three of sulphur, which was generally attended with good effect.
In severer cases, it may be necessary to have  recourse to aci-
dulated drinks.
  When the  constitution is  broken down, and the digestive
organs deranged, the patient will  derive benefit  from  succu-
lent and milk  diet.  If the skin is  delicate and irritable, all
irritating applications should  be avoided ; if, on  the  contrary,
the skin is rough and dry, saline and alkaline  lotions ought to
be employed, and  alkaline, vapor,  or salt water baths alter-
nately with them.  Ointments are  seldom of much use.  When
the pruritus is subsiding,  friction  with alkaline or sulphur
lotions is often serviceable;  earlier in the disease they are
injurious.  The internal use of opiates is sometimes necessary
to allay the irritation produced by the excessive itching.  In
young persons and in children, sulphur  combined with  mag-
nesia is often  beneficial, and at the same time diluents, simple
or emollient baths; and at a later  period, alkaline baths  in the
proportion of  one to four ounces of subcarbonate of potass to

  * Prurigo sometimes returns habitually every spring and autumn, and may dis-
appear without any treatment, neither of which ever occurs in scabies.
                                                   H. D. B.
  t The irritation of prurigo when long continued has a tendency to injure both
body and mind, and has  been known to undermine the constitution, and even to
induce mental imbecility.                                 H. D. B. 
214
DISEASES OF  THE SKIN.
each bath, according to the age  of the patient.  Venesection
is seldom necessary, unless in young and vigorous subjects ;  it
may be very injurious.   All these measures should  be accom-
panied with an appropriate regimen.
   2. Prurigo senilis vel pedicularis  scarcely differs from the
preceding varieties as regards the papulae; they are merely a
little less  raised,  more flattened,  and less numerous.   The
dryness  of the skin,  which is merely accidental  in P. formi-
cans, is a specific  character of P.  senilis; but the leading dis-
tinction  is  the  swarm  of insects with  which  the  skin  is
infested  in the  latter  affection.   It most  commonly  attacks
old  people.    M.  Biett,  however, observed  it  in a  young
woman immediately  after child-birth.   Nevertheless it almost
invariably occurs  in  debilitated persons in the  decline of life.
   Old  people of  strong  constitutions  are seldom  attacked.
The skin becomes brown, its  functions  are disordered, and  it
is covered with  insects, which are multiplied and reproduced
with surprising rapidity.   The insects are usually of the genus
pediculus, but those of  the genus pulex have been seen.   The
presence  of  these insects  is sufficient to  prevent prurigo
senilis from being  confounded with any  other affection.   It  is
a severe disease, and is often incurable.  The  remedial mea-
sures  already pointed  out  are  also  appropriate  for  this
variety; but the  sulphur baths  should  be used more  freely.
Cinnabar fumigation  is by far the most effectual remedy;  it
destroys the pediculi  in a very short time, and is much prefer-
able to mercurial friction.   The general health of the patient
should be recruited with tonics, the preparations of  iron,  &c,
and the utmost cleanliness should be observed.*

  * The obstinacy of the disease in many cases  will often tax the resources  of
the practitioner to the utmost.  Watson {Lect. Prac. Med.) recom mendssarsapa-
rilla, alkalies, arsenic, the iodide of potassium, and dulcamara, as among the most
hopeful remedies.  Dr. Graves {Clin. Lect.) speaks of nitric acid with sarsaparilla,
and cream of tartar with powdered bark, as among the best remedies  for P. senilis.
When preceded by a scanty flow of urine, the diuretic remedies, he says, often effect
a great deal, and must be varied according to circumstances, and combined with
articles calculated to improve the state of the digestive organs.  I have derived by
far the most benefit from the sulphuret of potash, and have given it in pill, in com-
bination with laxatives, as rhubarb or aloes, with small doses of ipecac, and some-
times with quinine, or in solution with extract of sarsaparilla or rumex, or the two
combined.  The diet  must  be adapted to the constitution and age of the patient,
but, as a general rule, must be nutritious, but simple and unstimulating in those past
middle life.  Tepid baths, and especially of salt water, assist materially in the cure.
Alkaline and sulphurous baths also often do much good.
  To  relieve the itching, which  is often intense, various means have been used
besides those mentioned  under the head of lichen.   Dr. Graves speaks very highly
of a lather of soap and warm water, the water  to be as hot as the patient can
bear it, applied with a  very soft brush or sponge—also afterwards sponging the
parts at bedtime with  hot whiskey and  laudanum, Oj of the former  to 3 j of the
latter ; also of the following liniment, which he considers as one of the best appli-
cations in this disease, viz.  J£ Acetate of lead, 3j ; wine-vinegar and water, aa 
PRURIGO.
215
   Several local varieties have been described,  in  which  it is
very difficult to distinguish the papulae, but they are evidently
allied  to  prurigo by the intense  itching  which accompanies
them.   The pruritus may be confined to a small surface, and
constitute certain varieties, of which the  most interesting are
P. genitalium and P. podicis.
   Prurigo  genitalium occurs on the scrotum in men, and on
the pudendum  in females, and may in both cases spread to the
neighboring parts.   It often extends to the vagina, producing
nymphomania.   It may coexist with  P. podicis.  When it
occurs in men, an exudation of sebaceous matter takes place.
In general there are no papulae present, but in some rare cases
very slight papular elevations may be detected with the finger.
The skin of the scrotum becomes  brown,  and  sometimes
thickened;  there is always an intolerable itching, which exa-
cerbates, and the patients scratch and  tear themselves in the
vain attempt to obtain  relief.
   When it  occurs in females it is still more distressing.  It
frequently  excites onanism,  voluptuous desires,  and violent
nymphomania.   M. Biett observed a case of this kind  in a
woman sixty years of age.   He  examined the parts with a
lens, and could  not discover any lesion.  Nevertheless, this
female was  excessively addicted to self-pollution.   The dis-
ease commenced with  slight itching of  the  genitals,  which
became gradually augmented until it assumed the character of
nymphomania.   The  patient frequently  fainted  on  seeing
young men.  The  intense  burning pruritus, and the absence
of all redness, and of vesicles, distinguish  this affection from
certain varieties  of eczema which are developed in the  same
region, and  accompanied with  itching.  P. genitalium often
occurs without any appreciable  cause.   The  rubbing  of the
under  garments  against  the  parts, violent' exercise in warm
weather, and the general causes  of prurigo, may influence the
development of  this distressing  complaint.  It is  sometimes
the result of leucorrhoea when long continued, and it also fre-
quently occurs at the critical period.    It often coexists with
P. podicis.
   Prurigo podicis differs from the preceding variety merely

^ ij, rubbed up with enough olive oil to make  a liniment—to be shaken up when
used—a  lotion of dilute prussic acid, 3 j to  5 VJ or §yhj  almond emulsion is also
recommended, but should be used with caution ; also a lotion of bichloride mer-
cury, even as strong as 3j to Oss of water in old persons, and in some of the local
forms.   Watson says {Lect. Prac. Phys.) that he once relieved a case by smear-
ing the itching surface with an ointment containing a small quantity of aconitine,
when other means had been tried in vain. The tincture of the root of this article
might, perhaps,  be a useful application, and also  a lotion or ointment containing
veratrine.                                            H. D. B. 
216                DISEASES  OF THE SKIN.
in its seat.  It most frequently appears in persons of seden-
tary habits.  It is often  an accompaniment of haemorrhoids,
ascarides in the  rectum,  or- chronic inflammation of that in-
testine.   The patient experiences an intolerable itching about
the sphhicter of the rectum,  which extends upwards in  the
gut for some short  distance, and is always increased towards
evening, and after a hearty meal.
   These local varieties of prurigo are sometimes exceedingly
severe  complaints.   They are  always very rebellious, and  it
requires considerable  tact and attention to  allay the itching.
Sometimes it yields to the application of  leeches round  the
parts, together with emollient, cold, and narcotic lotions, and
afterwards the alkaline and sulphureous water baths.   Sulphur
and cinnabar fumigations are also often very useful in these
cases.   M. Biett  invented an apparatus by  which the vapor
of  sulphur and  mercury can be applied to  the diseased part
alone, which is in daily use at the  Hospital of  St. Louis.   R
has  this advantage,  that the rest  of the  body is preserved
from the  immediate  contact  of these  vapors,  and  from  the
debility which must necessarily ensue.   However, notwith-
standing the employment  of these several remedies, prurigo
genitalium has often  continued for six months  and  longer.
We have  known it continue for years.  It often  subsides for
a certain period, and then reappears in its original form and
intensity.*

  * The excessive itching which  occurs on the genitals and about the anus some-
times arises from other causes than prurigo, and must then be treated  accordingly.
When dependent upon this, or any other cutaneous affection, it will  generally be
found to be connected more or less with constitutional causes, and these various
and sometimes opposite in their nature, which require attention, at the same time
that local  means are used to relieve the itching as a symptom.   Of local applica-
tions, a great  variety  have been  recommended, some of which afford temporary
relief, and others fail altogether,  and hence the convenience of having several  on
hand for trial.  In addition to those already mentioned, are the nitrate of silver in
solution, of different degrees of strength, and in substance ; also tobacco in form of
infusion or poultice, or ointment of the oil, which, however, must be  used with
caution ;  diluted lemon juice ; also black wash, yellow wash, preparations of lead,
both of the acetate and carbonate, &c.  In some cases warm fomentations answer
best, and in others cold and even iced applications, and sometimes an alternation of
the two.
  Dr.  Simpson, of Edinburgh, mentions brushing the affected surface in severe and
distressing cases of prurigo of the cervix, vagina,'and vulva, often with hydrocyanic
acid (of the strength of that of the Ed. Pharm.) as  often  giving  the greatest
relief—{Month. Journ. Med. Sci., Ap. 1850.)
  Dr.  Meigs,  of Philadelphia, recommends a solution of borax in rose water, with a
small proportion of sulphate of  morphia, in this affection, to be applied by means
of a sponge or cloth wet with it, after having washed the parts with warm soap and
water, and wiped them carefully.
  Wilson says that the lotion upon which he chiefly relies to relieve  pruritus in
different eruptions, is one composed of bichloride of mercury, from 5 to 10 grains,
spirit of rosemary and spirit of wine, of each an ounce, and six ounces of the emul- 
                                 PRURIGO.                            217

sion ot bitter almonds.   He has also sometimes succeeded with a lotion of chlo-
rate of potash.—{Dis. of Skin, Phil. edit. 1847, p. 159.)
  It is sometimes necessary to  tie up the hands in a bag, to prevent  the  patient
from adding to the irritation by scratching.                         H. D. B. 
SQUAMA.
   This order comprehends certain chronic diseases  of  the
skin, characterized by  the  formation of inorganic  laminated
scales of a greyish-white color, dry, friable, more or less ad-
herent,  and  of  various degrees of density.  These whitish
lamellae of the cuticle are called squamae; they are always
elevated above  the skin, which remains  red and  inflamed
after they fall off.  They are the result of  a morbid secretion
of the epidermis, and  are very different from those vesicular
incrustations already spoken of, which depend on the concre-
tion of a  serous or sero-purulent fluid.  The squamous  dis-
eases are essentially chronic in  their nature ;  they are in
general very slowly developed, but sometimes they run on
rapidly, and  the eruption is  completed in  two or three days.
Their duration varies from  a few months to several years.
   Symptoms.—They generally  commence  with a  few red,
slightly elevated,  and distinct patches.    Sometimes  these
spots unite and become confounded together, and are speedily
covered with laminated scales.  The formation of the erup-
tion is rarely  attended   with  constitutional   disturbance.
Indeed, the patient is frequently not aware  of the existence of
the disease  until the patches are fully formed, or the cuticle
is  on the point of being detached.
   The squamous eruptions occur  most  frequently on  the
limbs; however, they  are  also  met with  on the  head and
trunk.   Sometimes  the patches are distinct,  scattered here
and  there, and  are limited in  number; but  they  are often
diffused over the whole extremity, and form a  kind of general
envelope.   The-lamellae present some difference of formation,
according to the variety to which they  belong:  thus,  for
instance, they are often  thin and flimsy,  as if composed of
one or two layers of  the  cuticle, which  become  dry and
whitish, and are detached  with much  facility, and in great
abundance;  in  other instances they are  firm and adherent,
and consist of hypertrophied portions of the epidermis.  The
long list of symptoms described  by authors  is rarely met
with; a slight degree of  heat and itching  are the most usual
concomitants.  When  the  disease occurs  in  the vicinity of 
LEPRA.
219
the joints, the movements of the latter are stiff and painful;
and if  the  eruption is of long standing,  the  skin becomes
indurated and thickened.
   Causes.—None of  this class  of diseases are contagious.
They are sometimes hereditary, and one of them (ichthyosis)
is most frequently a congenital affection.   They are not con-
fined to any classes of society, to  any age, or to either sex;
but they generally occur in adults.  They appear in the rich
as  well as  in the poor, and  are  supposed to prevail  more
frequently in autumn than in any other season, if there is
really any difference.
   Diagnosis.—The diseases belonging to  this class  cannot be
mistaken  for  any other  cutaneous disorders.   The presence
of  the laminated scales is alone sufficient to distinguish  them.
The vesicular, pustular, and  papular incrustations  and  scales
are very different in formation and  appearance  from true
squamae; besides the  presence of  vesicles, of  pustules, 01? of
papulae, in  the  neighborhood of  the  eruption, which can
always be detected with a little attention, will at once indicate
their real nature.  They are never attended with the forma-
tion of the  thin,  dry, micacious looking scales peculiar to the
squamae.    These diseases are  never dangerous, but  are
always rebellious, and require an energetic plan of treatment.
This order contains four species—lepra, psoriasis, pityriasis,
and ichthyosis.   Although some writers have objected to the
latter affection being included amongst the squamous diseases,
we shall describe it,  along with Willan, as belonging to that
class.

                         LEPRA.

Syn.—Lepra  vulgaris ;  Psoriasis  circinata ; Dartre furfu-
              racee arrondie ; Scaly leprosy.

   The Arabians considered elephantiasis as synonymous with
lepra, a term  which  they used indiscriminately for  all severe
and obstinate diseases of the  skin, however different  they
might  be  from each other in their elementary characters.
Medical writers  are now, however, agreed in designating by
the word lepra a squamous affection of the skin, characterized
by circular scaly  patches, with elevated borders and  depressed
centre, and  which may run together and form a continuous
patch.
  Willan  has described  two  varieties of this disease, L.
alphoides  and L. nigricans, which, as  we do not  intend  to
describe separately,  we shall simply  mention  here.   The
first, which occurs chiefly in children and debilitated subjects,
differs from lepra vulgaris merely  by the smaller size and 
220
DISEASES OP THE  SKIN.
whiter color of its patches.   The other is an exceedingly rare
affection, of the nature of  which we possess little  positive
information.   We believe it to be in the majority of instances
a variety of syphilis.   We have, however, seen two  cases in
M. Biett's ward that were decidedly not syphilitic.
  Symptoms.—Although lepra  may  appear on every part of
the body, the  limbs, the neighborhood of the joints,  particu-
larly  the knees and elbows, appear to be the special seats of
the disease; at least it is in these regions it  generally com-
mences, in the form of small, red, scarcely perceptible spots,
slightly elevated above the level of the skin.  These  patches,
which are smooth and  shining at first, are soon covered with
a very thin lamella, which  is not long in falling off.  They
gradually increase, always preserving their circular form ; the
scales are  renewed and  become  thicker, especially at the
circumference ; which  is elevated above the rest; at the same
time the centre remains intact, if  we except  some rare cases
in which one or  two  isolated  patches  are covered  all over
with  the squamous crusts.
  These patches are sometimes several inches in circumfer-
ence, but generally smaller.   They usually vary,  however, in
size  from that of a shilling to that of a crown  piece.  The
centre is depressed and of the natural color, whilst the borders
are elevated and covered  with an imbricated  layer of whitish
adherent scales.   The annular patches are not  always entire
and distinct;  they often become intermixed  and confounded
with each other, especially about the  joints, as the knees and
elbows;  and it is in consequence of this that  some authors
have  alleged  that there is no distinction between lepra and
psoriasis, but that, in point of fact, they  are one and the same
disease.  With a due  regard  to  accuracy, these affections
cannot be described as one.   Lepra vulgaris and psoriasis are
much more distinct from one another than herpes zoster from
herpes phlyctenodes;  wherefore we shall still  continue to
describe them separately.
   Whilst the scabs are thus  individually increasing  in dia-
meter, the eruption is becoming more general, and extending
progressively  to  the abdomen,  back, shoulders,  chest, some-
times to the  scalp and forehead, but rarely to  the face or
hands.  The  scales fall  off and are renewed  incessantly.
Their bases are red, slightly inflamed, smooth when the erup-
tion is recent, but furrowed  and wrinkled when of long stand-
ing.   These  are  the  characters  exhibited  by lepra  in  the
generality of cases; but it sometimes appears with very differ-
ent and very  remarkable symptoms.  Thus,  for example, the
eruption, deviating  from  its ordinary course, appears in the
form of small red circular  points, which  unite  at their edges, 
                         LEPRA.                      221

and by their eccentric arrangement  they  acquire  an enor-
mous size, and  the patches are not covered with scales, or if
they happen to be so, and fall off,  they are never  renewed.
We have observed several patients  at the Hospital .of St.
Louis in whom this variety was well illustrated.
  The trunk, and particularly the back, was the seat of broad
red patches, sometimes more than a foot  in circumference.
These patches  were formed by a prominent circular ring but
a few  lines  broad, accompanied on  both  its edges  with a
reddish border, also but a few lines  in breadth, and quite free
in every part from scales.  Sometimes two or three of  these
circular rings  extended over the  whole  of  the  back;  and
even, in some  cases, there was  only one large ring.   We
have  observed  that  in  other localities,  as the  limbs, the
patches were developed in the ordinary manner, and pursued
the ordinary course of the disease, as above described.
   Lepra  may  exist  for  a  long  period without occasioning
any bad symptoms, unless the vital functions become altered;
but it generally produces a  stiffness about  the joints, the
movements of which cannot  be accomplished, frequently,
without considerable  pain.  The ulcerations and cicatrices
which sometimes form are the result of some severe  compli-
cation ; they do not belong to this disease properly speaking.
If left to itself,  lepra may disappear and return quickly again,
or if may continue for a long period, and require very ener-
getic  treatment.  However, from whatever cause it subsides,
its cure is always slow  and protracted.   The patches first
begin to fade in the centre, the scales diminish  in number,
they cease to be renewed, and the process of  cure invariably
proceeds from the centre to the circumference.  The circular
rings  break in many  places, the raised borders sink,  and the
patches finally disappear.  In that variety, where the disease
manifests itself in the form of those large red circles without
scales,  above described,  the  morbid surfaces become much
more inflamed immediately before disappearing, the  raised
edges  then  quickly fade, and some portions  are here  and
there reduced to the level of the  skin ; the color also fades,
and  there  only remains  a slight erythema, which is not long-
in disappearing.
   Causes.—Lepra is not contagious ; it appears in all seasons,
but most frequently in autumn.   Men are more  frequently
affected  than women, while women,  on the  other  hand, are
more  subject to certain  forms of psoriasis, and especially of
psoriasis guttata: children are seldom attacked.  The causes
of lepra are but little known.   It may be produced by a cold
and damp atmosphere.   It frequently supervenes  soon after
partaking of salt food and sea fish.   Certain professions pre-
                            15 
222
DISEASES OP THE SKIN.
dispose to the  disease; for instance, those who are daily  in
the habit of handling and being otherwise  in contact with
pulverulent substances, metallic dust, &c, are very liable to
it.  It results more frequently from strong mental emotions,
than from any other causes.   Thus, it is by no means uncom-
mon  for  lepra  vulgaris  to  supervene after violent fits  of
passion, grief, or fright.  It may also be hereditary.
  Diagnosis.—The diagnosis of lepra is ordinarily very easy,
and the slightest attention will enable the observer to distin-
guish it from all other diseases.  We shall, however, recapitu-
late the peculiar characters which distinguish it from certain
cutaneous  affections with which it has  been  sometimes con-
founded.
  1. Porrigo scutulata (ringworm), at  certain periods of  its
progress, either at the commencement or at the end, when
the crusts  fall  off  and  leave  behind red,  annular-shaped
patches, may for a moment be mistaken for lepra of the scalp,
especially if there are patches on other parts of the  body at
the same time.   But  P. scutulata  occurs as seldom on  the
trunk  and limbs, as lepra appears on the scalp; and besides
the elementary  characters of the former—favous  pustules—
which are always present in the neighborhood of the rings,
will at once indicate  the true nature of  the disease.  The
appearance of the scabs, the destruction of the hair,  and the
contagious character of P. scutulata, will prevent the possibility
of these two affections being  confounded with one another.
  2. Syphilis.   The circular form of the patches of tubercu-
lar  syphilis  on  the forehead  and  back, sometimes resemble
those of lepra.   But  the coppery  and  violet color, and the
cicatrices which are always present in the  neighborhood of
the eruption in  the former case, together with other concomi-
tant symptoms, will readily distinguish  it.  Moreover, if the
patches are carefully examined, they will  be  found, not per-
fectly continuous circles, but isolated  tubercles, arranged in
an annular form, and  having  distinct intervals between them.
They are smooth and shining,  and are not covered with scales,
unless in some rare cases, and then the lamellae are extremely
hard  and thin,  and cover only  a part  of the  circumscribed
induration.   Sometimes, when the tubercles begin to undergo
resolution, and  are less prominent than in their earlier stages,
they may also  be mistaken  for leprous rings in  the act  of
healing.   A knowledge of the distinctive characters  of each
disease, as above described, will obviate this error.
  3. If we compare  lepra  with  the  irregular patches  of
psoriasis, the only affection of the  same order with which it
can for an instant be  confounded, we may see at a glance  the
marked distinction that exists between them.   There  is, how- 
LEPRA
223
ever, one variety of the latter disease, psoriasis guttata, cha-
racterized by isolated patches, which it is difficult to distinguish
from lepra during the process of cure.  The patches of P. guttata
are always smaller and more irregular than those of lepra, and
their centres are never round nor depressed like those of lepra;
and even during the process of cure, when a portion of  the
circular rings  of lepra disappear,  that which remains  will
always suffice  to distinguish the disease.  Finally, when  the
patches of the latter affection become agglomerated and run
into one another, there are always some portions of  the rings
distinctly visible, either in the neighborhood, or even in the
centre of the diffused patches, or on other parts of the body,
or  some new  spot  will be seen in the process of develop-
ment, which will leave no doubt as to the nature of  the erup-
tion.
   Prognosis.—Lepra is never attended with  danger, but it
is always a very rebellious and is frequently an incurable  dis-
ease.
   Treatment.—The treatment of lepra consists  in  external,
internal, and hygienic measures ;  but before adopting any
plan of treatment, the age and strength of the patient, and the
state of the eruption, should be carefully considered.  When
the patient is young and vigorous, and the disease has pursued a
rapid course, at the same time that the skin is red and  inflamed,
and the  pulse  full  and quick,  venesection,  simple  baths,
diluents, strict regimen, and quiet, will  be  necessary.  In old
and feeble patients, and those  whose constitutions are broken
down by excess or by  privation,  in  whom  the eruption is
never  attended with inflammation, it will  be advisable to
administer a course  of tonics, in order to invigorate the health,
with the view of having recourse to more energetic  measures
at a later period. If these precautionary measures are attended
to, the disease  may  then be vigorously attacked, both exter-
nally and internally.
   The  external agents, when employed alone, are  generally
inefficacious, and are sometimes even attended with inconve-
nience.  We shall not enumerate the various irritating appli-
cations employed by the ancients in this disease.  They should,
in our opinion, be rejected, together with blisters and cauteri-
zation, from the treatment of  lepra.   With regard to external
remedies, we have frequently  seen the application of a gently
stimulating ointment, no matter of what  kind, attended with
the greatest success.  But  here an important question pre-
sents itself for consideration,  namely, whether is an external
or internal plan of treatment the most appropriate for lepra ?
Our own experience, and also that  of M. Biett, goes to prove
the inefficacy  of the former whenever employed alone.   In 
224
DISEASES OP THE SKIN.
nineteen cases  out  of twenty,  the external applications pro-
duce  merely a  momentary  amelioration  of the  complaint.
We have often observed the  disease return in less than fifteen
days after being cured by some  of the supposed infallible oint-
ments.
  External applications are, however, useful auxiliaries during
the internal treatment, especially towards the decline of the
eruption.   They should not be employed alone unless in very
rare cases, when the disease  is recent and confined within  a
small compass.   Amongst those which we have seen attended
with the most advantage at the  Hospital of St. Louis,  in lepra
as well as in other cutaneous  diseases, we may mention an
ointment  composed of the ioduret of sulphur in the propor-
tion of twelve to fifteen grains  to an ounce  of lard;  the sul-
phur  may be increased to  half a drachm.   This should be
rubbed  over a  certain number of the patches  morning and
evening.   It stimulates  the  skin  gradually into a  certain
degree of inflammation when the squamae are thrown off, and
their elevated borders  sink and  fade.   In the course of a few
days the skin is restored  to  its natural color, and then other
patches ought to be  treated in the same manner.  Tar oint-
ment also produces a rapid but most  frequently only a tempo-
rary disappearance of the eruption.   The patient should con-
tinue to take some bitter infusion—dulcamara, mezereon, &c.
—while the ointment is being employed.*
  Baths are also very useful adjuvants towards the  cure of
lepra, especially sulphur and salt-water baths, which undoubt-
edly modify and alter the progress and  condition of the eruption.
The vapor bath, however,  excels all the  others as  a local
application.  It  increases the circulation, stimulates the skin
into more  healthy  action, detaches  the scales,  and  bedews
even the diseased parts with a gentle perspiration.  The sul-
phur  fumigations are  by no means  so efficacious  as some
writers would have us  believe.   In the majority  of cases they
produce merely  a transient modification of the disease.   It is
a fallacy to say  that lepra can be cured by external remedies
alone, which are often not  only useless but even  injurious.
We must  have  recourse to internal treatment to remove this
disease effectually.  Amongst the internal  remedies which
have  sometimes proved  serviceable, we  may  mention  the
decoctions of dulcamara, much extolled by Carrere and Crigh-

  * White precipitate ointment, and ointments of proto-iodide  and deuto-iodide
of mercury, the strength to be varied according to the irritability of the  skin in the
particular case, are often useful when the disease  is limited in extent and of long
standing.  Creasote ointment also assists in its  removal, and M. Emery recom-
mends naphthaline ointment, 3 j to 3 ij to § j lard.  Sometimes the most simple oint-
ments, and at  other times narcotic ones, succeed best.            H. D. B. 
LEPRA.
225
ton; of mezereon, and ormis pyramidalis bark, the watery
extract of white hellebore, rhus radicans, rhus toxicodendron,
&c.; their virtues, however, are very uncertain.  Dulcamara
is  more favorably known than the other articles enumerated,
but M. Biett has not found it attended with such good results
as those who first recommended it.  It may, however, prove
of service, and  deserves further  trial.  Sulphur appears  to
be in some cases a useful auxiliary.   The sulphuret of anti-
mony is always unsuccessful.  Mercury in the metallic state,
and in the form of the deuto-chloruret, has not been more effi-
cacious.   Calomel alone has often succeeded, but it seemed to
act as a purgative.   Pitch or tar has been followed with vari-
able results.
   The result of M.  Biett's experience at the Hospital of St.
Louis goes to prove that the most  successful internal treat-
ment consists in the exhibition of purgatives, tincture of can-
tharides and the different preparations of arsenic.   1. Pur-
gatives.  These are generally most serviceable when the dis-
ease  is recent and  of limited extent, especially in  children.
Calomel may be administered every morning fasting, in four-
grain doses, either alone or combined with the same quantity
of jalap.  Sometimes from two drachms to half an ounce of
the sulphate of soda or of magnesia in a pint of some bitter
infusion, produces a good effect.   In other cases, more active
purgatives, as aloes,  colocynth, scammony, and gamboge have
succeeded, more particularly when combined.   It is difficult
to  select any particular remedy beforehand.   The choice
should be guided by the condition of the patient, the state of
the  eruption, and the  effect  of the  medicine previously
employed.   Calomel, however, continued as directed for two
months or more, is admitted to be attended with  most success.
 It  often produces a complete cure within  that  period.   In
 some instances,  it is true, it produces salivation, but the cases
 are very rare in which it will be necessary to push the medi-
 cine to that extent.   It  is an invaluable remedy in children,
 and should be administered in sugar, in doses regulated accord-
ing to  the  age of the patient.   Its  action is not quick  and
rapid in. any case.  It operates slowly but surely in  establish-
ing a cure.   None  of the medicines, which it will  be neces-
sary to continue for  any lengthened period, should be adminis-
 tered in other than small  and divided doses,  as the action
 required is that of gradual and certain derivation, and not that
 of active and  sometimes  injurious  revulsion.    It  is often
 very advantageous, and sometimes even necessary, to suspend
 the treatment for three or four days, and then commence anew.*

   * In the last edition of the work, the whole of this paragraph respecting purga-
 tives is left out, and no mention is made of their use in the treatment of this dis-
ease-                                              H. D. B. 
226
DISEASES OF THE SKIN.
   2.  The  tincture of  cantharides  is more useful  in cases
where the disease has reappeared without any evident cause,
when it is diffused, and has resisted  the action of purgatives,
and when it occurs in subjects of a soft  and lymphatic con-
stitution.   It ought to be prescribed in doses of from three to
five  drops  every  morning in a little water, and the dietetic
regimen should  be at the  same time severe.  The effects of
the medicine ought to be carefully watched, and  if it does not
produce any  irritation of the digestive or  genito-urinary
organs, the dose may be increased five  drops every six or
eight days.  If, however, it produces heat at the epigastrium,
nausea, vomiting, ardor urinae, erection of the penis, &c, cir-
cumstances which rarely occur, the medicine should be sus-
pended immediately; but  when administered with caution,
and  by gradually increasing the  dose,  the latter may  be
extended to twenty-five or thirty drops and beyond, without
occasioning any evil  result.  It generally  effects  a cure, espe-
cially in females, in the course of forty-five to fifty  days, and
we have seen  a  case  of lepra  at the Hospital of St. Louis of
eighteen years' standing disappear  in the course of a month
under the influence of this remedy.*
   Arsenical preparations  must  be had  recourse to if the
disease resists all  the remedies already enumerated, when it
is  of several years' standing, and diffused over a large surface
of the body, when the skin  is thickened, and its condition
otherwise altered.  They often have a most surprising effect
even  after all other remedies  have failed.    The  preparations
©f arsenic  commonly used are Pearson's  and Fowler's solu-
tions, and if the proper precautions be observed,  these are
invaluable remedies, and no more dangerous than any  others.
Pearson's solution, the mildest form  in which  arsenic  can be
given, should  be  prescribed  in doses of a scruple to half a
drachm or  a drachm ; and Fowler's solution, which is much
more active, is to be given in doses of  three  drops  to begin
with, ever}'- morning  fasting, which may be increased two or
three drops every five or six days until  twelve or fifteen
drops are taken  daily; but it  should never exceed  this, and,
like the tincture of cantharides, it will be desirable to suspend
its use  from time to time, and when  employed again,  we
should begin with the smallest doses mentioned.  Sometimes,
when Pearson's  solution fails, that of Fowler will be attended
with  success.    Should any  symptoms  of gastro-intestinal
inflammation  supervene, it will be  necessary  to suspend at
once  the employment,  of  both  these remedies;  but  at  the
same time  care  should be taken that there are good grounds

 * Mr. Wilson says {Dis. Skin) that the best mode of giving tincture of cantha-
rides is in combination with equal parts  of tinctura opii camphor., and taken with
tinct. cinchonae.                                       H. D. B. 
LEPRA.
227
for depriving  the patient of  the salutary  effects  of such
valuable remedies. The preparations of arsenic are, no doubt,
very dangerous remedies  in unskilful  and incautious hands;
but administered  with tact and attention to the precautionary
measures, they will not produce  any ill effects ;  on  the con-
trary,  they  will be of incalculable service  in promoting  the
cure of the disease.   When first administered,  they usually
stimulate the morbid  parts into greater activity.  The patches
become less insensible, the centres heal, and the circular rim
breaks down and gradually fades, so  that in the course of a
few months, sometimes less, a severe  and inveterate disease,
which has existed for  years, may vanish under the  judicious
employment of the above mentioned preparations of arsenic*
   Hygienic measures are very serviceable as adjuvants, espe-
cially  in preventing a return of the disease.   The diet of the
patient should be restricted, the use of ardent spirits strictly
prohibited,  and the causes of the disease, if possible, avoided.
The trade or vocation of the individual often exercises much
influence on the development of the  eruption, in the event of
which it will be necessary to give it up, at least for a period.
   [The iodide of arsenic is very efficacious in obstinate cases
of lepra.   The  dose 1to begin  with is  about the tenth of a
grain,  to be given three times a day.   It may be increased to
a  quarter  of a  grain.   The  iodine  acts  on the absorbent
system, while the arsenic alters the vitality of the skin.
   My  attention was  directed  several  years  ago,  by Mr. A.
Walker, to  a preparation  of sulphur and iodine, the vapor of
which  is  an  admirable  local  application  in a  variety of
cutaneous  diseases.   These remedies  combined,  seem  to
possess  healing  properties  which are  not  manifested  when
they are used separately.   When employed  judiciously,  and
in appropriate cases,  they appear  to alter the vitality of the
morbid parts, and to induce a state of healthier action.  If the
eruption is  indolent, they generally stimulate the  diseased  sur-
face into greater activity ;  and  by  regulating  the strength
of the  medicine, according to  the  nature  of the  case  and
the object  in  view,  the most salutary effects may  often be

  * For a paper on the use of arsenic in diseases of the skin, by Mr. Erichsen, well
deserving careful study, see Braithwaite's Retrospect, No. VIII., p. 10, Amer. Ed.,
taken from London Med. Gaz., May, 1843.  In the same valuable republication
(No. XXII., for Jan., 1851) will be found an abstract of valuable practical remarks by
Mr. Thomas Hunt, on  the medicinal action of arsenic in cutaneous and other dis-
eases, taken from the  Medical Times (London) for Aug. 10 and Sept. 14, 1850.
He insists particularly, and with great propriety, that arsenic should never be given
on an empty stomach, but always with  or  after a meal; and also that it should
never be administered in increasing doses.  A memoir on this subject by the  same
writer was published in the Trans, of the Prov. Med. and Surg. Assoc, vol. xvi.
                                                     H. D.  B. 
228
DISEASES OF  THE  SKIN.
derived from its  use.   I have  seen cases  of lepra, of several
years'  standing,  which had resisted every  other treatment,
cured in a very few months by the application  of  the vapor
of sulphur and  iodine.  It is  particularly applicable to squa-
mous  and tubercular  diseases,  and  to  foul,  ill-conditioned
ulcers of the  lower  extremities.  It may be administered in
this form—$  sulphuris, 3  iij;  hyd. sulph. rubri,  3 ij ;  iodinii,
gr. x. M. fiant pulv. sex.   One of the powders to be  used  in
the following  manner  three times  a day:—If the  disease is
seated  on  the  limbs, a  tin case, or even a common jar—which
will answer as well,  provided  it  is large  enough to hold the
limb—should be procured, a heated iron is to be placed  at the
bottom of this apparatus, with a .grating  above it to protect
the foot or hand.   One of  the  powders being placed on this
heated  iron, the limb is to be  instantly put into the bath, the
top of  which  should be covered over*,  to  prevent the  vapor
from escaping.   The  limb may  be continued in the bath for
from fifteen to twenty minutes, according to circumstances.
In the  course  of a day or two the  proportion  of iodine may
be increased;  for example, thirty grains  of iodine, and at a
later period double that quantity, may be incorporated with
an ounce and  a  half  of the flowers of sulphur, to be  divided
into twelve powders,  and  used in the  same manner as the
former.
  I do  not mean to extol this preparation  as a specific for the
cutaneous eruptions  indicated above;  nevertheless, I think it
is worthy  the  attention of practitioners, and that it will .often
be found a very efficacious remedy.   B.}*

  * The liquor hydriodatis arsenici et hydrargyri, a compound of iodine, arsenic,
and mercury, first made known to the profession by Mr. Donovan, of Dublin, and
hence often called  " Donovan's liquor,"  has proved successful in the treatment of
many cases of long standing and obstinate lepra and psoriasis, as well as  in some
other cutaneous diseases.  Details  of its composition and effects will be found in
numbers II. and IV. of Braithwaite's Retrospect.  The dose, as recommended by
Mr. Donovan, and used by others whose cases are reported, is from twenty drops
to half a  drachm, three times a day. I have been pleased with its effects in several
cases, but have seldom given more  than  fifteen drops at a dose, three times daily,
and have had patients who could not get so far as ten drops at a dose without
unpleasant effects.   It is a powerful remedy, uniting the properties, to a certain
extent, of the three heroic remedies of  which it is composed, and must be used
with corresponding caution.  It is most prudent to commence with a small dose,
and increase the quantity every few days, as the patient can bear it.  Irritation of
the stomach or bowels, or of both, has usually been the earliest of its unpleasant
effects in my experience, and requires its suspension if it increases or continues
under its  use.  It may be given in the tincture or syrup of ginger, or in any aro-
matic infusion.                                         H. D. B. 
PSORIASIS.
229
                       PSORIASIS.

 Syn.—Psora  leprosa;  Dartre ecailleuse;  Dartre  squam-
                     meuse lichenoide.

  Psoriasis is a chronic inflammatory cutaneous disease, cha-
racterized by patches of various extent,  irregularly formed,
slightly raised above  the level of the skin, and covered with
thin, dry, white scales.  There are several distinct varieties of
psoriasis, depending  either on  the degree of intensity or on
the situation they occupy.  In one variety  the patches  are
distinct,  small, and  scattered ; in  another they are  larger,
confounded together, and irregular;  in  a  third they are still
more extended, and  form one continuous surface;  and in a
fourth they appear  twisted or in lines.  Hence the  names,
Psoriasis guttata, diffusa, inveterata, gyrata.
   1. Psoriasis guttata  is  a  mild  form of the disease, and
appears to be an intermediate affection  between lepra and
psoriasis.   It  is characterized by small red distinct patches,
irregularly rounded,  raised  at  the centre,  covered with  thin
white scales, and seldom exceeding two or three lines  in cir-
cumference.   It first appears  in the form of small, distinct,
red points, in the centre of which  a very thin scale is soon
seen.  The  patches  always remain isolated, and the inter-
stices between them are sound, and retain the natural color
of the skin.   Their appearance is that of large drops of fluid,
scattered  over  the surfaces on which  they  are seen.  The
scales are more or less adherent, and on  falling off leave bright
red,  slightly painful, and prominent  patches.  This  variety is
met  with  on every part of the body, but  most frequently on
the  back and on the  external aspects of the  limbs.  It is
rarely accompanied by febrile symptoms; but the heat of the
bed  towards evening, and  in  the  night, occasions a slight
degree of itching, and the scales, when scratched off, or when
they desquamate naturally, are quickly reproduced.  It appears
most frequently during spring  and autumn, and disappears in
summer  or in winter.  This  is not a rare variety of the
disease, nor is it very severe.  It occurs oftener in adults than
in children or old people.  It sometimes coexists with one of
the other forms of psoriasis.
  2. Psoriasis diffusa occurs  in the  form  of flat, angular,
irregular,  and larger  patches than the  foregoing.    They are
at first red, of a papular form, and distinct;  they speedily unite
and  form continuous  surfaces, covered with thick, whitish, and
pretty adherent scaly incrustations.  Although it may appear
on every part of the body, the limbs are much more frequently 
230
DISEASES OF THE  SKIN.
affected than any other part.   It is by no means uncommon
to see  one  continuous  patch covering the  whole  of the
anterior  surface  of the leg,  or the posterior aspect of the
fore-arm.  The elbows and knees are constantly affected ; and
even  when it has disappeared from any other part of the
body, it will remain fixed in these  regions, from which it will
be difficult to remove  it.  In  some rare cases, the  disease
appears simultaneously on different parts of the body.   We
have  seen cases, at the hospital  of St. Louis, in which  it
covered  the  greater part of the  back,  abdomen, and  both
arms, spreading  down to the fingers, which were encased as
with a glove.  Beneath  these  scales the surface is very red
and polished.
  Psoriasis diffusa is generally preceded by  slight constitu-
tional disturbance, together with a troublesome severe  itch-
ing, which, however, soon subsides, and  disappears when the
eruption is developed.   In some cases the  patches  are not
inflamed, and the patient merely complains of slight formica-
tion ; but in a few rare instances there is considerable inflam-
mation  present;  the patches are  prominent and  the scales
thick, and painful fissures and  chaps are established, which
annoy the patient considerably.  P. diffusa generally attacks
adults;  nevertheless, it sometimes  occurs in young  children
(P. infantilis, Willan), and its progress in those cases is  often
remarkably rapid. It is always a  severe and intractable dis-
ease ; lasting frequently for months, and even for years.
  3. Psoriasis inveterata is the same affection as the forego-
ing, but of a more severe form.   It occurs most frequently in
aged  persons and in broken-down  constitutions,  and  often
attains a high degree of intensity.   The skin becomes thick,
hard, and hypertrophied ; it is split  in different directions, and
the scales are no longer  of the usual size and thickness,  but a
sort of furfuraceous desquamation  takes  place, which fills up
the furrows of fissures, and is readily detached.  Sometimes,
in these cases, the morbid  surfaces  are  entirely deprived of
scales, and are red, slightly inflamed, and furrowed in every
direction.  On pinching up the  skin between  the fingers, it is
found to be deeply altered, and  feels rough, hard, and uneven.
The eruption is sometimes  confined  to the limbs;  in  other
instances, it  spreads  over the whole  body ; and in some rare
cases, the patient seems as if incased in a scaly envelope.   The
slightest movement of the joints produces deep, bleeding, and
painful fissures.   The nails  are also  affected;  and are  mis-
shapen, rough, and ragged;  they  split into pieces,  and are
replaced  by  misshapen, scaly incrustations.   This variety is
occasionally  complicated with inflammation of the  mucous
membranes, particularly of the intestinal canal; but this never 
PSORIASIS.
231
occurs in young and vigorous  subjects.   This is  the  most
severe form of psoriasis.
  4. Psoriasis gyrata is a very rare variety of the disease,
for which lepra and some syphilitic eruptions have been often
mistaken.  It consists in  long, narrow, tortuous,  or spiral-
formed  stripes,  resembling worms ;  and sometimes bending
into rings, occurring generally  on the  back.  M.  Biett has
seen but a few cases of this kind amongst the external patients
at the Hospital of St. Louis.  Willan gives a good description
of it.   We have observed many intermediate forms of the
disease, between the four varieties now described, which, with
one remarkable exception, we shall pass over for the present.
We have occasionally observed, in young persons of fair com-
plexion and  fine delicate skin, regularly rounded patches, the
borders or centre of which  were not  raised.   The circular
patches were almost  always distinct, flattened, and about the
size of a crown piece, covered with  thin slight  scales, which
adhered only slightly to a rose-colored and very slightly in-
flamed base.  It occurred most frequently on the body and
 arms.'
   There  are some more essentially  local varieties of  the dis-
ease which present several peculiarities worthy attention.
   1.  Psoriasis  ophthalmica  appears  sometimes  in  small
squamous patches, seated about the angles of the eyes and on
the eyelids, which are swollen, tender and painful, especially
when moved.   Although  it may be accompanied with an
analogous eruption on the face, it often  occurs alone, particu-
larly  in  children.  It often  occasions  a  smart itching, and
spreads to the  conjunctivae, when  the disease  is very  ob-
stinate.
   2.  Psoriasis  labialis  occurs  generally alone.  It  appears
in the form of  a circle about half an inch broad, which sur-
rounds  the mouth.  This circle gives off a number of lines,
giving the parts a puckered appearance.  These lines project
from the  circumference all round to  the borders of the lips.
The epithelium is thickened, the scales  are larger than  in the
other varieties.   It is generally a very obstinate affection.
   3.  Psoriasis prceputialis also occurs  alone, but  sometimes
accompanies that of the scrotum, and  is characterized by a
thickening and corrugation of the skin, which is chapped, and
often so  much contracted  as  to produce  phymosis.   The
slightest attempt to draw back the prepuce causes  considera-
ble pain, and frequently an oozing of blood from  the parts.  It
is a tedious and painful affection.
   4.  Psoriasis scrotalis, and that of the  pudendum in females,
 are of very rare occurrence, for which cases of chronic eczema
have been often mistaken.  However, P. diffusa may  some- 
232               DISEASES OF THE  SKIN.
times appear on these parts, when the skin is dry, rough, thick,
and furrowed, and the penis is sometimes surrounded with a
scaly envelope : syphilitic tubercles developed in these regions
have often been mistaken for spots of P. guttata.
  5. Psoriasis palmaria,  commonly  called  grocers'  and
bakers' itch, commences with slight inflammation, followed by
the development of red,  firm, hard spots in the palms of the
hands, sometimes attended with burning and smarting. It more
rarely appears on the soles of the feet.  The raised spots are
soon covered with a dry white scale, which is replaced as soon
as it falls off, and according  as the centre heals, the circum-
ference increases until the whole hand is affected.  The cen-
tre is of  a livid  color when  denuded, the  skin  is thickened,
furrowed, and chapped;  the fingers,  the palmar  aspect of
which is also affected, cannot be fully extended without excit-
ing considerable pain.  In females this affection is often com-
plicated with psoriasis of the pudendum.   It is difficult to be
cured, and is the more liable to return from the fact  that those
accustomed to manual labor are most  subject to it, and such
persons are always  anxious to resume  their occupation as
soon as they are cured.
  6. Psoriasis dorsalis is sometimes confined  exclusively to
the dorsal aspect of the  hands and  fingers.   The  squamous
patches are  harder, drier, and larger than those of the forego-
ing, and there are  deep and  painful fissures in  the  neighbor-
hood of the articulations.  This variety is also called grocers'
or bakers' itch, and affects the same class of persons as P. pal-
maria.  Washerwomen are  also very subject to it, evidently
from the constant irritation produced by the soap.  It is occa-
sionally met with in the better classes of society.
  7. Psoriasis unguinum.   This  variety was first  described
by M. Biett in his lectures ;  it frequently coexists with other
forms of the disease, especially with P. guttata.   The disease
affects the matrices of the nails,  the  secretion  of  which be-
comes altered, and the nails are misshapen, rough, uneven, and
laminated.  This complication is  not peculiar to psoriasis ; it
frequently accompanies  lichen, which, when seated on  the
fingers, manifests itself by frequent eruptions,  and penetrate^
to the roots of the nails.
   Causes.—The causes of psoriasis are as obscure as those of
lepra.  It is sometimes hereditary, but never contagious : both
sexes are liable to it, and adults more  frequently than  young
persons.   It occurs  more frequently in spring and autumn
than  at  any other period.   It sometimes  occurs in healthy
persons who are both well-fed and clothed. It  often follows
the abuse of spiced food and of spirituous liquors,  the use of
sea-fish, violent  mental emotions, and irritating local applica- 
psoriasis.                      233
tion.  It sometimes alternates with other diseases,  and we
have seen it succeed to articular rheumatism.*
  Diagnosis.—Psoriasis may always be distinguished  from
lepra, by bearing in mind the following facts: in the latter the
patches are broad, round, depressed at the centre, and raised
at the circumference.  In P. guttata, the variety most likely
to be confounded  with lepra, the patches are small, and their
centre is raised.   In P. diffusa they are irregularly quadran-
gular, rough, and  uneven;  and in P. inveterata the  patches
are large  and  furrowed, and envelope the whole limb.  It is
unnecessary to make any remarks on the peculiar character-
istics of P. gyrata.   The rounded patches of  lichen circum-
scripta may sometimes be mistaken for psoriasis ; but it will
be always easy to discover the central papulae  of lichen in  or
about the eruption.  M. Biett did not coincide with Willan,  as
to the conversion of lichen into psoriasis diffusa; he admits,
however, that patches of lichen may be covered with scales;
but  adds,  that the papulae are always to be distinguished
with the slightest  attention,  and  that  the  scales  are only
accidental.
   One of the commonest forms of the syphilitic eruption may
be confounded with psoriasis  guttata; as for instance, when
syphilis appears  on the skin  in the form of round,  isolated.
prominent patches; but in psoriasis they are covered with
scales, and of a bright red color, whilst in syphilis they are  of
a coppery color; they  are  seldom  covered with true scales,
but in their stead with a sort of thin, slight crust.  M. Biett
has often  pointed out in his lectures a peculiar  and pathogno-
monic character—a small  white  border, analogous  to that
which succeeds a  vesicle, surrounding the base of each eleva-
tion.   Sometimes the debris of syphilitic squamous  patches,
and  especially of syphilitic tubercles during  the process  of
cure, have been mistaken for P. gyrata.  But here, as in the
foregoing  cases,  the  coppery tint  and  other  concomitant
symptoms, independent of the respective characters  of each
affection, will be sufficient to prevent this  mistake  from
occurring.
   The latter variety has  also  been confounded with certain
forms of lepra, but the distinction is  so evident, that  we shall
not dwell on it here.  The thickness of the scales,  and the
presence of hard, firm, projecting spots, will prevent that form

  * The  connexion between both lepra and psoriasis and derangement of  the
digestive apparatus, in some one or more of its [functions, is not so much insisted
upon by the French writers as its influence in a practical point of view deserves.
English authors generally take this view. Prout {on Stomach and Renal Diseases)
and Holland {Medical Notes) both speak of their intimate connexion with  the
gouty diathesis.                                         jj, D g_ 
234
DISEASES OP THE  SKIN.
of psoriasis which appears on the scalp from being confounded
with pityriasis.   It  is sometimes more  difficult to be distin-
guished from chronic eczema. However, in the latter affection,
the scales are yellow, and the  surface beneath humid, besides
there are always  some elementary vesicles  to be seen round
the parts.   Psoriasis of the lips still more resembles  eczema, as
it presents the same kind* of chaps or fissures ;  but the absence
of vesicles, the large size and hardness of the scales, and the
thickness  of the epithelium,  are diagnostic  of  the former.
Several of the squamous diseases may exist  simultaneously.
This  disease may also be  accompanied with eruptions  of a
different order,  as,  for  instance, porrigo favosa;  but  such
complications are rare.
  Prognosis.—Psoriasis  is,  generally  speaking,  a  severe
affection, especially on account of its rebellious nature, and
long duration.  The prognosis  will vary  according  to the age
of the eruption and condition  of the patient.  For example,
P.  guttata, although not  a  severe form  of the  disease, is
nevertheless  very obstinate:  P.  diffusa still  more so, espe-
cially when it attacks old people, or persons of  a debilitated
or broken-down constitution. P. inveterata, the severest form,
sometimes resists every kind of treatment.
  Termination.—Psoriasis  may sometimes disappear without
the aid of any treatment.  The patches dwindle  and  fade,
and the skin resumes its natural  color.   In other  cases, one
variety passes into another; thus P. guttata and diffusa are
changed into the  inveterate form.  Sometimes it disappears
on the accidental appearance of some other disease, as inter-
mittent fever, erysipelas, measles.  It rarely terminates fatally,
unless when it attacks persons far advanced in years.   In the
majority of cases it may be cured by the  application of appro-
priate measures.   The  patches gradually decline,  the  skin
becomes more  pliant,  and by degrees  resumes its  natural
color and  condition.  In  some severe cases, it resists every
kind  of treatment.  The skin increases more and more  in
thickness, and its natural condition is altered ; even the  nails
participate, as already mentioned, in the  general tegumentary
lesion.  The disease may continue in this  manner for years
without exciting any dangerous complication ;  but the patient
sometimes sinks under chronic inflammation  of the mucous
membrane of the stomach and bowels.
   Treatment.—The  treatment  of psoriasis  is essentially the
same as that of lepra, and the curative indications of the latter
disease are also  applicable to psoriasis  ; but as psoriasis is
often more rebellious than lepra,  the remedial agents, espe-
cially the preparations of arsenic, should be pushed further, and
with more energy, than the latter affection  requires.   Those 
PSORIASIS.
235
who  have  had experience in the treatment  of this disease,
know how little value is to  be attached to the use  of mere
topical remedies, and  narcotics and emollients.  We do not
hesitate to say, that a permanent cure,  unattended with any
dangerous results, may be obtained by the judicious adminis-
tration of  the arsenical preparations, which  are  indeed the
only effectual remedies  for P. inveterata.  We say this after
long experience in the  treatment of these diseases;  and M_.
Biett entertained a  similar  opinion for the last twenty years.
We have published a  case of psoriasis  inveterata  of fifteen
years' standing, which was cured  at  the  Hospital of St. Louis
in twenty-six days, with Fowler's solution, without occasion-
ing the  slightest  accident.   (Vide Journal Hebdom. vol. i.  p.
259.)   Another preparation of arsenic—the  Asiatic pill—is
also very serviceable  in the  severe forms  of psoriasis.  R.
Arsenici protoxidi, gr. i.; Pip.   Nig. gr. xij.; Pulv. Acac.
gr. ij.; Aq.  distill, q. s.; Divide  in pil.  xij. vel xvj.—One  of
these pills to be given daily, sometimes two, but never more ;
their continuance to  depend upon the state  of the  eruption
and  of the patient.   If no perceptible  improvement  lakes
place within  fifteen or  twenty days, they  should be discon-
tinued ;  but  if their effect is favorable, they may be given for
six weeks, with  occasional suspensions, and  with  the same
caution as is  necessary  in the use of the  other preparations of
arsenic.  M. Biett has  obtained  successful results  with the
arsenite  of ammonia,  administered  in  the  same  doses   as
Pearson's solution.   The ointments of  the  proto-iodide and
proto-nitrate   of  mercury, are  useful  in  stimulating  the skin
into  more  healthy action,  when  the  patches are obstinate.
When more active applications are required, the deuto-iodide
of mercury, tartar emetic ointment, or blisters, may be resorted
to.   In  adopting Ambrose Pare's  plan of vesication, it will be
necessary to  apply the blisters eight or ten times successively,
to have any good effect.*

  * In"some cases of acute and sub-acute psoriasis, especially of P. diffusa, liquor
potassa?, given as recommended under the  head of eczema, will be found very
beneficial after the secretions from the bowels have been properly regulated.   As
the case becomes more chronic, Plummer's  pill may also be given at night, or a
mercurial  laxative exhibited two or three times  a week.  The diet must also be
strictly attended  to, avoiding salt or smoked meats, fish, pastry, gravy, and all
kinds of stimulating food and drinks, and also all articles known to cause acidity of
the stomach.  In chronic cases it  is often  necessary to change the habits of the
patient entirely.  Sometimes even a change  of climate is necessary to accomplish
a cure.
   In chronic cases, the bichloride of mercury will sometimes succeed when other
means have failed.  It may be given in fluid extract or syrup of sarsaparilla, or in
some bitter tincture, and in doses varying from an eighth to a quarter of a grain,
three times a day.  I have found this particularly useful in P. palmaria.
   M. Emery, of  St. Louis Hospital (Paris), gives, as the result of long and exten- 
236
DISEASES  OF  THE SKIN.
   The  local  varieties  of psoriasis  require  other  measures,
independently of the  general  treatment, which consists  prin-
cipally  in  the administration  of  purgatives.   In P. ophthal-
mica, the application of three  or four leeches behind each ear
at the commencement of the treatment, will often be attended
with advantage ;  and at a later period, frictions, with an oint-
ment of the proto-chloruret of  mercury over  the seat of the
eruption, as  in psoriasis of the  lips.   Emollient local baths,
and the use of  the  same ointment,  are  the most appropriate
remedies for  P.  preputialis.    Sulphur, and  even  cinnabar
fumigations,  are  attended with great  success in psoriasis  of
the  scrotum.   In P.  palmaria,  after  soothing the diseased
parts with local baths of the decoction  of bran,  &c, the  parts
should be gently stimulated with  the iodide  of mercury  oint-
ment, which produces the happiest results.  The arsenical pre-
parations are  often required in the treatment  of this variety.
It is  in  these local varieties  that  the iodide of sulphur  is  so
beneficial.   The  pitch ointment  is  sometimes  useful  as  an


sive experience, the opinion that the internal use of arsenic (Fowler's solution), and
the external application of tar ointment, in the proportion of \ or \ part  of tar,
constitute the best treatment of psoriasis and lepra. He has also derived benefit from
an ointment of proto-iodide of mercury, and also from one of iodide of sulphur.
—{Bull, de Th'er., Juin 15, 1849 ;  also  Braithwaitexs Retrospect, Jan., 1851.)
  Sir Henry Marsh relies upon the use of sulphur, both externally and internally,
in the  treatment of these diseases, attributing to this article a peculiar action upon
the capsules of the blood.—{Dublin Med. Press, July, 1850.)
  Infusions of tar are said, by some, to effect a cure, even when only taken inter-
nally,  while others recommend the use of them externally at the same time.
  M. Cazenave has recently used the carbonate of ammonia internally with success
in psoriasis, when chronic, in the form of a syrup,  with an infusion of balm and
senna.—{Gaz. des H6p., Oct. 12, 1850.)
  Dr.  Neligan usually commences the  treatment of the squamous diseases with
iodide of arsenic, when nothing forbids its use ;  and after the lapse of five or  six
weeks, gives a combination of Fowler's solution and iodide of potassium, to which,
in inveterate cases, he adds iodide, so as to give  a quarter of a grain to each dose.
Locally, he prefers ointment of iodide of sulphur, very much diluted—8  grs. to  § j
of wax cerate, and gradually increased, but never exceeding 20 grs. to §j-  The
parts to be well washed before applying the ointment.  The  arsenite  of iron has
also been used with benefit.
  External applications are sometimes useful, and must be adapted to the stage of
the eruption, and particularly to the irritability of the skin.  Some of those in most
common use have already been mentioned under the head of lepra.  Oily applica-
tions seem, as a general rule, much the  best adapted to squamous  affections, and
the mildest are often the most grateful as well as the most efficacious.   Among
these the cocoanut oil,  or butter of cocoa {ol. palm, cocc), has been recommended
highly, and has the advantage of never  becoming rancid.  Fresh butter and sper-
maceti cerate may also be used. Oiled  silk, however, is one  of the best applica-
tions in this as well as in  some other forms of  cutaneous disease, and  often suc-
ceeds alone better than any ointment, but may also be used with advantage at the
same time that other applications are made.
  When there is  great thickening both of the cuticle and cutis, particularly about
the knees  and elbows, Dr.  Cumin {Cycl. Prac. Med.) recommends very  highly the
application of strong acetic acid.  If there are excoriations or  fissures, they must
be protected by some mild cerate.                              H. D. B. 
PITYRIASIS.
237
 auxiliary in these cases.   Both the general and local treat-
 ment should always be accompanied and assisted with the free
 use  of  baths.  Baths, and even the vapor  douche, are  pre-
 ferable  to  all other remedies  for the local varieties, with  the
 exception of psoriasis of the scrotum, which may be promptly
 cured by fumigation.
   [The sulphur and iodine vapor, noticed under the head of
 Lepra, will be found very serviceable in some of the varieties
 of psoriasis.  B.]                     •

                      PITYRIASIS.

 Syn.—Dartre furfur acee volante; Porrigo  Chloasma; Pso-
           riasis ; Herpes furfureux ; Dandriff.
   Pityriasis is a superficial chronic inflammation of the skin,
 characterized by  a copious  furfuraceous cuticular desqua-
 mation, which is  incessantly renewed.  It may attack any
 part of the body, but its most frequent seats are the  scalp, and
 the  parts  covered with hair.  It is frequently attended with
 some change of color in  the skin, on which is founded the
 division of pityriasis'into four different varieties :  Pityriasis
 capitis; P. rubra; P. versicolor ; P. nigra.
   1.  Pityriasis capitis  appears  frequently  in   new-born
 infants, in the form of a  slight  scurf, which soon  becomes
 converted into a multitude of small imbricated scales ; when
 these fall off,  slight superficial red spots appear beneath. This
 variety is  also met with  in adults, of which  we have seen
 numerous instances.   In  this case, it does not present a con-
 tinuous  layer, as in children,  but a constant desquamation,
 which is often very obstinate in its resistance to remedies.   It
 is difficult to  describe this disease in the order  of its develop-
 ment, as its existence is only known by the presence  of minute
 scales. It is accompanied by no other symptoms than a slight
 itching; the patient scratches himself, and produces  a copious
 exfoliation of the  cuticle; the small scales are almost imme-
 diately replaced, and when tiiey fall off, the surface beneath
 does not look inflamed; on the contrary, if  a small scale is
 raised with the nail, which  can  easily be done, the surface
 from which it was  detached has  an indolent appearance;  on
 rubbing this spot, another thin lamella, analogous to the first,
 may be raised; and several  may be removed in this manner,
 without arriving at the  inflamed  surface.  A multitude  of
 extremely  thin, white, and dry lamellae, generally adherent  at
 one extremity and free at the other, are visible on the skin.
 Sometimes they resemble  a peculiar envelope, which appears
furrowed, and divided into innumerable minute and extremely
                           16 
238
DISEASES OF THE SKIN.
thin lamellae.  The slightest movement produces an abundant
furfuraceous desquamation.   This exfoliation seems composed
of small portions of cuticle, like molecules of meal, especially
on the chin, and on passing the hand over it falls  off freely,
and is instantly reproduced.  The scales are sometimes larger
on the  scalp, where they resemble a split  pea or lentil, but
more  flattened.
  Causes.—The causes of pityriasis are not easily ascertained.
Its  development is of^en accompanied by an inactive condi-
tion of the bulbs  of the hair.  It appears  in the infant, in
whom the  hair has not yet grown, and in old people, when it
has fallen off.   It is often produced on the chin by the irrita-
tion of the razor.   The irritation produced by constant comb-
ing with a fine-tooth comb also excites the disease.
  Diagnosis.—The large size and prominence of the patches
of psoriasis, the  peculiar shape of those of lepra,  and the
characteristic  farinaceous  desquamation  of pityriasis,  will
prevent these diseases being confounded together.  The cuti-
cular desquamation which  takes place in the  exanthematous
affections, is very different from that of pityriasis, besides that
the previous symptoms would soon remove  any doubt in the
case ; and when it occurs in  chronic eczema, there are always
some  elementary vesicles to be seen in the vicinity of the dis-
eased  parts; besides, the  small scales  are not incessantly
renewed, as in the former affection ; the presence of  papules,
and the thickening of the skin in lichen, and the difference in
the kind of  the  exfoliation,  will distinguish the disease.  The
peculiar color of the ephelides, and also the size and  singular
shape  of the patches, will  distinguish  it at once from pityri-
asis ; and a variety of ichthyosis, which is sometimes mistaken
for the latter disease, may  be  distinguished  by the profound
alteration of the  skin, its rough, thickened  appearance, and
the dirty gray color of the scales; while in pityriasis the skin
is rather softened  than thickened, and  the  scales  are white.
One  is also almost always congenital, while  the  other is
always accidental.  Pityriasis  capitis  can  hardly be  cih-
founded with porrigo.   The yellow or  favous  pustules, so
characteristic of the latter affection, are sufficient to distinguish
it at a glance.
  Prognosis.—Pityriasis  capitis is in general a slight affec-
tion.   It may co-exist occasionally with other chronic inflam-
mations.  Its duration is often  very protracted.
   Treatment.—The only treatment required, are some#bitter
infusions, to which may be added one or two drachms of the
sulphate of  soda, or subcarbonate of  potass, to the pint, and
alkaline lotions to  the  parts  affected;  sometimes  alkaline 
PITYRIASIS.
239
baths, or the vapor douche.   In infants and children, brush-
ing the head with a soft  brush, and cleanliness, are  the  only
measures required.   The irritation of the brush excites new
action in the parts, and  the  exfoliation  soon ceases :  a fine-
tooth  comb should not be used.  When the disease  is seated
on the chin in adults, the beard ought to be cut with a pair of
scissors, instead of a razor.*
   2.  Pityriasis rubra is  characterized by the appearance of
slight red patches, or spots, the size of a split pea, which soon
coalesce, and  extend  gradually, so as to form  large, continu-
ous, red surfaces, covered  with a multitude of minute scales,
which fall off, and are  reproduced  continually.  The surface
is generally hard, but is  sometimes  soft  to the touch, which
depends on a kind of oily exudation  which it gives out.   It
appears to occur frequently from the action of heat, the rays
of the sun, and especially  from acute moral affections.   The
shape, elevation, thickness, and extent of  the  scales of lepra
and psoriasis, distinguish these diseases from pityriasis rubra.
Its red or rosy hue distinguishes it from the pale yellow color
of P. versicolor.   If the  patient is young and vigorous, vene-
section may be  employed, but if old  and feeble, mild tonics
should be administered; and alkaline lotions, together  with
simple, vapor, or sulphureous baths, are the external  agents
from which most benefit  will be derived.
   3.  Pityriasis versicolor manifests itself in the form of con-
tinuous patches,  of various  size, covered with  a continual
furfuraceous  desquamation.   It is distinguished by the varie-
gated yellow discoloration of the cuticle, which continues  for
a considerable period after the cure of the disease.   It appears
chiefly on the neck, abdomen, chest,  and  sometimes on  the
face.  It often arises from  exposure to  the  sun in  warm
climates, from the ingestion  of acrid  food, spices, &c.   It is         •
distinguished from the ephelides by the furfuraceous desqua-
mation, and from all other affections of the skin, by the pecu-
liar pale yellow discoloration of the  cuticle.  It is  a slight,
but usually a very obstinate  eruption, and requires the same

  * P. Capitis is sometimes a troublesome and obstinate affection, being accom-
panied by great heat, tension, and a severe itching  of the sealp ; and, in addition
to an abundant desquamation, an oozing  out of a serous, tenacious fluid, which
unites the hair and epidermic secretion together.  This sometimes extends over a
large portion of the scalp.  In these cases, after the removal of the incrustations
by emollient poultices, alkaline washes and stimulant and astringent  lotions and
ointments may be used, of degrees of strength proportioned to the irritability of the
scalp in particular cases.  The creasote ointment, in such cases, is often useful. It
also sometimes  appears in well defined patches, without any fluid secretion, and
lasts for months and years, and is very liable to return.  In all cases of long con-
tinuance of this disease, the general health requires  attention.         H. D. B. 
240                DISEASES  OP  THE  SKIN.
           remedial measures as the foregoing variety, especially sulphur
           baths and  lotions.*
              4.  Pityriasis nigra.—Numerous  examples of this variety
           were observed in  Paris in 1828-9.   The furfuraceous desqua-
           mation  occurred  on a black surface,  sometimes  of a deep
           shade.    The  disease appeared in two distinct forms.   In the
           one,  the epidermis was  the seat of  the  coloration;  and  if
           detached, a red surface appeared beneath.   In the  other, the
           epidermis  was transparent, and  the  cutis vera was the part
           discolored.  The  treatment of  the other varieties  will also
           answer in  this form of the disease.f



                                   ICHTHYOSIS.

                               Syn.—Fish-skin disease.

              Ichthyosis differs in many points from the rest of  the squa-
           mous diseases.  It is not merely  the result of an  accidental
           alteration  and thickening of  the epidermic  lamellae.   It  is
           evidently a profound and special organic lesion of  the  whole
           cutaneous  tissue;  but as  it would be  difficult, in the present
           state of science, to indicate precisely the class of cutaneous
           eruptions to which it really belongs,  we shall be content  for
           the present to describe  it, as Willan and Bateman have done,
           amongst the scaly diseases. J
              Ichthyosis is characterized by the  development upon one


             * P. versicolor is very apt to be mistaken for a syphilitic affection, but there is
           no cutaneous disease produced  by that virus which commences with small eleva-
           tions covered with  minute scales,  which enlarge and soon coalesce, so as to form
           large patches on the chest, abdomen and arms, which are accompanied by  itching,
           and covered by a branny exfoliation, as is the case with p.  versicolor.  Syphilitic
%         spots are  usually  but few  in number, are  nearly or quite circular, do  not run
           together and form large  patches, are not confined to the chest, abdomen and arms,
           are of a darker and coppery hue, are  unaccompanied by itching,  and  without
           exfoliation.
             Mr. Acton  says, in speaking of the diagnosis of P. versicolor from a syphilitic
           eruption  {London  Lancet, Amer. Rep., Nov. 1847), " in my own practice, I have
           always placed the greatest  dependence upon the  absence of condylomata, psori-
           asis palmaris, and  sore  throat; when these are absent, and the patient in good
           health, you may be sure that you have to treat a simple case of pityriasis versicolor,
           a complaint which is very harmless."                          H. D. B.
             t Rayer describes Pityriasis under the head of general and local, the former of
           which corresponds with the P.  rubra of our authors.  P. versicolor and P. nigra
        ,  he places under the head of morbid alterations of the color  of the skin, the former
           under the name of  chloasma and the latter under that of melasma.     H.  D. B.
             [t Surely this disease is misnamed as well  as misplaced.  There is  nothing
           scaly about it. The name, warty disease, would be much  more appropriate than
           that of Fish-skin.  It is true, the cuticular appendages are not organized, like true
           warts, and do not bleed on being removed ; but otherwise their physical characters
           have a much greater affinity to those of warts than to the scales of a fish.   B.] 
ICHTHYOSIS.
241
or more  parts of the tegumentary envelope,  and most  fre-
quently over the whole body, of thick, hard, dry, imbricated
scales, of a dirty grey color, resting upon a perfectly unin-
flamed surface,  and  never accompanied by  pain, heat, or
itching.  Although  this disease may appear on every part of
the body, it is met  with less frequently on the palms of the
hands, soles of the  feet, internal  aspect of the limbs, groins,
armpits, face, and particularly the eyelids, than on the other
regions ; even when the disease is almost general, these parts
remain intact, or else become very  slowly, and at  intervals,
affected.
  A case of this kind was under our care at the Hospital of
St.  Louis for  some  time: a boy, twelve years of age, was
suffering from ichthyosis, which  had spread over every  part
of the body except the face; but,  singular to relate, whenever
the slightest irritation of  the gastro-intestinal mucous mem-
brane  occurred, the patient's face assumed first a dirty color,
it then became covered wi'th small, dry, greyish scales with a
slight  thickening of  the  skin.   These scales  were  much
thinner than those  of the rest of the  body,  which,  on the
other hand, were broad, hard, and blackish, imparting to the
face a peculiar aspect, like that of an old  man.  According
as the internal  irritation  subsided, the scales fell off.   The
face gradually resumed its natural appearance, and nothing
remained after the disappearance of  the eruption but a slight
thickening of the skin.  The scales on the other parts of the
body  did not present anything peculiar.  The boy's health
was  very good,  but the mucous  membranes were extremely
susceptible  of the slightest excitation.
  Ichthyosis appears principally on the external aspects of the
limbs, round the joints, on the knee and elbow, on the upper
part of the  back, and on those  regions where the skin is
naturally thick and coarse.  It is  most usually general; but is
sometimes  limited  to a particular part, especially when it is
accidental,  sometimes affecting the arms or the legs only. It
is generally a congenital disease, and lasts during life.  Even
when it is developed accidentally, it may be prolonged for an
indefinite period. In  some instances, however, it may disap-
pear, but its duration  is always long, and varies from several
months to  as  many  years.   Congenital ichthyosis is never
strongly marked  at the period of  birth; but the skin, instead
of presenting that  smooth and delicate appearance common
to new-born infants, is dull, thick, and fretted.   The disease is
more  apparent  as the infant grows older, and  may  appear
under different forms.   Sometimes the skin, although altered
and slightly thickened, remains soft; it becomes covered  with 
242
DISEASES OF THE SKIN.
small, greyish, slightly resistant epidermic lamellae, accompa-
nied with a continual furfuraceous exfoliation.  According to
some writers, this  variety chiefly attacks old people, but  it
appears to  us that they have mistaken some other affection,
having some analogy with it, for ichthyosis.
  It often appears, however, in a much more severe form than
the foregoing,  and becomes much more distinct according as
the patient  grows  older.  The skin is  thick, furrowed, and
covered  with  genuine scales, which are dry, hard, resistant,
greyish,  and sometimes pearl-colored, often very glossy, and
surrounded  several times  with  a kind of  blackish circle.
These scales  are  formed by thickened cuticle, furrowed all
over, divided into small irregular-shaped portions, of different
sizes, which are free at  one extremity and slightly imbricated
at the point of attachment  to the skin.  Some of them are
small, and surrounded with a  multitude of small farinaceous
points, which correspond  to the furrows of the epidermis.
Others are larger, and are much  diffused over the wrinkled
surface.  These scales  may be removed with impunity, and
without occasioning the slightest pain, with  the exception of
the larger ones, which are more deeply and firmly attached to
the skin.  None  of these scales  leave the slightest redness
after them when they disappear.   But  the  skin  is so rough,
that on passing the hand over it, it conveys  the sensation of
the surface of a file, or even  of the backs of certain fishes.
The scales  are thicker  and more  apparent on  the limbs, the
front of  the patella, the elbow, the external  surfaces of the
arms and legs, than elsewhere.
  However so much extended this scaly eruption may be, and
whatever alteration it may produce in the tegumentary enve-
lope, it never occasions  any  serious derangement of the func-
tions of organic life.  There is no pain or  itching; the skin,
however, is no longer able to  perform  its transpiratory func-
tions, unless at certain  points, as for example, by the soles of
the feet,  which are generally  free  from scales even when the
disease is diffused over the whole  body, and are always mois-
tened with copious perspiration.  Congenital ichthyosis seldom
undergoes any modification.   However, in some rare instances,
and at certain periods, it subsides for a time, under the influ-
ence of internal organic inflammation, but  it  reappears at the
following season with all its  former characters and symptoms.
We have seen a case of this disease complicated with a papu-
lar eruption  in a  young child, neither of which seemed to
interfere with the other.
  Autopsy.—Post-mortem examinations of persons who have
died with ichthyosis, have not revealed any pathological con- 
                       ICHTHYOSIS.                     243

dition evidently depending on that disease.  The skin, how-
ever, appears to be deeply altered  in structure, and its whole
thickness is involved in the morbid thickening  and formation
of the scales.
   Causes.—Ichthyosis  may be   congenital or  accidental.
When congenital, it  is  generally hereditary.   In other in-
stances it seems to be the result of fright, or some other acute
moral  affection on the part of the mother.  When it is acci-
dental, and especially when it is  partial, it depends on exter-
nal causes.  It is endemic  in  some climates,  and frequently
appears in towns along the sea coast, evidently caused by the
ingestion  of putrid fish, stagnant  water, and by the constant
dampness and moisture of these districts.   However, it has
been  known to occur under circumstances directly  opposed
to these, and even from intense grief, fear, or rage.  The fun-
damental causes  of this  affection are, however, still involved
in much obscurity.  It may appear in either sex, but in men
much  more commonly than in women,  in  the proportion of
nineteen  out  of  twenty cases, according to the experience of
M. Biett at St. Louis Hospital.
   Diagnosis.—When this disease is well marked, it cannot be
mistaken for  any other cutaneous affection, but when it is
partial and superficial, and the scales are thin  and small, the
cuticular exfoliation which supervenes resembles the desqua-
mation which succeeds eczema and lichen;  but the origin of
the disease,  the  absence  of  vesicles and papulae,  and the
peculiar character of its own eruption, will at once distinguish
it from these affections.
   Prognosis.—Congenital ichthyosis is an  incurable disease.
The  prognosis  is not,  however, very  unfavorable,  as the
patient continues to enjoy pretty  good health, and no internal
disease ever supervenes as a consequence of ichthyosis.  The
accidental form  is ever rebellious, and  may continue during
life.
   Treatment.—It is evident from the history and causation of
this disease, that the only remedial measures  that are at all
likely to give relief, are palliatives and external applications;
mucilaginous lotions and  vapor  baths,  for example, seem to
 have  the  effect  of modifying  the roughness,  and otherwise
 altering the condition of the  skin.  In accidental ichthyosis,
 Willan has recommended the  internal use of pitch, as having
 the effect of restoring the  skin  to its natural  pliancy.  We
 have not found this remedy at all so efficacious in this  affec-
 tion at the Hospital of St. Louis.  The only remedies of the
 slightest use are  those above mentioned  and blisters, which in
 some rare instances  have cured this affection when  it was 
244
DISEASES  OF THE  SKIN.
 partial and accidental.*   [The iodide of arsenic administered
 internally, and the vapor  of sulphur and iodine applied to the
 diseased surfaces as directed under the head of lepra, might
 be attended with benefit.]!
   It is unnecessary in a manual  of this kind to enter into an
 account of the different  varieties of ichthyosis, which  are
 merely  interesting and curious deviations from  the common
 form of that disease, the history  of which would be attended
 with no practical utility.
   [A case of congenital  ichthyosis was recently exhibited at
 the different Medical  Societies  of  London.   The   patient,
 Thomas Jones,  appeared  to be otherwise a  healthy boy,  of a
 fair complexion.  He was a native of Wales, eleven years of
 age, and  the youngest but one  of a family of ten children.
 None of the rest of the family were affected with the  disease,
 and  the mother attributed the  cause  in this instance to a
 severe  fright which she  received  during the last  months of
 pregnancy.  The disease was extensively  diffused  over  the
 skin.   It was more strongly marked on  the  lower extremities
 than on any  other part, and the  morbid product was in some
'places nearly half an inch in  length.   The  skin on the palms
 of the hands, on the  face, the neck, the upper regions of the
 chest and back, was  perfectly free and remarkably fair  and
 healthy looking.   Although the soles of the  feet were, at  that
 time, free from the disease, the dark discoloration of the  skin
 of these parts indicated the previous existence of the morbid
 appendages.   The disease first made its  appearance about five
 or six weeks after  birth  ; it  proceeded slowly and gradually
 until it at length became diffused over the body.   It never
 interfered  with the  boy's general health,  which  has  been
 always  excellent.   The eruption, if I may  so call it, is shed
 at intervals of variable extent, and soon grows  again.   The
 scaly appendages fall  freely during the night, from  the  heat
 of the bed and the friction of the body against the bedclothes,
 and  the disease may be  seen in various stages on different


   * In their last edition, our authors omit all the passages  which describe an acci-
 dental as distinct from a congenital form of ichthyosis, in every part of  the article
 on this disease, not using the word accidental at all.              H. D.  B.
   + Mr. Clay, of Manchester, gives an account {Land. Lancet, July, 1841) of a
 boy, four years old, who had suffered from the disease three years, and who was
 cured by the application, over the whole surface night and morning, of an ointment
 of sub-carbonate of potash, 3 iij to § viij of lard.   He afterwards took an infusion
 of gentian and sub. carb. pot., and was sent to the seaside.
   In one case under my care, the  disease was sensibly improved by baths of car-
 bonate of soda, § iv to a bath, during the few weeks the patient continued their
 use.  The liquor Donovani was given in moderate doses at the same time.
                                                     H. D.  B. 
ICHTHYOSIS.
245
parts  of the skin.  The cuticular appendages  are perfectly
unorganized; they  emit a disagreeable smell, similar to that
of mice, and when ignited, give out a strong odor of burning
feathers or horn.  Cows are occasionally affected with a dis-
ease somewhat similar to ichthyosis.—B.] 
TUBERCULA.
  The diseases which have been classed under this order, are
characterized by small, primary, circumscribed, solid tumors
of various sizes, formed in the substance of the skin, and very
different from  those indurations which succeed some of  the
pustular diseases.  These small tumors constitute a peculiar
elementary lesion, to which the name of tubercle has been
applied  by dermatologists, and they generally terminate in
suppuration or in  ulceration of a rebellious character.  The
essentially tubercular diseases but seldom occur in European
countries;  indeed they appear to be peculiar to the tropics.
  We  propose to describe in  this  order, only three of the
numerous diseases arranged by Willan and Bateman amongst
the  tubercula—these are Elephantiasis Graecorum, Frambae-
sia, and Molluscum—as we consider that several of the affec-
tions mentioned by those writers belong, properly speaking, to
the  province of the surgeon, and the others have been more
appropriately arranged and treated  of elsewhere.
  Tubercular diseases are essentially chronic in their nature ;
they are slowly and gradually  developed, and continue for
months and even for years.
  Symptoms.—The tubercles  are red in frambcesia; they are
reddish, sometimes the  color  of the  surrounding  skin, in
molluscum; and of a dark livid tint in elephantiasis.  Their
size is very variable; in some cases  they are not larger than a
pea, in others they are as large as an egg.  They are generally
distinct and isolated;  sometimes, however, they are set close
together, and collected in groups, as for example  in framboe-
sia.  These diseases are rarely accompanied by general febrile
symptoms, with the exception of elephantiasis,  which is  fre-
quently complicated with chronic inflammation of  the mucous
membranes of the stomach and bowels.   The eruption is com-
monly confined within a limited compass.   It is, however,
sometimes general.  It may  remain stationary for a certain
period, or terminate by resolution, or else the  tubercles  may
suppurate at their summits, when they become covered with
scabs of variable thickness.  After a time these scabs are de- 
ELEPHANTIASIS GRAECORUM.
247
tached, and expose unhealthy looking sores.  In other instances,
they are merely slight excoriations, whence oozes a kind  of
serous exudation, which  terminates  in  dry, thin,  and very
adherent incrustations.
   Causes.—The causes of the tubercular diseases are involved
in obscurity.   They are  of exceedingly rare occurrence  in
these countries, but are common enough in the tropics.  Fram-
bcesia and  one of the varieties of molluscum are contagious.
   Diagnosis.—The tubercular eruptions are characterized by
symptoms and appearances  so peculiar, that they are not only
easily distinguished from all other cutaneous diseases, but one
of them can never be mistaken for another of the same order.
The small, solid, circumscribed and enduring tumors above
mentioned  are peculiar to this class of diseases.  There is, it
is true, a variety of syphilis characterized by the presence of
tubercles ; nevertheless, there are striking differences between
these affections—in the form and color of the eruption, the pro-
gress of the tubercles, and the character  of the symptoms.
   Prognosis.—The tubercula  are in general severe diseases,
principally owing  to their long duration and rebellious nature.
Elephantiasis  Graecorum  is in particular a formidable affec-
tion.   It soon  exerts its destructive influence upon the system,
and  is generally complicated with diseases  as  rebellious as
itself.   It  resists  every  method of  treatment, and  finally
terminates in death.
   Treatment.—As these diseases rarely occur in France, and
as they have  been but little investigated in the countries to
which they are peculiar, we cannot be expected to know much
respecting their treatment.  The rebellious character of Ele-
phantiasis Graecorum, which is better understood than any of
the other eruptions of this order, depends, perhaps, in a great
measure on the fact that the physician  rarely sees the disease
until it is already far advanced.


           ELEPHANTIASIS GR^CORUM.

Syn.—Tsardth of the Hebrews; Lepra Arabum; Lepra He-
  brmorum;   Lepra tuberculosa ;  Leontiasis;  Satyriasis ;
  Elephantiasis tuberculata  and anaisthetos; Lepre elephan-
  tiasis; Morphee of Brazil; Radesyge of Norway;  Ma-fung
  of the Chinese.

  Elephantiasis Graecorum, or tsarath of the Hebrews, is most
frequently characterized by  the appearance of patches of a
yellowish or fawn color, with lesion  and very  often loss of
sensibility, which  spots are succeeded by elevated tumors, 
248
DISEASES OF THE SKIN.
irregular both in  shape and size, of a fawn or purplish color,
soft  and smooth  to the touch, and which  may, at  a  later
period, become the seat of unhealthy ulceration.  Such ulcera-
tions may also exist at the same time with the tubercles in the
same patient, or may occur alone, without having  been pre-
ceded  by tubercles.   This  disease, fortunately unknown in
temperate climates, may still be carried to them from other
regions, and is at the same time both the oldest and the most
terrible of diseases of which we have any record.
  The Greeks gave it also the  name of leontiasis, on account
of the great deformity produced by it when its large irregu-
larly shaped tubercles covered the nose, lips, and  forehead,
and, together with  the yellowish color  and oily aspect of the
patient, gave the  face the appearance of that of a lion.
  As tubercles are not always found in this disease, and as the
word tubercle is  used to describe a special pathological pro-
duct, we propose  to designate Elephantiasis Graecorum by the
word tsardth, making two species, tsardth phymatodes and
tsardth aphymatodes,  according  as it  is tubercular or not
tubercular (cpv^a, tubercle;  a privative) ; these  species to be
subdivided into anaesthetic and  hyperassthetic,  according as
there is increase or loss of sensibility, the last state being the
rule, and the first  the exception.
  We  shall describe the disease from the details furnished by
Drs. Robinson and  Winterbottom respecting it in Africa, by
Larry  as it occurred  in Egypt, by Ainslie in Hindostan, by
Adams at the Island of Madeira, by Dr. Fabre  in Brazil, Dr.
Skene in New Brunswick, and Dr. Danielssen in Norway, com-
paring their observations with  whart we have ourselves seen.
  Causes.—The effect of climate on the development of tsarath
or Elephantiasis Graecorum is most marked.  It is not met with
at the  present time  in temperate regions, but there is a dispo-
sition  to it as you approach the equator on the one hand,
aud  the poles on the other.  It is found on the coast of Norway
from 60° to 70°  of latitude.  It does not exist in Europe
between the 40° and 55° of north latitude ; but this is not true
with regard to Asia and America.   It is said to have been of
very frequent occurrence in France, England,  Ireland, Italy,
and  Germany, during the  middle  ages, and  to have  been
carried to those  countries  from the East by means of the
crusades.   But, doubtless, many other diseases of an entirely
different nature were confounded together during that period.*

  * Tubercular leprosy is said also to be of very common occurrence in China and
to be very prevalent at Canton.
  For an account  of  the disease in New Brunswick, see essay by Dr.  Robert
Bayard, London Lancet (Am. Rep.) Jan. and Feb., 1850.         H. D. B. 
ELEPHANTIASIS  GRAECORUM.
249
  All ages and both sexes are liable to it; but it appears to
attack males in a larger proportion than females, to appear
more frequently before puberty, and to affect more especially
those of the bilious  temperament.  It has  been seen in the
new-born  infant, but rarely, if ever, commences after the age
of forty years.
  Elephantiasis Graecorum is admitted by all to be hereditary,
but it often passes over one generation and appears in young
children.  Its contagion is not admitted  at  the present day.
The opinion that  it has any connexion with syphilis has  been
for  a long time abandoned.
  Insufficient  nourishment, the  use of indigestible food, the
prolonged and exclusive use of salted food, and of smoked and
dried fish, have great influence in  developing it in the coun-
tries where it prevails.  The use of pork  is also said to have a
similar effect upon  the strangers and  upon natives.   To the
above causes may be added, neglect of cleanliness, residences
in low and damp  places, the neighborhood of marshes, expo-
sure to weather, great fatigue, venereal excesses, and abuse of
alcoholic liquors.
  Invasion.—Elephantiasis Graecorum sometimes shows itself
without any particular alteration  in  the health, and  without
any immediately appreciable  cause ;  but, in other cases, its
appearance  is preceded by general symptoms, more  or less
marked, as  languor, remarkable depression of spirits, and a
decided febrile state.   Occasionally, its development is  pre-
ceded by deterioration of the general health for several years.
  The tubercular form of the disease commences with the
appearance of spots, which are usually of a fawn, but  at other
times of a yellowish or dark red  color.  Sometimes tubercles
of these different colors appear at the  same time on the same
person.
  The face, forearms, and the external surface of the legs, are
most frequently tbe seat of the first  appearance of these spots.
In  some cases the  spots, and afterwards the  tubercles, are
confined to particular parts, as the  nose  and the ears, when
they are  accompanied by a peculiar  swelling of the cellular
tissue.  The disease comes on so insidiously at times, and in
the midst  of such apparent health, that the spots would cause
no  anxiety, if it were  not for the insensibility of the skin at
these points.  This  insensibility is not  constant; but there
may be such  an increase of the sensibility, not only of the
spots themselves and of the tubercles, but of other parts, and
especially of the  hands  and feet, that the touch will cause a
sensation  like that produced when  the elbow is struck, or by
a smart electric shock. 
250
DISEASES OF THE  SKIN.
   Usually there are other symptoms indicating serious lesion
of the spinal  nerves, such as  general  prostration,  debility,
muscular cramps in different parts of the body, and diminu-
tion,  rarely increase, of  the  venereal appetite.  The skin
becomes dry, while the  sebaceous secretion  seems  to  be
increased, and an oily matter is spread on the surface, which
is most  apparent on  the  face.  All these symptoms increase
with the increase of the disease, the tendency of which is to
extend itself and attack other parts.  The spots may remain
stationary for a variable time; from a few weeks to a year or
more.
   Progress.—Usually  the number  of the  spots  gradually
increases, they increase in size and  in elevation,  and soon
losing their smooth and  even  surfaces,  become rough  and
uneven.   When seated on the face, a swelling of the cellular
tissue of the nose, forehead, eyes, chin, cheeks, and especially
the ears, accompanies  the development of  the  tubercles  on
these parts, giving rise to fawn-colored or livid tumors, soft
to the touch, which produce  great deformity, and may reach
a large size.
   When these tubercles  are seated only  on the lower limbs,
they  frequently occupy the lower part of  the thigh, or  the
parts about the external malleolus, in which  latter case there
is frequently oedematous swelling.
  These tumors sometimes become  confluent  from  larger
groups, and at other times they  remain isolated.  Their size
varies from that of a small pea to that of a hen's egg.  They
can be raised and taken, as it were, between the fingers, and
may be bent or cut off even with  the  skin  without causing
the least pain.
  When the face is attacked, the mucous membranes of the
nose, mouth,  pharynx, and eyes, rarely remain  a  long time
unaffected.  The voice  begins to be hoarse, the respiration
becomes more frequent and more labored, at the same time
that the color of the tubercles  becomes more livid, and the
smell of  the breath peculiarly  offensive.  The eye is attacked
and  vision destroyed, the hair falls  from  every part of the
body, the testicles become atrophied, and the nails white and
brittle.   When  the patient has reached this stage, the defor-
mity is great,  and the unfortunate sufferer an object of dis-
gust, which is still more increased by the  excessive foetor of
the breath, and of the discharge from the nostrils.
  The second period, or  the tubercular, which succeeds the
spots, may continue months, and even years, with ulceration
or suppuration of the tumors.  Death may even take place
before ulceration occurs.   Those which ulcerate are gradu- 
ELEPHANTIASIS GRAECORUM.
251
ally  covered by a blackish scab,  leaving, when it  falls offj
fungous  and ill-conditioned ulcers,  which are  bathed  by a
fetid sanious pus, the concretion of which forms still thicker
scabs at  the same time that the ulceration goes on increasing
in depth, and  denudes the muscles after destroying the skin.
When resolution of the tubercles takes place,  a  depression
follows, and their former seat is marked by a change in the
color of the skin.
   The ulcerations usually destroy  the  subjacent tissues,.thus
mutilating the nose, and destroying the septum and palatine
arch.  On the extremities,  the  ulcers extend in  depth, and
may  cause  death by becoming gangrenous, and  the patient
may thus witness the slow destruction of his limbs, and some-
times one finger after another is gradually removed.
   The general symptoms are those principally of lesions of
motion, and derangement of the digestive functions ; there is
sometimes alternately constipation and diarrhoea, and often a
voracious appetite.  The circulation is slow,  and is  some-
times hardly felt at the extremities.
   Tsardth aphymatodes, or the non-tubercular  form of Ele-
phantiasis Graecorum, is  characterized by the appearance of
spots, also livid or  fawn color,  but  which,  instead  of being
succeeded  by hard,  elevated  tumors,  become  covered with
bullae or  vesicles, and sometimes with pustules;  and, in some
cases, there is atrophy of the dermis, and ulceration destroy-
ing in depth.  The bullae are sometimes isolated and at  other
times grouped, and  vary in size.  They open after a certain
time, and are succeeded by ulceration.   They appear first,
according to  Dr.  Fabre, principally  on the" hands,  arms,
feet,  and legs, and  afterwards on the  back  towards the
shoulders, and on the thighs  about  the trochanters.   The
pustules  are also followed by ulceration of the  parts, and
when on  the  extremities, almost  always destroy  the  pha-
langes.                              .
   This variety may co-exist with the  tubercular  form, or
may be developed alone.   The  insensibility of the skin  is
most  frequently preceded by a remarkable state of hyperes-
thesia; and, according to Dr. Danielssen, this increase of sen-
sibility often precedes the eruption  on the hands and feet, and
may continue for years;  but it gradually diminishes, and
anaesthesia soon commences, at the same time that all secre-
tion  ceases on these points.  The skin  in these places under-
goes a kind of atrophy; it becomes  pale, dry, and hard like
parchment, and  loses all its elasticity.  The want of sensi-
bility gradually extends over  the  rest  of the surface.  The
mucous  membrane  of  the  nasal fossae afterwards becomes 
252
DISEASES OF THE  SKIN.
affected, and the septum is destroyed by ulceration.  Necrosis
attacks the phalangal bones gradually in succession,  and after
several weeks or months of suppuration one or more of them
is  thrown off, and  the ulcer heals  with shortening  of  the
finger.  All the  toes  and fingers  may thus be  destroyed
alternately  and  gradually,   and  the  extremities  slowly
removed.
   The non-tubercular  variety of Elephantiasis Graecorum is
much more rare than the tubercular variety, even in those
countries  where it  most prevails.  According to Dr. Fabre,
their  relative  frequency  is  in   the  proportion  of  one to
twenty.
   Death in the non-tubercular variety is sometimes owing to
a  cutaneous  complication, but  more  frequently  to internal
lesions  either abdominal, thoracic,  or,  what is more rare,
cerebral.  Colliquative, diarrhoea, and discharges of blood, in
consequence of intestinal ulceration, are the most frequent
causes of the fatal  termination  in the  abdominal  affections,
and tubercular phthisis and chronic forms of  inflammation of
the lungs in the thoracic cases.  Death is sometimes hastened
by obstructions of the  glottis and larynx, causing suffocation.
Among the cerebral lesions, apoplexy is not rare,  but those
forms of mental derangement are not met with in this  disease
which occur so frequently in pellagra.
   Complications.—The  tubercular  form of  Elephantiasis
Graecorum may be accompanied or complicated by Elephan-
tiasis Arabum.  It may also be complicated by tubercles in
the lungs, or in the mesentery, and may appear as a sequel of
other affections.
   Duration.—The  duration  of  both forms of the  disease is
usually from seven to fifteen years, but it may last thirty or
forty years.  It may sometimes disappear spontaneously, or
as the effect of remedies ; but almost always reappears, and in
a more grave form.  ,
   Post-mortem appearances.—These are various,  and depend
on the duration and intensity  of the disease.  The integu-
ments,  as we have alfeady mentioned,  are  studded  with
tubercles of various  sizes; some appear  to occupy the tissue
of the true skin;  others seem  to  be the effect of repeated
attacks of inflammation in  the  laminated tissue  underneath
the dermis, producing whitish  firm  indurations.   The  skin
which covers them is commonly thin and shrivelled.   The
skin of a patient whose case is detailed by M. Fabre was mace-
rated for several days, and presented, first, a thickened  state
of the epidermis; second, beneath this a very vascular layer, 
ELEPHANTIASIS GRiECORUM.
253
similar to erectile tissue ; third, another layer  of hard, thick,
and dark tissue, with several cavities, containing pale yellow
or white masses, and, below all, thickened adipose tissue.
  The mucous membrane is mostly of a bronze color ;  some-
times there is a diminution of the color; the tubercles are
effaced, and there is no hypertrophy remaining.  The lips and
the conjunctivae are more or less tumefied and changed in
color ; the mucous membrane of the tongue is often thick and
fissured; the lining membrane of the palate, in most  of the
cases examined by M. Biett,  contained  agglomerated tuber-
cles in a state of ulceration, and extending to the  uvula.  In
several cases, where  the  voice  was greatly  changed, the
mucous lining of the larynx contained tubercles. In a patient
from  Guadaloupe, M.  Biett found the  arytenoid  cartilages
carious, and  nearly all  destroyed.   The  gastro-intestinal
mucous membrane is generally softened ;  in the stomach it is
often thinned;  in the small intestines thickened.   In  the
majority of cases, death  is  occasioned by ulceration  of the
ileum,  colon, or ileo-coecal  valve; the  ulcers either occupy
the glands of Peyer, or are the results of the tubercles.   In
many subjects the lungs are more or less diseased.  Scrofulou?
tubercles, either softened  or  in a  state of crudity,  have been
noticed by M. Biett in a patient from Guyana, and in another
who  had made  several  voyages  to the East Indies.   He
regards  this lesion, however, as  accidental;  we have never
seen  it ourselves.
   Baron Larrey has seen scrofulous tubercles in the  mesentery
and disease  of the liver.  We have seen the  inner membrane
of the cavse and pulmonary veins and aorta of a brown color,
the blood being fluid, oily, and of a dark red hue.   The bones
 are occasionally spongy, softened, and deprived of marrow.
 In conclusion, we should remark, that the pathology of this
 disease  has  been  chiefly investigated  by European prac-
 titioners, particularly  Schilling,  Valentin,   Raymond, and
 Biett.  It were desirable that further researches  were made
 by practitioners in hot climates,  where  the disease  chiefly
 prevails.
   Dr. Fabre, who studied this disease in Brazil, was struck
 with—1. the remarkable diminution of size of the brain and
 spinal  marrow, which  presented  a kind  of  atrophy, without
 any  appreciable alteration of structure; 2. the quantity of
 serum effused into the ventricles and the  vertebral canal; 3.
 the constant presence  of a very  great number of the small
 glandular bodies, called glands of Pacchioni; 4. the occa-
 sional existence, on the surface of one of the hemispheres, of
                             17 
254
DISEASES OF THE SKIN.
circumscribed  suppuration of the membranes  of the  brain
adherent to it, from which was discharged a colorless plastic
pus.
  Diagnosis.—The loss of sensibility in the majority of cases,
and the opposite  state of its abnormal increase  in the excep-
tional ones, will always  distinguish the spots  of tsarath from
those of erythema and of ephelis.  Much obscurity has arisen
from the manner in which writers have confounded different
diseases under the same name; still elephantiasis Graecorum
(tubercular lepra) cannot  be  mistaken  for lepra, properly so
called (lepra vulgaris), which has been described in the chap-
ter  devoted to  scaly  diseases; although  bearing the  same
name,  their respective characters are too well  marked  to
leave any  doubt.  The  Arabian  elephantiasis  is  a disease
altogether  sui  generis.  Instead of tubercles, or  ill-looking
tumors, separated by deep folds, and developed in the dermoid
or subcutaneous  cellular tissue, we  have an uniform tume-
faction  of some portion  of the body, especially of the legs.
The disease, in fact, is not seated, at least in  the commence-
ment, in the integuments.  Elephantiasis Graecorum has been
confounded with  syphilis; and, by some authors,  said to  be
a modified  form of this latter complaint.  An attentive consi-
deration of a single case  is  sufficient to prove the difference
between the two diseases.  Besides, the tubercles  of syphilis
are  hard, small, and copper-colored; while those of elephan-
tiasis are large, soft, distinct tumors.   In syphilitic ulcers  the
edges are  hard and clean, the bottom of the  sore greyish,
deep, and surrounded by  indurated cellular tissue.   The form
of the ulcer  is circular; while the ulcers  produced by ele-
phantiasis  are superficial, smooth, and rest on  a  soft, fungous
tumor.   Finally,  we cannot confound  syphilitic  spots with
those of elephantiasis ;  the former have a peculiar color, being
always  indistinct,  and  never  red, or accompanied  by  the
puffy appearances seen in elephantiasis.  The  sensibility  of
the  skin is  not altered.
  Prognosis.—Elephantiasis of the Greeks  is  a  dangerous
disease, and almost  always an  incurable one.   The patients
generally die, worn out by their sufferings and by slow fever,
or the mucous  membrane of the viscera  becomes involved,
and they are  cut off  by chronic gastro-enteritis.  But the
disease  sometimes  terminates more  favorably;  the indolent
tubercles are  attacked by inflammation, they gradually dimi-
nish, and finally disappear.  In other cases they  ulcerate; the
ulcers are covered with dark adherent scabs.  The latter fall
off,  and the skin underneath is  cicatrized.   Unfortunately, 
ELEPHANTIASIS GRjECORUM.
255
 such cases are rare;  they seldom occur  except  in young
 healthy persons, attacked for  the first time, and  not  long
 exposed to the influence of  the exciting causes of the disease.
   Treatment.—The various remedies  employed in  the treat-
 ment of this  disease are generally unavailing ; first, because
 the patients have been long subject to the disease, and have
 tried almost every remedy before they came to Europe;  and,
 secondly, because  in its  advanced stage, elephantiasis Grae-
 corum  is  frequently  accompanied  by  an irritation  of  the
 mucous membrane  of the intestinal canal, which prevents the
 use  of energetic and  otherwise  efficacious   remedies.   If
 encountered  at its commencement,  the  disease should be
 treated with  energy and vigor.  In addition to general reme-
 dies, means should  be used  to produce  a strong impression on
 the affected parts.   After the example of Larrey, the actual
 cautery  might be  fearlessly employed.  We  ourselves even
 saw admirable results by means of cauterization, applied by
 Biett to  a case in which the tubercles were confined to the
 face, and were arrested in their progress by it.
   If this is not resorted to, topical means must be used for the
 purpose of increasing the vitality of the  parts.  Blisters may
 be applied on the  affected  parts, and frequently renewed: a
 plan, by means of which we have  seen Biett restore the sen-
 sibility to  parts when  it had been lost.  Dry frictions, or
 frictions with  stimulating liniments, may be used for the same
 purpose with  advantage; also  irritating vapors, baths,  and
 vapor douches, which last may be directed upon the seat of
 the disease for fifteen or twenty minutes, the patient being
 directed to knead the tubercles constantly at the same time.
 Frictions with ointment  containing iodide of potassium may
 also be used.
  Preparations of arsenic are among the most useful internal
 remedies,  and are  the more likely to  be of service, as the
 disease is the more recent. Pearson's solution  and the Asiatic
 pills  have seemed to us to answer better than Fowler's solu-
 tion.
  Cinchona appeared to be very useful  in a case treated in
 London by Dr. Bishop, who  employed stimulating frictions at
the same time.  Mercurial preparations have  always proved
useless, and sometimes have  caused inconvenience, at the St.
 Louis  Hospital.  Sometimes constant  irritation  of some
portion of  the  mucous  membranes renders the use of  any
remedies impracticable.  In  such cases soothing and mucila-
ginous drinks,  low  diet, warm  baths, and especially opiates,
are very beneficial.   Sulphur baths, and particularly vapor
baths, constitute indispensable  auxiliaries  to  every kind of 
256
DISEASES  OF THE SKIN.
treatment.   The regimen  should  always  be supporting and
nourishing.
  It is  absolutely necessary that the patient should leave the
country where he  contracted the  disease, as long as the least
chance of cure remains.*
                       FRAMBCESIA.

        Syn.—Pian ;  Yaws ; Micosis of M. Alibert.
  The  American disease,  called pian or  epian, seems to be
identical with that denominated yaws in Guinea.   They have
been described  by Bateman under  the name  of framboesia,
derived from the peculiar appearance which the disease gene-
rally assumes.   It is very rare in Europe, but is indigenous in
Africa, and very common  in America  and  the  West Indies.
It has been particularly studied by Hillary, Bancroft, Winter-
bottom, Schilling, Ludford, Horn,  Mosely, Adams, Rochoux,
Levacher,  and Dazelle.f   We saw one very remarkable case
of this  complaint in the wards  of M. Biett.
  Framboesia is characterized  by  the  presence of small  red
tubercles, like vegetations, which are isolated at their summits,
but  collected together at the  base,  and often  resembling in
color and form raspberries or mulberries.   It may occupy any
part of the body, but most frequently attacks the scalp, face,
axillae,  groin, margin  of the anus,  or  genital organs.  It is
impossible  to determine the duration  of this disease ; it is com-
monly  proportionate  to  the state of the  individual  and  the
strength of his  constitution; it  may continue  for years,  or
even perpetually.
  Symptoms.—In the majority of cases there are no general
precursory symptoms ; in others, the patient experiences some

  * A new remedy  for elephantiasis, called assacou, the name of a tree (hura
Brasiliensis), indigenous to the Brazils, was sent to France by their minister to that
country in 1848.  It is given in the form of extract of the bark, and also in infu-
sion and in baths ; but its true therapeutic value has not yet been established by a
sufficient number of observations.—{L'Ab. Med., Oct. 1848 ; also Braithwaite's
Retrospect, Jan., 1850.)                                     H. D. B.
  t Dr.  James Maxwell has published  a valuable essay on this subject, founded
on extensive  observation of the disease  in Jamaica, for which, as an inau-
gural dissertation, a gold medal was awarded by the University of Edinburgh.  He
regards yaws  as the source from which tubercular leprosy originally sprung, and
afterwards spread over the globe, by virtue of its hereditary power.   The work is
illustrated by engravings, giving representations of the disease in its different forms
and stages. Dr. M. mentions a paper by the late  Dr. James Thompson, in the
Edinburgh Medical  and Surgical Journal (vol. xviii.), as the most original and
best monograph  on  yaws with which he is acquainted, and also alludes to other
sources of information respecting  the disease.  {Observations on Yaws, and its
influence in originating Leprosy.  Edinb., 1839.)                H. D.  B. 
FRAMBQSSIA.
257
malaise with pains about the loins,  after which the disease
appears in the form of small, dusky-red spots, like flea-bites,
which  are  usually collected in groups.   Each spot becomes
the seat of  a papular-like eminence,  the  epidermis  soon
exfoliates,  the eminences become more prominent,  and we
now find  a spot  covered by a number  of vegetations which
are isolated at the summit and  united at the base; they are
indolent and of a dull red color.   The tumors are  sometimes
circumscribed, and resemble raspberries  or mulberries.  In
other cases they extend over a large surface, and  in the one
which  we saw, the eruption occupied the anterior  and  lower
third  of the thigh; the epidermis was completely  destroyed,
and the disease seemed to consist in  hypertrophy of the skin,
which  was raised into a great number of vegetations.
   The parts in the neighborhood of the diseased skin are  hard,
and  the tubercles likewise firm, slightly inflamed,  and gene-
rally covered by thin, dry, tenacious  scales.   Sometimes the
inflammation  is more severe, ulceration sets in, and a yellow
or sanious  fluid, of very  nauseous  odor,  is discharged.  The
discharge  now  collects  between  the  tubercles and  forms
scabs,  which may for  a time conceal the real nature of the
disease.
   Such is the usual progress of yaws; but it is probable that
there are  several varieties which, though differing from the
present description, yet belong to the same disease.
   M. Biett had a patient in his ward laboring under a modi-
fied form  of  yaws ; the tubercles were round and of a violet
color, varying in size from a pea to a nut; they were seated
in the inner and lower part of the thigh, were  collected in a
circle, and formed a fungous eminence strongly adherent to
the subjacent parts ; around  were numerous scars from old
tubercles, and there were some recent ones on the back and
instep.
   Finally,  in the last stage of the disease, one of the tuber-
cles  enlarges, ulcerates,  and discharges a very acrid  fluid,
which corrodes the surrounding  skin;  in the colonies this
is called the  mother  yaw.   The  disease may  last  for  an
indefinite   period without any serious  derangement  of the
health.
   Causes.—Yaws appears to  be  a contagious malady; it is
communicated through the matter  discharged from the tuber-
cles.   Some have thought it may be carried from one indivi-
dual to another by flies, &c. ; it is said to attack  only  once,
and may arise spontaneously.  Yaws occur at  all ages and in
both sexes, but children are most subject to it.   Atmospheric
influences, the poor food, filth,  and the habits of the negroes 
258
DISEASES  OF THE SKIN.
seem  to  favor its  development.*  It attacks, in preference,
persons  of weak, lax fibre, and those who  are scrofulous or
rachitic.; besides, it is almost exclusively confined to the black
population.
   Diagnosis.—The characters of this disease are extremely
well marked; but  it may  not be  amiss to state briefly  the
symptoms which distinguish  it from syphilis, the more parti-
cularly as some writers have confounded them together.
   In the  general characters of the two complaints there is no
resemblance whatever.  They are both, it is true, contagious,
and syphilis occasionally produces a tubercular affection ;  but
it attacks whites as often as blacks, and never arises spontane-
ously.  Syphilis also may occur an indefinite number of times,
and the tubercular form is almost  always attended by other
signs of secondary syphilis.
   Again,  the  particular appearance  of  tubercular syphilis is
very different  from that of  yaws;  in the one we  have  the
mulberry-looking  tubercle, in the  other indurations  of a
copper or violet color, circumscribed,  &c,  and generally
attended  with  various  other  symptoms  of syphilitic  conta-
Sion\
   Still, cases of framboesia are recorded, which are evidently
cases  of  pustular or tubercular syphilis.  Whether they  are
really  such, we are unable  to decide, at the same time that
our study of the disease,  as described  by authors,  does  not
warrant us in regarding it as a form of syphilis.f
   Prognosis.—Yaws is not a dangerous complaint; it is less
severe in the white than in the negro.   Some  forms  of  the
disease are more obstinate than others; its duration  is less
when  it attacks females or children, and  its severity and dura-

  [* Since negro emancipation, this disease has become much rarer in our colo-
nies. B.]
  t Dr. Maxwell gives  the following diagnostic marks between syphilis  and
yaws:—
  1.  Syphilis appears in six or eight days after contagion ; yaws takes from six
weeks to three months.
  2.  Syphilis may occur frequently from distinct infection ; although yaws  may
recur oftener than once, from the susceptibility not having been  destroyed, yet it
cannot be communicated  by future inoculation, so as to display the disease in its
normal state.
  3.  The constitutional symptoms of the venereal disease are generally progressive,
and seldom disappear without the aid of medicine ; the yaws generally admits  of a
spontaneous cure.
  4.  Syphilis is capable of affecting the foetus in utero ; yaws has never been known
to do so.
  5. Exanthematous eruptions and  febrile affections  have a temporary power in
suspending yaws ; not so in syphilis.  {Prize  Essay on Yaws, by Dr. James
Maxwell.  Edinb. 1839, p. 34.)                            H.  D. B. 
FRAMB03SIA.                      259
tion seem to be directly proportionate to the condition and
extent of the eruption.
  In mild cases nature sometimes  effects a cure;  the tuber-
cles gradually disappear; in the majority  of cases, however,
they ulcerate or yield to caustic applications, and leave inde-
lible scars behind them.  In  other  cases, they resist every
means employed, and may continue indefinitely without seri-
ous injury to the health;  or the disease may become consti-
tutional, attacking the bones,  and sometimes  terminating in
death.
   Treatment.—The treatment of yaws is chiefly local, though
certain internal remedies are highly spoken  of.  Sudorifics
and purgatives are occasionally useful, but the main remedy
is mercury.   Some writers, however, pretend that  mercury is
not only useless, but may aggravate the  disease, and that the
cases in  which  it succeeded were examples  of syphilis mis-
taken  for yaws.*   The country people, especially the  negro
women, use sudorifics with benefit, to drive the disease to the
surface, as they say, and afterwards  add to  the usual articles
for this purpose guaiacum and sarsaparilla.
  In all cases we must confine the patient to a proper regi-
men, and if he  be of weak  or scrofulous habit,  administer
some tonic.   It is probable that some of the preparations of
arsenic might be administered with advantage. As  an external
application, the ointment of the proto or deuto-iodide of mer-
cury should be had recourse to.  When  these means fail, we
must employ more powerful  remedies,  and apply, as a caus-
tic,  the arsenical paste, or the binitrate of mercury.   M. Biett
employed the actual cautery with complete success in a very
severe case, where every other means had failed.
   The  arsenical paste (of Frere Come) is an excellent remedy,
and we have seen M. Biett use  it for  other diseases without
the slightest inconvenience; but it should never  be applied
over a surface larger than a half crown piece.   The binitrate
of  mercury  also acts powerfully, and  should be sparingly
used.

  * Dr. Maxwell states that experience led him " to look upon  mercury as an
exceedingly  dangerous and destructive medicine in the treatment  of yaws," and
that he abandoned its use in every case.  His  plan of treatment consisted of the
warm bath, decoction of sarsaparilla, and the internal use of hydriodate of potassa,
from which latter article he derived the greatest benefit in alleviating the pain and
producing sleep, as well as in its effects in improving the general health, which is the
most important point in the management of the disease.  He cautions particularly
against the use of local applications of a nature to dry up  the spots suddenly,
before they have matured perfectly.  He considers all topical applications perni-
cious, until we first endeavor to destroy the susceptibility of the disease by consti-
tutional remedies.  {Op. Cit.)                               H. D.  B. 
260
DISEASES OF THE SKIN.
  Finally, the remedies just mentioned may be followed up by
vapor baths and douches.


                     MOLLUSCUM.

         Syn.—Mycosis fungoides of M. Alibert.
  The disease of which we are now about to speak has been
called molluscum, from the similarity of the  tubercles which
characterize it to the eminences that grow on the bark of the
maple tree.  We  know little of the  history of this  disease,
which was first noticed by Bateman.   Molluscum consists in
the presence of numerous small tubercles, with very slight
sensibility, varying in size from that of a pea  to  a  pigeon's
egg; they  are round,  or  flattened,  and irregular; sometimes
seated on  a broad  base, at others they are attached by a
peduncle ; in a few cases, they are of a brown color, but gene-
rally preserve the color of the skin.  They grow very slowly,
and  may last during the whole period of life; they occur
chiefly on the face and neck, but may cover the whole body.
Bateman divides this disease into molluscum contagiosum and
molluscum  non-contagiosum.
  The non-contagious species, consisting in indolent tumors
of variable size and  form, and frequently pedunculated, is less
rare than the contagious.  Writers, however, are not agreed
on the true nature of  the disease.   Tilesius published a very
remarkable case, in  which the  face and body  were  covered
by small tumors, containing an atheromatous substance.  M.
Biett had seen several cases  of the same kind, but the tumors
were solid.  In a patient affected with prurigo senilis at the
Hospital of St. Louis, we saw a number of those small tumors
spread over different parts of the body : the largest was as big
as a nut; the  rest not larger  than peas;  they seemed to be
formed  of dense fibrous  substance, and were not painful to
the touch.
  M. Biett observed  another species of  non-contagious mol-
luscum, occurring chiefly in young puerperal  females; here
the tumors are small,  flattened, slightly divided at the summit,
irregular in form, and of a brown  or yellowish  color; they
chiefly  occupy the neck.
   Contagious molluscum is a very rare disease:  it  has not
been met with in France, and Bateman  saw two cases only;
it consists in  round, prominent, hard tubercles of  various
sizes;  the tumors are smooth,  transparent,  sessile,  and dis-
charge  a whitish fluid from their apex.  One of the cases
described by Bateman  occurred in the person of a young 
MOLLUSCUM.
261
female; her face and neck were covered with numerous small
tumors, some  not larger  than  pins'  heads, others as large as
small  beans;  they  were hard  and  semi-transparent;  their
surface smooth and shining, and their color nearly the same
as that of the  skin ;  they were slightly contracted towards the
base.   On pressing  the  largest of the tumors, a milky fluid
was discharged through a central opening which had not been
visible previously.   The disease  had  existed for a year, but
only a small number of the tumors had continued to increase ;
some of the latter appeared to be on  the point of suppurating.
The patient's health  was bad,  and she had become very thin
since  the  development  of the  cutaneous  affection.    The
disease  was  communicated from a child  whom  the  woman
nursed, and on inquiry it was found that the child  took it from
a servant who had it on the face.
   In the  second  case mentioned by  Bateman, the complaint
had been  communicated  from  one child to another.  Dr.
Carswell  has  brought under our notice  a  remarkable case of
molluscum, similar to  those related by Bateman:  he observed
it at Edinburgh, with  Dr. Thomson, in a child  at the breast,
who had  taken it from  his brother, the latter having taken it
from a schoolfellow.   The  disease passed  from  the  infant's
face to  the  mother's breast,  and  also  attacked two  other
members  of the family.  The  child  died, but no  examination
of  the body could be  obtained: the  symptoms of the disease
in these cases were the same as those given by Bateman.*


  *  In  the Edinb. Med.  and Surg. Journ. for  July 1, 1841, are papers by Drs.
Henderson  of Edinburgh and Robt. Patterson of Leith, describing this disease,
with drawings of the general appearance of the  tubercles, and also of  their inti-
mate structure.  Dr. H. had seen five cases, which, with the three of Dr. Patter-
son, he says, make twenty cases of the disease on record.  In the Lond.  Lancet
for May 15, 1841, is also a clinical lecture on it by Mr. Fred. H. Thomson, and
two plates exhibiting its appearance and character ; and in the Brit, and For. Rev.
for Jan., 1840, is a case by Mr.  C. Fowler of  Cheltenham,  taken from  the
" Transactions of the Provinc. Med. and Surg. Association," vol. vii., which work
is said to contain an excellent engraving of the disease.
  Dr. H. H. Smith, of Philadelphia, has described an interesting case  of disease
under this name, in the Amer. Journ. Med. Sciences for Oct., 1851, illustrated by
three woodcuts, showing the  general appearance of the  tumors and their distribu-
tion on the body, and the appearances presented  under the microscope by the con-
tents of one of the largest of them; he  has also given a summary of  the views
entertained by different writers on the subject, and accounts for the discrepancy
between the  descriptions given by them by their having described different varieties
of the same disease. He regards as the pathology of  the disease " an obstruction,
or a fibro-scirrhous or medullary degeneration  of the sebaceous follicles." His
case occurred in a female about fifty-five years of age, and followed an injury, the
first tumor appearing at the seat of the injury, at the end of about six weeks.
Tumors of different sizes appeared afterwards on different parts of the body and
head, and the disease proved fatal at the end of about two years.   The contents of
the tumors showed his  case to be of the medullary variety.          H. D. B. 
262
DISEASES OF THE  SKIN.
  Causes.—Upon this point nothing positive is known.
  Diagnosis.—The form,  color, arrangement, and progress
of the tumors will enable us to distinguish them from  the
tubercles  of syphilis,  yaws, or elephantiasis of the  Greeks.
The contagious species is easily distinguished from the non-
contagious one, and if we had a sufficient number of accurate
observations of the two species, we would  probably find that
they bear little resemblance to each other.
  Prognosis.—The prognosis of  the non-contagious variety
is favorable; the progress of the tumors does not seem to
depend on any constitutional derangement;  they seldom pro-
duce  irritation, and after a certain period, become stationary
for  the rest of life.   Contagious molluscum is a much more
severe and rebellious affection.
  Treatment.—We know  so  little  of this disease  that it is
difficult to say  anything satisfactory of  the treatment.  M.
Biett has employed a great number of remedies in cases of
non-contagious  molluscum.    In  the first  variety  he was
unsuccessful:  in  the  second  he  found  some benefit from
stimulants and  styptic lotions: in  one  case, where several
tumors occupied  the  neck of a young female, he  obtained a
complete  cure in a few  weeks with a lotion containing  the
sulphate of copper.  Finally, Bateman has given the prepara-
tions  of arsenic,  and  particularly  Fowler's  solution, with
benefit, in contagious molluscum.*

  *  Sulphate of copper, both in strong  solution and in substance, caustic potash,
and nitrate of silver in substance, have been used, with success in the contagious
variety.  The tumors are said to be so insensible that escharotics give no pain.
Dr. Patterson {loc. cit.) considers internal remedies as generally too tedious, when
local means give so little pain, and  are so speedy and effectual in their operation.
I have but very slight practical acquaintance with the disease.      H. D.  B. 
MACULM,
     Syn.—Dermatoses dyschromateuses of M. Alibert.

  In addition to the various inflammatory affections already
described, the skin may be the seat of certain changes  of
color which merit attention.  In speaking of these changes,
we  shall confine our description to such as are really con-
nected with the  tegumentary  system, omitting those which,
like chlorosis and jaundice, are merely symptomatic of some
other and  more  deep-seated  disorder.  Hence, under the
order Maculae we shall include those  diseases only  which
depend on some  alteration of the coloring matter of the skin :
they are characterized  by change or absence of the natural
color of the skin, giving rise to spots of various appearance
and different size.
  Maculae are either general or partial; the latter,  it is true,
may cover nearly the whole of the body, but then  they are
separated by intervals of normal-colored skin ; sometimes they
occupy  one  region only, as in  lentigo, when confined  to the
face;  in other cases, nmvus for example, we have a  single
spot.  The duration  of  this  order  varies with each species ;
when the disease is congenital, or spread all over the body, it
generally lasts for an indefinite period ; the ephelis is the only
species to which  a definite duration  can, in  a certain degree,
be attributed.
  Maculae evidently depend on some alteration of the  color-
ing  matter.   It is, therefore, important to  distinguish  them
from those changes of color  which  depend  on the vascular
system, or on  the presence of coloring  matter in the blood;
for we cannot but think that ephelis and icterus, vitiligo  and
chlorosis, differ essentially both in their seat and nature.
  Causes.—The cause of most species of maculae  is totally
unknown.   We are aware, for example, that  the skin assumes
a general bronzed tint after the administration of nitrate of
silver, but as yet neither chemists, anatomists,  nor medical
men have been able to explain this  curious phenomenon.  We
are  equally in the dark as to the cause of naevi materni, and 
264
DISEASES OF THE  SKIN.
must  rest  contented at present with  the  popular  opinion
which  attributes them to impressions made on the mind of
the mother.  These effects are often imaginary, and often
referred to a cause which is transient in its nature, and only
thought of when the attention is directed to it.  Still, there
are authentic cases in which there was such an exact corre-
spondence between the object by which the mind of the mother
was impressed  during  pregnancy and the mark on the child,
that we are tempted to admit that a certain degree of influ-
ence may be exerted on the foetus by impressions during that
period.  Ephelides  appear  under  the influence of  a cause
which we can,  up to a certain point, appreciate.
   Diagnosis.—Maculae are easily distinguished from all other
diseases of the skin, and the symptoms peculiar to each variety
will readily enable us to recognise  them.  Certain syphilitic
spots, it is true, resemble maculae, but we shall point out the
difference in speaking of the former.
   Prognosis.—Treatment.—Though generally incurable, these
affections are never immediately dangerous, and seldom injure
the health.  The species which admit of cure, commonly yield
to simple remedies; of the others we know so little, that the
failure of our therapeutic means is not much to be wondered
at. We shall  divide  maculae  into  those  accompanied  by
change of color, and those characterized  by absence of color.
                CHANGES OF COLOR.

These  are either general or partial, the bronze color consti-
  tuting the only general change; lentigo, ephelides, and naevi
  the partial ones.

                   SLATE-COLORED SKIN.

  It sometimes happens that the skin assumes, more or less
suddenly, a bronze or slate-color ; this especially occurs after
the internal use of nitrate of silver; but the change of color
may manifest itself in persons who have never employed  this
remedy; we have seen two cases where the disease'could not
be attributed to any known cause, and M. Biett saw several
others  of the same kind.  The skin, however, in these cases is
much less dark-colored than when nitrate of silver  has been
taken ;  it has rather a dirty tinge than a deep hue.
  In cases succeeding the use of nitrate of silver, the skin
assumes a greyish slate-color, deepening into green under the
influence  of  light.  M. Biett, who  employed  the nitrate of
silver with success in  several cases of epilepsy, has  often had 
CHANGES  OF COLOR.
265
occasion to observe this effect on  the  skin.  The change of
color usually begins to appear some considerable time after
commencing  the  employment of the remedy; the skin first
assumes  a bluish  tinge, which  gradually  becomes  a light
bronze-color, particularly in the parts exposed to light.   The
whole  body is attacked  at  the  same  time, but the color is
deepest where the skin is most  fine  and exposed : in some
cases it gets nearly black.  The  conjunctivae, and the line of
junction between the mucous membrane  and skin, are gene-
rally of a livid copper color.
  It is worthy of notice that the color of the  face  becomes
deeper under  the  influence  of causes which in the natural
state would have produced paleness, and vice versa.  The dis-
ease may last for a considerable time, or even during life.  M.
Biett saw two persons at Geneva, in whom it had continued
for twenty years without any diminution ;  for the last fourteen
years he had been in the habit of frequently employing nitrate
of silver for epilepsy; and in many of  his patients the disco-
loration continues unabated.   It sometimes diminishes gradu-
ally, but there is no example of its  having  completely disap-
peared.  The  general  health is never deranged, nor is there
any change in the  tissues intimately connected with the skin;
the hair remains intact, but the nails have commonly a bluish
tinge.  Old cicatrices usually present the  same bronzed color
as the skin, but those which arise from .wounds inflicted after
the appearance of the disease  are white.
  The  discoloration of the skin, now under consideration, has
been observed by a great number of medical practitioners, who
have employed the nitrate  of  silver in the treatment of epi-
lepsy.   Fourcroy was the first who directed attention to  this
point;  since  his  time  we may cite the names of Powell,
Marcet,  Roget, in England; Albers, Reimar, Schleiden, in
Germany ; Butini,  Delarive, and  Odier, in Switzerland; and
of M. Biett, in France : the latter gentleman has had twenty-
two cases under his care (fifteen males, seven females), with-
out counting those which he had seen in England and  Switz-
erland.   In most of these cases time had  no influence  on the
disease.
  We may now ask how does the nitrate  of silver act  on the
coloring matter of  the skin ?   does  the  effect of the remedy
depend on some chemical combinations produced through the
agency of light ? We are unable  to tell: the theories hitherto
advanced are not  satisfactory ; and most  of the questions on
this point, addressed by Albers ,of Bremen  to the  Medico-
Chirurgical Society of London, still remain unanswered.
  We are not  acquainted with any remedy for this  disease ; 
266
DISEASES OF THE SKIN.
every mode of treatment hitherto adopted  has  failed.   The
stimulating baths, recommended by some writers, can produce
no effect; M. Biett tried them, in some cases, without success;
blisters also fail,  though an English author pretends that they
restore the skin to its natural color;  M. Biett has proved this
to be  erroneous.  It  is probable, however, that  successive
blisters might have some effect, but it is evident that so severe
a remedy could never be applied to the face, or other exposed
parts of the body.
  [Dr. Patterson, who  has  recently instituted a series of ex-
periments,  with a view to clear up this subject, considers that
the nitrate  of silver is readily decomposed by the  saliva, by the
simplest articles of diet, and by the healthy and diseased secre-
tions of the stomach itself;  so that it cannot  pass into  the cir-
culation  as the  nitrate, but in some  other  combination (the
chloride, perhaps), to which must be attributed  its  beneficial
and  curative effects in epilepsy, &c.  Dr. Patterson attributes
the discoloration  to the decomposition of the chloride of silver
circulating  in  the  cutaneous tissues, through  the chemical
action of the sun's rays, and the deposition there of its metal-
lic basis in a state  of extreme disaggregation.   Persons of a
fair delicate skin are much  more liable to it than others. Dr.
P.'s  researches lead him to believe that the  ioduret of  silver
might be advantageously substituted for the nitrate ;  and, as
the sun's rays  have not any decomposing influence on that
salt,  it is not likely  to produce  the discoloration  above  men-
tioned.  He has found a solution of hydriodate  of potash  to
remove the stain  on the skin produced by the external  appli-
cation of the nitrate of silver, and  that  nascent iodine will
remove the writing of indelible  marking ink, made with the
nitrate; hence he supposes that the cutaneous  discoloration
may be removed  by the internal and  external employment of
the preparations of iodine.—B.]*
                         LENTIGO.

Syn.—Ephelis lentiformis ; Pannus lenticularis; Freckle.

  Lentigo is characterized by the presence of small spots, of
a dusky yellow color,  never larger  than a lentil, and  often
much smaller.  It is most frequently a congenital disease, but
sometimes appears about the age of nine or ten, and continues
during the rest of the patient's life.  The spots are of a deeper

  * The oxide of silver has been more recently recommended as a substitute for the
nitrate, and is said not to give rise to discoloration of the skin.       H. D B. 
EPHELIDES.                     267
 color during youth, and usually occupy the face, front of the
 chest, neck, and hands.  The parts exposed to light are thus
 the usual seat of this affection, but it may extend over the
 whole body.
   Symptoms.—The spots of lentigo are round, of a yellowish
 color, sometimes very bright and  irregularly  scattered  over
 the skin; on  the neck  and cheeks they often run  into one
 another, and  form  large discolorations.  They  do not rise
 above the level of the skin, are not attended by pain, or even
 itching, and rather  cause a disagreeable appearance than con-
 stitute a disease.
   Causes.—Lentigo  generally occurs in persons with a fine
 white skin, and light or auburn  hair;  it is rarely seen in the
 dark-complexioned.   The action of the sun sometimes excites
 it; and in such case it may disappear in time, or with a change
 of climate.  It  is most common in warm countries, and  in
 persons of lymphatic temperament, rarely occurring in those
 of vigorous and plethoric constitutions.  It is generally a con*
 genital affection.
   Diagnosis.—When seated on the body, lentigo might some-
 times be mistaken for a species of purpura. The latter occa-
 sionally appears in  the shape of small round spots, like those
 of lentigo; but they are of a livid  red color, while in lentigo
 they are  yellow : they may exist on the trunk and limbs, with*
out appearing on the face,  which rarely happens  in lentigo;
finally,  they last but a certain time, and are generally  accom-
panied by some derangement of the health, while those of len*
tigo remain for life, and never cause any unpleasant symptom.
  When  several spots of lentigo  are  united  together they
may be mistaken for ephelides;  but the  presence of small
round maculae, their duration, and the absence of pruritus, are
sufficiently  diagnostic signs.   Lentigo sometimes disappears
of itself;  sometimes  continues during  life; but as it is  not,
properly speaking, a disease, it requires no treatment.*
                        EPHELIDES.

    Syn.—Pannus hepaticus;  Chloasma;  Liver spots.

  Ephelides are irregular spots,  of a yellow saffron  color,
much  larger than those of lentigo, often  attended by itching,

  * Mr. Wilson recommends in lentigo {Diseases of Skin) the lotion of bitter
almonds, containing five grains of bichloride of mercury to the half pint • or a
weak solution of citric acid in infusion of roses. He has also seen the liniment
01 nme  water and oil, with a small quantity of liquor ammonia, of service.
                                                  H. D. B. 
268
DISEASES OF THE SKIN.
and  sometimes  terminating  in  a slight  exfoliation  of  the
cuticle.   They may occupy any  part of the  body ; but gene-
rally the front of the neck, chest, abdomen, axillae, and groin ;
they seldom appear on the face, except in pregnant women.
They may continue for  a few days only,  or for one, two, or
more months; they sometimes appear spontaneously, and  dis-
appear quickly, as at the period of menstruation ; but in most
cases they  are  developed slowly, and if not submitted to
proper treatment, may persist for several months.
  Symptoms.—The first symptom is a  slight degree of itch-
ing, which is soon followed by the appearance of small round
spots; these  are,  at first, of a greyish color, but gradually
assume  a yellow tinge, sometimes  deepening into saffron.
The color, however, varies much with the  individual and  the
seat of the affection.  At the commencement,  they vary also
in size, but gradually become  more  numerous, run  together,
and form extremely large spots,  covering  a  great surface of
the skin; they are not prominent, nor are  they attended with
any symptom, except troublesome itching.   The patches  are
sometimes so large that,  at the first  glance, the morbid color
might  be  mistaken for  that of  the  skin  itself, and the  few
points  where the natural color of the  skin  remained, be
taken for the discolored  parts.  The itching is  augmented by
the least error  in diet  or  moral impressions;  it is  likewise
increased at the  menstrual period and by the heat of the bed,
being sometimes carried to such a degree as to deprive the
patient of sleep.   Ephelis may pass away in a few days, or in
a few hours, but in other cases its duration is much longer.
   Causes.—This affection occurs indifferently in both sexes,
but chiefly in women of fine white  skin; in  dark-complex-
ioned females the spots are of a deeper color.   They may be
produced by the action  of the sun, errors of diet, the use of
salt  meat, &c.;  and often  coincide with  the suppression of
some habitual discharge.   As ephelis sometimes  occurs in
persons laboring under  a chronic disease  of the liver, it  has
been attributed to the latter;  but the coincidence is rare,  and
the  cutaneous disease is not necessarily connected with  the
disorder of the liver.  In  the majority of cases, persons affected
with  ephelis enjoy excellent  health, the disease merely con-
sisting in some change of the coloring matter of the skin.   It
is this which constitutes the mask sometimes seen on the faces
of pregnant women.
   Diagnosis.—This is  generally easy; but ephelis may be
confounded with pityriasis, syphilitic spots, or some naevi.
   Pityriasis.—Pityriasis versicolor  is  a  scaly disease ;  the
desquamation is formed  by layers of  altered epidermis, while 
EPHELIDES.
269
in  some rare forms  of ephelis we have  a slight  farinaceous
exfoliation.   Still the  diagnosis  may be  difficult when  the
former is attended  with a yellow tinge; it never, however,
presents  the pruritus constantly existing  in ephelis.
    Venereal  spots.—The  livid,   copper-colored   spots,  the
absence  of desquamation  and itching,  the  previous history
and attendant  symptoms, will  always  serve to  distinguish
spots depending on  a venereal taint.   Some ncevi of  a dark
yellow  color,  and  not elevated  above the  surface, may
resemble ephelis, but they may be distinguished by their being
few in number, or  single, by the  absence of itching, their
being congenital, and their incurability.
   Prognosis.—Ephelis is  a very slight affection.   The spots
which appear during pregnancy soon fade away, but  should
they persist,  they require  no treatment; the  same remark is
applicable to  ephelis  when connected with menstruation.
Under other circumstances, it causes no other inconvenience
than  a  considerable degree  of  itching, which  is  usually
removed by  appropriate treatment.
   Treatment.—Astringent,  alkaline,  and stimulating  appli-
cations,  intended to  give tone  to  the  skin, are  useless,  and
may prove injurious.   A more simple treatment is all that is
required.  Some  sulphureous water,  as that  of  Enghien or
Cauteretz, may be given internally, with two or three sulphur
baths every  week,  the bowels being  kept  open  by laxative
medicine.   This  treatment  is  generally successful.  When
first administered, the Enghien water should be diluted with
two thirds of  milk  or barley-water, and the quantity of the
sulphureous water  gradually increased until it can be taken
pure.  When the spots occupy the inside of the thighs,  groins,
&c,  and cause severe pruritus,  it maybe  useful to'apply,
alternately with baths, a lotion  containing an ounce  of  sul-
phuret of potassa to a quart of water.  It is scarcely necessary
to  add, that  the patient should  avoid all excess  in  diet,  and
abstain from stimulating drinks.*

                           N^EVI.
   Syn.—Spili; Maculae maternae;  Mother marks ;  Moles.
   Under this  head are comprehended all  those congenital
  * Dr. Lilienfeld recommends for the removal of" macula hepatica" that a pur-
gative should first be taken, and warm soap-suds baths used for three or four  days,
to  soften the skin.  The spots are then to be washed every night  on going to bed
with the tincture of hellebore {veratrum album), and in the morning washed and
rubbed with a piece of flannel, wet with warm soap-suds.  The tincture of helle-
bore should be prepared with the fresh root.  He says that the spots begin to fade
after three days' treatment, and soon disappear completely. {Bull. Giner. de Ther.,
Jan. 30,1850.                                         H. D. B.
                             18 
270
DISEASES OF THE  SKIN.
discolorations of the  skin which  are  commonly attributed to
impressions transmitted  from the mother  to  her child.  In
some cases the spots (spili) evidently  consist in an  alteration
of the coloring matter of the skin, and are not raised above
its level;  they may occupy any region of the  body, but most
frequently the face.   Their color may become less bright, but
they never disappear  completely; and they assume such a
variety of tints and forms that it is impossible to comprehend
them all in a  general  description.  They are, however, com-
monly of a yellowish color or black, and in the latter casp are
covered by short  stiff hairs.  They  are usually  of irregular
form ; but sometimes resemble, in a very curious manner, the
shape  of  certain objects.  They may be  small, or occupy a
considerable  surface,  one-half the face, a  whole limb, or a
great part of the body.  They occasion no  pain  and are not
attended with itching.
  Another form  of naevus  is connected with the vascular
system, and may be divided into two species. In the first, the
spots are  entirely superficial and are under the  influence of
the circulation.  They are commonly  red  or purplish, and
become deeper from mental impressions, errors of diet, at the
menstrual periods, &c.  The skin sometimes  appears  to be
slightly swollen.  In the  second species  they are more or less
elevated above the skin, oblong, flattened, or pediculated, and
constitute the erectile tumors of Dupuytren.  Finally, writers
have described, under  the name  of moles, small brown spots,
which are either superficial  or  slightly prominent,  usually
perfectly round, rarely larger than a lentil, and generally sur-
mounted   by  a few hairs.  They seem to be intermediate
between spili and navi, but  are  more allied to the  latter, for
they sometimes excite itching, swell, and become painful, on
the least irritation.  They are generally congenital, but some-
times occur after birth.  We are quite ignorant of the proxi-
mate cause of naevi;  and, even  admitting the vulgar idea of
maternal influence, which certainly does not exist in a great
majority of cases, we  still would  have  to  account for their
mode of origin.  Some authors think  that naevi are more fre-
quent  in the children of women who have been subject to
inflammatory affections of the skin ;  but,  even if  this  were
the case,  it would throw no light on their origin.
  Naevi,  generally speaking,  require  no treatment; the  first
species (spili) may be  abandoned to nature.  We could only
destroy them by the knife or by  caustics; but the resulting
scars would be more  disagreeable than the original disease.
The treatment of vascular naevi belongs exclusively to the
surgeon, and  consists in the use of pressure, ligature, removal 
VITILIGO.                     271
by the knife, or the ligature  of  the vessels  which supply the
tumor.  The cautery seems to be too dangerous a remedy in
cases of this latter kind.
                   LOSS  OF COLOR.

  The  absence of the coloring matter of the skin may  be
congenital or accidental, general or partial.

                       ALBINISMUS.

  This  affection consists in a general and congenital absence
of coloring  matter in  the  skin, and is  the more remarkable
that albinos do not constitute a separate race of men, but are
found amongst all  nations.
  The skin  of the  albino is of a dull, white color, like that of
milk; the hair is smooth and silky, like the silvery clothing of
the goat,  and  sometimes of a snowy whiteness.  The eye-
brows, eyelashes, and beard, and the hair in the axilla and on
the genital organs  are of the same color;  the whole  body is,
besides, covered with a woolly down of a snowy whiteness,
and remarkably soft. The iris  is of a rose color, and the pupil
deep red; circumstances which depend on  the  absence of
pigment in the choroid and uvea. The eyes of the albino are
unable to  sustain a strong light,  under the influence of which
the lids  contract perpetually, and the pupils oscillate in a very
rapid  manner; at  the  approach of night they see distinctly.
The moral and physical constitution of the albino corresponds
with  the  weakness  of his organization.   He is generally
weak, small, and delicate,  and  the  intellect dull.   Several
idiots  are albinos.   There  is  no example of the  occurrence
of this  state accidentally; its  primary cause is  completely
hidden from us. Though more common in some parts of the
world than in others, it occurs in every climate, and amongst
all races of mankind.  The characters of this peculiar state
are too well marked to render its diagnosis  doubtful.   It is
beyond  the reach of our art, and requires no treatment.
                        VITILIGO.

            Syn.—Achroa ; Achrome vitiligne.

  The skin is sometimes the seat of a partial decoloration, or
absence of color,  constituting  an affection known  by  the
name of vitiligo, which has been  confounded with diseases
entirely different from it.  The porrigo decalvans of Bateman. 
272
DISEASES OF THE SKIN.
is  a certain form of vitiligo, that is, an essential  absence of
color of the skin, complicated with an alopecia of a peculiar
kind.
  Vitiligo is, then, an especial and partial decoloration of the
skin, and may be either congenital or accidental.   The first
of these forms qccurs only among negroes, on different parts
of whose  bodies  white spots of various shapes and  size are
sometimes  found, and who are then called pied negroes.
When  these  patches are on parts covered with hair, that is
also white.
  Symptoms.—Vitiligo is  most  frequently accidental,  and,
indeed, this is the only form which affects white persons.  It
may appear on any part of the  body.  On parts not covered
with hair it is characterized by smooth patches,  of  a milk-
white color, usually of a circular form, but sometimes in lon-
gitudinal  striae or streaks. Its  development is unattended
with either heat or itching, and its most frequent seat is the
scrotum.
   When on the hairy scalp, without any  precursory  heat  or
itching, the hair begins to grow thin on a certain part, and  a
whitish spot is soon seen, indistinctly defined, and losing itself
in the surrounding healthy skin.  The  decoloration and alo-
pecia progress together; and when the disease is  fully deve-
loped,  it consists of an  entirely  bald spot, of a remarkably
milk-white color and with a smooth and shining surface, and
with limits so perfectly defined  that the hair about its borders
is  as strong and  thick  as on  any  other  parts  of the head.
There  may be several spots, and they may extend and  become
confluent, and thus cause baldness of the greater part of the
head.  The disease  may  affect  any part of the scalp,  but
occurs more frequently  on its posterior  portion.   It  usually
lasts for some time ;  sometimes for years.  Tt  may appear on
all parts covered  with hair, and present the same character as
on the scalp.
   Causes.—Vitiligo occurs at  all ages, but more  frequently
from twenty to thirty years, and is more common in  females
than in males.  It seems to be connected with the lymphatic
temperament; but it is difficult, if not impossible, to ascertain
its causes.  It is  never contagious.
   Diagnosis.—The  characters  of vitiligo are very  distinct
and easily recognised.  When  on the  hairy scalp, the bald-
ness which it produces might be confounded with that result-
ing from favus; but in vitiligo the skin is colorless, retains its
normal thickness, and is always covered with a kind of down ;
while in favus the  skin is thin because there is a cicatrix, it
has  a  peculiar color, and  is entirely destitute both of down 
VITILIGO.
273
and of hair.   We should not confound it with the white lines
which are found on the mammae or abdomen of women who
have been pregnant or affected with dropsy, &c.;  for the lat-
ter depend on laceration  of the  rete  mucosum,  from over dis-
tension of the skin.
   Treatment.—We have seen several cases  of vitiligo in the
wards of M. Biett at  St. Louis;  but  the means employed  in
the  treatment  of  this affection  were  never  attended  with
benefit.   Fortunately, it  is one  which calls for  little interfer-
ence on the part of the medical man.*


  * The term vitiligo is applied to affections entirely different from each other by
different writers.  Wilson makes it a synonym of lupus exedens,  while Erichsen
{Lond. Med. Gaz., Nov. 14, 1845) describes it as characterized by tumors occur-
ring in clusters, larger than the papula? of acne, and more solid, and having a ten-
dency to creep along in particular directions, leaving a white shining cicatrix, as if
from a burn.   J. P. Frank {Traite de Med.  Prat., Paris, 1842, vol. i. p. 349)
used the word in a still different sense.
  In the last edition of their workour authors say, under the head of prognosis,
that vitiligo is  never a serious disease, and that all the cases which they have
observed have yielded to appropriate treatment perseveringly used ; and that  the
success has been more complete and more prompt when the disease was seated on
the hairy scalp  ; w%ile  under the head of treatment they state that the different
means used by Biett, in cases seen by them, have been followed by no good result, and
that they have themselves since used different means with  varied success.  The
treatment, they add, consists of means calculated to  stimulate  and  excite  the
affected surfaces, and they have seen patients improved by the use of warm sulphur
waters.
  M. Cazenave, in his  clinical  lectures on the subject, at the St. Louis Hospital
{Gaz. des  Hop., Sept. 17,  1850), mentions alcohol, ammonia,  and sulphate of
quinine as the applications for this purpose, and says that he has often succeeded
by rubbing the affected  parts night and morning with a piece of linen impregnated
with a solution of sulphate  of quinine.  At the end of a few weeks, he adds,
young hair sprouts up, and the natural color of the skin begins to return.
  The vitiligo of English writers is a very rare affection, and requires entirely dif-
ferent remedial  means, but we do not feel that it would be profitable to devote any
more space to the subject in a work like the present.                H. D. B. 
DISEASES
WHICH DO NOT ADMIT  OF BEING  ARRANGED UNDER ANY ONE OF
                   THE PRECEDING ORDERS.
                         LUPUS.*

 Syn.—Lupus vorax ; Herpes exedens; Formica corrosiva.

  Lupus commences sometimes with violet-red spots, or more
frequently livid  indolent  tubercles; the chief character  of
which is their tendency to end in  destructive ulceration of the
surrounding parts, and even of the subjacent Ussues, forming
ichorous and  ill-conditioned  ulcers, giving rise  to brownish
and usually very adherent scabs,  which are followed by fresh
destruction after they fall.  It presents great varieties in the
seat,  progress, and extent of the ulcerations, and  also in its
mode of destruction, and the form of the subsequent ulcera-
tion.   Sometimes they run along  the surface of the  skin;
sometimes destroy the subjacent tissues.   Sometimes lupus is
attended by hypertrophy.  Hence M. Biett  was led to make
three principal varieties:  1, a form which destroys the surface
only;  2, a form which destroys  deep-seated parts;  3,  lupus
with hypertrophy.  These distinctions are founded on  prac-
tice, and facilitate our description of the disease.
  The most common seat of lupus is the face, and it attacks
the nose more frequently than, any other part of the body ; but
we are unable  to explain  this peculiarity.  The cheeks, lips,
and chin, are the parts most  subject to it, after the nose.   It
may,  however, attack any other portion of the body ; for the
trunk, we  generally find it seated on the chest or shoulders ;
for the limbs, in the neighborhood of the joints, the  external
surface of the forearm, the back  of the hand, or the dorsum
of the foot.   In some cases  it attacks the  neck.   It may be

  * Lupus is classed among tubercular diseases by Rayer and Gibert, and also by
some  of the English  dermatologists, and seems properly to belong among them,
for its elementary form is a tubercle in the great majority of cases ; and even when
it commences on the mucous membrane, the  difference in the elementary form is
only owing to a difference in the structure of the parts.           H. D. B. 
lupus.                       275
confined to a single point, or may attack several points simul-
taneously, or spread to  several parts  of the body.  The first
sign of this  disease is,  generally, a dull red, small, hard emi-
nence  or tubercle,  which  increases  slowly, and  seems to
occupy the superficial layer of the skin.  The summits of the
tubercles are occasionally covered by white dry scales.  In
many cases, several tubercles unite together, and form a soft
indolent tumor, which terminates, after an uncertain period,
in ulceration.
  This  is the usual way  in which the disease commences;
but it  is certain  that tubercle is not  always the elementary
lesion of lupus.   It sometimes begins with inflammation of
the mucous membrane of the  nares, attended by redness and
tumefaction of the nose.  A  small crust forms on the part,
and is scratched off.  A second scab  appears, and ulceration
has now set in.  In other cases, we find a purplish spot, with
slight tumefaction, on some part of the face, but chiefly on
the tip of the nose.   For  several months  the color becomes
deeper and brighter; then appears a slight ulcer covered by a
scab,  and the  ulceration  gradually  extends in  length  and
depth.   Finally, in  some  cases the skin  gradually  gets  thin
and looks like a cicatrix,  without tubercle, ulceration, or any
other lesion, except a livid spot, from which the cuticle occa-
sionally scales off.
  Superficial lupus.—This form of the disease presents some
varieties which are worthy of notice.  In a few rare cases it
seems  to be confined  to the most superficial layers of the
dermis, and occupies chiefly the face and cheeks.  There are
no tubercles or scabs, but the skin  assumes a reddish tint;
the cuticle exfoliates, and the integument gradually becomes
thin.   It is now smooth, red, and shining; and, finally, looks
like  a  cicatrix after a  superficial  burn.   The redness dis-
appears under pressure with  the finger, which gives rise to
pain, although not  painful when not touched.  After violent
exercise, or excess  in spirituous liquors, although not painful
when not touched, the affected  surface  becomes  sensitive.
When the progress of the disease is arrested, the redness dis-
appears, the  epidermis  ceases to exfoliate,  and  the  skin
remains thin and shining.  This is the form to which  Biett
gave the name of erythema centrifugum,  of which we have
already spoken.
  In other cases several  small soft tubercles,  of a dull red
color, form  upon the skin; they remain  indolent  for  some
time, then suddenly increase, become numerous, and the skin
which separates them is slightly tumefied.   They now  unite
at the  base, ulcerate at the points, and form an irregular, ill- 
276
DISEASES  OF THE  SKIN.
conditioned  ulcer, covered  by a dark tenacious crust, which
gradually  spreads  to  the  neighboring  parts.  -  When  the
disease extends in this manner, we find several white irregular
lines of cicatrix, like those from large  burns, forming on the
original seat of the complaint.   They  generally occur  after
treatment has been employed.*
   Lupus may thus attack very extensive surfaces of the body,
the  whole face,  for  example :  and while it is  making  fresh
ravages, the  cicatrized  parts,  being  surrounded by tubercles,
often give way.   It is always by the formation of  new tuber-
cles which circumscribe the ravages of lupus by an indurated,
rough, and  swollen border, and which  afterwards ulcerate,
that the disease progresses.   We  saw a patient at St. Louis
in whom the disease commenced in the submaxillary region:
thence  it gradually extended,  in  spite  of  treatment, to the
neighboring parts; and, in a few years, had reached the  chin,
a great portion  of  the  cheeks, and all  the front of the neck.
In  some cases  the  tubercles commence at the angles of the
mouth; the ulcers  are covered by thick scabs, and the patient
finds much difficulty in  opening his mouth.


  * The superficial form of lupus differs so much from the other varieties in its con-
stitutional origin, and in the effect of treatment upon it, as well as in its termination,
as to render the difference worthy of notice in a practical point of view ;  and of
this form the two varieties described in the text differ essentially in their progress,
and in  the effects of remedies on them, the first being indolent in its nature, and
presenting a desquamating instead of an  ulcerating surface, while the second is
characterized by ulceration.  The  latter variety appears sometimes in those who
have had the venereal disease at some period, perhaps long previously, and at other
times in those who have suffered from the use of mercury, or from the combined
effect of these  two  causes—and at other times is more directly connected with a
strumous  constitution.   This is the form which has given rise  to some confusion
among writers, some describing it as a form of lupus and others  calling it scrofula,
and which is sometimes described in the journals under the name of " strumous
phagedenic ulcers."  It is this form which is so favorably affected by iodine, and
usually easily controlled by it, at least temporarily.  There is also another variety,
which I have been in the habit of referring to the head of superficial lupus, which
is characterized by groups of small reddish tubercles, arranged in patches of a cir-
cular or oval shape, usually very indolent in their progress, and which are also the
seat of desquamation, and not of ulceration, but which are easily converted into
ulcerating surfaces by irritating applications.  The patches spread very slowly by
the formation of fresh  tubercles on their outer  edges, while the centre gradually
assumes a whitish and slightly puckered appearance, resembling somewhat  the
cicatrix left by a burn.   I have seen this form  most frequently on the face or fore-
head, and most usually in females of strumous diathesis, and  have found it very
little influenced  by treatment.   In one case under my observation for a short time
the disease had  lasted several years, and had covered almost the whole  of one side
of the face in a female about thirty years of age.  This variety never extends
beneath the skin, and is seldom, if ever, attended with hypertrophy.  Pain seldom
accompanies either of these three varieties.
  M. Cazenave, in a recent clinical lecture, {Gaz. des H8p., July, 1850), describes
the last of these varieties, and insists upon the importance of  its diagnosis.  We
have recognised it several years.                                H. D. B. 
LUPUS.
277
   The nose is seldom the primary seat of this variety of lupus,
but  it  is  attacked  in its  turn, and  the ulcers frequently
destroy the sides or extremity  of  this  organ.  By  proper
treatment, however, the  formation  of  fresh  crusts may be
prevented.  The  surface is sometimes  rough  and covered
with small red tubercles.  In other  cases it is lined with fur-
furaceous  scales, like  those of the epidermis, which fall  off,
and leave a white cicatrix underneath.   In this state, when
the ravages of the disease have been extensive, the face pre-
sents a very remarkable appearance ; it is covered with irre-
gular scars, some of which are of a  pale red color, tense, and
shining; thick in some points, but in others so thin that they
appear  to  be  on  the  point of giving way altogether.  The
latter  appearance  exists  in the  parts  which have  been
frequently destroyed by repeated ulceration.  In almost all
cases these scars are united to the base of tubercles, from
which they seem to spring.  Sometimes the edges  of  the
scars are  partially covered by dark tenacious  scabs.  This
variety may also occupy extensive surfaces of the body.
   Deep-seated  lupus.—This  form generally occurs  on  the
sides  or extremity of the nose.   It  is often preceded by red-
ness and tumefaction  of the part, with coryza.  One of  the
alae of the nose swells,  gets painful, and  is of violet-red color.
A slight ulcer now forms, and is covered  by a thin scab; this
is removed; another scab forms, which is thicker, and each
time a portion  of the  substance  is destroyed.   The redness
and tumefaction often extend over the  tip of the nose to  the
other ala.   The  affected parts are  now  covered by a scab,
which gradually  increases in thickness.  The patient suffers
little.   The skin  and  cartilages of  the nose are  destroyed
underneath the scab  ; and when  the  latter falls off we find an
ill-conditioned  ulcer underneath, discharging a  quantity of
sero-purulent fluid.  Some  foetid matter,  likewise,  is often
discharged  from  the  nose.    The swelling conceals   the
destruction which takes place, which  is only  appreciated
when that has gone down.   In other cases we have no tume-
faction  or coryza, but a single  red, smooth, soft  tubercle,
which terminates in  ulceration after a longer or  shorter time.
   The extent of parts destroyed is  very  variable.   In some
cases the whole nose is eaten away;  in others only the point.
But,  as new tubercles form on  the scars, fresh ulcerations
occur, and the surrounding spots are extensively  involved.
The nose and the septum also may then be entirely destroyed,
leaving ouly an opening leading  into the nasal fossae.  Some-
times the  superficial tissue of  the  nose  only is destroyed,
giving it a pointed appearance.   The nares have then a ten- 
278
DISEASES OF THE SKIN.
dency to become closed up, and are of a red color, except at
the superior  angle, where the cartilage  forms a yellow  line.
This tendency is more  evident in cases of lupus with hyper-
trophy.   In other cases the  nose  looks as if a portion were
removed with the knife.
  The destruction of parts is not  proportionate to the dura-
tion of the disease.   Sometimes the whole  nose is destroyed
in ten or fifteen days; at others a small portion only has  been
removed at the end of several years.   We saw a very rapid
case in the wards of  M. Biett; a woman, thirty-six years of
age, had lost a part of  the left ala, but the  disease had  been
arrested   by  cauterization.    The  extremity  of  the  nose
assumed,  from time  to time, a livid red  color ;  scabs,  with
purulent discharge, formed in the nares.  The livid tint occa-
sionally disappeared, and  at other tinies was  very marked.
There were no tubercles.  The livid color,  however, became
deeper, and ulceration set in.   The scab became thick within
a few days.  The patient experienced  severe pain ;  and in
five or six days, when the scab  was removed, the extremity
of the nose was g'one.   The disease  was  again arrested  by
the bi-nitrate  of mercury; but three weeks afterwards, the
cicatrix assumed a deep  red color, and ulceration again  set
in.   A red and very painful point was now  seen on the  right
side of the upper lip.   A thick scab  formed here, and  in a
fortnight a portion of the lip was destroyed.  As every other
means failed,  M. Biett again had recourse to cauterization
with  the  arsenical paste, which succeeded.  This  case  illus-
trates the rapid  progress of lupus, and shows  that it is not
always attended with tubercles.  A morbid redness and slight
swelling of the extremity of the nose, were all  the precursors
of the ulceration  and destruction  of the  part; and  on  the
upper lip, the ulceration  preceded  the  redness only a few
days.
  In almost every case of lupus when seated in the nose,  the
mucous lining of the nares is attacked, and sometimes the sep-
tum is  destroyed even before the external parts; in  other
cases the disease spreads from the skin to the  mucous mem-
brane, and destroys successively the lining of the nares, palate,
and even the gums.*

  * In most cases, when the nose is  the seat of the  disease, the ulceration is
accompanied by the constant discharge of a thin foetid matter from the nostril of the
affected side, which may arise either from inflammation of the Schneiderian mem-
brane, caused by the ulcerated tubercle, or from the actual development of the dis-
ease in the mucous membrane of the nose itself.  In the former case the discharge
partakes more of the character of common mucous coryza.  {Houghton, Cycl.
Pract. Med.)                                         H. D.  B. 
                          lupus.                      279

   This form  of lupus too often spreads to the face also, and
 produces more or less destruction of parts.
   Lupus with hypertrophy.—This form generally commences
 on the face, with soft indolent  tubercles;  they are numerous,
 slightly prominent, and occupy a considerable portion of the
 cheek or face,  to  which they are  usually confined.   They
 rarely ulcerate at the summits, but the base enlarges, and the
 subjacent cellular tissue becomes engorged.  After a certain
 time the whole face is covered with red points, which  are
 tubercles brought to the level  of the skin  by the swelling of
 the  subjacent parts, and  here  and there we  see a few white
 spots from the scars of old  tubercles.   The existence of the
 scars is very remarkable, for the tubercles, which they replace,
 seem neither to have  ulcerated nor to be covered with scabs;
 they appear  to be removed  by successive  desquamations.
 The  face may  acquire a most extraordinary size in some
 cases of this disease,  the soft, hypertrophied cheeks assuming
 somewhat the appearance of elephantiasis. The eyelids and
 skin of the forehead hang over  in folds, and the eyes are con-
 cealed in the orbits ;  the lips form two enormous  masses  of
 flesh, and the ears are occasionally involved in the same con-
 dition.   The tubercles,  as we have already said, are rarely the
 seat of ulceration;  those ulcers which do occur are slight and
 covered by a thin, tenacious scab.  The surface of the tuber-
 cles is dry, of a bluish color, and generally the seat of slight
 exfoliation.
   This disease may continue for an indefinite  period of time.
 When, after judicious treatment, the affected parts begin to
 assume a healthy condition,  the  swelling  gradually subsides,
 and the tubercles diminish; the circulation through the vessels
 of the skin becomes more active, and the integument gradu-
 ally assumes  a  healthy appearance, although it is seldom
 completely restored to its original state.  In another form of
 lupus with hypertrophy, the ulcers are covered by small, soft,
 fungoid  tumors, which  are  very prominent, and give the
 face a disgusting appearance.   This  variety is usually  a seri-
 ous one.
   The different varieties of lupus may coexist  in  the  same
 subject, or even be  mixed  up together.   When the latter
occurs, the case is of a most formidable nature; the lower eye-
lid is frequently destroyed, and  the skin of the  face is con-
tinuous with the conjunctiva; under such circumstances the
eye is attacked by chronic inflammation, the cornea becomes
opaque, and vision is completely lost; or the eyelid is everted
from partial destruction of its  tissues.   In  other cases, when
the thick scabs  are detached from the  nose, we find ulcers, 
280
DISEASES OF THE  SKIN.
surrounded by hypertrophied tissue, which latter closes up the
opening of the nares, unless great care be taken  to prevent
such an accident.  Finally, in some cases  the  angles of the
mouth and a portion of the lips  are destroyed, and the scars
which ensue not only cause more or less deformity, but con-
siderably diminish the aperture of the mouth.   Notwithstand-
ing these local  ravages,  the general  health  of  the  patient
remains unchanged, though occasionally menstruation seems
to be  deranged when the disease is very extensive.
   Lupus is often accompanied by erysipelas of the face; this,
instead of being  an evil, is frequently a fortunate occurrence.
We have many times seen erysipelas produce the  most favor-
able  effects in  cases  of lupus with hypertrophy, the disease
terminating in a rapid and unexpected manner.   In the most
severe forms, when the substance of the skin, cartilages, and
bones, have been extensively destroyed, the patient is cut off
by chronic gastro-enteritis, with slow fever and  colliquative
diarrhoea.  This fatal termination is, however, very rare, and
the disease may  continue for  years, destroying successive por-
tions  of the healthy skin, or the parts already attacked by it.
Lupus may attack the nasal cartilages, and leave the bones
untouched ; indeed, it  seems to select the skin, in preference
to all  other tissues.  We have seen many patients  at St Louis
who had labored under this affection  for years, and seldom
witnessed destruction of any part of the osseous system, except
the bones of the  nose.  These have sometimes entirely disap-
peared, leaving  only a triangular opening  divided into  two
parts  by the remaining portion of the septum.
   Causes.—This disease  occurs most  frequently amongst
children  and adults : it seldom attacks persons beyond the age
of forty years; both sexes are equally liable to it;  we meet it
more frequently in the country than in towns, and in children
of a scrofulous habit;  it may recur at the period of puberty in
persons attacked during their childhood.  On the other hand,
lupus occurs in  persons enjoying excellent health, and in the
vigor  of youth.   Lupus with hypertrophy is  the  form most
closely connected with the scrofulous diathesis.
   Diagnosis.—As lupus  may  be confounded with  several
cutaneous affections of the face, it is necessary to point out the
characters by which it may be distinguished from  them.  The
circumscribed  indurations  of acne rosacea  might be con-
founded  with the tubercles of lupus, in its early stage ; but in
acne  the indurations  succeed to pustules, they are of a red
color, and are surrounded by an erythematous areola; while
the tubercles of lupus are livid, indolent, and have been pre-
cede'd merely by a livid tint of the skin. 
LUPUS.
281
  Lupus with hypertrophy might, in some cases, be confounded
with Greek elephantiasis, but the tawny tint of the skin, and
the small, irregular tubercles of elephantiasis will serve to dis-
tinguish this latter disease.  The  same characters will assist
us in cases where tubercular  lepra has become  ulcerated  in
different points, and presents here and there dark-looking scabs.
These ulcers are  more superficial than those of lupus, and have
no tendency to attack the healthy points of the skin.  Finally,
Greek  elephantiasis  shows itself on several parts of the body
at the  same time, and then is attended  by a variety of local
and  general symptoms,  which are  never seen  in  cases  of
lupus.
  The superficial observer might mistake the incrustations of
ulcerated lupus for the scabs of impetigo;  but the latter are
yellow-colored, prominent, rough, and seldom adherent; those
of lupus  are brown, thick, and very tenacious ;  besides, the
cicatrices accompanying lupus, and  the ulcers which  appear
when the incrustations are removed, are decisive characters
of that disease.   There are, however, two affections which
may be confounded with lupus; we allude to noli me tangere,
and some forms of syphilis.
   Under  the former term have been confounded lupus and
cancerous affections of the face, but they differ essentially from
one  another.  Lupus  seldom occurs in  persons  of advanced
age, like noli me tangere ; it commences with several tuber-
cles, while in cancer of the face we have a single tubercle
only ;  its tubercles  are indolent, while  those of cancer, sur-
rounded by a hard circumscribed  base,  are accompanied by
lancinating pains.  Finally, noli me  tangere  is attended  by
inflammatory swelling of the soft parts, is exasperated by the
use of caustics, and destroys the deep-seated parts of the face.
Cancerous ulcers are painful, moist, and everted, and present
a fungous appearance, without the  dry, thick scabs, which are
characteristic of lupus.*
   The diagnosis of lupus from certain forms of syphilis affect-
ing the face, is sometimes a matter of much difficulty.  When
the diseases  are confined to tubercles without ulceration, it is
sometimes difficult to distinguish  them.   Syphilitic tubercles
are rounded and larger;  they are of a dusky copper-color,  do
not  exfoliate, and have much less tendency to ulcerate than
those of lupus, which are softer, flatter, and generally covered

  * Cancer is followed by glandular engorgements ; this is never the case with
lupus.  Cancerous ulcers have no tendency to reparation, but are always destruc-
tive, while in lupus, when only superficial, there is such a tendency.  Cancerous
ulcers are most usually aggravated by cauterization, while those of lupus are bene-
fited, and often cured by it.                               H. D. B. 
282
DISEASES OF THE SKIN.
by a thin layer of epidermis, partially detached ; lastly, syphi-
litic tubercles of the  face  generally occur in adults, after the
period of manhood, while lupus usually attacks young persons.
   We must not lay much stress on the disease being seated on
the cheeks or side of the nose, and conclude from this that it
is lupus;  for experience teaches us  that  the  presence of a
tubercle on the side of the nose  is  almost a pathognomonic
sign of syphilis.
   In its ulcerative stage, syphilitic tubercle also differs essen-
tially from that of lupus; the syphilitic ulcer is deep, its edges
swollen, of a dusky copper-color  and sharply cut; the ulcer
produced by lupus is of a dull red  color, and looks as if con-
fined to the surface of the skin.  The mode of destruction of
parts will also serve to distinguish the two diseases.  In lupus
the skin is first attacked, and  then the  cartilages, and after a
considerable time the bones.  In syphilis, on the contrary, the
disease commonly commences with the bones, and when these
have been struck with  caries or  necrosis, it extends to the
skin.  Finally, the tubercle of  syphilis is almost constantly
accompanied  by  constitutional symptoms, as  pains in the
bones, nodes, iritis, or ulcers in the throat,  palate, &c.
   Prognosis.—Lupus  is always  a  formidable  disease, not
because  it  threatens  life, but  from its  obstinacy  and the
destruction of parts by which  it  is  often attended,  and the
numerous, unseemly, and indelible scars  which are  left  on
healing.   The prognosis is favorable in proportion as we are
called to treat it in an early stage.   It is  more  serious when
accompanied  by considerable  tumefaction  of the  affected
parts, and when the old cicatrices  open  afresh.   As  long  as
the cicatrices  remain  soft  and doughy  to the touch, are of a
bluish  color, and surrounded  by  tubercles,  there  is great
danger of the recurrence of the disease.   The full establish-
ment of menstruation, at the period of puberty, is not attended
with sufficient change to render  the prognosis more favor-
able.
   Treatment.—The   constitutional  treatment  of lupus  is
simple enough; it consists in  proper attention to the rules
of hygiene, the use of baths  and bitters.   These means are,
generally, of little avail against so serious and obstinate  a
disease.   When  the patient, however, is of a scrofulous con-
stitution, we  must have recourse  to appropriate treatment;
some benefit may be obtained from  the muriate  of  lime, in
solution  (one  drachm to the  pint  of water) ; a teaspoonful
may be given every morning,  and the dose increased  by a
spoonful, every four or five days, until the patient takes twelve
spoonfuls  a day.  We may also try a course of chalybeates 
LUPUS.
283
 (the  sulphate of iron, for example), and  submit the patient to
 a generous  diet and the action of pure  invigorating air.   In
 other cases we may employ the animal oil of Dippel, in doses
 of  five  or six drops, gradually increased to twenty-five;  the
 decoction of  Feltz, or the  preparations of arsenic;  but these
 means  are of very  doubtful  utility, unless  aided  by local
 applications.  Extremes of heat and cold must also be avoided,
 because they tend to make the cicatrices break out  again;
 and in females, the menstrual function must  be attended to.
 The  local treatment consists,  1st, in the use of resolvent appli-
 cations, more  or  less irritating, for the purpose  of modifying
 the vitality of the skin ; and 2d, of caustics, which we employ
 with a view of destroying the diseased surfaces,  and arresting
 the progress of the malady, and making healthy cicatrices.*
   Before ulceration has commenced in  the tubercles, and in
 cases of lupus with hypertrophy, we should have recourse to
 such remedies as favor absorption.  Ointments, containing the
 proto or deuto-iodide of mercury,  are  the most powerful, and
 should be rubbed in over every point occupied  by the tuber-
 cles.   M. Biett has often employed the ointment of the iodide
 of  sulphur with very great  effect;  we  remember particularly
 two cases  of  lupus with hypertrophy, in which considerable
 benefit was obtained from  frictions with this remedy.   Some
 writers  apprehend the development  of erythema, or erysipelas,
 under the  influence of these  frictions;  but should any such
 complication  occur, it  is  of  no consequence, and might, on
 the contrary,  be beneficial.f

  * In the form of superficial lupus, accompanied by ulceration, and which is so
 analogous to, if not identical with, affections described under the name of scrofula,
 preparations of iodine have a commanding influence—of which I have generally
 given the preference to the iodide of potassium or of iron.
  In the different forms of the superficial, and in that with hypertrophy, the liquor
 hydriodatis arsenici et hydrargyri, or Donovan's liquor, referred to under the head
 of lepra (page 228), has been  highly recommended by practitioners  of standing,
 and is well deserving of a trial.
  Gibert reports a case {Bulletin de I'Academie, Nov. 1844), in which the  face
 was eaten away by tuberculous ulceration, and the fleshy parts  of the nose com-
pletely destroyed, which was cured by the internal and external use of the cod liver
oil, after different forms of iodine and various caustics had failed. The disease had
lasted six years, and the remedy was taken eighteen months.  The patient was a
female, twenty years old. {Ranking's Half-yearly Abstract, vol. i, p. 86, Amer.
edit.)
  This  article is  now extensively used in this affection, and is a very  valuable
 adjuvant.  We have derived the most marked benefit from it in this as well as in
 the other forms of disease connected with a strumous habit, and usually give it
with the syrup of iodide of iron.
  Liquor potassa has also been used with advantage in 1. with hypertrophy.  It
may be given as recommended under the head of eczema (page 87),  and its use
should be persevered in for some time.                          H. D. B.
  t In 1. with hypertrophy, vapor douches will assist the action of resolvent oint- 
284
DISEASES OP  THE SKIN.
                When the  frictions  now spoken of are attended with  no
              benefit, and the tubercles begin to ulcerate, we must abandon
              our line of treatment, and have recourse, at once, to caustics.
              These are of different kinds, and may be  divided into  solid,
              those in the form of powder, and liquid.  There is hardly any
              other of the solid form than nitrate of  silver, and this is  of no
              avail in the treatment of lupus.
                Under the  second head belong:  1. Dupuytren's powder, a
              mixture of  calomel and arsenious acid, in the proportion of
} wc ifc jv**tr   one or two hundred parts of the  latter.   This forms  a very
              mild caustic, and is still one of considerable activity, and  is
              adapted to cases of lupus of moderate extent, and when  it
              occurs in children, females, and those of irritable habit.  This
              may be applied by sprinkling over the  surface, when properly
              cleansed, a  thin layer  of the  mixture, by means of a  small
              puff.  Although it  seldom causes any pain, or is attended with
              any  swelling of the surrounding parts, it should not be  applied
              over too large a surface at once,  not to exceed the size of a
              quarter of a dollar.  A very adherent, greyish incrustation  is
              formed, which often continues for a long time, unless removed
              by emollient  applications.  2. The  arsenical paste of Frere
              Come, a more active and more valuable article, requires cau-
              tion  in its use; it is better suited to old  and obstinate  cases
              of the disease, which have resisted  milder means,  and espe-
              cially to that severe form of lupus which destroys from without
              inwards.  A small quantity of this  spread upon a piece of
              slate or porcelain, may be applied with a spatula over a space
              not exceeding a shilling piece in size.  We have seen this
              article frequently applied  at St.  Louis Hospital, and never
              knew any severe constitutional symptoms produced by it.  It
              almost always produces local excitement, which  sometimes
              seems to threaten  trouble, but which usually yields to  the use
              of proper means.   It is, for instance, almost  constantly fol-
              lowed by erysipelas, which  is  sometimes  very slight, and at
              other times very severe, causing  great swelling of the face,
              and violent pain in the head. These symptoms,  however, yield
              in a  few days  to the use  of  stimulating pediluvia, a few
              leeches behind the ears, diet, and emollient or laxative ene-


              ments. A very formidable case of this kind, in which the upper lip and both cheeks
              were  so much swollen  that the patient had kept his face covered for eighteen
              months on account of the deformity, yielded in a few weeks to the internal use of
              Donovan's liquor,  and the external use of ointment of iodide of lead and the vapor
              douche, and the occasional use of one or two leeches to the parts most swollen
              and inflamed.   The effect of a single leech was often very marked.
                The use of leeches in this and other forms of lupus has been favorably spoken of
              by different writers.                                     H. D. B. 
LUPUS.
285
mata, and the face returns to its natural state, leaving nothing
but  a very thick,  dark colored,  and very adherent scab,
which often remains for a long time.
  Under the head of liquid caustics belong :  1. The animal oil
of Dippel, which has an action peculiar to itself in the irrita-
tion which  it produces, and  is particularly suited to those
cases in which the  nose is  the  seat  of indolent and chronic
inflammation, presenting a violet color, with epidermic exfo-
liation.   2.  The  butter of antimony, an article of but little
value;  the acid nitrate  of mercury, a very active caustic,
which Biett used with great success.  This also causes an
erysipelatous inflammation, as arsenical paste does, but  less
severe.   It  may be applied over the tubercles, and also over
the scars, which continue soft, of a  bluish  color, and with an
appearance as though on the point of breaking out, as well as
over the ulcerated surfaces.   It is used by touching a surface
of the size of a dollar with a pencil of lint dipped  in the acid;
scraped lint is then placed over the cauterized surface, which
is moistened with the  acid.   The  surface touched  imme-
diately  becomes white ;  a  yellowish scab  gradually  forms,
which is not very adherent, and which falls  off in the  course
of eight to fifteen  days.  The application of this caustic is
usually very painful;  but it is only  momentary.
   Caustics  in the form of paste are now generally preferred,
because they are easier in their application and management.
Among these, the one most used is : 1. the paste  of the chloride
of zinc, a mixture of the chloride of zinc and flour, in the pro-
portion of one of the former to two of the latter.   This should
be  applied, in a very thin layer,  over a limited space; it
causes considerable pain, which increases and lasts for several
hours.  A  thick, hard,  greyish scab follows, surrounded by
considerable swelling, which disappears in twenty-four hours ;
the  scab falls off at the end of two  days, leaving a  surface
without ulceration.   This paste is useful to destroy tubercles,
the  resolution of which it  soon affects when applied in very
minute quantities.    2. Vienna paste, composed  of  caustic
potassa  and quicklime, is  a more energetic  article,  and is
suited to cases in which a rapid effect is desired oyer a  sur-
face of limited extent.   A layer of  the paste is  applied to the
part left uncovered,  by making  a  small hole  in a piece ot
adhesive plaster  placed over the affected surface. 1 his paste is
allowed to  remain  ten minutes, at the end of which time it is
removed, and  the  surface  cleansed.  It causes considerable
pain, and is followed by a scab, which is  thicker than  that
produced by the chloride of zinc.   3. Arsenical paste, com-
posed of ten parts  of white oxide  of arsenic, twenty parts of
                             19 
286
DISEASES OF THE SKIN.
 sulphuret of mercury, and fifty parts of animal charcoal. This
 preparation, now perhaps  too  little  used, excites the  part to
 which it is applied, and produces  active  caustic effects.  Its
 application is followed by symptoms which seem severe, but
 which rapidly disappear.   A solid cicatrix is produced,'which
 circumstance  renders it  very valuable  in old  and  obstinate
 cases of lupus,  especially  those which destroy  deep  seated
 parts.
    Whatever  the  form  of  caustic  employed,  it should  be
 applied only over  surfaces  of limited  extent, on  account of
 the accidents which it might occasion, and its activity should
 always be in proportion to the  effect desired, lest you add to
 the  destructive  power  of  the disease itself.   Antiphlogistic
 means must be used to relieve the irritation which may follow
 their  use,  and  care  is  necessary  not  to interfere  with  the
 process of cicatrization by too  early a removal  of the  scabs.
 In the majority of cases, a single cauterization is not  sufficient
 to arrest  the  disease;  we  are  compelled to repeat it over
 and  over again, perhaps  for  years.  When the disease is
 extensive, the greatest perseverance is required,  on the part of
 the patient and his medical attendant.    We saw a young girl,
 in the wards of M. Biett, the  whole of whose  face  had been
 successively attacked  by lupus; but  she was  cured  after  a
 lapse of several years, and the use of more than fifty cauteri-
 zations.*

   * The chloride of zinc paste is now a favorite application with many.  One
 part of this substance is mixed with two or three of flour, and moistened with as
 httle water as possible.  Dr. Ranking says {Half- Yearly Abstract, vol. i.) that it
 is a caustic of great power, and requires delicate management.  He directs that it
 should not be applied thicker than one or two  lines, nor left on  longer than six to
 ten hours.  He says that an application of one line in thickness, for ten hours,
 will, in some cases, form an eschar of nearly a quarter of an inch in  depth.  He
 represents the pain as being of a very endurable character, compared with  that of
 the arsenical paste, or the nitric acid, and  says  that he knows of no caustic to be
 compared with it in the doubtful looking ulcerations which are met with in various
 parts of the body.
   The chloride of zinc has also been used in paste with the anhydrous sulphate of
 lime, one part of the former to two or three of the latter.  A case in which it was
 thus applied with success is recorded in the London Lancet, Aug., 1840.
   The chloride of antimony and the proto-nitrate of mercury have both been used
 with success by Phillips.   {Lond. Med. Gaz. Mar. 20, 1840.)
   I have used pure creasote, with occasional benefit, freely pencilled over the sur-
 face with a brush, in the milder cases of the ulcerating form.
   A local application which M. Cazenave has been more recently using,  and
 which  he has seen answer the best, is a mixture of deuto-iodide  of mercury in oil,
in  the proportion of 15 to 40 grains to § j of olive oil, to be applied to  the affected
surface every day or two.  He sometimes adds lard to  give it  consistency.  He
says that the pain produced by it is slight, and that it often causes the resolution of
even quite large tubercles.  {Gaz. des Hbp., July, 1850.)
  In other cases, he uses equal quantities of the deuto-iodide and olive oil, with the
addition of lard to give it consistence, so as to make a  kind of liquid paste.  When 
PELLAGRA.
287
  During the treatment  of lupus,  the  physician must  not
neglect certain  precautions  which  are  essentially connected
with the future  well  being of his patient.  Thus he must be
very careful  to  prevent occlusion of the nostrils  during con-
traction  of the  scars,  by introducing  daily  a piece  of pre-
pared  sponge ;  this must be  done  for  a considerable time,
because the  tendency to  obliteration  of the  nares exists not
only during the  ulcerative stage, but long after the formation
of the  cicatrices.
  Lastly, the local and general treatment of lupus may some-
times be aided, with benefit, by the  use  of common or vapor
baths,  and particularly vapor douche, which are well suited for
lupus with hypertrophy.


                       PELLAGRA.

Syn.—Pellagra ; Pellarina ; Scorbuto Alpino; Dermatagra;
  Scorbutic  paralysis; Endemic or Pellagrous  Erythema;
   Elephantiasis Italica.

  By the word  pellagra is intended a peculiar diathesis, very
common in Lombardy, characterized pathologically by various
functional disturbances of the digestive  organs and  of  the
nervous system, and by a desquamation, of different shades of
chocolate color, of the epidermis of parts exposed to the sun
in the  spring, a desquamation usually preceded by an erythema,
which isjnore or less marked, but always  ephemeral, and which
ceases when the parts are withdrawn  from exposure.   These
characteristic marks  of pellagra vary very much, not only in
intensity, but also in  manner of appearance, being sometimes
isolated,  and at  other times together; showing themselves  in
some cases first  on the  skin, and in  other cases first affecting
the digestive organs,  or the nervous system.
  The opinion that pellagra always  produces physical deterio-
ration is  not true;  those  with this diathesis from infancy
usually present  as healthy an aspect as any others, and some-
times retain  their flesh and color to  the  last stage of the  dis-
ease.   Sometimes  some members of a  family are  attacked,
while other members of the same family escape, without any
apparent cause  for this exemption.
  In  our description of  pellagra,  we   differ  from the plan

of this strength, it is applied with  a camel's hair pencil, and limited to small surT
faces at  a time, on account of the irritation by which  it is followed.  The pain is
sometimes severe, and lasts for several hours. A scab is produced, which falls off
in the course of six to ten days.  These applications-may be renewed every six or
eight days.                                           H- D- B- 
288
DISEASES OF THE  SKIN.
adopted by most of the authors who have written on it, of
describing it according to periods or degrees, and much less
according to years.   The division into commencing, confirmed,
and  inveterate, is not  a practical  one;  for pellagra may be
beyond hope  from  its commencement.   The expressions,
period or degree, which convey the idea of certain  fixed
symptoms and appearances, are not adapted to the description
of a disease so capricious as pellagra.  The term degree seems
to indicate an increasing intensity ; while the second or third
time of appearance of the disease may be less  severe than the
first.   When we employ these terms, therefore, we shall use
them only as synonyms of a  more  or less advanced stage of
the disease ; for, like every other disease, pellagra has a begin-
ning, a progress, and a termination.  The only natural  divi-
sion  is according to its progress, and this may be either inter-
mittent, remittent, or continued.  It is intermittent when the
different symptoms  appear in the spring, then disappear, leav-
ing the person in perfect health during  the remainder of the
year, to reappear with greater or less intensity the succeeding
year ; remittent, when appearing in the spring with an increase
of one or more symptoms, the disease decreases  in severity,
but does not disappear entirely; and continued, when it per-
sists  during the whole year with very little change in its cha-
racter.   The progress of pellagra is then essentially irregular,
for while it sometimes destroys life in a short time, it is  often
so mild in its nature that the subject of it may for a long
period suppose himself in  good health.   In other cases, after
affecting a person  seriously  for some years,  its  progress is
suspended for some time, and it then rapidly proves fatal.
   The commencement of pellagra  is marked by  the appear-
ance  of either a single one of the characteristic symptoms of
which we have spoken, or several of them at  the same  time.
We will briefly review the different symptoms: 1. The cuta-
neous affection ; 2.  The symptoms  connected with the diges-
tive  organs;  3. Those connected  with  the  cerebro-spinal
system.
   1.  Of the Cutaneous Affection in Pellagra.—This always
appears on parts most habitually exposed to the sun's rays, as
the backs of the hands and the external  part of the  forearm,
sometimes as far up as the elbow, the dorsum  of the feet and
the inferior and  anterior  part of  the legs, the superior and
anterior portion of  the thorax, and sometimes the forehead
and sides of the face.  The first thing noticed on these points
is most  commonly simple  desquamation of  the epidermis,
which grows dark,  and assumes a more or less deep choco-
late color, dries up, and is detached without either inflamma- 
PELLAGRA.
289
tion or redness.   It is a sort of pityriasis, without any decided
itching and without any pain,  a morbid change reaching to
the vessels which secrete the coloring matter, and effecting a
change in it.  In other cases, on the contrary, there is a more
or less marked erythema, especially when the rays of the sun
have  been bright, or the patient "has been  long exposed to
them ; the inflammation may  even  be almost erysipelatous,
with the formation of bullae.  In these cases  there is a  severe
burning  sensation accompanying the  inflammation,  which
gradually goes off when  the exposure to the sun ceases.  But
this is succeeded by  the blackish desquamation of the epider-
mis, which gives to pellagra its  characteristic physiognomy.
   In  the earlier periods of the disease,  the  erythema, even
when well marked, disappears entirely; the darkened epider-
mis is detached, and the skin  resumes  its usual color.  But
this is not the case when the desquamation has been of long
standing.   The  skin then looks thin  and has a shining sur-
face, and resembles  the  cicatrix of a very superficial  burn;
patches are often seen on its surface of a more or less  brown
color, but it is all soft to the touch.  Other cutaneous affections,
as impetigo, scabies, &c, may complicate pellagra.
   The desquamation in pellagra appears more particularly in
the spring, but very often bears  no direct ratio to the duration
of exposure to the sun; and different individuals are very dif-
ferently affected in this respect.  Nor do differences in the extent
or  severity of  the  desquamation bear  any  relation to the
internal symptoms, but it appears to be in  some respects inde-
pendent  of these symptoms.   The desquamation,  and still
more  the erythema  in pellagra, does not appear  unless the
person is exposed to  bright light and to the sun's rays.
   2. Symptoms  on  the  part   of the  Digestive  Organs.—
According to Strambio, functional  derangement of   these
organs is one of the most constant precursory symptoms of
pellagra;  it is also  the  most frequent  symptom during the
progress of the  disease.   Still  it does not always  take place,
and some patients with pellagra reach  the last stage  of the
disease without  any  trouble of this kind.
   Inordinate  appetite  and diarrhoea are the most  frequent
symptoms  of gastro-intestinal  disorder;  dysentery  is  rare.
The boulimia is  accompanied by neither cardialgia nor faint-
ing ; the  functions of the stomach are rarely deranged, the
principal trouble being in the intestines.   The food is rapidly
digested  and soon passed by stool, followed by an immediate
return of the great  desire for  more.  The diarrhoea is often
very obstinate,  and  may itself alone cause  death.  Still, in
some  cases,  constipation equally obstinate continues  to the 
290
DISEASES OF THE  SKIN.
  close of life, and in other cases these two conditions alternate-
  There is sometimes emaciation, and at other times the natural
  flesh is retained to the last.
,   The alvine evacuations, which are always very watery, and
  usually yellow  or  greenish,  are  sometimes greyish and even
  black, and are occasionally mixed with blood.
    The  mucous membrane covering the cheeks,  the  tongue,
  and throat, is  occasionally sprinkled over with ulcers ;  and
  dryness and  cracking of the lips,  with lividity,   have been
  mentioned as a characteristic  symptom  of the  pellagrous
  diathesis.   Other symptoms  have also been mentioned, as a
  very salt  taste in the mouth, especially in the morning, free
  expectoration, and even profuse salivation.
    3. The Nervous Symptoms do not usually occur as precursory
  symptoms of pellagra, but are very marked during the pro-
  gress of the disease.   Occasionally, however, they precede all
  the other symptoms except the desquamation.
   Great depression of spirits without cause at all sufficient
  to produce  it,  exaggerated  fears, vertigo,  disturbed  vision,
 ringing in the ears, buzzing in the head, sharp shooting pains
 along the limbs, burning of the  feet, very painful  cramps in
 the limbs,  tetanic contractions, involuntary movements, hasty
 walking forwards,  weakness of the lower limbs,  paraplegia,
 propensity  to suicide, especially by means of drowning,  a
 peculiar expression of countenance of a  fierce   character,
 sometimes  convulsions,  and  paroxysms of epilepsy,  belong
 under this head.  The most constant among these symptoms
 are vertigo, wandering  pains, burning of the feet, cramps,
 tetanic contraction of the muscles, delirium, and passion for
 drowning.
   In addition to these symptoms, chronic pulmonary affections
 almost  constantly exist in confirmed cases of pellagra, and
 contribute to the fatal  result.
   Lesions after Death.—When death is caused by any inter-
 mittent disease, no special lesion is usually found which  can be
 referred to the pellagrous affection.  In chronic cases,  on the
 other hand, and when there are symptoms of marked lesion of any
part, whether of the nervous, or respiratory, or digestive sys-
 tem, changes  are always found corresponding with the  symp-
toms observed during life, the most frequent of which are those
,of the digestive organs.
   Predisposing Causes.—Pellagra occurs at the earliest age,
and is even sometimes congenital.  In three hundred and fifty-
two cases, Calderini found eighty-three in which the disease
appeared before three years  of age, and one hundred and
twenty from twenty to twenty-five years.  It is often, but not 
ALEPPO EVIL.
291
necessarily, hereditary, and is not contagious, and is but very
rarely communicated by a nurse to a sucking child.  It is met
with more especially in the upper part of Italy and in agricul-
tural districts.  All causes which have a tendency to depress
the nervous  system and derange the  digestive organs, may
predispose to pellagra.
  Exciting Causes.—These have been referred  to five distinct
heads: 1,  insolation ; 2, the habitual use of undigestible food;
3, the exclusive use of diet not sufficiently nitrogenized; 4, the
habitual use of Indian  corn; 5, some peculiar  and endemic
effect of the soil.
  Diagnosis.—No precise diagnosis of pellagra can be made
when the  cutaneous affection is absent—this  affection is well
characterized by its cause, the appearance which it presents,
its progress, and the marks which it leaves on  the skin.  It
consists of:  1, an irritation of the skm; 2, epidermic desqua-
mation ; 3, persistent marks.  Of these  three changes, the first
two are ephemeral.
  Nature of the Disease.—Pellagra,  whether endemic, epide-
mic, or sporadic,  is a peculiar diathesis, sui  generis,  and
which most  frequently  denotes a  cachectic  state  of  the
system.
  Prognosis.—Confirmed pellagra seems to be incurable; but
even in this case the prognosis would be less unfavorable if the
patient  would persevere in the use of means which have
produced  favorable results, and would change his location and
habits of life.   After it has reached a certain point it is  beyond
the reach  of art.
  Treatment.—Simple  change of nourishment often produces
the best results ; but wine and animal food do not seem to be
indispensable,  since  individuals with symptoms of pellagra
have improved very much in prison when confined to bread
and water.   But active measures are sometimes required to
meet the severe symptoms of the disease,  either of a nervous
or a congestive character, or both together, as local and gene-
ral blood-letting, antispasmodics, and opiates.   But in  the use
of these means, the nature of the disease must be kept in view.
For the cutaneous affection, simple tepid baths  and emollient
fomentations are all that is required.


                    ALEPPO EVIL.

         Syn.—Malum Alepporum; Bouton d'Alep.

  Under this name is comprised a tuberculous disease of the
skin, almost unknown in France, but which prevails endemi- 
292
DISEASES OF THE  SKIN.
 cally at Bagdad, in several  towns on the banks of the Tigris
 and Euphrates,  and  particularly at Aleppo, v*hence it derives
 its name.
   We had a very imperfect idea of this affection from the
 descriptions of  M. Bo  and Mr. J. Russell, until two French
 physicians,  MM.  Guilhou  and Lagasquie,  studj^d  it  with
 great care during their travels in  Syria in 1835.  The thesis
 of M. Guilhou contains the most complete and correct history
 of this disease that we possess.
   The Aleppo evil  consists in the eruption of one or more
 tubercles, varying in size, but regular in  their progress and
 duration ; it occurs only once during life, and is followed by a
 more or less disagreeable and indelible cicatrix.
   There are two species of this complaint; in one the tubercle
 is single and denominated male ; in the other, the buttons are
 called female, several principal tubercles being surrounded by
 a  number of smaller ones.   MM.  Guilhou and Lagasquie saw
 a  case in which were  seventy-seven principal buttons, sur-
 rounded by so great a number of smaller tubercles as to give
 the disease the appearance of confluent small-pox.
   The Aleppo  evil  may attack any  part of the body, but it
 chiefly occupies the face.   This is its favorite  seat  in  the
 inhabitants of Aleppo;  while in strangers, it more frequently
 appears on other parts.  Traces of it have been seen  on the
 genital organs.  It  usually  lasts  for.a year, but it may con-
 tinue longer, and has existed from infancy to puberty.  We
 may distinguish three .periods  of  this disease, viz.,  that of
 eruption, of suppuration, and of desiccation.
   In the  first or eruptive stage, the point of the skin  where
 the evil is about to appear presents a slight lenticular emi-
 nence, and  this  gradually increases  during four or five
 months;  there  are no local or general symptoms at this time.
 The suppurative stage now commences, preceded by pain,
 which is  sometimes very acute, especially in parts but slightly
 covered  with flesh, and about the joints; ulceration then
 occurs,  and the ulcer is covered  by a moist, whitish scab,
 which separates in part or in whole, and leaves underneath a
 number of suppurating fissures, from which  there is  a dis-
 charge of pus which  is often inodorous, clear, and  of a slightly
 yellowish  color.  The ulcer is  superficial and irregular; its
 diameter from  half  an  inch to three or four  inches.  The
 scab now falls  off and is reproduced, or it adheres from the
 commencement of the ulceration,  and a thick ill-conditioned
 matter is discharged from underneath it.   This period may
continue  for  five or six months, and  terminates  in the for-
mation of a dry, tenacious  scab;  this is the third stage or 
ALEPPO EVIL.
293
period of desiccation, which commonly lasts for the rest of the
year.
  The Aleppo evil occupies the whole thickness of the skin,
and consequently leaves an indelible cicatrix behind it, which
is  usually  superficial, but sometimes  deep.  The latter  is
generally white;  sometimes it is brown and wrinkled ; some-
times of a very ugly appearance, distorting the eyelids, nose,
&c.   The  disease occurs in persons of the best constitution,
and is rarely complicated with scrofula; but should the latter
be the case, it may  last for years.   It attacks persons of all
ages,  sexes, and conditions of life; it is found amongst  all pro-
fessions.   Children are attacked about  the age of two or
three  ; and at Aleppo, where M. Guilhou observed the disease,
not a single child  reached the age of ten years without having
had it, and scarcely a single adult had escaped it.  It is not
contagious, and  attacks strangers as well as natives.  It  is
endemic not only at Aleppo and its neighborhood, but also at
Bagdad  and  many other  cities, and especially in the towns
between these two  cities.  There  is  no fixed time for the
appearance of the disease in  strangers;  some are attacked
after  six months, others not until  fifteen or eighteen years
have  passed  oven   In many  cases a short sojourn  in the
country  has been sufficient to develope  the  germ  of the
malady, which  breaks out at a long subsequent period and in
some  distant country.  M. Guilhou mentions two  curious
facts  in  connection  with  this point.  An  English traveller,
who merely  passed through Aleppo, was attacked in London
several  years afterwards.  A  French merchant,  who  had
escaped  the disease during a residence  of  twenty years at
Aleppo, was  seized by it at Marseilles, long after his  return
from  Syria.   Facts of  this  kind  are,  besides, extremely
frequent.  The  proximate cause  of  Aleppo  evil is  quite
unknown.   It has been long attributed, in Aleppo, to  the use
of water from  a  particular  stream, of  which the inhabitants
drink; but  although this opinion has been strengthened by the
minute researches of MM. Guilhou and Lagasquie, it is diffi-
cult to adopt it without reserve.
  Dogs  are subject to the Aleppo  evil, which  attacks them
exactly  in  the  same  manner as'it  does the human subject;
but no other domestic animal seems to be liable to it.
  This is not a formidable disease ;  its greatest inconvenience
being the  inevitable  occurence of a scar, which may be
very  unsightly.   According  to M. Guilhou,  the mode of
treatment  consists in  emollient applications, simple  lotions,
and the  preserving the evil from contact with the air.   The
remedies generally  employed  seem to have had  no effect 
294
DISEASES OP THE  SKIN.
whatever  in arresting  the progress of the tubercles.  M.
Salina, however, of Aleppo,  assures  us that he invariably
succeeded in reducing the extent and duration of the eruption
by using the actual cautery previous to the period of suppu-
ration.  He likewise recommends the  use of  an ointment
composed  of camphor, vinegar, and litharge, or of cassia-pulp
moistened with rose-water. 
SYPHILITIC  ERUPTIONS.

         Syn.—Syphilida ; Syphilides.
  The venereal disease appears to have  first shown itself in
Europe under the form of cutaneous eruptions.  The earliest
writers on syphilis confine their descriptions of that complaint
to a pustular affection of the skin;  and from their use of the
terms moist, ulcerated, crustaceous pustules, they seem to have
been acquainted with the several forms of the malady.
  For several  centuries the syphilitic diseases of  the  skin
attracted little attention, and were but very briefly noticed by
writers.  In  the early part of the  nineteenth century, how-
ever, they were arranged under a separate class, denominated
syphilides, a name given to every species of cutaneous affec-
tion  consequent on  the venereal disease.   The species were
arranged according to their different conditions or accidental
appearances, without any reference to  the elementary form of
the disease.   Hence, distinct varieties  were confounded toge-
ther, and species established on characters that were altoge-
ther secondary and  insignificant.  M.  Biett paid considerable
attention to  this class of cutaneous affections, and studied
their progress and development with great care.   He endea-
vored, above all, to trace  their elementary  characters ; and
thus  succeeded  in  clearly and  satisfactorily distinguishing
several varieties.   We  shall take the results of M.  Biett's
researches as the groundwork of our descriptions.
  We confine the term syphilitic eruptions  to cutaneous dis-
eases  of venereal origin, actually seated in the skin, and simi-
lar, in their elementary  characters,  to  other well known
diseases of  the integumentary system.   We thus  reject a
number of  local  symptoms  which do not  belong to cuta-
neous  affections, properly so  called,  together with every
species of ulcer not preceded by a scab  or tubercle.  Thus,
the true venereal chancre, which is not preceded by any ele-
vation of the epidermis,  condylomata, warts, &c, form essen-
tial lesions  of a peculiar kind, and should  not be  arranged
amongst the syphilitic eruptions. 
296
DISEASES OF THE  SKIN.
  Syphilitic cutaneous eruptions may be divided into exanthe-
matous, vesicular,  pustular,  tubercular, papular,  and  scaly.
The eruption  may  be primary, that is  to say, occurring soon
after infection, and in most  cases attended  by other  symp-
toms ;  or it is secondary, coming on at an uncertain  period
after the disappearance of the primary symptoms of the dis-
ease.*   It is generally a chronic affection ; but primary syphi-
litic eruption, especially the exanthematous  form,  may be
acute.   Persons of all ages, from the  infant to the old man,
are liable to it.f
  The  symptoms  of syphilitic  eruptions  may  be  arranged
under  three heads.  First, we have those common  to syphili-
tic  eruptions in general; second, those peculiar to each class ;
and third, the constitutional  symptoms by which they  are so
constantly accompanied.
  1. Symptoms in common.—Syphilitic eruptions  are  com-
monly  of a copper  color,  though in acute cases the tinge is
lighter; it never,  however,  assumes  the  true inflammatory
redness.  Their form is almost always circular.   This is mani-
fest in the smaller  spots ; and, in  the larger  ones, the tendency
to a circle may be traced over the greater  part of the ring.
The scales are always thin, dry, and  of  a  grey  color; the
scabs thick,  hard,  fissured,  and of a dark or greenish  tint.
The eruption  may  occur on  any part  of the body, but those
most frequently attacked are  the face, forehead, nose, back, and
shoulders.  According to the experience of M. Biett,  it rarely
occurs  on the  hands or wrists.  The skin,  in  the intervals
between the affected parts, is often of a brownish tint, and
the patient exhales a peculiar and extremely repulsive odor.
Cold  favors  their  development, while heat has  the contrary
effect.
  The  scars left by syphilitic eruptions present also a peculiar
and characteristic aspect; they  are round, depressed,  of  a
dull white color, and sometimes marked by deep furrows.
  To complete the list of the symptoms common to syphilitic
eruptions, we must add absence of heat and of itching.

  * It may be also transmitted, and constitute hereditary syphilis.    H. D. B.
  t The time of appearance of secondary syphilitic eruption is usually from six
weeks to two months after the primary sore, but Ricord saw one well-marked case
of its appearance at the end  of a week  after the occurrence of the  chancre.
{Acton—Ven. Dis., Lond., 1841.)  Gibert never  saw  a  case earlier  than  the
beginning of the third week after the first appearance of the primary symptoms,
and says that, in most cases, the interval between  primary  and secondary symp-
toms is much longer.  M. Martin has published an analysis of sixty  cases, in
which he fixes the extreme limits between a few days and a number  of years,
even as many as forty.  {Gibert—Mem. de I'Acad. Roy. de Med., vol. x., 1843.)
Ricord does not believe  that syphilis can break out after a lapse of years. 
SYPHILITIC ERUPTIONS.
297
   2. Particular Symptoms.—We have  already  enumerated
the elementary forms of syphilitic  eruptions,  and shall now
enter on a particular consideration of each.
•   Exanthematous syphilitic eruption.—This species presents
two distinct varieties :
   The  first (syphilitic  roseola)  appears  under the form of
small, greyish, irregularly-shaped spots, of a coppery red color,
slightly confluent, and which disappear, although slowly, under
the pressure of the finger.   It occupies chiefly the trunk and
the limbs; it often accompanies primary symptoms, and espe-
cially gonorrhoea.   It is frequently preceded by malaise, and
soreness  and  wandering  pains  in the  limbs;   sometimes,
although rarely,  by slight febrile  disturbance, and extends
somewhat rapidly, so that it is sometimes general at the end of
twenty-four hours.  It may remain stationary several days, and
even weeks; in this case, the redness fades, and changes into
a greyish color, which continues for a still longer period, and is
rendered more distinct by any cause which quickens the capil-
lary circulation.   Syphilitic roseola  is  accompanied  by a
peculiar form of angina, characterized by  a violet red color
of the mucous membrane  of the mouth, the velum, and pha-
rynx, and by marked dryness of these parts.  This is often a
very important diagnostic symptom.  These are  the charac-
teristics of primary and sub-acute  roseola; it is sometimes
consecutive, and in these.cases assumes a chronic form.
   The second variety (erythema papulatum) constitutes  that
peculiar form  of eruption which, as  it almost always accom-
panies gonorrhoea, has been erroneously attributed to the use
of balsam  of  copaiba, and regarded as the effect of that arti-
cle.   But it appears  when that disease has been treated by
other remedies, and never occurs when that article  is given
for other complaints.
   Syphilitic erythema papulatum is  characterized by spots of
moderate size, slightly elevated above  the surface, of  a dull
red, or  rather of a brownish-grey color, which only partially
disappears under pressure of the finger.  It is almost always
primary.
   Vesicular Syphilitic  Eruption.—This  variety  was for a
long time considered as  one of the most rare forms  which
syphilis could  assume.   Biett met with it but a few times ; but
we have seen it repeatedly,  and believe that, if not very
common, it occurs  more  frequently than  is  generally sup-
posed.
   Vesicular syphilitic eruption may present two  forms: the
first, that in the form of varicella, is fully described in the fol-
lowing history of a case which we had occasion to observe in 
298
DISEASES OF THE  SKIN.
the wards of M. Biett:—A young girl, sixteen years of age,
of healthy constitution, had complained for a few days of some
sense of heat in the throat, with  difficulty in swallowing,
anorexia, and irregular fever ;  a number  of small eminences
now appeared on different parts  of the body, and she entered
the Hospital of St. Louis.  The eruption was at  once seen to
be vesicular, and pronounced chicken pock.  It was the sixth
day  of the eruption; it  covered nearly the whole body,  and
the vesicles were  in different stages; some being  nascent,
others dried up.  M. Biett, having examined the patient,  dis-
covered a strong resemblance  between this eruption  and  two
other cases of syphilitic vesicular eruption which  he had occa-
sion to observe before.   This  diagnosis was soon  confirmed
by the progress of the disease.   The vesicles  were  small,
resting on a broad base, and surrounded by an areola of vivid
copper color; their  progress was slow, and they were unat-
tended by any local symptoms.  They gradually faded  away,
and the fluid was absorbed; but in  some  the contents of the
vesicle hardened into  a thin, scab, which adhered  for some
time.  Every one of them, however, left behind a  poppery
injection of the skin, which presented all the characters of a
syphilitic  blotch.  In addition to these  circumstances,  and
confirmatory of M. Biett's diagnosis, a careful inspection of the
throat disclosed a round, greyish ulcer, with sharp-cut edges, &c.
The treatment employed  was insignificant, as M.  Biett desired
to see if any more decisive symptoms would manifest  them-
selves ; but the patient left  the hospital in a fortnight.  After
the expiration of a month she was visited at home, when her
whole body was found covered with true syphilitic pustules.
   The second form of vesicular syphilitic eruption is syphi-
litic eczema,  characterized  by  groups  of vesicles, scattered
over  different parts, and resting upon patches of a  coppery
red color.   The vesicles are  usually  of large  size and more
elevated than those of eczema simplex; the progress of each
individual vesicle is also slower ; absorption is  more tardy;
and  the  disease terminates  with  slight exfoliation, which
forms on the affected parts  numerous borders, the more strik-
ing in their  appearance from  contrast with the  points  which
were the seats of the vesicles.
\\  Syphilitic eczema may  also assume the form of eczema im-
petiginodes.   The  patches are then covered with  small,
black, furrowed  scabs which  are more adherent than  in the
simple form of  this disease, and which are followed by cha-
racteristic ulcerations.
   Vesicular syphilitic  eruption  is preceded by  some consti-
tutional disturbance, and  is  most frequently   a  secondary
symptom. 
SYPHILITIC  ERUPTIONS.
299
  Bullar syphilitic eruption.—This may appear under the two
forms of pemphigus and rupia.
  Syphilitic pemphigus is an affection  which seems peculiar
to new-born  infants.   Dr.  Krauss published,  in  1834,  an
interesting thesis on  this  affection,  although it  evidently
embraces facts which do  not belong to pemphigus.   Dr.
Paul Dubois has since observed many  cases of this kind, and,
was  the first to establish the syphilitic nature of the disease.
In all the cases which he has collected he has established  the
previous existence of syphilis in the mother, and  has seen
characteristic ulcers under the bullae.   The disease is marked
by  the presence  of several  bullae, varying in size, rarely
exceeding that of a filbert, most  frequently  seated  on  the
palms  of the hands and soles of the feet, surrounded by  a
violet colored areola, and filled with a sero-purulent fluid.  It is
primary, and  always fatal.
  Syphilitic rupia is much  more rare ; it is characterized by
large irregular bullae,  distended by a blackish liquid, followed
by dark conical scabs, which cover deep and characteristic
ulcers.   This form is essentially secondary.*
  Pustular syphilitic  eruption.—This form  is characterized
by the presence of small elevations containing an ichorous or
purulent matter.  They are succeeded by greyish blotches,
ulcers, or cicatrices.   The  history of this form of syphilitic
eruption derives interest from the fact that almost  all writers
on  this  subject have  described  and confounded all venereal
affections of  the skin under  the vague  term of pustules, at
the same time that the precise definition of this form of syphi-
litic disease is not even now  very well  understood by prac-
titioners.                              .                  n
   1.  In one  form, the pustules  (psydracious) are either small
and narrow; or of a large size, elevated, and round.  They
have a hard  base, and are surrounded by  a  copper-colored
areola. The pustules themselves are of a dull reddish hue, and
are developed in successive crops, presenting examples ot the
disease in its origin,  maturity, and decline.   Their progress
is slow, and  the inflammation attending them moderate ; in
some  cases,  however, it destroys the true skin, and leaves
behind it a small,  white, circular scar, depressed in the centre,

  * Raver says that the bullar form of syphilis is very rare but that a bullar areola
forms around the base of a certain  form of pustular syphilis, which is afterward
^redTiJha large, brownish, P^^^ ffi^fXwS
r«r.rrp=snonds with mv own experience on tne suDjeci, auu io yivu* }
STKX ••'* lihS;rSyphb2 &Z£L°SZZ.A
the same time there is no doubt that a true sypmuiu, uu           ^ ^  ^  . 
300
DISEASES OF THE  SKIN.
and not larger than a pin's head.  These scars, which have
been  erroneously  supposed to  follow  papules  because the
affection has been confounded with a papular eruption, are, in
a great majority of cases, the sequels of true pustules.   This
form chiefly  occurs on the face and forehead, where it bears
some  resemblance to acne rosacea; but it  may  appear on
every part of the surface.  The pustules  dry off, and form a
small  greyish scab, which separates,  and may leave behind it
either a cicatrix or some injection of the skin.   The psydra-
cious  pustules rarely terminate in ulceration, and then only
when several of them have become confluent.
  When seated on the limbs these pustules present a different
appearance.   They are  sometimes of the size of a lentil, quite
numerous, and but slightly elevated  above  the  surface, and
with a hard  base, and contain but a very small quantity of
yellowish  white matter, which presents a strong contrast to
the copper-colored elevation on which it rests.  They are not
followed by ulcers ; a thin scab forms  on them, which is fol-
lowed  by a scar, or  sometimes by a livid discoloration,  or a
small chronic induration.
  This form  of syphilitic eruption (called also lenticular pus-
tular eruption) is the most common of all those which assume
the pustular  character,  and is the one most frequently mis-
taken for the papular form, doubtless in consequence of the
rapidity with which it passes into the purulent stages, and the
persistence of the induration which so early follows, and also
on account of the peculiar arrangement of the eruption, which
is always spread over a large  surface in  isolated elevations.
This explains why  the  papular form  of syphilitic eruption
has been  erroneously regarded as the  one of most frequent
occurrence.
  2. Syphilitic impetigo.—This  form is usually  preceded by
slight malaise, and commences with redness of the affected
points;  this  is  followed by  small  collections  of purulent
matter, forming  irregularly shaped patches, more or less con-
fluent, resting upon surfaces of a coppery red  color, which
are soon covered by scabs irregular in  shape, harder, darker
colored, and  more adherent than those of common impetigo.
Beneath these scabs are characteristic ulcerations, which are
followed by scars, varying in extent  and  shape.  This is the
form called pustulo-crustaceous syphilitic eruption.  It may
affect any part of the surface, but more frequently attacks the
face.  It  sometimes appears on several places  at the same
time, but has no tendency to spread to neighboring parts.   It
is always secondary.
  3. In the third  variety of syphilitic pustular  eruption, the 
SYPHILITIC  ERUPTIONS.
301
pustules are still larger (ecthyma syphiliticum) and resemble
those of ecthyma.   They are few in number, isolated, and
chiefly occur  on the limbs, and especially the legs.  They
appear at  first under the form of a large livid spot, about the
size of a shilling, or larger ; the epidermis is now raised over a
considerable  portion of the spot,  by a greyish, sero-purulent
matter ; the elevation increases slowly, and  is always  sur-
rounded by a broad  copper-colored areola, quite different from
that  of ordinary ecthyma, which is of a violet red.   After a.
few  days  the pustule  breaks, and the contained matter con-
cretes  into  a  dark,  hard scab,  which gradually becomes
thicker, and fissured at the edges, being of a circular  shape.
All this occurs without any local inflammation: there is little
heat, and no pain ; the  scabs are extremely tenacious, and
may remain for an  indefinite time  without separating.  When
they do come  away, we  find underneath  them deep  round
ulcers, with sharp-cut hard edges,  of a purple color, whilst the
bottom is  greyish and  ill-looking.  They have little tendency
to spread;  the scabs now gradually  form  again, and  are
frequently renewed, until, under  the use  of appropriate means,
they become thinner,  while the  ulcers get clean  and heal,
leaving behind them circular and lasting cicatrices.
   This is the  most common  form of the  syphilitic pustular
eruption, and the one which usually occurs  in new-born chil-
dren.  Here the pustules  are broad, superficial, flat,  of an
oval shape,  and in great numbers;  the scabs are  dark and
thick,  and conceal small ulcers underneath.  The counte-
nance  of  the patient presents, at the  same time, a peculiar
appearance, which  it is difficult to describe :  the skin is of an
earthy hue ;  the child is emaciated, the  face is drawn  in and
marked, like that of an old person, by numerous wrinkles,
while the  whole body exhales a most disagreeable odor.
   In some cases the skin, near the roots  of the nails or under-
neath  them, is  the  seat of  syphilitic pustules, which ulcerate,
discharge a sanious matter, and  finally destroy the nail.  The
latter  may  grow again, but its appearance is spoiled.   The
ulcers heal, but the  skin remains red, bleeds on the least touch,
and  is sometimes  the seat of excessive pain.    Pustular
syphilis is most generally consecutive.
   Tubercular syphilitic eruption.—This is  one of the most
frequent forms under which the venereal disease  attacks  the
skin.  It commences with  tubercles  of  different sizes,  and of
oblong, flattened, or  conical  shape; they  are of a red  or
copper-color, sometimes  isolated, but generally agglomerated
into patches of a circular  form.   They  may remain indolent
for an indefinite time, and  are smooth  or shining, or covered
                            20 
302
DISEASES OF THE SKIN.
with a slight epidermic exfoliation.  In other cases the tuber-
dies  ulcerate, and the  ulcers, which  are covered by  thick
scabs, may destroy deeply the subjacent  tissues, or spread
more or less superficially along the skin.
  Tubercular syphilis may occur in any part of the body, but
chiefly attacks the face; and the  cartilages of the nose or
angles of the mouth are so frequently its seat, that a tubercle
on these parts may almost be considered as pathognomonic
of venereal infection.   It likewise  appears on the eyebrow or
scalp, destroying the roots of the hair.   We saw a patient in
M. Biett's wards, the whole of whose body  was covered by
venereal tubercles.  The following are the principal varieties
of this form of syphilitic eruption.
 .  1. Tubercular syphilitic  eruption  in  groups.—In  some
cases the tubercles  are  small, not larger than a pin's head or
a pea, rounded, and  of  a copper color;  they are collected
together into circles of various sizes.   Each tubercle is sur-
mounted by a small  disc of exfoliated epidermis, which is hard
and  greyish,  and does not entirely cover its summit;  while
the centre of each circle is entirely sound.   Ulceration rarely
occurs in this variety ; the tubercles  gradually subside and
leave behind them  a  livid red spot, which also vanishes after
some time.  It is never primary, and  principally  shows itself
on the forehead and neck.
  2.  Disseminated  tubercular syphilitic  eruption.—In the
other cases the tubercles are larger and collected irregularly
into  groups ;  they  are oval or pyriform, and very prominent,
being sometimes as  large as a small olive.   Their summits are
smooth, shining,  and free from desquamation; they are  unat-
tended by pain, and may remain indolent for years together.
They rarely,  if ever, ulcerate.   This variety is always secon-
dary, and generally  occupies the face, cheeks, or nose.
  3. Perforating tubercular syphilitic eruption.—In a great
number of cases, we find large, isolated, round tubercles, few
in number, of a purple red tinge, and surrounded by a copper-
colored areola, seated on the face, and  especially on the  upper
lip or nose.  These may remain  stationary for  some  time,
but  at length become tense and painful;  an  erythematous
blush surrounds them, of a peculiar deep violet color.   The
summit of the tubercle  soon ulcerates deeply,  and a  thick
scab is formed.  Fresh  tubercles now  form in  the neighbor-
hood, progress rapidty, and  the ulcers soon coalesce to give
rise  to a large, black,  and extremely tenacious incrustation of
matter.   If  the  scab be  removed, we find underneath an
irregular ulcer, with  cleanly cut edges, formed by indurated
and  engorged tissue  of a purple color.   The  centre of the 
SYPHILITIC ERUPTIONS.
303
ulcer is always more  or  less excavated.   Fresh scabs now
form, and as they are detached, we find the  subjacent  parts
more and more destroyed.   Thus  the  side of the nose or a
portion of the lip is removed; the  portion of  tissue which re-
mains is  of a  violet-red color, and always presents  more or
less of a  circular form.  In  cases where the whole nose, with
its bones and  cartilages, has been destroyed, many of which
we have  seen at St. Louis, the disease almost always com-
mences in the hard parts,  and destroys from within outwards.
This form is always consecutive.
  4.  Serpiginous  Tubercular Syphilitic  Eruption.—In  the
fourth variety we  have  tubercles sometimes as large as a
hazel-nut, hard, round, and  of a red color, scattered over dif-
ferent parts  of the  body, but generally  seated on  the  back.
They are not covered by scales, and  may remain stationary
for a  considerable  time;  finally, however, they ulcerate,  and
the ulcers extend from them to the neighboring tissues, which
they destroy  in a  curious  manner.   They  describe  circles
or  segments of circles, spirals, zig-zags,  figures of all kinds,
&c, are superficial, and generally  a few lines  broad only.
They are covered by  thick, hard, black, and very tenacious
scabs, and  when  they heal leave irregular  scars,  which are
never got rid of.  In the  majority of cases new tubercles are
constantly appearing, and the ulceration  passes  from one to
another,  healing in  one place, while it breaks out elsewhere.
We  saw a patient in M. Biett's wards covered from head to
foot with tubercles of this kind ; the  face,  the scalp, arms, and
back were  traversed  by long  irregular  scars, spotted with
large red tubercles, and every now and then the diseased parts
were  the seat of serpiginous  ulcers  concealed  under thick
scabs.  This  variety is always a secondary affection.
   5. Syphilitic Eruptions  with fiat Tubercles.—Finally, we
have  a variety of tubercular syphilis, which is sometimes  a
primary symptom.   Here the tubercles are round,  thick, and
flat, and perforated on the  top  by  small linear ulcers.   The
tubercles are occasionally as  small as lentils, at other times
thick, of  a deep livid red color, and as large  at the base as  a
shilling;  the  former are found chiefly on  the sides of the nose
and lips ; the latter on the scrotum, penis, pubes, thighs, and
anus. The  summit of the  tubercle soon ulcerates, and  pre-
sents the appearance  of  a  narrow slit, from which a sanious,
foetid matter  is discharged.   The  whole scrotum is  sometimes
covered by these tubercles ; they are isolated, perfectly round,
 and very prominent.  Around  the  margin  of the anus they
 may coalesce, and form larger  surfaces,  but the  ulceration is 
304
DISEASES  OF THE SKIN.
always superficial.   This  form is  most frequently second-
ary.*
  Papular Syphilitic Eruption.—This consists in  the  erup-
tion of small elevated points, which are hard and solid, contain
no  fluid,  and  terminate in resolution or desquamation;  but
never ulcerate.  The papular syphilitic eruption may be  acute
or chronic.
  In the first variety (lichen  syphiliticus; scabies venerea),
the papulae are exceedingly minute, slightly conical, and often
in immense numbers ; they are of a copper color, and the deep
areola which  surrounds them  sometimes gives the skin  the
appearance of a large copper plate sprinkled with a number
of elevated points a little less deep  in  color.  They  often
coexist with gonorrhoea, or come out soon after its disappear-
ance, a circumstance which confirms the  opinions of Mr. Car-
michael.   The papulae usually occupy the whole  of the  body,
and especially the face, coming out within the space of twenty-
four or forty-eight hours.  Generally speaking, there are no
constitutional  symptoms, but  we have  sometimes seen them
preceded by   headache and  some  fever, and  attended with
pretty smart itching.
  This is one of the  least formidable varieties of syphilitic
diseases of the skin.   Bateman says that the  papulae some-
times ulcerate, and certain writers  even  go  so far as to  say
that if left to  themselves, they always end in  ulceration and
the  formation  of purple-colored scars.    This is  clearly an
error.  When abandoned  to nature, they often disappear in a
short time after slight desquamation.   Ulceration of the point
of  the papule may  sometimes occur,  as it does in lichen
agrius; but this is exceedingly rare, and when it does happen,
the  ulcer  leaves  no  cicatrix  behind it.   But it  is  worthy of
note, that occasionally the papules are followed by  small cica-

  * This form of eruption, which is  most commonly but  erroneously called
mucous pustule,  and  sometimes mucous tubercle, and which Ricord proposes to
call "plaque" or "papule muqueuse," is considered by him as the prototype of papu-
lar syphilis, and as " incontrovertible evidence of constitutional infection."  He
says that" it begins by a papule, formed on one of those portions of the skin where its
texture is thinner/more vascular, and more abundantly furnished with sebaceous
follicles ; also where habitual friction has modified more or less the tissue, so as to
render it analogous to mucous membrane, as the anus, groin, fold between the penis
and scrotum, umbilicus, meatus auditorius externus, axilla," &c.  He says that " a
remarkable degree of symmetry is observable in its development on both sides of
the  body, even when  contact does not exist."  Gibert gives a case {Mim. de
I'Acad. Roy. v. x., 1843) in which it occurred on the internal surface of the lower
eyelid, of which he had seen but one case besides.  He says that this form of erup-
tion is sometimes a primary and sometimes a secondary symptom.  It is a symptom
which, of all others, may happen the soonest, and may even appear on the seat of
^e primary sore.                                          H. D. B. 
SYPHILITIC  ERUPTIONS.
305
trices,  without having  been preceded by ulceration.   Most
usually, however, the eruption fades at the end of a few days,
with slight  desquamation, leaving only small stains,  which
soon disappear.
  The  second variety of  syphilitic papular eruption  is a
chronic affection; the papulae are large, flat, and of a copper
color, very prominent, and of a regular circular shape.   They
first appear  as small  yellow points, which gradually rise into
indolent papulae, without areolae ;  they are commonly collected
together in  great  numbers, free  from itching, and the  inter-
vening skin is of a dirty and faded appearance!  They chiefly
occur on the limbs, in the line  of extension, the forehead and
hairy scalp.   In all cases they are a secondary symptom, and
generally accompany other constitutional  signs ot the disease,
especially pustules.  They commonly terminate  in the follow-
ing manner :  The summit of each papule is covered by a dry,
greyish pellicle; this falls  off,  and is perpetually renewed,
until the papulae sink to the level of the skin, leaving nothing
but a  greyish white  spot, which  persists  for a considerable
time.   When the eruption is very thick, the desquamation is
sometimes so abundant as, at the first glance, very much to
resemble a scaly affection.
   Scaly Syphilitic Eruption.—Sometimes the skin is the seat
of small copper-colored elevations,  covered by scales, &c. ;
these we have referred to scaly affections, and divided into
several varieties.  This  form  is always  consecutive, and
usually of very long  duration.  It  terminates  by  resolution
and desquamation, never  by  ulceration;  and  never  leaves
scars.
   1. Syphilitic Lepra.—One of the most remarkable forms of
this eruption  is that in which the spots, analogous to those of
lepra, are of a deep  grey, almost black color;  this probably
has often been described  as a variety of simple lepra (lepra
nigricans).   It is a very rare complaint,  but we once had an
opportunity of observing a curious example of it in the wards
of M. Biett at St. Louis, in a patient in whom the eruption dis-
appeared  under  the  influence of abdominal irritation, and
again appeared, so well marked that we could trace its deve-
lopment very satisfactorily.
   The  leprous spots,  in this case, were perfectly round, from
two or three  lines  to six  or  eight in diameter;  they were
raised at the edges and depressed at the  centre, and were of
a very  dark color, especially in the centre.  The scales were
thin, dry, friable, and but slightly adherent; underneath  them
the elevated surfaces were smooth and shining.  The affection
gradually disappeared  under  the influence  of an internal 
306
DISEASES OF THE  SKIN.
inflammation ; the scales  ceased  to  be formed; the edges of
the leprous spots subsided, and at length nothing  remained
but a dark round stain.   At the expiration of  six weeks,  the
internal disease was cured, and the cutaneous affection broke
out afresh;  the  leprous spots commenced in  the centre of
the old ones, and soon assumed their original appearance ;  the
elevated points which subsequently constituted  the spot were
not of the same color  at first as  the stain in which they
formed, but were of a coppery-red color ; a few discs appeared
on the healthy skin, and here  they were not preceded by a
deep red spot, as is the case in lepra, but by  a  greyish injec-
tion of the skin, without heat or itching.   The skin, in  the
intervals,  was of a dirty  hue, and the patient emitted a very
peculiar smell.
  Syphilitic lepra may be general, as in the case just men-
tioned ; it is very  seldom a primary symptom,  though   M.
Biett used to mention a  remarkable case in his clinical  lec-
tures, where it  broke out a short  time after  unclean con-
nexion.
  2. In the majority of cases this form assumes  the characters
of psoriasis,  and most usually of P. guttata.  The spots may
be  confined  to  one region of the body,  but they generally
occupy the neck, back, chest, and abdomen at the same time,
or the limbs,  face, and scalp.  They vary in size from the  dia-
meter of a farthing to that of a  half crown  piece ;  they  are
generally  isolated and irregularly circular,  a little  elevated
above the surface, and covered by thin, hard,  greyish, tena-
cious scales, which fall off and expose a smooth, shining  sur-
face,  of a coppery tint, unlike the red, fissured elevations of
psoriasis.  Even  when more allied to P. guttata, they present
a peculiar appearance, which M. Biett considers as pathogno-
monic; this is a small, white border, surrounding the base of
each disc  at the  point where it commences to rise above  the
level of the skin, and evidently produced by laceration of the
epidermis.  Some writers pretend that this is a sign of little
importance,  inasmuch as it is common to other cutaneous
affections, as in  vesicular eruptions, and  especially in vari-
cella ; but these assertions  are erroneous.  The venereal border
adheres firmly to the circumference  of the spot, which is  not
the case in varicella.
  In  some  cases several spots  coalesce, and  form a large
copper-colored discoloration, covered here   and there with
scales, which fall  off,  and  are  reproduced  slowly.    The
disease generally commences on the arms, whence it extends
to the chest,  back, and face ;  the first thing seen being small
copper-colored  points,  which cause  considerable itching, 
SYPHILITIC ERUPTIONS.
307
extend gradually, and as  they become  elevated, are covered
by scales.
   3. Horny scaly  syphilitic  eruption.—Finally, this  form of
scaly syphilitic  eruption  appears on  the soles of the feet or
palms of the hands, in  the  variety  denominated by M. Biett
the  horny.  It  commences by slightly  elevated points  of a
copper color;  these are elevated in the  centre,  and covered
by greyish, hard, fissured scales, which  become very  nume-
rous, and  as they  coalesce form a kind of spot, divided  by
crevices or fissures.  M.  Biett has termed  this variety horny,
from the  horny, cylindrical  substance which  in  old cases
occupies the centre of the spot.   It very rarely exists alone,
but is generally  accompanied by other  symptoms of consti-
tutional  syphilis.*
   The various forms of syphilitic eruption  just described may
occur  together  in  the  same  individual.  Thus  papulae often
exist with pustules, and the latter with tubercles.  In general
the scaly forms occur without complication of any other, but,
like the  rest,  are  almost always attended by constitutional
symptoms of syphilitic  infection.
   Concurrent symptoms.—The  cutaneous forms of  syphilis
may be complicated with  all the  other symptoms of that dis-
ease, but  we  shall confine ourselves  at present to such  as
most frequently  coexist with  syphilitic eruptions.
   The most common are ulcerations of the throat, amygdalae,
or posterior part of the  pharynx, easily recognised by  their
peculiar  form  and  appearance, and which consist, as Hunter
says, in  a real loss of substance, as if a part of the tonsil  or of
the  mucous membrane of the pharynx had been  removed,
presenting regular  edges and an excavated  centre, covered
with very adherent greyish matter.  Next come pains in the
bones, inflammation of the periosteum  or exostosis.   These
chiefly occur  in the superficial bones, as the tibia, ulna, and
bones  of the  cranium.  Hunter  thought  that this  tendency
depends  on  the exposure  of such  parts  to  cold, but more
recently  these affections have been attributed to the use of

   * When scaly  syphilis appears on the parts where the skin is in contact with
itself, the surfaces of the spots become  soft, and are moistened by a whitish matter,
which is foetid and oily, and instead of scales are covered by a smooth epidermis,
of a dull white or  greyish color.—{Rayer Mai. de la peau.)
   It  sometimes appears  on the  tongue, and  then presents itself in the form of
slightly depressed patches, irregularly oval in shape, with their long diameter from
a quarter to a third of an inch in length, and parallel with the length of the tongue,
smooth and glossy, of a dull or coppery-red color, and destitute of villi or epithe-
lium, with  small  intervals of sound  surface between  them.  Several of these
patches  may exist at the same time.   They  cause  little or no uneasiness, and
frequently heal up  in  a short time, though liable to reappear.       H. D. B. 
308
DISEASES OF THE SKIN.
mercury : the latter opinion does not seem to be correct;
since the  year 1816  M. Biett has seen every year from five
to six hundred persons who, in consequence of their peculiar
occupations, were literally saturated with mercury, yet he
never witnessed any disease of the bones or exostosis amongst
these individuals.
   A frequent  attendant symptom of venereal  eruptions is
iritis, the  syphilitic nature of which  has  been established by
Saunders, Wardrop, and more recently by Lawrence.   The
importance of this complication induces us to  say a few
words on  it.  Iritis commences  with  violent pain in the head,
followed by dull,  deep pain in the eyeball, increased on the
admission of light: the pupil now contracts uniformly, and
the movements of the iris are gradually impeded ; its circular
fibres assume a deeper or a reddish tint, and  the edge of the
iris loses  its regular  appearance.  At a later stage the pupil-
lary margin  becomes  angular, the iris is  tumefied,  and
advances  towards the cornea; small abscesses form and open
into the anterior chamber, and unless the disease be arrested,
it makes a rapid progress :  the  inflammation extends on one
side to the capsule of the lens, which  gradually loses its trans-
parency ;  while- on  the other  the cornea becomes  opaque,
and coagulable lymph is effused, causing adherences which
may be altogether fatal to vision.
   Another attendant symptom of syphilitic  eruptions, is the
tumor  denominated  gummy by some pa'thologists,  and to
which  M. Biett  has  particularly  directed  attention in  his
clinical lectures.   These tumors appear  to  spring from the
laminated tissue underneath the skin; the first symptoms are
a slight uneasiness and  elevation of  the affected part, with a
livid tinge of the integument, but when the tumor is deep-
seated  the skin may retain  its natural color.  The progress
of the  disease is  slow;  the tumor gradually becomes  more
prominent and the color more livid, especially over the point
where  it is about to give way; and then some obscure fluctu-
ation is perceived.  The tumor  may terminate in resolution,
and of  this  M. Biett mentions a remarkable example; but
more frequently the skin gives way, the edges of  the fissures
are lacerated, and in two or three days a large venereal ulcer,
with its clean cut edges, appears.
   Such are the constitutional  symptoms which commonly
coexist  with venereal affections of the skin ; but there are
many others of a similar nature, or unconnected with syphilis.
Thus the patient may be cut off by ulceration of the bowels;
or erysipelas may ensue on syphilitic  eruption of the face,
when the latter disappears for a time.   Lastly, they may be 
SYPHILITIC  ERUPTIONS.
309
accompanied by  ozoena, destruction of the  cartilages of the
ears, scirrhous enlargement of the testicles, or inflammations
of various organs, by which the progress of the  cutaneous
affection is more or less modified.  They may be complicated
with non-syphilitic eruptions, as eczema, herpes, and particu-
larly  the itch.  They often cause baldness.   Different ele-
mentary forms of eruption may also appear at the same time,
as  papulae  with  pustules or  tubercles.   The  scaly form is
found most frequently alone.
  Pathology.—Patients are never  cut off by the cutaneous
affection itself, although they sometimes sink under the con-
stitutional symptoms  which may accompany it.  The post-
mortem researches of M. Biett have disclosed a great variety
of lesions—necrosis, exostosis, caries of the bones of the foot,
&c, and fistulas.   In one patient, who died with all the symp-
toms of laryngeal phthisis, he found ulceration of the mucous
lining of the larynx, with caries of its cartilages, and a fistu-
lous canal opening externally.   In other cases he has found
peculiar ulcerations of the  intestinal canal,  and chiefly near
the coecal valve.   An effusion of serum also frequently exists
in some of the great splanchnic cavities.  Most of the bodies
of those who die with these symptoms have a peculiar and
foetid odor, and decompose very rapidly.
   Causes.—Syphilitic diseases of the skin may be excited by
a great number of occasional causes, such as severe exercise,
excess in eating, violent passions, an attack of fever, irritating
applications, active  medicines,  wounds,  contusions,  &c.
Sometimes it is impossible to discover any exciting cause, but
in every  case the remote and invariable cause is syphilitic
infection.  Under certain circumstances they are clearly con-
tagious, and may be transmitted from parent to child; infants
are occasionally born with syphilitic pustules, or the eruption
may. break out shortly after birth.   In other cases the infant
contracts  the  cutaneous affection  from its nurse;  or an
apparently healthy infant, if born of a mother laboring under
the disease, may communicate it to a perfectly healthy nurse.
   The cutaneous affection, however, in the majority of cases,
breaks  forth without any appreciable  cause, and while the
individual seems  in the enjoyment of the best health ;  but it
may be excited by mental emotion, excess of any kind, or the
influence of another disease ; sometimes it is preceded by
general derangement  of the economy, or headache, depression,
febrile languor, &c.  Experience proves that it may succeed
gonorrhoea, as well as chancre and bubo,  and vice versa.
 3 The relation between anv particular form of primary symp-
toms and a particular form "of eruption, which Mr. Carmichael 
310               DISEASES OP THE  SKIN.

endeavored to establish, is not sustained by facts.  The form
of the primary disease has no influence upon that of the erup-
tion which succeeds it.
  Age has no effect upon  the appearance of syphilitic erup-
tions;  they  are of more frequent occurrence from twenty to
thirty years  of age, because the primary disease is most com-
mon at this period.
  Cold is more  apt  to  act as a predisposing cause of these
eruptions than heat.
  Facts seem to prove that they occur much less frequently
after a mercurial course of treatment than after simple treat-
ment alone.
  Diagnosis.—Although the characters of syphilitic eruptions
are clearly marked,  they are often  overlooked, or mistaken
for other  diseases  of the skin.  Their symptoms, however,
are very distinct, and the experienced eye will  seldom fail to
detect  a  certain ensemble, which  is difficult  to describe,
depending on the peculiar color and arrangement of the erup-
tion, and general state of the patient.  We  cannot,  as some
pathologists  pretend, place any reliance on  the  influence or
failure of mercury as a diagnostic sign.
   1. The disease most likely to be confounded with syphilitic
exanthematous affections of the skin, are roseola, urticaria, and
ephelis;  the two former bearing some resemblance to acute,
the latter to chronic  exanthematous syphilitic eruption.
  Roseola.—This affection differs from the  greyish  spots of
the syphilitic variety in its color, which is light red, and in
the general  symptoms accompanying it.  The progress of
syphilitic roseola is quite different from that of the simple dis-
ease ; but we should not forget that at an early stage of the
exanthema the spots present  a  reddish instead of a  copper
color;  as the disease advances they  assume a deeper tint,
while in common roseola they gradually fade, and soon disap-
pear altogether.
   Urticaria.—The  small spots of urticaria,  arising  without
any  apparent cause and attended  with itching, bear  some
resemblance to acute exanthematous syphilide;  but the color
of the spots is different in  the two affections; in the former
they are either  whiter  or  more red  than the  healthy skin,
never  of the grey color peculiar to the  syphilitic eruption ;
they are likewise  more  elevated, and attended with  greater
itching;  finally, they disappear suddenly  and break out again
after some time, a circumstance which  never  occurs in the
syphilitic  variety.   Acute exanthematous syphilitic eruption
almost always  accompanies  gonorrhoea or primary venereal
symptoms, or at least appears very soon after their cessation. 
SYPHILITIC  ERUPTIONS.
311
  Ephelis.—The ephelides  differ from syphilitic blotches in
several respects ;  they are usually larger and irregular in form,
occupying a more extensive surface of the body, and particu-
larly  the  abdomen and  chest.  Syphilitic spots, on the con-
trary, are round,  and seldom larger than a half crown piece;
they are generally few  in number, and chiefly seated on the
forehead, face, or eyebrows.   Ephelides are of a yellow color,
covered by a furfuraceous exfoliation, and attended with some
itching.   Venereal spots are of a red copper tinge, occasion
very slight if any pruritus,  and are rarely covered by  epider-
mic scales.  Finally, they never coalesce, like  the  ephelides,
to form irregular discolorations which may cover a very large
portion of the body.
  Syphilitic maculae are almost always accompanied by some
other venereal symptoms,  and are  often complicated with
iritis.
  Elephantiasis Graecorum.—Syphilitic maculae may be con-
founded with this disease at its commencement.   But  in  ele-
phantiasis, the spots  are of fawn color ; the skin is smooth and
shining, and there is insensibility of the spots, which is patho-
gnomonic of this disease.   The history of the case will also
afford aid in the diagnosis ;  and in  the case  of elephantiasis,
it can always be traced to the country where it is endemic.
  2. Vesicular syphilitic eruption  is  especially characterized
by  the  persistence  of  the  individual vesicles,  the copper-
colored  areola  about their  base, their  number and arrange-
ment, which distinguish  it entirely from varicella and eczema.
In the impetiginous variety, the syphilitic form is known  by
the adherence and dryness  of the scabs,  the ulcerations, &c.
The coppery color  of  the  syphilitic form, which extends to
the centre of the patches, will distinguish  it  from herpes cir-
cinatus.
  3. The pustular syphilitic eruption may be  confounded
with acne and ecthyma.
  Acne.—The pustules of acne, especially-those  seated in the
forehead and face, resemble psydracious syphilitic pustules, but
they are more prominent, red, and surrounded occasionally by
an erythematous areola, whereas the latter  are  of a  purple
color and  inclosed by a copper-colored  circle.   The  inter-
vening portions of skin  in  acne are red,  shining, of a greasy
appearance, and covered with small dark points ; in  the vene-
real eruption they are of an  earthy hue and faded appearance.
Finally, the syphilitic pustules are often succeeded  by small
scars, which seldom  occur except in  cases of acne indurata,
where the cicatrices are of a different character, being  oblong
in acne and round in the syphilitic disease. 
312
DISEASES OF THE SKIN.
  Ecthyma.—It is  sometimes exceedingly difficult to distin-
guish phlyzacious syphilitic puslules from those of ecthyma;
but  the areola of  ecthymatous pustules is  of a purple-red
color,  while  in syphilis it is always copper  colored.   The
incrustations of the  latter are  thicker and  more  tenacious,
and  sometimes almost black; they are,  likewise, fissured all
round the edges ; the  ulcers which  follow them are round and
deep ;  their edges  perpendicular,  &c, and  they constantly
produce  depressed  and  indelible  scars.  Finally, they are
usually attended by other signs of constitutional syphilis.
  4. Tubercular Syphilitic Eruption.—The  cutaneous dis-
eases likely to be  confounded  with  tubercular  syphilis are
lepra, some varieties of psoriasis, acne indurata, and lupus.
  Lepra.—In the syphilitic affection, although the spots are
sometimes circular,  they are never so completely so as in lepra;
they are formed by  isolated, smooth, prominent tubercles of a
purplish or copper color, covered by thin, hard lamella?, which
are always smaller  than  the subjacent induration;  the scales
of lepra are larger,  and cover the edges of the spot, its centre,
or even the whole of it.
  Psoriasis gyrata.—Tubercular syphilis, partially cured and
presenting imperfect  circles,  has   often been mistaken for
psoriasis gyrata ; but  the points of difference which apply to
lepra, will serve as  means of distinguishing it from this affec-
tion likewise.
  Psoriasis guttata.—It seems certain that tubercular syphi-
lis of the scrotum has been frequently confounded with P  gut-
tata, which is but seldom seen on that part; but the former is
characterized by round, thick, flat tubercles, which ulcerate at
their summits, and discharge a sanious and very foetid  matter ;
while in the latter disease we have merely dry eminences of
a papular appearance, which are covered by  scales of various
sizes, but  never terminate in ulceration.
  Acne Indurata.—This variety of acne may be followed by
circumscribed indurations, which occasionally resemble those
of syphilis in  being  separated by a  number of cicatrices ;
but the tubercles of the venereal  affection are hard, copper-
colored, round, and often as  large as hazel  nuts;  they  have
not, like the circumscribed indurations of acne, been preceded
by pustules ;  they frequently ulcerate and burrow underneath
the skin to a considerable extent, are  covered by thick scabs,
and leave behind them, not the oblong cicatrices of acne, but
irregular tortuous scars.
  Lupus.—It is sometimes no easy matter to distinguish the
nascent tubercles of lupus from those of tubercular  syphilis.
Those of  lupus, however, are  reddish, soft,  and but  little 
SYPHILITIC ERUPTIONS.
313
developed ;  they are fissured or shrivelled at the summit;  the
adjacent skin is slightly oedematous; the tubercles of syphilis
are more prominent and harder; smooth, shining, and of a
copper  color.   Lupus generally  commences on  the cheeks,
while the venereal tubercle most frequently attacks the fore-
head  or sides of  the nose.  Finally, lupus  occurs mostly in
individuals of scrofulous habit  and young persons of lax fibre,
while the venereal tubercle is  usually found in  adults, and is,
besides, almost  always attended  by other signs  of constitu-
tional syphilis.
   5. Papular Syphilitic Eruption.—This variety  should be
distinguished from lichen and scabies.
   Scabies.—The syphilitic papular eruption is sometimes very
small, slightly conical, and, if some writers are  to be credited,
presents the transparent serous collections so characteristic of
scabies; but the  least attention  will suffice to show that the
disease is a papular and not a  vesicular one.
   Lichen.—Syphilitic lichen may be distinguished from lichen
simplex by the following signs  : The papulae of the former are
very small  and numerous,  slightly  conical, of a deep  color,
and the areolae sometimes coalesce to form a large copper-
colored blotch, dotted with fine points ; in lichen simplex the
eruption is  generally confined  to a single region  of the body,
particularly to the limbs ; in  the syphilitic  variety it covers
the whole body, is most abundant on the face,  and the papulae
make their  appearance nearly  at the same time  in the different
regions.*
   In some cases of syphilitic papulae, the papules are flattened,
broad,  and  covered by small  scales, which  conceal the inter-
vening healthy spaces, and give the disease some resemblance
to the  scaly variety; but the  two forms now  spoken of could
only be confounded  at a particular period of the disease; in
its early stage the papulae are  perfectly distinct, and at a later
period  are again easily recognised, when the scales have fallen
off; the progress  of the eruption, then, will sufficiently demon-
^trjitG its n3.tu.rG.
   6. Scaly Syphilitic Eruption.—-The diseases from which this
 form should  be distinguished are psoriasis and  lepra.
   Lepra.—When the edges  of the  scaly syphilitic eruption
 are prominent, and the centre of the spot depressed, it may be
 mistaken for lepra, as the only diagnostic mark is its coppery
 color;  in lepra nigricans the  very dark color of the spots  is
 quite characteristic.

   * Lichen simplex is most commonly accompanied by itching, which ta  some-
 times quite severe; syphilitic lichen itches but little, if at all.       H. D. B. 
314
DISEASES OP THE  SKIN.
  Psoriasis.—The  syphilitic cutaneous affection may occa-
sionally simulate psoriasis, and especially psoriasis guttata;
in the former,  however, the color  is coppery ;  the  spots are
covered by small, thin, grey scales, which are much  thinner
than those of psoriasis ; and finally, they are surrounded by
the  white  rim  altogether peculiar to them.
  Such are the different affections which more  or less resem-
ble  syphilitic diseases of the skin: we may add, that in addi-
tion to their  distinctive characters, the latter  are  generally
attended by certain constitutional  symptoms, the presence of
which  is  of   much  aid in  a  diagnostic point  of  view.   It
remains for us to say a few words  on  two conditions  some-
times attending cutaneous diseases, and giving them  some
resemblance to analogous affections of syphilitic  origin :  these
are  incrustations and ulcers.
  7. The  incrustations of syphilitic pustules or tubercles may
be mistaken for the scabs of impetigo: but the  latter are yel-
low and easily detached; while those of syphilis are greenish
or nearly black, hard, and in all cases excessively tenacious,
penetrating more or less deeply into the skin.
  8. Syphilitic ulcers may resemble those  of lupus, but if we
remember their peculiar characters, we cannot easily con-
found them.   The venereal ulcer  is  deep and  excavated, its
edges hard, cleanly cut, and surrounded by a copper-colored
areola; the ulcer produced by lupus is more superficial, its
edges soft and violet color ;  the surrounding skin is generally
engorged,  and, as it were, oedematous.   When lupus spreads,
its ulcerations do  not  assume those spiral or  zigzag forms
which  characterize  serpiginous syphilitic  ulcers.  But when
the  diseases are confined to a small  portion of  the body, the
nose for example, and destroy  the  parts on which they have
fixed, it is not so  easy to distinguish them.   We should
remember, however, that  in  lupus  the  destructive  process
almost always commences in the skin,  while in syphilis it has
its origin in the bones ;  in  the latter it is  much more rapid,
and  finally is  attended, as  we have so frequently observed
before, by other constitutional symptoms.
  Prognosis.—Syphilitic diseases of the skin are seldom dan-
gerous.  The  tubercular, and  some varieties of the pustular
form, are the  most severe ; the  scaly eruption is often very
obstinate ; all the rest are, generally speaking, of shorter dura-
tion.   The prognosis is less favorable when the patient  has
long suffered  under syphilis, or been  the  subject of several
relapses, and when the cutaneous affection  is complicated by
several other constitutional symptoms.  In the latter case, the
patient may sink into the most frightful state ; the pulse becomes 
SYPHILITIC  ERUPTIONS.
315
  weak, the face loses its color; diarrhoea  sets in;  blood is dis-
  charged from the nostrils, and death ensues.
     Treatment.—It  were useless  to enumerate the long list of
  remedies  which have been employed in the treatment of con-
  stitutional syphilitic  affections; we shall, therefore, confine
  ourselves  to a consideration of those, the utility of which  has
  been demonstrated by experience.
     The antiphlogistic method, and  the use of emollients, have
  been vaunted as sufficient to effect  a cure in the majority of
  cases;  but from considerable experience we must say :  1st,
  that they are often useful, and occasionally  indispensable as
  auxiliaries ; 2d, that sometimes, though very rarely,  they will
  effect a cure ; 3d,  that in the immense majority of cases they
  tail, except in  acute  papular  or  exanthematous  syphilide,
  which are in general temporary eruptions, appearing and dis-
  appearing with the primary symptoms.
     In the  treatment of syphilitic eruptions, both  internal and
  external remedies  are used.
     The remedies sanctioned  by long experience are the follow-
  ing :
     Mercury.—The  preparations of mercury  are,  beyond
  doubt,  the  most  useful  remedies  that  we possess against
  syphilitic  diseases  of the skin ; though sometimes unsuccess-
  ful, they answer our fullest  expectations in a great  majority
  of  cases,  and it seems  probable that their occasional failure
  may depend on the manner in which they have been adminis-
  tered.   Thus, mercury ought never  to be given in the acute
  stage of a syphilitic disease of the  skin.   It is impossible to
  lay down  any positive rules for the quantity that should  be
  administered,  this depending on  the  patient's constitution,  the
  nature of  the symptoms, the effects of the medicine, &c.  We
  may  employ  Van  Swieten's solution, or pills  composed of
  corrosive  sublimate and  opium.   When  the patient is  weak
  and irritable, and  it is expedient to avoid excitement of  the
  digestive  apparatus, we may have recourse to the soluble mer-
  cury of Hanhemann,  in  the dose  of a grain daily.   Among
v  preparations  of this  article,  the protochloride  of  mercury,
  although sometimes too mild, has often a very good  effect in
  certain cases of affection of the pituitary membrane, used by
  insufflation; and the bichloride of mercury, a very efficacious
  remedy in venereal eruptions, but which is apt to  disagree
  with patients ;  and especially the proto-iodide  of  mercury,
  introduced into practice  by M. Biett, and which  time and
  experience have proved to be, at present, the best article for
  the treatment of syphilitic eruptions.
     When  carefully administered, mercury  seldom produces 
316
DISEASES  OP THE SKIN.
any injurious effects ;  still, we must keep a watchful eye on
the  state of the  digestive  organs during its use, and suspend
it if symptoms  of  irritation supervene.   The  time during
which it is to be  employed must depend on the  effects  of the
remedy;  but we  cannot  agree with some writers, that the
treatment should be continued for a month or longer after the
disappearance of the symptoms, with a view to preventing  a
relapse.*
   Sudorifics.—This class of remedies is of much  value, in
combination with other means of a more active  nature.   The
sudorifics generally employed are the decoctions of guaiacum,
sarsaparilla, and mezereon ; an ounce of the  sudorific syrup
may be added to the first dose  of the remedy, taken in the
morning before eating.
   Tizan  of  Feltz.—This  occasionally  succeeds  in  cases
where  mercury  fails ;  the  patient  may  take  two or  three
glasses a day.
   Muriate of Gold.—This preparation has been  highly spoken
of, but its  advantages have been  greatly overrated ; we  have
seldom seen it succeed.  A tenth of a grain may be applied
in friction on the tongue twice a day.
   Subcarbonate of Ammonia.—A speedy cure has been some-
times obtained  through means of this remedy, especially in
cases where mercurial  preparations  fail.   M. Biett was in the
habit of commencing  with a drachm, in some mucilaginous
fluid,  and  gradually increasing  the  dose to  two  or  three
drachms during the day.
   Acids.—M.  Biett frequently  administered  nitric and  sul-
phuric acids with benefit in certain forms  of syphilitic disease
of the  skin.   We have  often seen simple cases,  syphilitic
roseola for example, cured  in  this way ; and even inveterate
cases, especially  some  forms of the  pustular eruption,  will


  * Gibert says that  the mean duration of this treatment has not exceeded five
weeks, but that he considers it prudent, as a general rule, to continue it longer, and
usually does so in private practice.  {M&m. de I'Acad. Roy., vol. x.,  1843.)
  Cazenave himself, in another place {Traite  des Syphilides, Paris, 1843), says
that if the eruption is slight, and  it disappears at the end of a month  or six
weeks, the treatment must be continued a month longer, diminishing the doses by
gradually decreasing one third of the whole quantity.  When the treatment is
long, the patient may be allowed intervals of rest of fifteen days at a  time.
Rayer recommends a continuance of the treatment for fifteen days and even a
month after the entire disappearance of the symptoms.  Others recommend its
continuance for two months in ordinary cases, and three or four months in severe
ones.  I have always advised the continuance  of treatment from three or four to
six or eight weeks after the disappearance of the eruption, giving the remedy in
diminishing  doses, and at gradually increasing intervals of time, and have also
urged the importance of attention to regimen, more or less severe, for  a still  longer
period.                                                H. D. B. 
SYPHILITIC ERUPTIONS.
317
 sometimes yield to the acids after having  resisted much more
 active remedies.
   Iodide of Potassium.—This article has of late years been
 highly praised as a remedy for secondary syphilis; still, when
 used alone, it is less efficacious than the proto-iodide of mer-
 cury ; but is exceedingly valuable when the system is  suffer-
 ing under syphilitic cachexia.
   The internal treatment will occasionally require the aid of
 external medication.  Thus the  resolution of syphilitic tuber-
 cles may be assisted by the use of ointments containing the
 proto-nitrate, proto-iodide, deuto-iodide of mercury.  Gentle
 inunction should  be .made  with the finger over the largest
 tubercles.  The  most efficacious  ointment, however,  is one
 composed of twenty or thirty grains of the iodide of sulphur
 to  an ounce of lard.   We saw  M. Biett  employ this remedy
 with good effect in a case where nearly  the whole body was
 covered  by  scars  and  large  tubercles.  As for the different
 lotions recommended by some writers, we reject them altoge-
 ther ; they are  either useless or injurious.
   The venereal ulcer may sometimes require a mode of treat-
 ment especially  suited  to it; thus  it may be necessary  to
 arrest the destructive progress of the sore, or modify its con-
 dition by the use of an ointment, containing the deutoxide,
 deuto-iodide,  or cyanuret of mercury.  In  other cases we may
 be  compelled to cauterize with the binitrate of mercury; and
 M. Biett often succeeded in alleviating the severe pain attend-
 ing these ulcers, with small pledgets of lint smeared with the
 hydrocyanic cerate*
  The remedies just mentioned  will receive powerful aid  in
 the proper administration of baths, &c.  Thus, alkaline baths
 are beneficial in most cases of venereal pustular eruption ; and
 the resolution of tubercles  is considerably aided by directing
 a vapor douche for twelve or fifteen minutes over the affected
 parts.  Vapor baths contribute in no small degree to the cure
 of scaly syphilitic eruptions.  The flat  pustules  of Cullerier,
 which so frequently appear on  the  scrotum  and round the
margin of the anus, generally yield to the use  of fumigations
with cinnabar, f

  *  One of the best applications for ulcers which are painful and disposed  to
spread I have found to be an ointment of white or red precipitate, of the strength
of half a drachm to an ounce  of opiated cerate or stramonium ointment, and
sometimes with the addition of a few drops of tincture of opium.   H. D. B.
  t  In addition to constitutional treatment,  M. Ricord recommends for these flat
pustules a lotion of one part of chloride of soda to four  of water, to be used three
or four times daily ; the parts are then to  be dried and well sprinkled with dry
calomel.  I have used black wash for them with advantage.       11. D.  B.
                             21 
318
DISEASES OF THE SKIN.
   Several experiments  have been recently made with baths
containing corrosive sublimate; but we do not think that they
have been conducted with sufficient care to draw any conclu-
sions from them.   The  corrosive sublimate was generally
added  to water containing  a quantity  of alkaline salts, and
must necessarily have undergone some  change; besides,  the
action of the remedy, when administered in this way, must be
extremely variable,  and, in some  cases, not  unattended by
danger.  Our own experience thus far authorizes us in regard-
ing  this mode  of  treatment as always  inefficacious, and as
possibly dangerous.
   Under certain circumstances which, unfortunately, are not
very rare, syphilitic diseases of the skin resist all the modes
of treatment just  pointed out, and become complicated  by
alarming symptoms of constitutional infection.  In such cases
we have seen the best effects produced by the administration
of opium, commencing with half a grain in the day, and gra-
dually  carried (by increasing the dose every three or four days
by half a grain) to four grains, or even  more, daily.   Under
the use of this powerful remedy, the symptoms often improve
in a very rapid manner, and the most  inveterate affections are
completely removed.
   Finally, in some cases, where the resources of the regular
practitioner  are exhausted, the disease has rapidly yielded to
empirical remedies.  Of this we have seen many remarkable
examples in  the  wards  of  M. Biett, particularly with the
decoctions bearing the names of Zittman and Arnault.  The
work of M. Lagneau contains full information relative to the
method of Zittman ; and the  composition of his decoction
will be found in our formulary.   We are far  from recom-
mending these  empirical modes of treatment;  but we must
acknowledge that  we have  seen them succeed in the most
desperate cases, where every other remedy had been tried in
vain.  The  decoction of Zittman sometimes produces diar-
rhoea, which  compels us  to suspend its  administration for a
short time;  but, in the majority of cases in which we have
seen it tried, the patients bore it well  enough ; and  it was
almost  invariably  successful,  even  in  the  most desperate
cases.
   The symptoms attending syphilitic eruptions will, of course,
require special treatment.  In ulceration of the throat, palate,
&c, we may employ, with advantage, gargles containing the
deuto-chloride of mercury and a few  drops of laudanum.  In
iritis, general and  local bleeding will often be requisite; but
calomel, in large doses, as recommended by English writers,
is the remedy which we have found most efficacious.   When 
SYPHILITIC ERUPTIONS.
319
an infant at the breast is attacked, the nurse  should take Van
Swieten's solution, or  what  is  still  better,  employ frictions
with the Neapolitan ointment and camphor over the legs and
thighs.   Should  the  nurse be too weak to undergo a course
of mercury, the  infant  must be fed  with  the  milk of a goat,
treated  in  a similar  manner.   We have seen  the best effects
produced by this mode of treatment, at the dispensary attached
to the Hospital of St. Louis.*


     The proto-iodide and deuto-iodide of mercury are both  very valuable forms
of this remedy, in different varieties of syphilitic cutaneous disease, especially when
there is  any tendency to the strumous diathesis ; and it is in  patients of this dia-
thesis that syphilis is apt to  make its greatest ravages, and to  prove  most  intract-
able to remedies.
   The proto-iodide may be given in pill, with extract of conium, beginning with
half a grain of the former and one grain of  the latter, morning and evening, and
the quantity of the proto-iodide may be increased, giving a pill of this kind three times
daily, or by giving a pill night and morning, containing one grain  each of these
articles.   The  quantity may  afterwards be varied to suit the particular case, and
may then be gradually diminished until a pill is given at night only. I have also
given this remedy,  with very satisfactory results, in combination with conium, in
the fluid extract of sarsaparilla, either alone or combined with the fluid extract of
rumex acutus.
   The deuto-iodide may be given in pill, in  doses of a sixteenth to  an eighth of a
grain, two or  three times a day, or much better in combination with the iodide of
potassium, in  simple sirup or sirup of sarsaparilla—one eighth of a grain of the
deuto-iodide and five grains of the iodide in  half an ounce of the sirup.   M. Gibert
i s very partial to its use in this way.  It may also be given in combination with
the iodide of  arsenic and conium, forming a combination similar in  its nature and
effects to Donovan's liquor, already spoken  of, and is thought, in this form, to be
particularly adapted to eruptions of the squamous kind, which are  well known to
 be among the most obstinate of  this class.   Mr. Erichsen speaks highly of  a pill
 consisting of  one  twelfth of a grain of iodide of arsenic, one sixth of a  grain of
 deuto-iodide of mercury, and two grains of extract of conium, to be given  night
 and morning.—{Lond. Med. Gaz., May, 1843.)
   The  bichloride of  mercury is better suited to some cases than either of the
 iodides, from the greater control  which it seems  to exercise over the capillary cir-
 culation.  This may be given in pill, with extract of conium, or with opium and
 guaiacum, or in solution in alcohol, or, as I  have preferred giving it, in some  bitter
 tincture, as tinct. cinchon. comp., or tinct. gentian, comp.,  to which may  often be
 added with advantage the tincture of capsicum—giving from one eighth to one
 fourth  of the bichloride and a teaspoonfol of  the bitter  tincture at a dose.  In
 broken down  constitutions, or in cases  a long  time under  treatment, M. Gibert
 gives a mixture of one quarter of a grain of the bichloride, and eight grains of
 common salt, sprinkled on a fresh egg, and  considers this as  one of the best forme
 of administering this remedy to  prevent salivation and pain  in the epigastrium.—
 {Gaz. des HSp., Jan. 8, 1850.)
   When the disease resists the use of these remedies, M. Gibert has recourse to a
 modification  of mercurial frictions, proposed by Dr. Scatigna  of Naples, which
 consists in placing in the hollow of the axillae of the  patient a drachm of strong
 mercurial ointment.  This is repeated the next day, and omitted on the third day,
 when the patient takes a bath, after which the  plan is recommenced.  M. Gibert
 Baw a case of tubercular syphilitic eruption cured by this method,  which had
 resisted other means for three years: some  salivation was  produced by it.—{Mai.
 de lapeau, Paris, 1840.)
    Whatever form of mercury is used, salivation must not be sought for but avoided,
 as it rather interferes with  than promotes its good effects, as a general rule. 
320
DISEASES OF  THE  SKIN.
                         PURPURA.

Syn.—Hcemorrhaea petechialis ; Petechia; Morbus maculosus
         haemorrhagicus; Hemorrhee;  Land scurvy.

  Purpura is a disease of the skin, characterized by patches
of a bright red or deep violet tint, of variable extent, always
retaining  the  color  under  pressure of the  finger.   These
patches  are  sometimes merely  minute  spots ;  but  are often
several  inches in width.   They are generally confined to the
skin  alone,  but  frequently  appear simultaneously on  the
mucous  membranes,, and are then accompanied with consider-
able haemorrhage.
  This  affection  has been  incorrectly classed  amongst the
exanthemata  by Willan.  The  latter  eruptions  are accom-
panied,  amongst  other symptoms,  by febrile   disturbance,
inflammation and injection of the cutaneous capillary system,
whilst in purpura  these phenomena are  absent,  and in  their
stead  we  find an extravasation  of blood in the  superficial
layers of  the skin.   Purpura  appears  to us  to have no ana-
logue, and we have  therefore placed it amongst the indeter-
minate diseases of the skin.   The red patches, characteristic
of purpura, are often  designated by writers, petechias, and are
always considered indicative of danger, as for example, when
they occur in  typhus fever,  the  plague,  &c.
  Willan  describes  five  varieties of Purpura:—P. simplex ;
P. haemorrhagica; P. urticans; P. senilis; P. contagiosa.

  The iodide of potassium acts very favorably in some cases, when the patient is
in a cachectic state, either from the long continuance of the disease, or the exces-
sive or injudicious use of mercury, or from both combined, and the iodide of iron
may  also be given with advantage at times, under similar circumstances, as may
also quinine and other tonics.  Chalybeates are sometimes of very great service in
the treatment of constitutional syphilis, and may often be given with advantage at
the same time with the mercurial used, and sometimes even combined with it.  M.
Ricord is partial to the tartrate of iron.  I have used  the citrate with benefit, some-
times in a bitter tincture, and at other times in solution with iodide of potassium.
The mineral acids are also sometimes very useful under certain circumstances.  It
is always important to adapt the particular form of  mercury used, as well as the
dose and frequency of administering it, to the state of the mucous membrane of the
alimentary canal, without attention to which the good effects of any remedy used
will be sensibly diminished, if not entirely counteracted.
  Attendant symptoms sometimes require  a modification of the general treatment,
especially iritis, which demands the prompt administration of mercury,  in such a
way as to affect the system  speedily, for which purpose calomel or blue pill, com-
bined with opium, is almost always to be preferred.
  In infantile syphilis I am in the habit  of giving to the child  small  doses of
hydrarg. cum creta, or calomel with chalk, sometimes combined with minute por-
tions of Dover's powder, and having the warm bath  used freely.  The nurse must
be put under appropriate constitutional treatment at the same time.   H. D. B. 
PURPURA.                     321
   1. Purpura  simplex.—(The petechias sine febre of some
writers.)  The patches are of a light red color at first,  and of
small extent.   The eruption appears in the course of a few
hours, and generally in the night ; it is gradually diffused in
the form of a number of distinct patches, which appear first
and  most commonly  on the legs and thighs, and at  a later
period on the arms and shoulders, but with less intensity.  In
general, several successive eruptions appear:  thus whilst  the
first crops fade, fresh ones are developed.   In other instances
a certain period of time, of various extent, intervenes between
the appearance of each  eruption.  One of the nurses at the
Hospital of  St. Louis, of a  strong and healthy constitution,
was subject  to this disease for two years, which used to  vanish
for a while,  and then appear again, during the whole of that
period.   This woman  was about  forty years of age, and was
subject to dysmenorrhoea, which generally induced a high
state of plethora.   The duration of purpura simplex  varies
from  three or four weeks to eighteen  months or two  years.
The patches last  from six or eight days to a fortnight.   It is
frequently accompanied by  giddiness, uneasiness, and lassi-
tude, but never with  any  disturbance  of the  circulatory
system.   In some instances the disease appears without any
symptom whatsoever.   The patches are of a bright red color
during the first few days, especially when the patient is young.
In old people they  are of a  deeper and more livid color, and
are irregularly  rounded and  distinct.  After the  lapse of
several days, they become still darker in color, then yellowish,
and at length slowly disappear.
   Causes.—Purpura simplex may occur at any period of life,
but it appears most frequently in young  persons before  the
age of puberty  and in females.  It often  occurs  under very
opposite circumstances.   For  example, it sometimes attacks
individuals of a vigorous and sanguineous habit, in whom  the
circulatory  power of the heart is perfectly healthy and  the
tissues of the  body firm : in other cases it manifests itself in
persons of  debilitated  and   broken-down  constitutions.  In
general, persons of fair, soft, delicate skin  are more liable to
purpura than  those of a dark bilious complexion.  It occurs
more frequently in dry summer weather than in winter or in
autumn.  During  the  intense heat which prevails in Paris in
July and August, the dispensary  attached to the  Hospital of
St. Louis is  frequented by persons laboring under  this disease.
   Diagnosis.—If  the  patches of purpura  simplex are exa-
mined attentively, they cannot possibly be confounded with
any other cutaneous  eruptions, especially with the exanthe-
mata.   The persistence of  the  color of the patches  under 
322
DISEASES OF THE SKIN.
pressure of the finger, which invariably characterizes this dis-
ease,  a phenomenon  that never  exists  in  the simple and
uncomplicated exanthematous diseases, is alone sufficient to
distinguish these affections from  each other.   The bites of
insects, flea-bites,  &c, are  easily recognized by  the  deep
central point  where the skin was penetrated,  and cannot be
confounded with purpura.*
  Prognosis.—Purpura simplex is never a dangerous disease,
even  when it  attacks  feeble  and debilitated persons.  It
almost  invariably  disappears by  improving the diet  of the
patient, and by administering appropriate remedies.
  Treatment.—When the disease appears in young and vigor-
ous subjects, after severe exercise or the abuse of  stimulants,
venesection, strict  regimen, tepid baths,  and  rest, are the
most  appropriate remedies.   In persons of a broken-down or
debilitated constitution, however,  bleeding  is not indicated :
the treatment  must be tonic in these cases, consisting of the
preparations of iron, the mineral acids  diluted, stimulating
friction.  The fumes of  alcohol have been employed  with
success at the Hospital  of St. Louis.
  2. Purpura Hcemorrhagica (morbus maculosus  hcsmorrha-
gicus).  In this variety  the patches are more numerous,  more
diffused, and dark-colored; some are broader than others, and
of a more  livid color; others again resemble recent contusions.
They generally appear first on the lower extremities, then  on
the arms  and  trunk, but rarely on the face or hands; we
have, however, seen a case  in which  they were evolved  on
the eyelids.  They are not usually raised above the surround-
ing surface ; but the cuticle is sometimes elevated in the shape
of blisters or bullae: cases of this kind have been described by
Biett, Bateman, and Reil.  Patches of the  same nature and
appearance are developed on the  gastro-intestinal  and pul-
monary mucous membranes, which frequently  give  way, and
considerable   haemorrhage  ensues, sometimes  terminating
fatally; but in general the sanguineous discharge is  not  copi-
ous ;  it returns again and again, and finally disappears spon-
taneously.  In some cases it assumes a periodic character.
In others there is a continual oozing of blood.   These haemor-
rhagic discharges are produced by the  rupture of large ecchy-
moses on  the gums, on the tongue, on the lining membrane of
the mouth,  and  even in the bronchia, in the stomach, the


  *  Dr. Lamprey  says that if the shirts of the patients present the appearance of
blood dots, it is conclusive that the spots are caused by fleas, and that  a knowledge
of this fact has often determined the nature of the eruption when the puncta could
not be found.—{Dubl. Quart. Journ., Aug. 1849.)               H. D. B. 
PURPURA.
323
intestines, the uterus, and the bladder.   We have seen a case
in which there was  an accumulation of blood in the arach-
noid.
  This variety is often preceded  by wandering pains, espe-
cially in the limbs, by a certain degree of depression, and inapti-
tude for either mental or corporeal exercise;  but  in other
cases,  the eruption is evolved without the appearance of any
premonitory symptoms, and without any apparent transition
from health to disease.   M. Biett relates a case in which a
young and vigorous man retired to rest in perfect health after
his usual day's labor, and awoke next morning with extensive
ecchymosis of the  skin, and the blood poured in abundance
from his nose and mouth.
   In general, purpura haemorrhagica  is accompanied  by a
state of languor and  great depression of spirits.   The pulse is
often feeble and easily compressed; in  other instances, it is
full and resistant;  some  patients  experience pain at the epi-
gastrium, and in the loins or abdomen, immediately  before
the  patches appear.   Others are  subject to a dry  hacking
cough at that period.   The digestive organs are also variously
altered.  Sometimes they  remain in their natural condition ;
in  other instances  there is constipation or diarrhoea, with
swelling and  tension in the hypochondrium and epigastrium.
   If these  symptoms become aggravated or are  prolonged,
the  patient emaciates, the skin presents a bloated appearance,
particularly on the face  and lower extremities, and when the
patient has lain long in the horizontal position.   The dura-
tion of this variety of purpura, like that  of the former, varies
 considerably.  It  sometimes  terminates in  the course of a
few days, in  other instances it may be prolonged for several
 months and  even for  years.  When it terminates  fatally,
 death  results from  one  or other of the  following causes:—
 from  violent haemoptysis, from  haematemesis, from severe
 intestinal haemorrhage, or in some rare  cases  from  flooding,
 which supervenes at  the  termination of child-bed, or  at the
 critical period.  M.  Monod relates a case in which death was
 occasioned by an  effusion of blood into the glottis, causing
 suffocation.
    Causes.—The causes of this variety are also very obscure.
 It appears  under the same contradictory circumstances as P.
 simplex.   Sometimes it succeeds  some of the exanthematous
 eruptions,  in  other  cases it takes place after  delivery.*  P.

   * Bateman speaks of a fatal case, developed during a course of severe salivation
 produced by a few grains of mercury, combined  with opium, given in a case of
 rheumatism.                                         H* ^' °' 
324
DISEASES OF THE  SKIN.
 haemorrhagica appears  most commonly in females and in
 young persons before the age of puberty.  Some subjects seem
 predisposed to the  disease, in whom the slightest pressure
 with the  finger on the skin will produce  ecchymosis.   The
 proximate cause of the disease is attributed to a want of tone
 in  the capillary  vessels, which  allow  the  blood  to escape
 upon the cutaneous and mucous surfaces.  This  unhealthy
 condition of the vascular system is supposed to arise from the
 same causes which debilitate and undermine the constitution.
 But how  are we to explain  the  causes which  induce  the
 disease in strong and healthy subjects ? The blood itself seems
 to be altered so as to favor its exudation  through the capilla-
 ries.   We  have  seen  it in a remarkably fluid  state, even in
 the tissues into which  it was effused.   Some English patholo-
 gists attribute the disease to venous congestion ;  and this is
 not an improbable opinion.   M. Biett saw  one case in which
 this  evidently existed.   The tongue was greatly enlarged, and
 both it and the lips were of a deep blue color.*
  Autopsy.—In  subjects dead  of this  disease,  the purple
 patches and ecchymosis  are perceived to result from sanguine-
 ous  effusions  into  the cutaneous and subcutaneous tissues,
 the one superficial,  the  other deep seated.  The  blood can
 easily  be  removed by washing, but we have never been able
 to discover the vascular  ramifications in the neighborhood  of
 the effusion.  Patches  of purpura may sometimes be detected
 on the mucous membrane of the mouth and pharynx.  They
 are generally seen scattered upon the mucous surfaces of the
 stomach and intestines.  They are less frequently  observed
 on the peritoneum and  pleura.   They are also to be seen
 under the pericardium, upon the surface of the heart.
  Aneurism sometimes coexists with  purpura haemorrhagica.
 The lungs  are in some  instances sound, but there is generally
 an effusion of blood in  the parenchymatous  substance of more
 or less extent, constituting true pulmonary  apoplexy.
  In other cases, partial ecchymosis may  be detected in the
 substance of the muscles, in the viscera, and in the  subserous
 tissues.  In short,  any  organ in the body may be the seat of
 similar extravasation.   In M. Monod's case, and that which
 we ourselves have seen,  the brain, the lungs, the kidneys, and
 the spleen, in short, almost every organ in the body, were
 engorged, and seemed  so many masses of extravasated blood.
 These are, however, rare cases.   M. Robert has  published
 one of a similar kind.f

  * According to Andral, the fibrine of the  blood probably exists in less than its
normal proportion in every case of p. haemorrhagica.             H. D. B.
  t Dr. Dunglison {Cycl. Pract. Med., Amer. edit., Art. Purpura) alludes to a 
PURPURA.
325
  Diagnosis.—When th£ pustules of syphilitic ecthyma  are
set  close  together, they often leave behind patches and spots
of a purple-red color,  which at first sight resemble those of
purpura;  but the pre-existence of pustules, and the progress
of the disease, will clear up the diagnosis.  Ecchymosis pro-
duced by violence cannot be mistaken for that which occurs
spontaneously.   Haemorrhage  never  occurs  either  in  the
purple  patches of ecthyma, or in the latter case.   We have
known a  case of this complaint to be mistaken for a gangre-
nous disease, but such an error could not have occurred unless
from gross ignorance.
  Scurvy, when accompanied by spontaneous ecchymosis  and
haemorrhage, appears  to be  identical with  purpura  haemor-
rhagica.  The distinctions  described by authors  as  existing
between  these diseases, are :  1.  That scurvy  generally results
from bad feeding, fatigue, exposure to cold and damp,  depress-
ing emotions, &c, whilst P. haemorrhagica  occurs indepen-
dently of these causes.  2.  That scurvy disappears  under a
tonic plan of treatment, and the use of fresh vegetables, which
is not  the case  with  P. haemorrhagica.  But in advancing
that  these   diseases are  distinct  from  each other  in their
nature and  characters, it  is necessary that that  position
should be supported on some  more positive  data  than those
now mentioned.   In fact, the causes to which is attributed
the development  of scurvy, are  the same  as those  which
commonly produce P. haemorrhagica;  and if the tonic treat-
ment  does  not always succeed in the latter disease,  it some-
times fails likewise in the former.   But even admitting their
identity,  it is still difficult to account for the development of
P.  haemorrhagica under circumstances the reverse of those
commonly associated  with scurvy.  Too rich food and want
of  exercise  may produce the same results as causes directly
depressing in their nature ;  or the  difference must perhaps be
attributed to idiosyncracy.*

fatal case of diseased spleen, in which that organ was found greatly enlarged, and
encephaloid in  certain parts, and in which signs of p. haemorrhagica  had super-
vened.  In  another case of purpura the spleen was sound, but the liver was scir-
rhous, and incurable jaundice preceded the fatal termination.       H. V. H.
  * The following tabular summary of the diagnostic marks between purpura and
scurvy are given by Dr. Curran:—
            PURPURA                         SCURVY.
Most frequent between five and eighteen  Most frequent after eighteen years of

FeSsSy affected.             MaTs chiefly affected.
Gums bleed sometimes, but are never  Gums more or less sore and spongy. .

PetecS' spotrteyquenet': ecchymosis Ecchymosis more  frequent than pe-
rarer.
techiae. 
326
DISEASES  OF THE SKIN.
  The diagnosis of these concomitant affections is often diffi-
cult, and requires considerable attention.  The epigastric and
abdominal pains, and nausea, might appear as the  forerunners
of gastro-intestinal inflammation, if the slowness of the pulse,
and the absence of heat of  skin, did not indicate a state of
internal congestion as their true source.
  Prognosis.—The physician should always be  guarded in
his  prognosis in this disease;  for although it may  appear mild
and unimportant  at the commencement, it may suddenly
assume an  intense character,  and  even terminate fatally.
The age  and  constitution of the  patient, and the duration of
the eruption, the frequency of the hEemorrhage, and especially
the amount of blood lost, should  be taken  into  account in
forming the prognosis.   P. haemorrhagica  is generally  a
dangerous disease, and often terminates in death.
  Treatment.—The treatment  of  purpura haemorrhagica is
exceedingly  difficult.   Medicines  of  a perfectly  opposite
character have been recommended at various periods for the
cure  of this disease.   The general  debility of  the system
would apparently indicate the exclusive employment of active
tonic remedies ; but in  many cases  they would  be not only
inefficacious, but absolutely injurious.   Tonic medicines  are
only serviceable in case of children or persons debilitated by
age, bad feeding,  and general privation, being attacked; and
even then, they should be prescribed cautiously and conjointly
with hygienic measures.   Those which we commonly employ
are the decoction of bark, extract of  rhatany (in  the propor-
tion of a scruple  to  a drachm  in the day),  old  wine, dilute
            PURPURA.                          SCURVY.
Eruption always dark colored at first.    Shades of eruption the most various.
All parts nearly equally a^ected.        Lower extremities almost  exclusively
                                  affected.
Never any muscular indurations.        Muscular indurations nearly always.
Haematuria not infrequent.             Haematuria almost never.
Bloody stools frequent.               Bloody stools very rare.
Haemoptysis occasionally.             Haemoptysis (true) never.
No neuralgic pains.                 Neuralgic pains and pain in spots invari-
                                  able.
Never effusion in joints.              Effusion in joints frequent.
Never contraction of flexors.          Contraction of flexors frequent.
Rarely lasts more than a few days.      If not interfered with, lasting for months.
Scarcely ever fatal.                 Frequently fatal, if unchecked.
Connected with no discoverable error in  Always in connexion with an  error in
  diet.                             diet.
Sporadic ; epidemics extremely rare.     Affects large numbers of individuals at
                                  the same time.
Cured by turpentine and purgatives.     Speedily cured by lemon juice and fresh
                                  vegetables.
  (Curran on Scurvy, Dubl. Quart. Journ.  Med., Aug. 1847.)      H. D. B. 
PURPURA.
327
mineral acids, and  succulent food, according to the age and
habits of the patient.  On the other hand, when the patient is
young, robust, and plethoric, and there are pain and tension
in the abdomen, together with hardness or frequency of pulse
and constipation, these remedies should be carefully avoided.
   Purgatives have been strongly recommended in large doses
on the ground that the  pain which is felt in the epigastric
region and in different parts of the abdomen, and the derange-
ment of  the digestive functions,  is the  result of  congestion,
and not of inflammation—a view which seems to derive sup-
port from the entire absence of fever in these cases, from the
success of this  mode of  treatment, and also from autopsic
examination.  Those commonly used are spirits of turpentine,
calomel,  jalap, and  castor oil.    Bleeding also seems to  be
indicated by the congested state of the system.  Neverthe-
less, it should be very carefully and cautiously employed, in
consequence of the haemorrhage which succeeds it, which is
often difficult to be  arrested, and  especially on account of its
increasing the general debility of the system.  Indeed,  the
only  cases  in  which it  is at  all indicated, are where  the
patients  are young  and vigorous, and symptoms of inflamma-
tion are present, and when the haemorrhage from the skin  and
mucous membranes is not copious.
   The treatment which M. Biett found most  successful con-
sisted in  the employment  of acidulated drinks and laxatives.
In some  cases he employed  the  extract  of rhatany with ice
with much success.  M. Brachet has also found this remedy very
serviceable.  Lotions or injections of iced water, acidulated,
and rendered styptic, and plugging, will  be necessary when
the haemorrhage continues from any of the natural outlets of
the body.  As the  blood does  not  coagulate or clot in these
instances, every symptom should be  carefully watched,  and
promptly attended to.  Cold ablutions  of  the entire body are
sometimes useful;  perhaps the cold shower  bath  might  also
be  advantageously  employed ;   compresses  saturated  in
vinegar and water,  in a solution of the chloride of lime, or in
a mixture of alcohol and water, may be applied to the purple
and ecchymosed patches of the  skin with advantage.  The
pains which sometimes  exist in  different parts of the body
may be assuaged by opiates, emollient lotions, and  cataplasms.
During convalescence, the patient should  live upon generous
food, animal jellies,  roast meat, good wine  slightly diluted  and
iced,' and should avoid damp or moisture.   Tonics may be
advantageously employed at this period.
   The other  varieties of purpura  described  by  Willan  are
merely modifications of the  foregoing.  In P. urticans  the 
328
DISEASES  OF  THE SKIN.
patches  are sometimes raised above the surrounding surface,
instead of remaining on a level with the skin ; but this slight
tumefaction disappears in the course of  one or  two days.   P.
senilis presents no other peculiarity than that of occurring in
old people ; and P. contagiosa is merely  the petechial eruption
which accompanies  the severe forms of typhus fever.*
                ELEPHANTIASIS ARABUM.

Syn.—Barbadoes leg;  Sarcocele d'Egypte ; Eolica Japonica;
   Lepre elephantiasis; Elephantiasis  Tubereux ; Glandular
   disease of Barbadoes.

   As  we have already observed, two very different  diseases
have been described under the common name of elephantiasis.
The one—elephantiasis of the Greeks—a tubercular affection,
and accompanied by fawn color of the skin, diminished sensi-
bility  of the parts, and loss  of the  eyebrows,  eyelashes, &c.



  * Plumbe was  very  partial to the use of active  purgatives,  especially of a
mercurial kind, attributing the disease to derangement  of the functions of the
liver.
  M. Gibert mentions the  favorable effects of rhatany, given freely  in extract,
and used in decoction as a drink, in a case in which other means had failed.
  Dr. Barclay, of Leicester, reports, in Provinc. Med.  and Surg. Journ. (see Med.
Examiner, Phila., July, 1845), a case in  a girl, eleven years old, attended with
haemorrhages from different parts, in which gallic acid  was given, five grains every
four hours, combined with sugar, with a stimulant mixture containing carbonate of
ammonia, with a very favorable result.  Wine had been first given.
  Oil of turpentine is a favorite remedy with some in p. haemorrhagica.  Dr.
Neligan thinks very favorably of it, and gives it in the form of both draught and
enema, the usual dose for adults being from ^ j to § iss, and  for children from 3 ij
to § ss, generally with castor oil.  {Dublin Jour. Med.  Sci., vol. xxviii., p. 191.)
  Nitric acid  has also been given with benefit in this form of purpura, freely
diluted  in water, with gum arabic and sugar.   I have also exhibited this^gamedy
with advantage in p. simplex when it has  persisted for some time.       fjjr
  Creasote has also been recommended, in doses  of half a  drop to a drop, dis-
solved in alcohol and suspended in mucilage, and given every six  hours.
  In p. urticans there is less danger of complication of haemorrhages, and mercu-
rial cathartics  are most usually indicated, this variety of the disease being appa-
rently more nearly allied to urticaria than to purpura, and requiring laxatives and
mild tonics.  Quinine is often useful in this form.
   The disease exists in  two distinct, and indeed sometimes opposite, conditions of
the system, and may consist of either an  increased or a diminished action of the
capillaries.  The latter  condition more frequently prevails, and hence the more fre-
quent demand for tonic  and stimulating measures ; while, in other cases, depletion
by cathartics, and even  by abstraction of  blood, may  be called for.  Hence, in all
the forms of purpura, our treatment  must be  governed by the  constitution and
habits  of the  patient, and the character of the symptoms in each individual case,
much more than by the name of the disease or its external appearances.
                                                           H. D.  B. 
ELEPHANTIASIS ARABUM.
329
The other, elephantiasis Arabum, which  was first described
by the Arabian writers, is characterized by an indolent hard
enlargement  or swelling of the skin, and of the subjacent
cellular and adipose tissues, producing great deformity of the
parts.
  Elephantiasis Arabum may appear on any part of the body.
It has  been  observed on the  face, neck, breast, abdomen,
scrotum, penis, pudendum, and  margin of the anus ; but the
lower extremities seem to be the special  seat of the  disease.
It appears more frequently on the legs than on any other part
of the body, and  imparts to them  a singular and  striking
appearance.  It seldom attacks both limbs at once, but usually
fixes  itself upon  one side.  The  duration of elephantiasis
Arabum is invariably long;  it often continues during the life
of the patient.  Sometimes it disappears for a short time, and
then reappears on the same or on  some other parts of the
body.   It generally sets in with considerable rapidity, but soon
assumes its characteristic chronic character.
  Symptoms.—This  is  not  a  common  disease in  Europe.
Several diseases have been described under this name which
are different in their nature, or  at least the commencement of
which is not characterized by acute inflammation of the lym-
phatics, and which still are followed by thickening  and  hard-
ening of the subcutaneous cellular tissue.  This was  the case
with two patients whom  we saw at-the Hospital of St. Louis.
In one case the subcutaneous cellular tissue of the  leg became
the seat of chronic inflammation, which terminated in hyper-
trophy and hardness of the skin,  and  in enormous development
of the limb.
  In another case, a sailor, who had been in the habit of con-
stantly standing in the water, the disease supervened on the
cicatrization of a varicose ulcer of the leg; the skin and sub-
tegumentary tissues became hard and hypertrophied ; it spread
upwards, and the leg and almost the whole of the thigh were
increased to double  the  natural size, and were hard, tense,
shining, and very  slightly painful.   The disease was accom-
panied, in this case, by engorgement of the inguinal glands,
which, however, was  a consecutive  symptom ;  for the lym-
phatic system did not appear at  all affected in  the early stages
of the disease.  M. Bouillaud records a similar case, in which
the lower extremities  of  a young female became enormously
enlarged, so as  to resemble the  legs  of an elephant, resulting
from obliteration of the crural and cava veins.   (Archives
Gen. de Med., tom. vi., p.  567.)   In  the great majority of
cases,  however, elephantiasis  Arabum  consists  of hyper-
trophy of the affected parts, a hypertrophy of  a peculiar kind, 
330                DISEASES  OF THE SKIN.
and which is essentially connected with inflammation of the
lymphatic vessels.*
   This disease generally begins in rather a  sudden  manner,
and without any  premonitory symptoms.   The patient sud-
denly experiences a violent deep-seated pain in the part about
to be affected, which extends along the course of the  lympha-
tic vessels.   The latter  becomes hardened and  tense,  and
stretched  in the form  of a  nodulated cord,  which  is often
extremely painful to the touch, and extends to the glands of
the  groin, or  of the axillae.   When the disease attacks the
limbs, as it  most commonly  does, erysipelatous inflammation
supervenes, the subcutaneous cellular tissue becomes inflamed,
and general engorgement and tumefaction of the parts ensue.
These morbid conditions  are  accompanied by febrile symp-
toms—thirst, nausea, vomiting, rigors of considerable dura-
tion, succeeded by burning heat, and often by copious perspi-
rations.   The brain is sometimes sympathetically affected, and
delirium ensues.
   All these symptoms, with the exception  of the swelling  of
the limb, cease for a certain period and return again.   At the
end of each accession of these phenomena, the chain of lym-
phatic vessels loses its inflammatory appearance, but the swel-
ling increases each  time,  and continues long  after the other
symptoms have ceased;  and  the  limb becomes so  hard as to
resist the firmest pressure with the finger.   The disease  may
go  on in this  manner for  an indefinite period ; and, when its
progress becomes arrested, it  may  remain stationary for seve-
ral years, when  the limb exhibits   that  peculiar  unseemly
appearance, and enormous development, from which  the  dis-
ease derives its name.   Sometimes the swelling is  even  and
continuous along  the extremity;  in other  instances it  is

  * Mr. Bascome of London, who saw this disease during a long residence in
British Guiana, thinks that the hypertrophy is caused in  two ways :—1. By erysi-
pelas, more or less complicated with visceral disease ; 2. by a want of  toj^rin the
lymphatics, induced by a sort of sub-inflammation of them, seldom or never com-
plicated with visceral disease, being more of a local character, and occurring more
frequently in lymphatic temperaments.  He gives the distinctive symptoms of the
two forms, with practical remarks on the treatment of the disease.  {Lond. Lan-
cet, Amer. Rep., Aug., 1846.)
  Dr. Bellingham, on the other hand, contends that this  hypertrophy of the lower
extremities is neither the result of inflammation of the lymphatic glands or absor-
bent vessels, nor of obstruction or inflammation of the venous system of the limb ;
but is produced by repeated attacks of erysipelas of the part, and hence that it is
only in the early stage of the disease that treatment can  prove effectual. {Edinb.
Monthly Jour, and Retrosp., Aug., 1849, from Dublin Med. Press, Dec. 13,
1848.)
  Mr. Southam gives a striking case of this disease affecting the leg and thigh of
a woman (with a plate), and remarks on its  pathology, in Med. Chir.  Transact.,
vol. xxx., 1847, p. 69).                                   H. D. B. 
ELEPHANTIASIS ARABUM.
331
broken here and there by deep furrows, producing  a hideous
deformity.
  Elephantiasis Arabum occasionally evinces a tendency to
spread, and gradually proceeds from the arm  to the forearm,
or from the leg to the thigh.   The subcutaneous  tissues con-
tinue the morbid alteration, and become finally converted into
a soft, fungous, and  even lardaceous  substance.   In other
cases again, it is confined to  a single region, and may occa-
sion but  slight enlargement of the limb ; but in every instance
the palms of the hands and the soles of the feet are free from
swelling, whilst these extremities are considerably tumefied in
the lines of extension; evidently the result of the more com-
pact  nature of the cellular  tissue in  the  former  localities.
Towards the  close of the disease, the skin  may  present  a
variety  of appearances.   It  may assume  merely  a  sickly
whitish  color, without any  other  morbid character ; or the
veins  may be enlarged  and distended, the skin  grooved
and furrowed in  various parts, or it may be covered with
varicose tumors, which give it a sort of livid appearance.
  Independently of these, the  skin may become the seat of
other  morbid  alterations.  Thus,  for example, erythematous
or even  vesicular inflammation may supervene.   In the latter
event a slight exudation is established, and, at a later period,
small, thin, soft, yellowish scabs.  In other cases the rough-
ness  continues to  increase, and  scales  closely resembling
those of ichthyosis appear, or it becomes covered with small,
soft, fungoid  vegetations.  Finally, fissures, excoriations, and
ulcerations of the cuticle, covered with thick yellow scabs,
may sometimes occur.  The lymphatics are  often  hard and
scirrhous.  They  suppurate,  and  sometimes even become
gangrenous.  Deep-seated indolent abscesses form on different
parts of the'limb, which is by this time enormously enlarged,
and pour out  large quantities of foetid pus.
   This disease most  commonly attacks the  limbs; but not
unfrequently  occurs on the penis, whence it generally extends
to the scrotum.  The  penis sometimes attains a considerable
size.   M. Biett had  a case  in which its circumference was
increased four-fold.*
   The mammae also  appear to be liable to this affection, and

  * Mr. Key operated on a Chinese  peasant, who came to  London for that pur-
pose in 1831, who had hypertrophy of the prepuce to such a degree that the tumor
reached to the ankles, and measured four feet in its greatest circumference, and
weighed fifty-six  pounds after its removal.  Baron Larrey once removed a tumor
of the scrotum of this  kind, which weighed sixty-two. pounds, and Clot-Bey
removed one, with a successful result, in Cairo, which weighed one hundred and
ten pounds.                                           •  • 
332
DISEASES OP THE  SKIN.
become so enlarged that they are obliged to be suspended
with a bandage placed round the neck of the patient.  Small
isolated scirrhous tumors are often developed in these cases,
which suppurate  and give rise to incurable ulcerations.   The
sensibility of the  parts is rarely destroyed in this disease; but
the joints in the neighborhood  become the  seat  of chronic
inflammation; adhesions take place, the articular movements
are obstructed, and the limb becomes a useless encumbrance
to the patient.
   Causes.—Elephantiasis Arabum is neither contagious nor
hereditary;  it attacks  indiscriminately males and  females,
rich and poor.  It occurs  most  frequently in adults;  but it
occasionally appears in young people and in children.  And
even the induration of the  cellular tissue of new-born infants
(sclerema)  seems to be  related  to this disease.  It occurs
principally in the West Indies.  It is endemic in some of the
tropical countries, in the torrid  zone, near the equator, &c.;
and its existence  in these regions is attributed to the  draughts
and vicissitudes of temperature which occur night and morn-
ing.  It sometimes results  from  obliteration  of the  veins  of
the leg, or parts affected ;  it also supervenes on cicatrization
of old ulcers, and from chronic inflammation of the cuticle,
extending to the subtegumentary  tissues.
  Autopsy.—The skin is generally indurated,  covered with
yellowish scabs, or with thick incrustations, and is sometimes
furrowed and covered with small  hard scabs, not unlike those
of ichthyosis.   1. The epidermis is greatly thickened,  fur-
rowed, and  firmly  adherent.  2. The  papillary  bodies  are
highly developed and perfectly distinct from the cutis.  They
are described by  Andral and Chevalier as being  elongated,
enlarged, and prominent.   3. The true skin appears consider-
ably thickened and hypertrophied, sometimes to the extent  of
more than half an inch.  4. The cellular tissue is also greatly
increased  in density,  and  sometimes  contains  within  its
meshes a semi-fluid gelatinous matter;  but it is more com-
monly indurated,  slightly scirrhous, and  becomes lardaceous
as it approaches the cutis.  5.  The muscles are generally pale,
soft, discolored, and atrophied.   The  veins  are  sometimes
found obliterated, and  in the case reported by M. Bouillaud,
this obliteration  extended  even to the  vena cava itself.  No
other  lesion is found  which can  be  referred to this disease,
except, occasionally, glandular engorgements in places remote
from the seat of the disease.
  Diagnosis.—However distinct  the inflammation and nodu-
lated  appearance of the lymphatics may be,  it is not easy  to
say whether these symptoms are  the forerunners of  elephan- 
ELEPHANTIASIS ARABUM.              333
tiasis, any more than of those other diseases which they pre-
cede, that never terminate in hypertrophy of the subcutaneous
tissues.  Even  when  elephantiasis is accompanied by all its
characteristic phenomena, it may still be confounded with
anasarca or with oedema.  Indeed, it is not unlikely that these
diseases  have been  mistaken for, and described as, cases of
elephantiasis.   However, the presence of general symptoms,
and  the  morbid condition of some of the internal organs, in
the one, or at  least  the softness  of the tumor, its mode of
development, and the state  of  the  patient's  health ; and in
the other the progress of the disease, which is entirely local,
the integrity of all  the other organs of the body, the  form,
resistance, and indurated condition of the tumefied parts,  are
quite sufficient to distinguish these different diseases.
   Prognosis.—The  prognosis of Elephantiasis  Arabum is
generally unfavorable, especially when it is of  long duration,
when the skin and subcutaneous strata are deeply and exten-
sively involved, and  when the disease arises from obliteration
of the veins.
   Treatment.—At the onset of the disease, when the lymphat-
ics are inflamed and swollen, and  when the eruption is much
diffused, repeated bleeding should be employed, and this will
not prevent the application of a number  of leeches along
either side of the nodulated lymphatic cords, a remedy which
is often  sufficient   in itself,  without  general  bleeding.
Emollient poultices  are also  used in this  stage.  When  the
disease assumes the chronic character, as it almost invariably
does, the  treatment  becomes  more  difficult.   Both local and
general bleeding have also been recommended in this instance,
but evidently with little benefit.  They are not appropriate
remedies for the chronic form of Elephantiasis Arabum.   We
have seen the  limbs of patients  suffering from that disease
scarified  all round, without  deriving the slightest benefit or
amelioration of the morbid structure.  The same with regard
to blisters and cauterization,  and the internal use of mercury.
Mercurial frictions have been'proposed, and  in our opinion
are more  likely to  be  beneficial  than any of the foregoing
measures.  Our experience at the  Hospital of  St. Louis leads
us to think that the  best mode of  treating elephantiasis is by
compression, by iodine frictions, and  by the vapor douche.
  Compression  is the best remedy that  can be employed in
this disease.  It should  be made with a long bandage, two or
three fingers broad,  and  moderately  tightened.  It usually
soon reduces the tumefaction of the parts ;  and if  it does not
restore them altogether to  their natural  condition, it facili-
tates  the employment  of other  measures.   Friction,, with
                             22 
334
DISEASES OP  THE SKIN.
certain  absorbent  remedies, may be employed with  some
chances of success.  An ointment, composed of a  scruple to
half a drachm of the iodide of potassium to an ounce of  lard,
rubbed over the  swelling, is the best application of this kind.
The use  of this remedy  must be  suspended, if, as  often
happens in Elephantiasis Arabum, the diseased parts should
become attacked with  acute   inflammation.    The vapor
douches are especially serviceable in these cases.   By increas-
ing the vitality of the part, they promote resolution, and con-
tribute  powerfully towards the cure of the disease.  They
should be applied for a quarter of an hour at a time to the
swollen parts,  and  during  their administration the patient
should rub  the  swollen  and indurated  surface  briskly and
repeatedly.*
  Internal treatment is in general useless.   The administra-
tion of purgatives appears  occasionally to  produce a  good
effect.   The  treatment should  be modified when other affec-
tions  accompany this  disease.   As  for example,  erythema,
and an eruption of vesicles, often supervene during its pro-
gress, and induce smart  inflammation of the skin.   In these
cases, emollient  applications and simple baths will be neces-
sary ; and at a later period sulphur baths may be usefully em-
ployed.  In the great majority  of cases, however, the disease
will resist every  plan of treatment.   With regard to  amputa-
tion, which  has  been  both recommended and  practised, we
are of opinion that the cases where it is indicated are exceed-
ingly rare; and we have seen a patient at the Hospital of St.
Louis, whose  leg had  been  amputated for  Elephantiasis
Arabum, and  in the  course of a short period the disease
attacked the  left  arm.
                      CHELOIDEA.

                Syn.—Keloide;  Cancroide.

  This is  a chronic tuberculated swelling of the skin, first
described by Alibert under the names of cancroide and keloide,
from its supposed  resemblance to a crab or tortoise.  It is an
exceedingly rare disease, so much so that  Bateman denied its

  [* A case of this disease came under my observation about a year ago, in which
the local application of the vapor of sulphur and iodine, together with the adminis-
tration, internally, of the iodide of iron, was attended with success.  The patient
was a married woman, aged twenty-one, of a full and plethoric  habit of body.
The right leg and thigh were enormously enlarged, tense, hard, and painful at times.
She suffered exceedingly for upwards of a year with this complaint, but is now in the
enjoyment of good health.  B.j 
CHELOIDEA.
335
existence.  But nevertheless it does exist, and is distinguished
from  all other cutaneous affections  by peculiar  and well-
marked characters.
  It appears in the form of a slight tumefaction of the skin,
which gradually enlarges.  It forms small flat tumors, often of
an  irregular form, but  commonly oval-shaped, with  a slight
depression  in the centre.  In other cases it is elongated, angu-
lar, and shining.   The epidermis covering it is thin and wrin-
kled, which gives its surface the appearance of the cicatrix of
a burn.  It is hard and  resistant to the touch, and its color is
sometimes  deep,  sometimes pale red.   Moreover, this color
varies with  the  degree of temperature,  and especially  in
women during the menstrual period.   These small flat tumors
only rise a few lines above the level of the skin, and this ele-  .
vation is generally more marked on  the circumference than
in the centre.   In the majority  of instances there is only one
small tumor present; but in  others several appear together.
M. Biett saw a young woman with eight of these  small flat-
tened tumors on the neck and lateral part of the breast.  We
have lately seen  a young Belgian woman with more than
twenty spots of cheloides upon the breast and over the course
of the superficial lymphatic vessels of the arms and forearms.
They were indolent, perfectly round, some of them of a rose  ^
color, and  others  of  a distinct red.  They were seated in the
dermis.  In front of the mammae, which  had  become, as it
were, atrophied, there was a group of these patches touching
at their edges, but not running  together.
   The tumors may reach an inch and a half to two inches in
their largest diameter, whilst they often do not exceed a few
lines, especially when there are several present.  They  are
often  accompanied  by  deep,  sharp, shooting pains, which
occur  most  commonly after  meals, and  on  atmospheric
changes.   But  they are also frequently developed without the
occurrence of  any of these symptoms.   This disease, when
left  to itself, advances  very  slowly.  It rarely terminates in
ulceration, and in some  cases it fades and disappears sponta-
neously, leaving no other trace  of its existence than that of a
firm white cicatrix.  The usual seat  of the cheloidea is  the
chest, between the mammae.   They have  also been met with
on the neck and arms.
   Causes.—We  have  no precise knowledge regarding  the
etiology of this disease.  It occurs in some cases, as we have
seen without being  preceded or accompanied by either local
or  general symptoms.   It sometimes appears to result from
external causes;  and we have seen it  supervene on a deep
scratch on the breast of a female.  It has never been observed 
<     336                 DISEASES  OF THE SKIN.
   to  attack children.   It  commonly  appears  in  young people,
   and is not confined to either sex.*
     Diagnosis.—The cheloidea should be carefully distinguished
   from the cancerous affections, with  which  they have  not the
   slightest analogy.   In general, cancer of the skin gives rise  to
   round, prominent, livid-colored tubercular indurations, which
   ulcerate at  the summit, and are surrounded by dilated veins.
   The neighboring  glands  become  engorged, and  sometimes
   acquire  an  immense size.   The  cheloidea,  on the contrary,
   when situated  on the  breast, consist of a  flattish  elevation,
   depressed in the centre, raised at the edges,  and developed on
   a  healthy  surface.   Neither  should  this  affection be  con-
   founded with  syphilitic tubercles, which are always  copper-
   colored, round at their summits, often assembled  in clusters,
   generally intermingled with cicatrices with loss of substance,
   and accompanied  by other characteristic symptoms.
     When the cheloidea are  more  numerous than usual, they
   are generally separated from each other by intervals of sound
   skin; they  are rose-colored,  sometimes square,  sometimes tri-
   angular-shaped, but never rounded like syphilides.   The che-
   loidea cannot be confounded with sanguineous  tumors, which
   sometimes  assume the form of vascular vegetations, and are
t   either scattered or dispersed in groups. At first they do not rise
   above the level of the skin,  but at  a later period they extend,
   become yellowish, and take on the appearance of a true vege-
   tation.   The erectile tumors do not resemble this disease ; they
   are generally  of  a brownish  color, granulated on the surface,
   broad  at the base, deeply implanted  in  the skin, soft to the

     * M. Velpeau makes two kinds of cheloides :—1, the spontaneous, or that pre-
   ceded by no known cause ; 2, the cicatricial, or that forming on a scar, the shape
   of  which it assumes.  The latter variety sometimes follows the pustules of small
   pox, as well as other phlyzacious pustules ;  also long incisions and wounds of dif-
   ferent kinds, as sabre cuts, &c. I have seen it follow syphilitic pustules, also an
   irritating  ointment which had produced ulceration ; and in  one  instance, in a
   female, saw it  follow the long continued pressure made by wearing a key in  the
   bosom.
     In a case of this affection in a negro, between forty and fifty years of age, whom
   I have had occasional opportunities  of seeing  for seven.or eight years past, there
   are twelve or fifteen spots, of various fo/ms and sizes, scattered over the chest,
   back, and limbs, the largest one being in the  middle of the chest, and measuring
   between three  and four inches in length, and about an inch and a half in breadth,
   its longest diameter crossing the chest transversely.  Some of the other spots are
   cylindrical, others olive-shaped, and others conoidal, varying in length from half an
   inch to an inch and a half, and in breadth from a third to  half an inch.  The spot
   where he was  vaccinated, when first seen, which was eight years since, became, at
   the end of three or four months, the seat of the same disease, covering the whole
   surface of the scar.  The first spot was noticed about twenty-three years before,
   and was  preceded by itching, and came out after getting very much heated.  Two
   of his brothers had the same disease, and of his own children, four girls and six
   boys, three boys only had it.  His general health is very good.      H. D. B. 
CHELOIDEA.                    337
touch, and frequently moving with the pulsation of the  arte-
ries.  In fact, the cheloidea have no real resemblance to any
other disease.
  Prognosis.—These tumors  are never dangerous ;  and  if
they ulcerate, it is the result of injudicious treatment.   They
generally occur in persons whose health is otherwise perfectly
good.  There is some reason to believe that they may disap-
pear and leave  only a slight cicatrix.
  Treatment.—Extirpation and  cauterization of the  tumors
does not  seem  to be attended with much benefit.  The sul-
phur douche is sometimes used with advantage in softening
the tumors.   Friction with the ointment of iodide of potas-
sium, or the application of a  plaster  containing iodine and
opium  if there  be any pain present, occasionally succeeds in
reducing  deeper seated swellings, and  may be tried  for the
removal  of these.  We saw good results in one instance from
the internal use of the  iodide of potassium,  in a case where
the patches  were numerous and appeared to depend  upon a
strumous diathesis. 
BIETT'S   FORMULARY.
PRINCIPAL REMEDIES EMPLOYED BY M. BIETT  AT  THE HOSPITAL

                            OF ST. LOUIS.
                       INTERNAL REMEDIES.

                                I. PTISANS.

  1. Bitter infusions.—Leaves of saponaria, half an ounce ; boiling water, one
pint.  Infuse for half an hour; strain and sweeten.   The infusions of chicory, hop,
scabiosa  arvensis, &c, may be prepared in the same manner.   Dose—Indefinite.
Use—In  most chronic diseases of the skin.
  2. Dried root of the lapathus, one ounce ; boiling water, one pint.  Infuse for
six hours ; strain and sweeten.  The infusions of inula and burdock may be pre-
pared in the same manner.  Use and dose as before.
  3. Pounded gentian roots, one  drachm;  water  a  quart; boil for five or six
minutes, and then add two drachms of bitter herbs, infuse for two hours, strain and
sweeten.   Dose—Indefinite.  Use—Chronic diseases of the skin.  Scrofula.
  4. Acidulated lemonade.—Dilute sulphuric acid, twelve to twenty-four drops ;
decoction of barley, one pint; sirup, q. s.
  5. Hydrochloric acid, twelve to twenty-four drops ;  decoction of barley, one
pint; sirup, q. s.  Or,
  6. Dilute nitric acid, twelve  to twenty-four drops ; infusion  of saponaria, one
pint ;  sirup, q. s.   Dose—Three glasses daily.   Use—Eruptions accompanied by
pruritus.  Lichen ; eczema ; some syphilitic eruptions.
  7. Alkaline mixture.—Subcarbonate of potass, half to one drachm ; bitter infu-
sion, one pint.  Or,
  8. Subcarbonate of soda, half to one  drachm ; barley-water, one pint.   Dose—
Four glasses daily.   Use—Lichen ; prurigo ; ehronic diseases with itching.-
  9. Laxative mixture.—Sulphate of soda, half an ounce;  infusion of  chicory
flowers, one pint.  Or, bitartrate Qf potass, two drachms ; whey, one pint.   Dose—
Two or three glasses in the forenoon.
  10. Sudorific mixture.—Scraped guaiacum, one ounce.  Boil down to a pint in
a pint and a half of water ; strain and sweeten.  The decoction  of sarsaparilla or
china may be  prepared in the same  manner.  Dose—Two  glasses in the morning,
and two at night.   Use—Syphilitic affections.  Or,
  11.  Scraped guaiacum, one ounce;  water, a pint and  a half; boil down to a
pint, and  add  a scruple of mezereon. Dose as above.  Use—M. Biett often used
this drink with success in cases of secondary syphilis.  Or,
  12.  Sarsaparilla, one ounce ; water as before; boil down to a pint, and add a
drachm of coriander seeds.   Use and dose  same as above.
  13.  Feltz's mixture.—Sulphuret of  antimony, four  ounces;  place in a  small
linen bag, and boil in  water for an hour ;  then remove it and place it in a vessel
with sarsaparilla, in pieces, three ounces ;  isinglass, fourteen scruples ; water, six
pints.   Boil  down to one half, and then strain.  Dose—Three glasses a day;
morning, noon, and night.  Use—Constitutional syphilis.  t
  14.  Zittman's decoction.—(No.  i.) Sarsaparilla, twelve ounces; water, twenty-
four pints; boil for two hours.   Suspend in the liquid a linen bag, containing sul- 
POWDERS--PILLS.
339
phate of alumina, an ounce and a half; mercurius dulcis, half an ounce ; sulphuret
of mercury, one  drachm.  Towards the' end add liquorice, an ounce and a half;
senna leaves, two ounces; anise seed half an ounce.   Remove from the fire, and
allow the fluid to infuse.   Strain so as to have sixteen pints of decootion No. i.
   15.  (No. ii)  Take  the residue of  decoction  No. i. ; sarsaparilla, six ounces;
water, twenty-four pints, boil for two hours, and add orange peel, cinnamon, carda-
moms, of each three drachms ;  liquorice, six drachms.   Infuse for an hour, and
strain to sixteen pints.   Use—Constitutional  syphilis.  Dose—The patient com-
mences by taking, the evening before, six of the following pills at intervals of  one
hour between them : jalap, two grains ; gamboge, half a grain ;  aloes, four grains.
On the following morning  he  begins  early with half a bottle of No. i., taking a
glass every half hour, while in  bed.  At midday  a whole bottle of  No. ii. in
glasses, every half  hour.  In the evening, the remainder of the bottle containing
No. i. in glasses.   The decoction is taken for twenty-two to forty-five days.
   16.  Decoction of dulcamara.—Dulcamara, half an ounce ; water, a pint and a
half.   Boil down to two thirds.   The quantity  of the remedy may  be increased to
one ounce, or  an ounce and a  half.  Dose—Half a glass at first; then a glass,
morning and evening.   Use—Lepra vulgaris ; chronic diseases.
   17.  Decoction of orma.—Orma pyramidalis four ounces; water, four pints ; boil
down  to a half.   Dose—Two to four glasses a day.   Use—Scaly diseases.

                       II. MIXTURES—SOLUTIONS—SYRUPS.
   18. Syrup offumaria, twelve ounces ; syrup of viola tricolor, four ounces ; bisul-
phuret of soda, two drachms.   Mix.   M. Biett often employed this mixture in
cases  of eczema, hchen, and several  chronic  diseases of the skin.  Dose—Two
spoonfuls a day.
   19.  Syrup of fumaria, a pint;  bicarbonate of soda, three drachms.  Dose—Two
teaspoonfuls : one before breakfast; the other at bed-time.   Use—Eczema; lichen ;
prurigo.
   20.  Pearson's solution.—Arsenite of soda,  four  grains ; water, four ounces.
Dose—From twelve drops to a drachm or more.   Use—Most chronic diseases of
the skin ; eczema, impetigo, lichen ; but chiefly in squamous diseases, lepra, psori-
asis, &c.
   21.  Fowler's  solution.—Arsenious  acid, and carbonate of  potass, of  each
seventy-eight grains ; distilled water, a pint; alcohol, half an  ounce.   Use—The
same as Pearson's solution.   Dose—Three or four drops gradually increased to
twelve or fifteen.
   22. M  Biett's  solution.—Arsenite  of  ammonia, four grains; water,  four
ounces.   Use—Same  as above.   Dose—Same  as Pearson's solution.
   23. Larrey's syrup.—Sudorific  syrup, one pint; bichloride of mercury, hydro-
chlorate  of ammonia, and  extract of  opium, of each five grains ;  Hoffmann's
liquor, half a drachm.  Dose— Half an  ounce  to two ounces.   Use—Syphilitic
eruptions.
   24. Carbonate of ammonia mixture.—Syrup  of mezereon, two ounces ; balsam
 of tolu, four ounces ; subcarbonate of ammonia, half an ounce.  Dose—A spoon-
ful morning and  evening.  Use—Constitutional syphilis.
   25  Solution of Hydrochlorate of  lime— Crystallized chloride of lime, two
drachms to half an  ounce ; distilled water, a pint ; add syrup of gentian, eight ounces.
 Vose—Onz or two spoonfuls morning and evening.   Use- -Scrofulous lupus.
   26   Van Swieten's  liquor.—Bichloride of  mercury,  eighteen  grains;  water,
 twenty-nine ounces ; alcohol, three ounces.  Dose-A teaspoonful daily in a glass
 of decoction of sarsaparilla.   Each ounce contains a little more than half a grain.
 Use—Secondary syphilis.

                             ill. POWDERS.  PILLS.
    27  Sublimed sulphur,  magnesia, of  each  half an  ounce.    Make eighteen
 rackets   Dose—One daily.  Use—Chronic eczema ; scaly diseases.
    28  Proto-iodide of mercury, twelve  grains ; extract  of lettuce, two  scruples.
 Make forty-eight pills.  Dose—One to four.    Use—Syphilis.   Or, 
340
BIETT'S  FORMULARY.
  29. Proto-iodide of mercury, half a drachm ; extract of guaiacum, one drachm ;
extract of lettuce, two scruples ; syrup of sarsaparilla, q. s.  Divide into seventy-
two pills.  Dose—One, and then two  daily.   Use—Syphilis.
  30. Hydrochlorate  of  gold.—Hydrochlorate of gold, two grains ; gum arabic,
six grains.   Divide into twelve parts.  Dose—One  part  rubbed upon the  tongue
twice a day.   Use—Syphilitic eruptions.
  31. Bichloride of mercury.—Extract of aconite, six grains; bichloride of mer-
cury, two grains ; marshmallows powder, eight grains.   Make eight pills.  Dose—
One to four.   Use—Syphilis.
  32. Deuto-iodide of mercury.—Deuto-iodide  of mercury, six grains ;  marsh-
mallows powder, half a drachm. Make thirty-six  pills.  Use—The same.  Dose—
Two or three a day.
  33. M. Sedillot's pills.—Strong mercurial ointment, one  drachm ;  soap, two
scruples ; mallows powder, one scruple.   Make  thirty-six pills.  Dose—Two or
three daily.   Use—The same.
  34. M. Biett's pills.—Mercurial  ointment, powdered sarsaparilla, of  each a
drachm.   Make forty-eight pills.    Use—The same.   Dose—One to four daily.
Or,
  35. Phosphate of mercury, half a drachm ; extract of fumaria, one drachm.  Make
forty-eight pills.   Dose—One or two a day.   Use—As before.
  36. Aconite pills —Extract of  aconite, half a drachm ; mallows powder, two
scruples.  Make  forty-eight  pills.   Dose—One  or two morning and evening.
Use—Syphilitic eruptions ; nocturnal pains.
  37. Asiatic pills.—Arsenious acid,  one  grain ;  black pepper, powdered, twelve
grains ;  gum arabic, two  grains ; water, q. s.   The arsenious acid and pepper to be
rubbed together in an iron mortar for several hours,  and  the gum arabic and water
to be then added.  Make twelve pills.  Dose—One or two a day.
  38. Arsenite of iron.   M. Biett.—Arsenite of iron,  three grains ;  extract of
hop, one drachm ; mallows powder,  half a drachm; orange flower syrup, q. s.
Make forty-eight pills ;  each contains the one-sixteenth of a grain.  Dose—One
daily.   Use—The two preceding formulae are chiefly  used  in cases of chronic
eczema  and  lichen ; in the scaly diseases, lepra, lupus, and psoriasis.
  39. Arsenite of soda.  M. Biett.—Extract of conium, one scruple; arsenite
of soda, two grains.  Make twenty-four pills.   Dose—One or two daily.    Use—
As above.
  40. Hydrochlorate of iron.—Hydrochlorate of iron, twelve grains ; gentian, in
powder, twenty-four grains.  Make twelve pills.  Dose—One to four daily.  Use
—Employed with success by M. Biett in scrofulous eruptions.
  41. Sulphate of iron.   M. Biett.—Sulphate of  iron,  one scruple ; powdered
mallows, twelve  grains; syrup, q. s.  Make twelve pills.  Use and dose the
same.


 »                      EXTERNAL REMEDIES.

                         I. CATAPLASMS.  LINIMENTS.

  42. Potato-poultice.—Potato flour, infusion of  marshmallows, of each, q. s.
Mix  the flour with a little cold water, and then boil  it.  M.  Biett commonly
employed this  poultice with great benefit, in cases of eczema, impetigo, mentagra,
&c.
  43. Charcoal poultice.—Powdered  charcoal, linseed meal, and warm water, of
each.q.  s.   Use—In ulceration after ecthyma, &c.
  44. Conium poultice.—Conium, two ounces ; water, two pints.  Boil away one
quarter,  and to this add ground flaxseed, q. s.   Use—Scrofulous ulcers.
  45. Marshmallows infusion, one pint; solution of sub-acetate of lead, one to
two drachms.   A lotion  in cases of lichen or chronic  eczema.  Or,
  46. Dulcamara, hyosciamus, solanum  nigrum, of each a handful.   Boil  toge-
ther, with some marshmallow roots, and use for  the purpose of moistening  com-
presses.   Lichen, acne.   Or, 
OINTMENTS--POWDERS.
341
 t„47u Cyanuret of Potassium, twelve grains; emulsion of bitter almonds, six ounces.
 in chronic eruptions with itching.   Or,
 „rt-« Hy^rocvanic acid, two drachms ; corrosive sublimate, two grains ; emulsion
   iS  v    °"    te" ounces-  ^se—As above.  Or,
   49. Extract of belladonna, two drachms; lime watertight ounces ; oil of sweet
 aimonds, tour ounces.  A liniment.  Use—For the  inflamed surfaces in cases of
 eczema and impetigo.   Or,
   50. Alum, three drachms; hydrochlorate of ammonia, one drachm;  Bareges'
 water, one ounce ; water,half a pint.  A lotion, towards the termination of eczema
 and impetigo.  Or,
   51. Subcarbonate of potass,  one drachm;   sublimed sulphur, two drachms;
 water, a pint.  Use—In prurigo, especially  when the itching has diminished.  Or,
   i>z. Acetate of ammonia, three ounces; alcohol, four  drachms ;  rose-water,
 lour ounces   In  lichen.   To be applied with a fine sponge, when the pruritus is
 excessive.  Or,
   53. Sulphuret of potass, one drachm ; white soap, two drachms; distilled water,
 eight ounces.   Use—In  prurigo, scabies, porrigo.
   54. Sulphate of zinc, acetate of lead, of each one scruple ; rose-water, five
 ounces ; mucilage of quince, one ounce.  In some cases of eczema and impetigo
 of the face.
   55. Nitric and  hydrochloric acids, of each  twenty  drops;  distilled water, ten
 ounces.   Use—Lichen, chronic eczema.
   56. Alkaline lotion.—Subcarbonate of  potass, distilled water, of each  two
 drachms ; mucilage of bitter almonds, eight ounces.  Use—Lichen, prurigo.
   57. Gowland's solution.—Deuto-chloride  of mercury, one, two, or three grains ;
 emulsion  of bitter  almonds, six ounces.   Use—Porrigo.
   58. Dupuy tren's lotion.—Sulphuret of potass, four ounces; sulphuric acid, half
 an ounce  ; water, two pints.   Use—Scabies.
   59. Barlow's lotion.—Sulphuret  of potass, white soap, of each two drachms;
 lime-water, seven ounces ;  alcohol,  one drachm.  Use—Porrigo.
   60. Jadelot's  liniment.—Sulphuret of potass, six  ounces ; white  soap,  two
 pounds ; olive  oil, two  pints; oil  of thyme, two drachms.   Use—Scabies  and
 prurigo.

                          2. OINTMENTS.   POWDERS.

   61. Alkaline  ointment.—Subcarbonate of  potass, two  drachms;  lard,  two
 ounces.   Use—In pustular diseases  and porrigo.
   62. Compound  alkaline  ointment.—Subcarbonate  of  soda, two drachms;
 extract of opium, ten grains ; slaked lime, one drachm ;  lard, two ounces.    Use—
 In some cases of prurigo.
   63. Ointment  of   cyanuret of  potassium.—Oil  of  bitter  "-almonds,  two
 drachms ; cyanuret of  potassium,  twelve grains ; Galen's  cerate,  two ounces.
 Use—In lichen and prurigo, when the skin is very dry and the itching excessive.
   64. Hydrocyanic cerate.—Hydrocyanic acid, twenty drops ; cerate, two ounces.
 Use—In syphilitic ulcers.
   65. Ointment of cyanuret- of mercury.—Cyanuret of mercury, three to six
 grains ;  lard, one ounce.   Use—As above.
   66. Ointment of carbonate of lead.—Subcarbonate of  lead, two  drachms ;
prepared  lime,  half an  ounce; Galen's cerate,  two  ounces.   Use—In  papular
eruptions with itching.
   67. Chloride of lime ointment.—Powdered  chloride of lime, half an ounce;
sweet-almond oil, two ounces ; lard, three ounces.  Use—As above.
   68. Proto-chloride of mercury ointment.—Proto-chloride of mercury, twenty
grains to  a drachm ; lard, one  ounce.    Use—In  most  chronic diseases,  and
towards the end of some scaly affections.   Or,
   69. White precipitate of mercury, half a drachm ; camphor, ten grains ; almond
cerate, one ounce.   Use—In  aone and sycosis.
   70. Proto-chloride of mercury and acetate of  lead, of each two scruples ; cam-
phor, six grains; lard, half an ounce.  Use—For tubercles. 
342
BIETT'S  FORMULARY.
  71. Ointment  of deutoxide  of  mercury.—Deutoxide  of mercury,  half  a
drachm ; camphor, four grains ; lard, an ounce.   Use—In papular diseases of the
face.
  72. Sulphuret  of mercury ointment.—Sulphuret  of mercury, half a drachm ;
camphor, ten grains ;  cerate,  one ounce.    Use—In chronic,  vesiculo-pustular
affections.
  73. Sub-sulphate of mercury ointment.—Sub-sulphate  of mercury, one scruple ;
camphor, six grains; purified lard, one ounce.  Use—Same  as last.
  74. Ointment  of  proto-nitrate  of mercury.—Proto-nitrate  of mercury,  one
scruple ; lard, one ounce.   Use—In lepra and psoriasis.
  75. Iodide of mercury ointment.—Proto-iodide of mercury, twelve to twenty-
four grains ; lard, one ounce.   Or, Deuto-iodide of mercury, twelve grains ;  lard,
one ounce.
  These preparations were introduced by M. Biett, and are  extremely efficacious.
M.  Biett  chiefly employed them in  syphilitic eruptions,  and in  certain forms of
inveterate  scaly disease.   The preparation  with the deuto-iodide is by  far the
more active, and should therefore be applied to a much smaller surface of the skin.
It is occasionally used as an escharotic in lupus.
  76. Iodide of sulphur ointment.—Iodide of sulphur,  fifteen to thirty  grains ;
lard, one ounce.  This preparation was also introduced by M. Biett; and,  next to
the former one, is that on which most reliance is to be placed.   It is chiefly suited
to cases of  acne, prurigo, and scaly diseases.
  77. Depilatory ointment.—Subcarbonate  of  soda, two  drachms ;  lime,  one
drachm ; lard, one ounce.   Use—In porrigo.
  78. Banyer's ointment.—Litharge, two ounces ; calcined  alum and calomel, of
each one ounce and a half; Venice turpentine, half  a pound; lard, two pounds.
Use—Same as  last.
  79. Hydriodate  of  ammonia  ointment.—Chloride of  ammonium, eighteen
grains; mutton suet, half an ounce ; sweet-almond  oil, two drachms.   Use—As
above.
  80. Hydriodate of potass ointment.—Iodide  of potassium,  half a drachm ;
lard, one ounce.   Use—Scrofulous ulcers, some papular eruptions, Arabic  ele-
phantiasis.
  81. Iodine ointment.—Iodine, fifteen grains ; iodide of potassium, one drachm ;
Rousseau's  laudanum, two drachms ; lard, two ounces.   Use—As  above.
  82. Soot  ointment.—Soot, one drachm ; lard, two ounces.  In porrigo.
  83. Sulphur  and charcoal ointment.—Powdered charcoal, one ounce ; sublimed
sulphur, two ounces ; lard, five ounces.   Use—In porrigo.
  84- Sulphur  and cinnabar ointment.—Cinnabar,  two  drachms ; sublimed  sul-
phur, half an ounce; laudanum, two drachms ; lard, five ounces.   Use—Scabies
and prurigo.
  85. Pringle's ointment.—Root of the white hellebore powdered, two drachms ;
hydrochlorate of ammonia, one drachm ; lard, two ounces.   Use—As above.
  86. Helmerich's ointment.-^Sublimed sulphur, half  an  ounce ; subcarbonate
of potass, two  drachms ; lard, two ounces.  To be divided  into  four portions.
Use—Scabies.   A portion to be rubbed  in, night and morning, over the  affected
parts.
  87. Sublimed sulphur, half an ounce ; hydrochlorate of ammonia, two drachms;
lard, two ounces.  Use—As above.
  88. Sublimed sulphur, five ounces ; subcarbonate of potass, two  ounces ; water,
one ounce :  olive oil, four drachms.   Dissolve the potass, then  add the oil,  and
incorporate the sulphur.  Use—Scabies.
  89. Sublimed sulphur, white soap, of each two ounces.   Dissolve the soap in a
sufficient quantity of water, and add the  sulphur gradually.  Use—Scabies.
  90. Sublimed sulphur, white soap, of each half an ounce ; lard, two  ounces.
Use—Scabies.
  91.  Willan's ointment.—Subcarbonate of potass, half an ounce ; red sulphuret
of mercury, one ounce ; rose-water, one  ounce ; oil of bergamotte,  half an ounce ;
sublimed sulphur and lard, of each nine ounces.   Use—Scabies.
  92. Turner's pitch ointment.—Pitch, half an  ounce ; lard, an  ounce.  Use— 
BATHS--FUMIGATIONS.                     343
Scabies.  This ointment was  in  much repute about the middle  of the last cen-
tury.                                   r
   93.  M. Giroux's  ointment.—Pitch, two drachms ; laudanum, a drachm;  lard,
an ounce.   Use—In prurigo and scaly diseases.


                                 3. CAUSTICS.

 •  9^'  N}irate °f silver lotion.—Nitrate of silver, half a drachm ; distilled water,
six drachms.   Use—In rupia, impetigo.  A  feather moistened with the lotion is
passed over the diseased surface, which immediately afterwards is  copiously sprin-
kled with water.  Dilute sulphuric, nitric, or muriatic acids may be employed in
the same manner.
   95.  Binitrate  of  mercury.—Protonitrate of  mercury,  one,  two,  or three
drachms ; nitric acid, an ounce.   Lupus, syphilitic eruptions.  A brush, moistened
with  the  caustic, is passed  lightly  over a small extent of the diseased surface.
The animal oil of Dippel,  and  the butter of antimony, are employed in the same
way.
   96.  Come's powder.—White oxide  of arsenic, ten grains; sulphuret  of mer-
cury, two scruples ; animal charcoal  powdered, ten grains.   Use—Ulcerated lupus.
A small quantity to be moistened on some solid  body, and spread with a spatula
over a surface not to exceed  three quarters of an inch in diameter.
   97.  Dupuytren's powder.—Arsenious acid, eight to twelve grains ; calomel, an
ounce.   Mix carefully.   Use—As above.  This is a milder caustic, a small quan-
tity of which is to be sprinkled over a surface, so as to form  a thin covering.
   98.  Chloride of zinc pastes.—No. i. Flour,  two parts;  chloride of zinc, one
part.
   99.  No. ii. Flour, three parts;  chloride of zinc, one part.
   100.  No. iii.  Flour, four parts ; chloride  of zinc, one part.  Mix the zinc  with
the flour, adding as little water as possible ;  then  expose the paste to the air until
it  absorbs enough of moisture to be fit for use.   I'he dermis should be exposed
before the paste is applied.
   101.  Antimonial paste.—Chloride of  antimony, one part; chloride of zinc,
two parts.   Add flour according to the strength desired.   Use—As above.
   102.  Vienna caustic.—Caustic  potass and unslaked lime in powder, equal parts.
Use—As above.  This paste is diluted with alcohol, and applied with a spatula
over a very small  surface.

                          4.  BATHS.   FUMIGATIONS.

   103.  Emollient bath.—Potato-flour  starch, one pound ; cold water, one quart.
Mix, and add four quarts of hot water ;  then boil to the consistence of a paste, and
add the latter gradually to  the bath.
   104.  Gelatine bath.—Prepared  gelatine, a pound ; dissolve in a quart of warm
water ;  add four  quarts of warm water, and boil for a quarter of  an hour.   Mix
with the bath.
   105.  Acid bath.—Muriatic acid, two to four ounces ; water, four hundred and
sixty quarts.   Use—Chronic  prurigo and lichen.
   106.  Alkaline bath.—Subcarbonate of soda, four to eight ounces ; water, four-
teen pails.   Use—Chronic diseases of the skin.
   107.  Sulphur baths.—Sulphuret of potass, four to six ounces ;  water, fourteen
pails.   Use.—Chronic eruptions.  To mitigate the action, if necessary, some starch
or gelatine may be added.
   108.  Iodine  bath.—Iodine, two to four drachms ;  iodide of potassium,  four  to
eight drachms ;  water, fourteen  pails.   Use—As above.
   109.  Mercurial bath.—Deuto-chloride of mercury, from twenty-four grains to
half an ounce,  gradually ; water, fourteen pails.   Use—Scaly and syphilitic erup-
tions.
   110.  Sulphur fumigation.—Sulphur,  half  an  ounce; evaporate on a warm
plate, in an apparatus ad hoc.   Use—Scabies, scaly diseases, lichen, prurigo.
   111.  Cinnabar fumigation.—Cinnabar, half an ounce to one ounce.  The tin- 
344
BIETT'S  FORMULARY.
nabar is  volatilized with five or six ounces of water in D'Arcet's apparatus, at
54° R.   The patient remains in it from fifteen to twenty minutes.   Use—Prurigo,
syphilitic eruptions.  General fumigation is not readily supported ; hence M. Biett
invented  an apparatus for the purpose of fumigating locally.
  112.  Vapor baths and douches.—This  is the best form in which baths, can be
administered ; they are suited to almost every species of chronic disease  of the
skin.  The patient may employ them for fifteen to twnety minutes, at a heat of
40° to 42° R. 
INDEX.
                                Page
Acarus scabiei,......108
Achores,........158
Acne,.........164
----simplex,......165
----punctata,......166
----indurata,......166
----rosacea,   ......167
----sebacea,   ......168
Acrodynia (epidemic erythema), .    36
Aleppo evil,.......291
Albinismus,.......271
Ammonia, arsenite of (Biett),   .    89
Arabian elephantiasis,   .   ...  .  328
* Arsenic, preparations of,  .  .  .    27
---------in eczema,   ....    88
---------in lepra,.....226
--------iodide of, in ichthyosis,  244
---------in elephantiasis Graec.    255
Arsenical paste of Frere Come,    284
Asiatic pill,.......235

Bakers' itch (psoriasis of the hands), 232
Barbadoes leg,......328
 Bareges, waters of,.....87
 Barbie,  M.,  distinction  between
   miliaria and sudamina,  ...   73
 Biett, M., formulary of,   ...  338
 Blebs, vide Bullae,.....115
 Borserius,  views   of,  in  chronic
   herpes,........100
 Bouton d'Alep,......291
 Bricklayers' itch, vide  Impetigo
   of  the hands, and Eczema im-
   petiginodes.
 Bullae,     .......
Chin welk,
Chloasma,
Classifications,
Cancroide, vide Cheloidea,   .   .
Cantharides, general use of,   .   .
-----------in Eczema,   .   .   .
-----------in Lepra,  ....
Carswell, Dr., case, of molluscum
  by,.........
Causes,  general,  of  cutaneous
  diseases,.......1"
                         ...    87
                         ...   334
                         ...    74
115

334
 27
 88
226

261
Cauteretz, waters of,
Cheloidea,
Chicken pox,
Chicory root,.......1' *
Chilblains, treatment of,   ....   44
              Alibert's,  .   .   .
            - Plt'nck's,  .  .' ,
-------------Willan's,  .  .   .
------•------Frank's,   .  •   •
-------------Wilson's,  .  .   .
------------Biett's,  ....
Climate, influence of, on the skin,
Cold, influence of, on the skin,  .
Color, changes of,......
Color, loss of,......
Copper  nose,.......
Cow-pox,........
Cows,  affected  with  a  disease
   analogous to ichthyosis,   .  .
Cow-rap,........
Crusta  lactea,......
Dandriff,........
Dartres,........
Diagnosis, general, of cutaneous
  diseases,   .......
Dippel, aflimal oil of,   ...  .
Dischroa, vide Maculae,   .   .  .
Dry Scall, vide Psoriasis,  .   .  .
Dupuytren's powder,   ....
Page
 174
 267
  13
  14
  14
  14
  15
  16
  17
  20
  21
 264
 271
 164
 141

 245
 151
 158

 237
   14

   23
 283
 263
 229
 284
Ecthyma,  ,.......147
---------' cachecticum,   .  .  •  149
Eczema,........   '"
-------simplex,.....77
.-------rubrum,   .   :   .  .  .   77
-------impetiginodes,    ...   78
_______. chronic,.....80
    .____of the mammae,  ...   90
_______of the scrotum,   ...   90
__— of the scalp and ears,  .   90
Elephantiasis Graecorum,  .  .  .  247
____._______Arabum,    .  .  .  328
Electric spark, effects of,   .  .   .   20
Ephelides,   .......267
Equinia,........1"0
Erysipelas,.......37
_--------verum,.....37
—--------erraticum.....38
__________cedematodes,   ...   39
---------phlegmonodes,    .   .   39
* For these and other medicinal
preparations, see also Formulary. 
346
INDEX.
Erysipelas gangrenosum,
----------of the face,
---------of the scalp,
---------of the umbilical reg:
----------of the limbs,
Erythema,    .  .   .
--------papulatum,
---------tuberculatum,
---------nodosum,
--------intertrigo,
--------fugax,
--------laeve,  .   .
■--------centrifugum,
--------r epidemicum,
Exanthemata, characters of,
Exercise, influence of, on the skin,
Page
  40
  41
  41
  41
  42
  31
  31
  32
  32
  33
  33
  33
  35
  36
  29
  21
 Farcy,.........184
 Favus,.........181
 Food, influence of, on the skin,  .    20
 Foville,  M., on Mentagra,...   177
 Framboesia,.......256
 Frere Come, paste of,   ...  .   259
 Freckle,........266

 Gale, vide Scabies,.....107
 Gales, M., researches on itch,    .   108
 Gilibert's,   M.,  views   on  pem-
   phigus,  ........117
 Glanders and Farcy,    ....   190
 -------in the lower animals,   .   191
 -------in the human subject,   .   193
 Gold,  muriate  of,  vide  Sycosis
   and Syphilis,   ....  «179,  316
 Gras-Albin, M., experiments on
   the acarus scabiei,   ....   108
 Grocers'  itch, vide  Psoriasis  pal-
   maria,........   232
 Grease,    ........141
 Gruby, M., on cryptogamia in the
   roots of the beard,  ....   177

 Hamont, M-> views on  glanders,   191
 Hsemorrhcea petechialis, vide Pur-
   pura,    ........320
 Helmerick's ointment,  .  .   .   .   113
 Hereditary predisposition,  ...    19
 Herpes,........92
 ------phlyctenodes,  ....    93
 ------labialis,......95
 —----praeputialis,.....96
 ------zoster,  zona, or shingles,    99
 ------circinatus,.....103
------iris,.......105
 Hives, vide Varicella,  ....    74
 Humoral  pathologists, theory  of,    21

Ichthyosis,.......250
----------case of  T. Jones,    .   244
                                 Page
 Idiosyncrasy and predisposition, .    22
 Itch,.........107
 Impetigo,........151
 --------figurata,.....152
 --------sparsa,.....154
 --------scabida,.....154
 --------erysipelatodes,  .  .  .   155
 --------rodens,.....155
 --------larvalis,   ...'..   158
 --------granulata,    ....   163
 Iodine  and sulphur, vapor  of, in
   lepra,........227
 —:— in elephantiasis Arabum,   334

 Keloide, vide Cheloidea,  .  .  .   334
 Kreasote, in porrigo,   .  .  .  .   186

 Larrey's syrup, vide Formulary.
 Lentigo,........266
 Lepra vulgaris,......219
 ----alphoides,......219
 ----nigricans,......219
 Lichen,     ........204
 ------simplex,......204
 ------pilaris,......205
 ------lividus,......205
 ------• circumscriptus, ....   205
 ------gyratus,......205
 ------urticatus,.....205
 ------strophulus,.....206
 ------agrius,......207
 ------local varieties of (note),   207
 Liver spots,.......267
 Lupus,.........274
 -----superficial,'.....275
 -----deep-seated,.....277
 -----with  hypertrophy,  .   .   .  279

 Maculae, general  characters  of,  263
 Magnifying  glass, utility of,   .   .   25
 Malum Alepporum,.....291
 Measles,........48
 Mentagra,........174
 Miliaria,........70
-------rubra,......72
-------alba,......72
Miliary fever,.......70
 Moles,.........269
Molluscum,.......260
---------contagiosum,  .   .   .  260
---------non-contagiosum,    .  260
Morbili, vide Measles,    .   .   .   48
Mother marks,......269

Naevi,.........269
Nettle-rash,  vide Urticaria,   .   .   62
Nitrate of silver,  effects of, on the
  skin,.........264 
INDEX.
347
Ointments, vide Formulary.
Olophlyctide, vide Herpes,
Papulae,.....
Patterson,  Dr.,  experiments
  nitrate of silver by,   .
Pearson's solution of arsenic,
Pellagra,......
Pemphigus,.....
Pityriasis,......
--------capitis,   .   .   .
--------rubra, ....
--------versicolor,   .   .
-------- nigra,  .
Pompholix solitarius,
----------diutinus, .   .
----------pruriginosus,
Porrigo, characters of,  .
------favosa,   .   .   .
        scutulata,
Prognosis,  general,  of skin  dis-
  eases,    ........
Prurigo,........
------mitis,.......
------formicans,.....
------senilis, or pedicularis,
------genitalium,.....
       podicis,......
Pruritus,
Psora leprosa, vide Psoriasis.
Psoriasis,   ......
-------guttata,....
------- diffusa,  ....
-------inveterata, .   .  .
         gyrata,
— ophthalmica,
— labialis,
— praeputialis,
— scrotalis,
— palmaria, .
— dorsalis,
— unguinum,
Psydracia, vide Impetigo,
Purpura,.....
-------simplex,   .   .
-------haemorrhagica,
-------urticans,   .   .
         senilis,
Page

  92

 203

 266
  88
 287
 116
 237
 237
 239
 249
 240
 118
 119
 120
 179
 181
 181

   24
 211
 211
 211
 214
 215
 215
 211

 229
 229
  229
  230
  231
  231
  231
  231
  231
  232
  232
  232
  151
  320
  321
  322
  327
  328
   129
                                 Page
Roseola, autumnalis,   ....   47
         annulata,.....47
Rubeola,........48
Rupia,.........   124
      simplex,......124
Pustulee, general characters of,

Rayer, M., views on glanders,  .   198
Red gum,........206
Re-vaccination,......140
Ribes, M., pathology of erysipelas.
Ringworm,   •  •   •   •   •   •  •   ]°l
___I_____of the scalp (note),  .   189
Roseola,........     .„
._______infantilis,.....46
_______aestiva,......46
Rupia prominens,.....125
-----escharotica,.....126
" Salt rheum " (note),  ....
Satyriasis,   vide   Elephantiasis
  Graecorum.
Scabies, vide Itch,.....
Scarlatina,    .......
---------simplex,.....
--------anginosa,.....
--------maligna,.....
Scalled head, vide Porrigo, and
   Impetigo of the scalp.
Scurvy,   ........
Shingles,........
Slate-colored skin,.....
Small-pox,........
         - inoculated,  .   .  .  .
Spilus, vide Naevus.
Squamae, general characters of,  .
Strophulus,.......
---------intertinctus,....
---------confertus,  ....
---------volaticus,  ....
---------albidus,.....
---------candidus,  ....
Succory, or chicory root,  .  .  .
Sudamina,    .......
Sulphur preparations,  ....
Sulphur and iodine, vapor of, .  .
Swine pox,   .  .,.....
Sycosis,........
Syphilitic eruptions,.....
-------exanthematous eruptions,
____vesicular eruption,
----bullar eruption,  .
----pustular eruption,
----tubercular eruption,
— papular eruption,
— scaly eruption,
207
107
 54
 55
 56
 56
325
 99
264
131
134

219
206
206
206
206
206
206
171
  70
  27
  27
  74
174
295
297
297
299
299
301
304
305
 92
181
206
Tetter,.........
Tinea, vide Porrigo,   ....
Tooth-rash,.......
Trades  and professions, influence
  of, on the skin,.....20
Treatment, general, of cutaneous
  diseases,.......25
Trousseau, M.,  case of pemphigus
  by,.........H8
Tsarath,........247
Tubercula, general characters of,   246
Tubercular  lepra  (Elephantiasis
  Graecorum),......247 
348
INDEX.
	Page
	62
	63
	64
	64
	141
	26
Vapor of sulphur and iodine in	
	227
	74
--------lenticularis, . . .	75
	75
	131
	131
	134
Varioloid,........137
Vesiculae, characters of,   ...   67
Vitiligo,........271

Wanner, M., method recommended
  by, for regenerating cow-pox,  .  146
White gum,.......206

Yaws,.........256

Zittmann, decoction of, vide For-
  mulary.
Zona, vide Herpes,.....99 
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