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A                 <y 1^
PRACTICAL COMPENDIUM
OF THE
DISEASES OF THE  SKIN,
INCLUDING
A PARTICULAR CONSIDERATION OF THE MORE FREQUENT

  AND INTRACTABLE FORMS OF THESE AFFECTIONS;
    WITH CASES.





BY JONATHAN  GREEN, M.D.
MEMBER OF THE KOTAL COLLEGE OF SOHGEONS IN LONDON1; FELLOW OF THE


   ROTAL MEDICAL AND CHIHUHG1CAL SOCIETY J AND LATE SURGEON


              IN THE ROTAL NAVT.

FROM THE SECOND LONDON EDITIOaV
             PHILADELPHIA:

PUBLISHED BY A. WALDIE, 46 CARPENTER STREET.

                  1838. 
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TO
SIR HENRY HALFORD, BART., G.C.H., F.R.S.







        PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS,



                 PHYSICIAN TO THE KING, &C.






    THIS WORK, ON THE  DISEASES OF THE SKIN,







               IS, WITH HIS KIND PERMISSION,






                    MOST RESPECTFULLY INSCRIBED,







                        BY HIS OBLIGED







                AND VERY OBEDIENT HUMBLE SERVANT,









                              JONATHAN GREEN. 
■A
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PREFACE TO  THE  FIRST  EDITION.
  It has been my object  in  the following pages to present a sys-
tematic yet condensed view of the particular branch of pathology of
which they treat.   In pursuit of the end proposed, I have not only
drawn from the stores of my own experience, but have freely used
whatever additional information has recently been given  to  the
public,  under the name or with the sanction of the highest autho-
rities on cutaneous diseases, whether of this country or the conti-
nent. The writings of Lorry,1 Plenck,2 Willan,3 Bateman,4 Alibert,5
Plumbe,6 Rayer,7 and  Cazenave and Schedel,8 I have constantly
consulted.  To the later  French writers especially I  have been
indebted for many hints in  the  matter  of arrangement, and occa-
sionally for assistance  in  my definitions, and now and then in my
descriptions, of those diseases which are  of rarer occurrence, and
with which I am consequently less familiar myself.   Some morbid

  1 Lorry, Tractatus de Morbis cutaneis, 4to. Paris, 1776.
  2 Plenck, Doctrina de Morbis cutaneis, 8vo. Viennse, 1776.
  3 Willan, Description and  Treatment  of Cutaneous Diseases, 4to. Lond.
1798, completed by Bateman, 1817.
  4 Bateman, A Practical Synopsis of Cutaneous Diseases, 8vo. Lond. 18J3,
5lh  ed. id. 1819.   Thomson, Atlas  of illustrative Delineations, royal Svo.
Lond. 1829.
  5 Alibert, Descr. des Maladies de la Peau, fol. Paris, 1806—1825.  Noso-
logie Naturelle, torn. i. 4to. Paris, 1817.  Monographie des Dermatoses, 4to.
Paris, 183—.
  6 Plumbe, A  Practical Treatise on the Diseases of the  Skin, 2d ed. Svo.
Lond. 1827;  3d ed. 1836.
  7 Rayer, Traite Complet theorique et pratique  des Maladies de la Peau,
2 vols. 8vo.  Paris, 1826,  1827;  2d  ed. augmented,  3 torn. 8vo., atlas 4to.,
Paris, 1835;  Englished by R. Willis, M. D.,  8vo. Lond. 1835.
  8 Cazenave et Schedel, Abrege pratique des Maladies de la Peau, surtout
d'apre.s les documens  puises dans les lecons cliniques de M. le Docteur
Biett, 8vo. Paris, 1828, 2ieme ed. id. 1833. 
VI
PREFACE.
conditions frequently included in works on the diseases of the skin,
such as Cyanosis, Icterus, and Chlorosis, are so evidently mis-
placed, that no long apology seems to me necessary for having left
them out; Cyanosis is  synonymous with a  malformation of the
heart,  Icterus with an obstruction of the biliary ducts,  and Chlo-
rosis with a derangement  of the  uterine system and  chylopoietic
viscera.   The present state of pathological knowledge, in fact, did
not  allow me  to  discuss  these affections in a treatise expressly
dedicated to the diseases  of the skin.
   Notwithstanding all that has been done in illustration of the
diseases  of the skin,  it is  unquestionable that they remain at the
present day among the  least understood of  all  the  affections to
which the human body is  liable.  A knowledge of the elementary
forms  under which they appear is an essential preliminary to the
study of the whole of their after-stages; a strange alphabet has to
be learned before the page of information can be  approached; and
the  slight obstacle thus encountered at the  outset too  generally
rebuts the enquirer, who  then  either sits down  contented in  his
ignorance, or  assumes unguardedly that because  he  has not at a
glance been able to appreciate  all that such writers as the learned
and  ingenious  Willan, for  instance, declare to  be demonstrable, the
whole  subject is deception, or, if well founded, unavailable for any
practical  and  useful  purpose.   A very  moderate exercise of  the
virtues of patience and  perseverance would certainly  lead to very
different conclusions.  Cutaneous diseases are notoriously rebelli-
ous  to all the modes of  treatment  usually  recommended;  and
although  Eczema,  Impetigo, Lepra, Psoriasis, Prurigo,  &c, may
not directly interfere  with  the  probabilities of a  man's existence,
yet no one will ever succeed  in persuading him who is suffering
under  any one of  these  diseases,  that because his malady is not
likely to bring him to the grave it is therefore  trifling in its nature,
and  altogether  unworthy of the serious  attention of the true phy-
sician.
  The treatment of cutaneous diseases needs no  longer be under-
taken under the guidance of unenlightened  empiricism: in the
following pages I  have shown it reducible, under every variety of
circumstance, to the principles of a rational therapeia.   I have also
had  repeated  occasion to  mention heated air and sulphur fume
baths, as ulterior means of altering the state of vitality of the skin
and  arousing it from morbid into healthy action.   I may well be
excused for  holding these  powerful agents in the estimation  I do.
For  some years after entering on private practice in London, I 
                          PREFACE.                         Vll

may say I  saw few  or  none but cases of cutaneous disease that
had  already gone the  round of the profession, that had  resisted
every known remedy prescribed, not by the mere routinier, but by
the very first men, surgeons and physicians, practising medicine in
this  metropolis, and that were  consequently  held  incurable.  Of
course I was at first without the experience necessary to guide me
in the use of the powerful therapeutic agents we possess in  the
heated air and sulphur fume baths; but by  constantly watching
their effects, and by giving up the whole  of my  time, and  per-
sonally attending to the cases intrusted  to my  charge, 1 soon disco-
vered  the  conditions essential to success, and  I am now enabled to
say that I very rarely  meet with  a case of  ordinary  cutaneous
disease,  that is not either completely within the reach of medicine
and curable, or  that may not be so much amended as to be  made
very endurable.
                                                        J. G.
  40, Great Marlborough street.
      February 12th, 1835. 
 
PREFACE TO THE  SECOND  EDITION.
  The favourable way in  which my Practical Compendium
was received by  the profession, and the sale of the first edition
within a year from the time of its issuing from the press, induce
me to give it a  second  time  to the public, in a corrected and
amended form.
  For the term Porrigo,  which embraces alike impetiginous and
eczematous eruptions of the scalp, I have substituted that of Favus,
in conformity with the latest and best authorities on the continent.
  The additional experience I have had in the treatment of skin
diseases, since the first edition appeared,  has only confirmed  me in
the general correctness  of the pathological views and therapeutical
principles I then  advocated.   My confidence in the vapour and
fumigating baths, as ulterior agents in subduing  these diseases,
remains  unshaken.   When every thing else has been tried and
found  unavailing, these  baths,  with due preparation  and proper
management, may still  be held as specific in the immense majority
of instances.
  I have been  taken to  task by some  of my reviewers for  not
entering more into detail  relative to these remedial means ; suffice
it to say, that in 18*22, at  the Hospital of St. Louis alone, at Paris,
127,752 of these  baths were administered.  In  1833, the number
had increased to upwards of 150,000 in the year.   In 1834 and
1835, upwards of  180,000 were  administered  each year.   In
November, 1836, I was informed the numbers would be about the
same, as the baths  were always full;  and of sixty-two  patients
whom I saw present themselves  to the Baron Alibert, one morning,
for  consultation, only seven were prescribed for, exclusive of one
or other of these baths as part of the treatment.
  These numbers may surprise  the reader, and the surprise will be
increased when he considers that these baths  are  erected at the
other  hospitals, prisons, and poor-houses throughout Paris, where
they are continually taken, not only as a  curative of disease, but as
preservative of health.
       8__<r*                                     grn b 
X
PREFACE.
  In this country, it is true, no such opinion of the worth of vapour
and fumigating baths  at present exists among  the  members of the
medical profession ; yet I  should  imagine that the  time was not
far distant when their utility will be generally acknowledged; and
in confirmation of* this idea, I may say that I  have lately superin-
tended their erection at three of our metropolitan hospitals.  These
facts speak loudly for the efficacy of the  remedy to  which I have
such frequent occasion to refer in the following pages,

    40, Great Marlborough street^
       January 27, 1837, 
TABLE   OF  CO.NT
                                                                         PAGE
Introduction............     .    1


                       Inflammatory Affections of the Skin.....17

                            I. EXANTHEMATA.                           ib.

Erythema       .............18
Erysipelas       ............•'**
Roseola    .......■■•••■••    ^
Urticaria   .     .         •     •    •    •     •    •    •     •     •    •     '    .
Rubeola..............37
Scarlatina............     .    39

                               II. VESICULiE.                              42

Scabies..............4o
Eczema    .......•••••••    47
Herpes..............    o9
Miliaria..............64

                                III.  BULLJE.                               65

Pemphigus or Pompholix...........**•
Rupia..............69

                               IV. PUSTULE.                              72

Variola..............JJ
----- discreta............fj:
------ confluens.............'
----- (per insitiouem) Inoculated small-pox.......**■
  Varicella or modified small-pox.........78
    Pustular varicella.....•    •          •    '     'in
    Vesicular varicella...........V*
    Papular varicella...........~jj
Vaccinia..............zz
Vaccinella or modified cow-pox      ........."°
Ecthyma..............* "
Impetigo.............         q0
-------of the face (Porrigo larvalis)........»«
--------of the scalp (Porrigo favosa)........«°-
Favus..............1"*
------dispersus (Porrigo lupinosa.  Willan.).......»»•
-----confertus (Porrigo scutulata.   Willan.)      ......|07
Acne, Gutta Rosea or Rosacea..........j"pj
Mentagra or Sycosis       ...........

                                V. PAPULA.               .              H6
                                                                          117
Strophulus..........                118
Lichen..............-no
Prurigo.............

                               VI. SQUAM/E.                            133

Lepra,  scaly leprosy       .........           144
Psoriasis        •..........         "  , ,.-
Pityriasis       ......... 
Xll
CONTENTS.
VII. TURERCULA.
Lup.n
Elephantiasis Grfficoruin
Cancer
Moiluscutn
FratubtEsia
VIII. FURUNCULI
Fnrunculus
Anthrax
Pustula maligna
TAGE
 1G0
 lli-2
 172
 176
 178
 179

 180
 181
 182
 184
Diseases which appear with the Elementary Characters of almost all of the above
                                     orders.  .     .     .    •    •    •    .187
Svphilis.  Svphilide
ib.
Diseases which are severally Types of new and additional orders.
Pellagra
Purpura
Elephantiasis Arabum
Cheloidea
.  212
.  213
.  216
.  219
   Original or accidental unusual Stales of the Skin, not referable to Inflammation.

                                 ACHROA, or
Colourless state of the skin........     .     .  221
Leucopathia     ............
Vitiligo    .............
 ib.
222
                                DISCHROA, or
Discoloured states of the skin, (Maculae, Willan.)
Lentigo, Freckle     ......
Ephelis.........
Chloasma       .......
Ncevus     .     .    .    .     .     .        ■ .
 ib.
223
224

227
    Diseases of the Appendages of the Skin;  more propetly of the parts which
                            secrete and support these.
Alterations of the cuticle.  Iclhyosis      ........  231
Alterations of the nails    ...........  234
  Simple Inflammation    .     .     .    .  i  .     .     .     .     .     .    .   ib.
  0nych'a.............  235
Alterations of the hair...........  236
  Plica..............237
Useful formula?
239
Alphabetical index and table of synonyms
.   246 
A PRACTICAL COMPENDIUM
OP THE
DISEASES   OF   THE    SKIN.
                     INTRODUCTION.

  It is my purpose in the following pages to present a systematic
view of the diseases usually  regarded as belonging more peculiarly
to the skin.   It  is not my intention, however, to enter into a par-
ticular detail of the symptoms, treatment, &c., of every one of the
species composing this class  of complaints, many of them being of
such rare occurrence, that, in this country at least, their names are
all that are known to us. My great object will be to describe those
cutaneous affections which I have had  repeated occasion to study
myself, and which are perpetually falling under  the notice of the
practitioner.  Having had my attention particularly directed to this
order of diseases from an early period of my professional life, and
derived from my position during  the last sixteen years as head of
an  establishment of fumigating  baths,  unusual opportunities of
observing almost every variety of skin complaint in its  most dis-
tressing form, I hold myself  entitled to come before the public with
something like a systematic view of this branch of pathology, whilst
I present the results of my  varied experience in regard to  several
of the more intractable cutaneous  diseases, and offer some special
remarks on the therapeutic agents which I have observed to prove
of greatest avail in their treatment.
  It might indeed be made matter of astonishment that so little has
hitherto been done to secure uniformity of result in the treatment
of diseases of the skin—the  most accessible,  and the most imme-
diately under our control, it might be imagined, of all the infirmities
to which our bodies are liable.  But whilst almost every other par-
ticular  branch of pathology is now made part of the general plan
of education  pursued by the student, and afterwards followed up
by the practitioner, the  truth is,  that the diseases of the skin are
still almost totally neglected in  the  present plan  of elementary
instruction; and patients afflicted  with them, after having  been
made to pass  through a certain routine, from which they commonly
       5—b                                      g™ l 
2
GREEN ON DISEASES OF THE SKIN.
derive no benefit, are either after a time abandoned altogether, sent
off to some watering-place, Bath, Harrowgate, Leamington, <fcc, or
find  their way into the  hands of some empyric, to the great relief,
but infinite discredit, of the regularly educated surgeon or physician.
  I  feel assured, and know'that very different "results might  be
obtained in an immense majority of these cases.   In  England, we
may truly be said to have remained standing on the threshold of
the  beautiful  structure,  which  the genius of  our  countryman,
Willan, designed as a beacon for  our guidance, and a sanctuary
for our instruction, in this department  of medical science.  We
may indeed have amended a few of  the errors he committed in his
arrangement  of  cutaneous diseases, but we have added little  or
nothing to the stock of knowledge  he possessed  of their etiology
and pathology, and it might even^ be made a question, whether we
had not absolutely  retrograded in the views we  entertain of their
proper treatment.  All that has  been done in regard to the treat-
ment of this class  of complaints in  this country, of late years,
amounts  to a few  experimental  trials of certain  heroic remedies;
among which mercury,  arsenic, and prussic  acid, figure  in  the
foremost  rank, and endeavours  to  force ourselves into the belief
that  cutaneous diseases were uniformly  owing to some mysterious
and  indefinable affection of the digestive organs, nowise observable
in nine cases out often, in any derangement of their functions, but
for which the blue  or Plummer's pill and purgative medicines were
the  approved specifics.   One or other of these pills was  therefore
almost uniformly commenced forthwith,  and ample doses of purga-
tive  medicine were prescribed.   This course being persevered in
for  some  time,  and no  good resulting, as was  most frequently,
though perhaps by no  means invariably, the case, small doses of
the hydrargyri oxymurias, combined with decoction of sarsaparilla,
followed.   This failing in like manner, Fowler's arsenical solution,
and  perhaps decoction of dulcamara, were next recommended, and
these either proving ineffectual against the disease, or causing some
suspicious  and unpleasant disorder of the system', were in their
turn abandoned.   The patience of the physician, as well as of the
patient, (still truly patient in one, but no longer so in  each sense of
the word,) being now worn out, they usually parted company at
last, little satisfied with each other, the one lamenting  the obstinacy
of skin complaints, the other inveighing against the inefflcacy of
medicine, if not  against the ignorance of its practitioners.
   It is to the French physicians especially that we are indebted for
better and more rational views in regard to the pathology of the dis-
eases of the skin, as well as for the introduction and vindication of by
far the most powerful ulterior agent yet discovered in their treatment ■
I mean the vapour and fume  bath, and douche of different descrip-
tions, which, when properly administered  to  patients labouring
under numerous affections of the skin,  have often a singular and
most powerful influence on the progress and issue of these diseases.
   The whole of the initiatory and attendant symptoms of cutaneous
affections,  are those either of  acute or chronic inflammation.  We 
VIEWS GENERALLY ENTERTAINED.
3
have increased redness, uneasy sense of heat, some modification of
pain,  variously  characterised as itching, smarting, tingling, &c.,
and a certain degree of swelling, conjointly or separately, in every
one of them.  The immediate dependence of these diseases on an
inflammatory condition of the portion of skin immediately affected,
at least, is a circumstance of the  highest importance to be borne in
mind, inasmuch as it gives the clue to the whole plan of treatment
that can  be rationally pursued in regard to them.  In their acute
stages and accidental  paroxysms,  they are to be  attacked  by
general  antiphlogistic  means,  blood-letting, purging, low diet,
rest, &c, and  external remedies of the most soothing description—
tepid  baths, emollient fomentations, &c.   In their chronic stages,
again, general measures are commonly much less necessary and of
much less avail; the diseases then require to be assailed in their
immediate seats, by stimulating applications of different kinds, to
induce new actions—by the warm and sulphureous, the alkaline
and acid, water bath, the  hot air, vapour, and fumigating  bath.
Irritating washes and unguents,  also, of different kinds, then  come
into play; and  lastly, such  medicines  as powerfully modify the
constitution, sulphur, mercury, arsenic,  &c, and which seem occa-
sionally to prove beneficial on the principle  so  much insisted  on
by the greatest of all modern medical philosophers, John  Hunter,
the inability of the constitution or its parts to  support two orders or
kinds of action at the same time; these powerful medicines do, in
fact, occasion  new  diseases, during the  continuance  of which the
old ones have  time to get well.
  So  much for the essential nature or proximate cause of cutaneous
affections,  and for the leading idea that ought to guide us in our
treatment  of  them  generally.   This class of diseases, however,
occurs with such variety  of forms, shows  such dissimilar ten-
dencies,  and entails such  different consequences, and  therefore
requires  modifications of treatment so various, that attempts  were,
at a very early period, made to assist the mind in their discrimina-
tion, by the adoption of  some system of arrangement  or classifica-
tion.   I pass over those, in  general extremely objectionable in their
principles,  and even more useless in  their practical applications,
that were imagined previously  to  the  time  of Willan, who, pos-
sessed of a naturally acute mind, and deeply imbued with the
learning  both of ancient  and modern times, arranged the diseases
of the skin according to their primary  external characters, under
eight  orders :—1st,  Papulae ; 2d,  Squamae  ;  3d,  Exanthemata;
4th, Bullae; 5th, Vesicular;  6th, Pustulae;  7th, Tubercula; 8th.
Maculae.   This arrangement, with the modifications which time
and better information,  mainly  obtained through its means, have
introduced, is  that now adopted  in  almost all the medical schools
of Europe; and being based on  the elements of the diseases  them-
selves, not on the ever varying  products of  their  presence, or the
presumed  and often imaginary  remote causes of their origin, it is
found applicable in every stage of their  existence.
                                                 gm 1* 
4
GREEN ON DISEASES OF THE SKIN.
  The eight orders of Willin, in a different sequence, are charac-
terised in the following manner :—
  I.  Exanthemata,  or diffusive  inflammations,  by patches of dif-
ferent degrees of redness, of irregular and indefinite shapes, which
disappear  under pressure, and end in resolution  with  or without
desquamation of the cuticle; frequently  also in recession, or deli-
tescence, as it is entitled by  the  French writers.  This order com-
prises six genera: erythema, erysipelas, roseola, rubeola or measles,
scarlatina, and urticaria or nettle-rash.
  II. Vesiculae, or  vesicular inflammations, distinguished by the
formation of vesicles, or the effusion  under different  points of the
epidermis of a globule of serum, colourless and transparent at first,
but  which may subsequently become opaque, and even in some
measure purulent.   The effused fluid  of vesicles is either shed out-
wards, or is re-absorbed  into the system.
  This form of inflammation ends in a slight exfoliation of the
cuticle, or the  formation of a  few flimsy crusts  and  superficial
excoriations.   The order of vesiculae  includes sudamina or miliary
eruptions,  herpes,  scabies or itch, and  eczema.  Varicella and
vaccina-vacca,  chicken  pox, and cow pox, included in this order
by Willan, are here referred to the pustules, from their manifest
affinity to the  variolae, or  small pox tribe, as well as from the
nature of the eruption itself, which a careful inspection shows to  be
at least not vesicular in its characters.
  III. Bullae or blebs, also distinguished  by the effusion of a quan-
tity  of serous fluid under the cuticle, but  to a much  greater amount
than occurs  in the vesicular  diseases.   Blebs, indeed, are true
blisters, and are to be closely simulated by  the application of can-
tharides to the skin.  They commonly end in the formation of a
circumscribed scab of varying thickness, and  frequently very sin-
gular  shape.  The two principal genera of this  order are pem-
phigus and rupia.
  IV. Pustulae.  Pustules are characterised by the formation or effu-
sion of matter, either on the surface, or into the substance of the true
skin.  Pustules are followed by scabs of various kinds, sometimes
hard and horny, at other times friable and pulverulent, which com-
monly  cover indurations, excoriations, and even  ulcers.  Several
principal  of this  order  are  reckoned: variola, (including the dif-
ferent varieties of varioloid, varicella, or chicken pox,) vaccina or
cow pox,  acne or stone  pox> mentagra, ecthyma, impetigo  or
running tetter, and favus.
   V. Papulae are  small, firm, and solid  elevations, containing  no
fluid in their centre, which  are  generally  attended with itching of
the most violent description.  These end  in resolution with desqua-
mation of the cuticle.  They only seem  to ulcerate and present
scabs  when they  are lacerated by scratching.  Three principal
genera belong to this order: strophulus, the red  gum,  the white
gum, and tooth rash of nurses, lichen, and prurigo.
   VI. Squamae, inflammations of the  true skin, accompanied with
the  formation of small papular looking elevations of a red colour 
CLASSIFICATION OF CUTANEOUS DISEASES.          5
which are by and by covered  with squamae or lamellae of the
cuticle,  altered  in  its appearance,  having  become dry, white,
opaque, and commonly thickened;  these squamae are  commonly
very promptly renewed when they  are by any  means detached.
Three distinct genera of diseases are referable to this order:  pity-
riasis or  dandriff,  psoriasis  or  scaly tetter,  and lepra or scaly
leprosy.   Ichthyosis, included by Willan in the order of squamae,
is unaccompanied with any thing like diseased action in  the true
skin, or vascular and sensible tissues that have been described as
belonging to it by anatomists. The  cuticle, in this  peculiar state,
seems to be simply secreted of unusual thickness and colour, but in
consequence of no morbid process.
  VII. Tubercula,  distinguished by the occurrence of  small hard
tumours,  projecting in  different degrees  from  the  surface, and
imbedded in the substance of the skin.   These  occasionally end
in resolution, but much more frequently in partial suppuration and
destructive ulceration.  Five principal  genera are referred to this
order: lupus,  Greek  elephantiasis,  cancer, molluscum,  and fram-
boesia.
  VIII. Maculae.   By this term, is  understood a permanently dis-
coloured state either of a few particular spots,  or of the  whole sur-
face of the skin.  These  are not  commonly  attended with any
general disturbance of the system,  and are frequently  permanent
and congenital  conditions.  The albino  state seems  to  depend
merely on  the absence of colouring matter in those tissues that are
usually furnished with it.  Vitiligo is the term used to designate
the partial occurrence of the same  state.   Lentigo, ephelis or sun
spot,  chloasma or liver spot,  and naevus, appear to depend on the
contrary  condition, the increase or accumulation  of colouring
matter within the appropriate tissues of the skin.
  Besides  these eight orders, to one or  other of which  the greater
number of the  cutaneous  affections we are called  upon to treat
may be referred, several others would be required to be  added in a
complete work on the diseases of the skin, which should include
certain affections that seem  to  stand alone, each presenting cha-
racters sui generis, such as pellagra, purpura, Arabian elephantiasis,
and the  very important class of syphilitic eruptions which affect,
indiscriminately, almost the whole of the eight primary forms par-
ticularly enumerated.  Another  order would have to be  created, in
which furunculus  or boil, anthrax  or carbuncle, and the disease
called pustula maligna,  anthracion  or  Persian  fire, the  pustule
maligne of the French, might be included.  Further, orders would
have"to be established, in which alterations of the cuticle, such as
ichthyosis, and of the appendages of the skin, the nails and hair,
such as onychia and plica,  would be placed.
  A tabular view of the  diseases of  the skin,  and its appendages,
may be readily constructed according to these principles:— 
6
liREEN ON DISEASES OF THE SKIN.
Forms of Inflammation
  of the Skin, and Dis-
Exanthemata:  Erythema,  Erysipelas, Roseola,
  Rubeola, Scarlatina, Urticaria.
Vesicuue: Miliaria, Herpes, Scabies, Eczema.
Bullje: Pemphigus, Rupia.
Pustule: Varioli, (including  Varicella,)  Vac-
  cina, Ecthyma, Impetigo, Favus, Acne, Men-
  tagra.
  eases , which appear),   —&•-•
  under these severally.  PAPUL*:  Strophulus, Lichen, Prurigo.
                   '   Sciuamje : Pityriasis, Psoriasis, Lepra.
                      Tubercula: Lupus, Elephantiasis Grseca, Cancer,
                        Molluscum, Frambcesia.
                      Furunculi: Furunculus, Anthrax,  Pustula, Ma-
                     L  1'gna.

Diseases which appear
  with the  elementary
  characters of almost > Syphilis.
  all of the above or-
  ders.

Diseases which are se- ! p    °
  verally types of new )■ -r,,  ",  '• •  «  ,.
                     ! Elephantiasis Arabica.
and additional orders.
J Cheloidea, (Keloide, Alib.)
Original or accidental^ AcHRQA:  Leucopathia, (Albinismus,) Vitiligo.
  unusual states of the
  skin, not referable to
  Inflammation.      J

Diseases of the append-
  ages of  the skin ;
  more properly of the
  parts which  secrete
  and support these.
} Dischroa (Macul.e,  Willan):  Lentigo, Ephelis,
   Chloasma, Nssvus.
 Epidermis—Ichthyosis.
• Ungues—Onychia.
 Pili—Plica.
  The above arrangement which  I  have sketched out, is possibly
itself not free from objection, but at the present day it was impos-
sible  to  continue erysipelas among the bullae, where it was placed
by  Willan; it  is  too  obviously  an exanthematous disease,  the
phlyctaenae  or  blisters with which' it is so frequently accompanied,
being merely accidental to, and forming no necessary  part of, the
complaint.   Scabies, or itch, is also, beyond all possibility of doubt
a vesicular disease in its origin, and is therefore transferred from
among the pustules ; whilst cow pox invariably, and chicken pox
in ninety-nine cases out of a hundred,  decidedly pustular,  had to
be taken from  among  the vesicles, and classed with the pustules
Acne, or stone  pox, and its  worst form, if not another disease'
rosacea,  again,  are certainly  pustular, not  tubercular in their
origin ;  the lumps with which they  are  accompanied beino- conse-
quences of the  preceding inflammation, and showing no tendency
to ulceration, which is the distinguishing feature of true tubercles
These  affections are consequently translated to their proper place
among  the pustules, from  the objectionable  one  they  occupied
among the tubercles.
   Besides the specific  local symptoms which constitute  or  are 
            CONSEQUENCES OF CUTANEOUS DISEASES.          7

 assumed as characterising, the particular diseases of the skin, and
 which are constantly referable to some modification of acute  or
 chronic  inflammation, the functions of that portion at all events of
 the integument which is immediately affected, are always more or
 less disturbed.   The insensible perspiration is diminished or ceases
 entirely in the greater number of cases ; the oleaginous secretion
 that moistens  and keeps  the surface  supple in health, is no longer
 poured out; the formation of the cuticle  itself is modified,  for it
 becomes dry and rough, and dull, and dirty looking at least, if it be
 not more obviously changed.   From all these circumstances,  the
 skin  no longer communicates the peculiar  velvety sensation  of
 moist warmth, so pleasant to the touch, and so characteristic of a
 healthy state of its surface.
   Every acute form of cutaneous inflammation is further accom-
 panied by symptoms of constitutional or general disturbance of a
 greater or less degree of severity.  The usual symptoms of fever—
 quick pulse, hurried respiration, loss  of appetite, suspension of the
 secretions,  sleeplessness,  lassitude, &c.—precede and accompany
 the attack, in  a large proportion of these affections.   Such consti-
 tutional  symptoms  may  very  frequently be  traced to the simul-
 taneous affection of some internal organ, as of the  air-passages in
 measles, and of the serous membranes in scarlet fever; but it  is the
 digestive apparatus which, of all others, is believed to be most fre-
 quently and materially affected in this class of complaints, and this
 to such an  extent, as I have already  said, that the opinion is very
 currently entertained in Great Britain, of cutaneous diseases  being
 invariably the consequence of some disturbance of the stomach and
 alimentary canal.  Now, although in  acute diseases of the skin the
 functions of the digestive apparatus may be suspended or deranged,
 as those of all the internal organs of  the economy are, under such
 circumstances, my own experience warrants me in saying, and the
 testimony of the ablest writers of the day on cutaneous diseases,
 Rayer and  Biett, bears me out in my conclusion, that the  great
 majority of chronic and inveterate diseases of the skin occur  with-
 out the slightest disturbance of the digestive organs; nay, I have
 even  observed that those persons who had been afflicted for  years
 with affections of this nature, made less complaint of their stomach
 and bowels being out of  order,  than  is  usually done by valetudi-
 narians of all descriptions in this country.
  Attempts to trace the diseases of the skin to a disordered state of
 the functions of any other particular  system, have not been  more
 successful than they have proved in regard to  those of the digestive
 organs.  All that  can be said is, that  diseases of the  skin are fre-
 quently complicated with affections  of  different internal  organs.
 Such examinations as have been made of the  bodies of those who
 have  died while labouring under chronic affections of the  skin,  do
 not exhibit  morbid alterations of the lungs, stomach, uterus, &c,
 in other proportions than similar lesions are known to occur under
different  circumstances, and in subjects who  have fallen victims to
a hundred dissimilar diseases. 
8
GREEN ON DISEASES OF THE SKIN.
  The causes of the  diseases of the skin,  indeed, are in general
exceedingly obscure.   We can frequently trace vesicular, papular,
and other eruptions, it is true, to the agency of direct causes, such
as sudden transitions of temperature, the application of stimulating
and pulverulent substances to the skin, exposure to the bright light
of the  sun,  neglect of proper cleanliness, the use of sulphureous
and  terebinthinate  preparations,  &c.  &c.;  but  these  affections,
though agreeing in their forms and symptoms with one or other of
the orders  indicated, are so  transient in  their nature, or yield  so
readily to curative means, that they must needs be held essentially
different from the diseases of the skin that endure for  months or
years,  that prove so  rebellious  to all treatment, and that recur
repeatedly, after having to all appearance got completely  well.  In
the great majority of cases, diseases of the skin appear without any
evident  or  assignable reason;  they seem connected with  some
peculiar morbid condition of the system, which, in the present state
of pathological knowledge, is altogether unknown to us, save in its
effects.  This idea appears  to be strengthened by the indubitable
hereditary nature of many cutaneous affections : as features, form,
and peculiar aptitudes, descend  from  sire  to son, so do states of
constitution that predispose to particular diseases ; among others, to
affections of the skin.
  It is impossible,  however, to overlook the influence of climate
and local situation on the  development of many of this class of
complaints.  This  is much more  remarkable than that exerted by
trades or occupations.  Framboesia, or yaws, is a disease known
only on the coast of Africa, and in  the West Indies; radesyge seems
confined to Lapland and Finland ; plica to Poland ; pellagra to the
Milanese, &c.  Certain ages also give a predisposition to one rather
than to another form of cutaneous disease : erythema, strophulus,
and favus,  occur with greater frequency among children and the
youthful; chronic pemphigus and prurigo are scarcely seen except
among the aged.  Lastly, certain diseases of the skin are  eminently
contagious, such as scabies or itch, and favus, whilst others cannot
be  communicated either by contact or inoculation.   The specific
cause, however, under the influence of which the whole  of the dif-
 ferent diseases of the skin are developed, and by which they appear,
 now as vesicles, now as simple papulae, now as scaly papulae, and
 so on, is altogether unknown.
   The  diagnosis or distinction of  one disease of the  skin from
 another, is among the most  important items in their  study.  With-
 out this, how shall  we  prognosticate in  regard  to the probable
 issue of the disease?  what plan of treatment will it be proper to
 adopt? &c.  The power to distinguish each disease of the skin
 from  every other, supposes a previous acquaintance with  the whole
 or  greater  number of  these affections.   But the  neglect of  all
 attempt on the part of writers generally to  elucidate this" part of the
 subject, is probably one great cause of the indifferent information
 commonly possessed, even by medical men, of diseases of the skin.
 So long as  such general  expressions  as tettery, scorbutic, and 
                  DIAGNOSIS AND TREATMENT.               9

scrofulous  eruptions, scales, spots,  rashes,  &c,  were  the  most
definite terms employed when speaking of this class of complaints,
certainty as to the species of disease  described was unattainable,
and progress in the knowledge of its nature and mode of cure im-
possible.
  The first point to  be considered in each  particular case is, the
class of elementary lesion to which it belongs ;  in other words, to
discover whether the eruption be exanthematous, vesicular, pus-
tular, <fec.   This being done, the symptoms, progress, and appear-
ance of the species under consideration, must then be contrasted
with  the small  number of  such affections as show themselves
under the same, though variously modified, generic characters.
  When the elementary forms remain  untouched, and the eruption
has not passed its height, there  is little difficulty in assigning to a
particular case its proper place in the system, under the guidance
of experience,  in selecting  the  plan of treatment most likely  to
prove of avail, and in foreseeing the probable term and issue of the
disease.  But  when the malady has existed for some time, and the
original inflammatory form has given place to new and consecutive
alterations, the case is very different, and the diagnosis is difficult
in proportion to  the  extent and variety of these changes.  Never-
theless, the consequences of the  affection, the scabs  or crusts, fur-
furae or scales, sores and cicatrices, to which it gives rise, frequently
prove indices of what the primary nature of the affection was; and
further, it very rarely happens but that some traces of the elementary
form of the disease may be discovered in the circumference of the
place last affected.  When it happens that several elementary forms
are discovered in the same  or  nearly  the same situations, one will
always be found predominating, and  this, together  with the pre-
vious  history,  always enables  us to conclude which is to be held
the principal affection, which the accidental  malady that must  be
attached to the other as a complication.
  From this,  it  appears that the secondary consequences of the
diseases of the skin, the appearances and forms of scabs, squamae,
ulcers, cicatrices, &c, are points in the history of these diseases by
no  means to be overlooked.   These, together with due attention to
the seat of the eruption, to its progress, its colour, and general cha-
racters, are so  many data that  lead the practised eye to unerring
conclusions in regard to its actual nature.
   The treatment pursued in cutaneous diseases, the true end and
aim of all  preliminary  study of their characters, has necessarily
partaken of the obscurity that has hitherto prevailed, and that still
prevails, in regard to their nature.   I have already hinted at the
fact that a  similar routine  is indiscriminately followed  in almost
every one of these affections;  in France a course of bitters and
sulphur, in England one of mercury (in one or other of the infinite
variety of forms into which it has been tortured by ingenuity) and
of purgatives, are the approved and  universally received specifics ;
it matters not that disappointment again and again attends the pre-
scription of these medicines; the mind familiarised with a notion 
10
GREEN ON DISEASES OF THE SKIN.
is not often emancipated from its empire even with the evidence of
its falsity;  and then the diseases of the skin were held such rebel-
lious affections, that the medicines were generally excused for their
want of efficacy, and prescribed as before in the next case that
occurred.
   The chief diseases of the skin, I repeat, are essentially inflam-
matory affections, acute  or  chronic in  their nature, and as  such
require  to  be treated in the same way as inflammation generally.
In their acute stages, and when attended with symptoms of general
febrile  excitement, blood-letting must be practised, the temperature
regulated, the patient restricted to slops, kept quiet, and supplied
with plenty of cooling drink, whilst the return of the secretions
that are suppressed  is solicited by appropriate remedies.  A certain
number of  eruptive febrile affections, usually included in treatises
on the  diseases of  the  skin, measles,  scarlatina,  small pox, &c,
demand peculiar watching, and very cautious enforcement of these
general  measures;  these,  in fact,  are  diseases that  necessarily
require  to  pass  through certain  stages, that have a natural ten-
dency to recovery, and that in all probability could not be interfered
with to such an extent as to arrest them entirely in their progress,
with safety to the patient.
   The  acute stages of the  diseases  of the skin at  large, are not
commonly  of long duration ; they, for  the most part, soon get into
such a state as is unaccompanied  with  evident  febrile or constitu-
tional disturbance.  And now it is that the skill of the  true  phy-
sician appears, in adapting his means to the several forms of erup-
tion that present themselves  to his observation.  Far from finding
one  and the same  plan  of  treatment applicable to  the  whole, he
never fails  to lament that his remedies  are not  more various, and
that his  knowledge of the  effects of such as he commands is not
more intimate, in order  that  he might be enabled to vary his pre-
scriptions in conformity  with the infinite variety of modifications
he encounters in the degrees  and circumstances under which affec-
tions of the skin occur.   General blood-letting, where the state of
the constitution admits of the practice, will still be  found a prelimi-
nary measure of the greatest importance in insuring success  to
every step  of the after-treatment adopted, in a great  majority  of
cases.   The application  of  a number  of leeches to the healthy
integument,  in the immediate vicinity of the portion  affected,
either subsequent to and in aid of venesection, or as a substitute
for this measure when it is not deemed advisable, is also a piece of
practice that deserves  to be much more  frequently  followed than it
is in England.
   Dietetic  measures,  abstinence, strict  temperance, food of the
lightest kind, great regularity of life, and the use of some diluent,
such as barley water, veal or chicken broth, &c,  and rest, are all
frequently of great avail in treating the diseases of the skin; severe
fasting, the hunger cure  of the Germans, when  patients have the
resolution  to  encounter  the  self-denial and  painful  privations  it
implies, has frequently proved of signal advantage in many affec- 
THERAPEIA OF CUTANEOUS DISEASES.
11
 tions of the skin.   The cures accomplished in this way, however,
 are unfortunately not always permanent; as the strict regimen is
 departed from, and the strength returns under the influence of more
 nutritious diet, the complaints of the skin are very apt to recur.
   Purgative medicines,  not prescribed with a view of rectifying
 any latent disorder of the digestive  apparatus in particular, but as
 a means of modifying the state of the general system, or as deriva-
 tives  from  the  skin,.frequently prove of the  greatest service in
 chronic cutaneous affections.
   The mineral acids, and the alkalis, are medicines of great avail
 in many affections of the skin.   These have often a very excellent
 effect in allaying the pruritus that is so troublesome a symptom in
 many of this class of complaints.
   Sulphur is a medicine from among the  class of alteratives  that
 has long enjoyed a very  extensive reputation in the diseases of the
 skin.   Save in  combination, however, and as it exists  in  some
 mineral waters, it is not nearly so often prescribed by  the regular
 practitioner  now as it used once  to be.  This decline of faith in the
 virtues of the mineral, is in my opinion  mainly attributable to the
 improper way in which it has been prescribed.   In the  large doses
 in which it is commonly ordered, it either proves an aperient, of no
 more avail  than any other medicine of this class, or, according to
 the constitution, and if any degree of inflammation be present at
 the time, a stimulant that aggravates the local malady, and renders
 the general system more irritable.   In very small doses, and under
 circumstances favourable to its exhibition, it has in  my  hands
 proved a valuable alterative, and most gentle but efficient diapho-
 retic.   Sulphur is unfortunately an inelegant medicine, and cannot
 be taken to  produce these its most beneficial effects without per-
 meating  the whole  system,  and tainting very unpleasantly the
 cutaneous exhalations.  These  consequences are probably to be
 reckoned  among the causes  of its declining  favour.   They are,
however,  happily very greatly  lessened by its exhibition in the
way of vapour,  by  means of the fumigating bath,  which I shall
have occasion to mention by and by.
  The preparations of antimony, after having been long and almost
universally prescribed in the diseases of the skin, have fallen into
nearly total neglect,  and,  as  far   as  my experience goes, not
unmeritedly.  The same fate has  by no means yet overtaken the
 credit  possessed by  the  preparations of mercury,  at least in this
 country.   I  am  myself most decidedly of opinion that these medi-
 cines  are seriously abused, and just as undeserving of the universal
reputation they at present possess in England, as many of  the now
neglected articles that figure in the most conspicuous places in the
formularies and  pharmacopoeias of our forefathers.  I would not be
understood as saying that the preparations of mercury are altogether
useless in diseases of the skin; far from it, they are extremely valu-
able medicines in some cases; but they are not the general  specifics
in this class  of complaints, which they are imagined to be by many
otherwise very enlightened members of the  profession. 
12
GREEN ON DISEASES OF THE SKIN.
   Arsenic is another medicine of more recent introduction, which
 is much  and deservedly prized on account of its  influence  over
 many of the most inveterate diseases of the skin.   The same may
 be said of cantharides used internally.   Both of these medicines are
 among the most active that are employed in the practice of physic.
 They consequently require at all  times to be prescribed with the
 greatest caution, and their effects on the system watched with the
 strictest attention.   The moment unpleasant symptoms make their
 appearance, that  moment must the  exhibition of either of these
 medicines  be abandoned.   Administered in small and  only very
 gradually increasing  doses,  with these precautions, they  may  be
 taken for months without detriment of any continuance  to  the
 general health, whilst their beneficial effects on  disease are fre-
 quently great and permanent.  The iodine is another of the invalu-
 able items which  modern  science  has  added to the stock of medi-
 cines that  powerfully modify the constitution, and accomplish  the
 cure of different forms of disease that  were  formerly regarded  as
 incurable, or believed  to be only under  the influence of time.
  I  might add immensely to  this list of the important articles,
especially of the vegetable materia medica, that have been recom-
 mended as  internal medicines in  diseases of the skin; I might
 particularly mention the decoction  of sarsaparilla, of dulcamara, of
 mezereon  bark, &c.; but must refer to  the ordinary books on the
materia-medica for further  information.  Many  of these  ought
probably to be classed as simple diluents, the medicinal effects  of
several of them being certainly no  greater  than those of the like
quantity of grit gruel,  barley water, or lemonade;  and here I may
add a very few words  in regard to simple acidulated drinks, which
in my opinion deserve to be more generally prescribed than they
are in cutaneous  affections.   I have always  found them useful,
particularly among plethoric subjects, and  indeed  generally when
there were no symptoms of gastro-enteritic  irritation present.  By
many I know that acids in every form are strictly forbidden, but
for  what  reason I have still to learn; they do, it  is true, disagree
 with some delicate  stomachs at first, but  by continuing them for
a time, they will almost always be found to sit lightly at last.  The
good effects of lemon juice in the treatment of the disease entitled
scurvy is known to all, and since the introduction of this article
into the navy, the morbid phenomena comprised under  the  above
name are never seen.  In the pruriginous class of skin complaints
I have always found  acids, both  vegetable and mineral, of great
service, as well as the  alkaline  medicines which are much more
commonly prescribed.
  When we admit as physiologists the immense importance of the
functions of the skin to the maintenance of health, it is impossible
not to regard every means that tends to aid this  extensive  mem-
brane in its office, as a therapeutic  or curative agent of the first
consideration. Of all such means  baths of different descriptions
must undoubtedly be held as occupying the foremost rank.  Baths
are simple or medicated;  and the same  title is given to the vapour 
EFFECTS OF THERAPEUTIC AGENTS.
13
of water  and the fumes of different medicinal substances, as of
mercury,  sulphur, chlorine, &c. applied  in  a proper apparatus to
the surface of the body, or to any region of it, when, instead of bath,
the partial application receives the title of douche.
   The simple  cold or tepid bath frequently gives great  relief in
many diseases of the skin, greatly allaying the itching, and state of
nervous irritation that attend them, and thus  conducing to  the
ultimate cure.   I am inclined to  believe that the  value of sea-
bathing is greatly overrated in its effects upon affections of the skin.
I have seldom  known it accomplish any permanent  good in  this
class of complaints, and, on the  contrary, I have often heard  the
origin of different forms of skin disease  ascribed to  its influence.
Baths of the natural mineral waters have been long known to
prove very serviceable in many diseases of  the  skin.   These  are
susceptible of being closely imitated by art;  we can, indeed, in this
way produce more powerful and more  speedy effects than result
from bathing in the natural mineral springs.  The artificial  sul-
phureous  water bath, with a quantity of  gelatine  or fine  glue
dissolved  in it, is one of the  best baths known in many inveterate
diseases of the skin.
   But every form of water bathing  that has been  tried falls im-
measurably short of the  hot air and  vapour bath, in their imme-
diate and  powerfully curative influence on the great majority of the
diseases of the skin. The hot air and vapour bath may very properly
be spoken of together, inasmuch  as their effects on the system are
very nearly similar.   I am  in  the  habit of administering the hot
air bath to patients at first, at the temperature of about 98° Fahren-
heit, and of raising  it gradually in  the  course of from fifteen to
twenty minutes to 110°, and, if the full  effect of the bath is not
obtained, to 120°, or even 130° of the same scale.  The patient,
seated in the apparatus and  exposed to this degree of heat, is  only
sensible at first of a slightly increased but pleasant warmth.  With-
in a few minutes the expression becomes cheerful and  animated,
the eyes sparkle, the countenance looks florid and then flushed, the
pulse rises in frequency, and gains much in fulness, but  is soft;
the whole body,  the face (which of course is  not enclosed) as  well
as the other parts, next become bathed in perspiration, so  that the
sweat is seen standing in beads upon the forehead  and trickling
down the  cheeks.  The patient is now no longer sensible of any
increase of temperature, although  he is perhaps exposed  to a  heat
of  150°  of  Fahrenheit.   It  is  matter of  astonishment to  the
generality of persons how such a temperature can be borne without
injury. But it is in virtue of the same  physical  law  which fits
man to become  the denizen of  lands  within  the tropics and of
regions near the pole.   All increase of activity in the vital processes
of respiration and circulation, the  furnace and flue of the systemr
induced by stimulus of any  kind, especially by that of augmented
temperature, is accompanied with a commensurate increase in the
exhaling functions of the skin, and of  consequent evaporation from
its surface, a process the cooling effects of which are  familiar; the 
14
GREEN ON DISEASES OF THE SKIN.
strata of hot air immediately in contact with the body are success-
ively robbed of their excess of heat,  by the conversion  of  the
watery products of perspiration into vapour, in which  the caloric
that was sensible, and that tended to raise  the  temperature  of  the
body, immediately becomes   latent.  There is  consequently  no
means of cooling a hot air bath, say of 120°, down to its own tem-
perature 98°, so^effectual as the immersion within it of a  living
human  body, and this  is the reason that the temperature falls so
rapidly  in ill-constructed baths, and that it  has to be kept up so in-
cessantly even in those of the best construction.
  After the perspiration has appeared  about five or six minutes on
the forehead, the full effect of the bath has  been obtained, and  the
patient should immediately quit the apparatus.  If the stimulus be
continued longer, it is at the expense of  the agreeable feelings first
induced; a degree of languor and  exhaustion  succeeds to  these,
and patients then feel drowsy and disposed to  sleep.   But if  the
bath be  quitted when the effects are at  their height, a comfortable
degree of warmth  is experienced for  some hours afterwards, and
the activity of the body and the elasticity of the mind, far from
being diminished, are  on the contrary very much increased.   It
sometimes happens that the skin is  in so dry and unperspirable a
state, that a moderate degree of heat in the  bath fails to induce sen-
sible perspiration, and then, if the temperature  be allowed to  rise
rapidly, patients complain  of an unpleasant scorching  sensation.
In these cases, a little watery vapour let into the  bath by an appa-
ratus contrived for the purpose, gives immediate relief, and very
speedily induces the state of surface we  are desirous of obtaining.
  The  effects  of  a remedial  agent  of this power, it  may  be
conceived, require  to be closely watched, as its  use in the first in-
stance in diseased conditions of the system ought to be  cautiously
undertaken; and here I would most earnestly urge on my profess-
ional brethren the  necessity of their superintending in  person  the
effects of, at all events, the  first few  baths they may think it
advisable to  prescribe:  medicine is an experimental art at best, and
it is impossible to predict with certainty a priori what the precise
effects of any remedial  measure  may be.  From my  particular
position, I am enabled to speak with some  authority on  this  point,
and that which I make an invariable  rule of'doing myself,  I may
surely be excused  for wishing to exact of the profession at laro-e.
  Powerful therapeutic agents as are the simple hot air and vapour
bath in themselves,  their activity is  susceptible  of beino- further
increased, and their powers adapted to particular cases, by impreg-
nating them with certain substances, which, under the influence of
heat, arise in the state of vapour or  fumes.  Of these the most
important, in a general point of view,  is sulphur.  This is now
administered by a  process of sublimation;  the  mineral  is not  set
fire to and burned, as used formerly to be done,  and as is still prac-
tised in  imperfectly constructed fumigating apparatuses, by which
the patient is enveloped in an atmosphere of sulphurous  acid gas
and runs considerable risk of being stifled each time he adventures 
EFFECTS OF THERAPEUTIC AGENTS.
15
himself within  them.  In my establishment, although twenty sul-
phur  baths  are  frequently  administered every day  for weeks
together, no smell of burning brimstone  is ever perceptible.   The
mineral is raised unchanged, in a state of impalpable vapour, and
is thus applied in a form which we  may presume to be  the  most
favourable possible, either for exerting its influence on  the system
at large, through the medium of the absorbent vessels, or  upon the
skin immediately, with which it is brought into such intimate con-
tact.  Applied in this way, sulphur has certainly a greater curative
influence on many of the  inveterate  and  chronic diseases of the
skin, than all other means besides when added together.  Besides the
powerful excitement of the skin, accomplished by the application of
a high temperature to its surface, the sulphur fumes have the pro-
perty of causing a remarkable desquamation  or peeling of the
cuticle, to which probably some portion of their efficacy may justly
be attributed.
  Neither the hot air, vapour, nor sulphur fume bath  appears to
me  calculated to prove of any benefit during the more active stages
of several cutaneous diseases, such  as eczema, ecthyma,  impetigo,
&c. in all of which I have known the whole of them frequently
prescribed; I may go further, indeed, and say, that when symptoms
of acute local inflammation or of general febrile excitement are
present, these remedies are all alike improper; it is only when the
local actions  have  become languid, and when constitutional dis-
turbance or irritability has been subdued by  blood-letting, purging,
spare diet, diluents, &c., that it becomes reasonable in  point of
theory,  or  fair, as regards our therapeutic or remedial means, to
say nothing of our patients, to test the value of these  powerful
agents.
  Nor  is it  only as an instrument in the  cure of tangible and
definite diseases,  such as those  of the skin, that the hot air, and
especially the sulphur fume bath, is invaluable; in many shattered,
languishing, and, as they are entitled, worn-out conditions of the
system, in which there is little of positive and decided disease to be
detected, yet in which no function goes on as it should do to render
life  a blessing, instead of a state whose continuance is only marked
by ceaseless repercussions of pain, this simple remedy will often be
found  to  give  an  impulse to the flagging spirits  and  corporeal
powers, that permits the constitution finally to rally under the use
of appropriate medicines and well-directed general dietetic means.
When properly managed,  these baths, administered under such cir-
cumstances, are always satisfactory to patients.  I generally, indeed,
find valetudinarians inclined to anticipate too much  from  their
operation, and sometimes  hold it necessary to check unreasonable
expectations. Dr. R., aged eighty-five, for nearly thirty years senior
physician to the largest hospital in this country, had long been in
very  indifferent health, and affected with  a constant  nervous
shaking of the  arms, when he was  incidentally persuaded to try
the effects of the sulphur fume bath  for a troublesome impetiginous
disease  of the legs.   Under the use of this remedy, not only did the 
16
GREEN ON DISEASES OF THE SKIN.
affection of the legs gradually disappear, but  such a  signal im-
provement took place in the general health, that the doctor declared
he thought if he had known and made use of the sulphur fumiga-
tions sooner, he  might very possibly have  extended his life to a
hundred years.   In little more than a month,  he told me that
though for years he had scarcely been able to digest any thing, not
even a potato, unless boiled until  ready to fall to pieces, he now
thought he could eat a raw carrot without  inconvenience.   For
further information on  the use, efficacy, and mode of administering
fumigating baths generally, I  beg  leave to refer to the writings  of
Gales  of Paris,  Wallace of Dublin, Bardsley of Manchester, and
Decarro of Vienna especially.1
  The douche is a mode of applying vapour, or cold or warm water,
which is not so much practised as it ought to be.  A  column  of
vapour or of water, by a particular modification  of the douche
apparatus, is made to jet with force from a small  orifice  upon the
parts which  it is held advisable to expose to this influence.   This
kind of bath is best administered at one or other of the regular
bathing establishments; although for private use, when the cold or
warm  water douche is  wanted, a large garden  syringe  or engine
pump may occasionally be found available for the purpose.
  Baths of different kinds, which may be termed the most general
external means applied in treating  the diseases of the skin, are often
materially aided in their action by the simultaneous use of unguents
and washes  of different descriptions.   The oxides and salts of lead
have  been employed in every form of  outward disease from time
immemorial, and these  preparations are often found of considerable
service in allaying  irritation, and lessening the  quantity of the
morbid discharges  poured  out under  particular  circumstances.
The oxide of zinc is prescribed in  an ointment with similar views.
The acids alone, or united in excess to various metallic oxides, par-
ticularly mercury, are among the most valuable external remedies
we possess in this  class of diseases.  These, properly diluted, are
either used by way  of lotion, or, being  incorporated with lard or
simple cerate, they  are applied to  the diseased surfaces by being
rubbed on them immediately, or, by the medium of a pencil or a
pledget of lint dipped into them, they are employed as escharotics.
The nitrate  of mercury and the nitrate of silver are invaluable as
escharotics in destroying morbid growths, as well as in arresting
diseased and inducing healthy actions in parts  under  innumerable
circumstances.   Blisters are  even occasionally  employed  with
similar views, and at times with considerable success.  Dr. Rayer,
in his work  on cutaneous  diseases, informs us that he  has found
an ointment of the white precipitate almost a specific in  two of the
most  obstinate  of the  scaly eruptions, lepra  and  psoriasis.   The

  1 Mem. et  Rap. sur les  Fumigations Sulfureuses,  8vo., Paris,  1816.
Observ. on Sulphureous Fumigations, 8vo„ Dublin, 1820. Bardsley, Hos-
pital Reports, 8vo., London, 1820.   Obs. sur les Fumigations Sulfureuses
8vo., Vienne,  1819. 
EXANTHEMATA.                     17
salts of copper have also been frequently employed in affections of
the skin, and a solution of the sulphate makes a good  stimulating
wash.  Among the more recent of the external applications intro-
duced  in. the treatment of skin diseases, iodine is one of the  most
powerful and valuable.  An ointment of this  substance in impal-
pable powder, or in combination with the proto-ioduret of mercury,
is  one of the most efficacious applications to many  phagedenic
ulcers  resembling or  analogous to lupus, and occurring in persons
of scrofulous constitution.  I think it unnecessary to treat in, this
place,  apart from the diseases  in which they are  employed, of
several other articles of greater or less efficacy or  reputation in
different  forms of cutaneous affection.
     INFLAMMATORY  AFFECTIONS OF THE  SKIN.

                       EXANTHEMATA.

   The exanthemata, as a class, are acute inflammatory affections
 of the skin, for the most part accompanied with a considerable
 degree of constitutional disturbance, and characterised by a diffused
 redness  that disappears for an instant under the pressure of the
 finger.  The natural termination  of this order of diseases is in
 resolution, followed  by the desquamation of the cuticle.   In  the
 slighter  forms of the species it includes, the inflammation does not
 appear to extend beyond the most superficial parts of the cutis vera;
 in  the severer cases, however, it  not only implicates the entire
 thickness of this tissue, but even spreads  to the subjacent cellular
 membrane, which is then infiltrated and swollen.
   Erythema, Erysipelas, Roseola,  Rubeola,  Scarlatina, and Urti-
 caria,  are the diseases that appear'with these characteristics.
   Each  species of exanthematous  affection  is  distinguished  by
 symptoms in a great  measure peculiar to  itself.  A certain degree
 of languor, disinclination to food, and feverish sensations, usher in
 their attacks generally ; but in one the redness is evenly diffused,
 in  another it is  shaded in different  degrees,  now it  appears  in
 patches  very irregular in their outline, and again, in blotches very
 well defined.   A distressing sense of heat and tension, but little
 actual pain, and some degree of swelling, are particularly observed
 in erysipelas.   Scarlatina is remarkable for its vivid red ; urticaria
 for the unappeasable itching  that accompanies it.   The exanthe-
 mata, especially measles and scarlet fever, are very apt to be com-
plicated with inflammatory affections of some internal organ ; this,
       5—c                                       grn 2 
18
GREEN ON DISEASES OF THE SKIN.
indeed, is the chief hazard incurred in passing through these dis-
eases.  These are  the  only two  diseases of this  group  which
appear susceptible of being  propagated by contagion.   They are
peculiar, also, in only affecting individuals once during the course
of their lives.  The causes of the other exanthemata are frequently
traceable to irritation of the common integument, to  impressions of
cold, and the ingestion of indigestible, unwholesome, or poisonous
articles of food.
   Two of the exanthemata,  erysipelas and erythema, often compli-
cate different other  diseases  of the skin ;  but they are not liable to
be  mistaken for  any of these.   The antiphlogistic, with such
modifications as experience has  shown  to  be necessary,  should
form the basis of the treatment in this class of complaints;  and the
state of convalescence, especially  from scarlet fever and measles,
requires to  be narrowly watched, a host of dangerpus affections
being apt, without the greatest care, to make their attacks  at this
period.

            ERYTHEMA, OR INFLAMMATORY BLUSH.

   Erythema is the lowest degree of inflammation to which the skin
is subject.   It is distinguished by  the occurrence of red blotches,
slight, superficial, irregularly circumscribed, and of very  various
extent.  It is commonly essentially acute in its characters, lasting
from  eight  to  ten  or twelve days.  In a few rare instances it
assumes  the intermittent type, but the  affection  is then symp-
tomatic, and its continuance  depends on that of the  disease which
causes it.
   Erythema occurs with a considerable variety of character.  The
continued contact, and especially the friction of two  neighbouring
surfaces of the skin, as in  the groins, upper parts  of the  thighs,
axillae, neck, &c, of young children, and  even  of adults of delicate
complexion  and considerable embonpoint, are generally followed
by more or less of inflammatory  blush, and  sometimes by  very
smart inflammation, in which case there is an exudation of a faint-
smelling sero-purulent looking fluid, and some disposition to chap-
ping of the skin.   This is the erythema intertrigo of authors.  It
is attended with a very evident increase of heat and some degree of
smarting in  the parts affected, but  with little constitutional  disturb-
ance, although, when it is extensive, the pulse will get frequent.
   The cheeks of children when teething are often  observed to be
affected with one  or two bright  inflammatory patches; and any
accidental circumscribed cutaneous excitement, such as the sting
of a gnat, the presence of any other affection, or of a wound or  sore
as well as the distension of the integuments by anasarca, all cause
a superficial inflammation, accompanied with heat and  itching or
smarting, which have received different denominations by nosolo-
gists,  but which may well  be assimilated and placed  under one
head—erythema from irritation.
   Among females, and  young persons of both sexes, a number of 
EXANTHEMATA—ERYTHEMA.
19
small red spots, irregularly circumscribed, slightly prominent, the
size of a herring  scale or split pea,  and of a bright  red colour,
which soon acquires a purplish cast about their centres, and dis-
appears  almost entirely under pressure, are frequently thrown out
on  the  neck, breast,  arms,  and face—eryth. papula-turn.  This
affection is  generally preceded by some constitutional disturbance;
loss of appetite, sense of lassitude, slight fever, &c.   It is also an
occasional attendant upon attacks of acute  rheumatism, when the
spots, by running into  one another, often form clusters of consider-
able extent.  The elevations, within  from thirty-six to forty-eight
hours, sink to the level of the surrounding skin, and the red blush
then remains alone, to  disappear after  continuing visible from one
to two weeks.  This variety is sometimes observed with symptoms
of greater severity, when it has been entitled eryth. nodosum.  It
differs from the disease last  described by the larger size, the oval
shape, and longer continuance of the raised spots, which often seem
as if they tended to suppuration; an event,  however, which never
occurs, for after remaining distinctly  perceptible to the finger for
ten or twelve days, they subside, leaving bluish or yellowish stains
behind  them,  which also vanish in the course of a week or two.
A third variety, which has been denominated eryth. tuberculatum,
only differs from the  preceding two  in  being accompanied with
numbers of small, slightly prominent tumours between the suffused
papular  patches.   These  lumps vanish within a week, when the
inflammatory blush becomes rather livid in its appearance, and
continues for a week or ten days longer.
  The  patches of erythema, again, occasionally assume something
approaching to regularity of shape; their edges are sharply defined,
slightly raised above the level of the surrounding skin, and papular
both to the eye and finger—eryth. marginatum.  In other instances
they appear as complete rings, their centres seeming in every par-
ticular healthy—eryth. circinnatum.
  The  most extensive form of the  disease is that in which,  under
the influence of some constitutional  cause, the whole surface of the
body becomes suffused with a blush of different degrees of intensity,
accompanied with a feeling of heat and dryness of the skin, which
retains the print of the finger, or whole  hand, for a moment, when
applied to it—eryth. fug ax.  This suffusion sometimes assumes
the intermittent form; it is usually followed by  desquamation of
the cuticle, and, when it has been of long continuance, by the loss
of the hair.  A certain degree of inflammatory blush very frequently
accompanies a dropsical state of the lower extremities, and, indeed,
follows  upon any unusual distension, such as happens in the last
months of pregnancy, or any unwonted excitement of the skin, the
suction of the infant at the breast, for instance—eryth. Iceve.
  Erythema consequently appears to be frequently developed  under
the influence of external and evident causes, as well as to  follow
symptomatically in the train of certain and unknown but disturbed
states of the system.
  Erythema is not particularly apt, with a very slight degree of
                                                 grn 2* 
20
GREEN ON DISEASES OF THE SKIN.
attention, to be confounded with any of the other diseases of the
skin.   It  can only be mistaken  for erysipelas in  those cases in
which it is rather  extensive  and diffused;  the  circumscribed
patches of other and common varieties of the disease prevent any
error of the kind from being  committed;  and even  when it  is
widely spread, the evidently superficial character of the blush, the
absence of  swelling and  of  smarting  pain, and the speedy  and
happy termination of the disease,  all  proclaim its nature.  It  is
generally held  very possible  to  confound erythema with  roseola,
or summer rash ; but the two eruptions differ materially in colour,
the roseola  always exhibiting a pink or rosy hue,  which  is very
characteristic.  The patches  of erythema nodosum are  never so
well defined as those of roseola,  and differ from these as well in
this particular, and in their shade of colour,  as in the tumefaction
that attends  them.  I have never seen this variety of erythema,
save in females;  it  was always  in oblong, oval,  or longitudinal
shaped patches, in a line with the tibia.  Measles and scarlet fever
are preceded and  accompanied by  a set of symptoms that must
always prevent any mistake  in  the diagnosis between them  and
erythema ; to say nothing  of the crescent or semilunated forms of
the eruption of the one, and the raspberry-juice colour of the broad
stains or  blotches  that characterise the other.    The  papular
variety of erythema might be mistaken at  first sight for urticaria,
or nettle rash;  but the eruption of urticaria is raised  in  a much
greater degree above the general level of the integuments, is with-
out the violent tint of the erythema,  is accompanied  by such a feel-
ing of itching as is never experienced in this disease, and  is most
irregular and capricious in its  attacks.  There is  one species of
lichen, a papular  disease, with which this variety of erythema
might very well be confounded.   The distinguishing characters of
these will be better given when  we come to treat of the lichenous
eruption  in  question.   Syphilitic  blotches at times assume a good
deal of the appearance of  erythema in  one or other of its  shapes.
The continuance of the eruption, but above  all,  the  coppery or
grayish colour,  and the presence of various symptoms of lues, dis-
tinguish the venereal from the more simple erythematous eruption.
   The treatment of erythema is abundantly simple.   If the  dis-
ease arise from any evident cause of irritation,  this must be
removed; if from  constitutional disturbance, it will speedily sub-
side under the agency of means directed against the general symp-
toms.  Topical  applications are not commonly either necessary or
useful, except, indeed, intertrigo from the contact or friction of two
neighbouring surfaces of the  skin, when any weak  metallic wash,
as of the sulphate of zinc, or sulphate of copper, will be found very
effectual in suppressing the discharge and allaying the irritation.
This affection also  gets well by simply bathing the parts with tepid
water, and interposing something, a piece of fine rag, a little hair
powder, or some oxide of zinc, between them.  In the constitutional
varieties, the antiphlogistic regimen, spare diet, diluents, rest, <fcc.
a few gentle aperients, and, if the  symptoms run  high, and  the 
                  EXANTHEMATA—ERYTHEMA.  .             21

 circumstances under which  the  disease appears to be peculiar,
 such as the suppression of some  habitual discharge, the detraction
 of a little blood, aided by the use of the  tepid or vapour bath, very
 speedily and certainly accomplish a cure.
   In the years 1828 and 1829, an epidemic distemper, then and
 since entitled  acrodynia, was very prevalent in  Paris, one of the
 main  features of which was a peculiar  erythematous affection  of
 the hands, and still more of the feet.   These parts were of a crim-
 son red, which disappeared under pressure, and were either very
 painful, or very much deranged  in their sensations.  This local
 affection was  accompanied with general symptoms of considerable
 severity, headache, nausea, and retching, dull pains in the limbs,
 restlessness,  and,  very commonly, obstinate  diarrhoea.    Blood-
 letting,  and particularly the application of a number of leeches  to
 the feet and hands, together with the use of the simple tepid, alka-
 line, and vapour bath, were the measures that were found of most
 avail in this epidemic erythematous disease.

                     CASES OF ERYTHEMA.

   A young lady of fair complexion, of a sanguine but very nervous
 temperament, after considerable  exertion, found herself covered on
 the upper parts of the body and  neck, as well as over the arms,
 with red patches, varying in form and size, and  showing in their
 centres whitish and hard elevations, similar to gnat bites.  In some
 places  the patches,  from running together, produced a curious
 marbled appearance of the surface.   The complaint was attended
 with much inconvenience, but little  pain, and had existed more
 than a month when I saw the patient for the first time.  There
 was a regular aggravation of the symptoms every day ; the small
 whitish  tumours then became larger, and the redness of the other
 parts assumed a darker hue; the surfaces affected then looking
 shining, tense, dry,  and as if swelled, the red colour fading towards
 the healthy parts.   The patient had little appetite, and her nights
 were sleepless, or  her rest was  broken; the tongue was  covered
 slightly  with   grayish  mucus, and she  complained of extreme
 lassitude.  I advised a trial to  be made of the simple vapour bath;
 medicine did  not seem to be needed.  After the third bath, the
 patient fell into a profuse perspiration ; the skin then  became  soft
 and moist to the touch.   The parts which had been the seat of the
 disease became wrinkled and faded, the small elevations  gradually
 shrunk  away, and in ten days there were no traces of the disease
 left.
  A gentleman of a robust and sanguine temperament, aged about
 fifty, received a hurt in his back by a fall  from his horse, for which
 he was treated as usual in such cases.  Amongst the means resorted
 to, he had used the  essence of  mustard (spirits of turpentine) as an
 embrocation,  and to this  was attributed  a very general attack of
erythema, extending from the  forehead to the ankles, with which
 he was  immediately  afterwards seized;  but the back and parts 
22
GREEN ON DISEASES OF THE SKIN.
rubbed by the embrocation, and fretted perhaps by  the  close con-
tact  of  the  clothes, were those which were more particularly
affected with  this superficial  inflammatory blush.   Even  in the
midst of these, however, there were some linear spaces  where the
skin appeared almost as in health; neither, indeed, did the very
reddest  parts of  the skin look tense or swollen,  but simply as  if
they had  been stained with a red, and in some parts purplish red,
ink;   The constitutional derangement was not severe; but  there
was  still considerable depression of strength and  spirits,  loss of
appetite, small and frequent  pulse, tongue  covered slightly  with
mucus at the base.  The inflamed surface was uniformly extremely
tender, and  felt, as the  patient expressed himself,  as though hot
water had been  applied to it.  Gentle laxatives and diaphoretics,
with the use of the vapour bath  daily, proved sufficient to remove
all the symptoms  within a fortnight; the patient then, for a  short
time, took the nitric acid in small doses, as a tonic, and soon became
well.

          ERYSIPELAS,  ROSE, OR ST. ANTHONY'S FIRE.

  Erysipelas is a diffuse inflammatory affection, characterised by a
deep red colour of the  skin,  accompanied  with  heat, a peculiar
smarting but not very violent pain, and a certain degree of swell-
ing, which frequently extends  to the subcutaneous  cellular tissue.
The disease attacks portions of the skin of very various  extent,
and  has even, although very rarely,  been seen implicating the
whole surface of the body.  It usually begins after  certain initiatory
symptoms, which are those of general fever, such as languor, de-
pression, slighter or more violent shivering fits, quick pulse, thirst,
loss of appetite, &c. with a bright yellowish red suffusion in  some
small district of  the skin, from whence it spreads to the surfaces
around, which are perceived, by the elevation of their edges,  to be
somewhat swelled at the time they are attacked;  the red colour
disappears  very  completely under  the pressure  of a finger, but
returns  again  the  instant  this is removed; the disease is accom-
panied through  its whole  progress with a sensation of dry and
burning heat, and with  pain of a  stinging,  smarting, or scalding
character.  The cuticle  covering  the inflamed  surfaces  is fre-
quently raised  in  small,  and  sometimes  in larger,  blisters, or
phlyctenae, as they are  entitled, from the effusion of a quantity of
yellowish  serum under it; these  mostly burst on the very day of
their formation, when the fluid they contain, by drying, forms an
incrustation over the parts in this way affected.   Both local and
constitutional  symptoms keep  pace together, increasing in severity
for three or four days,  continuing unabated for  about the  same
length of time, and then beginning to decline; they do not,  how-
ever, appear to occur at any exact ratio of relative severity; the
constitutional  disturbance is  frequently  extreme, when the  local
disease is very moderate, and the local symptoms often run high
when but slight derangement of the general system is manifested. 
EXANTHEMATA—ERYSIPELAS.              23
   The most favourable as well as most frequent termination of ery-
 sipelas is in resolution, and the approach of this is indicated by the
 decline of the symptoms, after the time specified, the gradual disap-
 pearance of the redness, which  has  all along been verging more
 and more into a shade  of yellow, and the diminution of the heat,
 pain, and swelling, after which the cuticle begins to be detached in
 shreds of different sizes, according as the parts affected are naturally
 covered with  this membrane of a thicker or thinner substance.
   Erysipelas  is one of the diseases most liable to exhibit the morbid
 phenomenon entitled  metastasis; instead of running its course in
 one particular region, it frequently  quits this, and invades several
 others in succession, and very remote from each other, leaving little
 trace of its former presence, except  some slight discoloration of the
 skin, and a tendency to desquamate  in  the cuticle,—erysip. erra-
 tica.
   In some cases, the swelling that accompanies the disease is much
 greater than common, and this is in  consequence of no unusual
 degree of violence, either in the local  or general symptoms ; on the
 contrary, the former,  and especially the redness, are often less than
 wont; the skin is smooth and shining, pits readily on pressure, and
 retains the print of the finger for  a long time; a serous effusion to
 some extent has, in fact, taken place into the interstices of the skin
 and meshes of the cellular substance beneath  it,—erysip.  cedema-
 tosu.
   Besides  the form  of  erysipelas  and  its  modifications now
 described, there is another which seems to partake of the nature of
 phlegmon and erysipelas at  the same time,—erysipelas phlegmo-
 nodes, or phlegmonous  erysipelas.  In this  every symptom of  the
 disease is greatly aggravated; the skin and strata  of cellular sub-
 stance immediately under  it, are not alone inflamed; the deepest
 layers of this  tissue,  even  those  that penetrate between the mus-
 cles, and that  lie under the  aponeuroses, participate  in the morbid
 condition;  there is very violent burning pain, extreme redness, a
 great degree of swelling, and a brawny feel of the  parts affected.
 The constitutional symptoms, at  the  same time, run so high, that
 the life of the  patient  is brought into jeopardy.  This form of the
disease rarely  ends naturally in resolution.  On the  fifth  or sixth
day the pain becomes pulsative in its character, the redness grows
less and appears more circumscribed, but the swelling increases and
acquires a doughy feel, the patient has then a shivering fit  or two,
and from a state of excitement sinks rapidly into one  of exhaustion,
 —the disease  has terminated  in suppuration ; abscesses  often of
great extent are  formed, which, being opened either naturally or
artificially, a  considerable  quantity of laudable pus, mixed with
shreds of mortified cellular membrane, is discharged.  Nor is  the
disease now near a close; all its consequences have to be repaired;
extensive solutions of  continuity to be restored, excessive discharges
of matter to be endured, &c. and this by a constitution exhausted
in a struggle with one of the most  violent of all the diseases that
assail life. 
24
GREEN ON DISEASES OF THE SKIN.
  The disease sometimes appears with  a character of still  greater
intensity, and with tendencies even more unfavourable than those
that have just been described.  Within two or three days the local
symptoms attain their maximum of intensity, and the patient, deli-
rious and burnt up with  fever, appears to suffer the extremity of
distress;  by and by the inflamed skin begins to look livid, and then
gray, and is covered with phlyctenae full of sanguinolent serum ;  it
next loses its sensibility, and whilst abscesses are formed  under-
neath, a portion of integument, and a quantity of subjacent cellular
membrane, greater or less  in extent, are stricken with gangrene.
The sloughs in this case  are tardily detached, and the  injuries oc-
casioned repaired with extreme  slowness.  Patients, indeed, most
frequently sink under the disease at last; their strength not enabling
them to bear up against the exhausting influence of extensive sup-
purating surfaces, and the  absorption of pus into the system, by
which  the blood is  poisoned, and life is attacked from its  centre.
This gangrenous species or form of erysipelas, as it has been
entitled, seems to be induced as well by the violence of  the  disease
as by the aponeurotic sheaths causing a kind of strangulation of
the inflamed tissues within them ; it is consequently more frequently
observed  occurring in the feet and hands, where these structures
are so abundant, than any where else.
  Erysipelas is accompanied  with peculiar symptoms, and partakes
in a greater or less degree of the  characters of one or  other of these
two principal forms  of the disease, according to the region in which
it is evolved.  The  disease is more frequent  in the face, perhaps,
than in any other part of the body.  Here it is distinguished by the
great degree of swelling that attends its progress : the lax tissues of
the eyelids, lips, cheeks, ears, &c. are soon so  much loaded, that the
features are no  longer recognisable.   In this situation it  is very
constantly  accompanied  with violent headache, sleeplessness  and
rambling, and slight delirium during the night;  the disease,  too,
seems particularly liable to recede,  when the face is its  seat, and in
this case  to be followed by an inflammatory affection of the brain,
or its membranes.
   When the hairy  scalp is affected, the disease  has generally a
good deal of the phlegmonous character, and the whole ol" the symp-
toms run high; there is,  however, no great degree of redness visi-
ble ; only the scalp  is excessively painful  to the touch, and the
swelling is great.  The cellular  membrane under  the  integument
appears to be the principal seat of the inflammation, and accordingly
is frequently affected with suppuration and  gangrene, whilst the
skin itself  almost invariably escapes ;  a  circumstance  which  is
undoubtedly owing to the mode in which the scalp is supplied with
blood-vessels:  these have not to  traverse the cellular substance in
minute branches to reach this part, as they must to gain the skin in
general, but wind in  large trunks immediately under and are dis-
tributed to it in particular.
   The inflammation  which  often  attacks the breasts of women
a few days after delivery, has many of the characters of phlegmonous 
EXANTHEMATA—ERYSIPELAS.
25
 erysipelas.  The inflammation of the skin, however, is a secondary
 rather than a  primary affection  here, the mischief being usually
 begun in the  lactiferous ducts, called into unwonted action and
 over-distended with milk.
   Erysipelas, when it attacks the  extremities, is more frequently
 accompanied with serous symptoms than when it is developed on
 the trunk or head.   When the inflammation extends among the
 fasciae and tendinous sheaths  of the arms  and hands, or  legs and
 feet, it occasions constitutional symptoms of greater intensity than
 are seen under almost any other circumstances.
   Erysipelas of the scrotum and penis is remarkable for the great
 degree of oedematous swelling that usually attends it.
   Erysipelas frequently prevails like  a pestilence in hospitals and
 other situations where many persons  are crowded  together.  The
 slightest operation cannot then be undertaken without vexation  to
 the surgeon and hazard to the patient.  In lying-in hospitals many
 infants  are  lost through an erysipelatous affection, which extends
 from the umbilicus to the parts around.
   The  causes of erysipelas are  generally  very  obscure.   Even
 when we see the disease following trifling injuries, as  it often does,
 [traumatic erysipelas,) we know nothing of the state of constitution
 which renders individuals liable to such a consequence.  Almost all
 seem open to an attack  of the disease, at one time  or another, but
 the intemperate, and those who, without  being held  deserving  of
 this title, consume considerable quantities of fermented liquors and
 ardent  spirits, are  the usual subjects of  the disease in  its most
 aggravated forms.  The loaded  state of tongue,  nausea, and inap-
 petence, with  which the appearance  of the disease  is  always
 associated, have led to  the opinion very commonly entertained  of
 its being dependent on a deranged  state  of the  digestive organs.
 Erysipelas would seem  to  be  more frequently encountered during
 the spring time and autumn than at other seasons.
   It does not seem  possible, with the most ordinary attention,  to
 confound erysipelas with any other affection of  the  skin, unless,
 perhaps, in some  very slight case, when  it might be  mistaken for
 erythema.   The distinguishing features of the two affections have
 been already given  under the latter head.
   In the slighter cases of erysipelas, the treatment may be restricted
 to rest in the horizontal posture, especially if the disease be  seated
 in either of the lower extremities, the use of some mild diluent, and
 observance of the antiphlogistic  regimen.   If the  disease appear
 with symptoms of greater severity, and show a disposition  to ex-
 tend widely, as well as more deeply than the  common integument,
 and complaints be made at the  same time of a hot  and parched state
 of the surface at large, of thirst and clamminess and a bitter taste in
 the mouth, together with a hard  and frequent pulse, it will be pro-
per to  let blood,  in quantity proportioned to the strength  of the
patient, and  the intensity of the general symptoms: timid bleeding
does no good;  to be serviceable it must be practised boldly.  The
parts  immediately  affected are  at  the same  time to be  bathed 
26
GREEN ON DISEASES OF THE SKIN.
repeatedly with cool or cold washes, and for this purpose there is
nothing better than plain water, and internally some aperient medi-
cine is to be given, until the bowels are completely unloaded.  On
the following day a number of leeches may be very advantageously
applied beyond the boundaries of the  inflamed circuit, as a means
of securing the good effects of the general depletion ; this will often
be found an auxiliary of such importance and power as to render
additional energetic measures unnecessary.   If the antiphlogistic
regimen and absolute  rest were requisites in the simpler cases of
the disease, they become, it may be presumed, doubly needful when
the attack is severe.
   It was an old practice to prescribe an emetic at the  beginning of
most diseases, and especially of erysipelas;  and this measure is so
frequently followed by an improvement in the symptoms  of this
disease, that it is always worth while  to try it.   A combination of
the ipecacuanha and tartrate of antimony seems to answer best.
   Some successful attempts have  recently been made to arrest  the
progress of erysipelas by touching  the  parts immediately around
the seat of the disease with the lunar caustic.  The circuit proposed
to be so cauterised is wetted lightly with a sponge, and the caustic
in substance drawn steadily over the surface once or  twice.  This
application  has  proved especially useful in bounding the erratic
form of erysipelas.
   In phlegmonous erysipelas the most energetic  measures are re-
quired from the  beginning.   General  and local  blood-letting in
proportion to the strength and constitution of the patient, are pri-
mary steps that must never  be neglected.  The parts affected  are
at the same  time to be put repeatedly, and  for long periods, into  a
tepid bath.  The general warm bath will also be found an auxiliary
of some importance.   An emetic and some active purgative medi-
cine are  at  the same  time to' be exhibited by the mouth, and the
patient is to be strictly kept to the antiphlogistic regimen.  If under
this treatment, the local inflammation  and general symptoms show
a tendency to decline, the plan may be followed up with a prospect
of the  disease being finally resolved through its agency.  But if, on
the contrary, the fever continues unabated, and the redness and
swelling go on increasing, experience has  amply proved that the
practice first recommended by my friend Mr.  Copeland Hutchison,
of making one or more incisions through  the whole thickness of
the inflamed skin and cellular substance down to the  fasciae, is the
best that can be followed.  By this  means  the over-loaded vessels
are most effectually depleted, the fibres  that  were on  the  stretch,
and the parts that were suffering  strangulation, are alike set at
liberty, and a drain is established, that gives vent to effused serum,
and to such collections of purulent matter as may chance to exist.
But it is by no  means necessary to wait till abscesses have been
formed, or gangrene has taken place,  before resorting to the prac-
tice in question :  there are no means  more  effectual than free inci-
sions in preventing these mischiefs; and if they have taken place
we have no method by which the labour of  separation that must 
EXANTHEMATA—ERYSIPELAS.
27
then be undertaken by the constitution can be better assisted, than
by establishing a free outlet for pus, sloughs, &c.  Should we have
been in time to prevent the sloughing and the extensive purulent
deposits that so constantly follow  phlegmonous  erysipelas  in  an
aggravated  form,  resolution takes  place  as  usual:' the swelling
abates, the limb shrinks to its original size, and the incisions that
seemed most formidable gaps in the midst  of  the brawny and infil-
trated tissues soon appear as superficial cuts, scarcely implicating
the skin, which contract and heal rapidly.  Should sloughing and
purulent deposition have unfortunately taken place, the strength of
the patient must be supported during the long and tardy process by
which sloughs are thrown off, and extensive  suppurating surfaces
are consolidated.  A quantity of animal food, and, if the stomach
will bear it, some sound fermented liquor, such as porter, or  an
allowance of wine and water, with  opiates to allay irritation, then
become proper; and,  the first  accidents  happily surmounted,  if
diarrhoea and hectic  do not disturb the reparative processes, patients
commonly do well.
  What has now been said in regard to  the treatment of phleg-
monous erysipelas generally, is more particularly applicable to the
disease affecting the  limbs.  The same  plan, too, may be enforced
in those cases in which the  scalp is the part implicated.  Here a
free incision at an  early stage of the disease produces the very best
effects, and,  of itself,  frequently proves adequate to the cure of the
disease.
  Compression, which has been spoken  of as a means in the cure of
phlegmonous erysipelas, is only really useful in the after-stages of
the disease ; it  is more admissible, is indeed a valuable remedy, in
the variety of erysipelas which  is  attended with symptoms of less
acuteness generally, but with a much  greater degree of cedematous
swelling than  usual.
  The more indolent and lingering forms of erysipelas, especially
of the lower limbs, attended with  much cedematous swelling, are
always greatly  benefited by the  hot air, and  still more by the sul-
phur fume bath.   The disposition  to attacks of this kind exhibited
by some individuals, may be got rid of  entirely by the occasional
use of this means.   I have even seen very acute  attacks of erysi-
pelas arrested in their progress and resolved by the use of the sul-
phur fume bath;  and this  is a  means I am now in the constant
habit  of resorting to, after the first violence  of the symptoms has
been subdued by the enforcement of the antiphlogistic system and
measures of general  depletion.

                     CASES OF ERYSIPELAS.
  A lady, aged forty-five, very pale, and very fat or fleshy, but evi-
dently of a weak and flabby constitution, had been subject to attacks
of erysipelas twice and often three times  a year, for several years.
When called to see this lady for the first time, October 12th, 1831,1
found her labouring  under one of her  usual attacks.  One eye was 
28
GREEN ON DISEASES OF THE SKIN.
 completely closed, and the other very nearly so, from extensive and
 general tumefaction, attended with much diffused redness of every
 part of the head and face ;  febrile  symptoms  were running high ;
 the pulse was quick and small, the thirst urgent, headache distract-
 ing, bowels constipated, and the skin dry and burning;  she could
 not bear the light, but did not  complain of any great  degree  of
 pain, though the features were  extremely  disfigured by the swell-
 ing, and the patient's whole appearance was that of a person greatly
 distressed.   This lady had numerous enlarged glands in the neck;
 and the head had for months  been drawn  to  one side by constant
 pain and swelling, apparently of the muscles of this region.  These
 glands were now more swollen and painful than  they had  ever
 been during any former attack;  indeed, the general symptoms, she
 assured me, were also severer than they had yet been, and this she
 ascribed to the attack having come on  after a cold caught whilst
 under the influence of mercury for her general constitutional ail-
 ments.  One knee was also enlarged, and a collection of fluid could
 be distinctly felt within the capsule.
  I directed a purgative dose of calomel immediately, to be followed
 up  by diaphoretic  medicines and diluents,  and the patient was
 enjoined to  keep her bed.   October 14.  The bowels  had been
 freely opened.  The skin was still dry and unperspiring, and the
 patient very irritable.  The swelling about the eyes was somewhat
 diminished, but the  ears, and parts about the mouth and lower
 region of  the face, were very much puffed, and the patient now
 complained  of some difficulty of swallowing.  Four leeches were
 ordered to be applied behind each ear, and the aperient to  be re-
 peated.  The phlegmatic and sluggish temperament of this patient
 would, I felt persuaded, enable her to bear the excitement of a fumi-
 gating bath, even at this stage of the erysipelas under which she
 laboured;  and my experience of the good effects which in such
 cases followed  the general stimulation of the  vascular  system
 through the medium of the skin, and the restoration of the proper
 functions of this extensive membrane,—to the suppression of which,
 and the unequal distribution of  the circulating fluids, I attributed
 first the local disease, and  next  the general distress under which
 this patient suffered,—I had no hesitation in recommending a sul-
 phur fume bath, as the speediest, safest, and best means of cutting
 short the complaint.  Accordingly, on the  15th, the patient took a
 fume bath for the first time.  She felt so much relief immediately,
 that she herself proposed repeating the  remedy in  the evening of
 the same day.  I, however, advised her to wait till the  17th, when
 she had another bath, and this was taken for the next few days in
 succession, when she felt herself perfectly recovered.  By continu-
 ing the baths for some little time longer, the glandular swellings in
 the neck disappeared ; the enlargement  of the knee also  subsided,
 and the fluid it contained was reabsorbed.  This patient has since
 enjoyed better health than she had done for a long time previously,
and up to  the present date (December 1834) has remained free from
 her old enemy, erysipelas. 
EXANTHEMATA—ROSEOLA.
29
   The use of the sulphur fume bath in such a disease as erysipelas
 may appear bold practice ;  I am satisfied both of its efficacy and
 perfect safety.  The first case of the kind,  indeed, which  I  saw
 treated in this way, caused me some alarm for the patient's safety,
 but also made a powerful impression on my mind.  It was that of
 a gentleman about forty years of age, labouring under an attack of
 erysipelas of the head  and face, of the  most violent description :
 both eyes were buried in the head, and every part was so  much
 swollen, as almost to obliterate all resemblance to the human coun-
 tenance ;  the patient seemed farther to be in a half stupified or
 comatose state.   I learned that he was subject, once or twice a year,
 to attacks of this kind,  mostly from exposure to  damp  cold, occa-
 sionally from errors in diet, but sometimes also from no evident or
 imaginable cause.
   I saw this gentleman, in the state  I have described, placed in a
 sulphur fumigating  apparatus by the  foreign physician, whose
 patient he was, and, I  confess, not  without  some anxiety for  his
 safety; but the result soon dissipated my fears,  for the general  per-
 spiration had set  in but a few minutes, when the swelling  of the
 face seemed to subside, and the features  to acquire something more
 of relief.   Next day, the patient would have been readily recognised
 by his  friends, and his articulation, from being perfectly unintel-
 ligible, had become distinct.  The baths were continued every day;
 on the fourth day  afterwards, I met  the patient  in the  street,
 walking as if he had had nothing the matter with him.
   During the last twelve years, cases of this kind have been familiar
 to me, and now that I reflect on the power which the hot air and
 sulphur fume bath possess in restoring at once the proper functions
 of the skin, I no longer  view their effects with  any portion of the
 doubt or wonder which mingled at first with my speculations  on
 their modus operandi.

                           ROSEOLA.

   This is a slight and  transient exanthematous eruption, distin-
guished by the bright rosy red colour of its variously shaped patches,
which  are  not raised above the general  level of the integuments,
and  which are preceded by febrile or other symptoms of constitu-
tional disturbance.
   From this definition it is evident that roseola  must bear a strong
affinity to erythema ;  and many authors have owned themselves at
a loss  to  distinguish  at all times between the two  groups, which
indeed appear to be kept distinct at the present day, merely through
deference to the authority of Willan.
  Roseola is always an acute disease, and is a common symptom of
some irritation of the system, the nature of which is frequently very
apparent.   In young infants whose stomach and bowels are out of
order, or who  are teething, an eruption of numerous and crowded
deep rose  red spots or patches, from a third  to a quarter of an inch
in diameter, and of a circular shape, which continue  vivid between 
30             GREEN ON DISEASES OF THE SKIN.

twenty-four and thirty-six hours and then vanish, is a very com-
mon occurrence ; this is the ros. infantilis of authors.
  Another variety of roseolar efflorescence, which seems to hold a
kind of middle position between erythema and an eruption presently
to be described, (urticaria,) usually makes its appearance during the
heats of summer, having been preceded for some days by general
symptoms  of some severity,—ros.  cestiva.   This eruption com-
monly first appears  on the face, neck, and arms, and spreads from
thence within a day or two  to the  rest of the body; it is accom-
panied with a very considerable degree of itchiness, and often with
so much fever and difficulty in swallowing, from having extended
to the mucous membrane of the pharynx, that it is at one time  pre-
sumed to be measles, at another, scarlatina.  This state of things
commonly continues three or four days, when  the eruption disap-
pears without any evident desquamation.  The whole progress of
the  affection is however extremely irregular, sometimes appearing
with little  or no initiatory or  accompanying fever, at  other times
with a great deal of both ; now disappearing suddenly for a time,
to return after a brief interval, and again vanishing altogether.
  An eruption  presenting external  characters nearly  similar to
those of the one just described, frequently appears in the autumn,
whence it is characterised as ros. autumnalis.   Children are its
usual subjects.   It commonly shows itself on the  arms  in distinct
circular or oval-shaped spots of a  dusky red colour  from half an
inch to three quarters of  an  inch in diameter.   It is  a slighter dis-
ease than the summer variety.
  Instead of appearing in round patches, the eruption of roseola
occasionally shows itself under the form of distinct rosy rings,—ros.
annulata.  These rings gradually enlarge from the  dimensions of
a small split pea, in their outer circumference, which they present
at first, till they approach an inch  and a half in the  round, which
encloses in every instance a  circular portion, greater  or less in ex-
tent, of integument that appears perfectly healthy.   Two or three
of these rings may frequently be seen one within the other.   An-
nular roseola is principally observed upon the abdomen and lumbar
regions, on the buttocks and along the thighs.
  Several other varieties  of  roseola have been described by writers
on cutaneous affections, which appear to be nothing more than an
erythematous blush accompanying various constitutional affections ;
such are the roseola rheumatica, which is frequently seen along
with acute rheumatism;  ros. febrilis, with fever of a continued or
typhoid  character;  ros. variolosa, and  ros. vaccina, with the de-
velopment of the variolous and vaccine pustule after  inoculation.
  Roseola, with the characters of  the  variety entitled cestiva, is
occasionally seen reigning epidemically  during very hot summers.
Children and women of delicate complexion appear to be most sub-
ject to its attacks.
  The immediate causes of  the disease are often evident enough ;
in numerous instances however they are  very obscure.  The dis-
ease has never been suspected  to be contagious; it attacks indivi- 
EXANTHEMATA—URTICARIA.
31
duals repeatedly in the course  of  their lives; some  even show a
kind of susceptibility to this disorder.
  Roseola is very apt to be mistaken both for measles and scarlet
fever ; indeed it might be made a  question whether  several of the
varieties of exanthematous eruption  thus  entitled might not  with
propriety be referred to the head of anomalous measles.  Roseola
however is in  general distinguished  from both measles and  scar-
latina  by the  more regularly  circular shape and  circumscribed
appearance  of its patches, which  are  of a deep  rose  red colour,
larger than those of measles, and smaller than those of scarlatina.
The constitutional symptoms of these  two affections are peculiar,
and should always be attentively  considered in coming to conclu-
sions in regard to diagnosis.  There are several  other diseases of
the skin that affect the annular form,  as  well as roseola; but as
they belong to groups characterised by elementary lesions of dif-
ferent descriptions, there  is no risk of confounding the one with the
other, they have but the annular form of their patches in common,
nothing more.
  Roseola, save as a symptom  of constitutional disturbance, might
be safely left to itself.   When it is symptomatic of another affection,
it is towards this that the chief attention is to be turned.  A good
application to  the patches of roseola  is  the tincture of cantharides,
rubbed on with the point of the finger  three or four times a  day;
it does not vesicate, but causes  the spots to fade more quickly than
they do when  left to  themselves.  In  every case, rest, the use of
some mild diluent, and abstinence  from all animal and heavy arti-
cles  of food, will be  proper.   It may happen, however, that the
symptoms run so high, and  the disease is accompanied with such a
degree of itching and  restlessness, that more active measures become
necessary.  The effect of a smart purge may then be tried ; and
if this should  fail, the detraction of a few ounces of blood from the
arm will certainly give relief.   The course of these  roseolar  affec-
tions may also be cut short by the use of the hot air or sulphur fume
bath, and the  constitutional peculiarity that  renders  individuals
habitually subject to such complaints,  be  entirely removed by the
same means.

                 URTICARIA, OR NETTLE-RASH.
  Nettle-rash,  as its name implies,  is a  non-contagious exanthema-
tous eruption, characterised by.prominent patches, or wheals of
various sizes  and irregular shapes; in the majority of instances
extremely transient, usually paler, although they are  in some  cases
redder, than the  integuments  at  large, and always accompanied
with a burning and very annoying kind of itchiness.
  Nettle-rash  very often appears as an  acute affection, lasting for a
few days only ;  but in other instances of still more frequent occur-
rence, it continues for  months, and sometimes even for years, a fresh
eruption of wheals occurring as soon as the old ones begin to decline,
with the characters therefore of an inveterate and enduring disease. 
32
GREEN ON DISEASES OF THE SKIN.
  This disease attacks individuals of all ages and constitutions, but
children, the youthful, and females, especially those of nervous and
sanguine temperaments and  fine skin, seem more peculiarly liable
to its invasion.  It would appear to be more prevalent during spring
and summer than in autumn and winter.
  Nettle-rash is  the  cutaneous  eruption which of all others may
most frequently be traced to  its causes, among the most frequent of
which is the ingestion of some  particular article of food, such as
shell-fish of different kinds,  lobster, shrimp, crab, &c.  mussels, bit-
ter almonds, mushrooms, cucumbers, raw salad, and even oat-meal,
vinegar, and honey;  many  medicines, such as  turpentine, balsam
of copaiba, &c.—one or other of these substances taken into the
stomach, in ever so small  a  quantity, by certain predisposed indi-
viduals, always occasions the disease; nay, so susceptible are some,
that the pressure of any part of the clothes, or the slightest pinching
or rubbing of the skin, is shortly followed by  the evolution of a
prominent  itchy wheal.
  Urticaria is  extremely irregular in its progress and general symp-
toms,  in one case appearing  with all the characters  of a local dis-
ease, in another accompanied by constitutional symptoms, even of
great severity.   In one case the eruption  appears once, and, after
continuing for a few hours, vanishes finally; in another, a number
of wheals  are evolved repeatedly  for several successive days or
weeks, with but short pauses between each attack; in a third the
disease disappears for a time, but recurs at intervals for months and
even for years.
  The most common and striking form of the disease is that which
follows the ingestion of one or other of the  articles mentioned. After
the lapse of an  hour or  two, and occasionally  of a much shorter
space  of time, a sense of great  general uneasiness, of sinking and
giddiness, together with a feeling of weight and pain about the pit
of the stomach,  are complained of;  these sensations  are speedily
followed by nausea,  sickness, and  vomiting; the skin begins to
tingle and  feels  very hot,  and an eruption of pale elevated spots,
surrounded by a bright red circle, makes its appearance over almost
every part of the body, but especially the shoulders, loins, and inner
aspects of  the arms and  thighs, and around the knees.  These
wheals are prominent, hard  around  their edges,  of different sizes,
and often of a circular shape ; they are frequently also very irregu-
lar in their outline.   A very considerable  degree of febrile excite-
ment accompanies this eruption in. its course,—mt. febrilis.  When
the eruption is very copious, the wheals  run  into each other in
various places, and then the integuments  and particularly the fea-
tures look swollen, feel stiff, and the whole surface is often suffused
with a bright red blush,—urticaria  conferta.  An itchiness and  a
sensation of stinging of the most unpleasant kind, which  are greatly
aggravated during the night by  the heat of the bed, accompany this
eruption.   The individual wheals are generally of short duration,
lasting from a few minutes to two  or three hours.   In some cases
of rarer occurrence, the wheals continue  unaltered for  two or three 
EXANTHEMATA--URTICARIA.
33
weeks,—urt. perstans,  accompanied, all  the  while,  with febrile
symptoms, depression, disinclination to  food, and disturbance in a
greater  or less degree of the digestive functions.   This variety of
the disease is more apt to supervene upon some  moral paroxysm,
acute grief, violent anger, &c. than the  ingestion of any unwhole-
some article of food.
  Besides appearing in this acute form,  urticaria  frequently shows
itself as a  purely chronic disease.  Without being accompanied by
fever, or any other appreciable constitutional disturbance, the erup-
tion flits about from  place to place, frequently, however, selecting
one upon  which it seems to appear  in preference to any other, but
disappearing from all in the course  of a few hours, and being only
attended with a violent itchiness whilst it lasts.  The wheals are
then very irregular in their shapes, and  are not surrounded by any
inflammatory blush;  they often bear a great resemblance to the
marks produced upon the skin by flagellation,—urt. evanida.   This
form of the disease is very obstinate; it usually continues  for
months, and has been known to last for seven and even a greater
number of years.   It can occasionally be traced in connection with
a disturbed state  of the  digestive functions; but it frequently tor-
ments individuals who in all other respects enjoy the most perfect
health.
  Another and very rare variety of the disease (urt. subcutanea) is
not at all times attended with any eruption of wheals, and the usual
feeling of burning pruritus.   The sensation that accompanies this
variety  is  such as is produced by a needle piercing the skin, and
the only external indication of the disease is the evolution of a num-
ber of red and scarcely raised points.  The occurrence of  a proper
nettle-rash wheal, however, every now and then, proclaims the true
nature  of the affection.
  The  disease again at times possesses characters of great seventy,
and is distinguished  not merely by an eruption  of slightly raised
wheals, that itch for a time and then disappear, but by the develop-
ment of hard, deep-seated, and painful lumps or tuberosities, which
impede  motion.   These usually appear in the evening, about the
lumbar  regions  and  on  the  extremities, and  vanish next  day,
leaving the patient worn out and fatigued, weak, and excessively
depressed.  When these  lumps are thrown out about  the  face,
throat, and chest, they  cause enormous swelling of  the features,
and so  much dyspnoea, accompanied with .such irregular action
of the heart, that patients occasionally appear in danger of suffoca-
tion. The  intemperate are the usual subjects of this variety of the
disease, (urt. tuberosa,) although this is  by no means universal, for
I have met  with  it in a most  abstemious  gentlewoman, of very
susceptible constitution.                                        f
   Urticaria is easily distinguished from every  other  form  of
cutaneous disease.   The form, elevation,  general colour,  and
transient  nature of the  eruption,  combined with  the  peculiar
character of the  pruritus that  attends  it, prevent it from being
mistaken  for any other of the exanthematous  diseases.   1 he only
        5-d                                     grn 3 
31
GREEN ON DISEASES OF THE SKIN.
one, indeed, with which the species entitled tuberosa is at all likely
to be confounded, is the erythema nodosum; but the regular, acute,
and continuous course pursued by this affection is the very reverse
of that observed in the urticaria;  and,  therefore,  though  at first
sight some doubt might be entertained as to  the  nature of these
two affections,  a day will always proclaim their difference.   In
lichen urticatus, a papular disease,  the  eruption is  rounder,  less
prominent, less extensive,  harder  under the finger, of a deeper
colour,  and much more enduring  than  the  wheals of urticaria
generally  prove.  In the  vicinity  of the  spots  of this  variety of
lichen, a number of true papulae, sufficient to  declare its  nature,
may also  always be discovered.  It is necessary to remember that
the various  species of urticaria now and then  occur complicated
with erythema  and roseola especially, and  occasionally with lichen
and impetigo.
  When  urticaria is caused  by any  article  of food which  has
disagreed  with the stomach, or proves poisonous through peculiarity
of constitution,  vomiting, if it have not already taken place, should
be excited.   No medicine  in these cases generally proves more
efficient than the ipecacuanha.  It is time enough to resort to  the
more powerful  emetic metallic salts  when this has been tried and
found inefficient.  It is  generally advisable to prescribe a few doses
of aperient  medicine subsequently, and to  keep the patient upon
spare diet, and some acidulated diluent.   The vegetable acids in
general answer very well for  this purpose, but they disagree with
some stomachs, and I have even known lemon-juice produce the
disease; in these cases the sulphuric or nitric acid, in barley water,
may be substituted.  If the disease be very violent,  and these
measures  do not afford relief, or if the symptoms run very high, it
may even be proper  to  bleed from the  arm at once, and this will
always be found a very effectual remedy.  The blood withdrawn
in such  cases is constantly buffy.  The  other particulars in the
treatment may  then be pursued with great advantage, and the tepid
alkaline bath added, in case the itching prove extremely troublesome.
In the common febrile  nettle-rash, should the eruption  appear in
preference upon any one district more  than another, bathing  the
parts with a cold acetate of lead, or subcarbonate of potash wash,
will generally   be found very  grateful.   These  measures, with
particular attention to diet,  will  commonly  prove sufficient to
subdue urticaria in its acute or febrile form.
   The disease  with the chronic  type is much  less  under   the
influence of remedial measures.  If there  be nothing  to  contra-
indicate the practice, a quantity  of blood, in proportion to the   age
and constitution of the patient, may betaken away as a preliminary
step,  or a number of leeches may be applied to the arms or groins
as a substitute.   In these  cases,  the diet and general  regimen must
also be most particularly regulated, or little good will be  done ;  the
lightest, and yet adequately nutritious, articles of food must alone be
used, and spices, and spirituous and fermented liquors of every kind
 abstained from.  After a time, the use of the hot  air or vapour bath 
EXANTHEMATA--UTICARIA.
35
may be commenced, and diligently used until all traces of the disease
have disappeared.   This form of bathing will be found much more
powerful  in  subduing  the disposition to nettle-rash exhibited  by
many individuals, than any kind of simple or medicated water bath
that can be employed.   In the, later stages of  some  of the  most
severe species of the disease, it may even  be necessary to call in
the aid of the sulphur fume bath,  which rarely disappoints us in
altering those morbid conditions  of the skin  that  predispose to
cutaneous eruptions of so many kinds, and to urticaria in particular.
In these latter instances, however, it is advisable  to give the baths
at a low temperature.  At the same time^ gentle aperient medicines
must be exhibited at regular intervals, all  violent exercise abstained
from, and moral impressions of a painful nature avoided as much
as possible.
  When urticaria assumes any thing of an intermittent type, which
it does occasionally, the  disease frequently proves rebellious to every
variety of treatment, unless combined with that which is adapted
to  febrile affections of  the  same  character.  In  these cases, con-
sequently, the bark  or  sulphate of  quinine  must  be prescribed,
whilst all the other measures recommended generally are enforced.
Should  these vegetable febrifuges  prove  unavailing* the Fowler's
arsenical solution must be tried in small doses gradually increased;
and this is a medicine that seldom fails to interrupt the sequence of
morbid actions upon which nettle-rash then depends, and to produce
such a modification of constitution as leads to its ultimate cure.

                    CASES OF URTICARIA.

  M.  R., a young lady  of delicate  fine skin and sanguine tempera-
ment, after eating heartily of lobster for supper, was during the
night seized  with pain  in the  stomach, oppressed  breathing,
headache, restlessness, and violent  itching and tingling of the skin.
On assistance being called,  the skin of the face  and eyelids was
found greatly swollen, and of a florid red interspersed with whitish
hard elevations, some the size of a bean.  This appearance extended
over the throat,  chest, stomach, and arms.   She first took some
castor oil, which, without operating, made her feel  sick.  An emetic
was then administered,  and pieces  of lobster in an undigested state
were  ejected.  She was placed in a warm  bath, and had a dose of
colocynth and  scammony, with only tea and spoonmeat directed.
In the evening  her  breathing was relieved, and the medicine had
operated ;  she was still very restless, and complained of itching and
tingling, and a considerable degree of thirst.   The tumefaetion of
the face,  arms, and  trunk  was not  diminished  in extent  or
appearance.   She was directed to repeat the bath, and take a dose
of opening medicine every three hours, till copious discharges from
the bowels were produced.  During  the  second day the medicine
operated  plentifully,  and the symptoms abated.  Some cooling
febrifuge was directed, and she was perfectly well on the fourth day
from  the attack.   This is  simply a case of nettle-rash, showing
                                                 grn 3* 
30
GREEN ON DISEASES OF THE SKIN.
itself  in a few hours, after taking food not congenial to the con-
stitution of the patient.
  Intermittent nettle-rash with derangement of stomach.—Mrs. S.,
aged 4 S, of a phlegmatic habit, and often ailing,  had for some
months  been teased with a rash, principally on  "the chest, but no
part of the whole trunk or extremities  was entirely free from the
disease.   She suffered  an accession  of  tingling  and smarting
regularly as evening came on, which continued  most  part of the
night; in the morning, some abatement of the irritation took place,
and, worn out with fatigue, she then  usually fell  into a short sleep,
on awaking from which,  there was no appearance of rash, wheals,
or spots on the skin, to account for the long-continued disturbance
she had undergone.   On scratching any part of the body, however,
elevations or wheals of various figures, and lighter  in colour than
the surrounding skin, would  appear, and  not  again subside, until
some hours had  elapsed'; during  their continuance, they  were
attended with  smart stinging sensations.  Other  circumstances
contributed  to occasion this lady much mental irritation, which no
doubt aggravated or caused a continuance of the  complaint.
   She had  undergone several courses of medicine,  but  without
benefit; mercury, sulphur, and various lotions and ointments, which
had been tried, seemed all to be useless ; she had always been what
is called a dyspeptic patient, and every little irregularity in diet had
been followed by symptoms  more or  less intense  of nettle-rash,
previous to  this  last more continued and very severe attack of the
disease.
   Under these  circumstances, and unadvisedly, she chose to take
the sulphur fume bath,  with which she for some time persevered,
but only with aggravation  of the symptoms of her malady.   After
this period she placed herself under my care, September 16th, 1833.
She had been previously taught the advantages of the mildest diet,
and abstinence from wine, spirits, and fermented  liquors.   She was
confined almost to milk  and  rusk diet.  Tea, in which she  had
been in the habit of indulging, with much sugar, was  quite discon-
 tinued; she was directed to avoid fatiguing or exciting exercises,
 and to  keep herself  as tranquil as possible.  She was ordered a
 wine-glassful  of  the following medicine every  morning:—R.
 magnes, sulphat. dr.vj. magnes.  calc. dr. iss. mannae opt. oz. ss. aq.
 menthae virid. oss. M.;  and twice during the day a teaspoonful of
 the following drops in water,—R. acid, nitric, dr. i. infus. rosae, oz. ij.
 She  was further  directed to take  a water bath at only 90 deg. of
 Fahrenheit, in  which was to be mixed a large basinful  of thick
 gruel, and to remain in the bath from a half to three quarters of an
 hour, each  night previously to going to bed.
   The internal  functions of this lady  were performed with much
 irregularity; she arose in  the morning languid and  unrefreshed,
 with no appetite for breakfast, and  the bowels constantly  required
 the assistance of medicine.   The pulse was moderate and regular,
 the tongue clean except at  the base, which was  covered with a
 grayish mucus.  After three days  this patient  declared  she had 
EXANTHEMATA—RUBEOLA.
37
already experienced more comfort than she had known for months.
The medicine was followed by copious purgation, but without any
feeling of consequent weakness ; on the contrary, she felt a renewal
of strength.  Even on the simple diet prescribed, she  felt able to
continue the medicine and baths ; soon, however, she was in a state
to partake of well-boiled vegetables and jellies.  September  26th,
Mrs. S. continued improving ; the quantity of the purgative medicine
was  lessened, she began to take broth and animal food sparingly.
On the 4th of November she  considered herself well,  and  I lost
sight of her.
  January 10th,  1834,  she again visited me with a recurrence of
the  symptoms  of nettle-rash,  but much milder in degree.   She
resumed the plan of treatment formerly pursued, and was again well
by the 24th.   She was  then  directed the following  medicine, in
consultation with my friend, Dr.  Ridgway,—R. flor. sulph. dr. iss.
pulv. myrrh, opt., pulv. rhei. aa, dr. ss. pulv. ipec. scr. j. terebinth.
venet.  dr.  ss. m. ft. pil. sing.  gr. iv. cum aquae q. s. sumat ij. mane
nocteque.   February 1st, this medicine  occasioned no aggravation
of symptoms,  and she  began the use  of the sulphur  fume bath,
which  from its powerful influence in modifying diseased actions in
the skin, and causing the obstructed cuticle to peel off in shreds, I
am inclined  to trust, has placed this patient beyond the risk of a
recurrence of her tormenting malady, at least for some time to come.
  The first of these  two cases shows that urticaria or  nettle-rash,
arising from substances that  immediately disagree  in a peculiar
manner with the  stomach, may  be remedied  by the commonly
indicated  means; the second, that when the disease proceeds, or is
continued, from a deranged state of the stomach and general system,
it may be subdued  by these  means properly  modified,  and  the
disposition to it, perhaps, even permanently removed by the  use of
the sulphur fume bath.

                     RUBEOLA, MEASLES.

  Measles is a contagious exanthematous disease, of  which  the
cutaneous efflorescence constitutes but a very small  part.  The
attack  is ushered in by feelings of languor and  depression, chilly
or shivering fits,  sneezing, running of the nose and eyes, a hard
barking cough, and symptoms of general fever.  Towards  the
third or fourth  day a number  of small, distinct,  and circular red
spots, slightly raised above the general surface, appear upon the
face; and the neck, chest, trunk,  and extremities, are  covered in
succession with  an eruption  of a similar description.  These, at
first  papular-looking spots, increase in size, and sometimes appear
vesicular  in their centres, run into each other, and form aggregate
patches of an irregular  crescentic shape,  with  intervals  between
them in which the skin appears healthy.   The eruption reaches its
height within twenty-four hours after its appearance, and is usually
completed in about twelve hours more.  On the sixth  day  of the
disease, the brightness of  the  efflorescence begins to abate on the 
38
GREEN ON DISEASES ON THE SKIN.
face, but rather  increases on the other regions of the body.  Next
day, the seventh, the eruption begins to disappear, and by the ninth,
a slight yellowish staining of the skin alone  proclaims  its former
presence;  this tint also  disappears gradually, and is by and  by
succeeded by a furfuraceous desquamation of the cuticle,  more or
less conspicuous, and usually accompanied by a considerable degree
of itchiness.
  The  constitutional and general symptoms do not abate with the
appearance of the  eruption; it is only after it is completed, and as
it begins to decline, that' they diminish in severity.
  Rubeola is a disease which occurs with very different  degrees of
intensity; in one  case the  symptoms  run so high that bleeding
and active treatment become indispensable ; in another they are so
slight, that but for the attention which the known existence of the
disease in a family excites, some of its members might be supposed
to have escaped the infection altogether ; slight symptoms of cold
alone marking its presence in one, and some degree of eruption
proclaiming its  occurrence .in another.
  In itself  rubeola is not  a dangerous disease, but its  frequent
complication  with bronchial and  pulmonary inflammations, and
the delicate state in which it frequently leaves children, during the
tardy  recovery that follows  its invasion, renders it one of the most
formidable diseases of infancy.
   The precursory symptoms, the known prevalence of the disease,
which almost always reigns epidemically at the end of winter and
beginning of spring, and  the punctuated and then mottled and
crescent-shaped appearance of the eruption, distinguish measles
from scarlet fever.  In some cases, however, it is extremely difficult,
 from the mere  external  characters of the eruptions in these two
diseases, to distinguish the one from the other.  The predominating
general symptoms, the nature of the prevalent epidemic, &c. then
aid essentially in coming to a conclusion.
    The treatment of measles is   so generally  well understood,
 that I hold  it unnecessary  to enter at length upon this subject.
 Antiphlogistic measures, and protection against sudden alternations
 of temperature, during  both the  active  stage of the disease and
 convalescence from it, form the basis of the treatment; intercurrent
 affections, particularly inflammation of the bronchi and pulmonary
 tissues, must be met in  the usual way, by the abstraction of blood,
 &c.  But the  sequelae  or dregs,  as they  are  called, and that
  disordered  state of the  general health which so frequently follows
  measles,  often  prove more serious evils  than  the disease  itself.
  There is indeed  almost no complaint which does  not occasionally
  follow in the tram of measles ; but a consumptive  tendency, and  a
  disposition to scrofulous enlargements of the glands, are amongst
  the most common of its consequences.   It is seldom that children
  recover from measles without continuing long subject to a  hard,
  dry cough, and a parched and unperspiring  state  of skin, which,
  indeed, very commonly precede  the other evils that  have been
  mentioned.   I know of no remedy more powerful in any disease, 
                 EXANTHEMATA—SCARLATINA.              39

than the hot air or vapour bath in altering this peculiar state of the
system.  Taken  once or twice it  restores the proper  functions of
the skin; the irritable condition of the bronchial membrane then
subsides, and the  patient frequently regains health and strength in
an incredibly short space of time.

                         SCARLATINA.

  This is another contagious eruptive fever, a brief notice of which,
for the sake of connection, appears necessary in this compendium.
Scarlatina is distinguished, after one or two days of general febrile
excitement,  by an eruption of minute red points, which soon  run
together and form broad patches of a vivid red colour,  and which,
by coalescing, give to extensive regions, or to the entire surface of
the body, the "appearance of having  been stained with raspberry
juice.   Nor  is the  skin  alone affected  in  this way; the lining
membrane  of  the  eyes, nostrils, mouth, tongue,  and  pharynx
especially, is of the  brightest  scarlet, and it  is probable that the
efflorescence extends through the whole  course of the alimentary
canal.
  The general febrile excitement  runs very high in scarlet fever;
the pulse is excessively rapid, and the heat of  surface frequently
higher than it is observed to  be  under almost any other  circum-
stances.  This state coincides with a total suppression of perspiration
in particular, and  of the  secretions generally; there is intense
thirst; little or no urine is secreted, the bowels are constipated, &c;
and, in connection with the affection of the mucous membranes,
pain in  the throat, and difficulty of  swallowing, are  among the
most  common and  characteristic  symptoms of scarlatina.  It is
generally within the first four and twenty hours after the appearance
of the febrile symptoms, but sometimes not until  the following day,
that the  eruption of scarlet fever shows  itself upon the face  and
neck, from which it spreads successively but rapidly to the rest of
the body.   The  eruption  consists of an infinity of  minute  red
points, so closely crowded  together that  the surface presents one
uniform bright red tint.  The skin then feels dry and rough under
the finger, and the parts upon which the  body has been lying look
highly  irritated and inflamed.
  The  tongue, in  scarlatina, has often  a singular appearance;
covered  in  the middle and posteriorly with a whitish fur, the tip
and edges are of the most vivid  red, and  the papillae,  of the same
hue, project  in many places, especially towards the tip,  through the
covering, so that it bears  a  pretty strong resemblance to a ripe
strawberry.
  The  febrile symptoms do not  generally  decline  with the  ap-
pearance of the eruption; the heat of  surface continues as high as
ever,  the thirst  as  urgent, there is  frequently some degree  of
drowsiness,  and the features often look puffed.  There are generally
well marked exacerbations  in the  evening, when the colour of the
eruption becomes more bright than ever. 
40
GREEN ON DISEASES OF THE SKIN.
  This  state of affairs continues till the fifth day, when both the
fever  and  eruption, and all  the distressing symptoms, begin to
decline;  the swallowing is  less painful, the skin perspires often
copiously, the  kidneys resume their functions, the bowels are often
relaxed, thirst  is no longer complained of, and the appetite returns,
though  it still causes  considerable pain to swallow.   About the
seventh day, desquamation of the cuticle commences, attended with
a considerable degree of itching, and  frequently continues for a
month or six weeks,  being several  times  renewed over the same
regions.
  This is the  disease in its most simple form,—scarlatina simplex,
which lasts in all from eight to  ten days.  The whole  of the
symptoms, however, may be  much more  severe, the deglutition
especially may be so much affected that nothing can be got down,
liquids  being  returned by the nose when the attempt to swallow
is resolutely made.  The patient may also complain, from the very
outset, of a great degree of stiffness about  the  throat and  lower
jaw;  the tonsils are  then  enormously swollen, the voice is hoarse,
and there is greater restlessness and more frequent rambling during
the night, than in the simple variety.   The eruption is also later
in showing itself in this  than the  former  species, not  appearing
till  late in the second day, often not before the third,  and varying
in its characters, not being nearly so generally diffused, but rather
consisting of broad,  irregular, scarlet-coloured blotches, dispersed
here and there over different regions.
  Besides the vivid efflorescence of the  lining membrane of the
mouth and  throat, a pultaceous exudation or deposit—generally of
a whitish-gray colour, but in bad cases of a brown or black, from
being stained  with extravasated blood—frequently occurs on the
pharynx and amygdalae, in this severer variety.   The tongue and
lips are then dry  and brown,  the  latter often becoming chapped
and bleeding.   The  variety of the disease now described is entitled
scarlatina anginosa.   It continues considerably longer than scarlat.
simplex, the eruption often vanishing and reappearing on different
regions at irregular intervals.
  When the  symptoms of scarlatina  anginosa  are of extreme
severity, the disease is entitled scarlatina maligna, a variety which
must be regarded merely  as one of degree,  for a detailed account
of the disease turns out a list of the morbid phenomena  already
enumerated, much increased in severity, with greater prostration
of the general powers, and a  more unfavourable tendency in the
morbid actions.
  Scarlatina is always to  be regarded as a serious disease.   It is
impossible to say in the beginning  whether the symptoms  may
turn out slight or severe : and even when the disease itself is hap-
pily got over, a host of dangers attend upon convalescence; one
of the most unpleasant  of which is general  anasarca,  an affection
that is very apt to occur eight or  ten days after the disappearance
of the efflorescence.  Scarlatina maligna is a very fatal malady, 
EXANTHEMATA—SCARLATINA.
41
and often sweeps off two, three or four members of a family, within
the space of a few days, one after the other.
  The treatment of the lighter cases of scarlatina may be limited
to dietetic means, the enforcement of the mild antiphlogistic plan
during the continuance of the disease, and afterwards the precau-
tionary measures against exposure to cold or over-indulgence of the
voracious appetite, which, with children and the youthful especially,
accompanies recovery.  When the symptoms run high, more active
steps require to be taken.   Bloodletting, both generally and locally,
must  be resorted  to; and in adult,  and youthful, and vigorous
subjects, may be practised fearlessly and with the greatest  advantage.
Venesection in the beginning of scarlat. anginosa,  and especially
in scarlat. maligna, is the best, if it be not perhaps the only means
we  possess of giving a better and more  manageable character to
the disease in its after stages.  At the same time the return of the
secretions must be solicited by  the  exhibition of gentle  aperient
and diaphoretic medicines.  The cold affusion is another powerful
means of allaying the intensity of the febrile excitement.  The
reserve that so long attended the  recommendation of  this  measure
is never felt at the present day, at least in this country:  it  is perfectly
free from danger; unfortunately,  however, it frequently  proves un-
availing  either in cutting short or in mitigating the  symptoms of
the  disease.  When happily it has so beneficial an effect, its action
is almost instantaneous; the patient passes nearly at once from the
state of agitation that  attends a  burning fever,  to a  tranquil and
refreshing slumber.
  Should symptoms of anasarca appear during convalescence, their
progress may be almost certainly  arrested by the use of  the vapour
bath.   Besides  being the most  effectual and  speedy  means of
checking this frequent and unpleasant attendant upon convalescence
from  scarlatina, the  vapour bath has the advantage of not only
not retarding  the  patient's ultimate  recovery,  as all the other
curative  measures  usually enforced necessarily do,  but  even of
accelerating it.  When the eruption only appears  partially, or
when it recedes after having made its appearance, the same means
will be found very  effectual in bringing it  out,  or in restoring it
to the surface.
  Whatever be the view taken of the  manner in  which  the atropa
belladonna acts, there seems little room to doubt of its  prophylactic
power in scarlatina; those who have  taken this medicine generally
escaping the disease altogether,  or,  if they do  become  affected,
having it in the mildest  possible form.  Perhaps the best way of
administering  the medicine is to dissolve from six to  ten grains of
the  extract in an ounce of distilled  water, and to give  from 5, to
10,  15, or 20 drops  for a dose, three or four times a day, according
to the age and strength of the patient.   This very small quantity
of the belladonna has actually seemed to give immunity in innumer-
able instances, amidst the most virulent epidemic prevalence of the
disease.  Such a simple means of escaping  entirely, or  mitigating 
42
GREEN ON DISEASES OF THE SKIN.
the violence of so serious a  disease as scarlet  fever, is always
worthy of a trial.  I had very lately an opportunity of witnessing
the good effects of this medicine among the children  assembled at
a boarding-school where scarlatina broke out;  four of the children
who where placed under  my care, and to whom I prescribed the
belladonna,  escaped entirely,  whilst  among  the others, to whom
no prophylactic remedy was given, the disease spread so extensively
as to cause  the temporary suspension of the business of the esta-
blishment.
                         VESICUL.E.

   Those diseases  of  the  skin are  entitled vesicular,  which
appear primarily under the form of minute collections or globules
of transparent  fluid effused  beneath  the cuticle.   The fluid  in
vesicles either continues transparent to the last, or  becomes turbid
and purulent  in appearance.  It is occasionally  reabsorbed into
the system; but is  much  more frequently shed upon the surface.
Vesiculae, when  their  contents  are  reabsorbed,  are  commonly
followed  by some degree of epidemic exfoliation in  the shape  of
flimsy squamae ; when their fluids become sero-purulent they con-
crete  into thin yellowish coloured laminated  crusts; some of the
species very regularly give rise to painful excoriation; and one  or
two of them are pretty frequently followed by  ulceration properly
so called.
  Of  the four  species of vesicular inflammation which we shall
here describe—Scabies,  Herpes, Eczema and Miliaria—the first
and last  are  contagious,  and all, except the first, perhaps, are
essentially acute in their nature.   Scabies, which by Bateman was
ranked among pustular diseases, is now generally admitted to  be
primarily vesicular; and vaccinia  and  varicella,   which he and
those  who have followed him have classed among the vesicles, are
now generally spoken of under  the head of pustules,  from their
evident, and acknowledged affinity to the varioloid group.   Vac-
cinia, indeed,  is to all  intents and purposes a pustular affection
from the  first.
  Some of the vesicular diseases are  preceded by very evident
constitutional  symptoms;  others make  their  attack without the
slightest apparent disturbance of the general system.  Some of them
also  appear without any previous redness  of the surfaces they
invade;  others follow a violent  excitement of these parts.  The
vesicles,  in one species,  repose  on a red and inflamed basis,  in
another  they  are  not  surrounded by  the slightest inflammatory
blush. The vesicles are now crowded and confluent; and  again,
they are distinct and disseminated.   In one variety of vesieular
disease they are  minute and acuminated or globular ; in another
they are  broad, and either prominent or flattened  in their forms.
Vesicular eruptions are  seldom  general;  they usually  appear as 
VESICULAE—SCABIES.
43
irregular  patches  confined  to  certain  districts,  and  frequently
assume particular shapes, such as bands, rings, &c.
  In almost  all stages of their  existence,  vesicular diseases may,
with a slight degree  of attention, be distinguished from every other
form  of  cutaneous eruption.  From bullous affections they are
distinguished by the greatly inferior extent of their serous effusions;
from pustular diseases, by the primary appearance of each particular
spot as a transparent vesicle,  and the flimsy laminated scale, rather
than the consistent scab that  results from the escape and drying of
its contents upon the surface.
  The vesicular are not in general either serious or very intractable
diseases.  They vary in duration from a few days  to a few weeks
or months, but if no  means  be  used for their cure they may be
protracted even for years.

                        SCABIES, ITCH.

  This is one of the most  common  of cutaneous diseases, and
though it be especially met with  among the poorer classes of
society, which are the most  negligent of personal cleanliness, still
all are alike  open to, and occasionally suffer from, its attacks;  for
it  is  one of the most contagious of diseases, and  one individual
affected  is enough  to  contaminate thousands.   The disease  is
characterised by an eruption of distinct, slightly acuminated vesicles,
transparent in their summits, and accompanied with such a degree
of pruritus as has caused  the eruption  to be vulgarly designated
by the name of this concomitant symptom—itch.
  Scabies attacks almost every part  of the  body, but is much more
frequently seen between  the  fingers and toes, about the wrists, in
the bends of the arms, axillae,  popliteal regions, and groins, than
elsewhere.   The  disease  does  not appear  even  to  arise  spon-
taneously; it may always be traced as a consequence  of infection.
The time that elapses between  the  inoculation of the disease and
its appearance, has  even been  pretty accurately ascertained: in
children it varies from four to five or six days;  in adults from ten
to twenty days, according to the season, the period of incubation
being  longest in winter;  in the aged the interval  is still  further
protracted.
  The first symptoms of scabies is a violent itchiness in the parts
that have been  inoculated.   This increases  at  night,  and  is
exasperated at any time by  the ingestion of stimulants of every
description, and by the warmth of bed.  If the parts thus  affected
be now examined, a number  of vesicles with the characters already
indicated will be discovered.   These in  youthful  and  robust
individuals are of a  pale rosy red colour,  and increase rapidly in
number ;  in the aged, and those of weakly  habit, they do not differ
perceptibly in tint from that of the integuments generally.  In any
case they are filled with a serous and viscid fluid, which flows out
when they are  punctured, or torn  by the nails of the patient in 
 44            *GREEN ON DISEASES OF THE SKIN.

 scratching.  When the eruption is thinly scattered,  the pruritus
 is not excessively  troublesome;  when  it is thickly sown nothing
 can appease the intense itching with which it is accompanied.   At
 no time however is the pruritus that attends scabies  of a painful
 description: it is not associated with any of the smarting or burning
 sensations that characterise this symptom in different other diseases
 of the  skin.
   Tailors, sempstresses, and persons who work for the upholsterers
 at mattresses, <fcc.  are of all others those who are most frequently
 affected with scabies.
   The immediate cause of scabies has  been a subject of repeated
 investigation among medical men, both of ancient and of modern
 times.  Why the contagious  properties of this,  more than any
 other malady,  have been held to require particular explanation,
 it is not easy to imagine;  but so it is, and the cause of the disease,
 and  the ease with which it is communicated, have been again and
 again at different times attributed  to the presence of an insect, which
 has  even  been described  entomologically, and  its place in  the
 natural system assigned to it.  Until very lately, however,  there
 had still been at least as weighty authority opposed to the admission
 as in favour of the existence of this insect as the cause of scabies.
 I had myself always inclined  to  side with those who maintained
 that the  insects, figured as the  acarus and sarcoptus scabiei, were
 nothing more than stray pediculi, or cheese mites.  Recent enquiries,
 however,  would seem  to place  the existence of the acarus beyond
 the  reach of doubt, and very lately  indeed (Nov. 1836,) whilst
 passing through the wards of the Hopital St. Louis,  under the
 guidance of the Baron  Alibert, I had an opportunity of seeing Dr.
 Gras extract three  specimens of living acari  with the point of a
 pin from the hand of a female  recently  admitted into the hospital
 to be treated for scabies.
  The diseases with which scabies is most apt to be confounded
 are prurigo  and lichen simplex,  both of them papular eruptions,
 and therefore to be  distinguished from  the vesicular affection that
 now engages us, by  the difference of their elementary form. Besides
 this  primary character, however, which is frequently masked in
 a great degree, there are other particulars, that give us  a  hint,
 not to be mistaken, of  the  real nature of the disease submitted to
 our inspection.   Prurigo, for instance, principally attacks the  back
 and shoulders, and  affects the outsides of the limbs in  the  line of
 their extension,  whilst  scabies  is most  usually developed on the
 abdomen, and on the extremities  along  the line of their flexions.
 The papulae of prurigo, when torn, pour out a little blood only,
 which concretes  into a small  black  crust, whilst the  vesicles of
 scabies,  when broken,  shed a viscid fluid upon  the surface  that
 dries  up into a thin yellowish  coloured scab.   The character of
 the pruritus in  each affection  is  also different;  the sensation  in
prurigo  being extremely sharp and  biting, whilst in scabies it is
unmixed with any  thing that can be entitled pain.
  In lichen simplex the papulae  are usually very much crowded 
VESICULAE—SCABIES.
45
together, and occur in patches on the backs of the hands, when
these parts  are the seat  of the  disease,  not between the fingers.
The papulae of the lichen  do not  in  general differ greatly from
the prevailing tint  of the integuments; the vesicles of scabies are
almost  always  slightly red and inflamed.  The pruritus in the
lichen is  not usually  much complained of,  and the disease itself
is not contagious like scabies.
  Scabies is even  more apt under some circumstances to be con-
founded with  eczema  simplex.  The elementary forms of both
diseases are the same,  but careful examination  shows the vesicles
of the eczema to  be flatter, and generally  more confluent than
those of scabies ; the clusters of eczema are further attended with
a much higher degree of  inflammation than the  distinct and
pointed vesicles of scabies.   The pruritus in the two diseases also
possess perfectly distinct characters;  in the eczema it is a painful
smarting, which scratching does not allay, but rather renders more
intolerable ;  in scabies it is  not altogether an unpleasant sensation,
for which a hearty application of the  nails proves  a sovereign
and most  delightful remedy.   The diagnosis of scabies is occasion-
ally complicated and rendered much more difficult, by the attempts
made to cure it by the application of irritating unguents.  These
even cause  vesicular  and pustular  eruptions  as  troublesome
whilst  they last,  as the  disease they  were intended to  remedy.
It is, however, enough to  be aware  of this fact, to  avoid being
led  into error by  its means.
   Scabies does not appear to be a disease that exercises any
influence upon the general constitution, at least this is the opinion
generally entertained  by those members of the medical profession
whose  minds  are  unoccupied by  peculiar and theoretical views
of  pathology.   The disease does not  tend naturally  to a cure like
so  many other complaints, but may continue for an  unlimited
length  of time if not  interfered with.  It is, however, in general
speedily and readily got the  better  of by the  use of sulphur in
one shape or another.
   The most effectual  mode of treating scabies is unquestionably
by anointing the whole of the person eitheT with the simple sulphur
ointment, or with an ointment  of one dram of the sub-carbonate
of  potash, two or three drams of sublimed sulphur, and one pound
of  hog's  lard  or  fresh  butter.1  With one  or other  of these
ointments the person affected with scabies,  being placed  before a
good fire in the evening, should be thoroughly anointed from the
nape of the neck to the ends of the fingers and soles of the feet by
an assistant, with as much  of the  ointment  as he  pleases, and
having pulled on a pair of old drawers, socks and gloves, in addition

   1 Another  ointment has been lately recommended  to me by Dr. Sir
William Russell, which has been long used in India, and found particularly
serviceable in scabies, composed as follows:—R. sulph. loti oz. ss, sodae
boracis, ammon. muriat.  aa dr. ss, hydrar. praecip. albi scr. i, ungt. simpl.
oz. i. to which dr. ij. or dr. iij. of ol. terebinth, may be added or not at
pleasure. 
46
GREEN ON DISEASES OF THE SKIN.
to a calico  night gown, betake himself to  bed,  where  he must
remain for the next twelve or eighteen hours, when he may rise,
and having a warm bath in readiness, free his skin from the remains
of the application by  means of soap and  a soft flannel.   One
effectual application of the sulphur  ointment in  this way, which
was the mode of using it recommended by the late Mr. Abernethy,
frequently proves  sufficient to cure the itch.  It is certainly of
more  avail than twenty partial inunctions, in which half an ounce
or an  ounce of the specific only is  expended at a time.  Should
the disease not appear  to be completely eradicated,  the  same pro-
cess must be repeated.
   This then is  the most certain mode of attacking scabies;  but
it  is one which  is very far from pleasant,  and  to  which many
patients, in the wealthier ranks of life especially,  when  they have
accidentally contracted this disease, show an insuperable  repug-
nance.   In  these  cases the  sulphurous water  bath,  with due
perseverance,  generally  proves  effectual.   Half a  dram  of  the
sulphuret of lime, mixed with a  little olive oil, and rubbed twice a
day, for ten  or fifteen minutes each  time, upon the  palms of  the
hands, also proves a remedy.  A wash, composed of the sulphuret
of potash  dissolved in water,  with or without  the addition of a
small  quantity of the  sulphuric  or  muriatic acid, applied to  the
affected parts,  cures the disease rapidly, but is frequently attended
with the inconvenience of exciting vesicular and papular eruptions
in irritable subjects.  The sulphur  fume bath is another effectual
remedy, and, perhaps, the most elegant of all, for  scabies.   It may
be taken once, or even thrice a day, by which the cure is consider-
ably expedited.   The cleanliness, and freedom from all unpleasant
smell  of this mode of  using sulphur, give it deserved preference
among those classes of the community to whom these considerations
and secrecy are objects of importance, and the trifling additional ex-
pense it entails is a matter of no moment.  When any of our remedies
for scabies seems to  excite new  vesicular or papular  eruptions,
prudence suggests the propriety of immediately suspending it until
these temporary excitations have passed away.
   I have  not sooner spoken of any other than purely local forms
of treatment in this disease,  because it generally  yields  readily to
these.  Where the disease proves obstinate, however, there can be
no doubt but that scabies, like so  many other cutaneous affections,
becomes  much  more  tractable  under outward application after
blood-letting has been  practised, and a dose or two  of  purgative
medicine, combined with attention to regimen and the use of some
mild diluent, have been premised.  It  will be enough for  me  to
hint at this circumstance at present, leaving  my reader  at libertv
to make his  own application of the fact in the particular  instances
he may encounter.
   The woollen  clothes that patients  affected with  scabies have
worn, may be disinfected by being exposed in an oven to a certain
temperature, or by  being suspended in a close box and  subjected
to the fumes of sulphurods  acid gas procured by the ignition of
a rag dipped in melted sulphur. 
VESICUL.<E—ECZEMA.
47
                ECZEMA, OR HEAT ERUPTION.

  Eczema is a disease characterised by the eruption of great num-
bers of minute vesicles, clustered together in broad and irregularly
defined patches, generally affecting one region of the  skin only,
though this is often  of considerable extent, and most commonly
terminating in the production of moist excoriations ; this at least is
the case  when the  disease attains any degree of severity.   The
whole of the varieties or species of eczema that are usually described
might very well be discussed under two heads only:  as they are
acute or  chronic in their types.
  Acute  eczema.—When the vesicles are  very minute, closely
crowded together, and evolved without any appearance of inflam-
mation or swelling of the skin either around the clusters or in the
intervals between them, the disease constitutes the eczema simplex.
These minute vesicles  are  perfectly transparent at first, but the
globule of serum they  contain  grows turbid within  a few days,
and is then either absorbed, or, as more frequently happens, the
fine layer of cuticle which  confines it being  torn  by  scratching,
it is shed upon the surface and dries into a thin yellowish coloured
incrustation,  which is detached in a few days, leaving a small red
print  upon the skin, which is either dry, or bedewed with a serous
exudation poured out by a minute orifice in the centre of the spot.
This  exudation soon  hardens into flimsy squamae, and the disease
would come to an end anon, but for a fresh  crop of vesicles that
is very apt to make its appearance at this period of the complaint.
The natural period of the disease, which extends to no more than
a week or two, is thus frequently much protracted,  and it may
continue for months unmitigated.
  The eruption of eczema simplex  has  been seen general, but it
is  much more frequently confined to particular districts, as to the
arms  and fore-arms, backs of the hands and intervals  between the
fingers, when, without proper attention, it  is very likely  to be
confounded with scabies, which it is, indeed, at all times very apt
to  complicate, being excited  by the  stimulating applications used
for  the cure  of this disease.  Eczema simplex is not generally
accompanied with any apparent derangement of the constitution ;
the most troublesome symptom attending it is the smarting pruritus,
which, when violent,  is hardly to be appeased by any means.
  Besides this mild form of the disease, eczema often occurs  with
symptoms of much greater  severity.  The  parts upon  which the
eruption is about to appear are swollen, hot, tense, shining,  and of
a bright red colour.   These, upon a careful inspection, are anon
discovered to  be beset  with an infinity  of minute prominent and
glistering points, which by and by acquire the characters of true
vesicles,  being at first transparent, of the size of pins'  heads, and
surrounded by decided  areolae, but in  general speedily becoming
confluent.  The contents of these vesicles,  whether  distinct or
confluent, soon become milky, and  commonly bursting their en-
velopes, escape under  the appearance of  a reddish coloured  fluid, 
48
GREEN ON DISEASES OF THE SKIN.
whence  the  disease has received its distinguishing  title—eczema
rubrum.  The diseased surfaces in this state have a very character-
istic appearance: denuded of cuticle to a considerable extent, they
are of a reddish  colour, and  seem studded with  small round
granules or points, each of which is set within or surrounded  by
a circular,  ragged-edged,  white-coloured rim; the discharge from
the inflamed surfaces in this state  is frequently profuse, so much
so that no  incrustations  are formed  at first;  it  is only as the
discharge diminishes in quantity and becomes thicker in consistence
that  it impregnates the remaining cuticle, and dries into thin scaly
looking,  greenish or  yellowish incrustations,  which are  soon
detached, only to be succeeded, however,  by repeated formations
of crusts of a similar  kind though of greater  permanence  and
solidity.  The symptoms  of inflammation  now frequently decline,
and if no fresh eruption of vesicles takes place, a new and healthy
cuticle is formed, and the disease terminates of itself, having run
its course in the space  of from two to three weeks.
  A third species or degree of eczema  is marked by the secretion
of a purulent as  well as of a serous fluid, and from presenting many
features in common with impetigo, a pustulous affection which
will  be mentioned by and  by,  has  been  denominated  eczema
impetiginodes.  The surfaces affected by the disease in this aggra-
vated form are scarcely observed to present a distinctly vesicular
appearance, or, if they  do, it is for a  very short time only; the  fluid
under  the cuticle is milky and sero-purulent almost from the first;
acute scalding or smarting pains accompany the evolution of these
pustular vesicles; the cuticle soon gives way, and the fluid it con-
fined escapes, or being detached in broad flaps, it exposes raw and
excoriated  surfaces inflamed to the  highest pitch of intensity,
frequently  covered with false membranes and pouring out a faint,
sickly smelling discharge, in such profusion that no dressing which
is  not incessantly renewed is sufficient to  absorb  it completely.
The surfaces affected in this way become covered  from  time  to
time with thin, yellowish,  laminated incrustations, which are never
of long continuance, but  are detached  and renewed  in rapid  suc-
cession until the inflammation begins to decline; they then become
thinner,  remain attached longer,  and as  they are thrown off at
length, expose surfaces  of a less and  less intensely fiery hue.  The
disease in this aggravated form, especially when of considerable ex-
tent, is apt to be attended with symptoms of constitutional  disturb-
ance, such  as acceleration of pulse, restlessness, some  degree  of
thirst, loss of appetite, &c.  When mild, eczema may generally be
regarded as a disease purely local in its  characters.
  The eczema simplex, eczema rubrum, and eczema impetiginodes,
constitute, in fact,  but  so many grades  in severity  of one  and the
same disease.  The inflammation is  moderate in the first, and the
vesicles are distinct though collected in  clusters,  and transparent;
in the  second it is  more severe, and the  vesicles  are milky  and
confluent;  in the third it runs very  high, and the vesicles coalesce
from the first so as to constitute a kind of blebs, which  contain a 
VESICULAE—ECZEMA.
49
quantity of purulent matter and pseudo-membranous formations as
well as  proper serum.
  Even in the most severe form of acute eczema, the inflammation
hardly extends beyond the dermal structures immediately affected.
The lymphatic glands, indeed, in the  near  neighbourhood of the
districts which are the seat of the disease, frequently become swelled
and painful, but they always return  to their natural state on the
decline  of the inflammation.
  The whole of the varieties of eczema, especially those  entitled
rubrum and impetiginodes, have a tendency to become chronic in
their characters ;  instead of ending within from two to three weeks,
successive eruptions of sero-purulent  vesicles and the profuse se-
cretion of a thin ichorous fluid keep up  the irritation for months;
the  skin then becomes profoundly  inflamed, furrowed with  deep
fissures, particularly when the parts around articulations are the
seat of  the  disease, and  affected  on  the  surface with painful
excoriations.  The  subcutaneous cellular membrane even partici-
pates in the swelling and irritation.   No kind of dressing that can
be applied now proves adequate to absorb the whole of the discharge;
it penetrates every  thing; and the dressings, getting glued to the
abraded surfaces, must be forcibly torn off when they are renewed,
so  that the affected  parts bleed,  and  are even further irritated  by
every attempt to  protect them.  The surfaces affected in this vyay
have been very  aptly compared to  a blister  in a state  of active
suppuration.  They seem  to be perforated with  a  multitude of
pores,  from which  the discharge is  poured out; they are at the
same time the seat  of a smarting  or scalding pruritus of the most
violent  description,  and the sufferings  that patients undergo,  who
are affected with chronic eczema of the external organs of generation
and verge of the anus, are frequently excessive.
   When chronic eczema declines, the pruritus and smarting become
less unbearable, the  serous  discharge diminishes, and at length
ceases,  incrustations of some consistency and dryness  are  then
formed,  and,  being detached  after a time, are succeeded by others
still firmer, thinner, and more adherent, whilst the surfaces of the
dermis, exposed, look gradually less and less inflamed.  Long after
all discharge has ceased, however, and no more laminated incrust-
ations are produced,  the parts  that have been affected continue
to present a preternaturally red and very tender  appearance.  The
disease gets well from the circumference towards the centre of the
parts affected, which shrink very much in extent as they approach
recovery, and remain at  length quite free  from every thing like
 mark or scar.                                               ,
   Eczema may appear  on every part of the surface of  the  body,
 but those parts which are most  plentifully provided with follicles,
 seem  more  particularly exposed to its attacks.  It therefore more
 frequently occurs  about  the  groins, scrotum,  permaeum, axillae,
 bends of the arms, and  popliteal regions,  and  in infancy on  the
 scalp, than elsewhere: and the disease assumes such peculiarities
        6—a                                     grnA 
50
GREEN ON DISEASES OF THE SKIN.
according to the district in which it is developed, as to make several
of these local varieties deserving of particular notice.
  Eczema of the organ of generation,  verge of the anus, and tops
of the thighs, is one of the most distressing and obstinate of these
local forms of the disease.   It usually begins in  one only of the
parts affected, as the scrotum in men, and the labia in women, and
invades the others in  succession.   The  evolution of the vesicles
is accompanied by pruritus, of the most intense and painful descrip-
tion, so that it is often difficult to find even a single one that has
escaped the patient's nails, who generally applies them so relentlessly,
that the whole of the diseased parts present a continuous excoriated
and chapped bleeding surface, from which a sanguinolent ichor is
constantly exuding.  The act of emptying  the bladder,  and  of
going to stool, in these cases, is attended with great suffering; and
as  no dressing long proves adequate to absorb the discharge, and
motion of every kind adds immensely to the misery that is endured,
patients  are often  reduced to despair.  Eczemas  of  the  axillae,
bends  of the arms,  groins, and popliteal  regions,  have  many
characters in common with the disease affecting the private parts.
In the regions now indicated, however, the eruption  is attended
with much less suffering, although the excoriations and deep fissures
that occur in consequence of the constant motion of the parts, never
fail to prove sufficiently distressing.
  Eczema is  occasionally  seen attacking the nipple,  when the
disease is apt to be mistaken for simple chapping of this part, from
which it  may nevertheless be readily  distinguished.
  Eczema of the hairy scalp is one  of the  local varieties  most
worthy of notice, as well from its frequency  as from the circum-
stance of its having been long confounded under the name of tinea
and porrigo,  with other affections of the same  part  essentially
different in their elementary forms and general  nature.   This
variety of eczema often occurs among  infants of five or six months
old, but frequently also at a later period during the progress of
teething.  The  discharge is  very profuse, and when the scalp is
thickly covered with  hair,  the head from this cause  looks at  all
times as if it had just been dipped in some glutinous liquid.  The
secretion  by and by dries into crusts which bind the hair into little
separate tufts,  and these getting gradually connected into larger
and larger masses, the whole head is frequently seen covered with
one unseemly  moist  mass  of hair and scurf, in which  pediculi
swarm in myriads.  When the hair is removed by a careful use of
the flat scissors,  the surface of the scalp appears swollen, preter-
naturally red, pierced every where with minute pores, and bedewed
with a glutinous  secretion.  The  parts affected are  at the  same
time the seat of an excessive itchiness, so that infants and children
labouring under the disease seem never to cease from rubbing their
heads upon their pillows or shoulders,  or from tearing themselves
with their nails, if their hands be  not secured.  The disease may
attack the whole or only a part of the hairy scalp; when extensive,
it seldom indeed  remains  confined to  this part alone, but extends 
VESICUL.iE—ECZEMA.                    51
 to the forehead, cheeks, nape of the neck, and ears.   The inflam-
 mation is sometimes so violent that it extends to the subcutaneous
 cellular  membrane, in which small abscesses  are then apt to be
 formed,  and to the lymphatic glands of the neck, which become
 enlarged and painful, and occasionally even run into  suppuration.
 It is seldom that the bulbs of the hair suffer,  and notwithstanding
 the apparent severity of the disease, infants  affected with it do  not
 often show any symptoms of constitutional  derangement.
   Eczema of the face at  an advanced stage,  occurring in young
 children,  has frequently been described under the title of crusta
 lactea.   It very commonly coincides with a similar affection of the
 scalp.  The vesicles that characterise  it  are small and evolved
 in clusters.  They  burst or are torn within a few  days, when
 their contents are shed upon the surface, where they concrete into
 crusts, which  increasing gradually, by the  drying of the secretion
 continually poured out below them, attain a considerable thickness
 at last.   The  surfaces affected,  when  freed  from incrustations,
 present the general appearances  that have already been described
 under the heads of eczema  rubrum and eczema  impetiginodes.
 When the parts about the corners of the mouth are affected, they
 generally present deep and painful  fissures in addition to the  ex-
 coriations which  are a  uniform feature of the disease.  Eczema
 of the eyelids  is apt to  extend to the conjunctivae, when we have
 all the symptoms of acute ophthalmia.
   Eczema of the external ear is another of the most common and
obstinate of the local varieties of the disease  we  are discussing,
which may occur alone, though it is generally observed at the same
 time with one or both of the two last mentioned varieties.  The
 disease is characterised as  usual by the eruption of small vesicles
 upon an inflamed ground, which  burst and  pour out an abundance
 of a reddish and  glutinous ichor, which concretes into laminated
 crusts.  The ears are often swelled  to twice their natural size, and
 the meatus  auditorius is so much obstructed, that fears are  often
entertained of  its complete closure, and measures even adopted to
 prevent  so  disastrous a conclusion;  but  these fears and these
 measures are alike vain; as the inflammation subsides, the concha
resumes its proper size,  and the meatus appears as patent as before.
 The  small abscesses that so  frequently  form in the parietes of the
meatus auditorius, are one of the  most painful concomitants of this
variety of eczema.
  Among the aged, the lower extremities are a very common seat
of eczematous  eruptions,  that are  readily recognizable  by their
distinguishing  characters,  though frequently confounded  with
diseases  having other elementary forms, and  different tendencies.
 When the legs  are  affected, the  eruption usually extends to  the
 insteps and toes.
  The backs of the hands, the fingers,  and the intervals between
 them, are also the frequent seat of eczema, which, in the last situa-
 tion, is not always  easily distinguishable from scabies; the means
 of arriving at right conclusions have  been  already mentioned.
                                                grn 4* 
52            GREEN ON DISEASES OF THE SKIN.

Eczema of the hand is a very troublesome and painful form of the
disease.  The parts being extremely movable, every joint is ere
long surrounded by deep chaps, which penetrate to the quick, and
bleed each time the fingers are  used.  The fissures, too, secrete a
reddish coloured  glutinous serum  continually, which,  hardening
along the edges of the gaps into brownish  laminated incrustations,
make these appear still deeper and more formidable than  they are
in reality.   The disease,  in these cases, frequently attacks  the
parts about the  roots of the nails, and  either causes these append-
ages to be produced with various characters of deformity, or to
be lost entirely.
  Eczema  sometimes  appears  as a  symptom  of  constitutional
disturbance, induced by the specific action  of certain  medicines.
The most remarkable variety of the disease arising under  these
circumstances, is the eczema mercnriale, or  hydrargyria, as it has
been  denominated,  this  eruption having  by some  writers  been
separated from the group of eczemas,  and described by itself.  In
the  mild  form of this  affection,  the  vesicles are so minute  that
particular aids  are  required to  prevent the inflamed ground  upon
which they are congregated from being regarded as a patch affected
with simple  inflammatory blush.   The affection, however, is pre-
ceded  by  such sensations  of heat and smarting, that particular
attention is  attracted to  the spots affected, and then by throwing
the  light upon them properly, or by using a magnifying glass,  they
are  discovered  to  be thickly beset  with  exceedingly small  but
transparent vesicles. In the severer forms of the disease, charac-
terized as febrile and malignant,  which seem  generally to be
induced by persistence  in  the  use of mercury after  the eruption
has once made its appearance, the vesicles are larger, and evolved
amid extreme constitutional disturbance, violent febrile  symptoms,
great heat of surface, and swelling of the  parts upon  which  they
are about to appear.  The eruption  is of a dusky red or purple
hue, and the vesicles, when they burst, which they do before long,
discharge abundantly.   The cuticle, in bad cases, is even  detached
in large flaps, and extensive excoriated and  bleeding surfaces  are
then  exposed.   These  are covered by and by with laminated
incrustations, and the disease is always followed by repeated exfolia-
tions of the cuticle.  The pain which accompanies its progress
is excessive.
  Eczema a sulphure.  In the same way as we have  an eczema
from mercury, I have met with several individuals who, from some
peculiarity of constitution, could not bear sulphur in  any of its
forms; and who, from being subject to the action of this mineral,
became affected with an acute  vesicular eruption, possessing the
general characters of eczema ; the secretion of glutinous serum that
followed the rupture of the vesicles being, in many cases, as profuse
as it is in the eczema rubrum.
  The causes of eczema are, in general, extremely obscure.   We
do,  it is true, frequently see vesicular eruptions, with all the outward
characters of eczema, evolved under the influence of appreciable 
VESICULAE--ECZEMA.
53
causes, such  as exposure  to  the  sun's  rays, the application of a
blistering or  stimulating plaster, the inunction of the sulphur and
mercurial ointments, the contact of sugar, 6cc. &c.; but these differ
from  the proper  or constitutional  eczemas in their essentially
transitory nature,  and the readiness with which they either disap-
pear of themselves  or yield to remedial measures.   The disease
does not appear to  be truly contagious in any of its forms, although
the contact  of the discharge has in  a  few instances been known
to excite transient vesicular eruptions.
  Eczema is a disease which appears under such variety of aspects,
according to the situation it occupies, the subject it attacks, and
the intensity of  the inflammation, that the fact of its having been
confounded  with many other diseases of the skin,  cannot be made
matter of surprise.   Of all the affections for which eczema simplex
is apt to be  mistaken, scabies is undoubtedly the one, the diagnosis
of which offers  the greatest difficulties.  In  many  cases, indeed,
they  are but collateral and adventitious circumstances, aided by
time, that enable us to decide definitely between the  two.
  From herpes,  another vesicular disease, eczema is distinguished
by the minuteness of its vesicles, and the little inflammation that
surrounds them, those of herpes  being rounder, larger, collected
into clusters  or bands, and always set within an  inflammatory
areola of some breadth.
  From the papular affections,  particularly  lichen  simplex, the
eczemata are to be  distinguished by careful  observation of the
elementary forms of the several eruptions.  In the more advanced
stages of the severer species of lichen, when the papulae have been
crowded, and are  now lacerated, and covered  with  incrustations,
the diagnosis is frequently very difficult; close watching, however,
enables us before long to discover whether they be papulae or vesicles
that are evolved in the vicinity of the  principal clusters, or in some
other situation, and these  prove certain guides to right conclusions
in regard to the nature of the eruption under review.   Pruriginous
(papular) affections of the  genital  organs,  and chronic eczemas
of the same parts, are distinguished from each other by the absence
of discharge in the papular, and  its profuseness in  the  vesicular,
eruptions.   A very moderate degree of care  will prevent eczema
in  any of its forms from being confounded with impetigo.  The
elementary forms of the two diseases, in the first place, are different;
the worst cases of eczema impetiginodes are still vesicular in their
origin,  or  at most contain  a little purulent matter suspended in a
large quantity of serum.  The scabs  and incrustations that follow
these two diseases also present characteristic differences in  their
appearance; those of the  eczema  being broad, thin, laminated, and
friable, when not moist;  those of impetigo being thick, consistent,
firm, of a yellow colour, and very rugged and uneven ; around the
margins of the eczema, too, vesicles of the variety entitled rubrum,
are constantly to be discovered, which is not the case in impetigo.
  Eczema of the  scalp  has several features  in common  with
pityriasis, a scaly affection  of the same part; but  the want  of 
54
GREEN ON DISEASES OF THE SKIN.
vesicles,  of proper incrustations,  and of serous discharge in the
latter disease, distinguish it sufficiently from eczema.  There seems
little  risk, with the most  ordinary powers of discrimination,  of
confounding eczema with any of the varieties of psoriasis, another
scaly affection, in which the squamae are whiter, drier, and more
friable than the incrustations of eczema; in  which, besides,  no
vesicles are ever to be seen, and no serous exudation ever occurs.
  Without being a dangerous disease, eczema often proves a very
serious one, and one which resists every the  best-directed  means
of cure.   In infants and the youthful, the disease either ends  of
itself, or yields, after a  time—on the conclusion  of the  process  of
teething, on the appearance of the menstrual flux, or to the remedial
measures pursued  for  its relief.  When  the  disease is hereditary,
it is seldom more than temporarily benefited  by medicinal means.
When it  affects the lower extremities  in  the aged, it  frequently
baffles every effort that is made for its relief,  and continues to the
end of life unmitigated or but a little improved.
  In  a disease presenting such  different degrees of severity, and
affecting  such  a variety of parts, it may well  be imagined that
very  various  modes  of treatment are required.   In the milder
forms, abstinence, rest, and the use of some mild diluent, frequently
prove sufficient gradually to cure the disease.  When the  disease
proves obstinate under these measures, the effects of the simple
tepid bath, of the alkaline bath, made by  adding five or six ounces
of the subcarbonate of soda or potash of commerce, to an ordinary
tepid bath, or the sulphurous  water  bath, made by substituting
three or four ounces of sulphuret of potash for  the alkali, conjoined
with  the use, from time to time, of some gentle aperient, may  be
tried, whilst the diluent is acidulated with lemon juice, or better
still with a few drops of the nitric acid, and a wash of the liquor
plumbi sub-acetatis properly diluted, is  kept applied  to the parts
immediately affected.
  In the eczema rubrum and impetiginodes the symptoms generally
run so high that,  besides insisting on the observance of the most
rigorous  antiphlogistic regimen, we are justified,  and  indeed fre-
quently required, to adopt more energetic measures ; blood must be
taken from the arm, and a number of leeches attached around the
regions principally affected, when the disease is confined to particular
districts.    It may even be necessary to repeat the venesection; and
if the patient  be young and vigorous, and the  operation the first
time have been followed by an improvement  in  the symptoms,
there will be the greater inducement to try its effects again.  All
topical applications must be of the most soothing kind, and sulphur
and mercurial unguents of  every description  are to be  absolutely
interdicted.
  When eczema can  be traced to evident causes, as to  the  action
of particular medicines upon  the  system, the contact of irritating
pulverulent substances with the skin, &c,  it may seem superfluous
to say that these must immediately  be discontinued, when their
injurious effects will  almost invariably and  very  speedily cease. 
VESICULAE—ECZEMA.
55
 Such a degree of excitement,  however, is sometimes produced in
 this way, that measures of general depletion have to be enforced
 for its removal.
   When  eczema appears with decidedly chronic  symptoms, the
 sulphuric  or nitric  acid, in  conjunction  with general dietetic.
 measures, will be found a  medicine of great value.   Any of thn
 neutral salts, in gently purgative doses continued for  some length
 of time, frequently proves  of signal  service in  these cases.   The
 alkalis as well as the acids also deserve a trial;  the liquor potassae
 in doses of ten drops  in barley-water, twice  a day, and gradually
 increased,  has sometimes the best effects in modifying eczemas of
 old standing.   When the pruritus is very  troublesome, an alkaline
 bath taken in the evening will  often be found to allay this distress-
 ing symptom greatly, and procure the patient a  good  night.   The
 sulphurous water bath has frequently the  same  effects and seems
 farther, in  many old  cases, to modify the eruption  favourably.
 When the disease is indolent, the more powerful stimulus of the
 vapour bath or douche may be tried, often with the happiest effects ;
 but the action of this bath requires to be closely watched, as eczema
 will not bear to be tampered with in  any of its forms, and the
 application of stimulating remedies of all kinds is apt to be followed
 by an  aggravation  in the  symptoms  of the  disease.   For this
 reason  it is, that the hot air and sulphur fume bath are seldom
 applicable  in  cases of eczema.   They can  only by possibility do
 good  when the disease is in an  indolent  state, and when the system
 has been prepared for their action by previous depletion and ab-
 stinence.   Then, and especially among  the aged, I have known
 them of service in this disease after all other means had been tried
 and proved unavailing.
   During the course of the whole of the varieties of chronic as well
 as of acute, local as well as  general, eczema, a wash of the liquor
 plumbi sub-acetatis and  emulsion  of  bitter almonds, or of the
 diluted  hydrocyanic acid, may be freely used with a view to  allay
 pruritus.
   Among the internal medicines  that deserve a trial in obstinate
cases  of eczema, the decoction  of dulcamara is  one which ought
never to be neglected.  The tincture  of cantharides has also  been
tried in these cases, in doses  gradually  increased to the extent of
thirty drops daily, and with success.  But arsenic, in one or other
of its forms, is frequently the only medicine that seems to produce
appreciable or permanently good effects  on the inveterate  forms
of this  most obstinate disease.   The  Fowler's solution may  be
begun in doses of five or six drops daily in  some convenient vehicle,
and, being gradually increased and its effects closely watched, per-
severed in until some evident effect is produced on the general con-
stitution, or on the disease.

                  CASE OF CHRONIC ECZEMA.

  A lady, aged about 40, of a sanguine bilious  temperament, had 
56
GREEN ON DISEASES OF THE SKIN.
for several years been afflicted with eczema on the hands.  She had
tried all the  customary modes  of cure again and again, and had
been under the  care of the most reputed medical practitioners in
London and other places;  she  was also an annual visitant at Har-
rowgate, but had never obtained more than  temporary and partial
relief from any  of the systems of treatment pursued.
  When she first consulted me, I found both hands greatly inflamed,
swollen, deeply fissured both  on  the backs and palms, and dis-
charging abundantly a clear and watery secretion.  The complaint,
she told me,  was then in a state of abatement, but  was attended
with severe itching, and often with so much irritation  as to cause
hysterical fits;  at these periods of aggravation, she  informed me,
she was accustomed to have  a pillow slung round her neck, on
which  she rested the hands, whilst various lotions, embrocations, &c.
were applied to them.  She had not  only not been able to use her
needle, nor assist in dressing herself, but had even been incapacitated
from feeding herself, during a great part  of the  period she  had suf-
fered from  this annoying complaint;  her health  generally was
tolerably good.
  At the time of her consulting me, February 16th, 1830, she was
daily expecting the exacerbation of all the distressing symptoms of
her malady,  which at this season commonly took place, and was
particularly  desirous of at once trying the fumigations of sulphur,
having essayed  every other reputed  means of relief, except these,
without avail.   I did not, however,  dare to give this lady much
encouragement from the sulphur bath, without  resorting to certain
preparatory  measures;  to  which having assented, she was bled to
the  amount of ten ounces ;  twelve leeches were applied to each
hand, and the common bread  and water poultice was afterwards
applied. She also took the following at bed time,—compound ex-
tract of colocynth ten grains, powdered scammony and Venice soap
of each five grains, made into  four pills with syrup of buckthorn,
and three spoonfuls of the following mixture, morning and  evening,
—infusion of cloves twelve ounces, tincture of hops one ounce, tar-
trate of potash one ounce, and tincture of senna half an ounce. On
the 21st, this lady came prepared to take the bath ; the bowels had
been actively operated on  by the  medicine, the blood showed no
signs of the buffy coat, but was very tenacious, with little serum ;
the swelling and inflammation of the hands seemed little abated.
  She commenced the  fumigations, and  was directed  to continue
the mixture. 25th.  No amendment in the parts  affected, but rather
an increase of irritation, and the patient expressed disappointment
—directed to discontinue  the  fumigations ; again bled to sixteen
ounces, and more  leeches applied to the hands ; another dose of
the pills taken and the mixture continued; two warm water baths
were also taken during the next four days.  March 3d.  The irrita-
tion was less, and the bleeding and medicines had answered expec-
tations.  The patient now took a simple  vapour bath every other
day, and continued the mixture.  9th. The  swelling and irritation
)f the hands were abated, and the fingers more pliant;  the sulphur 
VESICULAE—ECZEMA.                   57
fumigations were resumed, first daily and then every other day, but
still with aggravation of the symptoms, and increase of the general
irritation ; they were therefore discontinued.  The pulse being full,
the patient was again bled in the arm to sixteen ounces, took another
dose of pills, and to the  former mixture  was added two drams of
calcined magnesia and half an ounce of  manna;  lemonade as a
diluent was also prescribed.   17th. Again  commenced the fumiga-
tions, one every other day, the affected parts during the interval
having become more quiescent, although but little better in appear-
ance.  23d.  The patient was now decidedly better, and took  the
fumigations  daily, till after the 26th, when  they were again ordered
every  other day  only, and, some aggravation  of the symptoms
having been experienced, a fourth  bleeding was practised  to  the
extent of sixteen ounces.   After each bleeding the patient was satis-
fied that she felt lighter, cooler, and even  stronger, though  at  the
commencement of the treatment she had had objections to the prac-
tice.  From the 4th of April she was enabled to bear  the fumigations
daily; she had gone  on  improving regularly  from the 26th of
March.  April 20th, much better: hands nearly healed;  can dress
herself, and  thinks she  will get well.  This lady continued to take
the fumigations till the end  of May, gradually leaving  them  off.
During this  period she  applied poultices to the hands whenever  the
irritation was great, and at other times simply a little Goulard oint-
ment.  She  was restricted to simple  diet, and abstained from wine,
and sweets.   I have had an opportunity of observing this case from
the time of  treatment  until now.   The patient remains well; at
spring and autumn  she generally has threatenings and some slight
appearances of a  recurrence  of the complaint, but  by attention to
diet, the loss of a little blood, and the use of the sulphur fume bath,
she has had no actual return of the  malady to such an extent as to
occasion her any inconvenience.
   Case of Eczema following the free use of mercury.—It had
been judged advisable to give mercury largely to  Colonel----, aged
60, of a phlegmatic, weak habit.  The usual effects on the  mouth
were  produced, and the  salivation  proved of obstinate  and long
continuance.  As he got  better of this affection, the general irrita-
bility of the system became  extreme, and was  accompanied with
itchino- over the whole  surface of the skin, so that  in  a  few days
there was scarcely any part which was not  suffused with redness,
and which did not gradually become covered with vesicles, from
which issued  an  abundance  of ichorous  discharge, requiring  the
constant application of soft rag, and incessant changes of the  pa-
tient's body and bed linen.  A considerable degree of irritative fever
continued, in despite of the best directed treatment resorted to. The
ichorous discharge after the first fortnight abated in  some situations,
but continued to be poured out from others; wherever it abated  the
discharge became gummy, and ultimately formed yellowish  crusts,
which, in course of time, became black.  This gentleman had been
suffering in  this way for ten weeks, when he was  referred to me,
September 26th, 1831.  The whole surface of the  body, with  the 
•
58            GREEN ON DISEASES OF THE SKIN.

exception of the flexures of the joints, was covered with these black
crusts;  from the bends of the joints there still continued to issue a
thin ichor through cracks in the skin, which was here of a deep
red colour, shining and excessively tender; in other situations the
great tenderness that existed in the earlier stages of the complaint
had subsided ; extreme irritability of temper however still continued.
The eyelids were so incrusted that they were with difficulty opened,
he had  not once been able to shave, and his face was covered with
a complete mask of incrustation. The ears were also much affected,
but the  complaint had not extended beyond the margin of the hairy
scalp.   He wore a veil; for the parts to which the air gained  free
access were afterwards affected with severe smarting or itching.
   Notwithstanding the active treatment this gentleman had under-
gone, and the little rest he had enjoyed night  or day for ten weeks,
his general health was not much impaired ; his pulse was little more
than seventy, full, and even  hard, to the touch, his appetite  was
good, and his other  functions were little disordered.   I therefore
urged his being bled to  fourteen ounces, directed an active purge,
and the next day a warm water bath with a large basinful of thick
gruel put into it, with a view of softening the hardened crusts and
sheathing the other parts that  were tender;  the bath  I ordered to
be repeated twice, with intervals of a day between each, for I felt
satisfied the disease was not in a sufficiently chronic state to receive
benefit from the sulphur fumigations, for the  use of which he had
been induced to consult me.
   October  2d, commenced the sulphur fumigations, which occa-
sioned smarting, but this sensation he preferred to the more usual
itching  and  irritation which were almost incessant.   He  merely
took some aperient medicine.   6th. No very manifest improvement
in the appearance of the complaint; on the contrary, the hands, feet,
and legs were more swollen, and the cracked parts of the skin more
painful  than common.  I recommended  the  patient again to  lose
blood, but this he declined to do, and was  therefore put on low diet,
purged, and directed to repeat his  emollient  water  baths on those
days on which he  did not take the fumigations, now only admin-
istered every other day.   A little simple cerate was applied to the
cracked and abraded parts.  12th. The swelling, inflammation, and
itching  had much subsided, and in many parts  large crusts had
fallen off, leaving the  surface  underneath  red, shining, and tender;
these, in the course  of twenty-four hours,  would  again  become
covered with yellowish crusts, but they  were thin in substance.
Treatment continued without alteration. 20th.  Considerably better,
irritability lessened.   23d. Still improving rapidly, and the crusts
when now detached were no longer renewed,  although the surface
they had covered long continued red, shining,  and tender in appear-
ance.  After this the patient got rapidly well,  the extreme excitabi-
lity both of mind and  body left him, and after retiring to the country
for a few months he returned to London, where he has been long
engaged in the  discharge of multifarious and  active duties, having
suffered no relapse of  his disease. 
                     VESICULjE--HERPES.                  59


                           HERPES.

  Herpes as a genus is characterised by the eruption of well defined
clusters of vesicles, generally of a circular form, seated upon an in-
flamed ground, separated from each  other by intervals of various
extent, in which the integuments appear perfectly healthy, and ter-
minating at the end of from six or eight  days to a fortnight in the
formation of laminated incrustations.
  Several  species or  varieties  of  this disease are now generally
admitted by pathologists ; the individual and distinguishing features
being derived in one case from the seat of the eruption, in another
from the form it usually assumes, and in a third from the colour of
the inflamed areola that surrounds its clusters.
  The variety  of herpes entitled phlyctenodes may be taken as a
type of the  whole group.   After sensations of smarting and of burn-
ing heat have existed  for an hour or two in the place where the
eruption is  about to appear, the surface is found hot, and beset with
an infinity  of very minute red points.  These on the  morrow are
found to have given place to an uniformly inflamed patch, thickly
covered with prominent vesicles, firm to the  touch, and varying in
size from that of a millet seed to that of a small  pea.  A very dis-
tinct  inflammatory areola surrounds the cluster  thus  produced.
The vesicles are globular in their  shape, and transparent at  first,
but they soon  become milky; and, beginning to shrivel  from the
third or fourth day, they all  run their course within seven or eight,
when  they give place  to thin, brownish coloured incrustations,
which, being thrown  off a few  days afterwards, leave red marks
behind them, that disappear slowly.   A  few of  the vesicles occa-
sionally  become purulent, and  the  skin under  these ulcerating
superficially, the scabs that are formed are longer  of being detached.
  This disease is not generally preceded or accompanied by general
symptoms of any importance ; some degree of fever and an unusual
irritability  of temper, however, may frequently  be remarked pre-
viously to an attack in those who are habitually subject to the erup-
tion.  The local symptoms that accompany the evolution of each
group, are painful sensations of smarting and  of burning heat.
These subside when the vesicles are fully formed, so that neither
local nor general symptoms, when they do occur, are ever observed
to last longer than two or three days.  The extent of the disease
does not commonly exceed one or two clusters, which vary respec-
tively in size from that of a shilling or a half-crown piece, to that of
the palm of the hand.  The eruption appears, perhaps, more fre-
quently on  the  cheeks, ears, and nose, than elsewhere.   The youth-
ful are the  individuals usually attacked.
  The elementary form of this disease—a cluster of vesicles of dif-
ferent sizes,  crowded together  upon an inflamed ground of the
extent indicated, will always, with due attention, prevent  its  being
mistaken for any other affection  of a different nature.   It is to  be
distinguished  from the other varieties of herpes by the peculiar
forms affected by these, or the special seats they occupy;  these con- 
•
60             GREEN ON DISEASES OF THE SKIN.

siderations indeed supply the sole assignable reasons for their being
described as other than mere varieties of herpes phlyctenodes, for
the mode in which  their clusters are evolved, the  appearance of
their vesicles, the course  they run, and the sequelae are  all very
similar.
  Herpes phlyctenodes may be treated on general principles.  Rest
for  a few days, abstinence, and  the  use  of some  gentle aperient,
being all required to bring it to  a speedy and favourable  termina-
tion.
  One of  the  most common and familiarly known of the  local
species of this aflection, is the herpes labialis.   After exposure to a
cold wind,  and  frequently as one of the sequelae of a catarrhal affec-
tion, and still more frequently of an  attack of intermittent fever, a
peculiar sharp and burning sensation is experienced  in some part
of the lip, very often in the line of demarcation between the coloured
portion and the common integument.  This part feels hot,  is tense
and shining, and evidently swelled, and, if carefully examined after
an hour or two, (and sometimes after a much shorter interval,) will
be found occupied by a small cluster of transparent vesicles, several
of which commonly run  into each other,  and frequently form glo-
bules little  short of the size of a pea.  The fluid does not long con-
tinue transparent, but soon  becomes milky, and  then  yellowish,
when  it begins  to dry up, so that  by  the fourth or fifth day a
brownish incrustation  is  formed, which is  usually  loosened and
removed about the  eighth  or ninth, leaving a smooth, red, and
shining spot which is not of long duration.
  This is usually so trifling  a disease, that no measures are taken
or required for its  alleviation.   When the  sensations that accom-
pany the evolution of the vesicles are very troublesome, they may
be relieved by bathing the parts  repeatedly with cold water.
  Clusters  of vesicles are occasionally developed  on the prepuce,
having all the characters of  those that have just been described  as
evolved upon the lips; the disease is then entitled herpes preputialis.
It is altogether a trifling affection, and soon runs its course, without
requiring the interference  of  art.  It is only important from being
now and then mistaken for a syphilitic affection, by those who can-
not see any form of excoriation about the parts of generation without
immediately setting it down to a venereal cause.
  The most interesting of the varieties of herpes which are  denomi-
nated from the form assumed by the clusters of eruption, is shingles,
the herpes zoster, or zona, of pathological  writers.
  Herpes zoster  occurs   most  commonly on  the parietes of the
abdomen, in the form of a half girdle, composed of a succession  of
vesicular clusters, usually in contact, or nearly so, by their sides,
but sometimes  separated by spaces,  more or less  considerable,  of
healthy skin.  The disease  commences  by one or more irregular
patches of a bright red colour, which are  successively followed  by
others of a  similar description on either side of  those first evolved,
unless the disease have begun at the  middle line of the body, when
they occur on one side only.  These erythematous patches, when 
VESICULAE—HERPES.                  61
closely examined soon  after their appearance, are  found thickly
beset with numerous small, shining, and silvery-looking points,
which increase rapidly in size, and soon acquire the form and
aspect of distinct transparent vesicles.  These attain their maximum
development within three  or  four days  after their  appearance.
They seldom exceed a large pea in size; although it does occa-
sionally happen that, by coalescing, larger bleb-like collections of
fluid are formed.  In this case the included serum is generally of a
dark colour.  The ground upon which the vesicles are forrrled is
now of a very vivid  red, and the several clusters are surrounded by
an inflamed areola of some breadth.   This state continues till the
fourth or fifth day from  the formation of each particular group,
when the redness begins to fade, and the vesicles  to look turbid,
dark-coloured, or purulent, and shrunk on their surfaces.  Most of
them dry up and are succeeded by small, thin, lamellar incrusta-
tions of a dark brown  colour, which are detached about the tenth
or twelfth day of the disease, leaving  deep red stains behind them,
which only disappear  very gradually.   Several  of  the vesicles
usually burst of themselves, and shedding their contents on the sur-
face, are followed by superficial and very temporary excoriations.
When the vesicles have been extremely confluent, and the accom-
panying inflammation has been violent, thicker  and more adhering
crusts are produced, under which a process of ulceration of an in-
dolent character is very apt to  take place ; and in  the very worst
cases of zona, portions of the affected integument are even observed
to become gangrenous;  in either case  indelible  cicatrices follow
upon the parts affected.
  As the clusters of zona are evolved successively, so do the changes
that have been described take place in the different groups one after
another.   The eruption is consequently seen in a nascent state in
one part of the band, whilst the dried incrustations are in the course
of being detached from another.  The whole duration of the disease
does not usually exceed three weeks.  When it has been very vio-
lent, however, and excoriation  and ulceration to some extent have
taken place, it may last much longer.
  Herpes zoster occurs as frequently, or perhaps much more fre-
quently, unpreceded and  unaccompanied by the general or consti-
tutional symptoms,  such as feverishness, thirst, depression, &c.
which have been very currently believed to  usher in the attack,
and to attend the disease in its progress.  In more than five hun-
dred cases of the disease  which M. Biett had seen  at the Hospital
St. Louis, merely local symptoms, generally of  little severity,  were
observed.
  The local symptoms of herpes zoster consist of a  feeling of heat,
tension, and pain, sometimes of great severity, in the parts about to
be affected, and of a deep-seated, dull, and very distressing neuralgic
pain, which frequently continues in the situation of the eruption
long after all traces of its existence have disappeared.
  It is very remarkable that herpes zoster should never form more
than a half girdle around the body.  Commencing  by the side of 
62
GREEN ON DISEASES OF THE SKIN.
the anterior or posterior median lines, and frequently by both at the
same time, it gradually extends backwards or forwards over the
ribs or  flanks, but never trenches on the parts beyond those that
fall fairly within that half of the body on which it is evolved.  The
course of the girdle, however, is frequently very irregular, being
crooked or tortuous in one case, in another extending to the top  of
the thigh, and in another across  the shoulder like a T.  The dis-
ease is  by no means confined  to the trunk.  It is now and then
seen on the face and hairy scalp, and occasionally on one or other
of the lower extremities, down which the band then usually stretches
from the hip.
   The relative degree of frequency with which herpes zoster occurs
on the right or on  the left side of the body has been particularly
studied by pathologists; but the results  that have been come to by
different enquirers  by no means tally with one another.   Messrs.
Cazenave and Schedel say, that nineteen times in twenty the disease
will be found on the right side, and Rayer gives the  proportion  of
eight to ten.  But I have no hesitation in saying that those writers
have been alike precipitate in their conclusions.  I have myself seen
herpes zoster at least as  frequently on the left side as on the right,
and I make no doubt but that, as facts are accumulated, the disease
will be discovered to attack both sides of the body with similar fre-
quency.
   The causes of herpes zoster, like those of so many other diseases
of the skin, are buried  in obscurity.   Individuals of delicate com-
plexion and fine skin seem most exposed to suffer from its attacks.
The disease has been known to prevail epidemically.
   Herpes zoster at  its height is  not liable to be mistaken for  any
other disease.   In its earliest stages it might very possibly be con-
founded with another  form of the same eruption, namely, herpes
phlyctenodes ; this  error would only be temporary, and would prove
of no consequence were it even otherwise.  Herpes zoster is by no
means the formidable disease which  it is esteemed by the vulgar;
who have  a  notion that there  is great risk of the belt extending
entirely round the  body, in which case it would certainly prove
mortal.   It is only when the eruption is followed by ulceration  or
sphacelus of a  portion of the skin, that the affection proves at all
serious.
   With  this view  of the  disease it  may be  conceived that little
treatment is required in the vast majority of cases of herpes zoster.
Rest in bed and the use of a mild diluent, with some little attention
to  the  non-naturals, as  they were  strangely termed  by  the old
writers, namely, eating, drinking, and the excretions, are all  that
are necessary to secure a regular and uninterrupted course to the
disease, which  ends naturally within a fortnight or three weeks.
When feeble subjects and the aged labour under the disease, it  is
advisable to keep them as  much as  possible from lying long upon
the side or parts affected with eruption, as the pressure seems fre-
quently to induce excoriation and even the death of the skin. When
either of these  untoward events has  happened, the parts must be 
VESICULjE—HERPES.
63
gently washed with tepid fomentations, and after the eschars are
detached, a  compress spread with simple cerate, or the unguent.
oxid. zinci, applied to the sores.   Generous  diet, and an allowance
of good malt liquor or of wine, should be at the same time prescribed.
   When the vesicles of herpes, instead of appearing clustered into
simple groups, or  strung together  into bands, assume an annular
form, the disease is described as herpes circinnatus.  The eruption
is announced as usual by an inflamed ring or patch, but slightly if
at all affected  in the centre, commonly perfectly circular, but some-
times also oval in  its shape, and usually  from an inch to an inch
and a half in diameter.   The circumference of this ring or patch is
before long  covered with  small globular  vesicles  very closely
crowded together,  and perfectly transparent at first.  They however
soon become turbid; the cuticle which covers them then gives way,
and a little fluid is shed upon the surface, which hardens into a thin
squamous incrustation that remains  adherent till the eighth, tenth,
or  fifteenth day, when it is detached, and a  bright red mark is left,
the disease having run its course within this period of time.  Some
of  the smaller rings do  not even pass through the whole of these
phases, but the fluid their vesicles contain being absorbed, a slight
epidermic exfoliation alone takes place from their areas, as the con-
clusion of the disease.
   This disease  occurring in annular  patches has frequently been
spoken of under the title of ringworm, and confounded with a pus-
tular disease—favus, of a very different and much more intractable
nature, which appears in patches of a  similar shape.  But the two
diseases  may  always be distinguished by  the difference of their
elementary forms ; by the products of their existence,  which in the
favus are thick scabs, in the herpes flimsy squamae :  by their effects,
the loss of the hair  invariably following the favus ; by their duration,
which in the favus is always protracted and uncertain; and by the
contagious nature  of the  pustular disease.
  Herpes circinnatus is developed most frequently on the neck,
face, breast, shoulders, and arms, and  occurs most frequently among
children and females.
   The itching and heat that  accompany the evolution of the vesi-
cles of herpes circinnatus, may be allayed by dabbing the rings with
a rag dipped in cold water, of in water holding a little sub-carbonate
of potash or sulphate of  zinc in solution.  Should the eruption be
very copious,  and  appear in successive  crops, a cooling  regimen
should be prescribed, and a few doses of aperient medicine exhibited
at intervals, until the disease  is no longer produced.
  The title of herpes iris has been given to a very rare species of
the disease, in which each cluster of vesicles is surrounded  by a
number of erythematous  rings, presenting different shades of colour.
An inflamed patch as usual announces the appearance of this species
of herpes, but  it  is  speedily broken into the peculiar  rings that cha-
racterise the disease.  On the second day its centre is seen to be occu-
pied by a  distinct vesicle of considerable size, round which a number
of other vesicles, much more minute, are congregated. After the lapse 
64
GREEN ON DISEASES OF THE SKIN.
of two or three days the central vesicle shrinks, but the erythematous
rings that surround the cluster deepen in their  colour, so that they
have been frequently compared to party-coloured cockades.   They
form in fact four distinct concentric circles the size of a shilling,
the innermost of which is of a reddish  brown, the next of a yel-
lowish or dirty white, the  third of a  deep or  dusky red, and the
fourth of a paler red  or rosy hue, which fades imperceptibly into the
colour of the surrounding skin.  The  whole of  these rings are
occasionally observed to become covered with vesicles.  The dis-
ease terminates by the re-absorption of the fluid, and a slight subse-
quent epidermic exfoliation, or by the bursting of  the cuticle and
the shedding of the  serum upon  the  surface, when it dries into  a
flimsy scale  of incrustation, that  is detached before long.  Herpes
iris is most commonly  met  with  on the face and neck,  hands,
fingers, ankles, and insteps.  It is a trifling  disease, and does not
require special treatment of any kind.  It is only  met with  very
rarely in practice ; so that  among  the host  of patients  labouring
under cutaneous diseases who seek the Hopital St. Louis for advice,
no more  than three or four  cases of it are encountered in the course
of many  years.

                           MILIARIA.

  The eruption of vesicles of the size of millet seeds, that used so
frequently, in former times, and that does still occasionally occur in
the course of various acute  diseases, has been held  worthy, by
several nosological writers, of a place  in their systems, in which it
is found  variously denominated febris miliaris,  sudamina, miliaria,
and suette miliaire.   It  might, however, be made  a question for
consideration  whether, under any  circumstances,  an eruption of
this kind has any title to be elevated to the rank, or viewed  in the
light, of an idiopathic disease.  I  am myself inclined to believe that
miliaria ought never to be  regarded otherwise than as a symptom
of some more serious and generally constitutional aflection.
  Accidental eruptions of miliary vesicles  are  very  frequently
observed in  the course especially of gastric  and intestinal, and of
puerperal affections.   They also occur along with  any disease in
which profuse perspiration forms one #f the principal features;  thus
they are  very common in the last  stages of phthisis,  when the body
is nightly drenched in perspiration, and in the  suette, or sweating
disease of Picardy.   A heating plan of treatment, too, will  almost
certainly induce an eruption of the same description, in the course
of most of the common febrile and inflammatory diseases, such as
scarlatina, rheumatism, &c.  Sudamina even  occur under less
complicated circumstances,  as when the body has been  excessively
heated in consequence of taking violent exercise.
  This affection, therefore, does not seem to require more particular
notice.   Its diagnosis is never attended with any difficulty, and its
treatment is subordinate to that  adapted to the principal  disease
along with which it occurs. 
BULLAE—PEMPHIGUS.
65
                           BULLAE.

  The blister, or serous elevation of the cuticle that follows a scald
or the application of a plaster of Spanish flies, may be taken as a
general type of the diseases included under the head of bullae or
blebs.   These  are two in number, Pemphigus and Rupia.  The
blebs characteristic of these affections  vary in size from that of a
pea or small hazel-nut, to that of a hen's and even of a  turkey's egg.
The size of these  blebs in bullous  affections is by no means the
only feature that distinguishes them from the vesicles, in vesicular
eruptions, which are also, as we have seen, serous  elevations of the
cuticle.  The whore train of symptoms accompanying the evolution,
course, and termination of the different species included in each of
these two genera of diseases, is  as  different as possible;  a circum-
stance, nevertheless, which  has  not prevented even distinguished
writers, Dr. Rayer among the number, from referring truly vesicular
diseases, in which several of the vesicles sometimes  show a tendency
to coalesce, as  they do in herpes zoster, to an  erroneous  position
among the bullae.1
  Bullae are frequently  evolved without any evident  antecedent
redness of the parts upon which they appear, although the contrary
of this is the more common case.  They are usually small  when
first discovered, and increase rapidly  to the  size- they ultimately
attain.  They are tense and round in their earlier stages, but soon
become flaccid, and, to  appearance, half filled with fluid.  This
fluid is commonly limpid and transparent, or slightly tinged with
blood, when first poured out;  it becomes turbid, and often purulent,
and.more consistent at a later period.   As may be  imagined, except
in those situations in which the cuticle is thick and strong, blebs
are not of a long duration ;  they speedily break, and their  contents
escape.  They are subsequently covered with incrustations, which
in one disease are of extreme tenuity,  in another  of as  remarkable
thickness and density. Under these incrustations ulceration, which
continues superficial, or extends deeply, according to  the species of
•disease, is very apt to occur.
  Bullae appear on every part of the body, but more  frequently on
the extremities, especially the lower extremities, than in any other
situation.   Unless when  they occur  in the aged, among indivi-
duals of broken-down constitutions, or along with an affection of
some internal organ, bullous diseases are not to be regarded as at
all formidable  in their nature or tendencies.

                          PEMPHIGUS.

   Pemphigus or pompholix, assuming the disease described by dif-
ferent authors under these two names  to be the same, is character-

   1 This mistake in arrangement has  been rectified in  the second French
 and English editions of Dr. Rayer's excellent book.
        6—b                                       gm  5 
66
GREEN ON DISEASES OF THE SKIN.
 terised by the formation, on various districts of the body, of one or
 of several generally isolated bullae of varying magnitude, but com-
 monly of large size, being sometimes as much as two inches and
 more in diameter,  containing a fluid which is transparent and
 colourless at first, but which soon grows reddish and somewhat
 turbid, and terminating in the discharge of the fluid, and the forma-
 tion of flimsy and superficial incrustations.
   The  whole of the varieties  of  pemphigus which have  been
 described, may be referred to two  principal  species,  according  as
 they are acute or chronic in their type.
   Acute pemphigus appears to  be  so rare a disease,  that its very
 existence  has  been called in  question.  But the  most weighty
 authorities of the present day on the subject of cutaneous diseases,
 the Drs. Rayer and Biett, are of one mind on this point, and admit
 that the disease is occasionally,  though rarely, met with acute in
 its type.
   The disease may be confined to a particular region, or  invade
 the whole surface of the body at once.  The initiatory symptoms
 of the  eruption are in one case very slight, consisting of mere
 indefinite feelings  of general uneasinesss, some degree of pruritus
 of the  skin, and a greater quickness and sharpness in the pulse
 than  are natural.  In another they run much higher;  irregular
 shivering fits, a dry and parched state of the skin, thirst, &c, pre-
 ceding the attack,  by from twenty-four to forty-eight  hours.   The
 eruption then makes its appearance, consisting at first of a number
 of small circular  patches,  which spread  rapidly, and are either
 almost immediately or by and  by covered with a bleb, which  may
 occupy the whole of the inflamed spot, or only a part of its surface;
 some of the  spots indeed are  never covered  by blebs at all;  the
 cuticle  over  these, however, is always very readily detached, the
 slightest pressure of the finger sufficing to remove it.   Each of the
 blebs, now varying in size from that of a pea to that of a hazel-nut,
 is  surrounded by an  inflamed areola, which  is very bright during
 the first  few days; the skin in the intervals  between them con-
 tinuing perfectly free from disease.   Several of the blebs frequently
 rnn together so as to form one, that may even exceed a goose's egg
 in its dimensions.
   At  their height these bullae  are  distended  with  pale yellow
 serum;  when they begin to shrivel, the fluid grows turbid.   The
 greater  number burst, some in the course of the first  twenty-four
 hours, though generally not till after the second, third, or even the
 fourth day; those  that continue  long form little flaccid bags half
 full of liquid.  They are uniformly succeeded by very thin, brown-
 ish-coloured incrustations.  The disease lasts in all from one to
 two weeks, when there is no more than a single eruption of bullae;
 but when successive  crops  of these appear, as frequently happens,
it may be protracted for a month and more.
   The general symptoms that accompany acute pemphigus  in  its
progress, vary as much in  the degree of intensity they present, as
those that precede the eruption: in one case they are so slight, that 
BULL.E—PEMPHIGUS.                  67
 the patient is not even obliged  to keep his bed,  in another they
 seem even to put his life in jeopardy from their violence.
   One very remarkable variety of acute pemphigus is characterised
 by the evolution of no more than a single bulla at a time, which is
 generally of large size,—pompholix solitarius, Willan.  It is pre-
 ceded by feelings of tingling  and itching in the part about to be
 affected;  an erythematous patch makes its appearance, and almost
 immediately afterwards the cuticle is raised by an effusion of serum,
 frequently amounting to  several ounces beneath it.   The bleb
 attain sits maximum development rapidly, for it bursts within eight
 and forty hours, and is succeeded by a slight excoriation.  The dis-
 ease, however, does not usually terminate with the formation  of one
 bleb.   Within a day or two after the first has disappeared, a second
 is evolved in some spot near it, and this is frequently followed by a
 third and a fourth, all of which pursue a similar course.
   Chronic pemphigus (pompholix diutinus) is by no means so rare
 a disease  as  the  acute affection just  described.   Like the acute
 disease, this  one  may appear  confined  to particular situations, or
 may attack the whole surface of the body  simultaneously.   It is
 not necessarily either preceded or accompanied by general febrile
 symptoms, like the acute affection;  these, indeed, are scarcely'
 observed in this, except when the eruption is very extensive.
   The bullae in chronic pemphigus are evolved very nearly  in the
 same manner as in the  acute  form of the disease.   They attain  a
 large size with equal rapidity, have the same general  appearance,
 being  filled with  pale  yellow serum, and end in the same way,
 bursting, and giving rise to superficial excoriations, or becoming
 opaque, they shrivel and  dry up into flimsy, brownish, epidermic
 looking scabs, which cover red and tender surfaces, around which
 the cuticle looks wrinkled and thicker than natural.
   Before  the first crop of bullae has  run its course,  however, a
 second  and a third have made their appearance, which having to
 pass through  the same phases,  may be studied  in  every stage of
 their growth  and decline, in the immediate vicinity of  each  other.
 These secondary bullae are  by no means regularly announced by
 erythematous spots, similar to those that so constantly precede  the
 first.  Some of them appear surrounded by areolae,  others not.
   When the bullae of chronic pemphigus run  together by their
 bases, they are apt to become purulent, in which case  they dry off
 into harder and yellower, but still thin, incrustations, the  spaces
 between these being covered with squamae that  overlap each other
 slightly.  This variety of the disease  is, perhaps, more frequently
 seen on the face than elsewhere, but it also  makes its  appearance
 on several other parts of the body, especially on the fore-arms and
 legs, on which bullae sometimes continue to be evolved in succes-
 sive crops for  years, causing painful  excoriations, and reducing
 patients to extremity by the incessant irritation they keep up.  The
disease  in  this way may be protracted  indefinitely, lasting from a
 period of a few weeks to one of several months, and even of  many
years. 
OS
GREEN ON DISEASES OF THE SKIN.
  Chronic pemphigus  is frequently complicated with  different
internal maladies, especially with inflammatory affections of the
stomach and bowels.  The disease, indeed, in bad cases, may very
commonly be observed attacking the  mucous membrane  of the
mouth and  fauces,, on which distinct bullae are frequently to  be
perceived, and there can be  little doubt but that the pemphigoid
inflammation, under these circumstances, often extends throughout
the entire length of the  intestinal canal;  for though, from the
absence of a proper cuticle or epithelium in the stomach and intes-
tines, no bullae can be produced, still  we have  redness in patches,
with softening of texture, ulceration of the mucous membrane, and
every other appearance which would  lead to the belief that the
alterations observed were  due to a disease  of the same nature as
that which affects the skin.  It is frequently one of the symptoms,
and never a favourable one, of a general break up of the constitu-
tion.
  The disease is  also occasionally seen conjoined  with various
other external  or cutaneous affections, especially with herpetic
eruption and prurigo; its  complication  with the last has even been
described as a particular species of the disease, under the  title of
pemphigus pruriginosus, the most remarkable and distinguishing
symptom  being the intense pruritus with  which the eruption is
accompanied.   The aged are the most common subjects  of the
disease, although no age,  not even infancy, gives immunity from
its attacks.
  Pemphigus is a disease  which, with  proper attention, is so little
liable to be confounded with any other cutaneous affection, that I
hold it unnecessary to enter into any lengthened discussion of the
diagnosis.  The size and generally isolated appearance of its bullae,
unsurrounded, for the most part, by any inflamed areola, and their
termination  in flimsy, lamellar incrustations, are characters enough
to distinguish it from rupia, which is always followed  by ulceration,
and scabs of great thickness ; from ecthyma, in which the eruption
consists of distinct pustules; from herpes, in which the vesicles are
minute and evolved in clusters in the midst of an inflamed  patch ;
and from the phlyctenae, or watery blisters that occasionally appear
in the midst of surfaces affected with active erysipelas.  The marks
which the bullae of pemphigus leave behind them, have even some-
thing peculiar, which, to the practised eye, proclaims  the nature of
the disease which  has produced them.   They are of a dusky red,
isolated, irregular in shape, of very different sizes, and affected from
time to time with a slight  cuticular exfoliation.
  Pemphigus in itself is not a serious  disease.  In the acute form
it runs  its course  naturally within  a  few weeks.   The chronic
disease is alarming in proportion as it is complicated  with import-
ant  affections of internal organs, or accompanies a weakly and
cachectic state of the general constitution.
  With regard to treatment: the symptoms in acute pemphigus do
not often require very active measures  for their relief; rest, absti-
nence, and diluents commonly  prove sufficient aids  to guide the 
BULLAE—:RUPIA.
69
disease to a fortunate issue.   When a considerable degree of febrile
excitement ushers in the eruption, it might be proper to bleed.
   The antiphlogistic is still the plan of treatment proper to be fol-
lowed in cases of chronic pemphigus.  In the aged, we must be on
our guard not to push  this system too far; but a regulated diet, the
use of some  acidulated drink, and the tepid, and occasionally the
warm alkaline bath, should always  be  tried at first.  Pain  and
sleeplessness may be relieved by opium in one or other of its forms,
the bowels being protected from the constipation that follows the
use of this medicine, by means of the mildest laxatives, and clysters
of warm  water.  Concomitant diseases must at the  same time be
sedulously watched, and treated according to the usual methods,
without  regard  to the cutaneous affection.  When the soothing
plan of treatment fails to do much good, an opposite or tonic system
is frequently attended  with the best effects.   Patients should then
be allowed light nutritious  animal food, in such quantities as the
stomach will  readily digest,  and as the system will bear without
excitement; a little old and generous wine, or some  sound malt
liquor, may be cautiously tried in addition, and patients should be
removed into the pure air of the country.   That the use of medi-
cine of every kind may not be given up entirely, one or other of
the chalybeate preparations, and the decoction  of bark with sul-
phuric acid, or the sulphate of quinia in regulated  doses, may fre-
quently be prescribed with excellent effect.   This plan of treatment
is not adapted to the aged only, with worn-out constitutions; many
youthful subjects of cachectic and debilitated habits also derive the
greatest benefit from it.

                            RUPIA.

   Rupia is characterised by flattish and isolated bullae of  various
sizes, containing a fluid essentially serous, but frequently mixed
with purulent matter, and often with  blood,  which are followed by
thick dark-coloured scabs, whose  bases cover  ulcers of variable
depths.
  The disease in its simple form,—rupia simplex, makes its appear-
ance by the development, without evident previous  inflammation,
of one or two blebs the size of  a shilling, and very similar  at first
to those  of pemphigus, being plump and filled with transparent
serum.  The included fluid, however, soon grows turbid, evidently
from an admixture  with it of a quantity of pus and blood; the
bleb becomes flaccid and its contents  increase- in consistency, and
ultimately harden into a deep  brown-coloured scab, rough  and
wrinkled on the surface, thickest and  most prominent in the mid-
dle, and adherent by its edge to the surrounding cuticle.  The part
of the skin covered by this incrustation is superficially ulcerated;
but on its detachment,  which happens naturally within a very few
days, the sore usually heals rapidly, though it does sometimes
remain open for some time, being alternately free from and covered
with a scab.   When the sore is at length completely cicatrised, a 
70             GREEN ON DISEASES OF THE SKIN.

deep red mark continues for a long time to indicate  the situation it
occupied.
  The disease  in this form  is commonly evolved upon the legs,
and occasionally on the loins and thighs.  It is very rarely seen in
any other situation.
  The variety of the disease entitled rupia prominens,  is distin-
guished by the greater size of the bullae, which are slowly evolved
upon circumscribed inflamed bases, and contain, not a limpid and
serous, but a thick and sanguinolent fluid, which being secreted for
some time both  under and around the portion first poured out, and
which soon concretes, gives rise to rough dark-coloured scabs, that
continue for a time to  increase both  in breadth and  thickness.
The bleb and scab of rupia prominens are always surrounded by a
broad inflammatory areola, from  which the cuticle is  raised by
successive effusions of purulent and bloody serum; it is,  in fact, by
the desiccation of this fluid that the original  extent of the scab is
increased;  the areola apparently extending, and the cuticle becom-
ing detached anew, in consequence of the irritation caused by the
encroachment of the ring of incrustation last produced.   This pro-
cess  sometimes  goes on for a week, and then the scab has acquired
the size and very much of the shape and general appearance to the
hollow shell of an oyster.  When the  scab  increases in thickness
much more than in breadth, it bears a very great resemblance to
the shell of  the limpet, with which it has been  compared  by all
modern writers on cutaneous  diseases.  These scabs often continue
to adhere for a long time, and it is only with  great difficulty that
they can be got rid of by artificial means.  The parts which they
cover are always ulcerated in a greater or less degree.   In some
cases the diseased surfaces are very apt to reproduce these scabs;
in others the sores, though deep and of a bad character, secreting
nothing  but  a  little glutinous pus, and continuing long to resist
every means tried for their cure, show  no disposition  of the kind.
When cicatrisation is at length accomplished, livid or dark purple-
coloured marks remain that are very long of being effaced.
  Rupia prominens is almost constantly seen confined to the lower
extremities.  It frequently happens that no more than a single bulla
is formed.   In  no case are they very numerous,  and in none are
they ever observed to be  confluent.
  This variety  of rupia, probably in an aggravated form, when it
attacks infants of a bad habit  of body, has been described as a par-
ticular species under the title of rupia escharotica.  The disease
begins in livid and slightly raised spots, upon which the  cuticle is
gradually raised  by a serous effusion,  into flattened bullae  of an
irregular shape, surrounded by a livid areola.  The fluid in these
grows  thick  and black; it is usually  soon discharged,  the blebs
bursting before  it has time to concrete into scabs ; each exposed
surface then presents a painful excoriation, which degenerates into
a. foul and ill-conditioned ulcer, secreting an unhealthy and  fetid
ichor.   Several successive bullae are evolved in the same way one
after another, and are attended with the same results.  The disease 
BULLAE—RUPIA.
71
 is evidently accompanied  with very severe suffering during its
 whole progress.  It even frequently proves fatal to the cachectic
 and miserable  infants, who are its  usual  subjects.  The sores at
 best are very long of healing.
   Rupia is to  be distinguished from pemphigus by the different
 colour of the fluids contained in its bullae, as well as by the products
 and by the consequences of the disease.   But rupia is more apt to
 be confounded with some forms of ecthyma, than with any of the
 varieties of pemphigus.  The two diseases have in fact many fea-
 tures in common ; yet due attention to the differences of elementary
 form, and of the scabs that cover  the two eruptions at length, as
 well as of the sores that succeed them severally, will generally pre-
 vent any mistake from being committed.
   Rupia is not generally a dangerous disease.  The sores that
 succeed the escharotic species, indeed, are intractable enough;  but
 they generally yield to attention and appropriate treatment.  If the
 cachectic state of system, along with which  rupia always appears
 in infancy, be happily got over, the  bullous  affection is sure to do
 well.1
   The treatment of rupia may be inferred from the description that
 has  been given of the disease,  and a consideration of the circum-
 stances  under which it  occurs.   The  general means must be
 directed with a view to  give strength and  tone to  the system at
 large.  Light and nutritious diet, with a due admixture of animal
 food, and a residence in a pure and bracing country air, with warm
 clothing, are the only means we know of calculated to accomplish
 this great end.
   As a local measure, it is of the first importance  to free  the  sur-
 face from scabs.  Before this can be done,  the part affected has
 frequently to be fomented repeatedly, and kept long covered with
 a  soft poultice.   When the irritation  consequent on this procedure
 has  subsided, the sores, being essentially indolent or atonic in their
 character, require stimulating.   They may be touched with a solu-
 tion  of the  nitrate of silver  in water, or with this caustic in  sub-
 stance, with great advantage.  Or if a less degree of excitement be
 held  adequate to make them  take on a healing disposition, they
 may be washed  twice a day with a mixture of red wine and water,
 and  their surface covered lightly over with finely powdered cream
 of* tartar.  The  nitrate of silver, however, can be so nicely regu-
 lated in its action, that it may generally  be  made  to supersede all
 other stimulating and escharotic applications.  The sores should
 be lightly dressed with any mild cerate spread on soft lint.  Rest,
 the horizontal posture, and the gentle pressure of a roller, when
 the lower extremities are the seat of this affection, as they are


  1 Mr. Keate details a case in the Medical Gazette, April 4, 1835, of rapidly
deleterious effects following  the exhibition of mercury, on  two successive
trials of it, after rupia had made its appearance.  The rupia escharotica of
 infants is little or not at all distinguishable from.the bullo-pustular syphilide
of children born with secondary symptoms. 
72
GREEN ON DISEASES OF THE SKIN.
generally, all conduce essentially to the success  of the  treatment.
The vapour bath, sulphur fume bath, or artificial sulphurous water
bath,  made  by adding three or four ounces of the sulphuret of
potash to a common tepid  bath, will be found  excellent <reneral
stimulants, and restorative to the cachectic and debilitated subjects,
who are the usual sufferers from rupia.
                         PUSTULiE.

  The pustular diseases compose a very important division among
the inflammatory affections of the skin.   They are distinguished
by the development of small  collections of purulent matter, gene-
rally  entitled pimples  or  pustules, within  one of the elementary
tissues of the skin, or simply between the surface  of the cutis vera
and cuticle.
  The diseases  now generally regarded as pustular in their  ele-
mentary forms are Variola,  including various modifications, (the
Varicellae,) Vaccinia, Ecthyma. Impetigo,  Acne,  Sycosis or Men-
tagra, and Favus or Tinea.   This list differs considerably from the
one that will  be found in the works of Willan and of -Bateman.
These,  for example, include scabies, and  exclude  the varicellae,
vaccinia, and  acne.   But scabies we have already seen  to be  a
vesicular disease, and we shall by and by find that the vesicular is
only one of the varieties of form in which varicella, itself a modifi-
cation of variola, occurs ;  that vaccinia, whilst it is intimately con-
nected with the variolae, wants the essential character of a vesicular
disease; and that the tubercles which present themselves  in acne,
and which have induced authors generally to arrange the affection
among the tubercula, are  consequences of the  disease, and by no
means antecedents  of its existence ;  and farther, that these  acci-
dental indurations show nothing of the tendencies of the acknow-
ledged tubercula, which is to destructive ulceration.
   The majority of the pustular diseases are chronic in their nature;
but two of them, variola and vaccinia, possess the opposite character
in a very marked degree.   They are in general unaccompanied by
constitutional  symptoms of the least severity;  one  of them, how-
ever, variola, proves among the most formidable of the diseases* to
which man is subject,  from the intensity of the general  febrile dis-
turbance with which it is preceded as well as accompanied.  With
the exception of small pox, consequently, the pustular  diseases,
though they may make life a burthen, seldom prove fatal of them-
selves.
   The pustules which give the whole class its peculiar  and distin-
guishing  character,  present varieties in their  general appearance,
which, although they be of no  great moment practically,  still
deserve to be noted; those pustules  which crown broad inflamed
bases, and they  are such as are encountered in the  acute  pustular
diseases, are entitled phlyzacia;  those, on the other hand, which 
PUSTULE.                         73
 appear with little or no  surrounding redness,  are denominated
 psydracia.   Pustules of the latter description are usually smaller
 than  those  of  the former.  Pustules are farther subdivided into
favi and achores; by favi being understood the minute pustules
 which appear set, as it were, within the substance of the true skin,
 which contain  a fluid that concretes almost as soon as it is secreted
 into a pale yellow scab,  cup-shaped on the surface, often of great
 hardness, and that increases in thickness  and size, frequently for a
 considerable length of time.  By achores, again, are meant those
 larger, more confluent, and irregularly shaped, superficial pustules
 resting upon inflamed bases, the matter contained in which  raises
 the cuticle, and  being subsequently shed upon the surface, forms
 broad, laminated, and generally friable incrustations, of a brown
 or yellow colour.
   Pustules  terminate, though rarely, in  the reabsorption of their
 fluid  contents; in the formation of crusts or scabs of various and
 characteristic appearances, under which  ulceration to a great  or
 less extent is apt to  happen, when cicatrices  transient or indelible
 in their nature succeed ; and in the production of indurations, often
 designated by the objectionable name of tubercles.
   Several of the pustular  diseases are eminently contagious, and
 only occur under the influence of a peculiar specific cause,—variola
 and its modifications, and vaccinia, which last indeed can only be
 excited in the human subject by the inoculation of its proper virus.
 Other pustular diseases  are readily transmitted by contagion, but
 seem also capable of  arising- of themselves under certain  circum-
 stances, without the agency of infection,—favus.   The remaining
 diseases of this order appear under the influence of some internal
 or constitutional cause,  the nature  of which is  wholly unknown
 to us.
   Pustules are more analogous to vesicles in their general charac-
 ters than to any of the other elementary forms of cutaneous disease.
 Several of the diseases decidedly  pustular in their after-periods, are
 plainly vesicular at first, and several of the vesicular as  certainly
 contain purulent matter mixed  with their proper serum,  in the
 latter stages of their existence.   Nevertheless, there is not often
 any great practical  difficulty in  distinguishing a pustule from a
 vesicle.  The pustule is filled with  consistent yellow pus, almost
 from  the moment it appears;  the vesicle with  a mere  milky  or
 slightly turbid fluid, the  pus being an after-product of the continu-
 ing inflammation.  The products of the  two elementary forms  of
 inflammation also differ materially from each  other ; the  incrusta-
 tions  of vesicles being thin and flimsy, and pale in colour, those of
 pustules thicker, more solid, and  generally darker in their tints.
   Those pustular diseases  that appear with the acute type are only
 successfully  treated  by  general depletion, and attention  to  every
 particular in the antiphlogistic method ;  those that  are essentially
 chronic in their nature, though often greatly benefited by measures
 of a similar kind, especially at first, and then during the periods of
 exacerbation which many of them present, are  seldom or  never 
74
GREEN ON DISEASES ON THE SKIN.
subdued without  the  assistance of topical applications,  and  the
internal use of medicines entitled alterative, many of which have
a powerful influence in modifying the state of the skin  in particu-
lar, as well as that of the constitution  in general.

                     VARIOLA,  SMALL-POX.

  Variola is an acute and contagious inflammatory affection, cha-
racterised, after three or four days of general febrile disturbance,
by  the appearance of a pointed, and at first vesicular eruption,
which speedily becomes purulent—which  attains its height about
the eighth day, when the pustules are for the most part depressed
in the centre—which continues in a state of suppuration for several
days  longer—and which finally dries off into hard, dark-brown
scabs, that  are detached in  due season, atid generally leave inde-
lible cicatrices behind them.
  The eruption or affection of the skin goes for so little in  the idea
we form to ourselves of this formidable disease, that I shall be brief
in my account of it, referring to any of the general treatises  on
pathology, particularly to the writings of Dr. John Thomson, and
to the essays of Dr. Gregory in the  London Medical Gazette, and
Cyclopaedia of Practical Medicine, for more ample information  on
the subject.
  Small-pox occurs with considerable  variety  in its symptoms,
according as it is developed artificially or naturally, before or after
vaccination, and  as  the pustules are confluent  or distinct.   The
eruption in inoculated small-pox differs in nothing from that which
follows infection by the lungs ; neither is the course of the disease
altered, nor its period abridged, but the whole of  the symptoms are
rendered incomparably milder, and, from being a most dangerous
disease, it becomes one in encountering which there  is little risk
incurred.   When  the disease is engendered in  the  natural way,
again, after exposure to its contagion, the severity of the symptoms,
and danger incurred, especially in the after-stages, are  very different
according as the eruption is distinct and scanty, or confluent and
very copious.   It is, therefore, of the highest  consequence to  the
practitioner to be aware that he has it in his power to control, in a
great measure, the extent and nature of the eruption: in  a word,
to render it distinct and sparing,  by his treatment during  the initia-
tory stages of the disease.
  But by far  the most  important modification of any observed in
the symptoms of small-pox,  is  that induced by the influence of
vaccination.   Now that prejudice and party feeling  begin to sub-
side, it is seldom contended  that vaccinia proves a complete and
unfailing preservative against small-pox, or that the disease, which
exposure to the contagion of variola frequently engenders among
those who  have  gone  through  cow-pox,  is not true small-pox.
Neither is it now often said  that vaccination  is useless, and that
cow-pox proves no protection whatever against small-pox.   Fully
one half or more of all who  have been vaccinated enjoy complete 
PUSTULE—VARIOLA, SMALL-POX.             75
 immunity from small-pox during  their lives; and  those who, less
 fortunate, still remain accessible to the attacks of the disease, escape
 in the vast majority of instances, with a modified form of the affec-%
 tion, which very rarely brings life into jeopardy, which is attended
 with no  great degree of suffering, and seldom leaves any lasting
 disfigurement behind it.  And surely to have been the means of
 benefiting humanity to  this amount is  high renown, and cause
 enough why the name of Jenner  should  still and for ever be pro-
 nounced  with tin mingled admiration.
   Let us briefly enumerate the  symptoms  of the  natural and
 unmodified small-pox, the course  of  which has been  divided into
 five periods—incubation, invasion, eruption, suppuration, and de-
 siccation  or scabbing.
   The period of incubation extends from the instant of exposure
 to, and reception of, the  contagion, to that at which morbid symp-
 toms make their appearance.   This interval extends to eight, ten,
 or twenty days.
   The invasion of the  disease is marked by feelings of general
 uneasiness, and of unusual lassitude and disinclination to exertion,
 transient  shivering fits, acceleration  of pulse, headache, pains in
 the back and limbs, distaste to food, thirst, sickness, and very gene-
 rally vomiting, pain in the epigastrium, obstinate constipation, &c;
 in a word, symptoms of general fever, often of great intensity, and
 accompanied with  delirium  through the night, which  continue,
 and even increase  in severity, during  several days, but usually
 begin to decline immediately on the appearance of the eruption.
   The eruption commences most commonly on the third day after
 that of the invasion, and  is completed within about four and twenty
 hours.  The face is the part on which it is generally first observed,
 and here especially it is  often preceded by an uniform erythema-
 tous blush, when it always proves confluent.  It  appears in the
 form of minute, red, papular spots, which, as the disease is subse-
 quently to be distinct or confluent, are separate from each other,
 and capable of being counted, or crowded together,  and blended by
 their bases.  At the  end  of twenty-four hours, however,  the erup-
 tion is still far from  having attained its perfect and characteristic
 appearance.  The papulae have increased in size, become pointed,
 and apparently vesicular in many  instances, although nothing
flows from them if they be punctured; these spots extend, assume
a flattened form, and on the third day many of them  show a depres-
sion in the middle, which becomes more  and more remarkable as
 the period of suppuration approaches, for no true pus is  yet  con-
tained within them,  their growth being mainly attributable to the
secretion of a quantiy of  coagulable lymph, which  by and by con-
cretes  into a circular disc of this substance, and is attached to the
surface of the cutis vera.   At this stage the pustules are whitish in
colour, and surrounded by a distinct inflamed areola.   When the
eruption is confluent, the depressions in the centres  of the indi-
 vidual pustules are  wanting, and the whole  surface appears over- 
76            GREEN ON DISEASES OF THE SKIN-
spread with a general exudation of coagulable lymph between the
cuticle and true skin.
   Suppuration usually sets in between  the fourth and  fifth day
after the appearance of the eruption, being preceded by a general
swelling of the integuments, and accompanied with a renewal of
the fever, and, unless it has already occurred,  an unusual secretion
of saliva.  The pustules  now appear more turgid than ever, lose
their umbilicated form, and become spherical, and from being white
acquire a yellow colour.   The local inflammation and  pain  are
now greater than ever, and it is at this period that  unfavourable
symptoms of the worst kind commonly make their appearance, and,
indeed, that the disease proves fatal, when it is severe  in its form
or of a malignant character.
,   A pustule of small pox,  opened at its period of maturity, contains
a quantity  of yellowish pus, and, at the bottom,  a small whitish-
coloured umbilicated disc  of coagulable lymph, presenting the most
perfect  resemblance to the appearance of the pustule previously
to the commencement of suppuration.
   The  pustules in a  state of suppuration do not long  continue
stationary;  they either burst within a day or two, and give rise to
thin superficial incrustations spread over the surface, or the several
pustules harden,  without breaking, into firm, dark brown  scabs.
In those situations where  the eruption  is confluent,  the  scabs
continue soft and moist, and the part,  the whole  face for instance,
is hidden under one uninterrupted sheet  of incrustation.
   During this, the period of desiccation,  the swelling of the skin
and subcutaneous  cellular membrane subsides,  but the surface
continues very tender, and is  often affected with a considerable
degree of itchiness,  which induces patients to scratch themselves,
when  deep and  painful  excoriations  result; the patient emits a
peculiar faint and disagreeable smell, and his linen is soiled by the
exudation of the  pus from innumerable  points of the body.   The
scabs and incrustations begin to be detached between the fifteenth
and twentieth day from the invasion of the disease, and are followed
by a furfuraceous desquamation of short continuance, over the deep
red stains which they leave behind them.   These  stains vanish
very  gradually, giving place, in their turn,  to cicatrices or pits,
which are at first of a paler colour than the unaffected portions
of integument  around them, and usually continue for the remainder
of life.
   The various periods that have now been described  are subject
to some slight  irregularities;  and the whole of the processes com-
mence  and are concluded on the face sooner than on any of the
other parts of  the body.  The  eruption,  for instance, is drying off
there whilst the pustules  are still in full suppuration on the arms
and legs.
   The eruption in small pox is by no means  confined to the skin;
the  whole  of  the  mucous  membranes  which  line the  internal
passages of the body frequently present pustules,  or the rudiments
of pustules, analogous in their  character to those  of the  outer 
PUSTULAE—VARIOLA.
77
integument, but variously modified by the peculiarity of structure
in the part upon which they are  evolved: the conjunctivae, the
nasal fossae, mouth,  pharynx, and intestinal canal, and even the
larynx and bronchial membrane,  are almost constantly observed
to be affected  in this  way, to a greater  or less degree.
   Distinct and confluent small pox do  not differ essentially  from
each other, save in the generally greater severity of the accom-
panying febrile symptoms in the latter than in the  former.
   This disease, however, is greatly modified  by being inoculated.
When this is done, a slight  degree  of redness is discovered on the
third day around the puncture by which the virus was inserted;
a little hardness can also be detected in this point at the same period,
and  especially on  the following day, by passing  the finger over
the  surface.  On the  fifth  day the  inflammation has increased
considerably, and on the sixth the cuticle appears  raised by the
effusion of a fluid under it.   On the seventh the spot grows white,
and is generally depressed in its centre, the surrounding inflamma-
tion  is very active, and the areola is of  a  deep or livid red colour;
a considerable degree of pain is now felt  shooting along the  limb
into which the virus has been inserted, and extending to the axilla
or groin, as the arm or leg has been  the  member  selected for the
inoculation.  On the eighth, besides the  local symptoms, which
continue much as before, traces of general or constitutional disturb-
ance begin to be manifested.  These are  very nearly the same as
the initiatory symptoms of the small pox taken naturally—shivering
fits, hot skin, quick pulse, headache, depression, nausea, vomiting,
&c.  On the ninth, tenth, and eleventh, the  pustule continues nearly
stationary, though evident signs of commencing desiccation appear
in the centre ; the general febrile symptoms persist; on the twelfth,
a  general  eruption makes its appearance, precisely similar in  its
external  characters  to that  which  appears about  the fourth day
from the period of invasion  of natural  small-pox.   This eruption
is seldom copious, and very rarely  confluent.  It appears first  on
the face, and extends successively, on the two following days, to the
trunk and extremities.   The pustules of which it consists run pre-
cisely the same course as those of natural  small pox, becoming de-
pressed in their centres, surrounded with a deep  red areola, and
filled  with pus, remaining stationary for  a time,  then shrinking,
whilst the surrounding inflammation subsides, and drying off into
brownish scabs, which, being detached,  at the usual period, leave
deep red  stains on the skin, and superficial cicatrices that are not
usually of any long duration.
   The scab of the original or inoculated pustule is loosened between
the twentieth and twenty-fifth day from  that of inoculation, and
leaves a scar behind it which is indelible.
   Small  pox always appears under the influence of a specific con-
tagion, which is  transmitted mediately as  well as immediately; it
may be carried in articles of clothing from one quarter of the globe
to  another, and seems to be  borne on  the  wind  to a  considerable
distance from the  persons of those affected.   The disease very com- 
78
GREEN ON DISEASES OF THE SKIN.
monly appears epidemically.  It spares no  age nor sex ;  even the
foetus in utero may catch the contagion.   Some individuals, how-
ever, resist its influence in a very remarkable manner;  and although
it does»not  commonly affect the same person oftener than once
during his life, innumerable instances are on record  of its having
done so twice, and even thrice, in a modified shape, so that small-
pox itself is no more an infallible preservative against a  future
attack of the disease than cow-pox.
  And this  consideration leads me  naturally to speak of  variola
developed under these  circumstances, and especially after vaccina-
tion, as well as with  certain modifications which have caused the
disease to be entitled varioloid and varicella.   These modified dis-
eases  have lately undergone the most ample investigation, and the
subject is now one upon which the minds of the unprejudiced part
of the profession seem generally made up.
  Modified  variola, varioloid, or varicella, appears with various,
but in each particular instance pretty regular characters.   The
varieties of  varicella may all be included under two heads,  accord-
ing to the nature  or  form  of the eruption.  These  are  pustular
varicella—the modified small-pox, or varioloid of late writers;  and
—vesicular  varicella,  or chicken-pox, properly so called.   The
disease also occurs, though very rarely, with a third elementary
form, which might be made the ground of a farther division, namely,
the papular ; the eruption,  which in every case possesses this shape
at first, in the particular variety  alluded to never advancing be-
yond it.
  Pustular varicella.   The precursory  symptoms  of pustular
varicella vary extremely  in severity; in  some cases they are very
slight, in others fully as  intense  as  they are ever observed to be.
even  when  they  usher in  a bad  attack  of  confluent legitimate
variola.  As to the particular  symptoms themselves, they do not
differ materially from those that precede small pox  generally ; they
differ in this, however, that  they bear no necessary relation, as in
legitimate variola, to the extent of eruption which is to follow them.
  The eruption comes out, on the third or fourth day, over the face.
trunk, and extremities, with great abatement as usual of the general
symptoms, under the form of minute red papular elevations, which
for the most part become  successively vesicular and  pointed, next
depressed in the centre, and then pustular, or  filled with pseudo-
membranous matter, though many of them abort at different stages
of their progress.  These changes frequently go on  pretty evenly
till the seventh or eighth day from that of the eruption, the pustules
being even confluent on the face, and the  disease to all intents and
purposes small-pox: but now a remarkable difference occurs; in-
stead of advancing to a state of suppuration, and a  secondary fever
being lighted up, to bring the patient's life into danger, the pustules
shrink and become rapidly  covered  with  scabs, whilst  every mor-
bid symptom vanishes, secretion is renewed, the pulse falls in force
and frequency, appetite returns, and the patient feels himself sud-
denly restored to health. 
PUSTULAE—VARIOLA.
79
   Such regularity in the course of the modified small-pox, varioloid
 or pustular varicella, however,  is not  very commonly observed.
 The disease is observed most frequently among those who have
 been vaccinated, occasionally among those who have already had
 small-pox, and now and then among individuals who have never
 either been vaccinated or had small-pox.  It is not always a very
 mild disease, and one devoid of all danger; on the contrary, it some-
 times,  though  very rarely,  proves  fatal.   The scabs,  on being
 detached, leave dark vinous red stains  and superficial cicatrices
 behind  them,  which, although very conspicuous  at  first,  do  not
 generally all prove  permanent; after lasting for some months or a
 few years, they for the most part disappear.
   The inoculation of the virus of pustular varicella appears to cause
 at one time a merely local eruption, similar to cow-pox; at another,
 a general eruptive disease, similar to itself, that is, small-pox with-
 out secondary fever; and at another, legitimate  small-pox with  all
 its concomitant and distinguishing symptoms.   This eruption, like
 vaccinia and variola, even seems to give security, in some  measure,
 against small-pox, or to render those who have had it less suscep-
 tible of the contagion of that disease.   Pustular varicella  is also
 observed to prevail at the  same time as epidemic variola.  These
 are so many considerations,' all alike tending to  show, that the dis-
 ease is in fact small-pox modified  by various and generally appre-
 ciable circumstances.
   Pustular varicella does  not always appear  with  external cha-
 racters so closely resembling those of small-pox.  The  pustules,
 instead of being umbilicated  or  depressed  in the  centre, are fre-
 quently conical, when the disease is named swine-pox ; or globular,
 when  it is entitled hives, by the vulgar.   The pustules in these
 cases contain a certain portion of coagulable lymph, but owe their
 size and plumpness, in a great measure, to  a sero-purulent fluid
 with which they are filled.  The  general symptoms are essentially
 the same as those of small-pox, though in general infinitely less
 severe, and always occurring with the entire absence  of secondary
 fever.
   Varicella, again occurs in a form which cannot be considered  as
 pustular at all, the eruption never advancing beyond  the vesicular
 stage, but attaining  its height under  this elementary form.   This
 constitutes the vesicular varicella, a disease denominated  chicken-
pox by the vulgar.  Vesicular varicella is generally  preceded, for
from four and twenty to  forty-eight hours, by symptoms of general
constitutional  disturbance, such   as listlessness, headache,  inap-
petence, sickness, sometimes vomiting, thirst, quick  pulse,  &c, but
these symptoms are often so slight  as scarcely to attract attention  at
the time, though they are also occasionally so severe as  to  excite
fears of a much more serious  disease than that which eventually
occurs.   When the  eruption is first perceived upon the chest and
face, it is in  the form of small red papular elevations.   In the centre
of most of these, a  minute  vesicle is by  and by perceived, filled
with a pale straw-coloured and transparent fluid, which continues 
80            GREEN ON DISEASES OF THE SKIN.
to increase in quantity for two or three days, some  of the vesicles
mean time becoming pointed, others assuming a rounded or flat-
tened appearance.  On the third day from their development, the
fluid in the vesicles becomes a little turbid ; and the day after, the
majority of them are perceived  evidently to have become flaccid
and shrunk.  On the fifth day they begin to dry off, and on the
sixth are succeeded by small thin brownish-coloured crusts, which
are usually detached on  the eighth, ninth, or tenth day, leaving
deep red marks, but very seldom cicatrices, upon the skin behind
them.   The eruption of chicken  pox, however, is not simultaneous,
but successive, and continues for two or three days; so that vesi-
cles in nearly all the different stages of their progress may generally
be perceived in the  near  neighbourhood  of each other.  A great
deal of the eruption in chicken-pox never becomes vesicular, some
of the spots advance no further than the red point which first pro-
claims their existence, others get farther and attain the papular state
before they abort; and this leads me to speak of yet another variety
of varicella, namely, the papular, entitled horn-pox by the vulgar.
  Papular varicella.   This form of varicella is extremely rare,
and, indeed, is  scarcely ever seen otherwise than associated with
one or other of the varieties of the disease that have already been
described.   In its essential nature it does not differ from these
varieties, except in so far as the eruption stops short of the stage
which they attain.  The  precursory symptoms, when any are ob-
served, are of the same general  description, and the disease arises
under the same  circumstances; namely, during the epidemic pre-
valence of variola, or of one or other of its modifications entitled
varioloid and  varicella.  The disease has even been produced by
inoculating persons who had already had small-pox with the virus
of this disease.
   The eruption of the papular  varicella  appears as usual  in the
form of red marks, which  are rapidly transformed to papular eleva-
tions of the same colour.   After continuing for a day or two, these
begin to shrivel, and  by and by disappear, without  being attended
with any thing like  secretion, or any other morbid  process  in the
parts  of  the skin they occupied.  As I have said, this papular
varicella  is almost  always met with associated either with the
vesicular, or with a few of the pustules of the globular, variety  of
pustular varicella.
   Treatment of variola  and its modifications.—Small-pox is a
disease whose course, once commenced, is necessary.  All attempts
to cut it short, consequently, must needs fail of their object at least,
if they do not prove positively injurious.   Here it is only proper to
follow nature, not to thwart her in her efforts;  and it is undeniable,
that the severity of the symptoms in almost every one of the stages
of small-pox, may in  general be  greatly lessened,  and their ten-
dencies very considerably modified, by the interference of art.
   When the intiatory symptoms of small-pox prove mild, and the
 eruption  makes its appearance without any great amount of febrile
 derangement, we have commonly little opportunity, as there is little 
PUSTULjE—VARIOLA.                   81
occasion, to interfere farther than is usually done in cases of slight
fever; the patient has  only to be put to bed and kept cool, whilst
abstinence is  enjoined, and a  liberal supply of any cooling drink
is allowed him.  The return of the secretions must  be solicited,
mean time, by the exhibition of such  medicines as the liquor am-
monias acetatis, the nitrate of potash, and gentle  aperients.  Par-
ticular symptoms must be treated as  they arise,—severe headache
might induce  us to apply a few leeches behind the ears, or to  the
temples ;  for sore throat and pain in the mouth generally, we would
prescribe cooling gargles ; and so on.
   When  the  disease appears with symptoms of greater severity,
and the patient  is young and vigorous, venesection is resorted to
with the greatest advantage.   This  measure,  when  decided on,
should be carried to such an extent as produces an evident effect
on the system at large.  If but a few ounces of blood be taken away,
the violence of the symptoms will not  be permanently abated, whilst
the patient is left with diminished powers to struggle against a
most subduing disease.  If, on the contrary, twenty or thirty ounces,
or such  a quantity as produces symptoms approaching to syncope,
be taken, the morbid  actions that were exhausting  life  are  all
materially allayed, and the patient,  though enfeebled, is left with a
much less amount of disease  to contend against.  In  addition to
general blood-letting, the application of a number of leeches, in the
neighbourhood  of those parts that are most severely affected, will
frequently be found to give considerable relief.  Should congestion
or inflammation  of any important vital organ be suspected during
the course of the disease,  particular attention  must be paid to  the
complication.   Accidents of this kind frequently occur at so late a
period of the disease, that general  blood-letting is no longer admis-
sible as a means of arresting their progress: neither, indeed, do they
ssem to be so much under the control of venesection as when they
arise without being traceable to a specific cause.
   After the height of the disease is attained, and the period of sup-
puration  is about to commence, gentle laxatives are generally of
great service, and seem frequently to  have the power of putting a
stop to the insidious inflammatory or congested state of the lungs,
so often found to prevail in the  cases  of small-pox that terminate
fatally.
   Local treatment of several kinds has been proposed, principally
with a view of preventing or  lessening the deformity which small-
pox, especially when confluent, seldom or never fails to occasion.
It has been proposed to rub the surface of the body roughly with a
coarse towel, as soon as the eruption made its appearance ;  but this
procedure does not materially interfere with the future progress and
usual tendency  of the  pustules.  With better success others have
practised  the  cauterisation of each particular  pustule in distinct
small-pox, as it arose, and of the whole surface beset in the confluent
form of  the disease, with nitrate of silver, in substance or in solu-
tion.   The head of each vesicle is removed with the point of a
lancet, and a  sharp pencil of nitrate of silver, or a gold needle,
       6—c                                      grn 6 
82
GREEN ON DISEASES OF THE SKIN.
charged with a strong solution of this caustic, is carried  into its
interior.   When this is done  at a sufficiently early period, the pus-
tules  so  treated are almost invariably  arrested in their progress.
This procedure is  of course inapplicable in the confluent form  of
the disease ; all that can then he done, is to touch the whole surface
of the face with a pretty strong solution of the nitrate of silver in
distilled water, by  means of a hair-pencil.  This operation seldom
puts a stop to the course of the eruption.  The number of indelible
cicatrices may indeed be lessened, but when the incrustations and
eschars come to be detached,  many pustules will be found to have
run through their  different periods  unmodified, and to  have left
traces of their presence that will remain through life.
   The well known influence of mercury  in checking the deposit,
as well as in promoting the absorption of coagulable lymph, has
induced some practitioners strongly to recommend some of the pre-
parations of this metal externally as a dressing to the pustules, as
well as internally by way of an aperient and alterative.
   At a very early period in the history of medicine, it was the prac-
tice to open the pustules of small-pox, and by gentle pressure to
evacuate  the purulent matter  they  contained.  In a great many
cases  this plan might be revived with the best effects.
   Very recently it  has been proposed to inoculate with the vaccine
virus, those who were presumed to exhibit the initiatory symptoms
of small-pox.  And it is possible that this operation, done  at a very
early stage of the disease, might have the effect  of modifying, in  a
greater or less degree, the natural course of the eruption, and the
violence of its concomitant symptoms.
   During recovery from small-pox, it has been usual to  prescribe
aperients.  The propriety of this practice, however, is very ques-
tionable.   Constipation should certainly be guarded  against; but
if the  patient be going on favourably, there seems no  reason, upon
the presumed necessity of evacuating peccant humours, to put him
upon a course of purgative medicine.  On the contrary, convales-
cence is often  retarded by  the occurrence of  diarrhoea, and then
mild opiates are of the greatest utility.
   I think it unnecessary to enter into farther details upon this part
of my subject.  Neither have I much to add in regard to  the treat-
ment of variola in its  modified shapes.   When the  symptoms in
any of these run high, the  same general measures are required as
in legitimate variola.  When, on  the other hand, they are of little
intensity,  the expectant method, as  it  has been entitled, may be
pursued, and the arrival of the seventh or eighth  day of  the erup-
tion confidently looked forward to as the crisis, or term of the dis-
ease.

                      VACCINIA, COW-POX.

   Nearly akin to the family of the variolae, if not absolutely one of
its members, as analogy, and several  circumstances that have been
recently  made known, would lead  us to believe, cow-pox  is the 
PUSTULvE--VACCINIA.
83
 next form of pustular eruption  that will briefly engage our no-
 tice.
   It had long been known, in the great dairy districts of England
 especially, that cows were subject to  an  eruption upon their teats
 which frequently infected the milkers, communicating to them a
 disease precisely similar  in  its outward characters  to  that under
 which  the animals laboured.  It was,  further, very  commonly
 believed that those individuals who  had accidentally become  in-
 fected in this way, were proof against the contagion  of small-pox.
 Living in the midst of a peasantry among whom these notions were
 current, it seems  at an early period  of  his life  to have become a
 point  of faith with Edward Jenner, that this peculiar disease of
 the  cow, artificially inoculated  upon the  human subject,  would
 prove as effectual a preservative  from small-pox, as  the eruption
 accidentally  engendered  by immediate  contact with the animal,
 whilst the benefits  of the infection might by  this means be  much
 more  extensively  diffused.  Jenner  had arrived at  man's  estate
 before he found an opportunity of reducing  this idea to practice.
 The result of the  experiment needs  not to be  particularly stated
 here;  the  name of Jenner  is  now  pronounced with reverence
 wherever civilisation sheds her light, and his memory will be che-
 rished through all future ages as one of the most truly illustrious
 among the benefactors of mankind.   And this, in spite of the cir-
 cumstance that  his  hope  and belief of cow-pox being a complete
 preservative  against small-pox in every  shape, have  not been
 realised to the letter; cow-pox  does not in every instance give im-
 munity from small-pox; but  it disarms this scourge of its terrors ;
 it renders one of the most formidable diseases incidental to humanity,
 one  generally of extreme mildness and no danger, to say nothing of
 the very large proportion of those subjected to its influence who pass
 through life unscathed by small-pox in any even of its most modi-
 fied  forms.
   Cow-pox occurs but  rarely among cattle; from all accounts more
 rarely now than  it used to do.  The disease  is communicated
 artificially, either by inoculating directly from the animal   to the
 human subject, or  from a vaccine pustule originally  developed in
 the human subject by this means ;  the latter is now almost the only
 method practised.   The process by which the vaccine virus is  trans-
 ferred from one individual to another is abundantly simple; the
point of a  lancet, charged with the virus, is insinuated a very little
way into the substance of the integuments; there it is allowed to
remain for a few seconds, and being withdrawn, slight pressure for
a short time upon the seat of  the puncture, with  a view to prevent
bleeding, completes the  operation.   That part of the arm into which
 the point of the  deltoid muscle is  inserted is  usually selected for
 vaccination, and it is perhaps as convenient as any.
  Great care should be taken to  select vaccine virus of the most
 active description.   Experience has shown that this virus possesses
its greatest energy on the fourth and fifth  days from the appearance
of the pustule, which corresponds with the eighth and ninth days
                                                gm 6* 
84            GREEN ON DISEASES OF THE SKIN.
from the date of the vaccination.  Too many vaccinations shonld
not be performed from the same  pustule, experience having shown
that whilst those first vaccinated from a particular subject almost
invariably  received  the  infection,  many of those vaccinated last
escaped it.   It has also been recently surmised that the protecting
influence of vaccinia is most certainly transmitted from infants to
infants,  and from adults to adults.1   The vaccine virus is best trans-
ferred immediately from the pustule to the skin of the subject to be
inoculated.  But it may be kept  for a day or two upon the point of
a clean  lancet  without apparently  losing any of its activity, and
may be  preserved for a  much  longer period upon  bone or ivory
points made for the  purpose, or dried between two plates of glass.
When these bone points are used, a slight puncture should be made
in the skin with a lancet, into which one of them is then insinuated
and allowed to remain for a few  seconds.  When the virus, pre-
served in a dry state  upon a glass  plate, is employed, it requires to
be moistened with the smallest possible quantity of cold water, when
it is taken up on the point of a lancet, and inserted  under the cuticle
in the usual way.
   It is now customary to make  more than one puncture in vacci-
nation, generally with a view to give the  operation an additional
number of  chances of succeeding.   But some vaccinators have of
late insisted on a great extension of this practice, in the idea of in-
fecting the  system more  completely.   Jenner  was careful to insert
no more than a single puncture  in each arm; and it is unphiloso-
phical,as well as against experience, to suppose that twenty vaccine
pustules produce a greater amount  of specific effect upon the system
than one.   One puncture on each arm will be found amply sufficient
in cases whence we do not care to derive  any virus ; but two or
three may be made when we wish  to procure a supply of this pre-
cious poison for ourselves or our friends.
   As in variola, there are  four  distinct periods observable in the
progress of the pustules of cow-pox ;  the first extends from the
time of  inoculation to that when  the virus begins to exert its spe-
cific influence upon the part into which it was inserted, and upon
the constitution ;  for these two  incidents are simultaneous :  the
nascent vaccine vesicle  has been  arrested  in its  progress by the
application of caustic, and stiU the  constitution has been influenced,
the vaccine and even the variolous  virus subsequently inoculated
exerting none of their peculiar effects upon the system ; the second
period extends from the time when the vaccine vesicle begins to be
developed,  till its complete evolution, which happens on the eighth
and ninth day; the third  period is marked by the pustule being at
its height and stationary, and  lasts  till about the tenth day; the
fourth period is distinguished by  the decline  of the local  inflam-
mation, the formation of evident  purulent matter within the cellular
structure of the pustule, and the desiccation of this fluid into a horny
scab.

   1 Vide Lond. Med. Gazette, July 12th, 1834. Experiments on Vaccination. 
PUSTULAE—VACCINIA.
85
  The first period is one of entire quiescence, but the punctures
never die away entirely;  their places can  still be made out by the
presence of a minute but very distinct red  point.   On the third or
fourth day—the commencement of the second period, the slight red
point enlarges, it is evidently more inflamed, the part rises and feels
hard under the finger—the disease is in its papular stage.  On the
fifth day the cuticle  of the part is evidently detached by a serous
effusion under it—the vesicular stage ; on the sixth, this effusion
is greater in quantity, and already  differs essentially in its  appear-
ance from serum—the pustular stage (for want  of another word)
has now been attained ; the advancing spot is, in fact, filled with a
kind of cellular coagulable lymph, and is umbilicated or depressed
in its centre.  Neither at this nor at any other period anterior to
that at which the vaccine pustule  becomes filled  with yellow pus,
which it does eventually, can  it be at once discharged, by a punc-
ture, of its contents like a vesicle.
  The pustule preserves the appearance now described,  with little
alteration save in size, till  the eighth  or  ninth day.   It  is then
usually of the size of a large split  pea, flat in its form, umbilicated
in the centre, of a dull waxy white colour,  and when punctured in
several places, suffers  a limpid and  perfectly  transparent fluid to
exude from the reticulated disc of coagulable lymph, to the presence
of which it mainly owes its form and general appearance.  This is
the stage at which the vaccine  virus appears to possess its specific
properties in the highest perfection, and when of course it ought to
be employed for the purpose of inoculation.   On the ninth day the
vaccine pustule is at its height.  It is now surrounded by a distinct
areola of a bright red colour, and forms the centre of a hard elevated
tumour, produced by the tumefaction  of the subjacent cellular mem-
brane and surrounding skin, the surface of which frequently appears
covered  with  minute serous  vesicles.  On the tenth day  these
appearances  are even more  distinct  than  on the ninth, and the
patient in addition exhibits symptoms of some slight constitutional
disturbance.   The pain  in  the affected part  is often severe, and
stretches up the limb towards the  axilla, the lymphatic  glands of
which enlarge, and become tender;  the  pulse is quicker than
natural, and there is restlessness and some degree of general febrile
excitement.
  By the eleventh day, the local symptoms of inflammation are on
the wane : the areola looks more diffuse and of a  duskier or paler
hue ; the pustule  now acquires more  of a yellowish  colour, and
probably already contains a  little  purulent matter ; it also begins
to dry in the centre,  where it becomes brown.   On the twelfth day
the surrounding  inflammation  and  tumefaction are  rapidly  sub-
siding, the pustule is distinctly purulent, and the cuticle is scaling
off  from the circle that was most violently  inflamed.  On the thir-
teenth day the pustule  is no longer cellular, as it has hitherto been ;
it forms a yellow phlyzacious pustule, which can now be evacuated
entirely of its  contents by the prick of a lancet.  The areola is now
very small, and of a dark or livid hue, the pustule itself is rapidly 
86
GREEN ON DISEASES OF THE SKIN
drying off into  a scab, which grows gradually darker, harder, and
smaller, until the period of its detachment, which happens about the
twenty-fifth day, when falling off, it leaves a characteristic and per-
manent cicatrix  behind it.
  The progress of vaccinia is not always thus regular.  The period
of incubation, for instance, may be greatly extended, so that no
symptoms of inflammation appear for  ten, twelve, or even twenty
days; on  the other hand, it may be so much shortened, that  the
eliminatory inflammation follows the puncture almost immediately,
when the pustule that is produced runs through its different stages
in half the usual period of time, and the scab is detached without
leaving a trace of cicatrix.  Sometimes again  the pustule seems to
advance regularly enough to the seventh  or  eighth day, when it
stops short, never becomes surrounded with an areola, nor accom-
panied with  the swelling and hardness  so remarkable in the regular
disease on the ninth and tenth days.  In other instances the pustule
continues acuminated and much smaller than  it ought to be, and
only becomes surrounded by a pale, widely diffused areola, at some
other than the proper period.   The disease, in this irregular shape,
is entitled false cow-pox, or vaccinella.   It seems to arise under the
influence either of some peculiar  idiosyncrasy, which renders indi-
viduals unsusceptible of the proper contagion of cow-pox, or of a
constitution  which  has already  been  modified by having passed
through cow-pox or small-pox, or in  which the contagion of this
last disease was dormant at the period  when the vaccine virus was
inoculated.
  These modified species of cow-pox  are not nearly so efficient in
preserving the constitution from the effects of small-pox contagion,
as the true disease.   And here it often becomes an important con-
sideration, as to what is to be done in those cases in which a spuri-
ous disease, or vaccinella, has followed inoculation, instead  of the
regular vaccina-vacca.  We  are usually told to wait awhile, and
vaccinate again; but I believe it will  generally be found that pro-
per cow-pox cannot be engendered in those who have been affected
with vaccinella.   It cannot but be viewed as unjust to the indivi-
dual to  leave him exposed to  the infection of small pox ;  neither
would it probably be held fair to the  community to inoculate him
with this poison.  Under proper precautions, however, would not the
latter be the  most advisable procedure ?
  Cow-pox  is so mild  a  disease, that no treatment is commonly
thought necessary during its progress.  A dose or  two  of some
gentle aperient  is often prescribed, after the scabs have fallen off;
a practice for which it would  be difficult to assign  any satisfactory
reason.

                          ECTHYMA.

  Ecthyma is a  disease of the skin characterised by large, round
pustules, almost  always distinct, and seated upon an indurated and
highly inflamed base.   To these pustules, which are models of  the 
PUSTUL.E—ECTHYMA.
87
 phlyzacia of  Willan, and appear in successive crops on different
 regions of the body, more especially on the extremities, shoulders,
 and buttocks, succeed thick, brown, and adhering scabs,  which,
 upon being detached, are found occasionally to  leave  superficial
 cicatrices behind them, but much more commonly mere dark red
 stains, covered with new epidermis, that disappear entirely  after a
 time.  The four varieties of this eruption, which have been parti-
 cularly described, may all be arranged under the heads of acute and
 chronic ecthyma.
   In its acute and  most simple form, ecthyma appears on a single
 region of the  body, very commonly about the shoulders  and neck,
 in the guise of a crop of circumscribed, hardened, raised red spots,
 which are by and  by observed to  contain pus in their summits,
 whilst their  bases  are  very much  inflamed.  This eruption com-
 monly goes on for three or four days, after which  no fresh pustules
 are formed.   The summits of the pustules generally break within
 a day or two of their formation, and pour out their contents upon
 the surface, which then harden into olive-brown incrustations, that
 adhere very firmly to the skin.   In  the course of  from ten days to
 a fortnight, these incrustations are detached, and circular marks of
 a livid red colour remain in their stead ;  and when any degree of
 ulceration has taken place under the scabs, as occasionally happens,
 small cicatrices, very similar to those of small-pox, but more super-
 ficial, are left  behind.  .
   The pustules of acute ecthyma vary in size from that of a split
 pea to that of a shilling.  Their progress is accompanied by shoot-
 ing pain of a pretty severe description, and the lymphatic glands in
 their neighbourhood occasionally  enlarge  a little, and become
 tender to  the  touch ; but it seldom  happens that we have much
 evidence of constitutional disturbance in this variety of ecthyma—
 the ecthyma vulgare of the  great original authority on cutaneous
 diseases.
   Chronic ecthyma is a much more common affection  than the
 acute form of  the disease, and consists of  several  successive erup-
 tions of pustules, which appear at intervals variously remote from
 each other,  on the neck, scalp, face, or extremities, and severally
 run  through their  course  in a  manner  already mentioned.   In
 these chronic  cases, the pustules occasionally acquire very large
 dimensions,  their bases are very extensive, highly inflamed, of a
 dusky red or livid colour, and, from the participation of  the  subja-
 cent cellular substance in the inflammation, extremely prominent;
 they look, in fact, very like boils.  The disease in  this state con-
 stitutes the ecthyma luridum of Willan.   These immense pustules
generally burst within  eight or ten  days, and discharge a quantity
of sanguinolent sanies.  They are commonly succeeded by some
degree of excoriation or ulceration, which often spreads beyond the
bounds of the original pustule.   They become at length covered
with hard, black, and usually very adherent incrustations, which
are not detached till several weeks have elapsed, and which, when
they do fall, leave marks and cicatrices behind them.   When the 
88
GREEN ON DISEASES OF THE SKIN.
scabs are removed artificially, a small indolent ulcer with callous
edges, and secreting an ichorous fluid, is exposed.  When the scabs
continue very long adherent, they are apt to be followed by indura-
tions of some continuance in the parts of the skin they occupied.
  In children of weakly constitution, half-starved and badly clothed,
ecthyma is a frequent disease, and then the eruption is very irregular
in its general dimensions, some of the pustules being very small,
others very large—ecthyma infantile.
  Among the aged, again, of broken constitutions, and addicted to
spirituous liquors, ecthyma often occurs, and with characters which
have led to its distinction by a particular title—ecthyma cachec-
ticum.   Here  it principally  attacks the legs, although every other
part of the body may  be affected.  The pustules are surrounded
by a great extent of diffuse inflammation, and  they  contain  a
blackish ichorous fluid rather than pus; they, in fact, bear a strong
resemblance to the bullae of rupia.
  Chronic ecthyma is not necessarily accompanied by much general
constitutional  disturbance; it is, indeed, only when the  eruptions
take place  in  rapid succession, when the pustules are extensively
inflamed, or fall into a state of ulceration, that any thing like febrile
excitement appears.   It  is very common, however, to have symp-
toms of gastric and intestinal disorder along with ecthyma.
  Ec'thyma occurs at all ages; and as the disease is very commonly
traceable to indifferent  lodging, bad food,  and neglect  of proper
cleanliness,  the poorer classes of society  are its  most frequent
victims.   Ecthyma  frequently follows small-pox,  scabies of an
inveterate character, and other diseases—measles, scarlatina, &c,
that seem to have peculiarly pernicious effects upon the general
health.
  The size of the  pustules of ecthyma, the manner  in which they
are developed, and the extent of inflammation  by which they are
surrounded, are so many characters  which generally prove suffi-
cient to distinguish this disease from the other pustular affections,
such as acne, impetigo, sycosis,  and  porrigo.  Due attention to
antecedent and  concomitant symptoms, will  always prevent it
from being mistaken for the pustular form of syphilis.   Phlyza-
cious pustules, like ecthyma in their general appearance, frequently
occur in the course of scabies.  A knowledge of this circumstance
will  always  prevent  the two  diseases from  being  confounded.
Ecthyma is distinguished from furuncle  or boil, in  its mode of
development, the surface being first attacked, and the inflammation
extending to the deeper tissues; in furuncle, on the contrary, the
irritation commences in  the subcutaneous membrane, and spreads
to the  more  superficial tegumentory  strata.   Furuncle is charac-
terised by the formation of a slough in its centre,  around which
only a  very  small quantity of pus is formed;  the pustules of
ecthyma never contain sloughy cores, but are distended with fluid
almost from the first.
  Ecthyma in itself is  not a dangerous disease; but it sometimes
occurs in connection with a state of constitution that might inspire 
PUSTULAE—ECTHYMA.
89
fears  for the patient's safety.  The prognosis consequently must
always depend on the circumstances along with which the disease
appears.
  When ecthyma appears as an idiopathic disease, and is of trifling
severity, rest, and the use of diluents and gentle aperients, generally
prove sufficient to subdue  it.  Should there be a succession  of
eruptions, and the inflammation run  high, and  no circumstance
connected with the general health present to contra-indicate the
practice,  venesection may  be  resorted to  with great  advantage;
and this, as a preliminary  measure,  followed up by the  others
already indicated, will rarely fail in subduing the  disease.
  When  ecthyma possesses  the  purely chronic  character, and
occurs in subjects debilitated by previous illness, or with broken-
down constitutions, we must depend on general dietetic means, and
the use of tonics,  for bringing the  system into such a  state  as will
enable it to  conquer the disease.  If the patient be an infant, a good
wet-nurse is the first, and  often the only,  condition  required for
this end.  If he be in the decline of life, a quiet and regular life in
a healthy situation, wholesome food of the  most digestible kind, in
quantities proportioned to the digestive powers of the stomach, a
little  generous wine instead of spirits, the occasional use  of the
tepid,  simple,  or sulphurous  water  bath,  of the simple vapour
bath, or,  still better, of the sulphur fume bath, are almost all that
can be recommended.  If the general health improve,  little trouble
is usually required to subdue the ecthyma.
  In the way of local treatment something is necessary; so long as
the pustules of the succeeding sores are irritable, emollient applica-
tions  are alone to be  thought of.  Ecthymatous ulcers, however,
are essentially indolent in their characters, and soon require stimu-
lating to make them heal kindly.   Their  surface may be touched,
at proper intervals, with the sulphate of copper in substance,  or
a solution of nitrate of silver of  graduated  strength, and under
either of these preparations  (it being  always understood that the
general  health  is improving) they  will  generally be found  to
amend rapidly.

                  CASE OF  CHRONIC ECTHYMA.

  Captain G.,  aged 26, had for several summers been regularly
attacked  with pretty copious  eruptions of what he  called small
boils.  The large pustules, which  he  thus designated, appeared in
succession on the legs and arms,  and in still greater  numbers  on
the shoulders and trunk of the body.   In all these situations, there
were many  faint cicatrices to be seen.  The patient was of a san-
guine phlegmatic habit, and otherwise  in good health.  The legs
were swollen ; the pustules, raised on a hard circular base of a
fiery  red colour,  contained a transparent yellowish fluid in their
summits, and, on being  broken, were succeeded  by  thin  brown
crusts, which, on falling off, were in their turn followed by a
desquamation of the cuticle.   The skin of the affected places was 
90            GREEN ON DISEASES OF THE SKIN.

red at first, but soon recovered its natural appearance.  Other pus-
tules, not  so  far advanced,  showed  merely  like red elevations,
whilst others,  in a still less forward stage,  might  be felt as  small
indurations under the cuticle.
   Captain  G.  applied to me on the 20th of  May, 1833, and as the
sulphur fume  baths may be safely recommended in every stage and
in all cases of ecthyma, he  commenced them immediately after
having taken a smart dose of purgative  medicine, which was con-
tinued every day, in aperient quantities, together with the  fume
bath.   This, with some attention to regimen, was all that was held
necessary.   June 6th; the pustules had now ceased to form in every
situation except between the shoulders, where a few appeared, pro-
bably by a flannel waistcoat, and the friction of the braces;  the>red
elevations  were fainter and  fewer, and showed  no  tendency to
advance  to  suppuration; not one with the  tuberculous feel could
be discovered under the cuticle.  The treatment was continued, a
calico shirt being substituted for the one of  flannel.  On the  18th,
the pustules had all disappeared, and the treatment  discontinued,
the patient  being quite well.
  In  April, 1834, this gentleman  again applied to me, having a
return, in a slight degree, of the same complaint.  He resumed the
treatment as before, and in a fortnight there was  not  a vestige of
the complaint to be  seen.
  He told me that, after the treatment of the year preceding,  he had
had a continued peeling of the skin for a period of more than  three
months.  I am strongly inclined to believe that it was from this
desquamation, or general  peeling of the dry and  hardened outer
skin, that this  gentleman had enjoyed immunity so long from this
pustular  complaint, under which  he had  laboured  for so many
years, for he was scarcely ever quite free from it.  In proof of the
skin having recovered its healthy state, his complexion, from being
sallow, had now become clear, and his appearance approaching the
florid.
  In  cases of ecthyma generally,  the  sulphur fumigations are
greatly to be relied on.  In cases more acute in their type than the
one related above, it is well to have  recourse to one or two small
bleedings, in conjunction with the use of the sulphur fume bath.
I  hold this disease to be so manageable by  the mode of treatment
inculcated,  that to adduce more cases would be useless.
                 IMPETIGO, RUNNING TETTER.

  The title impetigo is  given  to an affection of the skin charac-
terised by the formation of a number of minute pustules, distinct
and  scattered, or connected into clusters, which, bursting, shed
their contents upon the surface, and become  covered with thick,
laminated, or prominent incrustations.   These are  the pustules
which are entitled psydracia by Willan.
  I have said that the pustules of impetigo are either scattered and 
PUSTULE—IMPETIGO.
91
distinct, or collected into clusters of various extent and fused one
with another; and this happens to such an extent, and so regularly,
that two varieties or species of the disease have been founded upon
the circumstance.  One of these, the impetigo figurata, in which the
pustules are agglomerated, occurs most frequently on the face, the
cheeks especially, and attacks the youthful of a lymphatic tempera-
ment.   It is not necessarily preceded  by much constitutional dis-
turbance; some degree of uneasiness, inaptitude for active exertion,
loss of appetite, &c, are, however, very commonly observed before
the attack.  The eruption makes its appearance in the shape of one
or more small red patches, very slight  though well defined, and in-
creasing gradually in intensity, accompanied with a good deal  of
itching.  Anon these patches are thickly covered with small yellow
pustules, which  soon become confluent, never having been either
prominent or acuminated, each smaller group composing the aggre-
gate patch  appearing in the middle of a bright red areola, the pro-
gress of the eruption is attended with severe pruritis and scalding
pain.  The  pustules are not of long continuance; they burst within
three or four days, and discharge a quantity of purulent fluid, which
quickly dries into semi-transparent and very friable incrustations of
a peculiar yellow colour, and bearing a considerable resemblance
to a layer of concrete  honey.   The discharge continuing, often  in
surprising abundance, under these incrustations,  adds  immensely
to their thickness; when detached, the secretion is found to proceed
from a multitude of points on the surface  of the inflamed and
denuded corion.  The parts  in  the  circumference  of  the crusts
always continue red and inflamed, and upon these a few psydracious
pustules, in different stages, may very commonly be discovered.
   When the disease is not kept up  by a succession of pustular
eruptions, it continues  in this crusted state, apparently stationary,
for two, three, or four  weeks, when the secretion diminishes, the
crusts fall off gradually and irregularly, leaving a surface red,
shining, and very tender, which long continues  to  bear traces of
the disease,  though it never leaves any permanent cicatrix.
   Impetigo figurata of the face, however, is very apt to assume the
chronic type,  being continued indefinitely by a succession of pus-
tular eruptions.   In this case, the deeper layers  of the skin, and
even the subjacent cellular  substance, are frequently implicated;
and then deep chaps, and  even ulcers of some extent, seam and
excoriate the surface of the parts affected; at all events, no sooner
is one incrustation detached  than  a fresh exudation of purulent
matter gives rise to another, and so on  for many times successively,
until the inflammation at length seems to acquire something of a
squamous form; the skin, red and  shining, is covered with fur-
furae so long as the disease continues.  Impetigo figurata of this
character is met with  on other regions of  the  face besides the
malar;  frequently,  indeed, confined  to very  small districts of the
integuments, as to the under eyelids, to the upper part of the phil-
trum of the upper lip, &c, and then the incrustations occasionally-
dry into stalactitic forms, which have been even made the ground 
92
GREEN ON DISEASES OF THE SKIN.
 of a further subdivision of the disease, which seems very unneces-
 sary.
   Impetigo figurata is occasionally seen on the trunk and extre-
 mities, as well  as  on the face.   When the incrustations acquire a
 very great degree of thickness in this variety, the disease has been
 entitled impetigo scabida  by Willan.  The clusters  of  pustules,
 and the scabs that succeed them  in these situations, are very com-
 monly circular in form;  they are also of larger size on the inferior
 than on the superior extremities.
   Infants at the breast, and during the period of teething, are sub-
 ject to a variety of impetigo figurata, which has long been  fami-
 liarly  known  under the  title of  crusta  lactea,  and  has  been
 variously  classed among  the tineas  and  porrigos, by  different
 writers, under the name  of tinea  muciflua of the face, porrigo
 larvalis, &c.   The  eruption  in  this affection is certainly impeti-
 ginous ; it consists,  in fact, of a  number of small superficial  pale
 yellowish  pustules,  more  or less  confluent, and  collected  into
 clusters.   These bursting in four or  five days,  are  succeeded by
 greenish yellow coloured  incrustations, sometimes thin and  lami-
 nated, at other times thick and rugous, exactly as  in impetigo
figurata.   Fresh crops of  pustules  are evolved  in the neighbour-
 hood of the first clusters, which add to the extent of  the disease, at
 the same time that a good deal of exudation is going on under  the
 incrustations, and adding  to  their  thickness.    The surface of a
 portion of the scalp, the ears and lips, and even the whole of the
 face, are  often seen covered  in  this  way with a kind of mask,
 whence the epithet larvalis, assumed by  Willan as  characterising
 the disease.
   This variety of the disease appears with very different degrees of
 intensity.  It is in one case very  mild, in  another extremely acute,
 and apparently attended with excessive  pruritis and  much  pain.
 But it is satisfactory to be aware, that however severe the accom-
 panying  inflammation,  and  however  deep  and  formidable  in
 appearance the chaps which  surround the lips and eyelids,  per-
 manent cicatrices are hardly known  to follow this variety  of
 impetigo.
   When the hairy scalp is the  peculiar seat of impetigo, the dis-
 ease is yet farther modified; the pustules are still crowded together,
 but not so distinctly  collected  into clusters as in common impetigo
figurata of the face  ; they are of a whitish  or pale yellow colour,
 and each  seems traversed in its centre  by a hair.    They  soon
 burst,  spontaneously, or in consequence  of the  application of the
 nails to relieve the severe  pruritus  with which  their  formation is
 accompanied, and  pour out  a  viscid semi-opaque  pale straw-
 coloured fluid  in great abundance, which moistens  the hair and
 concretes into  small ragged  masses,  very like the  granules of
 tapioca, or bits of candied sugar.  This variety of impetigo has
 also been described as a tinea, or  proper affection of the scalp, with
 the  affix granidata, from the peculiar form assumed by the dis-
 charge in concreting, and as a porrigo, with the epithet favosa, by 
PUSTULAE—IMPETIGO.
93
Willan.  The pustules  are psydracia in the first instance, and the
plentiful discharge  that for some  time succeeds  their rupture, is
precisely similar to that which is poured out in the other varieties
of impetigo.
  In impetigo of the scalp, the inflammation sometimes extends to
the subcutaneous cellular  membrane, and  gives rise to the forma-
tion of small circumscribed  and very painful abscesses, which
usually  burst externally, although  they are also  occasionally
absorbed.  The lymphatic glands of the neck are also very com-
monly  enlarged  and  painful in  this complaint.   The hair is
scarcely thinned by the disease, unless it has continued for a very
long time, but it is generally matted together, dripping with dis-
charge, and full of pediculi.   It  also exhales a very unpleasant
smell, which has been  aptly enough compared  to  that emitted by
rancid  butter  or spoiled cheese.   This, however, is a mere conse-
quence of inattention  to  all measures of  cleanliness.   The  dis-
charge  itself  has   very little smell;  it  is in the  hot-bed of the
tangled hair that it undergoes corruption.
   Instead of  being clustered together, the psydracia of impetigo
are often observed distinct, and rather widely scattered—impetigo
sparsa.   In this variety, which is especially apt to attack the legs,
the evolution of the pustules is  accompanied  with insupportable
prurilis.  They very generally  make their  appearance  upon the
insteps, ankles, and especially the outer aspects of the legs.  They
run their course in the same manner as the agglomerated pustules
of the impetigo figurata, bursting after a day or two, and shedding
their contents upon the surface, where they  harden into yellowish
laminated incrustations, which are kept moist  by the  glutinous
discharge that is   continually poured out beneath  them.  This
diminishes after a time, and the  crusts become firmer, and seem
about to be thrown off,  but precisely at this  moment  a fresh erup-
tion of pustules makes its appearance, and the disease is  renewed
with all its original intensity, and generally with a considerable
extension of  its boundaries;  so  that as the same thing happens
again  and again, the whole leg, from the instep to knee  or  thigh,
is at  length  frequently seen  encased in one  continuous rough,
thick, and adhering yellowish brown incrustation, very similar in
its appearance to the bark of a tree—impetigo scabida, Willan.
   It may well be conceived that  the motions of the  limb affected
in this way, are greatly impeded and very painful, and that motion
should be followed by deep and  angry chaps, which traverse the
limb  in all directions, and by the  discharge they pour out,  add to
the roughness and thickness of the incrustations.   When the
surfaces which  are thus  affected are freed from crusts, the corion,
denuded  and inflamed, is exposed, pouring out, from a multitude
of points, a profuse sero-purulent discharge, which, by drying very
speedily, covers the parts with a fresh scab.
   Impetigo sparsa, arrived at this stage of severity, is always an
obstinate  disease, frequently continuing  for  months,  and even for
years, in spite of  the  most  sedulous attention  and  best-directed 
94
GREEN ON DISEASES OF THE SKIN.
treatment.   The inflammation  is no longer confined to the super-
fices, but extends to the whole  thickness of the  corion, giving rise
to intractable ulcers;  and spreading to the ends  of the fingers and
toes, it  at length implicates the secreting matrices of the  nails,
which are then produced distorted in  their shapes, or are detached
and lost entirely.
   When  the  disease tends  to a conclusion,  the incrustations
become drier and  firmer, and once detached, are no longer repro-
duced.   The  surfaces they covered,  long  continue in  a very
tender state, shining, of a deep red colour, and often marked with
superficial cicatrices.
   Impetigo  sparsa is also occasionally seen  on  other   regions
besides  the legs; it  occurs, for  instance,  on the  arms, on the face,
and not unfrequently, in  infants, on the  hairy scalp.   In the last
situation, it has been  described under the  name of tinea mucosa,
tinea granulata, and  porrigo lupinosa.   For the sake of connect-
ing this variety of impetigo with another, the  crusta lactea, or
porrigo  larvalis, to which  it bears the greatest affinity,  I have
described it immediately after that affection.
   In none of its  forms, and at no stage of its existence, is impetigo
a contagious disease.   Infants and young persons  are the usual
subjects of two of its  varieties, the larvalis and granulata.   Indi-
viduals  in the prime of life oftenest suffer from impetigo sparsa of
the legs.  The disease often follows other affections of the skin,
different in their elementary forms, and can sometimes be traced to
severe  bodily fatigue, to  continued excesses in  eating and  drink-
ing, &c.  But its etiology is in general exceedingly obscure.  The
filth  and wretchedness in which the children of the  very poor are
reared, seem to expose them to become the victims of the impetigo
larvalis and impetigo granulata.
   Impetigo is  a disease   that  is not generally  very difficult of
recognition.  It  will hardly be confounded with  any of the family
of variolous pustules.  The smallness of its pustules sufficiently
distinguishes it from ecthyma.   The thickness and continuousness
of incrustation,  and  the copiousness  of  the discharge,  prevent
impetigo from being confounded with acne and mentagra.   Impe-
tigo is discriminated with more difficulty from the severer forms of
eczema, one of which, indeed, approaches this pustular disease in
so many  particulars, that  its  specific  title,  impetiginodes, is
derived  from the circumstance.   To the head of eczema I beg to
refer for the elements of the diagnosis.  Impetigo  is remarkably
distinguished from  favus—the tineas or  porrigos, in the non-con-
tagiousness of its  nature, and in the form and character  of its
incrustations, which are moist, rugous, and  continuous,—not hard,
dry, dimpled, and moulded, like those of the true favus.  Impetigo
is at once distinguished from the originally squamous diseases, by
its pustules, incrustations, and plentiful discharge.
   When impetigo  appears  as an  acute inflammatory affection,
which it frequently  does,  it must be treated  upon  the general prin-
ciples which guide  us in  this class of complaints.  In the milder 
PUSTULAE—IMPETIGO.
95
forms, the antiphlogistic regimen and emollient tepid fomentations,
as of milk and water, decoction of bran, &c, and light dressings of
the unguent, oxid. zinci, or plumbi superacetatisjin the severer,
the local and even the general abstraction of blood, when there is
nothing in the state of the  constitution forbidding  the practice, in
addition to these measures, seldom fail to subdue the violence of
the symptoms.   The application of a couple of leeches, one behind
each ear, in children of two or  three years  old, when the inflam-
mation runs high, unremitting attention  to cleanliness,  the  hair
being  clipped short when the scalp is the part affected, the con-
stant use at first of emollient tepid fomentations, and  subsequently
of  weak alkaline washes, whilst the parts affected  are touched
night  and morning with  the  unguent, nitrat.  hydrarg.  properly
diluted, combined with the  exhibition, now  and then,  of  some
very gentle aperient medicine, will generally be found sufficient to
bring to a happy conclusion either of the two varieties of impetigo,
(impetigo larvalis, imp. granulata,) to which they are most  sub-
ject.   When abscesses form, if they  be opened with the point of a
lancet, they usually soon heal up without further trouble.
  In  older  subjects,  after  the due employment of emollients and
antiphlogistics. the vapour douche  will be found of the greatest
service in freeing the skin from incrustations, and in altering the
morbid actions of the parts affected.  It is very essential, however,
not to have recourse to this  remedy at too  early a stage of the
disease, in which, instead of proving beneficial, it will certainly
aggravate the whole of the symptoms.
  Should impetigo appear in connection with a deranged state of
the general health, or particular  affection of the digestive appa-
ratus, as sometimes happens, a great portion of the treatment must
be  directed with a view to rectify, what is amiss either  generally
or particularly.
  When impetigo assumes a decidedly chronic type, the habitual
use of a drink,  acidulated with the  nitric or sulphuric acid,  the
occasional exhibition of an  aperient dose of one of the  neutral salts,
as of the sulphate of magnesia, prolonged immersion  in  the  tepid
bath,  and  the  topical  application  of a  stimulating wash,  (the
hydrocyanic  acid properly  diluted  has  been strongly  recom-
mended,) may often be employed with decided advantage.
  Should the inflamed  surfaces  continue  indolent under  this
system of medicamentation, the  more powerful influence of the hot
air  or vapour bath may be cautiously tried.   These  baths should
be administered at a low temperature at first, and their effects care-
fully watched.   If they do  not cause too great a degree of reaction,
and yet fail to bring about a decided improvement in the disease,
the parts affected, after being  cleared from  scabs  as  much as
possible by the  use of the tepid  douche  and vapour bath, may
be touched with a weak solution of the nitrate of silver in distilled
water.  The citrine  ointment  is  another stimulating application
that is frequently employed under these circumstances  with  very
good effect. 
96            GREEN ON DISEASES OF THE SKIN-

  Impetigo, however, often  proves a most inveterate disease, and
may coutinue unabated in spite of the employment of the whole of
these measures.  It is under such  circumstances, that I have seen
the sulphur fume bath operate a  change which every  remedial
means  till  then  called into  requisition had failed  to accomplish:
and although I  have occasionally been disappointed in my expec-
tations of a complete cure, in very bad cases,  within a reasonable
length  of time, I  have always had to congratulate myself on a very
great improvement, as well in the  state of the local disease, as in
the general appearance and health of the patient.
  The Fowler's solution frequently proves a powerful adjuvant in
these inveterate cases.  The medicine must of course be  begun in
small doses, and  only increased very gradually.  No good is to be
expected by acting in a hurry in such a disease as  chronic  impe-
tigo ; and if by small doses of energetic medicines, continued for a
greater length of  time, the  wished-for results can be  obtained,
without risk to  the  patient,  it is surely better than by larger doses
continued for a shorter time,  to arrive at the  same  end,  but with
hazard, immediate or remote, to the patient's well-being.
  Impetigo  is one of the diseases which comes  most frequently
under my observation; it is,  I am inclined to believe, a much more
common affection  than is generally supposed.  It usually makes
its attacks,  on  those who suffer from it annually, in the early
summer months, at first in the small pustular form ; the parts thus
affected get crusted  over, and then become squamous,  and are by
and  by left apparently nearly  well.  But the same changes  are
taking  place in  a similar  order  on other   districts  not before
affected; and  even  to the  decline of the malady, psydracious
pustules  continue  to be  evolved.  The flexures of the joints, the
hams,  groins, arm-pits, in the order here set  down, now become
affected with an  eruption, in  which vesicles, rather  than  pustules,
are  often  the   prevailing  elementary form—eczema  impetigi-
nodes,  W.   I have often  observed the disease in  these  obstinate
cases,  as the termination of the annual attack approached, to fix
itself about the eyes, behind  the ears, and on the lower parts of the
face, where it continued for weeks or months subject to the exacer-
bations so common in impetigo and eczema, before finally leaving
the patient.  Vesicles are  easily demonstrated in  these cases, but
never  entirely free  from all admixture of pustules.  Decidedly
impetiginous and pustular in the beginning, the disease, therefore,
becomes  mixed  with vesicular eruption during its  progress, and
towards it termination  seems even  to  have more of the characters
of an eczema than of an impetigo.
   Fortunately, the means of cure adapted to the  One,  are with
little modification  advisable  for the other, at least this is so in the
chronic stages of both.  It is  in the pustular  aflection,  however,
more particularly—in the impetigo, even though there were much
diffuse and vivid redness, and a plentiful crop of pustules, that I
have found  the  sulphur fumigatory mode of treatment  to prove of
the greatest advantage.   This would not at first be supposed ; 
PUSTULAE—IMPETIGO.
97
but the sulphur seems to have a sedative and most advantageous
effect,  both in forwarding  the  disease to  the  crustaceous  and
squamous state, and in  diminishing  the itching and acrimonious
discharge which is often so profuse.
  This effect of the sulphur fume bath in impetigo, is no where to
be found mentioned in the French writers on cutaneous diseases;
but, from repeated  experience, I am positive of the accuracy of
what has been stated above.  This remedy seems even of itself to
prevent the disease from acquiring the variety of forms which dis-
tinguish  it when inveterate;  nevertheless, in my own practice  I
commonly advise bleeding before trying the  fume baths; but this
not being always submitted to, or enforced,  led to the observation
of the effect just mentioned.
   The following cases  will, I believe, be found not uninteresting,
as containing details of aggravated forms of impetigo.

                      CASE OF  IMPETIGO.

   Iii 1822, a gentleman of a sanguine bilious habit consulted  me,
who had beeu afflicted from boyhood with a running tetter, which
he attributed to having been bathed in the sea, by way of strength-
ening  him, when a weakly child.  The  disease then  made its
appearance in various parts of the body, and he had scarcely ever
been free from it till the time when he consulted me, at the age of
forty-five.  He had been under  the  care of  the  late Dr.  Willan,
and of all the most eminent professional gentlemen in this country
and on the continent; and  as his liberality and refined manners
soon attached his medical attendants to him, they in succession
became his most anxious friends, and of course left no means that
were either  likely  or  unlikely  to do  him  good untried; even
measures the  most opposite and unknown  in the circle of regular.
practice  had their trial, and very commonly with  the consent of
his medical  advisers.  The  greatest  relief  he  had  ever  expe-
rienced, was derived from the use of sulphurous fumigations, but
being dissatisfied  with the rude mode in which they were adminis-
tered, a medical friend brought him to consult me.
   He was at  this time  nearly covered  from head to foot with the
malady;  he durst not rise from his chair, save slowly and with
extreme  caution, for any quick movement occasioned the  skin to
crack in various places,  and besides the pain which this occasioned,
a profusion of excoriating discharge speedily poured out from  the
fissures, spreading and extending the disease wherever it was suf-
fered to remain.   The thighs  and legs  looked like the stumps of
decayed  trees, (impetigo scabida,) and the  feet were  so much
swollen as to compel him to wear large slippers.
  Notwithstanding the apparent extent of the disease under which
he laboured, the patient's general health and spirits were good, and
it was decided that he should try the  fumigating baths alone; of
these, he took one hundred and twenty-seven, almost in daily suc-
cession, and during the  whole of the time took no other medicine
       6—d                                      g™ 7 
98
GREEN ON DISEASES OF THE SKIN.
but a cooling aperient on three or four occasions.  From the com-
mencement  of the  treatment  by means of the fume  baths,  the
patient was watched  by several of  his medical friends, some of
whom had advised him not to commence it, whilst others said that
as his case was incurable it would  be useless to proceed.   When
he  had  taken the  fume  bath about  forty times,  however,  the
amendment  was so  evident, that all united in encouraging him to
persevere.   It is usual  for the  sulphur fumes to occasion, at first,
some aggravation of the symptoms of most skin diseases.  It is not
the nature of this therapeutic  agent  to do good by  palliating  or
soothing disease; on  the  contrary, it is  by arousing the skin  to
new action, and overwhelming habitual derangement of function,
under an excitement  whose tendency is to subside  into  health,
that it proves  beneficial.   The disease, however, in the present
instance, was  of so ancient a date, and its chronic  character  so
completely established, that from the first time of taking the fumi-
gating bath to the  last, it went on progressively amending.  The
disease had always been worst  in the spring season ; it continued
during the summer and autumn, and on the approach of winter,
commonly subsided in a considerable degree, though it seldom  or
never quite  disappeared, except on one occasion, when it vanished
almost entirely for a period of four years, neither himself nor his
medical friends being able to assign any cause for this remission of
the complaint; the medicines which  he had been taking when it
disappeared,  were resumed on  its return,  but without benefit.
With the exception of this respite,  then, the patient had gone on,
better and worse, for the lengthened period of  forty  years, never
evidently  benefited  by medicine, until the sulphur fume bath was
tried, under the  influence of  which  he at once felt  relief,  and
ultimately recovered to all appearance entirely.  The  disposition
to the disease indeed remained  long; and for  twelve  successive
years, during which I had  an opportunity of watching the patient,
he still continued to have  occasional  recurrences of his infirmity.
During  all this  time,  his  main, his sole reliance was on the  sul-
phur fume bath, to which  he constantly resorted whenever he felt
symptoms, or perceived a spot  indicating the  approach  of his
ancient  enemy.   The  year 1823 he got through without having
much occasion  for  recurrence to  the  baths; though during the
spring and summer of that year he did occasionally take one as a
measure of security.   The whole of 1824 he passed  much in the
same  way, but had to visit the baths more frequently.  In the June
of 1825, he had a sharp accession of the disease, which began with
heat and  swelling about the ankles, followed by a crop of vesicles,
which were either mixed with pustules, or soon became pustular,
the heads almost immediately containing yellow pus.  These by
and  by  ran together,  and formed crusts or scabs of  considerable
thickness  and extent, from under which an abundauce of ichorous
discharge continually issued.  The general health of the patient
did not suffer.  He took the fume baths daily, and in ten days the
malady seemed to have expended its virulence in the legs;  but it 
PUSTUL.E—IMPETIGO.
99
now showed  itself  on the thighs,  chest, and  arms,  and went
through a  similar process.  By the end of the month, the legs
were already  assuming their natural appearance, and  the whole
mass of pustules and vesicles became crusted;  the profuseness of
the ichorous discharge, which  surpassed any thing of the kind I
had ever witnessed,  requiring several sheets many times folded
each night to absorb it, also began to abate, the crusts by and by
to be detached,  and the parts last  affected gradually to recover
their proper and healthy look.   The disease, however, had not yet
exhausted itself,  for the patient was now attacked with heat, small
vesicles, and then pustules in the flexures of the groins, axillae.
and bends of the arms, from which the discharge  was as profuse,
considering the  extent of surface which the disease occupied, as  it
had been from the other parts of the body.  He went on with the
fumigations until the end of July, when the parts just  mentioned
got well.  The  disease next broke out behind the ears, and on the
chin, where it followed much the same course as usual.  All the
other regions  affected being  now well, or nearly so, the patient
took the fume baths only every other day, until the end of August,
when he considered himself as again restored to health.
  This patient having an extreme aversion to medicine, very little
was taken during the progress of these attacks ; a simple aperient.
administered occasionally, was all he could be induced to take.
  The years,  1826,  1827, and  1828  were passed without  much
suffering, though not without occasional accessions of the disease,
which the patient had learned to keep under by the frequent use of
the fume baths.   1829 he passed at Paris, where he was copiously
bled on account of inflammation of the kidneys, and took the medi*
cines usually prescribed in such cases; and this year he escaped
without any  recurrence of his old disease, which always  com-
menced with evident inflammation of some district of the skin, of
severe character, for which however he had always resisted any
proposal  to bleed  him.   In April, 1830, he was bled  to  twenty
ounces; and this year he  passed without much  annoyance from
the disease of the skin ; he took a fume bath once a week during
the whole of the ensuing winter, in'hopes of conquering his dis-
ease altogether.   Through 1831 and 1832, he lived in comparative
comfort, though  not without some appearances of the disease.  The
same may be said of the spring and summer of 1833 ;  but in the
autumn of this year, which he spent at Bath, from not confining
himself to his customary regular habits, he had a severe accession
of his disease  for six weeks, until in London he could again resort
to the fume baths, under the use of which he soon became well.
  The history even of the leading  features of this case has been
long, but the details are interesting, and the results well calculated
to show the value of sulphur fumigations in a case of the most
inveterate description, which had  lasted upwards of forty years,
and had never been visibly ameliorated by any of the innumerable
systems of treatment previously employed.  I do not flatter myself
that the disease was  cured, or rather that the disposition to it was
                                                 grn 7* 
100
GREEN ON DISEASES OF THE SKIN.
 eradicated, by the means ultimately found so efficacious in control-
 ling its progress.  But the remissions are  now of such long con-
 tinuance, and the attacks of such comparatively short duration,
 that I think it possible even the disposition  may in the progress of
 years be subdued; meanwhile, at all  events, life to this individual
 is made the blessing it ought always  to be, at a very small cost of
 personal inconvenience.
   Before  concluding, I may just say that I had hesitated  at first
 whether to give this case under the head of eczema impetiginodes,
 or of impetigo.   The primary form of the eruption was certainly
 vesicular, but it passed so rapidly into the pustular state, and ulti-
 mately partook  so completely of the  characters of those diseases
 which are generally acknowledged to  be impetiginous, that I have
 preferred  placing it where it stands.
   Case 2. A gentleman, nearly 60, of a gross, robust habit, applied
 to me, in  the summer of 1832, on  account of an eruption on  the
 skin, from which he had suffered more or less during the last eight
 years.  The eruption consisted of numerous small yellow pustules
 on the insteps, ankles, and lower parts of the legs, which were now
 much swollen, and encased with lamellar crusts,—impetigo sparsa:
 the hands and several parts of the trunk of the body were similarly
 affected.  The patient's chief complaint arose from  the  itching,
 which was  at times  very annoying; otherwise he  was in fair
 health, and went, about  his  affairs, though it often required  the
 exercise of considerable ingenuity to apply a sufficiency of rag  in
 such a manner as to absorb the abundant sero-purulent discharge
 that issued from the parts affected with the disease.   June 12th,
 the patient was bled to the  amount  of sixteen  ounces, and was
 directed to take  every morning four table spoonfuls of an aperient
 mixture consisting of infus.  sennae  3vi.,  tinct. ejusdem  3i., syr.
 rhamni 3 i.   His diet was also regulated, and a sulphur fume bath
 administered daily.
   The gross  habit of this patient seemed to require bleeding and
 purging;  otherwise the  shining redness  and  heat  of skin that
 attend impetigo should not deter from the use  of sulphur  fumiga-
 tion, which, although apparently contra-indicated, I never knew
 otherwise than of the greatest use in this complaint:  let the exter-
 nal appearances of inflammation be never so great, it is surprising
 how soon the discharge and redness begin  to abate under the use
 of this application.
   On the  30th, not a vestige of the disease was to be seen, except
 between the  thumb and  fore-finger of each hand, where it had
 probably only been kept up by the patient picking the parts with
 his nails ; all itching had ceased, and for a week  previous the
 opening mixture had been discontinued ; the fume baths were also
discontinued, as  no longer needful;  the  patient appeared restored
 to perfect  health.
  To celebrate this redemption from his long-continued and harass-
ing complaint, my worthy patient gave a grand feast to his nume-
rous friends, who were invited to rejoice with him on  occasion of 
PUSTULAE—IMPETIGO.
101
his happy recovery.   Moderation is difficult in the moment of
victory, and my patient committed an excess, which after twenty-
four hours brought on an almost general attack of inflammation
of the skin, followed by a copious eruption of pustules ; so that he
returned, depressed in spirits, to resume the former treatment.  In
the short space of  eight days, however, this active  and  general
accession of disease was completely subdued, and all remedies were
left off.
   I have had an opportunity of frequently hearing of this patient:
he has had no relapse of his disease worth naming; a few pustules
on the hands are all he has seen of it since he was under my care.
I have been rather surprised at this, for I know that his habits are
such as are  most commonly held to be inimical to complete  reco-
very from chronic affections of the skin especially.
   Case 3. Mrs. H., of Favershara, aged 74, was recommended to
try the effects of sulphurous fumigation under my direction, by the
medical gentlemen she had consulted in London, Dr. Gordon, and
Sir Benj.  C. Brodie, on account of an  eruption of impetiginous
pustules, extending over the whole surface of the body, except the
face, the palrns of the hands, and soles of the feet, under which she
had laboured during the  last four years.  From the  nape of the
neck and  throat to the heels and insteps, the surface of this gentle-
woman's  body was  generally inflamed and covered with small
yellow headed pustules and laminated incrustations,  from under
which a profusion of sero-purulent fluid was constantly pouring.
The itching and general irritation of the surface were very dis-
tressing, so that the patient  scarcely ever  enjoyed an hour's  quiet
and uninterrupted sleep.
   In spite of the apparently high state of inflammation, the sulphur
fumigating bath was  immediately entered; and with so happy an
effect, that the succeeding night was tranquil, and a considerable
portion of it passed in  refreshing sleep.   After the fourth bath the
amendment was so  great, that the patient, with a view of accele-
rating the cure  still more, insisted upon taking two  baths daily.
In the short period of a fortnight, during which time Mrs. H. had
taken twenty-two baths, not a vestige of this extensive disease was
to be seen, and she returned into the country quite recovered.
   These three cases of impetigo will be sufficient to show the great
and beneficial  influence of sulphur fumigations in this severe, and,
under other systems of management, intractable disease.
   I have preferred detailing these cases to many others in my note
book, because of their severity  and long continuance,  the  last
especially (the case of Mrs. H.),  as I learned that she had  been
recommended to me with a view of putting the merits of the sys-
tem of sulphur fumigation to the test, and because not one dose of
medicine of any description was taken  during the course of the
treatment.  Mrs. H. has sent me several patients since her return
home, and if she had had any relapse herself, I should certainly
have seen or heard from her.
   The whole of the complaints of the skin which are accompanied 
102            GREEN ON DISEASES OF THE SKIN.

with discharges, I have always found much more readily influenced
beneficially by the fumigating method  of treatment, than those that
are of a dry nature.

        favus (rayer), pokrigo (willan), tinea, &c.
  By favus I understand a pustular and contagious disease of the
skin,  which commonly affects the scalp, but  occasionally appears
on other regions of the body also.  This affection  assumes two
principal forms ; in the one, the pustules characteristic of the dis-
ease  are distinct and disseminated; in  the other, they are confluent
and  collected into clusters, and ultimately into annular  patches,
In both  varieties  the pustules are favi;  that is to  say, small,
rounded, pale yellow pustules, set, as it were,  in a frame of epider-
mis,  and containing a fluid, which almost immediately concretes
into cup-shaped, straw-coloured scabs; these  go on increasing  in
thickness for many days, and at length,  by  cohering, compose a
thick, hard, grayish  yellow coloured  incrustation, the surface  of
which presents a congeries of cup-shaped  cavities, like the sealed
cells of a honey-comb; this character,  however, is frequently lost.
  Under the head of porrigo, Willan, and those who have followed
him, describe six different affections: porrigo larvalis, pox. favosa,
por. furfurans, por. decalvans, por. lupinosa, por. scutulata.
  I have already had occasion to speak of two of these affections,
porrigo larvalis and porrigo favosa, as species of another pustular
eruption—impetigo, of which they are  undoubtedly varieties.   Por-
rigo  furfurans may generally either be referred to one of the squa-
mous affections,—pityriasis, or be  discovered  to be an eczema  or
impetigo of  the scalp.  Porrigo decalvans is a title that  does not
seem chosen with Willan's usual  felicity; an effect of numerous
diseases of the scalp being here assumed, as characteristic of a
particular species.  The state of baldness is a consequence of some
affection of the bulbs which secrete the hair, and porrigo is only
one of the forms of inflammation that attacks these organs, and
either temporarily suspends  or  entirely destroys their functions.
Finally, porrigo lupinosa, which I shall treat of under the title  of
favus dispersus, and porrigo scutulata, which I shall discuss under
the name of favus confertus, stand apart, and are  distinguished
from the whole of the other diseases which  have been described
under the general title, porrigo, in the circumstances of their com-
mon contagious nature, and the form of their pustules and  primary
incrustations.

        FAVUS DISPERSUS (PORRIGO LUPINOSA, WILLAN).
   Favus dispersus or porrigo lupinosa most commonly appears
on the hairy scalp, in the  shape, when first observed, of  an  erup-
tion  of very minute pale yellow pustules, surrounded by an inflam-
matory blush, which did not rise above the level of  the skin, and
are accompanied during their development with an intense degree
of pruritus.  These  pustules, in  the first  instance, are mostly 
PUSTULAE—FAVUS DISPERSUS.
103
isolated, although they are occasionally  so  crowded as to form
something like a continuous punctuated surface.  They appear to
be set within a rim of the cuticle, and, almost from the moment of
their formation, may be seen either  by the naked  eye, or with  the
help of a magnifier, to  be depressed  or cupped on their surface.
Their contents  are  at  first fluid, but very speedily  harden  into
scabs of the same form as the primary pustules, and of a bright
yellow colour; these scabs increase slowly in size, the cupping of
the surface  becoming more and  more apparent, till  they attain a
diameter of two or three lines, whence the  epithet, lupinosa, of
Willan ; and some of them have  even been seen which measured
more than an inch across.  When the pustules have been crowded,
the scabs blend and become united on their edges, so as to form a
continuous incrustation, of very considerable extent, upon the sur-
face of  which the  foveae or depressions, indicative of the nature of
the original pustules, may still be  distinguished.
   Whilst the scabs of favus dispersus are somewhat recent, they
are of a clear brownish yellow colour; when older, they split in
all  directions, and fall  at length into a  pale yellowish powder.
They adhere very firmly to the skin, and can scarcely be removed
in the dry state, without being followed by a little bleeding.  When
they are detached by means  of emollient poultices and fomenta-
tions, the parts to which they adhered present appearances charac1-
teristic  of the disease:  small, superficial,  rounded  excoriations
appear in the situations of the several scabs, and when these have
been somewhat crowded, without  being actually confluent, the sur-
face presents a honey-comb appearance.   The corion is denuded
and inflamed, but not ulcerated; it pours out a yellowish viscid
fluid, which soon concretes into  a rough laminated incrustation,
without any of the characteristic  favi of the  primary scabs : each
cup-shaped scab that makes  its appearance is due to  the develop-
ment of a fresh  pustule;  and it is in  this way that the disease is
continued in the chronic and  inveterate state  for so long a period,
one crop of pustules  being succeeded by another, till the disease
either ends  of itself,  or yields to the remedies employed for its
cure.
  The hair  falls off, or  may be pulled out by the roots, from  the
very commencement of  the disease ;  and in case the  affection  has
continued very long in a chronic state, is never reproduced.  The
patches that are thus rendered bald, are white, smooth, and shining.
When the disease has  been   arrested, however,  the  hair grows
again, though it is always thin and woolly at first, and generally
continues lighter in  colour than  it  was before.  These circum-
stances tend to show, that  however seriously the secreting bulbs of
the hair become affected at last, they are not  the primary seat of
the disease.
  The loss of the  hair is not the only or  ultimate evil attendant
upon  inveterate chronic  favus dispersus or porrigo lupinosa of the
scalp.   The whole substance of the corion is indurated and altered;
the subjacent cellular membrane inflames, and sometimes contains 
104
GREEN ON DISEASES OF THE SKIN.
small abscesses ;  finally, in the most severe cases, the inflammation
extends even to the  periosteum  and bones, which undergo altera-
tions greater or less  in amount.   When the disease has gone thus
far, it is possible that it may  be attended with  the  consequences
which have been attributed to it, namely, a certain hebetude of
intellect, and an approach  to  idiocy in the unfortunate children
who are its victims.   But neither favus dispersus nor favus con-
fertus have in  themselves any particular or  specific deteriorating
influence upon the  brain and nervous  system.   The fact is, that
children who labour under these diseases are looked upon with a
kind  of  loathing, as lepers were of old, by interested pedagogues ;
and  shunned, neglected, and untutored, it is no wonder  that they
fall behind the youth of  their age in acquirement, and even appear
deficient in that vivacity and  quickness of apprehension which
belong so essentially to childhood.
   Favus dispersus  appears occasionally on other regions of the
body besides the scalp.   It is  not, however, nearly so disgusting
and  rebellious a disease under these circumstances, as when it
affects the integument of the head.
   It is a remarkable fact, that  although favus dispersus spreads
rapidly among children who  are much  together, who sleep in the
same bed, make use of the same hair-brush,  comb, towel, &c, yet
that attempts to inoculate the disease directly, very generally fail.1
The disease attacks  individuals of all ages ; but children between
the ages of six and ten seem particularly obnoxious to the infection.
It is  not always possible, even in the first instance that occurs, to
trace the disease to any of the peculiar circumstances—such as
neglect of proper cleanliness,  insufficient or improper food, resi-
dence in low, damp  situations,  a scrofulous or lymphatic habit of
body, &c, which have been indicated as its occasional causes.  Its
progress  afterwards  is in general evidently enough due  to conta-
gion, and then children of weakly and the most robust constitutions
are indiscriminately affected.
   Favus dispersus  is easily distinguished from every other pustu-
lar affection, by the  peculiar appearance of its pustules and incrus-
tations.  Except  favus confertus, in fact, no other disease of the
skin  is characterised by minute yellow pustules, whose  contents
concrete, almost as soon as they are visible, into  little cup-shaped,
hard, and  extremely dry yellow  scabs.  When  the  incrustations
are older they split into pieces, and often hang among the hair like
the crusts of impetigo granulata; but the absence of discharge,
and the loss  of the  hair, always distinguish the favoid from  the
impetiginous affection.
   Favus dispersus is always an obstinate disease, and only yields
reluctantly to the best directed curative means, long and sedulously
enforced.  The disease, indeed, may often be seen continuing for

   1 M. the Baron Alibert,  on my recent visi^t to Paris, asserted that we were
altogether mistaken in England in supposing favus to be contagious.  He
maintained that the disease  in none of its forms was infectious. 
PUSTULAE—FAVUS DISPERSUS.
105
months, and even for years, after the whole of these have been tried
in vain, and only getting well at last, apparently after exhausting
itself, under the employment of some insignificant and inert appli-
cation.
  As in all obstinate diseases, an infinity of remedies and remedial
measures have been proposed as sovereign and infallible in favus
of the scalp.   The disease is in general so purely local  in  its
nature, that we have not a great number of internal medicines to
discuss.   Nor  indeed do I  feel  greatly inclined to notice particu-
larly more than a very small number of the host of external appli-
cations  that have been vaunted, either  as occasionally or as uni-
formly successful in this rebellious affection.
  Experience would seem to warrant the greatest confidence being
reposed in that system of treatment  which makes the eradication
of the hair from the affected regions its first and most essential
measure.   This used to be accomplished in a very barbarous way,
in former times, by means of the pitch cap, which tore out not the
loosened and diseased hairs only, but those also that were healthy
and that needed not avulsion.  More  lately it has been proposed to
remove  the  hairs from the  affected  bulbs, with a pair of tweezers
contrived for the purpose.  But this is a tardy process, and one  by
no means free from objection ;  for it is still attended with acute
pain ; so many adhering hairs mingle with such as are loose, that
it is next to impossible to avoid seizing the one  in attempting to
take away the other.  The latest experience has  shown  that the
process of depilation might be accomplished much more effectually,
and without the infliction of any pain, by the use of alkaline appli-
cations, and the  small-tooth comb,  passed lightly but repeatedly
once or  twice every day,  through the hair of the affected regions,
cut of a convenient length.
  The first step to be taken then, in the treatment of  favus dis-
persus, is to cleanse the  scalp completely, and  to  free its surface
from  incrustations.  Nothing  must be attempted violently or hur-
riedly in this  disease; on the contrary the hair must be clipped
with  scissors,  and  left  about a couple  of inches in  length, not
shaved off with a razor ;  and the affected parts are to be very long
bathed with tepid  milk and water, or tepid water made milky by
the addition of a  small quantity of white soap, and  then covered
with a soft bread  and water poultice  for eight or ten  hours, when
the bathing is to be repeated, and the  poultice reapplied ; and  this
is to be done for two or three days in succession, or till  every ves-
tige of incrustation is removed.  When this  is accomplished, the
poultices may be left off,  and a little hog's lard and  subcarbonate
of potash, in the proportion of an ounce  of the former to a dram of
the latter, rubbed  gently  over the parts, night and morning, these
having  been previously  bathed  with a weak  alkaline wash, com-
posed of from one to two drams  of the subcarbonate of potash or
soda,  to each pint of tepid water.
  These measures continued uninterruptedly for a time will gene-
rally be found  to  produce a manifest improvement in the state of 
106            GREEN ON DISEASES OF THE SKIN.

the disease.   When the simple alkaline wash appears to lose its
efficacy, it may be replaced by a lotion of the sulphuret of potash,
compounded as under,1 or by a weak solution of the  chloride of
lime or soda.
  Should the abraded surfaces show symptoms of irritability at
any time, a weak metallic solution, as of eight or ten grains of sul-
phate of zinc  or of copper, to  the ounce of water, or  better than
either of these, of the nitrate of silver in rather smaller proportions.
may be used with the best effects.  When the whole of  the disease
consists in a few pustules only scattered here and there, these may
be touched individually with the nitrate of silver in substance, or
one or other of the mineral acids may be employed for this purpose.
  Most of the unguents that have been  recommended in favus or
porrigo, seem  to exert very little influence over the disease.   They
are all inferior to the one already mentioned, of  the subcarbonate
of potash or soda.   When  the parts have become habituated to the
action of this, however, the unguentumnitratis hydrargyri, properly
diluted with hog's lard, may be advantageously substituted for it,
for a season.  Very recently, an ointment of the iodide of sulphur,
in the proportion of from a scruple to a dram of  the compound, to
an ounee of lard, has been introduced to public notice  upon  very
high authority.2  This unguent is said to modify the affected parts
in the most  favourable manner, to prevent  the formation of fresh
pustules,  and  to cause the hair to be  reproduced  exactly of the
same strength and colour as it was before.   The successive appli-
cation of small blisters first  on one  arm and then on the other, is
said to be often attended  with great advantage in  this disease.
  Whilst these various remedies are tried  in  succession, the  most
unremitting attention is to  be paid to the ablution of the parts, and
to the removal of incrustations and dead hair.  This, indeed,  is the
sheet-anchor in the treatment of favus.  In ninety-nine cases in a
hundred,  the disease will yield  within three months to any plan of
treatment adopted where this  forms  the principal  feature, whilst
every plan that can be pursued will fail nearly in the same propor-
tion where it is neglected.
  I have said nothing of internal medicines, nor am I  aware that
remedies of  this class have ever been  much insisted on  in cases of
favus.   The occasional  exhibition of a gentle aperient  will,  how-
ever, be found to aid  the action of the topical applications;  and,
generally speaking, more than this will  not be necessary.   Should
there be  any  concurrent affection of the chylopoietic  viscera, it
would of course be essential to endeavour,  by appropriate  dietetic
and alterative measures, to  rectify what was amiss.   Although I
am far from  thinking that every disease of the skin is owing to
some obscure and undefinable affection of the stomach and  bowels,


  lft. Potass, sulphuret. 3 ii- sapon. alb. 3 iiss. aq. calcis gvii. alcohol.
rectif. 3ii.
  1 M. Biett.  Vide Cazenave and  Schedel, Abregg Practique, &c. 2d edit.
p. 266. 
                PUSTULAE—FAVUS CONFERTUS.              107

I am too well satisfied of the extensive influence exercised by these
organs over  every part of the animal organism, and particularly
the skin, to neglect for a moment any evident derangement of their
functions.


FAVUS CONFERTUS (RAY.)—PORRIGO SCUTULATA  (WILL.), RING-
                            WORM.

  I might have spoken of this  disease under the same head as the
last, for the one is in  reality no  more than a variety of the other;
the favous pustules,  characteristic of each, being disseminated in
the favus dispersus or porrigo lupinosa, and collected into clusters,
and  ultimately assuming the form of rings, in the favus confertus
or porrigo scutulata,  whence the vulgar title of the  affection, ring-
worm.
  Favus  confertus  may  be  considered  as  a disease  essentially
belonging  to the scalp ;  it does, indeed, occasionally  make its
appearance on  other  regions, but on  these it  is in  the first place
very rare, and in the  next has little in common with the affection
of the scalp, save the  primary form of the eruption.
  The disease begins in  the shape  of one or more circular red
patches attended with intense pruritus, upon  which  numerous
minute yellow pustular points level with  the  skin  make  their ap-
pearance.  These pustules  are  every where very much crowded,
but  more especially so in  the  circumference of the  patches.  The
pustules severally have precisely the  characters already described,
as belonging to those  of favus dispersus or porrigo lupinosa: they
are small, circular, set within a rim of cuticle, depressed on the sur-
face, and almost uniformly traversed  by a hair.  The fluid within
them dries up very soon after it is poured out, into a minute cupped
scab, which adheres by its edges to those in its immediate neigh-
bourhood, so that a continuous incrustation is thus produced of the
form and dimensions of the original  pustular patch.   The crusts
in favus confertus or porrigo scutulata,  however, do not  usually
continue long adherent, nor, indeed, does the primary patch long
retain its first dimensions; for successive eruptions of pustules in
its circumference speedily enlarge its diameter, and  the crusts fall-
ing out  of their cells in  the central  parts, the integument  there
becomes dry  and subject to an habitual desquamation.
  As in favus dispersus, the hair in this  form of the disease soon
looks altered, becomes thin, and is then  lost, so that the circular
patches are all but bald, the few hairs that still sprout from their
surface  being  crisp,  woolly,  and readily detached.   When the
disease has continued long, even this imperfect hair is no longer
produced, and  it may happen  that the hair  bulbs are so deeply
affected as to be incapable, when the  disease is cured, of resuming
their functions, in which case irremediable baldness is the conse-
quence.
  It generally happens that several patches  appear in  succession
on different parts of the scalp in this disease, probably from inocu- 
108
GREEN ON DISEASES OF THE SKIN.
 lation performed by the fingers of the patient in scratching.  These
 extend till they are one, two,  three,  and  even more inches in
 diameter, and frequently meet by their corresponding edges, so that
 the entire  surface of the scalp and even parts of the forehead and
 cheeks are occasionally covered by the disease, the nature of which
 may however  be discovered at every stage  by the arcs of circles
 which still make their appearance in its circumference.
   On  the scalp, at the  same  time, the intervening  portions  of
 integument are always affected, to a greater or less extent, with a
 furfuraceous desquamation.
   When favus confertus has been  entirely neglected, the  parts
 affected are  found  covered with a dry  and friable incrustation  of
 a greyish  yellow colour, which is continually breaking off in dust
 or in small pieces,  like pulverulent and dirty mortar.  All trace of
 the cupped appearance of the primary pustules  is  then  lost.  In
 these cases the disease may very frequently be studied in its various
 stages at the same  time: the patches are  of  a bright red in  their
 circumference; at  a short'distance within the  edge, small  yellow
 pustules are discovered in greater or smaller numbers  ; farther in,
 crusts  of  various thickness  are  encountered, and finally a white
 and shining space  here and  there  meets  the eye, in the  midst  of
 the affected  surfaces, which is  entirely bald,—porrigo decalvans,
 Willan.  The parts affected  in this way sometimes  continue  bald
 through life ;  more commonly, however, they subsequently become
 covered with hair, though this very frequently remains  lighter  than
 the rest ever after.
   Favus confertus may thus continue during an  indefinite period
 of time.   The  disease does undoubtedly, and is indeed  too fre-
 quently abandoned to get well of itself, but this only happens  after
 it has continued for months, and even for years.  It is  a very obsti-
 nate disease then, and never yields readily to any form of remedial
 administration, so that between the want of perseverance on the
 part of practitioners, and the anxiety of teachers to get rid of the
 children affected with  ringworm, lest they should contaminate
 others, the disease is generally looked upon as an opprobrium not
 only to the surgeon, but to the unfortunate child who is affected.
   Favus confertus is  a contagious disease, and  spreads  rapidly
 among children who  make use of the  same comb,  hair-brush,
 towel, &c.  The disease also rises  spontaneously among children,
 between the age of  two and ten especially.
   So many peculiar characters distinguish this from other diseases
 of the scalp,—the form of its pustules and their circular arrange-
 ment, the appearance of its incrustations, the baldness it occasions,
 and its contagious properties,—that  there seems  little danger of
 confounding it long with  any other affection of the skin.   From
 favus dispersus it is distinguished by the clustering of its pustules,
 and the regular annular arrangement they assume.   Impetigo
figurata affecting the scalp is distinguished by the greater degree
 of inflammation surrounding the pustules, which are slightly raised,
 and contain  a fluid which only dries into a scab very gradually, 
PUSTULAE—ACNE.
109
&c.   From herpes circinnatus and the patches of lepra  on the
road to recovery, favus confertus may always be discriminated
without difficulty, by watching the progress of these diseases for a
while, as well as from the particulars of their previous history.
  In regard to the treatment of favus confertus, I have little to add
to what has already been said  under the  head of favus  dispersus.
In the earlier stages  of  the disease, antiphlogistics  and emollients,
and the eventual application of some slight stimulant, such  as the
citrine ointment, will frequently bring the disease to a  happy ter-
mination.  When it has been neglected, or when, in spite of the
remedial measures which have been pursued, favus confertus runs
on into the chronic and inveterate state, precisely the same  system
of treatment must be adopted which has been  recommended in ob-
stinate favus dispersus; to the treatment of which disease, there-
fore, I beg to refer, to save needless repetition in  this place.

               ACNE, GUTTA-ROSEA, OR ROSACEA.

  Acne is a chronic  pustular affection of the skin, characterised by
a deep-seated and very indolent inflammation of  the tissues imme-
diately  surrounding  the sebaceous follicles, or  of these follicles
themselves; followed by  small isolated pustules supported  on a
deep  red base,  which, besides a quantity of sero-purulent  fluid,
usually contain a slender  mass of sebaceous matter, and are suc-
ceeded by small circumscribed livid red and indolent tumours, that
disappear with extreme slowness, leaving indelible but very minute
cicatrices behind them.
  Three principal varieties of this disease have  been described by
two of the great dermato-pathologists of  recent times,  William and
Bateman.  The  simplest  and  commonest form—acne simplex,
attacks young persons, more especially about the age of puberty;
in the youthful of both sexes it is very common to see the sides  of
the face, the forehead, shoulders, and upper parts of the bosom and
back, become the seat  of an eruption possessing the characters
which  have been described, and  producing a  kind  of deformity
which  individuals at  this age of all others are  most anxious to
escape.  In acne simplex the"pustules generally appear in  succes-
sive crops, on various parts, and  in various numbers at the same
time.    Each particular pustule runs its course independently of the
others.  When close attention is paid to the progress of the eruption,
each  particular spot may be detected at first as a deepish indurated
point, and whilst there is still, if any, but  a very slight degree of
surrounding inflammation.  The point enlarges, the skin over and
around it becomes red, and at length something  like  a pale yellow
head  is perceived; this gives way by and by, and a small quantity
of sero-purulent fluid escapes,  which hardening into a scab, of the
most  flimsy description, adheres for a few days,  and is then  brushed
off by the friction of the clothes, leaving a small  hard  induration of
a dark or slightly livid  red colour behind  it. This induration is
only resolved very slowly, but its tendency is towards  resolution ; 
110
GREEN ON DISEASES OF THE SKIN.
and when it is at length entirely dispersed, a small glistening white
cicatrix is discovered in its place.
  The pustules of the disease, as  it has  now  been described, are
evolved almost without pain, and  are  frequently seen  intermixed
with a considerable number of circular black points: these indicate
the external orifices  of so  many follicles, filled  with concrete
sebaceous matter, which, in all probability, will by  and by become
affected with inflammation, and add to the extent  of the disease.
This  view  of the particular  appearance in question, makes the
fourth of the different species of acne described by Bateman—acne
punctata—unnecessary.
  When the inflammation extends more widely around the par-
ticular sebaceous follicle  affected,  or when  several  follicles in the
immediate vicinity of each other  are  simultaneously implicated, a
larger and more  indolent elevation appears than in the form of acne
just described, in which  case  suppuration is very  tardy in taking
place,—in which, indeed, it often happens that no  matter ever
makes  its way  to the  surface.   The disease  in this  shape is
denominated acne indurata.   It is frequently very trifling in ex-
tent, being confined to a few pustules or indurations on the temples,
sides  of the face,  or forehead.   The  progress  of the disease is
always  very slow; the matter of the pustules  seldom makes its
way to the surface in less than from two to three weeks.  The base
of the pustule afterwards remains  hard, indolent, of a more or less
dusky red hue, and, as the cellular membrane  then participates to
some extent in the disease, forms an induration of such magnitude,
as without attention to other antecedent circumstances  would lead
to the conclusion, along with Willan and Bateman, that the disease
was tuberculous in its nature.
  Instead of consisting of but a few scattered pustules and indura-
tions, acne indurata frequently appears with  symptoms  of  much
greater severity.   The whole face,  for  instance,  may become
covered with the eruption; the pustules, supported on broad, livid,
and  indurated bases, being crowded  together and mingled with
numerous black sebaceous points, the skin in every  part hyper-
trophied and unctuous, and all the features distorted  in  the most
unseemly manner.   The disease in  this  aggravated form very
frequently attacks  the shoulders, and  there particularly is apt to
leave indelible traces of its presence in the shape of small oblong
cicatrices.
  Acne indurata, like acne simplex, very generally attacks youth-
ful subjects, otherwise in the enjoyment of excellent health.
  A  third variety of acne, on the contrary, rather occurs among
individuals who have attained, or  have even passed, the meridianof
life;  and  instead of attacking such an extent of parts as either of
the species described, is confined almost exclusively to the face, and
often to the nose and portions of the cheek near this member: this
is the acne rosacea, or gutta-rosea.  In acne rosacea, the point of
the nose is generally first observed to become unusually red after
meals, or  upon occasion of exposure to the stimulus of a high tempe- 
PUSTULE—ACNE.                    Ill
rature, after a few,glasses of wine, &e.  This redness by degrees be-
comes  habitual, the veins of the part enlarged, and at length a few
small yellow pustules make their appearance in the midst of the in-
flamed surface, and by their presence seem to add to the irritation,
for the skin around them very commonly gets thickened and hyper-
trophied, and begins to look greasy and rough on the surface. The
disease extends gradually from the nose to the cheeks, and may
spread successively to the chin, forehead, and indeed to every part
of the face, which then acquires  a very fiery  and characteristic
appearance, being of a general vivid red colour, studded here and
there with bright yellow points and indurated  masses of a dark
red hue,  over and between which numerous tortuous and dark blue
veins are to be  seen  meandering in  different directions.  The
suppurative process in acne rosacea is never more decided than it
is in the simple and indurated  varieties  of the disease.  In all
it is a tardy and imperfect effort, and forms no true crisis or termi-
nation to the disease.  Acne rosacea  always produces a certain
amount of deformity.  Even when the disease gets well, it is seldom
that the features recover their pristine form completely; they almost
always  remain thickened, and show traces of its presence in  the
shape of roughness, inequalities and cicatrices of greater or less
extent.
  The  causes  of acne, as of most other cutaneous  diseases, are
buried in the greatest obscurity.   The  two varieties first described
appear at particular period of life; but  what  connection  there
should be betwixt the establishment of certain new capacities in the
economy, and an inflammatory affection of an  unpleasant nature
of the sebaceous follicles of the skin, is not very evident.  In one
case I have known a few pustules of acne indurata very constantly
follow indulgence in  particular articles of food, especially cheese.
The connection of acne rosacea with certain intemperate habits, is
a more conspicuous and generally admitted circumstance; but as
intemperate habits are by no means invariably followed by rosacea,
neither is  rosacea necessarily  and in  every case  owing to  in-
dulgence of the animal appetites of eating and drinking: individuals
of the most moderate and even abstemious habits, do not always
escape the attacks of this  disease; so that the vulgar, although
perhaps generally, are not uniformly, right in  setting down, as  a
dram-drinker, the he or  she who has the misfortune to have a fiery
nose and pimply  cheeks.
  Acne is a disease which there is generally little difficulty in dis-
tinguishing at once from every other affection of the skin.
  The pustules of ecthyma, to which it has been  supposed to bear
some resemblance, are much broader, covered with such thick and
adherent  scabs as are  never  seen in  acne, and followed by no
tuberculated indurations, as this disease is constantly.  In acne no
such continuous and laminated  incrustations  are  ever  seen  as
follow impetiginous eruptions.  The tuberculations  of syphilitic
origin which occur on the  face, are  generally ulcerated on  the
summits, and are at least always surrounded by a copper-coloured 
 112           GREEN ON DISEASES OF THE SKIN.

 areola, if they are not themselves very decidedly tinted with  the
 same peculiar hue.
   Acne simplex is rarely a disease of great  consequence; it tends
 naturally to a termination as the period of manhood is approached,
 and usually disappears in  a  great  measure  when  this state is
 attained.   Acne indurata is  a  higher degree and more rebellious
 form of the disease, and often continues to harrass individuals, more
 or  less, through the whole  course of their lives.  It  frequently
 proves, indeed, a prelude to the third  and most serious species of
 acne, namely the rosacea, which is always an obstinate, and, in
 many cases, an incurable disorder.
   Acne is  not often seen at an age when debility can be suspected,
 or among subjects who can very properly be held to  be weakjy in
 constitution: the very name of the disease (from uk/xv, vigor,) is
 calculated to assure us on this head.   The treatment of the disease
 therefore may be the more freely conducted on  the antiphlogistic
 system.  The  individual affected should  live  temperately, nay
 abstemiously, giving up the use of wine, strong  beer, spirits, coffee,
 and stimulants of every description, and heavy meals of animal food.
 He should keep the bowels open, with a little of  any of the common
 neutral aperient salts  taken  from time to time, and  should  avoid
 fatigue of mind as well as of body, exposure  to a  burning sun, to
 hot rooms, &c.  If the eruption is copious, and causes much dis-
 figurement, a bleeding may be  practised  from  the  arm,  and  a
 number  of leeches applied  repeatedly behind  the ears,  with  the
 greatest advantage.  A stimulating wash should at the same time
 be regularly used to the parts affected, twice or three  times a day.
 A mixture of an ounce or two of alcohol, to eight ounces of rose
 water, may be tried at first.   A more powerful application is made
 by adding six or eight grains of corrosive sublimate to this mixture.
 The Gowland's lotion,  which  has so  long enjoyed  an extensive
 reputation  in  this malady,  consists  of an  alcoholic solution of
 corrosive sublimate diluted  with an emulsion  of almonds, and it
 really is an excellent wash.
  When the pustules in the  acne indurata have not been very
 numerous, but attained a large size, and become very unsightly
 when they were allowed to run their indolent course, I have long
 been in the habit of pushing a fine lancet down  to the collection  of
 sebaceous  matter and  purulent fluid  the  moment its seat was
 indicated by a hard point and an increase of redness in the skin,
 and pressing out its contents forcibly, and this always with the effect
 of cutting  short the progress of the particular  pustule so treated.
 The operation is not very painful, and all  traces of  it disappear
 within four-and-twenty hours.  I have known  many individuals
 continue this practice themselves, and  thus  escape the  annoyance
 of constantly  bearing  about upon their faces  five  or six livid
 and unseemly whelks.  Bathing the pustules in  their nascent state
 with water as hot as it  can  be borne, is another  and frequently
effectual way of arresting them in their career, and dispersing the
hardness around them.  The same thing may also, in many cases, 
PUSTULjE--MENTAGRA.
113
be accomplished by rubbing the parts affected with a compound of
calomel, sal  ammoniac, and  hog's  lard,  or better still  with an
ointment of the iodide  of sulphur.   A small quantity of either of
these unguents is to to be rubbed over the indurations night and
morning with the point of the finger.
  More active agents still are  occasionally employed to modify the
state of the parts affected with acne.   A certain extent of surface
may be wetted and rubbed over with the nitrate of silver, or very
lightly brushed with one of the concentrated mineral acids, often
with the happiest  effects.  These powerful escharotics of  course
require to be used with great discretion, lest their action extend too
deeply, and cicatrices,  productive of more deformity than the dis-
ease itself, follow their application.   The application of a  blister
is another  powerful means of changing the morbid action of the
skin, when affected with acne; and provided the surfaces covered at
a time be not too  extensive, the remedy is quite free from danger.
  The hot air and vapour  bath are  most powerful auxiliaries in
the treatment of acne, much more efficacious indeed than the vapour
douches to the face  and other districts immediately affected, which
have been  so  much more  commonly recommended.  The  excite-
ment of the surface of the body at large produced by these means,
is most influential in checking and changing the current of diseased
action in any particular district of the  integuments.  Bathing in
one of  the natural sulphureous  waters, as of Harrowgate, Bath,
Leamington,  &c. is very often prescribed in this complaint, but
not always with very evidently beneficial consequences.
  When by the persevering use of any means  acne has yielded at
length, it is always  advisable,  as a precautionary measure against
the return of the disease, to continue  a weak spirituous lotion, or  a
wash of the  sulphuret of  potash, to  the  parts which  have been
affected, for some  weeks or even months after all traces  of the
disease have disappeared.
  In addition to these various  means, the local abstraction of blood
is frequently of the greatest service in cases of acne rosacea.   The
application of a few leeches from  time to time, around the regions
that are particularly affected, will generally be found productive of
much benefit.  In this variety of the disease, dietetic means and
strict attention to  the  manner in which each  function  of the
economy is performed  are of the most indispensable  importance,
and often  constitute the main  features in the treatment: without
strict adherence to an unstimulating  regimen and a tranquil mode
of life, little good will be done  by the most skilful combination of
purely medicinal means.

                   MENTAGRA, OR  SYCOSIS.

  Mentagra is a pustular affection, so denominated from occurring
most commonly on the chin, although the disease is by no means
confined to this part, but attacks every district of the face  which is
occupied by the beard.
       6—e                                      g™ 8 
114
GREEN ON DISEASES OF THE SKIN.
  A had attack of mentagra is  very generally preceded by many
minor  eruptions of a few pustules on the upper lip, among the
whiskers, or  over the submaxillary region.   These  are attended
with a considerable degree of tension, unpleasant itching, and even
pain.   In the course of a few days they shrink, and are covered
with thin crusts, which fall off in a few days more, and attract no
further attention.
  When the  eruption is more copious, it is preceded by redness and
a feeling of tension, heat, and pruritus in  the parts which are about
to be affected.  A number of points of a brighter red are next  per-
ceived in variable quantities, disseminated over the generally in-
flamed surface;  these points in the course of a day or two more be-
come distinctly pustular, the pustules being acuminated, and con-
taining a yellowish  fluid which exudes when they are punctured.
The pustules of mentagra are small, generally traversed by.a hair,
and severally surrounded with a hard, round, tuberculated base, so
that when they are crowded together, the whole of the integument
affected looks very much thickened, completely mamillated on its
surface, and  the inflammation then'extending to the subcutaneous
cellular tissue, a considerable degree of deformity ensues.  When
the pustules of mentagra in this crowded state burst, the indurated
masses that surround them are frequently observed to be moistened
on their surface by the matter that exudes from their  interior,  and
have been supposed to  offer some resemblance to a small moist fig,
whence the other title of the disease,—sycosis.  When the inflam-
mation runs  high, the  peliferous bulbs are always more or  less
affected, but  seldom  or never  permanently destroyed; for though
the beard be  entirely lost over a patch even of some extent, as soon
as the  disease subsides it reappears, and speedily regains its original
characters in regard  to strength, colour, &c.
  Were mentagra to consist of one eruption only, the disease would
speedily be at an end;  but chronicity is one  of its most essential
characters; and even before one crop of pustules has  half run its
course, another is in the course of springing up on the peripheries
of the older pustules, as well as  on parts  yet  unaffected, till the
whole surface of the regions implicated presents a confused mixture
of nascent spots, ripe pustules, crusts, and moist tuberculations, of
the most unseemly aspect.
  Mentagra is a disease of the  prime of life, and  very commonly
makes its attacks in the spring; it frequently gets well sponta-
neously with the progress of years; individuals who have once
been severely affected by it suffering less  and less from its effects
every season, until at length it ceases entirely.  The causes of the
disease, or what the peculiar states  of constitution may be which
lead to its origination, are quite unknown to us.  It has never been
suspected to be contagious.  It attacks individuals in every grade
of society, and exercising every variety of profession and handicraft.
It is said however to be  more particularly frequent  among  those
whose faces are habitually exposed to strong heats, such as founders,
cooks,  smiths, (fee.  The disease  is almost peculiar to men; if it 
PUST0L-E--MENTAGRA.
115
does occur among women, it is always confounded with rosacea.—
Is not the disease another  and  severe  form of acne?  I am very
much inclined to believe that it is.
   The pustules of mentagra differ from those of ecthyma in their
smaller size, being seldom seen larger than a  millet  seed, in  be-
coming covered with thin flimsy crusts, instead of thick, hard, and
adhering  scabs,  and in leaving  indurated tuberculations behind
them, which ecthyma never does.  The eruption of impetigo figu-
rata  is clustered, not  scattered, and not acuminated  like that of
mentagra;  its progress  is also more  rapid,  its accompanying
symptoms more  acute in  their character, and  its incrustations
much more extensive, thicker, and more continuous than they are
ever observed to be in sycosis.  The impetigo, moreover, is  not
followed by lobulated tuberculations like  mentagra when severe.
Pustules of syphilitic origin  are seldom evolved on the chin, or on
districts  of the face covered  with beard, like mentagra.  They
are also flat, not acuminated, they are supported on copper-coloured
bases, and are evolved without any of the pain and excitement that
so constantly accompany mentagra.  When syphilitic eruptions of
the face have passed into the tubercular state, they are  at first sight
perhaps more apt to be confounded with  mentagra;  but  if it be
borne in  mind that the cutaneous  eruption  is only a very small
part of the disease in  syphilitic cases, that numerous  other local
and constitutional symptoms constantly attend it from  first to  last,
there  will be little danger  of making a mistake  in  regard to  the
diagnosis.
   Mentagra when once fairly established  is always an obstinate
disease; in some forms one of the most rebellious of the inflam-
matory affections of the skin. It is quite free from danger, however,
and does  generally, under the influence of time and  the  regular
and persevering employment of therapeutic means, yield at length
without causing any deformity.
   The same general mode of treatment, which has been laid down
as proper  for acne, is applicable, in mentagra.  In a youthful and
robust individual, a bleeding may be practised from the  arm as a
preliminary and very efficient measure; and this should be followed
up by the  repeated application of leeches in the vicinity, but beyond
the limits of the  disease,  the  parts immediately affected being at
the same time regularly bathed two  or three times a day with some
soothing decoction, as thin gruel, bran water, poppy-head water, &c.
The diet must at  the same time be regulated; stimulating articles of
food being interdicted, and the habitual use of some mild diluent
prescribed.  The bowels in this disease should be kept open, but
purging is neither necessary nor conducive to its cure.
   So  long as the  disease  shows  any signs  of activity,  these
measures  will be found most conducive to  recovery.   When it has
merged into  the  chronic  state and the tubercles are large and in-
dolent, the parts affected will generally bear stimulating by means
of the vapour douche, and the inunction, night  and  morning, of
one of the ointments  recommended in  acne.  In this posture of
       6—e                                     gm 8* 
116           GREEN ON DISEASES OF THE SKIN.
affairs  too, the decoction of sarsaparilla, combined with minute
doses of the  bichloride (muriate) of mercury, is  often  found of
service.  Chalybeates have also been successfully prescribed  under
similar  circumstances.  In very  obstinate cases of mentagra, the
application of the same powerful topical stimulants, which  have
been mentioned in connection with acne, may be cautiously tried.
Mentagra is a more excitable disease than acne, however, and this
practice must be  resorted to  even timidly, and  its effects watched
with the  greatest attention.  During  the  whole  course  of the
disease  the razor  must be laid aside, the beard being meanwhile
clipped  short  with a pair of flat, curved, and fine scissors.
                          PAPULAE.

  The diseases included in this natural order are characterised  by
an eruption of papulce, or small, firm, and solid elevations of the
skin, the development and progress  of which  are attended  with
much and often severe itching, and which terminate  in  resolution
and furfuraceous desquamation.
  Papular diseases  affect, for  the most part, the  chronic type,
though one or two of them do occasionally occur as acute affections,
and they continue from a period of a few weeks to  one of many
months, and even of several years.  There is no region of the body
upon  which  they do not occasionally occur, and they  frequently
affect districts very remote from each other at the same time.   On
the extremities, the  eruption very uniformly occurs  on the outer
aspects of the limbs, and in the line of extension.
  The pruritus which attends  every form  of papular  disease, is
one of the most characteristic features of the group.  The papulae
are frequently to be detected rather with the  finger than  by the
eye; for even in the severest forms they are  often precisely of the
same colour as the integuments upon which  they are evolved.   In
other species of the group, again, the  papulae are  paler, and  in
another redder, than the general tint of the skin.
  The papular diseases  belong  to  no particular period of life;
infants at the breast are the usual  subjects of one species, and the
aged of another form of papular eruption.  They are not always,
nor even  generally, attended with  any very evident general consti-
tutional disturbance; although infants, when labouring under them,
commonly show something like  irritation  of the  stomach and
bowels.   The  pruriginous papular affection, of which persons
advanced in life are the ordinary victims, is frequently to be traced
to  privation, and neglect of personal cleanliness.   None of the
papular diseases are contagious.
   In themselves the papular diseases are not dangerous affections.
Some of them yield readily to very simple measures, others con-
tinue in spite of every  mode of treatment that can be  imagined, and
render life a misery. 
PAPUL.E— STROPHULUS.
117
   Three  principal  forms  of papular  inflammation have  been
reckoned, Strophulus,  Lichen, and Prurigo.  The two first might
very well be assimilated, and described as mere varieties of the same
affection, modified by the different ages of those who are its subjects.

                         STROPHULUS.

   Strophulus is a papular eruption, as familiarly known to mothers
and nurses as to the physician, under the name of red gum, white
gum, and tooth-rash.  It occurs  very frequently in infants at the
breast, and during the period  of teething, and is distinguished by
an eruption of itchy papulae of different dimensions, red in one case,
white in another, which appears  upon the face and extremities,
which occasionally dies off and returns intermittingly, and ends in
resolution, which is followed  by a trifling degree of furfuraceous
desquamation.
   This eruption presents considerable diversity in its appearance;
the papulae are sometimes very prominent, of a vivid red. scattered
over different regions, and mingled with erythematous patches of
various dimensions, and then they are apt to prove capricious and
evanescent,—strophulas intertinctus.  At other times, the papulae,
though prominent, are white, and  only surrounded by a faint  red-
dish  blush, in  which  case  they frequently prove  pretty steady,—
strophulus  albidus.   When the  papulae have  this  white  colour,
but are  of  unusually  large dimensions,  and  evolved in scanty
numbers, far  remote from each other,  and without surrounding in-
flammation, the disease has been denominated strophulus candidus.
When the opposite of this state obtains, and  the papulae are very
much crowded together or confluent, which they often  are, the
eruption is entitled strophulus confertus.  Lastly, when the eruption
is evolved in  little circular  clusters, as occasionally happens, each
consisting of six, eight, or ten  papulae, it is named strophulus
volaticus.
  Two or  three, and even  the whole, of  these various forms of
strophulus are frequently to  be observed affecting  the  same child.
The eruption in all its stages is  evidently attended with a great
degree of itchiness.  It almost always invades in successive crops;
as one is dying off another is appearing, and the disease may be
protracted during several  weeks, although each particular crop
runs its course  within a very few days.
  Strophulus is not very apt to be mistaken for  any other disease,
save some of the varieties of one that will be immediately described,
—lichen, from which it differs in no essential particular; a circum-
stance that might warrant us in discussing the two diseases  under
one and the same head.  Strophulus affects infants, lichen youthful
subjects and adults.  Strophulus is more remarkable  for its inter-
missions and periods of exacerbation than lichen.   Strophulus is
also essentially a milder disease than  lichen, and  never terminates
in  the  excoriations which seem the  natural  tendency  of the
latter in an  aggravated shape.  The papulae of strophulus differ 
118           GREEN ON DISEASES OK THE -SKIN.

from those of prurigo, in being either redder or whiter than the
integument  at  large.  Strophulus is also a  disease of infancy,
prurigo one of maturity, or even of the decline of life.  The solidity
of the papulae, and the absence  of exudation  and of  incrustation,
distinguish  strophulus  from any  of the  vesicular  or  pustular
complaints.
  Strophulus, in itself, is never  a disease of any severity;  it is only
sometimes of consequence in warning us of the existence of a state
of irritation  of the mucous membrane of the stomach and intestines,
to which the principal attention must then be  paid.
  The treatment of this disease  is soon discussed; the infant must
be laid cool, and may be put into a tepid bath  of plain  water, of
milk and water, or of decoction  of bran, every day.  It must also be
restricted in the quantity of milk it takes for some days, and, if any
medicine be thought necessary, a few  grains  of magnesia will
generally be found sufficient to  move the bowels, should they be
confined; should they be relaxed, however, a couple of tea-spoonfuls
of gum water, may be given three  times a day, with more pro-
priety.  The irritation upon which the eruption depends, is mostly
transient in its nature, and  as it passes off the cutaneous affection
disappears.

                           LICHEN.

  Lichen is the title given  to an inflammatory affection of the skin,
distinguished by an eruption of minute  itchy papulae very red  in
one case, little different from the colour of the skin in another,
either scattered, or, as much more generally happens, collected into
clusters, and dispersed over different regions  of the body.  This
eruption commonly terminates in a furfuraceous desquamation, but
frequently also in superficial and very obstinate excoriations.
  Lichen sometimes shows itself with  the  acute, but much more
frequently with the chronic character, and though  it may spread
to every part of the surface, it  is much more  commonly seen as a
local disease especially affecting the backs of the hands, the fore-
arms, the neck, and the face.  The  papulae in the  most common
form of the  disease,—lichen simplex, are minute, red, often pointed,
and  irregularly scattered over  the  district upon which  they are
evolved.  They continue severally for seven  or eight days with
these characters;   they then begin to fade, and end with a desqua-
mation  of  the cuticle.  The disease, however, seldom or never
comes to  a conclusion thus; one eruption has  hardly begun  to
decline when another makes its appearance, being ushered in by a
painful sense of tingling, or of mingled smarting and pruritus  of
the parts which it is about to occupy; lichen  therefore, instead  of
lasting a week, may be reproduced during months, and even years.
Each successive attack is not necessarily oreven commonly attended
with symptoms of general fever, as has been stated;  excitement  of
this kind only appearing when the eruption is very considerable, or
is combined with some inflammatory affection  of an internal organ. 
PAPUL.E — LICHEN.
119
  Instead of being irregularly scattered, the papulae of lichen occa-
sionally  appear collected  into  pretty  regular  and  well-defined
groups,—lichen circumscriptus.  This is particularly apt to hap-
pen on the back of the hand, fore-arm, calf of the leg, and trunk  of
the body.   The papulae,  in this case, are generally less inflamed
than in the variety last described, differing but little in colour from
the ordinary hue of the skin.  These circumscribed patches extend
by the development of fresh papulae  around their  edges, and then
their centres get smooth, though they continue of a pale red colour,
and subject to a furfuraceous desquamation.  Some of the clusters
also disappear  from  time to time;  but being replaced  by others,
evolved on parts of the integument  still unaffected, the  disease  is
thus indefinitely protracted.
  Besides appearing under the form  of circumscribed circular  or
oval patches, the papulae of lichen have now  and  then  been seen
composing a kind of lengthened band, which, in one case that  is
particularly mentioned, stretched from the anterior part of the chest
to the inner surface of the arm, along the whole  length of which it
extended, twisting on itself, until  it  reached the  point of the little
finger,—lichen gyratus, Biett.
  When lichen affects parts covered  with  hairs, the papulae very
commonly appear to be traversed in their centres by these, and the
pilipherous bulbs participating in the  inflammation, a more than
usually obstinate form of the disease results,—lichen pilaris.
  When the eruption of lichen  has a dusky, red, or livid  colour,
the variety has been  entitled lichen  lividus.  It  is principally met
with on the legs in elderly and debilitated subjects.
  The eruption of this papular disease presents  another variety
remarkable in point of appearance, which has been designated lichen
urticatus.   The papulae in this are, in fact, much larger than  in
any of the other species of lichen, and bear considerable resemblance
to the wheals that follow stinging with nettles;  they are not very
uniformly regular in shape, but  inflamed  in their circumference,
mixed with smaller highly irritable  papulae, and  accompanied with
a smarting pruritus  of the most  unpleasant kind.   This eruption,
which is for the most part accompanied with  general febrile symp-
toms, commonly appears on the sides of the face,  and on the neck
and throat, in successive crops, but  often extends from thence, and
shows itself upon the trunk and  extremities in  confluent patches.
It is only seen during the heats of the  late spring and early sum-
mer.
  The species of "lichen which has been described under the  title of
lichen agrius, is  no more than one or  other of the  preceding
varieties, especially the lich. simplex and lich.  circumscriptus,  in
its most aggravated form, and terminating in excoriations, in con-
sequence of the violence committed  upon his person by the patient,
in endeavouring to appease the intolerable pruritus with  which he
is distracted.   The papulae  in the severer forms of lichen,—lichen
agrius, are numerous, closely crowded, and of a vivid red colour,
which spreads  to  the integument immediately  around the seat  of 
120           GREEN ON DISEASES OF THE SKIN.
the eruption.   The appearance of the papulae is commonly preceded
by a well-marked febrile paroxysm, and their evolution and progress
are accompanied with a  burning pruritus, of the most unbearable
description, which scratching does  not  alleviate, but  only changes
into a painful sense of smarting.   It is no wonder, therefore, that
the papulae, in  these severe forms of the disease, rarely escape
laceration, or that, being torn, they pour out from their summits a
little glutinous fluid, which concretes into  flimsy scaly-looking  in-
crustations.  The disease in  this aggravated shape  is frequently
seen degenerating into, or becoming complicated with, a truly pus-
tular form of inflammation, which has been denominated impetigo ;
it is then almost invariably attended with symptoms of slow fever,
and as it may be protracted indefinitely, patients who labour under
it, worn out with suffering and  want of refreshing sleep, are often
reduced to extremity.
  The papular eruption which  has been described under the title
of lichen tropicus, and is known to the  inhabitants  of intertropical
countries by the name of prickly heat,  does not appear to differ in
its symptoms and tendencies from lichen simplex or lichen agrius,
to one or other of  which it may be assimilated, as it occurs under
a milder or more aggravated form.
  Lichen, if strophulus be assumed as one of its species, affects  in-
dividuals of every age.   It  occurs most frequently towards  the
end of the spring, and during the course of the summer, and appears
to be so much under the influence of temperature, that it  is even
endemical in tropical  countries  generally.   Its  attacks can often be
traced to exposure to the light and heat of the sun, to errors in diet,
to indulgence in particular kinds of food and drink, and to  the use
of certain medicines,  especially of the  terebinthinate  and balsamic
classes.  It is  also frequently symptomatic of disturbance of the
primae viae.  At other times, and when individuals apparently in
possession of perfect health are attacked with it, the  causes of the
disease, as may be imagined, are altogether unknown to us.
  Lichen simplex has  sometimes been mistaken for scabies, and
lichen circumscriptus for one of the varieties of herpes.  The dif-
ference of the elementary forms under  which these diseases occur,
ought always to give security against such an error.  The papulae
of lichen, moreover, occur generally on  the backs of the hands, and
outsides of the limbs, in the sense of  extension;  the  vesicles of
scabies, again, are evolved  between the  fingers,  on the  palmar
aspects of the wrists, in the bends  of the arms, groins, <fcc.—along
the line of flexion consequently.  As to the herpetic disease, with
which the  lichenous  eruption  has been  said  to have been con-
founded, the mistake could only have arisen from utter neglect of
every one of the distinguishing features of the  two affections.   It
would be a more excusable error to mistake the circular patches of
lichen circumscriptus of some standing, and on  the way to recovery,
for the rings of lepra vulgaris  in the same condition ;  a  practised
eye indeed may be required  to  make the  distinction, but it is  not
liable to be deceived ;  and, in sooth, the red-pointed and somewhat 
PAPULjE—LICHEN.                    121
raised and variously cleft edges of the leprous patches, when care-
fully examined, will always be seen not to be composed of papulae
like those of the variety of lichen mentioned.
  Lichen simplex is principally distinguished from prurigo, another
papular disease, by the smaller size and redder colour of its papulae.
The itchiness in prurigo is  also much more intense than in lichen
simplex, in  which it  is ordinarily rather a kind of tingling and
tickling sensation, and only acquires the character of pretty severe
pruritus when the body has been heated by exercise, or stimulated
by hot and spirituous drinks, &c.
  Lichenoid eruptions of syphilitic origin are readily discriminated
from all the varieties of  lichen described, by their coppery colour,
their indolent nature, their freedom from severe or continual pru-
ritus, and their combination with other symptoms of a suspicious
or unequivocal character.
  The diagnosis of lichen agrius from  eczema, in one or other of
its forms, is often at first sight a matter of some difficulty.   The
actual nature of the particular case investigated, indeed, is often
only to  be determined by searching  carefully-around the margins
of the affected parts, for the eruption in its nascent state, when it is
easily ascertained  whether it  be  papular or vesicular in its form.
The diagnosis becomes doubly difficult when, in consequence of the
irritation of scratching, sero-purulent, vesicular, or pustular spots
are found thickly mingled with the lacerated papulae of this severe
form of lichen;  though, even  in  these complicated  cases, care and
attention will generally enable the intelligent practitioner to make
out which is the primary and  which the secondary affection.
  Lichen agrius, even in its worst form, will hardly be confounded
with pure impetigo.   The scaly crusts which cover papulae, when
lacerated, always remain thin, flimsy, and for the most part distinct
from each other; they never  form thick and continuous incrusta-
tions, as in the pustular disease.
  Psoriasis,  a squamous affection,  is distinguished  by  so  many
characters  from lichen, in any of its shapes, that  I do not think
it necessary to contrast in detail the particular features proper to
each.
  Lichen, in the greater number  of  its forms, is  a  trifling disease,
and no  wise dangerous.   In its severer  shape,—lichen  agrius,
however, it is always to  be  regarded as  a serious affliction, and by
the incessant irritation it keeps up, it undermines the health of its
victim,  and makes life a burthen to him.  Those cases in which
the eruption can be traced to the direct action of an evident cause,
generally last a few weeks only; but those in which  it has ap-
peared  without any assignable reason, frequently  continue for
years, despite the enforcement of every imaginable variety of treat-
ment.
   Every variety of lichen is to be treated at the outset on the sooth-
ing system.   Patients are to be put upon a bland and unstimulating
diet, the habitual use of an acidulated drink, of some cooling lotion,
arid of the cold bath in summer.  These means alone will generally 
122
GREEN ON DISEASES OF THE SKIN.
be  found adequate  to  dissipate the simple, circumscribed,  and
urticated forms of the eruption.  Should they fail  of the  desired
effect, stricter abstinence must be enforced, a sherbet of the nitric or
sulphuric acid prescribed, the bowels cleared  out, and every cause
of excitement of the  sanguiferous and  nervous systems carefully
avoided.   Should the eruption be  extensive, very  acute in its
general characters, and attended with a febrile paroxysm, it maybe
advisable to take a quantity of blood from the arm, in proportion to
the severity  of the symptoms, and the strength, (fee. of the  patient,
and this especially if the  disease shows itself rather as a  general
eruptive, than as a local affection.  In the latter case, and when the
eruption  appears strictly confined to a particular region, the appli-
cation of a quantiity of leeches in the vicinity, but still without the
limits of  the parts immediately affected, may be  recommended
instead  of the general bleeding.   Very weak alkaline  washes
applied cold will commonly be found to relieve the pruritus con-
siderably, and the  acid diluents and absteminous regimen must be
continued.
   When the activity of the  local inflammation subsides, the  dis-
tricts may be advantageously  anointed with the unguent, hydrarg.
nitratis very much reduced, or an ointment composed of a dram of
subcarbonate of lead,  two drams of prepared  chalk, and an ounce
of simple cerate.   An ointment of sulphur and the sub-carbonate of
potash has also been  recommended  under similar circumstances.
Should the individual affected be past the meridian of life, or of
weakly constitution, his strength must not be allowed to give way
under  too rigid  an  adherence to  the antiphlogistic  regimen ;
nourishing but light and unstimulating food must be ordered,  and
the effect of some mild tonic tried.  If, under this change of system,
the local malady is not aggravated, the hot air or vapour bath,  at a
low temperature, may be cautiously adventured on ; and if the
eruption stands this kind of stimulus, we shall generally be able to
cure the  disease  either by continuing the remedy, or  recurring to
the more powerful sulphur fume bath. *I have had repeated occasion
to remark, that the hot air and sulphur fume bath were always
better borne, and produced more decidedly beneficial effects, when
the parts affected were excoriated and moist from discharge ; I have
then no hesitation in prescribing this remedy,  and  always feel con-
fident that it will prove beneficial.   Even  in the  most chronic
forms of this disease, a lax state of the bowels will be found of  ser-
vice.
   Lichen is a very capricious disease, however, and will not always
bear the stimulus of the air or vapour bath.  A course of purgatives
should then  be entered upon,  if there be nothing to contra-indicate
the practice, and the parts affected tried with the stimulus of one of
the recently introduced iodurated  ointments,—the proto-iodide of
mercury, in the quantity of a scruple to  the  ounce of hog's lard,
first, and then the deuto-iodide of mercury-in  about the same pro-
portion.
   The  preparations  of arsenic  have  occasionally succeeded  in 
PAPULAE—PRURIGO.
123
dissipating chronic lichens, that had resisted every other form of
medication.
                            PRURIGO.

   Many diseases of the skin are attended with itching, but the one
 we are now about to describe, has even received its title from the ex-
 traordinary severity of this symptom, which is such that it actually
 forms one of the distinguishing characters of the eruption.
   Prurigo  is an uninfectious chronic inflammation of  the skin,
 characterised by an eruption  of papulae, which are  nearly of the
 same colour as the skin, and accompanied with pruritus of the most
 intolerable kind.
   This eruption is either general or local;  and it  is impossible
 occasionally to say in  which of these forms' it occurs with the most
 distressing symptoms.  The  general  eruption is  usually  more
 especially concentrated about the shoulders and neck, and on  the
 limbs attacks in preference the surfaces in the sense of extension.
 The disease ends naturally in  resolution, and with a good deal of
 cuticular  desquamation.   When the papulae are excoriated, as they
 almost always are by the nails of the patient,  they become covered'
 with small, thin, and blackish  scabs, from the drying of the  slight
 bloody exudation that  follows the rude application of the nails.
   Prurigo in its  mildest form,—prurigo mitis, is characterised by
 an eruption, over the  breast and shoulders, back, loins, and inner
 sides of the arm  and thighs, of small soft papulae, larger and less
 acuminated than those of lichen, and  nearly  or altogether of the
 same colour as  the skin, the evolution afld continuance of which
 are attended with  an  intense degree of pure  pruritus,  which is
 especially aggravated by whatever  tends  to stimulate the system,
 or to raise the temperature of the surface, such as warm and espe-
 cially spirituous drinks, active exercise, the heat of a bed, &c.   The
 eruption in this form of the disease is always successive, and gene-
 rally continues to harass patients for several months.
   The disease frequently  appears  with characters of greater
 severity.   The papulae are broader, but still less prominent than in
 the variety described, and instead of being redder, are even  some-
 what paler than the tint of the integuments; they are also  more
 widely scattered, and sometimes  occur simultaneously over  every
 part of the body, except the palms of the hands and soles of the feet.
 The itching in this species is no longer unmixed, but has a  sharp
 and-stinging character, as if burning needles were thrust through the
 skiri, or it  were gnawed by myriads"of ants, whence the trivial name
formicans by which it is distinguished ;  it is  of such intensity in-
 deed as frequently  to throw  patients into a kind of  frenzy,  when
 they tear  themselves with their nails like  madmen, preferring the
 pain and smarting that succeed this operation, to the more intolera-
 ble pruritus which  it  puts to flight for a  time.  It may  easily  be
 conceived  that few  of  the  papulae  in  the prurigo formicans long
 escape destruction;  they are  in fact almost uniformly immediately 
124
GREEN ON DISEASES OF THE SKIN.
torn by the nails, and then become covered with the little blackish
scaly incrustations which have been mentioned, and which, though
purely accidental, are nevertheless very characteristic of the disease.
The duration of prurigo in this shape is very uncertain; it seldom
terminates, however, in less than three or four months.
  When the disease in  this aggravated form  attacks the aged and
weakly in constitution, it  always proves an obstinate and most
harassing complaint, lasting for years and poisoning existence;  the
papulae then generally appear more crowded  than in younger sub-
jects, they are  also larger  and more prominent  than usual, and
when the same parts have been  long and repeatedly affected, the
entire substance of the integument becomes thickened and indurated,
and the subcutaneous cellular membrane infiltrated, so that the feet
and ankles are very commonly  swelled  and cedematous.  The
pruritus under these circumstances is of the same distressing kind
as in the prurigo formicans, and is even more incessant and unap-
peasable.   From appearing among the aged,  this variety has been
entitled—prurigo senilis.
  When very intense, general prurigo, especially  the  prurigo for-
micans, is apt to become complicated with various other vesicular,
pustular, and sometimes even with furuncular inflammations. The
skin is then deeply and severely inflamed, chapped in many places,
and in others hypertrophied to a great extent.   The whole surface,
too, when the disease has continued long, almost uniformly becomes
affected with an abundant furfuraceous desquamation.   In this pos-
ture of affairs, it may well be imagined that the general health
suffers : patients complain of headache, lassitude, uneasy sensations
about the stomach, and general feverishness; their rest is incessantly
broken, and they acquire a worn-out and haggard look.  It is then
also that the disease is apt to become complicated by the presence of
pediculi, which, when all measures of cleanliness and all remedial
means are neglected, are said to  swarm in  countless multitudes.
The disease, indeed, in its aggravated forms, is always  seen in
individuals with weak and worn-out constitutions, marked by cold
extremities, cedematous feet and legs, (fee.  The surface is always
dry and withered-looking in prurigo.
  Besides appearing as the general affection now described, prurigo
frequently shows itself in a variety of local forms.   The symptoms
in these do not differ from those that  have been signalised as cha-
racteristic of the eruption more  widely diffused.  The presence of
papulae, in many of the  local varieties, is sometimes a  matter dif-
ficult of demonstration, and, indeed, care and repeated examination
are often required before they can be  detected.  The peculiar and
violent character of the pruritus, however, generally gives the clue
to their true  nature.  The principal species of local prurigo that
have been described are  the following.
  Prurigo podicis, which has all the features  of the prurigo formi-
cans, aggravated if  possible,  although  the  eruption  extends  no
farther than the parts around  the  anus  and  the  cleft between the
buttocks.   The disease  in this situation  is always of long con- 
PAPULA--PRURIGO.
125
tinuance, and rebellious to treatment of every description.  It almost
invariably becomes at length complicated with vesicular or pustular
eruptions, and sometimes  seems even to lose its original characters
entirely, and to acquire those of the form of inflammation that was
at first accidental only.
  Prurigo  genitalium is another very distressing local variety of
the disease, more especially in the female, in whom the eruption is
apt to spread from the labia to the mucous membrane of the vagina,
which then becomes inflamed, and is attended with symptoms of
the most distressing and painful description.  In the male, the sur-
face of the scrotum is strongly corrugated, dark coloured, and often
covered with a kind of sebaceous exudation.  The accompanying
pruritus  is of the most  violent kind;  it  usually comes  on in
paroxysms, and then  nothing can  allay  it.   In  the  female, the
attendant  symptoms are even more intolerable, and hardly less dis-
tressing morally than they are physically.  The disease is a com-
mon cause of nymphomania.  The pruriginous affection entitled
prurigo scroti in the male, prurigo pudendi in the female,  is not
always a demonstrably papular disease.  It is, however, not vesi-
cular, and has none of the characters common to the exanthemata.
The kind of pruritus with which it is accompanied, and the state
of  exaltation  which  marks  the  severer paroxysms,  associate it
plainly with the rest of the  prurigos.  Besides, in some rare cases
of prurigo pudendorum,  papulae are said  to  have been actually
seen.   There is no reason therefore to doubt of the proper position
and denomination of these  local pruriginous inflammations. Prurigo
scroti is a disease I very frequently see :  it is  generally associated
with  a good deal of  intertrigo, and complicated  with numerous
impetiginous pustules.  It is always a very distressing  complaint,
and one which, under the ordinary methods of treatment, proves
little less perplexing to the practitioner, than it is annoying to the
patient.  I have invariably found it to  yield to ten or  a dozen ex-
posures in  the sulphur fume bath, in addition to the ordinary con-
stitutional treatment employed.
   No age or circumstance seems to confer immunity against an
attack of  prurigo.  But  the  disease is certainly more  frequently
seen in youth  and the decline of life, than at any other period.
Neglect of proper cleanliness may  possibly have some influence
over  its occurrence ;  but it  occasionally attacks individuals in
classes of society, where such a cause cannot be suspected of exert-
ing any influence.  It is sometimes seen following moral affections
of a depressing nature. Most generally, however, the specific causes
of prurigo escape our observation entirely.
   Prurigo is a disease which is  only apt  to be confounded with
lichen, yet the  eruption has characters so  entirely its own, and is
attended with pruritus of so severe and so peculiar a kind, that with
due attention to these, there seems no great necessity for committing
such  a mistake ; the broader papulae of prurigo, their colour pre-
cisely similar to that  of the skin  at  large, and the thin black scale
with  which they become covered when they have been torn, are so 
126           GREEN ON DISEASES OF THE SKIN.
many characters that distinguish this affection from  the analogous
ones of strophulus and lichen.
   The  differences  of elementary form should  always suffice  in
enabling us to distinguish prurigo from any of the vesicular or pus-
tular  inflammations.  There is greater difficulty when the papulae
have  been destroyed, and  still greater when the  disease is actually
complicated with numerous accidental vesicles and pustules.  But
even  in these cases the  difficulty is more  in semblance than  in
reality; close attention  for a day or  two to the  appearance and
progress of the affection, and a few hints  in  regard to its  previous
history, generally giving the clue to an accurate diagnosis.   The
same elements and considerations which guide us in the diagnosis
of the general,  serve us  in discriminating the local  varieties  of
prurigo.
   In youthful subjects  prurigo does not generally prove a very
obstinate complaint;  with appropriate  treatment, it  seldom lasts
longer than a few weeks.   In the aged, on the contrary, the disease
is always one of long duration, and has the reputation of frequently
proving rebellious to every kind of treatment.  I am happy to say,
however, that of late  I have been enabled to look upon prurigo  in
every state as a very manageable disease.
   The local varieties  have the same  character for intractability  as
the more general eruption.  I  have already  said  that chronic
prurigo, by  the sleeplessness it  occasions, and the irritable state  of
the system it keeps up, frequently exhausts the strength of patients
and reduces them to extremity.  Indeed, rather  than  continue the
life of torture they are condemned to by this  disease, patients have
been  known to  lay violent hands  on themselves, and end their
misery by suicide.   Such a consummation, if hinted at or suspected,
should consequently be guarded against if possible.
   The slighter cases  of prurigo are successfully treated by  a re-
stricted diet, the  occasional use  of a  gentle aperient, and prolonged
immersion in the simple, weak alkaline, or sulphureous water-bath,
according to the  degree  and endurance of the eruption.  In  some
cases it may be necessary to add  the use of a diluent, acidulated with
one of the  mineral  acids, or made slightly alkaline by the  addition
of half a dram or a dram of the sub-carbonate of potash or soda,  to
each pint of the liquid, for a few days.  A combination of sublimed
sulphur and magnesia, or sub-carbonate of soda,  is also a good me-
dicine in  these  cases ; but the sulphur should be given in much
smaller doses than those in which it is usually prescribed to produce
its most beneficial effects:  from two to four grains, with about ten
or twelve  of calcined magnesia, or sub-carbonate of  soda, twice  a
day, will be quite sufficient.
   In none of its forms does this papular disease  appear  to be so
much  benefited  by blood-letting  as  most  of the other cutaneous
inflammations.   When blood has been drawn, however, even after
the disease had merged into the chronic and inveterate  state, it has
always shown the buffy coat, or the  large and firm crassamentum,
characteristic of  an inflammatory condition of the system.  Though 
PAPULAE--PRURIGO.
127
it may be mostly held unadvisable to bleed generally in this  com-
plaint, the application of a  number of leeches around the seats of
the local varieties will often be found a measure productive of great
relief; and this practice, seconded by due attention to regimen, will
often bring the disease into a state to bear the stimulus of the vapour,
hot air,  or sulphur fume bath.  When patients have been lowered
by abstinence and the exhibition of a few doses of purgative medi-
cine, I  always recommend the vapour bath to  be tried at  a low
temperature at first, and i£ to the  temporary excitement which im-
mediately follows the use of this remedy, an abatement of the symp-
toms succeeds, as usually happens, I then know that I can com-
mand the disease.  I have  even observed that the more inveterate
the affection appeared to be,—the more  severely the parts affected
were excoriated, the  more they were complicated with discharging
sero-purulent eruptions, the more certainly were  they amended and
ultimately cured by perseverance in the use first  of the vapour, and
then of the hot air and sulphur fume bath.  Under the use of these
means,  the thickening of the skin  and cedematous state of the sub-
cutaneous cellular membrane are very speedily dissipated, and the
withered, dry, and unperspiring surface rendered sleek and velvety
to the touch as it is in health.

                     CASES  OF PRURIGO.

  Madame A. a  French lady, aged about 60, of a full, sanguineous
habit, shortly after her arrival in England, in  the early part of
1828, had suffered from an attack of pneumonia ; from this illness
she recovered under the ordinary means  of treatment employed,
but became subject to a pruriginous affection of the skin, which
continued to  torment her  in  various degrees up to the spring of
1833, when she was advised by a physician of high authority, whom
she had consulted, to try the  effects of the sulphur fume bath on
her complaint of the skin ; for all the medicine she had taken, the
external applications she had made, and the hot baths she had used
for the preceding five years, seemed to have been without influence
in abating her infirmity.   Of the plan of treatment hitherto followed,
or the precise nature of the medicines prescribed. I was at this time
uninformed;  but on the fourth of April,  1833, this gentlewoman
had the first sulphur  fume bath administered, and it was continued
regularly twice a week to the 28th.
  At this time no improvement had taken place ; on the contrary,
the  symptoms were always aggravated upon the  days on which the
patient took her bath, and her night was rendered more miserable
than usual.   Her physician now advised Madame A. to take the
fume bath as  I might direct it, and otherwise to place herself under
my  care for a time.
  April 30th. At this period the symptoms of the distressing  com-
plaint under which Madame A. laboured were of the severest de-
scription ; the pruritus she endured was incessant, and mixed with
various  other painful sensations, such  as are described under the 
128            GREEN ON DISEASES OF THE SKIN.

head of prurigo formicans: she felt as if hot needles were repeatedly
thrust through the parts of the skin affected, or as if insects were
creeping over her body, and torturing her with their stings.  When
warm in bed, all these distressing sensations were so much aggra-
vated that she was always afraid to lie down, or when down to get
up  again,  for transitions  of all kinds  regularly brought on  a
paroxysm of unappeasable and painful pruritus.
  On all the parts affected, and they extended to the greater portion
of the surface of the body, numbers of the small colourless slightly
raised papulae, characteristic of prurigo, could  readily be detected ;
but by far the greater number of these, having been torn with the
nails or other instruments employed for scratching, appeared covered
with a minute  black  scab; the nails had long been found insuf-
ficient for the purpose of allaying the itchiness, so  that a hard nail-
brush, and occasionally a comb, were  the implements commonly
used.
  Active measures I saw would alone prove of any advantage  in
this severe case ; and on the 30th, Madame A.  was bled to the ex-
tent of sixteen ounces ; at night she took  an aperient composed  of
six grains of calomel  and twenty of jalap, and next morning a dose
of the common black draught (infusion of senna and sulphate  of
magnesia).   She was farther directed to  take a wineglassful of a
mixture consisting of magnes. sulph.  3i. mannae 3ss. magnes. cal-
cin. 3iss. antimon. tart. gr. ii. syrup, rhamni Sss. aq. menth. virid.
oss.   The sulphur fume bath was discontinued, and a tepid water
bath,  containing a large basinful of thick gruel, substituted for it,
with a view of soothing and softening the irritated and excoriated
skin.
  On the 8th of May, the itching was less constant, and the patient
got  some sleep at night, though her rest was still greatly disturbed.
The skin had lost  much  of its harshness; the bowels were freely
acted on by  the medicine.   15th, The sulphur  fume bath was now
ventured on every other day  at a low  temperature, and the emol-
lient water bath continued on the intervening  days;  the medicine
as before.  20th, The patient still  found that on those  days on
which she took the sulphur fume bath, she was more teased with
itching,  than on the others : she was  directed to use the simple
heated air bath on alternate days; and the purgative medicine,
proving rather too active, was reduced to half the former doses ;
the  water baths were continued as before.   25th, More irritation on
those days on which the heated air bath was taken, and a bath  of
watery vapour was tried instead.  30th, Madame A. was bled again
to sixteen ounces, and ordered to abstain from all animal food.
The blood was buffed, and the serum thick and turbid.  June 8th,
Considerable mitigation of all the symptoms ; the patient complained
of weakness after  the vapour bath.   The warm air bath resumed
every other day.  And for the purgative  medicine, which seemed
to be doing no good, the following mixture  was prescribed,  R. liq.
ammon. sub-carbon. 3i. mucil. gum. acaciae 3jss. tinct. lyttae  3ij.
syr.  simpl. tinct. aurantii aa.  gss. M.   Cochl. these  bis in die e 
PAPULAE—PRURIGO.
129
cyatho aquae sumendum.  A pill of colocynth and scammony was
ordered at bed time, to keep the bowels regular should any aperient
be required.  The patient was also directed to drink plentifully of
milk and water, orangeade, lemonade, &c, and to confine herself to
the simplest and blandest diet.
  The abraded surfaces, torn with scratching, were at this date re-
duced in size, and the little black  spots considerably diminished in
number, but the  itching still continued severe after  eating, during
the night,  and  particularly towards  three  o'clock in the  morn-
ing, previous to which time she now obtained  most needful sleep
for one or  two  hours, and  again  after  seven  in  the  morning.
18th,   The patient did not complain of being  weakened  from
her restricted  diet, but  looked haggard  and worn out from her
disturbed nights,  and  the incessant  irritation  of her  complaint.
She was again bled to  twelve ounces, the blood  was still buffed,
and the  serum yellowish and  oily in appearance.   The  medi-
cines  last  prescribed were  continued;  on  the 20th,   Madame
A. was  better, and on the  29th, she resumed the hot  air bath,
which was repeated every other day, as it was no longer fol-
lowed  by any great degree  of excitement of the skin.  July 6th,
Going on favourably, and was  allowed jelly  and broth, or a little
chicken daily.  12th, Symptoms  all abated; both days and nights
were passed in comparative tranquillity—there was slight natural
perspiration, and the skin had lost in a great degree its harsh  parch-
ment-like feel.  Resumed the sulphur  fume bath, and after it slept,
for  the first time  for some  years, through the night.  Thus en-
couraged, the sulphur fume  bath was repeated on  the 14th with
similar good effects, and it was then pursued  daily, all medicine
being left off.
  On the 26th, there seemed some disposition in the complaint to
return, but this was accounted for by the patient's having been
incautious  in her diet, and remaining in company late.  She  took
an active purge, and on the 28th resumed the sulphur fume baths
daily, until the 12th of August, at which date she considered  her-
self quite well, and left off all remedies, not a little thankful for her
relief from  a disorder, which began  to be looked upon  as beyond
the reach of all known remedial means.
  On leaving off the sulphur  fumigations, the skin had  acquired
the peculiar dark and hardened appearance which commonly pre-
cedes  the desquamation, or rather the peeling of the  cuticle,  which
follows the action of the sulphur, and which continued in  this  case
for four months after the baths were left off.   Madame A.  left Eng-
land for Aix la Chapelle early in the September, and I occasionally
hear of her remaining well.
  Had this lady continued to pursue the treatment by means of the
sulphur  fumigations, unassisted by general depletory  measures, I
believe she would have derived no advantage from the method. It
was very long, indeed, before the disease could be brought to a suf-
ficiently chronic  state, or  the system  sufficiently lowered, to  bear
the action of the remedy;  each new attempt to hasten matters only
       6—f                                    grn 9 
130
GREEN ON DISEASES OF THE SKIN.
produced an  aggravation  of the symptoms, until the patient was
reduced  by the bleeding, purging,  (fee. when the sulphur fumes
acted in the most beneficial manner.
   Case 2.  A gentleman, aged 84, of a spare  habit of body, and a
free liver, had been the subject of prurigo senilis for nearly a year,
when he came recommended  to me by the same high medical au-
thority as Madame A., in the month of June, 1833.
   The skin in this case had a hard,  thickened appearance, though,
according to the patient's own account, it was naturally  of a fine
and delicate texture;  at all events  it now looked thick, yellowish
in colour, dusty, and  very dry; the patient informed me he had
long ceased to perspire.   Scattered  over the  whole  surface there
were  numerous little black specks, evidently points of concrete
blood, which had  followed the application of the nails; some of
these  specks were as large as split peas, and covered inflamed spots;
there  were  also many  longer and shorter lines of inflammation un-
doubtedly produced by scratching, and over almost  every part of
the body multitudes  of  small whitish papulae,  raised above  the
genera] level, and  to be felt as well as seen  without the aid of a
magnifier.
   The itching which accompanied this eruption  could  be charac-
terised by no other title than that of torture ;  it never left him for
an instant, and  was always  greatly aggravated after meals, and
during the  night;  of late, indeed, the patient was so much afraid of
going to his bed, seeming to regard it as going to the rack, that he
frequently preferred sitting up all night to encountering the misery
he there endured.
   This  gentleman's legs  were swollen from oedema,  and pitted
deeply under pressure with the fingers.  Although at. an advanced
age, his general health was good, and to want of rest, owing to his
disease of the  skin, all that was unfavourable in  his appearance
seemed fairly attributable.  The whole of the usual remedies had
already been tried, without  producing the slightest  mitigation in
the symptoms of his complaint, and it was with a view of essaying
the sulphur fumigatory plan as a last resource, that he first visited
me.   The  sulphur fume  bath was  accordingly commenced; but,
after  being persevered in for a fortnight,  it produced so much
aggravation of all  the symptoms of the prurigo,  that it had to
be  abandoned.  This result was not different from what I had
anticipated.
   In  consultation with the other medical advisers of the patient, I
recommended a plan of treatment to be  pursued in this case, very
similar to that which had been  followed in the last, before again
resorting to the  sulphur  fume baths.  This being acceded to, the
patient was bled to twelve ounces from the arm,  took an active
purgative dose of calomel and jalap, and a teaspoonful three times
a  day of a mixture of the liqu.  ammon. sub-carb. 3i., mucilag.
acac.  3 ss.,  tinct. lyttae 3 ii.,  tinct. aurant. syr. simp. aa. 3  ss.  His
diet was restricted to vegetables or farinaceous articles for a time ;
he was supplied with  plenty of whey for drink, having a scruple 
PAPULiE—PRURIGO.                  131
of nitre added to  each pint, and was directed to take an emollient
gruel bath at a low temperature, for an hour or an hour and a half
every day.  The  bowels were kept open by means of a colocynth
and scammony pill, once or twice a day, as might be required.
  The  blood  abstracted was buffed, and the  serum thick  and
turbid.  The medicines prescribed seemed to agree.
  On the 29th of June,  the  patient expressed  himself as much
relieved, and commenced the simple vapour bath every other day,
taking his gruel bath on the  intermediate days.   His medicine
produced  two or three evacuations from the bowels daily, and he
passed urine abundantly, but with some irritation; in consequence
of which, the  following compound was substituted for the mixture
hitherto taken:—R. Antim.  tart. gr.  iss., nitrat. potass. 3ss., mist.
amygd. 3viij.   Sumat cochl.  maj. ij. 4ta qu. hora.  The aperient
pills were continued.  July 10. The skin was less harsh  to the
touch ;  many of the black specks had disappeared ; the patient
declared himself much more  comfortable generally, but still, at
times, greatly annoyed with  the  itching, which now generally
attacked him in paroxysms.   In the hope of accelerating matters,
he desired to  return to the sulphur fumigations, but still found
them such a source of irritation, that he was glad to give them up
again.   He used the  simple vapour  bath  with better  success. A
variety of lotions and ointments were at this time tried, but none
of them seemed to do good for more than a day together, and the
patient declared  that he relieved himself more effectually from the
burning and  tingling of his paroxysms, by a good tearing or
scratching, than by all else that  was prescribed for him.   The
swelling of one leg  had  now  disappeared, as  well  as  a slight
degree of  puffiness he had formerly shown about  and below the
eyes.
  July 6th.  In addition to the complaints already enumerated, the
patient was seized  with weakness  in the  loins, accompanied with
the most severe itching and  tingling down his legs to the feet, and
a paralytic feeling  as though he could not move  his limbs forward
to walk.   He  was cupped in  the loins, and on  the  8th had lost
much of this feeling and itching.  10th. The sulphur fumigations,
at a low temperature, were resumed, and the water  and  vapour
baths left  off.   Instead of aggravating the itching, as heretofore,
the  sulphur fumes were now most soothing to  the patient, who
passed his nights in  comparative comfort; the mixture was given
up,  but the  pills were continued ; the swelling of the other leg
had now disappeared.  On  the 19th. he was again attacked with
feelings of weakness in the  back and legs, with increased tingling
and  itching, for which he  had eighteen leeches  applied to the
loins, and took  a purgative dose of calomel, which relieved him.
He continued  the  sulphur fumigations daily, till August the  6th,
when he considered himself  well, and left them off.   He had  sub-
sequently an abundant peeling of the outer skin,  which continued
for several weeks, during which time, and to facilitate the removal
of loosened shreds  of cuticle, he occasionally resorted to the vapour
                                                grn 9* 
132           GREEN ON DISEASES OF THE SKIN.

bath.  This gentleman  has since continued free from his former
very distressing complaint.
  Case 3.  A lady, aged upwards of seventy, had been subject to
prurigo for nearly three years.   There was little to be seen on the
skin,  which  presented  the appearance usual  at her age,  save
numerous little black specks, evidently the effect of scratching off
the heads of the papulae, which, on a closer inspection, were found
disseminated over most parts of the  surface.   She was the subject,
too, of spasmodic asthma, and the legs were swollen, and pitted on
pressure.  The irritation from the  skin complaint was the source
of continual  topment to her, but particularly so during the night.
She conformed to a strict regimen,  took opening  medicine, but
objected to lose blood.  On the 6th of April, 1833, she commenced
the sulphur fumigations, which proved a source of great allevia-
tion to her breathing and cough, but of no benefit to the  prurigo;
on  the 12th, she consented to  be bled, and  twelve ounces  were
taken away.   The blood had the usual appearance in  such  cases,
being buffy,  and the serum turbid and yellowish.   The  patient
from that night felt  the troublesome  itching abate, and was after-
wards  enabled to take the sulphur fume  bath  without having it
increased.  It was soon  evident, from the darkened appearance of
the skin, that she  would have  the  usual  peeling which follows a
course of sulphur fumigations,  and desisted from taking more of
the baths  until that  process was completed.   During this period,
she  continued free  from her old  complaint,  and  had only the
trifling itching that is  common whilst the cuticle is detaching
itself.  To assist the process of desquamation, the patient took
half a dozen  vapour baths at intervals, and by the end of a month
from this time, found herself recovered not only from  her affection
of the skin, but so greatly relieved of her asthma as to forget to
allude to it altogether.
  These three cases will be sufficient to give an idea of the diffi-
culties and disappointments I had  to  contend  with, when I first
began  to  practise with the sulphur  fume baths,  as  a principal
means in the treatment of diseases of the skin.   They were stated
by  the French authorities to be curative of prurigo,  but no men-
tion was made of the modifications  and restrictions that were by
further experience found  needful, nor of the  previous preparation
that is essential to  their  success.   In cases  where  the  disease
attaches itself to particular parts, as the scrotum in the male, the
external organs in females, <fcc, the same preparatory  and adjunct
means of treatment are  necessary, though  perhaps to a more
limited extent. The local  varieties of prurigo,  indeed, when they
are accompanied with  excoriation of  the skin, and discharge from
its  surface, may be  said to be  at once under  the control  of the
sulphur fume  bath. 
SQUAMA.
133
                           SGIUAMJE.

   The assumption of a squamous or scaly state of the skin, that is,
 of a mere consequence of inflammation affecting this structure, as
 the  distinguishing feature of a particular order of its diseases, is,
 it must be  allowed, a departure from  the  principles  by  which
 Willan and  the dermato-pathologists of modern times have gene-
 rally been guided in their classifications: the squamous diseases
 cannot be said to be traced  to their  elementary  forms.  Never-
 theless, the alterations of the cuticle, which are assumed as charac-
 terising the group of squamous affections, are so  peculiar, and so
 unlike  all that occurs in any other form of cutaneous inflamma-
 tion, that,  practically at least, there seems little cause for regretting
 that the farther step has not been taken, which would have  led us
 to consider the morbid states of the dermis that precede alterations
 in the cuticle, as the primary forms of those diseases we are now
 about to discuss.
   By  squamous  diseases, then, are  understood  certain chronic
 inflammations  of the skin, characterised by  the occurrence of a
 variable number of elevated  red spots  or  patches, which speedily
 become covered with squamae, that is,  with lamellae of the  cuticle,
 altered  in its general appearance and texture.   These squamae  are
 very different from the products of numerous  other inflammatory
 diseases of the skin, already frequently spoken  of as scabs or
 crusts, which are due to the excretion, and subsequent drying of
 purulent  and  sero-purulent  matters,  upon the surfaces affected.
 Squamae, on the  contrary, consist, as described, of portions of  the
 common cuticular covering  of the body altered in its  qualities;
 they are laminated, of a grayish white colour, often of a glistening
 appearance, dry, friable, and  of very various thickness.
   The  number of  squamous diseases  now  generally  reckoned,
 amounts to  three—Lepra, Psoriasis, and Pityriasis.  Ichthyosis,
 included by  Willan and  his followers in this order, being for  the
 most part a congenital affection, and never seen to  follow as a con-
 sequence  of unusual action in the  surfaces it  covers, I  have
 referred it, along  with Dr. Rayer, to another place, where I shall
 mention it briefly.
  The whole of the three forms of squamous inflammation  have
 many  characters  in common ; two of them, indeed,  lepra and
 psoriasis,  have actually been treated of by some writers as  mere
 modifications of one and  the same disease; and as if to confirm
 this  view, these  two affections are observed  to occur  very fre-
 quently together in the same  subject.
  The whole of the squamous diseases  are essentially  chronic in
 their nature, and they almost uniformly commence, advance, and
frequently  attain a great pitch of intensity without the appearance
of a single symptom indicating general  or constitutional disturb-
ance.  Neither  are the  local symptoms  which accompany the
squamosae  in general of any great severity;  a little itching and 
134
GREEN ON DISEASES OF THE SKIN.
heat are the  most usual  concomitants, and  even these are  fre-
quently  not  perceived.   Some  degree of stiffness  in  the parts
affected, and, when the disease occurs  in the vicinity of joints, of
chapping and excoriation, and of impediment to  motion, are very
commonly  complained of.   When squamous diseases are  of  old
standing, the integuments of the  districts affected often become
much indurated and thickened.
  Squamous  diseases  occur among individuals in all ranks of  life.
If they appear  to  be  most frequent among the poorer classes, it is
only because these are the most  numerous  in  all communities.
The most  delicate gentlewoman,  in  the  daily  or rather  hourly
observance of all  the rites of personal cleanliness, appears to be
about as subject to lepra as  the most  negligent and filthy artificer
alive.   These  affections,  if there be  really  any difference,  are
thought  to occur  in the autumn more commonly than at other
seasons.   None of them  is even  suspected of being contagious,
although, like  all  other  bodily  peculiarities  and predispositions,
they are susceptible of being  transmitted hereditarily.  All  the
causes that have been assigned at  various times for  their appear-
ance, are extremely doubtful.  Neither in  themselves, nor in their
consequences on the  economy, are the squamous  diseases to be
considered  as dangerous ; but they are unseemly ; often the cause
of  considerable annoyance;  and for the most  part  extremely
rebellious to every form of treatment that has yet been proposed.
   The external characters of the  squamosae  are  so peculiar, that
they are not liable to be  mistaken for any of the other forms of
cutaneous  inflammation already described, nor,  indeed, with  any
which still remain for description.  None of the vesicular, pus-
tular,  or papular diseases are ever attended  with a formation of
thin dry micaceous looking scales.   The  slight desquamation of
the cuticle that accompanies recovery from  several of these  dis-
eases,  is but  an increase of the natural process  which  appears at
all times to be going on  from  the surface of the body, and never
acquires the distinguishing and prominent features of a morbid act.

                    LEPRA, SCALY LEPROSY.

   By  the word lepra, or lepra vulgaris, medical  writers are now
agreed in  designating a squamous affection  of the  skin, charac-
terised by  the  occurrence of circular scaly patches, raised  in the
circumference, and, after  they have existed  for  some time, appa-
rently depressed in the centre.   There is an earlier stage of lepra,
however, when the eruption appears like large red papulae, smooth
and shining on the  surface, and within  a  few days  becoming
covered with a single micaceous scale, the size of the spot beneath.
This scale is by and by detached, when the surface of the  spot is
found to be  rough  and dry;  the  circle of inflammation now
gradually  extends, till it  is an  inch  or more in diameter every
way, and  the  whole  patch  becomes  covered with an imbricated
layer of thin but  tough and shining scales, of a slightly yellowish 
SQUAMAE—LEPRA.
135
 or pearl gray colour.  The several  patches of lepra, in this state,
 are of a perfectly circular  shape, and surrounded by a bright or
 purple  red and slightly raised  margin.  The squamae that  cover
 them are in a constant state of increase or reproduction; lying one
 over another, they often  form laminated and friable masses of con-
 siderable thickness, and, if detached, are very speedily renewed. .
   Lepra, like every other  disease of the  skin, occurs with cha-
 racters  which  vary  more or less  from that which is  regarded as
 the standard state, and  are made the  basis of a distinction into a
 number of varieties or species.  Thus, when the scaly patches  are
 of unusually small  dimensions, increase with extreme slowness,
 and are but very slightly elevated around the margins, the disease
 is entitled  lepra  alphoides.  The squamae in  this variety  are very
 white  (whence the title) and small;  the patches  seldom or never
 run  together;  the disease is scarcely seen, except upon the limbs,
 and it occurs  among children much more frequently than among
 grown  up persons.   The disease which  Willan, Bateman, and
 their followers, have described as a second variety of scaly leprosy,
 under the name of lepra nigricans,  is  certainly  misplaced.  The
 affection so styled is not  even squamous in its nature,  but consists
 of an irregularly darkened or shaded state, either of the pigmentary
 membrane under the  cuticle, or of  the cuticle itself, and is very
 generally believed to be  one of the many changes induced by the
 syphilitic poison lurking in the system; but as this is problematical
 in some cases, to make sure of  avoiding error I have referred it to
 my order of Dischroa or discolorations, where it will be found dis-
 cussed, and the particulars of an  interesting case of the affection
 detailed.
   Lepra is a disease which occurs of very  various extent; it may
 often  be met  with  confined  to  the sharp ends of the  elbows and
 knees,  and it is just as  frequently seen extending to almost every
 portion of  the  surface  except the  hands and  the  face, which are
 very rarely affected, although  in  bad cases it occasionally impli-
 cates even  these.  The elbows and  knees  are very  generally the
 parts which are  first affected, and from which the disease spreads
 along the  arms and  thighs  to  the  breast,  and  loins, and  other
 districts of the body.   Lepra is one of the diseases which almost
 invariably  shows itself upon corresponding parts of both  sides of
 the body at the same time, in opposition to others—herpes zoster,
 for instance, which  is hardly known to appear, save  on one side
 of the  body at a time.   This  is a  consideration not practically
 important,  indeed,  but  still  one of  interest to the reflective
pathologist.  Lepra always extends by the successive development
of several distinct points  of inflammation ; these only increase to a
certain  size,  from that of a shilling to that of a  half crown or a
crown  piece;  but they are often developed  so  close to  each other,
that they coalesce,  and  thus give rise to patches of much  larger
dimensions than  those indicated:  the  compound nature  of these
large squamous patches is always proclaimed by the arcs of circles
of different radii visible around their margins. 
136
GREEN ON DISEASES OF THE SKIN.
   When  the patches of  lepra  have  attained  their  maximum
 development, they begin to get well;  and it is remarkable that this
 process of cure, whether  spontaneous or brought  about by art,
 very uniformly commences in the centre, and  extends towards the
 circumference, so that the patches which  have continued distinct,
 at length present the appearance of rings.   When  the disease is
 getting better, the squamae once detached, are no longer renewed;
 neither is the patient harassed with any of the unpleasant  pruritus,
 which is one of  its  constant symptoms when  it is on the increase
 or stationary.  Unless the disease be  extremely  severe,  it  is not
 attended with pain; when the patches surround  the articulations
 and have existed long, indeed, motion is painful and very much
 impeded; but  the pain  is  then a  consequence of  mechanical
 violence done to parts in a preternatural state, which may even be
 heard  crackling in a very singular manner, when  the joints are
 first bent.  In  very  severe  and  inveterate cases,  a  quantity of
 serous fluid is occasionally observed  to  be  poured out by the sur-
 faces  affected ; this, too,  is probably a consequence of the mecha-
 nical  irritation of the hardened squamae, for the  discharge  ceases
 when  these are  softened, and  removed in a considerable  measure
 by means of emollient applications.
   The Messieurs Cazenave and Schedel  have  described, under the
 head of lepra, a variety of disease characterised  by the immense
 size of its circular inflamed patches, 'or rather wings, (one of  which
 they have occasionally seen  occupying  the whole  extent of the
 back,) and  the  freedom  of these  from scales.  The central parts
 were of greatest extent,  and  apparently  quite healthy, the disease
 being,  in fact, confined  to a prominent  circular ring,  but  a few
 lines  in  breadth, which, both on its outer and  inner edge, was
 bounded by a reddish border, also but a few lines  broad, quite free
 in every  part from squamae.   On the extremities of the  patients
 thus affected, several leprous patches, which  presented the usual
 appearances, were observed.
   What  has been said in  regard to the causes of squamous dis-
 eases generally,  applies to lepra  in particular; all that have been
 quoted by different authors,  as capable of producing the disease,
 having been called in question or denied by  others.  It has been
 known to follow the  use of spiced  food and spirituous liquors,
 exposure  to cold and damp,  (fee, but in the immense majority of
 instances, it appears  without  any evident  or assignable reason.
 The disease is certainly not  contagious; when writers are found
 who speak of the  transmission of lepra from one  individual to
 another,  they mean some  other than  the squamous affection we
 have described under this title.  Of  the  hereditary disposition to
 scaly leprosy, there can be no doubt.   The disease is one of very
 frequent  occurrence.
  Lepra  is a disease which, with  some little time for observation
and very moderate attention,  is not at all apt to be mistaken for
any other affection of  the skin,  save one perhaps, and that  is
psoriasis,  another scaly  disease,  between which  and  lepra it  is 
SQUAMAE—LEPRA.
137
frequently  very difficult  to  draw a  line of distinction.   This,
happily,  is of  no  great consequence, especially as the obstacle
arises in  all probability from the circumstance of the one disease
being a mere variety or modification of the  other.  The general
points  of difference between these two  diseases will be  better
appreciated when we have spoken of psoriasis.
  Syphilis, among other  forms,  frequently manifests itself exter-
nally in  squamous patches, which  resemble those of lepra  in  this
particular,  as  well as in their  circular shape.   Their edges are
also occasionally raised, and  their centres depressed, and these last
being only covered  with a very flimsy epidermic scale, they some-
times appear  to be occupied by portions of integument, healthy or
very little affected.   But the  squamous patches which are of
syphilitic origin, are of a  dusky  or coppery  colour, and instead of
being rough and  dry on the surface, and hard, like those of lepra,
are smooth and soft like any other part of the skin.
   The patches of impetigo  figurata  have  sometimes been  mis-
taken  for  those of  lepra; but  the elementary  forms of the  two
diseases  being different, and the laminated  scabs that follow the
pustules of the impetigo  being of a greenish or brownish colour,
the error has only risen  from want of proper acquaintance  with
the two diseases in  question.  The same may be said with regard
to  the  distinction between  lepra and favus confertus (porrigo
scutulata), independently of the circumstance that lepra is seldom,
or  perhaps never, seen confined to the  hairy  scalp,  while favus
confertus is seldom'seen any where else.
   Lepra is not generally a formidable  disease.   When it exists on
the extremities only, or in scattered patches over the body, it may
continue for a lifetime without  apparently influencing the general
health  in  any notable manner.  When  the  eruption is  very
copious, however, and when the whole or the  greater portion  of
the body is  encased,  as  it  were, in a suit  of  scaly armour, the
functions of the skin are interrupted in a degree incompatible with
health ;  the lungs  and  kidneys are  then required  to execute  a
double office,  and the constant state of  excitement in  which they
are thus kept, is  apt to  lead to consequences  which,  in the  aged
especially, are frequently  fatal.  Lepra  very  seldom gets  well
spontaneously; and in nineteen cases  out of twenty, it resists treat-
ment of every kind long and obstinately; it is not, however, on
this account  to be  regarded as a disease generally  incurable; on
the contrary, it very commonly yields at last to  one or other of the
 modes of treatment  which experience has approved.
    The treatment  of lepra must always be conducted in conformity
 with the evident state of the eruption, and the circumstances under
 which  it  is  developed.   If the  disease be of recent date, and
 attended with considerable inflammation,  itching,  and constant
 uneasy  sensations in the patches, general blood-letting and emol-
 lient measures of various kinds, such  as the tepid gelatinous or
 jrruel bath, the simple vapour bath, and the application of cream
 or  hog's lard to  the irritable surfaces, will be found to give  great 
138
GREEN ON DISEASES OF THE SKIN.
relief, and of themselves frequently dispose the disease to recovery.
To these measures, if the patient be still youthful, or in  the vigour
of life,  and of robust constitution, must  be  associated strict regi-
men, the use of some mild diluent,  and absolute rest for a  time.
When,  in this way, the irritable state of the disease and general
system  has  been reduced, experience has shown that a course of
treatment, which  includes, or consists  essentially in the  internal
administration of certain energetic  medicines, in combination with
the external use of baths of different descriptions, may for the most
part be  entered upon with greater prospects of success than any
plan which is  wholly restricted to outward applications.  In recent
cases, however, I should always feel  inclined to give a trial to the
topical plan, in conjunction with the regular use of the vapour, and
by and  by of the hot air and sulphur fume bath, before resorting
to the prescription of such  medicines as  arsenic,  cantharides, and
dulcamara, or a long-continued course of active cathartics, which
have each been found  in  innumerable instances to produce the
happiest effects upon the disease, even in its most inveterate forms.
  Simply irritating  applications, such  as pitch-plasters, tar  oint-
ment, salves of the bryonia alba, chelidonium, (fee, which used to
be mostly employed in cases of leprosy by our forefathers, are now
acknowledged  to  be even worse than  useless,  often  positively
aggravating the disease.   Instead of these, an  ointment of the
nitrate of mercury of graduated strength, of  the white precipitate
of the  same metal, of the iodide of sulphur in the  proportion of
twelve or fifteen grains to the ounce of lard, or of a secret  remedy
known  by the name of the  pearl ointment, may be rubbed gently
over a certain number of the leprous patches,  or a limited extent
of squamous surface, every night at bed-time, with the happiest
effects; the white precipitate salve is particularly  worthy  of a
steady trial.   The patient  should at the same time take  a tepid
bath every morning, and at intervals, say every other  day, a simple
vapour  bath,  to cleanse the surface  from grease, and  to  detach
squamae and render the parts they cover apt to be acted on by
these chemical applications.  Should  sufficient progress not appear
to be made  by the use of these means alone, perseveringly  con-
tinued  for several weeks, the hot air and the  sulphur fume  bath
may be  associated with one or other of the unguents recommended,
with every prospect of advantage.
  In inveterate cases of  lepra,  however,  that  have lasted for
months or years,  external applications  are found  to have little
influence, unless combined with a course of internal medicines,
which,  so far as their action is understood, seem to modify the
state of the general constitution, or to produce new  actions in the
system,  and its parts, during the continuance  of which pre-existing
morbid processes cease, and diseases have time to recover.
  Experience  has satisfactorily demonstrated  the powers  of this
kind possessed by a continued course of purgatives, and  by the
prolonged but cautious  use of the arseniate of potash or soda, as
also of the tincture of cantharides.   Tt is difficult at all times to 
SQUAMAE—LEPRA.
139
specify the exact circumstances under which one of these courses
is to be preferred to another, but we have the authority of Biett, in
favour of the purgative plan among youthful subjects, and in cases
which are not of very ancient date, especially if the attack  be the
first which the patient has had.   The same eminent  physician is
of opinion,  that the tincture  of cantharides is more particularly
useful in cases of lepra  which have relapsed, which occur among
subjects of soft or flabby constitution, in which the disease is very
extensive, and when a course of purgatives has  been undergone
without advantage.  Lastly, Dr. Biett conceives  that the prepara-
tions of  arsenic are especially available in the  more inveterate
cases of the disease, when it has existed  for several years, has
spread over almost the whole surface of the body, and  caused
extensive thickening and alteration of the integuments, and when
all  the other  medicines  and plans of treatment  mentioned,  have
been previously but unsuccessfully enforced.  My own experience
has  lain  principally among the more inveterate cases of lepra, and
in these I  have  generally  succeeded by combining a  purgative
course,  and the  exhibition  of  the  tincture of cantharides, or
Fowler's solution internally, with the external stimulus of the hot
air and sulphur fume bath.
   There is no better purgative to begin with in cases of lepra,
than a mixture of from three  to  five grains of calomel, with from
ten to fifteen of jalap.   This  may be given every other night at
bed-time, and a dose of the common purgative mixture of infusion
of senna and sulphate  of  magnesia ordered every morning.  By
and by,  a  colocynth and scammony pill, or  the compound aloes
and gamboge pill in an adequate dose, may be substituted, as less
nauseous and equally effectual in its operation.   Calomel uncom-
bined, in purgative doses of four or  five grains,  is in great repute
in  France as a cathartic in leprous cases.  When calomel is used
in  this  way,  its  operation  upon the system must  be  carefully
watched, and as the specific  effects of this medicine  are perfectly
unavailing  against  lepra,  it  is always  better  to avoid these  if
possible.
   The tincture of cantharides may  be prescribed in doses  of four
or  five  drops twice a day in any bland vehicle, such  as barley
water, and  gradually increased, till  ten, fifteen,  or twenty drops
are  taken  each time.   The  effects  of this medicine, of  course,
require  to  be most sedulously watched.  The dose ought only to
be increased very slowly, and the moment any complaint is heard,
of sickness or heat of stomach, of scalding of the urethra in making
water, of pain in  the bladder, (fee, that moment  ought the dose of
the  medicine either to be greatly diminished in quantity, or its use
suspended  entirely  for a season.   The  tincture of cantharides,
cautiously  administered,  is  undoubtedly  a medicine  of  great
potency  and value  in the rebellious  disease of which we are now
treating.
   Arsenic  is now almost invariably prescribed in  combination
with potash, as it exists in Fowler's solution.  Three, four, or five 
 140           GREEN ON DISEASES OF THE SKIN.

drops of this solution may be given once or  twice a day in barley
water, and very gradually increased till  from twelve  to fifteen
drops are  taken daily.   It  can never be out of season to remind
the practitioner of the necessity of watching the effects of this
active but perfectly safe medicine.  When peculiar  sensations of
itching occur about the eyes, or wandering pains are felt in  the
abdomen, we know that the  arsenic is exerting its  influence on the
constitution; and if, at this time, the leprous  patches begin to look
red, the centres to lose  their scales, and the rings to break in dif-
ferent places, we  have every prospect  of  seeing  the  disease dis-
appear entirely in  the course of a very few weeks.  The arsenical
solution  should never be pushed so fast and so far  as to compel us,
j ust as its beneficial effects on the disease  are becoming apparent,
to suspend its use for fear of its too powerful specific effects on  the
system at large.  In these chronic and most obstinate diseases, no
good  is to be done in a hurry ;  it is only by patience and per-
severance, that a  permanent  cure  is  either to  be  expected or
secured.
   I do not think it worth while to  mention particularly any other
of the numerous medicines that have been  successively introduced
to the notice of the profession as curative of lepra, and then subse-
quently  abandoned as  inefficacious; among these, I  reckon the
decoctions of dulcamara, of mezereon and ormus pyramidalis bark,
the watery extracts of the white hellebore, of the rhus  radicans,
rhus toxicodendron, (fee  That lepra may now and then have got
well under the influence of dietetic  or medicinal courses,  of which
each of these articles formed parts, it would be  unfair  and absurd
to deny; but of themselves  they seem to be totally without influ-
ence on the progress of the disease.
   A plan of treatment purely dietetic will seldom, if ever, be found
adequate  to cure lepra.  Attention to diet, however, and to every
particular  of  general hygiene, are very important in preserving
individuals predisposed to the disease  from suffering a relapse,
after  having recovered from  an attack of the disease; nor,  as
means tending powerfully to the same end, ought the  influence of
some of  the  natural  sulphureous  mineral  waters,  as  those of
Harrowgate, Leamington,  Bath, (fee, to  be overlooked;  one  or
other of these may always be confidently  recommended  to the
leprously disposed.

                   CASE OF  LEPRA VULGARIS.

   A lady, aged 25, came to consult  me in the beginning of April,
1832, on account of leprosy, under which she had laboured for the
last seven years.   When she applied to me, the  disease was not
confined to any particular region, but extended over the whole of
the body, with the exception of the hands, feet, and  face.   The
head  had been shaved regularly  once a fortnight  during the last
three years, for the convenience  of making applications to the
spots.  The squamous patches, on  the  body and  limbs, varied in 
SQUAMAE—LEPRA.
141
size from that of a crown piece  to that of a sixpence ; they were
all of a very regular round shape, though some of them had run
together in different places, and formed broad continuous patches.
The edges of the several patches were of a more vivid red, and
appeared more raised than their centres, which, for the most part,
were  covered with thin scales,  constantly falling off, but  as  con-
stantly reproduced.  Several of the spots, however, were declining,
and presented nearly the same pale colour as the skin at large; the
red raised edges which surrounded these, formed simple rings,
enclosing patches of apparently  healthy integument.  Other spots
again were on the increase, and  appeared as small red elevations,
covered  with a thin shining  scale of  similar  dimensions.   The
patient informed me that this process of decline in one part, and of
increase  in another, had been  constantly going on for rather more
than the last  seven years.
  The  patient  was  otherwise  in  good  health,  complaining  of
nothing  except  a proneness  to occasional headache.  She had
made trial of all  the usual remedial means prescribed in cases of
scaly leprosy without success,  with  the  single exception of the
sulphur fume baths; and it was with the view of trying the effect
of these that  I was now consulted.
  This patient began  by taking three  vapour baths, in  order  to
free the surface in some degree  from  the thick covering of scales
spread over it, and a few doses of aperient medicine as preparatory
measures.  The  sulphur fume baths were only commenced on the
17th of April, one being taken every other day.  But the disease
was  still in too active a state to  be benefited by this treatment;  in
a week, the  patient  was literally of a  uniform and bright scarlet
red colour, and very many new spots were brought out,  to which
her attention  was directed.   She therefore ceased to take the baths
till the 30th,  when she again commenced them.   By this time, the
general redness  had disappeared, but the leprous  spots were much
in the same  state as before.  May  10, The  new  spots had not
maintained the character of the  former ones, not having gone on
gradually extending, and  many of  them having even  receded
entirely.  The baths were now  taken daily ; but  up to the 20th of
May  so little progress has been made in the cure, that I bled the
patient  to fourteen ounces.  The blood was natural, but firm in
texture.
  30th. A great improvement  had taken place  since the  bleeding,
many of the  spots having  disappeared, and left red rings, some of
which were  broken through  in different places,  the skin in the
gaps  presenting  its natural   appearance.  June 9th, Improved,
though not to so great an extent as during the interval up to last
report.   Few entire red patches remained, but the old rings had
undergone little variation.  To  these,  with a camel's hair pencil,
the patient was directed to apply a little diluted aromatic vinegar
every night,  and she commenced taking four drops of the arsenical
solution, morning and  evening, in  a cup of barley water.  19th,
The  patient  began to  complain of a troublesome itchiness of the 
142           GREEN ON DISEASES OF THE SKIN.

skin, which very usually occurs in consequence of the excitement
occasioned by the heat of the bath and the effects of the sulphur;
this, however, did not deter  her  from continuing the fumigations
till the 24th, when the pruritus was so much increased, that they
were discontinued for  a few days.  Having suffered from  pains
and uneasy sensations in  the stomach and  bowels also, the arse-
nical medicine, which had been increased to ten drops twice a day,
was likewise left off for a time.
  July 3d. The patient, being now free from pain in the abdomen,
and the pruritus of skin having subsided, resumed the fumigations,
together with the medicine.  At this date she was greatly better.
13th.  The skin had become much darkened and hardened, from
the effects of the sulphur.   This state I knew to be the herald of
the process of peeling or desquamation which always follows  the
continued use of the sulphur fume bath, and from which I anti-
cipated the best effects in this case;  I therefore  advised  the sul-
phur bath  to be discontinued for six weeks; and to facilitate  the
peeling of the skin,  I  recommended a few water baths, and now
and then a vapour bath, to be taken, whilst the  arsenical  solution
was steadily persevered in, so long as no unpleasant constitutional
symptoms supervened.
  I did not see this lady again until the end of  September, when
the whole of the leprous spots had disappeared, except two or three
on the abdomen.  To these she was advised to apply the aromatic
vinegar as before, and still to await the result of  the treatment, as
desquamation of the cuticle had not yet come to an end.
  This lady  visited me again in the April of 1833, with  a return
of her complaint,  but of very trifling extent, showing itself only on
the body, and consisting in all of not more  than a  dozen spots.
She was so much convinced that the bleeding had exerted a bene-
ficial influence  in the treatment  of the year before, that  she had
had herself bled before  visiting me, with the intention of resuming
the sulphur fume baths.   Eighteen  of these,  on this occasion,
removed every trace of the disease.
  This lady informed me that she had gone on peeling during the
greater part of the winter, and had lost all vestiges of her complaint,
till on the return of spring, when, as just stated, it showed a dispo-
sition to recur.
  Since this trifling  attack  the patient has remained quite  well.
On this latter occasion, no medicine whatever was taken.
  Case 2.  Very nearly at the same time (April,  1832) as the last
patient, a  lady  from Ireland consulted me on the same  form of
squamous disease—leprosy, and it was an odd coincidence, that this
lady, on comparing notes with the one whose case has been just
detailed, found that they had both been assailed  with the  disease
about the same period, and were so similarly affected, that  the ac-
count of the symptoms in the one proved to  be a correct detail of
those in the other.   It is not very usual for lepra to appear on the
hairy scalp, but this latter patient, like the former, was so attacked,
and had been in the habit of having her head shaved for three  or 
SdUAM^E—LEPRA.
143
four years, every ten days, or once a fortnight, for the convenience
of making applications of different kinds to it.  The only difference
in the cases was that this second  patient was twenty-nine years of
age, very prone to what she described as feverish heats, and to head-
aches, and was further of a very constipated habit.   The numerous
spots and patches were in all particulars alike in both patients, who
were both  of  strong make, and in  the enjoyment of fair average
health.   The  first lady took the sulphur fume bath fifty-one times,
between the 17th of April and the 13th of July, before the complaint
disappeared, and she had a slight return of it  the following year.
The latter lady had forty-seven fumigations  administered, between
the 20th of April and the 23d of June, when it was judged unneces-
sary to continue them longer.   After  the process of peeling was
completed, this lady found herself quite well, and has had no return
of her malady up to the present time.
   She was bled, and took medicines similar  to those prescribed in
the first case, with the addition of an aperient draught most morn-
ings, when she first commenced the  use of the fume bath ;  aperient
medicine, indeed, was required  from time to time, throughout the
whole course of the treatment.
   The arsenical solution,  given  with  the  usual precautions, has
long and justly held  a high reputation in  most countries, for its
influence over lepra.   I  am anxious, from my own  experience, to
attest its  beneficial powers in this disease.   It is not improbable but
that both of the cases detailed would have recovered under the use
of the sulphur fumes, without the addition of so powerful  a medi-
cine as arsenic ;  and, indeed, I  have known many cases that have
been of short standing recover  without any assistance from other
means, even without the use  of bleeding.   But in cases of longer
standing, I have reason to conclude that both of these adjuncts are
advisable,  and  tend  greatly  to abridge  and   facilitate  a cure.
Leprous  patients  perspire readily  and abundantly  whilst in  the
fumigating bath; in psoriasis, another  scaly disease, I have found
them to perspire less freely, and still less in general pityriasis, when
the scales are much thinner, for the most part smaller, and much
more continuous.
   I have selected these two cases of lepra on account of their long
standing, and  because I think they  tend to  show the powerful re-
medial influence possessed by the sulphur fume bath, in this peculiar
and generally intractable disease.   These cases I also consider as
fair specimens of the utility of conjoining internal medicines with
the fumigatory method ;  for although the latter has been upheld as
adequate to cure lepra by itself, and I have  known many instances
of the fact, yet when we have a disease of an acknowledged rebel-
lious character to contend with, it seems to me well to meet it with
the whole of the corrective powers we possess.1

  1 Dr. Bardsley, in his  " Hospital  Facts,"  abstains from detail relative to
the medicines given when putting to the test the  efficacy of fumigations in
the cutaneous diseases.
  Of the value  of his preparatory treatment there can  be no doubt, and al- 
144           GREEN ON DISEASES OF THE SKIN.

  Few are  aware how  very commonly scaly leprosy prevails  in
London ;  those who are  affected with it, and indeed with any cuta-
neous affection, generally concealing the circumstance  even from
their most intimate friends, as if there  were  something disgraceful
attached to this class  of  complaints.   Individuals in every class of
society are, however,  subject to most of  these, and to lepra in par-
ticular.  The disease  I  find one of every-day occurrence, and by
no means so intractable as I used at first to believe it, or as is sup-
posed.  Most slight cases will get well readily under the use of the
sulphur fumigations,  assisted by very  gentle  medicines;  others
require greater perseverance, and the administration of medicines of
a more active  kind, among the number of which I believe the pre-
parations  of arsenic to deserve the preference.   I  never had but
three cases  of leprosy, which by their obstinacy disheartened both
myself and patients ;  one was  that  of a gentleman  who took the
sulphur fume  bath upwards of a hundred times,  without deriving
much or any permanent good from it.   Another gentleman, after a
trial to the same extent of this means,  and a similar result,  went to
India, and I heard no more of him.  The third is a medical gentle-
man, who has had the disease from  puberty, and is now fifty  years
of age.   He too has taken more than a hundred fumigations, though
very irregularly, and considers himself incurable of  the disease  in
question; otherwise he is in fair health.


                           PSORIASIS.

   Psoriasis, or dry scall, is a chronic inflammatory affection of the
skin, characterised by patches of various extent, irregular  in their
outline, uniformly but slightly raised  above the level of the sur-
rounding surfaces, and  covered for the most part with brilliant
white and very dry scales.
   This disease occurs under a considerable variety of forms, which
have been classed under different heads : in one case the  patches
are distinct and of small size ; in another they are larger and blend
with one  another; in a third they occur twisted or in lines: and in
a fourth they  are  so broad, and the  traces of their original outline
so completely lost, that extensive  regions of the  body appear en-
cased, as  it were,  within one continuous scaly covering.
   In its first and  simplest form, psoriasis appears in the shape  of
small, red,  distinct  elevations, the  size  of large  pin-heads, which
speedily become  covered on their  summits with thin, dry,  white
scales.   These little  raised spots  enlarge gradually, but not very


though he  speaks and his tables show so favourably in regard to the  merits
of  the fumigatory method of treatment, I  have  reason either to doubt the
excellence of the construction of the apparatus employed, or to judge un-
favourably of the way in which  the fumigations were administered, from
the results as shown in  the  tables. Dr. Bardsley's other statements relative
to the fumigatory method deserve the particular consideration of the profes-
 sion. 
                     SQUAMiE—PSORIASIS.                  145

evenly, and whilst they are on  the increase always continue more
elevated in the centre than around the circumference; it  is only
when they begin to go off that they appear depressed in the middle ;
for the patches of psoriasis, like those of lepra, get well chiefly from
the centre towards the circumference.  The patches at their height
are not more than about two eighths of an inch in  diameter, and
being  covered with somewhat  translucent and rather opalescent
squamae, they look very much like large drops of liquid adhering to
the surface of the region upon which they are evolved, whence the
distinguishing title of this variety of the disease,—psoriasis guttata.
The squamae when detached are very speedily  renewed; the spots
they conceal appear  highly inflamed, and somewhat  raised above
the level of the surrounding surfaces ;  they are  also the seat of con-
siderable pain, when denuded of their sqaly covering.
   Psoriasis guttata is met with of very various  degrees of severity;
occasionally the disease is confined to a few spots upon the  back of
the trunk, and outer aspects of the limbs ;  at other times, it  extends
over almost the whole surface of the body, which is either covered
at once  by a general burst, or successively  by  partial crops of
the  eruption.   When  the  disease is general, the  patches  are
always most  numerous  on the back,  and  along the outer and
posterior aspects of the extremities.   This variety  of psoriasis
is not observed to be attended  with general constitutional symp-
toms ;  it is also the form of the disease which is  most easily sub-
dued.
   Besides this distribution  of the  patches over various extents of
surface, at pretty regular intervals,  the  papular eminences that
constitute the elementary form  of psoriasis, are sometimes, though
very rarely, seen evolved in  convoluted lines,  which give  the dis-
ease a  very peculiar and characteristic appearance.   This rare
variety of the disease, when it occurs, is  commonly observed on
the back or shoulders.   It. is entitled psoriasis gyrata.
   Instead of continuing in the shape  of distinct scaly spots, with
intervals of healthy  integument  between them, the  red papular
looking spots,  which form the first stage of  psoriasis,  are often
evolved so close  to each other  that  they  speedily unite, and thus
cover entire districts with  one continuous and irregular shield of
scaly incrustation.  The disease  in  this case is entitled, psoriasis
diffusa.  This and psor. guttata, just described, begin precisely in
the same manner ; indeed  they differ  in no  one essential  feature,
save in the accidental greater abundance of the eruption in  the  lat-
ter than in the former variety, and the consequent continuity of the
squamous patches to which the circumstance gives rise.  The two
forms of psoriasis, therefore, are frequently observed on different
parts  of the same patient's person: on the trunk  the disease has
generally the characters  of psor. guttata, on the extremities  those
of psor.  diffusa.  Psoriasis diffusa, however,  is indicative of  the
disease in  a  much  severer and  more  intractable shape  than
psoriasis guttata.  The eruption is  accompanied with  a higher
degree of local irritation, the parts affected are the seat  of severe
       6—g                                     gm 10 
146
GREEN ON DISEASES OF THE SKIN.
burning pain and violent itching; which are both greatly increased
by whatever stimulates or tends to raise the heat of the surface;
psoriasis diffusa  is also very generally attended with symptoms of
constitutional  disturbance ; we have restlessness, quick pulse, thirst,
furred tongue, and evident gastric  derangement present whenever
the disease shows itself in any degree of intensity.
   The extremities are the usual parts upon which diffuse psoriasis
is evolved, and it is  not  uncommon to see the whole  of the leg,
from the knee to  the ankle or instep,  and the entire surface  of the
fore-arm, from above the elbow to  the  wrist, encased in one thick
and unyielding  shell of  squamous  incrustation, furrowed  and
chequered  on  its  surface generally, and  cracked and pulverulent in
the neighbourhood of  the articulations.  These shells are oftenest
seen on the anterior aspect of the leg, and posterior surface  of the
fore-arm, and  when in  these cases the  incrustation is partially de-
tached along its edges, as frequently happens, a bright red, shining,
and highly inflamed surface is  exposed. These are the parts  also
from which the disease always recedes most reluctantly, under the
operation of remedial measures; the elbows, the backs of the fore-
arms and the  shins, often show patches of the eruption, perfectly
characteristic, when  it  has yielded in  every other quarter  of the
body.
   When psoriasis has continued for many months, and, perchance,
for several  years,  in whatever form it may have begun, it acquires
peculiar characters at  length, which have led to its designation by
the title of psoriasis inveterata.  Under these circumstances, those
parts of the skin  which are the seat of  the disease are thick, hard,
and unyielding, by no means highly  inflamed under the squamae,
(which are white, often of great thickness, and constantly evolved
in  immense quantities,) and  intersected with deep, bleeding, fre-
quently discharging, and always very painful fissures.   The squa-
mous  crust, which then encases the parts  affected, is extremely
rough  and  uneven on the surface, and has been compared  not
unaptly to the rugged bark of an aged oak or elm tree covered with
lichens.
   This very aggravated form of psoriasis is always attended with
much  suffering;  large patches of the hypertrophied skin  occa-
sionally lose their cuticle along with the case of incrustation  that
covered them,  and then painful and extensive excoriated surfaces
are exposed, that  seldom fail to have a very unfavourable effect on
the general health of  the patient; and when  it is considered  that
psoriasis  inveterata is principally met with among aged subjects
with broken down constitutions, and frequently of dissipated habits,
it may be imagined that the disease we have to do with is one of no
slight or insignificant description.
   Psoriasis inveterata may appear as  a partial disease, confined to
one or two regions, or as a general affection and implicating nearly
the whole surface of the body.  It is however most frequently seen
on the limbs, with the morbid actions of the disease extending even
to the matrices of the nails, which are  then misshappen, rough, and 
SQ.UAM.E--PSORIASIS.
147
ragged, split into pieces, and more like friable squamae than the firm,
elastic, and horny plates they form in the healthy state.
   Besides these, which may be held the grand divisions of psoriasis,
the disease presents several peculiarities, according to the part upon
which it is developed, that deserve more  than a passing notice.
   Although not frequently seen on the scalp alone, still psoriasis is
occasionally met with on this part, when it usually causes inflam-
mation of the secreting bulbs of the hair, and the temporary loss at
least  of this appendage.  On the face it  is oftener confined to the
eyelids or lips, than  more  extensively diffused over  this region.
Psoriasis  ophthalmica is characterised by the  occurrence of little
squamae or squamous patches about the angles of the eyes, and over
the eyelids, which are tense, painful, itchy, and a good deal  im-
peded in their  motions.   The inflammation in this variety often
extends to the conjunctiva,  and then we  have the external disease
complicated with a very obstinate affection of the outer covering of
the eyeball and the lining membrane of the eyelids.   This affection
is common in  childhood.
   The coloured part  of the lips is also subject to an inflammation,
with  frequent  desquamation of the  epithelium, which has some
analogy to psoriasis, and  has been described as a variety  of this
disease under the name of psoriasis  labialis.   The  epithelium in
this affection is thickened, then  cracks, and is at length detached in
shreds of considerable size.  A new cuticular  covering is formed
under the old one ; but even before this is completely detached, the
recent formation begins itself to harden and to crack, and is by and
by detached like that  which preceded  it; and this process goes on
incessantly often for months and even for years, the lips being all
the while hot,  painful, and very stiff.
   Psoriasis is occasionally seen seated on the scrotum and even on
the prepuce, without  implicating any other part of the body.  The
disease in these cases  is apt to prove rebellious and  of long con-
tinuance.  The skin  of both the parts  affected thickens, and mostly
becomes badly  chapped, and  frequently  extensively  excoriated.
The disease of  the scrotum is  very generally complicated with an
evolution of impetiginous pustules.   The pain  and  pruritus then
endured are, as may be imagined, extremely distressing.
   But the most important and interesting local variety of psoriasis
is that which attacks the palms and backs of the hands, and is vul-
garly entitled grocer's itch and  baker's itch.
   Psoriasis palmaris begins in the same manner as  the  distinct
and diffuse varieties of the disease, by one or more  red and slightly
raised spots on different parts of the palm of the hand.   These are
soon covered on their summits with little  dry white scales, which
are themselves by and by surrounded  by bright circles of inflam-
mation, over which the cuticle thickens, dries,  cracks,  and is par-
tially detached.  The first circle of inflammation is soon surrounded
by another, this by a  third, and so on, till the entire surface of the
palm, and frequently the palmar aspects of the fingers to their points,
are implicated ;  the whole of the parts then become hard, stiff,  and
                                                grn  10* 
148
GREEN ON DISEASES OF THE SKIN.
 dry; the hand remains fixed in a state of semiflexion, and cannot
 be opened without much pain ; the lines naturally observed on the
 palm are greatly increased in depth, and  the spaces between them
 covered with thick laminated cuticular squamae.  When  the dis-
 ease has continued for some time, these lines are changed  into fis-
 sures, which add greatly to the suffering of the patient, and bleed
 whenever he attempts to  use the  hand.  The whole  of the parts
 thus affected are highly inflamed, and in general acutely sensitive.
 The  disease, as the name implies, is  frequently met with among
 grocers, bakers, dyers,  washerwomen, smiths,  and various  other
 handicraftsmen.
   Instead of the palms being the  parts affected, psoriasis is occa-
 sionally seen confined to the backs of the hands.  In this case, the
 disease is evidently a mere partial  variety of the psoriasis diffusa,
 from which it does not differ in its mode of appearance and pro-
 gressive development.  This, like  the palmar  variety, is  a very
 painful and troublesome complaint, being  attended  with deep but
 generally dry chaps in the line of the  articulations, and wherever
 any thing like regular motion occurs.   Like the last, this variety of
 psoriasis is frequently observed  among bakers, grocers, and others
 whose hands are habitually exposed to  the contact  of  pulverulent
 and irritating substances, alkaline or chemical liquids,  (fee ; but it
 is also occasionally met with among individuals in classes of society,
 where none of these causes can be supposed to have  had any in-
 fluence in its production.
   The causes of psoriasis  generally are extremely obscure ; a very
 few local varieties only appear occasionally to  be evolved  under
 the influence of direct stimuli.  Individuals  in the  prime of life,
 and in other respects in apparently perfect health, frequently suffer
 from its attacks.  The distinct variety  is by far the most common  ;
 this, indeed, is one of the most common of all the chronic affections
 of the skin.  When the disease is partial, it is rarely attended with
 symptoms of constitutional disturbance; when  general,  however,
 it is often complicated with derangement of the chylopoietic viscera,
 and  is  either  preceded or accompanied with languor, inaptitude
 both mentally and bodily, and loss of appetite.  Psoriasis  is not
 contagious in any  of its forms ;  but it is one of the diseases the dis-
 position to which is most certainly known  to be transmitted from
 parents to children.  It  occurs at all seasons, but especially in the
spring and  autumn;  and  it attacks individuals in all classes of
society, although it is undoubtedly more frequent among those who
 live in the midst of filth and wretchedness.
   Psoriasis is not apt  to be mistaken for a great number of other
 diseases  of the skin, but it  bears a very strong resemblance to one
 or two, especially to lepra, from which it is at times distinguishable
 with the greatest difficulty,—to  say nothing, for  a moment, of the
fact that the two diseases seem often to change into one another, or
 to assume the characters respectively, which are usually held dis-
tinctive of each.   In general, however, psoriasis guttata and lepra
are distinguished from  each other by  the  dissimilar appearances 
SQUAM.E—PSORIASIS.
149
presented by their patches, those of psoriasis being smaller, some-
what irregular in their outline, and raised in their centres, but not
at all so in their circumferences, whilst the patches of lepra are of
considerable breadth, depressed in their  centres, raised in their cir-
cumferences, and extremely regular in their outline.   When the
patches of lepra coalesce and give rise to a continuous scaly surface,
the circles of which it  is made up are still indicated by the even
circular sweeps observable  in its circumference;  when  psoriasis
diffusa, again, occasions a surface of this description, it is always
irregular  and very  frequently angular in its  outline.   Psoriasis
inveterata of the  extremities is always readily distinguished from
all  the other forms of  squamous  eruption, by  the rough and fur-
rowed shells with which it invests, as it were, the parts affected.
   Psoriasis guttata of the scalp differs from pityriasis of the same
part in  the larger size and greater thickness of its squamae, and in
the presence of a distinct papular elevation in  the middle of each
of the scaly spots.
   From the squamous blotches, under form of which the syphilitic
poison lurking in  the constitution occasionally proclaims its pre-
sence, psoriasis in all its varieties may commonly be very readily
distinguished.  Syphilitic squamous patches, for instance, are of a
dusky copper colour, those of psoriasis guttata of a  bright Vermil-
lion red.  The squamae of the syphilitic spots  are few and flimsy,
those of psoriasis thick  and  abundant; syphilitic blotches, divested
of their squamae, are smooth, soft, and scarcely if at all raised, those
of psoriasis are hard,  rough, and  prominent  under  the finger;
squamous blotches are but one, of a host of other symptoms, which
proclaim  the  presence  of the  venereal poison when  it  has  con-
taminated the system,  and  these always give hints sufficiently
intelligible of their  true nature and origin.  1 say nothing of the
diagnostic inferences which are to be drawn from the influence of
various curative means  upon these different eruptions, conceiving
that diagnosis ought always to precede and be subservient to treat-
ment.
   I do not think it  necessary to enter  into the particulars of the
diagnosis  between psoriasis  and various other diseases, especially
chronic eczema, which  are  accompanied with  laminated incrusta-
tions, but  appear under  different elementary forms.  The presumed
resemblances  of these affections are more in imagination than  in
fact.  Neither does it seem requisite to state minutely the points of
resemblance and of difference between psoriasis and lichen circum-
scriptus, attended with a squamous desquamation from the surfaces
upon which  it is developed ; the previous  history of the two dis-
eases, and the presence of the naked  elementary papulae of the
lichen, being always sufficient to distinguish  the papular affection
from the scaly one in question.
  In distinguishing between psoriasis and other diseases, it is very
necessary to be aware that this affection sometimes occurs associated
with several of a different as well as of the same order.  Thus it is
not uncommon to find a patient affected with psoriasis and lepra at 
150
GREEN ON DISEASES OF THE SKIN.
 the same time.   Psoriasis and pityriasis also occur pretty frequently
 together.  In young children, psoriasis  and impetiginous eczema
 in combination, occasionally attain a  high degree of intensity, and
 this association  has even been described by Willan  as a further
 variety of psoriasis, under the title of psoriasis infantilis.   Psoriasis
 of the hairy scalp has been observed associated with favus (porrigo);
 and I have myself, oftener than once, seen psoriasis  of the scrotum
 linked to a pustulous eruption (ecthyma) of the same part.   These
 complications are to be regarded as purely accidental,  and not as
 transformations of psoriasis into any other species of cutaneous dis-
 ease.
   Psoriasis in every one  of its  varieties must be admitted to be a
 severer and more intractable disease than lepra.  Generally speak-
 ing, and of itself, it is not dangerous;  it is only when it occurs in
 shattered constitutions as one in a long list' of other evils,  that it
 seems to prejudice  life.  Psoriasis guttata, obstinate  as it almost
 uniformly proves to every plan of treatment, is nevertheless the
 most yielding  variety of the disease.  Psoriasis diffusa  is much
 more rebellious, and psoriasis inveterata sometimes absolutely in-
 curable, or only to be subdued by months  of the most persevering
 and energetic treatment.
   When psoriasis guttata begins to yield  to the means employed,
 the patches sink to the  level of the  surrounding integuments, the
 squamae fall off and  are not again  reproduced, and the  points
 affected  gradually lose their harshness  and  increased  redness.
 Psoriasis diffusa and psoriasis inveterata  on the way to recovery,
 first lose  their continuous  scaly crusts, and acquire  the form of
 psoriasis guttata.  The symptoms of  inflammation  gradually sub-
 side, the chaps disappear, the surface loses its  tense, shining, red
 appearance, the  parts affected  regain their pliancy and  softness,
 and by slow degrees resume the characters of the healthy integu-
 ment.
   What has already been said with respect to the treatment of lepra
 is applicable  without restriction to that  of psoriasis.  Topical ap-
 plications in combination with  general  means, the  abstraction of
 blood  from the arm, and the prescription of arsenical  and other
 powerful medicines, are perhaps even more valuable in this disease
 than in lepra.   When  the disease is confined to particular districts,
 the attachment of a number of leeches around the parts  affected is
 often of great service ;  and when the malady is on the  increase, the
 patches may frequently be prevented from extending and  running
 into one  another by the argentum nitratum applied in  substance
 around their circumference.   When the patches are thickly covered
 with squamae and very indolent, they may often be advantageously
 aroused into new action by the use of a  liniment consisting of an
 ounce  of olive-oil, half an  ounce of the liquor polassae, and an ounce
of rose-water.   The same good effect is  frequently  obtained by
touching the spots with the strong acetic acid or aromatic vinegar,
a little diluted.
   Of all  the internal  remedies which  have  yet   been tried in 
SQUAMA—PSORIASIS.
151
 psoriasis, arsenic in one or other of its forms is unquestionably that
 which is deserving  of the greatest share  of confidence.   I  have
 already hinted at the precautions proper  to be observed in admin-
 istering this as well as  several other active  medicines;  and having
 done so, I shall only repeat here, that with these arsenic is no  more
 a dangerous medicine than any other article of sovereign power
 upon  the system, such as opium, antimony, mercury, (fee which
 we are in the every-day habit of employing without a thought of
 their deleterious influences in excessive doses.
   The arseniate of soda appears to be the mildest  form in which
 arsenic can be administered ; this, however, is not the most potent
 in its effects upon disease, being greatly surpassed in this particular
 by the arseniate of potash, which, dissolved in water, under the title
 of Fowler's solution  or liquor arsenicalis, is the preparation of the
 metal now most commonly and universally prescribed. There is still
 another formula for the administration of arsenic of even greater po-
 tency under certain circumstances, and with which we occasionally
 succeed in  curing psoriasis after having failed  with the Fowler's
 solution ; this is  the pilula asiatica, the" asiatic pill, a combination
 of the arsenious acid  or white oxide of arsenic, with black pepper.
 The formula I follow for the preparation is the following : R. oxid.
 arsenic,  alb. 3i. pulv. rad. glycyrrh. 3vii. pulv. piper,  nigri.  3vi.
 syrup, simp. 3i.  Ft. pil. no. 840.   The  dose at first is one daily.
   For my own part then, I have no  objection to urge against the
 use of arsenical  medicines ;  on the contrary, I have not a word that
 is not in their favour : I have never seen  them produce more  than
 the most transient disturbance of  the constitution, which I have
 often known exceeded  in  amount by that which follows the brisk
 action  of an ounce of sulphate of magnesia, and I have repeatedly
 seen psoriasis in its  most  inveterate form, which  had  existed for
 six, eight, and ten years, and resisted every  other remedy and  plan
 of treatment prescribed, yield at once to their powerful influence.
   But  1  have lately held myself independent even of this most ex-
 cellent medicine in the  treatment of psoriasis.  By taking away a
 little blood from the arm, exhibiting a few aperient  draughts, and
 soothing the irritable state of the  surface by means of an emollient
 gruel bath in the first instance, and  then resorting  to  the vapour
 and subsequently to the sulphur fume bath, I have  seldom failed
 either in effecting the most  signal  amendment in the state of this
 rebellious disease,  or in  subduing it entirely.  The cases which  I
 shall select from among many others, are  given not  on  account of
 their peculiar interest, but  from  their strong resemblance  to each
 other, and to illustrate the method of treatment I am in the habit of
 pursuing in the disease.
  The local varieties of psoriasis are to be treated in the same man-
 ner as the more general forms of the disease.  A course of purga-
tives has often a marked and  very beneficial influence  on several
of them.   The application of a number of leeches in the neighbour-
hood of the affected parts ought never to  be neglected :  they  may
be attached under the  angle of the jaw or behind the ear in psoriasis. 
152
GREEN ON DISEASES OF THE SKIN.
ophthalmica, and around the wrist in  psoriasis  of the palm and
back of the hand.  The watery vapour and  sulphur  fume douche
are often of essential service in these partial affections, as the steam
and sulphur fume bath are in the more  general disease.
   When the parts are freed from squamae by the use of the vapour
bath or douche, a variety of unguents are often extremely useful in
giving a favourable turn  to the  inflammation.   I have  already
spoken  of the liniment of the  liquor potassae.   The unguentum
hydrargyri nitratis of graduated strength, or  a salve  of the preci-
pitated sub-muriate of the same metal, will often be  found useful,
especially in the ophthalmic and labial forms of the disease.  In
several of the other varieties, an ointment of the proto-iodide, or
deutoiodide of mercury, (twelve grains  to the ounce of lard,) or of
the iodide of sulphur, (fifteen to twenty grains to the ounce of lard,)
will be found to  infuse  activity into the few indolent patches that
sometimes remain about the elbows, having obstinately resisted the
curative means that have been successfully used against the disease
in other quarters. The ointment of the tartrate of antimony (twenty
to thirty grains to the ounce of lard) is often employed with similar
views.  Psoriasis of the scrotum, when complicated  with impeti-
ginous pustules,  which used  to be held,  and with reason, one of the
most rebellious of diseases, I can calculate with much certainty on
subduing in the  course of a  fortnight or  three weeks by means of
the sulphur fume bath.

                      CASES OF PSORIASIS.

   In the summer of 1833, a gentleman of phlegmatic delicate habit,
aged about 50, who had served many years in warm  climates, was
recommended to me  for my advice in  a complaint of the skin,
which had existed for ten years, during the whole of which time he
had never been quite free from it.   The disease  appeared in the
shape of small red spots, on the summits of which, in  the course of
twenty-four hours, minute silvery scales were formed. These spots
then went on extending, and became  covered with thicker and
broken scales, which were  in a state of continual decadence and
renovation.   They were attended with  a feeling of heat and itching
under them.   This gentleman's health was good, but he  was of
weakly constitution.  During the lengthened period  of ten years,
he had  tried  all reputed  means of cure, and medicines of every
description for the removal of this complaint  without  avail.
   When he applied to me, May 5th, 1833, the back  was  covered
with one continuous  dry  and hard scaly plate of incrustation,
extending from the level of the scapulae to the nates, and occupying
one side of the whole front of the body, from the  mamma to below
the umbilicus; the other side was free from disease.   There were
also many large patches of various sizes on the thighs, legs, and
arms, and the scalp was covered with a thick layer of the same dry
incrustation.  The patient was subject  to feverish  heats, and to
dyspeptic symptoms, but not of an aggravated kind. 
SO.UAM.E—PSORIASIS.
153
  He was directed to take a tepid water bath every day, with four
ounces of the subcarbonate of potash  dissolved in it, and to remain
immersed for an hour or as much longer as he could conveniently.
This was "done with a view of softening the skin generally, and
aiding in the dislodgment of the scales.   On the 15th, the surface
appeared in general pretty free from squamae; the patches from
which they had fallen, but especially their edges, were of a vivid
red.   He now commenced by taking  each  day a vapour  bath, and
to the patches the following liniment  was applied, night and morn-
ing, with a view of detaching still more the hardened squamae.  R.
Liquor, potassae 3i. ol. oliv. 3iss. aq. rosae 3i. ft. liniment.  20th,
From the united action of the vapour baths and  the application of
the liniment,  the old scales were now almost all  detached, but thin
ones would form during the course of a single night.  Some of the
smaller spots seemed to be extending in size  and looked very red.
The patient now took a sulphur fume bath every other day, using
the vapour  bath on  the  intervening days,  and  continuing the
liniment.  As yet no  internal  medicine had been directed, the
patient expressing great reluctance to begin a new course of physic.
30th, The patches and spots comparatively clear  of squamae and
red, no diminution of size;  the scales are renewed  through the
night.   The  vapour baths given up, and  the sulphur fume batb
taken daily.   June 10th,  The  appearances  much the  same; the
smaller spots have ceased to extend; those  about the  size of a
sixpence which are nearly covered with one thin scale, on its being
lifted up and forcibly detached, show an adhering pedicle in the
centre, and a corresponding depression leading to the under or true
skin, precisely as seen in lepra.  The  edges of the spots and patches
were of an increased red, though not elevated  as in leprosy, nor
were the centres depressed and of a paler hue as  they are in that
disease; here the patch or spot was of an uniform  red all over, the
edges only being of a  more vivid tint than  the other parts, and the
whole of the  patch or spot raised above the level of the  adjoining
healthy parts, apparently to the amount of about the thickness of a
sixpenny-piece.
  A dozen of leeches were directed to be applied contiguous to some
of the spots that were more isolated  than  the rest.  The bites-of
these occasioned a considerable  hemorrhage, and the patient com-
plained on the 15th of feeling weaker since  their application; his
pulse indeed  was feeble; two of the leeches had fastened themselves
within  the area of one of the  spots, and  one within the area of
another.  On the 20th, both of  these spots were paler, flatter and
more easily folded between the finger and  thumb  than the others,
and the large patches  or  spaces, generally, looked somewhat less
inflamed; the scales still continued to form during the night, but
were thinner in substance.  On account of the evident  amended
appearance in the spots, the patient assented to  the application of
twenty  leeches to some of the larger patches; he objected to general
bleeding.   20th, Complains of weakness, though gratified with the
apparent amendment in the spots and patches; directed to take the 
154
GREEN ON DISEASES OF THE SKIN.
fume  bath every other day, and the following mixture: R. Liq.
amnion, sub-carb. 3iss. iufns. caryoph.  3vss. two t:ible  spoonfuls
twice or thrice a day in barley-water.
  25th. The patient thinks the medicine is  of service  to him;  he
awakes in the morning with some little perspiration on the skin.
He  had  from the  beginning used  the  liniment to the scalp, and
worn an oiled silk bathing-cap under his wig. The scalp was now
quite  clear, and had  ceased to form  scales;  the  feeling of general
weakness  had gone off; the fume bath was resumed daily.
 ' June 5th. Many of the spots now seemed  about to disappear, as
the  red circumference is broken in various places, and the parts
cleared have  the colour of the skin when it is healthy; the edges
of the larger agglomerated patches have the  same appearance, and
in their areas there  are numerous spots of the  natural colour;
generally, very few scales are now formed.
  10th, The apparent amendment since last report has continued;
the  edges of the spots and patches almost uniformly appear  as
broken red rings, the centres approaching the pale natural colour
of the skin, as those of the spots of leprosy do when declining.  To
some  of  those remaining  red parts the diluted aromatic vinegar
was applied, and others were toiJched with the lunar caustic in sub-
stance; the latter proved the better application.
  The entire surface had become much darkened from the  action
of the sulphur, and the commencement of the peeling process was
now daily to be expected.  July 20th.  Many of the patches were
sore from the repeated application of the caustic.   Half a dram of
the  liq. potassae in a solution of extr. sarsaparilla was ordered twice
a day, in addition to the fume bath every other day, whilst the
cuseased parts were left to themselves.   30th. The parts made sore
by the use of the caustic had healed; there still  remained  much
disfiguration  of the surface from the red broken lines and partially
healed patches of the disease.
  August 1st. The patient now consented to try the asiatic pills,
though he had taken them some years before without benefit. 20th.
Found himself constitutionally inconvenienced by the medicine;
he had taken but -Jy of a grain night and morning. It was there-
fore discontinued, and the use of the fumigating bath, of which  he
had now had sixty-three, was also suspended for a season.   This
gentleman may be said to have begun the treatment on the 15th of
May, and in three months its effects were very conspicuous, for the
disease had disappeared from many places that were thickly beset,
and in none did it now extend in broad continuous patches:  it was
every where broken up and on the way to recovery.  To my great
mortification, I lost sight of my patient at this interesting moment,
and did not see him for nearly a year.  In June, 1834, he visited
me  again.  He informed me that after giving up his visits last year,
he had gone to Bath  and taken the warm water baths, and thought
his  astonishment would never cease from the abundant and con-
tinued thick peelings he had undergone from the skin.  The result
was  very gratifying; he  had been  perfectly free from all skin 
SQUAMAE--PSORIASIS.
155
complaint, till within a fortnight of the time of his now visiting me.
He had also  grown robust.  On  examining him, I found  all the
large spaces which before had been  occupied  by the disease, of a
darker hue than the other parts of the skin,  but perfectly free  from
heat and itching, and as pliable  as the most  healthy integument.
  During the last fortnight a number of red spots had appeared on
the body and limbs, which  extended rapidly, and became covered
with scales.   Some of the spots  were already as  large as a crown
piece, but none of them occupied the sites of the old disease, and
most of them were only the size of a shilling.  His health had be-
come so good, that he  made no objection to being bled at once, and
I took from  him a pint of  thick buffy blood, the serum of which
was turbid and oily in appearance.   The spots were touched all
over with caustic, the  fume baths were  recommenced, and tl of a
grain of oxidum arsenici was prescribed, night  and  morning; this
was on the 4th of June 1834.  By the 14th"many small spots had
made their appearance, seemingly brought  out by the stimulus  of
the fumigations which he took daily.  These spots, however, were
of no long continuance; some of them indeed were already on the
decline,  all  were  paler and certainly not any  extending.  The
larger spots as before were excited to oozing by the caustic.   24th.
Several of the spots had now disappeared;  others seemed to have
expended their virulence, or passed their height, and looked  of a
brownish red.  The medicine agreed with the patient, but the dose
was not increased, lest by its disturbing the internal functions, he
might be obliged to discontinue the  sulphur fumigations, on which
the ultimate success  of the treatment was mainly placed.   July
24th. The fume baths which had  been taken but irregularly of late-
were now given up entirely, as it  appeared  that the disposition to a
continuance of the disease was subdued, and it seemed probable that
after  the process of desquamation was  completed, all traces  of  its
presence would gradually be lost.   This happened exactly as I had
anticipated;  and all  my  experience in  the disease in  question
(psoriasis diffusa) gives me reason to hope that this maybe the last
attack this gentleman will suffer;  at all events, that  any symptoms
of a recurrence of the disease, if taken in  time, will at  once and
readily yield to a small bleeding, and the  use of the sulphur fume
bath for a fortnight.
   Case 2. A lady of a healthy and florid appearance had been the
subject of psoriasis guttata for four years,during which time she had
never been quite free from the  disease, though  she  had enjoyed a
respite from  the symptoms during the spring and summer months;
paying for this, however, by an aggravation of all her sufferings in
the autumn and winter.  Almost  every point of the surface of the
body of this lady, with the exception of the face, palms of the hands,
and soles of the feet, was covered with red spots, surmounted  by
thin, silvery shining scales;  the itching which attended this eruption
was exceedingly troublesome; the scales  were constantly falling off
and renewing  themselves;  the patient had long been in the habit of
collecting nearly half a wash hand  basin full of these small  scales 
156
GREEN ON DISEASES OF THE SKIN.
 from her bed every morning;  her general  health was good;  the
 pulse full and  strong.  This  lady "had no  want of perspiration
 when excited by exercise.  She came to me intending to commence
 the sulphur fume baths immediately; I advised her first  to take
 some opening medicine and to be bled.
   This done, she began the sulphur fume bath on June 18th, 1834,
 taking one daily.  On the 24th there  was a diffused redness be-
 tween the spots all  over  the  skin, and  the  scales were  gone—
 discontinued the fume bath.   2Sth. Scales  had again formed  all
 over  the body, but so  flimsy in their  nature  as  to appear  thinner
 than  the film that covers  the  white  of a boiled egg]  the  general
 vivid redness had disappeared, and the spots were again more dis-
 tinct; the sulphur fume bath was resumed  daily.  July 4th, The
 whole of the spots again free from scales, and  the general  redness
 of the surface reproduced, accompanied  with  much  itching; I did
 not, however, think it necessary to suspend the baths on this occa-
 sion ; a dose of calomel was ordered at night and a  black draught
 next  morning.   10th. General redness  much abated, itching con-
 tinues, and a numerous crop of red pimples, attended with great
 itching, has appeared  on various parts, particularly on  those that
 are irritated by  the pressure  of the dress.   Again bled to  twelve
 ounces, and the  baths discontinued for  two days.   13th. Pimples
 and redness gone, and itching much abated; the fumigating baths
 resumed, one  being  taken  daily until the 25th. The  skin then
 appeared as it generally does preparatory to a general peeling, and
 all treatment was now left off, the patient considering herself well.
 I rather  expect, however, that before the year is at an end, she may
 S*ive  some slight return of her complaint; it  had existed  for too
 long a period to  allow of any reasonable expectation being enter-
 tained that it would be finally and permanently subdued by a course
 of  treatment that lasted for little more than five weeks,  during
 which time the patient was bled twice, and  took thirty-six fume
 baths.
   I think it unnecessary to quote a greater number of cases either
 of these or of any of the other  varieties of psoriasis.  The local
 varieties  of the disease are in general very readily controlled by the
 means employed in  these more  general  cases.  The  psoriasis
 scrotalis in particular, though generally  regarded as a most obsti-
 nate disease, I have repeatedly succeeded in subduing in the course
 of a fortnight or three weeks, by means of the local  abstraction  of
 blood and the use of the sulphur fume bath.

                         PITYRIASIS.

  Pityriasis, although often rather an obstinate disease, may be
 regarded as the slightest of all the squamous affections of the skin.
 It is characterised by the formation of numbers of small red  spots,
often  scarcely perceptible, from the surface of which a copious fur-
furaceous or remarkably fine desquamation takes place.
  This disease more  frequently appears as a partial  than  as  a 
SQUAMA—PITYRIASIS.
157
 general affection;  by much its most common seat is  the scalp, but
 it also occasionally attacks some of the other regions  covered with
 hair.  The disease is less commonly seen extending over the whole
 or a great portion of the whole surface of the body.   Besides these
 varieties in point  of extent and situation, pityriasis occurs with
 other  peculiarities  in regard to colour.   The number of species
 signalised by pathological writers, on one or other of these grounds,
 amounts to four: pityriasis capitis, pityriasis rubra, pityriasis ver-
 sicolor, and pityriasis nigra.   The disease spoken of by  Bateman
 under the title of pityriasis nigra, is not accompanied by any desqua-
 mation, and was therefore misplaced among  squamous diseases.   I
 have referred it, along with the more recent  continental writers, to
 the order of dischroa or maculae.  Messrs. Cazenave and  Schedel
 have,  however, very lately described a true pityriasis nigra, which
 was observed during the prevalence of an epidemic (acrodynia)  in
 the years 1828 and 1829 at Paris.
   The presence of pityriasis when it attacks the head,—pityriasis
 capitis, is much more frequently inferred from the itchiness with
 which the scalp is  affected, and  the copious furfuraceous  desqua-
 mation that follows the  application of the  nails  to  relieve this
 symptom, than from any conspicuous morbid alteration of the sur-
 face of the integument itself.  It is only in fact during the earliest
 stages of the complaint, and by means of a minute inspection of the
 surface of the scalp, that a number of small slightly red superficial
 spots or patches, of an irregular  figure and covered with flimsy
 squamae, are detected.  These patches are shining, dry, and  some-
 what  rough  to the  touch.  The redness  is only  a  temporary
 condition, for  after having desquamated repeatedly, as they do, the
 patches extend and become even paler than the healthy parts around
 them.
  Little spots having these various characters, are frequently ob-
 served on the forehead, cheeks, lips, and chin, especially of young
 people. '
  Pityriasis more rarely attacks extensive  regions of the body.  I
 have known it 5however, continue in a shape that might be held
 quite general,  from youth to a period considerably beyond that of
 puberty, in spite of every variety of treatment  that  could be devised,
 most perseveringly employed.  In this case an  universal pallor
 overspread the person, and the features always became evidently
 puffed  before each attack of the complaint; for the disease was sub-
ject  to periodical  exacerbations, although  it  never disappeared
entirely from the whole of the surfaces affected.   The desquama-
 tion then became extremely copious, and the scales on being rubbed
off',  showed  the  surfaces beneath  them to be  beset with numerous
irregular and slightly rough but not sensibly raised reddish  patches.
 The formation of squamae was not however confined to these ; the
intervening surfaces of integument seemed also to secrete them, so*
that their "production was general.  This variety may be  called
pityriasis diffusa.
  There is another variety of pityriasis occasionally though rarely 
158
GREEN ON DISEASES OF THE SKIN.
met with, which is distinguished, as it is generally seen, by the dull
crimson red colour and oily appearance of the surfaces affected,—
pityriasis rubra.   This form  of the disease  begins in  small spots,
the size  of a split pea, which gradually extend, coalesce, and at
length cover extensive surfaces of  the body.  The first case I saw
of this complaint  extended over the arms, a great portion of the
body, and the whole of the thighs and legs.  The squamae were of
considerable size, thin  and shining, many indeed of extreme thin-
ness, resembling the pellicle that surrounds the sprouting feathers
of a bird; others  were thicker, like the membrane  that lines the
shell of an egg; all of them were curled, and adhering by one ex-
tremity only, and, sticking  out,  actually  gave the  patient the
appearance of being feathered.  In the next case I encountered,
the appearances presented by  the disease were precisely the same,
but it was confined to the upper  extremities.   I have also met with
a third case  in which the disease showed itself only  on the legs.
The unctuous exudation formed a marked feature in the whole of
these three cases.   But this is not a regular concomitant of the
disease, which sometimes occurs without it, and  then the surfaces
affected are harsh and  dry to the touch, instead  of being soft and
pliant,  as they continue, in spite  of the constant formation of squa-
mae,  when it is present.
  When a  certain  extent of surface is affected with a continuous
desquamation,  not of dull  white, but  of  coloured—yellowish
coloured squamae, the affection is entitled  pityriasis versicolor.
Save in the colour of the squamae and of the surfaces  which pro-
duce them, this does not seem to differ from  the  ordinary varieties
of the  disease.  It even bears a stronger  affinity, however, in  all
points  save the one of continuous desquamation, to a disease of
which we shall have occasion to speak by and by among the dischroa.
  The causes of pityriasis are very obscure.  The disease is scarcely
ever accompanied with any appreciable derangement of the general
health, or of the functions of  the abdominal viscera in particular.
In infants and the  aged and bald, among whom it principally affects
the head, it seems often to depend on a neglect of proper  cleanliness.
Occurring on parts of  the face, again, that are covered  with beard,
it is sometimes evidently excited and kept up by the  irritation of
the razor.  Pityriasis rubra has  sometimes been traced  to exposure
to the bright light and  heat of the sun ; it. has occasionally followed
change of  climate ;  the use of acrid and highly seasoned food;
painful impressions of a moral nature, (fee   The conclusion from
all of which is, that the disease occurs under a great variety of cir-
cumstances, each  of which has  in its turn  been regarded as  its
efficient cause.
  Pityriasis may  in general  be esteemed a disease of no great
severity,  although  it often  proves one of long continuance, and lit-
tle under the influence of the remedial agents which have commonly
been prescribed for its relief.  I make this reservation, because there
is one which I know positively to control the disease in all its forms,
namely, the sulphur fume bath. 
SQ.UAM.E—PITYRIASIS.
159
   Pityriasis is distinguished from the  other two principal forms of
 squamous disease by the smaller size and more irregular form of its
 scaly spots, as well as by their being level with  the surface of the
 skin;  it also  differs  essentially from both of these in the inferior
 dimensions and more flimsy texture of its squamae.  A host of dif-
 ferent cutaneous diseases are accompanied in their decline by a fur-
 furaceous desquamation of the  cuticle very similar in  its general
 characters to that which characterises pityriasis.  The antecedence
 of the various and diversified elementary forms  of these affections,
 as of  vesicles, papulae,  &e and  frequently other products of their
 existence, such as discharges, scabs, incrustations, (fee will always
 serve to distinguish these from the particular disease  of which we
 are treating.  Ephelis,  lentigo, chloasma, and the rest of the dis-
 chroa, are distinguished from pityriasis  by the  absence of proper
 furfuraceous   and  often of all  desquamation from  the surfaces
 affected.  The scurf that  frequently  covers  the  upper  and fore
 parts of the  head in young children, is  a different affection from
 pityriasis: it  rather consists  of a  kind  of sebaceous incrustation,
 than of a desquamation of the cuticle consequent on a superficial
 inflammation of the dermis ; and when softened by the application
 of a bread and water poultice, or of a rag  wrung out of warm water,
 and removed by means  of a fine comb, is not in general reproduced
 if cleanliness be duly attended to subsequently.
   The treatment of pityriasis is to be conducted on' the same general
 principles as other cutaneous diseases essentially inflammatory in
 their nature.   Pityriasis capitis is so slight a disease, that it is often
 allowed to take its own course; and the hair being kept of moderate
 length, and regularly brushed with a softish rather than a very
 hard brush, it very generally comes to an end within a few weeks
 or months.  The cure may be accelerated by the occasional use of
 a very weak alkaline wash.
   When the disease spreads extensively over the person, it is de-
 serving of a greater degree of attention.  A gentle course of aperients
 is  frequently  recommended in these circumstances;  the habitual
 use of a light bitter infusion with moderate doses of the sub-carbo-
 nate of potash, combined with frequent immersion in the tepid bath,
 has also been advocated, and is said frequently to cure the disease.
 I have, however, known it much more frequently resist than yield
 to these and various  other  more energetic plans of treatment.   I
 have for example, known the disease of from fifteen to twenty years'
standing, yield to a course of corrosive sublimate in gradually in-
 creased doses, having resisted  every other medicine and method of
 cure enforced.  In another inveterate case I have known this active
preparation fail  to  produce the  slightest benefit.  I am happy to
 say, however, that  I  have never known  one instance of pityriasis
 (and I have had  cases  under my  care  of thirty years' standing)
 which resisted a few exposures  to the sulphur  fume bath.  I am
in the  habit, consequently, after prescribing a gentle aperient for a
few days, to  commence the use  of this  powerful remedial agent
with as little delay as possible, and hitherto with complete success. 
160
GREEN ON DISEASES OF THE SKIN.
  I believe the  same means to  be equally available in pityriasis
rubra.  Of the three cases I have encountered of this rare variety,
I indeed only know the result in the one which was the first I saw,
and happened to be the most severe.  The individual who was the
subject of the disease in this instance, I frequently meet in the street,
and he assures me he has continued well  ever since he ceased to
visit me professionally, now many years ago.  I presume the other
two patients also recovered, as, after taking the bath a  few  times
and improving greatly, they ceased their attendance on me, and  I
have neither seen nor heard any thing of them since.
  I have little  to  add with  regard to the treatment of pityriasis
versicolor.  This is also rather an inveterate form of disease under
the usual plans of treatment, and without the powerful aid afforded
by the sulphur fume bath.  With this  it is much  more under our
control.  When the nature of this variety, and its near affinity to
the ephelidae, or simple staining of the cuticle and pigmentary mem-
brane beneath it, are considered, we may suppose that  it is but  little
under the influence  of therapeutic agents generally, which,  how-
ever potently they may act upon  the organs  that are  more largely
endowed with vitality, cannot be supposed to possess, and indeed
do not possess, much power over those that  are almost abstracted
from the influence of the vital  processes.   We have in  fact no
medicine either external or internal upon which we can depend for
producing such a complete desquamation and renewal of the cuticle
as is accomplished by the sulphur fume bath;  and, as I have already
hinted in  several places, it is probably by reason  of this peculiar
property that the  remedy in question proves advantageous  in a
great many forms  of cutaneous disease, more especially in the one
which has just engaged our particular attention.
                        TUBERCULA.

  The diseases which have been classed under this head are of the
most dissimilar nature and tendencies.  This  may be said even in
regard to the restricted list contained  in the table of this compen-
dium ; it was, however, much more applicable to the catalogue of
tubercular cutaneous diseases given by Willan, Bateman, and their
followers, which included Acne, Sycosis, Furunculus, Anthrax,
Verruca, (fee in addition to Lupus, Elephantiasis  Graeca, Fram-
bcesia, Molluscum, and Cancer.
  \n the more limited signification attached to the word tubercle,
by recent and  original writers on affections of the  skin, it  is as-
sumed as  designating small, primary, solid,  circumscribed,  and
enduring tumours of various sizes, developed in the substance of the
integuments, the natural tendency of  which is to suppuration or
ulceration of an obstinate and generally destructive kind.
  This definition of course excludes  the secondary indurations of
acne,  rosacea, sycosis, &e the diffused hardness which is the mere
accidental concomitant of the furuncular inflammations, (fee 
TUBERCULA.                      161
    The class of tubercula as it now  stands, comprehends some of
 the most formidable though  not the most  frequently occurring
 diseases to which the body of man is subject.   All  have not, how-
 ever, the same fatal bearing on the life of those attacked by them.
 Molluscum in one of its forms, at least, is even a trifling disease; in
 the other it is sufficiently rebellious.  Framboesia is  not in general a
 dangerous disease.   Lupus, although it may not commonly bring
 life into danger, often produces such deformity as unfits its victims
 from appearing in the world, and makes existence a load instead of
 a blessing.  The destructive  influences of cancer  are  universally
 known, and Greek elephantiasis is a disease which  almost invaria-
 bly brings its victims to the grave at  an early age.
    The tubercles in some of the species of the  order occur in small
 numbers and  isolated, as in cancer; in others they are commonly
 numerous, and clustered together as in framboesia, and occasionally
 in lupus.  They are of the general colour of  the skin in one case,
 until they become inflamed and approach suppuration or ulceration ;
 in another, they are red or reddish from their first appearance, as in
 framboesia; and in a  third, they have a peculiar tawny or livid tint,
 as in elephantiasis.
   Tubercular  diseases  are essentially chronic  in  their  nature.
 Most of them remain for several weeks, months, and even  years,
 stationary; and some continue  through the whole of a long  life
 without undergoing farther change.  When  they do become excited,
 however, they commonly increase rapidly in growth; they then
 very generally fall into a state of partial softening first, and next of
 ulceration on their summits, when they become covered  with scabs
 of considerable thickness; these after  a time are detached, and  ex-
 pose sores  of bad character.   The incrustations are occasionally
 thin, adhere very intimately to the  parts beneath  them,  and when
 detached by art, an excoriated rather than a proper ulcerated surface
 meets the eye.
   The  different forms of tubercular disease are not commonly pre-
 ceded, nor even accompanied, during  a considerable period of their
 existence  at least, with  any  thing like marked disturbance  of the
 general system.  The affections of the gastric  and pulmonary
 organs, which  occur  in  the latter stages  of elephantiasis, may be
 held rather as complications,—as evidences that  the disease  has
 extended  to  the  mucous membranes of these systems, than  as
 sympathetic and  functional disorders  proclamatory  of a morbid
 condition  of the economy at  large.
   The  causes  of the tubercular diseases  are extremely obscure.
 Two of these are contagious—framboesia and one species of mollus-
 cum; and one—elephantiasis, which is at  the present day seen
 with extreme rarity within the  confines of Europe, in the middle
 ages spread over  each of its empires like  a  pestilence, and was
universally believed  to be communicated  from one individual to
another; a character  which the disease, as it now  occurs, has
certainly lost.  The disposition to the whole of them is probably
transmitted hereditarily.   When they  arise spontaneously, as they
       7—a                                      grn 11 
162
GREEN ON DISEASES OF THE SKIN.
most commonly do,  all we can say is, that  they are engendered
under the influence of peculiarities of constitution, the nature of
which, in the present state of our knowledge, is inscrutable.  Lupus
is very generally seen affecting individuals of a scrofulous consti-
tution.  Tubercular elephantiasis and framboesia are scarcely seen
save in  countries lying within  the  tropics, or in  individuals who
have long dwelt in these regions.
  The tubercular affections are easily distinguished from  all the
other forms of cutaneous disease; and each of them individually
has something in its general appearance and attendant  symptoms
so pectiliar, that it is  not even liable to be mistaken for any other of
the same order.  The  definition  that  has been  given  of  the
elementary form of the class,—small, solid, circumscribed,  and
enduring  tumours, having a natural tendency to disorganisation,
suffices to distinguish it from the various other orders of cutaneous
affection.
  Treatment, the  end and  aim of all pathological  enquiry,  has
unfortunately hitherto proved  of little  avail in  the majority of
the tubercular affections.  Of those that are oftenest seen  in  this
country, lupus  appears to be  in the greatest degree  within  the
influence of remedial measures; but this is not saying much; for
the tubercles  and the destructive ulceration that succeeds them
almost invariably advance unchecked to  the extent  of  producing
great and  irremediable deformity.   The  tubercles  of  cutaneous
cancer,  if  removed  with  the  knife or caustic,  the  only means
hitherto devised for their cure, very commonly either sprout afresh,
or appear in some new situation.  All the measures that have been
employed in Greek elephantiasis would seem  to  have been utterly
useless in arresting it.  The little tumours of molluscum also very
generally resist all the remedies prescribed.  Luckily the rebellious
nature of this disease is of less consequence, for it is not dangerous,
though often  productive of a very considerable amount of deformity.

                            LUPUS.

  Lupus very commonly begins on some part of the face, in the
shape of one or  more hard, circumscribed, and slightly  raised
tubercles, of a dusky or livid red colour, and in general of no great
size, though  occasionally of considerable dimensions,  even from
the moment  they attract  attention.  These, after remaining indo-
lent or stationary for any  length of time, extremely various in its
duration, terminate for the  most part in suppuration, when dirty
yellowish,  dark brown, or black, and very adherent incrustations
succeed, under  which a process of destructive ulceration  is esta-
blished.
  This, however, would appear not to be  the only mode in  which
this formidable disease  commences  its  attacks.   M.  Biett,  and
others, for instance, do not believe that tubercles are the elementary
lesions  in  every case of lupus;  and it is certain that the  disease
occasionally  begins in the nasal fossae, and is attended at first with 
TUBERCULA—LUPUS.                  163
simple external redness, and swelling of the alae  and extremity of
the nose.   By and by a thin scab is perceived  on  some point of the
inside or edge of the  nostril;  this is  usually picked off by  the
patient, and  is succeeded by a second,  this by a third, and  so  on,
each  thicker and attended with a more manifest loss of substance
than the last; for the destructive tendencies of the disease appear at
once.  Something of the same kind is even occasionally observed to
occur when the disease begins externally;  a particular spot (in  the
vast majority of instances this is the tip or ala of the nose)  swells
slightly, assumes a livid red colour, which increases gradually in
intensity, generally for several  months before evidence of other
mischief appears; but  by and by the inflamed  integument gives
way in  a  point,  often  of  very small  dimensions;  here a little
glutinous ichor exudes, a dark  and adhering  scab is formed, and
the destructive ulceration  which  forms the  natural tendency of
lupus  forthwith  commences its ravages.  It  sometimes happens,
indeed, that  under circumstances  similar to those just  described,
the skin is destroyed by a process of interstitial  absorption  rather
than of open ulceration ; the livid redness and swelling  that have
long indicated  the existence of  diseased action subside gradually,
and  then the skin is perceived  to be unusually thin, shining, and
stretched over  the subjacent parts, so  that the point of the nose
looks as if it had been sharpened by having had a portion of its
substance pared off superficially; occasionally, too, the puckering
of a distinct  cicatrice is evident in a situation where no sore had
ever existed.
  For practical purposes, and in conformity with what is observed
in the progress of the disease under the  various aspects it assumes.
M.  Biett divides  lupus into three principal  varieties:  first, as it
extends  its ravages superficially ;  second, as it attacks parts in  the
direction of their thickness  or depth ; third, as it is attended with
thickening or hypertrophy of the parts affected.
  The first of these  varieties is more particularly seen attacking
the cheeks, and is not uniformly  attended in  the commencement
with the formation of  evident  tubercles.  The skin of the parts
affected acquires  a dusky  red colour,  and is tense, smooth, and
shining, a slight epidermic exfoliation goes on  from its surface, and
by anoTby it presents all the appearances of a part that has cica-
trised after a  burn which has implicated the most superficial layers
of the corion alone.  The  redness disappears as the disease sub-
sides, and  the integument  then continues smooth to  the  touch,
shining  to the eye, and evidently reduced  in  thickness.   This
morbid process goes on  without the accompaniment of much pain ;
a slight degree of uneasiness is all  that is commonly complained of.
  This variety of lupus, however, commences in other, and, as I
believe, the great majority  of cases, with the evolution of very
evident tubercles. These are at first small, soft,  superficial, being
apparently developed in the outermost  reticulations of the corion,
and of a dusky red colour.   After  continuing stationary for a time,
which may extend to a few  weeks only, or be  protracted to several
                                                grn 11* 
164
GREEN ON DISEASES OF THE SKIN.
months, or even  years, these tubercles generally become irritable
on a sudden,  then enlarge  considerably by  the swelling  of the
parts around them, and seem to coalesce by their bases ; they also
increase  rapidly  in  numbers,  and over a considerable extent of
surface—the whole of the extremity of the nose, or of one  cheek,
for instance, is in this way converted into a  lobulated, indurated,
thickened mass; of a  dusky  red hue.  The most elevated  points,
together  or  successively, or  a  considerable extent  of the affected
surface simultaneously, next  falls into a state of suppuration, when
black and adhering scabs are formed, under which ulceration com-
mences, and this  spreading gradually around,  destroys in a greater
or less degree the surfaces  upon  which it is established.   In this
process, the parts first affected heal  imperfectly; tender pink, or
bluish and irregular cicatrices, similar to those  that  follow super-
ficial burns, succeed the open  or  incrusted sores, from the middle
of which dull white  bands may  often be seen  stretching  to a
tubercle of recent formation,  or to such parts as are still the  seat of
the disease  in its active state.  These bands are very apt to  give
way, when the tubercles to which  they so often  run become open
sores;  the ulceration  then  reverts upon them, and  they vanish
with extreme rapidity, so  that the  disease, though apparently
much amended,  is often  in the  course of a few days  made to
assume an aspect as formidable as  ever.
  Once fairly established, this variety of lupus frequently extends
its ravages  widely;  fresh  tubercles  are  incessantly developed
around the edges of those districts that have already  suffered, and
these, as  they fall into a state of suppuration one after  another,
lead  the  disease  to  attack  new parts, and by exciting  renewed
ulceration in the  bands of cicatrice that connect them with the old
seat of the  malady, continue  it among those that have already
been affected.
  It  may readily be imagined that these morbid processes  do not
take place without occasioning a great degree  of deformity: exten-
sive  surfaces are  occupied  by broad, puckered, and shining cica-
trices, of a pale  pink or rosy colour, stretched tightly  over the
subjacent parts, being  thick in some  places, in others so thin as to
appear translucent.   Nor is the ulceration always so  superficial as
it has been described;  when  the nose is attacked, as it is occasion-
ally in this variety, it rarely escapes mutilation ;  portions of its aloe
or its tip being very generally found to have disappeared when the
incrustations are  removed, and the course of the disease is checked
by the successful use of remedial means.
  This  variety  of lupus,  as  has been said, is most frequently
observed  on the  cheeks;  from these it spreads extensively to the
regions around,  and  sometimes implicates the whole front of the
neck.  It also occurs on the chest,  and occasionally on the ex-
tremities.
  The second variety of lupus, in  which parts are destroyed in the
direction of their thickness much more than in that of their super-
ficies, affects  the nose particularly.   The first indication of the 
TUBERCULA—LUPUS.                  165
disease is generally the appearance of one or more tubercles on the
alae or tip of the nose, smooth, soft, and of a dusky red, which,
after remaining indolent for a variable  length of time, degenerate
into a  crusted sore, that causes the  destruction of the parts upon
which  it is seated.  In other instances, the disease seems to make its
first attack with redness and swelling of the end and alae of the
nose, and some slight discharge from the nostrils.  In the midst of
the parts thus affected a small sore appears, or rather the presence
of a dark-coloured scab proclaims that  an ulcer has been formed.
The redness  and  puffing now generally extend; the scab also
increases in dimensions, until at length the extremity and both of
the alae of the  nose are  often covered  with one  continuous black
and adhering incrustation.
   Even  when  the  first scab that is formed is removed, attentive
examination detects a certain  loss  of substance,  which  becomes
much  more remarkable  after two or three have been successively
detached, especially if at  the same  time the puffing have subsided
under  the  influence  of appropriate treatment.   As the  disease
advances, the discharge from the nostrils frequently becomes offen-
sive ;  the secretion poured out by the sore is simply sero-purulent
and glutinous ; occasionally it is pretty copious, at other times
scanty.
   The extent of parts destroyed by the disease in this  its earliest
stage  of ulceration  is extremely  various; sometimes it is very
trifling,  little more than the skin having suffered, and again it is
rather  considerable, portions of the  cartilage, of the alae and tip of
the nose, having disappeared.  But  the morbid processes of lupus
rarely end here: numbers  of  tubercles are  evolved around  the
margins of the primary sore,  or on the surface  of the  imperfect
cicatrice  that has followed it, and  these in succession suppurate
and decline into unhealthy and phagedenic ulcers, which gradu-
ally destroy the whole of the tegumentary and cartilaginous struc-
tures of the nose,  the septum included, to the  level of the ossa
nasi, and the ascending  or nasal processes of the superior maxil-
lary bones, so  that  a large triangular opening at  length  leads
directly  from the face into the nasal fossae.   If the  process of
destruction have been confined to the alae or point of the nose and
common integument  which  invests  it,  the  deformity is of inferior
amount;  the  nose  looks  sharpened,   the nostril perhaps at first
shows a gap or two of some magnitude, but these gradually con-
tract from the shrinking of the newly-formed cicatrices, and  the
nostrils  then tend  to  complete, or nearly to complete, closure;  for
it is often  with  difficulty that a common probe can be passed
through the opening that remains, unless particular care have been
taken  to prevent the parts from contracting.
   This variety of lupus does not by any means always begin on
the external surface.  Some slight degree  of swelling, and  the
existence of a  scab within the nasal fossae, are often  the  first indi-
cations we receive of its existence.  The disease sometimes even
makes considerable progress, and destroys  the greater portion of 
 166           GREEN ON DISEASES OF THE SKIN.

 the cartilaginous septum before its presence or true nature is sus-
 pected.  Occasionally, too, the mucous  membrane of the floor ot
 the nasal  fossae is the part especially affected; in which case the
 disease is apt to extend backwards, to destroy a portion of the soft
 palate, and subsequently of the roof of the mouth and gums.  It is
 seldom indeed that lupus,- though it may begin in the nose, con-
 fines its ravages to this part; the disease almost always extends to
 the cheeks, some portions of which are commonly destroyed before
 its progress can be arrested.
   The third variety of lupus distinguished by M. Biett, lupus with
 hypertrophy, is almost confined to the face, where it begins in the
 shape of soft, slightly prominent,  and indolent tubercles, generally
 numerous, and developed  simultaneously  over a considerable ex-
 tent of surface.  The  bases of  these tubercles after a time begin to
 enlarge,  and  the surrounding  skin and  cellular  substance swell,
 apparently  from  the  infiltration of  a fluid  into  their   meshes.
 These parts then  seem  to rise up  between the tubercles till they
 attain their level, when the tubercles appear  to stud the  affected
 regions as it were  with spots of a dark  red hue.  The  tubercles in
 this ,variety  of lupus seldom  ulcerate or become covered with
 adhering crusts;  they desquamate freely, however,  and  many of
 them,  in the progress of the disease, shrink and  are removed by
 interstitial  absorption, by  which  means  numerous cicatrices at
 length result, and appear stretching hither and thither in the midst
 of  those  tubercles  which are of more recent  formation and  still
 continue at their height.   The features under these circumstances
 are sometimes enormously enlarged, and deformity  of the most
 hideous description is produced.
   The lupus  with  hypertrophy,  as  has  been  said,  is  seldom
 attended  with much ulceration, and when it is, this is  slight  and
 insignificant; but it happens occasionally that  the disease ulcerates
 more decidedly, and that  the  sores become  covered  with small,
 soft, fungous-looking, and very  prominent red  tumours, which add
 immensely to the deformity, already very great.
  The whole  of these  different varieties of lupus, it is very neces-
 sary to be  aware,  may,  and commonly do, exist together in the
 same  subject; indeed,  it may even be stated that any one of them
 occurring individually and unmixed is a rarity; the disease almost
 uniformly shows a disposition  to extend superficially in one part,
 whilst in another it destroys all the structures that lie between the
 surface and the bone, and in a third the tubercles are evolved amid
 much  swelling and apparent enlargement of the subjacent and
 surrounding structures.  The'skin is the tissue which of all others
 generally  suffers  most.  The cartilages  of the nose come next.
 The bones are much more rarely affected.   The disease, unopposed
by every thing like adequate remedial  measures, frequently exists
 for  years without  any apparent destruction of the osseous frame
supporting  the parts which are  the seat of its ravages.   The ossa
nasi do, however, suffer occasionally.
  The total  destruction  of the nose is a sufficiently  deplorable 
TUBERCULA—LUPUS.
167
effect of the continued existence of lupus ; but when large portions
of the lips, and still more of the  eyelids, are removed, the conse-
quences are  lamentable in a tenfold  degree.  When  the  lip, espe-
cially  the  lower  one, is  extensively destroyed in this  way, the
patient is harassed and distressad by the  constant flow of saliva
from his mouth, and by the difficulty he experiences in masticating
his food and in  articulating so  as  to  make  himself understood.
When either of the eyelids is destroyed to a considerable extent,
the patient's cheek is scalded  by the passage of the tears over it,
and the conjunctiva, no longer adequately  protected, soon becomes
inflamed,  the cornea grows dim and then opaque,  and often
staphylomatous,  so that"irremediable blindness follows.  Each of
these lamentable accidents  is in many cases remediable to a greater
or less extent by means of a surgical  operation.  Great freedom
especially may be used in bringing parts of the lips together which
are naturally at a considerable  distance  from each other; and the
whole of the lower lip  has even been  successfully  supplied by a
flap turned up from under the edge of the  jaw.  The same thing
has also been attempted, though with much less success, in regard
to a lost eyelid.
   The causes of lupus are little  known.  The  disease  is seen
among children and the youthful most frequently.  Young persons
of a scrofulous habit have been  believed  to be more particularly
liable  to  become  its victims.   But as individuals of the soundest
constitution,  in the  prime of life, and in the habitual and  present
enjoyment of perfect  health, are occasionally attacked, such con-
clusions  are shown to  have  been  arrived at hastily.  It is very
remarkable, too, that a disease so formidable in  its  tendencies as
lupus, and so rebellious to remedial measures,  should  occur and
continue its  ravages  for months, and even for years, without any
perceptible  deterioration   of the  general health—without  the
slightest  acceleration of pulse, implication of the secreting func-
tions, or disturbance of the chylopoietic viscera.
   Lupus, although  its individual characters bear a considerable
resemblance to those of several other diseases of the  integument, is
nevertheless little liable to be confounded with any one of them.
The  livid  or dusky  red colour of its tubercles suffices to distin-
guish them from those of Greek elephantiasis, which  commonly
preserve the same tawny tint as the surfaces upon which they are
evolved.  Lupus  is generally confined to  a single part  or  district,
and often occurs as a single tubercle ;  elephantiasis always shows
itself upon  different  regions simultaneously or successively.  In
lupus, the  ulceration soon  spreads beyond  the  confines of the
tubercle  originally affected;  in  elephantiasis it does not extend
beyond the new formation.   Lupus is unaccompanied with general
symptoms of the slightest  significance; Greek elephantiasis, when
it has attained any  degree  of severity, is regularly complicated
with  affections  of  the  respiratory and  often  of  the  digestive
apparatus, that eventually  prove of more importance than the dis-
ease of the common integument. 
 168            GREEN ON DISEASES OF THE SKIN.

   The  tubercles of lupus  may be distinguished from those of
 cancer by being unaccompanied with lancinating pains;  by being
 evolved on the nose and cheeks rather  than on the lips, especially
 the lower lip, like those of cancer; by occurring in youth and  the
 prime of life, not in its meridian and decline, as cancer does;  by its
 sores  becoming covered with dark brown or blackish adhering
 crusts, not showing everted and  callous edges, and a moist secret-
 ing and  fungous  surface, as those of cancer do.  Lupus is farther
 distinguished by the attempts at  reparation so constantly observed
 accompanying the destructive processes that characterise the dis-
 ease, whilst in cancer the acts are all destructive.
   The primary tubercles of lupus differ from the secondary  indu-
 rations of acne rosacea, and sycosis,  m having  been  gradually
 evolved within the substance of the  skin, and not appearing  as
 consequences of the small  acuminated  pustules that characterise
 these diseases.   The indurations of acne, moreover, are stationary,
 they  do  not tend to  ulceration; this,  on the  contrary, or the
 peculiar  interstitial absorption  which is followed by a puckered
 cicatrice, is the constant termination of the tubercles of lupus.
   The distinction of lupus  from  certain forms of syphilitic erup-
 tion, is one of the most  important points in the diagnosis of this
 disease.   In  the long run there  is seldom any difficulty in distin-
 guishing between the two, but in the beginning the differences are
 less remarkable, and the liability to error is consequently greater.
 The tubercles of lupus,  however, of a dark  vinous or dusky red
 colour, and firm consistency even at a  very early stage of  their
 growth, differ materially and manifestly from  the copper-coloured,
 broader, and softer tubercles of syphilitic origin.  The tendency of
 the tubercles of lupus  to destructive  ulceration  is also different
 from that displayed by those of syphilis,  which exhibit this dispo-
 sition in a much inferior degree.   The ulcers in lupus freed  from
 scabs, are of  the same colour as the tubercles, irregular, and not at
 all tumid; those of syphilis again are foul, their edges sharply cut
 and swollen.   The order in which different  structures  become
 affected, also differs in the  two  diseases.  Lupus  is essentially a
 disease of the skin ; there its ravages generally commence, from
 thence they spread to the cartilages, and only very rarely attain
 the bones.  In  syphilitic affections this succession is reversed : the
 bones are commonly the first parts that suffer, then the cartilages,
 and it is only  when these  have  become carious or are stricken
 with necrosis, that the skin gives away.   Syphilitic tubercles, in  a
 state of ulceration, are  never covered with the black and strongly
 adhering scab that conceals the mischief  in the  course of achieve-
 ment  by lupus. Syphilitic  tubercles, unlike  those of lupus, are
 never  unaccompanied  with symptoms of constitutional disorder,
and by a variety of other effects characteristic of the action of the
 venereal poison upon the system at large, such as a febrile state,
derangement of the secreting  functions  generally, pains in  the
 bones and joints, the presence of nodes, of ulcers in the throat,  &c.
  Lupus  is always  an obstinate  disease, and  seldom gets  well 
TUBERCULA—LUPUS.                  169
without leaving more or less of deformity behind it.  Although the
disease may not bring the life of the patient into danger, the prog-
nosis must consequently be unfavourable.   When the disease is
seen at an early stage of its existence, and well directed and active
measures are taken to cut it short, the amount of deformity it occa-
sions may be very trifling.  It is  generally more serious, as it is
attended with a greater  degree of swelling  or enlargement of the
parts it affects.  And so long as fresh tubercles are evolved around
the old seat  of the disease, and the cicatrices remain bluish  in
colour, and soft and doughy  to the touch, there is  no security
against a renewal of the ulceration, and the destruction of all that
had  been accomplished in guiding the affection to  a close.
  The constitutional treatment of lupus is to be conducted in  con-
formity with the general principles of medical science; there is no
specific for the disease;  so that whatever appears amiss among the
bodily functions, must  be set right,  if possible, by appropriate
medicinal and dietetic  means.  Above all things, patients should
be  supplied  with  wholesome and nutritious food,  in regulated
quantities, and  be  sent  to  live in a pure and bracing air.  If the
constitution be  evidently scrofulous, a seaside residence will often
be found of great advantage; and a course of chalybeates, tonics,
or of the muriate  of baryta,  or  of lime, may be very properly
prescribed.  Arsenical medicines have  also been  strongly recom-
mended  in cases of lupus; but the success  which has attended
their exhibition is very doubtful.
  Our main  reliance in the treatment of  lupus  lies in the perse-
vering use  of topical applications.   These are  of  very various
kinds, but the action  of  almost all that  prove beneficial is similar,
and is that of caustics or escharotics in general.  We have, indeed,
been advised to apply a few leeches  in the  neighbourhood  of a
recently evolved tubercle, and to keep  it covered with emollient
and narcotic cataplasms afterwards, in the hope  of discussing the
induration.   But this practice is not generally followed by success,
and the better mode of proceeding seems to be by the application of
some caustic remedy  at once, to modify the vital actions in the new
formation, and thus either  to accomplish its resolution, or to bring
it to a crisis by inducing suppuration.
  When the  tuberclesof lupus, then, are  still unulcerated, they
may be gently rubbed twice a  day with an  ointment of the proto-
iodide, or  dento-iodide  of mercury, or of the iodide  of sulphur,
which last has been found, in the practice of M. Biett, the  most
active of all resolvents in this disease.  The action of these reme-
dies must be  carefully watched, lest it  go  such lengths as to  do
mischief instead of good.   The  natural tendency of the prepara-
tions of iodine appears to be to excite a certain degree of inflamma-
tion in the structures with which it is brought into contact by fric-
tion.  A certain amount  of this, indicated by increased  redness,
tenderness, and heat,  is  not  to be  dreaded;  on the contrary, it  is
durino- the new action thus aroused that lupus appears  in general
to be more especially benefited, and the  object of the treatment  is 
170
GREEN ON DISEASES OF THE SKIN.
 even  to  call  it into existence.   But if the tubercles continue
 stationary, increase in size, or break out into open sores under the
.use of the preparations of iodine, it is always advisable to suspend
 their use for a time at least, if it perchance become not necessary
 in some cases  to give them up entirely, and  to substitute another
 form of stimulant in their stead.
   Under these circumstances  the animal oil  of  Dippel has occa-
 sionally been found of singular efficacy.  A dossil of lint is dipped
 in the preparation and passed repeatedly over  the  affected surfaces
 once or twice a day, or every other day only, according to the state
 of irritability of the disease.  The nitrate of silver appears to have
 less than its usual efficacy in  modifying  morbid  actions, when
 employed in the treatment of lupus.   In the  earliest stages of the
 disease, however,  this caustic  in solution of some  strength, may
 frequently be  used with  considerable advantage.   In the more
 advanced stages of the affection, it is greatly inferior to the liquor
 hydrargyri nitrici, or liquid super-nitrate of mercury.   The action
 of this solution is very energetic, and  it is  essential that it be not
 applied to too large an extent of surface at any other time,—a space
 the size of a half-crown piece is fully as much as it ought ever to be
 brought into contact with at once.  It is applied in the  same way
 as the animal oil of Dippel, the parts that are covered with incrust-
 ations having been previously freed from them by means of emol-
 lient poultices  and  fomentations.  The  action of this caustic is
 extremely painful;  bnt the suffering is of short continuance.  The
 eschars it produces are generally thrown off in the course of ten,
 twelve, or fourteen days.
   But  experience  has  shown that every  caustic must be held
 second to arsenic in its powers of modifying favourably the morbid
 actions in the formidable disease of which we are treating.  The
 mildest and not the least efficacious form in which  this active
 mineral can be used, appears to be according to the formula known
 in France by the title of  the Powder of M.  Dupuytren.  This
 powder consists of one or two parts of the white oxide of arsenic to
 ninety-eight or ninety-nine of precipitated calomel.   To apply this
 remedy, the parts (and these ought never greatly to exceed a super-
 ficial square inch in extent) must be thoroughly freed from incrust-
 ations,  and, whilst still moist, dusted completely and  rather thickly
 over with the powder, by means  of a dossil  of cotton wool.  This
 caustic is so mild in its  action that it  scarcely excites pain, and is
 very rarely followed by any thing like erythematous or erysipela-
 tous inflammation.   The eschar produced by the compound arse-
 nious acid and calomel powder is always very long of being thrown
 off naturally; its fall ought therefore to be solicited by means of
 softening poultices, the  vapour  douche, (fee, to the end that the
 application may be  repeated.
   The arsenical powder in common use on the continent, entitled
 of Frere Cdme, which consists  of a  mixture  of  white oxide of
 arsenic, cinnabar, and a  little animal charcoal, is a more energetic
 compound, and requires greater caution in its application, than the 
TUBERCULA—LUPUS.
171
powder of Dupuytren.  But it is invaluable in the more formidable
cases of lupus, and frequently proves  our sole and last resource in
checking the destructive career of this  disease.   The arsenical
powder is generally made into a thin paste with a little water, and
spread upon  the surface  freed from scabs which it is designed to
cauterise, by means of a small pliant iron spatula.  The size of the
surfaces covered with this active poison at any one time  must
never exceed that of a shilling.  Employed in this cautious manner,
the use of the arsenical powder is free from all danger.  It is, how-
ever, very constantly followed by local symptoms of greater or less
severity;  but these also are more formidable in appearance than in
reality.  The erysipelas which it excites yields readily to low diet,
a few leeches under the  angle of the jaw, and the  antiphlogistic
regimen generally.
   The actual cautery is now  generally agreed to  be the  least
advisable of all the modes ever recommended for checking diseased
and inducing new and more healthy actions in lupus.   This means,
indeed, often appears to be positively injurious instead of beneficial.
I very  lately saw  the actual cautery applied, at seven  different
times, in a case of lupus, under  the direction of  two eminent sur-
geons, and certainly the practice  was followed  by no good effects.
This formidable therapeutic agent  ought  therefore to be laid  aside
entirely in the treatment of lupus.           .
   Whatever  the form of caustic  employed in the  treatment of
lupus, perseverance and  repeated application are  essential to suc-
cess; and this, not  only for  months but often for years.   It is un-
doubtedly well when we are so fortunate as to cut short and quickly
to cure the disease entirely: but we still do much when we succeed
in merely arresting its  destructive progress; with the lapse of time
the morbid propensities inherent in the constitution  which led to
the formation, and which continue to keep up  the disease, will be
worn out, and it will  ultimately yield to measures which, in the
first instance, would have proved, and which probably did prove,
totally unavailing against it.
   The consequences of lupus, and the deformity it occasions, are
occasionally to be avoided, and  even to be remedied to a certain
extent.   Thus, when the nostrils tend to  close, they must be kept
distended during the shrinking of the cicatrices, and for a length of
time afterwards, by means of sponge tents, or a tube of elastic gum
of proper form.   All endeavours to prevent this contraction, how-
ever, sometimes  prove futile; and it is  then  not amiss  to leave
things alone for a time, until all symptoms of morbid action  have
subsided, and the disease is in every part  well.   The nostrils may
then be re-established  by means of the knife, and proper precau-
tions taken against  their  becoming closed in future, first by wear-
ing an elastic gum tube for a length of time  incessantly, and sub-
sequently by  introducing it for some hours every day, or  every
other day. according to circumstances.
  I have already hinted  at the nature of the operations by means
of which portions of the lips  and  eyelids may be restored, when 
172
GREEN ON DISEASES OF THE SKIN.
they have been unfortunately destroyed.  This does not seem the
place to enter more at large into the discussion of the processes
which are best adapted  and most usually practised  for the accom-
plishment of these important ends; I therefore content myself with
referring to the works of the several eminent modern surgeons  who
have written particularly on the subject.
  The disease generally entitled Greek elephantiasis at the present
day, is characterised by the formation on  different regions of the
body, but especially the face, of many projecting tubercles, various
in size, irregular in shape, soft rather  than hard in consistency,
and of a reddish or livid colour at first, but by and  by of the same
general tint as the integument, in the thickness of which they are
developed.  These tubercles are generally very indolent,  and are
accompanied with a considerable degree of puffing  of the parts on
which they are  evolved, in consequence  of which they  occasion
much deformity.   They tend naturally to suppuration and ulcera-
tion, though they also often disappear by resolution; the ulcers in
which they terminate  never spread, but become covered with an
adhering scab,  under  which cicatrisation  takes place slowly but
pretty certainly.
  The  tubercles of elephantiasis very commonly make their ap-
pearance in the midst of discoloured patches of the skin.   These
in whites are commqnly of a tawny hue, whilst in negroes they are
even blacker than the rest of the integuments.  When  first  per-
ceived,  they are not larger than a grape-stone or a pea,  but they
subsequently attain the size of an almond  or a hazel-nut.   When
fully developed,  they  commonly cause some diminution in  the
sensibility of the skin around them, and this often to such a degree
as to constitute a characteristic feature of the disease; during their
growth, however, they have occasionally been observed to be ac-
companied  with an exaltation  of the sensibility of the  skin, and
parts in their vicinity.
   Of all the parts upon which the tubercles of elephantiasis have
been observed to be evolved, the face and ears are those that are
attacked most frequently.  The  disease is sometimes confined to a
very small  district, as to the ears, eyebrows, or  nose.   In other
cases it  is much  more  extensive, and pervades the whole of the
features. In the first instance, the deformity produced is great, in
the second it is hideous, and has procured for the  disease some of
the titles by which it has at different times been distinguished, such
as  leontiasis,  satyriasis, <fee   The parts affected  are swollen or
enlarged generally, the forehead  is uneven, and traversed by deep
furrows, the  eyebrows are tuberculated and overhanging, the
nostrils sinuous and dilated, the ears  pendulous and lobulated, the
lips enormously thickened, the chin greatly increased  in size, and
the whole of the surfaces affected unctuous, and tawny to the eye.
   In this state  matters may continue for an  indefinite length of
time.  But no long interval usually elapses before additional symp-
toms make  their appearance.  The tubercles are  also  apt to fall
into a state of ulceration, when sores succeed, of an  unhealthy 
TUCERCULA—LUPUS.
173
aspect, and  pouring out an ichorous fluid, which concretes into
thinner or thicker, brownish or black-coloured incrustations, under
which cicatrices are slowly formed.  The sense of smell becomes
blunted;  that  of touch, too, is  often strangely affected; the  voice
grows husky, and is often entirely lost; the patient is affected with
cough, quick pulse, and is  singularly dejected in spiritSj as well as
weakened in his muscular powers.
  When the disease has reached this pitch of intensity, tubercles
are very commonly found to  have been  formed in the mouth,
where they  very generally  occur in the form of a band, stretching
along the palate from the front teeth to the uvula.  It is more than
probable that a similar  change takes place in the mucous  mem-
brane of the nasal fossae,  and that  the trachea and bronchi  are
affected with an inflammation  of a nature analogous to that which
precedes and  accompanies the formation  of the tubercles in the
skin.   Nor is the disease now  generally seen confined to the face,
or the single region on which  perchance it was first developed.  It
very  commonly makes its appearance on other districts of the body.
The arms, particularly the outer and posterior aspects of the fore-
arms, are very frequently affected.   The palms of the hands, too,
are often much swollen, the whole of the parts composing them
appearing to be thickened  and enlarged.   The lower part of the
thighs, the regions  about the  ankles, and the soles of the feet, are
also  very common seats of the disease.  The sensibility of the
parts affected  in these cases is in  general  greatly impaired.  The
integuments, unctuous  and shining, furrowed by numerous lines
passing  deeply between enormous  flattened tubercles,  and of a
tawny or dusky purple hue, present a very characteristic appear-
ance. The tubercles severally run their  course independently of
each other.
   One very singular effect of elephantiasis is  the  impediment it
seems to oppose to the  growth of the  beard, if the disease occurs
before puberty,  and the  frequency with which it  causes  this
appendage to  be lost, when it  makes its attacks after maturity of
years has been attained.  The tales which are to be found  in  the
older writers of the wonderful influence exerted by this disease on
the sexual organs and propensities, receive no confirmation from the
observations of more modern times.   The unfortunate  individuals
affected with elephantiasis at the present day, appear to be neither
more nor less under the dominion of the  sexual appetite than the
generality of mankind.
   It  is strange that a disease of so severe a kind, and of tendencies
so formidable, as elephantiasis, should generally attain a pitch of
great intensity without any evident disturbance in the functions of
the system  at large.  It is  only, in fact, during the latter stages of
the  disease, and when  it  has existed  for  several years, that the
general  health  begins to suffer; often, even then, apparently from
active, and  it may be accidental, disease of the respiratory apparatus.
   Greek elephantiasis  is  a   disease essentially of  intertropical
climates.  It  has not, so far as I am aware, been observed originat- 
 174           GREEN ON DISEASES OF THE SKIN.

 ing  among the  inhabitants of the more temperate climates of
 Europe, who had never  quitted their  homes.  But it  has been
 known to  occur  among the natives of these  countries, who  had
 either themselves visited intertropical latitudes, or were  sprung of
 parents who had  long dwelt in the European  colonies, established
 in the East or West Indies.   The disease is endemical, though not
 very frequent, in  the West Indies, at New Orleans, in Guadaloupe,
 St. Domingo, and the Leeward Islands; in many parts of the East,
 as in Sumatra, Java, Isle of France, (fee.  The disease is certainly
 not contagious, and at  the present  day is never even imagined to
 be communicable from one individual to another;  in this respect,
 therefore, it is very different  from the elephantiasis,  or Greek
 leprosy, which prevailed so generally in Europe during the middle
 ages, and was universally held to be highly contagious.   That the
 liability to this disease, as to so many others,  is transmitted from
 sire to son, there can be  little  doubt.  The causes  under  the
 influence of which the disease is primarily engendered are obscure.
 A hot and  moist climate and a sea-bound shore would seem to form
 important elements in its etiology.
   The disease which has now been  described  under the name of
 elephantiasis,  has been  designated  at  different  times   by  other
 denominations, particularly by that  of lepra.   The  term elephan-
 tiasis has also been appropriated to another affection of a very dif-
 ferent nature and  dissimilar tendency. Hence has arisen confusion
 to a great  amount, but still more in semblance than  in reality; for
 how was it possible to confound the squamous affection  we have
 discussed under the title of lepra, with the tubercular one that has
just engaged  our attention? Two  different diseases were merely
 designated by the same title.  The  two diseases entitled elephan-
tiasis, again, have nothing in common but the  swelling or enlarge-
 ment of the parts  affected; on this score, their  confusion one with
 another was excusable, but on no ground else.   The Arabian ele-
 phantiasis  appears originally to be  a  simple  hypertrophy of the
 subcutaneous cellular membrane, generally of  the leg or scrotum,
 to which the skin at first is a stranger, but in which it participates
 at length.   It is a very different disease, therefore, and  easily dis-
 tinguished from  the tubercular affection  that now particularly
 engages us under the title of Greek elephantiasis.
  The tubercles  of Greek elephantiasis are readily distinguished
from  those  of cancer, inasmuch as they occur almost invariably
clustered in considerable numbers, and not singly; further in being
 free from uneasiness, or accompanied with  diminished sensibility,
 and not the seat of acute lancinating  pains; lastly, in presenting a
tawny colour on the surface, not exhibiting the common tint of the
integuments, like those of cancer.  They are not more liable to be
 confounded with those of lupus, which are  of a dusky or livid red,
flattened form, generally larger size, and situated more superficially.
Advanced  to a state of ulceration,  the  diagnosis between Greek
elephantiasis and either of the diseases mentioned, is not rendered
more difficult.  The ulcers in each of them  have characters so 
TUBERCULA—LUPUS.
175
individual, that there is no mistaking those of the one affection for
those of the other.
   Considerable difficulty has ben presumed to exist in discriminat-
ing at all times  between the tubercles of secondary syphilis and
Greek elephantiasis.  But this is more in imagination than in fact.
The coppery colour of the syphilitic tubercles, their general or wide
diffusion  over different regions of the body,  the occurrence of
primary sores, bubos,  (fee,  the previous  history of the patient's
sufferings, and  the  coincidence of several  other  symptoms  of
venereal infection, contrasted  with the appearances presented in
elephantiasis, and the circumstances under which this disease is
developed, can never leave any thing  like doubt or  obscurity in
regard to the diagnosis.  I say nothing of the test afforded by the
influence  of the  curative measures employed;  the diagnosis that
follows results to which it should have served as a guide, is arrived
at rather late in the day to be of much real value.
   The prognosis in Greek elephantiasis is always unfavourable;
doubts even  hang about the few  cases  that are reported to have
been  benefited by the various courses of treatment prescribed—the
amendment in these was probably no more than temporary; for it
is certain  that the vast majority, if not the whole, of the cases which
have  been watched  for a sufficient  length  of  time, by the  enlight-
ened  practitioners of these latter days, have  terminated   fatally.
The organs of voice, and next those of respiration and of digestion,
almost uniformly become affected at length, and patients are then
hurried off by a chronic inflammation of  the lungs or  its conse-
quences, by phthisis, or by a slow  fever, apparently depending on
inflammation and disorganisation  of the  mucous linings of the
alimentary canal.
   What can be said  that will prove satisfactory in  regard to the
treatment of a disease so little understood in its nature and causes
as elephantiasis?  One  of the  facts, the  best  ascertained in the
history of the disease, is its  origin  within intertropical countries.
It seems natural  therefore  to  imagine  that removal  beyond the
sphere of those influences under which  it  is  engendered ought to
be prescribed  as the  first and most  important  of all the measures
likely to check it in its career.
   Of all internal  remedies those of a sudorific and alterative nature,
as they are  termed,  such as decoction  of sarsaparilla, of mezereon
bark,  and of the woods, have  been most frequently  tried.  The
tincture of cantharides in graduated doses is  another  and  a very
energetic  medicine that has been  often essayed in elephantiasis.
The preparations of arsenic, however, have long enjoyed the high-
est reputation for their powers in accomplishing the resolution of
the tubercles  characteristic of the disease. The asiatic pills and
Fowlers solution are the forms  in  which  this active mineral  has
been and is still usually prescribed.  The preparations of iodine, it
is probable, will be extensively tested before long  in their powers
upon  elephantiasis, by the practitioners of those countries in which
the disease occurs more commonly than it does in Europe. 
176
GREEN ON DISEASES ON THE SKIN.
   The most signal improvement that is ever observed to happen in
the tubercles of elephantiasis has occurred after attacks  of erysi-
pelas of the parts where they were evolved.  No wonder, then, that
it  has been the object with many, by  means  of stimulating  or
escharotic  applications, to arouse the seat of the disease to an
action as similar in  kind as possible to  that which distinguishes
erysipelas.   Blisters  have been  recommended  for  this  purpose,
under the sanction of the name of Biett.   The repeated inunction
of one of the iodated  ointments has been  lately used with various
success in  the  same intention.   The  arsenical paste is  another
powerful means of bringing the  tubercles of elephantiasis into .a
condition that  either leads to their resolution,  or destruction by
suppuration.  The experiments that have been  made with the
actual cautery in elephantiasis, prove it also a valuable means  of
accomplishing the same ends.
   When the disease becomes complicated with evident affections of
the viscera of the thorax or abdomen,  these  must  be  met by
measures as decided as the nature of the exigency and  state of the
patient will admit.  The antiphlogistic  regimen, rest  in  bed, and
the use of some mild diluent, will at all events be proper in every
case.

                           CANCER.

  Cancer of the skin is a disease of frequent occurrence, and as the
aflection then commences primarily in the substance of the dermis
in the shape of a tubercle or tubercles, it evidently requires at  least
a passing notice in this place.
  Cancerous  tubercles commonly occur  singly; they vary in  size
from that of a hemp seed or a small pea, to that of a pigeon's or
pullet's  egg; they are of a  stony hardness, and  in  their earlier
stages at least, of the same  colour  as the skin in their vicinity;
at a later  period they become  livid  on  the  surface, and   sur-
rounded with a ring of inflammation.  They then increase rapidly
in size, give  way externally, and fall into a state of unhealthy
ulceration,  in which the reparative processes are all so faulty  that
cicatrisation rarely or almost never occurs: the  granulations  pro-
duced are fungous growths incapable  of affording the basis of a
sound cicatrix.   Cancerous tubercles can scarcely  ever be said to
be indolent; even from their  first  appearance they are the seat of
sharp lancinating pains, and when they ulcerate, an incessant  sen-
sation of gnawing is added to this symptom greatly increased in
severity.
  Cancerous  ulcers  of the skin are  remarkable  for  their  uneven
and fungous-looking surfaces, and for their hard and everted edges.
They do not secrete proper pus, but pour  out a yellowish or bloody
ichor, that irritates the surrounding surfaces.  When ulceration is
fairly established, it does not  remain confined  to the tubercle, but
spreads to all the parts around it indiscriminately, destroying them
in the same manner as lupus. 
TUBERCULA—CANCER.
177
   The  most common seat  of the  cancerous tubercle is the lip,
 especially the lower one, and the  point or ala of the  nose; but it
 also occurs in various other situations, as on  the scalp, cheek, pre-
 puce, scrotum, and verge of the anus, and may appear on any point
 of the surface of the body.
   The causes of cancer are  unknown.   The occurrence of a single
 cancerous tubercle of the skin is not always to be held as an  indi-
 cation of what is  generally entitled the cancerous diathesis: the
 disease occasionally appears to be accidental and purely local.  At
 other times it is evidently connected with a peculiar morbid state of
 the  constitution at large, and its appearance  as a tubercle  in the
 skin is then but one of a series of pathological phenomena  as cer-
 tain in their fatal tendencies as they are irremediable  by measures
 of art.
   The tubercles of cutaneous cancer are  distinguished from those
 of lupus, Greek elephantiasis, and syphilis, by becoming the seat, at
 an earlier or later period of their growth, of sharp lancinating pains,
 whilst those of the three diseases mentioned  continue unaffected
 with every thing like  severe  pain to the last.   The solitary cancer-
 ous  tubercle of the nose or cheek long continues of the same colour
 as the integuments.  That of lupus, when its  elementary form is a
 single tubercle, and not, as almost invariably  happens, a cluster of
 tubercles, is of a livid  or dark vinous  red  from the beginning.
 Syphilitic tubercles are further distinguished from  those of cuta-
 neous cancer by their coppery colour, their  numbers, and their
 very general diffusion over the body.
   The prognosis in cutaneous cancer  accordingly varies,  and is
 favourable  or unfavourable  in the same degree as  the  disease
 appears  to be local and accidental, or general and constitutional.
 The prognosis in the first instance becomes much more serious if
 the  disease has been  neglected, has been allowed to get  into the
 ulcerated stage, and to contaminate the absorbents and lymphatic
 glandular system in its vicinity.
   Cutaneous cancer is only to be attacked successfully with the
 knife.   All attempts to resolve its tubercles constantly fail;  or they
 cannot, like those of some other affections which occur with the
 same elementary form, be  brought  to an end  by suppuration.
 Cancerous tubercles, and even cancerous  sores, when not of very
 ancient date, of the lips, nose, and cheeks,  are  very frequently
 removed by means of an operation, without the  disease exhibiting
 any  tendency to recur, or to  show itself in  new situations.  The
 result in these cases is different from that obtained when glandular
parts, such as the mamma, are the seat  of cancer; the extirpation
of the diseased mass in these latter instances, toe often proves but a
temporary and partial remedy for  a malady  that is  beyond the
reach of the surgeon's knife.
       7—b                                     grn 12 
178           GREEN ON DISEASES OF THE SKIN.

                         MOLLUSCUM.

  The affection of the skin to which the name of Molluscum is now
generally restricted, is characterised by the  presence of numerous
tubercles varying  in  size between that  of a  pea and that of a
pigeon's egg,  developed  within  the substance  of  the  cutis, and
rounded or flattened in their form, or adhering to its surface by
means of a kind of pedicle when they are  more elongated in  their
shape.
  The fleshy tumours of molluscum are  very indolent, and  often
exist for a life-time without undergoing any evident  change in their
appearance, or proving the source of a single unpleasant symptom.
  By Bateman, molluscum was  divided  into two  species, one of
them contagious, the other non-contagions.  The  non-contagious
form of the disease is that which  has just been described; the con-
tagious  molluscum is  characterised by the occurrence of  hard,
round, and prominent tubercles,  smooth, transparent, and pouring
out from an  orifice on their summits, when compressed, a  little
opake or milky fluid.
  Both are rare diseases,  the contagious form even more so  than
the non-contagious; Bateman never met with but two cases of the
contagious disease, and his account  of it from these leads to the
suspicion  that it consisted  in a morbid enlargement and derange-
ment of the sebaceous follicles, rather than in a tubercular affection
of the proper texture of the cutis  vera. The  contagious molluscum,
or the disease  of the sebaceous follicles  which Bateman described
under that name, has since been seen by Dr. Carswell, as we  learn
from the work of Messrs. Cazenave and Schedel. In Dr. Carswell's
cases, there seemed little reason to doubt of the  contagious nature
of the disease: the subjects of it were an infant at the breast, who
appeared to have caught  it of a brother, who himself contracted it
from a  boy at school.   The nursling's face was the seat of the
affection, and  he  communicated it to his mother, whose  breasts
were the  parts affected,  and also to two  other members of the
family, who were attacked upon their hands.
  There can be no doubt then, but that two  very dissimilar diseases
have been connected under  the common title  of  molluscum  by
Bateman and his followers.  The contagious disease at  least does
not appear to  be  tubercular.   Dr. Rayer has even separated the
affection described as non-contagious molluscum from the group of
tubercula;  for what reason is not very evident.
  The causes of molluscum are quite unknown to  us.  Attention
to its characteristic features, in  contrast  with  those of the  other
forms of tubercular disease,  will  always prevent  it from  being
confounded with any of them.   The  disease  constantly proves
extremely rebellious, and in many instances is quite incurable.
  Little can be said on the treatment of molluscum.  In the only
two cases which I have met with of the  disease, every thing  tried
failed to do any good.  M.  Biett is said  to have succeeded in 
TUBERCULA—FRAMBOESIA.
179
 accomplishing the resolution of the tubercles in one case, in which.
 they occurred  in  great  numbers  over the front of the neck  in a
 young woman after her acouchement, by means of a lotion of the
 sulphate of copper applied repeatedly during the course of the day.
   Bateman believed that he  had seen the contagious molluscum
 improve under the use of arsenical medicines.

                      framboesia;  yaws.

   Considerable differences will be found in the descriptions given
 by different  writers of the  disease entitled  yaws, pian, or fram-
 boesia.   One  represents  it  as  beginning in the  form of small
 red spots similar to flea bites, which gradually assume the form of
 papulae.   A second describes it as papular at first, i. e. as consisting
 of solid elevations containing neither purulent matter nor  fluid of
 any  description  in  their  summits.   A  third,  on the contrary,
 informs  us that  the disease begins  as  true pustules,  filled  with
 opaque and whitish  matter before they burst.  And a  fourth tells
 us that  the disease is  first papular,  then  pustular,  and lastly
 tubercular.   However this may be,  the  disease,  by the common
 testimony of all who have seen it, appears ultimately to be  charac-
 terised by the occurrence of surfaces of various extent, covered with
 indolent  fungoid growths distinct from each other at their summits,
 but connected by their  bases, of a dirty or  pale  red  colour, and
 very similar to a raspberry or mulberry in their general  formation.
 In the case which  Messrs. Cazenave and Schedel had an opportu-
 nity of studying at  the Hopital St. Louis, under the care of Dr.
 Biett, the disease  occupied the whole of the front and  inferior
 district of the thigh,  and seemed to  consist much less of a cluster of
 tumours developed within the substance of the dermis, than of this
 membrane itself in a state of hypertrophy, and covered or chequered
 by a multitude of growths (vegetations).   The surface affected  in
 this way was deprived of its  cuticle; but it does not appear that
 it  was affected with ulceration.  Writers generally agree in de-
 scribing one of the tuberculations or fungoid growths as acquiring
 much larger dimensions than the others, and then falling into a
state of unhealthy ulceration.   This tumour is universally spoken
 of by the negroes, who are the usual subjects of  framboesia, as the
 papa yaw, or mama yaw.
   Framboesia usually follows evident symptoms of constitutional
disturbance of a febrile character.   The disease once  established
may continue for an indefinite length of time without serious injury
to  the general health;  although it would appear that those who
labour under it do habitually  complain of lassitude, and inability to
enter upon or to endure active exertion.
   The disease  is only known to  occur  endemically in Guinea,
and  among the negroes in the West India colonies.  It  would
appear to  be  contagious, and whites do not always  escape the
infection.   I have never met  with the disease in this country.
                                                grn 12* 
ISO           GREEN ON DISEASES OF THE SKIN.

  The internal  medicines of any power  that have been recom-
mended in framboesia are chiefly preparations  of  mercury.  As
external applications, some of the recently introduced compounds
of iodine may probably be found of much service in promoting the
resolution of the tubercles, in the case which M. Biett had under
his charge at the Hopital St. Louis, the actual cautery was the dis-
cutient resorted to, and this was employed  with the  most complete
success.   It is very possible that several escharotics, so much  less
formidable in themselves, yet so generally influential in the promo-
tion of new and  more  healthy processes in the diseased integuments,
might be employed with similar good  effects.  At the head of all
the therapeutic agents of this class we must place the fluid or  acid
nitrate of mercury and the arsenical paste.
                        FURUNCULI.

  The  diseases which have  been ranged  under this  head are
characterised first by the inflammation and subsequently by the
death of one or more of the conical masses of cellular membrane,
which at all points  penetrate the true skin, from its under  to its
outer surface.   Strictly speaking, therefore,  these are diseases  of
the cellular  membrane rather than of the  cutis vera itself.   This
tissue, however, always participates eventually in the inflammation ;
and it therefore seems impossible entirely to overlook the class in a
general  and practical compendium of the diseases of the skin like
this, though its  particular  members are always fully discussed in
systems of surgery, and held to fall within  the  domain of the
surgeon rather than of the physician.
  The class of furunculi is generally described as containing three
species:  Furunculus, boil; Hordeolum, sty;  and  Anthrax, car-
buncle.   Sty seems  often to depend on inflammation of one of the
sebaceous follicles,  situated on  the edge of the eyelids, named
Meibomian glands;  and, although I might have described it here,
without impropriety, either as a modification of boil, or as a special
disease, I think it better to  refer for information on  this generally
trifling affection to the Dictionary of Surgery, by Mr.  S. Cooper,
which is in  every body's hands, or to any good elementary work
on this branch of medicine.
   To boil and carbuncle I have  associated a third  disease, little if
at all known in this country, namely, Malignant  Pustule, or Persian
fire.  This  affection is classed by Dr. Rayer along with the bubo
of the plague, in his order of Inflammations Gangreneuses.  As
sloughing of a portion of cellular membrane is inseparable from the
idea we form even of simple boil, and as a considerable patch of
integument frequently,  nay commonly, sphacelates in  anthrax,  I
have not held it necessary to institute a separate order of gangrenes,
merely for the sake of including  malignant  pustule; the bubo or 
FURUNCULI—FURUNCLE.
181
sloughing abscess that occurs in plague seeming to have no more
to do with the  special diseases of the skin, than the sloughing of
the rims of the ears and tip of the nose occasionally observed in
bad cases of typhoid fever.
  Furuncular  diseases  are  very generally connected with a dis-
turbed state of  the general health.   The rectification of this ought
therefore to be a principal consideration in the treatment.
  Furuncle is never in  itself a dangerous disease, and anthrax not
very commonly so.  Malignant pustule is  more formidable in its
tendencies,  although, when seen early, it is also, in general, very
much within the influence of remedial measures.

                       furuncle; boil.

   The appearance of a common boil is familiar to all, inasmuch as
there is, perhaps, scarcely an individual alive, who has not himself,
at one period of his life or another, been the subject of the disease.
Furuncle is  usually first perceived as a small, hard, conical-shaped
swelling, the size of a large pea, or larger, affected with a peculiar
dull pain, and  situated  most commonly about the buttocks, front of
the abdomen,  nape of the  neck, or axillae, although  it may also
occur on any  other part of the body.  This conical swelling in-
creases rapidly in size; it  becomes of a florid red colour;  its base
extends widely around, and evidently penetrates deeply; the pain
 which accompanies it also becomes  more severe,  and has been
compared to a gimblet piercing the skin, and is frequently distinctly
pulsative.  About  the  fifth or sixth  day the  summit of the cone,
which is now probably larger than  a hen's egg, and  often even
equals a  small tea-cup in size, becomes pointed and white, and by
 and by gives way, when a  very small quantity of bloody purulent
 matter escapes, aud a sloughy piece of cellular membrane is per-
 ceived through the very small opening that has been formed. This
 slough or core of the boil, as it is termed, commonly becomes loose
 about the tenth or twelfth  day, when it is either expelled sponta-
 neously,  or starts out with  the assistance of a slight degree of pres-
 sure on the base of the tumour.   The pain then ceases, the swell-
 ing subsides rapidly, the cavity which the core occupied contracts.
 filfs up,  and, in the course of a few days, a small  cicatrice and a
 slight degree of surrounding  dusky redness  are all the  traces that
 remain of the  disease.
    It rarely happens that one  boil is  all  that  appears.  There is,
 indeed, generally  one  pre-eminent  in size, &e, but  this is  very
 commonly surrounded by what may be called a successive crop of
 tumours of the same description, evolved in  the  vicinity of the
 great one.   These run their  periods  more quickly, and the small
 core they contain is frequently never expelled.
    Boils are most frequent among the  youthful.  Their appearance
  is pretty regularly connected with some evident derangement of the
 chylopoietic viscera.   In this  state of affairs, any accidental irrita- 
 182           GREEN ON DISEASES OF THE SKIN.

 tion of the  skin, such as friction, pressure, (fee, sometimes  proves
 the obvious cause of their development.
   Furuncle is occasionally a  troublesome disease, especially when
 one boil after another is evolved under the influence of a slightly
 deranged state of the  general health.
   It  would appear that the  disease may be checked if the part
 affected be touched freely at a sufficiently early period with nitrate
 of silver.   Discutients of all kinds always prove ineffectual in pre-
 venting its arrival at suppuration.   A soft poultice is therefore the
 best or only good application  to a boil that has passed  its  first or
 earliest stage.   The constitutional disturbance, under the influence
 of which  the  disposition to  the  disease is engendered, must be at-
 tended to, and the stomach and  bowels brought into  a  healthy
 state, by the regulation of the diet and the exhibition of an alterative
 and aperient for a few days.  By such a course, an individual who
 for months shall never have been able to  mount his horse, without
 paying for the act with a boil on his buttock, and a week's confine-
 ment to his  room, will speedily be enabled to ride the whole day,
 not only with  impunity, but with great advantage to his general
 health.

                   anthrax;  carbuncle.

   Anthrax often  begins very much in the  same way as furuncle.
 It then appears as a small, hard,  but rather flat tumour, frequently
 covered with a sanguinolent vesicle or bleb on its surface, of a dusky
 or livid red  colour, and the seat of a sensation of numbness at first,
 rather than of pain.  Frequently the disease appears with much
 larger dimensions, and  the  tumour is already an inch or  more
 across,  before  the patient or those  about him perceive  the  great
 progress it has  made.   Anthrax  generally extends rapidly, and in
 bad cases  may attain  a diameter of from  eight to ten inches in as
 many days.  The swelling is at first everywhere hard and brawny,
 penetrates deeply, and seems firmly rooted to the subjacent tissues.
 In every part  it is of  a deep dusky or livid red, which cannot be
 made to disappear with pressure; the circumference is of a brighter
 hue, which  yields for a moment before  the point of the finger.
 The accompanying pain is generally either dull and  gravative, or
 of a tensive and burning character.
   By and by the centre of the  tumour softens, becomes boggy, and
 evidently contains a fluid mixed with some other more consistent
 matter. Left to itself, the skin covering the tumour becomes  livid,
 thin, and at  length gives way in several points, when a little bloody
 pus is discharged as in furuncle, and the  point of a piece of spha-
 celated cellular membrane is perceived in the orifice.  The  same
 process continues  over  the whole or a considerable extent of the
surface of the tumour, and the several orifices  gradually fall into
one or more of larger dimensions.  The masses of sloughy cellular
 substance thus exposed exhale  a fetid odour, but not of so offensive 
FURUNCULI—ANTHRAX.
183
a description as parts that are stricken with gangrene do.  The
sloughs are gradually detached, when  broad  flaps of the skin
usually appear loosened in the circumference of the swelling, the
discharge, generally laudable in quality, diminishes in quantity, the
surrounding tumefaction and redness subside, the pain abates, the
loose flaps  of skin  become consolidated to the  parts beneath, and
the sore slowly fills up, leaving a very conspicuous, depressed
cicatrice behind it.
  Anthrax  frequently invades without  any precursory signs  of
constitutional disturbance, and these when  they are observed are
seldom of any intensity.  During the progress of the disease, how-
ever, symptoms of a febrile nature set in, and, when the tumour is
extensive, often run high.   The pulse is quick  and the respiration
hurried, the secretions are  suppressed, the appetite destroyed, the
bowels constipated, the urine scanty and high coloured, <fec.
  As furuncle appears to consist in  the inflammation and death of
one of the conical  masses of cellular substance  which  penetrate
the skin, so anthrax  would seem to result from the simultaneous
affection and  sphacelus  of a number, greater or less in proportion
to the extent of the disease, of these processes in  the immediate
vicinity of each other.  Both diseases have the peculiarity of being
developed from within outwards, not from the  more  superficial to
the deeper seated structures, as are the great majority of the cuta-
neous  affections we have already described.
   Furuncle attacks the  youthful, and  occurs principally on  the
anterior surfaces of the body; anthrax appears among adults and
the aged, and shows itself in preference on the posterior parts of the
trunk, as upon the  nape of the neck, the scapular regions,  the pos-
terior  and lateral parietes of the thorax and abdomen, (fee
   Neither furuncle nor carbuncle  are at all liable to be mistaken
for  any other form of cutaneous  affection.  The presence of a
sloughy core  is a peculiarity observed in no  other disease of  the
integuments.
   Anthrax is not in general a very formidable disease.   When it
occurs in an  aged  individual or in a subject of shattered constitu-
tion, however, it is by no means exempt from danger.   When  the
parietes of the thorax  or abdomen are its seat, it  is occasionally
complicated with an inflammation of the lining membranes of these
cavities, and acquires a character of intensity and of danger that is
foreign to  its nature when it occurs without such an accompani-
ment!
   If general  symptoms  were running high in a case of anthrax,
and there were nothing  in  the general appearance or constitution
of the patient to contraindicate the practice, it might be proper to
bleed  from  the arm. Blood-letting, however, will not subdue, to any
extent, the  constitutional disturbance in anthrax, and has even  less
influence on the system and disease itself, than the action of a brisk
aperient.   Rather  than  bleed therefore in the first  instance, it is
better to beo-in by prescribing five grains of calomel combined with 
184
GREEN ON DISEASES OF THE SKIN.
 ten or fifteen of jalap, and the same quantity of cream  of tartar.
 Should this not act within three or four hours, the jalap and cream
 of tartar may be repeated at intervals until it does.
   If the tumour be distinctly formed, and of moderate size, when
 we are  called to a case of anthrax it should immediately be divided
 by a  crucial incision which must penetrate completely through,
 and even extend on each side a little beyond it.   If the swelling be
 very extensive, a greater  number  of incisions must be made; so
 many, in a word,  as  are found necessary to set every part of the
 tumour at liberty.   The  local  bleeding, and the  relaxation of the
 tissues,  strangulated  and stretched  to the  uttermost, that follow
 these incisions, are of the greatest consequence in putting a stop to
 the morbid processes by which  anthrax is induced and continued.
 The pain soon ceases, the sloughs are rapidly detached, and repa-
 ration of the injury done commences immediately, and is achieved
 much more  rapidly than  when the  disease  is allowed to run its
 course  uninterrupted. Add to this, that the  constitutional  and
 febrile disturbance very speedily subsides, and it will be allowed
 that the treatment  of carbuncle  by  means of  incisions, is one of the
 most  evident triumphs of the  healing  art.  The  after-treatment
 consists in the application of a soft  poultice, or of a few folds of rag
 to absorb discharge;  the shreds  of sloughy  cellular membrane
 should be taken away as they become loose, and the pus prevented
 from lodging under the overlapping pieces of integument.  These
 last are  even occasionally  better  removed  with a sweep of the
 scalpel or fine scissors, than left to be slowly  absorbed, or to adhere
 to the parts beneath them still more tardily.  When the carbuncle
 has been situated upon parts whose  motions would  be liable to be
 impeded by  the formation  of  a hard cicatrice over them, or in
 situations where deformity  to a greater or  less amount would  be
 induced  by its  shrinking, great care must  be taken  to  insure its
 regular and proper organisation.
  I think it unnecessary to do  more than hint at the  propriety of
 meeting  the  internal  inflammations  which occasionally and acci-
dentally complicate anthrax, by  the measures appropriate to inflam-
 matory affections generally.

              PUSTULA MALIGNA J PERSIAN FIRE.

  This is a contagious and  gangrenous  inflammation of  the skin,
characterised at the outset by a vesication or  bleb filled with a sero-
sanguinolent  fluid, under which a small lenticular induration is
formed, itself surrounded before long with an erysipelato-phlegmo-
 nous areolar  swelling.  This tumour is next stricken with gan-
grene, which spreads  rapidly from its centre towards its circum-
ference.1

  1 This  is the definition  as given by Dr. Rayer in  his Traite, &c. des Mai.
 de la Peau.  Par. 1827. 
PUSTULA MALIGNA.
185
   Malignant pustule has been thought by some only to arise from
the contact of the matter of the carbuncle of animals, or of the
exuviae or bodies of such as had died when affected with this  dis-
ease.   But it has been pretty well ascertained by others  to arise
primarily in the human subject.
   The disease  begins with a considerable degree of pruritus in a
particular point of the skin ; this is succeeded some hours after-
wards by the formation of a small red spot like the bite of a bug,
which by and by appears covered with a vesicle, the size of a millet
seed at first, but gradually acquires  larger dimensions.  The vesi-
cation, full of sanguinolent serum, soon bursts spontaneously, or is
torn by the nails of the patient.  After between twenty-four  and
thirty-six hours from  the invasion of the disease, a hard, circum-
scribed  lump, uneven on the surface, and of the form and size of a
split pea, is evolved under or in  the seat of the vesication, around
which, as a central point, a yielding but firm swelling, of a  red-
dish or livid  colour, and covered  with secondary  phlyctenae,  is
developed.   The central part next becomes brownish in  colour,
hard, insensible, and gangrenous.  The inflammation extends  to a
considerable distance  around: the skin is red, tense, and shining;
the sub-cutaneous cellular  membrane is  swollen, infiltrated,  and
often  emphysematous; the whole of the  part  affected finally loses
its sensibility, and the gangrene of the centre spreads with rapidity
to the surrounding tissues.
   It may be conceived that this series of morbid acts does not  pro-
ceed unaccompanied by constitutional disturbance, often of a very
severe and dangerous kind.   All the symptoms of typhoid  fever of
the worst description are in fact associated with the  progress of the
local disease,  and these are sometimes so severe, and  the gangrene
so rapid and extensive, that the patient sinks and is  lost within the
first twenty-four hours of his illness.
   When the disease shows a more favourable tendency, an inflamed
circle of a vivid red appears around the gangrenous eschar, a  line
of separation is established between the dead and living parts,  and
the surrounding tumefaction subsides; the pulse at the same  time
acquires volume  and  strength,  and  declines  in frequency;  the
secretions are restored, and the patient feels better.
   Malignant  pustule occurs with every  degree  of severity,  and
may end fatally in the course of twenty-four  hours, or not run its
course, whether favourable or unfavourable, within a considerable
number of days.
   The spreading gangrenous character of malignant pustule, com-
bined with the  various other and accompanying symptoms of the
disease, distinguish it from all known affections of the skin.   In its
earliest  stage, and when covered with a sero-sanguinolent vesicle,
it might be "mistaken for anthrax; but the error would be but of
shorfduration.
   The prognosis in malignant pustule is not in general unfavour-
able.  Unless the disease proceeds rapidly and almost immediately 
186            GREEN ON DISEASES OF THE SKIN.

to a fatal issue, we  are  not without means of controlling  its pro-
gress, and bringing it to a happy termination.
  As in anthrax, a principal measure in the treatment of malignant
pustule is the division  of the  dead and mortifying  parts.  This
must be done completely, but the incisions need not extend beyond
the  structures  actually implicated, inasmuch  as in this  disease
escharotic or caustic applications are found to be powerful correc-
tives of the morbid processes that are going on, and any division of
parts beyond the circle of those immediately affected, without bene-
fiting the disease, causes  the escharotics which are  subsequently
applied to act  more extensively  than is  necessary. When  the
affected parts are freely  divided, then, a dossil of lint dipped in the
fluid acid nitrate of mercury, or liquid  muriate  of antimony, is to
be applied over the whole of the gangrenous surface, and retained
there for some  hours, after which  it is  to be replaced with  turpen-
tine or warm dressings  of any  kind.  If on  the morrow there be
no appearance of an extension  of the disease, if the heat  and pecu-
liar sensations which have hitherto accompanied it have subsided,
there is every likelihood that a  stop has been put to the progress of
the mischief, and that reparative will now take the place of destruc-
tive processes.   If,  on the contrary, the eschar appears  to be sur-
rounded with a  hard and brawny  swelling, and a  diffuse phleg-
mono-erysipelatous circle  of  inflammation,  the disease is  still on
the increase, and renewed incisions and a fresh application  of caus-
tic must be had  recourse to without loss of time ; should the eschar
from its thickness  or dryness  appear to offer any obstacle to the
adequate action of  the caustic, it may very properly be dissected
out.
  As we seldom or never see malignant pustule in Great Britain, I
have little to say on the general or  internal treatment.   Blood-
letting does not seem beneficial ; diluents  and the  antiphlogistic
regimen are the usual prescription on the continent, in  several
countries and districts of which the  disease is of frequent occur-
rence.  1 should think it highly probable that "purgatives, in doses
adequate to  excite  active secretion  from  the  alimentary canal,
would be attended with the  best  effects in  malignant pustule, as
well as in anthrax.
   The cicatrices that result from malignant pustule are of the same
description as those  that follow anthrax, and frequently require the
same management to prevent them from impeding the free  motions
of articulations, and proving the cause of considerable deformity. 
DISEASES
                       APPEARING


UNDER A VARIETY OF ELEMENTARY FORMS.
  Under this head, by far the best and fullest writer of the present
day upon diseases of the  skin, Dr. Rayer, has included Burns,
Chilblains, and  the eruptions consequent on a venereal affection
of the system, which he designates, along with Alibert, Syphilides.
  It does not fall within  my plan to treat of such  accidents as
burns ; neither do I think the place well chosen for the  discussion
of the subject; and to me it looks very like abuse  of  an excellent
system, (that, namely, of reducing the various lesions of the skin to
a number of elementary forms,) to speak of burns as exanthematous,
bullous, gangrenous, (fee, when the appearances presented depend
almost entirely on the degree of stimulation which the  parts injured
have undergone,—a slight scald occasions erythematous redness, a
severe burn induces effusion under the cuticle, and one still more
severe causes the death to a smaller or greater depth of the surfaces
implicated.  The same may be said of chilblain,—the  reaction that
follows the continued application of a low temperature is followed,
in lax and delicate constitutions, by erythematous redness, by vesi-
cation, and by sphacelus or  ulceration.  Had I inclined to discuss
these  subjects, (and  perhaps I ought to have  said a few words on
chilblain,) I should have spoken of them under the head of inflam-
mations of the skin from excess or undue subtraction of the stimu-
lus of heat.   In  the present  chapter I shall confine myself to  the
very interesting class of eruptions developed under the influence of
a constitutional venereal taint, they themselves often proving prin-
cipal sometimes sole evidences of the existence of  this infection of
the system.

                   SYPHILIS.  SYPHILIDE.

  The symptoms of syphilis  are generally spoken of  under  two
distinct  heads, as they  are primary,  and  as  they are  secondary.
The primary symptoms comprise such as follow locally  on  the
inoculation of the venereal poison;  the secondary,  those which
attend upon its absorption into, or action upon, the system at large.
  A natural and very marked division of the primary symptoms of
syphilis is established according as the poison acts, by  inducing a
muco-purulent discharge from the urethra, or surface  of the glans
penis in  the male, from the vagina, and occasionally the urethra, 
188
GREEN ON DISEASES OF THE SKIN.
in the female, or by causing a sore upon some part of the prepuce,
glands, or body of the virile organ, upon some point of the female
labia, or orifice of the vagina.   The first form of venereal affection
is universally known by the title of gonorrhoea or clap; the second,
with all its concomitants, by that of chancre or pox.1
   Great diversity of opinion has prevailed among medical men in
regard to the identity or difference of the  specific causes of these
two very dissimilar forms  of venereal infection.   Into the discus-
sion of this question it were foreign to my purpose,  and to the end
held out in this practical compendium, to enter.   I  shall only
say  that the  weight of evidence and character  of the witnesses,
seem to me decidedly to preponderate on that side which maintains
the identity of the  poison of gonorrhoea and chancre.
   Gonorrhoea is by much the most frequent form of primary vene-
real infection encountered at the present time.  A day or two after
impure sexual intercourse a sense of tickling is felt a short distance
behind the orifice of the urethra, which, on being examined, is
found  to be unusually red, and slightly tumid.  These symptoms,
in a few days more, are followed by a discharge  from the urethra,
scanty and colourless at first, but by and by abundant, and succes-
sively  of a yellowish white and then of a greenish  yellow colour.
The disease  is accompanied with a variety of adventitious symp-
toms, such as scalding in passing water, painful erections, chordee,
<fcc, and attains its height in  from  eight  to  ten days, when the
discharge becomes thick, and begins to diminish in quantity.
   We  have  the direct  testimony of all  the good writers of the
fifteenth and  sixteenth  centuries to the fact of gonorrhoea being, in
their day, one of the common initiatory symptoms of constitutional
syphilis.  This circumstance is brought under  our notice much
less rarely at the present time,  yet there is not wanting abundant
evidence of  secondary  symptoms,  such as  ulcers in the  throat,
coppery eruptions on the skin,  nodes, &e,  having followed simple
gonorrhoea, that is, muco-purulent discharge from the urethra or
vagina, without obvious or suspected solution of continuity.
  Those writers, and particularly Carmichael, who have imagined
and  endeavoured to demonstrate the coincidence  of  peculiar forms
of secondary  eruption along with each individual variety of primary
affection, inform us that the exanthematous  and  the  papular  are
the species of syphilitic eruption which most commonly succeed
gonorrhoea, in the event of  the  disease being followed  by constitu-
tional symptoms.
  The second of the modes in  which the poison of syphilis affects
the system primarily, is  the  production of a  small  pustule which


  11 do not here speak of bubo as a primary symptom of syphilitic infection.
I  do not know that  there  is one perfectly satisfactory  case on record, in
which secondary syphilitic symptoms followed the enlargement  and suppu-
ration of a lymphatic gland in the groin, unpreceded  by sores upon  the
penis, or discharge from the urethra. 
SYPHILIS.                       189
 speedily becomes an  open ulcer upon some part of the external
 organs of generation, most frequently on the glans penis and inner
 surface of the prepuce, in the male, on the labia, clitoris, caruncula
 myrtiformis, (fee, in  the female.   To the sore thus engendered,
 generally within from eight to ten days,  after the date of an impure
 sexual connection,  the  term chancre  has been  long familiarly
 applied.
   Too much attention, it seems to me, has been given to this ulcer,
 and too little to the  primary form of inflammation by which it is
 occasioned.  It is merely by the by and incidentally, as it were,
 that writers speak of the inflamed point and small pustule which
 proclaim the inoculation  of the venereal poison, whilst they exhaust
 whole chapters in the minute description of every varying appear-
 ance presented by the ensuing  ulcer.  Since Mr. Hunter's time,
 too, attempts have commonly been made to confine the title chancre
 to a particular species of sore,—the venereal  sore par excellence,
 the peculiar and specific product of the inoculated venereal poison,
 as the cow-pox pustule is of the inoculation of the vaccine virus,
 whilst every other variety of ulcer occurring on the genital organs,
 in consequence of impure sexual intercourse, is held as a modifica-
 tion of the chancre, and  less truly specific in its  nature.  My own
 conviction is, that the sores engendered upon the organs of genera-
 tion in consequence of impure sexual intercourse, present a variety
 of appearances, exhibit dissimilar tendencies,  and  prove more or
 less apt  to  occasion  secondary  symptoms according to the part
 upon which they are  developed,  to the state of health in which the
 individual affected happens to be at the  time, and to the treatment
 they receive.  The primary form of venereal infection is  a pus-
 tule in every case : and the influence of situation alone, upon  the
 appearance of its consequent ulcer, is made abundantly evident by
 the fact  that, speaking generally, each  variety described has its
 peculiar locality: thus the Hunterian chancre is scarcely seen save
 on  the glans penis;  and, in illustration  of this point, I may here
 state that I have known  one of the most practised eyes deceived,
 and the  acute mind  that saw through  it, proclaim a sore, which
 had been produced by the firm application, a few days previously,
 of a button of  lunar  caustic to the  surface of the part in question,
 as a case of undoubted Hunterian chancre.  All are familiar with
 the fact, that the simple wound or ulcer that was advancing rapidiy
 towards cicatrisation,  assumes an unfavourable or peculiar appear-
 ance on the patient's committing  any accidental imprudence, on his
 bowels becoming deranged, or on his general health suffering in
 any way ;  all know, moreover, that the  injury which in one state
of the system is merely local in its effects, is followed in another by
constitutional disturbance of the most  alarming kind.   I believe
 that it is precisely the same with regard to venereal infection.
  If the immediate consequences of the inoculation of the venereal
poison, or the  primary symptoms of syphilis, as they have been
termed, vary materially,  as they do, the secondary symptoms of 
190
GREEN ON DISEASES OF THE SKIN.
this disease present still greater  and more remarkable  differences.
Yet these, as a whole, form a group so perfectly characteristic, that
in no circumstances do  medical  men  generally feel themselves on
surer ground than when considering  a case of secondary syphilis.
Among the  more striking features of constitutional syphilitic infec-
tion, are the cutaneous eruptions with which it is almost invariably
accompanied.   These form the particular object of our enquiry in
this place.
   The eruptions characteristic of a syphilitic taint of the system,
have certain features imcommon, which distinguish them from cuta-
neous affections of like  elementary forms, but developed under the
influence of ordinary and unspecific irritation.  Among  the  more
remarkable of these must be reckoned the reddish yellow or copper
colour, of varying shades of intensity, of the eruption, the circular
form presented by the particular spots of which it consists, and the
annular  arrangement so commonly assumed  by these when col-
lected into clusters.  The districts of  skin upon which  these erup-
tions generally make their appearance are also  peculiar;  the fore-
head, the face, and particularly the alae of the nose,  the back, and
the shoulders, are the chosen seats of  the  entire class.  The scabs
or incrustations to which they give rise, are also very similar, being
all thick, of a dark greenish or  blackish colour, and furrowed on
the surface.  The general  symptoms  or constitutional disturbance
by which they  are preceded are, further, very similar in kind  and
character:  the patient is out of  health, his complexion is wan, his
skin is sallow,  and  an attack  of inflammatory fever of greater or
less  severity almost invariably  ushers in the  eruption.   As  this
last is a fact of the highest practical importance, I beg particularly
to solicit my reader's attention to its occurrence.  I believe I do not
go too far when I say, that the whole plan of treatment  proper to
be pursued in these cases depends on a true appreciation of the
febrile state which  precedes  them, and  accompanies their earlier
stages; and that all, or a very large proportion of the  mischief
which has  arisen,  and of the  obscurity that still envelopes our
ideas of  secondary  syphilis generally, and  of syphilitic eruptions
especially,  may be fairly ascribed  to  the prescription of mercury
during the acute  febrile  stage of these  affections.   I have  had
repeated occasion to insist on  the  necessity of abating the irritable
and acute inflammatory states of the system in cutaneous diseases
generally, before recurring to the use either of general or of topical
stimulating measures.  The same idea without restriction, is appli-
cable to the treatment of constitutional syphilis, and the cutaneous
eruptions to which  it gives rise.
   As to the diseased states  of the system entitled pseudo-syphilitic,
and the  eruptions generally denominated mercurial,1 I hold them

   ' I here throw out of the account, as may be imagined, the eczema, or
acute vesicular eruption which follows the excitement of a mercurial course
in some rare cases.  Vide p. 76. 
SYPHILIS.
191
to be each as much the effect and  the evidence of a secondary
venereal taint as I believe gonorrhoea and chancre to be indications
of the primary and local action of the syphilitic poison.  The term
pseudo-syphilis is a standing record of 'the ignorance of our imme-
diate predecessors, and even of contemporaries, of the fact that both
primary and  secondary syphilitic symptoms were curable without
the use  of mercury;  or of a  serious medical  error, by which,
through unenlightened attempts  to subdue one  form of local or
constitutional disease by the  exhibition of mercury, another  and
more  formidable  derangement of the system was engrafted upon
that which already existed.  I  do not therefore believe that  any
series of symptoms having a resemblance to those characteristic of
secondary syphilis either were  or can be induced by the use or
abuse of mercury.  The baths of the Hopital St. Louis, at Paris,
are annually  frequented by from five to six hundred individuals,
water-gilders, silverers of mirrors, and  others, who  make  use of
quicksilver in their  handicrafts, on account of illness induced by
the action of  this metal on their  system ;  but not one of these per-
sons is ever seen affected with  ulcers in the  throat, coppery erup-
tions of the  skin, or any other symptom which  we meet with in
those who have fallen into a bad state of health, who have com-
mitted excesses, or behaved imprudently whilst under a mercurial
course for the cure of a venereal affection.  The fact is, that when
the system which is tainted with syphilis becomes deranged under
the use of mercury, the poison continues to exert its specific effects
uninfluenced  by the medicine,  and we have  a new disease super-
added  to that which already existed: the whole  of the  morbid
phenomena thus induced have been grouped together, and desig-
nated by the  title of pseudo-syphilis.
  The  eruptions which arev developed upon the skin under the
influence of a constitutional syphilitic infection,  are distinguished
from each other by presenting a variety of elementary forms; thus
they are exanthematous,  vesicular, bullous, pustular, papular,
squamous, and  tubercular:  into the particular consideration of
each of these  we shall now  enter.
  The exanthematous appears  to  be the  slightest and most  ma-
nageable of all the syphilitic eruptions.  It occurs under two very
distinct forms, one of them acute,—roseola syphilitica, in which a
number  of irregular, frequently confluent, and dingy red  or pale
coppery coloured patches, which  gradually acquire greater depth
of tint, make their appearance during the course  of a single night
upon the trunk and extrernities especially.   These can be made to
vanish slowly under  the pressure of the finger.  The eruption is
accompanied  with a slight degree of pruritus,  and, as is said, with-
out any marked general disturbance of the system, although it is
probable that careful watching would always detect something like
febrile excitement preceding its  appearance.   The patches  are
often  evanescent, scarcely  lasting more than a  day or two witli
their original characters ; in other cases they are  more permanent; 
192
GREEN ON DISEASES OF THE SKIN.
they always leave a dingy stain behind them, which  is of longer
continuance, frequently not being completely effaced until after the
lapse of several months.
  This variety of exanthematous syphilitic eruption  is especially
remarkable from being the only one of the whole tribe of constitu-
tional  or  secondary symptoms  which, at the present  day, is ever
seen occurring at the same  time as those  of a primary nature.
Roseola syphilitica is in fact  occasionally seen  accompanying the
acute  stage of gonorrhoea.   But it also occurs as  a  secondary
symptom of syphilis, several  months after  all traces  of the  local
disease have  disappeared: in  this  case, however,  it  is seldom
observed alone, being almost always complicated with  one or other
of the syphilitic eruptions having a different elementary form.
  Syphilitic roseola is  distinguished  by its dingy and coppery hue
from simple roseola, the patches of which are of a bright and rosy
red.
  The second variety of exanthematous syphilitic eruption  is  of
very common  occurrence, and  is universally spoken  of under the
title of syphilitic blotches, or maculce syphiliticce.   These blotches
are usually pretty well  defined and  of a regular circular  shape.
They begin and spread from a central point of a dusky red till
they attain their full size, which varies between  that of a  silver
three-pence and that of a shilling, and even of a half-crown  piece,
becoming gradually of a deeper and more decided copper colour as
they extend.   These spots seldom or  never run  together; they are
smooth on the surface, and as  soft as the  healthy integument  at
first, but in their later  stages occasionally  become a  little rough,
owing to a slight degree of epidermic exfoliation that takes  place
from them; they can scarcely  be said  to rise  above the  general
level of the surrounding skin; they become paler, but cannot  be
made to disappear  under pressure ; sometimes  they are naturally
paler in the centre than towards the circumference, and sometimes,
though rarely, they present the form of rings.  The coppery colour
of the eruption always proclaims its true  nature, whatever the
variety of appearance it presents in point of form.
  Under  the  influence of rest, abstinence, and  general  dietetic
means, this form of syphilitic eruption after a time begins to abate,
and ends by disappearing entirely.   It very rarely happens that
syphilitic  blotches fall into a state of ulceration ; when  they do it
is probably owing to their accidental complication with some other
form of secondary eruption, such as the pustular.
  The most common seat of the  maculae syphiliticae is the  fore-
head, face, breast,  and  arms;  but they may show themselves on
almost every part of the body.   Whatever is said to the contrary, I
am satisfied that this eruption never makes  its appearance without
having been preceded by restless  nights, quick pulse, foul tongue,
pains in the bones and larger joints, and other symptoms of general
febrile disturbance.
  The vesicular form of secondary syphilitic eruption is very rarely 
SYPHILIS.
193
 seen.   The Messrs.  Cazenave and Schedel,  however, relate the
 history of a case which seems  unequivocal.  The patient,  after
 suffering  from heat in  the  throat and  difficulty in swallowing,
 slight general symptoms,—a little anorexia, and some trifling fits of
 fever, (quelques legers mouvemens febriles,) perceived an eruption
 which extended over the greater part of the body, and consisted of
 a  punctuated effusion under the cuticle of minute quantities of
 transparent serum at considerable intervals from each other.  Some
 of these vesicles were in a nascent state, others were  fully deve-
 loped,  and  others were  declining, when the patient entered the
 Hopital St. Louis, where  the disease was at first mistaken for
 chicken-pox.  M. Biett, however, when he saw the patient, imme-
 diately discovered the greatest resemblance between this eruption
 and two other cases of a  similar kind, which he had met with, of a
 decidedly  syphilitic nature, so that he came to the conclusion that
 this one also was venereal.   The progress of the  disease amply
 confirmed  his diagnosis.  The vesicles  in  fact were  small, sur-
 rounded with a distinct coppery areola, very indolent, accompanied
 with no pain,  scarcely  any appreciable  degree of heat,  and no
 pruritus.  The fluid  they contained  by and by dried up and fell
 off in the  shape of flimsy  scales ; they  every one  left a coppery
 injection of the skin behind them, which presented  all  the charac-
 ters of a syphilitic blotch.  Added to these circumstances, a careful
 inspection  of the fauces gave rise to the discovery of a rounded
 ulcer with a greyish  bottom, sharp  cut  edges, (fee  Little doubt
 therefore remained of  the truly syphilitic nature of the eruption
 under which this patient laboured ;  if this  point could be fairly
 called in question, it  was completely set at rest  by the whole of
 the body a month afterwards becoming  covered  with syphilitic
 pustules.
   The  pustular is among  the most frequent forms of syphilitic
 eruptions  encountered.   The pustules are commonly of large
 size,—phlyzacia,  as  they  are termed, and   approach those of
 ecthyma very closely  in their general characters ; more  rarely
 they occur of smaller size,—psydracia,  when they  have very
 many features in common with the  eruption  of acne  rosacea at
 its  height.
  The  phlyzacious syphilitic eruption appears most frequently on
 the breast and face, and generally in successive crops, so that pus-
 tules in all their different  stages of incipience, growth, completion,
 and decline, may usually be studied in the vicinity of each other
 at one and the  same  time.   These pustules occur for the most
part isolated and pretty widely scattered ; they are not very promi-
nent, and  are sometimes  positively flattened on the surface,  and
even depressed in the centre.   Their bases are hard and of a deep
coppery hue: at their height they may be  about the size  of split
peas, and they then contain a little apparently laudable pus, of a
pure whitish yellow colour.   After continuing  in this state for a
few days, they burst, and their contents  escape  and harden  on the
       7—c                                     grn 13 
194
GREEN ON DISEASES OF THE SKIN.
surface into brownish black scabs, which, whilst  they continue  to
adhere  are  surrounded  by coppery areolae,  and  when they are
detached discover deep stains or blotches of a similar description,
occasionally the cicatrix of a small superficial ulcer, and sometimes,
when the pustules have been large, the scabs broad and  thick, and
the  accompanying inflammatory symptoms  have run  high, the
irregular scar of a more extensive ulcer.
   The psydracious syphilitic eruption1 makes its appearance, like
the last, most commonly on the forehead and face, over the breast,
and between the shoulders, in successive crops, often in great num-
bers, and  thickly clustered together.  They are of small size, often
of a rionical shape, and  seated  on hard  bases  of a  coppery red
colour.   They go  through their different  stages slowly, and are
always  to be observed in  every period  of their progress in the
neighbourhood of each other.   The fluid they  contain  concretes
into minute scabs of  a dark brown colour, which, when  detached,
often leave  small but rather deep cicatrices,  capable  of receiving
the head  of a pin, sometimes  small indurations, and always dark
coppery red stains behind them.
   Both of these species of pustular eruption are preceded by fever
of greater or less severity, proclaimed in the usual way by restless-
ness, want of sleep, failure of appetite, constipated bowels, pains in
the  limbs,  (fee  They  are frequently  complicated  with various
other species of syphilitic eruption, particularly with the exanthe-
matous and papular,  which is one cause for the psydracious variety
having been sometimes described under the title-of lichen.
   The  bullous is another form of syphilitic eruption which  is of
very frequent  occurrence, but which is very  commonly described
either as  a merely larger  variety of the pustular,2 or as a species of
the  tuberculous  disease.3   In  this form  the eruption  is  seldom or
never copious, and is generally seen on  the forehead, on the body
and arms, but especially on the  legs.   It first appears as a dusky
or livid blotch as large as a sixpence, and even as a shilling, from
a greater or less extent of the surface of which the cuticle is by
and by detached, and slowly raised  by the effusion under it of a
sero-purulent or turbid sanguinolent  fluid.  This pustular bleb is
next surrounded by abroad copper-coloured areola.  In  the course
of a few days it bursts, when its  contents escape in part, whilst the
rest exuding slowly,  harden on the surface into a broad blackish-
coloured, circularly-wrinkled, very hard and firmly-adhering, in-
crustation,  which  gradually increases  both  in thickness and in

   1 This eruption is described by some continental writers, and very lately
also by  Mr. Bacot, as a lichen.  The  mistake has arisen from want of a
right understanding of the definitions of the elementary forms of cutaneous
disease, and from translating the Latin  word papula in its  pathological
sense by the English word  pimple.  No  uninitiated person would call a
pathological papula a pimple, which he certainly would a pustula.
   2 By Cazenave and Schedel, 2d ed. p. 440.
   3 By Bacot, on Syphilis, p. 236. 
SYPHILIS.
195
extent; for secretion goes on from the diseased surface underneath
it, and its edge encroaches  on the parts around, by a process of
tardy ulceration, which,  however, occurs very  regularly.   The
disease  in this state  presents the greatest resemblance to  rupia
prominens.  Occurring  on the forehead, these scabs  have  long
been  distinguished kby the strange title of corona Veneris.   The
blebs run their course without any degree of accompanying  local
inflammation : they are essentially indolent.  The scabs, if left to
themselves, continue to adhere for a great length of time with very
little appearance of change, save  perhaps some trifling increase of
dimensions.  When they do fall off, or are got rid of by means of
topical emollient applications, foul and unhealthy ulcers are brought
to view, which rarely fail to exhibit something  of a disposition to
spread circularly, the  circumference being surrounded  by a deep
red margin similar to what is seen in phagedenic  ulcers, as well as
again to  become covered with the limpet shell incrustation.
   This form of syphilitic eruption,  like the rest, is preceded for
some days by a disturbed and febrile state of the system.  This, or
a  modification  of this bullo-pustular disease,  is  also the form of
syphilitic eruption  which  the unfortunate infants that  are  born
labouring under secondary symptoms of the venereal disease com-
monly present.
   The papular  is the next form of  syphilitic  eruption (lichen
syphiliticus) which I shall notice.  In some cases this eruption
has  many of the characters of an acute affection,  when it  is ob-
served to accompany or to follow very shortly after the  disappear-
ance  of a gonorrhoea.  The papulae then show themselves  over
every part of the surface, but, as usual,  principally on the  face.
They are  of very  small dimensions,  slightly conical  in  shape,
closely crowded together, and surrounded by  dusky red areolae,
which* blending  together give to the  whole region affected an
uniform  coppery blush, beset  with innumerable prominent points
of rather less intensity or  depth  of  hue.  This eruption is  com-
monly completed within  from  twenty-four  to  forty-eight  hours
after its first appearance, and is generally preceded by obvious con-
stitutional disturbance.
   The syphilitic papulae  which appear with these characteristics
begin to shrink in the course of a few days;  a slight furfuraceous
desquamation then  commences and  continues for some little time
longer; this  gradually disappears, and  nothing then remains but
the "stained surface which  is characteristic  of every variety of sy-
philitic eruption.   When the syphilitic lichenous eruption appears
with symptoms of considerable severity, however, (a case in which
it  may be likened to lichen agrius), the papulae become  excoriated
on their surface, and may be succeeded by superficial ulcerations,
covered in the same manner as the disease mentioned with flimsy
incrustations, produced by the  drying of the small quantity of
serous fluid which  then exudes  from the  abraded apices  of the
papulae.                                             l3# 
196
GREEN ON DISEASES OF THE SKIN.
  It much  more commonly happens that the papular eruptions of
syphilitic origin appear with all the symptoms of chronic affections.
The papulae  are  then broad,  flat, and  sometimes as  large as a
herring scale, of a circular shape, and very evident copper colour.
They are slowly and successively evolved without pruritus or pain,
and are seldom or never surrounded  by an areola.   They appear
on the limbs in the same situations as the papulae of lichen,  but
also very commonly on the brow and over the surface of the hairy
scalp.
  The papular is a very general concomitant of the  various other
forms of syphilitic eruption.  It commonly ends in resolution, with
a pellicular and frequently repeated desquamation from the surface
of the papulae, as they sink to the level of the skin around them,
and gradually contract in size.  As usual, they leave stains of a
dingy red colour behind them, which are very long of disappear-
ing.
  Restlessness, inappetence, some elevation of pulse,  constipated
bowels, and pains in the limbs and joints, precede the outbreaking
of the papular as they do of all the  forms of syphilitic  eruption
already mentioned.  These are often slight certainly,  but they con-
stantly occur, and their importance ought never to be overlooked.
  To the squamous from the  papular form of syphilitic  eruption,
the transition is  natural and easy.  The squamous syphilide pre-
sents itself with  a variety of characters, which, however, may
severally be  assimilated to one or other of the simple squamous
affections of  the skin  which have already been described.  Thus
the eruption occurs with almost every one of the features of lepra
vulgaris in one case,  and of psoriasis guttata in another.
  There is a very remarkable case of syphilitic lepra detailed by
Messrs. Cazenave and Schedel.1  The  patches were exactly circular
and  varied  between a very few  lines,  and half  an inch  and
even more in diameter.  They were raised  around their margins,
depressed in  their centres, and of  a very dark colour, still more re-
markable in the middle of the spots than in the raised points which
formed their circumference.   The  squamae which covered these
spots were thin, dry. apt to split, and but slightly adherent.  When
detached, smooth and  polished elevations were exposed. The parts
upon which  these scaly spots  appeared were of a dusky colour, in
the first instance, and they were evolved with unusual heat, smart-
ing, or pruritus.   The raised or papular looking points that sprang
up upon these blotches and were afterwards covered with squamae,
 were of a red coppery colour; the disease consequently did  not
 commence, like lepra vulgaris, with  the development of a bright
 red papular-looking  point upon a  healthy surface.  The skin of
this patient, in the intervals between the squamous patches, was of
 an earthly colour, and exhaled a peculiar odour.
    This is the squamous disease to which, if to any,  the title lepra
• Op. Cit. 2d ed. p. 450. 
SYPHILIS.                       197
nigricansr is applicable. It is not the affection described under that
name by Bateman, however, and as it arises under the specific in-
fluence of the syphilitic poison, I should say it was better to speak
ot it as a squamous syphilitic  eruption of unusually dark colour,
presenting many of the external characters of lepra.   This form of
eruption  is rare; it is always  chronic in its nature, of very long
continuance, and ends in  resolution and  repeated desquamation!
never in  ulceration.
  A much  more common form of squamous syphilitic eruption
than the leprous, is that which occurs with the external characters
of psoriasis guttata.  The patches of this syphilide are generally
isolated, distinct, somewhat irregular in shape, slightly raised above
the general level of the integuments, and covered with thin, hard,
grayish coloured, and pretty firmly adhering squamae.  They are
usually observed to be successively evolved upon the arms, breast,
back, forehead, and face;  sometimes they extend to the scalp, and
generally over  the trunk  and  extremities.   They make their  ap-
pearance in  the guise of little points of a coppery hue, which rise,
spread, and  become covered  with  squamae; at  their height they
vary in size  from the dimensions of a split pea, to that of a shilling
or  more. When  freed  from  their  investing squamae, they  are
smooth, soft, and shining  on  the surface, not hard  and scabrous
like those of simple psoriasis.   They are farther of a decided dingy
copper colour, not of a vivid red like these last.
  Diseases very similar in their characters to psoriasis palmaris
and psoriasis plantaris, are  also occasionally evolved under  the
influence  of the specific irritation  engendered by the presence of
the syphilitic poison within the system.  These are distinguished
by the copper  colour  of the papular looking elevations in which
they commence.
  The general symptoms that precede and accompany the  first
stages of the  squamous syphilides,  are less remarkable than in
several or most of the other forms of syphilitic  eruption; yet  the
patient very constantly complains of feeling himself unusually low
and out of sorts, of restless nights, loss of appetite, torpid bowels,
pains in the  limbs and larger  joints, (fee   These symptoms often
pass unnoticed, and were they not  followed by so  remarkable a
phenomenon as an eruption of coppery points that spread and after-
wards acquire a covering of squamae, they would in  fact be unim-
portant.  Thus succeeded, however,  they assume a consequence
which in themselves they  do not possess.
  The tubercular is  the only other species of syphilitic eruption
which remains for me to  mention.   The elementary form of this
syphilide  is  frequently overlooked ;  the  disease is not described
until it has passed into its second stage, when the tubercles have
become ulcerated and covered  with hard, black, and often conical
scabs, and when of course it is spoken  of as a pustular affection.
But the primarily tubercular form of syphilitic eruption is of very 
198
GREEN ON DISEASES OF THE SKIN.
 common occurrence.   It presents a considerable variety of appear-
 ances, the principal of which I shall indicate rather particularly.'
   In some cases the tubercles are small, varying between the size
 of pins' heads and of peas,  rounded, generally arranged side  by
 side, with little space  between them, and in such wise as to form
 perfect circles of varying diameter, and of the usual coppery colour.
 Each of these tubercles frequently becomes partially covered  on  its
 surface with a hard,  dry, and grayish coloured scaly  plate.   The
 middle of the circles appears to be perfectly healthy.   This variety
 of the tubercular eruption occurs  principally on the forehead and
 on the neck.  It rarely ends in ulceration, but generally in resolu-
 tion, and leaves  dusky or livid red stains, in the situations  it oc-
 cupied, long after the tubercles themselves have disappeared.
   It happens at other times that the tubercles of this syphilide are
 of somewhat larger size, like horse-beans  or  small olives,  of  an
 oval or pear shape, very prominent, smooth  and polished  on  their
 apices,  and clustered together irregularly over a surface of variable
 extent.   These tubercles are principally seen on the  cheeks, and
 occasionally on the extremity of the nose.   They are extremely in-
 dolent, not disposed to fall into a state of ulceration, and are not, like
 the preceding variety, covered with any epidermic squamous disc.
   The  tubercles  again are  sometimes of very considerable size,
 few in  number,  isolated, rounded  and encircled with a copper
 coloured areola.   These are principally seen on the upper lip and
 nose.  They continue  indolent and stationary for a time, but by
 and by become painful, swell, and are surrounded with a  peculiar
 livid circle of erythematous  inflammation, and give way  on  their
 summits, when  a scab is formed, flimsy at first,  but increasing
 gradually in thickness  and in breadth, whilst the ulcer that  is
 formed  underneath it spreads both in  depth and in surface;  fresh
 tubercles are usually  evolved  in  the neighbourhood, or on the
 edge of the sore at this stage, which fall successively into ulceration,
 so  that  an  ulcerated surface, often  of considerable  extent  and
 hidden  under one continuous and  rugged  incrustation, at length
 results.   This variety of the syphilitic tubercle, both in its general
 characters, and in its destructive tendencies, bears a considerable
 resemblance  to lupus.   When it happens to be complicated with  a
 carious  affection of the bones of the nose, the whole of this  member
 is occasionally irrecoverably lost.
   Tubercles of a very similar description to those just discussed,
 but  of still  larger size, being occasionally as big as a  filbert, are
 now and then met with dispersed over different regions  of the body,
 but especially the  back.   These are hard, rounded, and of a dusky
 red  colour; they continue indolent for a  time, but  their  natural
 tendency is to destructive ulceration, which first attacks  the  tumour,

  1 Following  closely the excellent article of Cazenave and Schedel on this
subject, composed after the luminous expositions of Biett in  his clinical
lectures.   Op.  Cit. p. 442. 
SYPHILIS.
199
and then spreads superficially to the surrounding parts, frequently
healing on one side whilst it advances on the other, often in spiral,
circular, and zig-zag lines, of a few lines in breadth, in a very sin-
gular manner, so that extensive services of the integuments appear
at length as if covered with the brand marks of some strange and
unknown oriental writing.  The ulcers thus produced are covered
with  thick, hard, adhering blackish and  wrinkled incrustations.
When these are removed, the sores they concealed are discovered,
with foul grayish bottoms, and sharp cut, angry, and shining edges.
These sores always  leave indelible and characteristic  cicatrices
behind them.   The disease is essentially chronic in its type; fresh
tubercles  go on forming, whilst  those  that  already existed  are
falling into a state of ulceration, or as the sores to which they gave
rise are winding their way over  the  surface of the integuments,
and these, undergoing the same changes in their turn, the disease
is protracted indefinitely.
   One variety more of the syphilitic tubercle has been described,
remarkable for  the linear ulcer that  is formed upon its surface.
The  tubercles in this variety are  circular, thick, and compressed,
but mostly of the size and shape  of a lentil.   They then  usually
occur in  the cleft between the  ala  nasi and cheek, or  about the
commissures of the lips.  But they are also occasionally seen on the
scrotum, thighs, pubes, and about the anus, in which case they are
of larger dimensions, several lines in  thickness, isolated, very pro-
minent, especially when situated on the scrotum, and of a particu-
larly  dark livid  colour.   In every instance their surface by and  by
appears chapped, and a linear ulcer is formed, which pours out a
sanious discharge of a particular and very unpleasant sickly smell.
The  ulcers of this tubercular syphilide always continue superficial.
   I   have already hinted at the fact of two  or  more  of these
various forms of syphilitic eruption very frequently occurring com-
plicated one with another.  It even  rarely happens that any one of
them is met with singly; at some particular period of its  progress,
it almost  invariably becomes associated with a  different  form of
eruption.
   These  eruptions, further, are themselves no more than particular
items in  a long catalogue of symptoms, severally and conjointly
characteristic of a venereal taint of the system.   Among the more
significant of these must be reckoned ulceration of the parts  com-
posing the fauces, as of the tonsils, palate, (fee; pains in the bones
of the extremities, skull, and sternum, and of the larger joints, as of
the   knees and  elbows,  hips and  shoulders;  thickening  of the
periosteum; enlargement and caries of the bones, especially of the
nose  and palate; inflammatory affections of the eye, and particularly
of the iris;1 inflammatory affections of the ear;  the formation of

   1 In connection with this subject, let me particularly recommend the work
 of Mr. Lawrence, recently published, On  Venereal Affections of the Eye,
 8vo, Lond. 
206
GREEN ON DISEASES OF THE SKIN.
 hard movable knots, under the skin, termed tnmeurs gommeuses
 by Biett, (gumrnata,) which are apt to decline into foul and in-
 tractable ulcers, (fee
   The cause of all the various forms of syphilitic eruption as well
 as of these diversified symptoms, is by the common consent of all
 ascribed  to  the  absorption into the system of a peculiar specific
 poison, usually transmitted from one individual to another by being
 inoculated upon one or other of the mucous surfaces of the  organs
 of generation, during the sexual act.   The disease does not seem
 capable of being transmitted mediately, as by the lungs, by simple
 contact with persons infected,  (fee, although  this was currently
 believed to be  possible long after the first appearance of syphilis in
 Europe as an epidemic.
   I am not sure that any lengthened notice of the features  which
 distinguish the syphilitic  from the simple cutaneous eruptions of
 like elementary forms, is very necessary after the detailed account
 I have given of the peculiar characters  and appearances presented
 by each of these individually.   For the sake  of presenting this
 subject in a connected form, however, I shall run briefly over  the
 principal diagnostic marks of the several eruptions specified.
   Syphilitic roseola differs from simple roseola  in the less regular
 shape of its patches,  and its more tardy progress; the colour of the
 two eruptions is also different, that of simple roseola being a florid
 or rosy red, that of the syphilitic  efflorescence a more dingy or
 dusky shade of the  same colour;  the decided  coppery tint  is not
 apparent at first, but it gradually appears, deepens as  the disease
 advances, and even remains as a stain after the inflammation has
 vanished;  very different therefore from what takes place in regard
 to simple roseola, in  which the eruption is extremely vivid at first,
 and gradually becomes fainter and fainter till it disappears entirely.
 The coppery hue of the syphilitic exanthemata distinguishes it at
 once from every  simple eruption of the same elementary form, par-
 ticularly erythema.
  Syphilitic blotches (maculae syphiliticae) have a very characteristic
 appearance, which at once  distinguishes them from ephelis or liver
 spot, and, in fact, from  every other kind of cutaneous eruption;
 their rounded form,  circumscribed  size, complete  isolation, occur-
 rence on the forehead and face, their dark, dingy red, or  coppery
 colour, in  particular, and their  freedom from  pruritus  and from
 habitual desquamation, show them  very different from the broad,
 itchy, constantly desquamating, yellowish coloured and irregularly
shaped patches of chloasma, situated on the breast and front of the
 abdomen,  in the great majority of instances.1
  There seems to me no possibility of mistaking  the soft, smooth,
very slightly raised and copper coloured syphilitic blotch, for  the
elevated, hard, rough, and bright red papular surface of a patch  of
lepra or psoriasis freed from squamae.
1 See case of Capt. F. 
SYPHILIS.
201
   The vesicular syphilide is readily distinguished from the small
 number of simple diseases of the like elementary form, with which
 it can possibly be confounded, by the coppery areolae that surround
 the individual points of eruption.
   The phlyzacia of the pustular eruption  bears some analogy to
 ecthyma alone, and from this disease they are distinguished by "their
 evolution over coppery points, and  their being surrounded by dis-
 tinct areolae  of the same peculiar  colour.  The  psydracious
 eruptions of the same  class are  more apt  to be confounded with
 acne rosacea, and some of the allied species. The coppery injection
 of the  base of the syphilitic spots, however, again  comes to our
 assistance here;  add that the  syphilide  is  an essentially indolent
 disease, that there are no signs of increased  action in the surfaces
 affected, that  they are  not erythematous, unctuous,  and sensitive,
 but, on the  contrary, dry, withered,  sallow, and shrunken,  and
 mistake seems impossible.
   The bullous, or bullo-pustular syphilitic  eruption, is  known by
 the evolution  of the  pustular bleb on a  dingy red blotch, and the
 decided coppery hue of the areola that surrounds the thick scab
 that succeeds  it.  The  bleb of rupia, to which it bears the greatest
 resemblance, arises upon a ground of an ordinary red colour, and
 the ensuing scab and sore are encircled with a purplish red ring of
 pretty active inflammation.
   The papular eruptions of syphilitic origin  differ  from  the
 unspecific lichenous and other forms of of papular disease, by their
 wide diffusion over every part of the body, and their occurrence on
 the face especially;  by the dark coppery  colour of their areolae,
 which, coalescing, form broad surfaces of a  deep  dingy red, dotted
 over  with innumerable small, conical,  or  broader  papulae,  of a
 somewhat lighter shade of colour.   The differences of elementary
 form ought to give security against the error which, we must believe,
 has  been supposed  possible, when  we find elaborate diagnoses
 established between scabies and syphilitic lichen, between varicella
 and this eruption, (fee
   The  squamous forms of syphilide are  generally so perfectly
characterised  by the coppery, and sometimes nearly black colour
 of the eruption, by the soft, smooth surface presented by its patches
 when freed from  squamae, and by the flimsiness  and scantiness of
 their scales, contrasted with the abundant formation and  strength
of the epidermic laminae, in simple lepra  and psoriasis, that there is
no risk whatever of confounding the disease arising under specific
causes,  with these, which invade at least under unknown influences.
   The distinction of the various tubercular  eruptions of syphilitic
origin,  from  the several  diseases of  like   elementary form  with
which they are liable to be confounded, is one of the most im-
portant points in the diagnosis of the whole class of syphilides.  It
is enough to  be  aware that the  first variety of syphilitic tubercle
we have described, occasionally presents  itself in  an annular form,
the summits of the circle of tubercles of which the ring is composed 
202
GREEN ON DISEASES OF THE SKIN.
bein<r covered with isolated squamae, to avoid mistaking this  pecu-
liar form for a patch of lepra, whether it be of syphilitic or simple
origin.  Attentive examination, and the sensations conveyed by
the finger, ought  always, and  will always, enable us to detect  a
syphilitic  tubercle evolved on any part of the body, though covered
with flimsy squamae, from  the  papular-like spot of psoriasis gut-
tata,  whether  specific or unspecific  in  its  origin ; farther,  the
species of tubercle that bears the greatest  superficial resemblance
to psoriasis is sooner or later occupied on  its surface by a  linear
sore, or ulcerated chap, from which distils a stinking ichor that
irritates and excoriates, the surrounding parts.   It is possible that
the contoited  superficial serpiginous ulcers, in  a state  of half
cicatrisation, which  follow another variety of syphilitic  tubercles,
may have been mistaken for the twisted patches of psoriasis gyrata.
Yet these two diseases have, in fact, little or nothing in common,
save the  mode in which  they spread  over the  surface of  the
integuments.   The process of extension in the syphilitic disease is
always by ulceration, and the sore is covered along its course by
true incrustations, of a dark brown or blackish colour; in psoriasis
gyrata, nothing like  ulcerative absorption is ever seen, and  the
surface of the spiral  patch is invested with  distinct, dry, white, and
glistening squamae.   The  syphilitic  disease begins in a  large
isolated tubercle of a dusky red colour, which by and by becomes
an open  ulcer; the psoriasis,  in  a  bright  papular-looking patch,
that, from its first appearance,  is overlaid with  imbricated,  pearly
squamae.
   The indurations which  follow  acne indurata are distinguished
from the tubercles of syphilis by the fact of their consecutive  for-
mation, by the circumstance  of their having succeeded to pustules,
and by the tendency they constantly show to decline, not  to in-
crease in  size.  The  cicatrices that appear on the surface  of the
consecutive indurations of acne are also characteristic, being small,
oblong, and pale coloured,  not  puckered  or honey-combed, often of
considerable extent,  and always of a dingy red or coppery hue.
   There  is  perhaps greater difficulty in distinguishing,  at  every
stage of their growth and progress, between the tubercles of lupus
and those of syphilis, than  between this latter disease  and  any
other variety of known  cutaneous affection.  The  following con-
siderations,  however,  will generally suffice  to  prevent  mistake:
The  tubercles of lupus are  of a bright or  vinous  red colour,  and
are always evolved amid surfaces in a state of phlogosis, the parts
around them are puffed, and  they themselves are soft, but little pro-
minent, and uneven on  the  surface; those of syphilitic  origin, on
the contrary, are of a  dingy red or copper colour, are developed not
only  without evident  excitement, but even with something like a
diminution of healthy action  in the surrounding tissues, for the
 skin is sallow and shrunk between  them, and they are prominent,
 hard,  even,  and  shining on  the  surface.   Lupus,  moreover,  is a
 disease of an earlier period of  life than tubercular syphilis; is very 
SYPHILIS.
203
 uniformly confined  to the face, appearing especially on the cheeks
 and alae of the nose, and is mostly uncomplicated, save with signs
 of a scrofulous constitution,  which do not usually display them-
 selves in a deranged state of the  general health.  Tubercular sy-
 philis again occurs for the most part among individuals arrived at
 maturity of years, is evolved  upon the forehead particularly, when
 the face is the region attacked, and very generally shows itself at
 the same time over  the  back and shoulders; it  is further almost
 always  complicated with various other forms of syphilitic cuta-
 neous affection, and with symptoms of general constitutional dis-
 turbance, which there is no mistaking.   The inherent or essential
 characters  of the various forms of eruption evolved under the in-
 fluence  of  the venereal  poison, consequently, appear sufficient of
 themselves to distinguish these affections individually and from
 one another, as well as from  every species of unspecific disease to
 which they bear  affinity or resemblance.   When to the mere ex-
 ternal characters  derived from situation, form, colour, tendency,
 (fee we come to connect the disturbed state of general  health, the
 sallow skin, ulcers in the throat, pains in the joints and superfi-
 cially  situated bones,  thickening  of the periosteum,  formation of
 exostoses, (fee which are known to depend  on the presence of the
 syphilitic virus within the system, it happens very rarely indeed
 that there  is much room left for doubt in regard to the  actual
 nature of each or all  of the different elementary eruptions described.
   Some  of the syphilides  are  much more manageable than others.
 Several of them seem also to betoken a deeper and more complete
 infection of the general  system than the rest.   The tubercular is
 unquestionably by far the most  serious shape in which a syphilitic
 eruption can occur.  The bullo-pustular appears  to be the next in
 order  of severity.  The  phlyzacious and  psydracious pustular
 species commonly yield without difficulty to appropriate treatment.
 The squamous is perhaps  somewhat  more  rebellious, but it is not
 attended with any ulterior  ill effects.  The  papular and exanthe-
 matous eruptions, finally, are by much the most tractable and evan-
 escent of the  whole  tribe.  The prognosis,  however, does  not in
 every case,  nor perhaps  generally, depend  so much  either  on the
 species or even on the severity of the particular eruption  engen-
 dered, as on the stamina  possessed by the patient; and the state of
 his general  health:  a very trifling eruption  connected with  much
 emaciation,  great  prostration  and  irritability, sleepless nights  and
 derangement of stomach  and bowels, may  be a  more dangerous
 disease than a severer and in  appearance far more formidable sy-
 philide along  with which  there is little wasting of flesh, no great
 loss of strength, and fairish appetite, whilst  the nights are  passed
 in great part in refreshing sleep.
   The concurring testimony of every candid writer upon syphilis
of recent times has  established the important fact, that the secondary
symptoms  of  this disease,  several forms of cutaneous eruption
among the number, can  be successfully treated upon  what may be 
204            GREEN ON DISEASES OF THE SKIN.
termed  the  ordinary principles  of medical practice, the antiphlo-
gistic regimen, and the regulation  of the natural discharges suf-
ficing, in many instances, to bring these constitutional affections to
a happy termination.   As is usual  under such circumstances, this
discovery, if it may for a moment be so entitled, was carried to ex-
tremes ; every  case of secondary syphilis  was maintained to be
curable  by the  antiphlogistic method without  the aid of mercury,
and this long-valued and invaluable medicine  was threatened with
entire expulsion from the materia syphilitica at least.   Time and
further experience gradually rectified the error that was thus com-
mitted ;  it was speedily found that the cure of secondary syphilitic
symptoms upon general principles was a tardy process at best, that
in many instances little  or no progress  was  made  in this grand
object by months  of  confinement to bed, and observance  of the
strictest regimen, and finally, that in several cases the disease evi-
dently held on in its destructive career despite of all  that was done
and  endured.   The faith  in  mercury  consequently returned by
degrees, and we are now in a condition to estimate at its true value
each particular in the general therapeutic means at our disposal for
the cure of secondary syphilis. Our faith in mercury has returned;
but it is a modified belief; and  we are  no longer content to trust
to this medicine alone, or to prescribe  it indiscriminately during
every stage of the disease, and in  every variety  of circumstance,
without regard to the state of the specific affection or general health
of the patient.
   I have already insisted on the importance of the  febrile  or dis-
turbed state of constitution which precedes the sylphides generally,
and  accompanies them during their earlier stages, in giving us a
clue  to their rational and successful treatment.  During the period
of excitement  stimuli of every  kind  should  be abstracted;  the
patient should be kept at rest, in bed if possible, and confined to
spare diet of the blandest description. Were the patient still young,
vigorous, the pulse full as well as frequent, and the attack the first
that had been endured, no feasible objection could then be urged to
the detraction  of twelve or sixteen  ounces of blood.  At all events
a few doses of some saline aperient ought seldom or never to be
omitted, whilst antimonials  and a  saline diaphoretic, such as the
acetate  of ammonia,  should be  prescribed at frequent  intervals.
These preparatory measures will  be found to aid the after-treat-
ment essentially.
   When all symptoms of febrile excitement have been  thus sub-
dued, the use of mercury should be cautiously entered upon.  This
is much  more  advisable  than  trusting  to  antiphlogistic  means
alone : the symptoms  are more  speedily, still with  perfect  safety,
subdued at once, whilst the patient is far more certainly protected
against  a recurrence  of the disease, when  mercury is guardedly
prescribed, than when it  is not employed at all,—supposing  the
affection to  be controllable without this powerful adjunct, which
we know it  is not in a vast amount of cases.   Of all the forms in 
SYPHILIS.
205
which mercury is or can be prescribed for the cure of secondary
venereal symptoms, and particularly of the class of the syphilides, I
believe there is none  better than the  common blue pill,  in doses
graduated according to the  state of the disease and the condition of
the patient.  Concurring testimony has also shown  that the muriate,
or deuto-chloride of the metal, (corrosive sublimate,) is a most effi-
cient  medicine, in almost all the forms of venereal affection  that
engage us.  A sixth, a fourth, or a third of a grain of this salt  may
be taken at first daily in the shape of a pill, or in solution  in any
bland mucilaginous vehicle.   The dose  of the medicine may be
gradually  increased till half a grain is taken during the  course of
the day.  This quantity in combination with some gentle sudorific
or diet drink, proves sufficient in the  greater number of cases to
give an immediate  check  to the progress of secondary symptom's,
and by being continued for a sufficient length of time, to enable the
system to  purge itself of the syphilitic poison with which it is con-
taminated.
   The proto-chloride  or chloride of mercury  (calomel) is anothet
excellent medicine  in these cases, and perhaps  there is  no better
formula than the Plummer's pill  for its prescription.  This prepa-
ration may be begun  in five grain doses night and morning, and
continued cautiously so long as  the disease appears to be yielding
to its influence, or  as no symptoms  of general constitutional dis-
turbance arise under its use.   The sublimate has the advantage of
subduing  the disease without affecting the mouth, as calomel almost
always does when carried to such  lengths  as  are necessary to
eradicate the poison.  Cal miel is also more apt to disagree with the
bowels, and to produce purging.   When the blue pill acts upon the
bowels, which it is  apt to do, it must be associated with opium and
some  aromatic;  the opiate pill of the Edinburgh pharmacopoeia
and the opiate confection of the London College are excellent for-
mulae of the description required.
   The moment any notable degree of general disturbance ensues,
and the patient complains of restlessness, thirst, pains in the epi-
gastrium  and bowels, when the  pulse becomes sharp and frequent,
and the skin gets hot and dry, the mercury is  doing mischief, and
must  forthwith be suspended, and decoction of sarsaparilla and the
nitrous acid substituted for it.   The use of the medicine must only
be very cautiously resumed after every symptom of the excitement
induced has disappeared.   It is by the neglect  of these precautions
that so much injury has been inflicted through  the  means of mer-
cury, and that this excellent medicine has a kind of vulgar disrepute
attached to it.
   Experience has  amply demonstrated the value of mercurial in-
unction for the cure of syphilitic symptoms of a primary  nature.
This practice seems less applicable to the generality of secondary
cases, and particularly to those in which cutaneous eruptions form
prominent and  principal features.  Mercury administered  in this
way  frequently exerts its  specific effects upon  the salivary and 
 206           GREEN ON DISEASES OF THE SKIN.

secreting organs, but leaves the disease of the skin unchanged or
only very partially amended.  There  are  circumstances, however,
in which  an irritable state of the stomach and alimentary canal
makes us  feel scrupulous of prescribing mercury by the mouth ; in
which, indeed, such practice were sometimes incompatible with our
patient's safety, yet in which it is of the last importance to get the
system under the influence of this medicine.   It is in such a pre-
dicament that the  power  we possess of throwing in mercury by
inunction  often  becomes the sheet-anchor of the hopes we cherish
of guiding the case to a favourable issue.
   But inunction is not the sole, nor is it even the best means known,
though it  may often be the only one available by which the system
can be brought under the  influence of mercury, in  these delicate
and difficult circumstances.   We have another and a powerful  re-
source in  the practice of fumigation, which deserves all, and much
more than all, that has yet been said in its  praise.
   The  mercurial preparation commonly  used in  the fumigating
apparatus is  the cinnabar or red sulphuret;  the proto-chloride or
calomel is also  occasionally employed, but both of these are inferior
in efficacy, I  am inclined to believe, to the gray oxide  ; this has the
great and  obvious advantage, at  all events, of not making patients
cough, should a little of its vapour be breathed accidentally whilst
they are shut up  in the apparatus.   The system  is very readily
and rapidly brought under the influence of mercury by means of
the fumes of the gray oxide administered in a proper apparatus,
even after all other modes  of accomplishing this  end  have  been
tried  and found unavailing; and the importance of the  remedy
being made to pass by the pores of the skin, aud thus brought into
immediate contact  with  the  individual points upon  which the
syphilitic  poison has, as it were, fastened itself, will not and ought
not, I believe, to be considered as of little  importance, seeing  that
the general measures commonly pursued in these and similar cases,
are always aided  by topical  applications.   Mercury  administered
by way of fumigation has, in my apprehension, the further recom-
mendation of never exciting violent ptyalism : some  slight tender-
ness of the gums is commonly all it occasions; and if this  amount
of mercurialisation of the  system suffice  rapidly to  destroy  any
amount of latent syphilitic affection, and completely to secure the
patient against  a relapse, as by long experience 1 know it is, with-
out the slightest implication of his general health, this surely is bet-
ter than subjecting him to the torture of violent ptyalism,  and
making him run the risk of a shattered frame for  the rest of his
days.
   Besides mercury, a compound  decoction of sarsaparilla prepared
over a quantity of sulphuret of antimony alone, or of this substance
and calomel conjoined, has long enjoyed an extensive reputation on
the continent, under the title of Tisan de  Feltz, in the first case,
and of Decoction deZittmann, in  the second, for the cure of second-
ary syphilis, and particularly of syphilitic cutaneous eruptions. 
SYPHILIS.
207
  The muriate of gold is another remedy which has recently been
vaunted for its powers in the class of complaints that now engage us.
  The sub-carbonate of ammonia is a medicine that often produces
the best  effects  in  the disturbed conditions of the system which
accompany the progress of constitutional syphilis, or are induced
by the ill timed and injudicious use of mercury.  A  dram of this
salt may at first be  given daily in  barley water, and by and by in-
creased until two or three drams are taken in the course of the four
and twenty hours.
  Other  two  excellent  medicines, of most  appropriate and every
day use under similar  circumstances, are the decoction or compound
decoction of sarsaparilla,1 and the nitrous acid.
  But the means upon which I have long placed my most implicit
reliance  when the  system  has been largely  dosed with  mercury,
and the general health has  given  way without the syphilitic symp-
toms appearing to have yielded, is the sulphur fume bath.  I have
repeatedly seen  patients reduced to  extremity, so weak that they
could not stand, but had to be carried in  the arms like an infant,
and who were literally covered with ulcerations from the crown of
the head to the heel, make  a rapid recovery under the use of this
powerful means alone.   In other cases it seemed to act as a whole-
some stimulus to  the general system,  followed  by  so signal an
improvement  in  the  general  health, that  patients  were  speedily
enabled to resume the use of mercury, and thus ultimately to obtain
a cure.
   As in  the case of primary venereal  sores,  many symptoms of a
secondary nature are materially benefited by applications of a topical
description.   The most useful of these are such as  are applied to
abraded  surfaces, and such as are influential in promoting the reso-
lution of tubercles before they arrive at their suppurating or ulcer-
ating stage.   The  common  black wash, composed  of a dram of
calomel  to eight ounces of lime water, is an excellent application to
every form  of sore that arises  under  the influence  of a syphilitic
cause.   This may  in general be  made to supersede every form of
unctuous application.  Should any of these  be deemed necessary,
however, the  weakened citrine ointment,  the common blue oint-
ment diluted, and a salve of the proto-chloride of mercury, will be
found as good applications as any.  When  the ulcers consequent
on the  destruction of tubercles are foul  and indolent,  they  may
generally be  aroused to better action  by being lightly touched on
the  surface with the  liquid nitrate of mercury.  The  pain  they
occasion, which often becomes very distressing, may be successfully
appeased by the application of a compress dipped in a weak solu-
tion of the  acetate or muriate of morphia, or of  a  pledget spread
with cerate in which a little hydrocyanic acid is incorporated.

   » A good plan of giving sarsaparilla is to prescribe a dram or more of the
 extract in a cup of warm milk, or milk and water, with a little sugar, twice
 a day  Taken in this way it is not a bad substitute for coffee or chocolate. 
208
GREEN ON DISEASES OF THE SKIN.
   Still in a  torpid state, tubercles of syphilitic origin may some-
 times be resolved by being assiduously  rubbed by"means of the
 point of the  finger with an ointment of  the proto-iodide or deuto-
 iodide of mercury, and, still better, of the  iodide of sulphur.
   As an additional and very valuable means of treating constitu-
 tional syphilis, and  of making life endurable along with the shat-
 tered frame which the action of this  poison too frequently induces,
 I must not forget to mention opium, the importance  of which as a
 therapeutic agent  in such cases cannot be too highly appreciated.
   It  would scarcely be held within  my province were I to enter
 more particularly  into the treatment of the other and varied symp-
 toms of lues venerea.  Let me  only be allowed to hint at the pro-
 priety of meeting  incidental symptoms  of any importance as they
 arise, by the general measures  enjoined by a rational  therapeia as
 well as by those specific means which empiricism has recommended.
 Active inflammation, especially of the  internal structures of the eye,
 must be attacked  by general blood-letting, as well  as by the pre-
 scription of mercury, particularly  calomel in large doses, until  the
 system is affected.   Should  the system under these circumstances,
 from some peculiarity or idiosyncrasy, as  it is  termed, obstinately
 resist the specific action of  mercury administered in the ordin ry
 way, let  the  patient be placed in a  fumigating apparatus with a
 dram and a half of the gray oxide of mercury, and before he comes
 out, made to  respire the air of the  bath loaded with the impalpable
 vapour of this substance two or three  times, and it will very rarely
 happen that  the mercurial  action will not speedily  become ap-
 parent.
  The following  cases are selected  at random from among my
 papers'; they are of common occurrence, and therefore interesting.

 CASES OF CONSTITUTIONAL  SYPHILIS, ACCOMPANIED WTTH CUTA-
               NEOUS ERUPTION, ULCERATION, (fee

  In  the autumn of 1831, Captain T.  contracted  syphilis.   The
 primary sore  spread till it occupied nearly two-thirds of the  inner
 surface of the prepuce.  Mercury was prescribed internally as well
 as by external inunction, but without  any restriction  in regard  to
diet,  mode  of life, or otherwise,  and the  patient apparently got
 well.
  About five  months after this, his general health became much
deranged, and innumerable blotches appeared on the surface of the
body and limbs ; for these, and on account of his bad state of health,
he was advised to leave Ireland, and  proceed to Harrowgate, that
he might have the  benefits of the baths at  that place, and undergo
other appropriate treatment.
  He  had  scarcely  commenced the  baths, however, when the
blotches became open ulcerations, from the size of a sixpence  to
that  of a  common playing card.   The  irritability of  the patient
became excessive, and his health daily  worse;  he, notwithstanding, 
SYPHILIS--CASES.                  209
persevered in the treatment advised for eleven weeks, but only with
the effect of aggravating all the symptoms.  His physician then
recommended Captain T. to make the best of his way to London,
and try the sulphur fume baths under my direction.
   On his arrival, I found  he had an ulcer in  the throat; a fetid
discharge distilled from one ear; his  forehead, nose, and cheeks
were covered with one  continuous scab, whilst a copper coloured
red blush extended round it and the other ulcerations ;  he had fetid
discharge from the nostrils, indicative of disease of the nasal pas-
sages, snuffling speech, and nodes on each  tibia, the pains of which
occasioned his nights to be  sleepless.   The original chancre  was
further open to its former extent.  The patient was in a very weak
state, and the case seemed  formidable; nevertheless the sulphur
fumigations were commenced on the 26th of September, one being
taken daily.  Captain T.'s improvement, under  this mode of treat-
ment, was rapid.   In the  short space of a week, more than one
hundred of the ulcers had healed, the  throat was better, and the
general health seemed  improved ;  but the night pains  seemed
rather  to be increased.   No internal medicinal treatment  had as
yet been resorted to;  and  although  the  amendment thus far  was
manifest, yet the leading characteristics of the case being considered,
my knowledge  of the sulphur fumigations did not allow me to cal-
culate  dn the progressive  improvement of the patient, nor on the
permanency of the benefit which he had already received, without
the conjoint aid  of  mercury; I therefore  felt it my duty to urge
Captain T. to consult a  surgeon of eminence.   He consulted Sir
B. C. Brodie, who was also of opinion that mercury was necessary
to establish  a cure ;  and,  there being no  continuous surface  free
from ulcers, on which the  mercurial ointment could be rubbed, he
was  ordered fifteen  grains of blue  pill  every  twenty-four  hours,
with decoction of sarsaparilla,  and to  continue the fumigations.
He commenced the  mercury on  the  6th of October.  On  the 9th
he was under the influence of the medicine, which was diminished
to ten grains.  On the 10th it was further diminished to five grains
in the twenty-four hours.  On the 12th it was  needful to discon-
tinue the medicine altogether : he, however, went on with the sar-
saparilla and the  fumigations.   The rapid  progress now made will
perhaps be  most  readily conceived when I state  that by the 17th
every ulcer had healed ; that the pains  in  the shins and the nodes
had 'gone ;  and  that the  coppery redness had left the face, and
was disappearing from all  the healed patches on the surface of the
body and limbs.
   From this date the patient's recovery proceeded with the same
celerity as from the  first of the treatment.  He soon left London,
convalescent, and only taking the sarsaparilla.   In all, he took but
thirty-four fume baths between the 26th of September  and the 6th
of November.  This was  the whole of the  treatment resorted to,
with the exception of one dose of castor oil, which was directed
with a view of abating ptyalism.
       7_d                                     grn 14 
210            GREEN ON DISEASES OF THE SKIN.

  It  may be said, from the speedy recovery in this case, that there
was  a favourable idiosyncrasy, which disposed  the  system to be
readily influenced by the  treatment.  It might be so; but I have
treated many similar cases with like success.  No relapse occurred,
and years have now gone by since  Captain T. has felt as well as
ever he did.
  I have often had to observe the beneficial influence of the sulphur
fume baths, not only in venereal, but in other obstinate ulcerations.
The stimulus of the sulphur in a state of vapour certainly agrees
well with  indolent sores  generally, and even  disposes  venereal
ulcers to heal, as is instanced in the above case ;  yet T cannot con-
ceive that the sulphur fumigation  alone would  have done perma-
nent good in such a case;  the aid  of mercury was further neces-
sary.  It is the combination of the two remedies in cases of consti-
tutional syphilis, which I  think deserves the attention  of the pro-
fession.  The next is a case of a precisely similar kind, upon which
reflections  of the same  nature might be made.
   Case 2. Captain A.  B., of the Guards, placed himself under the
care of Mr.  Earle, when  already  reduced to extremities by the
united influence of secondary syphilis, and the constitutional dis-
turbance induced by the ill-timed  use of mercury.  The forehead
and  limbs were covered with numerous foul superficial sores, and
the parietes of the abdomen and thorax with ulcers of such depth,
that several of them seemed to penetrate  to the peritoneum  and
pleura.  One side  of  the scrotum  and  one testicle had  sloughed
away,  before I saw the patient; the other was lying naked, hang-
ing by the cord, when  he first visited me.  There was also exten-
sive superficial ulceration of the throat, and the shins were occupied
with several nodes. The  patient complained of severe suffering
from nocturnal  pains, and was greatly reduced  in  strength  and
spirits, and much emaciated, although in the prime of life.
   All that unwearied attention and  the best advice could do in this
case were done, but no decided improvement took place, and the
state of the general health was such, that  Mr. Earle felt it impos-
sible again to have recourse to mercury.  As a last measure, there-
fore, and with a view of arousing the drooping power, he recom-
mended a trial to be made of the sulphur fume bath.
   The first three exposures in the fumigating apparatus occasioned
a  good deal of smarting  of the open sores, and  seemed even to
increase the restlessness and general distress endured in the night:
on this account opiates were prescribed, and with the best effects.
After the fourth fume bath had been taken  an evident amendment
was visible.  The  patient  felt stronger, and generally  better; his
appetite began to return ; several  of the smaller sores had healed,
and others were in progress of cicatrisation; his spirits also  rose,
and his hopes of ultimate recovery  revived.  The baths were left
off after the fifteenth, for ten days, in  consequence of an attack of
diarrhoea, which, however, did not interfere with  the patient's im-
provement ;  for on his return, almost the whole even of the very 
SYPHILIS—CASES.
211
deepest ulcers had  cicatrised.  The remaining testis was nearly
surrounded with a  new integument;  and Captain A. B. was gam-
ing flesh and strength so  rapidly, that he very speedily declared
himself quite  recovered.  As a measure of precaution, small  doses
of the hydrarg. bichlor. were continued for about six weeks after-
wards ; and as several years have  now elapsed without any return
of syphilitic symptoms, it seems probable that the poison was com-
pletely eradicated from the  system.
  The remaining testicle was uninjured :  Captain A. B. is married
since his illness, and the father of four healthy children.1

  1  Since the former  edition of this work was published, the study of the
Syphilides has  been facilitated by the  publication of a series of beaut»ul
plates, devoted to the elucidation of these diseases, by Dr. Wallace ot Dub-
lin, and also by Mr. Judd.
grn 14* 
DISEASES
                 WHICH ARE SEVERALLY


TYPES OF NEW  AND  ADDITIONAL  ORDERS.
                         PELLAGRA.

  The disease thus designated has only been observed in the north
of Italy; and although  much  has been written  in  regard to its
nature, (fee there still seems some doubt whether it ought to be con-
sidered as a primary affection of the  integuments, induced by the
action of the bright light and heat of  the sun, or as a symptom of
a constitutional  malady, engendered by peculiarity of local situa-
tion, miasmatic  influence, or some other  unknown cause.   The
latter appears to be the opinion entertained by the best informed
pathologists.
  The disease of the surface is always preceded  by symptoms of
general constitutional disturbance.  The individual  affected  com-
plains of a singular feeling of depression, both mental and bodily,
of headache, giddiness, loss of appetite, pain and derangement of
the bowels, (fee   The cutaneous affection next makes its  appear-
ance in the  shape of small red spots or patches, upon the backs of
the hands, on the face and forehead, neck and breast, and exposed
parts of the legs and feet.  These spots extend gradually, accom-
panied with some tumefaction of the  skin, and a feeling of  tension
and pruritus.  The affected parts are of a deeper colour than those
that are possessed  by  erysipelas, and their surface,  which was
smooth and shining at  first, is  by and by covered with epidermic
squamae, similar to those of psoriasis.  The patches  gradually ex-
tend till they meet by their edges, and thus surfaces of considerable
extent are overspread with the  disease, the integuments of which
become thickened,  indurated,  and often  deeply  chapped.   This
attack commences in the spring, and continues till the end of  sum-
mer or beginning of autumn, when the affection of the integuments
begins to abate; before  the winter has fairly set in it has  usually
disappeared entirely.  But the general health  does  not return in
the  same measure  as the outward malady declines;  distressing
affections of the stomach and bowels, such as cardialgia, gastro-
dynia, diarrhoea, (fee, still continue.
   On the approach of the ensuing spring the symptoms of pellagra
return with renewed violence; the depression and  weakness are 
PURPURA.                      213
more marked than before; the patient is incapacitated from going
about his usual avocations;  he is much reduced by diarrhoea, and
distressed with cramps in the legs.  The disease of the skin again
makes its appearance also, and with greater severity than before;
the parts affected are  often of a brownish or  yellowish colour,
greatly thickened, covered with hard squamae, and deeply chapped,
especially in the neighbourhood of joints, situations in which  the
skin occasionally appears like folds of dry and wrinkled parchment
wrapped around the bones.
   The symptoms decline, as they  did formerly, during the autumn ;
but the remission is now later of happening and less complete.
   The return of the third spring  is the herald of a renewal of the
pellagra, aggravated in all its features.  The weakness is now ex-
treme, and  the  patient, emaciated  and worn out with  pain, is
scarcely able to support himself upon his legs.   The diarrhoea con-
tinues, or gives place to decided  dysentery;  the lower extremities
become anasarcous, or  there is an  effusion of fluid into one or other
of the great cavities of the body.   Symptoms of a serious affection
of the encephalon are  superadded;  the patient complains of giddi-
ness, falls down  in  fits  of  an epileptic character, and  frequently
becomes idiotic or insane.   Things cannot go on long in this state :
the powers of life are gradually exhausted, and patients commonly
sink in a state of marasmus, worn out with colliquative diarrhoea
and general suffering.
   Pellagra is always a formidable and generally a fatal disease. It
commonly lasts for several years, and may go on for six, eight, ten,
twelve, or  more years, before it destroys its victim.  The disease is
not contagious.   It  is scarcely seen save among the very poorest
classes of the community;  but it attacks all ages indiscriminately,
and women  appear  rather more  subject  to it than men.  The
peasantry of the Milanese are the principal sufferers from pellagra.
The disease is probably owing  to the  influence of some peculiar
miasm engendered in the deep, retentive, and often marshy soil of
the extensive plains of Lombardy.
   Treatment would appear to have little influence in  checking the
progress of pellagra.   The  first and most obvious indication would
be a removal beyond the  sphere  of those  influences under  the
 operation of which, whatever their nature, the disease is evidently
 engendered.   The use of the  warm  bath, and general dietetic
 means, are what have principally been recommended as curative
 measures in the disease.

                            PURPURA.

   Purpura is an eruption  characterised externally by smaller or
 larger dark red or livid spots,  scattered over  the surface of the
 body, and formed by an extravasation or effusion of blood into the
 substance of the cutis vera.
    This definition alone shows the necessity there was for separating 
 214           GREEN ON DISEASES OF THE SKIN.

 purpura from  the exanthemata, among which it  was placed by
 Willan and his followers.  Here there is no injection  of the capil-
 laries with consequent increase of redness and heat, but a positive
 escape of blood from its ordinary channels, without suffused redness
 or augmentation of temperature.
   Purpura  is  not always accompanied with any  very manifest
 derangement of the functions  generally, indeed the affection is
 known to occur  in individuals" who declare themselves  in  very
 good health,—purpura simplex, petechial sinefebre, (fee
   In this variety, the spots are of a  clear but  deep red colour at
 first, and are generally of small size.   They become of a darker or
 more purple hue  afterwards.   The eruption is  already copious a
 few hours after it  is observed, spreading from the legs and thighs,
 where it first appears, to  the  shoulders and arms.  The spots,
 though extremely numerous, seldom  or  never  become  confluent.
 They are constantly developed in successive crops, so  that some
 are fading whilst  others  are arising, and all the shades  of colour
 assumed by the eruption in its progressive stages of increase and
 decline are presented at once, often by very limited  districts of in-
 tegument ;  the spots are of  a deep, of a brownish, of a purple, and
 of a paler red, and of various shades of yellow, in the near  vicinity
 of one another.
  The duration of purpura simplex is indeterminate; it may last
 for a few weeks only, or continue for  many months, and even for
 some years.   The individual petechiae remain  visible between a
 week and a  fortnight.
  Purpura is not  uniformly the simple and comparatively trifling
 disease now described, although, even when it  occurs in  a more
 aggravated form, and with many alarming particular symptoms, it
 is not constantly either preceded or accompanied with febrile ex-
 citement, or very marked disturbance of the system generally.   In
 some cases the spots are very numerous, of an extremely deep red
 colour, and by coalescing, frequently form broad, irregularly shaped,
 livid or  purple patches, like recent contusions.   These, as usual,
 make their appearance first on the legs, and then successively over
 the arms and trunk.  The extravasation of blood to which they are
 immediately owing, generally takes place into the substance of the
skin, and subjacent cellular substance, but occasionally also upon
 the surface of the cutis vera, so that the  cuticle is raised into blebs
or blisters, filled with liquid blood.   Spots of the same description
as those of the outer integument next make  their appearance upon
the mucous  membrane of the mouth,  tongue,  and fauces,  and
unquestionably also of-the nasal fossae, stomach, intestines,  air  and
 urinary passages, (fee, from which  hemorrhage to a  greater or less
amount takes place, either by constant  oozing or by a more rapid
discharge, in which case patients have  been known to sink rapidly,
exhausted through.sheer loss of blood : this is the disease which  is
characterised as purpura hemorrhagica.
  This variety of purpura, although not necessarily,  is almost con- 
PURPURA.                      215
stantly preceded and accompanied by a state of depression, listless-
ne?s, and  inaptitude for  exertion,  either bodily  or mental.  The
pulse vanes remarkably in its character, being in one case full and
hard, in another small, weak, and easily compressible.   Symptoms
of a disordered state of the stomach and alimentary canal are also
very commonly observed.
  No term can be assigned to the duration of purpura hemorrhagica:
it may end in a few weeks, or  be protracted during many months
or years.   When the disease  ends fatally it  is  commonly by the
occurrence of  hemorrhage from some important organ, as from the
lungs or intestines, or of bleeding from several points at once, or of
acontinual drain from some particular  part, as the gums, nose, kid-
neys, (fee   It is often truly surprising to observe the quantities of
blood that are  lost in this way before the fatal result ensues.
  There is a third species of purpura spoken of by Willan under
the name  of purpura urticans,  in which the hemorrhagic spots of
the skin are slightly elevated.   In other respects this variety does
not differ from the simple or  hemorrhagic form of the disease.   The
fourth  species  which the same excellent author reckons under the
title of purpura senilis, is one or other of the two varieties parti-
cularly described  above, occurring in  the aged.  The variety
denominated purpura contagiosa, again, cannot be spoken of apart
from the general symptoms of typhoid  fever with which it always
appears associated.
  The causes of purpura are  extremely obscure.  We have seen
that the disease attacks individuals  in the enjoyment  of apparent
good health, nearly as often  as persons  who are ailing and infirm;
the etiology is rendered still  more obscure, when we see individuals
in the enjoyment of every comfort of life the subjects of the disease
nearly in  the same proportion as those who live amidst poverty and
wretchedness,  scantily fed,  badly  lodged, and thinly clad.   The
disease seems to occur most frequently among females and youthful
subjects before the age of puberty.  The blood in this disease has
sometimes been observed to be altered in its appearance and general
properties;  instead of looking opaque and black, and coagulating
as usual, and separating into serum and crassamentum, it continues
tremulous, translucent,~and is of a light red, like  thin currant jelly.
The disease has sometimes appeared to be connected  with  some-
thing like a stasis in the venous circulation.
  I am not aware that purpura  simplex and hemorrhagica are par-
ticularly liable to be  confounded with  any other disease, the skin
under no other circumstances appearing sprinkled over with smaller
or larger distinct dark red or livid stains, whilst there is hemorrhage
from the nose, mouth, anus,  urethra, (fee   The disease which used
to be so well known, but is  now so seldom seen, entitled scurvy,
appears to have had  many  characters  in common with purpura
hemorrhagica.  They are undoubtedly different diseases, however;
for purpura is  still  frequently met with, whilst the assemblage of 
216
GREEN ON DISEASES OF THE SKIN.
symptoms denominated scurvy is very rarely seen indeed, and then
only under particular circumstances.
  Purpura can never be considered as a trifling disease.   It is true
that it may exist for  months and  even for years without notable
deraugement of the general health; but of this we can never be
certain beforehand; and though  slight at  first, and accompanied
with no unpleasant symptom, it is apt  suddenly, and without evi-
dent cause, to acquire so great a degree of intensity, as to bring the
patient into imminent danger of his life.  The immediate danger
in purpura is always in  proportion to the  frequency with which
hemorrhage occurs, and to the quantity of blood that is lost.   The
quarter from which it flows must also be taken into account in cal-
culating the probable  issue  of the disease: by plugging, we can in
some sort command the flow from  the nostrils; coming from  the
lungs, the risk is greater than it is from the bowels, and from  the
bowels greater than from the kidneys, &e
  In treating a disease like purpura, the nature and cause of which
are so little understood, experience  is the only guide that  can be
safely followed.  The treatment of the disease requires, in fact, to
be modified according to the circumstances  under which it occurs.
Were a robust and still youthful individual,  with a pulse  strong
and full, its subject, it might  be proper to bleed guardedly.  This
practice  could  never be advantageous in  a  weakly  individual,
abstemious from inclination or necessity, of spare habit of body,
and whose pulse was  feeble and compressible.   Purgatives appear
to be much  more generally available remedies in purpura than
blood-letting; indeed the principal instances  of success  that  are
boasted in the treatment of this disease, have followed the regulated
and continued administration of aperient or purgative medicines.
The diet and regimen proper in this disease must also be modified
according to circumstances : it would be absurd to prescribe severe
abstinence to the miserable  being  who  has  become  the subject of
purpura, whilst struggling with want,  and  enduring privations of
every  kind;  and  no  less  incongruous to recommend nourishing
food, generous wine, (fee  to  him who has been attacked whilst  in
the enjoyment of every comfort in  life.  The system of diet pre-
scribed then,  must, like the other particulars of the treatment, be in
accordance with the condition of the patient.   The mineral acids,
in combination with  the purgative and dietetic plan, seem to have
been useful in many cases ;  it seems unnecessary to insist in addi-
tion on the  necessity of the patient living in the open air as much
as possible, in a pure, dry atmosphere, and taking exercise of a kind
and to an amount proportioned to his strength.

                  ELEPHANTIASIS ARABICA.

  The disease entitled Arabian Elephantiasis, not as occurring
very commonly or particularly in Arabia, but as having been first 
                  ELEPHANTIASIS ARABICA.               217

described by the Arabian  writers, is characterised by an indolent
enlargement or hypertrophy of the skin, and subjacent cellular and
adipose membrane, independently of evident external phlogosis, or
internal ordinary cedematous infiltration of  these tissues.
  This disease appears to be confined to no particular part of the
body;  in the island of Barbadoes it is frequently seen in  the leg,
and from  this circumstance has been described under the title of
the Barbadoes leg ;  in Egypt it has often been met with affecting
the scrotum, and has therefore been spoken of by the name of the
Egyptian Sarcocele, (fee;  but no part of the body, as I have said,
seems to be exempt from its invasion—the face, neck, breast, abdo-
men, nates, labia, and margin of the anus, have  all, at different
times and by different observers, been observed to be its seat.   The
disease frequently begins  in  rather a sudden manner, the  patient
feeling himself unexpectedly attacked with a violent and deep-seated
pain in the part which is about to  become the seat of the enlarge-
ment.   When this is the leg, the pain extends along the principal
line of the absorbent vessels of the limb, in the course of which  a
chain of enlarged and very painful lymphatic glands can be detected
as high as the groin, where the same bodies are swollen and very
tender to the touch.   The skin of the extremity now generally
shows something like a general erythematous blush, and  both  it
and the cellular substance under it begin to thicken and enlarge.
   This local disease does not proceed without symptoms of general
constitutional disturbance; the patient has a regular attack of fever:
shivering fits,  with sickness, vomiting, (fee usher in a hot stage of
extreme intensity, which is terminated by profuse sweating.  It  is
remarkable that these attacks, seemingly dependent on a local cause,
should still  intermit and return again and again  periodically,
although  at irregular intervals.  After each  attack, the erythema-
tous  redness,  which had  appeared in the integuments over the
course of  the lymphatic vessels, subsides;  but the swelling never
declines in the same proportion as  it had increased with the occa-
sion, so that the limb gradually acquires  an enormous size, and
becomes at the same  time  so hard as to resist the  firmest pressure
with the finger.  The disease in this way generally continues to
advance during several months, after which the faulty actions upon
which it depends usually abate ; local pain and uneasiness are no
lono-er complained of; the general  febrile symptoms also subside ;
buUhere  is no attempt  made to repair the  injury that  has been
done,  and the patient is left with a limb that is  both burthensome
and unsightly.  Far from any diminution happening in the hyper-
trophied skin  and cellular substance, during  the quiescent state of
the disease, there is. on the contrary, a perpetual tendency to further
deposition, so that no limits can be assigned to the deformity that
ensues.   A scrotum affected with Arabian elephantiasis has been
removed  which weighed  hard upon  sixty pounds, and one of the
lower extremities  has been seen  which would have  gone  near to
counterbalance the remainder of the individual's body. 
218
GREEN ON DISEASES OF THE SKIN.
  The skin is not always, nor perhaps even generally, the primary
seat of this affection;  sooner or later, however, it participates  in
the diseased actions  that are going on in the cellular membrane
under  it.   From having continued  for some  time pallid, smooth,
and shining, its vessels enlarge, and are often seen  permeating it in
tortuous lines;  it next loses its smoothness  and natural polish,
becomes rough, hard,  rugous, evidently thickened,  and covered
with knotty projections, warts, and foul epidermic homy-looking
incrustations or  scales; lastly, it  cracks in  various  directions,
especially in those situations where some degree of motion still
takes place, and deep and painful fissures then ensue.  The lym-
phatic glands, which have  continued all along hard  and swollen,
frequently  inflame actively, and suppurate, when  large abscesses
are formed that pour out a profusion of fetid discharge, whence the
disease  has been described by one able writer under the title of the
glandular disease of Barbadoes.
  The causes of Arabian elephantiasis, like those of so many other
diseases, are very little known.   It is not contagious;  neither does
the disposition to it appear to be transmitted hereditarily.   Both
sexes are  alike obnoxious  to its  attacks, and the wealthy who
dwell at ease, as much so  as the  poor who pass  laborious  lives.
In the island of  Barbadoes  particularly, where  the disease occurs
frequently  in the legs, it has been attributed to the impression  of
the draught of air which the inhabitants keep constantly blowing
through their houses.  But as the  same disease occurs  in the
scrotum and other parts that are kept covered;  and further, as the
disease  is seen in countries that are unrefreshed by  alternate sea
and land breezes, as in Egypt, for example, it is probable that the
cause assigned is rather presumed  than real.  It  is even doubtful
to my  mind,  whether, in   every  instance, Arabian  elephantiasis
depends immediately on an inflamed state of the  lymphatics and
absorbent glands, and  whether several diseases  have not  been
described under one common name, which are essentially different
in their proximate causes and ulterior tendencies.  But as I have
seen very little of Arabian  elephantiasis myself, and as the disease
occurs  with  extreme infrequency  in  this country,  my opinions
upon this point are necessarily hypothetical; I therefore pass on to
other parts of the subject, namely, prognosis and treatment.
  The prognosis in Arabian elephantiasis, by the concurring testi-
mony of all who have enjoyed extensive opportunities  of observing
the disease, is unfavourable.  The disease does not, indeed, gene-
rally prove fatal; but, neglected  in  its first stages,  it is little  under
the influence of treatment,  and  commonly ends in depriving the
patient of the use of a limb, or otherwise in making him burthen-
some even  to himself.
  Called to see a patient in the first stages of the disease,  there
could be no doubt of the  propriety  of  bleeding  freely from the
general system, and, in case they can be procured, of following up
this practice by the application of an abundance of leeches  along 
CHELOIDEA.                      219
the  line  of inflamed absorbents and  absorbent  glands;  where
leeches cannot be procured, cupping on each side of this line may
very properly be substituted;  the temperature of the part affected
is, at the same .time, to be regulated  by being kept in a suitable
position, and  covered with a few folds of linen cloth dipped in
some evaporating wash  or cold  water.  The disease is in other
respects to be treated as  an acute inflammatory and  febrile affec-
tion : antimonial and aperient medicines are to be prescribed; the
diet is to be restricted, (fee   The  oxide of zinc, in doses of six or
eight grains, has been particularly recommended for  its power of
controlling the vomiting, which is often so troublesome in the first
periods  of the disease.
   When  the  disease has  passed into the chronic stage, general
blood-letting becomes unnecessary, and  even the local abstraction
of blood is not always followed by any very evident advantage.
   The  friction, compression,  and even the kneading of the part
affected, have  occasionally been  attended  with good effects;  by
these means, indeed, combined with the  use of purga'ives, a leg
which had  been completely useless  for twelve years was restored
to its original  dimensions, and all its former usefulness, under the
superintendence of  Messrs. Alard and Bayle.  Scarification  and
local  bleeding, united to graduated compression,  have  also been
followed in some cases with  the happiest results.  Since the dis-
covery of the powerful action of the  various preparations of iodine
on the  absorbent system,  it is very probable that kneading, and
friction  with an ointment of this substance in  one or other of its
combinations, will be found  highly conducive to the success of
whatever additional  means of  treatment may be held advisable.  I
should think that the powerful stimulus of  the hot air and sulphur
fume bath, either locally  or generally, would also prove useful in
promoting the absorption of the fresh deposits that mainly increase
the bulk of the limb  ; I know of no means  at least half so efficient
in dissipating  simple cedematous  swelling of the ankles and legs.
Blistering, and the insertion of issues, have not been attended with
such results  as should induce us to have any confidence in their
powers.  When the  parts affected are chapped and  excoriated, the
use of emollient and  soothing applications is naturally suggested.
CHELOIDEA.
  The disease of the skin  which  Dr. Alibert first described under
the name of cancroide, and subsequently under that of cheloide, or
keloide,  from  x&vr, a  tortoise, is of extremely  rare  occurrence.
The disease begins with some slight swelling of a portion of the
integuments, which soon assumes the  appearance of a flattened,
irregularly  shaped, rounded,  oval,  oblong,  or angular  tumour,
shining on the surface, slightly depressed  in  the  centre, hard and
unyielding to the touch, of a pale or deep red colour, and covered
with a cuticle of such tenuity and so much wrinkled, that it looks 
220           GREEN ON DISEASES OF THE SKIN.

like the cicatrice of a burn which  has  penetrated deeply.  This
tumour is generally single, but is occasionally met with in greater
numbers, as many as eight having been  seen on different parts of
the body  of the same  individual.  Its  size  varies considerably,
never exceeding a few lines in  diameter in some cases, in others
measuring from an inch and a half to  two inches across.  It is in
one instance accompanied by a good deal of pain of a shooting
kind, and  with severe tingling  sensations after meals ;  in another,
it is evolved, and attains a considerable size without being even
observed by the patient.   This  tumour generally continues indo-
lent through life; it has also lately been said to have  shrunk and
disappeared spontaneously, in some few instances, after continuing
for  an indefinite period, in which event its situation is  marked
with a white and firm cicatrice, although nothing like ulceration
had ever taken place.
  This kind of tumour  appears most frequently among the youth-
ful, and its usual seat is the bosom, between the mammae, or on the
front of the neck.
  The tumour now indicated differs  in many respects from cuta-
neous cancer: the disease occurs among the youthful,  and consists
of a flattish, raised patch of integument, of varying form and mag-
nitude, standing  out in  pretty  strong  relief around its edges, and
rather depressed  in its centre, firm to the touch, forming an integral
part, as it  were, of the skin, which may be somewhat heightened
in its colour, but is obviously unaltered in its structure, and show-
ing no tendency  to  run into ulceration.  These are very different
from  the  characters  exhibited  by  cancerous  tubercles,  which
generally  show  themselves, among individuals of a  certain age,
in the guise of prominent, regularly rounded, dark purple  or livid
coloured tumours, surrounded  with a circle of dilated vessels, and
having a constant tendency to  become open  ulcers, and to infect
the surrounding  structures, particularly the absorbent vessels and
glands.  The firmness of the cheloid tumour, and the moderate
depth of  its colour,  distinguish  it sufficiently  from naevus,  or
bloody tumour,  of every description,  soft  to  the touch, of a dark
sanguineous hue, and frequently pulsating synchronously with the
arteries.
   The cheloid  tumour is  not a dangerous  disease.  It  occurs
among  individuals  who enjoy  perfect health, and, in  itself, shows
no tendency to any conclusion that can implicate the safety of the
individual affected.   When  it  has degenerated  into a  foul and
troublesome sore, this appears to have  happened in consequence of
injudicious  attempts to discuss it by means of caustic and stimu-
lating applications.
   Curative measures ought therefore to be  used with great dis-
cretion in this form of disease.  The sulphur douche has appeared
to reduce the hardness of the tumours,  and  gentle frictions, with
the hydriodate of potash and iodine ointment, have seemed to aid
the process of resolution. 
             ORIGINAL OR ACCIDENTAL


UNUSUAL  STATES  OF  THE  SKIN,


          NOT REFERABLE TO INFLAMMATION.
  The order of Maculae of Willan, Bateman, <fee, includes diseases
the most dissimilar in their  characters, appearances, and causes;
it even comprises conditions of the skin which are the opposite of
maculated  or stained, which consist, in fact, in the absence of all
colour.  I have, therefore, along with Rayer and others, separated
these unusual states of the skin into two divisions, the one charac-
terised by a diminution  of, or absence of,  pigmentary  matter—
Achroa;1 the other by an increase or alteration  of the natural
pigment, or colour of the surface—Dischroa.2
  These orders differ essentially  from  the whole  of the  more
general and comprehensive classes of cutaneous affections, as well
as from  the  individual  diseases assigned as types of additional
genera, which  we have hitherto  been engaged  in considering.
The achroa and dischroa are  unaccompanied with those symptoms
of local inflammation or  congestion, and  disordered  sensation,
which we have hitherto found inseparable from the exanthematous,
vesicular,  pustular, and other elementary forms of the cutaneous
diseases.   They are,  on  the  contrary, frequently congenital  affec-
tions, and are attended with  no symptoms  which  betoken  either
local derangement of function, or general constitutional disturb-
ance.
                          ACHROA.                     *

  By this term, I designate those congenital  or accidental, general
or partial, colourless states of the skin, depending upon a want of
the  pigmentary or usual colouring matter of the rete mucosum.

                        LEUCOPATHIA.

  The  state  familiarly known  by the name of leucopathia, or
albinism, in  which  the skin is of an uniform dull,  milky white
colour,  and the hair resembles  bleached flax or silk,  marks the
1 A, priv. and "xgx*-, colour.
*&>!, faulty, and xgo*. 
222
GREEN ON DISEASES OF THE SKIN.
    general occurrence of this peculiar state of integument.  The hair
    of every part of the body presents the same  peculiar appearance.
    The iris is of a decided pink hue, and the retina and choroid, seen
    through the pupil, present another shade of the same colour.   The
    albino cannot endure the bright light of day; he is only at his ease
    in a darkened chamber, during cloudy weather, or on the approach
    of  twilight,  when  he  distinguishes objects  very  accurately.
    Albinos are said generally to have exhibited indications of a  feeble
    constitution, and even of imperfect moral and intellectual as well
    as physical development.   There does not, however, appear to be
    any very obvious and necessary connection between the absence
    or abundance of the colouring matter of the skin, and the state of
    the intellectual and moral  faculties;  indeed, we occasionally see
    near approaches to the  albino  state  without any evidence of
    deficiency, mentally or  bodily.  Albino animals, which are fre-
    quently met with,  show much the same aptitudes as those that
    have coloured skins and hair.
      The albino state is invariably congenital.   It has been supposed
    to be more common in certain parts of the  world than in others,
    and to occur more frequently among the negro tribes, than the
    races with skins of various degrees of whiteness.   The condition
    is not remediable:  disordered function we  can often  arrest, and
    sometimes even rectify ;  original faulty formation we can no more
    change than we can control the succession of  events in the mate-
    rial universe.

                              VITILIGO.
      When,  instead of being general, a  colourless state  of the skin
    occurs partially, or in patches, the condition  is designated vitiligo.
    In  its congenital form it is very analogous to  what is obseived
    among piebald animals;  and as it is most frequently seen  among
    negroes,  these  in the colonies are actually  spoken of  as pied, or
    parti-coloured.  When the colourless patches  occur on parts natu-
    rally covered with  hair, this  appendage is of the same blanched
    appearance as the skin.  Vitiligo also  occurs  occasionally among
•   whites accidentally.  It  is then  usually seen upon the scrotum,
    which is covered with spots, patches, or striae, of a milky  white
    colour.   These are not accompanied either with heat or any other
    unusual sensation.  This affection is of no consequence, and as it
    does not require, so neither is it benefited  by,  treatment of any
    kind.
                         DISCHROA.

  Those who  are  the subjects  of organic disease  of different
descriptions, often exhibit a very sallow  and dingy  state of the
skin.   As  we  know that in  one organic disease especially—
melanosis—there is  an extraordinary deposit  of carbonaceous 
DISCHROA—
LENTIGO.
223
matter,  so  does  it appear that in certain disordered state of the
system,  the pigmentary or the colouring matter of the rete  muco-
sum is  secreted  in extraordinary abundance, or of an unusually
dark shade of colour.  Such changes of colour of the whole sur-
face are known occasionally to take place rather rapidly.  But as
it is impossible to separate the consideration of this accidental state
of the surface from that of the  disease of which it  forms a mere
and often a very  unimportant symptom, I shall say no  more on
this subject in this place.
  Another very  remarkable and  very permanent change of colour
in the integuments, frequently follows the continued internal use
of the nitrate of silver.   The colour thus produced is a dark leaden
gray,  and gives a  most unseemly and even frightful cast to  the
countenance.  It very frequently continues undiminished in  inten-
sity to the end of life, though some few cases have been  observed
in which  it faded materially; in none upon record, however, is it
stated to have disappeared entirely.  However deep the shade of
colour,  the functions of the skin do not seem to be sensibly  impli-
cated  ;  and  this being the case, it is impossible to consider  the
change  as  a disease, in the ordinary  acceptation of that  word.
None of the attempts that have been made to modify the coloured
state of  the skin, induced by the administration of nitrate  of silver,
have  hitherto  been attended with the least success.   It is probable
that the salt, after being received into the  circulation, is  deposited
within the substance of the cutis vera and  upon  the pigmentary
membrane, in the state of a muriate, where  it remains exactly as
charcoal, minium, vermillion, (fee, introduced under the cuticle by
means of punctures, do, without causing any irritation,  or inter-
fering with the ordinary functions of the tissues it impregnates.

                      LENTIGO ; FRECKLE.

  Lentigo is the title given to the small rounded  brownish-yellow
coloured stains that appear upon the face,  throat, bosom,  hands,
&e, more especially of individuals  who have hair of different
shades of red, and a clear complexion.  Freckles evidently appear
in greatest numbers on parts of the body habitually exposed to the
light and heat of the sun ; but they do not seem to result from the
direct action of the sun's rays, for in those of the complexion men-
tioned,  who are predisposed to  them, they  occur, even  from  the
period of birth, in situations never exposed to the light.   Freckles
are usually most abundant in childhood and  youth ; they are com-
monly  much less  conspicuous  in manhood and old age.   The
cuticle  covering the individual  spots is pliant and  natural; the
cutis  vera that  supports  them  is  unaffected with  the  slightest
symptom  of derangement.  They  appear to consist in  extraor-
dinary  accumulations of colouring matter on individual  points of
the surface.  The  cosmetics so  commonly  recommended for the
removal of lentigo, do not generally appear to have any influence
upon  its continuance. 
224
GREEN ON DISEASES OF THE SKIN.
                            EPHELIS.

    This word is often used in two senses :  in  the one it is taken as
  synonymous with lentigo, or with no greater  diversity of meaning.
  than as signifying  a less permanent  kind  of freckle, developed
  under the influence of exposure to  the sun  and weather;  in the
  other it is employed to designate the partial  discoloration which I
  shall proceed to describe under the title of

                     chloasma; liver spot.

    Chloasma is characterised by  one  or  more  broad  irregular-
  shaped patches, commonly of a lighter  or  darker shade  of yellow
  or yellowish brown, and occurring most frequently on  the front
  part of the  neck, on the breast, abdomen, groins, and inner  aspects
  of the thighs, although there is no point of the surface of the body
  upon  which  they  may not,  and  do  not,  occasionally  appear.
  These  patches  are  at  first isolated and distinct,  but increasing
  slowly, they coalesce, and spread  so much as at length to cover
  extensive regions with a single coloured blotch.   The patches of
•  chloasma do not generally rise perceptibly  above  the general level
  of the  surrounding surfaces;  in  some cases, however, they are
  very slightly elevated.  They are very commonly affected with
  some degree of pruritis, which induces the patient to  rub them
  with his clothes, and even to use his nails in scratching ; this sen-
  sation of itchiness increases  with  exposure to heat, indulgence in
  spirituous  liquors or highly seasoned food, and in  consequence of
  active exercise.  By and  by the cuticle splits, and is detached in
  shreds of larger or  smaller dimensions.  But this  is not a neces-
  sary termination of  chloasma, the patches of  which are sometimes
  very evanescent,  and do not continue  longer than a few days, in
  some cases  not longer than a few hours, when they  vanish as they
  came, without other evident alteration  in  the  part affected  than a
  simple change  in the shade of colour.  Females about their men-
  strual periods,  and during pregnancy, are  the usual  subjects of
  these evanescent forms of chloasma.
     The causes of^ chloasma are frequently not very evident.  In
  some  cases it  evidently depends  upon a particular state  of the
  system, such as that which occurs on the approach of  the men-
  strual period,  and  during the continuance of pregnancy.   Gene-
  rally, however, those in whom the affection in its more permanent
  form appears,  declare themselves to be in the enjoyment  of perfect
  health, so that it is often difficult to  assign any satisfactory reason
  for such an  accumulation  of pigmentary  matter in   particular
  regions.   We  do  see  pigmentary spots, very  similar in their
  general appearance to the  patches of chloasma, following the
  application of  blisters, the presence of the bullae of  pemphigus, the
  cure of venereal eruptions and ulcers, (fee; but in these cases there
  has  been  manifest, and  often violent, excitement of  the parts 
DISCHROA—CHLOASMA.                225
affected,  and this  is what certainly has not occurred in the sur-
faces that are the seat of chloasma.
  Chloasma is not apt to be confounded with any other form of
cutaneous affection.  The patches, indeed,  when dark, often bear
a great resemblance to naevi  of  different descriptions;  but these
last are congenital and permanent marks, free from every feeling
ot pruritus, and not at  all under the influence of treatment of any
kind.                                                        }
  The form of chloasma which has been mentioned as appearing
under  particular circumstances, or in conjunction  with  particular
conditions of the system, is generally a very evanescent  and  very
insignificant  affection, which requires no remedial  measures.
Occurring along with pregnancy,  it usually disappears  after the
earlier months  are  passed,  and  when  the system  has become
habituated, as it were,  to the change that has taken  place; yet it
occasionally continues during the whole period of utero-gestation,
and only disappears after delivery.
  Sulphur, in  one or  another of its usual  forms, appears to be a
kind of specific in chloasma.  Its spots disappear rapidly under
the internal use of any of the common sulphureous mineral waters,
as well as  by  the external employment of  the same agents in the
form of baths.   When  they resist  these measures, the sulphur  fume
bath will be found to dissipate them very rapidly.
  The following case  differs in many particulars from  chloasma
as now  described.  But  for  the entire  absence  of spontaneous
desquamation from the surface. I  should  have spoken of  it among
the squamous affections, as a variety of pityriasis (pityr. versicolor);
the absence of  every  symptom of constitutional  lues  made me
hesitate to  speak of it  among the syphilides, although the gentle-
man who was its  subject regarded it himself as  depending on a
secondary taint of  the system; in  short, I knew not where to place
it, save in the situation it  now occupies.  I have ventured to
entitle it
               A CASE OF CHLOASMA VERSICOLOR.

  On the 15th of November,  1825,  Mr. A., a medical gentleman.
consulted me for a peculiar discoloration of the skin, under which.
he had laboured for the  last eight years.   Mr. A. was apparently
in good  health, but the whole surface of the  body, as well as that
of the arms,  thighs, and legs,  was marbled over with dark parti-
coloured streaks and irregular patches of all dimensions.  No part
of the skin thus affected was  raised above the general  level, or
scaly, or the seat of any morbid sensation, as  it is in pityriasis and
psoriasis, and the patches were no where  orbicular, as they are in
lepra.  The  streaks  and  patches  exhibited various shades of
colour ; many  of the former particularly  were of a yellowish or
light brownish  colour, others were of a livid cast, but the greatest
number both of streaks  and  patches  were of deeper or lighter
       7—e                                     gm 15 
226
GREEN ON DISEASES OF THE SKIN.
 shades of a bluish gray, so that the surface of the body and limbs
 presented a very similar appearance to a slab of variegated marble,
 in which blue streaks and markings predominate.
    Many years previously, Mr. A. had contracted syphilis in India,
 and the staining of the  surface  described  he considered as an
 evidence of a remaining  constitutional taint, for the eradication of
 which he had tried all imaginable means  unavailingly, and it was
 for the purpose of ascertaining the effects of the sulphur fume bath,
 as a last resource, that he put  himself under my care.
   I could detect no symptom  to countenance Mr. A.'s  supposition
 of the cause of the discoloration of  the skin depending  on syphilis,
 so that the baths were commenced immediately.  He took a dozen
 baths, with no  other apparent  effect  than that of causing the
 detachment of some cuticular laminae, and making the  streaks and
 patches more visible than  before.   He discontinued the fume bath
 to see what the effect of further desquamation would be.  Decem-
 ber 24th, Mr. A returned to resume the  bath, considerable desqua-
 mation having taken place in the  interval, and the colour of the
 streaks and patches now appearing fainter.   His general  health
 was so good, that he informed me he would  not  have  thought of
 resorting to medical treatment of any kind had he not  been  about
 to be married.  He therefore came, resolved to put the efficacy of the
 sulphur  fume bath fairly to the test in his own particular case, at
 least;  and although six drams, or at most  an ounce, of sulphur is
 the quantity commonly used in charging the fumigating apparatus,
 he chose to have this quantity increased  an ounce every time he
 took  the  bath.  Four ounces were borne  with  impunity;  five
 ounces caused considerable smarting, particularly of the scrotum
 and flexures of the joints  ; six ounces occasioned so much  uneasi-
 ness that he was  obliged to leave the apparatus, but this was not
 done until the whole of the  scrotum was denuded of  its cuticle.
 Mr. A. was now obliged to stay at  home, to nurse himself and  to
 use appropriate remedies.
   January 8th, 1S26.  He again presented himself at  my house.
 There had not been sufficient time for much desquamation to take
 place, but the streaks and patches appeared still more  faint; the
 whole of the cuticle was thickened and hardened.   Sulphur fumi-
 gations were resumed daily,  four  ounces  of sulphur  being the
 quantity  used on each occasion.  On the  14th, six ounces  were
 tried a second time, but with the same consequence as before.   On
 the 23d, when I saw this gentleman once more, the  skin  had
 become  exceedingly  hard, the cuticle was cracking   in many
 places, and so dirty  looking and opaque,  that it was difficult to
 ascertain the effects of the  remedy on the discoloured  parts.   At
 this time there must have been little or no insensible perspiration
 thrown off from the  surface of the body;  water  was  made  fre-
quently and in  large quantities.  The sulphur fumigations were
 resumed  daily for twelve days, the quantity used never  exceeding
four ounces on any occasion.  At this time the skin looked exactly 
                     DISCHROA—N^iVUS.                 227

like dirty parchment  wrapped  round the  body.   The baths were
discontinued.  June 6th, the skin had gone  on  desquamating or
peeling from the date of the  last report, and the  cuticle  still con-
tinued to be  detached in the  form of furfuraceous dust.  There
were  now only indistinct vestiges of the discoloration to be seen.
The fumigations were resumed, each of four ounces of sulphur, in
order to bring about a repetition of the abundant desquamation, as
after each process of the  kind the chloasma had become  less appa-
rent.   Small doses of oxymuriate of mercury were on this occasion
combined with the use of the sulphur fumigations, and by the end
of the year, very  faint  traces only in a few  places were all that
remained to indicate the previous existence of the deep  discolora-
tions that have been described.
NCEVUS.
  Two very different forms of congenital affection of the skin are
commonly spoken of under the common title of Ncevi.  The first
of these depends on an alteration of the pigmentary membrane, and
is of no importance in a pathological point of view, nor indeed in
any other, save on account of the deformity which it sometimes
occasions.  This species of congenital malformation I shall speak
of under the title  of pigmentary ncevus, spilus, or mole.  The
second, or vascular  ncevus,  properly  so called, is  owing to  an
original morbid  condition of  the blood-vessels of some part of the
skin, or of the cellular membrane immediately beneath it, and is an
affection of more interest,  and one that often proves serious in its
consequences.
  Spili or pigmentary naevi  are met with  of all  dimensions, of
every form, naked, covered with  the softest down, or beset with
bristly hairs, and of  every shade  of colour between a pale tawny
and a deep black.  Spili in some cases do not differ sensibly from
the accidental  alteration  of  the pigment we have denominated
chloasma, save in the circumstance of their being congenital, and
not under the influence  of the remedial measures which promptly
cause chloasma to disappear.   Spili are observed to occur on every
part of the body, but with especial frequency on the  face, throat,
and bosom.   When of very small size they are not looked upon as
any deformity;  on the contrary, a small mole upon the cheek is
sometimes held rather as a heightener  of female beauty than other-
wise.   When large, the  effect is very different.  These spili, I have
said  are of various shapes, as  well as of different sizes: oblong and
covered with short  brown hair, they have been fancied to bear some
resemblance to a mouse, or to a portion of some other animal: in
which case  there  is seldom  wanting a tale  of how the  mother,
during her pregnancy with the child thus marked, was frightened
bv a mouse or a rat, or  had  had a dead mouse or  rat thrown at
her (fee   Tales of this  kind  are  never readily disproved,  and are
therefore very generally accredited by the  vulgar.  In the present
                                               grn 15* 
 228           GREEN ON DISEASES OF THE SKIN.

 state of our information with regard to the mode of existence of the
 embryo, it is impossible to speak as to the precise degree in which
 the  corporeal state of the foetus is or  may be  influenced by the
 mental condition of the mother ;  reason and philosophy, however,
 lead strongly to the conclusion that after the period of conception
 the embryo is evolved by its own inherent powers in a very inde-
 pendent  manner :  no  matter where the ovum falls, whether it be
 into the  cavity of  the uterus or of the abdomen, it contracts adhe-
 sions, and  the  included embryo then seems to  grow in no very
 essential particular differently, save in the  mode by which nutri-
 ment is conveyed to it, from that in which it continues to increase
 afterwards, when as an  infant it becomes dependent on  the breast
 for its support.   It would be out of place were I to pursue this sub-
 ject further here.
   Besides  the  tawny and hairy spili now spoken  of, Dr. Rayer
 informs  us that he once  saw a  young man  whose  eyelids,  and
 cheeks in the vicinity of the eyes, were  of a bluish colour, similar
 to that which follows  a burn with gunpowder, and a child upon
 the lumbar region of which there was a stain of blackish gray, very
 like what is produced by spreading a  thin layer of mercurial oint-
 ment upon the  skin.   These stains were  therefore of  the  same
 colour at least, and very probably of the  same nature, as those with
 which Mr.  A., whose case has just been related  under the head of
 chloasma, was affected.
   Spili are not remediable by any kind  of internal treatment, and
 can only be got rid of by being destroyed with  caustic or  removed
 with the  knife, by either of which means unseemly cicatrices, often
 productive  of fully more deformity than the original blot, remain.
 In general, therefore, it is better to resist  than to yield to the wishes
 of those affected with spili to have them removed by an operation.
   Vascular naivi, as their  name implies,  are not the product of any
 merely unusual state  of  the  pigmentary membrane, but of  the
 blood-vessels—arteries and veins, entering into the constitution of
 some portion of the skin.   Instead of the usual tawny brownish or
 blackish  tint of spili, vascular  naevi are mostly of the  colour of
claret or  port wine.  Far from  being, as it were, extraneous,  and
 beyond the influence of the more evident actions of the economy,
 like spili, vascular  naevi partake in the visible changes that accom-
 pany accidentally increased or diminished action of  the heart and
 sanguiferous system generally; thus they are much redder or rather
darker in colour under moral excitement than when the mind is at
 rest;  their  tint also becomes deeper  after meals, upon  exposure to
an elevated temperature, &e
  Cutaneous vascular naevi show tendencies of very different kinds ;
 whilst some of them continue indolent, on  a level with the skin,
 and unaccompanied with any thing like increased action  through
 life ; others, almost from the hour of birth, show a  disposition to
enlarge, to  rise above the surface of the skin, and to become formi-
dable from  the kind of actions of which they are the  seat.  The 
D tSCHROA—NCEVUS.
229
more indolent of these.naevi seem constituted by a simple dilatation
of the arteries,  but especially of the veins, distributed to the part of
the skin affected ;  the more active  species seem to  be new forma-
tions, and to consist of the erectile tissue which has  been so ably
described in recent times by the late celebrated Dupuytren of the
Hotel Dieu.  It is rather remarkable that the danger of increase in
these vascular  naevi should generally appear to  be  in the ratio of
the smallness of their dimensions at the time of birth : a broadish
purple naevus seldom increases or becomes formidable ; a red speck,
little larger than a pin's point, and of a bright  red colour, very fre-
quently acquires such dimensions in the course of some months or
years, that it becomes indispensably necessary to check its further
increase by an  operation.
  Vascular naevi bleed profusely when accidentally and even very
slightly wounded.   The more indolent species occasionally inflame
and ulcerate.  On becoming open sores they do not always show
a disposition to bleed.  When they are  large, and the ulcerative
process attacks their whole surface,  they are  generally succeeded
by hard  and unyielding cicatrices, which often prove  sources of
much inconvenience, and always causes of great deformity.  Com-
pression, and the continued application  of astringent and evapo-
rating lotions,  are the curative means which have been most  pow-
erfully recommended to our notice in the treatment  of this kind of
congenital malformation; and  it is certain, for the fact reposes on
the testimony of Mr. Abernethy, that these measures perseveringly
employed have occasionally succeeded in checking  the. increase,
and even in causing the disappearance, of one variety of naevus.
There is no question, however, of their frequent and perhaps their
more general inutility.  Tying the trunk of the principal artery of
the region affected, with the subsequent  assistance  of compression
and cold lotions, has succeeded in some important instances, as for
example when  the disease  was developed within  the  circle of the
orbit, in arresting the growth of naevus.  But this  is a procedure
that is  not often either available or advisable; and we have then
no  resource when the disease shows a tendency to extend but a
surgical operation.   The ligature  is frequently to  be preferred to
the knife in these cases;  and it has very recently been proposed to
attempt to bring about adhesive inflammation through the entire
substance of naevi, by injecting the cellular tissue which  enters into
their composition with some stimulating fluid, such as a dilute acid.
When the use  of the knife is determined on, the incisions must be
made  completely without  the  limits of  the disease,  and  in  such
directions  as shall  enable  us, by bringing  their edges together, to
form a linear cicatrice.
  Instead of being evolved within  the substance of the skin, vas-
cular naevi are  sometimes situated in the cellular membrane under-
neath it.  The same pathological views and principles of treatment
apply to these as to the cutaneous  species we have just considered
somewhat particularly. 
ALTERATIONS  OF THE APPENDAGES OF THE SKIN,


                      MORE PROPERLY OF


     THE PARTS WHICH SECRETE AND SUPPORT THESE.
  The proper appendages of the skin are the nails and  hair.
The cuticle is usually described as an integral part of the  tegu-
mentary envelope of the body; yet as neither vessels nor nerves are
distributed to it—as the exhalants merely pierce without ramifying
through it, and as it is exceedingly impermeable, perfectly insensi-
ble, and  a mere  secretion  of the more superficial  and  vascular
laminae of the sensitive structures it  clothes and defends, I have
ventured to  speak of it in this place as an appendage of the skin,
along with the nails and hair.
  Once secreted, the appendages of the skin are no longer under
the influence of the vital processes to  which they owe their  exist-
ence; it is only in the moment of formation that they feel the effects
of any thing like disordered function  in the surfaces, matrices, or
bulbs that produce them.   The malformations or alterations of the
cuticle, nails and hair encountered, consequently, are due to disor-
dered function in the parts upon which they depend  respectively;
those of the cuticle, in the vascular rete; those of the nails in their
secreting  matrices;  and those of the  hair  in its formative bulbs.
This consideration made me feel the propriety of adding the second
clause to the heading of this chapter.
  The appendages of the skin undergo a constant process of abra-
sion or decay and of renovation: the  cuticle is for ever falling  off
in minute plates, the nails wear away from the points, and the hair
becomes dry and  brittle at the ends, in the same  proportion as the
first is eliminated  by the  vascular structures beneath  it, as the
second are elaborated by their matrices, and the third is spun out,
as it were, by its secreting bulbs.  The  tales  that are current  of
sudden changes in the appendages of  the skin, particularly of the
hair, under the influence of grief and  other depressing moral emo-
tions, Jire to be  taken with extreme  reserve.  Certainly the vital
actions by which these parts  are produced, may be and  are  influ-
enced  by  all that powerfully influences the system generally, and
violent grief may indispose  the  hair bulbs for the secretion  of
colouring matter  in combination with the proper horny substance
of the hair, by which it will be produced of a dull white  instead  of
a brown or black hue; but this change can only take  place at the
root of the hair;  all that is beyond the surface of the skin  is  no 
ICHTHYOSIS.
231
more liable to be altered by any modified action in the bulbs than
it is when woven by the skill of the  perruquier into the net-work
of a wig.

         ALTERATIONS OF THE CUTICLE.  ICHTHYOSIS.

  The most remarkable morbid condition of the cuticle commonly
encountered, is denominated Ichthyosis, or Fish-skin disease.
  This alteration is almost always congenital;  at all events, it
appears at a very early period of extra-uterine existence,  and is
either general or partial.   Even when general, there  are  certain
parts  that mostly enjoy immunity from its presence, whilst there
are others, again, on which it is very commonly developed: the
eyelids, and face generally, the  axillae, groins, and prepuce, the
palms of the hands and soles of the feet, are rarely affected, even
when every other part of the body is incased, as it were, in a rug-
ged shell; the knees, and  fronts and outer surfaces of the legs and
thighs, the elbows and outer and posterior aspects of the fore-arms
and arms, on the contrary, are usually more thickly beset than any
other districts.   These, too, are the common situations  of the affec-
tion when it occurs partially, though it is also frequently met with
on the front of the neck, on the breast, and on  the upper and pos-
terior parts of the trunk.
  Ichthyosis is characterised by a morbid condition of the cuticle,
which appears thickened  in various degrees, split into square and
angular compartments of  different forms and sizes,  commonly ot a
dirty o-rayish, greenish, or  brownish  colour,  and resting  upon a
surface which  is not obviously, at least, the seat of any unusual
or deranged action.                                      .  ,  (
   This affection, as I have said, is  rarely visible at the period  of
birth; within the two first months,  however,  it generally shows
itself very decidedly.  The surfaces  about to become its seat have
a sallow or dirty appearance, become rough to the touch, and some-
times even feel'thickened and indurated. The cuticle then begins
to be secreted of greater thickness and a darker hue than common
and  bv and by,  splits into  various sized compartments of the
&?d£rib<&   The cuticle in ichthyosis »  never truly squa
mous;  that is, it never appears m im^lcatedQ^a^j1^ee *jtl
of a fish  or the squamae of lepra and psoriasis ;  the cuticle ot the
^affected cracks very commonly in the lines o theslight for-
;.„ ,hat 0ccur naturally on the surface both of the cutis aria am
  ■le after the  manner </the outer bark of a tree,  to which  when
  he' affection is of long standing, it in general bears a mmM-
 resemblance than  to  the skin  of any fish, or even to  the horny



 SS olefin $#3 fiTeS T<££ £ SucfaoS
 Tt seern to differ  from healthy cuticle  in its senstble or chem.cal 
232
GREEN ON DISEASES OP THE SKIN.
properties.   In some rare cases, instead of being of the dark green-
ish brown colour it usually presents, the thickened cuticle is  of a
grayish white, and somewhat opalescent, or pearly, on  its surface.
Instead also of  appearing  mechanically divided  or  cracked  into
angular pieces, as it usually does, the cuticle is sometimes produced
in the form of pointed prolongations, as if it had been moulded upon
the pipillae, like  the  shorterand blunter quills of the porcupine:
whence individuals affected in this manner have been described
under the fanciful appellation of porcupine men.
  The alteration of the cuticle denominated  ichthyosis occurs of
every degree of  intensity: occasionally very slight, the surface of
the region affected  merely looks dirty and a little  powdery, and to
the touch is simply dry and somewhat rougher than usual; in other
instances it is, as described, covered with a horny shell, cracked in
all directions, as hard  as shagreen, and as rough as the bark of
the elm-tree.  The hardened  pieces  of cuticle may generally be
detached in succession without pain, and without leaving any red-
ness behind them,  just as their formation has been accomplished
without increased  heat, or any uneasy  sensations of smarting or
pruritus.  It has happened  in some cases that, during the heats of
summer, the surfaces affected with ichthyosis have thrown off and
remained free from their horny  covering for  a time.  The same
result  has  also  been  brought  about by the  repeated  use  of the
vapour bath and various other means.   The integuments are  then
often found to be very nearly normal in  all respects; the cutis  may
perhaps appear in  a very slight degree thickened, and the furrows
of its outer surface rather more distinct than usual, but this is the
whole that  is visible.  The cuticle,  in its former thickened  and
altered state, is gradually reproduced.
  Ichthyosis, even  when  almost general, is not accompanied  with
any notable derangement of the  system  at large.  The cutaneous
perspiration is uniformly suppressed over the whole of the surfaces
affected, but sometimes appears to be more than usually copious on
such parts as continue free from the alteration.  Many individuals,
though affected with ichthyosis from their infancy, have lived to a
good old age. in  the enjoyment of as fair a proportion of health as
falls to the lot of the bulk of mankind.   The affection is very com-
monly congenital, and is developed under the influence of an here-
ditary cause, the nature of which is unknown to us ; when it occurs
accidentally, it has been said generally to follow some violent emo-
tion of a moral kind, such as a  paroxysm of anger, a fit of grief, &c.
Both sexes are liable to the affection ; but men seem to be the  sub-
jects of ichthyosis more frequently than women.   Edward Lam-
bert, who had laboured  under ichthyosis from  his  infancy,  and
whose case is detailed by Dr. Willan in his work  on cutaneous
diseases, had a son, now living in London, and whom I saw lately.
The son is affected to a less extent than  the father was, the  altera-
tion occurring only in large patches on the limbs, breast, and back;
still  it is very marked, as  may be  imagined  when I say that the 
ICHTHYOSIS.
233
horny cuticle is in some places half an inch thick.  This man has
cnimren;  the  boys, he informs me, become affected  during their
nrst year m the same manner as himself; the girls, without excep-
frh' fsc,aPe..entirel7-  This  I  believe was  the  case also in his
latner s  family, he and his two brothers being nearly in an equal
degree affected with ichthyosis from their birth,  whilst his  sisters
presented  no corresponding peculiarity  on any part  of the body.
 1 he same fact of hereditary transmission of ichthyosis, through the
male branches of families only,  has been remarked in  other cases.
  Individuals  in all ranks of society seem equally liable to be
affected with ichthyosis, nor does climate or mode of  life appear to
exercise any influence  on the frequency of its development; the
contrary of this has, I am aware, been advanced, but upon no suf-
ficient grounds.
  Ichthyosis appears with characters so  peculiarly its own,  and  is
so completely without all the symptoms  that accompany each and
every one of the affections of  the skin, which we have hitherto
described, that there seems no danger of confounding it with any
of them.   It would therefore be a waste  of time and space to enter
upon a lengthened enumeration of the particulars which  distin-
guish ichthyosis from the half dozen diseases to which it has been
presumed to bear some resemblance,—a resemblance which is much
more  in imagination than in fact.  The  absence of every thing
like the distinct forms of elementary lesion, by which  the vesicular,
pustular, papular,  squamous, and  other cutaneous diseases com-
mence, and the almost uniformly congenital nature  of the  altera-
tion, ought never to leave a doubt as to the identity of ichthyosis.
  Congenital and hereditary diseases generally are little under the
influence of remedial measures of any kind, and there is not one of
this class that is  more rebellious  than ichthyosis.  The altered
cuticle may indeed be detached by  the continued use  of the vapour
bath, and  of emollient topical applications, but it is speedily repro-
duced with all its original characters.  I once tried  the influence
of the sulphur fume bath in  the cases of two brothers,  privates in
the Coldstream regiment of Foot Guards.   Both of  the men im-
proved greatly whilst they were under  my care;  but  I make no
doubt the  amendment would have proved no more than temporary.
As it was, I soon  lost sight of my patients, they having been both
discharged from the regiment  on  account of some improper con-
duct.   Willan believed he had prescribed pitch or tar internally in
some  cases of accidental ichthyosis with advantage.   Other prac-
titioners have not been so fortunate with this article, the  use  of
which has consequently been  for some time entirely given up.  All
that seems really  useful in ichthyosis,  is to anoint  the surfaces
affected, from  time to time, with some softening liniment, and by
the use of the tepid bath occasionally, to detach,  as much as  may
be without violence, the horny and impenetrable covering of altered
cuticle under which they are concealed. 
234           GREEN ON DISEASES OF THE SKIN.

                 ALTERATIONS OP THE NAILS.

  The matrices of the nails are frequently affected with ordinary
inflammation ; but by much the most important idiopathic affection
of these structures consists in that  peculiar inflammation to which
the title of onychia has been given.
  The nails themselves, again,  are subject to what may be  held  a
chemical alteration of their forms and texture, from the application
of various substances employed in many of the mechanical arts
especially.  Hatters, dyers, bleachers, scourers, &c, have often the
nails of their fingers  split and deformed in a very singular manner.
The nails are also  liable to become secondarily affected  by the
extension of several diseases of the skin to their secreting matrices.
They are perhaps more frequently seen altered in conjunction with
inveterate lepra, and  psoriasis, than along with any other form of
cutaneous affection.   Implicated under these circumstances, the
nails  are  laminated  and friable, and at length differ little from  a
mass of squamae evolved on any other part of the surfaces affected.

                    SIMPLE INFLAMMATION.

  The most frequent cause of inflammation of the matrices of the
nails is a  bruise, or some other injury done to the extremities bf the
fingers and toes.  The detachment of the nail is the natural conse-
quence of such mechanical violence, if it  have been of any consi-
derable amount.  Acute inflammation of the ungueal matrix of the
toe or finger implicated sets in, accompanied with severe pain, and
sometimes no small amount of sympathetic fever; matter is formed
between the nail and  the sensitive structures under it, which soon
makes its way to the surface, and  is shortly after followed by the
fall of the nail.  The inflammation then subsides, and  by and by a
new nail making its appearance, the injury is repaired.
  The painful  affection styled the nail grown into the flesh, from
the mere mechanical irritation it occasions, is sometimes, though
rarely, followed by inflammation of the proper matrix of the nail.
The great toe is the usual seat of this affection, which seems almost
invariably to result from the practice of wearing tight shoes.  When
the affection is recent and slight, soothing topical applications, and
rest, with some means to defend the sensitive structures under the
edge of  the nail from its injurious pressure, will generally suffice
to remedy the evil.  If the nail  be very broad at  the point, and it
be a sharp corner that is causing the mischief, this may be removed,
and a small dossil of soft lint placed between the cut edge and  the
soft parts below, the whole end of the toe being then wrapped in a
piece of lint dipped  in the attenuated liquor plumbi subacetatis of
London Pharmacopoeia.
  When the nail in the flesh is of longer standing, and has occa-
sioned more extensive irritation, suppuration, and  the  production
of fungous growths by its side, various procedures have been recom- 
ONYCHIA.
235
 ^tBA as.,remedies  f°r the evil.  The parts by the side of the
 crooKeo. nail have been  destroyed  in  a variety of  ways,—by the
 application of caustic, the use of the actual cautery, removed with
 me mite, <fcc; still these measures, though in general very painful,
 were tor the most part discovered to'afford no more than temporary
 retiet: the faulty conditions upon which the disease depended were
 Jett unmodified, and  as  the  parts grew, the nail was commonly
 iouncl growing into them, and causing as much suffering as before.
    1 he best means of  remedying the evil in question, appears to me
 to be that proposed and  repeatedly practised with complete success
 by the late  Baron Dupuytren, which consists not in taking away
 the parts injured, but  in removing the  part inflicting the  injury—
 the nail.   This is easily done,  and is  by no means complained of
 as  so painful an operation as it might be supposed.  One blade of
 a pair of strong, but narrow  and finely-pointed  scissors, made for
 the purpose, is passed rapidly under the middle of the  nail from
 the point to the root, and the part divided  longitudinally into two
 halves.  The half whose edge is doing the mischief, is then seized
 with a pair of forceps, and by being turned back  upon itself, is
 readily loosened from  its  attachments with the matrix.  The other
 half need not in general be interfered with, but left as a defence to
 the  point of  the  toe.   The irritation  now  subsides rapidly; the
 parts contract to  their natural  dimensions, and as the new nail
 grows, which it does  very quickly, it covers  and defends, instead
 of irritating, the soft parts in  its vicinity; and this it will continue
 to do, provided the causes which led  to the disorder in  the first
 instance are prevented from again exerting  their pernicious influ-
 ence.  Dr. Henry Davies, in a private communication, informs me
 that he has seen the greatest  advantage from scraping the  upper
 surface of the affected nail, along about an eighth or a quarter of
 an  inch of its surface, by means of a bit of glass, and then cutting
 out  a piece of the front of the  nail in shape of the letter V.  By
 continuing  this process for some time; and wearing  boots or shoes
 that fit the feet, the painful affection of the nail  growing into the
flesh may very certainly be removed.
ONYCHIA.
  Inflammation of the matrices of the nails frequently occurs also
from  purely constitutional causes;. indeed it is only under  these
circumstances that this affection presents itself with the features
which may  be said to be proper to it.  Onychia appears to attack
the matrices of the thumb and great-toe nails more frequently than
those  of the other fingers  and toes.  In its earliest stage it is cha-
racterised by a red semi-circle surrounding the root of one or  more
of the nails; this by and by swells, increases in breadth, especially
in the middle, so as  to acquire a  crescent shape, and is accompa-
nied with a  considerable degree of pain, which is more particularly
complained  of along the line of union between the root of the nail 
236           GREEN ON DISEASES OF THE SKIN.

and  the  inflamed skin.   The inflamed parts soon ulcerate, and
generally discharge a profusion of fetid and discoloured  purulent
matter mixed with blood.  The nail  meantime becomes thick and
of a dirty yellow or greenish colour, and is gradually detached
from the  parts about its root; finally, it is loosened from its matrix
entirely,  and either appears on  the  dressings, or is taken away
when adhering by a mere film of cuticle.  The exposed matrix pre-
sents a rough, uneven surface, covered with offensive pus,  and sur-
rounded with an inflamed and prominent border, which bleeds with
the slightest touch, or even when the digit affected is moved.  The
matrix next begins to make many abortive  attempts to  produce
another nail; rounded pieces of a yellowish horny substance make
their appearance often on various  parts of its surface at the  same
time, and unite  subsequently into uneven and irregular masses,
that seem frequently to prove sources of continued and additional
irritation—the inflamed surface around them bleeding every time it
is exposed to the  air, and  being the constant seat of excruciating
pain.   The  local symptoms at this stage occasionally attain  such
a pitch of intensity that  the general system  suffers.  Indeed the
lymphatic vessels proceeding from the part affected may frequently
be traced like red lines underneath  the  skin, and then we  have
restlessness,  sleeplessness, quick pulse,  thirst, derangement of the
chylopoietic viscera, and  all the accompaniments often of pretty
severe sympathetic fever.
  Onychia, as now described, is always a tedious and painful affec-
tion.  It  is very little under the influence of treatment of any kind,
and it often happens that the only resource left us is with the  knife
to remove the  whole of the diseased parts ; or if this does not seem
very practicable, to perform the amputation of the unguiferous pha-
lanx of the digit affected.  Mercury internally  has  been recom-
mended on  good authority in onychia.  This medicine, however,
has  much more frequently disappointed  expectation  than  been
found beneficial.  As an external application there is nothing better
than the  black wash, (lime-water eight ounces, calomel one dram,)
and I am much  mistaken if I  have not seen this topical remedy
alone arrest the disease when applied in an early stage of its ex-
istence.
  The causes of onychia are very obscure; it is very generally
seen attacking individuals of a scrofulous habit.   The disease has
also been described as one of the consequences of a syphilitic taint
of the system.  Each of these considerations may, in its turn, influ-
ence us in some particulars at least of the treatment we should hold
it advisable to pursue, and ought consequently to be borne in mind
when we have a case of the kind in hand.

                 ALTERATIONS OF THE HAIR.

  I do not recollect that the hair is, under any circumstances, ob-
served to undergo changes similar in kind to those of the nails from 
PLICA.
237
the contact of acids, alkalis, &c.  We frequently see the hair become
ielted into cakes during the course of protracted illnesses, but this
accident is merely mechanical.   The  secreting bulbs of the hair
are secondarily or primarily affected in several^f the diseases we
nave  already described.  The exanthematous fevers are  particu-
larly apt to cause a temporary suspension of their functions, so that
the hair is generally shed on the return of convalescence.  In  some
instances this suspension is not  merely temporary, but amounts to
a complete annihilation of their office, when permanent baldness is
the consequence.  Favus,  whether situated primarily in  the hair
bulbs, as some have supposed, or not, is invariably accompanied by
at least the temporary fall of the hair from the parts affected.  The
morbid  processes of elephantiasis seem also to interrupt very com-
pletely, or even to destroy entirely,  the functions of the piliferous
bulbs.  But by much the most interesting affection of these organs
is the disease endemical in Poland, and known  to  us  under the
name of
PLICA.
  This affection seems'to consist in a peculiar inflammation of the
piliferous bulbs, and is mostly accompanied with, and in no incon-
siderable degree characterised by, a preternatural development, and
felting or matting together of the hair upon the regions affected.
  Plica is said to be commonly preceded  by symptoms of general
constitutional  disturbance.  The hairy scalp then  becomes ex-
tremely tender to the touch ; the particular hair-bulbs affected are
swollen, and so sensitive that the slightest  movement of their hairs
causes excessive pain ; they also secrete a viscid fluid in  consider-
able quantities, which agglutinates the hair into masses, without
the necessary accompaniment of any thing like felting,  although
this very commonly goes along with its division  into the masses or
ropes so constantly seen  in  plica.  The accidental  manner  in
which this matting  together occurs has  given  an  opportunity to
some  nosologists to  divide the disease into several  species; thus
when the hair is clubbed into  one uniform  and irregular mass.
Alibert  has denominated the affection plique en masse ; when it
is divided into several separate and twisted locks, he entitles the
disease plique multiforme ; and when the whole or a considerable
portion of the hair is united into a single tail, which often grows to
a great length, and bears no inconsiderable resemblance to  the tail
of a horse, he names the disease plique en queue.
  Plica is by no means always confined to the hairy bulbs of the
scalp; those of the face, axillae, pubes, and other  regions habitually
covered with strongish hair, are also liable to be affected; the hair
of the pubes has been seen growing to such length under the in-
fluence of plica  as to reach  below the knee.   It  is remarkable that
the nails should very generally be diseased in cases of plica: they
are uneven and  discoloured, and either grow extremely long and 
238
GREEN ON DISEASES OF THE SKIN.
crooked, or  are  shed in consequence of their matrices taking on
disordered actions of a nature analogous to those of onychia.
   Plica is an aflection which is never seen in this country; and in
spite of all that has been written on the subject, a considerable de-
gree of obscurity still surrounds  the  pathology  of the disease.
There can be little doubt but  that the principal seat of the com-
plaint is, as I have described it, in  the hair-bulbs;  but we have no
precise information on the source of the discharge which accompa-
nies it, nor on the morbid anatomy of the parts affected.
   The causes of plica have  been sought for in the custom which
the inhabitants  of the districts in  which it is endemical have of
keeping  their heads closely shaved.  This practice, however, is
universal all over the East, and was  once very common through-
out Europe, yet  I have never heard that plica prevailed extensively
anywhere save in Poland.  It seems probable, therefore, that the dis-
ease must be sought  for in some  other contingency than in the
habit of shaving the head, to say nothing of its frequent occurrence
on the pubes, axillae, &c.—parts which are not usually shaved, nor
exposed to extensive varieties of temperature.
  All that has been said in regard to the treatment of plica amounts
to this, that the parts affected are to be freed  from the tangled
masses of hair which cover them, by means of sharp scissors; that
they are  to be bathed repeatedly with emollient tepid fomentations,
and kept lightly covered, sudden alterations of temperature being
guarded against; and that particular  attention is to be paid to per-
sonal cleanliness. 
USEFUL FORMULA.
                           BATHS.

     SULPHUREOUS WATER, OR ARTIFICIAL BAREGES BATH.

                R.  Sulphuret. potassae, fei.
                    Aquae,  Cong. xxx. M.

                SULPHUREO-GELATINOUS BATH.

               R.  Sulphuret. potassae, gij—3iv.
                   Aquae,       Cong. xxx.
  Add to this solution,
                   Ichthyocollae, fei—ftij.
                   in aquae bullientis soluta fex.   M.  .
  This bath is preferable to the artificial Bare'ges bath, as  it is
neither irritating, nor apt to occasion feverishness, which the com-
mon sulpherous water bath is.
  A cheaper and not less efficacious  gelatine may be  procured by
dissolving from ifeiss to feii of parchment clippings in water by long
boiling, or by using a neat's or calf's foot for the purpose.

                      EMOLLIENT BATH.

  To an ordinary tepid water bath add a large basinful of thick
gruel or paste, and mix it well with the water.
  One or other of these  baths is often of great use  in prurigo,
eczema, lichen and impetigo.

                  NITRO-MURIATIC ACID BATH.

                R?   Acid, nitrici, Siij.
                     Acid, muriatici, 3 i.  M.
  To be added to the water of a tepid bath, which should then be
about as sour as distilled vinegar.

                      SUBLIMATE BATH.

       R.   Hydrarg. bi-chlorid. (oxy-muriat.), 3ii— Si.
           Aquae tepid.                  Cong. xxx.
  Sometimes prescribed in  syphilitic affections, when we  would
avoid the action of the medicine on the stomach.  Thirty are said
in general to be sufficient for the cure.                      ,
  s                      Formulaire de l'Hopital des Venenens. 
240
USEFUL FORMULA.
                       ALKALINE BATH.

                R.  Potassae sub-carbon.  3iv—3 viii.
                    Aquae tepid.  Cong. xxx.  M.
   Very useful in  promoting desquamation from the skin, and in
 allaying pruritus in several forms of prurigo especially.

               ARTIFICIAL HARROWGATE BATH.

                R.  Sodae muriat. feij.
                    Magnes. sulph. dr. iij.
                    Potassae sulphuret. Ifei.
                    Aquae.         Cong. xxx.


            FUME BATHS,  OR FUMIGATIONS.
                          SULPHUR.
               Sulphur, sublimat. 3 i— 3 i— 3 iij.

                         CHLORINE.

               R. Oxid. nigr. manganes. 3ss.
                   Acid, muriat. 3i.
  It is in some cases advisable to substitute this bath occasionally
for that of the sulphur fumes, when the disease of the  skin, for
which these are prescribed, proves very rebellious.  It  soon occa-
sions the mouth to become sore, like the nitro-muriatic acid bath.

                         MERCURIAL.

               Hydrarg. oxid. cinerei,  3i—3ij—3 iij.

  The gray oxide is preferable to the red sulphuret of mercury or
cinnabar, as it does not  occasion coughing when  inhaled, which
cinnabar always does.   It is, on the same account, greatly superior
to cinnabar for fumigating ulcers in the throat.

                         AROMATIC.
               R. Gum. benzoin.  3iv—oz.  i.
  Aromatic effluvia may also be raised in the heated air bath from
any other of the fragrant gum resins, essential oils, &c.

               LINIMENTS AND LOTIONS.

               R. Potassae sulphuret.  3 iij.
                   Sapon. mollis, 3i.
                   Aq.  calcis, oz. viij.
                   Spirit, vin. rect. 3ij. M. 
                      USEFUL FORMULAE.                    241

  This is a  good wash in favus especially, but is also  useful in
many other species of cutaneous disease.

                  R.  Liq. potassae, 3ij.
                      01. oliv. 3iij.
                      Aq. rosae, gi.   M.

                   R.  Liq.  potassae, £ij—3iv.
                       Aq. rosae, §ij.  M.
  These are both of great service in cases of obstinate lepra and
psoriasis especially.

                   R.  Acid, nitrici,
                       Acid, muriat. aa. gtt. xx.
                       Aquae rosae, §vi.  M.
  This may sometimes be used with good effect in cases of pityriasis
and of chloasma.
                   R.  Hydriod. potassae, 3ss.
                       Spirit,  tenuior. §i—§iv.
                       Aq. rosae, ifess.   M.
  R.   Hydrarg. bi-chlorid. (corrosive sublimate), gr. viii.
       Aquae rosae, Jbi-
       Spirit, vini rectif.  §i—§ij.
  These are  both excellent lotions in cases of acne.  They may be
made with emuls. amygd. amar. instead of rose water.

                     Eczema  of the fingers.

                   R.  Hydrarg. bi-chlorid.  gr. ij— vj.
                       Spirit, vin. rect. §i.   M.
                       Aqu. destil. §i— §iii.

                 Impetigo, Eczema, Lichen, fyc.
                   R.  Liq.  plumb, sub-acet. 3i.
                       Spirit, vin. rect. §i.
                       Aq. destill. rfei.   M.

                   R.  Acid, hydrocyanici,  Sij.
                       Hydrarg. oxy-muriat. gr. iij
                       Mist, amygdalae,  gvj.
                                     A.  T.  Thomson.

                       Impetigo, fyc. fyc.
                   R.  Sulphat. alumen.
                       ---------zinci, aa, 3i-
                       Aq. forventis, Ifess.   M.
                       Adde acid, sulphur.  3ss
        o   f                                       grn  16 
242
USEFUL FORMULAE.
                  R.  Acid, hydrocyanici, 3ij.
                      Plumb, acetatis, gr. xvj.
                      Aq. destill. gviiss.
                      Spirit, vin. rect. 3ij.  M.
                                    A. T. Thomson.

                     Scabies, Pediculi, fyc.

                  R.  Hydrargyri, 3i.
                      Acid, nilrici, gii.
                      Aq. destill. Jfev.

  Treat the mercury with  the nitric acid, and complete the solution
by adding the distilled water ;  half an ounce is used morning and
evening as a lotion in scabies, prurigo  formicans, &c.  It does not
stain the linen.  The solution of the mercury in an excess of nitric
acid is one of the best caustics and escharotics  we possess, in
arousing indolent sores generally, and  in arresting the morbid ac-
tions of phagedenic ulcers, as of lupus, &c.
  A solution of uniform  strength for use as a caustic, may be pre-
pared as follows:—

       R.  Hydrarg. proto-nitrat. sice. 3i.  (red precipitate.)
            Acidi nitrici, gi. M.


                 OINTMENTS, CERATES.

       R.   Hydrarg. chlorid. (sub-muriat.) 3i.
            Adepis suil.  giss.   M.
  This is one of the best of all topical applications in  lepra, and
several other forms of squamous disease.

                  R.  Unguent, hydrarg. nitrat.
                      Cerati plumbi  acet. aa. gij.  M,

                  R.  Hydrarg. chlorid. .(calomel.)
                      Plumbi acetat. aa.  9ij.
                      Unguent, hydrarg. nit.
                      Unguent, simpl. aa. gss.  M.

                  R.  Unguent, zinci, gi.
                      Hyd. chlorid. gij.  M.
                  R.  Hyd. praecip. alb. 3ij.
                      01. oliv. 3vj.
                      Unguent, cerae alb. 3ij.
                      Tinct. benzoin, comp. gtt. xxx.  M.

                  R.  Hyd. bi-chlorid. (oxy-muriat.) 9ij.
                      Vitelli ovi, iij.
                      Unguent, cerae alb. gij.  M. 
                     USEFUL  FORMULAE.                   243

               R.   Hydriod. potassae,Bi—9hj.
                     Unguent, cerae, gi.  M.
               R.   Iodini, gr.  xij.
                    Hydriod. potassae, 9iv.
                    Unguent, simpl. gij.  M.  Lugol.

               R.   Deuto-ioduret. hydrarg. gr. xv—xxiv.
                    Adepis praeparat. gij.
                    01. limonis, gtt. xx.  M.  Biett.

               R.   Proto-iodur. hydrarg. 3ss.
                    Adepis praeparat. giss.
                    01. limonis, gtt. xx,  M.  Biett.

                R.  Iodur. sulphuris, gr. xx—xxx.
                    Adepis  praepar. gi.

  The  ointments  of iodine  are all  powerful resolvents, and are
often  of great use in discussing indolent enlargements, tubercula-
tions, &c.
                R.  Unguent,  cerae alb. gii.
                    Plumbi sub-carbon. 3ii.
                    Cretae praeparat. gss—gi.  M.

  A useful  application in the acute stages of eczema, impetigo,
lichen, &c.

                R.  Emplast.  plumbi,  gi.
                    Cerae alb. gss.
                    01. oliv. gss. vel q. s. ut ft. unguent.
                                             Willan.
                          In Impetigo.

                R.  Sulph.  sublim.  gii.
                    Potassae sub-carbon, gi.
                    Adepis  suillae, giv.  M.
   Better than the common sulphur ointment in scabies.

                R.  Sulphur,  loti, gss.
                    Sodae boracis,
                    Ammon.  muriat. aa 3ss.
                    Hydrarg. praecip.  alb.  $i.
                     Unguent, simpl. gi.  M.
                              Du.  Sir W. Russell.
        Used much in India for the cure of scabies.

                R.  Sodae sub-carbon.
                     Potassae sulphurati, aa 3ij.
                     Adepis praeparat.  gij.    Alibert.

                            In favus. 
244
USEFUL formulae.
                 R.  Unguent, hydrarg. nitrati, sij.
                     --------• zinci oxydi, gss.
                     --------cetacii, gss.   M.
                                         Bateman.

                 R.  Sodae sub-carbon. 3ij.
                     Ext. opii aquosi, gr. x.
                     Adepis, gij.               Biett.

                          In prurigo.

                R.   Sodae sub-carb. 3iij.
                     Calcis, 3ij.
                     Adepis, gij.   M.

                As a depilatory in favus, <fcc.

                    ARSENICAL PASTE.
                R.  Oxid. arsenic, alb. gr. x.
                    Hydrarg. sulphuret. rub. gij.
                    Pulv. carbon, animal, gr. x.

  A little of this powder is moistened, at the  time  of application,
with water, and spread upon the diseased  surface  with a small
spatula.
                      ASIATIC PILLS.

                R.  Protoxidi arsenici, gr. Iv.
                    Piperis nigri, 3ix.  M.

   To be well benten for several days, at intervals, in an iron mor-
tar, and when impalpable, to be made into a mass with water, and
divided,in 800 pills.  Each  pill contains about TV part of a grain
of arsenic.   7'he dose is one daily, and must not exceed two, if we
wish to continue the medicine long.
   There are  varions  other formulae for the preparation of the
Asiatic pills.  The one I follow myself may be  found page 151.

                R.  Proto-arseniat. ferri, gr. iij.
                    Kxt. humuli lupnli, 3ij.
                    Pulv. althaeae, 3ss.
                    Syrupi q. s. ft. pil. 48.     Biemt.

  Dose, one pill  a day, which after a considerable time may be in-
creased to two.

                R.  Sulphur, sublim. 3iss.
                   Pulv. myrrhae.
                   -----rhei, aa 3ss.
                   Terebinth.  Venet. 3ss. 
                  USEFUL FORMULA.                    245

Aquae q. s. ft. massa, et divide in pilulas, singul pond. gr. iv.

       One or two morning and evening.
                                   Ridgway.
                R.   Hydriod. potassae, 3i.
                     Aq. destillat. gi.   M.
         Dose xv.—xxx drops twice or thrice a day.
                R.   Iodini, gr. v.
                     Hydriod. potassae, gr. x.
                     Aq. destillat. giv.

  Dose, six drops twice a day, gradually increasing to forty.

                R.   Tinct. lyttae, gss.
                     Mucilag. gum. acaciae,  giijss.  M.
                     Tinct. aurantii, gi.

            A teaspoonful twice a day.

            In varions chronic affections of the skin.

                R.   Liquor,  potassae, gi.

  From five to thirty drops in divided doses, taken in gruel or mild
beer, in the course  of the day,  This  medicine is useful in lepra,
psoriasis, prurigo, &c.
8—f*
grn 16" 
A  TABLE OF SYNONYMS,
BEING AT THE SAME TIME
AN  ALPHABETICAL INDEX  TO  THE  WORK.*
Sarcoptus scabiei.  Acarus ciro.  Ciron
Acarus scabiei.
Achores
Acne. (Pustulae).   Varus.   Ionthos.  Grutum.   Milium.  Puncta mucosa vultus.
    Bacchia.  Rosacea.  Gutta-rosea.  Dartre  pustuleuse miliaire.   Dartre pus-
    tuleuse disseminee.  Dartre pustuleuse couperose.  Couperose.  Copper-nose.
    Stone-pock.   Grubs or worms in the skin.
  Acne simplex.
PAGE
  44
  73
Achroa
Albaras.
Albohak.
Albino.
Alphos.
Ampulla.
Andrum.
punctata
indurata
rosacea
109
 ib.
110
 ib.
 ib.
221
182
65
          Lepra.
          Lepra.
         Leucopathia.
         Lepra.
          Pemphigus.  Phlyctena.
          Elephantiasis Arabica.
Anthracion.   Pustula Maligna.
Anthrax.  (Furunculi) Carbuncle
Area.  Porrigo decalvans (Willan).
Aspredo.  Aspretudo.  Urticaria.

Bacchia.  Acne rosaeea.
Baker's itch.   Psoriasis of the hands.
Baras.  Elephantiasis Groecorum.
Blactiae.   Rubeola.
Blebs.  Bullae.
Boil.   Fhrunculus.
Bricklayer's itch.  Eczema impetiginodes, and Impetigo of the bands.
Bullae.  Phlyctenae.  Ampulla?        ....

Cancer.  Carcinoma.  Scirrhus.  Noli me tangere.    ....    176
Cancroide.  Cheloidea.
Cheloidea.  Keloide.  Cancroide      ......    219
Chicken-pox.   Varicella.
Chin-whelk.   Sycosis.   Mentagra.
Chloasma.  (Dischroa.)   Pityriasis versicolor.  Pit. nigra.  Ephelide scorbutique.
     Ephelis.  Melas.  Macula hepatica.   Liver-spot.        .       .       .    224
  Case of Chloasma versicolor   ......            225
Cingulum.  Herpes zoster.
Cinzilla.  Herpes zoster.
Cnesmos.  Prurigo.
Colica Japonica.  Elephantiasis Arabica.
Couperose.   Acne rosacea.
Courap.  Impetigo.
Cow pox.  Vaccinia.
Crusta lactea.   Impetigo and Eczema of the face.
Crystalli.  Vaccinia.

  *  N. B. The words here printed in small capital letters,  are the titles under which the
several diseases of the skin and the subjects connected with them are discussed in the foregoing
pages.  By referring to the capital letter titles, in their proper alphabetical places, the particular
pages at which they are treated of will be found indicated. 
TABLE OF SYNONYMS.
247
Crystallina.   Herpes praeputialis.  Syphilis primaria.
Cuticle, alterations of the      .       .       .       .       .       •      •    231

Dandriff. Pityriasis.
Dartre.  Tetter.  A word which has been used at  one time  or another to desig-
       nate almost the whole of the diseases of the skin.  The following are from
       the works of Alibert principally.
     Dartre furfuracee volante.   Pityriasis.   Eczema.  Lichen.
     ------  ------ arrondie.  Lepra.
     ------  squameuse humide.   Eczema chronicum.  Lichen agrius.
     ------  -----— orbiculaire.   Lepra.
     ------  ------ centrifuge.  Psoriasis palmaris.
     --------------lichenoide.  Psoriasis inveterata.
     ------  crustacee flavescente.  Impetigo figurata.
     ------  ------ stalactiforme.  Impetigo figurata.
     ------  ------ en forme de mousse.  Ecthyma.  Impetigo.
     ------rongeante idiopathiqne.  Lupus.
                    scrophuleuse.  Lupus.
                    venerienne.  Tubercular Syphilis.
pustuleuse mentagra.   Mentagra.
------  disseminee.  Acne simplex.
------  couperose.  Acne rosacea.  Lupus.
------  miliaire.   Lichen.   Acne simplex.
phlyctenoide confluente.   Pemphigus.
------  en zone.   Herpes zoster.
erythemoide.  Chronic Erythema.  Urticaria.
farineuse (Sauv.), Lichen.
fongueuse.  Ecthyma.
laiteuse.   Eczema.  Impetigo, &c.
se"che.   Lepra.  Psoriasis.
vive.  Eczema.
47
Dischroa, or discoloured states of the skin.   (Maculae, Will.)         •       •    -^
Djuzain, or Juzain.   Elephantiasis Graecorum.
Dry scall.  Psoriasis.

Ecthyma. (Pustulae.) Phlyzacia. Dartre crustacee.  Furunculi atonici.  Psoriasis.
       Scabies fera.  Agria.  Dartre fongueuse
    Ecthyma vulgare          .       .       •       •
    ---------luridum         .
    ---------infantile        •
    ---------cachecticum    .
    Case of chronic ecthyma   .       .       •       •              "     .  '
Eczema.  (Vesicate.)   Dartre  squameuse humide   Dartre v,ve.  Crust.Mac tea.
       Gale  epid^mique.   Teigne amiantacee.   Teigne  furfuracee.   Pous.ee
       Running scall.   Humid tetter.   Rubores cum vesiculis et pruntu.  Heat
       eruption         ■                                                       j^
    Eczema acutum simplex   .                                                4g
    ------  ------ rubrum   .                                                ^
    --------------impetiginodes    .                                         ^
    ------  chrrfnicum        •       •       •       •     e                     en
     ______  of the organs of generation, verge of the anus, &c.             •      ^
    ------  of the nipple                    •       *                           n,
    ______of the scalp, entitled porrigo, tinea, <5fc.  .       •      •              "
    ______-  of the face, entitled crusta lactea,  porrigo larvalis, <5fC.         •      .fc
    ______of the ear         •                                                j£
    .------  of the lower extremities   •       "       '       '                   ib
     ------  of the backs of the hands and fingers, &c.       .      •       •
    _______  mercuriale.  Erythema mercuriale.  Hydrargyria.   Lepra  mercu-   ^
               rialis.  Mercurial erythema.   .       •       •                   ^
    ______a sulphure        .                                                55
   Case of chronic eczema      .                                                27
   Ca-if of eczema mercuriale   .       .       •       •       "      *  ,     ,'
Elephantiasis Gracorum.  (Tubercula.) Ban... Lence. Lepra- Lepra uberculo a
       Spra leontina.  Leontiasis.  Satyriasis.  Tele de Veau.  Vitiligo. (W ill.)
       Djuzam.  Ladrarium.   Mai rouge de cayenne 
248
GREEN ON DISEASES OF  THE SKIN.
Ignis sacer.   Rose.   St. Anthony's
Elephantiasis rfrabum.  Andrum  Dal fil. Barbadoes leg.  Galle leg. Glandular
       disease of  Barbadoes.   Colica  Japonica.   Sarcoceic d' Egypte.  Lepre
       elephantiasis    ........
Ephelis.  Chloasma.  Lentigo.   Lenlicula.   Macula Solaris.   Vitiligo.   Kelis
       fulvescens.  Hale.   Tachcs de rousseur.  Freckle
Epynyctis prurigincsa.  Urticaria.
Erysipelas.  (Exanthemata.)  Rosa volitica.
       fire.     .....
     Erysipelas crratica
     ----------cedematosa
     ----------phlegmonodes
     ----------gangrcenosa  .
     ----------of the face   .       .
     ----------of the scalp
     ----------of the mamma.
     ----------of the scrotum and  penis
     ----------of the extremities
     Case of Erysipelas
     Erysipelas zoster.  Herpes zoster
     --------phlyctenodes.  Herpes zoster.
     --------pustulosus.   Herpes zoster.
Erythema.   (Exanthema.)  Maculae  volaticae.   Gum.
       Dartre Erythemoide.   InHammatory blush.
     Erythema intertrigo
       ------ab  irratione
       ------ papulatum
       ------ nodosum
       ------ tuberculatum
       ------ marginatum
       ------ circinnatum
       ------  fugax
       ------  lasve
     Case of Erythema
     Ervthema mercuriale.
Essera.   Urticaria.
Exanthema.  Efflorescence.
Tooth-rash.   Intertrigo.
Eczema mercuriale.

  Eruption
Favus. (Pustulae.) Tinea, Porrigo, Willan and others
    Favus dispersus.  (Porrigo lupinosa, Will.)
    ------ confertus. (Porrigo scutulata, Will.)
Febris bullosa.   Pemphigus.
------erysipelatosa.   Erysipelas.
------ miliaris.  Miliaria.
------ morbillosa.  Rubeola.
Fish-skin  disease.  Icthyosis.
Formica.   Herpes phlyctenodes."
    Formica corrosiva seu Formix.  Lupus.
Frambcesia. (Tubercula.)  Yaws.  Pian.
Furunculus.  Boil     ....
21G

224
 31

 22
 23
 ib.
 24
 ib.
 ib.
 ib.
 ib.
 25
 t/>.
 27
18
ib.
ib.
19
ib.
ib.
ib.
ib.
ib.
ib.
21
 17

102
 ib.
107
179
ltfl
Gale.  Scabies.
Glandular disease of Barbadoes..  Elephantiasis Arabica.
Grutum.  Acne.
Grocer's itch.   Psoriasis and Impetigo of the hands.
Gum.  Strophulus.   Red gurn.  Strophulus intettinclus.  White gum.  Stroph.
       albilus.
Gurta rosea.   Acne rosacea.
Hair, alterations of the
Hale.  Ephelis.   Lentigo,
Hemacelinose.  Purpura.
Herpes.  (Vesiculae.) Dartre.
     Herpes phlyctenodes
     ------- labialis
     ------- praepulialis
Tetter.  Olophlyctide
236
59
ib.
60
ib. 
TABLE OF SYNONYMS.
249
                                                                            I'AGE
     Herpes zoster.  Cingulum.  Shingles. Zona.  Zona ignea. Zona serpiginosa.
         Erysipelas pustulosa.  Erysipelas zoster.  Erysipelas phlyctenodes. Ignis
         sacer.  Dartre phlyctinoide en zi.ne         ....     60
     ------ circinnatus.  Vesicular ringworm.       ....     63
     "-------■ lTis        ........     ib.
Herpes exedens.  Lupus.
Hives.  Globular Varicella.
Haeinorrhcea petechialis.   Purpura.
Hydrcea febrilis.  Herpes labialis.
Hydrargyria.   Eczema mercuriale.

Icthyosis.  Fish-skin disease   .                                           .   > 231
Ignis sacer.  Erysipelas.  Herpes zoster, &e.
Impetigo.  (Pustulae)  Running tetter.  Crusted  tetter.  Dartre crustacee.  Lepre
       humide.  Cowrap.  Melitagre         .....     90
     Impetigo figurata.   Porrigo lupinosa.   Porrigo larvalis. (Willan.)  Tinea
         granulata.  Tinea mucosa.  Crusta laclea.   Teigne.  Mentagra infan-
         tum.  Dartre crustacee flavescente   .....     91
     --------of the face (impetigo larvalis)  .....     92
     --------of the scalp (impetigo granulata)      ....     ib.
     --------sparsa  .       .       .       .               ...     93
     --------scabida         .......     ib.
     Case of impetigo of forty years'standing         .       .       .       .97
     A second case  of impetigo        ......    100
     A third case of impetigo   ...      .       .       .       .       .    101
Impetigo Erysipelalodes.   Eczema impetiginodes.
Intertrigo.   Erythema intertrigo.
Itch.  Scabies.
Juzam.   Elephantiasis Graecorum.

Keloide.   Cheloidea.
Ladraiius morbus.  Elephantiasis Graecorum.
Lentigo. (Dischroa.)  Freckle  ...••••
     Lentigo naevus.  Naevus.
     -------leprosa.  Lepra.
     -------ephelis.  Ephelis.
Leontiasis.  Elephantiasis Grscorum.
Lepra.  (Squamae.)  Alphos.  Melas. Dartre furfuracee arrondie.  Lepra icthyosis.
       Morphae.  Scaly leprosy.   (Both the Arabian and Greek elephantiasis and
       vitiligo have also been spoken of under the name of lepra.)
     Lepra vulgaris.
     ------alphodes
     ------nigricans
     Case of lepra vulgaris
     A second case of lepra
Leucsethiopia.  Leucopathia.
Leuce.   Greek Elephantiasis.  Vitilligo.  Lepra.
I-EucorATHiA.   (Achroa.)   Albinismus       .      •       •       •
Lichen.  (Papulae.)   Papulae.   Pustulae  siccae.   Scabies  sicca.   Scabies agria.
       Scabriiies.  Dartre furfuracee volante.  Dartre pustuleuse mihaire.  Dartre
       farineuse.   Poussee
     Lichen simplex.
     .------circumscriptus
     .------ gyratus
     ------pilaris
     ------ Ih'idus
     ------ urticatus   .
     ------agrius
     ______tropicus, prickly heat
Liver spot.  Chloasma.
Lupus.  (Tubercula.)  Herpes exedens.  Herpes esthiomenes.  Formica corrosiva.
       Dartre rongeante.   Noli me tangere   .
223
134
 ib.
135
 ib.
140
142
221
118
 ib.
119
 ib.
 ib.
 ib.
 ib.
 ib.
120
162 
250               GREEN ON DISEASES  OF THE  SKIN.
Maculae.  Dischroa.
Maculae Hepaticae.  Chloasma.
Maculae syphilitica?.  Syphilitic exanthema.
Mai rouge de Cayenne.  Elephantiasis Graecorum.
Measles.  Rubeola.
Meladermia.  Dischroa.
Melas.  Dischroa.  Lepra.  Psoriasis.
Melitagre.  Impetigo.
Mentagra.  (Pustulae.)  Sycosis.  Dartre pustuleuse mentagra.  Chin-whelk      113
Miliaria.  (Vesiculae.)  Miliaiia sudans.  Miliaria sudatoria.  Sudor anglicus.
      Suette.   Suette des Picards.  Sudamina.       ....     64
Milium  Acne.
Mole.  Spilus.  Naevus.
Molluscum.  (Tubercula.)   .......     178
Morbilli.  Rubeola.
Morbus Gallicus.   Syphilis.
Morbus maculosus hcemorrhagicus.   Purpura.
Morphaea.  Lepra.
Mother-mark.   Naevus.
NjEvus.  (Dischroa.)   Mother-mark.
Nails, alterations of the
*----  simple inflammation
Nettle rash.  Urticaria.
Noli me tansrere.   Lupus.  Cancer.
Spilus.  Mole
227
234
 ib.
O'ophlyctidos.
Onychia.
Herpes.
235
Papul.e       .........
Peliosis.  Purpura   ......       .      .
Pellagra.   Dermatagria. Icthyosis.  Erysipelas periodicus nervosus chronicus.
      Scorbutus Alpium.  Malattia di miseria, &c.
Pemphigus.  (Bullae.) Pompholix.  Phlyctena.   Bulla.  Hydatis. Dartre phlyc-
      teuoide confluente.  Febris pemphygodes.  Feb. vesicularis.  Feb. ampul-
      losa.   Feb. bullosa    .......
    Pemphigus acutus       .......
    --------solitarius      .......
    --------chronicus  (pompholix diutinvs. W.)   .       .       .
    --------pruriginosus   .......
Petechiae sine f'ebre.  Purpura.
Phyma.  Furunculus.
Pian.   Frambossia.
    Pian Ruboide.   Impetigo of the scalp.
Pityriasis.  (Squamae.)  Dartre furfuracee volanlo.  Porrigo. Chloasma.  Psoria-
      sis.   Lichen.  Dandriff
    Pityriasis capitis
    --------diffusa
    --------rubra
    --------versicolor
Plica.  Trichoma.   Plicatio.
Pompholix.  Pemphigus.
Porcelana.   Urticaria.
Porrigo.   (Pustulae.)  Favus.
      Impetigo of the  scalp.
      Tinea favosa.  Tinea annularis.   Tinea rugosa.
    Porrigo larvalis. (Willan.) Impetigo larvalis
    ------favosa. (Willan.) Impetigo granulata
    ------ furfurans. (Willan.)
    ------decalvans. (Willan.)
    ------ (lupinosa, Willan.) favosa
    ------ scutulata  .....
Prurigo.  (Papulae.)  Cnesmos.  Scabies papuliformis.
    Prurigo mitis     .....
    -----r- formicans        ....
Plicatura.
116
213

212
65
ib.
67
68
ib.
156
157
 ib.
160
 ib.
237
Tinea.  Pityriasis.  Porrigo favosa, (Willan.)
Porrigo favosa, Porr. lupinosa.  Scalled  head.
                       Ringworm
Pruritus
102
 ib.
 ib.
 ib.
 ib.
103
107
123
 ib.
 ib. 
TABLE OF  SYNONYMS.
251
    Prurigo senilis    ....
    -----podicis    ....
    ------ genitalium :  scroti et pudendorum.
    Case of prurigo.    .       ,      .
    A second case of prurigo
   ' A third case of prurigo
Psora.  Scabies.  Psoriasis.
    Psora leprosa.  Psoriasis.
Psoriasis.   (Squamae.)  Serpedo.  Serpigo.   Scabies sicca.  Dartre ecailleuse
       Dartre squameuse lichenoide.  Dartre squameuse seche.  Dartre furfuracee
       Scabies farina.  Psora leprosa.  Dry scall.  Scaly tetter
    Psoriasis guttata
    ---------gyrata
    --------diffusa
    --------- inveterata
    ---------ophthalmica
    ---------labialis
    ---------scroti,  praeputii
    ---------of the palm of the hand, (palmaris,) grocer's itch or baker's itch
    --------of the back of the hand
     Case of psoriasis often years' standing.
Psoride. (Aiib.)  Scabies.  Lichen.  Eczema.  Psoriasis.  Prurigo.  Impetigo, &c.
Psydracia.   Impetigo.
Purpura.  Hemacelinose.   Hoemorrhcea petechialis.  Morbus maculosus hcemor-
       rhagicus.  Petechia.    .......
Purpura urticata.  Urticaria.
Pustulae       .........
     Pustules divided into phlyzacia, psydracia. favi, and achores
Pustula Maligna.  Malignant pustule.  Anthracion.  Bouton d'Alep.  Carbuncle.
       Persian fire      ......••
PAGE
 124
  ib.
 125
 127
 130
 132
144
145
 ib.
 ib.
146
147
 ib.
 ib.
147
148
152
213

 72
 ib.

164
Ringworm.  Porrigo scutulata
Rogne.   Scabies.
Roseola.  (Exanthema.)
      lous rosy eruption
      tosa.  Rash.
    Roseola infantilis
    ------aestiva
    ------autumnalis
    ------annulata
    ------rheumatica
    ------febrilis     .
    ------variolosa
       Herpes oircinnatus.  Impetigo figurata.

Rossalia.  Rossania.  Rosacea.  Rose rash.   Anoma-
 Rubeola.  Rubeola spuria.  Effbrescentia erysipela-
Morbilli.  Blactiae.  Roseola
Rougeole.  Febris mor-
Rubeola.  (Exanthema.)
       billosa.  Measles
Rupia.  (Bullae.)   Ulcus atonicum
    Rupia simplex
    ------prominens
    ------escharotica

Satyriasis.  Elephantiasis Graecorum.
Scabies.   (Vesiculae.)  Gale.  Rogne.  Psora.  Itch
Scarlatina.  (Exanthema.)  Morbilli confluentes ignei. Angina maligna.
       sore throat.  Scarlet fever      .....
    Scarlatina simplex       ....••
    --------anginosa       ..••••
    ---------maligna       .       •       •       •                 .
Scalled head (indefinitely used) Favus.   Impetigo and eczema of the scall
Scarlatina urticata.  Urticaria.
Shingles.   Herpes zoster.
Spilus.  N^vus.
Squamae        ....•■
Stone pock.  Acne.
Strophulus.   (Papulae.)   Ebullitio.  Tooth rash.  Gum or gown    .
    Strophulus intertinctus.   Red gum      .
Putrid
29
30
ib.
ib.
ib.
ib.
ib.
ib.

37
69
ib.
70
ib.
43

3.9
ib.
ib.
ib.
133

117
 ib. 
252
GREEN ON DISEASES OF THE SKIN.
Ephemera Briltanica.   Suette miliuirc.
     Strophulus albidus.  While gum
     ---------canCidus
     ---------confertus
     ---------volaticus
Sudamina.  Miliaria.
Sudor anglicus.   Morbus sudatorius.
     .  Suette des Picards.   Miliaria.
Sycosis.   Mentagra.
     Sycosis capilhtii.  Impetigo figurata of the scalp.
Syphilis.   Lues venerea      ......
Swinepox.  Pustular Varicella, (var.)  Varicella conifonnis.
Syphilide.  Syphilis.  The cutaneous eruptions that accompany constituti
       Syphilis are denominated Syphilides by the French writers
PAOE
 117
  ,h.
  ib.
  ib.
I8't
ib.
Tanne.  Grub or worm of the skin.  Acne punctata.
Tinea.  Favus.  Porrigo lupinosa, Tinea lavosa, Favus confertus.   Tinoa granu-
       lata, Impetigo  figuratn.   Tinea  furfuracea (Aiib.)   Eczema, Psoriasis,
       Lichen. Tinea amiantacea. (Aiib.)  Eczema ot the scalp.  Tmca mucosa,
       Porrigo larvalis, Impetigo of the scalp.
Tetter.   Dartre.
    Humid tetter.   Impetigo.
    Scaly tetter.   Psoriasis.
Trichoma.   Plica.
Tubercula.    .       .      .      .       ,       .       .       .       .160
Uredo.   Febris urticata.
Purpura uriir-ata.  Scar-
Aspretudo.  Dartre ery-
volaticse.  Pusillt
 Uredo.   Urticaria.
 Urticaria.   (Exanthema.)   Nettle-rash.  Procelana.
       Exanthema urticatum.  Epinyctis pruriginosa.
       latina urticata.  Essera.  Papulae cuticulares.
       th^moide
     Urticaria febrilis
     ---------conferta
     --------perstans
     ---------evanida
     --------- subcutanea
     ---------tuberosa
     Cases of urticaria

 Vaccinia.  (Pustula.)  Variola vacca.  Cow-pox
     Vaccinella.   Spurious cow-pox.    ....
 Varicella.  (Pustulas.) Psendo variolae.  Variola? spuriae. Var. .„
       Crystalli.  Varioloid.  Modified small-pox. Swine-pox.  Horn-pox. Chicken
       pox.   Hives.  Water-jags.
     Pustular varicella
     Conical pustular varicella or swine-pox
     Globular pustular varicella or hives
     Vesicular varicrlla or chicken-pox
     Papular varicella or horn.pox
Variola.  (Pustulae.)  Small-pox
Varioloid.  Pustular Varicella
Varus.  Acne.
Vesiculae       .
  Vitiligo.   (Achroj.)  Alphos.  Leuce.
Wrheal-worm.  Acarus.
Water-jags.   Varicella vcsicularis.
Yaws.  Frambcesia.

Zona.  Herpes zoster.
Zoster.   Herpes zoster.
31
32
ib.
33
ib.
ib.
ib.
35

82
86
78
ib.
79
ib.
ib.
8(1
74
42
Melas.  Greek Elephantiasis, (Wil.)  222
THE END. 
 
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