out. confluent than those of scabies, which are acuminated and distinct. But when the disease is passed to an ulcerated and scabby state, such distinguishing characters may be wanting, and then other circumstances must be sought Eczema is for the most part a local affection, and when the itch has in any place assumed the ulcerations and soft scabs which resemble it, the eruption has proceeded to a considerable extent, and will doubtless shew its proper form in the parts which it has most recently invaded. The irritation of eczema is a stinging or tingling sensation very different from the pruritus of the itch, and its origin may be often traced to the action of irritating causes upon the skin, as sugar, lime, and other acrid substances, or to exposure to the solar rays or great heats. Very lately a female presented herself to the writer with an eruption at the root of the right middle finger, which from its situation and appearance was difficult to distinguish from scabies. She ascribed its origin to milking cows, whose teats were in a diseased state. The pruritus was not that of scabies, and after a careful examination it was concluded to be a vesicular form of impetigo. Bateman calls attention to the possibility of confounding the pustular form of scabies with impetigo, and even with ecthyma; and although this seems remote, it is yet only a prudent caution to keep in mind every form of cutaneous disease which bears any affinity to it. A circumstance in the history of scabies of the greatest moment, is the simultaneous presence of the diseases which we have just contrasted with it for the sake of diagnosis. This is indeed rare in ordinary cases of itch, but the fact of its occasional occurrence forcibly impresses the necessity of cautious examination, and adds much practical importance to the diagnosis, because those complications require a line of treatment quite distinct from that of scabies. They are met with in the cases in which much inflammation has attended the scabid eruption, and (which serves to illustrate what we have said as to their different treatment) they are very frequently produced by improper applications for its cure, such as powerfully irritant lotions or frictions. The actual complication which may be present will be much influenced by the constitution and age of the subject; in young and vigorous habits, the excess of irritation will mostly take the form of eczema or of impetigo, while in those of an opposite condition pustules of ecthyma may appear, or the inflammation may seize on the cellular tissue, and an eruption of boils be the consequence. Cazenave and Schedel remark that the same subject may present at once" vesicles of itch, pustules of impetigo, pustules of ecthyma, and boils,"* a case which would exercise the diagnostic tact of the physician to discover the primary contagious disease amongst so many complications. Causes. The universally diffused cause of Abrégé Pratique des Mal. de la Peau, Paris, 1828, p. 120. scabies is contagion, and it appears to be the disease which of all is most readily communicated by contact. When it once gains admission into a family the greatest caution often fails in preventing it from infecting every individual. A question exists undecided amongst pathologists as to whether it ever originates from any other source than contagion. It was observed by Sir John Pringle, that in military hospitals the patients often became the subjects of itch after the crisis of fevers ;* but there remains little doubt in our mind that this excellent physician in these instances mistook some of the papular eruptions, as lichen or prurigo, for scabies, for those are not uncommonly observed to occur when the skin recovers its tone in the convalescence from fever. We would make the same remark with respect to a kind of it which Heberden describes as primarily contracted by contagion, but which being cured by the customary remedies, "tamen non cessat redire semel vel bis quotannis." This is rather the description of the lichen simplex, occurring periodically in a person who has been once affected with scabies; for this faithful observer adds, that after its first attack it is no longer communicable by contagion, even to those who lie in the same bed, and that it as often terminated spontaneously as was removed by any remedy. Bateman thought that it might originate without contagion in crowded, close, and uncleanly houses, and wherever the means of cleanliness were not obtainable. These are, however, just the circumstances which facilitate the propagation of contagion. On the whole, there are no facts which contravene the opinion of those who assert that the latter is its sole origin, and it appears to us that it agrees best with every analogy. We have reserved to this head the notice of a very remarkable circumstance connected with the etiology of scabies, the existence of the insect called by Linnæus and by preceding naturalists "acarus scabiei." First in the writings of Avenzoar, the Arabian physician, and subsequently in those of Ingrassias, Gabucinus, and Joubert, notices of a minute insect occurring in a certain disease of the skin attracted the attention of the English entomologist Thomas Moufet, who examined and described them with considerable accuracy. They are, according to him, minute animalcules similar to the acari of decayed cheese or old wax, which burrow under the cuticle, and excite intense itching, with an eruption of vesicles. His observations were repeated by various naturalists in different parts of Europe, and Hyacinth Cestoni, at the end of the seventeenth century, investigated the characters of this insect with much exactness, and was the first proposer of the theory which regards it as the proximate cause of the itch. § Bateman's Synopsis, p. 288, note. + Op. cit. p. 102. Synopsis, p. 289. This was communicated by Cestoni's coadjutor, G. Bonomi, in a letter to an eminent physician, Francisco Redi, in whose works it was first published, an. 1685. (Dict. des Sc. Méd.) This doctrine gave rise to a controversy which has continued ever since, and seems at the present day to be as far from being settled as ever. In the order of time, two questions are involved in this subject. By the first the acarus, or (as Latreille denominated it generically) sarcoptes scabiei, was universally received; but issue was joined on the opinion, first mooted as a conjecture by Cestoni, that scabies is nothing else than the bite of these small insects, which produces the itching and an extravasation of serum collecting into vesicles; moreover, that the contagion is effected by the transfer of those insects from one individual to another. Experiments were made, and opinions were contested negatively and affirmatively, by many eminent medical men in different countries. Redi, Wichmann, Osiander, Pringle, and many others, considered the contact of the insect as the only exciting cause of the itch; while as great a number insisted that the acarus was produced by the disease. Again, a middle opinion was embraced by the majority, to which Morgagni attached himself. They held that in most cases the insect was the product of the disease, but admitted that in some instances the latter owed its origin to the insect. M. Galés, apothecary to the Hôpital St. Louis in 1812, undertook a series of investigations, which he conducted with the greatest variety and perseverance, and which finally seemed to leave nothing undecided as to the whole subject. He observed with the microscope upwards of three hundred of the insects taken from the scabious vesicles. He confined the insect upon his hand with a watch-glass, and observed it penetrating the cuticle, upon which, after a few hours, three vesicles appeared, the intense itching of which left no doubt of their identity with scabies. He inoculated in the same manner three children with the insect, who became covered with the itch. These experiments were testified to by many of the first naturalists in Paris; and as they appeared to have the force of demonstration, after their publication the opinion that the itch was produced by the insect was ratified by the assent of almost all. They doubtless proved the presence of the acarus, and moreover that its penetration of the skin is an occasional cause of scabies; but with all, this may be a very secondary matter in the production of the disease. In fact, it seems to us somewhat singular that these observations were permitted to prove more than that the insect taken from a scabious vesicle, being charged with the virus, the fluid of the vesicle, by penetration of the cuticle, inserted this virus, and produced the disease, like the inoculation of cow-pox. At a later period, however, the opinion His descriptions of the insect agree with those of Linnæus and Latreille, but are much more extended and exact. It has six legs, with a few filaments besides projecting from the body, and is not unlike the minute pulix sometimes accompanying prurigo. It lies in the centre of the vesicle, round the margin of which it deposits its ova. supposed to be thus incontestibly fixed by M. Galés' experiments was not only called in question, but, singular to relate, the existence of the acarus was again doubted. M. Suriray of Havre, and afterwards MM. Lugol and Mouronval, revived the discussion of the subject, and, as the result of their researches, denied that any insect could be found. This extraordinary revulsion of opinion was confirmed by M. Biett, who, even with the use of microscopes of high power, was unable, in a great number of trials, to discover it in a single instance. Cazenave and Schedel state that many others have made an equally unsuccessful search for the insect; and rejecting for themselves the idea of its existence, they announce a kind of challenge to M. Galés to transport himself again to the Hôpital St. Louis, and demonstrate it anew. It would follow from these negative researches, that while at one period the disease is attended by the acarus, at other times it exists without it. In these countries it is a notorious fact that the insect is frequently found. Moufet originally stated that the common people were in the habit of extracting it from the vesicles with the point of a pin; but that more usually it may be found in a small channel, which it frets from the vesicle in the adjoining cuticle. We have conversed with those who have frequently seen them, and whose description of their being found not in the vesicle, but in the red streak adjoining it, exactly coincides with Moufet. Bateman and Mr. Plumbe bear the same testimony; and the latter adopts an hypothesis proposed by Galés and Fournier, by which it is conjecturally affirmed, that when the elevation becomes large and full of lymph, it being no longer possible for the insect to exist in it, in obedience to a preservative instinct it makes its way laterally, and is then found beside, and not within the maturated vesicle. He supposes, also, that it is sufficient to account for the ill success of those who have not found it, to presume that they happened to select for their researches vesicles which had been evacuated by the acari. This does not occur to us as by any means satisfactory; but the opinion of Sauvages, adopted by Bateman, seems more plausible, that the insect is generated only in some instances of scabies, of which cases Sauvages proposes to make a particular species under the title of "scabies vermicularis." This is not irrational; yet we deem it more consonant with the varying history of the researches to suppose that there is a variation in the disease itself in this respect at different epochs. This view is more consistent with analogy, as we know how often the type of diseases changes at different epochs in the same locality, without therefore losing their identity. Of this fever is a familiar example, which it is unnecessary to do more than mention in respect to its change of type; but an occasional phenomenon which it presents (as was remarked by M. Ranque of Orleans) may be adduced, *Dict. des Sc. Méd. art. Gale, tom. xvii. p. 199. and reflected on in connection with the generation of the acarus scabiei. We allude to what is occasionally observed when a favourable crisis takes place at the last extremity of typhus; the head is sometimes swarmed by a sudden production of lice, so unaccountably numerous as only to permit the supposition that they are secreted by the skin. According to the view here propounded, and in agreement with the analogy just mentioned, the animalcule of scabies is regarded as a secretory product of the disease, which at certain periods is endemic; but ignorance is professed as to the circumstances which give rise to it at one time more than another; and at the same time we agree with Bateman that the contagious property of scabies exists in the fluid, and not in the insect, which, however, may be the occasional means of transport of the latter. We would finally remark, with regard to the whole controversy, that it includes a lesson at least to medical theorists: here many ingenious men oppose each other in a matter of fact and observation; with what sobriety, then, should dogmatic opinions be entertained, when it is often so difficult even to lay their foundation in certain facts! Treatment. The cure of scabies appears to have been considered a matter of no slight medical interest. Treatises have been written upon it, and a vast variety of means discussed with so much earnestness, that we are led to the conclusion, (which we believe coincides with general tradition,) that it was formerly a Scourge to the community of greater extent and virulence than at the present day. It is now regarded as of trivial importance. Never in itself dangerous, it gives much annoyance to the individual by its unappeasable itching; but the fear and restraint which it puts upon him of infecting others often causes as much discomfort to him as its action upon himself. Neglect of the appropriate means may indeed protract it to an indefinite length; but by their use its treatment is conducted with so much certainty that we have scarcely any other care in the choice of remedies than to select that which experience has approved of as effecting a riddance of the disease in the most secure and speediest manner. A multitude of such has been vaunted, but modern practice has contracted the most useful within a small circle; and it is unnecessary to enumerate here any of minor efficacy, as we are in possession of some whose virtues are almost infallible. Sulphur is considered in the light of a specific remedy in the cure of itch. It is the basis of the applications which by universal consent are considered its most effectual antagonists. In the ordinary forms of the disease the common people have long used it as an ointment, mixed with equal parts of hog's-lard or butter, with which they smear the parts on which the eruption exists once or twice a day. They administer it internally at the same time, in doses of from ten grains to half a drachm given in milk at bedtime. By this treatment they scarcely ever fail to cure it expeditiously. The internal use of sulphur is adapted for it in children, and is occasionally combined with magnesia; in adults, however, it is unnecessary to have recourse to any but the external use of the sulphur ointment. The assiduous use of it for a fortnight is sufficient to cure the common forms of it, if they be attacked with it speedily after its first appearance, as the duration of the treatment will be longer if long neglect has permitted it to gain a certain inveteracy. A great improvement was made in the application of the sulphur ointment by the combination of an alkali with it. This adds to the specific effect of the sulphur the advantage of a detergent action, which loosens and dissolves crusts or scabs, and permits the skin to be well penetrated by the ointment. M. Helmerich, a French army surgeon, became famous for a method of using sulphur which cured the itch more promptly, and also permitted the greasy stain of the ointment to be removed from the linen by washing, obviating an objection to the use of unguents which was very generally felt. He kept it a mystery, but it was analyzed by M. Burdin, and found to consist of the following ointment: Sublimed sulphur, two parts, Axunge, eight parts, intimately mixed.* This deserves a preference over all other methods of applying the sulphur externally. It has the most constant and prompt success, and is seldom attended by the cutaneous affections which sometimes result from the use of other stronger but more irritating sulphureous applications. It is the ointment which Biett has exclusively employed at the Hôpital St. Louis for several years. He orders half an ounce of it to be rubbed, morning and evening, over all the parts occupied by the vesicles. The action of this ointment is favourably promoted by the use of a tepid bath every second day during its application, which will rarely have to be continued beyond ten or twelve days. Another sulphureous friction which, in the Paris hospitals, rivals the reputation of the above-mentioned ointment, is made with the sulphuret of lime. A scruple or half a drachm of this powder is to be triturated with a small proportion of olive oil, so as to render it sufficiently fluid for using as a friction, and this quantity is to be rubbed upon the affected parts twice a day. This is a very effectual cure, but it is not so applicable as the former, when the itch has already spread to any considerable extent. The use of ointments over an extensive surface of the skin may be considered unadvisable in some cases, as interfering with the cutaneous transpiration. When these objections exist, substitutes of no less efficacy are found in the proper use of lotions. None of these is preferable with regard to activity to the solutions For the sake of depriving this ointment of the smell and appearance of sulphur, it would be agreeable to add to each ounce of the axunge a few drops of oil of lavender or bergamotte, and ten grains of the hydrargyri sulphuretum rubrum (vermilion). of sulphuret of potash, or of lime. These have been long known and extensively used in scabies, and a saturated solution of the latter is an excellent remedy in the mange of sheep or dogs. The following formula of a lotion was prescribed by M. Dupuytren, and highly extolled in France for the promptitude with which it effects the removal of the disease :R.-Sulphureti potassæ živ. Aquæ puræ lb. iss. Acidi sulphurici 33, dissolve ut fiat lotio. Whatsoever part the eruption has invaded is to be moistened by a gentle friction with this lotion twice a day. It has the advantage of not injuring the linen of the patient, nor does it compel him to renounce his employment during its use. However, it produces a smarting of the skin, which will sometimes require it to be used in much weaker proportions, and renders it not so appropriate in some irritable habits. If the individual entertain insuperable objections to the use of sulphur from disgust to its odour, many other external remedies of approved efficacy are at hand. The ointment of white hellebore in the proportion of a drachm of the powder to an ounce of lard, is both a safe and expeditious application. Solutions of the chloride of lime or of soda have been extolled as highly beneficial by some practitioners; they are used as a lotion in the proportion of an ounce to a pint of water. The aqua chlorinii applied in the same manner is also mentioned with applause. Heberden strongly recommended a lotion composed of a solution of the muriate of mercury, made with one drachm, or two, (according to the inveteracy of the disease,) to a pint of water. This is acknowledged to be a remedy of great power in curing scabies, but it is objected to by some as liable to produce the constitutional effects of mercury. We have, however, been assured that these fears are vain, by an esteemed practitioner, who has had a very favourable experience of this lotion, and has used it on his own person with success; and in our own more limited sphere of observation, we never saw any such effects from it. Sulphureous baths are an excellent auxiliary means in many cases of scabies. In cases of very irritable skin they are frequently the only form in which general applications of this remedy can be made to the surface; in young children, therefore, they are a very valuable resource. The artificial are found to answer the purpose equally well with the water of sulphureous springs, and their employment possesses the advantage of being proportioned according to circumstances. They may be prepared by simply adding to an ordinary sized warm bath six ounces of the sulphuret of potash in powder, and agitating it until it be dissolved, and the water be reduced to a lukewarm temperature. Sulphureous vapour baths are another means which possess great power in this as well as in some other diseases of the skin. This is evident from the testimony of all who have used them, from M. Galés, who was the first to con VOL. III. struct an apparatus for their convenient administration, to Mr. Wallace, who has also ably illustrated their use. Dr. Bardsley informs us, that he has "always seen the most obstinate and neglected cases of it yield very speedily to a few fumigations." It is happily to such inveterate cases that they are mainly applicable; for even if they did possess the superior advantages over ordinary methods of treatment which are claimed for them, they are too stimulating to be employed in any cases except where the disease has become chronic through neglect, and has induced an unhealthy torpid condition of the skin. They are particularly contraindicated where there exists any tendency to congestion in the gastric or pulmonary mucous membranes, and in females with complaints depending on morbid conditions of the uterine functions. In the conduct of the treatment the practitioner has but little to be solicitous about; but, having used his discrimination in the adoption of the most appropriate remedy, he perseveres until the cure is complete. He should inculcate great attention to cleanliness and change of linen, especially during the convalescence. A vigilant inspection must be made for the purpose of detecting any of the complications previously noticed as apt to coexist with certain forms of the disease, or to spring up under improper treatment. If any of those be present, it will be necessary to modify his plan accordingly, and often to suspend the use of the stimulating remedies, with which he had commenced to combat the scabies. The state of the alimentary canal now demands particular attention; cooling laxatives and alteratives will be proper; and for topical applications recourse should be had to emollient fomentations, and the other soothing means specially adapted to the individual complication, for which we refer to ECTHYMA, ECZEMA, IMPETIGO, LICHEN, &c. (James Houghton.) SCARLATINA.-Syn. Morbilli Confluentes, Morton: Rubeola Rossalia, Hoffman: Febris Scarlatina, Sydenham : Febris Rübra, Heberden: Scarlatina, Sauvages, Vogel, and Cullen: Purpura, Schultz, Junck: Enathesis Rosalia, Good: Fièvre Rouge, Scarlatine, Fr.: Der Scharlachaufschlag, Germ.: Scarlet Fever. Scarlatina designates a contagious febrile disease, the distinguishing characters of which are, a scarlet efflorescence of the skin and of the mucous membrane of the mouth and pharynx, appearing on the second day (though often later) of a febrile disorder, and terminating about the fifth; accompanied, in the majority of instances, with inflammation of the throat, either of a phlegmonous or gangrenous character; and occasionally with tumefaction of the cervical absorbents and subcutaneous cellular membrane. Other organs become also sometimes involved in the progress of the disease, giving rise to lesions of greater or less severity. The type of the accompanying fever is various, and modifies remarkably R Hosp. Facts and Observations, p. 198. 2 T the whole aspect of the malady. In some cases, the constitutional disturbance is so trivial as scarcely to attract notice; in others, the febrile symptoms are those of strong inflammatory excitement; while in individual instances, or during the prevalence of an entire epidemic, the fever is of a low typhoid form, the local inflammation, with which it is associated, partaking very much of the same character. The origin of scarlatina is involved in great obscurity. It was evidently unknown to the ancients; no allusion to it can be discovered in the writings of Hippocrates, or in the early Greek and Roman writers; and, notwithstanding the opinion of some modern authors of the French school, that it was described about the middle of the sixteenth century, it is generally admitted that Prosper Martianus, an Italian physician, who gave a description of the disease as it prevailed in Rome about the middle of the seventeenth century, if not the first, is among the earliest writers on scarlatina. It made its appearance in London in 1689, and was described by Sydenham and afterwards by Morton, though it is evident, by comparing the description given by these two writers, that they had observed different epidemics; the one described by Sydenham being a very mild disease compared with that of which Morton has given an account. From the various names, however, given to scarlatina on its first appearance, it is evident, that about the period to which we refer, the notions entertained with regard to it were vague and unsatisfactory; indeed, it was scarcely distinguished from measles, roseola, or purpura. For example, it was named by Morton morbilli confluentes; by Hoffman rubeola rossalia; by Heberden, febris rubra; and even till within a little more than half a century, both these diseases (measles and scarlatina) appear to have been considered by medical writers as the same, or at least as so closely allied, as only varieties of a common species. Morton, indeed, maintained their identity, and considered their relative connexion to be nearly the same as that existing between the distinct and confluent small-pox. The description of the epidemic given by Huxham under the name malignant ulcerated sore-throat, which prevailed in the year 1734, resembles in almost every particular one form of scarlatina-that form in which the eruption is accompanied with affection of the throat. The treatise on this subject is a valuable record of the characters of this epidemic, the description being evidently taken from what he had observed in his intercourse with the sick. Dr. Fothergill also has given the history of a "sore throat attended with ulcers," which appeared in London in 1747-8, which there can be little doubt was an epidemic scarlatina, and from the remarks he has made, it is evident, that he had observed various forms of the disease, from the mildest to the more malignant. Dr. Withering published an essay on scarlet fever in 1778, a second edition of which appeared in 1793; to this author is due the merit De Morbillis et Scarlatina, Exercit. iii. of having first accurately described scarlatina as a distinct disease; since that period, various treatises have appeared both in this and other countries. Causes. Nothing satisfactory is known as to the exciting causes of scarlatina. It appears to be induced, like the other eruptive fevers, by exposure to the influence of a specific poison. Attempts have been made to induce the disease by inoculation, by inserting the thin scales, which are thrown off at the period of desquamation, under the skin of individuals who have never had scarlet-fever, but hitherto without success. How far inoculation with the blood might be followed by different results is a question which can only be determined by experiment. That scarlatina may be propagated by contagion is, we presume, admitted even by those who profess themselves sceptical on the question of contagion in general. Instances of the disease spreading in a manner which can only be explained by admitting its contagious origin are so numerous, that practitioners of the most limited observation must have had repeated opportunities of determining the question. We have known, in several instances, convalescents from scarlet-fever, on their removal to a considerable distance from the situation in which they had passed through the disease, infect individuals with whom they came in immediate contact, though several weeks had elapsed from the period of desquamation. The period of invasion after exposure to sources of contagion is exceedingly various. Some individuals are seized within a few hours; others do not exhibit any of the peculiar symptoms for several days; and in some more rare cases, five or six weeks have intervened between the period of exposure and the accession of the disease. The poison also appears to affect individuals very differently. Of a number of persons exposed to the same source of infection, some may escape altogether; others have a mild form of the disease; or it may happen, perhaps, that in several, the disease proves severe. Even in the same family the various forms which scarlatina presents may occasionally be observed. One or more may have both the efflorescence and the sore throat; in others there may be fever with the characteristic rash, but without any affection of the throat; another case may present the characters of the malignant disease; while, again, those who have been in constant attendance on the sick become indisposed with smart inflammation of the throat and a considerable degree of fever, which lasts for some days, and then subsides with the local affection. In these latter cases, (though there have been no efflorescence) desquamation of the cuticle occasionally occurs. Dr. Rush, in an account of an epidemic scarlatina which prevailed at Philadelphia, remarks, that such was the prevalence of the contagion which produced the scarlatina anginosa, that many hundred people complained of sore throat without any other symptoms of indisposition. The slightest occasional exciting cause, particu larly cold, seldom failed of producing the |