Archives of Surgery

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ABCHIVE8 OF SUHGEBY.

ARCHIVES OF SURGERY

BY

JONATHAN HUTCHINSON, LL.D., F.E.S.,

Consulting Surgeon to the London Hospital, cmd late President of the

Boyal College of Surgeons.

VOL. IX.

Xon^on :
WEST, NEWMAN & Co.

64, HATTON GARDEN.
1S98.

LONDON :
PRINTED BY WEST, NEWMAN AND CO.,
HATTON OABDEN, E.G.

LIST OF PLATES.

XX.

LXVII.

LXVIII.

LXXVI.

LXXVII.

XCVII.

CXLII.

CXLIV.

CXLVI.

CXLVII.

CLII.

CLIII.

CLVI.

CLX.

Arsenic-Kebatosis and Arsbnic-Canceb.

Multiple Lupus Vulgaris.

Multiple Lupus Vulgaris.

Multiple Lupus Vulgaris.

Multiple Lupus Vulgaris.

Pemphigus in Secondary Syphilis.

Lupus Erythematosus on Face and Chest.

Cystic Hydrosis op the Face.

The Eruption of Yaws.

The Eruption of Yaws.

Mortimer's Malady.

Mortimer's Malady.

Pemphigus Vegetans.

Frambcesia in an Englishman.

Note. — The reade]^ is requested to observe that the Plates do not always
bear consecutive numbers. They have been printed for a smaller Atlas of
Clinical Illustrations of Disease (of which an announcement appears on the
following page), and the plate nimibers refer to their position in that work.

371058

_ _ - r'ttt. "^ Its' ia- -

I^IWWWW

LIST OF W0BK8 BY MB. HUTCHINSON.

ILLUSTBATIONS OF CLINICAL SURGERY. Vols. I. and H. Only a
few complete copies of this work now remain on hand. The price
of Vol. I., containing ten fasciculi, is 70s. ; and that of Vol. II., con-
taining thirteen fasciculi, is 90s. Most of the fasciculi can he had
separately, price 6s. 6d. ; and each one is complete in itself.

CLINICAL LECTURES ON RARE DISEASES OP THE SKIN.
Pp. 382. Octavo. Price 10s. 6d.

THE PEDIGREE OP DISEASE, being lectures delivered at the Royal
College of Surgeons. Price 5s.

ON CALCULI AND THEIR LESSONS, a reprint from the New Syden-
ham Society's Atlas of Pathology. Price 2s. 6d.

PRESIDENTIAL ADDRESS, delivered before the Neurological Society,
1889. A reprint. Price Is.

THE HUNTERIAN ORATION POR 1891. Price Is.

All the above may he had of

J. & A. CHURCHILL, 7, Gbeat Mablbobough Stbeet, London, W.

ON SYPHILIS. Price 9s. Messrs. CasseU & Co.

•published by
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ARCHIVES OP SURGERY. This work is issued quarterly, and it is
purposed to continue it for a few years. Vols. I., II., III., IV., V., VI.*,
VII. and VIII., are now ready. Price, bound in cloth, 12s.

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Price U. net. Subscription for one year 11$. net.

A copy of any one number of the " Home University " will be forwarded as
a specimen free on receipt of twopence in stamps for postage.

AECHIVES OP SURGERY.

JANUARY, 1898.

SELECTED CASES IN ILLUSTEATION OF
INHEEITED SYPHILIS.

When in 1878 I resigned my appointment on the staff of
the Moorfields Ophthalmic Hospital, my sphere of observa-
tion in reference to the later results of inherited syphilis
became greatly reduced. In private practice such affections
are fortunately rare. It was at Moorfields that I had collected
the cases upon which were based my observations as to the
keratitis, choroiditis, and other eye affections which occur in
connection with inherited taint, and also as to the peculiarities
in the teeth by which such taint may be recognised. My
Work on these affections which was published in 1863 con-
tained narratives of most of the cases which had come
under my observation up to that date, and after its publica-
tion it did not seem worth while to continue to collect cases
in illustration of doctrines which were generally accepted
by the profession. Since that time I have taken note
almost solely of such cases as seemed either exceptional to
the views which had been advocated, or which suggested
new ones. From time to time I have since published brief
annotations on these topics.

It may be convenient to briefly recapitulate some of those
which have appeared in Archives.

Vol. I., p. 51, et seq. Two cases of infantile convulsions in connection

with inherited syphilis.
Vol. I., p. 51. Severe chronic bone disease, one node having suppurated.

No other indications of taint in the child, set. 13, but

mother syphilitic.

VOL. IX. 1

2 SELECTED CASES OF INHERITED SYPHILIS.

Vol. I., p. 58. A case in which a mother showed secondary symptoms

apparently from foetal contamination.

Vol. I., p. 53. Choroido-retinal disease in an infant after convulsions.

I may now add to this record that four years later the
child was partially idiotic.

VoL II., p. 65. Are women liable to transmit syphilis to offspring during

longer periods than men ?

Vol. II., p. 66. A woman bore syphilitic children four or five years

after her own disease (erroneously stated in text to
have been eight years). The fallacy was that she or her
husband might have contracted it again more recently.

Vol. II., p. 118. A case in which, of twin infants, both dead, the bones

of one showed syphilitic changes, and those of the

other were free. (Seen at Berlin.)
Vol. II., p. 291. A case in which two sisters, bom with an interval of

seven years, both suffered from late lesions, neither of
them having had infantile symptoms. Both parents
were probably tainted, the mother by foetal contamina-
tion. (A very remarkable narrative.) Again referred
to, with additional particulars. Vol. V., p. 70.

Vol. II., p. 294. Case in which it might have been believed that a man

who married four years after his syphilis, communi-
cated the disease to his wife.

Vol. II., p. 295. An example of glandular gumma in the neck of a girl

the subject of inherited syphilis.

Vol. IV., p. 324. A case in which a man who married, with my consent,

four years after syphilis, was supposed to have been
the father of a syphilitic child. Diagnosis as regards
the child erroneous.

Vol. v., p. 72. Severe syphilis inherited from a father. The mother

remained in excellent health. Severe keratitis and
nodes, but no peculiarities in teeth or physiognomy.

Vol. v., p. 75. Case of acquired syphilis (severe) in a man who was

reputed to have had symptoms of inherited disease in
infancy and also interstitial keratitis.

Vol. v., p. 76. Four healthy children born to parents both of whom

had suffered from syphilis.

Vol. v., p. 76. Palmar psoriasis in a girl of eighteen the subject of in-
herited taint, and whose mother had the same affection.

Vol. v., p. 183. Good health, and entire absence of physiognomical and

dental peculiarities in a gentleman, aged 26, whom I
had myself treated for infantile syphilis. He had
suffered from a severe attack of keratitis at the age
of nine.

Vol. v., p. 216. Several cases illustrating paralytic dementia in the

subjects of inherited syphilis.

GENERAL STATEMENTS. 3

Vol. v., p. 264. Gumma in the tongue in a patient the subject of in-
herited syphilis.
Vol. v., p. 360. Arrest of sexual development, with mental peculiarities,

in a boy the subject of inherited syphilis.
Vol. VI., p. 16. On the differences between syphilitic teeth and the

malformations due to mercurial and other forms of

stomatitis.
Vol. VII., p. 60. "Ringworm tongue " in a child of six years, who had

suffered from mherited syphilis.
Vol. VII., p. 62. An instance of very severe keratitis, with choroiditis and

vitreous opacities in a syphilitic girl of twelve, who

showed no peculiarities of physiognomy. Synovitis

of one knee.
Vol. VII., p. 63. Reference to the case described in Vol. II., p. 291.
Vol. VII., p. 294. An instance of severe syphilitic pemphigus present at

time of birth. (Drawing kept.)
Vol.VIII.,p.246. Synovitis of the knees preceding keratitis in a young

man the subject of inherited syphilis.
Vol.VIII.,p. 280. A case of complicated and relapsing inflammation of

the eyes in a young woman (one of twins) who

inherited syphilis.
Vol.VIII.,p.283. On deafness in connection with inherited syphilis and

on the greater liability of girls to suffer from it.

I now purpose to give from my private note-books a few
facts which I have not previously recorded. Some of these
appear to be of value because they supply further detail
respecting cases already recorded, but most of them will
concern wholly new ones. Amongst the special points
which will be illustrated by them the following may be
mentioned : —

That the subjects of taint often grow up into healthy
men and women.

That complete exemption from other indications of taint
does not exempt from the risk of an attack of keratitis.

That it is not unusual for one child in a family to suffer
very definitely whilst all the others apparently escape.

That it is very exceptional for any considerable series of
children to suffer in succession from inherited taint.

That the mother of one or more syphilitic children may
herself remain throughout quite free from sjmaptoms and
apparently in good health.

4 SELECTED CASES OF INHERITED SYPHILIS.

That a condition of general arrest of growth may be one
of the consequences of inherited taint.

That it is possible for children bom within dangerously
short periods of the primary disease in one or both parents,
to entirely escape the inheritance.

That although, as a rule, after keratitis, choroiditis, &c.,
the recovery is permanent, there are exceptional cases in
which certain progressive changes continue.

That it is by no means improbable that some who really
inherit taint never; either in infancy or subsequently, show
any symptoms.

That the children of those who have suffered from inherited
syphilis are usually quite healthy. That syphilitic infants
may be suckled by their mothers as a rule without risk to
the latter. (My life's experience affords no trustworthy
exception to either of these two propositions.)

No. I. — Uterus and Appendages from a case of inherited

Syphilis showing arrest of growth.

The woodcut here given is from a drawing which I have
had many years in my possession. It represents the exact
dimensions (measured by compasses) of the uterus and ovaries

of an adult woman (set. 20) who was the subject of inherited
syphilis. She was of low stature and displayed a general
arrest of development. Her mammae were extremely small,

DWAEFING IN CONNECTION WITH TAINT. 5

and her skin was dry and of earthy pallor. She had, I
believe, menstruated a few times. Her physiognomy and
teeth showed the usual characteristics. She died in the
London Hospital, and as we had noted the especial absence
of feminine development we were interested in examining
the organs here delineated. They were the smallest I have
ever measured. Thus the uterus was only an inch and a half
(a to b) in length (half of what is normal), and the appen-
dages were in proportion. The sketch shows the parts as
seen from behind. The right ovary is laid open. C indiciates
a dark stain probably from ecchymosis ; d, a small peduncu-
lated growth.

A case which I have recorded in Vol. V., p. 360, is a good
example of a parallel condition in the male sex. Although
seventeen, the boy was quite feminine in his build and had,
I have no doubt, arrest in development of the sexual organs.
He had extensive choroido-retinitis.

No. n. — A strong^ healthy son bom of a mother who had
suffered severely from inherited SypMlis — The mother
dwarfed in stature.

Mrs. H was herself a sufferer from inherited syphilis

in a very severe form. She was dwarfed and quite deaf.
She had had under my care an attack of keratitis, and sub-
sequently was much troubled with noises in the head. She
was married and had borne one child. I saw this child
when he was twelve years old. He was a fine, strong lad
without a symptom of taint, had perfect teeth, and was as
tall as his mother, to whom he offered a strong contrast.

No. III. — Inherited Syphilis — Keratitis and Internal Otitis
at the age of thirteen — Beport on state of health at the
(^^ of forty — Important facts as to family history,

Maria D was my patient at Moorfields Ophthalmic

Hospital, for a severe attack of interstitial keratitis, in 1870.
Twenty-three years later, in August of 1894, through the
courtesy of Dr. W. H. Johnson, of Limehouse, I had an

6 SELECTED CASES OF INHEBITED SYPHILIS.

opportunity for investigating her then present condition.
She was now a tall, well-grown woman of 37. Her features
were not peculiar, and the notches which ha'd formerly been
present were worn out. She was absolutely deaf. The
history of her deafness was that in 1871, whilst still taking
small doses of mercury, which I had prescribed for her
keratitis, her hearing began to fail, and that within a fort-
night she had become quite deaf, and had remained so ever
since. She had learned to talTk with her fingers, but of
late her sight had failed so much that it was feared she
would lose even this means of intercourse with others.
She was liable to attacks lasting a few moments at a time,
during which she was in darkness. Her comese showed the
characteristic steel-haze, and the pupils were small. There
were white patches near the borders of the comeae, and a
conspicuous white arcus at the upper part.

As regards family history, this patient was the fourth
child, and had younger brothers and sisters. She was the
only one who had suffered. I saw one sister only eighteen
months younger who had ailed nothing whatever.

Three years later still, in November, 1897, I again ex-
amined this patient, and obtained from her elder sister in
more detail the important facts at to the history of their
family. Fortunately the fears which had been entertained
as to the advancing failure of sight had not been realised.
She had ceased to be liable to retinal epilepsy, and although
her left eye was disabled by pupillary occlusion, could still
see fairly well with the other. It was impracticable, owing
to the smallness of the pupil, to examine the fundus ; at any
rate I found it so, and a note on a Moorfields Hospital letter
recorded the same result. In spite of this, however, I was
assured that she was a great reader and could do the finest
needlework with ease. Apart from her disability from deaf-
ness, &c., she enjoyed excellent health, was of a happy
disposition, and always busy. She was now 39.

An elder sister who brought her to me in November last
at my request, that I might ascertain her present condition,
gave me the following important particulars as to their
family : Maria D is the third living, and there are six

CASE-NAEEATIVES. 7

younger than her. All these six are in good health, and
have never suffered anjrthing suspicious of syphilis. My
informant's remark was : ** We are a remarkably healthy
family, and all well grown and strong." Asking as to their
parents, I was told that their father, who was a pilot, was
a man of splendid frame and always healthy, but who had
'*lost part of his palate after a bad sore throat.*' He finally
fell down dead from heart disease when between sixty and
seventy. Their mother enjoyed good health until her death
from bronchitis at 65.

No one can reasonably doubt that this woman is the sub-
ject of inherited taint ; her deafness and keratitis sufficiently
prove that, and the statement that her father had a perfora-
tion of his palate as a consequence of a bad sore throat
indicates the source from which the disease was derived.
As her sister, only three years older than herself, is wholly
without indications of it, there cannot be much hesitation in
believing that her father acquired the disease after his mar-
riage, and not long before our patient was begotten. It is of
interest to note that not only does his wife appear to have
wholly escaped, but also all their subsequent children. The
man and wife continued to live together as though nothing
had happened, and a succession of six children were bom,
all of whom lived and have remained well up to adult life (all
being, in fact, still living and robust). The one next to our
patient is not more than eighteen months her junior.

I am well aware that the absence of symptoms in infaaicy
and childhood, and good health up to adult age, does not prove
escape from taint. Those who have so escaped may still in
exceptional cases suffer from keratitis or other of the less
common late manifestations. They may, however, be fairly
held to have escaped so far as serious peril to health is
concerned.

No. IV. — Syphilis inherited from the father — Severe infantile
symptoms and subsequently Keratitis — A younger sister
free from symptoms, hut showing typical teeth.

The next case which I have to relate is a very conclusive
one in proof of what has just been remarked as to the possible

8 SELECTED CASES OF INkSBITED SYPHILIS.

escape from all obvious sjonptoms, in childhood, of those who
yet most certainly inherit a taint. A gentleman who had
suffered from syphilis resumed, after a short time, cohabitation
with his wife and became the father of a child (a girl), who
suffered severely in infancy. It was not expected that she
would survive. With great care, however, she was reared
and became a healthy woman. At the age of twenty-nine,
however, she passed through a most severe attack of keratitis,
which left her comeae permanently damaged. It was for
this that I was consulted when she was thirty-two years of
age. The bridge of her nose was much sunken, her corhesB
opaque, and her teeth very characteristic. Her whole frame
was somewhat dwarfed. With her came a younger sister,
aged 28, who was married and the mother of a fine, healthy
child. This woman had never suffered anything. She was
well grown and showed nothing peculiar in physiognomy, yet
she had teeth as characteristic as any that I have ever seen.
Between the patient and this her younger sister, two births
had occurred. One of the infants was stillborn, and the
other lived five weeks and then died of diarrhcea. In this
instance the mother, who had continued to live with her
tainted husbaoid and had borne to him during five years four
tainted children, never herself suffered in any way. She is
still living and in excellent health. She suckled her eldest
child for some time whilst it was ill, and never contracted
any sore on her nipple.

Incidentally in the above narrative we have an instance of
healthy offspring in the second generation.

No. V. — Hereditary Syphilis — Interstitial Keratitis at the
a^ge of twenty-six — Patient the father of healthy children.

The following case is of interest as an example of the
production of healthy children in the second generation,
and also of the late occurrence of keratitis.

** December 11, 1873. J. C , a six-foot soldier,

attended me in 1862, set. 26, for interstitial keratitis. He
got well, and remained well for five years. Then he had
ophthalmia, which ended in granular lids. He was a tall,
stout, florid man in splendid health, and the father of six

VARIOUS CASE-NARRATIVES. 9

healthy children. Yet his teeth were quite characteristic as
also was his keratitis.

"His elder sister came with him (five years older), and
she had no signs of hereditary syphilis. I was informed
that a yomiger brother had had an attack of inflammation
of the eyes."

No. VI. — Healthy child of a mother herself the subject of

inherited Syphilis.

Mrs. C , aged 28, had borne two children. One

had died of bronchitis after measles, aet. 18 months; the
other, aged three months, she brought with her, and it
appeared to be perfectly healthy.

This woman came to be inspected at my request, because
I had diagnosed inherited syphilis in a younger sister.

Mrs. C had deep scars about the mouth, and her teeth,

although not greatly malformed, were quite characteristic.
She had suffered from keratitis at the age of eleven, and
the comese were still hazy. She now appeared to be in good
health. She stated that she had been told that up to three
months old she had a bad rash on the face.

No. VII. — Effusion into one knee-joint in a hoy aged 5,
pale and puny — Interstitial Keratitis of marked
character three months later — No history of infantile
symptoms. April 9, 1873,

A further note on August 29th of the same year records
that the eye was well, but the knee still somewhat swollen.
It will be seen that the synovitis, contrary to rule, preceded
the keratitis.

No. VIII. — Hereditary Syphilis in a child of eleven, whose
mother I had attended for a syphilitic gumma — Inter-
stitial Keratitis — Teeth not malformed. July, 1873,

No. IX. — Congenital Syphilis — Infantile convulsions followed
at the age of eight by threatened dementia,

Mr. C 's child, aged 8J years, was brought to me in

February, 1892. At the age of three months she had had

10 SELECTED CASES OF INHEBITEd' SYPHILIS.

pain in all the epiphyses, and a month later she had a
convulsion. When six months old she had a very severe
fit, attended by squint. Last summer her mind seemed
to fail, and she was no longer able to say hymns as before.
Although she had not been taught at school, yet she had
picked up a good deal. During the past few months she
had become dirty in her habits. I examined her eyes, and
found grey degeneration of the optic nerves.

There were two younger children of the same family who
were quite healthy.

Comments. — ^I do not know the sequel of this case. The
child was obviously threatened with failure of mind, &c.,
such as is illustrated by the cases cited at p. 216, Archives,
Vol. v., and concerning which Dr. Shuttleworth has
published some important facts.

No. X. — One only in a family of eight showing signs
of inherited Syphilis — The others living and quite
free.

Clara T , 8Bt. 16, attended on September 10, 1870,

on account of the remains of interstitial keratitis. Her
teeth, physiognomy, and eyes were in most characteristic
conditions. With her came two sisters — one eet. 24, the
eldest of the family, and one eet. 7, the youngest, neither of
whom showed the slightest indication of inherited taint.
Both had perfect teeth. I was told that there were eight
living children in the family, that Clara had suffered severely
all her life and none of the others at all. The attack
of keratitis in Clara was very severe, and she had to be
kept in a dark room for six months. There are three
younger than Clara living and four older. Two had died
in infancy.

Comments. — The above facts are best explained by sup-
posing that the father of C. suffered from syphilis not long
before her begetting. This would explain the escape of all
bom previously. The husband of her mother was a sea-
captain, and often away from home, and in connection with
this fact several possibilities suggest themselves. Unfortu-
nately I have not noted how long the interval was between

INHERITANCE FROM FATHER ONLY. 11

C. and the one bom next to her. It may have been long
enough to allow of the infecting parent having got rid of
the taint. Possibly the two who died intervened.

No. XI. — Inherited Syphilis — Father alone the source of
infection — Mother remaining quite healthy througJiout,

A surgeon had a chancre on his index finger in August,
1883. He took mercury, and did well under it. His wife
bore a child in December, 1884. It was a fine child at
birth, but when two weeks old, quite suddenly, as the nurse
said, it, in one night, became covered with an eruption.
After that it never thrived. Grey powder was at once
given, and when the child was brought to me on January
16th, at the age of five weeks, the rash had faded, but there
were unmistakeable symptoms of inherited taint. Its
buttocks were then covered with a red excoriated eruption,
which tended to assume a polished surface. There was
also some eruption about its mouth. It had had no snu^es.
Under mercurial inunction the symptoms disappeared, and
the child afterwards throve well.

In this case I know that the mother remained throughout
quite free from symptoms. It appears to be a good instance
of inheritance from the father only. As the chancre was
not on the penis, there was but little risk of direct contagion
to the wife. That a woman should bear to a syphilitic
husband a sjrphilitic child, and yet, apparently, wholly escape
herself, is, I believe, not uncommon. Foetal infection,
although a possibility, is by no means invariable. Much
probably depends upon the development attained by the
virus in the infant during its intra-uterine life. In this
instance the child at the time of birth was in perfect
condition. The virus was then apparently latent, and
we may suppose that it was possibly inactive as a means
of contagion.

It is interesting to add to the narrative, that three years
after the date of my notes the father reported to me
that his wife, his child, and he himself were, all in
excellent health.

12 SELECTED CASES OF INHERITED SYPHILIS.

No. XII. — Congenital Syphilis — Keratitis severe in eldest
and youngest of three children — Absence of teeth
symptoms,

Mr. D brought me his three children.

W. (M.), set. 14, had suffered from keratitis, and had a
characteristic forehead. His cornese were now clear.

F. (M.), apt. 12, showed nothing and had ailed nothing.

E. (F.), set. 10 (my present patient), had now the remains
of most severe keratitis.

None of the three had peculiar teeth.

No. XIII. — Scrofula and congenital Syphilis together.
Keratitis of several years' duration on and off; cured by
setons. I had treated both father and another for Syphilis
only four months before this child's birth, yet no very
definite symptoms had occurred in the child. Inherited
tendency to Phthisis, and great enlargement of the glands
in the neck. May 20, 1892.

No. XIV. — Syphilitic Pemphigus developed during intra-
uterine life — Bicord*s Plate and Archives VII. 294.

No one who has seen the 46th plate of Eicord's Atlas can
doubt the occasional occurrence of the intra-uterine develop-
ment of syphilis. The infant whose body is depicted was
born dead, and it is covered with abrasions and pemphigus
blebs. The hands and feet are affected with special severity.
The infant was a male, and bom at full time. Its father
had suffered from syphilis quite recently, but the mother
remained, so long as she was under observation, in perfect
health, and had never had a sjmaptom. The child was
believed to have been dead three or four days before birth.
It had no special visceral disease.

No. XV. — Becovery from Syphilitic Pemphigtcs in an
infant — Choroido-retinitis and m/uch damage to Eyes.

Nellie B , aged 6 years (July 13, 1873), had been in

infancy the subject of syphilitic pemphigus. She had at
birth crimson palms and soles, and ten days afterwards buUas
as large as grapes appeared on her hands and forearms,

INFANTILE PEMPHIGUS. 13

feet and legs, and were confined to those parts. She was very
ill, but recovered under grey powder and mercurial ointment.
She also had sores at the comers of the mouth, snuffles
and patches at the anus. These facts were supplied to me
by the surgeon who had treated her.

Her father had contracted syphilis six months before his
marriage, and her mother, after a first miscarriage, had a
syphilitic eruption. A previous child was syphilitic. The
child born next after our patient had an eruption on the
buttocks, and got well under grey powder, but died from
tuberculosis and inflammation of the brain at three years of
age. The next child, a male, had no symptoms of syphilis.
He was at the time of my notes nine months old, and had,
I was told, some tendency to rickets, as shown by late
dentition and large ends of the bones.

To return to our patient. She was brought to me on
account of her failing sight. Her eyeballs were constantly
rotating (not oscillating), and there was convergent strabis-
mus. The left eye saw ^%; the right saw f^, perhaps
more. There were in both numerous very irregularly
shaped patches of choroidal absorption. Some of these
were small, with black dots in their centre, while others
simply showed removal of choroidal pigment. The patches
were arranged quite irregularly. The left disc was grey and
waxy, and there was much pigment at its edge. The move-
ment of the eyeballs and defective sight had been recognised
at the age of two years, so that it is probable' that the
choroiditis occurred early in life. When I saw the child
she was healthy - looking, with no malformation of the
head, and with good temporary teeth.

No. XVI. — Case of Infantile Pemphigus of hands and feet,
probably Syphilitic — Death of two children in early
infancy with similar symptoms.

On the 6th of May, 1874, I was called upon to visit Mr.

B 's infant, a seven months baby then twelve days old.

It was suffering from spots of erythematous pemphigus on
the hands and feet, and a few small excoriations about the
anus, not true condylomata.

14 SELECTED CASES OF INHERITEP SYPHILIS.

The father admitted gonorrhoea some years ago, but
denied having ever had either sore throat or rash. The
mother appeared to be perfectly healthy. There was, how-
ever, a statement that some years before, after nursing a
syphilitic child of her brother's, she had experienced an
inflammation of one eye, which was supposed to be
syphilitic, and was cured by mercurial treatment. This
was not followed by any symptoms of secondary syphilis.
Since that time she had had one other child, which had
snuffles very badly, and died with pemphigus when a
fortnight old.

The child was ordered mercurial treatment, but died
thirty-six hours after my visit.

Comments (written at date of notes, May, 1874). — Though
' the parental history in this case is too imperfect to justify a
positive conclusion as to its syphilitic nature, still the pro-
babilities are all in favour of such a conclusion, for it is
certain that the children of syphilitic parents do frequently
suffer from pemphigus, and that the disease very usually
makes its appearance immediately after birth. Indeed, I
should believe that it is often a disease of intra-uterine life,
and is a common cause of the death or premature expulsion
of the foetus. And on the other hand, I cannot say that I
have ever seen the disease make its appearance immediately
after birth in any case where there was no suspicion of
syphilitic taint. (This opinion has been since modified.)

No. XVII. — Congenital Syphilis in a first-horn child — No
treatment in infancy and but slight symptoms — Very
severe Keratitis at the age of twenty-one, with Periostitis
and Synovitis of knees — No indications in fa^ce or teeth
— No relapse, and in good health at the age of forty.

The first and only child of her mother's second marriage.
Sores at the anus were her only infantile symptoms. Her
mother died of bronchitis set. 69. Her father died young
after a badly ulcerated throat. Her physiognomy shows
nothing obvious : teeth good. In 1896 she was florid and
looked well. Suffered from nothing but leucorrhoea and
dyspepsia. Much distressed that she had had no children.

CASE-NARRATIVE S.

15

In this case although there were extensive iritic adhesions,
no recurrence of iritis ever occurred. In 1896 she could see

TEAR.

1877
1878
1879
1880
1881
1882
1888
1884
1885
1886
1887
1888
1889
1890
1891
1892
1898
1894
1895
1896

AGE.

21
22
23
24
25
26
27
28
29
30
81
82
38
34
35
36
37
38
39
40

DETAILS.

A most severe attack of syphilitic keratitis. Synovitis of knees.
A long treatment. Node on tibia : pupils fixed by adhesion.

Married : never conceived.

Began to suffer from leucorrhoea, possibly gonorrhoea.

" Ulcers on the womb " diagnosed, and some operations done.
Still much trouble with leucorrhcea.

Excepting ilidigestion and leucorrhoea, in good health.

Comes on account of dyspepsia. Teeth are good.

almost perfectly. Her front teeth were of perfect form, and
had such good enamel that I mistook them for artificial
ones.

No. XVIII. — Family history in the case of a man who had
suffered from Syphilis, and continued to show symptoms
long after his marriage,

1 attended Mr. H about the year 1870 for severe

syphilis. He married within the two years. The disease
hung about him for long. He had an attack of hemiplegia
with aphasia about a year after his marriage, and much
later became the subject of very severe tabetic pains in his
legs. He also suffered from hydrocele, which required
tapping once a year. In spite of all these infirmities,
however, he was a cheerful, happy man, very proud of his
wife and family, and never neglecting his business. He
finally, in 1896, died, after a few months' illness, of abdominal
cancer. I had had many opportunities for seeing his wife and
children. The former never ailed anything whatever, and
was always the picture of health. She was aware of her

16 SELECTED CASES OF INHEBITED SYPHILIS.

husband's anxiety about their children, and used to smile at
his fears. None of their children ever had any infantile
symptoms conclusive of syphilis. Their eldest was bom at
seven months, and was said to have an enlarged liver, and
was for some time so delicate that she was not expected to
live. She has, however, developed into a fine young woman,
now set. 22, and her teeth show nothing.

No. XIX. — Hereditary Syphilis — Enlargetnent and partial
displacement backwards of head of each radius.

David H , aet. 28. (Sent by Mr. Tay, September 8,

1876.) Has been in London Hospital for some trivial ail-
ment. Considerable haze of each cornea from severe old
keratitis. Pupils sluggish, and L. more than E. Slight
dots of whitish deposit on each lens capsule, but no
synechise. Eefraction highly myopic in each. Consider-
able crescent in each. Eetinal veins and arteries normal.
Abundant peripheric, old choroiditis, large patches of black
pigment, a few of atrophy without pigment. Blue irides ;
darkish "brown hair. There are a few dense circumscribed
floating bodies in each vitreous. Teeth screwdriver-shaped.
No deafness. Physiognomy not characteristic. There is
slight enlargement of inner part of E. patella (after a small
wound in or close to knee some years ago ; the joint was
much swelled). The L. outer malleolus is considerably
larger than E. No nodes on tibiae.

He is an only child. There was one miscarriage after he
was bom. Has never to his knowledge had inflammation
of the elbows or ankles. The enlargements at his elbows
have been as they are now as long as he can recollect. At
each elbow the head of the radius is very considerably
enlarged and projects backwards. That of the right radius
is the larger of the two.

[To he c(yncluded,)

PEMPHIGUS AND ITS VAEIANTS.

(Continued from page 336, Vol, VIII,)

Before proceeding to make some general comments, I have
a few additional cases which must be recorded.

The following letter from Dr. Groome, of New Cross,
gives some additional particulars as to the latter part of

Miss L 's illness. Hers was the last case recorded, and

was left incomplete.

" My dear Sir) — I attended Miss L in Jime, July, and August,

1895, for a recurrence of the pemphigus, and in September of the same
year she had not a blemish on her skin except the staining of the
epidermis left after the eruption. She then left for the country and
remained clear until December, 1895, when she came to me with the
rash developing in the chest and arms. From this time she got from
bad to worse, and the rash appeared over the whole cutaneous surface
with the exception of the malar portion of each cheek. Her gums,
together with the buccal mucous membrane, were extensively involved,
as also were the soft palate and tongue. The bullae were very large, and
extended from head to foot; in fact, her skin was virtually one raw
surface, covered here and there with large yellowish crusts, the whole
exhaling a most ofifensive odour. As to the treatment, I confined myself
to quinine and arsenic in gradually increasing doses, and applied soothing
ointments locally, but all to no purpose, for the disease steadily progressed
and, as I said before, the patient died in a pitiable condition consequent *
on the pemphigus and the exhaustion following it. The death certificate
contained the words * Pemphigus foHaceus * and * Exhaustion.* "

A Pemphigus Eruption affecting only the limbs — Very large
bullcB — Inflammation of Conjunctivce and of Mouth —
Partial obliteration of conjunctival sa^s and inversion of
eyelids.

The subjoined schedule and notes concern a case in which
the most distressing condition was the affection of the con-
junctivae. There appeared much reason to fear that the
boy might lose his eyes. The pemphigus eruption which

VOL. IX. 2

18 PEMPHIGUS AND ITS VAEIANTS.

had preceded and accompanied the conjunctivitis had
apparently followed typhoid fever, and had been wholly
confined to the limbs. My patient was brought to me with
an introduction from a physician in Lausanne, which
informed me that he had in the early stages suffered from
bullae on the conjunctivae, and that he could not take
arsenic. The diagnosis given was pemphigus of the con-
junctivsB, with consecutive atrophy. He was in a most
deplorable condition. I advised as a preliminary measure
excision of the eyelashes ; but I did not see him again, an3
believe that he left London.

YEAB.

1890

1891
1892
1893
1894
1896
1896

AGE.

1

2
3
4
5
6
7

DETAILS.

Bom in Guernsey. He is one of five.

Quite well.

Was taken to the Biviera, and had a severe attack of typhoid.

Very weak, and liahle to whitlows, and sores in nose and
corners of mouth.

Liahle to hullee on face, hands, and feet (sudden). Eyes in-
flamed.

Suffering severely both in eyes and skin.

October 30, brought to me.

Additional Notes.

He has never had pemphigus on his body, but his hands have suffered
severely. It might be taken for a form of ** blistering chilblains." Both
eyes are affected, the comeae being opaque and vascular, and the con-
junctival sacs contracted. The right eye has been considered to be lost.
He screws the eyelids up and turns the lashes of both upper and lower
lids in upon the comese, and it is difficult to say how much may be due
to this. He is of pale complexion and flabby skin. His skin on the
limbs blisters wherever touched. I am told that he has had very large
bullae on thighs as big as eggs.

Acute Pemphigus with Sore Mouth, following a patch of
Eczema on the neck — Arsenic disagreeing.

Mrs. E , aged 35, the mother of three healthy

children, was brought to me on April 2, 1897, by Dr.
Hampton Brewer, of Dalston. I was told that she had,.

CASE OF MRS. R . 19

some months ago, sxiffered from haemorrhage from the
bowel, and that in former life she had presented some
indefinite nervous symptoms with ''paralysis." She had
also, in 1895, had an attack of acute general eczema. The
first indication of her present skin disease was a rough
patch (eczema?) on the back of the neck. Some weeks
after the first appearance of this, a general pemphigus
eruption appeared on the limbs and trunk. There were
bullfie of large size. Arsenic was given from the first, but
only with irregular benefit, and finally it had seemed to
disagree with the general health. Mrs. E had emaci-
ated, and although she had no fresh bullae when she was
brought to me, she looked very ill. The statements as to
the disagre6ment of arsenic induced me to advise its dis-
continuance, at any rate for a time. We agreed to sub-
stitute quinine and small doses of opium. She had
complained of sore throat and mouth.

Four weeks later, on April 30th, Mrs. E came to me

a second time. She had now many bullae and of large size,
especially on the limbs. She said the blebs would rise very
rapidly, ** often a large one would form in five minutes.'*
They would remain clear for two or three days, and then
become purulent. They now occurred on all the limbs, on
the abdomen and the back. The mouth and lips showed
plum-coloured patches. It was clear that quinine had failed,
and I now advised resumption of arsenic. Four days

later Mrs. E attended one of my Demonstrations. She

had still very numerous bullae on the limbs, but her mouth
was better. As she could not be well nursed at home, I asked
my colleague. Dr. Stephen Mackenzie, to be good enough to
take her under his charge into the London Hospital. This
was done the same day.

The date of her admission into the hospital was May 5,
1897. The following notes as to her condition and progress
under treatment have been kindly supplied to me, through
Dr. Mackenzie, by his House Physician, Mr. Sears.

*' On admtisaion, — Patient was in fairly good health, but said that she
had not slept more than two or three hours on any one night for the last
week. She complained of a feeling of * soreness ' of the body and throat

20 PEMPHIGUS AND ITS VAEIANTS.

and a general sense of weakness, but was not at all depressed. Her
temperature on admission was 99*4° F. and there were no signs of disease
in the heart, lungs, or other viscera.

" The entire iaurface of the body, with the exception of the face and
back, was covered more or less completely with a bullous eruption, the
bullsB varying in size from a pea to the top of a teacup. The contents
were either translucent, opaque, or hsemorrhagic in character, the latter
variety being the smallest in number. There was no actual pain, but
only a feeling of irritation previous to or during the development of the
bullae. When, however, the bullae became very distended with fluid, they
caused a good deal of pain and had to be pricked, the pain disappearing
on the outlet of the fluid. On various parts of the body there were dry,
hard scabs which marked the remains of bullae which had been absorbed,
some of which were sHghtly pigmented, and along the edges of these
patches (which were well marked on the hands) small clear vesicles were
seen. The glands in the axillae were enlarged.

^* Progress and Treatment, — Up to May 11th the patient continued in
the same state as before, crops of bullae appearing on various paj:ts of the
body, the temperature, however, rising about half a degree every evening
till, at the date above mentioned, the thermometer registered 101*6° F.
On the morning of the 12th she complained of feeling ill and very
depressed, and could not take soUd food on account of a feeling of
enlargement of the inside of the throat. A laryngoscopic examination
at this date, however, revealed nothing abnormal, and it was not till two
days after that a large oval bulla was detected at the junction of the hard
and soft palate. The patient was by this time in a very serious state, her
condition causing great anxiety, as she was unable to swallow either soUd
or liquid food, the smallest amount being almost immediately rejected,
and showing traces of blood. The temperature at this time varied
between 102*4° F. and 99° F. This condition lasted up to May 17th, when
the throat symptoms abated, though the feeling of depression continued ;
the patient being now able to swallow small quantities of milk without
vomiting. At this time she was taking Liq. Arsenicalis m. x. t.d., the
dose having been increased from the original one of m. v. which she was
ordered on admission. During this severe period of her illness crops of
bullae continued to appear on different parts of her body, the character
of the eruption not varying in any way ; and on May 22nd, when the dose
of Liq. Arsenicahs was increased to m. xv. t.d., no improvement of a
marked character had taken place, though her general condition was
much better. On May 25th the patient was ordered Ext. Opii gr. ^, in
pill form, every four hours. No improvement was noticed bill the first
week in June, when the face became clear and the crops of vesicles
gradually became less ; and in a few days no new vesicles showed them-
selves, the last bulla being noticed between the second and third week
of that month. Her general condition improved, and she left the hospital
on June 25th on account of some family trouble, still feeling more or less

A NOTEWORTHY RECOVERY. 21

weak and thin. Since then, however, she has been seen and is at
present looking remarkably well, and has had no recurrence of the above
illness."

This patient attended one of my Demonstrations for a
second time on December 7th, five months after her discharge
from hospital. It is long since anything has given me
keener pleasure than I then received fjrom seeing in perfect
health one whom I had beUeved would die, and who had, I
knew, been saved not by the resources of nature but by the
timely use of drugs. On the former occasion of her
attendance, just before her admission under Dr. Mackenzie's

care, Mrs. E was a pitiable object, emaciated, covered

with bullae, with a sore mouth, and, worst of all, her symp-
toms had apparently resisted the influence of the two
specifics arsenic and opiunu It was this latter fact which
made me especially unhopeful as regards her recovery. Yet it
was by these drugs, when used with the advantages of hospital
supervision, that the cure was effected. Dr. Mackenzie has
since informed me that during the first few weeks of her
hospital residence she got worse, and that the improvement
did not begin until the dose of opium was increased. He
credits the combined use of the two drugs with the cure.
At the time that she left the hospital the eruption had not
quite disappeared, and at this date the opium was left off
and arsenic alone continued. I should Uke to insist on the
completeness of the disappearance of the symptoms. Mrs.

E had, when I last saw her, a perfectly sound skin ; she

had fattened and looked quite well. This completeness of
result is not unusual in pemphigus cases, and is a very
important fact. It seems to prove that there is some con-
stitutional element of causation of a very definite kind, the
removal of which may permit of return to perfect health.
Nor is it very unusual for cases to resist treatment for a
while which finally yield to it in this complete manner. Of
this the next case which I have to narrate is a yet more
definite example, for the disease had lasted longer and had
relapsed repeatedly. Yet the patient, after being long at
death's door, was finally cured, and has now for nearly
three. years enjoyed excellent health.

22 PEMPHIGUS AND ITS VABIANTS.

This susceptibility of absolute cure is a feature which,
pemphigoid dermatitis shares with the malady which we
know as Lichen planus. This latter will often for a time
resist treatment, and although it does not, like pemphigus,
threaten the patient's life, yet it may cause extreme dis-
comfort and much reduce his health. At page 88 of Vol. II.
will be found the narrative of a case in which the disease
was one of much severity, and in which suddenly under the
influence of antimony it began to decline and the skin was
soon restored to perfect soundness. It is like pemphigus
also in that there is a definite risk that a return of the
dermatitis may take place after an interval of some years-
It is much to be desired that those who have the oppor-
tunity would put on record their observations as to the
permanency of cure in cases like the foregoing. It is
unfortunately the fact that many of the case-narratives
of pemphigus are only fragments, and do not take us
further than the disappearance of the eruption. We know
that in many the eruption does relapse, and it can scarcely
be asserted that we know for certain that there are any in
which, sooner or later, it does not do so. This is really a
very important point, and more definite- knowledge respect-
ing it might help us much in our endeavour to form correct
ideas as to the real nature of the malady. It is, I think,
highly probable that some patients who have passed through
a pemphigus illness and been cured by drugs do remain well
ever after. At any rate I have myself quite lost sight of
some patients who would, I think, have returned to me if
they had had relapses, and such, I doubt not, has been the
experience of other observers.

Femphigus in a hoy — Itepeated temporary cures by Arsenic —
Severe illness with Ascites — Subsidence of the Pemphigus
— Paracentesis six times — Return of Pemphigus — Cure
by Arsenic — Becovery and good health three years later.

In my next case, as I never myself saw the patient and
have not had any detailed notes supplied, the safest way will
be, I think, to let my friend's letters give the narrative.

SEVERE PEMPHIGUS WITH ASCITES. 23

It will be seen that it is a case of great therapeutical
importance.

On March 18, 1894, I received from my friend. Dr.
Clement Dukes, of Rugby, a letter, of which the following
is an extract : —

^* Dear Mr. Hutchinson, — I wonder if you can be a good Samaritan
and give me a hint on a hospital patient who will die unless I can do
something more for him.

** A boy, est. 6, has suffered from pemphigus on and off for about two
years. I got him cured for a time by making his meat and drink of
arsenic.

" A month ago, solely from interest in the case, I went five miles to
see him as he had ascites, and no pemphigus. I removed him to the
hospital, and tapped him three times, letting out 120, 90, and 72 ounces
at the three times. Since the last tapping Ms pemphigus has returned,
and he seems very prostrate.

** In addition to the arsenic, I have used mercury and iodide of
potassium."

The following note bears date ten days later : —

" Ma/rch 29, 1894.

" Dear Mr. Hutchinson, — Thank you for your kind note about the
pemphigus boy. I am sorry that I cannot give you complete notes, for
I have only seen him intermittently.

'^ When I first saw him, some two years ago I think, he was one mass
of bUsters as large as the palm of the hand. It was about a month ago
that the village doctor asked me to see him, and take him into the
hospital.

" I have again tapped him twice since I wrote to you, and I must do
it again to-morrow I fear, as he has incessant abdominal pain unless it
is done.

** The pemphigus has now subsided, and he seems better while he fills
so rapidly. I thought that the case would interest you. I have not
detected any disease of liver."

After that I did not hear anything until, in 1897, I wrote
to inquire what had been the sequel, quite expecting to hear
that the boy was dead. The following was Dr. Dukes'
reply :—

** December 6, 1897.
"Dear Mr. Hutchinson, — This lad remained under my care from
February, 1894, to August of the same year, when he returned home

24 PEMPHIGUS AND ITS VARIANTS.

cured. He was tapped in all six times. I got liim nearly black with
arsenic. He hovered between life and death for long, often with a tend-
perature of 104°. When he was at last mending, and I had to stop the
arsenic, I think because of diarrhoea, I gave him thyroid gland, as he
was such a miserable object, and he seemed to thrive on it.

** I have httle doubt that he keeps well, otherwise I should have had
him in hospital again."

Not feeling quite assured that a good recovery had been
established, I wrote again, asking that inquiries might be
made as to the lad'fe present state of health. I had the great
pleasure to receive the following reply : —

" December 9, 1897.

" Deab Mr. HuTCHDiSON, — To-day is the first opportimity I have had

to drive out to Easenhall to inquire after Walter W . He resides in

the same cottage with his father and his father's sister. His mother ia
dead. He left my care in the autumn of 1894.

** In the spring of 1895 he went to Pailton village school. He ha&
attended school ever since (two miles away), has never had a day's
illness, is fat, strong, and hearty. Only the other day the aunt said, ' I
only wish the doctor could see Walter now ; he wouldn't know him, and
he wouldn't believe it was the same lad.' He has never had a spot on
his skin since he left the. hospital."

Most certainly we have here a very remarkable instance
of recovery from a very unhopeful condition. The ascites
was probably of a more or less inflammatory character, as
evidenced by the pain, high temperatures, and the rapidity
with which refilling: occurred. It was in connection with
this diagnosis that I advised my friend to continue the mer-
cury with opium which he was already giving. I have known
ascites in more than one case in the late stages of fatal
pemphigus, and in one in which the patient had been treated
for psoriasis. This latter case led me to entertain a suspicion
that possibly arsenic might cause it. On this account
I was inclined to advise Dr. Dukes that the arsenic should
not be pushed, more especially as the pemphigus had sub-
sided when the ascites set in. A subsequent relapse of the
pemphigus made it necessary to give arsenic again. We
are obliged to leave it a little doubtful as to what remedy
it was that at last brought about the restoration to health,

PEMPHIGUS WITH STOMATITIS. 25

for several had been tried simultaneously. That the arsenic
controlled the pemphigus temporarily there could be no
doubt, and probably it had in the end the main share in the
cure. The disease had probably been quite conquered at the
time it was left off.

PemphigiLs with Inflamed Mouth — Partial Cure by Opium.

In the following case the patient had been under careful
treatment by opium for some seven months before I saw
her.

At the time that Mrs. T was with me she had nothing

more to show than mere stains. These were visible under
her breasts, on her bald scalp, and, to a slight extent, on
her face and other parts. She gave the history, however, of
having been liable to pemphigus blebs on various parts for
the last eighteen months. It began, she said, by a most
troublesome ** eczema" on the scalp, which proved intract-
able. The parts next affected were the folds under her pen-
dulous breasts. Her nose and mouth had been inflamed. She
counted three definite attacks. She described very sore lips
and tongue (with blisters) ; they used to stick together and
were covered with discoloured secretion. The opium had,
she thought, cured this.

Additional Memoranda, — Quinine makes her head ache. She has
Xanthelasma palpebrarum affecting the right upper eyelid and both
outer oanthi, but not the left upper eyelid. In youth she used to have
much liability to " biliousness " in the form of giddiness, for which she
used to take calomel by " dipping her finger in it."

She was formerly stout and has lately lost much fat. She inherits
gout from her mother, father, and one grandfather.

For two years she has been liable to profuse perspiration, which usually
begins about five in the afternoon and affects her head and forehead first
and next her trunk.

She menstruated regularly till 54, but, although married at 30, never
conceived. She once had a throat which had white exudation and was
considered diphtheria, but this was doubted by one observer. This was in
August last.

Two years ago she took ether to have her sphincter stretched. She
has had constipation all her life. Jerusalem artichokes were her best
aperient. Her attacks have occurred at two different places of residence.

26 PEMPHIGUS AND ITS VARIANTS.

A severe outbreak of Pemphigus in a mem of intemperate
habits for seven years the subject of Albuminuria,

Early in May of '88 I went to Foots Cray to see a gentle-
man (aged 43) who was in a most deplorable condition from
general pemphigus. He was confined to his bed and couch,
and covered with bullae and excoriations. He had for some
time been under medical care on account of albuminuria,
and he had suffered from epilepsy. His habits had been
intemperate. In the October preceding my visit he had
suffered from "herpes," which, however, soon got well.
In March, during hot weather on board ship at sea, his skin
showed an eruption of minute red spots which itched. These
Were scratched, and, apparently as a consequence, a bullous
eruption rapidly developed. This, however, under quinine
and iron and the local use of carbolic acid, disappeared
to a large extent, and it was only ten days before my visit
that a relapse occurred and the disease assumed the severe
form above mentioned. The bullae had been large, and he
had rapidly become very weak. No albumen was present
in his urine when I saw him, but it had a low specific
gravity.

I prescribed arsenic, and a fortnight later I had the
pleasure of hearing from his medical attendant. Dr. Fegen
(now of Molton, Beds) , that from the day that the medicine
was begun the production of bullae had ceased, and that his
skin had rapidly got quite well.

Some General Remarks on the Series of Cases and on the

Employment of Names,

Just as religious teachers recognise in the human mind a
constant proclivity towards idolatry — a preference for the
concrete rather than the purely spiritual — so in pathology
we have to contend against the tendency to substitute a name
or a definition for the perception of essential nature. As
it is easier to most of us to worship a personality, a name, or
even a book, rather than to conceive of non-material power,
so we more readily become accustomed to content ourselves
with some euphonious name for a disease rather than acquire

EEMABKS ON NOMBNCLATUEE. 27

the habit of constantly trying to reahse its nature and its
relation to possible causes. The concrete has always for the
indolent mind — and who in this sense is not indolent — ^more
attractions than the abstract ; and not infrequently our
minds accomplish for themselves the further feat of giving
to the abstract a concrete form in the imagination. Thus in
the case in point we assign to the name Pemphigus a defini-
tion and give to the group of symptoms which it comprises
a» sort of individuality, and but too often rest content with
our attainment. All that we attempt thereafter is to keep in
memory our definition and our name, and to arrange future
facts accordingly. Just the same process takes place in
reference to such names as ** Dermatitis Herpetiformis," and
even ** Herpes " itself. When once, however, names have been
aJlowed to assume this kind of significance they become a
bar to progress, however useful they may be in every-day
intercourse with others. Whilst, therefore, it is a matter of
necessity that for the sake of conversation and debate a man
should make himself familiar with the meanings of the
names in common use, I feel sure that he will find it
best in the recesses of his own mind to discard names as
much as possible and to think only of relationships and
<;auses.

My main object in narrating the cases which have been
given as illustrations of the various forms of what is known
as " Pemphigus ** has been to throw light, if possible, upon
their real causes and their relations to other maladies. I am
sanguine that this has to some extent been accomplished.
It has been proved, I think, that the pemphigus process
depends in part and in certain cases upon congenital
pecuUarity in the structure of the skin. It is only by appeal
to such peculiarity that we can explain the occurrence in
several members of the same family of children, of a pre-
cisely similar tendency to form bullae on any slight irrita-
tion or injury. The peculiarity appears to involve a defective
adhesion of the epidermis, and to permit of its easy
elevation by fluid secretion under it. It is an element
not alone in those cases of pemphigus which occur in
childhood, but is met with also in adults in whom the type

28 PEMPHIGUS AND ITS VAEIANTS.

of pemphigus does not differ materially from that long known
as ** diutinus." It has long been known and mentioned
as occurring in the latter, although it has, I believe, only
recently received the distinctive and convenient name of
" epidermatolysis."

Another point which has, I think, been established, and
which is an important advance, is that in some cases there
is a definite relationship of the pemphigus process to that
of herpes. This assertion implies that there is a large
neurotic element, and that the vesications are produced in
direct connection with the nervous system. These are the
cases in which frequent and sudden relapses occur, in which
vesications on the lips and in the mouth may have preceded
perhaps by years the appearance of any dermatitis, and in
which there is burning pain in the part before the bullae
form. Some of these cases never go beyond the stage of
affection of the mouth, and in some the dermatitis is not
bullous at all but may even be papillary. The alliance is
perhaps more close with dermatitis herpetiformis than with
any other of the more strictly herpetiform maladies, for, so
far as I am aware, there is never any definite deviation
from bilateral symmetry, and but rarely any tendency to
spontaneous cure. The case narrated at page 128, in which
a man had suffered for several years from recurring herpes,
in the mouth, and subsequently developed pemphigus-
vegetans, and finally died of the bullous form, is an example
of this type of the disease. So also is the case of Miss-

L given at page 333, Vol. VIII., in which attacks

of sore mouth preceded by nearly a year the eruption
on the skin. In this instance the dermatitis was always
a bullous pemphigus, and never attended by vegetations.
It was also always under the temporary control of
arsenic.

Whilst suggesting that these two essential features of
causation — congenital peculiarity in structure and herpetic
tendency — should be kept clearly in mind in our discussions
as to the nature of pemphigus and our attempts to group
our cases, I by no means wish to imply that they suffice to
separate them. Many cases appear to partake of both

PLATE XCVIL

PEMPHIGUS IN SECONDAKY SYPHILIS.

This Plate represents an eruption of acute pemphigus, which
occurred as the exanthem in the secondary stage of syphilis. The
bullsB were exceedingly well characterised and very large. The
eruption covered the arms and legs with bullsB, but on the trunk
it caused only erythematous patches. It was said to have exactly
resembled the chicken-pox at the time of its first appearance. The
chancre was still present, as also some very hard glands in the
groins, and ulceration of the tonsils. The early treatment had been
neglected. The treatment proved very difficult. Iodide of potassium
made the eruption worse, and mercury did not cure it. When, at
length, arsenic was given simultaneously with mercury, but not in
combination, then very satisfactory results were obtained. The
patient was, however, still, at the end of two years, not perfectly
well. He was in good health, but the eruption tended to return
unless the two specifics were continued. The case is recorded in
detail in 'Archives,' vol. iv., page 195.

Postscript. — Since the publication of the case in * Archives,' the
patient has remained under treatment, and a perfect recovery has
resulted. He has attended several times at my Clinical Demon-
strations.

This case and some similar ones which I have published prove,
I think, that the special type which the secondary eruption of
syphilis assumes depends upon the pre-existing peculiarities of the
individual. Hence the necessity for modifications of treatment.

> • r •

•i ,

r" •

V ' ,;•

r

CLINICAL GROUPS OF PEMPHIGUS. 29

tlities, and others do not in any appreciable extent dis-
y either the one or the other.

[t may be freely conceded that the two features to
lich I have adverted by no means cover the whole ground,
lere still remains much that is unexplained, and for the
osent perhaps inexplicable, as regards the real nature of
•mphigus and its exciting causes. To the two established
cts we may, however, add a third, perhaps yet more im-
)rtant, because of more general application. It includes
:)th the others, and is this, that in seeking to explain
omphigus we must look to the idiosyncrasies of the in-
ividual who is its subject rather than to the influences to
/hich he has recently been exposed. Some persons are
)om liable to pemphigoid dermatitis in any one of its
arious forms, and others are less so, or not at all. In
lOme of those thus congenitally predisposed the poison of
sjrphilis may act as the determining or exciting cause,* and
in others other influences which as yet we cannot recognise
may take the same role. In all instances, however, we shall
probably be safe in supposing a pre-existing proclivity.

For clinical convenience we may perhaps suitably classify
our cases of Pemphigus, or better of Pemphigoid Dermatitis,
under the following groups : —

Group I. — Those occurring in connection with acquired
syphilis. In these the whole surface is a£fected, the eruption
is severe and the general health fails, a rapidly fatal course
being threatened. Arsenic, and not mercury, is necessary.

Group II. — The pemphigus of congenital syphilis. The
eruption affects almost exclusively the extremities. It
appears within a few days of birth, and is usually followed
by death.

Group III. — The pemphigus of infants not the subjects
of syphilitic taint. This, as in the specific form, is usually
more or less confined to the extremities; it begins im-
mediately after birth. It is attended by severe failures of
health, but does not lead to death, and may last into adult

• See two most important cases given in Archives, Vol. V., in which
severe general pemphigus occurred as the secondary eruption in S3rphilis, and
was controlled not by mercury but by arsenic.

30 PEMPHIGUS AND ITS VAEIANTS.

life. Arsenic exercises a beneficial influence, but does not
cure. It may affect several members of the same family ;
not usually attended by sore mouth.

Gboup IV. — Cases of severe pemphigus beginning in
young persons. These may be divided into two sub-groups
— those which run a rapidly fatal course uncontrolled by
arsenic, and those which, under arsenic, are either wholly
cured or lapse iiito a chronic form. In these the eruption
comes out over the whole body.

Group V.— ^Cases resembling the preceding, but with the
peculiarity of a sore mouth preceding the pemphigus. These
are at times acute and rapidly fatal ; see Dr. Penrose's case,.
Archives, Vol. VIII. p. 127.

Group VI. — Cases in which a sore mouth follows soon
after the beginning of pemphigoid dermatitis. A good
example of this is given at page 135, Vol. III. (At whatever
stage sore mouth occurs it is a complication of bad omen,
and implies that arsenic alone will not cure.)

Group VII. — Cases of pemphigus beginning in healthy
adults. These are almost invariably amenable to arsenic,
though sometimes with marked tendency to relapse, or only
an imperfect cure.

Group VIII. — Cases in which the pemphigoid dermatitis
has been preceded by attacks of herpetic inflammation in
the mouth. These are far less amenable to arsenic, and
more so to opium than the preceding.

Group IX. — Cases in which the pemphigoid eruption
rapidly passes into a generalised dermatitis without bullaB,
and attended by exfoliation. These are for the most part
incurable. They are very rare. Pemphigus foliaceus : see
portrait in New Sydenham Society's Atlas and one in
Hebra's Atlas, representing precisely similar conditions.

Group X. — Cases in which a tendency to the production
of papillary excrescences is shown (*' Neumann's malady,"
or ** Pemphigus vegetans"). In many cases the tendency
to vegetations is only temporary, and in the rest of its course
the disease conforms to Group VII. Opium is the remedy.

Group XI. — Cases in which pemphigoid bullae remain
for a long time restricted to one region.

PLATE CLVI.

PEMPHIGUS VEGETANS.

Tms portrait shows the condition of the skin in Mr. S 's

case three or four weeks after his arrival in London. The growth
of vegetations had already been much checked by local treatment.
The portrait was taken under difficulties, as the patient could not
bear long exposure. It may suffice, however, to indicate the
arrangement of morbid changes and the bulbous character of the
greater part of the eruption. Attention is asked to the fact that
the comers of the mouth are ulcerated. The vegetations occurred,
as usual, with greatest luxuriance in the armpits and groins, but
they had been present in an earlier stage over other parts, more
particularly on the chest, neck, and arms.

The narrative of the case begins on page 129 of * Archives,*
vol. viii.

^' i'. • . '•. 'a '.. ..1

I.- .■■■■ n^ U%(: J rL':^."

• '^^ V ...
I -u I"

J. .it',-'-'! .!■

. I ". . r
. I'' >^^' \ '■

)■>■

RECENT ADVANCE OF KNOWLEDGE. 31

In proposing these Groups, it is clearly to be understood
that they are constructed with a full knowledge that they
in no sense constitute species. They indicate only variant
types of the same malady or of forms of dermatitis which
occur in association with causes more or less closely alHed
in all. It must be expected, therefore, that individual cases
will be found to present in different stages the features of
more than one group.

POSTSCEIPT.

Although for the most part I restrict myself in the pages
of Archives to the record of my personal experience, and
do not attempt any general purview of the literature of the
subjects on which I write, yet I cannot resist the expression
of pleasure at the rapidity with which our knowledge of
Congenital Pemphigus has recently increased. With the
exception of one or two examples of that form, — concerning
which, perhaps, some doubt might have been felt, — we knew,
until a few years ago, nothing as to infantile pemphigus
beyond the fact that it might occur in congenital syphilis.
Although Dr. Wickham Legge and Dr. Payne had both
previously recorded cases, it was a paper by M. Hallopeau
published no longer ago than 1890 which first drew
definite attention to the malady. The writings of
Besnier, Brocq, Beatty, Goldschiedes, Koebner, Valentin,
Galloway, Augagneur, and others have contributed to our
knowledge of the subject. We now know by the con-
current testimony of these observers that a very peculiar
form of pemphigus of the extremities may occur as a family
disease and may show itself in the first weeks of infancy. It
may affect only one or several members of the same family,,
and may be inherited from a parent (see Vol. VIII., p. 317).
Although usually differing much from the more common
forms of pemphigus, yet it may undoubtedly merge into it ;
that is, the eruption may spread to the trunk and persist
for years (see Vol. VIII., p. 321). It does not appear, how-
ever, that it is ever attended by the severe constitutional

32 PEMPHIGUS AND ITS VABIANTS.

disturbance and danger to life which acute spontaneous
pemphigus involves.

The observation of this group of cases is a most valuable
addition to our clinical knowledge. By it a broad ray of
light is thrown over the whole subject, and we are made to
recognise a congenital peculiarity in the structure of the
skin as the predisposing cause to all forms of pemphigus. It
is true that this had been suspected before, but it ig now a
matter almost of demonstration.*

* Koebner of Berlin had in 1886 described " epidermatolysis bullosa heredi-
taria," and in 1882 Dr. Wickham Legge had published two cases of the same
which he had observed in the same family. Dr. Payne, also, in the same year
gave an excellent account of a case. It is unfortunate that a new name was
coined, and still more so that it was subsequently superseded by that of
" traumatic bullous dermatitis." These names have led to the endeavour to
separate such cases from '* pemphigus," instead of recognising them as being
really forms of it. The lesions in these cases are certainly not always trau-
matic, and epidermatolysis is a factor in all pemphigus. So 'recently as 1893
Dr. Payne wrote : "It is alleged by some and denied by others that there is
A second form of pemphigus neonatorum which is not syphilitic. I have
never seen such a case, and am disposed to think that it is extremely rare, if
not entirely unknown in this country" (Lancet, August, 1893, p. 426). Yet
in spite of this statement, to Dr. Payne himself belongs the honour of having
observed and published one of the first cases (see St. Thomas's Hospital
Beports, vol. xii. p. 187, 1882).

ON THE SO-CALLED EETINAL EPILEPSY.

Amongst the many items of original observation in disease
for which we are indebted to the clinical genius of Dr.
Hughlings Jackson is the description of what he once named
" Retinal Epilepsy.'' The name was, I believe, subsequently
abandoned as not being strictly appropriate, but no one
has found a better, and meanwhile the conditions so
designated remain a reality. They consist in the sudden, but
quite temporary, loss of function on the part of the retina or
some portion of it. It is possible that in some cases a
deeper region of the nervous apparatus of vision is affected.
At any rate the patient becomes suddenly either in part or
wholly blind, and after a longer or shorter time the sight
returns again. Thus proof is afforded that the suspension
of function is not due to structural changes, but rather to
some alteration either in the nervous state or the vascular
supply which may completely pass away. Sometimes both
eyes are affected, and sometimes only one or a part only of
one. As the phenomena are purely subjective, we have only
for our guidance the patient's description of them, and as
they are often of very short duration the opportunities for
observation are often not the most favourable. Many
circiunstances suggest that they are of reflex origin, for
they often occur during attacks of liver derangement, and
are followed by other indications of disturbed health. They
are very prone to recurrence, and often after more or less
regular intervals. Thus in many features they conform to
what we know under the name of Epilepsy, and may
perhaps still be placed conveniently not far distant from
that group of nervous phenomena.

I purpose in the present paper to describe some recent
examples of the eye symptoms referred to, but before doing

VOL. IX. 3

34 ON THE SO-CALLED EETINAL EPILEPSY.

SO may perhaps suitably give a resumS of such cases as I
have previously recorded.

At page 169 of the first volume of ** Clinical Illustrations"

will be found the case of a man named S , aged 45.

This man had suffered much from his liver and sick head-
aches, and had large patches of xanthelasma on his eyelids.
He had for long been liable to attacks of temporary blind-
ness, lasting only a minute or two and followed by sick
headache. Sometimes both eyes were involved and he was
for a time in almost absolute darkness, but more usually it
was only one, and the right more often than the left. After
this liability had been going on for several years (the eyes
always recovering sight after a short time), he one day while
at work found a cloud rapidly coming over the right eye,
and in a minute or two it was quite blind. After this a
headache as usual followed, and he had great sense of
pressure on the top of the head. From this attack the eye
never recovered. I made an ophthalmoscopic examination
a fortnight after its occurrence, and could find no difference
between the discs of the two eyes. Five .years later,
however — ^the eye being still blind and the other retaining
perfect sight — the disc of the right was quite white and
atrophic. His general health was much as formerly.

An almost exact parallel to the above is afforded by the

case of Miss E , which I published in Aechives, Vol.

Vin., p. 376. This lady was very liable to sick headaches
and disturbance of sight. After one of these attacks at
the age of 26 she lost the sight of the left eye. This

occurred twenty-six years ago. I have seen Miss E

quite recently. Under continued treatment by nux vomica,
&c., she has lost all liability to sick headache. Her left eye
remains blind, its disc being now quite white. The other
eye is perfect. She is of dark complexion and comes of a
bilious family. She is now aged 52.

In the same volume of ** Illustrations,'* &c., at page 171,
is the narrative of the case of Miss A- , aged 46, who was

IN ASSOCIATION WITH XANTHELASMA. 35

the subject of xanthelasma with serous cysts. She had not
menstruated since the age of 25. She did not consider
herself "bilious." For many years she had been liable
to attacks of numbness during which her hands would be-
come useless on account of inability to feel with them. The
numbness would last usually about an hour and then give
place to a short sick headache, to be followed in its turn by
abnormal' hunger. During one of these attacks of numb-
ness she had experienced considerable loss of sight, and her
speech had become so thick that she had difficulty in making
herself understood. The attack lasted half an hour, and
was followed by a bad headache. Her attacks of numbness
would usually occur two or three times a year, but she had,
I believe, loss of sight on only one occasion. She was quite
bald on the top of her head.

In a case of severe and protracted Jaundice recorded by
Eichter, and which I have quoted in Aechives, Vol. III.,
p. 6, it was stated that the man had been liable to attacks
of transitory blindness with vertigo.

At page 151 of the " Illustrations," I have mentioned the
case of a woman whom I saw in Guy's Hospital on the invi-
tation of my late friend. Dr. Hilton Fagge. She was the
subject of xanthelasma with jaundice. This woman, a cook,
assured me that on one occasion, after her day's work and
when dressing for the evening, she had become quite blind.
She said that she was in absolute darkness and had to grope
her way downstairs by the aid of her hands. When she had
got into the kitchen her sight began to return, and after a
short time was as good as ever. A severe headache followed.
This was one of the most marked and complete cases that
I have seen, for the woman's description was very clear.
She was not jaundiced at the time, but became so afterwards.
I believe that she had had many minor attacks of failure of
sight. •

At page 75 of Akchives, Vol. III., is a detailed description .

by the patient herself of very peculiar attacks of defective m

36 ON THE SO-CALLED BETINAL EPILEPSY.

sight to which she was liable. In addition to dimness, she
had what she described as "kaleidoscopic lights in the eyes."
On one occasion she had been much alarmed by the
occurrence of total blindness in the left eye, but it lasted
only a few minutes. She was the subject of chronic
retino-choroidal disease, and had probably suffered from
syphilis. She could, however, still manage to read the
smallest type.

At page 377 of Vol. VIII. I have mentioned the case of a
lady of 30, in whom in connection apparently with liver
disturbance, prolonged attacks of dimness of vision were
liable to occur. She did not become by any means blind,
and probably suspension of the power of accommodation
was the main element in her state. There was, however,
something much more than what hypermetropics are liable
to, for the attacks were sudden, and would last several hours,
to be followed by headache.

In my experience the cases of ** Betinal Epilepsy '* group
themselves into two classes. (1) Those which occur in
association with definite liver disturbance, and which may
happen to persons whose eyes are apparently quite healthy ;
and (2) those which occur to patients with eyes damaged by
previous retino-choroiditis. Of the latter I have just men-
tioned an example, and shall have to record several others-
Most of those which I have seen have been in the subjects
of inherited syphilis who had suffered many years before
from keratitis and retinitis, and in whom the disc was pale
and the central vessels small. It may be plausibly suspected
that in these patients ischsemia of the retina is the cause of
the loss of function, for the attacks occur to those in whom
the structure is very poorly supplied with blood. At one
time I was disposed to regard this as a sufficient explanation,
but some recent facts have raised the suspicion that the
attacks do really partake somewhat of the characters of the
petit mal. They occur to patients in whom degenerative
changes in other parts of the nervous system are in progress,
and who sometimes are liable to other phenomena more or

DIAGNOSIS FROM ISCHiEMIA. 37

less allied to those of epilepsy.* I freely grant that I have
never yet observed a case in which they occurred in associa-
tion with ordinary epilepsy. It is not forme to attempt any
definition of the term epilepsy, or to say how widely it may
be used. Some idea of reflex causation of sudden liberation
of nerve force and of temporary suspension of function is, I
suppose, essential. It was, I suspect, the belief that the
failures of sight referred to were due simply to bloodlessness
of the retina, and were unattended by either reflex causation
or introductory ischsemia, which led Dr. Hughlings Jackson
to abandon his name. Nor is there any doubt that the name
had been applied by others to cases of this kind which had
probably nothing in common with epilepsy.

Importance of differential diagnosis between the Betitial
Ischcemia of Optic Neuritis and true ** Betinal Epilepsy,''

Cases of **Eetinal Epilepsy" must be kept in a wholly
separate group from those of the temporary blindness to which
those who are suffering from optic neuritis are liable. In

* ** No doubt some of the many nervous disorders that result from ureemic
poisoning are due to the noxious influence of the morbidly altered blood upon
the nervous tissue, while others are more probably explained by sudden
partial interruption of the blood-supply to certain parts of the nervous
system. This statement may be illustrated by a reference to the two forms
of impaired vision which are very frequently associated with advanced renal
degeneration. In one class of cases dimness of sight comes on more or less
gradually, affecting one or both eyes, and is permanent. This form of
impaired vision is found to be associated with peculiar structural changes in
the retina, results of the so-called albuminuric retinitis. In the other class of
cases the impairment of vision may be so sudden in its onset that, in a few
minutes or even seconds, there is complete blindness, which usually passes
away as suddenly as it came. These attacks of sudden and transient blind-
ness may recur again and again. That they are closely allied to epileptiform
attacks is shown by the fact that they are sometimes immediately followed by
general convulsions. The most probable explanation of this sudden transient
form of amaurosis is that which attributes it to sudden anaemia of the retina,
or of the central origin of the optic nerves, the result of arterial contraction,
excited by the morbid quality of the blood. It is, in fact, a form of circum-
scribed partial epilepsy, * epilepsy of the retina' as it is sometimes desig-
nated." — The Limileian Lectures on "The Muscular Arterioles: their
structure and function in health and in certain morbid states." Delivered
at the Royal College of Physicians of London by George Johnson, M.D.,
F.R.S. (British Medical Journal, May 12, 1877, p. 677.)

38 ON THE SO-CALLED RETINAL EPILEPSY.

these latter we have no difficulty in believing that inter-
rupted supply of blood is the cause of the loss of sight ; and
considering the state of the disc as to swelling, &c., the only
wonder is that sufficient blood finds its way on to allow of
any sight at all. We are here again indebted to Dr. Jackson
for the original observation — now universally accepted — that
the swollen disc of neuritis is often compatible with good sight.
That such conditions involve, however, great liabihty to its
suspension cannot be doubted. Many neuritis patients are
blind, and in many who are not so when the head is at rest
and in a position favourable to circulation, sight may be lost
by stooping or even by suddenly assuming the erect position.
The heart is at a great disadvantage and may easily find
it impossible to fill the retinal vessels. This is simply a
question of hydraulics, whereas in ** retinal epilepsy" the
hypothesis is that no mechanical causes for the attack are
present. In the neuritis cases both eyes are, I believe,
always aiSfected (that is provided both are involved), whereas
in the epileptic form it is often only one.

A good example of this form of temporary blindness with
optic neuritis is recorded in Vol. IV. of Archives, page 184.
In it the patient, a lady whose urine was loaded with
albumen, was liable to find her sight leave her if she stood
up suddenly or if she stooped. The ophthalmoscope showed
swollen discs, but none of the more usual changes of
albuminuria. Her attacks of bUndness, during which she
might be for some seconds in total darkness, were never
followed by headache or other sjmaptoms. My comment
at the time was, "No doubt the temporary failures of sight
are due to the inability of a weak heart to overcome the
local impediments to arterial circulation caused by the
neuritis."

I will now narrate the histories of some patients recently
under observation, and which have led me to write the
above remarks.

IN ASSOCIATION WITH INHERITED SYPHILIS. 39

** Retinal Epilepsy '* in a patient whose eyes had suffered
severely from Syphilitic Keratitis ^ dtc, — Unusual duration
of the attacks — History of other nervous phenomena.

Miss M is a lady whom I have known for many

years, and who has suffered with very unusual severity
from inherited syphilis. Her physiognomy is deformed by
the sinking and widening of her nose, and her general
growth has been arrested, ifier skin is opaque, pale, and
earthy. I should much doubt whether the sexual system
is well developed. She has had most severe inflammation
of her eyes; not keratitis only, but involving the whole
organ. Her left eye is lost, and diverges, there being
secondary cataract and vitreous opacities as well as choroido-
retinal atrophic changes. Her right eye has up to the
present time enabled her to read fairly well at times, but in
it also there are vitreous opacities and a greyish ill-defined
optic disc, with very small retinal arteries. The tension of
the globe is perhaps below normal.

The symptom which brought Miss M to me in

September of the present year was the very alarming
occurrence of periods during which she could not discern
even the largest objects. These had occurred ten or twelve
times during the last year, and were new to her. On more
than one occasion the attack had lasted a whole day.
During them she was not, she said, in darkness; on the
contrary, there was often too much light, '*as if a number
of lamps were lighted all around me and were dazzling
me." Sometimes, however, she was almost in the dark.
The attacks had usually been brought on by exposure to
strong light, or by fatigue or worry. The eyeball was,
she believed, usually a little red during the attack, and felt
tender. She is very much afraid of ophthalmoscopic ex-
amination, believing that it would bring on an attack. As
the attack passes off, which it usually does gradually after
lasting a few hours, she is again able to read. She never,
however, reads more than a quarter of an hour at a time,
as it tires her eyes. Severe neuralgia in the forehead has
often attended and followed the attacks.

40 ON THE SO-CALLED RETINAL EPILEPSY.

In looking back to my former notes of Miss M 's case.

I found the following, written, I believe (for it has no date),
three or four years ago.

** She describes an attack during which she was quite con-
scious, but could not move her limbs ; she thought she was
paralysed, and was much alarmed. She spoke to her friends,
was rubbed for some time, and recovered. Her hands were,
she says, cramped. She now seems quite well again, but
has much headache, and is easily tired. She describes a
distressing sensation in her tongue and abdomen. It be-
gins in the tongue and passes downwards, as ' if it
were on fire.' She has had violent sickness more than
once. Her' pupil acts, and there is fair knee-jump ; no
tabetic pains. Gnawing sensation in the bottom of stomach.,
and slowness in micturition."

The following are some additional particulars as to her
symptoms and present state.

Miss M says that she feels a sort of throbbing

in her eyes for a day or two before her attacks. Then
neuralgia attacks her forehead — not hemicrania, but across
her forehead. After this she loses her sight. She con-
siders herself perfectly well except for her eyes. Can see
-^Q%. She feels the cold very much, and has had chilblains.

What she terms '* loss of sight " involves being in a deep
fog so that she could not count fingers. If it is lamplight
she is in a yellow fog. More than two years ago she
found in her drawing that she could not see so well as
formerly. The eye had failed rather rapidly. She went

into the G-erman Hospital in 1896, imder Dr. J , and

had two months' mercurial treatment without result.

She is now 36, and her attack of keratitis was at the
age of 18. When she had recovered from it she could
see to do anything with E. until two years ago; read,
paint, draw, and sew. The eye then failed rather suddenly.
Her left eye oscillates. There is much thinning in the
ciliary region in the left eyeball and elongation of globe
from this region, the anterior chamber being very deep.
She has no perception of light with this eye. She had an
operation for her cataract at 21 (Mr. B ). She describes

' IN ASSOCIATION WITH INHEEITED SYPHILIS. 41

three needle operations, and says that it was done for appear-
ance sake only.

On October 14, 1897, I examined Miss M 's left eye

with the ophthalmoscope. The pupil had dilated well.
There were numerous small films in the vitreous, and a
single small opacity at posterior pole of lens. It was not,
however, difficult to see the fundus. The choroid was
everywhere thin and pale, and showed a few small well-
margined spots of absorption near the macula. Near the
periphery, on the outer side, was a very irregular area
covered with coaJ -black pigment. The disc itself was pale
and waxy-looking. Its margins were indistinct, appearing
to merge gradually into the surrounding parts. The central
vessels were very small and indistinct, the artery being
reduced to a mere thread.

Nervous phenomena in a subject of Inherited Syphilis,

The following description of a nervous attack was re-
ceived from a young man who was the subject of inherited
syphilis, and in whom extensive choroidal and retinal
changes were present. He had consulted me respecting
his eyes, and mentioned that he had had two of what
he called " seizures," attended by failure of sight. I did
not feel sure that there were any aggressive or degenerative
changes going on in his eyes. One eye had been for years
quite disabled.

In both eyes keratitis had occurred some years ago, and
in both the periphery of the fundus showed many small
patches of denudation with pigmented borders. Nearer
to the centre, however, there were many whitish, ill-defined
patches which might represent recent deposits. He did
not think that his sight was worse than it had been for two
years past. He had been treated before I saw him on
the diagnosis of acquired syphilis, but he assured me that
he had had intercourse only three times in his life, and had
never had any local disease. I found no indication of
acquired disease, and those of inherited were indisputable.
The day after the consultation he wrote me as follows :
** I left your house yesterday and came here. I in-

42 ON THE SO-CALLED EETINAL EPILEPSY.

tended to make my preparations for going home this
morning, but was taken very strange through the night,
sickness and trembling in every part of my body, which
lasted a good part of night ; and to-day I am like one
stupefied, and have not proper control of my legs, and cold
shivers passing through my limbs and body. This is the
third attack I have had like this. It appears like a form of
paralysis ; it starts from the forehead and around the heart,
and like as if I am passing out of the world.**

Although the attacks described occurred to a man in whom
syphilitic degenerative processes were present, yet we naust
not hastily assume that such were really the cause of them.
The patient was a young man at an age at which the
sexual system often exercises a great disturbing influence
on the health. He himself suspected this connection,
alleging that he was liable to frequent escape of semen.
It may have been the fact that the syphilis had damaged
his nervous centres, and rendered him liable to suffer more
than usual from sexual causes.

The same suggestion, although the patient was of the

opposite sex, holds good as to the case of Miss M ,

although I confess with less of plausibility. Both patients
may, however, have been under the influence of mastur-
bation or other causes of sexual irritability. It has been
seen that the chaj'acter of the attack, as described in the
patient's own words, was very similar in the two.

Hereditary Syphilis — History of severe Keratitis at the age
of fourteen — Liability to attacks of " Retinal Epilepsy '*
at the age of twenty,

Ellen D , set. 20. I had attended one of her brothers

who suffered severely from inherited syphilis. She had
been under Mr. Critchett's care six years ago for ** a dulness
over the eyes *' ; the ** dulness ** being visible to her mother.
The affection lasted, more or less, for probably two or three
years, and was, no doubt, an attack of syphilitic keratitis.
She now sees J. 1 with each eye easily. Ophthalmo-
scopic examination (after atropine) shows nothing ab-
normal. For about two years she has been liable to

IN ASSOCIATION WITH INHERITED SYPHILIS. 43

curious nervous attacks, during which she becomes quite
blind for about ten minutes. Generally the blindness is
the only symptom, but sometimes (two or three times) she
has been giddy, faint, and felt ** numb and cold, and
trembling,'* but she never actually fell, or became uncon-
scious. She would fall unless she rested against things.

I regret that my notes of this important case were taken
hurriedly, and in only a fragmentary manner. It will be
observed that temporary attacks of blindness occurred in
eyes which enjoyed almost perfect vision and showed no
changes.

Secondary changes in the Eye after Keratitis — Liability to

attacks of Epileptic Hemiopia,

The following note concerns a lady, now aged thirty-
three, whom I had attended at the age of seventeen for
exceedingly severe interstitial keratitis.

" She complains of being liable to attacks of dimness before
the left eye. They last a few minutes or half an hour. If
both eyes are open she has an uncomfortable feeling before
her right, and then on shutting the right finds that she
cannot see with the other. She describes an imperfect
hemiopia. She does not see distinctly on her left side.
The disc of L. is decidedly pale, and its vessels small. It
is seen through a certain amount of haze from opacities on
the lens. The other disc is seen brightly, and is of good
tint."

Pains in Boiies, d-c. — Doubtful diagnosis of Congenital
Syphilis — History of attacks of sudden and quite
temporary Deafness — Auditory Nerve Epilepsy.

Miss S , aged 26, came to me in May, 1887, on

account of pain in the right arm of over two years' duration,
and for which she had seen several medical men. There
were no physiognomal signs of syphilis. Her mother said that
she had been a delicate baby and had bad snufifies. At the
age of one year an abscess had formed in the thigh. At the
age of two, a swelling developed below the knee and the foot

44 ON THE SO;CALLED RETINAL EPILEPSY.

dragged. She had been treated also for thickening of the
bones of the legs. Two years before I saw her she had had
a bad illness, with pain in. the head. I dilated the pupils
with atropine, but found no choroiditis. Her mother said
that although she complained much of the pain she was
quite able to throw it aside. Her younger sister had
had inflammation of the eyes when a year old. There had
been several ihiscarriages between the two. This sister
had also suffered from neuralgia and a peculiar form of
deafness. It would come on very suddenly, and at times
she would become ** stone-deaf *' during a drive, and then
the hearing would return suddenly. One ear was worse
than the other. The father was gouty.

Comments. — ^Although in this case the diagnosis is not
fully established, I yet think it highly probable that both the
patients were really syphilitic. I am induced to record it on
account of the parallel which the attacks of temporary deaf-
ness afforjl to those of so-called ** epilepsy of the retina.'*

ON INFECTIVE DISEASES OF THE LYMPHATIC

GLANDS.

(Continued from Vol. VIII., p. 294.)

The starting-point for almost all forms of gland disease is
probably to be found on the surface either of skin or mucous
membranes. Scarcely ever is the gland affection really
primary. Yet in a large majority of the infective forms no
primary source of irritation is to be found. This is true
even of the more malignant forms. Two explanations may
probably be offered of this fact. First, that in almost all
the primary sources of irritation the condition is one only
of non-specific inflammatory action, which may pass away
and leave no trace, and next that it is not infrequent for
the glands to have received their infection at a long period
prior to the manifestation of disease in them. Both these
hypotheses are fully supported by facts. It is very common
to be told of a transitory sore throat as having preceded
gland disease which proves persistent and infective. It is
also very common to learn that a gland has been in a quiet
state of enlargement many years before any aggressive
development. Some change in the mode of growth — as
inexplicable as that which occurs when leucoma on the
tongue passes into epithelial cancer — takes place, and at
once that which was hitherto purely local and quite quiescent
becomes infective and generates a plasma which will produce
its like in all structures of a similar character to its own. If
the infection has started from the mouth, nose, or throat,
and the cervical glands have been first affected, it will spread
downwards on the neck, thence to thorax, taking the axilla
in its way ; from the thorax, through the abdomen in the

46 ON INFECTIVE DISEASES OF THE LYMPHATIC GLANDS.

chain of glands clinging to the great vessels, and so from
the pelvis out under Poupart's ligament to the glands in th.e
groin. The whole affair is one of infection in continuity of
structures ; and if the source of irritation have been on one of
the lower limbs or in the pelvis, the infection will travel in
the opposite direction, and the neck be the last to suffer.
According to the pre-existing proclivities of the individual
will be the precise histological character of the growth. If
the tuberculous tendency be strong, crude tubercle may restdt
and suppuration may follow, with the beneficial sequel of
arrest of the infectious process. If, on the other hand, the
scrofulous proclivity be but moderate, we may then have the
chronic inflammatory hypertrophy, without obvious tuber-
cular deposits and without the tendency to suppuration,
which characterises Hodgkin's disease or lymph-adenoma.
Although tubercle may not be demonstrable, no clinicist can
doubt that lymph-adenoma is essentially scrofulous. If the
patient's inherited proclivities be towards cancer rather than
tubercle, he may then become the subject of one of several
modifications of lympho-sarcoma. In some cases an enormous
local growth may develope with tendency to inflame and
suppurate, and there may be little evidence of spreading-
to more distant parts. In others, the original gland mass
may remain but slightly developed and quite free from
irritation, whilst other growths are being produced in distant
glands or even in cellular tissue and skin. The ability to
leave the glandular system and to grow in the subcutaneous
cellular tissue, or even in the skin itself, which is witnessed
in these cases and constitutes their characteristic feature,
although very rare in lymph-adenoma, is not wholly un-
known in it. I have in more than one instance seen growths
in regions where no glands exist. Probably in all these cases
the infection takes place in lymph channels instead of in
glands, and thus their peculiarity is not so great as at first
it appears.

The case with which I concluded the last part of my Eeport
was one in which inflamed toe-nails caused enlargement of
the glands in Scarpa's triangle, which was quickly followed
by infection of the pelvic glands and by a very malignant form

MALIGNANT DISEASE FOLLOWING INFLAMMATION. 4Y

of lymph-adenoma. The patient, previously a strong, healthy
man, was dead within twelve months of the first injuring
of his toe-nails. The case is of great value as giving support
to one of the chief propositions with which I set out, namely,,
that as regards their initial stages no distinction is to be drawn
between inflammatory and malignant affections ; or, in other
words, that the cancerous process is only a modification of
that of inflammation. The case which I have now to adduce is
perhaps a yet stronger fact in the same phalanx. In connection
with a diseased tooth, a gland became enlarged ; it remained
quiet but swollen for ten years, and then began to grow. A
rapid sequence of lymph-adenoina and secondary sarcoma
of the skin was the result.

Case XXVII. — Enlarged Gland in the Neck secondary to
inflammation in the mouth — Quiet condition for ten
years — Sudden development of infective qualities —
History of Cancer in family.

In the following remarkable case we have an inflamma-
tory process appearing to be the exciting cause of a malignant
one, as in the case already recorded at page 293, Vol. VIII.

The history was as follows. Ten years ago, in connection
with a decayed and painful tooth, a gland enlarged imder the
angle of the jaw on the right side of neck. It gave no trouble
for seven or eight years, when it began to increase in size
and to be more or less tender. From this other glands in
the same side of neck enlarged, and then some on the other
side and in both armpits.

His mother's sister had died with cancer in liver, aet. 66.
Before her death she was covered with secondary growths in
skin. No history of tuberculosis in family.

"When Mr. H was brought to me (by Dr. Douglas^

of Newbury), he presented some very pecuHar conditions.
The mass of glands in the right side of his neck was of con-
siderable size, and extended from the angle of the jaw to the
clavicle. There was a considerable fulness under the clavicle,
evidently due to glands concealed by the great pectoral
muscle, and from these a chain passed down into the armpit.

48 ON INFECTIVE DISEASES OF THE LYMPHATIC GLANDS.

On the opposite side the conditions were similar, but the
gland masses were not so large. On both there were some
enlarged veins coursing over the clavicular regions. The
aflfected glands were for the most part of almost stony haa-d-
ness, and they adhered to each other and to the surrounding
tissues, but there was no tendency to inflame or suppurate.
Over the larger glands were a few very small, hard, movable
lumps, not bigger than currants. The most curious feature
was, however, the condition of the skin. It did not adhere to
the glands, but presented a considerable area of isolated little
patches of infiltration. These were quite movable with the
skin — indeed, almost superficial in it — and they were attended
by a slight blush of congestion. They were exactly like what
we often see when the skin is affected at a little distance from
a scirrhus of the breast. One of these patches, flattened
and thin, occurred just over the upper part of the sternum.
It would not have been noticed by the eye, but was distinctly
perceptible to the finger. I had no doubt that these skin
patches were due to secondary infection from the glands.
They showed a tendency, though as yet on a small scale, to
the production of the en cuirasse condition.

Nothing definite could be proved as to the presence of
gland disease in the chest. The patient had a certain amount
of difiiculty of breathing in exertion, and the breath sounds
were very feeble on the right side. Judging from the con-
ditions elsewhere, it was exceedingly probable that the
mediastinal glands were involved. There was as yet no
afifection of the inguinal glands.

It will be observed that the secondary infiltration of the
skin occurred only in proximity to the affected glands.
There was no tendency to generalised production of skin
cancer.

The important fact that one of the patient's aunts had died
with her skin covered with nodules of cancer might very
nearly have escaped record. The patient himself did not
know of it, and, as is not unusual, strongly denied that
any relative of his had ever suffered from cancer ; his
surgeon, however, was better acquainted with the family
history.

MALIGNANT LYMPH-ADENOMA. 49

Case XXVIII. ^Fery large Lympk-adenomatous Tummirs
rapidly developed in an elderly man — No hereditary

history.

Amongst the patients who attended my Demonstration on
November 24, 1896, was a man aged 66, who had been sent
by Dr. Stocker, of Forest Gate, with large glandular masses
in his neck. On the right side there were two chief masses,

each made up of distinct glands which had adhered together.
The lower mass completely concealed the clavicle. The skin
over them did not adhere, but it was somewhat reddened.
The congestion of the skin, attended by slight thickening,
extended in a large and definitely bounded area upon the
chest and over the upper parts of Bteruum. There were
enlarged glands in the right axilla and also in the left side of
the neck. In both positione they were non-adherent. The

VOL. IX. 4

60 ON INFECTIVE DISEASES OF THE LYMPHATIC GLANDS.

patient, a very intelligent man, was very weak and ill, but
had no enlargement of the spleen and no indications of
leucocythemia. He said that he knew of no history of
either tubercle or cancer in his relatives. He thought that
he had first observed the enlarged glands on the right side
about a year ago, and those on the left soon afterwards.
They were increasing rapidly, and with some pain. I could
see no indications of primary disease in the mouth, nose, or
throat. He had formerly suffered from nose-bleeding, and
had had an attack of hemiplegia. The accompanying wood-
cut illustrates this case.

The large size and rapid growth of the gland tumours in
this case induced a strong suspicion that they must be of a
malignant nature, and secondary to some central growth in
the nasal passages or sphenoid cells. There was, however,
no evidence of the existence of such, and the fact that the
axillary glands were also implicated showed that the malady
was conforming to the type of acute lymph-adenoma. I
wish to ask special attention to the congestion and slight
infiltration of the adjacent skin, which was exactly like whq^t
is so often seen in cancer of the breast, and is introductory to
what is known as scirrhus en cuirasse. The same condition,
but in a yet more definite stage, was present in the preceding
case.

Case XXIX. — Lymph-adenoma Tumour in the Neck — Ex-
cision — Subsequent development of sarcomatous growths
in the subcutaneous cellular tissue of various parts,

I have recorded at page 208, Vol. VIII., the case of a
medical man past middle age in whom, secondary to a gland
tumour in the neck, a great number of growths were pro-
duced in the subcutaneous cellular tissue. Death occurred
about three years after the beginning of the illness.

There is at present in the Cleveland Street Sick Asylum a
man whose case is almost an exact counterpart of his.
Through the courtesy of Mr. Hopkins, the medical super-
intendent, I have several times presented this patient to my
clinical class. He is about fifty years of age. His first
ailment was a gland mass in the right side of his neck.

MALIGNANT LYMPH- ADENOMA. 51

This attained a considerable size, and presented, as he
describes, a congeries of firm but loose glands when it
was excised at Charing Cross Hospital. His neck shows
a very long scar left by the operation, which must have
been an extensive one. This was now three years ago.
My friend Dr. Abercrombie, physician to Charing Cross,
has kindly taken much trouble in the endeavour to find for
me the description of the tumour and its microscopic ex-
amination, but without success. The wound healed well,
and there has been no extensive recurrence in the neck.
All that is now present are a few loose glands as big as grapes
under the scar. They show no tendency to grow. There
are a few small, hard glands in the other side of the neck,
and some in other positions, but none of large size. In the
subcutaneous cellular tissues, however, all over the trunk,
hard, isolated growths have occurred, and there are some
also in the abdomen. Very slowly the man's strength has
failed, and he is now confined to his bed. When I last saw
him, in the early part of December, he had drooping of one
eyelid, an indication not improbably of some growth implica-
ting the third nerve. There can be little doubt that he is
the subject of generalised sarcoma, but it began in glands.

(To be concluded,)

ON CEETAIN FOEMS OF PSOEIASIS-ECZEMA
CHIEFLY AFFECTING THE HANDS AND FEET.

Severe crippling of the Hands from Psoriasis-Eczema —
An acute attack of General Dermatitis — Partial
recovery — Death from Cancer of CEsophagus after
having taken much Arsenic,

I saw at Bamet, with my friend Dr. Thyne, an old gentle-
man named C , who had been for many years a sufferer

from an almost universal form of dermatitis. He was 70
years of age, and had quite recently become the subject of a
stricture of the oesophagus which was probably malignant.
I was told that I had myself seen him for his skin disease
many years ago, and that it had then been called " psoriasis."
It was believed that he had in former years taken a good
deal of arsenic. He said that he had never been quite free
from the skin affection since it had first attacked him ; but
it had varied a good deal at different times. He had been
liable to what he described as severe attacks of it, during
which his hands had become especially severely affected.
Dr. Thyne told me that during one of these attacks, about
two years ago, the whole surface had been affected, and that
he had been at a loss whether to call it ** diffuse eczema " or
"pityriasis rubra." The term eczema seemed justified by
the fact that there was moist discharge which stiffened
his bed-linen. When the more severe attacks subsided
there was always very profuse desquamation, so that his
bed every morning would be full of scales. During the

attack to which Dr. Thyne referred, Mr. C had been

so ill that it was feared he would die. I found Mr. C ,

at the time of my visit, confined to his bed by debility
and much emaciated. He had retired from business fifteen

HANDS CRIPPLED BY PSORIASIS. 53

years before on account of the state of his skin and especi-
ally of the disablement of his hands. During the greater
part of that time he had been unable to use his hands
for any purpose. They had been constantly affected by a
diflfuse exfoliating dermatitis, under which the fingers had
wasted and become much distorted. The digits were as thin
as they could possibly be — ^mere skin and bone, and the skin
atrophied and covered with dry flakes of peeling epidermis.
The digits were bent backwards at the metacarpo-phalangeal
joints, and forwards at all the others, giving them a claw-lik$
appearance. The nails were somewhat thickened and rugged,
but there was no large accumulation of epidermis imder
them.

Mr. C *s face, at the time I saw him, was scarcely

affected, and he was florid and of a thin transparent skin.
He retained his hair, which was white. So far as anything
was shown in his countenance he might have been supposed
to be a healthy old man. He told me, however, that his
face had often suffered with the rest of his skin, and I found
a good deal of scaly accumulation over the whole of his scalp
at the roots of his hair. He had a clean, red, and somewhat
glazy tongue. Over the whole of his body and lower ex-
tremities the skin was atrophied, very dry, and covered with
peeling flakes, a condition suggestive of diffuse psoriasis.

My visit to Mr. C at his own house was on March 2,

1893. On returning home I was fortunate enough to be able
to find my original notes of his case, Sept. 23, 1876. I
had then diagnosed his disease as ''a pecuhar form of
psoriasis,'* and had written against my notes ** an important
case." The following is almost a verbatim transcript of my
notes : —

" Mr. C , aged 53, was sent to me by Mr. Crowfoot of

Beccles. He has recently been for some time under Mr.
Naylor's treatment, and has just returned from a long stay at
Harrogate without any benefit. He is in excellent health,
and tells me that he never needed a surgeon until the last
two years. In boyhood he had no skin disease whatever, and
his present affection began only two years ago. It com-
menced in the palms of his hands. He has taken much

64 ON CERTAIN FORMS OP PSORIASIS-ECZEMA.

arsenic, and it has not disagreed in any way. He is covered
with scaly, peeling inflamed patches, which are located with
accurate symmetry. Both his hands are very severely
affected. The patches on them are abruptly margined.
There is considerable contraction in the skin of the palras.
The eruption occurs both on his elbows and legs ; but there
are no spots on the fronts of his knees. On the legs the
patches are large, ill-margined, all of them eczematous, but
never actually moist. His trunk, with the exception of tlie
buttocks, is exempt. His nails are severely affected, being
rough and thickened. Their disease appears to begin at the
lunula and not, as in true psoriasis, at their free edges ;
indeed, some of the nails have fallen and grown again. On
his hands cracks are liable to occur.*'

Although Mr. C believed that he had been taking

arsenic under Mr. Nailor for two years, I could yet see
nothing more hopeful for him than to prescribe it in a fresh
combination. I accordingly ordered Pearson's Solution in
m. xii doses. A month later I saw him again. He was then
worse, his fingers more contracted and talon-like, red, tender,
tense, and covered with scales. His hands were quite useless,
and he was in a most distressing condition ; * the backs of
his fingers solid, but not the backs of the hands. He told
me that in boyhood he had a dry skin, but that of late he had
perspired profusely. He believed that his mother, an old
woman of 80, had two or three dry patches on her skin ; and
one of his sons had once had a few patches. The condition
of his feet was similar to that of his hands, but they were
much less severely affected.

It will be seen that this case belongs to the group in which
eczema-psoriasis begins on the hands, and continues through-
out to affect them with excessive severity. Of this I have
not seen many examples; but a few very definite ones.

Miss C 's case is probably one of the same group, and

another is Mrs. , who was temporarily cured by opium

(see Clinical Society Transactions and Atlas Plate XXII.).
I have also preserved a portrait in the collection of the College

* I have written against my description of his hands, " I have never seen
hands so bad."

CONGENITAL ICHTHYOSIS OP HANDS AND FEET. 55

Of Surgeons, which shows a very severe and disabling form
of psoriasis of the hands. Most of these cases were hable to
very severe exacerbations, and in several attacks of universal
dermatitis occurred much resembUng pityriasis rubra. These
attacks equally merit the name of " diflfase eczema/' They
differ in no respect from those seen in the workhouse
epidemics. It does not seem very probable that the con-
traction and crippling of the hands was in any way due to
arsenic, but this is a possibility which must at any rate be
kept in mind. Not long after my visit the patient died, his
death being caused by the malignant stricture of his oeso-
phagus. We have here another instance of cancer in a
patient who had taken much arsenic.

•

Congenital Ichthyosis limited to the Palms and Soles occur-
ring in many members of the same family in several
generations.

On Oct. 31, 1877, Mr. Tay showed me at the hospital an
exceedingly interesting series of cases of hereditary ichthyosis
of the hands and feet. The mother, a woman of near 40 and
in excellent health, was herself the subject of it, and she
brought her infant and two boys, all of whom had exactly
the same conditions. In all of them the whole palm and the
palmar aspects of all the fingers were affected. The condi-
tion was uniform, not in patches, and the epidermis was
accumulated in thick, rough layers of a yellowish colour,
which were crossed by the natural creases, the latter being
much deepened. The parts were not sore, and there were no
fissures, but the thickness of the crusts interfered with
pliancy of the hands, and the mother said that in herself it
quite prevented doing needlework. The condition ceased
abruptly where the palm joins in the wrists. The backs of
the hands were free, but on the fingers over the last two
phalanges and about the nail roots there were thin scales.
The hands of all four patients were exactly aUke, and we
were told that the feet were, so also. In all it had been
present at birth, and no alteration had been observed subse-
quently. In none was there any skin disease of other parts,

I

66 ON CEBTAIN FORMS OF PSORIASIS-ECZEMA.

and in none was there the slightest tendency to general
ichthyosis.

The condition was known to have occurred in four previous
generations, and in several families three or four individuals
had been affected.

In the facts as regards inheritance and in the circumstance
that it affected several members of a family and was present
at birth, this malady fits with what we know of ichthyosis
and differs from what is usual in psoriasis. There can be
little doubt that its real affinities are with ichthyosis. Yet the
entire exemption of all the rest of the skin is remarkable.
There was no evidence that ichthyosis had ever occurred in
relatives.

Case of Psoriasis {Qy. Ichthyosis) limited to the Palms and

Soles in a boy,

I brought before my class at the London Hospital, at the
same time that this group of cases attended, a boy who was
then in the hospital on account of another disease, but
whose palms and soles were in almost the same condition.
He was about nine years old, and asserted that the condition
had been developed only recently. This was perhaps doubt-
ful. In him the condition was limited to the palms and
soles, with the exception that the tip of each elbow showed
an ill-defined scaly patch. These patches on the elbows were
not exactly like those of psoriasis, because there was no
thickening and no abrupt borders, only a sUght desquama-
tion. Still, their position was probably sufficient to denote
an alliance with psoriasis.

In some minor features the conditions differed from those
present in the cases just described. Thus on the backs of
the hands and fingers there were separate scaly patches over
all the knuckles and over all the phalangeal joints. The
skin over the phalangeal bones and that over the backs of
the hands was quite free. These patches were like those
on the elbows, without thickening or congestion, being
simply scaly. In the palms there was much less of epidermic
accumulation than in the other cases, but just as in them the
entire palmar aspect from finger-tips to beginning of wrist

ECZEMA OF PALMS AND SOLES. 57

was uniformly involved, and there was no tendency to cracks
or fissures. He was in fair health, and there was no history
of importance.

A reason for calling this psoriasis rather than ichthyosis iis
that it was (as is asserted) not present at birth. Another is
the existence of the elbow patches. Yet the close similarity
in the conditions to those present in the congenital cases is
most remarkable.

Case of severe dry Eczema of Palms and Soles only after general
Eczema in childhood — Influence of local causes.

A robust sailor, aged 24, who came to the Skin Hospital in
October, 1875, presented an example of severe Ary eczema of
the palms and soles. The entire palms and the palmar
aspect of all the fingers were dry, hard, red, and fissured.
In front of some of the finger joints the skin was raised and
so hardened as to prevent complete extension of the fingers.
There was no tendency to the formation of patches, and the
peeling was in irregular flakes. On the soles the same con-
ditions were present, but much less severely. The dorsal
surfaces were not affected, nor did the nails suffer.

The question arose as to whether the condition should be
regarded as a dry eczema or as xerodermia. The man said
that in boyhood his skin had been dry and rough all over,
but this state had now wholly passed away, and his skin was
quite supple in all parts excepting the palms and soles.

In favour of its alliance with eczema were the facts that
he had been told by his mother that in infancy his head was
broken out very badly for a long time and that he had scabs
over him, and that he is still at times liable to an eruption
on his cheeks which is ** watery.*'

He suffers very much from his hands when at sea, in con-
sequence of large, deep cracks forming. This is especially
the case when exposed to wet and cold. His feet also
become worse if he goes about in the wet without his shoes
and stockings.

It seems, therefore, clear that the eruption is an eczema
which has become localised by local irritation. Probably the
effect of the sea air has been good as regards his skin gener-

58 ON CERTAIN FORMS OF PSORIASIS-ECZEMA.

ally and has helped to cure the diffuse eczema, but the wet
and cold handling of ropes, &c., has kept his palms bad.

He stated spontaneously that whenever he was using fresh
tar his hands got better. No other application did any good.
He was almost driven to abandon his occupation.

Dermatitis of the Hands and Feet — Cure.

Mrs, S , aged 64, was sent to me by Dr. Martin, of

Huddersfield. She was in good health, but of a very dark
bilious complexion, the xanthelasma positions and the parts
beneath the lower eyelids being extremely dark. In early
life she had suffered from sick headaches, but not much
since her marriage. She had twelve living children, and
her menstruation had ceased comfortably some years ago.
Above the left inner canthus in the xanthelasma position
were some little spots and cysts which no doubt showed
a tendency to that disease.

Mrs. S consulted me on account of very severe chronic

inflammation of her palms and soles. This had troubled
her for eighte^ months, having commenced between the
toes and next in the palms of her hands. The disease had
progressed to such an extent as to almost disable the hands,
and to render walking very painful. The influence of walk-
ing in aggravating the disease was well shown in the soles of
the feet. She had a high arch, and the part immediately
beneath it was consequently quite exempt, and here the skin
was quite natural. There were painful cracks both in the
palms and soles. Her nails were not affected, nor was there
any eruption on her face or head. There were, however, a
few peeling patches on the backs of the hand, and on the
legs and forearms there were ill-marked groups of irregular
spots quite dry and much scratched. During the last week
or two there had been much tendency to dry eczema in the
axilla. She had been liable to cramp in her calves before
the eruption appeared. She had not used her hands for any
particular purpose or in any manner which would explain
the location of the disease on them.

Mrs. S *s case is interesting as an example of chronic

dermatitis beginning symmetricaUy on the four extremities

DERMATITIS OF HANDS AND FEET. 59

without any obvious predisposition, and without exposure to
any local cause. It shows also the tendency to gradual
implication, possibly by infection, of other parts of the skin.
It is similar to some cases which have been claimed as
having alliance with pityriasis rubra, and showing a
tendency to terminate in that malady. It is not wholly
nnlike the remarkable case which I published in the Clinical
Society's Transactions, in which a remarkable recovery took
place under the use of opium internally, after all other
measures had failed. In connection with this latter point I
am glad to be able to record the interesting results of treat-
ment, although at the same time I must admit that my
measures were too complicated to admit of any safe
inference as to the degree of credit to be assigned to any

one of the drugs used. In the case of Mrs. F just

alluded to it was different,, for in her almost all local and
constitutional remedies had been tried before the opium was
used.

Treatment — On March 25, 1890, 1 ordered for Mrs. S

a mixture containing min. v. of Pearson's solution of arsenic,
min. iii. of liq. opii sedativus, with a little nux vomica and
cascara to prevent constipation. She was to use an oint-
ment containing a little chrysophanic acid with ammonio-
chloride of mercury in lanolin and lard. She returned to
her home in Yorkshire, and remained under the care of Dr.
Martin, her medical attendant. I did not see her for six
months, and during that time she had steadily continued
the prescription. She returned to me on October 26, 1890,
with her skin quite well, but somewhat out of health
generally.

(To he continued.)

ON CANCEE AND THE CANCEEOUS PEOCESS.

A Cystic and Hcemorrhagic form of Sarcoma commenczng
in the vagina and spreading with extreme rapidity in
the cellular tissue of the pelvis and abdominal wall —
Death within four months from its beginning,

I saw with Dr. Elam, at New Barnet, in January, 1896, a
married woman, aged 35, concerning whom I had been told
that she had some peculiar and very suspicious growths in
the vagina. Just three months before our consultation an
operation had been done for the removal of " cysts " or soft
growths in the vaginal wall, near to the urethra. On this
occasion two quite distinct tumours, described to me as about
the size of cherries, had been dissected from the vaginal
wall. One of them contained ** grumous fluid,*' but the
other was ** like blood clot in a loose tissue.'* Unfortunately
no microscopic examination was made, as the portions re-
moved were accidentally thrown away. The parts healed
well, but there was soon evidence of return. A florid mass,
as big as a cherry, would become prolapsed from the upper
wall of the vagina in the erect position, receding when the
patient was recumbent. At this time the patient became
the subject of a very severe eruption, a sort of bullous
urticaria. This confined her to bed, and for some weeks
absorbed attention. The general health now failed very
rapidly, partly from the irritation of the eruption and
partly from repeated haemorrhages from the growths.

It was under the circumstances described that I was

asked to see the case. I found Mrs. C in bed, very

pale and very thin. She was still covered with the erup-
tion, but it was said to be fading fast. On exposing the
vagina the first object attracting attention was a smooth,

H^MOBRHAGIC SARCOMA. 61

pale swelling, the size of a half cherry, just to the left of the
meatus and below it. It was soft, and might have been
supposed to contain fluid. The mucous membrane over it
was quite sound. On passing the finger into the vagina
I found two rows of soft, partially pedunculated growths
running up from the sides of the urethra, crossing the
bladder, and almost reaching the cervix uteri. These were
very soft and much lobulated, and together constituted two
parallel ridges, each as thick as the thumb. From the lower
end of the right ridge it was easy to bring down into view
a mass which looked like a livid pile and at least as large as
a cherry. The growths did not bleed much on pressure.
Although very near to the meatus, they did not actually
involve it. The urine, which easily escaped during the
examination, was quite clear, and there had never been any
difficulty in micturition. There was no enlargement of
glands. On examining the abdomen above, I found in front
of the bladder and crossing the supra-pubic regions a large,
soft, cake-like mass as big as an outspread hand. This
mass was distinctly circumscribed at its sides, but not below,
as it passed under cover of the pubic bones. It was appa-
rently in or adherent to the parieties of the abdomen, but
the skin was quite loose over it. The patient's attention
had never been drawn to the presence of this growth.
There were no indications of growths elsewhere. We
could only advise palliative measures. I did not see the
patient again, but Dr. Elam was kind enough subsequently
to furnish me with the following particulars :—

After the consultation the growth extended, as it had done
before, with most astonishing rapidity. Only a week before
the consultation the abdominal wall had been carefully
examined and nothing found. On January 5th, date of
consultation, it was very obvious and extended a hand's-
breadth above the pubes. A week later it was higher than
the umbilicus, and at the time of death (January 17) it
nearly reached the epigastrium. It apparently extended
between the peritoneum and the abdominal wall. The
growths in the vagina did not increase perceptibly. The
patient suffered much pain and became rapidly exhausted,

62 ON CANCEE AND THE CANCEROUS PROCESS.

and SO sank. Unfortunately no post-mortem could be
obtained. From the date of the first operation (October 7)
to that of death (January 17) was little more than three
months, and the growths removed had been recognised by
the patient only about six weeks prior to the operation. It
should be added that Dr. Elam had excised a mucous cyst
from the vulva four years previously, and on two occasions
abscesses in the vulva had occurred.

The patient had lost a maternal aunt from cancer. She
had been married five years and had borne three children.

I append a description of the original growths and of the
operation in Dr. Elam's own words.

"On October 9th, 1895, I removed two growths from
vulva ; one she had noticed about one month and the other
rather longer. There had been profuse haemorrhage from
both. That in the left labium was smooth on its surface
except at one point, from which what was apparently a blood
clot projected. It was freely movable and painless. This
was clearly encysted and was easily dissected out. The
other was situated partly in the right labium and partly in the
vestibule to right of the urethra. It was not well circum-
scribed, and was bleeding on its surface. It was partly
cystic and partly made up of large venous spaces. It was
with difficulty dissected out. The wounds healed in two or
three weeks. When the growths recurred, then rapidity of
growth was more remarkable than anything.'*

Keloid recurring in the Scar of an Excision,

I have just seen again the young man whose case, as
illustrating the association of keloid with inherited liability
to cancer, I have recorded in the Edinburgh Medical
Journal. His keloid in the first instance developed in his
vaccination scars, but subsequently it attacked almost every
abrasion that he received, and at present he has on different
parts of his limbs more than a dozen separate growths.
Many years after their first formation a surgeon excised
one of the vaccination keloids, and subsequently did skin
grafting to complete the healing. The scar of the excision
developed a keloid plate far larger than that which had

AESENICAL CANCER. 63

preceded it, and in addition the sites of the suture wounds

and that of the skin graft (in the shoulder) all formed little

buttons of keloid. It was with this experience to warn me

tliat I yet felt obliged to advise the excision of a growth on

the shoulder opposite to that of the vaccinated arm. This

growth was not smooth and glossy like keloid, but dusky

and superficially ulcerated. It had formed from some

abrasion so slight that it had never been noticed, and it

had become very painful. Its conditions were such that

I much feared malignant ulceration, more especially as

raany of the lad's relatives had died of cancer.

A Case of Arsenical Cancer.

Dr. Bullock, of Netting Hill, brought to me on October 9th
a very important example of the evolution of cancer in a man
who had taken arsenic for long periods. The cancer had
developed, as was supposed, in the site of a patch of psoriasis
a little above Poupart's ligament on the right side. When I
saw the case it was a sore as large as a child's palm, with
rolled everted borders and a red granulating surface. Portions
of the edge had been excised and submitted to an expert for
microscopic examination, with the result that nothing im-
plying cancerous growth had been discovered. As a con-
sequence of this verdict, the man had been subjected to a
long and rather severe treatment on the hypothesis that the
disease was syphilitic. No benefit had accrued, and in the
meantime the glands in the adjacent groin had enlarged and
suppurated. The man denied all history of syphilis, and the
naked-eye aspect of his ulcer was characteristically that of
cancer.

Mr. F thought that it was as much as three years

since he first noticed that the patch of psoriasis was ulcera-
ting, but it was only during the last year that it had attracted
much attention. Quite recently it had spread rapidly, and
the implication of the glands had been rather sudden and
attended by much inflammatory swelling. The structures
around the enlarged and suppurated glands were glued
together and adhered to the abdominal wall. It was im-
possible to ascertain whether or not the glands within the

64 ON CANCER AND THE CANCEROUS PROCESS.

brim of the pelvis were implicated. The conditions, taken
altogether, appeared to me to forbid any operation.*

Mr. F , the patient, was a man of 46, very thin, and

almost cadaverous looking. He had suffered from psoriasis
from boyhood. At the age of 14 he had been taken to Mr.
James Startin, subsequently to Sir Erasmus Wilson, and
lastly to Mr. Milton. Arsenic had been given by all, and he
had repeatedly taken it to definite disagreement. His skin
generally had become dry and of a light brownish tint. The
palms of his hands had become harsh and dry, but liad
never developed definite corns.

* This was exactly what had occurred in my first case of arsenical cancer.
See Pathological Society Reports, vol. zzzix. p. 352 ; and I may add that the
appearances of the ulceration were in some respects exactly similar in the
two cases.

'DISEASES OF THE NEKVOUS SYSTEM.

t

(Contintted from Vol. VIILj p. 378.)

No. XCVIII. — On subjective Numbness unaccom-
panied by any demonstrable Ancesthesia.

This peculiar symptom, one often mentioned by patients,.

was present in the case of Mr. P , whom I saw several

times in consultation with the late Dr. Eamskill. Mr. P

had had syphilis twenty-five years ago, and had for about five
months been the subject of complete paralysis of the left
sixth nerve. Not long after the failure of his external rectus
the skin of his chin on the opposite side became numb. From
his description, I should judge that the mental branch was
first affected. By degrees it spread over the whole right half
of face, including the forehead and side of nose. On October
lf5th, when the symptom had been present two months, I
carefully tested by pin-pricking, pulling hairs, &c., and could
not prove any loss of sensation. He thought that if there
was any difference he felt his moustache pulled on the right
side more acutely than on the left. Yet he still insisted that
the whole right side of face was **numb." He had no " pins,
and needles,'* but *'a general perception of stiflhess, as if the
cheek, &c., were of wood or leather." The pupils showed
nothing peculiar; they were sluggish, but still acted, and
were of equal size. He had no headache and no other
symptoms except the two mentioned, of numbness of the
whole right side of face and paralysis of left external rectus.
Possibly an exception ought to be made in that he was a
little hoarse.

VOL. IX 5

66 DISEASES OF THE NERVOUS SYSTEM.

No. XCIX. — Threatened Paraplegia with pupil
symptoms eleven years after Syphilis — Becoveyy
under Mercury,

The following note is of much interest in reference to
the diagnosis of syphilitic affections of the nervous system,
and also as to the use of mercury during long periods of
time.

A married man, aged 33, was brought to me in April of
1893. Great anxiety was felt as to his spinal' cord. His
legs had become weak, so that he was unable to walk
more than a few yards, and micturition was so feeble and
uncertain that he was compelled to use the catheter
habitually, though not quite invariably. He had pain in
the middle of the back, and there was a girdle of hyper-
sesthesia around the chest. On one occasion he had had
retention of urine. His left leg was more weak than the
other. In both the knee-jerk was exaggerated, but
especially so in the left. He had suffered from neuralgic
pains of great severity in his chest — ** fearful pain, as if
red-hot needles were being pushed in." There had been no
pain in his limbs. His sexual vigour had almost ceased.
It was eleven years since his syphilis, and during the
whole of that period he had been taking iodide of potassium,
although not quite continuously. His pupils were almost
motionless, the right very small, the left of normal size.

My advice was that he should avoid the iodide of
potassium and take mercury with nux vomica. I did not
see him again for four years, but he was meanwhile under
the observation of a very careful surgeon.

In November, 1897, he called on me for a second time,
and chiefly to report his cure. His only remaining troubles
were a certain amount of chronic cystitis and entire loss
of the sex-function. I made the following note of his
condition.

On April 13, 1893, I ordered a pill containing half a
grain of calomel, a fifth of a grain of opium, and a third of
extract of nux vomica. These pills he took regularly
without intermission for two years, and since then less

RECOVERY FROM PARAPLEGIA. 67

regularly. He omitted the opium after a time because it
caused constipation.

He has steadily improved. Within six months after
beginning the treatment he was able to disuse the catheter,
and has never employed it since excepting for washing
out. For the latter purpose it is still needed. The urine
still smells badly. The pain in the chest also ceased. He
now looks robust and well. He can now walk ** as well as
-ever he did in his life." Has been shooting on the moors.
His only remaining inconvenience is mucus in his urine, with
proneness to decomposition. Salol makes the urine dark
.and removes all odour, but it is very uncertain in its action.
He is still costive. As a rule he is obliged to go to the
-closet to relieve his bladder, as he cannot make water
standing ; sometimes, however, he can pass it without effort
when standing. He walks well with the eyes shut.

For the two years whilst taking the pills he never had a
pain or ache. The pupils are still all but motionless, and
the right one twice the size of the left. The right dilates a
little when shaded, the left scarcely moves. They do not
act in accommodation. He can read easily, and as long as
he likes. His sexual function is in abeyance, and he never
attempts intercourse.

The fallacies as to therapeutics are many, and they are
by no means absent in this case. That the patient has,
with certain persisting disabilities, recovered from a very
threatening group of symptoms is undoubted. It is also
-certain that during the period of his improvement he was
taking half a grain of calomel three times a day. We must
remember that he took also nux vomica and opium, and
that he abstained from the idiode of potassium which he
had taken far too freely before. It may be that the latter
drug had much to do with the loss of sex-function. On the
other hand it may be the fact that the result simply proves
the superior efficacy of mercury.

68 DISEASES OF THE NERVOUS SYSTEM.

No. C. — Epilepsy after SypJiilis — WJiite Atrophif
of optic discs — Complete recovery of healthy zvitli
blindness.

The following fragment, although disgracefully inconaplete^

may be useful for purposes of prognosis. Mr. B ,

aged 42, came to me first in June, 1887. He was blind,
and had suffered from epileptic seizures. The discs were in
a state of white atrophy. Twenty years previously he liad
contracted syphilis. I advised him to continue specifics
which he was already taking. In May, 1891, I saw him
again, and advised that mercury should now be given up.
He had been very busy during the intervening three years,,
and had had much excitement. His health had, however,,
been very good, except for an attack of sleeplessness.
There had been no sign of syphilis for several years. No
fits had occurred since 1874, except one or two after long
intervals. Previously he had one, two, or three a day for
four or five months. Mercury and iodides had effected the
cure. There was no knee-jerk. There were no pains in
the legs ; and although they felt tired he could walk well.
The pulse was very soft. The pupils were rather large and
fixed, and the eyes diverged. The hearing was good, and
there was just perception of light.

No. CI. — Severe Contusions (two occasions) of 07ie
thumb — Amputation of terminal phalanx, and
subsequently of the proximal one — Neuralgia and
contraction of all the digits into thep^ahn — Ampu-
tation through forearm — Cure.

The following notes refer to the case which the appended
woodcut illustrates. I have recently had a report of the
patient, and am assured that since the amputation through
the forearm, now five years ago, the man has had no return of
pain. He has been able to use his stump freely, and has en-
joyed good health. The question of exaggeration and of feign-
ing had been freely discussed during the whole course of the
case. The patient's sex, and the fact that he was a married

PAINFUL CONTRACTION AFTER INJURY. 69

man engaged in business and with every motive for avoiding
"the r6Ie of a valetudinarian, seemed to negative such a
supposition. In support of it, however, were the entire
aljsence of lesions of nutrition in the skin and the main-
tenance of muscular health. The man was himself always
ready to consent to amputation, but his surgeons were of
course very unwilling to remove a hand which, except for
the contraction, appeared perfectly sound. Finally, how-
ever, this ultima ratio was resorted to with complete success.

Mr. S . aged 25, who had been married three years, was sent to

me in February, 1B91, by Dr. Thyne, of High Bamet, for an affection of
the hand. The condition was the result of two accidents, both nearly
five years before. At that time he was acting as third mate on board

ship, and on two occasions, with about one month's interval, he had had
his thumb end crushed. It never got well, and the whole hand became
painful. In April, 1888, Dr. Thyne amputated the last phalanx. He
was subsequently under Dr. Hughlings Jackson at Queen's Square
Hospital, from the middle of 1BB8 to the end of 1889. Whilst there I
was invited to see him. The proximal phalanx of his thumb had been
removed by Mr. Victor Horsley some months after Dr. Thyne's opera-
tion. When Mr. S — - was sent to me in February, 1891, the fingers
were bent strongly into the palm, and the wrist was flexed, as firmly as if
made of wood. They had been in that position tor three years, and any
attempt to straighten them caused pain. The tendons of the forearm
did not start forward, and the extensors were not atrophied. The nails
were grown like claws. There was not the slightest defect of nutrition
in the skin. Mr. Horsley hEid tried, under ether, to straighten the wrist,
bnt did not succeed. I was told that Mr. H. had wished to cut the

70 DISEASES OF THE NEEVOUS SYSTEM.

posterior roots of the nerves. The patient had a peculiar staring look
and nervous manner, and I found that he had been an opium eater before
his accident. He was a bad sleeper.

On February 26th he complained of pain in the left side of his head.
There appeared to be hypersesthesia of the skin of the hand and forearfn.
When it was touched anywhere, however lightly, e,g.^ by pulling a hair^
&c., fibrillation was produced in the small muscles of his thumb. Nutri-
tion of the skin still remained good; and there was no atrophy of t»Iie
forearm, nor of the small muscles of the hand. The girth of the forearra
was nine inches, as compared with ten inches in the other limb. In
March of 1892 Dr. Thyne amputated through the forearm. The neural^a
and insomnia which had been so troublesome immediately disappeared.
As already stated, the patient has during the last five years remained
quite well.

We have had two other cases recently under notice which
may suitably be mentioned in connection with the above
narrative. In one the facts were very similar. A woman
had had all her fingers amputated in succession on account
of pain and disability which had followed an injury to one
of them. She still retained her thumb, but she could make
no use of it on account of pain. It was not contracted, but
it was atrophied, and the skin was glossy and shrivelled.
I advised amputation through the forearm, and this was
done by my son in the London Hospital. It is only six
months since the operation, but thus far the stump is quite
free from irritability.

In the other case a young woman was sent up from
Devonshire with her fingers contracted into her palm, much
as shown in the woodcut, but with the difference that the
whole hand was much swollen, and covered with excoria-
tions. It had for long been disabled, and she was desirous
of amputation. On baring her upper arm I found evidences
of constriction, there being a deep furrow. She was
subsequently detected, by an unexpected visit in the night,
with a cord tied tightly round the arm. After this com-
plete exposure she desisted from her practices, and before
she left the hospital she could use the hand well, the oedema
having to a large extent disappeared.

DISEASES OF THE SKIN.

(Continued from Vol. VIII. ^ p. 369.)

No. XCIV. — Lupus Sebaceus occurring as a single
patch — Its association with family history of
Tubercle.

I have recently had under treatment two examples of
the single-patch form of lupus sebaceus. This disease is
of course a variant of lupus erythematosus, but with some
peculiarities. One of these is that it not unfrequently
remains for a long time, possibly through the whole of
its duration, a solitary patch.

In the instance of Miss C , a lady of 40, whose

brother had died of phthisis, came to me with a patch on one
cheek the size of a shilling. She thought that it had been
gradually spreading from a small point which showed itself
nine years ago. I applied fuming nitric acid very freely
over its whole surface, and a month later repeated the
cauterisation to one small spot which did not look healthy.
It is now four months since the first application and
nothing remains but a smooth, pale scar.

In the case of Mrs. T , my patient was an old lady

of 71. Mrs. T came under my treatment for a well-
characterised patch of lupus sebaceus in the middle of her
forehead. It was as large as a shilling, and had been
present six months or more. I destroyed it with fuming
nitric acid, and it healed with the florid scar which is

not unusual. Mrs. T had lost three of her sisters

in phthisis; and in early life had herself been considered
delicate on the chest. She had, however, regained good
health, and had borne fourteen children. She showed no
signs of delicacy at the time the lupus began.

72 DISEASES OF THE SKIN.

«

No. XCV. — A somewhat peculiar form of Psoriasis
of the Nails in association with Psoriasis patches
on the Scalp.

Mr. T 's nails are peculiar. In many the sides

are becoming discolomred and loose from the nail-bed. At
the free borders this has only proceeded to a very slight
extent, but under one there is an abruptly margined patch
of discoloration as big as a threepenny-bit. It is of a
brownish tint, the border being more discoloured than the
centre. It is clearly spreading, and is much like the patches
on his scalp. This patch does not touch the borders of the
nail, and is easily seen through its trq,nsparent structure.
Some of the other nails show brownish discoloration
running in ill-margined streaks. The nails are brittle and
split up. On the scalp are large scaly patches, as big as the
palm of the hand, of deep-red congestion and with scaly
surfaces. They have been present four years. He has only
noticed the patches under the nails for a few months. He
has been drinking whisky too freely.

No. XCVI. — A Comedonous and Spinous form of
Lichen spreading over the whole trunk and limbs
of an adult Woman.

Mrs. H , a lady of about 46, consulted me on Sep-
tember 3, 1897, at the suggestion of Dr. Blair, of Kew.
I was told that her eruption had begun in April as a patch
near right axilla, and that from thence it had spread over the
whole trunk and limbs. It had never affected the face, but
was plentiful on nape and to some extent on scalp. It

was very abundant on back. Mrs. H said that she

had never before suffered from any eruption, and that her
skin was usually smooth and quite free from spots. She
was covered, when I saw her, with small lichen papules,
many of which were little black comedones, and from some
of which distinct little sebaceous spines projected. These
latter could be easily picked out, and the plugs of sebum
beneath them could be ejected as in those of acne. The

PIGMENTED STAINS ON ABDOMEN. 73

eruption was general and diffuse, not being in the least
arranged in patches. I was, however, assured that in the
first instance there was a single patch, and that it was from

this that the spots had spread. Mrs. H was not out of

health, and the eruption had caused but little inconvenience.

At my suggestion. Dr. Blair removed some of the little
sebaceous plugs, and sent them to the Clinical Kesearch
Association for examination. The report returned was-
negative. No parasitic elements could be discovered.

Three weeks after our consultation I heard from Dr.
Blair that the eruption was receding, more especially on
the chest near to the parts where it had first appeared. A
month later the patient was good enough to attend at one
of my Demonstrations in order to show her very peculiar
eruption. It. was then still demonstrable on the shoulders
and some other parts, but in the main it had disappeared,
and the skin had resumed its healthy condition. No spines
could then be shown, but there were still some small
comedones. The face had remained quite free. The
principal measure of treatment had been the free inunction
of a weak ammonio-chloride of mercury ointment.

No. XCYII. — Pigmented stains on the Abdomen of

a middle-aged woman.

I recorded some years ago the case of a lady, whom I had
in the first instance seen with Dr. Buzzard, who had an
eruption of brown spots over the trunk which had excited
a suspicion of syphilis, but which persisted unchanged for
years. She was past middle age, and my diagnosis was, in
the end, a form of family freckles. I have just seen another
case which may, I think, be very fairly placed in company

with it. L — H is a remarkably well-preserved woman

fifty-eight years of age, but looking like forty. She has lived
many years in India, and was, indeed, born there. In early
and middle life her skin was healthy and never gave her any
trouble. Her complexion is that of a blonde, with brown
sandy hair. About three years ago, in her bath, she observed
that she had some dark spots ** like freckles " in groins, but

74 DISEASES OF THE SKIN.

beyond a thought that it was an odd place for freckles she
gave them no attention. They continued, however, to in-
crease in size and number, and spread over the whole lower
part of the abdomen, and she began to imagine that the skin
felt hot and irritable. She had much advice for them, took
a long course of arsenic, much iodide of potassium, and was
also sent to Buxton. No great change resulted. She
thought it probable that some of the many applications
which had been made had irritated the patches and made
them spread.

When on Sept. 23, 1897, I was consulted, her abdomen
at its lower part was covered with dark brown, almost black,
stains. Some in an early stage were not bigger than pins'
heads, others might have required the end of one*s thumb
to cover them. . Some were ill-defined, others presented a
more or less definite ring with a paler centre. None were
raised or perceptible to touch, but scattered amongst them
were a few small comedones around which there was staining.
A few of the stains passed as high as the chest, and under the
breast on both sides there was an intertrigo patch of slightly
thickened skin, upon which were many little indolent lichen
spots with some diffuse yellow-brown discoloration. These
patches were not actually eczematous, but threatened to
become so. There were no " freckles " on the face or arms,
and scarcely any on the back. A few small lichen acne
spots might, however, be found on the face and shoulders
on careful inspection.

L H was not out of health, and although her

eruption had caused her great annoyance, it had not much
interfered with her comfort. She inherited gout, and I had
myself prescribed for one of her sisters for eczema.

I thought it possible that the arsenic which she had taken
had deepened the colour of the blotches, but it was certain
they were not caused by it, nor was there any general pig-
mentation of the skin. No history of cancer was known
in the family.

I prescribed some applications for the submammary inter-
trigo, and as regards the stains advised that they should
be let alone.

PIGMENTATION OF GLANS PENIS. 75

No. XCYIII. — Aggi^essive Pigment Patches on the

Glans Penis and Prepuce.

Repeated references have been made in Akchives to the
remarkable cases in which pigment staining of an aggressive
form is occasionally the prelude to malignant growth. In
most of the cases which I have described the disease was
placed either on the eyelids or on the lips. I have, how-
ever, recorded other cases in which the same process occurred
at the roots of nails and in association with sarcomatous
growths in the sole of the foot and other parts. I have at
present under observation a remarkable example of pigmenta-
tion, of patches on the glans penis and in the scar of a cir-
cumcision done thirty years ago. The patient is a man of
64, and the disease has been in progress three years. He
was in the first instance (two years ago) sent to me in the
fear that the condition was malignant, but excepting increase
of pigmentation nothing further has been developed.

No. XCIX. — Type-Case of Severe TJrticarious Der-
matitis induced by Food Poisoning, and recur-
rem^t on the slightest possible provocation.

The following case may stand as a good example of that
form of urticaria which occurs suddenly to a person who has
previously not shown any special proclivities. Such out-
breaks are probably almost always evoked by dietetic
poisoning, but they leave the skin susceptible for a con-
siderable period after the special cause h^s been wholly
removed.

Mr. , a robust Scotchman, was sent to me by Mr.

Drummond, of North Shields, in October, 1897. He had
suffered from nettlerash for six weeks, and at times most
severely, although a rigid dietary had been enforced and he
had taken saline aperients freely. His age was 45, and he
assured me that until the present attack his skin had never
shown any irritability whatever. No change of under-
clothing ever caused him the slightest trouble, nor had he

76 DISEASES OF THE SKIN.

been liable to suffer in any special degree from the bites of

insects. On the morning that Mr. came to me he had

been three days in London, and his urticaria had wholly
left him. I made him strip, and found his skin pale and quite
free from all traces of irritation. He told me, however, that
he had often been covered over his limbs and trunk with
large red wheals, which he described as having been raised
as thick as his finger. He said that the medical men ^vho
had seen him had said that they had never seen so severe a
case. The eruption had not been persistent, and had often
left him for a few days at a time, but never quite so
completely as during the last few days that he had been
in London. He assured me that his underclothing did not
irritate him in the least, and it appeared quite evident that
the exciting cause was from within.

I asked Mr. to tell me in detail how his first attack

had been developed. He said that he had one night found
his skin irritable, and had scratched a good deal, and that in
the morning he had found himself covered with red wheals.
The next day he saw his doctor, and he had been under
treatment ever since. *' Had you taken fish for supper ? "
** Yes, in all probability, for I usually do ; but there had
been nothing particular. I never take shellfish. A day
or two before I had eaten mackerel, and this was what

Dr. D blamed." '*You have been forbidden fish

since?" ''Yes; I have taken none. I have been put on
a low diet, and had no salt meat, no stimulants, and no
beef or mutton. Milk I have taken freely and cocoa, but
no tea or coffee." "Have you been able to observe that
any article of food brings it out?" **No; it has come
without anything to explain it. I have been covered in
the course of an hour or two without knowing what had
produced it." *' Has it itched much? " " Oh, yes, intoler-
ably. I have often been scratching half the night." " Does
the scratching make it worse?" ** No, it relieves it. I often
scratch till the blood comes." ** And yet the eruption goes
away and leaves your skin sound ? " '* Yes, most com-
pletely ; my skin the next morning often looks as if there
had been nothing there."

PLATE LXXVL

MULTIPLE LUPUS VULGABI8.

Portrait of a boy the subject of multiple lupus in the eaxly
stage. For the later stage, after an interval of five years, see
Plate LXXVII. For further particulars see the description of
Plates LXVII. and LXVIII.

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PLATE LXVIL

MULTIPLE LUPUS VULGARIS.

Tms portrait shows the earlier stage of the same case as ihat
depicted in Plate LXVIII., the interval being about five years.
The patient was a healthy boy, in whom, at the age of about three,
an acute general eruption occurred, the nature of which was not
easily recognised. Some of the patches were almost rupial, whilst
others were lichenoid or pustular. At a later stage, however, many
of the smaller spots had disappeared, whilst the larger ones had
extended into patches characteristic of lupus vulgaris. It will be
seen that the individual patches in Plate LXVIII. are very much
larger than those in LXVII.

In Plate LXYII. it will be seen that the whole of the prepnce
is involved in a lupus patch. In Plate LXVIII. this had been
removed by excision. A full narrative of this case is given in my
Harveian lectures on lupus, which will shortly be reprinted. The
boy when about twelve years old was well grown, and in fair health,
but was almost covered by huge patches of exfoliative lupus. He
died, as narrated at page 77, with albuminuria and pulmonary
disease, probably tubercular, at the age of fourteen.

Coloured portraits representing the face of the same patient in
the two different stages of the disease will be found in Plates
LXXVI. and LXXVn.

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CONCLUSION OF A EEMARKABLE CASE. 77

No. CI. — Conclusion of a remarJcable example of

Midtvple Lupus Vulgaris.

A case to which I have many times referred as my best
illustration of multiplicity in the manifestations of lupus
vulgaris and of the peculiar phenomena which attend its out-
break has recently ended in the death of the patient. Por-
traits in illustration of its different stages had been taken and
are now reproduced (Plates LXXVI. and LXXVll., LXVII.
and LXVIII.), the originals being preserved in the Museum.

It is now ten years since Master L , then a healthy

boy, -developed a general eruption of pustules and lichen
papules, many of which inflamed and became covered with
crusts. The diagnosis was in doubt for some time, but after
a while much of the eruption disappeared, and what remained
settled down into patches of lupus vulgaris in its exfoliative
form. These were so numerous and soon became so large
that it was impossible to subject the poor boy to efficient
measures of local treatment, and after many trials the
disease was allowed to run its course, excepting as in-
fluenced by attention to the general health. Amongst other
measures, Koch's fluid had a full trial at the time when it
was in vogue. The patches increased steadily in size, but
caused but little discomfort. In the end, probably a full
third of the patient's surface was occupied by them. My
object in now recurring to the case is to record the fact that
the boy has died with albuminuria and tubercle of the lung.
He had enjoyed fair general health until the last six months
of his life.

SYPHILIS.

(Co7itinued from Vol. VII. , p. 177.)

No. LXXIX. — A peculiar form of Induration in
Sub-mucous Tissue ten years after a chancre
near the same site.

Mr. B contracted syphilis in 1872, followed by palmar

psoriasis, &c. He was treated with mercury, but not for
long, and got quite free from symptoms. In May, 1883,
aged 35, he came to me with a sub-mucous collar, almost as
hard as bone, in the prepuce, clos6 to the corona, in the middle
line of the dorsum. There was not the least soreness or
congestion. The mass was rather deeply placed, as big as
a horse-bean, but flattened and abruptly margined. It was
not like a chancre in the absolute absence of congestion, and

I thought it was a gumma. Mr. B thought it was not

exactly where the original chancre had been, but was not
far from it. He admitted repeated recent exposure to
contagion. The induration subsequently disappeared under
treatment.

No. LXXX. — The course of Secondary Syphilis un-
usual and precisely parallel in two Brothers,

A very demonstrative illustration of the influence of
individual idiosyncrasy upon the development of syphilis
has recently come under my notice. Two brothers con-
tracted sores from the same woman, and nearly at the same
date. They consulted me ten months later for a peculiar
form of eruption which was exactly alike in both. It had
been modified in both by treatment already adopted, and in
each it had assumed the type of an urticaria in wheals and

PLATE LXXVIL

MULTIPLE LUPUS VULGABIS.

PoBTRAiT of a boy the subject of multiple lupus in the later
stage. For the earlier stage see Plate LXXVI. ; and for further
particulars see the description of Plates LXVII. and LXVIII.

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PLATE LXVIIL

MULTIPLE LUPUS VULGABIS.

This portrait represents the condition of the Lupas patches in

the boy LI n, who was also the subject of Plate LXVII. A

comparison of the two Plates shows the extent to which the disease
has advanced during the four years which had intervened between
the dates at which they were taken. It will be seen that all the
patches are much larger in size, and that in some places several
have coalesced. The prepuce, which in the first Plate is seen to be
involved in lupus, has in the second been removed by circumcision.
The Plate is not to be regarded as anything more than a map
indicating the size of the patches.

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PECULIARITIES IN A FINGER-CHANCRE. 79

rings. In both it was wholly free from irritation, and both
stated that it became much more conspicuous after a warm
"bath. In both patients the original chancre had, after lasting
about three weeks, healed and disappeared spontaneously, and
in both the sore throat had been very slight. In both the
original eruption had been, I was told, quite different from
that which now persisted, and was described as a roseola.
It will be seen that the eruption presented by these two
men when they came to me in the tenth month of treat-
ment was precisely that which I have described as occa-
sionally occurring at that stage, and which is, I think, never
seen unless mercury has been used. It is by no means
common, and its development in the two brothers is there-
fore the more remarkable.

No. LXXXI. — Primary SypJdlis in Hindoos,

It is very desirable to collect trustworthy information as
to racial peculiarities in reference to disease. As such I
record the following fragment : — -

I am at present seeing three Hindoos for primary syphilis.
In all the chancre has been a very large induration. In one
the sore became phagedaenic after induration and required
cauterisation. All the three had large tonsils, and in all
superficial sores showed on their surfaces.

No. LXXXII. — SypJdlis from a Finger -Chancre
which was ill characterised in its early stages.

A surgeon has just been with me who has a chancre on
the side of his forefinger and is covered with a syphilitic
eruption. His case presents some features of special interest.
In the first place, he has, in addition to a considerable mass
of glands in his armpit, enlargement also of those under the
clavicle. This is just what happens in infection of the
lymphatics from cancer of the breast, but I do not remember
to have seen it before in the axillary bubo of sjrphilis. The
latter usually restricts itself to one or two isolated glands in
the armpit itself. The next point is that, although my
patient is an observant man, he cannot offer the slightest

80 ' SYPHILIS.

conjecture as to how he got infected. He says that he
never recollects any prick or scratch on his finger. He is
not to any great extent exposed to risk, not seeing many
syphilitic patients and not doing much midwifery. What
he first noticed on his finger was a little pustule, which he
pricked with his scarf pin to let out a small quantity of
matter. It was somewhat painful from the first, and latterly
has been very much so. No one of his medical friends to
whom he showed it would at first admit that it was suspicious,
and as a consequence he got no treatment until the eruption
came out, and this was five or six weeks after the first
observation of the pustule. The sore meanwhile had in-
flamed, and had come to present a hard, raised margin as far
round as a sixpence, with an ulcer in the centre.

No. LXXXIII. — A healthy infant nursed hy a
syphilitic mother — No contamination — Urticaria
pigmentosa mistaken for a syphilitic eruption,

A married lady (Mrs. K ), aged 27, consulted me in

February, 1892, she being then covered with a syphilitic
eruption. The disease had not been diagnosed, and no
treatment had been adopted. I found that she was nursing
an infant seven months old, and of couVse told her that
she must at once wean him. A year later she brought the
infant to me because he had an eruption which she had
assumed to be syphilitic. I found not the slightest indica-
tion of S3rphilis, and the spots appeared to be flea-bite
urticaria. They were said to come out at intervals, now
on one part and now on another, and were attended by
excessive irritation. A year later still I heard that the
child was in good health, but still liable to the eruption,
which was reported to leave brown stains. His mother
still held that the child must have suffered from her " blood
poisoning.'' Three years later the boy was again brought
to me, the behef being that I should now be forced to
admit that he was sjrphilitic, as his hair had begun to fall
off in patches. He was the subject of well-characterised
alopecia areata. The patches were large, and perfectly

A SYPHILITIC NURSE. 81

smooth. There was no history of ringworm, but I was
told that in an early stage the patches had been scaly.
The boy showed no indications of syphilis. He had his
twenty milk teeth, all still quite white, and none showing
any caries.

The facets which this case seems to prove are that an
infant may be nursed by a woman suffering most severely
from secondary syphilis without receiving from her milk
any taint and without contracting any chancre on the
mouth.

VOL. IX.

DIET AND THEEAPEUTICS.

(Continued from Vol. VIIL, p, 384.)

On the use of Indian Hemp.

I have of late years used Indian hemp freely for the
relief of chronic rheumatism, and often with very good
effect. I fear, however, that it cannot be denied that it is a
very variable remedy, and that the prescriber is much at the
mercy of the dispenser. This applies especially to the fluid
forms, which, imless carefully made up, may easily concen-
trate into one dose the quantity which should be divided
into many. For this reason, having been warned by a case
in which dangerous symptoms occurred, I now never prescribe
it otherwise than in pills. Even in pills, however, it is
variable. A patient who had some months before taken the
extract in grain doses, was made so ill by doses of one-third
of a grain that he had to keep his bed several days. His
symptoms were mental confusion and inability to walk
straight. He did not know what he was saying. He
persuaded his wife to take three or four of his pills, and
they had the same effect on her. I have just received the
following from a patient: "The last prescription you gave
me with the small pills seems to affect my nerves so much
that I really cannot take it any longer. It makes me
tremble all over." The dose in this instance was only a
third of a grain, with a grain of quinine.

Another patient wrote : "Your quinine and Indian hemp
pills quite paralysed my speech when I had taken only four.
I was very ill, and had to remain in bed some days." In
this instance the dose was only a third of a grain.

TREATMENT OF RAYNAUD'S PHENOMENA. 83

Opium in Baynaud's Disease.

I have just heard from Dr. Clarke, of Upper Clapton, that

Mrs. W , whom I saw with him three years ago, when

she was the subject of Eaynaud's phenomena in a severe
form, is now ** quite well.'* Small doses of opium have, I
believe, been the main influence in her recovery. Her case
is published in the Medical Week.

The following letter from Dr. Clarke gives more details.
It was written in reply to one of mine in which I inquired
whether it could really be said that the patient was
" cured,'* and also asked him to bring her, if possible, to
one of my Demonstrations.

" Nov. 4, 1897.

" Deab Mr. Hutchinson, — I have deferred writing, hoping to per-
suade Mrs. W to visit Park Crescent, but in vain, or to bring her

myself ; thus far my efforts have failed.

** I consider the case a cure, and so do the patient and her family.
The fingers have been well for a year at lea^t — no further micJvief at
those extremities. Feet and toes entirely free; but some six months
ago (I suspect from over- walking) superficial ulcerations — three or four
small but deep ulcers — ^formed in the triangular space above the os calcis.
The pain was most acute, as she described it, exactly like that in the tips
of her fingers when the disease was active. This was relieved by a 10
per cent, solution of cocaine, and the ulcers locally treated with boric
acid lotion and cajrbolic acid, and support by bandaging. The internal
treatment was solely pulv. opii gr. i. in pill twice or thrice daily. She is
now qtdte well, only suffering from time to time from dyspepsia, relieved
by ext : nuc : vom : gr. J ter die in pill. This smts her best."

A case illustrating the Treatment of Psoriasis —

Arsenical Zoster.

I prescribed for a boy aged 14, who was the subject of severe
and extensive psoriasis, an ointment of chrysophanic acid
si ad. 5i) and Fowler's solution of arsenic in four-minim
doses, three times a day. The effect of the ointment was
to cover him with erythema, which was for some days
thought to be scarlet fever and which was followed by
peeling. About a month after taking the arsenic he came
out in herpes zoster on the left side of the trunk. It was
well marked, but not a severe attack. As a result of the
combined influence of the arsenic and of the acute dermatitis

84 DIET AND THEBAPEUTICS.

produced by the chrysophanic acid, his skin was at the end
of a month almost entirely free. His father thought that
the so-called scarlet fever did it, for after the peeling the
spots of psoriasis were all gone. It is worthy of note that
the ointment, although continued afterwards, did not
irritate again. It was my usual ointment, which twenty
years ago obtained, I believe, some little reputation in the
profession as a compound petroleum ointment. When the
boy was brought to me a month after his first visit he had
the zoster still out, but with this exception his skin was
everywhere pale and soft.

Carbolic Acid as a Topical Bemedy in Lupus

Erythematosus,

A lady who recently consulted me for rheumatoid
arthritis of her knees told me that I had cured her of
**Batswing Lupus" some years ago. On inspecting her
face I could find only the faintest traces of scar on the
nose and cheeks. At first glance, indeed, I did not see that
there was anything. She told me that she had consulted
me only once, as she lived at a great distance, but that she
had continued my treatment for nearly a year. She was
exceedingly pleased with the result, having been told before
she saw me that the disease was almost incurable. On
turning to my notes I found her diagnosis confirmed by a
brief entry on December 12, 1893: "Mrs. E- — , aged 48.
Lupus erythematosus spreading symmetrically from the
nose over both cheeks ; sunburn on the nose the beginning
of it." I was naturally anxious to know what the measures
were which I had advised, and a week later at my request
her husband forwarded to me the prescription with a letter,
from which I extract :

**I beg to enclose you the prescription you gave Mrs. E in

December, 1893, for Batswing lupus, and which, as you saw, entirely
cured her. She was obliged to continue the use of it for a lengthened
period, but she was most careful and persistent in doing so ; indeed,
continued it for some time after the disease appeared to be cured."

The prescription was for a mixture containing tincture
of nux vomica with one minim of Pearson's solution of

ALCOHOL AS AN HYPNOTIC. 85

arsenic in tincture of « orange-peel. The more important
measure was, however, the topical use of undiluted carbolic
acid. The written directions were : ** With a bit of wood
paint this acid over the edges of the patches once or twice
a week.*' A boracic acid ointment (a scruple to the ounce)
had also been given for daily use, and especially after
applying the acid.

As regards the use of carbolic acid, I believe that I have
repeatedly published the opinion that for patients who wish
to carry out treatment at home and cannot see their
advisers often, it is by far the safest and most effectual
form of caustic. Some of the best and most complete cures
of lupus vulgaris which I have ever seen have been under
its persevering use. It has also the great recommendation
of leaving viery healthy and supple scars. It is necessary
that the patient should be persevering, and make the appli-
cation freely once or twice a week. In lupus erythematosus,
of which the present case is an example, I have been less
commonly successful, but this case is certainly one of the
best cures of a formidable example of it which I have ever
witnessed.

Alcohol as an Hypnotic,

I was urging very strongly on a man who well knew his
failing that he should reduce his quantity of whisky. In
giving a reluctant assent, he remarked: "But, you see, it
gives me such sound sleep. If I do not take my usual
allowance at bedtime, I dream dreadfully all night ; but if I
have had it, why I sleep like a child and never dream at all.**
** But,** I suggested, ** do you not wake with a dry mouth
and a headache?** "No,** he said, "I wake as bright as
possible and enjoy my breakfast.** His assertion on the
latter point was confirmed by the fact that he had a perfectly
clean and soft tongue. He had, as he well recognised, been
on the verge of delirium-tremens more than once, and was
anxious to amend his mode of life. What made it especially
difficult for him was that alcohol always seemed at the time
to suit well, and never gave him any immediate discomfort.
There are many who are, I believe, in the same position as

86 DIET AND THERAPEUTICS.

my patient, and those may be thankful in whom indiscretions
and excesses are followed by prompt and well-recognised
penalties.

Leprosy and Fish-eating in Persia,

The highlands of Persia are one of the districts which have
often been quoted as affording an objection to the accept-
ance of the fish-theory of leprosy. It has been said the
leprosy prevails there, and that the inhabitants, owing to
their position, can get no fish. I have before me a reprint,
from the Geographical Journal, of a paper by Capt. Vaughan
entitled " Journeys in Persia.*' For my benefit Capt.
Vaughan has been good enough to add some notes as to
the diet and food, from which I extract the following : —

** The chief diseases are —

** 1. Ophthalmia very common, and probably due to dust
and glare. The inhabitants attribute it to a diet of dried
fish and dates.

'* 2. Skin diseases.

*' 3. Some form of venereal disease. I saw no true syphilis.

** 4. Fevers are rare.

" I do not remember having seen any lepers. The diet of
the people all over the country consists largely of dried and
salted fish imported from the Persian Gulf and the Caspian
Sea."

Although Capt. Vaughan saw no leprosy, yet the testi-
mony of others establishes the fact of its occurrence. Pro-
bably it is not common. Capt. Vaughan's evidence entirely
overturns the assertion of those who say that fish is not
obtainable. Clearly it is obtainable, and that in its most
dangerous state, salted or dried. Very probably it is eaten
uncooked.

Zosteriform pigmentation of Skin as a consequence of the

medicinal employment of Arsenic.

It has been well established respecting arsenic that it may
produce diffuse pigmentation of the skin and also that it
may cause herpes zoster, a malady which affects the areas
of distribution of individual nerves. I have now to offer a

ZOSTEEIFOBM PIGMENTATION FEOM ABSENIC. 87

connecting link between these two different classes of
phenomena, and to suggest that this remarkable drug
may produce pigmentation which is not diffuse, but which
is arranged in streaks like those of herpes. In other words,
it would appear probable that the pigmentation may be
caused or permitted by special nerves. Three, if not four,
cases illustrating this fact have come under my observation,
but for the present I shall record the details of only one, as
the facts respecting the others were somewhat less conclusive.

Mr. S. A. C , a single man aged 44, was sent to me

from Yorkshire on account of an eruption which was sus-
pected to be in connection with syphilis, from which he had
suffered ten years before. When he was stripped, I found that
his "eruption" consisted only of brown stains, without
the slightest thickening or surface change. These stains were
arranged in long streaks curving forward on the sides of
the chest and abdomen. There were also streaks down the
inner aspects of the upper arms (in the district of the
humeral branch of the intercosto-humeral). A long streak
passed vertically up his back over the vertebral spines.
The ** eruption ** caused him no inconvenience, and he
would not have known of its presence if he had not seen
it. He had no other indications of syphilis, and the history
of the primary disease was, as I have said, ten years ago.

The appearance of the stains roused my suspicions as to
arsenic, and on inquiry I found that he had been taking
that drug on account of deafness. He was clear in his
statement that he had no stains before the arsenic was
given, and that he was in his usual health when he sought
advice for his hearing. The medicine which was given him
made him, he said, feel very ill. After taking it for about a
month he could not sleep, and had difl&culty in walking. He
was breathless and had much palpitation. It was in October
that the arsenic was prescribed, and it was left off, I believe,
in December. If was in February that he came to me for
the stains, which had then been present six weeks or more.
The other symptoms of arsenical poisoning had then for the
most part passed away. There had been no disturbance of
the nutrition of the skin in his palms or soles.

MISCELLANEOUS.

{Contimied from Vol. VIIL, p, 288.)

No. CCLXXXIX. — Frequent recurrence of Hay-
naud^s Phenomena with Hematuria in an other-
wise healthy man^ and in connection with
exposure to cold.

A somewhat remarkable narrative illustrating the
paroxysmal form of Eaynaud's malady was given me

by a gentleman from Lancashire, Mr. B , of T .

Although looking very well, and accustomed to vigorous

exercise in hunting, &c., Mr. B told me that he had for

years been liable to bloody urine if he was exposed to
unusual cold. During his attacks he became, he said, quite
blue, and had most severe backache. It was necessary to
put him to bed and wrap him in blankets, &c. The attacks
always began by shivering. The backache was often very
severe. He did not, however, refer the pain to the region of
the kidneys, but rather to the sacrum. It was, he said,
always relieved as soon as blood appeared in the urine.
Some of the attacks had been so severe that he had expected
to die, and, according to his account, large quantities of
blood had been passed. Sometimes a paroxysm would occur
every day for a week, but more usually they were only once
a week or once a month. They occurred only in winter,
and he could always trace them to exposure. He had been
obliged to be most careful as to exposure to risk, and during
the last year had managed to almost wholly avoid attacks.
The first attack occurred after a long drive in an open gig
in very cold weather. Although florid and looking well, Mr.

BALDNESS IN THE TWO SEXES. 89

B had a very feeble pulse. He had suffered from

syphilis many years ago, but had never lived in an ague
district.

No. CCXC. — On the relative frequency of Baldness

in the two sexes.

A distinguished author on skin diseases writes : —
** Females are more liable to alopecia than are males; their
susceptibilities are greater, and they are more open to the
influence of disturbing causes. In one hundred cases, sixty-
three were females and thirty-seven males."

Now I cannot but think that theje is a great fallacy in

this statement of fact, and if so, in the inferences. I do not

believe that loss of hair depends upon "susceptibilities," or

that ** disturbing causes " have much to do with it. Nor do

I believe for a moment that females are more prone than

males to become bald. The author quoted seems to have

trusted to his ** statistics " rather than to his common sense.

The susceptibihties of women lead them to be very sensitive

as to loss of hair, and they naturally seek help under

circumstances which a man would probably disregard. A.s

a rule, indeed, men accept the beginnings of baldness as

inevitable, or they have something more important to think

about. Possibly they even do not notice it until some

friend makes a kind remark. A woman's long hair enables

her to observe at once if it is falling unduly, and she takes

alarm and will often assert that she " is losing all her hair "

at a stage when no one else can see anything peculiar.

There are, I admit, a few men, mostly young, who are as

sensitive as women on this matter, but they are fortunately

exceptional.

In spite of Sir Erasmus Wilson's statistics, I have no
hesitation in believing that loss of the scalp hair is really
far more common amongst men than women. If there
were as many bald women as there are bald men, wig-
making would be a very profitable trade. One of the
reasons, and perhaps the chief, of the frequency of bald-
ness in men is, that the free growth of sexual hair on the

90 , MISCELLANEOUS.

face, and sometimes on the trunk as well, competes with
that of the scalp.

No. CCXCI. — Description of the condition of the limb
many years after detachment of the Upper Epi-
physis of the Humerus, with great displacement.

•

A gentleman of thirty, who consulted me about his right
shoulder, remarked casually that the left was permanently
damaged by an unreduced dislocation which had occurred in
boyhood. He added that his surgeons had at the time
repeatedly put the bone into place, but that it would not
remain there and was still out of its socket. I requested
leave to examine the shoulder, and found that so far from
there being any hollow under the acromion, there was a
lump of rather rough bone projecting strongly in front of it
and almost on its tevel. This bony mass was almost under
the skin, and was easily seen and felt. It concealed the
coracoid, and was close to its inner side. It was not difficult
to recognise in it the upper end of the shaft of the bone
from which the epiphysis had been detached. Its upper
surface presented the uneven ridges which are so character-
istic of that part. On further examination it seemed ahnost
certain that the epiphysis itself remained in the glenoid
cavity, and that the upper end of the shaft displaced
forwards was imited to its front aspect. There was nearly
an inch and a half of shortening, and although the acromion
did not project much, there was a hollow behind and at a
little distance below it. The movements of the joint were
fairly free, and my patient said that he could do almost any-
thing with the limb. He could not, however, easily get his
hand behind him so as to button his braces, and was
accustomed for this purpose to use his other hand. The
accident had occurred in the hunting-field at the age of
fifteen, when the bone had probably attained almost its
adult length. Had it occurred earlier the shortening would
probably have been greater.

I have seen, and have recorded some years ago, several
examples of detachment of the head of the humerus at the

DETACHMENT OF EPIPHYSIS. 91

epiphysal line, but I have never met with an instance of a
similar displacement to that in the present case. I have
liad but very few opportunities for ascertaining the state of
parts long after an unreduced displacement. It is not
cominon for the displacement to be complete, that is, for
the surfaces to so leave apposition to each other as to permit
of overlapping and real shortening. The large size of the
surfaces involved will easily explain this. When complete
displacement with shortening does occur, it is probable that
there is fracture of the end of the shaft as a complication
of detachment at the epiphysal line. Such it may be sup-
posed had probably occurred in this instance. If a fragment
had been broken from the posterior border of the upper end
of the shaft the kind of displacement which had occurred
would have been more easy of production, and the difficulty
encountered in keeping the bone in place more easy to
understand.

It is hardly necessary to ask attention to the almost
complete recovery of the movements of the joint, and con-
sequently of the usefulness of the limb, in spite of the
unreduced and very considerable displacement. Injuries
to the epiphyses of the long bones are often very difficult to
treat, and in some instances, as in this, it is found impossible
to keep the bone in the position of perfect reduction. They
often cause much undeserved loss of reputation to the
surgeon concerned. It is satisfactory to be able to assure
parents that however great may be the seeming deformity
at first, there will be in the end, after the lapse of years,
almost complete restoration of usefulness.

No. CCXCII. — Usefulness of the Hand after Anchy-
losis at Elbow.

Mr. W , 52, has an anchylosed left elbow (from boy-
hood), with scars in front of radius and much shortening of
bones of forearm. Pronation and supination absolutely
lost, the palm of hand looking downwards. He can do
almost anything with the hand.

92 MISCELLANEOUS.

No. CCXCIII. — Anchylosis of Patella on inneT Con-
dyle — Useful limb.

In Mr. W the left knee has the patella on its inner

side and there quite fixed. The quadriceps is wasted so
that I cannot discover it. Yet he has walked well all his
life on the limb. He can flex it a little.

No. CCXCIV. — A peculiar form of Lupus resembling

Psoriasis.

Mr. W , 8Bt. 52, has a very peculiar form of psoriasis-
lupus. Some of the patches are exactly like serpiginous
lupus, others Hke psoriasis. There are none in the psoriasis
regions.

No. CCKGY.— Sclerosis of Tongue in a non-smoJcer —
Syphilis doubtful — Xanthelasma of Eyelids in
a mother and son.

Mr. H , aged 50, a stout man in good health. In

very early life he remembers to have had a small chancre,
but he does not think that he had secondaries. He took
medicine for some time. He does not appear to have had
any reminders. His father had diabetes, and died of heart
disease and apoplexy set. 56.

Mr. H has a sclerosed tongue with many little

abrasions at the sides, and over the whole surface a thin
** white paint layer." Yet he has not smoked. He has
been fond of painting, and was accustomed to suck his
brush constantly. I can find no other local cause, and he
has not a single stopped tooth nor any artificial ones. He
habitually uses a gasogene.

He has xanthelasma in the usual situations, thick
yellow patches. His mother had them in middle life also.
Both were very bilious. He has been married twenty
years, but has no children. Lately has been out of tone ;
easily tired. Is very thirsty, and often wakes with dry
tongue.

THE CIECULATION IN PABALYSED LIMBS. 93

No. CCXCVI. — On the influence of Paralysis of
Muscles upon the circulation in the affected
limbs.

The influence of motor paralysis upon the circulation of
the blood and the nutrition of tissues was illustrated in a
very instructive manner in the case of a man who had been
twelve months hemiplegic. His hemiplegia had been in
the first instance complete, but had implicated the muscles
only, there having never been any degree of anaesthesia.
At the end of the year he had regained the power of walk-
ing, but his upper extremity was still to a large extent
paralysed, and he could not move his fingers in the least.
All the muscles of his forearm were somewhat wasted, and
those of his hand yet more so. His fingers were habitually
curved into his palm, but there was no fixed contraction
and they could be easily straightened. The difference in
the strength of the pulse at the two wrists was most
remarkable. He was a vigorous, well-nourished man, and
his pulse in the unparalysed arm was full and strong, whilst
that of the affected one was feeble, soft, and small. The
capillary circulation of course shared in the peculiarities.
His hands were of a dusky red tint, cold and flabby. He
was obliged always to keep a glove on this hand, whilst not
needing one on the other. In a warm room the hand soon
became warm and at the same time more florid and less
dusky. The circulation was much at the mercy of the
external temperature, for on going into the cold again
the duskiness and objective coldness soon returned. No
lesions of nutrition had occurred, nor had there been any
pain excepting a dull ache when very cold. It is, I
suppose, to be held that the main influence in causing the
defective circulation is the loss of functional use on the part
of the muscles, thus bringing on a large reduction in the
vis a f route. Some share may perhaps also be due to inter-
ference with the vaso-motor nerve supply.

94 MISCEUiAKEOUS.

No. CCXCVU.— Death of Sterne— Catarrhal Pneti-

monia during Chronic Phthisis.

. Laurence Sterne died rather suddenly in lodgings in
London at the age of 55 (1768). He had been suffering
from a chest aihnent for several years, and had been sent
for long periods to the South of France. He was liable to
attacks of what he termed ''my vile influenza." It w^as
from one of these that he died — ^no doubt intercurrent
catarrhal pneumonia.

No. CCXCVni.— D^a^^ of George II. frmi Rup-
ture of the Bight Ventricle of the Heart.

On the 25th of October, 1760, at his palace at Kensington,
King George 11., without having complained of any previous
disorder, was found by his domestics expiring in his chamber.
He had arisen at his usual hour, and said to his attendants,
that as the weather was fine, he would take a walk into the
gardens. " In a few minutes after his return, being left alone,
he was heard to fall upon the floor. The noise bringing his
attendants into the room, they lifted him into bed, where
he, with a faint voice, desired that the Princess Amelia
might be sent for ; but before she could reach the apartment
he expired. An attempt was made to bleed him, but with-
out effect. Upon opening the body, the surgeons discovered
that the right ventricle of the heart was ruptured, and that
a great quantity of blood had been discharged." The king
was seventy-seven years of age.

No. CCXCIX. — Last illness of Lorenzo tJie Magni-
ficent (Son of II Gotoso).

Lorenzo the Magnificent, the son of Lorenzo il Gotoso,
died at the early age of forty-eight. The cause of his death
is doubtful. He had long suffered from ill-health, and had
frequently had recourse to the baths of Siena and Porrettana.
He was, however, looking forward with confidence to the
enjoyment of rest and literary pursuits when his fatal ilhess

DEATH OF LOEENZO THE MAGNIFICENT. 95

seized him. I extract the following from Boscoe*s life of
laim : — " Politiano describes his disorder as a fever, of all
otliers the most insidious, proceeding by insensible degrees,
not like other fevers by the veins and arteries, but attacking
th.e limbs, the intestines, the nerves, and destropng the very
principle of life. On the first approach of this dangerous
complaint he had removed from Florence to his home at
Careggi, where his moments were enlivened by the society
of his friends and the respectful attentions of his fellow-
citizens. For medical advice his chief reliance was upon
the celebrated Pier Leoni, of Spoleto, whom he had fre-
quently consulted on the state of his health; but as the
disorder increased, further assistance was sought for, and
Ijazaro da Ticino, another physician, arrived at Careggi. It
seems to be the opinion of Politiano that the advice of
Ijazaro was too late resorted to ; but if we may judge from
the nature of the medicine employed by him, he rather
accelerated than averted the fatal moment. The mixture
of amalgamated pearls and jewels with the most expensive
potions might indeed serve to astonish the attendants and to
screen the ignorance of the physician, but were not likely
to be attended with any beneficial effect on the patient.
Whether it was in consequence of this treatment, or from
the nature of the disorder itself, a sudden and unexpected
alteration took place, and he sank at once into such a state
of debihty as totally precluded all hopes of his recovery, and
left him only the care of preparing to meet his doom in a
manner consistent with the eminence of his character and
the general tenor of his life." After this followed the cele-
brated interview with Savonarola, and others with his son
and friends. Although no definite diagnosis appears to have
been arrived at, it is clear the symptoms were held to pre-
clude all hope ; it is further clear that the patient retained
his faculties to the last. The malady, having regard to
the antecedents, may not improbably have been disease of
the kidneys and bladder.

96 MISCELLANEOUS.

No. CCC. — Syphilis in the Sixteenth Century.

The father of Catherine de Medici (the wife of Henri II.
and Queen-mother during the reigns of Francis II., Cliarles
IX., and Henri III.) is stated to have died of syphilis a few
days after his daughter's birth.* Catherine was an only child,
and her mother died at her birth (1518) . H^j portraits, which
are numerous, show no evidences of inherited taint. At that
time syphilis was a new disease in Europe, and, as it had
not then been in any way associated with sexual habits, no
disgrace was supposed to be attached to it. Historians felt
no delicacy in recording the fact that any one of whom they
wrote had suffered from it. Many deaths of ecclesiastics as
well as civilians were attributed to it.

* See vol. ii. Boscoe's " Life of Lorenzo de Medici."

AECHIVES OP SUEGEEY.

APRIU 1898.

ON SYMBIOSIS IN EEFEEENCE TO HUMAN

PATHOLOGY.

Kecent observations in what is known under the name of
Symbiosis are likely, if I mistake not, to throw light on many
of the problems of pathology. By this name is designated
a peculiar forip of parasitism, in which one organism lives in
the tissues of another, but without necessarily causing any
damage to them. The two thrive together in a sort of
partnership which may or may not be disclosed. There is
nothing to prevent the one becoming inimical to the other,
but at the same time there is nothing to necessitate it.
Sometimes indeed the intruder — or shall we say the visitor?
— ^is actually beneficial to the host. This may occur, for
instance, when a vegetable organism, living in the tissues
of an animal, actually decomposes carbonic acid and sets
free oxygen.

The intimate and seemingly permanent union in which
two vegetables live into each other in the case of lichens ib
one of the most startling examples of s3rmbiosis. Almost
all our more advanced physiological botanists now admit
that lichens do not constitute a separate family of plants, but
are produced by the structural union of an alga and a fungus.
The two plants which habitually live in this close union may
be artificially separated and cultivated apart. It is not easy
to say which is the host and which the parasite. The two

VOL. IX. 7

98 ON SYMBIOSIS IN REFBRBNCB TO HUMAN PATHOLOGY.

are in structural union and thrive together without undue
preponderance of either.

A more simple example of symbiosis occurs in the
instance of the green sea anemone (Anthea viridis). It is
known that the green colour of this coelenterate is caused by
the presence in its struct\ire, enclosed in its outer tissues, of
an alga of imicellular form. Mtoy others of the same class
of animals — corals, jelly-fish, and anemones, are known to
be coloured either green or yellow by the presence of similar
algse; and according to the researches of Mr. P. Geddes
these algae remove carbonic acid from starch and give out
oxygen, being in this way distinctly advantageous to their
fortunate possessor.

Now in reference to human pathology I would venture to
suggest that although we have arrived at the crude fact — a
very important one — that bacilli are present in many more
or less specific forms of disease, we as yet know but little as
to the possibilities of their intimate relations with the
tissues in which they dwell. It may be that they are
often present in a sort of symbiotic relationship and without
evoking any obvious disturbance of nutrition. It may be
that they are only liable to be excited into states of disease-
producing activity by influences which are by no means uni-^
versally present. Thus the bacillus leprae may possibly
have been present quietly in the tissues of the subject of
leprosy for years, awaiting the stimulus of salt-fish diet to
rouse it into activity. There is nothing in the present
condition of our knowledge to exclude the possibility that
the dormant form may be one of considerable diflfer-
ence as regards size, &c., from that finally produced
when it assumes activity and causes the phenomena of
disease.

Some such conjecture as this seems to me essential in
order to the explanation of inheritance, latency, and recur-
rence in reference to many specific forms of the inflam-
matory process. Those of scrofula, tuberculosis and leprosy
are perhaps the most important, but we have others
in erysipelas, elephantiasis, some forms of eczema, and
possibly in psoriasis. It is even possible that the tertiary

ON SYMBIOSIS IN REFEBENCE TO HUMAN PATHOLOGY. 99

stage of syphilis may depend upon the persistence of
parasitic organisms which have passed into a sjntnbiotic
state of existence and are no longer capable of leaving the
cell structures in which they dwell and of becoming infective
to others. In order to explain the local origin of a gumma we
must, I think, invoke the hypothesis of either a chemical or
vital element which has been left behind in the tissues.
There must have been some residuum which determines the
peculiar tj^e which the local inflammation or growth finally
assumes. That residuum is incapable of originating a specific
contagium which may be transferred to other persons or to
other parts, but it is not incapable of causing cell-contagion
in the affected part. Infection spreading by continuity of
tissue is one of the best characteristics of the gumma, and it
is more easy to explain it on a theory of symbio^s of living
organism than by one of a chemical ptomaine. So also I
think is the fact that tertiary gummata, however long may
have been the interval between their formation and the
original disease, and however complete the proof of their
non-contagiousness, are still amenable to the influence of
the specifics for syphilis, mercury and iodides.

It will, I know, be objected to all suggestions of symbiotic
parasitism in human disease that they lack objective demon-
stration. To this I reply that the microscope has never yet
shown us the organic element of syphilitic contagion, and
that in a disease so definitely tuberculous as lupus ery-
thematosus it has not as yet found a bacillus. We are
merely on the threshold of our knowledge in these matters,
and although I admit that what I have suggested is mainly
conjectural, yet there is so much of a priori probability
about it that I feel sure that it is worthy of our attentive
consideration.

» u

ON SUDDEN OCCLUSION OF AETEEIES BY

COAGULATION.

Ebfeeencb has been repeatedly made in the pages of
Archives to cases in which large arteries had become
obliterated without obvious disease, and in some instances
quite suddenly. In one of these a man in apparent health
had fallen unconscious on his own hearth, and had on
recovery remained hemiplegic with complete obliteration of
the opposite carotid. He had also obliteration of one femoral .
I have also asked attention to two valuable case-narratives,,
one by Sir William Gull and the other by Sir W. Savory, in
which one or other of the large arteries of the neck were
found (post mortem) to be quite obliterated. In one of
these the opening of the innominate from the aortic arch-
was smoothed over and the vessel itself was a solid cord. In
these cases there was no evidence of preceding arterial
disease, nor was there any explanation forthcoming of the
cause of the obliteration. One if not more of the patients
was under middle age.

At the date of the above reports, and, indeed, until the
other ddy, I was unaware of the existence of a most valuable
paper from the pen of Dr. Dickinson in the St. George's
Hospital Beports which supplies a sdrt of complement to
them. In all my cases, and those which I quoted from =
ptbers, the condition was of old standing and the account 6f
. :flie original symptoms somewhat imperfect. Dr. Dickenson
^ ^dfe'als with recent cases which had been treated in the warda
of St. George's Hospital, and in which autopsies had been
obtained. His facts go to establish the proposition that it is
possible for the blood to coagulate almost suddenly in large
arteries, and thus produce paralysis and obliteration of the
vessel concerned and corresponding paralysis. It implies.

DB. DICKINSON'S CASES. 101

although this may be considered as less assured, that this
coagulation may be quite independent of embolism and of
disease of the walls of the vessel and of any special form of
dyscrasia in the patient. The subject is one of so much
novelty and importance that I must give abstracts of his
cases.

In Case I. the whole length of the left internal carotid and
all its branches, as far as they were traced, was filled by a
black coagulum. Outside the skull the vessel was empty
and natural. Nothing abnormal could be discovered in the
walls of any of the cerebral vessels. There were no coagula
' in the heart or in other arteries, and no vegetations in the
valves. The subject of the case was a coachman, aged 39,
who until within twenty hours of his attack had been
supposed to be in good health. He had fallen in a fit quite
unconscious, and with foaming at the mouth, whilst in the
act of hanging up his harness after having been out during
^the greater part of a June night. His symptoms, in addition
to the unconsciousness, had been loss of sensition, motion
and all reflex action in the right limbs, with slight ptosis on
the left side. About an hour and a half before death there
was an accession of symptoms, with slight convulsions and
much foaming at the mouth, after which the breathing
became stertorous. It should be added that the right lateral
ventricle was full of fluid, whilst the left was empty. This,
however, could have nothing to do with the hemiplegia,
since it was on the same side.

This case is not unlike the one which I have recorded at
page 36 of Vol. VII. The only differences are that in my
case the patient survived, and that not only the internal
but the common carotid was obliterated.

In Case II. the circumstances which preceded the attack
were not known. The patient was forty-three years old
and the mother of six children.

*' The attack, which was the first that had occurred, was preceded by

a feeling of giddiness. She only Hved a few hours after her admission.

/There was no return of consciousness. The left side was palsied*; the

102 SUDDEN OCPLUSION OF AETEEIES BY COAGULATION.

right leg was frequently drawn up, and with her right hand she was for
ever wiping and rubbing her face. She swallowed with difficulty. Before
her death there was much foaming at the mouth."

The following is the account of the condition of the cerebral
arteries:—

" The arteries at the base were obstructed in many places by recent
coagula ; these were most abundant in the right hemisphere ; the end of
the right internal carotid was filled by a plug an inch and a half in length,
which was slightly attached to the wall of the vessel. The surface had
become slightly decolorised. Many similar plugs were found in the
smaller arteries. They were generally about an inch in length, and
manifested a tendency to place themselves on the cardiac side of a
bifurcation. The left posterior cerebral was one of the vessels affected.
There was no difference in consistence between the two sides of the
brain."

All the valves of the heart were the seat of fibroid
thickening, and the mitral orifice was contracted to the size
of a button-hole and quite rigid. There were, however, no
vegetations or fibrinous concretions.

The subject of the third case was a young woman of 23,
who had long been the subject of heart disease and was
liable to attacks of vomiting. She was admitted into the
hospital, and it was noted that her face was bluish and
flushed and her pulse indistinct. She was, however, up and
about. One morning, whilst washing her face, she became
suddenly faint, and died quickly without having spoken. Dr.
Dickinson writes: "Death was almost the first symptom"
of the coagulation. '* The patient must have expired almost
on the instant of its formation." In this instance coagula
had formed in both internal carotids. The plug on each
side measured two inches in length, and extended from the
bony canal up to the smaller divisions of the vessels. Many
of the smaller vessels contained detached coagula. Outside
the skull the internal carotids were empty, but on the right
side the external carotid was plugged.

In the fourth case, a man aged 36, who had tramped from

DR. DICKINSON'S CASES. 103

Leeds in July weather, was seized by a fit on his arrival in
London. There was partial paralysis of the left arm and
inability to speak, although consciousness was not lost. He
sank on the third day after his attack, having had a very
rapid pulse, profuse sweating, and incontinence of urine.
Long black coagula were drawn out of both carotid arteries
from the base of the skull. They were not adherent. All
the larger arteries at the base were similarly occupied, but
the coagula were not quite continuous. The heart and
arterial walls were healthy.

This case would appear to have been one not improbably
of only partial obstruction. The clots were still loose, and
did not fill the vessels. Some circulation still went on past
them, and thus the patient escaped the sudden fate which
occurred in the preceding one.

In the fifth case it was the basilar which was obstructed.
A firm buff-coloured coagulum distended its whole length and
also the adjoining quarter of an inch of the right vertebral.
The clot was an inch and a half long, hard, and somewhat
adherent to the walls of the vessel. It was more perfectly
decolorised in its outside than in its centre. There were
no coagula in other vessels and no trace of atheroma any-
where. The valves of the heart, especially the mitral, were
thickened and leathery, but there were no vegetations.
The other organs were healthy. Dr. Dickinson points out
that a coagulum large enough to distend the basilar artery
could not have passed upwards through either of the small
vertebrals, but must have formed in situ.

The patient in this case was an intemperate carman aged
26. His first symptom had been giddiness, which began
suddenly late one night. After this for two days he went
to his work, but was eventually obliged to take to his bed.
Four days later he suddenly lost his speech and had pins
and needles in his right arm, followed by loss of power.
He did not lose consciousness, but subsequently became
delirious. His pulse became very rapid, and he died on the
second day after admission and the ninth after his first
symptom.

1Q4 SUDDEN OCCLUSION OF ARTERIES BY COAGULATION.

This very remarkable group of cases appears to afford
conclusive proof that coagulation of the blood in the
cerebral arteries may take place suddenly and independently
pf disease of their walls. In no one single instance was
atheroma noted, and in none was there any indication of
embolism. The occurrence indeed of coagulation simul-
tpineously on both sides, and in one instance in the external
carotid independently, put the probability of embolism out
of question. In four out of the five cases — and this is a
point to which Dr. Dickinson draws especial attention — the
circulation was placed at disadvantage by the presence of
o^bstructive disease in the central organ. In only one case
was the heart free from disease, whilst in several the mitral
orifice was very definitely contracted. In one, however
(Case IV.), the heart was normal. This was the case in
which the man was probably much exhausted by a long
tramp in hot weather. In no single case is any suspicion of
syphilis recorded, but indeed in the entire absence of evi-
dence of disease of the arterial coats it is difficult to see
how syphilis could contribute to the conditions under con-
sideration.

Dr. Dickinson's paper refers only to the cerebral arterie^.
It is my wish ifco extend the conclusions deducible from his
facts to the rest of the arterial system, and to suggest that
what has been proved in the case of the intra-cranial vessels
may occur in any of those of the limbs, and that it is not very
infrequent. Naturally we do not get many opportunities
for post-mortem demonstration in the case of the latter. It
is only the vessels of the brain the sudden occlusion of
which endangers life. Surgeons are, however, familiar with
cases in which patients have experienced sudden pain in a
limb, and that pain has been followed by peripheral gan-
grene and other sjrmptoms of arterial obstruction. We
have been accustomed to assume that these are instances of
embolism or of occluding arteritis, but the not infrequent
suddenness of onset would suggest coagulation of blood as a
much more probable event.

During the last few months I have seen two such cases.
In one the toes had become gangrenous, and in the other

A CASE-NAEBATIVB. 105

there was sloughing of the skin of the leg. In the latter
the femoral artery could not be felt, but in the other the
obstruction was probably lower down. Both were remark-
$bble for the suddenness with which the symptoms of
obstruction had developed.

In amputations for gangrene it is not uncommon to find
the arteries plugged,- I remember well one in which the
hand had suddenly passed into gangrene, and in which I
found the brachial artery as high as the axilla stuffed with
firm coagulum ; and in several in amputation through the
thigh, a similar condition in the femoral has come undey
my notice. Hitherto it has been the custom to regard
arterial thrombosis under such circumstances as being
probably secondary to other changes, but in the light of
present facts it may reasonably be suggested that it is
primary.

In strong contrast with what usually occurs in syphilitic
pcclusion of arteries we have in these cases a remarkably
sudden onset. In the syphilitic cases the obstruction is
commonly somewhat slowly produced outside the vessel, and
if thrombosis finally occurs it is usually consecutive. In the
present group there is no external obstruction, and there
aore no premonitory symptoms.

Left Hemiplegia occurring suddenly in the night in a
healthy mafi who had suffered from Syphilis twenty
years previously — Diagnosis Arterial Thrombosis not
due to Syphilis.

In the following case, a year after the attack the loss of
muscular power is still almost absolute in the hand and
foot, and much less so in the face, thigh, and upper arm.
Thus the man can walk but cannot move his toes, and ca^
to some slight extent move his upper arm and bend his
elbow, whilst he cannot stir a finger. As regards his facial
muscles he can both frown and close his eye, but cannot
whistle, and his mouth is drawn to the opposite side. He
has control over his sphincters, and can protrude his tongue
straight. In all these points his case conforms, I believe, to
what is usual in patients recovering from almost complete

106 SUDDEN OCCLUSION OF ABTERIES BY COAGULATION.

hemiplegia. His account of the seizure which produced the
paralysis is that exactly a year ago, when he was feeling quite
well and was wholly free from discomfort in his head, he one
night went to bed as well as usual, but half tipsy. He woke
at his usual time with a call to make water, and on attempt-
ing to get out of bed found that he could not use the left
limbs. He was quite alone. He could not speak, and had
no alternative but to lie still till his housekeeper came to
know why he did not get up. He was then obliged to make
signs for his pencil, for he could not articulate. He
was perfectly conscious and wrote a request to fetch a
certain doctor. After this he remained in bed three
months. During that time he had constipation, but no
trouble with his bladder. His face was, he says, so com-
pletely paralysed on the left side that he could not move
it, and his tongue was pushed over to the left side so
strongly that he frequently bit it.

On the day following the attack he began to be able to
speak, but it was only very indistinctly. During the next
six months his speech continued gradually to improve,
and he can at the present date talk well if he -does so
deliberately.

This case appears much more like one of sudden throm-
bosis than of haemorrhage. I do not see any reason to
suppose that the previous syphilis had anything to do with
it. Neither before or since were any indications of syphilis
present.

I have recently seen another very similar case as regards
the suddenness of the attack. The patient was in the
second year of syphilis. Death followed after about ten
days of hemiplegia, with intervening symptoms not unlike
delirium tremens. As we did not get a post mortem it is
not worth while to record details.

THE SEQUEL OF A CASE OF
OPHTHALMOPLEGIA.

By the courtesy of Dr. E. J. Cross, of St. Neots, I have
just been suppUed with the details respecting the death of a

patient whose case I had recorded in 1878. B. B was

the subject of Case VII. in my original paper on Ophthal-
moplegia Externa in the Medico-Chirurgical Transactions
(see vol. Ixii. page 15). He had then recovered under
iodides from almost complete paraplegia after syphilis, and
was at that date slowly improving under similar measures as
regards the partial paralysis of the muscles of his eyeballs.
The case is of importance as an example of complete
recovery, without relapse, in the first place from paraplegia,
and, secondly, from ocular conditions which more usually
prove aggressive. He took pills containing a third of a grain
of calomel three times a day, with iodide of potassium in
scruple doses for, I believe, at least two years. From 1878
to 1895 he enjoyed good health, and had no tendency to
relapse. In the latter year he had, in addition to consider-
able dyspepsia, some return of diplopia, and again on his
own responsibility took iodides. His death was attended by
symptoms which might not improbably indicate an abscess
in connection with the gall bladder. There was slight
jaundice and clayey stools, and finally sudden profuse
vomiting of foul fluid. The symptoms were suggestive
rather of an abscess which had given way into the stomach
than of any form of syphilitic disease. Unfortunately there
was no autopsy.

108 THE SEQUEL OF A CASE OF OPHTHALMOPLEGIA.

Schedule of the Case of Mr. B. B-

DATE.

AGE.
26

1869

1870

27

1871

28

1872

29

1873

30

1874

31

1876

32

1876

33

1877

34

1878

36

1879

36

1880

37

1081

38

1882

39"

1883

40

1884

41

1886

42

1886

43

1887

44

1888

46

1889

46

1890

47

1891

48

1892

49

1893

60

1894

61

1896

62

DETAILS.

Syphilis complete. No record of treatment.

Threatened paraplegia, and for a time confined to bed.

Recovered under iodides, &c.

Paresis of ocular muscles. Ptosis and diplopia.

Under my observation with ophthalmoplegia externa.

Still under treatment (mercuir and iodides).

In January attended at Med. Chir. Society.

Well.

In good health. Married. In constant occupation as a butler.

Dyspepsia and flatulence.

Died on August 17th. Abscess about gall bladder ?

The following details as to his fatal illness have been
supplied by Mr. Cross : — •

" Present illness (August, 1896). — For the last two years he has had
pain in the stomach, a great deal of flatulence and some indigestion ; has
noticed that he has been getting gradually larger round the waist. Two
months ago he noticed that he began to see double again, and had an
old prescription of Mr. Hutchinson's made up, and now he sees quite
well again.

On examination, — A well-nourished (fat) man, complaining of intense
pain over region of liver, which is considerably enlarged and very tender.
A distinct lump may be felt at the level of the mnbilicus, and about two
Inches to the right of it. Tongue furred. Bowels constipated. Con-
junctivBB slightly yellow. Temperature 100°. '

Urine. — Acid 1020. No albumen, ^o sugar. Treatment — injection
of morphia and a calom<

THE SEQUEL OF A CASE OF OPHTHALMOPLEGIA. 109

Atcgtcst 9th. — Pain much easier. Has had a fairly comfortable night.
Bowels open twice. Motions clay-coloured.

Av^tist 10th. — Bather more comfortable.

August 11th. — Abdomen less distended. The lump is not nearly so
distinct nor so tender. Temperature 100°.

AttgiMt 12-14th. — Much the same. Fairly free from pain.

Aiigust 15th. — Bather more pain. Bowels not open since 12th. A
calomel purge.

Atigust 16th. — Diarrhoea very profuse.

August 17th. — ^^Sickness has eome on.. About 12.30 patiei^t raised
himself, vomited about three pints of very foul fluid, and expired almost
instantly. (I was present at the time.)"

f From this narrative of the symptoms which attended the
fatal illness, there does not appear any reason to suspect
syphilitic mischief. A gumma would have developed much
more quietly,' The symptoms were those of an acute in-
flammatory process, and the matters Vomited were most likely
the contents of an abscess. I have recently seen two cases
illustrating similar conditions. In one a lady vomited the
contents of a very large swelling which had formed in con-
nection with the stomach or liver, and nearly died at the
time. In the other a man who was extremely ill with
symptoms supposed to denote suppuration in the liver was
found at an operation to have a large abscess containing
grumous fluid behind the liver. ^ It was on the point of
giving way into the peritoneum.

f

ON THE NATUEE OF GUMMATA.

It is very necessary in order to a clear understanding of
tertiary syphilis that we should know what we mean by a
gumma. This word, which has come down to us from very
ancient times, was, I believe, originally applied to a soft,
indolent swelling occurring in association with a syphilitic
taint. More recently its meaning has been somewhat
extended, and it has been recognised that a gummatous
process may be present although little or nothing that can
be called a tumour is ever produced. It would perhaps
assist our comprehension of the matter if we were to speak
rather of '* the gummatous process " than of a gumma.
Under that term we should include all forms of chronic
inflammation attended by chronic swelHng, and tending to
break down, which occur in connection with a syphilitic
taint. I do not know that we gain much by calling o,
gumma a " granulation tumour,'* it is rather a somewhat
peculiar form of chronic inflammation. Its peculiarities
consist in an indolent character, a tendency to produce
swelling, and but little liability to suppurate. A gumma
may break down and soften, or it may slough, but it does
not as a rule form an abscess containing pus. We must
not, however, push these distinctions too far. Between
syphilitic inflammations in which the swelling is from the
first attended by considerable increase in vascularity and in
which there is a decided tendency to suppurative ulceration,
if not to the formation of a circumscribed abscess, and the
more characteristic gummata, we have all gradations. As a
rule, however, gummata resemble new growths rather than
inflammations in that they are not very vascular, are not
very painful, and are in all stages slow and indolent. The
cellular tissue is probably the invariable site of the gumma-

ON THE NATURE OF GUMMATA. Ill

tous process. An indurated chancre is an example of one
form of gumma. The lumps which sometimes form in the
substance of the tongue or in other muscles, and which are
sometimes very hard and closely resemble new growths, are
our best examples of tertiary gummata.

Just as definitely as primary indurations melt away under
the influence of mercury, so do these muscular gimimata
under that of the iodide of potassium. It is, indeed, this
easy amenability to specifics which chiefly distinguishes
these " tumour-gummata " from independent new growths.
When a gumma breaks down there is often disclosed a
sloughy mass of cellular tissue, and when this separates,
which it does very slowly if specifics have not been efficiently
used, an unhealthy base will be exposed, and there will be a
tendency to peripheral spreading, with induration of the
walls which may constitute a very close resemblance to
cancer. There are few more difficult problems in diagnosis
than to distinguish certain forms of open gummata of the
tongue from cancerous sores. The degree and quality of
the induration, and frequently the flabby state of the over-
hanging borders, are amongst the most useful signs.

Something of the gummatous process probably attends
many forms of syphilitic inflammation which yet do not
earn the name of gumma. Such, for instance, are many
examples of syphilitic lupus and of the ulcerative destruction
of the soft palate and adjacent parts which occur in the
tertiary stage. In these the tissues inflame and ulcerate
before any appreciable tumour has formed. The chronic
infective inflammations of the subcutaneous cellular tissue,
which ulcerate to a slight extent whilst they undermine
widely, are also gummata. These are often seen about the
knee in women. Some of these subcutaneous gummata are
often very like sarcomatous growths. A very remarkable illus-
tration of this is recorded at Vol. VIII. p. 221 . In this instance
a tumour gumma, which had been once cured by iodides,
relapsed, and was (by another surgeon) excised as a new
growth. It relapsed again and was again cured by iodides.

The gummatous process is certainly attended by the
development of cell elements which are infective. Whether

112 ON THE NATURE OF GUMMATA.

tdcerated or not, gummata tend to spread by " the contagion
of continuity." They need to be destroyed just as do
cancers. The least bit of gummatous tissue left living will
Reproduce the whole thing. On the other hand, if once a
sound scar have replaced the gumma in every part there is
but very slight risk of relapse.

' Gummata are very rare in the secondary stage of syphilis,
and the longer the interval since the primary disease the
greater is the probability that the peculiar features of a
gumma-'tumour will be well shown. Under these con-
ditions they are to be regarded as local, just in the same
sense as a cancer is local. They differ, however, from
cancer in having no power of infection, either to th6
lymphatic system or the blood. Their infection is, like that
of the rodent ulcer, limited to the tissues in continuity with
them. In these, however, it is often very strong, and
repeated recurrences after partially successful treatment
will be witnessed.

The treatment of gummata should be based, as just hinted-,
upon the same principle as that of malignant new growths.
They should be utterly destroyed. Fortunately it is not
needful to excise them. Their vitality is low and is easily
influenced by several different remedies. The local use of
iodoform will often remove those which are sufficiently
superficial to give it adequate access. Iodide of potassium
reaching them through the blood will have the same effect.
An attack of acute adventitious inflammation artificially
induced, as for instance by a free application of nitric acid,
will often succeed, and that even when the internal use of
the iodide has partially failed.

The important point to bear in mind is that every particle
of the morbid tissue must have been brought into a normal
condition, or the process will be reinitiated. There is no
more tendency to the spontaneous cure of tertiary gummata
than there i^ to that of cancers. In some desperate cases
scraping, excision, or even amputation of the part may
become desirable.

As i^egards the theory of tertiary gummata, they are, I
think, clearly residual in their nature. Something ha& been

ON THE NATUBE OF GUMMATA. 113

left behind in the tissues from the date of the secondary or
blood phenomena which originates these peculiar forms of
cell-growth. It does not seem probable that the " some-
thing*' is of a merely chemical natmre. If it were so its
action would probably be more widely manifested. I
incline rather to suspect that a process of the nature of
symbiosis must be taken into account, and that in a state oi
niodified vitality the specific germs of the syphilitic fever
must be regarded as having entered into a Hfe-partnership
with the cell-structures of the part concerned. There are
plenty of collateral facts in pathology to justify such an
hypothesis. It would also explain what the chemical
theory would fail to do, the fact that a drug which
certainly possesses some power over the inflammations of
secondary syphilis is also a specific for these, and further
that their type is often remarkably like that of the primary
sore.

One of perhaps the very best illustrations of the gima-
matous process is to be met with in the " recurred chancre.**
Here we may have, after the lapse of many years, during
^hich the part has appeared to be in a state of perfect
health, a new induration form of large size, and exactly
like a primary Hunterian sore. The chief difference is,
that whilst the one begins by an ulcer which indurates, the
other begins as an induration which ulcerates. These
gummata are almost always exactly in the site of the
original sore. They are not contagious to other persons,,
nor do they infect the lymphatic glands or the blood of the
patient himself.

VOL. IX. 8

CASES ILLUSTEATING EECUEEING HEEPES OF

THE MOUTH, TONGUE, &c.

The Herpetic group of affections assumes year by year
increasing importance. More and more clearly do we
accept, in all that we name as "herpes," illustrations of
what the nervous system can effect in inducing local patho-
logical changes, and in proportion as we perceive this does
our interest increase in the examination of the facts.
Herpes zoster and herpes labialis still remain for us, as
they were for our ancestors, the two type forms ; the one
of the single attack, the other of the frequently recurring
form. We recognise, however, a number of eruptions which
do not conform closely to the ordinary laws of either of
these, and which yet clearly belong to the group Herpes.
Thus we have cases in which a zoster form is frequently
recurrent, and we have cases in which the labialis form
recurs so quickly that it is almost persistent. We have
also certain generalised, eruptions on the whole body, or
large parts of it, which appear to partake of the herpetic
type, but which sometimes approach so closely to pemphigus
that we are puzzled how to classify them. An unexpected
observation has also recently accrued, to the effect that
certain forms of severe pemphigus of the limbs and trunk
are preceded by months, or it may be years, of liability to
recurring herpes in the mouth.

The collection of cases which I now propose to record
vdll comprise illustrations of many of the more infrequent
forms of Herpes. In the first place, however, I purpose to
deal with those just alluded to in which severe, and fre-
quently recurring, attacks occur, affecting the mucous mem-
brane of the mouth. It is not all of these that end in
pemphigus ; or perhaps it would be safer to say-since the

HERPETIC STOMATITIS SIMULATING SYPHILIS. 115

development period may occupy several years — ^it is not in
all that the pemphigus stage is attained. It is, however, a
matter of great importance to determine, if possible, what
the nature of the relationship between the two really is.
The cases which I have now to record are remarkable
examples of herpes of mouth without pemphigus of the
body, but in former papers I have given several of the latter
class. Thus in the case of so-called pemphigus vegetans,

given at a former page (Mr. S ), a liability to herpes

of the mouth, frequently recurring, had been present six
yegirs before the pemphigus was developed on the skin
(Vol. VIII,, page 130).

In the case of Miss L , given at page 333, liability to

herpetic sores in the mouth had preceded by one year the
appearance of pemphigus on the body.

The conditions presented in these cases of severe and
almost persisting herpes of the mouth so closely resemble
those of syphilis, that in almost all cases they are at one or
other period so diagnosed and so treated. This occurred in
my first case of " Inflamed mouth with eruption,'' published
in the Medico-Chirurgical Transactions, and has happened
in almost all examples of " pemphigus vegetans." It will be
convenient, therefore, if I first deal with this part of the
subject.

ON THE LIABILITY TO MISTAKE RECURRING HERPES
INSIDE THE MOUTH FOR SYPHILIS.

Herpes of the Mouth recurring with increasing frequency
during fifteen years — No previous Syphilis,

As I have said, the diagnosis of herpes of the mouth is
important on account of the risk of those not familiar with
the malady mistaking it for syphilis. The mistake is indeed
one of very frequent occurrence. It is especially likely to
happen in cases where the patient has really had S3rphilis,
for in such cases the patient himself abets the error. In
some sense such cases are perhaps syphilitic, but, like
recurrent herpes on the penis after chancres, they are not

116 RECURRING HERPES OF THE MOUTH, TONGUE, ETC.

to be cured by mercury or iodides, but by arsenic. Occa-
sionally, however, we may encounter recurring herpes of
the mouth in which there has been no antecedent syphilis
whatever. Of this the following is an example.

In 1889 Dr. Daly, of Amherst Boad, sent to me a gentle-
man of thirty-two, who was in excellent health, had a
healthy child, and who declared that he had never in his
life had a chancre. He showed me inside each cheek one or
two oval, greyish, superficial ulcers, and along the right side
of his tongue several little similar spots which were all but
healed. He said that they were going away, and the result
of his experience was that they would be gone in the course
of another week. The spots on the cheeks were exactly like
what are generally believed to be characteristic of sj^hilis.
He assured me that he was liable to them, and had been so
for fifteen years past. They had of late so much increased
in severity and frequency that he was scarcely ever free from
them. He was quite clear, however, in his statement that
no individual spots lasted long ; in a week or ten days they
would heal, and others would come. With these facts the
diagnosis of herpes was clear.

The diagnosis being made, I was interested in examining

the facts as to the history in a little more detail. Mr. F

told me that he had never had the eruption on his lips, and
he did not think that as a boy he had been liable to it there.
It had always come on the insides of his cheeks and sides of
his tongue. Sometimes it would be restricted to one si(Je,
and sometimes to the other, and sometimes, as on the occa-
sion when I saw him, it would be on both sides at the same
time. As far as he could remember, when he first became
liable to it, ten or fifteen years ago, it was a slight matter,
and did not come very often. His first attack occurred after
a visit to the seaside, and after he had bathed on a cold
morning. His tongue and cheeks became covered with sores,
and the former much swollen. He was for the first time
obliged to consult a medical man, and placed himself under
the care of a very intelligent friend of my own, who quite
refused to believe his story that he had never had syphilis.
The attack, however, passed quite away in the course of ten

HERPETIC STOMATITIS. 117

days. This was in July, 1888, and he did not have another
severe one until October of the same year, when he was
obUged to place himself under the care of Dr. Daly. Since
that to the present time, March, 1889, he had never been
free for more than a week or two together. He had not
been able to trace the attacks to the influence of any article
of food, or to any special derangement of health. He always,
he said, felt chilly and creepy before they occurred, and
during the last six months he thought that he had felt a
httle nervous and low. He still, however, had the appear-
ance of excellent health. Since October, the almost con-
stant soreness of his mouth had compelled him to desist
from smoking.

In June, 1890, he was very much better, after having taken
arsenic quite regularly for a whole year. Although he was
never more than a few days without the herpes, yet it was
not nearly so severe as formerly. I found on examination
only a single sore on the right side of the tongue, near the
tip.

Becurring Herpes of the Palate — No Syphilis — Arsenic given
— Immunity from the Herpes of Palate — Very severe
Zoster from the Arsenic,

Captain C , aged 50, formerly accustomed to go to

sea, but for six years residing on land, consulted me in
June, 1883, on account of liability to herpes in the mouth.
He was in excellent health, and had never had syphilis.
For the last two years he had been liable to attacks of
herpes on his palate once every month or two; they had
often been slight ones, but on the present occasion it was
very severe ; his whole palate was covered with little ulcers,
which also extended down the sides, and he was hoarse to
a degree which suggested some implication of the larynx.
The attack had lasted two weeks, and was now passing off.
I could find no cause for his liability excepting that he had
some bad teeth. For the prevention of his attacks I ordered,
as usual, arsenic. He took the liquor sodae arseniatis m. iii
three times a day from June 14th to August 23rd, and had
complete immunity during that time. Six weeks from the

118 EECURRING HERPES OF THE MOUTH, TONGUE, ETC.

beginning of the arsenic, however, he had a very severe
outbreak of zoster in the lower dorsal region ; the spots were
gangrenous, and when I saw him three weeks later they had
not quite healed. On account of the shingles he left off the
arsenic for about three weeks, but afterwards resumed it.
He subsequently became again liable, although continuing
it, to recurring attacks on the pillars of the fauces, but they
were on a much more limited scale and did not last long.
On September 22nd of the same year I saw him for a slight
attack of this nature. I advised him to continue the arsenic,
and I believe that he subsequently got quite well.

Becurring Herpes in the Mouth — No Syphilis — Besistance

to Arsenical treatment.

The case of Mrs. W is an example of great distress

caused by the very frequent recurrence of herpes in the
mouth. It. is also, I am sorry to say, an instance in which
arsenic did not cure. She came under my observation on
June 2, 1890. She was a married lady of fifty, and had
suffered from acne rosacea on the face. Her chief trouble
was, however, that for several years she had been liable to
recurring herpes on her tongue and lips. The ^.ttacks came
so frequently that the sores had scarcely time to heal in
their intervals. She said that the individual spots were
jfclways well in two or three days, but that fresh crops
came every few weeks. It appeared that they were seldom
non-symmetrical, but on the day when she came to me the
right side of the tongue and the right side of the lower lip
were the only parts affected. I ordered her liquor arseni-
caUs in two-minim doses three times a day, and gave her a
sulphur wash for her acne. She came to me again six
months later, February 10, 1891, with her face very much
better, and stating that she had had very few and very sUght
attacks of herpes. She was much pleased with the result,
Piud I thought that by persevering with the arsenic it Would
prove a cure. She came again, however, oji February 13th,
saying that her herpes had recurred, aud that she was now
scarcely ever free from it. It made her mouth so sore that

CASB-NABEATIVES. 119

she often could scarcely eat, and was obliged to keep to
fluids. She assured me that she had taken the medicine
steadily. The usual position for the herpes spots was on
the sides of the tongue and near to the fraenum. She
thought that as a rule both sides were affected at the same
time. At the time of her visit to me there was a single
large and much inflamed sore on the inner side of her lower
lip. She complained much of feeling out of tone, saying
that she could not give attention to things and could not
remember. It appeared possible that some of the benefit in
the previous autumn had been in connection with the visit
to Wales. I advised that she should increase her dose of
arsenic and get another change of air. I do not know the
ultimate result. There was no reason whatever to suspect
syphilis.

Herpes of the Mouth recurring with extreme frequency and

following Neuralgia — No Syphilis.

In the following narrative we have an example of recur-
ring herpes consequent, in all probabiHty, upon persisting
disease of the nerve centre. It had been preceded by severe
neuralgia. The patient, an old woman of sixty, was sent to
me by Mr. Waren Tay on February 1, 1872, when the notes
were taken which are subjoined.

The attacks recur so frequently that she is seldom quite
free. Its present stage is, she says, the best that it ever
gets into. She expects that in a few days a new " crop of
blisters" will make their appearance. At present she has
merely a number of superficial ulcers, most of them of oval
form; some are three-quarters of an inch long, others smaller.
They occur in the inside of left cheek, upon both sides of
hard palate, and upon the front gums. On the hard palate
and front gums they are placed almost symmetrically, but
there are none whatever in the right cheek. Some of them
are distinctly pellicular, and from one I peeled a membrane
three-quarters of an inch long and a third broad, firm and
coherent. It left a clean red surface which bled slightly.

She is a stout old woman of sudkM^H^B|a^y two years

12Q RBCUREING HERPES OF THE MOUTH, TONGUE, ETC.

since the eruption first came. It first showed itself on the
left gums, and in the cheek and on the tongue. At first
she used to have intervals of two or three weeks, much
longer than she now has. She had been liable to neuralgia
in the face, always on the left side, for many years. Since
the eruption appeared she has had less neuralgia. Never
had shingles; never any eruption on cheeks or lips. The
pellicular character of the eruption is a very marked feature.
In this case, as in the preceding, I lost sight of the
patient. Both were cases in which there was much reason
to fear that the herpes might prove introductory to
pemphigus.

Becurring Herpes of the Throat — Intervals very brief —

Bemote history of Syphilis.

The case of a gentleman aged 63, named S , afforded

a good example of recurring herpes of the palate. He
consulted me in July, 1886, on account of sore throats,
which constantly varied in severity, but hardly ever left
him. He had been Uable to them for three years, and
before that he had had what he described as an abscess in
the root of the tongue. His first attack of herpetic throat was
the worst that he had had, and occurred at Cape Town. He

was then a week in bed. Mr. S had lived much abroad,

and had in a general way enjoyed good health. He had been
told that his throats were syphilitic, and was curiously
anxious to believe them so. His syphilis had occurred,
however, at the age of twenty-one ; he had never since had
any reminders, and his children were in sound health.

My next case is a very important one, and must be given
in cletail.

A very severe case of Becurring Herpes of the Mouth, Lips,
and Tongue — Suspicion of Syphilis, but no other symp-
toms — Temporary benefit from Arsenic but relapses,

Mr. T consulted me on account of a liability to

herpes, which had persisted for four years. The eruption
came out symmetrically on the tongue and lips. I pre-

A TBRY SEVERE CASE. 121

scribed arsenic, and under its influence he became for a time
quite free from the attacks, and gained a stone in weight.
I asked him to write me out the details of his illness, fend
the following are his notes : —

** February 5, 1889. — A little over four years ago I first remember
the ulcers on my tongue and throat. The ulcers would disappear after
taking medicine, and reappear again about every two months. I was
under this treatment for two yeaxs, when my medical attendeuit was also
treating my wife for ulcerated womb, and he said that my ulcers were
caused by my wife being in that state. He changed my physic, but still
ulcers came. He ordered me away on the moors, but had to come home
again, as old complaint came on more severe. I then consulted one of
the leading allopathic physicians ; he also said it was liver complaint,
and he treated me for twelve months, but to no purpose. I then went
to another physician, and he examined me and pronounced it to be
syphilis. Treated me for same for fourteen months. I have continuously
taken the medicine, and have been most careful in my mode of living.
But still the ulcers came on about every four or six weeks, would stay
about a week, and then disappear gradually. During the period of my
mouth being bad I always lose my appetite, and am unable to put any-
thing inside my mouth except liquids, as the tongue is so sore I cannot
bear it. I also lose from seven to ten pounds in weight every time I
have an attack, but when I get well I pick up the weight again, and am
as well as ever. Until lately I have always had a slight thin running
from the nose of the influenza kind accompanying my mouth. I gene-
rally get an irritable itching all round the bag of the testicles a few days
before my mouth gets bad. Since taking the iod. pot. and mercury the
attacks have not been so severe as they were before, neither have the
ulcers remained as long on my tongue. The itching of my testicles has
always been an attending symptom of a recurrence of my tongue. I
always lose the saliva from mouth at these periods, and my tongue
and mouth get parched and dry. I have been very ill two summers
running, and have taken a trip to Jersey for fourteen days, and have
come back thoroughly well, and generally remained well for twice the
length of period to what I do when at home. A friend of mine at
Christmas (a medical man) told me to discontinue taking the last physic,
as he said I was not suffering from syphilis. He has treated me for dis-
ordered stomach, and I have been worse since then, having had two
attacks in a month, and being very bad each time. If I have a cold
when I am bad it thoroughly upsets me, and makes me feel very ill. Of
ftU the physic I have taken, I have felt better when well when taking the
kind prescribed for syphilis. It has driven spots out all over my face,
and greatly disfigured me. When well I am generally very windy, wind
sometimes belching up from the stomach, other times passing freely

122 EECUEEING HEEPES OF THE MOUTH, TONGUE, ETC.

through the bowels. But when I am bad this disappears, and I get
more costive."

When I first saw Mr. T *s lips I made not the

slightest doubt that it was a case of syphilis. His tongue
showed a number of red abrasions scattered on its surface,
and there were some also under its tip. His lips on their
inner aspect showed many sores, which, although quite
superficial, were much inflamed. Some similar ones were
seen on looking into the pouches of his cheeks. I had
rather hastily told him that it must be syphilitic, when he
at once led me in a different direction by saying that he had
had it over and over again, and that he expected it to get
well of itself. He said that he had already had much advice
about it, and that some had assured him it was syphilitic,
others not. On inquiry there did not appear to be much
reason to suspect that he had had syphilis. I may briefly
state that his history pointed to the conclusion that the
disease was recurring herpes, and that it probably had no
connection with syphilis. I sent him to Mr. Burgess to
have a sketch taken. This sketch does not show the disease
in its early stage, but only the condition of the ulceration
left nearly a fortnight after the outbreak. There was
nothing at that time distinctive of herpes ; in fact, as just
said, the abrasions looked like those of secondary syphilis.
The portrait was taken at the College of Surgeons on
Monday, February 4th ; and on Wednesday, the 6th, there
was no trace remaining of the sores on his tongue, and
little or nothing of those on his lips. I had some difficulty
in believing that he was the same patient. The following
are some of the particulars as regards his history.

It was four years since his first attack. It used at first to
come on the back of the throat, and was referred to the
drains by his medical man. At first it used to recur every
two months, but of late every month. He was accustomed to
experience itching on the penis for a day or two before the
herpes showed itself. He had seen several physicians in
Plymouth, and had different opinions given him. One
thought it syphilitic, and gave iodide of potassium and liq.

A VEEY SEVEBE CASE. 123

hydr. bichloridi, which he took regularly for fourteen
months with bark. He thought his health better under this
treatment, but the herpes still returned. He nearly always
had a sort of influenza cold, and felt chilly, especially down
his back, when the herpes was coming. The attacks were
attended by temporary dryness of the mouth, and it became
dry and parched. He had had much eruption, but it
appeared to have been due to the iodide. He was rather
thin and pale, and he counted each attack as causing a loss
of half a stone weight, which he regains in their intervals.

Six months later I received by letter the following report.
I had, of course, prescribed arsenic.

"Dbae Sir, — On the 4th day of Februaary I came to London to see
you about a very obstinate ulcerated tongue, which I had been suffering
from for four years, perhaps you will remember sending me to the
Boyal College of Surgeons to hare my tongue and lips sketched.
You at first sight thought it syphiUs, but afterwards said it was not so,
and gave me a prescription. I have been taking the medicine regularly
ever since, and I am pleased to tell you I have not had any serious return
of my old complaint. Last week I had one ulcer on my tongue, which I
attribute to my smoking cigars. I have felt so well that I smoked a
little too much, which I think brought on the ulcer, but having put aside
the smokmg, the ulcer soon disappeared. I have regained my usual
weight, 140 lbs. (which is 11 lbs. heavier than when I saw you), and am
well in every respect. It is now over three months, and before your
treatment I never went longer than a montii or six weeks."

After this, Mr. T once came up to see me and I

found his mouth well, and he was much pleased with his
almost complete immunity.

In July, 1893, not having seen or heard anything of my
patient for two years, I wrote asking for a report. The
following letter was received : —

" July 21, 1893.
" My dear Sir, — In reply to yours of yesterday respecting the sore
mouth and tongue you treated me for in February, 1889, I beg to say
that I frequently get relapses of same, but have not taken the medicine
regularly for two years, and have only had one bottle since Christmas.
I find a change of air does me most good. I was in London a month
ago, and my tongue was very bad then, and I intended to have called
upon you, but the day after I arrived I was so much better that I did not

124 RECURRING HERPES OF THE MOUTH, TONGUE, ETC.

call, but if you think I ought to see you when I am in town again I will
call. I have never been free longer than three months at a time, but
when I take the medicine it does me good again. If I catch cold the
ulceration on mouth or tongue generally accompanies it.**

After this letter I never saw the patient. In the present
y^ar, wishing to publish the case and having heard that the
man was dead, I wrote to my friend Dr. Clay, of Plymouth,
to ask if he could ascertain for me the subsequent history.
Dr. Clay unexpectedly replied that the patient had originally
been under his own care, and that he well remembered the
case. He told me further that the man had lived intemper-
ately, and that he had died of rupture of an oesophageal
varix in connection with cirrhosis of the liver. Bespecting
the latter. Dr. Clay was good enough afterwards to procure
for me full details, and these I shall make the subject of a
separate notice. It will be convenient here to deal only with
the herpes. Dr. Clay assured me that there were good
reasons for believing that the man really had suffered from
syphilis, and he thought that the sore mouth had at various
times been benefited by specifics, especially iodides. We
must therefore leave this question in some doubt. It
remains quite certain that at the date of my being con-
sulted there were no other indications of syphilis, that the
stomatitis was herpetic in nature and prone to spontaneous
cure, that specifics had not prevented it, and that arsenic
did, for a time at least, most definitely restrain it. It is
very possible that syphilis may have been a predisposing
cause, for we know that it often takes that role in reference
to recurring herpes. At the same time it is quite clear that
the herpes of the mouth was not sjrphilitic in the sense of
being amenable to anti-syphilitic treatment, and that it did
conform closely to the type displayed in other cases in
which specific history is wholly absent. It must also be
left an open question whether the patient's habits as
regards alcohol had exercised any influence in aggravating
liis herpes. He had not, so far as I observed, any of the
usual indications either of intemperance or liver disease. It
is to be observed, however, that a period of six years
•elapsed between the date of my seeing him and his death.

RECUBRING HERPES OF PHARYNX. 125

He appeared, when he called on me, to be in good health,
excepting his liability to sore mouth, and he so considered
himself.

My next two cases are examples of recurring herpes of
the pharynx, but were probably in more close connection
with syphilis than any of the preceding.

persisting hut variable Eruption in the third year of Syphilis
— Bepeated attacks of Herpes on Penis and in Throat.

Mr. M , a young man of florid complexion and good

health, had chancres two years ago. A year later he had a
gonorrhoea. I saw him for the first time on April 19, 1891.
He had then herpes on the under surface of his prepuce,
some spots like herpes on his soft palate and tonsils, and an
eruption of ill-defined and inconspicuous yellowish-brown
stains on his thighs. A few of the latter stains occurred on
other parts of his skin and body. He told me that they
were liable to come and go, and that he thought their
increase generally preceded an attack of herpes in the
prepuce. He had been taking mercury in pills for the
last six months, and could not get rid of the liability to his
herpes, nor of the sore throat and the blotches on the skin.
His gonorrhoea had for long been quite well, and there was
lio tendency to recurrence of his chancre, nor any enlarge-
ment of lymphatic glands. The herpes on his prepuce was
quite definite, and he described his attacks as occurring
about once a month. The eruption on his thighs, although
m.uch worse at some times than others, never quite dis*
appeared. It consisted of patches which were not abruptly
margined but of rather oval form, and were little more
than yellow stains. He was very confident in his statement
that this rash varied in severity with his preputial herpes.
Concerning the latter he volunteered the statement that it
was sure to come out after a nocturnal emission.

I was interested in the speculation as to whether in this
case the whole of the phenomena were of herpetic or, in
other words, of neurotic nature. It was certain that the

126 EECUEEING HBEPES OF THE MOUTH, TONGUE, ETC.

long-continued use of mercury had not cured it. That part
of them were herpetic there could not be the slightest
doubt.

Epilepsy eighteen months after Syphilis — Becurring Herpes

of Pharynx,

Mr. E. H. S , a gentleman aged 34, had primary

syphilis in May of 1888, for which he took mercury.
Subsequently he had herpes of the pharynx, and several
times after taking cold had sore throats, probably of an
herpetic character. For these he was under my care in
November of 1889, and he then gave me the history which
chiefly makes his case of interest. He had been suffering,
he said, from headache, and had had an epileptic fit. The
fit occurred when he was in the water-closet. It came with-
out warning, and was attended by tongue-biting. He had
been feeling unwell for some little time previously. . Thus
his hands used to shake, and he had frequently a feeling of
giddiness, and at other times of sleepiness. It will be seen
that this fit occurred within eighteen months of the primary
disease, and the question was whether it should be regarded
as in connection with the syphilis. His syphilis had in the
first instance not been very efficiently treated. I did not see
him until seven months after the chancre, and he then still
had his eruption out. The eruption quickly disappeared
under the mercury which I ordered, but even whilst taking
it he had a sharp attack of iritis in one eye. Of the latter
he got quite well, and I did not see him for nearly six
months, when he came with the history of his epileptic
£ittack and headaches.

In the cases of herpetic pharyngitis which occur, not
infrequently, soon after the secondary stage of syphilis,, the
vesicles are, I think, usually seen on one side only. In
these cases recurrences not unfrequently occur, but the
liability to them does not last very long. In such as those
just quoted, in which the recurrences are very frequent
and persist for many years, all tendency to unilateral de-
velopment is, I believe, lost. It. is seldom that any differ-

BEOUBRING HEBPES OF BUTTOCK. 127

ence can be detected between the two sides, and if it be so
it is seldom maintained in different attacks. These cases
stand apart from those to which I have next to ask
attention, in which groups of herpetic vesicles, like shingles
on a small scale, recur repeatedly on or near to the same
region of the skin. These cases occur in my experience
almost always either on the face or neck or near to the
buttocks. They are exceedingly rare on the limbs or on
any part of the trunk. The subjects of recurring shingles
on the face or neck are usually females and young children,
and there is no association with sjrphilis. Those who have
these attacks on the buttocks or upper part of thighs are, on
the contrary, usually adult men who have suffered from
syphilis. My next group will refer exclusively to the latter.

GBOUP OF CASES IN WHICH HERPES RECURRED
REPEATEDLY ON THE THIGH AND BUTTOCK.

Herpes recurring on the Thigh — Syphilis two years before.

Of this patient, Mr F , my notes under date March,

1880, record : — He has had four attacks of herpes on the
right buttock. He now shows me his fourth eruption, three
long oval groups of abortive vesicles sloping down the buttock.
He thinks that he feels rather ill whenever it comes, and the
right leg feels weak and there is some tenderness in the
inguinal region of right side. He never has herpes on the
penis, and he never had ordinary shingles. His first attack
of herpes was a year or more ago, and he has had three
since last Christmas. He had syphilis two years ago.

Becurring Herpes on the Buttock^ with history of former

Shingles.

Dr. P , aged 45, first consulted me in the spring of

1881. He had had half a dozen attacks of herpes on the
right buttock during the preceding four months. As usual,
I prescribed arsenic.

He told me that he had had a fearful attack of shingles

128 RECURBING HERPES OF THE MOUTH, TONGUE, ETC.

oh the chest twenty years ago, and also herpes on penis
several times.

In April, 1882, he reported that he had got rid of the
herpes on leaving H , but he had taken arsenic as well.

Herpes recurring on the Thigh,

The following letter from a surgeon in the country
describes his own UabiUty:—

" Deab Mr. Hutchinson, — Can you tell me what is the reason of my
having two or three times a year one single patch of herpes on the outer
and posterior side of right thigh, about two inches or so above the bend
of the knee ? It has come out pretty steadily two or three times every,
year for some years now, and I have taken no particular notice of it. Is
it due to some local nerve influence ? It is confined to the right thigh.
During the intervals nothing is to be seen or felt. I should be glad of
any hint or advice. I have the notes of your Lectures on Skin Diseases
at Blackfriars, but don't find anything referring to my case."

Becurring Herpes on the same spot on the skin of Buttock.

The case of Sir H. M. T offers us another example of

recurring herpes. He is a gentleman of forty years of age,
in good general health, liable to gout. It is possible that he
had syphilis many years ago, and it is certain that he has
had gonorrhoea on many occasions. Formerly he was under
the care of the late Sir Wilham Gull on account of recurring
herpes preputialis. His liabiUty to this ceased after a long
course of arsenic. His present trouble is the repeated re-
currence of a patch of ordinary herpes, exactly like zoster,
on the back of one buttock, midway between the crest of the
iUum and the great trochanter. During the last three or
four years he has had ten attacks, always in the same place.
One for which he came to me on April 9, 1881, was, he
said, the worst he had ever had. The patch was as large as
a crown-piece and of oval form. As is, I think, usual with
recurring herpes, the eruption seldom gives him much pain.
He told me that its outbreak was usually attended by a sense
of chilUness and general discomfort, as if he had caught a
cold. On the present occasion it was accompanied by a
distinct attack of nasal catarrh.

RECURRING HERPES OF BUTTOCK. 12&

Becurring Herpes on Sacral Begion and on Penis after
doubtful Syphilis — Hypercesthesia of whole back of
Thigh — Ten years later tingling in skin of Lip, dec.

Dr. W came to me in September, 1877, on accomit of

very troublesome herpes in the sacral region, which had
recurred over and over again. The eruption usually came
out on an area as large as the palm of a hand on the upper
part of right buttock. It sometimes crossed the middle line
in the cleft, but was always chiefly on the right side. It
ran the usual course of herpes and subsided quickly, but-
recurred every two or three weeks. At the same time some
herpes spots often came also on the penis, but this did not-
always happen.

Dr. W attributed his herpes to syphilis, but his history

was not conclusive. Three years previously he had con-
tracted a chancre. He described the sore as ** punched out,**^
and said that he was sure that it never hardened. It lasted
only a fortnight, and he was assured by the surgeon whom
he consulted that it would be followed by nothing. Six
months later, however, he had a sore throat, and, three
months later still, some eruption under each arm. At almost-
the same date he began to be liable to the attacks of herpes
on the two parts mentioned.

I saw Dr. W again two years later, in July, 1879. He

was then very anxious as to loco-motor ataxy, and consulted
Dr. HughUngs Jackson also. He had su£fered from vague
pains in various parts and was still liable to herpes. He was
now 28 years old. He told me that the outbreak of herpes
occurred usually every six weeks, and that it was attended by
hypersBsthesia of skin of buttock, extending down the back
of thigh to knee (small sciatic). Sometimes the skin would
be actually painful as well as 6ver-sensitive, and now and
then this hyperaesthetic state of skin would occur without
any herpetic eruption. Respecting the latter, he said that,
it now occurred sometimes on one side of the coccyx and
sometimes on the other, but never on both sides at the same
time. He was rarely more than six weeks without it, but
he did not now have it often on the penis. I did not find

VOL. IX. 9

130 RECURRING HERPES OF THE MOUTH, TONGUE, ETC.

any definite signs of ataxy. His pupils acted tolerably
well.

Nearly ten years later still I again heard from Dr. W .

He wrote that he had got rid of his "lightning pains,"
that his herpes recurred much more seldom, and that his
general health was better. He had, however, been recently
troubled (May 31, 1887) by "a burning sensation which
comes near the left angle of mouth and is followed by
tingling of lips, especially of lower one, and of anterior
part of tongue. These sensations used to pass away in about
an hour, but the tingling is now nearly constant. Movement,
articulation, taste, &c., are not affected."

I much regret that I cannot give the sequel to this case.

Becurring almost painless Herpes on the Buttock — No history
of Syphilis — Patient chilly and catarrhal.

As another example of this recurring herpes on the
buttocks, I may quote the case of a gentleman from York-
shire, aged 37, who had been for three years liable to it.
The patch of herpes always came exactly on the same place.
It was on the back of the thigh, just beneath the middle of
the fold of the nates. It usually occupied a space about as
large as a child's palm. He thought that on an average his
attacks had occurred once in three months, and, as is usual
with recurring herpes, they were attended by very little
pain. With one exception, the eruption had always dis-
appeared quickly and healing had soon followed ; but an
attack which occurred in October, 1890, left sores which did
not heal for some weeks. On the first occasion there was a
good deal of smarting and pain, such as made him suspect
he had been stung. During a stay of three months at

Bournemouth, Mr. E had been quite free from his

herpes. He attributed the attacks to catching cold, and
said that he was a very chilly subject, Uable to catarrh, and
never well unless the weather was hot. He had never,
either in youth or early life, suffered from herpes labialis.
He had never had syphiUs. He was a tall, thin man, very
bilious, and liable to diarrhoea. In youth he had been cured

RECURRING HERPES OF BUTTOCK. 131

of lupus of the nose by Sir Erasmus Wilson. The cure
was remarkably good, sound white scar remaining without
any teisdency to relapse.

Recurring Herpes on lower part of Abdomen — Bemote Syphilis*

Mr. S tells me that in former years he was liable to

herpes over the abdomen, on the root of the penis. It used
to come very frequently. He had, I beUeve, had syphilis
many years ago. He married six years ago, and since then
has only had an attack of herpes once every one or two
years. It almost ceased soon after his marriage. [January
9, 1891.1

(To be concluded.)

NOTES ON SYMPTOMS.

No. XXIX. — The liability to Cramp after sleep.

It is, I suppose, well known that the state of sleep pre-
disposes to cramp in muscles. The exciting cause is probably
always muscular action. Of all the muscles in the body the
gastrocnemius is probably the one most prone to it. The
usual time for its occurrence is just after waking in the
morning. It may, however, in restless sleepers who move
their limbs in bed, come on during sleep and put an end to
it by the pain caused. Those liable to cramp in the calf
must be very careful as to movements of their legs just after
waking. When once the sleep state has passed off and the
muscles are, so to speak, thoroughly awake, there is com-
paratively little risk of its coming on.

I was explaining the above to a patient who had suffered
much from cramp, when he replied : *' Yes, I have found
that out for myself, and I am so determined to avoid bending
my legs soon after waking, that I always take care that the
bed clothes are not tucked in, so that I can slide out of bed
feet first and so keep them straight.'*

No. XXX. — Additional Notes on Horripilatio.

"Creepy sensations," **A wave comes over me,** "A
wave runs down me,** — such are the expressions which our
patients use to describe what is technically designated as
Horripilatio. The phenomenon is so common, and under
most circumstances of such slight import, that it is disre-
garded. Now and then, however, it may, either by the great
frequency of its occurrence or the severity of the attacks,.

NOTES ON HOREIPILATION. 133

rise to the dignity of a disease, and may in itself compel
the attention of the patient and his adviser. Although allied
in nature to what we know as a rigor, or shivering, horri-
pilation is yet somewhat different. It concerns the skin,
and in all probability its muscles, whilst in rigor there is
arterial spasm. Spasmodic contraction of the muscular
coats of the blood vessels is probably the essential cause
of true shivering, whilst spasm of the arrectores pili is that
of horripilation. The two are both nervous phenomena and
often go together, but they may occur quite separately. At
any rate horripilation may occur without any real shivering.
It is perhaps less certain that shivering can occur without
horripilation.

Some general remarks in description of horripilation will
be found in Vol. VI. at page 3. In Vol. VIII. at page 311,
I have referred to a case in which the symptoms had attained
a high development. The patient spoke of his attacks as
his "seizures." They were little more than momentary
and from his description of his sensations it seemed probable
that they were really of the nature of horripilation. It
might be doubted, however, whether they should not have
been considered as a form of petit maly and this doubt
suggests a further inquiry whether the phenomena of
horripilation are in any degree allied to the epileptic state.
The patient in the case to which I have just referred was a
man o'f 50 who had had syphilis, and who had lived freely. His
nervous system was undoubtedly damaged, and he had twice
had attacks in which speech was temporarily lost, and had
once been for a few minutes unconscious. His knee-jerks
were excessive, but his pupils very sluggish. At the time
that he was liable to the attacks of exaggerated horripilation,
(or petit mal?) all the more serious symptoms were in
abeyance. His attacks would, however, occur several times
in a day. He described it as a sort of shiver, beginning at
the head and running down to his legs, and attended by a
creepy sensation. They were very quickly over, and were
not attended by any loss of consciousness. His wife said
that he always looked pale during them, and that his eyes,
one or both, were drawn back into their sockets. I pre-

134 NOTES ON SYMPTOMS.

scribed quinine, mercury, and iodides, and under these
remedies and a regimen of total abstinence from stimulants
he got rid of the liability and improved in health. He
returned after a time to a distant colony. I have heard that
he has since had severe epileptic seizures.

By the side of this case I may place another which is very
similar in some respects. Again I am puzzled what to name
the attacks. Again the patient is a man who has had
syphilis, and who has lived freely. He is at the present
time liable to periostitis on the skull at various spots, and is
obliged to take iodides for its relief. This patient complains
of attacks which may occur at any time, and which are
attended by creepy sensations and a feeling as if a wave
were passing over him. I asked if the creeping ran down
from his head to his feet. ** No," he replied, " not when it is
bad ; it then always begins in my back and runs upwards to
the head." He describes it as '' a horrible sensation," but as
always over in a few seconds and leaving no ill consequences.
He always feels inclined to clutch hold of something, and
although he never in the least degree loses consciousness, he
feels as if he should do so, or, indeed, as if he might die.
Under the use of iodide of potassium, in combination with
nux vomica, the liabiUty to these attacks has very much
ceased.

It will not surprise me if some of my medical readers
think that in the description which I have given there is
nothing more than what is known as petit mal. If it be so,
however, I feel sure that horripilation is an important
element in that state. The wave-like creeping sensation in
the skin was one of the feelings upon which both patients
laid most stress. The entire absence of any disturbance of
consciousness is also an important difference. The two
cases given are examples of the symptoms in an exaggerated
form. In minor grades, just what they mentioned is not
unfrequent.

In the description of these cases, the phenomena being
almost wholly subjective, we are dependent upon the
intelUgence and observing faculties of our patients. In each
of the instances adduced, I had repeated opportunities for

URETHRAL PAIN WITH PROCTALGIA. 135

listening to the statements made. I also requested the
patients to notice their sensations as accurately as possible.

No. XXXI. — Liability to pain in the Urethra^ and also
to Herpes on the Prepuce^ and Proctalgia —
Tabes suspected — Recovery under Arsenio and
Tonics.

In August of 1868 I saw a gentleman named G , aged

38, who had in all probability suffered from syphilis eight
years previously. He complained chiefly of recurring attacks
of pain in the urethra. He had no stricture and no gleet.
I thought that he might be liable to herpes in the urethra.
He had, however, some other symptoms which suggested
that possibly he was in an early stage of tabes. He was
losing sexual appetite, and was liable to proctalgia after
intercourse. He had also some backache, and his knee-
jump was poor. Arsenic and nux vomica were prescribed.
He had had definite attacks of herpes on the prepuce. From
boyhood he had been the subject of the ordinary form of
leucoderma over the whole trunk in patches.

In the following October he had, after a year's immunity,
a severe attack of herpes on the prepuce. In all other
respects he was better. After this he continued the arsenic
for a year or more, and was free from symptoms.

In July of 1894, he came to me for another rather severe
attack of herpes of the prepuce, with excoriation around the
meatus. He was still liable to the attacks of pain and
soreness in the urethra, but had been for a year quite free
from external herpes. He was still, as he had always been,
a healthy-looking man, and had no indications of sjrphilitic
taint.

In February, 1898, ten years after my first consultation,
he was brought to me again by his surgeon, Mr. Denton, of
Brixton, on account of an outbreak of skin eruption of three
months* duration. It had begun, he said, rather suddenly,
by severe irritation after his morning bath, on one leg. The
eruption was mixed on his legs, being in part pustular on hia

136 NOTES ON SYMPTOMS.

legs, but on his back, over the sacrum, and on the sides of
the abdomen it assumed the characters of lichen planus.
There was, however, none on his wrists.

This visit afforded me an opportunity of inquiring as to
his old symptoms as to herpes, tabes, &c. He said that he
had been for some years almost wholly free from them, and in
good health. He had taken a good deal of arsenic on and
oflf, and believed that it usually prevented the recurrence of
herpes. There was, however, no definite proof of this. He
had been for a year, at least, quite free.

No. XXXII. — Aggressive Pigment Patches on the

Glans Penis and Prepuce.

Repeated references have been made in Archives to the
remarkable cases in which pigment-staining, of an aggres-
sive form, is occasionally the prelude to maUgnant growth.
In most of the cases which I have described, the disease
was placed either on the eyelids or on the lips. I have,
however, recorded other cases in which the same process
occurred at the roots of nails, and in association with
sarcomatous growths in the sole of the foot, and other parts.
I have at present under observation a remarkable example of
pigmentation of patches on the glans penis, and in the scar
of a circumcision done thirty years ago. The patient is a
man of 64, and the disease has been in progress three years.
He was, in the first instance (two years ago), sent to me in
the fear that the condition was malignant, but excepting
increase of pigmentation, nothing further has been de-
veloped.

No. XXXIII. — Herpetic Teethache and Deafness ?

Certain cases raise the interesting question as to whether
there can be anything of the nature of herpetic inflammation
of the pulps of the teeth. Also whether a nerve of special
sense, such as the gustatory, can be attacked, and, if so, what
are the consequences. We know already that the eyeball as
B» whole is often involved in herpes. In severe cases white
Atrophy of the optic disc may ensue. Great defect of sight,

STUDY OF PAIN IN BONES. 137

unexplained by corneal opacity, is not very uncommon,
and in at least one case I have had to excise an eyeball
which was lost and painful after herpes. These cases prove,
with many others, that herpetic affections of nutrition are
by no means confined to skin and mucous membranes.
There may easily be such a thing as herpetic loss of hearing.

No. XXXIV. — Ptosis in a Boy — Becovery.

We had one day about a year ago, a boy in whom ptosis had
developed after an attack of headache and sickness, and in
whom, as his father was the subject of lupus, a conjectural
diagnosis of meningeal tuberculosis had been ventured. The
case is described in the Clinical Journal. I advert to it now
in order to record that the symptoms passed off, and that the
boy is now at school again, and quite well.

No. XXXV. — Pain in the Shin-bones — A Study of

a Symptom.

A gentleman has just been with me whose account was
that he had been laid up for six weeks with pain in his shin-
bones. He said that it had been most severe at night, and
had kept him awake night after night until early morning,
when he usually fell asleep. It had, however, never wholly
left him either night or day. He described it as ** just as if
I had been severely kicked." He assured me that there had
never been any swelling, nor, for the most part, any tender-
ness on pressure. He could always bear to have the bones
tapped without any discomfort on the subcutaneous surface
of the shin, but here and there on the edge there would be a
spot upon which a tap would elicit sharp pain. I examined
his legs, and found the shins quite clean. There was not the
slightest evidence of periosteal thickening. A note which
he brought me from his surgeon contained the following : —

*' He had syphilis fifteen years ago, for which he was well treated.
Ten years ago he was laid up with syphilitic rheumatism for seven
weeks. For the last six weeks he has had pains in his tibiae, chiefly at
night, and of a boring character. I have regarded it as a syphilitic re-
minder, and have treated him with iodide of potassium in four-grain

138 NOTES ON SYMPTOMS.

doses three times a day. He is now improving, but we should be glad of
your opinion."

It will be clear from the above statements that the
diagnosis lay between an arthritic affection and syphiHs.
The pain had been in both shins, and without any swelling,
and the patient assured me that it had begun in both almost
together and almost suddenly. There had been no tender-
ness, only intolerable aching. Although it is true he had
had sjrphilis, yet it was a long time ago, and he had for
seven years or more been wholly free from reminders. So far
against syphilis. In favour of gout were the following points :
The patient's grandfather (paternal) had suffered from gout,
and his own mother, in early life, had been through a severe
attack of rheumatic fever. He himself from boyhood up
had been liable to attacks of severe pain in his great toe
joints, sometimes attended by redness and swelling. He
had been a free beer-drinker all his life, and he had a pale
but rather bloated face, suggestive of both beer and gout.
For the sjnnptoms described he had often had colchicum
given. The attack which had been called syphilitic rheu-
matism ten years ago began, he said, very suddenly by most
severe pain in one knee-joint, which was followed by inflam-^
mation of almost all his joints, and kept him in bed six
weeks. There seemed no real reason for connecting it with
his syphilis. It had been an ordinary attack of acute
generalised rheumatic gout, with more of gout in it than
rheumatism. Lastly, as to treatment, iodide of potassium
had not relieved the pain in the shins in the definite way
in which it usually does that of syphilitic periostitis. It
is true, however, that some benefit had accrued, and that
the doses had not been large, Again, however, it is further
true that iodides will relieve the pains of arthritis as well as
those of syphilis.

On the whole I was inclined to regard the attack of bone
pain which he had just passed through as of a gouty rather
than a syphilitic nature, and I prescribed quinine with
colchicum and aconite, in addition to the iodides. The
suspicion that it might prove the precursor of tabes did
not escape me. If not better he must try mercury.

SELECTED CASES IN ILLUSTEATION OF
INHEEITED SYPHILIS.

f

(Concluded frofti page 16,)

No. XX. — Details of a Syphilitic family, both parents

having suffered.

In the following case I had myself treated a husband and
wife in the sixth year of their marriage for secondary
syphilis. Both suffered severely, the wife especially so,
She had a most acute attack of iritis. They continued
in unrestrained cohabitation, and the following list furnished
to me by their medical attendant shows the results. Prior
to the syphilis three healthy children had been bom. After
it were as under : —

1st child, a boy, bom whilst under treatment, lived six
months. Contracted smallpox, which was followed by
cancrum oris in cheek.

2nd child, a boy, bom twenty months after the primary
disease (premature seven months), lived five months; died
(convulsions).

3rd child, a boy, born two years and seven months after
(premature and stillborn).

4th child, a boy, bom four years after (full time — still-
bom).

5th child, a boy, bom nearly six years after (full time and
healthy) ; living now, in seventh year.

6th child, a boy, bom about eight years after (full time) ;
very strong and healthy.

7th child, a girl, about ten years after ; strong and healthy
now.

140 SELECTED CASES OF INHERITED SYPHILIS.

8th child, a girl, bom twelve months ago ; very strong and
healthy.

In this instance, although both parents had suffered and
the mother very severely, none of the children showed
definite sjrmptoms. We may, however, hold it as highly
probable that those stillborn were tainted. By this calcu-
lation the disease may be supposed to have persisted in the
mother with heritable potency for four years. After that
she bore four strong and healthy children.

No. XXI. — History of a Syphilitic family. [Notes taken

June 20, 1889.]

A Mr. L married eighteen months after syphilis.

Six months after his marriage his wife complained of sore
in the vagina, but nothing further was observed. She was
confined within a year of her marriage, and her infant, a
boy, had the usual train of syphilitic sjonptoms and re-
covered under the usual treatment. He was at that date
aged 18, and to all appearance perfectly well. The next
child, a boy, never showed any specific sjntnptoms, nor did
the third, a girl, although always delicate. The fourth, a
boy, suffered severely, worse even than his eldest brother
had done. He was brought to me for advice on June 20,
1889. He was eight years of age and suffered from a
chronic form of interstitial keratitis. The eyes had been
inflamed on and off for two years, in spite of much treat-
ment, circumcision of the cornea, &c. He still had some
superficial grey white deposits on both cornese with some
vascularity.

Three children younger than this boy had been bom and
were livijig. None of them had ever presented any symp-
toms. Both parents were apparently quite well.

Comments, — In this case probably the mother, who
acquired her disease two years after the father, was the
source of infection to their children. Hence its long persist-
ence. The entire escape of the mother herself, as regards
any obvious manifestations, is worthy of note, though not
very unusual.

C ASE-N ABRATI VE S . 141

No. XXII. — Primary Syphilis contracted during the late
months of pregnancy — A mild attack in the infant — No
constitutional symptoms in mother — The five following
conceptions diseased — Mother apparently in good health.

Mrs. T brought me an infant, aged three months^

covered with a syphilitic papular rash, but well-grown and
thriving. This was in December, 1866. My chief reason
for relating the case is to illustrate the absence of relation
between the severity of the symptoms in parents and off-
spring. Mrs. T herself appeared to be in robust health,

and was a remarkably fine-looking woman. She had borne
a large and healthy family. None of her infants before the
present one had presented a single symptom. Her account
made it probable that both she and her husband had suffered
from primary syphilis just before her confinement. Her own
sjmaptoms had, however, been ill-marked. She had had a
profuse discharge and much vaginal irritation, and after
delivery a large bubo in one groin. The bubo did not break.
She did not recollect any rash or sore throat, nor had she,
when I saw her, a single symptom. Dr. Armstrong, of
Gravesend, who had seen the infant, had told her the cause
of its symptoms. I treated the child by mercury and it got
quite well quickly.

In 1867 Mrs. T had a premature dead birth. She-

herself still remained in excellent health, and her husband,
though delicate, was free from symptoms.

In December, 1868, Mrs. T brought another infant

to me. It was two months old, and had a sjrphilitic rash on
the neck, face, and buttocks. It improved rapidly under

iodide of potassium and mercury. Mrs. T herself was

florid and in vigorous health. She reported the child first
treated to have remained quite well ever since and to be
now ** the picture of health."

I last saw Mrs. T , for her fourth child, on February

21, 1870. The child, a girl, had been bom healthy-looking ;
at the age of a month begun to snuiSe, but did not till three
months old show the rash. Her thighs, &c., were covered
with eruption, and there was some also on her face. She

142 SELECTED CASES OF INHEEITED SYPHILIS.

was much wasted. One child which I had not seen had
died with seveBe sjonptoms.

It will be seen that in this instance both parents had
suffered from primary disease. I do not know what treat-
ment they had had. The mother continued to bear syphilitic
children for at least four years. The case, therefore, gives
support to the opinion that the poison may maintain itself
in the mother much longer than it usually does in fathers.

No. XXIII. — Important family history of inherited Syphilis

with Keratitis,

Miss K , aged 16, was brought to me on December 19,

1873, for syphilitic keratitis of the left eye. It was quite
characteristic, as were also her teeth. She was a good-
looking girl, the physiognomy not being affected. The
attack had begun a fortnight before. The father was
living — a pubUcan by trade. The mother had died of
apoplexy, after a five hours' illness, nineteen years before
which she had had **slow paralysis of the legs." The
father had had a chancre, a rash, and sore throat a
year before marringe, and had been some time under treat-
ment. Since his marriage he had, he alleged, been per-
fectly well. He told me that he had always suspected a
taint of syphilis in his children. There were seven children
living; two had died in infancy, one of smallpox and the
other of cholera, and a third of asthenia.

The following is a list of the children : —

1. Female. Living. ''Headache sometimes.'*

2. Female. Died of variola, aged 4J.

3. Male. Living and healthy.

4. Male. Died of cholera in infancy.

5. Female. Has had "bad eyes."

6. Male. Died, aged 19, of ** asthenia and bronchitis."

7. Male. Aged 20. "A fine strong fellow and wonder-

fully healthy."

8. Female. Aged 16. The patient, ** delicate as a

baby."

9. Male. Aged 13. Has had bad eyes.
10. Male. Living, aged 11.

CASE-NABEATIVES. 143

Comments. — There is no proof that any were really
syphilitic till No. 8. Between the seventh and eighth
children there was an interval of four years, and I should
feel little doubt, looking at the fact that No. 7 is strong and
never suffered, that on the part of one or other parent a
fresh introduction of syphilis had occurred.

No. XXIV. — Inheritance of Syphilis erroneously suspected
by parents — Microcephalus and partial blindness after
severe infantile convulsions.

Mr. and Mrs. B had been married seven years when

they brought their infant child to me in July, 1893. The
husband said that he' had contracted syphilis about a year
before marriage. His wife had always been well. The
child, who looked healthy, had a narrow forehead with
closed fontanelle, and was believed to be blind. She used
to squint at times and turn her eyes up, and for two or
three days shortly after birth was much convulsed. She
was an eight months' child. The sight was certainly very
defective. The discs were of a greyish colour, but not
markedly atrophic. The child was the first born, and had
never had either snuffles or eruption. Means had been
taken to prevent conception during the early years of
marriage.

Comments. — I explained to the parents that the conditions
present were not those usually seen in syphilis, and that in
fact the infant did not display a single symptom of that
disease. On the other hand it was, I said, well recognised
that such results might follow severe infantile convulsions.
I assured them that they might continue normal cohabita-
tion, and that they need not fear that other children would
suffer. Seven years had now elapsed since the disease in
the father, a period abundantly sufficient to give safety.

No. XXV. — A healthy family after Vaccination Syphilis.

Mr. W , jun., was one of those whose cases are narrated

in my first Report on Syphilis from Vaccination. He suffered
rather severely, and his arm-chancre recurred several years

144 SELECTED CASES OF INHEBITED SYPHILIS.

later. He married in 1878, seven years after his syphilis.
In 1885 he brought his eldest child, who looked quite healthy.
He then had three living and healthy children, and had lost
none. He was himself in good health.

I mention this case because some authors hold that erratic
or non-venereal chancres are productive of more severe
syphilis than others.

No. XXVI. — Dactylitis in an infant with periosteal nodes
on skull and threatened abscess on bridge of nose —
Syphilis or Struma,

Alfred K , aged one year and eight months, was brought

to me on February 3, 1891. His father was living, but his
mother was dead. Six weeks before, he was said to have had
a blow on the bridge of the nose, which- had caused the whole
bridge to be now concealed by a soft swelling. For the last
week there had been a discharge from the nose. There were
large diffused periosteal swellings, symmetrically situated on
the sides of the skull just above the temples, and rounded
swellings of the fingers due to what is generally considered
syphilitic dactyUtis.

The patient was a big boy and looked well. There were
no definite symptoms of syphilis and no clear history.

Comments, — Although I was not able to get any clear
history of syphilis, yet the multiple periostitis was very
suspicious. I would, however, by no means feel confident
in that diagnosis, having seen precisely similar conditions
in connection with struma.

ILLUSTBATIONS OF CANCEE OF THE BEEAST.

The interesting paper which was recently read by Mr.
Marmaduke Shield at the Medico-Chirurgical Society, and
the important discussion which foUo^ved it, have drawn the
attention of the profession to the encouraging fact that
operations for cancer are in the present day far more
hopeful than they were regarded by our forefathers. The
paper referred to dealt with cancer of the breast only, but
its conclusions are applicable to all forms of maUgnant
disease which come within range of the knife. Nor is there
anything unexpected in the fact which was chiefly dealt
with, that many patients who have had cancerous breasts
removed remain afterwards free from recurrence. It is only
what those who believe in the local origin of these growths
have all along asserted.

It is not my intention to, nor would it be suitable that
I should, here attempt to go over the ground occupied by
Mr. Shield's paper. I have, however, been induced to look
into my case-books and to select for publication a few cases
of special interest.

Large, soft growth ofScirrhus Cancer of six months' duration
— Excision of breast and glands — Good health sixteen
years afterwards.

1 excised the breast and axillary glands of Mrs. B on

July 23, 1880. Her history was that the tumour had first
been noticed' enlarged in January, and that for a time it
seemed to subside, but had been rapidly increasing for two
or three weeks before I saw her. The tumour proved to be
a large, soft mass of scirrhus (microscope used). I did the
operation at her own house in the country, and did not see

VOL. IX. 10

146 ILLUSTBATIONS OF CANCER OF THE BREAST.

her afterwa«rds. She came to me in November, 1880, with a
perfectly sound scar.

I did not see her again for fourteen years. She came to
me in the latter part of 1894, being then in perfect health.

(N.B. — This case and the following were referred to in
my remarks at the Medico-Chirurgical Society, and have, I
believe, been previously mentioned in print.)

Bemoval of a rapidly -growing and ulcerating Cancer in a
young married woman — Good health six years later.

Mrs. J , of A-^= . I excised her breast at Mrs.

E 's in February, 1891, on account of a large tumour

with open, fungating ulcer. She had been quite unable to
get rid of her milk. After two pregnancies, she had had
profuse discharge of milk for six months, although not
nursing ; and in each pregnancy it had commenced six
months before delivery. She had no menstruation after
her confinements, whilst this flow of milk continued. At
the time of my operation, although it was eight months
since her last confinement, she still had milk running freely
from her left breast.

I took away the breast, all the adjacent skin, great pectoral
muscle, and the axillary glands, leaving a large wound to
heal by granulation. The tumour had grown very quickly,
and had been recognised only a few months. She did quite
well after the operation, and, six years later, had no sign of
return. The microscope had declared it a soft form of
scirrhus.

Mrs. J was only 29 years of age. Her father was 50

when she was bom.

Inheritance of tendency to Cancer — Both breasts affected in a

mother and daughter.

Dr. G. T , of W , related to me an interesting

example of inheritance of cancer which had occurred in his
own family. His mother and one of his sisters had, he said,
each had both breasts removed for scirrhus. In each the
operations were done with a considerable interval. His

SCIRBHUS RESEMBLING KELOID. 147

mother had survived the second operation several years, and
his sister was still alive ten years after her second. In each
of these cases the cancer had developed in senile periods of
life. The daughter was the eldest child of the family, arid
was now nearly 80. A sister of the elder patient (arid aunt
of the younger) had also suffered from cancer.

No evidence frorii the microscope is forthcoming in any of
these three case. The name of the operator in the younger
patient was given me, and I corresponded with him. He
told me that he had registered the cases in his notebook as
** cystic sarcoma," because there was in each " a cyst or
cavity in the deeper part." The tumours were, however,
hard, and looked like scirrhus. He had taken them for
scirrhus before the operation, but had felt encouraged, after
finding the cyst, to hope that there would be no* return.
The case may have been only one of lobular induration,
although it is scarcely likely that a well-experienced surgeon
would have been twice mistaken.

Scirrhus mass in the skin resembling Keloid, and developed
before any tumour in the breast was recognised.

About twenty-four years ago a lady from K came up

to town on account of an indurated patch in the skin over
the breast. The patch was scarcely larger than a shilling,
and was at least a quarter of an inch in thickness. It was
smooth and somewhat glossy. The involved portion of skin

was quite movable. She consulted Mr. P as well as

myself. One of the questions of diagnosis was between
keloid and scirrhus. The age of the patient, 54; the fact
that no scar had existed previously on the spot; and the
short duration assigned to it, three or four months ; as well
as some minor peculiarities in its aspect, led us to think that
it was scirrhus. Next came the question, was it primary
scirrhus of the skin ? This seemed a priori improbable, and
I carefully examined the mammary gland. The lady was
very stout and her breast large, but deep in its centre a
certain amount of thickening was felt, of very suspicious
character. We could not feel sufficient confidence in the

148 ILLUSTRATIONS OF CANCB» OF THE BREAST.

diagnosis of cancer of the mammary gland to advise th6i
fOiznidable operation of removing the whole, and she was
accordingly allowed to return into the country to have the
nodule in the skin excised by her own medical attendant.
This was done at once, but within a month or two it became
very evident that our suspicions as to the existence of primary
disease in the breast itself was correct. She put herself for
some months under the care of a quack, and it was not until
about a year after our consultation that she determined to
sujbmit to removal of the breast itself. This operation was
performed by an eminent provincial surgeon. The massi
removed was very large, and the axillary glands had to be
taken away as well. The patient sank within forty-eight
ho^rs of the operation. ;

Cancer of both breasts — Fracture of Clavicle from slight

violence — Good union.

The following notes, taken in May, 1893, describe a case
in which I declined any operation* Both breasts were
affected and in an advanced stage of the disease. A point
of much interest is that a fracture of a long bone had
occurred from very slight violence, and yet probably in-
dependently of any malignant disease in it.

Scirrhus. of both breasts in a woman, aged 52, with en-
larged glands in both axillae. In this case both breasts were
of considerable size and adherent to the chest-wall and to the-
skin, the latter being infiltrated and puckered. The exact
date of the commencement was uncertain, but it was probably
present 18 months. A point of some interest in the case was-
that the woman had a recent fracture of one clavicle, which
had united well, although with considerable thickening. It.
had been caused by a fall in getting out of bed in the dark.>
The poor woman, who was very anxious to. keep her more,
serious trouble secret, boasted that she had succeeded in'
concealing from . 1;he surgeon who treated her fractured
clavicle the faK^t that she had tumours in her breasts. V
do- not think that there was any reason to believe that the^
bone itself wad affected with cancer, although on6 may suspects

SECONDABY INFECTION OF BONES. 14Q

that it was unduly brittle. I have in other cases known
patients, who were the subjects of cancer, break bones,
which yet united quite well. '

Soirrhibs of Breast — Excision — No local recurrence — Death
five years later ^ after spontaneous fracture of thefefrjm/r,^

In May, 1881, I saw Mrs. B- , a married lady from

the country, concerning whose casiie the following letter

which I wrote at the time is the only memorandum I

possess : —

" 15, Cavendish Square, W.

"May 28, 1881.^
^ '* My dear Sib,— I should confidently believe the disease to be
scirrhus, and should, on tha whole, advise an operation. The case is
not, however, a very favourable one, and I would not urge an operation
if she is unwilling. If no operation is done I would cover the lump with
lint wet in a strong lead and spirit lotion, and so endeavour to retard its
growth.

" Believe me, yours truly,
r . . " JoN, Hutchinson."

Although I do not remember anything about the patient,
and have sought in vain for any record of the case, yet from
the tenor of my letter I have little doubt that the tumour
was unusually large and the patient much out of health. I
have always been a strong advocate for operations, and have
. never countenanced their omission if the conditions seemed
hopeful. Some years ago I received the following as a post-
script to a letter respecting another patient. At the same
time my own letter, as given above, was enclosed : —

" P.S. — I sent Mrs. B to see you about six years ago, suffering

from scirrhus of the left breast. You advised operation, but you did
■not advise me to press it if the patient was at all unwilling. She yi9&
quite willing and anxious to have it done. The glands in the, axilla were
affected. I renioved the breast and glands affected. Dr. Ed^^ard
Swales was present. I did it antiseptically, and there was no pus from
beginning to end. She lived five years afterwards, and then it did not
iattack the breast ; but she fractured her thigh by slipping downstairs,
and there was secondary deposit in the -thigh, and shei died |rppi
exhaustion.*' .^

Facts such as the above, whilst in the main strongly

150 ILLUSTRATIONS OF CANCER OF THE BREAST.

encouraging operative interference, would appear to prove
that blood infection may occur at a stage when the local
disease is yet restricted. The local cure was presumably
complete, for five years elapsed without any local return.
The growth in the femur may possibly have been wholly
unconnected with that of the breast, and an evidence only
of constitutional, possibly inherited, tendency to cancer*
On the more probable supposition that it is from infection
from the breast, the case illustrates the long latency which
is possible even when germinal matter has found access to
the blood. A fact which would favour the belief that the
disease of the femur was really secondary to that of the
breast, is that after scirrhus of the latter, spontaneous frac-
ture of the femur is not very uncommon. A singular
coincidence in illustration of this once occurred. Two ladies
for whom I had removed the mamma on account of cancer
in the same week and in the same home, both had spon-
taneous fracture of one femur about two years later, and
within a few days of each other. Neither of them had had
any local return (so far as I remember).

A lady whose breast I had removed on December 8, 1878,
wrote to me respecting another ailment on May 29, 1893,
and took occasion to remind me of the fact, and to report

that she had had no return (Miss B C ). . The weak

point in the case is that I cannot offer any proof as to
microscopic diagnosis.

Cancer in both Breasts, with a ten years interval,

I excised the left breast of Mrs. T in 1884. In 1889

I removed a gland from the axilla, and in 1894 the other
breast. In the interval I had also operated on a younger
sister for the same disease. Both sisters are now living,
and free from any return. The elder is now fifty-four.

We may safely assume in such a case as this that the
tissue-tendency to cancerous processes is strong. It is not
probable that the disease in the second breast was in any
connection with that in the one first affected.

CASES OF LONG IMMUNITY. 151

Examples of long immunity after Excision of the Breasts.

My friend the late Dr. Smith, of Cheltenham, related to
me several cases supplied by his long experience strongly in
favour of excision of the breast for cancer.

A lady whose breast was removed in 1849 by Mr. Phillips,
of the Westminster Hospital, and examined microscopically
by Mr. Quekett and declared to be scirrhus, lived till 1869,
and then died from " keloid of the skin of the chest.*' The
so-called keloid began on the other breast, and spread over
a large extent. In all probability it was cancer of skin.

Another lady whose breast was removed by the same
surgeon in the same or the following year, was at the time
of our conversation still alive and well (1870). In her case
also I believe the diagnosis had been confirmed by Mr.
Quekett's ncdcroscope.

PliLgging of Veins following Excision of the Breast on two

occasions — Gouty antecedents.

A lady aged 45, in excellent health, but with gouty ante-
cedents, required the removal of the left breast for scirrhus.
During her recovery, which was in all respects favourable,
she had an attack of plugging of the veins of the left leg.
Six years later (July, 1893) I had to remove her right breast,
and on this occasion, a week after the operation, she being
still in bed, a long tract of vein in front of the right elbow
became plugged. She was doing perfectly well at the time,
and no ill consequences followed from the phlebitis on either
occasion.

(2^0 he continued)

INCKBASB OF GENEBAL PARALYSIS OF THE

INSANE.

The outlook as regards the alleged increase of general
paralysis of the insane is not a cheerful one. It is asserted
to occur precisely amongst those in whom it might hove
heen least expected. Its victims are married men of the
well-to-do classes. Amongst women it is, as it has always
heen, rare, and is becoming yet more so, and the labouring,
or for Asylums the pauper class, shows no increase. The
same is true in the main of the unmarried amongst the
middle class who supply private establishments for the
insane, but when we come to the married we have a very
startling statement. I am taking these statements from a
paper apparently compiled with great caare by Dr. R. S.
Stewart, of the Glamorgan County Asylum. It may be
well before proceeding further to allow Dr. Stewart to speak
for himself. After showing that the total increase of
insanity in England and Wales is probably ;yery slight, he
proceeds to prove that the increase of general paralysis
amongst widowers and married men is alarmingly great.
The following are his figures on this point.

Contrasting general paralysis with other fprms of mental
disorder, the order of increase (per 10,000) of the average
annual admissions of the five years 1882-92 over the .five
years 1878-82 in relation to the marriage state, is as
follows : —

Acbndseions, excluding

General

Paralytica,

Oeneral Parahftics*

Married Men

01

Married Women

... 0-005

Single Men

0*2

Single Women

... 0-010

Single Women ...

0-3

Widows

... 0-026

Married Women

0-4

Single Men

... 0-060

Widows

1-4

Widowers

... 0-261

Widowers

1-7

Married Men ...

... 0-804

GENERAL PARALYSIS OF THE INSANE. 153

The most striking feature of the foregoing figures is the
position occupied by married men, for while the increase of
the admissions (other than general paralytics) is least of all
pronounced in their case, they most of all are responsible
for the increase of general paralysis ; in relation to these
two groups of mental disorder they occupy the extremes.
The extreme position occupied by married women and men
in the increase of general paralysis is another very note-
worthy point. The increase among single women is twice',
and among widows five times what it is among married
women; while as regards men the increase among the
widowed is over four, and among the inarried five times
what it is in the single.

The first thought which will occur to most in reference tp
these statistics is one which found expression in regard to a
yet more important narrative : '* Let us hope that it is not
true." The fallacies of statistics are indeed so many that
there is some ground for this hope. It seems at first sight
equally difficult to assign any plausible reasons of increase
of general paralysis amongst married in the present age as
for its greater relative prevalence amongst them in contrast
with single men. Married men are generally supposed to
lead lives more conducive to health in all respects than
those of bachelors. If the conditions of married life have
during the last quarter of a century changed at all, they
have probably changed for the better. Men drink less than
they did, gamble less, and take more holidays. No South
Sea bubbles have broke of late, and the days of the railway
mania are now half a century past. We have lived througli
comparatively quiet and absolutely prosperous times. Thu^
it is not easy to see that social conditions involving excite-
ment can have acted in causing an increase of this form of
insanity. If we turn to the question of syphilis as a pre-
disponent to it — and this is the aspect in which it chiefly
interests me — ^we are met by the fact that more of the
unmarried than the married have probably suffered. The
reason in very many cases for a man remaining unmarried
is that he has had syphilis. My own experience as- to

154 GENERAL PARALYSIS OF THE INSANE.

general paralysis is naturally fragmentary and one-sided. I
see not a few cases in which the thought occurs " that man
is in danger of general paralysis/' These are all cases in
which syphilis has preceded the nervous phenomena, or they
would not be brought to me. Almost all of these, under
the prolonged use of specifics, get quite well. Concerning
a minority I never know the sequel, and as to a very few I
am made acquainted with the fact that the malady does
develope. Of the latter class — although I may have known
of more — only three are well impressed upon my memory,
and in order to obtain some clinical basis for my remarks it
may be well that I should relate some particulars as to these
before proceeding further. They are good typical cases,
and were all three the subjects of repeated consultations
with others. Of these three, one was an honestly married
man ; a second married his mistress during the early stage of
his symptoms, and ought, so far as sexual habits are con-
cerned, to be counted as unmarried ; the third had never
niarried. All had had syphilis, and all are now dead.

Case I. — Tabes followed by General Paralysis of the Insane
and death — Patient a man of free life who had suffered
from Syphilis. »

In this instance the patient was a man of great business
ability, who had made a fortune and who kept it. He had
never had any sort of business anxiety, but he was accus-
tomed to speculation. When he became ill his delusions
were always in the direction of exaltation. He always
boasted of his wealth and prospects, and was never
depressed about anything. He had lived freely and was
fond of champagne, but he was too keen a man of business
to have ever been intemperate. He had probably indulged
very freely with women, but he had, I believe, always been
very vigorous, never until his illness experiencing any ill
results. As regards his syphilis, he appeared to have got
over it easily, and, excepting his nervous illness, no reminder
or tertiary symptoms ever occurred. As in the case which is
to follow, unless he had avowed his syphilitic history I
should have found nothing to make me suspect it.

CASE-NABRATIVES. 155

Mr. E 's illness began with symptoms of tabes. He

lost his knee-jerksy and optic atrophy followed. At this
stage he was seen by Dr. Hughlings Jackson, and I give the
diagnosis of tabes on his unquestionable authority.

My acquaintance with Mr. E began in 1894. He

then told me that he had had syphilis twelve years before —
but this he subsequently denied, and alleged, without the
slightest grounds, that he inherited the disease from his
father. This delusion became very firmly fixed in his mind.

During the whole of the time that Mr. E was under

my care I gave mercury and iodides, and often with apparent
improvement. He continued, however, to indulge in stimu-
lants and sexual intercourse, and in these directions I think
counteracted the drug treatment.

In February, 1896, I had the following diagnosis from
Dr. Savage, and he was now placed in an asylum and I saw
no more of him. I heard that he had died six months later.

DR. SAVAGE'S REPORT.

Feb. 18y 1896. — The patient is in the fat and demented state of
general paralysis. He has great want of facial expression, greasy skin,
bright capillary stigmata over malars, tremor of facial muscles and of
tongue ; when trying to speak there is a tendency to a kind of spasm,
giving a sardonic look ; swallows fairly but does not masticate properly.
His hands are waxy and wanting in fine power of adjustment ; gait very
ataxic ; K. J. absent ; he has loss of control over rectimi ajid bladder ; he
has only perception of light ; pupils equal, dilated ; discs not examined ;
hears well ; seems to taste and smell well. His memory is very defective
for recent events ; he is fairly amiable, and has lost all his old antipathy
to his father. He has a way of denying all things : thus, if asked where
he is, says ** nowhere " ; if asked if has money, says " there is none " ;
that he "has no parents," ** no relations," "no wife," " no house," etc.
When asked further, said he created himself ; that he had two shillings,
which were enough to keep him for two weeks. He has had no fits ; he
is now hopelessly demented.

Case II. — General Paralysis of the Lisane, beginning in the
tenth year after Syphilis, and ending fatally in its fourth
year.

The subject of the following case was a man in whose
family no insanity was known to have occurred. He had

156 GENERAL PABAI4YSXS OP THB INSANE.

suffered from sypbiUs, had been cured by specifiee^ and never
showed any further symptoms. Two years, or perhaps less,
after hi9 syphih^^ he married. His wife retained good, health,
and bore him four children, all quite healthy and all living
at the present tinxe. He had married above his own position
and acquired property with his wife, which was a source of
great satisfaction to him. This induced him to engage in
speculations, which, although they involved no serious
disaster, were not profitable and caused much disappoint-
ment. His first depression of . spirits was distinctly in con-
nection with them* He was a total abstainer as regards
alcohol, :and apparently a man of moderation in all things.
!No one would ever have suspected him of having had
syphilis if he had not voluntarily revealed it to' bis sui^oii
when he became ill. Although he had been wholly free
from symptoms for ten years, that is ever since the
secondary stage, yet when his more serious nervous
symptoms ensued he had a fixed idea that they were duei
to syphilis, and mentioned it . over and over again to every
medical map. whom he consulted. From first to last there
waiS an entire absence of indications of persisting taint, th^
ease being an ordinary one of general paralysis. '

Schedule of Case.

TZAB.I DETAILS.

1871 , Syphilis complete. Mercurial treatment.

1872 ! Details of treatment, &c., not known.

1873 I Married.^

1874 ,

No further symptoms of a syphilis. A family of four

[ healthy children, all still living.

1876
1876
1877
1878
1879
1880
1881
1882
1888
1884

Losses hy speculations and some anxiety.

His illness began by fits of depression.

Went abroad and zoade foolish speculations.

Liable to tongue symptoms, &c. (s^e memoranda below).

Symptoms pronounced (see memoranda below).

Died in an asylum.

From the date of his first depression of spirits to his death
was five years, but during only the last three of these had

CASE-NARRATIVES. 157

the symptoms been pronounced. Mercury was given twice
during his worse attacks, and pushed to sUght ptyahsm.
It was not, however, continued long. He was for a long
time the subject of very profuse flow of saliva, possibly in
connection with the mercury.

The case is the same as that briefly mentioned in Com,-
mentary LXIX. of my work on Syphilis.

Aiiditional Memoranda.

Oh March 5, 1882, his wife wrote : *' He has to-day had
a curious sort of a fainting attack in church. He felt a
sort of numbness in one side, and, on rising, found he could
not stand. He lost consciousness for a few moments, and
then after a rest was able to walk home, and now feels per-
fectly well again. His face looked, I thought, rather on one
side, and he complained of the feeling being all down his
left arm and leg. His speech was rather affected. During
the last nine months he has had three slight attacks in his
speech : his tongue seems to get cramped and for a few
minutes he cannot speak plainly. Then he recovers entirely
and is all right. This last seems to have been a similar
attack, but affecting more than the tongue. He has been
much better lately in general health, and he appeared quite
well this morning when he went to church. I have been
rejoicing to see him so well."

On December 20, 1882, one of his friends wrote: **He
forgets the names of such places as London and York, and
could not tell me how he had got here. He was unable to
write to his wife this morning to say that he was coming
home, and could not be made to understand the time at
which he would arrive. A telegram which he received about
business made him quite nervous and ill for the rest of the
day, though it contained nothing of importance. Anything
connected with money transactions seems to have a peculiar
effect upon him. He talks almost incessantly, and seeitis
impatient of any interruption. He often cannot or will
not answer a 'simple question. He tells you the same story
over and over again,' and sometimes forgets who he is

158

GENEEAL PARALYSIS OF THE INSANE.

speaking to, and talks to you about yourself in the third
person."

On June 5, 1883, the report of his wife was : " During the
last week he has been increasingly irritable, the least thing
putting him out. Last evening he seemed to quite lose his
balance, and he became almost violent. Two doses of
morphia were needed to get him to sleep.''

On July 8, 1883, the Medical Officer of an Asylum to
which he had been sent, wrote, ** In many ways he shows
the typical symptoms of G. P. of I., but he is constantly
alluding to an attack of syphilis which he says he had some
years ago, and of which he describes the symptoms very
accurately. He sleeps well and has a wonderful appetite.
His mental condition is one of extreme exaltation, with
hallucinations of sight and hearing. He was much excited
one day and broke the windows.'*

Case III. — General Paralysis of the Insane in the sixth
year of Syphilis — First symptom^ Paralysis of Third
Nerve — Death.

YEAB.

AGE.
32

1892

1893

33

1894

34

1895

36

1896

36

1897

37

1898

88

DETAILS.

February : a sore. May : roseola. Sore throat and tosgue.

Bupia on leg whole year. Mercury and arsenic.

Well. September : transient motor aphasia. Iodide and mercury.

Well. Little or no treatment.

January : brought to me, paralysis of left third and fourth nerves.

He was for a short time in an asylum with G. P. of I.

Death occurred nine months after leaving the asylum.

Additional Memoranda,

Mr. W was a man of no sHght attainments. I saw

him only once, and do not know details as to his progress
beyond the fact that he became a G. P. His mother and
two or three sisters had died of phthisis. He had cough
from boyhood, but at the date of the consultation he looked
well, and complained only of his digestion.

ON HYDKOCYSTOMA. 159

He had paralysis of all the muscles supplied by the
third and fourth nerves, and possibly some weakness of
the external rectus also. His attack of ophthalmoplegia
occurred suddenly. He had been out that morning on
horseback. Drooping of lid was the first symptom. No
headache had preceded it. He had been very busy in an
arduous avocation.

It will be seen that the treatment in the first instance
was not commenced until the secondary stage was well
developed. The treatment throughout was mixed and in-
termittent. In the third year the nervous system was
threatened.

ON HYDEOCYSTOMA.

It would appear that the condition known as Hydrocystoma,
and which is said to be fairly common in the United States,
is rare in England. When I published in the British
Jaumal of Dermatology, in May, 1896, the case of the
patient of whom I now give a portrait, I stated that I had
seen a few much less well-marked cases, but none others
which in the least approached it in definition. Now, four
years later, I have to repeat the same statement. No other
well-marked case has come under my notice in private
practice, nor have any of those who assist at my Museum
Demonstrations produced any.

Dr. Eobinson, of New York, who was the first to describe
the phenomena of Hydrocystoma as constituting a distinct
malady, stated when he read his paper (1884) that he had
four examples of it under observation, and he has sub-
sequently said that he has seen thirty or forty. It is said
to occur chiefly in washerwomen, whose faces are much
exposed to hot steam. It may be that there is something
peculiar in the kind of influence to which women of this
calling in New York are exposed which does not hold in
this country.

It will be seen, in the portrait, that the patient's face shows
a great number of little watery vesicles which might at first

160 ON HYDBOCYSTOMA.

sight be mistakem for those of a mild herpes. Although, how-
ever, they are in this instance far more abundant on the
right than on the left cheek, they occur on both. Nor do
they pass up the forehead as herpes would have done. In
the paiient there is no difficulty in excluding herpes, for the
little vesicles axe persistent and not transitory. The sub-
ject of the case ,was a florid woman, aged 64, whose chief
employment was in charge of a chufch as sextoness, and
who did no more washing than for her own/ domestic
purposes. She had on the whole enjoyed good health, but
had been subject through life to very severe headaches.
Her case gives support to the theory that the nervous
system takes a considerable share in the production of the
condition. This suggestion had already been made by Dr.
Hallopeau of Paris, and Dr. Allan Jamieson of Edinburgh,
both of whom have pubUshed cases very like mine.

..My patient had been liable to unilateral sweating of the
face and also to neuralgic pain of very severe character,
chiefly in the right side of the tongue. The vesicles or little
oysts had been present more or less for ten years. They
were tense, and varied in size from pins' heads to peas.
Their contents had an acid reaction. There could be little
doubt that they were sweat-cysts. Mr* Sequeira, to whom I
was indebted for the opportunity of examining the patient,
told me that he had often verified her statement that she
was liable to sweat on this side of the face. It was clear
that her neuralgic pain, her headaches, and the sweating
had all been most marked in the same side of the head as
that in which chiefly the cysts had developed. They had
not, however, been wholly confined to it, nor were the cysts
on the face wholly one-sided.

'We may regard Hydrocystoma as an affection of the
sweat glands-—** retention-cysts '* — to which those who
perspire freely on the face are liable. The cause of the
increased perspiration may probably be neurotic in some
cases and from external heat in others. In the neurotic
cases, of which the present is an example, we must expect
deviations from bilateral symmetry, whilst in others the
two sides of the face will probably be equally affected.

PLATE CXLIV.

HYDROCYSTOMA OF THE FACE.

The particulars of this case are given on page 159.

I .« 'I

HUTCMIN90HS OLINIOAL ILLU3TBATION8.

•••• •

• • • •

V:

TEEATOLOGY.

(Continued from Vol. VIII,, p, 361.)

No. XIX. — Congenital defects in lower extremities.

I once saw in the Ipswich Hospital, under the care of Mr.
Hetherington, an interesting example of defective develop-
ment of the lower extremities. The infant was a female
child about six months old, one of a family of five, the other
four being quite free from defect. The most conspicuous
feature was a form of talipes varus, the feet being much
bent and strongly turned inwards. For the relief of this
several tenotomy operations had already been performed.
There were, however, other and more exceptional defects.
Thus the knees were turned inwards until they faced each
other. It was even difficult to recognise the knee by sight.
On examination of the knee with the finger I could identify
the condyles of the femur, but could not find a patella or
any ligamentum patellse. The tibia was very loose on the
femur. There was a fleshy substance in front of the femur
which might be a quadriceps muscle ; but it never, so far as
I could tell, took on any action. The lower limbs were
altogether short, this being perhaps due to the fact that the
great trochanter was higher up than usual. As far as I
could tell, neither of the femurs had any neck or head, and
very probably the acetabulum was absent. As the child lay
on its back it was constantly lifting the extremities up into
the air, evidently by means of its psoas and iliacus. This
movement it accomplished very vigorously, but I never
noticed that it moved its knees or ankles. The conditions
appeared to be quite symmetrical.

VOL. IX. 11

162 TERATOLOGY.

No. XX. — Congenital defects in all the limbs.

A girl aged sixteen months, under Mr. Tay's care in the
London Hospital, had congenital defects in the development
of all its limbs. They were much more marked on the left
side than the right.

Left hand : the middle and ring fingers were webbed
together and dwarfed to one-fourth their proper size.

Eight hand: the middle and ring fingers almost of full
length, but wanting their nails and pulps. The last phalanx
of thumb wanting.

Left leg showing a little below the knee a deep furrow
as if it had been compressed by a band ; below this furrow
the limb was of normal size, but looked more dusky and
congested than the other ; the foot was twisted inwards, and
all the toes were very short and small. It appeared that the
bones of the digits were either wholly absent, or almost so.

The right lower limb was quite without defect, excepting
that the ends of the three middle toes were absent.

The child had no other defects.

No. XXI. — Depressions in the Skull behind the Ears.

William W , set. 37, came to see me November 10,

1888, with Dr. Tapson, for facial paralysis with numbness
on the left side. His history was that he had been very
delicate as a boy, and had suffered much from eczema, but
was now well of that. Four years ago he had partial
paralysis of the facial muscles, with numbness of the face.
There was much general weakness, and his pulse was very
feeble. Eecently he had had pain and swelling over the
antrum. He had previously been treated for syphilis.
There was a peculiar depression, quite symmetrical, behind
the ears; it was deep and shelving in the mastoid and
occipital bones at the base of the mastoid process. No
•deafness or defect of sight.

No. XXII. — Congenital defects — Multiple.

I saw Master C , aged 4, on Januarj^ 20, 1894, in con-
sultation with Dr. Molyneux. He was a seven months'

ABSENCE OF DIGITS. 163

child, and at birth weighed If lbs. The anus was im-
perforate, and two days after birth an operation was per-
formed, and at the age of eight months this opening had to
be enlarged. In infancy he was subject to obstinate consti-
pation, and when one year old enemata were used constantly.
The scrotum was divided by a deep raphe. Hypospadias
was present. The end of the sacrum projected under the
skin, and there were no signs of a coccyx. The left testis
was undescended, the right one being of normal size. There
was a doubtful tendency to spina bifida, and the child could
not walk well. The forehead was very suspicious of syphilis.
The mother had had three children in twenty-eight months.
Two children bom since our patient were dead ; one having
been bom at six, the other at seven months. One of these
infants was believed to have had some malformation in the
throat.

No. XXIII. — Congenital absence of one finger^ with
slight general excess in size of all the others.

In May, 1867, 1 had under observation a married woman
in whom the right forefinger and its metacarpal bone were
absent. There was no trace of appendage, nor even of scar.
The girth of the knuckles on this side was an inch less than
in the sound hand. All the digits were, however, individu-
ally larger than their fellows. This increase concerned their
bulk only, for they were not longer. Thus the middle
finger of the left hand had a girth of two inches and a half
round its middle joint, that of the right being only two and
a quarter. The difference in the size of the nails on the
two hands was very conspicuous. The wrist of the right
was a quarter of an inch greater in girth than that of the
left. Thus it would seem that the hand which had grown
only three fingers had used the nutritive force, or blood
supply, to increase the size of all its other parts, and that
with equal distribution. The woman was right-handed in
spite of the defect. She had six children, none of whom
had inherited any defect. She had the normal number of
toes on both feet.

164 TERATOLOGY.

No, XXIV. — A Spina bifida in the cervical region.

I saw at Shottermill, many years ago, a child nearly two
years old in whom a spina bifida was present between the
shoulders. The tumour was rounded, and the skin over it
very thin. It was as big as a fist. It evidently sprang by
a large neck from the lower cervical region, and certainly
did not pass up to the occiput. There was no positive
tahpes, but the lower extremities were fltabby and cold, and
the child made but little attempt to use them. The child
was well grown, but had a large hydrocephalic head.

I heard some time afterwards that the tumour had given
way and was draining a serous fluid, and still later that
the child and its mother were both dead in consequence of
accident. I record the case because spina-bifida tumours in
the cervical region are very rare.

No. XXV. — Optic Atrophy and white discs in asso-
ciation with Occipital Encephalocele,

An infant under observation in October, 1866, had an
occipital encephalocele as large as a hen's egg. The swell-
ing became tense when the child cried. It was well covered
with scalp hair, and bony plates could be felt in its walls.
The infant was blind, and had white discs. It died at the
age of seven months.

No. XXVI. — Conditions supposed to be characteristic
of Intra-uterine Constriction by Bands occurring
in four members of the same family.

Photographs representing the condition of the hands in
B. brother and sister, whose cases were briefly alluded ta
in my last Archives, p. 360, have been placed on the screen
in the Museum and may be examined by any one who takes
interest in the subject. It seems scarcely worth while to-
reproduce them as woodcuts, since the conditions are almost
exactly those shown in the illustration from another case
which I now, for the reader's convenience, again insert.

A FAMILY MAIFOEUATION. 165

The point is that a brother and two sisters have been bom
with their hands deformed on exactly the same pattern, aoid
that it seeniB impossible to explain such an occurrence by
supposing the deformities to be due to constriction by
amniotic bands. There is the further fact — possibly of great
importance — to he mentioned, viz., that a great-uncle pre-
sented the same malformation.

Now the conditions present are exactly and precisely those
usually attributed to the mechanical effect of constricting

bands; yet, as just remarked, it seems absurd to suppose
that such bands should chance to have been formed on the
hands of three different fcetuses, affecting in alt the same
hand and producing exactly parallel results. These facts
of family occurrence and inherited defect look much more
like some arrest of development. Yet if we admit arrest
of development as a cause in this case, surely it must be
allowed in others which are just like them. It seems highly
improbable that precisely the same result should be in con-

166 TERATOLOGY.

nection now with one and now with another cause, such
causes being extremely different. I can, I may confess, see
but one supposition by which it is possible to admit or
reconcile the two hypotheses. It is this, that possibly a
defect, originating in a mechanical cause (constriction by
bands) in the first instance, may be transmitted hereditarily.
This supposition, of course, contradicts the general creed
which denies that acquired defects are transmissible. I have,
however, on several occasions mentioned facts which seem
to invalidate that creed. If it can be got rid of, and if we
may believe that the results of injury and of disease may,
in some instances, have the effect of stamping peculiarity of
structure on future generations, a great step will have been
taken towards our comprehension of the phenomena of
family diseases as well as of the general possibilities in
reference to struX5tural inheritance. In the present in-
stance it is to be remembered that it is a great-uncle and
not a grandfather who is supposed to have shown the
malformation. On this point, however, my informant's
knowledge may be inexact, or it may be that the great-uncle
himseJf inherited from a predecessor.

I have been in correspondence with Dr. J. W. Ballantyne,
of Edinburgh, a very high authority in all that relates to
Teratology, and the following extract from his letter will,
I am sure, be valued by my readers.

" In reference to the influence of pressure — amniotic, fimic
or otherwise — in the production of the so-called intra-uterine
amputations ; that they are sometimes due to constricting
bands is, in view of the evidence of Simpson, Montgomery,
Eeuss and others, undeniable. I believe, however, that they
may also be due to a diseased condition of the skin itself, as
Jeannel holds, while it is just possible that some are really
want of development from inherent absence of formation as
occurs undoubtedly in the more advanced hemimelic and
amelic types. If they be due to these two latter causes, it
is easier to understand how they may be hereditary, but to
my mind it is incomprehensible to think of an amniotic
band, or the umbilical cord, producing similar conditions,
and necessitating exactly similar arrangements in successive

ENCEPHALOCELE WITH OTHER DEFECTS. 167

pregnancies. Nevertheless, although incomprehensible, it
may be true."

No. XXVII. — Absence of Limbs.

In the College of Surgeons Museum there is a specimen
of a child without limbs. It is a large baby and probably
lived some time after birth, a male. The skin over the
shoulders is smooth, there being no trace of arms. The
muscles of the left hip have been dissected (338). It is
otherwise well developed. (I have two portraits of the like.)

Specimen 278 is also a skeleton without limbs. There is,
further, the skeleton of a one-legged seagull.

No. XXYIII. — Occipital Encephalocele associated
vrith cleft palate, convulsions^ and blindness —
Death in the third year.

On June 5, 1868, an infant aged one month was sent to me
by my friend Dr. Dove, of Pinner, on account of a large
occipital encephalocele. The infant had been bom at full
time and was its mother's first. It was rather small. Both
fontanelles and the whole length of the sagittal suture were
open. The head was well formed with the exception of the
occiput, which looked very small, as if sliced off. The
tumour was of irregularly oval shape, its long axis being
horizontal and its chief projection to the right. It was as
large as an adult fist, and fully half the size of the rest of
the infant's head. At right projecting end the skin and mem-
branes were distended so as to be quite transparent: On the
tipper part the tumour was covered with scalp hair. This
filled up the nuchal cavity and hung upon the back; it
pushed the head forwards so that the child's ears touched
its shoulders, and its chin its chest. The spine seemed to
be rounded and to project backwards, but probably all these
deformities were merely the result of the displacement by
the tumour.

Parts of the skin of the tumour were in the condition of
port- wine noBvus. The palate was cleft nearly up to the

168 TERATOLOGY.

alveolus, the cleft being double and leaving the vomer in
the middle. The feet were not distorted. Convulsions
had occurred several times, attended by blackness of face.
Owing to the cleft palate the infant could not suck. The
infant did not use its arms well, but still it could grasp, and
perhaps there was but little deficiency.

Dr. Dove was subsequently kind enough to inform me
that the child had died at the age of three years. It had
been blind, or almost so, for some time before its death,
and had also repeatedly suffered from convulsions.

No. XXIX. — Spina bifida in two brothers.

An instance of spina bifida occurring in two children of the
same family was brought under my notice by Dr. Byles, of
Victoria Park, in 1870. The conditions were very similar
in the two. Death resulted, I believe, in both. Both were
boys. There were about eighteen months between them.

No, XXX. — Case of Hypospadias with apparent
absence of Testicles^ and some curious features
of resemblance to the female sex.

July 20, 1883. The subject of this case was a boy aged
16. He was short for his age, with wide pelvis and some-
what female gait. His voice was an ordinary boyish one.
Some fine hair on the upper lip and chin was commencing
to grow. The pubic hair was rather plentiful and long, and
there was also some on the scrotum as far back as the anus.
The penis was small. There was a large meatus at its
base and under-part, the lower lip of which was a thin fold
of mucous membrane. The penis was grooved, and in the
groove were three openings which seemed to pass only for
a few lines into the wall of the groove, and were probably
glandular follicles . A gum-elastic catheter passed fairly easily
for several inches, but no urine came, and it could be felt
by the fingers to be close to the rectum ; at the same time
no prostate could be felt. A silver catheter with some
difficulty was made to enter another canal leaving the one

INTBA-XJTEBINB BEPAIR OF DEFECTS. 169

mentioned at some distance from the meatus, and this led
more upwards and into the bladder. The lower canal could
not have been a false passage, as he had not been catheter-
ised before. The instrument passed readily, and no blood
followed its withdrawal. The scrotum had a marked groove
leading back from the meatus and the perineum also, the
bottom of which had the appearance of a scar.

The testicles could not be found either in scrotum or
abdominal wall. There was no impulse at the inner ring
when he coughed.

No. XXXI. — Intra-uterine repair in Goloboma.

In many cases of coloboma of the iris (congenital) we
have evidence of a sort of intra-uterine repair: of a defect.
In one eye there may be a large open coloboma, in the
other a wedge-shaped portion of fibrous-looking tissue in
the corresponding part which is destitute of colour of the iris.

In the case of the Eev. M. B. A. this wedge was grey

and pigmented, and looked exactly like scar tissue. The
coloboma was complete in the left and this scar existed in
the right. A similar evidence of repair is sometimes seen
in the upper lip, a child being born with a scar in place of a
cleft, looking exactly as if a harelip had been closed by
operation.

No. XXXII. — Congenital defect in development of the

femur.

There is in the University College Museum the skeleton
of a man in whom the femur on both sides is almost wholly
absent. The rest of the bones are almost normal ; those of
the trunk and upper limbs are remarkably well formed.
The front part of the pelvis is very light; the leg bones,
especially those of the left leg, are, I think, almost of natural
length and size. Those of the right leg appear to be smaller
and somewhat bent, and the right foot is small and with a very
high instep. The femur on each side is represented, above
by two fragments of bone as big as half-walnuts, possibly
the two epiphyses, and below by a fragment which clearly

170 TERATOLOGY.

represents the lower epiphyses. The whole of the diaphysis
is wanting, and the leg appears to have been attached to the
pelvis, just below the anterior iliac spine. I am describing
the specimen on a cursory examination, and without having
had reference to the catalogue. It has, I beUeve, been
figured and described by Mr. Liston.

No. XXXIII. — Hydrocele of the NecJc.

[A note written Nov. 18, 1878.] An infant now attend-
ing at the London Hospital has a large tumour in the right
side of the neck which bulges forwards in front and under
the chin. It consists of large cysts, most of which have a
bluish tint. They adhere closely to the skin. It is not quite
in the usual position, coming much more in front and less
in the side. On the left side, just in front of stemo-cleido
mastoid is a very soft swelling, only detected by the finger
(not visible). I did not notice it on the first occasion. It is,
I think, quite distinct from the other, but they meet in the
middle. The infant is four months old. I advise to defer
treatment.

No. XXXIV. — Dwarfdom and defective development

in many regions.

In May, 1883, I had under observation at the London
Hospital a very peculiar case of multiple and disconnected
defects in development. The young woman, although 23,
was, I should think, not more than 4 ft. 6 in. in height, and
looked like 16. Her frontal eminences were prominent,
and the forehead somewhat squared. The upper half of her
sternum projected strongly, but at its middle there was a
deep depression. There was a very curious depression of
the skull bones on the left side a little above the occipital
protuberance, much as if it had been indented by a severe
fracture, and at both elbows the head of the radius appeared
to be much larger than natural, and the external condyle
much smaller : thus the upper and outer two-thirds of the
head were quite free from the condyle. In the upper jaw

POSTEEIOE DICHOTOMY. 171

she had bpit two teeth, a bicuspid and a molar on the
left side. In the lower jaw she had no incisors or
canines, but six or seven bicuspids and molars irregularly
placed. The teeth that were present were of large size ;
the gums in the incisor region were much shrunk. She
had epicanthus, and the eyes looked small, the pupils
not being exactly in the middle, but rather towards
the nasal side : her sight was defective, and she had
a high degree of hypermetropia. Her forehead and face
were suggestive of inherited syphilis ; but I could not find
any evidence of periostitis in the long bones, and she had
never had keratitis. She was the eldest of six or seven,
and reported her brothers and sisters healthy. She had
had fits in infancy.

No. XXXV. — Note on cases of Congenital Absence of

part of the Pectoral Muscle.

In the cases of congenital deficiency of the pectoral
muscles to which I have twice referred (Vol. V., page 342,
and Vol. VIII., page 356), the fact is repeatedly noted that
the sterno-costal portion may be absent whilst the clavicular
part is perfect. The essential distinctness of these two
halves of the muscle is confirmed by what is sometimes
observed in the results of disease. Thus Gowers has noted
that in Duchenne's paralysis the sterno-costal portion is
often wasted when the other escapes.

Two cases of this congenital defect are recorded in
Virchow's Archives, vol. cxxi., p. 598, with a lithograph.
I am indebted to Mr. H. C. Durham for this reference,
which I am glad to add to those already given.

No. XXXVI. — Double Monsters — Posterior

Dichotomy.

In my last issue mention was made of two specimens of
the "Double Monster'* which had recently been obtained
and were in process of dissection. A graphic illustration

172 TEBATOLOGY.

(copied) of the condition in a living hare was also given-
This woodcut showed an animal with one head, but three
ears. Its shoulders were so joined that two of its fore-legs
came to the ground, whilst two others were on its back. Its
hind-quarters were quite separate, so that it ran vdth four
hind-legs all touching the ground. These conditions are
almost exactly reproduced in the two specimens which I
have recently dissected. One of these was a pig, the other
a kitten. I mention the subject again here in order to
reproduce the accompanying illustration which shows the
manner in which the bowel is united into a single trunk in
the ileum. The woodcut is copied from one given at page 288
of the Ephemeridum Medico-physicorum for 1686. It will
be seen that the bowel, which was of course double from
the anus upwards, in the dichotomised lower quarters of
the animal becomes single by union of the two at the certain
position in the middle of its course. In place of speaking
of union of the two bowels at this point it might perhaps
be more correct, though less convenient, to speak of division
commencing here. The result is, however, the same. This
union of the duplicated bowel at a certain point appears to
supply a strong argument in support of the doctrine of
dichotomy as opposed to union of two embryos. Were
these double monsters produced by the latter process it is
very difficult to understand how the organs should, in the
upper part of the trunk, become single in such a well-
ordered arrangement ; whereas it is just what would be
expected if division of the embryo had taken place from
below. On the dichotomy hypothesis it would appear to be
usual for there to be some simultaneous tendency to division
from above as well as from below; — anterior as well as
posterior dichotomy. In the specimens from which the
woodcut was taken this was marked, there being two heads,
and the upper extremities as well as the lower being dupli-
cated. It will be seen that there are two stomachs and two
spleens. Only a very short central region are the viscera
single. Thus it will be observed that the liver is single and
the gall bladder single. So also is part of the duodenum and
the whole of the jejunum. It is from the human subject,

ANTERIOR AND POSTEBIOB DICHOTOMY.

Expi.iKATiON OP Woodcut,— The viscera from a double n
in which the bodies were united only at the thorax and upper part of abdomen.
There are two Etomacbs and two spleens, a single malformed liver and a aingla
gall bladder. The first part ol the small intaatine is single, but dichotomy
occurs in the ilium, and below the bowel is duplicate. (Seen from behind.)

174 TERATOLOGY.

the twinned monster being united only along the chest and
abdomen and possessing a single mnbilicus.

In neither of the two specimens which I have recently
had under examination was there a double head, but in both
there were conditions which suggested a tendency to division
from above. In one there was cleft palate and non-union of
the symphysis of the lower jaw. In the other there were
four ears and a cleft palate.

DISEASES OF THE EYE.

No. XXIV. — Becurring (jbud persisting Hyalitis in one
Eye only — Great benefit from residence abroad —
Gout probable.

In the case which is to follow we have, I think, a good
example of the insidious form of inflammation of the eye-
ball with opacities in the vitreous which I described many
years ago as occurring occasionally in connection with gout
tendencies. We have also an instructive instance of the
benefit to be obtained in these cases from a change of
climate.

Mrs. P , aged 32 (?) was sent to me by a distinguished

ophthalmic surgeon. A letter which she brought with her
described her ailment as *' a very curious retino-hyalitis of the
right eye, which makes the fundus quite obscure,'' and gave
me the following additional particulars : —

*' The fandus has been more obscured than it is at present, and to-day
for the first time I thought I got a glimpse of the O.N. The vision has
usually been t\, and is to-day t\. The other eye has myopic astigmatism,
but I have not yet ordered glasses. She developed symptoms of glaucoma,
and I used eserine. It has improved since. Her husband had syphilis
many years ago. Inquire of him as to their marital habits, and let me
know if you think any part of the eye-mischief traceable to either cause.

Mrs. P had blue pill at first, with a blister, but latterly bark and

iodide of potassium, \mder which she thinks she has had much benefit.
It is a very obscure case."

I found the eye in the condition described in my friend's
letter, the vitreous full of fine films which obscured the fundus.
The ciliary region was somewhat congested and the eye very
irritable. It was necessary to wear a shade constantly, and

176 DISEASES OF THE EYE.

she never attempted to read. She was a florid woman,
rather thin, looking well, and of nervous temperament. I
could not find any indications of syphilis. It appeared that
she was her husband's second wife, and that his syphilis
was prior to his first marriage and more than seventeen
years ago. He had a healthy child by his first wife. The
eye affection had been coming on for about a year, but had

varied much at different times. Mrs. P had herself had

some attacks of pain in her toe-joints, but I could not learn
that definite gout had ever been recognised in her relatives.
Neither she nor her husband were in the least out of tone,
and I did not think it worth while to prosecute inquiries in
the direction which my friend very plausibly suggested.
My diagnosis was inherited gout, in spite of the absence
of history, and I advised most strongly an inunediate
change of climate.

My advice was promptly acted upon, and Mrs. P

spent the ensuing five months abroad in Egypt. She
returned to me at the end of that time with the statement
that her eye was no longer in the least irritable and that she
was able to read with it. I found the vitreous much less
hazy, the fundus easily seen, and the vision f g. It appeared
that the irritability had ceased six weeks after she left
England, and she had then been able to throw aside her
shade. It had never returned, and she had been able to do
a certain amount of reading. She thought that she had
again been threatened with gout in her toe, but she had not
had any definite attack.

Whilst abroad she had taken quinine, small doses of
aconite and iodide of potassium, and had been carefully
dieted (see page 184 for details).

My next case must be related in two letters from a surgical
friend. I saw the patient only once and very hurriedly. He
was a young man of 20, in somewhat feeble health, and
practically blind. His father came with him, and there was
a clear history of family gout. I could not find any symp-
toms to support the suggestion of syphilis, nor did any such
develope subsequently. The case seemed to me to be an

OPHTHALMITIS OF INHERITED GOUT. 177

tmusually severe one of the relapsing ophthalmitis of in-
herited gout. In the strongest language that I could use I
urged an immediate emigration to a southern climate as the
only chance of saving any sight.

The first letter gives the history of the case and describes
the patient's state when he was brought to me. The second,
written six months later, gives the sequel.

''Aprils, 1896.

** The first attack occurred seventeen months ago, taking, I gather, the
form of a severe iritis. He was under several men, but the iritis con-
stantly recurred. He came to me in May, 1895, with sight very much
impaired, suffering from an acute attack of iritis, which subsided under
leeching, belladonna fomentations, and pills of mercury and opium. The
media remained opaque for many days, but were gradually clearing,
when the other eye suffered in a precisely similar way, and this has been
the history for months, alternate eyes suffering. Gradually the other
tissues of the eye have became involved, and each time the media show
greater delay in clearing up.

'* Latterly he has had several (three or four times) attacks of pain,
inflammation and high tension of the eyeball, which have been only relieved
by tapping the anterior chamber.

'' I have tried to build up his system by diet, steady exercise, and all
that might conduce to good health ; have treated him for rheumatic gout
and with iodide of potassium.

'' I should say that when he came to me in May, 1895, he had a round
ulcer on the scrotum with hard raised edges, which soon yielded to lotio
nigra, and a hard, swollen condition of the left leg. No edema or apparent
obstruction of the veins.

** He denies having had syphilis.*'

" September 13, 1896.

" About ten days after seeing you, Mr. W and his father went to

Woodhill Spa ; his eye was then clearing. The next day he felt great
pain in the right eye and commenced vomiting ; they took train home.
The vomiting persisted on the journey home as well as the pain. They
put leeches on the temple, without any effect on the pain. In the night
they sent for me. He was suffering from acute glaucoma. I performed
an iridectomy, which relieved the pain at once. About a week afterwards
the pain recurred violently, and as the sight was completely gone, after
consultation I removed the eyeball. The left eye seemed to improve for
a time greatly, and he began to distinguish objects with it, when he had
another recurrence of the iritis, and he can now hardly distinguish light
from dark. Unfortunately there were pecuniary reasons which prevented
them adopting your advice as to residence in a tropical climate."

The whole history and progress of the case fits exactly

VOL. IX. 12

178 DISEASES OF THE EYE.

with what occurred in the girl Mabey, the first example of
this malady which attracted my notice. In her, although the
attacks were not so severe, they were recurrent after just the
same fashion and were attended by glaucomatous tension,
which was relieved repeatedlyby paracentesis and iridectomies.
In her also one eye was lost and excised. The other was
saved only by iridectomies, which in the end had taken away
almost the whole iris. Her father had had gout. She her-
self subsequently died of phthisis. In reference to the
suspicion of syphilis, it will be seen that the sore on the
scrotum occurred long after the first attack of irido-hyaUtis.

No. XXV. — Bemote results of a blow on the eye-
hall — Complete detachment of the retina and
secondary cataract.

Mr. C , a Lincolnshire farmer, aged 50, was sent to

me by Dr. Stiles, of Spalding. His left eye had long
been quite blind, and had recently become painful. It was
congested, rather hard and showed a swollen, cataractous
lens, which bulged into a widely-dilated pupil and almost
touched the cornea. I had no hesitation in advising its
excision. After the operation we found complete, umbrella-
detachment of the retina and entire absorption of the
vitreous.

Mr. C reminded me that he had consulted me some

years before, and on looking up my notes I found, under date
May 13, 1885, the following interesting facts : — Ten months

had then elapsed since Mr. C had received a severe

blow on the eye from the handle of a winch. He had after
it a bad black eye, but the sight was certainly not destroyed
at the time. He was confident that two months lafer he
had been able to shoot from the left shoulder. By degrees ^
however, the sight had failed, and when, on the date given,
he came to me he could not count fingers. The ophthal-
moscope showed subretinal effusion in several different
places. There was no great elevation of the retina, but
it showed long white streaks and thin folds. There were

RESULTS OF BLOW ON THE EYE. 179

also some films in the vitreous. There were some pig-
ment patches at one or two places in the retina, which
probably represented the remains of haemorrhages, and the
retina near the disc was hazy. Five months later Mr.

C could only just discern light with the injured eye

and the subretinal effusions had increased ; and three years,
later the lens had become so opaque that it was impossible

to inspect the fundus. After this I did not see Mr. C

until the occasion on which, in December, 1896, I excised
the eyeball. There had been no material irritability of
the remaining eye, and throughout it had enjoyed perfect
vision.

The case is of interest in reference to the prognosis
after blows on the eyeball. Although the eye was not
disorganised nor, indeed, apparently much injured at the
time, yet we find a tendency to subretinal effusion following
in the course of six months, which, gradually increasing,
led to complete detachment of the retina and absorption
of the vitreous. Through this process the eye retained
its normal tension. In connection, no doubt, with the
removal of the vitreous, the lens became opaque, and
finally, at the end of eleven years, a state of increased
tension with congestion and severe pain made removal
necessary.

No. XXVI. — Ophthalmitis of those hereditarily gouty .

Miss T . Left eye was formerly the worse, but is

now the better. She can read with it for hours together,
and does read a good deal.

The right eye has been worse since an illness at Christ-
mas, 1880. In February, 1881, she had an attack of
inflammation in the right eye, with great pain, and at
present she cannot read anything with it except the largest
print. Sometimes there is a little aching in it after reading,
but no recent relapses of inflammation. Still she thinks
eye worse during last few months. I found a large bees-
wing opacity in the vitreous, which caused the failure of

180 DISEASES OP THE EYE.

sight. The disc could be seen easily, but was veiled. She
was not liable to any form of arthritis, but five years ago
she had an affection of the hip, from which she had quite
recovered. There was gout in the family.

No. XXVII. — The Mdbey Group — Belapsing Gyclitis
with feeble circulation and Gout.

Miss F , aged 39, has got stout, but is not strong.

Iridectomy a year ago. Got through the early winter pretty
well. Caught neuralgia in the left jaw in April. Whilst
suffering from its effects the eye relapsed. Has been freely
blistered, and has taken belladonna till the pupils were large
and the throat dry. There is a large downward coloboma,
with much discoloration of the ciliary region, and some pits
due to sub-conjunctival scars. Every spring she is accus-
tomed to get eczema on her hands. This last spring she
** stopped it by a soda solution,'* and as soon as it was well
her eye inflamed. " See-saw Ailments."

No. XXVIII. — Inherited Syphilis — Consanguineous
marriage — Belapsing Ophthalmitis between the
ages of ten and eighteen — Keratitis — Gyclitis —
Iritis — Choroidal changes and glaucomatous
tension in one eye.

No. XXIX. — Vitreous opacities in both eyes — Patient
a young woman in poor health and liable to
severe headaches.

No. XXX. — Detachment of the Betina from Sea-
sicJcness in a healthy young man.

A young gentleman in good health, at sea in rough weather,
had prolonged retching with the head bent forwards. A few
days afterwards he found that there was a waved line across
the letters which he was reading, and that when he closed
the left eye he could see nothing above this line. In the

H^MOBBHAGE INTO VITBEOUS. ' 181

course of a week or two the affected eye had so far failed that
he could see nothing distinctly with it. An ophthalmic
surgeon recognised detachment of the retina, and ordered
him to bed. He was kept six weeks in the recumbent posture
and under the influence of pilocarpine, but with no benefit.
He came under my care for another matter two years after
this occurrence. His eye was almost blind, but had given him
no further trouble. His health was good, and he could see
perfectly with the other. As an example of detachment of
the retina from a definite cause, and apparently in a man of
sound tissues, the case seems worth mention.

No. XXXI. — Case illustrating the symptoms of

Hcemorrhage into the Vitreous.

A very voluble but at the same time keenly observant
woman has just been describing to me her husband's illness.
He is, she says, paralysed in one side of his body and blind
in one eye. The eye is affected on the same side as the
limbs, the left. **He lost his eye, you know, some days
before his paralysis. He went into his workshop one morning,
and suddenly exclaimed to the men, ' Look, look ! there is blood
running down the window ! * and then almost directly after,
* I am blind in my left eye ! ' After this he came to me,
and I tried to laugh at him. He said he felt quite well and
would have his breakfast, but in trying to go into the next
room he knocked against the door-post, and I saw that he
was really blind on that side. The paralysis came on
during sleep about two weeks later, and the limbs affected
have been disabled ever since.'* This was two years ago, and
the man still retains good health, but cannot walk or use his
left hand. ** The curious point is," adds his wife, " that he
is not always blind. Sometimes he will shut his right eye
and say, " I can see you with my blind eye. You are there !
Now you are gone ! Are you gone ? ' It is as if a curtain
came over his sight." The patient is a man aged 64.
Kespecting his paralysed hand, his wife gives the interesting
fact — ** The fingers are always contracted into his palm and
cannot be straightened. But this is only when he is up and

182 DISEASES OF THE BYE,

about. When asleep they are quite straight, and for some
little time after he wakes you can move them about quite
easily. They are as loose as those of the other hand.
Gradually, however, when he gets about they stiffen and
contract, and it is impossible to straighten them."

The diagnosis of intraocular haemorrhage preceding by a
fortnight haemorrhage into the right corpus striatum is here
clearly indicated. No doubt a large membranous opacity in
the vitreous has remained after the partial absorption of the
blood-clot, and it is by alterations in the position of this veil
that he is enabled at times to see with an organ from which
more usually light is shut out.

No. XXXII. — Retinitis pigmentosa in three
brothers — No consanguineous marriage.

In January, 1887, Dr. Osbom, of Dover, consulted me by
letter in the case of a gentleman, aged 62, who had lost his
right eye and in whom the left was failing. In November
of the same year the patient came up to tov^m for my
examination. There was most extensive pigmentation of
the retinae with pale, waxy discs. There was no history of
special cause. The chief interest of the case lies in the fact
that two of his brothers, both older than himself, were also
blind. In all the disease had been of a slowly aggressive
kind. In all the disease had begun in early life. The family
consisted of seven. Two sisters had wholly escaped, whilst
of five brothers three had suffered. In this instance there
had been no consanguineous marriage. It was believed that
a paternal uncle who was in the army had very defective
sight, and that he lost his life owing to his mistaking the
enemy for his own corps and riding into their ranks.

Mr. S was in fair health, and said that he had never

known a headache in his life. His pupils were small and
sluggish. He was frequently troubled with a glare of light
before his eyes, and at other times by the appearance as
of a white ceiling over him. He had but bare perception of
light and shadow when I saw him, and could not count

RETINITIS PIGMENTOSA. 183

fingers. It was a year since he had read, and then by the
aid of a hand-glass.

About ten years before I saw him, Mr. S had, with an

interval of a year, gone through two amputations. The first
was through the thigh for diseased bone, and the second at
the hip joint. On the second occasion there was almost fatal
secondary hsemorrhage. He himself believed that the loss
of blood on each occasion had very much prejudiced his
already failing eyes. After each operation he had been for
a time "in a mist," and after the second this was very
marked and he never regained his former sight. It is quite
probable that severe losses of blood might be felt by
structures already degenerate and with contracted arteries,
and not unlikely that such influence might be in some
degree permanent.

THEEAPEUTICS AND DIET.

Bheumatio Gout of the Knees and Diverticulum into the
Popliteal space — Record of Treatment.

An intelligent patient from the country, making a second
visit, two years after his first, very prudently brought with
him a memorandum which he had himself written of what
I had told him. It was so clear and explicit that I venture
to transcribe it here :

"Mr. H. said that my trouble was caused by rheumatic gout
which had led to a Diverticulum ^ that is a bursar communicating with
the knee-joint. On no account am I to have the bursar cut out or
interfered with. It is caused by rheumatic gout, and will cease when
the gout is less active. I am to use a salt-pack and take the medicine
prescribed as long as the knees are troublesome. I am to take any
exercise I like so long as it does not hurt the knee. To drink only
whisky and to take plenty of weak tea. No Burgundy. Eat plenty of
fresh green vegetables, but no fruit which requires sugaj:, e,g, gooseberries
or rhubarb."

Under these measures, aided perhaps by drugs, the
effusion into the knees had disappeared and the bulging
diverticulum had receded.

Arsenic causing Ascites,

I have recorded in detail two cases in which an inflammatory
form of ascites, requiring repeated tappings, occurred during
a long course of arsenic. One of these will be found in Vol.
VI. at page 389, the other at page 23 of the current volume.
The cases were much alike and both patients recovered and
regained good health.

. ABSENie ' AND ACONITE . 185

Effects of LanrgiR Doses of Arsenic,

On August 21st I ordered for an adult man six minims of
Pearson's solution of arsenic, with three of Fowler's, and
four grains of iodide of potassium. These quantities w^tq.
to be taken three times a day. For about a fortnight he
took, in error, double doses. It made his legs heavy, and
caused a dragging feeling, especially in the calves. After
walking a little way his legs ached so that he Qould go no
further. He had no pricking of eyes, no herpes, nor any
sickness, but he lost his appetite. On discovering his
mistake he reduced the dose and went on with that ordered ;
but finding his appetite still bad he left it off entirely. On
doing so he at once felt better, and three weeks later his
legs were all right again. The psoriasis for which the arsenic
had been ordered had been much better during its use, but
showed a tendency to relapse a month after its discon-
tinuance.

Absence of odour in the Urine from eating Asparagus.

The disagreeable odour which is communicated to the
urine by asparagus is well known. In the case of a gentle-
man of intemperate habits, who was the subject of albu-
minuria, the curious observation was made by his attendant
that when the albumen was absent asparagus might be
taken to any amount without causing any smell. When the
albumen was present, then the urine received its odour as
usual. The urine had a specific gravity of 1010. The
absence of odour was observed during several days. The
patient was at the time the subject of acute pemphigus,
and the return of odour and of the albumen was coincident
with marked improvement of his eruption under the use of
arsenic.

Physiological effects of Excessive Medicinal Doses of Aconite.

In December, 1890, I gave to a lady who had diverticula
from her knee-joints my favourite prescription for all active
forms of rheumatic gout. It contains ten minims of tincture

186 THERAPEUTICS AND DIET.

of aconite to the dose, three times a day. She took it for
several weeks with great benefit and not the least incon-
venience. It was dispensed in London. On a subsequent
occasion she had the prescription made up in Pau, and again
had no ill symptoms.

In the end of 1896, the same prescription was made up in
an English county town. Two doses of it made the patient
so numb and cold that she had to walk about the room to
keep warm. On that occasion she did not venture to take
any more, but six months later she ventured to try half-
doses from the same bottle. These had precisely the same
effect, though in less degree.

A year later Miss W called on me again and narrated

the above experience, bringing with her the prescription, and
declaring that although it had once cured her, she dare not
take it again. I asked her to tell me exactly what had
happened, and what precisely her symptoms had been. She
said that on the first occasion she took a dose at bedtime,
and slept through the night without experiencing anything
special. In the morning she took another dose, and very
shortly afterwards began to feel cold down her back and a
sense of constriction in the throat, just as if a bad cold were
beginning. The sense 6i coldness spread from the back to
the limbs, and the latter felt as if they would go to sleep.
Nothing relieved her but incessant walking. On the second
occasion two half-doses produced similar effects, the back
and the throat being again affected. No tongue sjmaptoms
were experienced.

There can be little doubt that in this instance the dose of
aconite as dispensed by the provincial chemist was from
some error much stronger than it ought to have been. The
patient had tak^n the same prescription from two other
chemists for considerable periods with impunity. The
patient was very careful as to her doses, always using a
graduated measure, and there had been no error in this.
Probably the quantities had been miscalculated by the dis-
penser. The symptoms produced were distinctly those of
aconite poisoning, and it is of interest to note their
character. I am in the habit of using tincture of aconite

MEECUEY IN SYPHILITIC OSTEITIS. 187

in ten-minim doses, three times a day, for strong adults
without the sKghtest fear. For the pains of neuralgia, of
rheumatic gout, and of cancer, it is invaluable, as also for
the control of all forms of arthritic inflammation. I always
enjoin great care in measuring the dose, and with that
precaution have never known any serious ill consequences.
The case now narrated is almost the only one in which I
have ever known any physiological effects to be observed.
In one sense it is a matter of satisfaction that such effects
should now and then be witnessed; they prove that the
remedy is really powerful. The production of coldness and
numbness is precisely what we want in the affections just
named.

Mercury in the treatment of Osteitis of the Tibice from

Inherited Syphilis.

The mother of a lad who was under my care for keratitis
told me, when I examined his shins to ascertain whether he
had any nodes, that he had formerly and for long suffered
from ** periostitis." She knew what she was talking about,
and added, when I asked whether iodide of potassium had
been prescribed, ** Yes, and it did no good. He took it for
two years, and it made him so weak that I thought he would
die. He suffered very much from pain in his legs, and got
no better until I took him to another doctor, who gave him
mercury, and in a few weeks he was well."

I cross-questioned my informant a good deal without in
any way shaking her testimony. She insisted that large
doses of mercury were given, and that the pains in the
bones and the lumps in them soon disappeared, and that
they had never returned. The boy's shins confirmed her
statement, for only very slight unevenness here and there
remained. He was now seventeen, and it was eight years
since the periostitis was cured, and there had been no
tendency to relapse. Thus I think we must accept it as a
fact that mercury did really cure a chronic osteitis which
iodide of potassium had failed to relieve. The fact is by no
means a novel one. Although as a rule iodide of potassium
is a specific for syphilitic periostitis, and equally as a rule

188 THEBAPEUTICS AND DIET.

mercury rather tends to increase the pain and the risk of
suppuration, yet we have long known that there are cases in
which the reverse is true. The practical rule seems to be
this : that when iodide fails, we should try mercury instead-

'* Fish is Leprosy.*'

Mr. W. Clark, who has long lived as a missionary in
Madagascar, has given me the following Malagasy proverb: —

Ny tbondro no boka = Fish is leprosy.

Mr. Clark tells me, as I have been told before, that the
consumption of a small fresh- water fish like a gold fish is
very large in the interior of Madagascar. The proverb bears
testimony to the native creed as to the association between
fish-eating and leprosy. •

Effects of certain Dmgs in Comhination,

The prescription referred to in the following letter con-
tained ten minims of tincture of aconite with two grains of
quinine in solution, together with a third of grain extract of
Indian hemp in pill. The pill and mixture were to be taken
together three times a day.

" Sir, — ^The enclosed prescription will remind you of a consultation
some three weeks ago. As soon as I began to take the physic and pill I
experienced a burning and stinging feeling in the hands and feet. This
extended to the rest of my body, and red splotches appeared all over my
body, accompanied by a most intolerable itching which effectually banished
all sleep. The rheumatism, however, disappeared except from my left
shoulder, where it still remains. After a fortnight of the physic (the
itching continuing all the time) I was obUged to give up taking it.
The spots and itching then disappeared, but the rheumatism is developing
again in my arms, but I am positively afraid to resume th^ physic. I
write, therefore, to ask whether there is anything in the prescription that
may be eliminated to avoid the itching which it sets up.**

The symptom of itching which was here complained of
may have been due to the Indian hemp, but I should incline
rather to suspect the quinine.

MISCELLANEOUS.

No. CCCL — Fatty Tumour on the side of one finger.

The tumour in the case referred to in the following letter
was about as big as a small marble flattened out.

** Dbab Mr. Hutchinson, — Perhaps you may remember a lady calling
some time ago to show you her finger, when you were good enough
to say you should be interested to know exactly what the growth
turned out to be. I had it taken out a week or two since, and it proved
to be a fatty tumoiur. The finger is quite healed now, I am happy
to say."

No. CCOII. — An Eruption after Vaccination.

An infant three or four months old was brought to one of
our Demonstrations a month after vaccination. It was in
good health. The vaccination sores were not yet healed.
The history given was that the child had had a general
eruption of red spots over the body, face, and limbs, but
this had disappeared, leaving only slight stains. There was
said to have been some peeling in the feet, &c. The eruption
was first noticed between ten days and a fortnight after the
vaccination, and came out suddenly. The child had not
been seriously ill. The eruption had disappeared without
any special local treatment. It had been attended in parts
by some little watery blisters.

QUESTIONS.

1. What may be inferred from the fact of spontaneous
disappearance?

2. What was the nature of the eruption ?

190 MISCELLANEOUS.

No. CCCIII. — Scarlet Fever after Measles.

A child of eight during an epidemic of measles passed
through an attack of moderate severity. She had appa-
rently got quite well, and was allowed to be out of doors,
when one evening she complained of sore throat and felt
unwell. Next morning a scarlet punctate rash appeared.
The throat was much inflamed, and the tongue was red.
The eruption developed during the next few days, and three
medical men who saw it declared that it was scarlet fever.
The temperatures for several days ranged from 101° to 103®.
The tongue was said to be characteristic as well as the
eruption, but it was a lobster tongue, not strawberry.
Several other children who had not had scarlet fever were
in the house, but no other cases occurred. There was no
known source of infection, and the disease was not in the
neighbourhood. Of course as soon as the diagnosis was
made, all precautions as regards isolation, &c., were taken.
The disease ran the usual course of scarlet fever, but was
not followed by albuminuria or oedema. Moderate but defi-
nite peeling took place, and during convalescence erythema
nodosum developed in the legs. The so-called scarlet fever
occurred about three weeks from the date of onset of the
measles. The child had never been further than the garden
of the quite isolated house in which she lived.

QUESTIONS.

1. Is it probable that the second illness really was scarlet
fever ?

2. If so, what was its relation to the measles?

3. What suggestions can be made as to the source of
infection ?

No. CCCIV. — Urticaria recurrent almost daily in
connection toith trivial exciting causes.

Miss P , a fair, florid woman, aged 43, consulted me

in July, 1883, on account of a liability to attacks of urti-
caria. Menstruation was still regular, but she was very

LUPUS OF PHABYNX. 191

liable to flush. The first attack had . occurred eighteen
months previously) and came on whilst at church during
the evening. Since then she had rarely been free for a day.
The eruption was better out of doors, but came on again
at night. Almost always it appeared after meals, without
much regard to the kind of food. . Changes in diet had
proved of no benefit. French plums were most certain to
bring out the eruption. Sleep fairly good. Bowels open.
Tongue clean and not abnormal in any way. For nine

years a total abstainer. Miss P had had a similar

attack of urticaria some years before.

No. CCCV. — Congenital and symmetrical prolonga--

tion of the Olecranon.

A man has both olecranons prolonged into a blunt . spur
which is directed inwards. It is developed from the inner
side of the bone. He thinks it has grown lately, but I feel
sure that it must have been congenital. It is quite sym-
metrical. I told him that it must be an assistance in getting
through a crowd, and he seemed quite aware of his
advantage.

No. CCCVI.- — Lupiis of the Pharynx.

Lupus of the pharynx is not a common malady, and when
it does occur is almost always secondary to lupus of the nose.
I have seen only two or three cases in which the disease had
begun in the throat itself. One of these has quite recently
come under notice. A delicate-looking little boy 8Bt. 9

was brought to me by Dr. , with the history that he had

already had much treatment for his throat, and that recently
lupus had shown itself at one nostril. The diagnosis had
throughout been that of lupus of the pharynx, &c., and
scraping and cauterisation had been repeatedly practised
with great benefit. The throat was now practically well,
the uvula and the free border of soft palate having been
destroyed. A small patch of ulceration on one tonsil was
all that remained which could be called lupus. At the orifice

192 MISCBIiLANEOUS.

of the right nostril, however, there were quite characteristic
conditions of lupus vulgaris. Here the disease had not as
yet involved much skin, but it clearly spread within the
nostril. I have no doubt that it had advanced from within
by direct contagion. The results of treatment in the throat
were most satisfactory.

No. CCCVII. — Severe Convulsions — Hydrocephalus

Loss of both Eyes with Iritis ^ Corneal Ulcers j

and probably Optic Neuritis.

. The following are the notes of a case which was sent to

me by Dr. B in February, 1878. I saw the child only

once, and do not know anything as to his subsequent
progress. He had been, I believe, an out-patient at Great
Ormond Street. I give his name, as it is possible that some
of my readers may identify the case and be able to complete
it. It was thought that one eye was clearing a little. The
case is of interest in reference to certain examples of destruc-
tive ophthalmitis which occur in children after the exanthe-
mata and severe illnesses.

William Barton, now two years and two months old (February 2,
1878). His mother's first. During his first year he ailed nothing, but
when he began " to cut his double teeth " he had fits. He had five
attacks of considerable severity within six months. The last was seven
weeks ago. His head began to enlarge after the first fit. He " seemed
to lose his sight with the fits," and his eyes inflamed. He is now believed
to be blind^ and has considerable leucomata in each cornea, but the pupil
of right is not covered. His mother thinks that he cannot see light. In
each there has been perforation of cornea, and anterior sanechisB have
formed. He has a very large head, the displacement of bones being in
the posterior two-thirds. The forehead is not enlarged. He is very
thin. Ko evidence of rickets. Premature growth of hair. He is
growing a distinct moustache, and his forehead is covered with downy
hair. Dentition rather backward. The lower incisors have fallen out.
I did not succeed in inspecting his eyes with the ophthalmoscope on
account of his fretfulness. He has probably had inanition ulcers of
comese in consequence of his severe illness, but his blindness is probably
due to optic neiiritis.

PLATE CXLIL

LUPUS ERYTHEMATOSUS.

This portrait is that of a woman of middle age who had been
several times, in the course of her life, suspected of phthisis. The
diagnosis of tubercle in the apex of one lung was confidently given
by a well-skilled physician at the time that her lupus commenced.
She has been the subject of lupus now for ten years. Her case is
a typical one of the erythematous form, with the somewhat unusual
feature that patches have developed in the chest. At the time of the
introduction of Koch's injections for tuberculosis she was made the
subject of systematic treatment by them. The result was on every
occasion a great rise in temperature and much constitutional dis-
turbance, but the lupus patches did not inflame and were not
benefited. This discrepancy was supposed to be explained by the
presence of tubercle in the lungs. During, however, the six years
which have since elapsed the patient has maintained fair health,
and has certainly not become the subject of definite phthisis. The
lupus has not been much benefited by any treatment, and still
maintains its hold. On some parts of the face cicatrisation has
resulted, and the erythema has disappeared, but the patches have
spread at their edges. All the usual remedies have been tried.
The patches on the chest have much increased in size, and have
been very irritable.

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JULY, 1898.

TWO CASES OF YAWS IN ENGLISHMEN.

The papers * on Yaws which have recently appeared ; the two
Oovemment Blue Books; and the Selected Essays repub-
lished by the New Sydenham Society, may be considered
to have brought the facts very fully and fairly before the
British profession. They may be held to have made it
certain beyond cavil that either yaws is syphilis modified by
•climate and race, or that it is a distinct malady of a pre-
cisely parallel type. Observation and experiment have con-
curred in showing that these two diseases always originate
in a primary local sore, that they observe the same periods
in their stages of evolution, are both of them attended in
their secondary stage by an abundant and general eruption
on the skin, and that both may have remote sequelae. In
each instance immunity is conferred for a very considerable
period. The chief points in which they are alleged to differ
are, that in yaws the primary sore is rarely on the genitals,
whilst in syphilis it is usually so placed ; that in syphilis
sores on the tonsils are common in the secondary stage,
whilst in yaws the mucous membranes are not affected ;
and lastly, that the secondary eruption, which in syphilis
may present many varieties of type, is in yaws always the
same, and always framboesial.

• See Archives, Vols. VII. and VIII., also The Lancet and British
Medical Journal,

VOL. IX. 13

194 TWO CASES OF YAWS IN ENGLISHMEN.

Those of US who have never visited districts where yaws
is indigenous have been at some disadvantage, in that we
could not critically examine these assertions. In the case
of diseases so much alike in their main features it has
always seemed to some of us a possible source of fallacy that,
unconsciously by the observer, the examples of "yaws" were
selected. We have proved that even in temperate climates
the eruption of sj^hilis is sometimes frambcesial, and it is
of course well known that the primary sore may be on any
part of the body. It has therefore seemed to us that in a
country where both maladies (if they be two) are prevalent
all the cases beginning from genital sores may be counted as
** syphilis," and so also all those which exhibited mixed erup-
tion and sore throats. By a few exclusions of this kind the
type of supposed yaws might be kept pure. It might easily
be asserted that yaws never had a sore throat, and always
had a framboesial form of eruption, by the simple expedient
of calling all exceptions to these statements syphilis. I do
not for a moment hint that any one did this consciously,
but I think it highly probable that it has really been done.

Amongst the weak points in the argument of those who
contend that yaws is a disease wholly distinct from sjrphilis,
has hitherto been their inability to produce an imported case
for the inspection of English surgeons. As the disease is
one which has stages as prolonged as those of sjrphilis, and
as it is asserted that it is no respecter of race, we might
have expected that, by chance, a case would now and then
find its way to England. If I were to assert that no case
of yaws, or what has been called so, has ever been recog-
nised in England, it would be going beyond the truth. A
few cases have been so named, but they have, I believe, all
been in negro patients, and all in the late or tertiary stage.
Now in this stage the diagnosis from syphilis is impossible,
and rests rather with the self-confidence of the observer
than with any demonstrable manifestations in the patient.
The cases which we have wanted were not cases of this kind,
but examples of the general eruption in the secondary stage.
Of this I believe that, until the last three months, no case
has been seen. I have often commented on this fact, and

TWO CASES OF YAWS IN ENGLISHMEN. 195

when conversing with those who have lived abroad, and who
beheve in the specificity of yaws, have challenged the pro-
duction of a patient. It is also remarkable that, although
it is asserted that in the yaws-districts Europeans are not
exempt, yet no one, writing on the malady, has given a good
circumstantial narrative of such a case. One such was
published long ago by Dr. Joseph Adams, but on examination
of his statements no one can, I think, doubt that his patient
really suffered from syphilis. I have recapitulated this case
at p. 79, Akchives, Vol. VII. Nor can I doubt that most of
those who have studied the cases as detailed in the reprint
of Professor Breda's essay in the New Sydenham Society's
volume, have come to the conclusion that the supposed
yaws was really syphilis. This conclusion is also supported
by the plates there given, illustrating, amongst other points,
ulcerations in the mouth and throat.

Such being the state of the facts, it has been with keen
interest that I have during the last three months been en-
abled to examine two English patients who had contracted
yaws abroad, and still displayed its phenomena in the
secondary or eruptive stage. Both patients have come
under my observation in private practice.

I will briefly record the chief facts as regards these two
most important cases so far as they have at present gone.
Both will probably be the subjects of more detailed state-
ments at some future time.

Case I.

In this instance the patient is a surgeon who pricked his
finger with an injection-needle which he had just used upon
a yaws patient. Nothing followed for nearly two months,
when a little tubercle showed itself at the site of the puncture.
Almost immediately another appeared by its side. They were
treated very liberally and repeatedly with sulphate of copper,
and never became painful and never showed any fungus
growth. The latter was, the patient beheves, prevented by
the repeated cauterisations. There was never any enlarge-
ment of the glands in the armpit. The puncture was on

196 TWO CASES OF YAWS IN ENGIilSHMEN.

July 17, and it was not till the beginning of September th«bt
the primary sores were recognised. Three months later
tubercles began to appear on the ankles, and these were
followed by a general eruption on the body. At this stage
the patient says that many of the sores were characteristically
frambcBsial, and he made no doubt as to the diagnosis of the
disease. The primary sore had now soundly healed. From
this date mercury and iodide of potassium were used, but the
former only in very small doses (m. xv of Liq. Hyd.).

It was on April 19, 1898, nine months after the inocula-
tion, that I first saw Mr. B . At that date he had a

general eruption of mixed character over his Umbs and body.
In the palms were peeling areas like the psoriasis pahnaris
so frequently seen in sj^hilis. On the wrists were well-
margined patches of congestion with spreading edges
slightly crusted, and on the limbs, &c., were many blotches
and indefinite papules. There were also many stains and
slightly marked scars where I was told framboesial masses
had formerly been. Nowhere, with a single exception, was
any framboesial growth still present. The exception was a
single strawberry-like growth on the side of one ankle. This
growth, the size of a shilling and raised much like the half
of a strawberry, was very peculiar and quite characteristic.
I inspected the throat and found nothing. The scars of the
primary sores were hardly visible, and there was no trace of
enlarged glands in the axillae.

I advised Mr. B to take the grey powder pill (gr. i)

four times a day, and with it five grains of iodide of potassium.

Six weeks later Mr. B called on me again. His eruption

had almost wholly disappeared. The palmar patches were
represented only by stains, and the strawberry had withered
and left only a florid scar. On the inside of one thigh a
patch still slightly thickened and papillary remained, but it
also was in course of disappearance. On the right tonsil were
two small filmy patches. These were either new or had not

been observed on the previous occasion. Mr. B told me

that the mercury had purged him, and that he had not con-
tinued it more than half the time since his last visit. He
had, however, continued the iodide, and been very diligent

J

TWO CASES OF YAWS IN ENGLISHMEN. 197

in the local use of an ointment containing the white pre-
cipitate. On the supposition that the filmy sores on the
tonsil were not part of the disease, but were caused by the
mercury, they are important as evidence of the constitutional

influence of the latter. Mr. B told me that at the time

that he left it off the f ramboesial sore on the ankle was still
persisting, and that the chief improvement had occurred since.
He was disposed to think that the iodide rather than the
mercury had worked the cure. There is, however, nothing
unusual in seeing improvement continue rapidly after
mercury is left off, if the iodide be continued and local
applications persevered with. At any rate, as regards the
gross result, !• may record the belief that I never saw a
syphilitic eruption yield more rapidly and satisfactorily
under specifics than this had done.

Case II.

My second case is that of a gentleman aged 28, who had
long lived in South Africa (Benin). He had seen much of
yaws, and had lived in company with those who had it.
In January of 1897 a sore formed on the front of one fore-
arm. He was not aware that he had been inoculated. The
sore, according to his description, fungated. It lasted two
months, in spite of repeated applications of caustic. In
March some spots appeared about the ankles. They were
called eczema, but were quickly followed by a general
eruption over the whole surface. This rash was not
attended by sores, and was probably in the main erythe-
matous. The doctors who saw it spoke of syphilis, but one
of the most experienced gave it as his opmion that it was not
syphilis. No definite diagnosis was given. This was in
May and June. In July the spots began to enlarge, and
some of them fungated. This eruption persisted in spite of
some treatment, and in December of the same year Dr.

F , who had seen yaws repeatedly and who was quite

familiar with the malady, declared that this case was
unquestionably yaws.

In April of 1898 Mr. W— returned to England, still

198 TWO CASES OF YAWS IN ENGLISHMEN.

suffering from the eruption. He placed himself under the
care of Dr. Adam, of Liverpool, a surgeon who had practised
abroad and was familiar with yaws. In May he came up to
London and called upon me.

On May 11th, I found Mr. W covered from head to

foot by a polymorphous eruption, which was especially
severe on the lower extremities. Excepting that it was
much more severe and abundant, the eruption was exactly

like that in Dr. B , and could not be distinguished from

many seen in the secondary state of syphilis when inefficiently

treated. Mr. W readily consented to my suggestion

that he should attend at one of my Demonstrations, and his
condition was there subjected to the observation of many
competent observers. A photograph of his legs was also
taken. At this stage no part of the eruption was definitely
framboBsial. It was exceedingly mixed in character. There
were lichen papules, pustules, erythematous areas, and
patches with abrupt margins and with more or less of crust
which resembled ill-marked forms of rupia or of lupus.
Everywhere the spots were dusky and discoloured. It must
be remembered that at this date the case had received much
treatment, chiefly by the iodides, and that the eruption was
probably in part controlled by it. There was no sore throat,
and had not been any from the first.

I prescribed mercury, as I had done in the previous case,
but do not as yet know the result. I also wrote to Dr. Adam,
who had been consulted before I had, to know his opinion.
He replied that he had considered the case as an undoubted
instance of yaws.

As these two cases are still under observation, I will for-
bear to comment in detail upon them. We shall probably
in the course of another year be in a position to speak more
positively as to their nature. I may, however, venture now
to point out that they quite discredit the statement that
the eruption of yaws is not polymorphous, but always keeps
to the framboBsial type. The two cases were alike, and in
both the eruption was mixed and closely resembled what
we see in syphilis. At the same time it is to be admitted

PLATES CXLVI. & CXLVII.

THE ERUPTION OF YAWS (AN EARLY FORM).

These two Plates, which have been executed from photographs,
are intended to illustrate an early form of eruption in Yaws. They
show the front and back aspect of the same patient, apparently a
lad or young adult. The eruption consists of small patches, for
the most part isolated, which occur freely over the trunk, limbs,
face, and even the scalp. They are arranged with fair symmetry,
and are tolerably uniform in appearance, with the exception that
there is one in the left groin much larger than the rest.

It would be unsafe to use these portraits as demonstrating
anything more than the location, size of patches, and generalised
character of the eruption in the secondary stage of Yaws. The
portraits do not show enough detail as to the condition of the crusts
to make any description trustworthy. It may be stated, however,
that in this stage the eruption of Yaws is described by authors as
presenting different characters in different cases, being sometimes
papular, sometimes scaly, and in others attended by greater or less
tendency to the growth of raspberry-like granulations. As a rule,
however, the latter are not seen till a later stage of the malady.
The eruption here shown is stated to occur usually at about two or
three months after the date of contagion.

N.B. — These two portraits, as well as the following one, have
been published before. I re-introduce them for the reader's con-
venience, in order to keep in mind how closely the secondary eruption
of Yaws, even on a dark skin, resembles that of secondary syphilis.
The next Plate, CLX., shows how closely secondary syphilis in an
Englishman may resemble Yaws.

HUTOHINW)Hr% ,

PLATE CXLVI.

/

/

PLATE CLX.

FBAMBCESIA IN AN ENGLISHMAN.

This Plate, copied from a photograph, represents a well-
characterised example of Framboesia or Yaws Eruption in aji
Englishman. In this instance there was not the sUghtest doubt
that the eruption, which was everywhere of framboesial type, was
syphilitic. The patient had had a chancre, and he was quickly
cured by mercury. His eruption disappeared without leaving any
conspicuous scars.

COMMENTS. 199

that in neither has there been any characteristic sore throat.
The absence of enlargement of the axillary glands in both
is probably no more than an accident, for no observer of
yaws has failed to remark that as a rule there is a bubo.
This was present in all cases in the series of experiments by
Dr. Charlouis (see New Sydenham Volume, p. 341). One
of my cases has yielded to mercury and iodides, just as
syphilis might have been expected to yield. Here, then, I
leave these important cases for the present, not, however,
without venturing to hint the belief that, thanks to the
attention which has been attracted to the subject, and the
ready communication which now exists between the yaws-
districts and England, the question is likely before long to
be finally set at rest.

POSTSCBIPT.

Since the above statements were in type, and only just
before going to press, I have seen for a second time the
patient who is the subject of Case II. He has taken mer-
cury for about five weeks and is almost well. His eruption
has everywhere faded and for the most part only stains
remain. As in Case I., the symptoms have disappeared as
rapidly as is ever witnessed in cases of syphilis. Some peel-
ing patches in the middle of his palms still persist. I had
omitted in my notes to say that he had suffered from pain
and tenderness over the upper part of the tibia. Of this also
he has been quite cured by the mercurial course. It was
precisely in the position in which syphilitic patients in the
secondary stage often have a slight and temporary periostitis.

I feel justified by what has occurred in this case, coinciding
as it does so exactly with what was observed in Case I., in
saying that I feel no doubt that yaws and syphilis are one
and the same disease. These two cases were unquestionably
yaws in Africa, and in England they have most certainly
proved to be syphilis. The supposed differences between
the two maladies are simply due to race and climate.

ON XANTHOMA AS A SYMPTOM.

To the zoologist some of the most interesting animals are
those which appear to afiford connecting links beween
species, or which indicate alliances between different genera.
It is the same in clinical pathology, although here the
lines of distinction between differing species are much less
definite than in the zoological field. In other words, the
factors of causation are more easy of combination, and
hybrids and mongrel forms are more easily produced.

We recognise in the Xanthoma or Xanthelasma group
four different types: 1. The common xanthoma which occurs
on the eyelids, and is often indicative of liability to sick
headaches from liver disturbance, but not of organic disease
of the organ. 2. A general eruption of sudden outbreak and
capable of spontaneous disappearance, which occurs to the
diabetic, and also sometimes to those who are severely bilious
but in whom the urine does not contain sugar. 3. A form
which is consequent on persisting jaundice and indicative
of organic liver-disease and great disturbance of health. In
this form plates and lines of xanthoma form in various
parts and notably in the flexures of the finger-joints. 4. A
congenital and family form in which, without any dis-
turbance of health, children present xanthoma spots and
patches on various parts', more especially on those prone to be
affected in psoriasis. Thus, then, we count X. palpebrarum,
X. diabeticorum, X. ictericorum, and X. congenitalis. The
bond of connection which allies them all is the circulation of
bile-acids in the blood as a primary cause, and this receives
its modifications from other conditions, such as inheritance,
the proneness to psoriasis, and the degree of persistence of
the liver-disturbance. We meet every now and then with
mixed cases, and one such, of very remarkable interest, I
have now the pleasure to narrate.

XANTHOMA IN EXCEPTIONAL POSITIONS. 201

Case I. — Xanthoma of Eyelids in exceptional positions —
Deep pigmentation of Eyelids, dtc. — Jaundice — Lobules
of Ears affected.

Miss B , a fair coraplexioned, thin, and somewhat

fragile-looking young lady, was sent to me last April by

Mr. K C , of H . She was twenty-three years

of age. Her eyelids were deeply pigmented, not in patches
but in a diffuse manner, the upper ones being especially so.
Large ill-defined patches of xanthoma were present on
both lids, but they occurred not, as usual, above and below
the inner canthus, but on the middle of the lid. They were
not in the least raised, but looked rather as if the skin had
been scorched. On the deeply pigmented skin they were
not very conspicuous, but sufficiently so to have caused the
patient great distress. On the tip of the lobe of each ear
was a patch as large as the end of the little finger, which at
first sight I took for lupus, but on careful inspection it was
evident that here also was the dull-yellow growth of
xanthoma. The patches on the ears, like those on the
eyelids, were accurately symmetrical. No other spots of
xanthoma were to be found on other parts of the surface

either on trunk or limbs. Miss B , however, alleged

that she had suffered much from eczema, and the eruption
to which she gave this name consisted of little dry nummular
patches on the face, arms, &c.

The history of the antecedents was as follows. Xanthoma
was not known in the family, but there was gout and liability

to severe bilious attacks. Miss B herself had suffered

much from headaches, often so severe as to make her go to
bed, and always attended by dark pigmentation around the
eyes. Her xanthoma on the eyelids had first been noticed
about ten years ago, at the age of twelve, and the patches
on the lobules of the ears had followed soon after. Two
or three years after this she experienced an attack of deep
jaundice which lasted a considerable time. This had, how-
ever, passed completely away, and had left the skin not in
the slightest degree tinged. With these exceptions the
general health, although not strong, had been fairly good.

202 ON XANTHOMA AS A SYMPTOM.

She had suffered from habitual chilliness, but not specially
from cold extremities. Her chief reason for seeking my
advice was the desire to get rid of the disfigurements. As
regards treatment, I advised that the ends of the lobules
of the ears should be cut away, but that the patches on
the eyelids should be left to themselves, as they were too
large and too ill-defined to admit of excision. A mixture
containing nux vomica, taraxacum, and small doses of
mercury was prescribed.

Amongst the noteworthy features in the case we may
remark : (1) the early age of the development of xanthoma
palpebrarum; (2) the unusual position of the patches;
(3) the extreme pigmentation of the eyelids; (4) the
occurrence of xanthoma on the lobules of the ears and
the simulation of lupus vulgaris in these positions ; (5) the
occurrence of a prolonged attack of jaundice in a patient
already the subject of xanthoma of the eyelids.

Case of sev>ere Nervous Disturbance in association with
Xanthoma of the Eyelids and Biliotcs Headaches —
Hemiopia and Petit-mal.

A case which is instructive in reference to the nervous
disturbances which occur in connection with the liver dis-
order which is denoted by xanthelasma palpebrarum, has
recently been under my observation. Its subject, Mrs. R.

E , is now forty-three years of age. She has been

married twelve years, but has borne no children. Her
xanthoma consists of very thin yellow patches placed in the
usual positions above and below the inner canthi. They
have been demonstrated to my class at Park Crescent on two
occasions. The patches are sjrmmetrical and extensive, but,
as usual, larger on the left than the right side. She has also
slight acne rosacea with tendency to eczema on cheeks.
The xanthoma patches had been present some years at

the date of my first consultation by Mrs. E in 1896.

The exact date of commencement could not be assigned.

At that date Mrs. R was described in my notes as of

*' a bright, clear, florid complexion.**

XANTHOMA WITH NERVOUS DISTURBANCE. 203

It seems probable that the liver disorder is on the increase
rather than otherwise, and in spite of treatment. At present

Mrs. E 's complexion could not be described as clear or

bright. Her nervous disturbances have also increased. She
asserts that her liability to sick headaches began only about
the time that she first noticed the yellow patches on her eye-
hds. At any rate she was never considered bilious in girlhood.
After the age of twenty, however, she became liable to a
bad sick headache about once a year. One of her grand-
mothers had been liable to similar ones. These had in-
creased on her until, when she came to me in 1896, she
frequently had them once a fortnight. She was also at this
time liable to what she described as "awful sensations" in her
head. A sort of wave, lasting not longer than half a minute,
would pass over her brain, making her feel as if she must
lose consciousness or might even die. She was liable also to
waves of icy coldness in her limbs. For eight years past
she had been annoyed by incessant noises in one ear. They
never ceased day nor night, and were synchronous with the
heart's beat. "When the pulse intermitted, so also did the
noises. To these statements, which all refer to April, 1896,
may be added that she had never had jaundice. I prescribed
small doses of mercury with nux vomica.

My notes in November of the same year record that her
sick headaches had been less frequent since she had taken
the pills, but that she was not better in other respects. She
had become liable to attacks which would seize her in the
street and oblige her to stand quite still for a few minutes,
feeling as if she would lose consciousness or fall. On other
occasions she would experience a feeling of faintness and
her face would become momentarily of a claret colour
and then white. She had also exaggerated sensations of
horripilatio and " tinglings as of electricity.'* She had
occasionally "flashes of electric light" in her eyes, and
her hands and feet often became quite cold.

After the above note I did not see Mrs. E for eighteen

months. When she came to me on April 22, 1898, 1 noted
that she had lost her florid complexion, and looked pale,
with a slight tinge of yellow. She had become liable to

204 ON XANTHOMA AS A SYMPTOM.

attacks of hemiopia, daring which she lost perception of
objects on her left side. These attacks would often last
half an hour at a time, and sometimes she lost all perception
of things around her, although never in absolute darkness.
Her custom was, when they occurred, to go to her bedroom,
draw the blinds, and lie down until the attack passed off.
Almost always severe headache followed. In addition to
these she was frequently troubled with palpitation and had
what she called ** seizures." During these she would have
to catch hold of some support to avoid falling.

On a subsequent occasion (June 1, 1898) I made the fol-
lowing note : —

" She complains very much of her heart. It is often rapid, and then
does not intermit ; but when it slows down, then she is troubled with
painful intermissions. The pulse is often 120, and very feeble. When
lying down, she says it is seldom that five beats occnr without an inter-
mission.

*' She was feeling better than usual at Christmas. She once took the
Yi-Cocoa, and it made her heart very bad. She has been liable to sensa-
tions in the top of her head, brought on by assuming the erect position
and attempting to walk. It comes as a sort of wave up the top of the
back of head and causes a dreadful sensation in the vertex, and makes it
impossible for her to walk. The important point is that the recumbent
posture quite relieves her. Dming the whole of January last this liability
was so distressing that she never did more than just leave her bed, dress,
and get to the sofa. She believes that nux vomica makes her worse, and
so also digitalis.

'* At present she is often obliged to sit up all night on account of noises
in her eax,"

General Comments on the preceding Cases.

1 have ventured into considerable detail in describing
the symptoms present in this case because I believe that
it presents a good example in an exaggerated form of
what is very common. It may perhaps be allowed to stand
as a type of what is possible in connection with long
persisting disorder of the liver. The xanthoma patches
are valuable as affording the most conclusive evidence of
such disorder. Although functional and only temporary
in the first instance, we may reasonably suspect that
organic tissue changes in the liver have been slowly set
up. Or it may be that the organic and permanent changes

GENEEAL COMMENTS. 205

are in the nerves which regulate the hepatic functions
rather than in its gland constituents. For clinical pur-
poses the distinction is perhaps not of great importance.
What we have to recognise is that liability to liver-
derangement may induce in youth paroxysmal attacks
attended by such symptoms as sick headache and the
like, which in more advanced age may culminate in retinal
epilepsy, migraine, hemiopia, and a variety of alarming
nervous phenomena. Amongst these we may probably
count some of the examples of Meniere's symptoms. The
ancient popular creed which attributes a large proportion
of human infirmities — especially those of the recurring or
chronic class — to the liver, is probably well founded. This
large and most important viscus is very prone to derange-
ment from very various causes, and when disturbed in
function reacts very seriously on the general health. This
it does partly by reflex influence on the nervous system
and partly by poisoning of the blood. As a revealing
symptom, giving, as I have already said, conclusive proof
that such agencies have been at work, we have the various
forms of xanthoma.

No doubt in the production of the sjmaptoms described
in the case before us the heart and the circulation take a
very considerable share. The derangement of function in
the heart is, however, yet secondary to that of the liver, and
not organic.

I am particularly anxious to assert, and if possible to
prove, the influence of the liver in producing the disturb-
ances of health alluded to, because it is possible to bring
that organ into a better ordered condition by the use of
drugs, exercise, and diet. More especially do we possess
in mercury and taraxacum two remedies which, if used
with judgment and at the same time with sufl&cient
freedom, are capable of effecting wonders for those who
are liable to recurring attacks of liver disorder. Many
patients who have in the course of treatment for sj^hilis
submitted to long courses of small doses of mercury obtain
complete immunity from bilious attacks to which they had
been for long previously subject.

CASES ILLUSTRATING EXCEPTIONAL FORMS

OF HEEPES.

{Concluded from page 181.)

Becurring attacks of Herpes, preceded by low spirits and

irritability.

A medical friend has supplied me with the following inter-
esting observation as to recmring herpes, of which he is
himself the subject. He is of a somewhat melancholic dis-
position and spare habits. Although married, he leads, I
believe on account of his wife's health, an almost absolutely
celibate life. His age is about 48. For several years he has
been Uable to recurring herpes, sometimes on the penis, but
more usually on the upper part of the right thigh. He
seldom passes more than a month or six weeks without one.
The attacks are, he says, always followed by a remarkable
improvement in his temper and spirits. For some days
before they occur he is moody, despondent, and irritable ; as
soon as the herpes begins he feels cheerful and himself again.
He assures, us that he often longs for an attack for a week
before it comes. He has been quite unable to associate the
attacks with any special cause. They do not, he thinks,
appear to be catarrhal.

General remarks on cases of Becurring Herpes,

It can scarcely be supposed in such cases as that just
narrated that the herpes is in itself any cause of relief to the
system. The extent of the dermatitis is far too small to be
productive per se of any material influence. It is rather to

EEOUEEING HEEPES. 207

be suspected that the herpes is itself caused by some more
general change in the organism of which it is symptomatic.

The study of the phenomena of recurrence in herpes must
be conducted broadly and with full recognition of the laws
of both physiological and pathological periodicity. There is
no doubt that changes in season have their influence on the
animal organism, and remotely connected with them, but to
a large extent independent, are also those of the sexual
system. Although only females menstruate, there can be
little doubt that the male organism also experiences periodi-
cally recurring excitement of a certain kind. Amongst
pathological facts we have the well-known proneness to
recur, after intervals, of epilepsy and of catarrh. We know
also that those who have once suffered from a malarial fever
are liable for many years afterwards to periodically recurring
symptoms which are in dependence upon some influence
then received by the nervous system. It is of causes such
as these that we must think if we would explain the recur-
rence of herpes. A previous attack of syphilis is probably by
far the most common cause. The sexual system and a
liability to catarrhal explosions probably come next, each
separately taking its share. In the English population
malaria is probably not now a very frequent agent. Amongst
maladies most nearly parallel with herpes in respect of recur-
rence we have erythema multiforme and cheiro-pompholyx.
Of all three it is, I believe, true that a long course of arsenic
will break the habit, and at the same time improve the
patient's general health. A very remarkable case in proof of
this is one which I have often quoted in which a mother
used to give her boy his arsenical mixture whenever she
observed him to be out of temper. It also always prevented
attacks of erythema, to which he was liable.

A severe Herpes of the Penis, Glaus, and Skin, after Ague
and Syphilis — Very frequent recurrences,

•

That herpes of the glans and prepuce often follows
venereal sores and may be very troublesome in its repeated
recurrences is well known. What the state of health ia

208 CASES ILLUSTEATING EXCEPTIONAIj FOBMS OF HEBPES.

which favours its development we have not yet recognised.

The case of Mr. V , who consulted me in August, 1877,

suggests that possibly the state left after severe ague may
have sometimes a share in causing it. He has for the last
eighteen months been seldom more than a week or two at
a time free from herpes on the penis in some form. Some-
times it comes on the glans or prepuce in oval patches, and
sometimes in long groups of vesicles on the skin of the
organ. Each crop fades in a week and heals, but fresh ones
recur so frequently that he is rarely well for long. He had
syphilis some years ago, and three years ago he suffered very
severely from ague in Bulgaria.

Becurring Herpes on the Cheek from cet 4 to 17,

Miss H . She is seventeen, and since the age of five

has been liable to recurring attacks of herpes on the right
cheek. Once she was a whole year without it. During the
last year she has had it more than once a month. It has
always been on the right cheek and near to the same place,
but not exactly. In the present attack it curves forwards
and downwards from ear to comer of mouth, just like zoster ;
but on former occasions she says it has been much more
limited. She is well grown and in good health. She is not
catarrhal, and does not associate the herpes with cold-
catching. She is regular, and does not think that the
herpes has anything to do with her periods.

Her mother once had shingles. (October 27, 1892.)

Becurring Herpes in the Nose in a girl whose mother and

brother were liable to Herpes.

Miss S , aged 15, has a crop of herpes spots on the

edge of left ala nasi. On the tip of the nose is a red patch
which has not developed vesicles.

Her first attack was a year ago, and she has had very
numerous attacks since. During June and July she was
exempt. The present attack has been one week, and the
spots are healing. Sometimes the attacks are so near to
each other that there is scarcely any interval of freedom.

HERPES OPHTHALMICUS. 209

Her mother has been liable to the same on the middle of
chin. She has had recurring attacks with long intervals
since girlhood. She feels sure that her attacks come from,
exposure to cold ; not so much catching cold as exposure to
cold wind.

A brother has very bad attacks of herpes labialis, and
others in the family are also liable. In all it is believed to
come in cold, damp weather, and to be in some sort a taking
of cold.

CASES ILLUSTRATING HERPES FRONTALIS AND HERPES

OPHTHALMICUS.

The following cases are additional to those which I have
pubHshed in the Ophthalmic Hospital Reports, Vol. V.,
1866, and in Archives, Vols. H. and VIII., 1866.

Herpes of the Forehead and Nose with affection of the Eye.

Mrs. Gr , a thin old lady of seventy-four, was sent to

me by Mr. L , of I , in August, 1884, on account of

fronto-nasal shingles with inflammation of the eye. The
eruption had been on the left side, and deep scars remained
both on the forehead and side of nose. The whole of the
side of nose had suffered. As regards the eye, it had been
very painful and much inflamed, and although it was six
weeks since the attack when I saw her, a condition
resembling phlectenular ophthalmitis was still present.

Herpes Frontalis of great severity — Some years of after-
pain — Extensive scarring.

Mrs. C , aged 54, consulted me on account of the

after-pain of herpes frontalis. It was three years since her
attack. She said that it began by pricking pain in the eye-
brow, " as if two little bits of glass were pricking or jagging
in it.'' ** I never had such a pain before." This pain was
present for two days before any spots came. The pain
increased when the spots came, and the skin sloughed. The

diagnosis of herpes was given from the first. Dr. G , a

physician who saw her, advised the use of cocaine. Cocaine

VOL. IX. 14

210 CASES ILLUSTBATING EXCEPTIONAL FORMS OF HERPES.

made her, she thought, very much worse and increased the
pain fearfuDy. So did carbolic acid.

I never saw such scarring from herpes. It looked at first
sight like morphoea. A line ran straight up her forehead,
and from it to the middle of the temple the whole was a
white scar. She had had dreadful after-pain, which had
lasted two years and had only recently abated. The pain was
now a burning one, and came only when she was tired, but
there was always some discomfort. Not the least scar was
present on the lower two-thirds of nose, and not the least
damage had been done to the eye itself, although the whole
upper lid was in a state of scar. There was a scar on the
side of bridge of nose, but it was abruptly limited.

Loss of Sensation (temporary) after very severe Herpes

Frontalis,

Mr. W , of Pontefract, aged 35, came to me in

January, 1884. He had been through a most severe attack
•of herpes on the left forehead. He had been in bed a fort-
night, and for a time was delirious. His forehead and scalp
were deeply scarred, and he still experienced much pain and
numbness. The skin had been so numb that at one time
he could not feel the prick of a needle in the least, but after
«ome months this had improved.

Severe Herpes Frontalis; rmcch after-pain,

Mrs. N , a lady of 63, consulted me on October 3,

1880, on account of the after-pain of herpes frontalis. She
had been in bed three weeks and the attack had been called
'* erysipelas.'' It had left her right forehead and upper
■eyelid covered with scars.

Severe Herpes Ophthalmicus attended by congestion of the
Eye — Severe inflammation of the Eye with Iritis three
months later.

Miss McT , aged 41, was sent to me on September 16,

1893, by Dr. McQuitty, of Belfast. On June 10th an attack
of shingles had begun, involving the left forehead. She was

ABORTIVE HERPES. 211

in bed a fortnight and was for a month in the dark. She
was taking medicine at the time for nemralgic rhemnatism of
the right arm and right side of the face. There was Httle
antecedent pain, but while the eruption was out there was
much throbbing in the temple. The vesicles appeared on
the whole side of the nose, with a group on the lower part of
the cheek and on the upper lip, and scars had been left in
these positions. Some vesicles also formed inside the
mouth. The eye had suffered at first, but had got fairly
well when, as she thought, she had caught cold in it. When
she came to me the eye was acutely inflamed. The cornea
was a little steamy and the iris very muddy and adherent at
its pupillary edge, but the pupil dilated well with atropine.
There was much congestion of the ciliary region and some
thickening of the conjunctiva. There was very severe pain,
especially at night. The sight of the eye, however,
remained fairly good.

ILLUSTRATIONS OF ABORTIVE HERPES.

The dermatitis of Herpes must always be regarded as a sort
of complication of neuritis. It is the latter which is the
essential part. Following on this is the admission that
very probably many cases of neuritis of what we may call
the herpetic type do not proceed so far as to produce vesicu-
lation over the end-organs in the skin. This latter being
absent, there would be no *' herpes " in the ordinary accepta-
tion of the word. To such cases the designation of ** incom-
plete " or ** abortive " herpes may be given. It may possibly
be the fact that they are far commoner than the completed
cases, and that the eruption should be regarded as an excep-
tional complication, present only in severe cases. Thus many
forms of localised pain, unexplained by any concomitants,
may be of herpetic character. The following cases appear
to bear upon these statements.

Abortive Symmetrical Zoster, from Arsenic.

Miss McE , set. 21. She has a very sHght, quite

abortive eruption on both sides, curving round about the
hips like herpes. Has taken arsenic m. vi. for one month.

212 CASES ILLUSTRATING EXCEPTIONAL FORMS OF HERPES.

The spots have been present a few days, and have caused no
pain. No vesicles have formed.

Zoster whilst taking Arsenic — Abortive Papular Eruption on
neighbouring parts, bilateral but not symmetrical.

Mr. S , aged 33, on May 20, 1893, presented on his

back, curving round the right side of chest and crossing
the lower angle of the scapula, the healing sores of a profuse
herpes zoster. The curious point, however, was that the
neighbouring regions, chest and arm, were covered with
papules. These were almost solely on the right side (back
and front), but there were also a few on the left upper arm.
I thought that he had used some irritant, but he assured me
that nothing stronger than vaseline had been employed. He
had been in good health throughout. Three weeks pre-
viously he had felt a pricking in his back and arm, and for
the last ten days had been taking Fowler's solution in five-
minim doses, three times a day.

On May 27th, the eruption was everywhere better. The
pustules were fading. There had been no pain.

Double and m/ultiple Herpes Zoster arrested at the papular
stage and then persisting for some weeks — Entire
absence of irritation.

The subject of the following case was a man who was sent
to me by Mr. Tay from the London Hospital, September 10,
1875. I print the notes as they were then written.

The peculiarity of this case consists in the fact that the
patient has on various parts of his trunk large groups of
papules arranged like herpes zoster, but which have, he
states, remained exactly in present condition for six weeks.
The resemblance to herpes zoster in an early stage is so
exact that at first sight I made not the slightest doubt as to
its being an example of that disease, nor was this similarity
diminished on more careful inspection; but it is the early
stage of zoster which alone is represented ; there being
papules only and no vesicles.

The chief patch, or rather group of patches, extends round

ABOBTIVE HBEPBS. 213

his right side about the level of the lower dorsal vertebrae to
the middle of the abdomen close to the ensiform cartilage.
It is a broad patch, and at its middle as large as the out-
spread hand. It is distinctly corymbiform, and there is a
small patch a Httle below crest of right ilium. There are
irregular areas of healthy skin between the principal groups
of papules. He has another distinctly corymbiform patch
half the size of the palm of the hand just over the middle of
the crest of the left iliac bone, and there are some scattered
groups of similar nature about the posterior margins of left
axilla, on side of chest just below axilla, and over the pos-
terior edge of deltoid. There are a few scattered spots also
passing from axilla backwards over lower part of scapula and
spine. There is a much less marked irregular patch just
over inner side of right knee, and another smaller about six
inches higher up on inner side of the right thigh. There
are some ill-marked patches on inside of upper part of cleft
of buttocks.

Thus it will be seen that the herpetic patches show a
tendency to symmetry ; i.e., there are two groups on each side
of the trunk, but not exactly on the same level. Those on
the iliac crests coincide very closely, but on the left side the
upper group is on a level with the lower border of the axilla,
whilst on the right side it passes considerably below the
nipple. There is no representative on the left knee of the
patches on the right knee. Thus the right side suffers more
than the left.

His statement is that the large patch on the right side was
the one that first attracted his attention, and that all the
others made their appearance ahnost immediately, or at any
rate within a week afterwards. He is a healthy man, set. 23,
of fair complexion. Never had shingles before. The patches
have been wholly unattended by irritation, and he states that
imless he had seen them he should never have been aware of
their presence. He thinks that they are now, at the end of
six weeks, almost exactly in the same state as when they
first appeared.

There is no suggestion as to cause. When I heard of its
long persistence I suspected that it must be syphilitic, but

214 CASES ILLUSTRATING EXCEPTIONAL FOBMS OF HERPES.

on inquiry it seems certain this is not the case. He had
not been taking any medicine.

Numbness and Pain in one Hand and Ann, probably in
connection toith Herpes Zoster — Some senile changes in
the Nerve supply,

Mrs. E , a thin old lady of 81, came to me in January,

1866, on account of pain, with numbness, in her right hand.
For about a year her little finger had been getting numb
and contracted, and she now had scarcely any sensation in
it. Within the last three months the other fingers had
followed, those nearest to the little finger being most
involved. Her thumb she could still use. In November,
1865, she had an eruption on the ulnar side of front of arm,
from axilla to wrist, which, from her description and from
the scars left, I should suppose to have been herpes zoster.
It caused her great pain. She had also a few spots on the

right chest and shoulder. Mrs. E complained very

much of pain about the ulnar nerve behind the inner
condyle, and said that it was tender when touched. All
her fingers were somewhat contracted, and all swollen and
glossy, but at their pulps somewhat shrivelled. They were
tender when touched. The swelling did not affect the
joints more than other parts. The arteries of the limb
appeared to be in good condition, and I could not feel any
rings of chalk in their coats. She could still see to thread her
needle without a glass, and had only a moderate arcus seniUs.
It was a curious feature in her case that the pain came on
only in the daytime. It was often very severe for hours
together, but at night it went off and she slept well. The
fingers ached very much if exposed to the air. She had
noticed that they soon got chilled if exposed, and hot if
covered. We kept her arm and hand enveloped in cotton-
wool, and thus protected, she was fairly comfortable.

A few weeks after her first visit to me she began to
have swelling of the right foot, and redness in the dorsum
of the great toe, and I feared that possibly an attack of
gout was threatening, or, worse, that she might have senile
gangrene.

HBEPES AFTER INJURY. 215

Herpes affecting the Cervical Plexus district and abortive

on the Peripheral regions,

September 13, 1871. Amy S , set. 10. Mr. Tay sent

me to-day a good example of herpes affecting the cervical
plexus tract of skin. The spots covered all the side of
neck and mastoid region, the whole also of the ear, and
also extended just above the ear a little way into the skin
of the hairy scalp. In front of the ear they covered the
aural region of the cheek, and passed downwards to-
wards the angle of mouth and chin. There were none
between the eye and temple, and none on the nasal half of
cheek, none on the lip-regions or within an inch of the
angle of the mouth. On the front of the neck they came
everywhere up to the median line. The spots ceased to be
numerous a little above the level of the clavicle, but there
were scattered groups of them on the clavicle and below it,
and these were especially abundant just in front of the
shoulder joint itself, and inwards over the tendon of the
great pectoral. Behind, the eruption did not pass so low
down as in front, ending for the most part just behind the
upper edge of the trapezius, but there were a few well-marked
clusters lower than this over the supra-spinous fossa, and
one very ill-developed on the infra-spinous district.

I may note in this case, what I have often seen before,,
that the groups outlying the legitimate district were every-
where faintly marked. Some of them were scarcely vesicular,
merely abortive papules. The further off the slighter was
their development, whilst those in the middle of the district
were acutely inflamed and contained bloodstained serum.

CASES OF HERPES AFTER CONTUSIONS.

Many observers have noticed herpes as a consequence of
bruises and other injuries. I saw recently a lady who, after
a severe fall down some steps in her garden, had great pain
over one hip. For some days it was supposed to be from
sprain or contusion, and she kept her bed, being quite
unable to sleep. After about four days of this pain and the
use of many forms of anodyne there appeared an eruption of

216 CASES ILLUSTRATING EXCEPTIONAL FORMS OF HERPES.

herpes, which ran its usual course and ended the more deep-
seated pain. I had myself seen this lady before the herpetic
vesicles made their appearance, and quite failed to predict
their advent. The pain was not referred to the skin, and
there was at first not the slightest redness.

Mr. Clouting, of Thetford, once reported to me a case in
which a woman who had received a severe blow on the side
from the handle of a windlass had zoster come out on the
bruised part.

Mr. Alfred Kebbell, of Flaxton, York, has given me the
notes of a case in which a boy was kick^ by a horse on the
side of his chest. There was no proof of fractured rib, but
he had great pain in inspiration. Six days after the kick
zoster was well out. It was reported that some appearance
of spots was observed as early as thirty-six hours after the
kick, but possibly this was a mistake.

Dr. Hirosa, of Buenos Ayres, was kind enough some
years ago to send me the notes of a case, with a sketch, in
which herpes of both arms had followed the use of the
interrupted electrical current.

MISCELLANEOUS CASES ILLUSTRATING EXCEPTIONAL

FACTS.

Herpes of Cervical Territory in Cheek,

Mr. C , aged 42, was the subject of herpes in front of

the ear and on the chin ; regions supplied by the cheek-
branches of the cervical plexus. There was one vertical
patch midway between the tragus and the eye, another in
the whiskers and another under the jaw. There had been
severe pain and stiffliess of the neck, and there was still
much swelling. (October 25, 1880.)

In 1884 I learned that Mr. C had had no further

attack of herpes. There was then a scar-leaving acne on
his forehead and temples.

Symmetrical and severe Herpes of both Ears in association
with a severe Bigor and Sore Throat.

A young man, aged 21, liable to sore throats, had on a
Thursday a severe rigor with a commencing sore throat. It

SBVEEE HEBPES OF PHABYNX. 217

proved to be a worse throat, and was a far worse rigor, than
he had ever had in his life before. He shivered till his
teeth chattered. This was on a Thursday, and on the
following Saturday he found both ears hot and covered with
little red pimples. On the Tuesday following. Dr. Sangster
sent him to me, and he then had ulcers in his tonsils and
a copious eruption of herpes on both ears. The latter was
remarkably symmetrical. It affected both lobules severely,
and spread over the helix and antihelix, but not to the upper
parts of the latter, nor did it pass into the concha. The
back of the ear on both sides was affected. It had been
developed a little more rapidly on the left than the right
side and was already fading there, on Tuesday, whilst still in
perfection on the other; but perhaps this was due to the
circumstance that it was more severe on the right. On both
sides the vesicles were in groups, and on both some small
groups occurred on the skin of the cheek just in front of the
tragus.

No doubt in this cg.se the herpes was symptomatic and part
of the consequences of the severe rigor. Probably herpes
of the ears may not unfrequently be in this relation ; but
I do not recollect ever to have seen it so definitely such as
in this instance. Nor have I ever, I think, seen it so
symmetrical. The young man told me that he had often
had spots on his lips (herpes) when he had colds.

A febrile illness with high temperature — Herpes of the

Pharynx.

A gentleman, aged 36, whom I had attended twelve years
before for syphilis, came to me with the following curious
history. He had been four days in bed with a febrile illness
and much sickness. His temperature had one evening
reached 105°. He had had no pain anywhere excepting
** just a little catch in my throat now and then.*' He looked
ghastly pale, and he had indeed very improperly left his bed
to come to me. I found a crop of herpetic sores on the right
side of his pharynx and one or two on his lip ; but on careful
examination, could not find any evidence of visceral inflam-

218 CASES ILLUSTRATING EXCEPTIONAL FORMS OF HERPES.

mation. In proof of his good health previously he had
presented himself for examination for life insurance on the
day before his attack commenced. (October 5, 1894.)

Extensive Herpes of the Lips and Chin in a child — Devia-
tions from symmetry.

Herpes is almost never present round the mouth on both
sides. In the following case, one might have at first sight
been inclined to exclaim " symmetrical herpes," but on
carefully looking it became evident that it was most
definitely non-symmetrical. The patient was a little girl
aged 8. The right upper lip was involved ; but the left
side had escaped. The lower lip was involved everywhere
excepting just below the oral commissure. The eruption
was also present below the chin on the left side, reaching to
the middle line but not beyond it in the least. There was
an oval patch in front of the right ear. (January 31, 1877.)

It is to be observed that this case was not an example of
herpes labialis only. Branches of the cervical plexus were
also affected.

Case in proof that Herpes labialis may be symmetrical,

1 have to-day (October 21, 1862) seen herpes labialis
acute, severe, and most characteristic whilst quite sym-
metrical. It involved both upper and lower lips, smd
completely surrounded the mouth, extending, as usual, to
some distance from its angles.

The patient was a healthy-looking boy aged 13, and the
rash had only shown itself one day before I saw him. He
said that his lips had never been sore before. He had
otorrhcea from right ear. He stated that on the day of the
outcome of the eruption he had much running from the
nose. He did not, however, to me, appear to have much
catarrh.

Zoster affecting branches of the Cervical Plexus.

Miss E , aged 26, was the subject of severe herpes

zoster on the left side of the back of the neck, extending in

EXCEPTIONAL FORMS OF HERPES. 219

an almost horizontal bar lengthwise over the whole clavicle.
The eruption was very abundant over the whole length of
the back of the neck, and there were some ill-developed
spots on the deltoid, but they did not extend on the chest
lower than the clavicle, and there was a free space between
the back of the neck and the affected area over the clavicle.
The important point was that the patch over the clavicle
ran almost horizontally (just like morphcea in my portrait).
It had begun a week previously. (November 1, 1893.)

Bilateral but unsymmetrical Eruption of persisting pustules,

Mr. E , aged 40, in good health, was the subject of

numerous and large groups of ulcerating pustules arranged
exactly like herpes zoster. Two groups on the left side of the
chest curved downwards and forwards just like those of zoster,
and there were other groups on the neck, arms, and thighs
and one just below the left knee. The eruption was bilateral,
but most definitely non-sjmametrical, and no two patches
corresponded. The pustules left scars, but had never
ulcerated extensively. They did not coalesce, but remained
as separate papules.

I am sorry that the above note is a very imperfect record
of the case, but I cannot give further particulars. It appears
to be important as an example of a most unusual form of
herpetic eruption. It had persisted for some weeks, but I
cannot state exactly how long, nor do I know the sequel.

A case in which Facial Paralysis followed immediately after

Herpes of the Teinple and Ear,

On July 12, 1888, Mr. F. M. Corner, of Manor House,
Poplar, sent me an interesting example of paralysis of the
portio dura in association with herpes zoster. The eruption
had affected the auriculo-temporal branch of the fifth nerve,
and had been severe. It had lasted three weeks, and was
fast disappearing when facial paralysis on the same side
occurred. The latter was very definite but not quite com-
plete. By strong efforts the patient could bring down the
upper eyelid so as to nearly touch the lower one. He could

220 CASES ILLUSTBATING EXCEPTIONAL FORMS OF HERPES.

not raise the lower one at all. The lower one drooped so as
to expose the conjunctiva. The mouth was drawn to the
left, and he had little or no power of moving the cheek. He
could wrinkle the forehead on both sides.

The patient was a man of about fifty, the superintendent
of a Sailors* Home. I believe that he recovered in the
course of a few weeks.

Severe Herpes of the Lesser Sciatic Begion during the use

of Arsenic.

A very marked case of herpes during treatment by
arsenic occurred to me in May, 1876. A young man, the
subject of psoriasis, was imder care at the Skin Hospital,
and had taken Fowler's solution in doses of three minims
three times a day for one year. He was just well of the
psoriasis and in good health, excepting that he had some-
what lost flesh, when his herpes occurred. It affected the
back of his left thigh, and a group of vesicles occurred
also just below the popliteal space, whilst other small ones
were present on each side of the ankle, just below each
maleolus. The calf wholly escaped, and there were no spots
on the perineum or scrotum. The region of the lesser
sciatic nerve was that chiefly affected. I admitted the man
into the London Hospital in order to demonstrate to our
students the very unusual distribution of the herpes, as well
as to illustrate its apparent connection with the use of
arsenic. We had cured this man of his psoriasis eight years
before, and he had remained quite well for five years. On
that occasion arsenic agreed with him well.

It is difl&cult to explain anatomically why with herpes of
the lesser sciatic region a few vesicles should occur below
the maleoli, but no doubt they proved that, in this individual
at least, some of the nerve twigs found their way there.

Two examples of Becurring Zoster.

. Mr. Davey, late of Eomford, related to me the facts of a
case of persisting shingles. It occurred in a lady of 65, who
for a year and a haK was liable to herpes in a belt on the
left side of the chest. Vesicles formed over and over again.

CASES WHICH ABE SLOW TO HEAL. 221

but always on the same area. At the end of the time men-
tioned the tendency ceased, and she lived ten years longer,
in fair health.

Mr. Davey also told me of another case, in which an
elderly gentleman had had three attacks of shingles with
intervals of a few years. They were all on the same side,
and nearly on the same region.

On Cases in tvhich the healing of Herpes is delayed.

Now and then, with extreme rarity, we encounter cases
of herpes in which the sores are slow to heal. "When this
occurs we may almost take it for granted that the patient
is the subject of syphilis. The only other cases which I
have met with in which herpetic sores lasted longer than
their usual duration, were one or two in which the herpes
had been caused by arsenic, and in which that drug was
continued after it had appeared. This happened in the
case of a young lady named B , for whom I had pre-
scribed arsenic in very full doses for the cure of psoriasis.
After some months' use of it she had a most copious eruption
of common zoster on the right side of the chest. She left
off her arsenic for a week only, and then resumed it.
Instead of disappearing, the scars assumed the condition of
scaly papules, and in this state they persisted, I believe, for
two or three months. They were not in the least irritable,

and Miss B was in good health and had no other

symptoms of arsenical disagreement.

The study of herpes as an illustration of peripheral
neuritis, and in reference to pathological doctrine, is of
extreme interest, quite apart from its clinical aspects.

Arsenic causing Zoster. {A note written in May, 1876.)

" Some years ago I published the opinion that arsenic,
given medicinally, might produce herpes zoster. No year
passes without my having under observation cases in con-
firmation of this belief. It is of much interest to note that
sometimes it occurs only after a long course of the drug,
which has not disagreed in the least. Indeed it is, I think,

222 CASES ILLUSTBATING EXCEPTIONAL FORMS OF HERPES.

never attended by the more common symptoms of intoler-
ance of arsenic, and the patient may resume or even
continue the drug without fear of a repetition of the
herpes, and without in the least interfering with its usual
course."

Ca^e of constantly recurring Herpes on the skin of the Penis
and on both sides of the Buttocks — Becurrences so fre-
quent that he was scarcely ever well — History of an
indefinite sore four years previously, cured by local
treatment and not followed by constitutional symptoms
— On the Buttocks scars left by the Herpes — Arrest of
Herpetic tendency by the use of Arsenic,

AESENIC-KEEATOSIS AND AESENIC-CANCEE.

At page 63 of the present volume, the case of a patient
under the care of Dr. Bullock, of Notting Hill, is briefly
recorded as an example of Arsenic-Cancer. The patient,
a man of forty-six, had been from boyhood the subject
of psoriasis, and had taken arsenic liberally for many years.
Finally two of his psoriasis patches had taken on cancerous
ulcerations, and in connection with one of them a large
gland growth had developed in the right groin. It was only
for about a year that the ulceration had attracted much
attention, but it had been present for a longer period. So
deceptively like syphilitic ulceration had the disease appeared,
that, under the advice of a distinguished physician who had
been consulted, although the history of sjrphilis was wholly
absent, a long course of mercury had been given. The same
history has, I may remark, been present in most of the
examples of arsenic-cancer which have come under my
observation. I am now enabled to record the conclusion of
this case and also to cite some others.

By the courtesy of Dr. Bullock I visited this patient at
his own house in February, 1898. He was now confined to
his bed, and very ill. We noted some important features in
the progress of the sores. The gland mass in the groin had
broken down, and formed a large excavation, at the bottom
of which masses of firm granulations projected. This ex-
cavation involved Poupart's Hgament, which stretched as
a bridle across it. There appeared to be also a large gland-
mass within the brim of the pelvis. No enlarged glands
were to be found in other parts. The original cancerous
ulcer on the abdominal wall had to a large extent lost its
features. Its elevated border had softened down, and its
surface showed florid low granulations. It might indeed

224 ABSENIC-KERATOSIS AND ARSENIC-CANCER.

have been supposed that it was about to heal. The sore
on the back had undergone similar changes, and was no
longer characteristic. It also looked clean and florid, as if
about to heal, but it had during two months made no pro-
gress in scarring. The man's skin generally was harsh and
dry, and in many parts of the abdomen and limbs there were
little dry scaly pits as big as a small finger-nail, with slightly
raised edges not unlike those which occur on senile skins
and sometimes precede epithelioma. Yet the process which
had produced them was in the main one of atrophy, and the
evidences of growth in their edges was exceedingly shght.
All traces of the original psoriasis had disappeared.

A few weeks after my visit I heard from Dr. Bullock that
the man was dead. He had died from exhaustion and pain.
It was not possible to obtain permission to make an
examination, and no specimens were obtained for the
microscope. I have, however, already recorded that a micro-
scopic examination of portions excised from the ulcer for diag-
nostic purposes had formerly been made by a highly skilled
histologist with only negative results. Exactly the same had
occurred in another case. Yet, in spite of the microscope,
both cases had run a malignant career.

Arsenic given in early life — Liability to Epilepsy — An
eighteen months' course of Arsenic — Subsequently Kera-
tosis of the palms and soles — Excision of Ulcers from
the palms — Cancerous implication of cervical glands —
Multiple Keratosis with ulceration — Bapid extension and
death,

A lady, aged 45, was sent to me with a very peculiar
combination of symptoms. She had long suffered from
keratosis of her palms and soles, and recently a growth had
developed under the skin of the left mammary region, and a
large glandular mass in her right neck. There were also
smaller gland tumours in the left groin. The keratosis had
been diagnosed and treated as specific, but the surgeon who
sent her to me wrote that there was no history of syphilis,
and that she had three healthy children. She had been
from time to time under several specialists. Her own

CASE OF ARSENICAL KERATOSIS AND CANCER. 225

account of her case was that her skin ailments had begun
twelve years ago by a loosening of the nail of her left middle
finger. The nail fell oflf, but the part did not become sound.
Three years later her heels and palms became dry and hard^

and she was sent up to London to see Dr. L . Syphilis

was not at that time diagnosed. The palms and soles sub-
quently became very troublesome, and in 1894 she went to
Harrowgate, where the opinion was given that the disease
was due to syphilis. Treatment on that hypothesis, how-
ever, did no good. About a year before I saw her she
recognised a lump in the middle of the right neck, and a
little later another under the breast. About the same time
warty growths appeared on several other parts. There was
something in the appearance of the palms and soles which,
together with the multiplicity of the lesions, led me to at
once suspect that she had suffered from arsenical poisoning,
and this suspicion derived some support from the facts that
new growths were developing independently in two distinct
regions, and that she had formerly suffered from epilepsy. She
told me that she had taken much medicine, but did not know
what. In her younger days she said that she had taken arsenic
for several years to clear her complexion. I communicated
my suspicion to the surgeon who had sent her to me, and he
was good enough to search out her old prescriptions, and
found that during the years 1879 and 1880 for twenty
months consecutively she had taken ten minims of Fowler's
solution a day. It was given her for her epilepsy, and this
was five years before the affection of her palms and soles
began. From admissions which the patient made to me,
however, there were grounds for suspecting that she had
taken more arsenic than her medical attendants knew of.
As has been said, she admitted having taken it for several
years in girlhood for the sake of her complexion, and not
improbably it had been the cause of the epilepsy which it
was afterwards prescribed to cure. This, however, is the
sum oi the evidence that was obtainable, and it is to be
added that her friends doubt much whether she had taken
any arsenic later than 1880. My diagnosis was that the
gland mass in the neck was of a sarcomatous nature. It was

VOL. IX. 15

226 ARSENIC-EERATOSIS AND ABSENIC-CAXGER.

Tery firm, and was in the middle of the neck ; not, as usual,
under the jaw. The glands composing were firmly welded
together. The mass altogether was as big as a child's fist.
The tumour xmder the left breast did not implicate the
gland itself, but was developed apparently in the cellular
tissue. It was somewhat ill-defined, and not very hard.

The sequel of the case may be briefly told. The gland
mass in the neck was excised. I was not present at the
operation, which was done in the country. ' It was attended,
I was told, with much difficulty, as the tumour had grown
rapidly since my consultation, and had become adherent to
the adjacent parts. It adhered both to the carotid and
subclavian, and was probably not completely got away. A
portion of it was sent to the Clinical Besearch Association
for examination. The report was that it was not sarcoma-
tous as I had suspected, but '' a squamous-celled epithelioma,
either in or closely attached to a lymphatic gland. There
are very few cell-nests, and in places the growth is de-
generative.''

The operation wound healed for a time, but the growth
quickly recurred. It grew most rapidly, and spread up the
neck to the side of the head. The patient became insane,
and subsequently comatose, and so died, about four months
after the consultation and three after the operation. It was
believed that growths had developed within the skull.
There was no autopsy.

In view of the verdict that the gland mass in the neck
was epitheliomatous, we had to seek for some primary growth
on skin or mucous membrane. There had never been any
growth in the mouth or throat, though at one time she had
had difficulty in swallowing. A not improbable supposition
seemed to be that the infection had come from the hand.
On two occasions thickened and ulcerated portions of skin
had been excised from the palm. These unfortunately had
not been examined microscopically. On each occasion the
wound had healed well, but the disease had soon returned.
In these features the course of the disease had closely
resembled that of the patient who was the subject of my
first report on Arsenic-Cancer. It was indeed the resem-

CASE OF CANCEE FOLLOWING ABSENICAL KEEATOSIS. 227

blance of her palms to his which made me suspect arsenic.
They were, however, in a less pronomiced condition. For
the reader's convenience I here reproduce the portraits of
the hands in the former case. In the present instance we
had no opportunity for taking a sketch. The suggestion that
the growths in the palm were the source of infection to the
glands in the neck is supported by the fact that the axillary
glands had not wholly escaped. In my former case the gland
tumour appeared in the armpit according to rule. It is clear,
however, that in these cases of arsenic-cancer the infection
is not quite according to rule. In the former case, growths
were found at the autopsy in the chest and adherent to
ribs. There is a definite tendency to multiplicity, the
tissues of the body generally appearing to have been
predisposed by the arsenic to take on the cancerous process.
I may state that not only were my own suspicions as to
arsenical causation at once aroused when I saw this patient's
palms, but that when I showed my drawings of my original

case to Mr. L , the surgeon who had excised the ulcers

from Mrs. L 's palms, he at once remarked that the

conditions exhibited were exactly alike. We may therefore
fairly assume that the appearances presented by arsenical
keratosis and arsenical cancer are peculiar, and that they
are to some extent trustworthy as a means of diagnosis.

In my next case, as yet, no cancer has been developed.
We have only the condition of arsenic-keratosis. The
arsenic has been wholly relinquished for some years, yet the
keratosis persists. In this we have an illustration of a
most important possibility. It would appear — for several
other cases confirm the fact — that the influence of arsenic
upon the skin in predisposing it, first to keratosis and next to
cancer, is not limited to the time during which the mineral
is in use, but may be evidenced years afterwards. It is,
indeed, not impossible that the prolonged use of arsenic
gives to the tissues a proclivity towards cancerous pro-
cesses which may last through the remainder of life.

In one of the cases above cited, although the evidence is
open to some question (since it is not certain that the

228 ARSENIC-KERATOSIS AND ARSENIC-CANCER.

patient had not taken arsenic on her own account and
unknown to her medical friends), the interval between the
disuse of the drug and the appearance of the cancerous
ulcers in the palms would appear to have been several years.
All the stages of the disease are, indeed, peculiar and
especially prone to delay. The early periods of the can-
cerous process are ill-marked, develope very slowly, and
infection of the l5miphatic glands occurs only after a long
interval. Even when the disease reaches the lymphatic
glands it is erratic in its course, and may be either very
slow or very rapid. In the case just referred to the patient
came under my observation for a large gland-mass in the
neck, which at first was thought to have been primary. It
was only on careful inquiry that the facts came out that she
had formerly had enlarged glands in the armpit, and before
that ulcerations in her palms, which had been excised and
repeatedly scraped.

Arsenical Keratosis of Palms some years after the disuse of
Arsenic — Conditions persisting without change for two
years.

Miss C , aged 35, a nurse, was in the first instance

sent to me in January, 1896. I saw her for a second time
in February, 1898, when she was good enough to attend for
demonstration at one of my Conferences. Her condition
during the two years had undergone little or no change.
She was the subject of keratitis of the palms and soles con-
sequent on the use of arsenic. The arsenic had originally
been prescribed for the benefit of an erythematous acne of the
face, and at that time the palms and soles were soft and
quite free from irritation. The prescription was continued
steadily for two years or more. Towards the end of that
time the palms and soles had become dry and homy, and
this condition had continued ever since.

At the present date, five years have elapsed since the
arsenic was left off. The soles of. the feet now show,
under the tread of the toes, thick and large plates of indura-
tion like widely spread-out corns. The same are present
under the heels. At other parts the skin is dry and

PLATE XX.

AESENIC-KERATOSIS AND ARSENIC-CANCER.

The palmar surfaces of the two hands of Dr. W , who became

the subject of arsenic-cancer. It will be seen that the palms are
exactly like that of the hand shown in Plate XVIII., but with the
addition of a fungating growth in each. That in the right palm
is of considerable size and thickness, and is placed just above the
wrist. That in the left is much smaller, having been of more
recent development, and shows only a reddened excoriation
between the index and middle fingers, beneath which there is a
certain amount of thickening. In this case common psoriasis had
been present in the first instance, and arsenic had been given in
large doses over a long time for its cure.

After this portrait was taken. Dr. W ^had his right hand

removed by amputation through the forearm. He died within a
year, with recurred malignant growths in the glands and viscera.
The form of cancer was a modification of epithelial.

The case is narrated in full in the ' Pathological Transactions,*
and I possess reprints of the paper.

,••.

PERSISTENT ARSENICAL KERATOSIS. 229

rough, and shows little corns and pits. Immediately under
the arch of the foot the skin is comparatively soft. The
palms of the hands and palmar aspects of all her fingers are
harsh and dry, and the skin uniformly a little thickened.
There are also numerous low corns, most of them slightly
excavated in their centres.
At my Demonstration I placed several drawings from other

cases by the side of Miss C *s hands, and the changes

present were seen to be most strikingly similar. It should

be added that the arsenic had in Miss C left no other

ill consequences. The rest of the skin was soft and healthy.

SOME FUETHER NOTES ON BAZIN'S MALADY.

One of the chief features of interest attaching to what are
now known as Bazin's legs is the deceptive resemblance to
syphilis which they present/ jl have seen many in which the
simulation was close, but none more instructive than the
following :—

Ulcers 071 the Legs spreading serpigiiiously and assuming the
Horseshoe form — No history of Syphilis — Diagnosis of
Scrofula,

The Rev. Mr. B brought to me his daughter, aged 16,

a blooming girl of florid complexion and fair skin. I had
previously heard respecting her that " a large horseshoe-
shaped ulcer*' had formed on the right calf, and "some
smaller ones on the left, deeply ulcerated and sloughing,
their edges blue and congested." My informant added,
" These ulcers have gradually taken a healthier tone, and
the large one is healing in its centre. In spite of this
improvement there seems to be forming a line of ulceration
outside the original sores, and taking the same shape."
These expressions well described the principal features, but
did not give an adequate idea of the extent of the disease.
On both legs the child had ulcers as large as the palm of the
hand, healing in their centres, but spreading and very
unhealthy at their margins. Outside the margins were also
a number of smaller ones with undermined edges and very
unhealthy surfaces. The horseshoe form and the punched-
out character were conspicuous features. In some places
the edges were ragged and flabby. I was told that the
ulcers had been present and advancing for four months.

FURTHER NOTES ON BAZIN'S MALADY. 231

and that the earliest condition had been a sort of chronic,
painless boil which broke down in the centre. The child
had not been obviously out of health, and she lived at the
seaside under favourable conditions. Her appetite was,
. however, always very poor, and her circulation feeble. She
had had chilblains.

Now against the diagnosis of sjrphilis we had in this case
the facts that all history of it was wanting, and that the
girl's physiognomy and teeth showed nothing whatever in
the least suspicious. Add to these that the ulcers on her
legs were just like those in other cases of Bazin's malady.

In support of the diagnosis of scrofula her mother, who
came with her, showed me extensive scars of scrofulous
ulcers in her own neck, and told me that several near
relatives had died of lung disease. Further, the child had
had inflamed eyes and eyelids of the strumous type.

There is a symptom which I always inquire for as cor-
roborative evidence in these cases. It is the condition
which Dr. Tilbury Fox named cacatrophia folliculorum, and
is usually present as little hard, livid, lichenoid papules on
the backs of the arms just above the elbows. Many persons,
have this who have no ulcers on the legs, but few who have
the latter fail to show also this cachectic or scrofulous form
of lichen. It was present in a marked degree in our
patient.

The question of treatment is very important in these
cases. With such extensive ulceration, and with a general
condition of slight oedema of the legs, it seems an obvious
thing to insist on confinement to the recumbent position. It
is, however, most certain that no definite improvement results
from that measure. I have seen several cases in which it
failed completely, and in which the ulcers finally healed
whilst the patient was walking about. Exercise and fresh
air are indeed important measures. It is well, however, to
insist on the recumbent position whenever, under other cir-
cumstances, the patient would be sitting, and a good deal of
time should be spent in bed. Warmth is essential. Tonics,
wine, cod liver oil, small doses of opium, are all valuable ;
but, above all, it is important to use ointments or lotions

232 SOME FURTHER NOTES ON BAZIN'S MALADY.

containing mercury. Great benefit sometimes accrues from
caustics, such as pure carbolic acid or the acid nitrate of
naercury.

As regards the association of these scrofulous ulcers on the
legs in children with scrofula in a parent, the explanation is
of great interest. It is difl&cult to believe that the inheri-
tance is solely that of tissues of a vulnerable kind. There is
not the slightest probability that any external infection is
necessary to evoke the malady. On the contrary, indurations
under the skin are almost always its first stage. This is the
second case in which the mother of the patient has shown
me her own neck seamed with scrofulous scars. The pro-
probability is, I think, very great, that at the time of
conception the bacilli of tubercule do in some form pass over
from parent to child, and that they remain in the latter latent
imtil roused into activity by local conditions pertaining to
the legs. The cacatrophia foUiculorum to which I have
adverted is probably a form of scrofulous lichen.

The results of treatment in this case were very satis-
factory. I prescribed an ointment containing several salts
of mercury, and advised that the legs should be carefully
bandaged and the patient allowed to go out. The diet was
to be liberal, the clothing especially warm. Six weeks
later I heard that the ulcers had been soundly healed for a
fortnight, and that the general health was much better since
exercise had been allowed.

Bazin^s indurations on one Leg in association with Lupus

Vulgaris on the other.

I saw with Dr. George, of Brondesbury, a very interesting
example of this affection, the point of exceptional importance
being that the patient had the typical erythema induratum
knots on one leg without any ulceration, and on the other a
large patch quite indistinguishable from superficial lupus.
Our patient was a young woman of about twenty-six, who
had a scar in one side of her neck which had been left by an
abscess in childhood. She had lost a paternal aunt in chronic
phthisis and a brother in ** consumption of the bowels." She

FURTHEB NOTES ON BAZIN'S MALADY; 233

herself was stout, but pale, and her shoulders were covered
with acne. She had never been suspected of lung disease.
The affection of her legs had existed for three years, but had
several times been nearly well. It had been wholly confined
to her left leg until within the last eight months. It was
during about the same period that the sore on the left calf
had assumed the condition of lupus.

A peculiar form of infective Ulceration of the Shin of the

Thigh in association with Scrofula,

A most peculiar, indeed in my experience unique, form of
infective disease of skin and subcutaneous cellular tissue was
presented in the case of a young lady whom I saw in March,
1898. She was twenty-six years of age, and had come over
from New Zealand with a letter giving a full description
of her case. She was tall, of rather dark complexion, and
bore not the slightest indication of inherited taint. Her
teeth were perfect. I mention these facts because there had
been doubts expressed, and her father had admitted that he
had, in youth, had a chancre. He had since enjoyed
excellent health, and none of his children had shown any-
thing. One of his sisters and ** all her family, one after the
other," had died of consumption. Our patient showed no
signs of scrofula, but had suffered very much from cold feet
and headaches.

The affection for which Miss K had been sent to me

consisted in a large, very irregular area of ulcerated cicatriced
and indurated skin in the front of her left thigh, about its
middle. It extended from near the great trochanter down-
wards and forwards to the inner side. There were no crusts,
and only the very smallest ulcers, at the time of my seeing
it, but the skin was in the condition of a hard, seamy scar,
with very irregular prolongations in various directions. The
induration was as great as that of cicatricial keloid, but it
involved the subcutaneous tissue rather than the skin itself,
and nowhere rose above the general level. It had been
diagnosed as an example of Bazin's malady, affecting the
thigh, and in some respects this name seemed appropriate.

234 SOME FURTHER NOTES ON BAZIN'S MALADY.

It did not appear, however, that there had ever been the
inflamed subcutaneous nodules which characterise that
affection. It seemed that there had been continuous
infection and no separate foci. The history was that it had
begun insidiously as "a rough, hardened spot " at the age of
seventeen, and had been slowly advancing ever since.

Erythema induratum of the Scrofulous under exceptional
cmiditions and in unusual positions — No Ulceration.

A most instructive example of subcutaneous indurations
which became erythematous, and which occurred in associa-
tion with scrofula, occurred in the person of a gentleman
who came to me from Southampton in May, 1898. He was
fifty-three years of age and in good health, but from boyhood
had been unable to digest fat, and nine years ago he had
required an operation for fistula. These facts were, I must
admit at once, all that I could get as justifying the belief
that he was scrofulous. Nor was there any known history
of tuberculosis in his family. He had never had syphilis.

The conditions shown me by Mr. H when he called

on me on May 26, 1898, consisted of a number of indurated
plaques in the subcutaneous cellular tissue. There were
six of them, and in various stages of development.
There were also some depressions in the skin where others
had formerly been, but as none of these had ever actually
ulcerated, there were no scars which really involved the
cuticle. The initial condition was a rather deeply-placed
knot, very hard and but little tender. These knots gradually
spread out and became closely adherent to the skin, but for
a considerable time without obvious congestion. In the
later stage the skin overlying the induration became of a
dusky red. Some of the plaques which I am describing had
attained the size of crown pieces, and the largest was as big
as the palm of the hand. Their edges gradually shelved off*
In their centres the induration was probably half an inch in
thickness. This largest one was threatening to soften in its
middle and to ulcerate.

Five of the indurations described were on the left lower

FUETHER NOTES ON BAZIN'S MALADY. 235

extremity, one of them being behind the hip, two on the
thigh, and two on the leg. The sixth, which was of quite
recent formation, was on the right leg, and as yet showed
no redness. Thus it will be seen that the left lower
extremity had chiefly suffered, and it may be added it was
on the left side of the anus that the fistula had been present.

Mr. H told me that it was five years since the first

induration (in his left leg) had formed, and from that time
onwards he had never been wholly free. Those which had
disappeared had vanished completely, leaving a thinned spot
in the skin. They had been very slow in their stages,
occupying many months in progress. None had ever looked
so much ulcerating as did the one now present in the left
thigh just above the knee. It was indeed the threatening

condition of this patch which had caused Mr. H to seek

further advice. The indurations had never been painful,

and Mr. H had throughout continued his occupation

and enjoyed good health. He had lived liberally, but not
too freely.

At first sight I was disposed to suspect that these indura-
tions were specific gunmiata, not observing that none of
them had shown any tendency to spread infectively at their
borders. My mind soon relinquished that suspicion, and
noted their similarity to the multiple strumous abscesses of
young children. We had, however, the obvious difference
that none of these had ever formed abscesses, and that
although one now threatened ulceration the inflammation
was quite superficial. The theory which finally I was in-
clined to adopt was that they were really of the same cha-
racter as those of children, and that their differences resulted
from the age of the patient and the vigour of his health.
Suppuration occurs far more readily in the young, whilst in
the sixth decade most inflammatory processes are slow. It
seemed very probable that the original tuberculous infection
had spread downwards in the lymphatics from the fistula in
ano. The case differed from the more ordinary forms of
Bazin*s malady (Erythema indur^ des scrofuleuses), in that
although it had begun on the legs on both sides, yet it had
spread to the thighs, and in that the tendency to suppurate

236 SOME FURTHEB NOTES ON BAZIN'S MALADY.

had been restrained. In this latter feature, however, the
case fits better with what Bazin described than do the large
majority of examples of the disease as observed in English
practice. Bazin, as the name chosen by him implies,
recognised erythema rather than ulceration. With us,
however, in England the erythematous indurations almost
invariably break down, and the resulting ulcers constitute
the most characteristic feature.

I

4

CANCEE AND THE CANCEEOUS PEOCESS.

Keloid caused by a hot poultice — Family history of Cancer,

A young lady at a boarding-school had a sore throat. A
hot linseed-meal poultice was applied just over the top of
the sternum. She complained of the heat, but was told to
bear it. Next morning there were blisters, and sores
followed. Three months later she was brought to me with
a group of glossy keloid buttons on the scar of the scald.
Some of them were a quarter of an inch in thickness.
There was a history of two relatives having suffered from
cancer. A grandfather had died of cancer of the tongue.

This is the third case in which I have seen keloid follow
the use of poultices applied too hot. The history of malig-
nant growths in other members of the family is quite usual.
It gives strong support to the belief that peculiarity in vital
endowment, and not the attack of any parasite, is the cause
of cancerous modes of growth.

Bodent Ulcer on the same part with similar peculiarities ^
and beginning at the same age, in a brother and sister,

I have had under observation for eight years a gentleman
of upwards of sixty of a very fair skin, who has had a rodent
ulcer on his right malar region. After repeated cauterisa-
tions it has soundly healed, and has now needed nothing for
two or three years. It was always somewhat remarkable
for its exceedingly superficial spreading. My reason for
now recording the case is in order to mention that a sister
of the patient, ten years younger than her brother, has just
consulted me for a precisely similar ulcer on the same cheek
and exactly in the same place. I never saw conditions
more precisely repeated, and it will be observed that in each

238 CANCER AND THB CANCEROUS PROCESS.

case the disease has commenced at about the same age.
Such cases make a strong impression in favour of the
hypothesis which attributes cancerous action to congenital
peculiarity of tissue and not to parasitic attack.

On the prospect of lifk in cases of Cancer of the Lower Bowel,
and on the inexpediency of premature operations,

I fear that I sometimes very reluctantly hurt the feelings
of my younger and more energetic colleagues by giving
my vote against what seem to me premature operations for
malignant disease of the lower bowel. Sometimes the
operation proposed is for artificial anus, and sometimes
a laparotomy in the hope of being able to excise the diseased
part. I am told that I much overrate the dangers attending
this latter procedure and the inconveniences of the former.
It may be so, but we must all base our judgment in these
matters upon the facts which have come before us. My
mind is so framed that I find it impossible to yield implicit
faith to statistical statements when they are at variance
with my own experience. I am frequently seeing patients
with cancer of the bowel, easily detected from the anus,
in whom the symptoms are but trifling, and the general
health is well maintained from year to year. One such
used to call on me once a year for four or five years
without getting materially worse, and the disease of which
he finally died was a catarrhal attack on his lungs. In
another, although at one time much reduced by bleeding,
the patient recovered and had two years of good health
before any serious symptoms set in. During these two
years he had enjoyed field sports and lived as others. I have
just seen an old gentleman of 80 whose case has prompted
me to write this note. He is in excellent health, but is
troubled by a bearing down in the rectum and a feeling as
if he had not completely relieved the bowel. This is all
that he suffers from. Yet it is more than two years
since I first recognised malignant ulceration with much
induration and polypoid growths. I might record many
such examples, but the following one must suifice.

RODENT ULCER IN A BROTHER AND SISTER* 239

Mr. K , whose case is published in Archives, Vol. V.,

was brought to me for a second time on September 24,
1895. It was then four years since I had recognised
malignant disease of the rectum rather high up, It had
then caused so much bleeding that a state of very serious
anaemia had been produced. The haemorrhage having been

arrested by ergot and steel, Mr. K had regained good

health and resumed his ordinary mode of life. He had
experienced very little trouble from his bowel until within
the last few months. He lived two years longer. His
death occurred on the 28th of December, 1897. It was thus
six years since the cancer had been first discovered, and
during the greater part of this period he had suffered little
or nothing.

I can only repeat that in consultations in cases of this
kind, I often encounter statements which seem to me
exaggerations in two or more directions. The danger of the
operation is put at much lower than it really is, whilst the
probable duration of life without it and the possible freedom
from pain are much under-rated. The facts which come under
my observation, as well in reference to the performance of
operations as to their avoidance, do not incline me to
recommend them excepting in cases in which the patient's
sufferings are considerable and not relieved by drug
treatment.

Bodent Ulcer on the same part, with similar peculiarities,
and beginning at the same a^e, in a brother and sister.

I have had under observation for eight years a gentleman
of upwards of sixty, of a very fair skin, who had a rodent
ulcer on his right malar region. After repeated cauterisations
it has soundly healed, and has now needed nothing for two
or three years. It was always somewhat remarkable for its
exceedingly superficial spreading. My reason for now re-
cording the case is in order to mention that a sister of the
patient, ten years younger than her brother, has just con-
sulted me for a precisely similar ulcer in the same cheek
and exactly in the same place. I never saw conditions more
precisely repeated, and it will be observed that in each case

240 CANCER AND THE CANCEROUS PROCESS.

the disease has commenced at about the same age. Such
cases make a strong impression in favour of the hypothesis
which attributes cancerous action to congenital pecuharity
of tissue and not to parasitic attack.

Epithelial Cancer on the skin of the abdomen in a young

woman — Paget' s Malady,

A very important and unusual case was brought to our
Demonstrations on May 26 by Dr. Jekyll, of Leytonstone.
The patient was a married woman of twenty-six, of spare
frame, but in good health. On the left side of the trunk,
just above the iliac crest, was a large patch as big as an out-
spread hand which, with some hesitation, had been called
"Lupus.'* It had been slowly spreading at its edges for
two years, but recently in the middle of it a fungating bossy
growth had developed which had ulcerated in its centre, and
now presented a very unhealthy, almost sloughy surface.
It must be understood that this tendency to fungate had
been present only two months, and was quite a new feature.
The rest of the involved area was congested and discoloured,
but not ulcerated, and was crusted in parts by a thick scab
which could be detached without causing bleeding. These
crusts were more like those of psoriasis than of lupus. Nor
was the margin of the patch like lupus. It was most
abruptly defined, and consisted of a low, sinuous roll like
that of a very superficial rodent ulcer. There was not the
least trace of apple-jelly-deposit nor of the flabby granula-
tion masses which occur in lupus. The part which had
been left by the advancing edge was not in a characteristic
condition of scar. It remained dusky and discoloured, but
it was not easy to demonstrate that there had been
destruction of tissue. The skin adjacent to the borders of
the patch was quite sound and white ; not the slightest
congestion preceded the advance of the disease.

The diagnosis of granuloma fungoides suggested itself, as
also that of cancer of scar. Under either hypothesis it
seemed very desirable that prompt extirpation should be
effected, and with this object I procured the admission

paget's cancer on skin of abdomen. 241

of the patient under the care of my son into the London
Hospital.

The operation performed consisted partly in excision and
partly in deep erasion.

Microscopic examination of the parts removed demon-
strated that the growth was epithelial, and of the type met
with after eczema of the nipple and now recognised as
^* Paget *s Disease.** In connection with this histological
diagnosis, for which I am indebted to my son, the descrip-
tion of the naked eye conditions acquires increased interest.
The character of the spreading edge was very similar to that
of the most superficial forms *of rodent. It may perhaps,
indeed, be doubted whether there is any real difference
between some of these and *' Paget *s ulcer.*'

A good portrait showing the appearances referred to has
been preserved for the Museum.

VOL. IX. 16

ON THE POSITION OF LICHEN SCEOFULOSOEUM
AMONGST TUBEECULOUS AFFECTIONS.

The affection of the skin which Dermatologists recognise
as Lichen Scrof ulosorum presents a very.interesting problem
to the students of tuberculosis. What is the nature of its
connection with the bacillus ? Why is it so easily curable ?
Why does it never merge into some one of the other forms
of tubercular disease of the skin such, for instance, as
lupus ? There does not seem to be any doubt that it occurs
chiefly to the scrofulous or to those in whose near relatives
other definitely tubercular disorders have shown themselves.
The worst examples of it that I have seen have been in the
subjects either of lupus vulgaris or angular curvature of the
spine. Yet here we see a very superficial and insignificant
skin affection which never runs on to ulceration, is scarcely
attended even by congestion, and which seems to get well
of itself. We have in the Clinical Museum an excellent
water-colour drawing which all authorities recognise at a
glance as exhibiting this disease in a typical form. It was
shown at the Congress two years ago and was accepted by
all. It is perhaps the best delineation of the disease extant,
for Hebra's plate and some others show it in an exaggerated
and not very typical form. It may be of interest if I briefly
record the facts as regards the patient who was the subject
for this portrait.

Mrs. W is a widow, whose husband died of pneu-
monia within a few years of marriage, and left her with two
fair-haired, blue-eyed, very delicate-looking boys. It was
the younger of these who developed the lichen scrofulosorum.
His elder brother has recently become the subject of
enlarged cervical glands. The boy with lichen was seven
years of age when the portrait was taken. He had then

LICHEN SCEOFULOSOBUM. 243

had the eruption out for about a month. On more than one
occasion I produced him for inspection at a Clinical Demon-
stration.

The following description of his eruption was written out
when I first saw him : —

Grouped minute lichen spots in areas as large as pennies,
but not abruptly margined, and with no tendency to form
rings. The spots in the middle of the patches persist, and
are usually rather larger than the more recent ones at the
periphery. No comedones. The spots where subject to
friction become polished, but do not show any tendency to
enlarge or to coalesce.

The patches occur most abundantly over the outer parts
of thighs and about the region of the great trochanters, but
they are seen also on the shoulders, upper arms, abdomen,
elbows, and sides of knees. They do not itch in the least.
The skin upon which the lichen spots occur is pale or but
very slightly congested. The spots themselves are scarcely
reddened. They make the skin rough and produce " the
nutmeg-grater condition," though on a very minor scale.

I prescribed for Master W as usual, giving him tonics

and using externally a weak ammonio-chloride ointment.
The spots remained just as they were for several months,
or rather increased in number. We tried various other
ointments, and used cod-liver oil both externally and by the
mouth. Nothing did any definite good, and as the boy re-
mained in good general health, his mother at length got tired
and desisted from treatment. I saw no more of him until,
two years later, he was brought to me with his brother as
the latter had enlarged glands. I now found that every trace
of the eruption had disappeared. I begged his mother to
tell me honestly and without any attempt at compliment,
whether she thought that anything prescribed either by
myself or any one else had helped the cure. She replied
that she did not think that anything had exercised any
influence. The eruption had, after lasting nearly a year,
gradually faded away of itself. Its disappearance had, how-
ever, been especially rapid during a month that the boy was
at the seaside.

244 SCBOFULOSOBUM AND TUBERCULOUS AFFECTIONS.

As regards duration the eruption was, I believe, in this
instance exceptionally prolonged. All authorities agree that
it is usually quickly cured, some attributing its disappearance
to one remedy and some to another. That the eruption,
slight as it is, is yet really tuberculous can scarcely be
•doubted. Nor can there be any reasonable hesitation in
believing that it is, in the early stages, contagious. A parent
patch originates others on the surface of the patient's skin,
in connection, in all probability, with the transference from
place to place of germ-material. The outbreak is always
sudden and the spreading rapid.

In these features it much resembles what I have
repeatedly insisted on as the first stage of lupus vulgaris
when it occmrs in multiple patches. In the rare examples
of the latter, in which the multiplicity is great, there are in
fact often many lichenoid pustules. Nor is it unknown in
these cases for many of the patches developed in the outset
to disappear spontaneously, leaving only a few, as persisting
lupus, to spread at their borders, and last, unless cured by
treatment, the rest of the patient's life. The outbreak
period, that of contagion and great multiplicity, is only a
short one. In these features lichen scrofulosorum and lupus
vulgaris have a parallel course. The same is perhaps true
of all forms of tuberculosis. Those which occur in glands
and those which affect bones, and those possibly of internal
organs as well, have all an early stage of virulence and
naanifold development, then lapse into quietude, cease to be
infectious, and undergo cur^ so far as local cure is possible.
The tubercle bacillus in symbiosis with living tissue has not
an unrestricted period of activity, but as a rule runs riot
only for a limited time. It must be admitted, however,
that in some of these forms, notably in lupus, local growths
remain permanently which are persistently locally con-
tagious. In this lupus multiplex and lichen scrofulosorum
differ.

It must, after all, be freely admitted that lichen scrofulo-
sorum is by no means a well-defined malady. It is probable
that it is present in a great number of children in whom it is
never diagnosed, and that it exists in conjunction with a great

LICHEN SCEOFULOSOBUM. 245

variety of other scrofulous manifestations. That it is almost
solely a disease of childhood seems clear. Any one, however,
who has been accustomed to inspect the skins of naked
children frequently must have often recognised, when not
looking for them, groups of little lichen papules in no respect
distinguishable from those of the most definite examples of
the malady in question. We have recently, at our Demon-
strations, had two remarkable illustrations. In one of these
the patches were found in association with lupus, and in the
other in conjunction with others which took the form of
lichen planus. In this latter we have been obliged to hold
the diagnosis still in doubt. Whilst some groups of spots
retain all the characters of L. scrofulosorum, others have
coalesced and acquired the polished surfaces of L. planus.

ILLUSTKATIONS OF THE TEKTIAEY STAGE

OF SYPHILIS.

The clue to the right comprehension of the sequelsB or
tertiary symptoms depends upon recognition of the fact that
during the secondary or humoral stage every tissue in the
body comes under the influence of the poison. The evidences
of this have already been discussed. We have next to accept
as a probable law that something is left behind in the tissues,
or that their mode of vitality is permanently influenced, so
that they are liable ever afterwards to develope inflammatory
or degenerative processes of a peculiar t3rpe. The tissues
are left, so to speak, with a specific vulnerability, and
may, imder the varying influences of the after-life, take on
various forms of morbid action. No limits as to time can
be assigned to the occurrence of these manifestations.
They may begin almost before those belonging to the
secondary stage have ceased, or they may be deferred for
many years.

Severe Bone-pains in the Tertiary Stages of Syphilis pre-
ceding^ the development of Nodes — Long contimcance of
specifics — Ataxy (?) — Aix treatment twice.

In the following case mercury was begun very early, and
secondary symptoms were almost wholly prevented. The
patient, however, had a prejudice to the drug, and did not
take it regularly. Specifics were, notwithstanding, never
wholly left oflf. He became, within two or three years of the
chancre, liable to pain in the bones and to severe pain in the
limbs. His own expression was that he had ** lived on mercury
and iodides," and that he could never for long keep clear of

ON TERTIAEY SYPHILIS.

247

the pains unless taking one or the other. In the tenth year
of the disease the pains were so severe that he went to Aix.
He was very liberally rubbed. In the following year he

went there again, and now saw Dr. B . His symptoms

were so entirely subjective that Dr. B , who had not

treated him on the first occasion, doubted whether he had
ever had syphilis, and only reluctantly allowed him to be
rubbed again. After this he continued internal treatment.
When he came to me three years later he had a large
osseous node on one tibia and some small ones on the skull.
I thought that he had suffered ataxic pains as well as those
of periostitis.

He appeared to have suffered severely from bone-pains
before he had nodes, and it was difficult to distinguish them
from tabetic pains. He described them as '' toothache
pains," and said that they often kept him awake at night.
They had occurred in both arms and legs. His pupils were
small and sluggish, but they certainly did act. He had fair
knee jump.

YEAR.

AGE.
86

1886

1887

37

1888

88

1889

39

1890

40

1891

41

1892

42

1893

43

1B94

44

1895

45

1896

46

1897

47

1898

48

DETAILS.

Syphilis. Mercury very early. Eruption, &c., very slight.
*• I was erratic, and had a strong prejudice to mercury."

\

) Pain in skull, &c. " Living on mercury and iodides."

Was at Aix (for tabetic (?) pains). "Was overdosed by
inunction."

Was at Aix again under Dr. B , and again rubbed.

March : comes to me. Large node on tibia, and liable to them
on head.

248 ILLUSTBATIONS OF THE TERTIAKY STAGE OF SYPHILIS.

Good health for thirty years after mild Syphilis — Front
thirty-first to thirty-sixth year a succession of Tertiary
phenomena — Gummata of Testes — Phagedcenic Ulcer of
Leg — Lupus on Neck.

The following case is a remarkable example of tertiary
phenomena, in different parts, developed after a very long
period of good health. They were amenable to treatment,
but continued to recur. The patient was sent to me by the
late Dr. Eamskill in 1895. He was much out of health, and
had an enormous superficial ulcer, with phagedaBnic edges, in
his right leg. It involved the whole of the outer side of the
limb almost from knee to ankle. I prescribed iodoform
externally and the three iodides internally, and sent him
home to keep his bed. It is to be noted that this ulceration
was not that of a gumma breaking down, but was quite
superficial and distinctly phagedsenic. It had advanced
rapidly during six months, but there had been a chronic
lupoid patch present for many years previously.

After a single consultation, I saw nothing more of him for
four years. In 1898 he again consulted me on accoimt of
swelling of his remaining testicle. He reminded me of his
leg, and showed a thin, supple, perfectly sound scar, one of
the largest I have ever seen. He told me that he had con-
tinued the remedies I had prescribed, and remained in bed
under the care of his family medical man for about two
months. At the end of that time the healing was complete.
No doubt the iodoform was the chief agent in the cure.
During this treatment the testis diminished much in size,
but it was never restored to a normal condition.

The condition of the remaining testis at the present date
(June, 1898) is very peculiar. It is very large and very hard,
but presents an irregular lumpy surface and nodulated form
quite different from the smooth roundness which usually
denotes gummatous infiltration. Nor has it shown the least
tendency to soften. The skin is not adherent to it. Above
the gland is a large encysted hydrocele. The testis itseK is
as large as a child's fist, and the two together make up a
very inconvenient bulk. Excepting its size, it does not
cause him much trouble. I have suggested its removal, but

TERTIAEY SYPHILIS.

249

he is not inclined to submit to another operation. It appears
to be beyond hope of cure by specifics. He has taken them
on and oflf for several years.

The subjoined schedule will afford a clear view of the case.

YEAR.

AGE.

DETAILS.

1860

21

1861

22

1862

23

1863

24

1864

25

1865

26

1866

27

1867

28

1868

29

1869

30

1870

31

1871

32

1872

33

1873

34

1874

35

1875

36

1876

37

1877

38

1878

39

1879

40

1880

41

1881

42

1882

43

1883

44

1884

46

1885

46

1886

47

1887

48

1888

49

1889

60

1890

61

1891

62

1892

63

1893

64

1894

66

1896

66

1896

57

1897

68

1898

59

Had a chancre and open bubo. Took mercury.

Does not remember any secondary symptoms. Iodides.

fHis wife remained well, and was living in 1898.
They had only two children, both of whom re-
tained good health, and in 1898 were strong men.

/ In good health, and wholly free from symptoms.

Lupoid ulcer on leg and sarcocele of left testis.

The testis had suppurated.

Left testis excised on account of gumma.

April : came to me for ulcer on leg.

Phagedsenic ulcers. Cured by iodides, idoform, and rest.

Well, but with persisting enlargement of testis.

Consulted me second time. Sarcocele.

Additional Memorcmda.

The surgeon who excised the testis stated at the time that he did the
operation in order to rid the patient of a trouble, and not because it was
absolutely accessary. There was no suspicion of malignancy.

During the last year (1897-8) he has developed a patch of syphilitic lupus
on the side of his neck. A sister of his died of lung disease.

He has always gained in health on the iodides, and got stouter.

In 1898 he looked in much better health than he did in 1895.

The ulcer on the leg had been present in a lupoid condition several years
before I saw him in 1896, but it had only been rapidly spreading for a few
months. Its freedom from relapse when once entirely healed was most
instructive.

ILLUSTRATIONS OF HEMIPLEGIA IN SYPHILIS.

(Continued from Vol. VL, p. 349.)

A distinguished neulogical friend aaid colleague is never
tired of telling me that there is no such thing as " Syphilitic
Hemiplegia." I sometimes let slip that expression in our
consultations, and he always corrects me by the assurance
that hemiplegia from syphilis is the same as hemiplegia
from other causes. I accept his correction, but am never
quite convinced that the expression is inappropriate. It is
quite true that there is no form of hemiplegia which is
directly due to syphilis and directly curable by specific
treatment. Intervening pathological changes are necessary,
and some of these are not peculiar to syphilis. It would, it
may be admitted at once, be more correct to speak of " the
forms of hemiplegia which occur in the subjects of syphilis,"
but at the same time it would be more roundabout. The
question as a practical one is this : Are there any cases of
hemiplegia the symptoms of which, taken alone, would
suggest the diagnosis of S3rphilis, and for which a prompt
resort to specific treatment is urgently demanded ? To this
question I incline to reply with a strong affirmative. In a
majority of the cases in which hemiplegia occurs in direct
association with syphilis there are peculiarities in the mode
of onset which, if carefully studied, give valuable aid to
diagnosis. The prognosis of such cases differs in important
features from that of other forms, and the welfare of the
patient depends to a large extent upon the vigour of the
treatment.

The explanation of the peculiarities of the syphilitic forms
as regards symptoms is to be found in the peculiarity of the
pathological changes. If we leave aside for the present
all traumatic cases and all cases of tumour, and confine our

HEMIPLEGIA IN SYPHILIS. 251

attention to cases in which a sudden " stroke " occurs, we
may, I suppose, say that the ordinary causes of non-syphihtic
hemiplegia are three — ^haemorrhage, embolism, and throm-
bosis. Now of these three, the last is the only one which
occurs to syphilitics. They are not, with rare exceptions,
liable to rupture of blood vessels, nor is there in them any
source of supply of embolic plugs. Thrombosis they are
very liable to, and it is often, indeed usually, of a peculiar kind.
The disease of the vessels which induces it is usually exter-
nal, and it has often been present for some time before it
induces anything approaching to complete stoppage of the
blood-stream. This involves the consequence that in many
cases premonitory symptoms precede the final attack. It
is these premonitory symptoms which so frequently stamp
with peculiarity the cases referred to. In all other forms of
hemiplegia premonitory symptoms are, I believe, exceptional
and vague ; in sjrphilis they are the rule, and are often more
or less pecuHar in character. In any given case in which it
is wished from a patient's history to decide whether a bygone
attack of hemiplegia was really syphilitic or not, careful
attention should be given to the narrative of the advent and
development of the symptoms. If there have been one or
more attacks of numbness and tingling in the limbs which
were finally paralysed, and if these conditions passed off for
a time and recurred possibly more than once, it may be
inferred that the arterial obstruction was from without, and
that for a time it did not wholly stop the blood-stream.
This is the condition which exists in a large majority of
examples of sjrphiUtic peri-arteritis. Small gummata are
present in the arterial sheath which gradually press upon
the vessel, and finally may induce coagulation of its contents,
or, by increasing pressure, complete occlusion of its canal.
When this occlusion from either cause is complete, then
comes the paralysis ; but before the advent of the latter
there have usually been, as just stated, certain half-results
which »nk ^ prlonitory .ympton.,.

Another feature which characterises many cases of
syphilitic paralysis, consequent as it almost always is on
arterial obstruction, is its complicated type. This results

252 ILLUSTBATIONS OF HEMIPLEGIA IN SYPHILIS.

from the fact that several arteries at different parts of the
same hemisphere, or it may be on the opposite sides, are
affected at the same time. When syphilitic arterial disease
occurs in the early stages of sjrphilis it is almost always
multiple, and it is therefore in these early stages that
multiple and mixed forms of paralysis are more usually
met with. In the tertiary stages one vessel is usually
affected alone, and the case will then approximate in this
respect more closely to the non-specific forms.

At page 319 I have described a case which was perhaps
one of the first in which hemiplegia from syphilis came
under my notice. It was in 1861. The symptoms did not
present any marked peculiarity, and had I not known before-
hand that the patient was liable to gummata I might not
have suspected the real cause.

Following the above another (page 320) was recorded,
which illustrated prognosis, the patient being in good
health twenty years after his attack, although still to a
large extent hemiplegic. This case was of great interest,
because more than a year before his hemiplegia the man
had gone through a brain illness (with coma), from which he
was not expected to recover. This illness was within a year
of his syphilis, and probably denoted extensive disease of the
arteries at the base of the brain. The hemiplegia was pro-
bably due to a return of gummatous disease at one focus,
and the occlusion of one large vessel.

At page 321 of the same volume is mentioned the case of
a man who in the fifth year of syphilis had facial paralysis
occur in association with defective articulation and inability
to write. No warning symptoms had occurred.

Case IV., given at page 322, is one in which left hemi-
plegia happened to a man who had suffered from syphilis
thirty years before. It was by no -means certain that the
paralysis was caused by thrombosis, or that it had any
connection with the preceding sjrphilis. As, however, the
patient had had other tertiary symptoms, it was very likely

HEMIPLEGIA IN SYPHILIS. 253

that he had local arterial disease at the base of the brain.
The attack had been preceded by temporary weakness in
the affected arm, and some discomfort in the head. He was
the subject, fom: years after the hemiplegia, of very painful
spasms in the affected limbs, which were brought on by
sleep.

In Vol. VI., at page 340, I have written some general
remarks on hemiplegia in syphilitics, and have recorded two
series of case-headings. One series comprises seven cases
in which the hemiplegia occurred within two years of the
primary disease. A second series consisted of twenty-five
cases in which the interval varied from two to sixteen
years.

(To he continued,)

THE VASCULAE SYSTEM.

Vascular Tumours in the Fingers,

I HAVE long been acquainted with the occurrence of little iso-
lated vascular tumours in the ends of the fingers and the palm
of the hand. These little growths are seldom much bigger
than a large pin's head, but they are very prone to bleed.
The epidermis over them is often broken away so as to leave
a little pit. Probably they result from some slight injury,
or they may be formed in congenital nsBvi which have never
been noticed. Minute naevi in the palms are not very
uncommon. I had two such myself placed with the most
precise symmetry in the lower part of the palm. They
were not bigger than pins' heads, and could be easily
emptied by pressure. When I closed my palms the one
exactly fitted upon the other. They never bled. At about
the age of forty I one day noticed that one of my little naevi
had disappeared, and a few months later its fellow had
vanished also.

I have had to treat one of the little bleeding growths
above described on the forefinger of one of my daughters.

My son Roger showed me in the finger of one of his
patients at Haslemere an unusual example of this vascular
disease. The patient was a woman of about 50, accustomed
to use her hands in household work, but who was not aware
that she had ever pricked or otherwise injured her finger.
It was, she thought, at least nine years since she first drew
the attention of her husband to the fact that there were
some little holes in one of her fingers. They gave her no
trouble until, three years later, they became liable to bleed.
Recently the spots had increased in number and the patch
in size, and on many occasions rather troublesome bleeding
had occurred.

VASCULAR TUMOURS IN FINGERS. 255

The above statements may seem to suggest a rather for-
midable condition, but really when I examined the fingers
on November 10, 1894, there was nothing more than a little
plum-coloured patch the size of a threepenny-bit in the pulp
of her right forefinger, and wholly free from thickening. It
was absolutely painless, and I was allowed to squeeze it, very
firmly, over and over again. The epidermis over it no longer
showed the ridges characteristic of the finger pulp, and was
a little rough as if pricked by a pin. The patch was made
up of an aggregation of little pin-head-sized spots of deep
tint. It was clear that these spots were in a state of throm-
bosis, for the blood in them could not be discharged by the
firmest pressure. By pressure the skin could be made white
excepting these spots, which, thus isolated, became more
conspicuous. On removal of pressure the intervening tissues
of the patch filled quickly with venous blood and restored
the plum-colour to the whole of it, merging in general con-
gestion the separate spots. I counted at least twenty-five
of the spots but they were placed close together and occu-
pied only a very small space. There was no tendency to
bleed when I examined the finger, and my experiments in
pressure did not cause any ecchymosis. I was told that
sometimes the finger-end would swell and ache, especially
after much washing.

I could feel no doubt that the little spots described were
vascular and not pigmentary, and that the whole should be
regarded as a form of acquired nsBvus. It appeared to be
placed in the substance of the true skin, and had not impro-
bably had its origin in some slight injury. If the patient's
account copld be trusted, there was something allied to an
infective process going on, for the patch was increasing in
size at its periphery. It had been cauterised with nitric acid
before I saw it, but no scar was perceptible and the original
condition had recurred.

The subsequent treatment of this case proved of much
interest. Nitric acid was applied several times, and yet the
naevus returned. It was not until it was used so freely that
a small portion of the terminal phalanx exfoliated that the
disease was finally cured.

256 THE VASCULAB SYSTEM.

I have witnessed this difficulty of cure and proneness to
redevelopment in several other cases. It is often needful
to apply nitric acid several times, but they are always cured
eventually.

Spontaneous obliteration of a large Ncevus after an attack

of Acute Inflammatory Swelling.

At page 131 of the Sixth Eeport of the Vaccination
Commission a case is described by Dr. Skinner, in which
a congenital nsevus inflamed and assumed the conditions
of a large tumour. This growth occurred after vaccination,
at the age of six weeks, and was attributed to it. The
tumour was diagnosed as sarcoma, but in the course of
a year it underwent atrophy, and entirely disappeared.
Apparently the tumour had attained its largest growth at
the age of eight months, when it measured 4 J by 6 inches,
and was estimated to have a thickness of two and a half.

The case is an interesting example of what is by no
means unknown, the inflammatory enlargement of a subcu-
taneous naevoid structure, leading to spontaneous cure. I
have recorded several such, and have suggested that these
attacks of inflammation are ordinary events in the life
history of these tumours.

NOTES ON CASES ILLUSTEATING

SYMPTOMS.

{Continued from page 138.)

No. XXXVI. — On Teethache as distinct frorrir

'' Tootli-acher

In common toothache the pain is in the fang of the toothy
and soon involves the jaw itself. More commonly one
tooth fang only is affected, and in the first instance this is-
almost invariably the case. The pain occurs usually in
" lunges," although it is more or less present between times^
It is sometimes unbearably severe. All these conditions are
reversed in the affection which I would like, for the sake of
distinction, to call "teethache." In this all the teeth in
both jaws, or at any rate all the front ones, are affected
together. The exposed parts of the teeth, and not the
fangs, are the seat of the pain. The jaw is not at any stage
involved. The pain is continuous for hours together, and
although it may be attended by a sense of pricking, it is
never unbearable, and is never attended by lunges. It is as
if ice had been kept in the mouth, or the mouth had been
opened in a biting wind. I have described this symptom at
page 51 of Vol. V., under the heading " A Peculiar Form of
Generalised Ache in the Teeth in association with defective
tone." I recur to the subject now in order to add a few
facts, and possibly to modify a little what was then said. I
feel less certain as to its being always indicative of low tone,
and am also less inclined to associate it with such influences
as set the teeth on edge. In a case recently under observa-
tion it has persisted during spring weather and east winds
for ten days in spite of champagne and port and sea-air. It
has been at times sufficiently annoying to prevent applica-

VOL. IX. 17

258 NOTES ON CASES ILLUSTBATING SYMPTOMS.

tion to any subject, but has never prevented sleep. It is, I
think, always relieved by a full meal with wine, and almost
always made worse by tea. It is still a doubtful point
whether it is in connection with gout and should be treated
with abstinence and alkalis, or whether quinine and v^ne
should be trusted to. I have no evidence in support of the
hypothesis of gout, and incline to the latter creed.

No. XXXVII. — Clear complexions in connection

with phthisical tendencies.

The three Misses Gunning, so renowned for their beauty
and their successes in marriage, all died of consumption.

Horace Walpole, in a letter dated August 1, 1760, writes :
** My Lady Coventry is still alive, sometimes at the point of
death, sometimes recovering. They fixed the spring ; now
the autumn is to be critical to her." This latter prediction
was realised. On October 5th Walpole wrote: ** The
charming Countess is dead at last; and as if the whole
history of both sisters was to be extraordinary, the Duchess
of Hamilton (Elizabeth Gunning) is in consumption too,
and going abroad directly. Perhaps you may see the
remains of these prodigies ; you will see but little remains.
Her features were never so beautiful as Lady Coventry's,
and she has long been changed, though not yet, I think,
above six-and-twenty. The other was but twenty-seven."

The popular belief that clear complexions, bright eyes, and
silken lashes imply delicacy in the direction of tuberculosis
need not in the least conflict with modern knowledge as to
the bacillus. They reveal the tissue-peculiarities which
favour its growth.

No. XXXVIII. — Lichen Planus -affecting the Palms.

I have just had a good opportunity for observing lichen
planus affecting the palms of the hands. The patient, a
man otherwise in robust health, had been for two months
the subject of lichen planus in a most characteristic form.
It was very irritable, and was still not subdued by treatment

DOUBLE MOBBUS COX^ SENILIS. 259

in any degree, when one morning he drew my attention to
the palms of his hands. In the middle of each was a little
group of spots somewhat larger than pins' heads, and
presenting in their centres a distinct excavation. There
were perhaps twenty or thirty of these spots in an area as
large as a halfpenny. They were quite dry and made the
surface rough. They were very much like what I have
occasionally seen on other regions in other cases of lichen
planus. I have described them in an unusual case brought
by Dr. Ferrace, and of which we have preserved a drawing
at the museum.

No. XXXIX. — Double Morbus Coxce Senilis.

Amongst the patients which Mr. Hopkins, the resident
medical officer at the Sick Asylum, offered me for a clinical
lecture to post-graduates on May 11th was a most interest-
ing example of double disease of the hip joints. It was
indeed almost the counterpart of the one which I recorded
at p. 347 of Vol. VIII. of Archives. The patient, an old man
of 66, has both his hips quite stiff in the straight position.
He walks with crutches, and can only shuffle along with
very short steps. "When lying in bed on his back the limbs
are quite straight, but both feet are everted, and the patellae
look outwards. This position cannot be rectified. Although
by effort the great toes can be made to touch each other, it
is solely by movement of the feet at the ankles. If one
limb is lifted into the air it lifts the pelvis and the opposite
thigh also. Very little movement in any direction can be
elicited at either hip. On examining the groins it is found
that large lips of bone have been developed quite symmetri-
cally from the upper borders of the acetabula. These crests
project upwards, and at first suggested the diagnosis of
exostoses. The femoral artery is on both sides lifted up,
and being a large thick vessel the suspicion of aneurism
occurred. The pulsations of the vessels can not only be
felt on the slightest touch, but can even be seen. The
thighs cannot be abducted, and it would be quite impossible
for the man to straddle a horse. (It may be remembered

260 NOTES ON CASES ILLUSTRATING SYMPTOMS.

that difficulty in doing this was the first symptom in Colonel

*s case.) The patient is a tall, well-made man, and

although now a workhouse inmate, is of good family, and
has long almond nails with smooth surfaces. His father
and grandfather suffered from gout. He himself has had
rheumatism, and on two occasions acute gout, once in one
elbow, and once in one wrist. Excepting one finger joint,
no joints other than the two hips are crippled. The disease
in the latter has been in gradual process of development for
the last ten years, and has not been attended by any severe
pain.

ON WAETS, COENS, AND VAEIOUS OTHEE FOEMS
OF GENEEAL OE LOCAL PAPILLOMATOSIS.

The papillae of the skin and mucous membranes are prone
to overgrowth under a variety of causative influences
and may assume very different conditions. Warts, corns,
cutaneous horns, framboesoid vegetations, condylomata, etc.,
offer us examples of the various types assumed. The
names Framboesia, yaws, acanthosis nigricans, pemphigus
vegetans, ichthyosis, papilloma senilis, tuberculosis, papil-
lomatosis, and some others, have been given to various
special forms of disease attended by proneness to hyper-
trophy of these structures. In attempting a general review
of the facts at our disposal in reference to them, it may be
well to conunence with the most simple forms, premising
that the term papillomatosis, although not unobjectionable,
is probably the best at our service by which to designate the
process in general.

Thus the word *' papillomatosis '* may be allowed to desig-
nate the state of body in which, from any cause, there exists
a tendency to the overgrowth of papillae, and the consequent
production of warts or any form of papilloma. We have
papillomatosis occurring as part of youthful or of senile
proclivities in connection with some definite failure in
health, as in acanthosis or pemphigus vegetans, or conse-
quent upon the introduction of a specific poison into the
blood as in syphilis and yaws. Whatever may be its cause,
it probably reveals, as a fundamental condition, a certain
degree of weakness of vital control in the individual
organism. The endovnnents of each individual animal
ought to be of such power, that every tissue and every
special structure or organ in the body shall grow no other-
wise than for the general good, and as parts of a whole the

262 WARTS AND OTHER FORMS OF PAPILLOMATOSIS.

perfection of which is the final aim of all. If any tissues or
structures take on, as it were, independent growth, and
develope to a size which is not helpful, but injurious to the
whole, we may recognise in the fact a tendency to reversion
to vegetative type. It is fair to assume that under such
circumstance the life-power of the individual must be
feebler than in one in whom all growth is subordinated to
the general good. The government, so to speak, is weak.
In common warts we have perhaps the simplest instance
of this defective control, which attains its highest in the
acute forms of malignant new growths. That the two,
although apparently so different, are really allied in a
common basis of somatic peculiarity there are abundant
facts to prove. There are plenty of connecting links. In
all, it may be repeated, the tissues lapse into a mode of
growth more nearly allied to that common in vegetables.
What has been said as to tissue proclivity and individual
peculiarity by no means excludes the recognition of local
exciting causes.

On the Belation of Corns to Warts,

One of the best illustrations which can be ofifered of what
has just been said as to local influences is afforded in the
phenomena of corns. Although we distinguish a com from
a wart, by saying that in the one the process is mainly a
keratosis or thickening of the epidermic layers, yet it is
certain that the papillae are at the same time involved.
Their hypertrophy is concealed under the thickened epi-
dermis, but it is there. The painfulness of a corn, the
freedom with which it may bleed when cut, and, finally,
the appearances presented on a deep section prove this. In
certain positions also, where comparatively exempt from
pressure, the papillary basis of a com is well shown. Thus
they are often seen under nails, sometimes in association
with warts on the hands and sometimes with corns on
the feet.

The appended woodcuts exhibit this association. The
patient's soles showed large corns, and all his toe-nails were
lifted up by the formation of horny and papillary growths

UNDSDAL DEVELOPMENT OF CORNS. 263

under them. The patient was a young man who consulted
me in August of 1897, and who at that date attended at

one of my Demonstrations in order to show hia feet. I
could not persuade him to stay and let Mr. Burgess make

264 WABTS AND OTHER FORMS OF PAPILLOMATOSIS.

a portrait, and the woodcuts are copied from very imperfect
sketches which a friend of the patient made in the country.
They must not be regarded as showing more than just the
position and size of the corns.

The following are the notes which I wrote out at the
time : —

Mr. G. E , aged 21, shows the largest development of

corns on the feet which I have ever seen. It is coincident
with chronic inflammation of the nail-beds of his toes and
the formation of subungual corns and accumulations of epi-
dermis. He is engaged in farm work, but if he takes a tool
or cricket-bat in his hand his hands at once blister. After
the blisters hard callosities follow. His palms, however, do
not suffer nearly so severely as his feet, no doubt because
not exposed to such constant pressure.

He has six sisters, none of whom suffer materially from
corns. He has himself suffered as long as he can remember.
He has had much treatment. He attended a London
specialist for three months, and was for six weeks kept in
bed five or six years ago. He says that paring the corns
does them no permanent good, for they thicken again very
quickly. His father suffers from gout badly.

He reports that he has never had a day's illness, his feet
being his only trouble. His feet sweat "profusely " until he
could wring his socks. His feet often feel hot and burning.

The callosities involve the heels, curving round their
borders ; they occur also under the tread of the toes as three
large separate corns as big as halfpence and a quarter of an
inch thick, and almost touching each other. On the toes
they affect the very tips and under-surface of the pulps,
being evidently located by his boots. The nails are thick,
fibrous, and lifted up by accumulations of epidermis under
them. One of them is raised at right angles. The great
toe has a large com under its nail, but none on its tip. His
finger-nails are not conspicuously affected, but there is a
slightly excessive accumulation of epidermis under their free
edges. He was liable to acne when a boy, and still is so to
a slight extent.

The skin on other parts of the feet is soft and supple

PAPILLOMATOSIS IN BELATION TO CANCER. 265

and perfectly healthy, there being nowhere the slightest
tendency to ichthyosis. His feet are always worse in
summer.

PapHlomatous growths around the Anus in an elderly man,

with family history of Cancer.

The association of tendency to common warts with here-
ditary proneness to cancer was well illustrated in the case

of Colonel F . This gentleman had lost his mother after

colotomy for epithelial cancer of the bowels. In youth he
had been much annoyed by warts on his fingers. At the
age of 68 he came to me on account of a large growth of
warts about his perineum and anus. Many of them were
low and flattened, with a great tendency to coalesce into
patches. None had as yet ulcerated, but some showed very
critical conditions. They advanced just within the orifice
of the anus. He had no doubt subjected them to much
rubbing and scratching. Under the influence of an
anaesthetic I used Pacquelin's cautery very freely, and with
the result of getting rid of most of the warts, though I am
not certain that the cure was complete.

A case of Senile Papillomatosis — Peculiar arrangement and
form of the patches — History of Cancer in the patient's
. mother,

Mrs. L , aged 58, a stout woman, was sent to me from

Brighton by her surgeon, Mr. W. Taylor. She had on chest
and upper part of abdomen some brown spots and streaks
which had attracted much interest. They were peculiar in
form and arrangement, nearly all being long ovals or comet-
shaped, and sloping downwards and forwards towards the
middle line. Some were round spots. All were attended
by some slight thickening, and were somewhat roughened
on the surface. They differed only from the ordinary senile
papilloma, or senile wart, in their form, and in the slight
amount of papillary development. They were very con-
spicuous. Mrs. L had very few on her sides and

shoulders, but on examining her neck I found a great number
of minute pedunculated warts. These were most of them

266 WARTS AND OTHER FORMS OF PAPILLOMATOSIS.

not bigger than large pins' heads, and could easily have
been snipped oflf.

On inquiring for the history of cancer in the family —
which is, I believe, almost always present in these cases
of aggravated senile papillomatosis— I was told that the
patient's mother had died in old age with a large open
cancer on the side of her abdomen.

As regards the explanation of the peculiar arrangement
and form of the patches in this case, I was inclined to
attribute it to the patient having scratched herself by thrust-
ing her hands downwards into her dress. She said that the
skin of the parts had itched very much, and that when in a
warm room she had often been obliged to leave her company
in order to undo her dress and rub herself. It is only fair
to say that she denied having scratched.

Senile Papillomatosis — Abundant development of Warts on
neck and trunk — Cancer in patient's mother.

Another case, very similar to the above, came under my

notice a few weeks later. Mrs. W , a lady of just fifty,

undressed in order to show me what she called eczema.
I found that her abdomen, back, and sides of chest were
covered with low warts, which had become much discoloured.
She said that she had noticed their presence for two years
or more. As in the preceding case, her mother had died of
cancer. The warts had been somewhat irritable, and more
so of late, and she had scratched and rubbed the skin until
it was almost eczematous in parts. On her neck and

shoulders Mrs. W had many small pedunculated and

fimbriated warts, quite different in these respects from those
on the parts covered by her clothes.

NOTES ON BEES AND ON SEX.

In connection with recent discussion as to the influence of
diet on sex and growth, the following memoranda respecting
bees may not be without their interest for some of my
readers.

There are no "neuters" in the beehive. The workers
are all females, in whom the sex-organs are present but
undeveloped.

The development of the sex-organs depends upon the food
supplied to the young bee when in the larval stage.

A certain stimulating food "jelly ** is given by the bees to
any larva which it is wished should grow into a developed
female, in other words a ** queen bee.*'

Under the influence of this food the larva grows more
quickly, both as regards size and development, than one fed
from the common food, and, as a most special feature, its
ovaries grow and become capable of forming eggs without
fecundation.

The queen bee attains her full growth in a shorter time
than a worker does.

Neither the developed females nor the males (drones) ever
concern themselves about work.

The males are called drones on account of their having
no instinct for self-preservation by work. Unless fed by
the workers they die.

The drones, or males, always form a very small pro-
portion of the inhabitants of a hive, and at some seasons
of the year they are wholly absent, having been killed off by
the workers.

The queen bee can at will, if she has been once impreg-
nated, produce eggs which will hatch out either as workers
or drones.

268 NOTES ON BEES AND ON SEX.

If a queen bee have not been impregnated, she can pro-
duce fertile eggs, but they will all hatch out males.*

Sexual impregnation is absolutely necessary to the pro-
duction of females.

A single impregnation serves a queen for the rest of her
hfe. A store of semen is preserved in her, and it would
appear that she can at will allow it to impregnate the eggs
or not.

Thus it might be said that a single impregnation makes
the queen hermaphrodite; she can in her own body dis-
charge the functions of both sexes.

Although in this sense hermaphrodite, an impregnated
queen bee retains, however, her parthenogenetic endowment,
and can, as before, produce eggs which are fertile, but which
have received no influence from the semen.

Thus if a queen wishes to produce drones, she deposits
unimpregnated eggs ; and if workers are desired, eggs which
have been impregnated.

Copulation in bees never occurs in the hive, always in the
air. The queen bee when fully grown takes what is termed
her " nuptial flight," in which she is accompanied by males.
A single impregnation suifices for her life. The store of
semen may be demonstrated by dissection.

If a queen bee, when fully grown, be unable from any
cause to leave the hive, she will lay eggs, but only drones
will be hatched.

* This is a marvellous fact, and suggests strange considerations. It may be,
after all, that there is some truth in the popular creed that males take chiefly
from the mother and females from the father. We are sometimes consulted
about very curious matters. The fungiform papillse of the tongue have brought
me many fees, the projecting end of the metatarsal bone of the little toe a
few, and more than once a young man has made application in the belief that
the froenum preputialis requires to be divided before marriage. One of the
most bootless consultations which I have ever had, however, was by a married
man, whose wife had brought him five sons in succession, and who wished for
a daughter. His friends had found out his weakness, and had made his life
miserable by 'reminding him of the proverb, *' It takes a man to get a girl."
I of course assured him that there was nothing in the proverb but an obvious
truism, and ^hat he ought to make himself happy. With, however, such facts
as the above before us, it is impossible to feel sure that prepotency on the part
of one or other parent may not have some influence in determining the sex of
ofispring.

INFLUENCE OF FOOD ON SEBORRHCEA. 269

Sometimes workers will deposit eggs, but in these
instances the bee is to be regarded as a partially developed
queen, and its larva has probably partaken of the " jelly."
This may have happened from the circumstance of the cell
of the queen-larva having been close to that of a worker.

The eggs deposited by workers produce only drones.
Such workers, although fertile, are yet insusceptible of
impregnation.

Beeswax a result of Seborrhcea — Its production caused by

modification of diet and exercise.

Beeswax is not a substance collected by bees from flowers,
but a secretion formed by their own bodies. It may indeed
be regarded in the same light as the smegma of the prepuce
or the " wax " of the ear. To form wax, bees eat honey very
freely and then go to rest in clusters. The wax exudes on
the sides of the abdomen, and is scraped away either by the
bee itself or one of its companions. Unless the bee has fed
to repletion on honey, it cannot secrete any wax. Several
pounds of honey taken as food are said to be required for
one pound of beeswax.

These facts suggest that possibly diet may be of more
importance in the treatment of seborrhcea, as a disease, than
has been supposed. Those troubled with greasy skins,
comedonous acne, wax in the ears, &c., ought perhaps to
reduce their consumption of sugar, bacon, butter, fat of
meat, and, above all, of honey. These several conditions,
I believe, not unfrequently go together, and are indicative of
general tendency to physiological seborrhcea.

ON INFECTIVE DISEASES OF THE LYMPHATIC

GLANDS.

{Contimied from page 51.)

In now resuming the series of cases illustrating infective
diseases of the lymphatic gland system, it is not necessary
to say much in the way of comment. My prehminary
remarks, and more especially the " Conversation " given
in Vol. VIII., p. 174, have sufficiently explained the main
lines of my argument. Since the time of Hodgkin, many
able observers have contributed to our knowledge of the
disease with which his name is associated. If I have been
fortunate enough — which I can scarcely hope — to add any
novel suggestion, it has been in the direction of the
recognition of predisposing causes. I have endeavoured,
so to speak, to look at these maladies from behind as well
as from before. It is not very difficult if we concern our-
selves only with fully developed cases — with those which
have run their course and brought out all their peculiarities
in full perfection — to classify them into different groups, and
to believe that such terms as scrofulous disease, lymph-
adenoma, and lympho-sarcoma may be applied definitely to
them. The successful accomplishment of such a classifi-
cation does not, however, go the length of proving that
these maladies are really and ab initio distinct. My con-
tention is that they are not so, but rather that they all
of them take their origin in common inflammation, and
acquire their peculiarities, as they proceed, from the inherited
proclivities of the patient. The quality of infectiveness
which enables them to spread more or less quickly to other
parts of the lymphatic system is the all-important one which
they have in common. It is not, however, a quality which
conclusively denotes either tuberculosis or malignancy,

FUTILITY OF MICROSCOPIC DIAGNOSIS. 271

but which both these share with processes which it is
impossible to name otherwise than those of chronic in-
flammation. I cannot think that in contending for this
view of the facts I am arguing for what is a merely verbal
matter. If we admit that these several maladies may have a
common origin, that they are excited by similar influences,
and are in their early stages indistinguishable, we shall,
I think, be on a sound basis, and shall be prepared for that
which we shall see in practice. Although in many cases
the course of the disease may be typical, we shall be pre-
pared to find that in many others it is not so. We shall
expect transition stages, mixed forms, and connecting links,
and these we shall find.

It will of course be suggested that by appeal to the
microscope we may make conclusive decision as to the special
class to which any case should be assigned. Without
doubting in the least that it is possible to recognise by
its aid a sarcomatous form of growth, and to distinguish
it from a tubercular inflammation, I yet venture to assert
that there are early stages of both in which it is impossible.
The microscope comes to our aid just when the battle of
diagnosis is won, and not sooner. Prone to deceive us in
all cases, it is especially so when lymphatic glands are in
question. On this point I speak from a good deal of
experience. The most recent item of it may perhaps be
here fittingly introduced since it concerns one of the cases
in my present series. Case No. III. at page 1»51 will be ad-
mitted by all to be a most typical example of Ijmaph-
adenoma with its final accompaniment of development of
nodules in the spleen. As such, the patient had twice been
the subject of clinical lectures. I sent some of the glands
and a portion of the spleen to the Eesearch Association,
not because there was any sort of doubt as to their nature,
but hoping to secure some good sections from which
drawings might be made. The report returned was to
the effect that the conditions were not those of lymph-
adenoma, but more probably those of syphilis. Apart from
the fact that the man had never had syphilis, there had not
been the slightest resemblance to syphilis in the clinical

272 ON INFECTIVE DISEASES OF THE LYMPHATIC GLANDS.

history of the case. About the same time I sent to the
same association — and I know of no higher authority —
a portion of skin which I had excised under the con-
viction that it was primary sarcoma, and received a detailed
report to the effect that it did not show any evidences of
sarcoma, but was probably a mole or naevus. "?et within
six months of that report the patient developed melanotic
sarcoma in the lymphatic glands. I mention these facts
not in the least as wishing to reflect on the ability of the
Clinical Besearch observers, but rather to show that in
attempting to pronounce upon the nature of new growths
in early stages, and of the results of chronic inflammatory
hypertrophy, the microscope is put to a task which it is
impossible for it to accomplish. It is needless to point
out that had measures of treatment been in question in the
cases which I have mentioned they might have gone
lamentably wrong.

If, however, it were possible — ^which I do not believe that
it is — for the microscope to tell ,us in the early stages of
gland enlargement what will be the course of the disease, it
would still remain unavailable as a diagnostic resource. At
that stage we cannot obtain the specimen for examination.
Nor are we in a better position as regards the patient's blood
changes. These are usually the consequences of the gland
mischief, and do not become demonstrable until the disease
is well advanced. The conclusion, then, is that we must
rely upon the patient's antecedents, the family history, and
a careful observation of the present conditions as the basis
both of prognosis and treatment. Nor is it, I think, desirable
that we should trouble ourselves too much with minute
pathological classification. If we can, taking each case on
its own merits, predict fairly well the results of treatment
and the final tendencies, we must be content.

{To he concluded,)

DIET AND THEEAPEUTICS.

Recovery from severe Spinal Caries under treatment hy

mechanical support and Sea-air,

In 1872 I was consulted in the case of a boy, aged 6, for
spinal abscess and angular curvature in the lumbar region.
He was fitted with a spinal apparatus, and sent to live first
at Swanage and subsequently at Margate. Three years
later he went to the Cape for a time. I saw him occasionally
for six years. At the end of that time the sinuses had
been for some time closed, and there was a strong angular
projection a little above the level of the iliac crests. He
was dwarfed several inches in height, and his chest was
thrown forwards, but he stood erect and no hump was
visible through his clothes.

I did not see anything more of this patient for twenty
years, when he consulted me for syphilis. I was interested
in learning that he had had no relapse of spine symptoms.
He had been married, was the father of one child, but had
lost his wife. He told me that he had been a good football
player and rower, and that he could walk thirty miles a day.
His back never gave him any material trouble. There
could be no doubt that the destruction of the bodies of the
vertebrsB had been considerable, for the angular projection
was great as well as the loss of stature.

I cite the case as a good example of recovery and repair
after disease of the bodies in the lumbar region, and a fact
in favour of treatment by the steel apparatus and change to
seaside. It is also an excellent illustration of the well-
known fact that even severe strumous disease, when once
cured, does not tend to relapse.

VOL. IX. 18

274 DIET AND THEEAPEUTICS.

Severe Pruriginous Eczema, protracted from childhood to
adult age — Cure under the influence of tar lotions and
Antimony,

There are certain very rare cases in which the general
•eczema of infants is protracted through childhood, and
remains uncured even to adult age. These go to supply a
contingent to what is known as **Hebra's prurigo," for they
are almost always very pruriginous, and they take their
origin in early life. They are, however, not absolutely
incurable, but may, if the patient will submit to treatment,
usually be got quite well. Sometimes, however, the malady
has lasted sufficiently long to interfere with the integrity of
the skin and in some degree with the general development
of the frame. Such patients are often very pale, of earthy
complexion, lean, and defective in sexual endowments, with
thin hair and badly formed nails. All these statements are
well illustrated in the case of a lady whom I have recently

had under care. Miss D , now set. 22, has been for eighteen

months absolutely free from a pruriginous dermatitis which
had been present from early infancy. Two years ago, when
she came for a second time under my care, the skin of her
face, neck, and arms was thickened and fissured by long-per-
sisting diffuse eczema. She had been more or less con-
stantly under treatment all her life, and although often
Jbetter for awhile, had never got well. Although well
grown, she was thin and extremely pale. Her final recovery
took place under the patient use of tar lotions and an anti-
mony mixture. The latter was taken for six months con-
tinuously, and I believe that to it much of the credit of the
cure is due, for the external applications had been used pre-
viously without success. Miss D 's cure is now so com-
plete that her skin is everywhere soft and supple and shows
not a trace of eczema. Nor has there been during eighteen
months past, and at various places of residence, the slightest
tendency to relapse. She is, however, still very pale, of a
somewhat pasty complexion and slightly muddy skin. The
hair on the chin and upper lip shows a tendency to grow,
and her menstruation is scanty and irregular. Her fingers
are thick and flabby and the nails stumpy and thin.

TREATMENT OF LICHEN PLANUS. 275

Antimony in the treatment of Lichen Planus.

One of the most interesting cases brought to my Clinical
Demonstration on June 14 was that of a man of about 60,
who had attended one month previously. On both occasions
he was brought by Dr. Sequeira, of Aldgate. He had been
for nearly six months the subject of severe Lichen planus.
On the first occasion the eruption was still, in spite of much
treatment, in full vigour and the cause of much irritation.
He had taken arsenic and used a variety of local applications.
I suggested that antimony should be used. Mr. Sequeira
brought him on the second occasion in order to demonstrate
the success of the remedy. Within a few days of its com-
mencement the irritability of the eruption had almost wholly
ceased, and the progress had since been uninterrupted.
Although still covered with stains, some of them in the legs
being almost black, not a single characteristic papule re-
mained. The dose given had been an eighth of a grain of
tartar emetic three times a day: It had not caused any
sickness.

ON THE AVOIDANCE OF SPLINT-TREATMENT

IN COLLES' FEACTUEE.

When I was on the acting staff of the London Hospital
I used to encourage my house-surgeons to treat many cases
of CoUes' fracture without any splint whatever. My
instructions were never to put on splints unless there was
displacement which could be removed by extension and
which returned when extension ceased. In all such cases
— probably a very small proportion — continued extension by
straight splints is clearly indicated, but even in these they
ought not to be kept on long. During the last twenty years,
my practice having been confined to private consultations, I
have seen little or nothing of recent injuries to the wrist.
I have, however, seen a great many at the end of long
treatment by others which the patients considered to have
been more or less unsatisfactory. The result has been a
very decided conviction that if the routine treatment by
splints could be wholly laid aside, it would be greatly to the
advantage of the patients and to the credit of the surgeons.
Case after case is brought under observation in which the
orthodox treatment has been patiently and skilfully carried
out, with the result that the wrist and the fingers are
stiffened and the hand painful and useless. Nineteen-
twentieths of these would, I believe, have done quite well
and escaped all stiffening if the wrist had been simply kept
for a fortnight between two cushion-pads, and at the end of
that time wholly freed from encumbrance. It is, I know,
exceedingly difficult to rid our minds of the idea that there
is a necessary connection between a fracture and a splint.
The public, as well as ourselves, are under the spell of the
same superstition. The surgeon who is bold enough to be

DISUSE OF SPLINTS IN COLLES FEACTUBE.

277

rational is in great danger of adverse criticisms, in the later
stages ol his case. Even if his patient is well satisfied at the
time, sooner or later some one is sure to recognise the fact
that the bone has been broken, and to express astonishroent
that it was not put up in splints. The end of the radius is
always left somewhat thickened, and the patient is but too
ready to entertain the belief that if only sphnts had been
used and the fracture " properly set " this thickening would
not have been there. As a matter of fact, some thickening
is unavoidable if the carpal end of the radius has been

fractured, and the main question is whether it shall be
thickening plus stiffening. The latter addition, so common
and so damaging, is, I am convinced, caused usually by the
treatment and not by the injury.

We have but to reflect upon what is the real condition of
things in a Colles' fracture to be convinced of the truth of
the above remarks. In many cases there is no displacement
whatever, and no movements on the part of the patient
could possibly produce any. In others there is definite
displacement of the carpal fragment or fragments back-
wards and to the radial side. If this is present, and can
be removed by extension, and returns when extension is
remitted, then a splint is necessary, but not otherwise.

FOEEIGN BODIES IN THE RECTUM.

A MIDDLE-AGED man, whose face expressed much distress,
came into my room with the laconic statement, ** My fissure
has come back again." When asked to explain himself, he
told me that ten years ago he had been the subject of a very
painful fissure in the anus, and that, having been advised to
take to his bed and have it cut, he had called on me, and
that then and there I had stretched the sphincter and cured
him. ** But," added he, ** it has come back, and is worse
than ever." A little further inquiry elicited the fact that he
had been, through the ten years, quite free from discomfort,
and that his present symptoms had set in suddenly the night
before. He said that he had been awake all night, and that
the pain was unbearable. On inspecting the part I found
the anus red and irritable, and on telling him to bear dcwn
he shrieked with pain, but succeeded in protruding some
enlarged veins, between two lobes of which there certainly
was a superficial but apparently quite recent laceration of
the mucous membrane. I was about to advise him to
foment and use some ointment, when my good angel whis-
pered, ''Don't neglect to use the finger." I had some
difficulty in persuading him to let me, for he flinched and
declared that I gave him pain which he could not endure.
Having, however, at length got my finger well within the
external sphincter, I came upon a fish-bone about as long as
a common sewing needle, and almost as sharp, lodged trans-
versely across the gut. Having succeeded in extracting this,
the case was at an end.

It may perhaps be usefully added to the above narrative
that, owing to the impossibility of persuading the man to

ON FIBE-STAINS. 279

keep still, the removal of the bone was very difficult. On
another occasion I would certainly make no attempt without
an ansesthetic.

I well remember many years ago in a similar case, but
with a much longer history of discomfort, removing from
the lower bowel part of the breastbone of a bird. In
another instance, in which constipation had been the chief
symptom, I found the rectum of a woman occupied by at
least a pint of maize, the corns of which had been swallowed
whole. They had finally accumulated, unmixed with feces,,
just above the anus and completely blocked the bowel.

CASE OF VESICATING FIEE-STAINS.

Miss J , aged 30, « has both her legs mottled all over

their fronts and inner aspects by dusky ** fire-stains/* The
peculiar feature in her case is that in winter these stains,
inflame, vesicate, and become covered with adherent crusts.
This state is quite confined to the tibial aspect of the legs.
On the other parts there is neither congestion nor staining,
although the orifices of the follicles are a little dusky. Her
feet are very cold, and always red. Formerly she had bad
chilblains on her feet, but never on her hands or ears. She
is of fair complexion and delicate skin.

I have never before seen legs in the condition which Miss.

J showed me on February 24, 1898. The stains above

referred to mapped out the whole of the fronts on her legs,
and on all the bars of these stains were thick, dry-pus crusts.
The crusts were thickest on the lower parts. I was told
that the legs would get quite well in summer, but in winter
always relapsed. During the mild winter of 1896-97
she was six weeks in bed with them. This last winter they
had been just as bad, but she had concealed their condi-
tion, fearing that she should again be ordered to bed.

In seeking for the cause of the condition, I learnt that
Miss J , suffering always from feeble circulation and

280 CASE OF VESICATING FIRE-STAINS.

cold extremities, had been in the habit of sitting much with
her legs exposed to the fire. She had been bom, and still
lived, in a place where ague until very recently had been
prevalent, but it was not known that she had ever herself
suffered from any definite malarial fever. She was a twin,
and her twin brother did not display any obvious peculiari-
ties of circulation. Some of her mother's relatives had

suffered from phthisis. Miss J herself looked delicate,

and was losing flesh. She had always been a chilly subject,
but until the last four years had not observed any tendency
to sores on her legs.

The measures of treatment recommended were — (1) warm
clothing and warm rooms, but careful avoidance of exposure
to fire-heat ; (2) if practicable, a prolonged change of place
of residence to a warm and non-malarious district ; (3) cod-
liver oil and quinine, minute doses of opium, and Dublin
stout ; (4) a weak mercurial ointment.

The diagnostic importance of fire-stains depends upon the
fact that they are fire-stains, and that they reveal the habit
which the patient has yielded to of sitting very close to the
fire. The next step is to find the explanation of the chilli-
ness which has induced this habit. The influence of the
malarial poison is undoubtedly one of the most potent and
persistent. The worst fire-stained legs which I have seen
have been in the subjects of ague. Many other quite
different influences may, however, produce the undue sus-
ceptibility to cold which is at the bottom of the matter. It
is, further, obvious that fire-stains can be acquired only by
those whose family circumstances permit of personal indul-
gence. Girls at school and servants engaged in household
work do not get them, because, whatever may be their
subjective chilliness, they are not allowed to sit close to the
fire. It is not a slight or occasional exposure which will
cause them, but the habit of cowering in front of a fire for
hours together, and this can be^^|^ onlyjM^hose whose
time is at their own disposal^^^Bbo^^^^Bnuch of it

alone. In Miss J 's case i^^^^^B^^^^^^^had left

school and gone to keep an un^^^^^^^^^^^^lpdition
was produced. It is very pos!

ON FIBE-STAINS. 281

also have had its share in aggi-avating the tendency. Many
young women suffer much from chilliness which is increased
at the monthly periods. It is a curious fact that marriage
and pregnancy give complete relief and may indeed induce
the opposite. Pregnant women are seldom chilly subjects.

In Wilson's Atlas of Skin Disease there is a good illustra-
tion of this form of Melanopathia. It is labelled '' syphili-
tica ,' but if, as is probable, a syphilitic dyscrasia and the
consequent use of iodide of potassium caused the chilliness,
I have no doubt that exposure to fire heat produced the dis-
coloration. It is to be noted that the discoloration in these
cases always takes a definite pattern. It is arranged like
the stains which appear in the skin of a corpse, or the bands
of dark hair on a dappled-grey horse.

\

L

MISCELLANEOUS.

No. CCCVIIL — Tabetic pains induced by Gold.

Mr. W- told me that he used formerly to be quite

unable to sit down in a cold leather chair without its pro-
ducing immediately nerve pains. These pains would shoot
through the hips and thighs. Now he has got rid of this
liability. The patient who thus described his peculiar
symptom was a very intelligent observer. He had suflfered
from syphilis some years before, and had taken iodides and
mercury for very long periods. He had become liable to
severe pains in his limbs, which it was difficult to diagnose
as to whether they were tabetic. Some years later he was
the subject of possibly a form of tabes. His pupils were
small and sluggish, but acted somewhat. He could walk
well with his eyes shut, and his knee reflexes were tolerably
good. He had nodes. His description of the pains which
he had suffered was exactly that of tabes.

No. CCCIX. — Pain in Stomach and Abdomen, very
severe and constant — Tabes probable — Pain
caused by warm bath.

Mr. B , whom I saw on November 19, 1889, with Dr.

E and Dr. H. J . We then ordered only nux

vomica and bromide of potassium. He has got much worse
in walking. He spent the winter in Monte Carlo. At Aix
les Bains he was promised a cure, but did not get one. He
walks on his heels, and very badly.

Last February a very bad attack of sciatica, right side.
He has of late had very troublesome pain at stomach. He
has taken antipyrin for a year for their relief, under Dr.
E *s advice. He has never had developed crises, that is,

THE LAWS OF INHEBITANCE. 'iSS

po severe vomiting. He is never free from the pain, but it is
always worse after making water. He can only pass water
sitting, and with some straining. He takes food well, and
always feels better after it. Sleeps well. He once had a
fixed pain in two inches of the tendo achillis, ** like a hundred
toothaches rolled into one.*' He has long used morphia injec-
tions, which always relieve most when made near the spot.
A warm bath of ordinary temperature would give him great
pain all over. He can only bear it just tepid. Much pain
between his shoulders. He has had pains in his great toe
very like gout, but without swelling. He is married, and
says that he is quite competent, and does not experience
any ill results.

No. CCCX. — Hysterical (?) affections of the Spine.

In the Eeport of the Hunterian Society for 1834, under
the head of '' Hysterical Affections of the Spine," the follow-
ing occurs: *' A case in which there is loss of sensation, as
well as of motion in the lower limbs. There is tenderness of
the spine. Though menstruation is regular, the young lady
is highly hysterical, and the paralysis is imputed to that

cause."

We have, I think, learned to be very careful as to calling
paraplegia "hysterical." A case recorded at page 311 of
Vol. V. may be read with interest in reference to the above.

No. CCCXI. — Some Apliorisvis respecting Inherit-
ance.

Although all maladies which can be inherited tend to
assume peculiar features when so transmitted, they but
rarely keep to a simple or uniform type.

Transmutation in transmission implies relationship in
nature and descent.

Whatever conditions are capable of frequent transmuta-
tion in hereditary transmission are probably closely allied,
if not the same — e,g., gout and rheumatic gout, the varieties
of ichthyosis.

When two different morbid states are frequently observed

284 MISCELLANEOUS.

to be transmuted the one into the other in hereditary trans-
mission, then it is safe to infer close relationship, if not
essential identity.

When two diseases appear to spring by common inherit-
ance, i.e,, the one in one child and the other in another of
the same family, and this is ascertained to be of frequent
occurrence, we may assume that there is some basis of
relationship between the two — e.gr., different types of cancer,
or of skin disease, or of arthritis.

No. CCCXII. — Fragmentary Notes on various

subjects.

The Bengalees have no lunulas. Jews, as a rule, have
large ones. In Greeks the thumb only has one.

There is an important portrait in the collection of the
Dubhn College of Surgeons showing gangrene of the ends of
the fingers (acro-sphacelus) in an infant suffering from con-
genital syphilis. It has been copied for the London College
collection.

The poison of syphilis enters into partnership with the
previously existing proclivities of the individual.

A tendency to perspire on the slightest exertion is not
unfrequently coincident with habitual chilliness, and both
are indicative of want of tone.

In elderly persons acne never occurs on the shoulders.

Amongst the maladies for which the climate of Pontresina
is unsuitable I find, according to a circular which has been
sent me, the following : ** Heavy diseases of the heart, fat-
heartedness, arteriosclorose, crispation of the kidneys, strong
emphysema of the lungs, heavy cachectical dispositions.
Disposition for articular rheumatism."

An Aphorism. — Don't try to make the diagnosis yourself ;
let the symptoms do it.

DISEASES OF THE SKIN AND GOUT. 285

A man aged 49 has had four attacks of ecchymosis of the
conjunctiva; always in the right eye. No cause can be
assigned. He is in good health.

No. CCCXIII. — Diseases of the Shin in connection

with Gout.

Dr. William Corlett, of Cleveland, U.S.A., read before the
Ohio State Medical Society, in 1886, a report of three cases
vvrhich he cautiously named ** Disease of the skin in the
subjects of gout." One of the three, of which a woodcut is
given, presents some features of similarity to the cases which
I have adduced. An Irish woman, aged 62, was the subject
of chronic rheumatism, which was apparently complicated
with true gout. She had had repeated attacks of inflamma-
tion of the great toe, coming on in the night and attended by
great pain. Although she knew of no history of gout in her
ancestors, one of her brothers, who was dead, had suffered
from sjmaptoms very like her own. Her face was pale and
puffy. She had been troubled for seven years with an eruption
on her legs, the spots being of a dark reddish colour, slightly
scaly, and moist only when scratched. Some of the patches
had ulcerated. Dr. Corlett gives a woodcut to show the
location of the patches and ulcers, but it is unfortunately
impossible to tell which are ulcers and which otherwise. It
shows the eruption on the backs and fronts of the forearms
also ; but no detailed description is given of it in these parts.
A circumstance which produces some doubt as to whether
the case is really similar to my own, is that although the
eruption had been present during so many years, it is stated
to have disappeared rather quickly under treatment.

No. CCCXIV. — Albinism as a family peculiarity.

Albinism may occur as a family peculiarity, and may be
perpetuated by breeding. White rabbits, rats, mice, and
ferrets are examples of the latter, and all are complete
albinoes. Birds are but very rarely complete albinoes ; that
is, they very rarely have pink or fiery eyes, which is the
final character. Some instances are, however, on record in

286 MISCELLANEOUS.

which the condition is said to have occurred in more than
one of a clutch of birds, and one at least in which there was
a probability of inheritance. Mr. White, of Bongate, found
white thrushes in two successive years. The nests were
within fifty yards of each other. In one nest of four young,
two were normal and two white with red eyes. In the
•other nest only one bird was white, and its eyes are stated
i;o have become darker as it grew up. Mr. J. Marshall, of
Belmont, has supplied a very cUrious observation. A pair
of thrushes had, in the summer of 1861, three broods. In
-the first there were three young ones, one white and two
normal ; in the second, three all white ; and in the third, one
white and three normal. Mr. J. W. Lukes observed an
instance in which two young birds in the same nest wore
of a light yellowish-brown colour, their breasts showing
incipient marks of the usual spots. Both parents were of
the normal colour.

I take these facts from Morris's ** British Birds,'' vol. iii.
^. 63. The thrush family would appear to be especially
prone to albinism. It is to be observed that the facts seem
ijo indicate that partial albinism is really a minor stage of
the complete form. Thus in Mr. Marshall's case, in which
rseveral complete albinoes had been observed, one was of a
rich fawn colour ; and in that of Mr. White, in one bird the
^yes evidently were not red, since *' they became darker as
the bird got older." Some facts as regards our domesticated
birds and animals might have seemed to imply that white-
ness of the feathers or hair may occur without any tendency
to find a climax in red eyes. White oxen are common, and
-so are white ducks and white fowls, but in none of these
does complete albinism ever occur.

No. CCCXV. — Danger of Meagre Statistics.

Sir Algernon Borthwick (now Lord Glenesk) once re-
marked to me, respecting some operation statistics, "You
surgeons seem to me to trust to too small numbers for
your calculations. Before you speak of a percentage you
should at least get your centum."

PKODUCTS OF INFLAMMATION INFECTIVE. 287

No. CCCXVI. — Spontaneous improvement in Hyper-

metropia in Children,

In some statistical tables given by Landolt, it appears
that nearly 30 per cent, of hypermetropic children experi-
ence spontaneous improvement. In some the condition is
simply reduced, in others enmetropia is attained, and in a
third group the state overpasses the line and myopia is the
result.

No. CCCXVII. — Infective Materies generated in the

act of Inflammation.

Whilst there can be little doubt that the introduction, at
the time of the injury, of some living germ matter (bacillus)
developed in connection with the process of inflammation
in the contributor, very greatly adds to the risk, and gives
character to the inflammation induced, there are good reasons
for doubting whether any such material is essential. It is
highly probable that in some instances a chemical product
of decomposition may take its place, and further that in
some cases no poison of any kind has been introduced. In
the latter group, we have to suppose that the tissues of the
person wounded are capable of generating, as the result of
merely mechanical irritation, a poison which shall prove
infective. We have to accept the proposition — in all
probability a truth — that the inflammatory process, how-
ever initiated, is always attended by the production of a
virus (living or chemical, or both). Inflammation in its
early stages always leads to multiplication of modified cell
organisms which may prove infective ; in its later stages it
leads to death of cells, and may favour the access to the
blood of chemical elements, the result of decomposition,
which may prove very injurious. All inflammations attended
by conspicuous gangrene are productive of fever and accom-
panied by ** poisoning of the blood."

No. CCCXVIII. — Erysipelas without Incubation

Period.

In a case (one of an epidemic) in which erysipelas followed

288 MISCELLANEOUS.

vaccination, redness was observed within twenty-four hours
of the operation, the infant's arm being inflamed from
shoulder to elbow. (See Appendix to Vaccination Com-
mission Beports, p. 230.)

No. CCCXIX. — Deformities of the Teeth cau-sed

by Mercury.

We have recently had at our Museum Demonstrations
some excellent illustrations of mercurial teeth. I use the
word mercurial because the teeth in question are, I believe,
almost always caused by the use of mercury in infancy,
though I by no means intend to deny that other forms of
stomatitis may produce similar results. The peculiarities
are damage to enamel of all the permanent teeth excepting
the pre-molars. The exemption of the latter is usually most
definite. These teeth present white, clean enamel, whilst
all the others are pitted, uneven, and discoloured. I take
especial interest in demonstrating these teeth and insisting
on their peculiarities because they are constantly mistaken
for syphilitic teeth.

No. CCCXX. — Osteitis Deformans in a Mulatto.

I have received from Dr. Kjiott, of British Guiana (for
the Museum), photographs illustrating a case of osteitis
deformans in a native of the colony. They show a very
large head and much bending of the femora and tibisB. The
lower jaw near to its angle on the right side is much
enlarged. The tibiae are not apparently much thickened,
but the bend outwards and forwards is very marked. The
patient is obviously of negro descent, and almost black.
Dr. Knott's notes state that she was aged 46 and a native.
Her head had been progressively enlarging for eight years,
and, owing to the curvature of the spine and lower Hmbs,
she had lost several inches in height. There were no
changes in the upper extremities or clavicles. She had
suffered from aching in her limbs, but the affected bones
were not tender.

As a contribution to international pathology the oase is
valuable.

AECHIVES OP SUEGEET.

OCTOBER, 1898.

EXTEACTS FKOM MY DIAEY.

June 9, 1898. — I have just seen Mr. W , who was one

of those whose cases are recorded in my first Eeport on
Vaccination Syphilis. It is twenty years since that occur-
rence. Mr. W suffered rather severely from the ayphilis ;

in consequence, I believe, of his not having persevered with
treatment. Two or three years afterwards he had some
cerebral symptoms, which were cured by specifics. He is
now seventy-five years of age, and looks ten years younger
than his age. Not having seen him for ten years I mis-
took him for his son. His son also had syphihs at the same
time, and curiously both in father and son the vaccination-
scars showed a tendency to recurrence of induration several
years later. The son is now a healthy man and the father
of a healthy family. Such cases are of value in reference to
the question of Life Insurance and Syphilis.

June 16. — I have received this morning a letter from
Mr. Eoyds, of Andover, informing me of the death, at the

age of 75, of Mr. W. D. B , at Dunedin, New Zealand.

Now I had removed this gentleman's tongue for sclerosis
and epithelial cancer in August, 1879. I am informed that
he has never since had any trouble in connection with the
tongue, but that he has died from some internal disease,
possibly cancer of bowel. His tongue is Fig. 3 in Plate L,

VOL. IX. 19

290 BXTBACTS FROM MY DIARY.

of my Illustrations of Clinical Surgery. He has lived since
the operation nineteen years.

June 26. — Miss L , of E , has just called on me

** merely to let you see that I am quite well.*' I removed her
right breast and axillary glands for scirrhus on August 14,
1889. The tumour had then been growing two years, and
she was 58 years of age.

July 11. — Mrs. G , formerly Miss C , who is the

subject of lupus erythematosus, has called on me to report
progress after a four years interval. Five years ago she
came under my care with the usual symmetrical patches
on the cheeks, on the nose, and in the ears. She developed
a troublesome cough, lost flesh, and looked so much like
phthisis, that I urged her to try a complete change of
climate. She accordingly went to Natal, and has lived
there ever since. Her general health has very much im-
proved. She tells me that the first effect of the sunny
climate of Africa was, apparently, to make her lupus worse,
but that after a time it improved. The patch on her
nose has coalesced with those on her cheeks, and the latter
have somewhat advanced towards the ears. In the concha
of each ear is a large scar. No new patches of lupus have
developed, and over the greater part of those on the face
the condition is that of a sound and not very conspicuous
scar. These patches have, it is true, an erjrthematous
border, but it is not advancing. The disease may be
considered to have come to a standstill. This is according
to rule, and it is probable that there will not now be any
relapse.

March 3, 1897. — I have just seen Mrs. D , whose

portrait is in the Museum and is PI. 72 in my Smaller Atlas.
The whole cheek is now one large scar, but perfectly sound,
and without any trace of lupus growth at its edges. The
scar extends more widely than the appearances shown in the
drawing would suggest, passing on to the side of nose.

ECZEMA SCROFULOSORUM. 291

Mrs. D. is now the subject of most peculiar cake-like in-
duration of the skin on the posterior parts of the deltoid
regions and extending upwards from them towards the neck.
I examined these four months ago at Park Crescent, and
they were, I think, larger then than now. They are not
inflamed and do not threaten to soften. Each patch is as
large as an outspread hand and of much the same shape.
The induration involves skin and subcutaneous cellular
tissue, and a process of atrophy is at work which makes the
surface uneven, producing irregular depressions. Over the
spines of the scapula the skin adheres to the bone. The
boundaries of the patches are indefinite, especially towards
the neck. Mrs. D. thinks nothing of them and is under no
treatment.

It is still a question whether the original disease of the
cheek was an ulcerating gumma, and whether the present
indurations are of the same nature.

In company with my esteemed friend Professor Boeck,
of Christiania, I have just inspected a dozen London
children, the inmates of a holiday home. My companion
noticed that several had scaly patches on the face, and told
me that he felt sure that these patches were indicative of
the presence of the tubercle bacillus in the child's system.
He added that the subject had attracted much attention in
Norway of late, and that the evidence was, he thought,
conclusive. The patches referred to were such as are very
frequently seen on the faces of delicate children, and are
attributed to using hard water and irritating soaps. Dr.
Boeck seemed inclined to go even further than I have
myself done in his suspicions as to the widespread pre-
valence of the tubercle bacillus, and its frequent connec-
tion with very minor phenomena. None of the children in
question were regarded as invalids.

It is very desirable to record facts which give encourage-
ment for early operations for cancer. I have mentioned
above, one in which a patient whose tongue I had removed

292 EXTRACTS PROM MY DIARY.

neaorly twenty years ago has only recently died of other

disease. I have just seen the Bev. Dr. A. S. F , whose

tongue I removed eleven years ago. Two years previons
to the final operation I had removed by superficial excision
some sclerosed patches which were in a doubtful condition,
but not positively cancerous. At the date of the second
operation there was no doubt whatever as to the nature of

the disease. Dr. F is now seventy-one years of age

and in excellent health.

July 16th. — Dr. S. B has just called on me with a

plentiful eruption of herpes on his forehead and side of head.
He is anxious lest his eye should suffer. I console him on
this point, for there is not a single vesicle on the side of his
nose, the oculo-nasal twig having escaped. His conjunctiva
for the present is not even congested, although there are
spots on the upper lid. Although the vesicles are very
abundant, they are very superficial and have the thinnest
possible walls. This fits well with his statement that it has
not been very painful, *' only a little pricking pain." He is
only thirty-five, and his youth probably explains the mild-
ness of the inflammation. He tells me that his father,
when an old man, had shingles on his chest and suffered
most severely. This suggestion of inherited, tendency is

interesting, and so also is the fact that Dr. B has been

recently taking arsenic. He thinks that he took his last
dose of arsenic — it was only a single minim three times a
day — at least three weeks ago. His herpes has, however,
now been a week out, and we do not know how long its
incubation stage may have been.

June 10. — An engineer who had been engaged in a South
American gold mine, working amongst fumes of arsenic,
gave me the following facts. He said that the metal was
deposited on the grass, and that the mules and asses died
from eating it. In them the symptoms were loss of flesh,
general drooping, with hanging heads, and death apparently
from pain and debility. In men a sore nose was usually

ACROMEGALY. THE SIX TEAR MOLAR, ETC. 293

the first symptom, and next a sore mouth and spots on the
face. Scarcely any one escaped a sore nose and choked
nostrils. He had himself suffered, and had taken iodide
of potassium as a remedy, which had made him weak, and
brought out boils. He looked sallow in face, but the skin
of his trunk was white, and not in any way pigmented.

August f 1898. — I have just heard of the death of a patient
who was the subject of Acromegaly, and who was indeed the
first in whom I had observed the curious characters of that
malady.

His case is published in Archives, Vol. I., p. 141. It was
one in which the features of the disease were extremely well
marked. I am informed by Dr. Birch, of Newbury, that

Mr. B had since my report of his case enjoyed fair

health, though still suffering from his headaches. He was
a man of keen intellect, which to the last did not in the^east
fail him. His death was preceded by profuse hsematemesis.
This was supposed to have depended upon ulcer of the
stomach rather than upon varices of the oesophagus. For
some months previously he had suffered a great deal of pain,
sometimes in the epigastrium, sometimes in a spot opposite
the third dorsal vertebra. The blood vomited was dark and
probably venous. There had been no reason to think that
he was suffering from cirrhosis of the liver.

I find that practical dentists are in the habit of speaking
of the first permanent molar tooth as the " six-year molar."
It might be convenient if this term were generally adopted,
as it serves to emphasise the fact that it is one of the first
of the permanent set, and that it comes up simultaneously
with the lower central incisors. It is the tooth which
usually shows the influence of mercury given in infancy (or
of other forms of stomatitis), the explanation being that it
is developed, and its enamel calcified, long before its fellows.

I have recently been consulted by a gentleman who has
just returned from Matabeleland, and has his hands covered

294 EXTRACTS FROM MY DIARY.

with dusky stains, which become conspicuous in the
depending position and give him much annoyance. There
are no actual scars and no traces of remaining inflammation-
It appears to be simply a condition of weakened capillaries
easily permitting of over-distension of the venules. The
patient is a very tall man and, although in good health, of
a somewhat feeble circulation. He tells me that when in
Africa his hands were covered with sores, caused by slight
bruises and exposure to sun, &c. He says that such sores
are very common there, most persons suffering from them
more or less. He will not admit that they are due to pricks
of thorns or to the bites of insects; but attributes them
entirely to mechanical injuries and to exposure of the hands
to weather.

I conversed with a surgeon who had practised in Africa,
in a Yaws district, and suggested to him that it was very
difficult to distinguish between yaws and syphilis.

** In some cases," he said, *' it is impossible to tell which
the disease is, but in others it is quite easy.

Ego, Is not that because you have determined to call
a certain group of symptoms Yaws and another group
Syphilis, and thus artificially put examples of the selfsame
malady into two classes ?

Ille, Very likely it is so.

Ego, It is said, for instance, that in yaws there is never
any sore throat ; but may it not be that if it was a sore
throat you would at once class the case as S3rphilis ?

Ille, It is very possible. I may repeat that I have seen
many cases in which I could not decide whether the disease
were syphilis or yaws.

Ego. Speaking of sore throats, may it not be that in the
tropics the mucous membranes are not so prone to suffer
as in colder climates?

IIU, I am sure you are right there. We very rarely see
sore throats from anything. I was myself very prone to
sore throats when I lived in England, but I never had
one in Africa.

MULTIPLE FEACTUEES IN YOUNG CHILDEEN

WITH TUMOUE GEOWTHS.

•

The two cases which I have to narrate bear a remarkable
resemblance to each other. In both, numerous fractures of
long bones occurred in early life. In both, symmetrical
deformations existed at the elbow joints suggesting a want
of development of the external condyle and consecutive
dislocation of the radius. In both, enlargements of bones
had occurred, more especially of the femurs. In one case
the enlargement of the femur, first of one, then the other, had
not been persistent, but in the other, what appeared to be
a very large intra-osteal cartilaginous tumour has developed.
In each case the tumour in one femur was at one time
so large and so suggestive of malignancy that amputation
was contemplated. Both patients were girls, and one
was aged 12 and the other 10 at the time that ampu-
tation was advised. In neither was there any evidence
whatever in support of the suspicion of congenital syphilis.
In one of the cases I much regret that I am not able to
complete the notes, and am obliged to be content with
describing the patient's condition as it was at the date of
my last seeing her, twenty-eight years ago. It is possible
that she may subsequently have come under the observation
of some one of my readers. If so, the supply of further
particulars will confer an obligation not, I feel sure, on
myself alone. The child's name was Emma Mackinnon.
Although in this cas6 I remember that I was at the time
disposed to suspect syphilis in consequence of the rapid
development of the osteal swellings and their disappearance
under treatment by iodides, yet on further thought, and
especially on comparing the facts with those of the second
case, I do not think that this suspicion can be sustained.
It seems more likely that the cases are to be assigned to a

296 MULTIPLE FRACTURES WITH TUMOUR GROWTHS.

small group in which interference with bone development and
tendency to cartilaginous outgrowth, occurs in connection
with some ill-understood inherited tendency. Althougli by
no means the same, they are probably allied to those
osteo-plastic conditions which sometimes result in dwarfdom.

Case I. — Numercms fractures of various bones in a
young child — Symmetrical deformity of elbow-joints
(congenital ?) — Enlargement of lower part of right
femAir.

The patient whose case is recorded in the following notes
was first brought under my observation by Mr. F. M.
Mackenzie (then my House Surgeon) before the enlargement
of the femur had occurred. On a second occasion she w^as
sent to me by Mr. Oswald Baker in September, 1869, when
the following notes were taken : —

September 19, 1869. — Emma M , sst. lOJ. The two elbows are

almost exactly alike. In each the head of the radius at the elbow-joint
can be easily felt and seen, owing apparently to an absence of the
external condyle. The internal condyle is well formed, and in dne rela-
tion with the olecranon, but the external appears to be wholly absent,
and the finger can be placed in the cup of the radius. This cup of the
radius does not present a cavity as usual, nor does it appear to be quite
so large or so evenly rounded as in the normal state. It is not at all
closely confined to the ulna, and can be made to project at least as far as
the extremity of the olecranon, being thus too long for its corresponding
bone. At the back of the lower part of each humerus on its radial
border is a strong ridge of bone with its convexity backwards. This
apparently represents the external condyle. When the arms are
extended they are not perfectly straight, but are bent a little inwards,
and the extremity of the displaced radius then projects considerably.
The ulna itself is in each arm considerably bent in its upper third. She
is reported to have had three fractures in the right forearm and two in
the left, three times of the right leg and once of the right thigh. Of
none of these fractures do any very evident traces remain. The power
of pronation and supination is limited, and the flexion also is in-
complete. The child cannot put her arm behind her, nor to the back
of her head.

Her mother states that nothing was ever noticed amiss with her
elbows before her arms were broken. The upper arms are both of them
very thin, but, as far as can be tested, all the muscles are present. Her
first fracture occurred at the age of fifteen months, and implicated her
right leg. The left arm was broken at the age of two years and three

A CASE-NARRATIVE. 297

months, and before the splints were removed she broke the other. Her
last fracture, three years and a half ago, was of her right thigh, and she
was treated at the London Hospital. A year and a half later she had
some effusion into the right knee-joint, which disappeared after treat-
ment. During the last two months the lower half of the right femur has
been slowly enlarging. The femur is now much enlarged in its lower
third, the enlargement implicating all psurts of the bone to the joint
itself, the condyles being involved. It is very hard, as if from a growth
within the bone. There is no redness, and scarcely any heat of surface.
Her mother states that it has been very painful, and has of fcen kept her
awake at night. *' Jumping pain" is described: She is said to have
lost her flesh since the bone began to enlarge. Girth of the right thigh
above the knee, 11 j^ inches ; of the left, 8^. There is no effusion into the
knee-joint at present.

She is the eldest of a family of seven, only one having died. There
is no history of mollities ossium, of rickets, or of cancer in the family.
None of her brothers or sisters have had fractures. The paternal grand-
mother had a fracture of the leg. There is nothing about her indicative
of inherited syphilis, nor are there any suspicious facts in her early
history. The conditions presented by the elbows are possibly consequent
upon fra,ctures of the ulna with injury to the humeral epiphysis and
unreduced dislocation of the radius in early life. The enlargement
of the femur is suggestive of a myeloid tumour, but the severe pain,
jumping, &c., must be kept in mind as possibly in connection with
inflammation and abscess in bone.

Some months later a very large swelling (periosteal) formed on the
middle of left femur, and went through the same stages as the other
had done.

December, 1870. — The swelling has almost wholly disappeared from
the right femur; but the one on the left remains. Another swelling
has developed on the left tibia.

After the last date I lost sight of my patient, and I have
now no clue to her address. The treatment under which
some of the bone tumours had to a large extent been
absorbed was the iodide of potassium, but it will be observed
that it did not prevent the development of others. It may
possibly have been the fact that the growths were in some
connection with the fractures, but on the other hand they
did not follow them immediately, and most of the fractures
had united well and without ** callus.'* The tumour of the
right femur was at one time as large as an infant's head, and
it will be noticed that it grew three years after the fracture.
Neither in this case nor the one to follow were there ever any

298 MULTIPLE FBACTURES WITH TUMOUR GROWTHS.

periosteal swellings on the skull. In both the Umb bones
were those which alone were affected.

I have recorded in a former volume of Archives some
other examples of deformities at the elbow very like those
which were present in these cases.

For the opportunity for investigating the following case I
was indebted to my friend Mr. Hastings Gilford, of Beading.

Case II. — Numero'^s fractures of long hones in early life —
Malformed elbows — Large enchondroma of one femur —
Severe cramps in legs — Fractures of ribs from coughing.

1865

1866

1867
1868
1869
1870
1871
1872
1873
1874
1875
1876

1877

1878
1879
1880
1881
1882
1888
1884
1886
1886
1897
1888
1889
1890
1891
1892
1898
1894
1895
1896
1897
1898

8

4

5

6

7

8

9

10

11

12

13

14
16
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34

A small child. Not suckled. Got on well. " Double jointed "

at elbows from birth.
Broke her arm when just able to walk. Could walk at twelve

months.
Good health. She cut her teeth early and well.

n

II

Broke the opposite humerus in a fall, and the first a second time.
Broke a rib in fall from sofa.

Great pain in left thigh and a swelling developed. In St.

Bartholomew's Hospital.
Amputation urged, but parents refused. She was very iU at

the time.
Menstruation commenced and has since been regular.
Broke her right leg in a fall.

\

During these years the tum^our, which involved the whole of the
\ left femur, persisted or even increased. It became finaUy of
enormous size and extended from knee to hip. It ceased,
however, to be painful, and became harder.

Became liable to cramp in one leg.

The cramp occurred in the other leg, brought on by walking.

Seen by me with Mr. Hastings Gilford.
Two ribs broken.

Good general health. Conditions stationary.

CARTILAGINOUS TUMOURS OF THE DIGITS. 299

Additional Memoranda,

She is the first-born. The next ohild died of diarrhcea setat 2. The third
always strong. Rickets has never been mentioned in respect to any of them.
There is no family history of brittle bones or of tvmiours. She is about
4 ft. 9 in. Her hands and feet are well formed. Wrists not in the least
thickened. The sternum projects forward a little above its middle. Both
tibiae are bowed outwards and forwards. At both elbows the radius is dis-
located.

Her teeth show no indications either of syphilis or mercury. Her physiog-
nomy can scarcely be said to be suspicious, but the skin is pale and dry and
the frontal eminences a little more elevated than ordinary.

In August of the present year (1898) Mr. Gilford kindly
reported to me on the state of his patient. The tumour of
the femur has not grown. Although the patient appears
to be in excellent health, yet her bones remain very brittle.
In November of 1896 she broke a rib in the act of coughing,
and whilst Mr. Gilford was applying a bandage another fit
of coughing occurred and another rib on the other side gave
way with an audible snap.

Cartilaginous Tumours of the Digits in association with Epi-
physeal Exostoses, and dwarfing of one lower limb (pos-
sibly after fracture) — Enormous development of the
cartilaginous growths so as to completely disable the
hands.

The following case is an example, not only of the
unusually free growth and multiplicity of cartilaginous
tumours of the digits, but of their association with ten-
dency to outgrowth at the epiphyseal cartilages. The
dwarfing of one lower limb amounting to nine inches was
obviously caused by arrest of growth of the femur, and
although there was no known history of fracture, it seemed
very probable that some injury to the lower epiphysis had
been sustained.

The notes given below do not record anything as to the
toes, but I remember clearly that there were some small
tumours and that they appeared to be attended by much
thickening of skin.

The case may be profitably compared with that of a man
whose lower limb I amputated on account of disabling
growths many years ago, and whose case is recorded in the

300 MULTIPLE FRACTURES WITH TUMOUR GROWTHS.

Pathological Society's Transactions. In him, also, one
lower limb only was severely affected.

The Clinical Museum contains portraits of both these
cases, and of several others in which there was remarkable
multiplicity of cartilaginous growths.

Mary Jane N , then aged 19, was in the first instance

sent to me by Dr. Elder, of Nottingham. Ten years later
I was taken to see her, when an inmate of the Nottingham
Infirmary, by Mr. Thomas Wright. The foUovdng notes
describe her condition when I first saw her :

" Her fingers are occupied by large, smooth, knobby outgrowths, looking
at first sight like chalk-stones. The largest, on the left thumb, has dis-
tended the skin until it looks tense and shiny like a scar, and in one
spot, apparently from mere tension, the skin has ulcerated. This mass
is as large as a hen's egg, and occupies the back of the thumb, leaving
its palmar surface quite free. As a rule the terminal phalanges escape.

" There is a very remarkable deformity of the left lower extremity. The
femur is much shortened, and there is an obtuse curve in its lowest fourth ;
with convexity outwards as if it had been broken. The knee is so much
displaced outwards that the patella has left the inner condyle. I think
it most probable that there has really been a fracture, or displacement of
epiphysis, in infancy.

** There is a marked family tendency to chilblains, and some of her
brothers and sisters^ suffer severely, but she has not done so in any
extreme degree.

" She looks well. No family history of similar conditions or of tendency
to gout. Her right leg was supposed to ail nothing, and is quite straight.
I found, however, just above the ankle on both tibia and fibula, little
bony outgrowths, quite definite and very hard. Also some neaor the
knee, very small. The symmetrical arrangement is very definite, but
the size of the growths on the two sides is very different. Although
both hands are extensively affected and alike so, yet the size of the
growths on corresponding fingers differs much. Most of the gro^rths
occur near to epiphysis, but some in the middle of phalanges. Right
limb from anterior superior spine of ilium to inner maleolus measures 33^
inches, left 24 inches.

*' In the hands it is to be remarked that whilst aU the phalanges are
occupied by tumours, all the metacarpal bones are free, as also all those
of the carpus. There is some little exception to this statement as to the
distal ends of some metacarpal bones which show ridges, but none have
tumours in them. The hand on each side is pushed over by overgrowth
of the ulna or arrest of that of the radius."

CASE ILLUSTEATING THE NEUEO-CATAEEHAL
NATUEE OF EEYTHEMA MULTIFOEME.

The appended brief Schedule gives the particulars of an
instructive example of erythema multiforme. The patient
was a young lady, aged 26, when in 1895 she first came
under my observation. It was her fifth attack, and was so
well characterised that I asked her to attend at one of my
Demonstrations, which she kindly consented to do. I have
recently seen her in another attack, and during the present
year, 1898, she has had no fewer than three. Previous to
these she had had an interval of two years without any. In
1895 I had prescribed arsenic in the hope of preventing the
attacks, but she took it only for a few months. We cannot
attribute her immunity during the two years to that treat-
ment, for, as the schedule will show, she had had periods of
freedom quite as long previously.

7EAB.

▲GE.
19

1888

1889

20

1890

21

1891

22

1892

28

1898

24

1894

25

1895

26

1896

27

1897

28

1898

29

DETAILS.

Her first attack. Saw her doctor. It was only unsightly.

No attack.

No attack.

A second attack.

No attack.

No attack.

Spring and autumn attacks.

April 6, Erythema multiforme. Arsenic given.

No attack.

No attack.

March 1, attack. May 2, attack. Jime 21, another.

It would appear that the attacks had rather increased in
severity than otherwise. Her first affected the hands only,
and although it was bad enough to induce her to consult her
doctor, it did not cause her much trouble. On subsequent

302 NEURO-CATABRHAL NATURE OF ERYTHEMA MULTIFORME.

•

occasions the face as well as the hands had been affected,
and during the last attack, when she came to me, there were
vesications not only on the hands and face, but on the tips
of the elbows and on the chest. On the elbows precisely the
psoriasis positions were affected, a fact which it is important
to note. On all occasions the eruption had disappeared
spontaneously after a very short duration. The earlier
attacks usually occurred in the spring. In 1894 she had an
autumn attack also, and in 1898 one in spring and two in
summer. The summer of 1898, it is to be noted, was cold
and wet, the weather being throughout much like that of
spring.

I have taken much interest in endeavouring to associate
these eruptions with the ordinary causes of catarrhal out-
breaks, and with influences brought to bear through the
nervous system.

In reference to these theories Miss P gave me some

items of evidence. She said that in girlhood she had always
been liable to "heat-spots" on the lips (herpes labiahs). She
thought that she was liable to catch cold, but said that her
colds did not cause running at the nose, &c., as in other
people. " When I get a cold I nev^r show it, but only feel
chilly and starved, and have a cold feeling down the middle
of the back.'' Now the association of herpes labialis with
rigors is well known, and the symptoms described by Miss

P are precisely those which would be likely to precede

an eruption of neurotic causation.

TWO CASES OF AN UN-DIAGNOSED DISEASE OF

THE SKIN OF THE FACE.

Case I.

Miss B , set. 20. In August, 1896, " a little pimple "

was noticed on the middle of lower eyelid. Nothing was
done to it, and after two or three weeks "the lids swelled
so that I could not open them.'* This subsided and left
the present condition.

There is now (December, 1896) a long, oval, elevated
patch running lengthwise of the lower eyelid and without
the slightest inflanmiation around it. Almost from the
first there has oozed from the surface from different points
a considerable quantity of clear watery fluid. The patch
shows some little yellowish granular dots. (Portrait pre-
served.) It is a quarter of an inch in elevation, and might
be taken for keloid, but is not so glossy and not so hard.
It is firm rather than hard, and a dull plum colour. There
are no enlarged glands nor any other form of eruption.

Her father is not in good health, but not consumptive.
The girl herself has been very hysterical and weak, but not
otherwise ill.

This patient attended on three occasions at my Demon-
strations, and her case excited great interest. At first
iodide of potassium was given, but subsequently steel.
The patch gradually and very slowly softened away, and
in March, 1897, although still visible as a discoloration, it
had no appreciable thickness. A few months later there
was nothing but a thin whitish scar.

30i UNDIAGNOSED DISEASE OF THE SKIN OF THE FACE.

Case II.

The following is an example of an induration almost
exactly like that above described, but less raised, and in
precisely the same position, the right lower eyelid : —

Mrs. S , set. 75. She first noticed a little spot on the

lower eyelid. It has not been painful, but has increased.
It was at first *' under the skin and quite loose." At present
there is an induration which involves the skin, and is
smooth and glossy on its surface. It is conspicuous as a
smooth, brownish-red patch, but is but little elevated. It
is about as big as a filbert flattened out, and is very hard. It
is a long oval in shape. She once had a violent fall and
bruised her cheek, but that is six years ago. There is
no history of tumours in her family, but much rheumatism
and gout.

When this patient consulted me her patch had been
present about two months. It was extending, and she
had been strongly urged to have it immediately excised,
and had been told that it was probably malignant. Ee-
membering the previous case I felt justified in advising
delay, and prescribed only the iodide of lead and a tonic.
A month later it was much less hard, and in the course of
three months it had disappeared. Just, however, as it was
disappearing, another similar one began to form in the skin
of the forehead, a little above the eyebrow (on the same
side). My patient lived at a great distance in the country,
and I had no opportunity for watching the course of the
second patch. She wrote me some months later that it
also, under the use of the same ointment, had disappeared.

Comments on the two Cases,

The two cases which are briefly recorded in the above
notes were, as far as external appearances go, very closely
alike. In each case the patch was on the lower eyelid, and
of a long oval form. In each it was raised above the level
of the skin, in one very considerably so, and in both abruptly
circumscribed. The patient in one case was a girl of 18,
and in the other an old lady of nearly 70. In the girl the

COMMENTS ON THE CASES. 305

patch disappeared slowly in the course of five or six months,
leaving behind it a very thin but quite definite whitish scar.
This patient was seen repeatedly by many observers, and
very carefully examined. She attended not only on several
occasions at my Demonstrations, but also once at a meeting
of the Dermatological Society of London. No nominal
diagnosis was ventured by any one. The girl was somewhat
out of health at the time, being anaemic and hysterical.
The disappearance of the patch occurred under no more
vigorous local treatment than keeping it covered with iodide
of lead ointment. Under a long course of tincture of iron
the general health was much improved.

In the older patient the process of involution was much
more rapid, and in the course of two months from its
commencement the patch had disappeared. Just as it was
disappearing, however, another similar but smaller one
showed itself above the eyebrow, on the same side. It also,
after a few weeks' duration, underwent spontaneous absorp-
tion. I have not seen my patient since the cure, but in
reply to a recent letter of inquiry she assures me that both
patches have quite disappeared, and have left little or no
trace. As indicating the threatening aspect assumed by

the disease in its early stage, I may mention that Mrs. T

came to me in consequence of having had an immediate
excision urgently advised to her under the diagnosis of
sarcoma. I will not venture on any diagnosis of the disease,
whether nominal or essential. In each instance I was at
first disposed to regard the malady ai probably lupoid, that
is of tubercular nature. The conditions were, however,
not at all closely similar to any recognised form of lupus,
and the almost spontaneous disappearance in each case was
more rapid than is ever seen in lupus. It was also much
more complete, for in neither instance is there any trace of
the original growth remaining. I cannot speak with cer-
tainty as to the elder patient, but in the younger one the
skin affected has been disorganised, and a scar has resulted.
In this the process has resembled that of lupus. In the
older patient there is no reason to suspect tuberculosis, for
she is in excellent health.

VOL. IX. 20

306 UNDIAGNOSED DISEASE OF THE SKIN OF THE FACE.

In the yonnger one, although there is no very definite
evidence of it, the state of health by no means precludes
suspicion.

These two cases are not, as regards the local appear-
ances, unlike those of which I shall treat in the following
paper. In the absence of multiplicity, however, and in
the tendency to spontaneous cure they differ widely. I
may add that in each instance I proposed excision of a part
for microscopic examination, but by both patients this
method of diagnosis was declined.

PLATE CLII.

MOBTIMEB'8 MALADY.

The upper of the two figures ehowe the condition of Mrs.
Morlimer'B face four years ago. At that time the disease had
existed only one year. It subsequently increased considerably, but
during the last two years baa been almost stationary. Six months
after the portrait was taken the bridge of the nose was involved in
a large suboutaneous soft swelling, which subsequently underwent
spontaneous involution and disappeared. The lobules of both ears
also became involved, and presented a fleshy thiokening, each as is
seen in the next Plate.

The lower figure shows the back of the right upper arm of the
same patient. On this part also the patches subsequently attained
a larger size ; hut still later, some of them have disappeared. Both
on the face and upper arms the patches ooourred with almost exact
symmetry. The patient is still living, and in fairly good health.

i CLIF4ICAL tLLUSTRATIONS.

• • • -

• • ••

.^'^

CASES OF MOETIMEE'S MALADY

{Lupus Vulgaris Multiplex non-ulcerans et non-serpiginosus),

I HAVE to describe a form of skin disease which has, I
beUeve, hitherto escaped special recognition. It may not
improbably be a tuberculous affection and one of the Lupus
family, but if so it differs widely from all other forms of
lupus, both in its features and its course.

Of the four cases which I am about to relate, the first two
are by far the most definite examples of the malady in
question. The other two, as well as the two which have
formed the subject of the preceding paper, are of much
interest as probably presenting aUied conditions, but I by
no means wish to claim them as identical.

The disease is characterised by the formation of multiple,
raised, dusky-red patches which have no tendency to inflame
or ulcerate. They are very persistent, and extend but slowly.
They occur in groups, and are usually on both sides and
almost symmetrical. The multiplicity of the patches, their
occurrence in groups, their bilateral symmetry, and the
absence of all tendency to ulcerate or form crusts, are
features which separate the malady from lupus vulgaris. To
none of the other forms of lupus has the malady any
resemblance.

The malady might perhaps be named Lupus Vulgaris
Multiplex non-ulcer anSy but for the present I prefer to
recognise it, by the name of one of its subjects, as Mortimer's
Malady.

Case I. — The first and as yet the most marked example
of the disease which has come under my observation is that
of a very respectable elderly woman named Mortimer. The
condition of her face and of one arm are shown in Plate
CLII. The portraits from which this plate was executed
were taken by Mr. Burgess in August, 1894. Ajfc that cUkte

'dm CASES OF HOBTDfEB S MALADY.

she was sixty-five years of age, and her sldii disease had
been present about a year. The latter consisted of a niunber
of quite separate patches arranged in groups on her cheeks
and on the backs of her upper arms. The arrangement was
accurately symmetrical, but the patches ^rere larger and
somewhat more abundant on the left cheek and right arm than
on the opposite parts. The patches were considerably raised
and abruptly defined, on skin otherwise healthy. They were
of dusky-red colour and rather soft structure. Although
nowhere ulcerated, and quite unattended by pustules, some
of them showed a sUgbt formation of exfoliative scale-crust.
(The portrait gives a much more definite impression of this
than was reaJly the case.) None showed any approach to
the apple-jeUy condition, nor was there any definite scarring,
though some of the patches were depressed in their centres
as if in process of cicatrisation. Six months after this por-
trait was taken the patches had increased in number and in
size. The lobuie of the right ear had become involved, and
presented almost precisely the condition often seen in this
part in cases of common lupus. Her nose, however, pre-
sented a very peculiar condition. It was much swollen
across the bridge, but without any implication of the skin,
presenting a thick, soft tumour. At this stage the patient,
who had often attended at my Demonstrations, was presented
at one of the meetings of the Dermatological Society of
London. The general opinion was, I believe, that the
disease was sarcoma, and it was strongly urged that portions
should be removed for microscopic examination. This I
subsequently suggested to my patient, and with the result
that I did not see her again for two years.

The above notes present a summary of the CEise, but have
been written out from memory recently. The two foUowing
are trans

Mrs. J
ago, cam
has 8om£
the least
the uppf
scarcel'"

MES. MORTIMBB'S CASE. QOQ

appeared interspersed with the principal group. The
tendency to symmetry has also been shown on the face, by
the appearance of another patch in the middle of the right
cheek. It is, however, much smaller than that on the left
cheek. The several groups on the left cheek have advanced
and coalesced so as almost to cover the whole of it, and the
patches on the left eyebrow have very much increased
in size and coalesced. The upper part of the external ear
on the left side is involved in general thickening with some
deep-seated indurations. There are, however, no tubercles
or other form of eruption on its surface. The other ear is
quite pale and not in the least inflamed. A soft swelling has
formed over the bridge of her nose. It adheres to the skin,
but implicates chiefly the subcutaneous cellular tissue.
There are some little sores just within the nostrils. The
characters of the tubercles are everywhere the same as
before. They consist of rather firm papules, which by
coalescing into patches form tubercles, some of which are
quite flat-topped and others nodular. The thickest are
about a quarter of an inch in thickness. They are of a dull
red colour and scarcely desquamate at all. They have not
the semi-transparent quaUty of apple-jelly. On the back of
the right arm there are thirteen or fourteen separate patches,
and on the back of the left nearly as many, but smaller ones.
All the spots are much smoother looking and more tuberous,
i.e., more elevated than they appear in the drawing. A very
remarkable feature in the disease, supposing it to be a form
of Lupus vulgaris, is its tendency to symmetry. There is no
history of tubercle in the patient's family, but her mother
died of cancer.

July 3, 1895. — She reports herself in fair health, but
looks thin. The patches in the middle of left cheek have
now coalesced, but still remain nodular and to a certain
extent distinct. Those on the sides of cheek, near to the ear,
are still quite distinct. On the right cheek the middle is
quite free, and so is the part in front of the ear. Nor has
the ear on this side ever suffered. Many of the nodules are
distinctly withering ; especially that in the lobule of the left
is much smaller and paler than it was, and so also are

L

310 CASES OF mobtiheb's malady.

those in her eyebrow. No new spots have developed lately.
The disease seems to have reached its height six months
ago. She herself feels very certain ''that it is going." The
evidence is also very definite on the backs of the arms, wliere
many of the nodules have shrivelled and left only thin
scars. [In 1897 the conditions were much the same.]

Case II. — The subject of my second case was a man aged
about forty-five, apparently in good health. His eruption
had been present several years, and he had of late paid but
little attention to it. It did not disable him from his occu-
pation, and he regarded it as an incurable disfigurement, but
nothing more. He was willing to beheve that he had many
years ago had syphiUs, but this was not certain, and unless
the eruption was of that nature he had had no reminders.
He was married, and had children who showed no signs of
taint. His own eruption was not in the least benefited by
specific treatment.

The eruption in this case is fairly well shown in Plate
GLIII. His face was covered with patches just hke those
of Mrs. Mortimer, but more numerous and of smaller size.
They showed no tendency to coalesce, and none whatever
to ulcerate or form pustules. Many of them were disc-like,
and had sUghtly depressed centres, but none had left definite
scars. The lobules of his ears were swollen and dusky, as in
lupus vulgaris, but in addition there were ill-defined patches
on the helix and anti-helix. A very important feature which
I think definitely connects this case with lupus has yet to
be mentioned. • On both his legs were very many large areas
of scar, at the borders of which the skin presented the con-
ditions seen in lupus exfoliativus. Here again there was
not and never had been any obvious ulceration. There were
no pus crusts, but yet it was clear that a serpiginous disor-
ganising inflammation was present, which left a scar behind
it. This condition involved the greater part of both legs,
and extended somewhat upon the thigh.

Under three years of observation, with more or less of
treatment, this patient's condition has changed but little.
At first I gave mercury and iodides, thinking that it might
be in part syphilitic, but subsequently tonics with very

J 1

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CASE OF LUPUS VULGARIS MULTIPLEX. 311

small doses of mercury were relied on. The local disease on
tlie whole improved. It will be seen that it was too ex-
tensive and of too Uttle importance to justify severe local
treatment. Various ointments were of course employed.

Whilst the man was under observation, one of his sons
suffered from diplopia and pain in the head, and the
diagnosis of meningeal tubercle was suggested. The symp-
toms, however, passed oflf. The boy did not present any
indications of inherited syphilis.

Case III. — A case of Luptcs Vulgaris Multiplex, with

very peculiar features,

m

L. M consulted me on July 8th for very unusual

conditions. Just below and to the right side of her right
nostril were two detached and quite isolated patches. The
upper one of the two consisted of a streak an inch long
and a quarter of an inch wide. It had an elevation of
a quarter inch, was quite smooth, but not so firm nor
so glossy as keloid. It had rather the brownish semi-
transparent appearance of lupus apple -jelly. Near to
this, on the upper lip, was a patch made up by the
coalescence of two small beehive-like papules of exactly the
same structure as that just described. If these patches had
been all, I should have diagnosed lupus vulgaris, though
fully recognising unusual features. Some spots in the palm
of the left hand, however, made the diagnosis much more
perplexing. Here was a little group of four smooth,
brownish tubercles, each the size of a small pea and quite
devoid of inflammation. They were like those on the upper
lip, but smaller and tending to be pointed rather than bee-
hive-shaped. The skin around them was pale and quite
free from congestion. The patient told me that if she
pressed suddenly on these spots a sensation of pins and
needles was j)roduced. My touching them, even firmly, did
not elicit this sensation, bat I was told that the sudden
grasping of a door handle would be sure to cause it and to
give '' quite an eleetiie tbodc/'

L. M 's (Tfm miirirt €t ber spots was that those on

312 CASES OF MORTIMER'S MALADY.

the face had made their appearance about three months ago,
when she was recovering from a confinement, and had
gradually progressed. They were, she thought, on the site
of scars which had resulted from scratches received in a fall
in childhood. These scars could hardly be demonstrated.

L. M was tall and of fair complexion. She had a

feeble circulation, and had suffered mucTi from chilblains on
her feet. She had, however, never had chilblains on her
ears or face. There was much gout in her family, and she
herself had been liable to pains in her joints which had
been considered gouty. There was not the slightest reason
to suspect syphilis. She had one child — a fine, healthy boy
six months old.

The patches in the palm of the hand reminded me of the
nodules on the ears, &c. ("gelatinous tophi") sometimes met
with in gout. I believe that it is a feature of certain forms
of gouty inflammation that a sensation of pins and needles
is elicited by sudden pressure.

August lOth, — It is a month since L. M 's first visit.

I have now little doubt that her spots are lupus vulgaris, but
the conditions are very peculiar. I am told that a brother
is in consumption, and that a sister has also spat blood.

L. M herself, as well as her sister who comes with her,

looks very delicate. They are both tall, thin, and of very
transparent skin.

L. M *s first patches were those on her face, and one

of these certainly developed in an old scar. The two spots

are much raised, semi-transparent, like those of Mrs. G

and the girl B — -—, They are red and semi-transparent, like
currant-jelly. To-day, however, L. M — '— shows me others,
one near one knee which she has observed only a few days.
It is a flat, lupus-like patch as big as a shilling, not raised
and not ulcerated. The third group is in the palm of one
hand, just below the wrist. It consists of four or five
nodules which join each other in two lines. They look
semi-transparent. A point as regards the patches on the face
is that the surrounding skin is not in the least infiltrated ;
the growths stand up abruptly on perfectly sound skin.

CASE OF DOUBTFUL DIAGNOSIS. 313

Case IV. — A case in which the diagnosis between Lupus
Vulgaris Multiplex and Lichen Planus is in question,

I append the notes of the following case with some
hesitation, not feeling sure that it belongs to the series
under consideration. By one distinguished dermatologist,
who had seen the patient before I did, it had been diagnosed
as Lichen planus. Eeasons for dissenting from this opinion
will be found in the notes, and, taking all the facts into
consideration, I am inclined to think that the sequel will
show that it belongs to the present group. It will be seen
that the eruption had been present about eighteen moliths
when the patient came under my observation. I transcribe
the notes as taken at the time of my consultation.

Mr. H , aged 82. He says that he has always been delicate,

suffering chiefly in his bowels. Never suspected of phthisis. No known
tuberculosis. In childhood he was not expected to live. He had pro-
bably a pericsecal abscess (set. 20). He is very tall and thin.

His first spot occurred in January, 1897. It was on his right thigh
behind the trochanter. He was in Australia^ and suffering at the time
from ** catarrh of the bowels." Other spots followed within a few weeks
on the same thigh, and soon afterwards some appeared on the other
thigh. Next a few, only two or three, showed themselves on the front
of the chest. Of these last he soon got rid, and only the very faintest
scars have been left. He has none lower than the knees. He once had
one on the front of right elbow, but it was cured, and has left no trace.
On the right thigh is a large group of very conspicuous patches. Some
of them are more or less ringed, but most of them show no subsidence
in their centres. Some seem to be leaving small scars. They are elevated
patches varying in size from a pea to a shilling, and irregular in form.
Their close juxtaposition in groups might seem to indicate local con-
tagion, but there is a very definite tendency to symmetry. He has had
none whatever on the forearms or legs. One occurs over the sacrum.

He took arsenic at one time until if disagreed, and he was obliged to
leave it off. It did no special good. He has indeed had no advantage
from any treatment, but a few of the patches have disappeared, appa-
rently spontaneously. The patches do not ulcerate or inflame. They
are of a dusky plum colour, and with here and there a sUght scale crust.
Some are rather rough, and all are firm to the touch. In their early
stages they itch much, and he scratches them, but the skin shows no
evidence of injury from this, bemg perfectly smooth and quite pale
between the spots. The case is certainly not one of psoriasis. The
patches are constituted by infiltrated skin, which is raised above the

314 CASES OF MOBTIMEB*S MALADY.

level of what Burrounds it, and they are not sunnounted by scale crust,
nor are they in the psoriasis positions.

It is not like lichen planus in several features, although some of the
individual patches might be supposed to much resemble the rough
papillary form of this disease. None of the patches at any stage show
the least tendency to polish. The patches are distinctly grouped, being
closely set on the right thigh, but there are none whatever on the wrists
or ankles. They developed rapidly, and have remained in bUUu qtio tot
more than a year.

In some respects the case closely resembles lupus vulgaris multiplex.
The grouping of the spots, their persistency, their multiphdty, and their
somewhat irregular approach to symmetry might easily fit with this
diagnosis. None of them, however, show any characteristic apple-jelly,
nor do they spread at their edges so fast as is usual in lupus ; nor are the
scars which are left so deep as those usual in lupus.

The subject of the above narrative came to me again on
September 20, 1898. We both of us thought that most of
his patches were receding, but the change was not very
marked. They were all less elevated than they had been.
Many showed a central depression of pale skin or scar.
Superficial slightly marked scars were certainly left v^here
patches had disappeared. No new patches had appeared,
and they were still restricted to his thighs, with a single one
over the sacrum.

Comment on the Series.

I feel the less scruple in thus placing in juxtaposition
cases which are possibly not identical in nature, because
I hold it to be important not to attempt to constitute species
in nosology. The truth is probably that the various
pathogenetic influences are capable of the most various
combinations, and that we have on all sides connecting-
Unks between maladies which have gained distinctive names.
We do not, for instance, know enough as to the causes of
what we call lichen planus to be sure that it may not have
a lupoid form when occurring in a tuberculous patient.
Patient investigation and great care in the observation of
phenomena are needed before we can hope to arrive at truth
on these matters. I have therefore thought it well at the
present time to place these cases on record, hoping that the
future may furnish materials for their better elucidation.

ON EEUPTIONS WHICH OCCUE IN CONNECTION

WITH GOUT.

I HAVE figured in "Illustrations of Clinical Surgery" the
hands of a man in whom abruptly margined patches of a
blue-black tint formed, in the first instance, on his hands.
During subsequent years the eruption became general, but did
not interfere with his ordinary health. He had suffered from
gout, and he finally died of contracted kidney. I wad inclined
to consider the skin-disease as essentially connected with
gout, although it undoubtedly displayed infective qualities.
Beference was md.de to a drawing shown me in Christiania,
exhibiting precisely the same condition of things on the
hands of a Swedish sailor. Since then I have published
several other cases bearing upon the subject, but none of
them so definitely characterised. I have also endeavoured
to trace a connection with another group of cases, of which
Dr. Judson Bury*s well-known case is a type, in which
somewhat similar conditions are met with on the hands of
those who inherit gout tendencies, and chiefly in early life.
The blue patches now under consideration occur chiefly to
adults who are themselves gouty. The conditions appear
to be halfway between chronic inflaiomation and new
growth. By some they have been claimed as sarcoma, and
I have but little hesitation in identifying Hebra's portrait of
** Sarcoma Melanodes** on the two hands of a brewer as being
of the same nature. The disease, however, does not run the
clinical course of a malignant sarcoma. It usually begins
symmetrically on the two hands. It is very slow in pro-
gress, does not affect the he^alth, nor does it tend to ulcerate
or to implicate lymphatics or viscera.
I make these remarks as introductory to the narrative of

316 ERUPTIONS IN CONNECTION WITH GOUT.

a case in which I have been fortunate enough to obtain a
microscopic examination, and to some others which have
recently come under my observation, more or less cognate.

Purple-tinted patch on the Shin in connection with Gout —

Excision and Histological Beport.

A man, aged 43, was sent to me in January, 1897, by Dr.
Baber, of Brighton, with one of these patches behind his
right ear. It was of irregular shape, and about as large as
a small almond, slightly granular on its surface, but pre-
serving a uniform level. It was raised about the twelfth of
an inch, and had a very abrupt border. It had given him
no trouble, and had been present about four months. He
had none elsewhere. He was a rather stout man, of bloated
aspect, and clearly a free liver. He said that his grand-
father and great-grandfather, both of whom had lived freely,
were reputed to have suffered much from gout, and that
his father, who lived carefully, also suffered frequent attacks,
though not often disabled. An aunt was at the present
time crippled with rheumatic gout. Asked as to his ovm
habits, he replied, ** I have been obliged to give up beer,
because it always goes to my toe. Curiously I can drink
a little stout without its affecting my feet, but as soon as I
try beer, which you would think was lighter, my toes
become painful, and I am obliged to leave it off."

My diagnosis in this case before I knew the history was
the pseudo-sarcoma of gout. The patch was in all respects
exactly like those shown in the illustration to which I have
referred. The tint was not the coal-black of melanotic
sarcoma, but had a peculiar bluish tint. Nor did the patch
tend to thicken in its middle as sarcoma does, but rather to
spread at its borders, producing a flat area. The man
attended at one of my Demonstrations, when special atten-
tion was asked to these features and portraits of my other
cases were produced for comparison. Eecognising the fact
that in former cases the patches had appeared to possess
some power of infection, I advised a free excision. This
was done by Dr. Baber, who was good enough to send me

SAECOMA MELANODES. 317

the portion of skin removed. This latter I forwarded at
once to the Clinical Eesearch Association, and in due course
received a mounted section and Eeport which I append.

'* The specimen consists of a portion of skin a little over half an inch in
diameter, and circular in shape. It shows faint bloish-black pigmenta-
tion to the naked eye.

" On microscopic examination, the upper layers of the cutis are found
to be irregularly infiltrated with collections of newly formed round and
oval cells. The infiltration is found to be greatest in the papillary layer
of the skin ;^in certain cases individual papillae show the presence of the
infiltration, while the immediately underlying cutis is nearly free. In
consequence the papillae are, as a rule, swollen and flattened, while the
interpapillary processes of the epithelium show corresponding elongation.*
The cells composing the infiltration are roimd or oval in shape, and
present the characters of the cells forming a new growth, rather than
those of a granuloma due to the action of specific micro-organisms, or
mechanical irritation.

^^ Presence of Pigment — Scattered throughout the new cell-infiltration
are seen cells considerably larger than their neighbours, and frequently
presenting well-formed processes. The protoplasm of these cells is full
of the characteristic dark brown granules of melanin. These pigment-
containing cells are found in greatest numbers at the apices of the
papillae. In this situation these cells are not only more numerous, but
larger than the similar cells scattered sparsely throughout the infiltra-
ting cells. A few small pigment-containing cells are also seen at the
periphery of infiltrated areas. The large pigment-containing cells at the
apices of the papillae do not occur in the layer of cells immediately
underlying the rete malpighii, but lie several layers deeper than the
basement membrane, well within the limits of the cutis vera.

** Diagnosis. — The specimen therefore presents the aspect of a con-
genitally pigmented patch of skin, and gives evidences of recent growth
of new cells of connective tissue origin, some of them containing
pigment, while the majority do not. In other words the specimen
seems to be a pigmented mole (naevus) imdergoing early sarcomatous
changes.**

As regards the suggestion in the last part of this report
that the growth was in a congenital mole, I do not think
that it can be upheld. The man knew of no mole, and
assured us that the patch had been present only a few
months. Nor had it, to the naked eye, any appearances
suggestive of a mole. It was quite uniform in its surface
and showed no disposition to ulcerate. I may add that

318 EBUPTIONS IN CONNECTION WITH GOUT.

before the above report was sent to me, Dr. Galloway, into
whose hands the specimen had in the first instance been
placed, had very kindly written me an informal report,
thinking that it might be of importance in the further treat-
ment of the case, assuring me that the growth presented
the characters of an infective sarcoma. We may therefore
take it as established that the appearances presented to the
microscope were not distinguishable from those of melanotic
sarcoma. How far these appearances could be trusted in
the direction of clinical diagnosis is another matter and more
open to question. So far as I at present know, the man has
remained during the two years which have elapsed withont
return.

Note on the effect of Brine Baths on the Urine — Purple-
tinted spots on the backs of hands in connection with
Gout.

Colonel S , the subject of rheumatic gout, has recently,

on my advice, visited Droit wich. His experience has been
that whilst taking a twenty minutes brine bath every day,
his urine was loaded with urates all the time. It is usually
quite clear. He is a very temperate man, but inherits gout.

He has now, November 23, 1897, a very peculiar eruption
of purple spots on the backs of both hands. Small discs,
some polished ; some confluent and rather rough.

I leave the above brief note just as it was written at the

time. Nine months later Colonel S called on me again,

this time to report the effect of mud baths which he had
recently been trying. I was much interested in inquiring
as to the condition of his hands. They were quite well.
The spots had disappeared within a few months of my
seeing him. As there had been no development of eruption
elsewhere, I am not inclined to consider them as lichen
planus, and having regard to their purple tint and peculiar
features, am disposed to associate them with the patient's
gout-history. I may add respecting the case that Colonel
S *s chief ailment consists in disorganisation by rheu-

A CASE-NABRATIVE. 319

matic gout of the right knee, with great thickening of the
synovial membrane. He has been under my observation
for this for more than ten years. He is in other respects in
excellent health, florid, and moderately stout. His age is
fifty-six. If we accept the diagnosis of gout as regards his
eruption, the case proves that these purple-tinted papules
axe not always persistent or aggressive.

Inheritance of Gout — Liability in a young lady to a scar-
leaving Eruption on backs of hands, neckf and trunk —
Non-crystalline Tophi on the ears — Lymph-adenoma.

»

The following case is of much interest in reference to the
connection of certain diseases of the skin with inheritance
of gout. Imprimis let me say that both the mother and
maternal grandmother of my patient had suffered from bond
fide gout, having both of them had attacks in the great toe.
Next, the patient herself, a lady of only thirty, had in both
ears, exactly in the position where chalk-stones * are so often
seen, little indolent irritable swellings just like tophi, except-
ing that they could not be proved to contain any concretions.

Miss K — — was a tall, thin lady of feeble circulation and
liable to cold extremities, but who had never suffered much
from chilblains. She did not consider that season or
weather ever caused her eruption to be worse, and the date
of her consulting me was in the summer of 1898 (August 12).
In girlhood she had been considered delicate, and had
always been encouraged to take beer and wine in modera-
tion. At school, however, at the seaside, she improved and
got, as she said, plump and well. Since then, that is since
8Bt. 17, she had been thin and constantly liable to the
eruption which I have to describe. At the age of fourteen a
chain of glands enlarged in the right side of her neck, and it
had never wholly disappeared. For three or four winters
she had been taken to the Mediterranean for the winter in
order to avoid the cold of England. She had never, how-
ever, been thought to be phthisical. Of one thing she

* See paper on " Tbphi which are not Chalk-stones/' AacHiyEB, Vol. Vn.,
p. 146.

320 ERUPTIONS IN CONNECTION WITH GOUT.

expressed hdrself as quite certain, that whenever she took
steel in any form her eruption was worse. She thought
that quinine also aggravated it, but about this she was less
positive. If we add to this that at the age of fourteen she
had an attack of typhus fever and an abscess near one knee
after it, we may next proceed to describe the eruption.

Miss E 's hands, on their backs and chiefly over the

thumb, index and middle fingers, showed a pustular scar-
leaving eruption. The scars were abundant but not deep,
and they were quite sound. The little pustules began as
minute erythematous spots, which ran a very chronic
course, but finally produced a small quantity of pus in their
centres. When the pus had escaped they would dry up and
leave a white scar. The little and ring fingers were .exempt
from both spots and scars, but the others were almost
covered with them. The eruption ended at the wrist, and
there was none on the forearms. It was symmetrical on
the two hands. Many similar pustules occurred on the
neck and behind the ears, and there were some on the
trunk and especially on the sides of the abdomen. Here
white scars which had been left were far more numerous
than the spots, but the latter were conspicuous, and in some
places occurred in groups. The eruption on the trunk was
not in the least restricted to the acne-positions, though
some occurred on the shoulders. As regards the persistence
of the eruption, I was told that it never got quite well,
though it was often better and worse, and that it was not
liable to sudden outbreaks. The symmetrical distribution
on the hands and the exemption of two fingers suggested a
nerve causation, and this was in part supported by the
arrangement of the scars on the abdomen.

It may be well to speak of the lymph-adenoma complica-
tion in the above case separately, since it probably had no
connection with the eruption. The right side of the neck
had a long string of slightly enlarged glands, extending
from the angle of the jaw to the clavicle. None of these
glands were larger than small grapes, and they remained
isolated the one from the other. They had been recognised

CASE OF LYMPH-ADENOMA. 321

for fifteen years and had never shown any tendency to
inflame or to grow. Recently, however, they had shown
infective prpperties, and a cluster of much larger glands
had developed in the armpit of the same. Their conditions
were characteristically those of lymph-adenoma.

VOL. IX. 21

ON INFECTIVE DISEASES OF LYMPATHIC

GLANDS.

(Continued from page 272.)

THBEE CASES OF ACUTE LYMPHO- SARCOMATOUS
DISEASE ENDING RAPIDLY IN DEATH.

Case I.

Case XXX. — Syphilis without recognised chancre — Enlarged
gland in neck — Acute Lymphosarcoma in the second
year — Death — A utopsy .

Mr. B came under my care in the first instance on

June 22, 1896. Part of his ailment was an enlarged and
elongated gland in the right side of neck, over the carotid.
It received pulsation in a most deceptive manner, and
might have been suspected as an aneurism. He said that
he had never in his life had syphilis, and that for some
years he had never had intercourse. Before the gland
enlarged his throat had been sore. In addition to this gland
affection he was covered with a dusky erythematous (almost
urticarious) eruption which did not itch in the least. He
told me that two years ago I had prescribed for him for
headaches, of which he had been almost wholly relieved.

I was much puzzled as to whether or not the eruption
was syphilitic, and the state of his throat was also open to
doubt. It seemed possible that he might have had a
chancre of his lip. If so, however, it had healed without
special treatment. At the time that the sore was present
on his lip the glands in both sides of the neck were some-
what enlarged. The eruption was, however, more uniform
in appearance than sjrphilitic rashes usually are. It may be
added that he had pruritus ani, and that the skin around

LYMPHO-SABCOMA AFTEB SYPHILIS. 323

the anus was white and thickened by scratching. I pre-
scribed mercury.

On July 10 the eruption was less conspicuous, but still
present. He had abrasions on his tongue, and filmy sores
on tonsils. I wrote in my notes, **I think there can be no
doubt that he has syphilis." There were soma very hard
glands in both groins, and some abrasions or mucous
patches at thp anus. He had balanitis, but there was no
definite sore. In August, under the continued use of
specifics (mercury and iodides), he was " almost well.**

On Dec. 12 I wrote, ** He has long been quite free from
eruptions, but his tongue has relapsed, and is now covered
with red patches. His tonsils still show films. There is not
the slightest doubt as to syphilis.**,

More than a year later, on April 22, 1898, my note records,
" He has continued free from symptoms with the exception
of some relapses on the tongue.**

On May 10 he was quite free from symptoms of syphiUs,
but complained that for three weeks past he had had much
pain in the back. He said that this aching pain was on '
the increase, and that it was always present in the morning
on waking.

He now looked ill, and he drew my attention to some
enlarged glands in both groins. He was passing almost
sleepless nights from the pain in the back, and his tongue
was dry and furred. He looked so ill that I advised him to
go home and keep his bed. I feared, from the symmetrical
enlargement of the glands and the groin and the very severe
pain in the back, that he had some malignant growth com-
mencing in connection with the vertebrae. At my sugges-
tion he placed himself under the care of my friend, Dr. F.
M. Mackenzie, of Hans Place, near to whose house he had
lodgings.

Dr. Mackenzie wrote me on May 15 that the condition of
things was no better, that there was some elevation of tem-
perature, and much pain in the lumbar and sacra regions
and outer sides of thighs. He was now taking iodide of
potassium and salicilate of soda.

A fortnight later, as there was no improvement, the

324 ON INFECTIVE DISEASES OF LYMPHATIC GLANDS.

glands increasing in size, &c., and the patient's financial
circumstances not good, I obtained his admission under the
care of my son into the London Hospital. My diagnosis at
this time was an acute form of lymph-adenoma. It should
be noted that his mother and maternal grandmother had
both died of cancer.

I did not see Mr. B after his admission into hospital,

and I am indebted to my son for the facts which conclude
my narrative.

After admission the pain in the back continued to be very
severe, and there was increasing general weakness. The
axillary, cervical, inguinal, and popliteal glands were all
enlarged, some of them attaining the size of hen's eggs.
Neither liver or spleen could be made out to be enlarged,
though the former was tender on pressure. The tonsils
were both enlarged, and sloughy in their centres. About
June 6th a hard lump was noticed, the size of a walnut,
attached to the right fifth rib in the mid-axillary line.
Another firm swelling (evidently lympho-sarcomatous) sub-
sequently formed over the second rib close to the sternum.
Later on this invaded the sternum itself. Progressive weak-
ness and loss of appetite, emaciation, sometimes delirium
and coma, with almost constant elevation of temperature
(100® to 101°) were the chief symptoms before death. He
was given liquor arsenicalis in steadily increasing doses up
to one drachm daily, with, as a rule, iodide of potassium.
These drugs had a marked effect in checking the growth of
the glands, which for a time actually diminished. The
arsenic brought out an attack of herpes zoster, and caused
some general pigmentation. The blood was very carefully
examined by Dr. Bullock with quite negative results as
regards the presence of micro-organisms. The white cor-
puscles were relatively increased, but not excessively so.
The urine was always normal. The condition of the throat
was a curious one ; it and the tongue were always dry and
the tonsils greatly swollen, though the latter diminished
somewhat after some sloughs had come away from them.
Death occurred on July 24th from exhaustion.

Post-mortem examination (by Dr. Schorstein) : — Heart

LYMPHO-SABCOMA AFTER SYPHILIS. 326

and lungs normal. Spleen large and soft, weighed 9J
ozs., otherwise normal. Liver weighed 6 J lbs. ; scattered
throughout its substance were numerous round white secon-
dfifcry deposits. Kidneys also contained many secondary
deposits, the largest ones measuring about an inch in
diameter. Lymphatic glands : The abdominal, inguinal,
mediastinal, axillary, and cervical glands were greatly
enlarged, soft, greyish in colour, but with no caseation. In
the anterior mediastinum they were matted together to form
a mass at least five inches in diameter. This invaded the
pericardium. The aorta was completely surrounded by
growth, which everywhere had the character of lympho-
sarcoma.

Although in this case, in the first instance — owing to the
patient's positive statement that he had not had intercourse
for two years, and the corroborative absence of traces of a
primary sore — ^I felt some doubt as to whether his symptoms
were really those of syphilis, yet in the end it quite vanished.
I have little hesitation in believing that the primary sore
was on his lip or in his mouth, and that the enlarged gland
in the neck was due to it. Thus, then, we appear to have
a case in which the adenitis of sjrphilis, in spite of specific
treatment, passed on into lympho-sarcoma.

In the case which is to follow, the main facts are
similar, but the patient did not live long enough for such
extensive implication of the lymphatic system. In him the
syphilis was more remote, it having appeared to be quite
cured three years before the gland disease showed itself.
The latter, as far as could be ascertained, began as a primary
affection of the axillary glknds. The patient was, at the
time that this was discovered, apparently in robust health.
I by no means wish to suggest that in either case the pre-
ceding syphilis was an important factor. It is, however,
well known that in the secondary stage of syphilis the
lymphatic glands are often somewhat enlarged for a time,
and my supposition is that lymph-adenomatous processes
usually originate in glands which have at some former
period been inflamed.

326 ON INFECTIVE DISEASES OF LYMPHATIC GLANDS.

Case II.

Case XXXI. — Primary enlargement of Glands in both Arm-
pits in a healthy man who had had Syphilis — Rapid
progress, with acute heal inflammation and high
temperatures — Death — Autopsy,

C R 's case was in its early stage of interest as

apparently an example of inflammatory enlargement of
axillary glands without obvious exciting cause. I had
treated him, some years before for syphilis, but he had
since enjoyed robust health, and there did not seem any
ground for the supposition that syphilis had anything to do
with his gland disease. He was a big, strong man, and
considered himself in excellent health at the time that the
gland enlargement began. He had been dancing in a dress-
coat which was rather tight, and on undressing to go to bed
found that there was a lump in his left armpit. There was
no material pain, and he had at the time no sore on his hand
or elsewhere. This was about three months before I saw
him, and during the greater part of the interval he had,

under the advice of his family surgeon. Dr. A. T , of

B , who knew of his sjrphilis, been taking iodides and

mercury. So far from these remedies having reduced the
glands, the latter had steadily gained in size, and one had
also appeared in the other armpit.

When C R was brought to me by his surgeon on

March 3, 1898, he had in the left armpit a mass of adherent
glands which filled it, but of which the separate glands,
though matted together, could be identified. There was no
evidence of suppuration, and no redness of the skin. His
chief discomfort was caused by. the desire to rest the elbow
on something at a distance from the side so as to avoid
pressure. At a hand's-breadth below the armpit there was
an area of inflamed subcutaneous tissue and reddened skin
where suppuration seemed threatened. This had been pre-
sent only two or three weeks. In the other armpit there
was a single enlarged gland as big as a walnut, and quite
movable. There were no enlarged glands on the neck or

LYMPHO-SARCOMA AFTER SYPHILIS. 327

elsewhere, and I sought in vain for any source of irritation
on his trunk and limbs.

There was no definite history of tuberculosis or of malig-
nant growths in the family. At the time of this consulta-
tion I expressed a fear that the disease might prove acute
lymph-adenoma, or possibly sarcoma. Large doses of
arsenic were prescribed, and at the same time it was agreed
to continue the mercury. I could find no reason to connect
the disease with the previous syphilis. The inflammation
of the cellular tissue on the side of the chest was such that
I confidently expected that an abscess would form. As
there was already gland disease in the other armpit, I did
not think it a suitable case for excision. We agreed, at any
rate, to defer the decision on this point.

A fortnight after this consultation, which took place at

my house, I was asked to visit C R at his home in

the country, and to come prepared to excise the tumours if
it seemed advisable. I was told that the advance had been
rapid, and that the general health was rapidly failing. I

found C R in bed, and looking ill. He had lost

flesh, and his complexion was slightly yellow. The arsenic,
&c., had been laid aside, as it appeared to cause nausea.
The temperatures had during the past week usually ranged
at 102^ in the evening. The gland mass in the left armpit
had increased in size. That in the right armpit was much
as it had been, and was still quite loose, but in the root of
the neck above, where none had been discoverable on the
previous occasion, several could now be felt. The inflamed
patch on the left side of chest, which had seemed to threaten
suppuration, had, under the application of an evaporating
lotion, lost much of its congestion and oedema, and now pre-
sented a fine cake-like mass as large as the palm of an adult
hand. It now seemed clear that the disease was of a sarco-
matous character, and that no operative treatment could be

advised. From the manner in which C R during

conversation seemed to lose his breath, I could not help
suspecting that some impediment to respiration existed in
the chest. We could not, however, on auscultation, find any
evidence of this, and C R himself assured me that

328 ON INFECTIVE DISEASES OF LYMPHATIC GLANDS.

he was not conscious of any difficulty in breathing. He
drew a deep breath, and assured me that he felt all right.
Although his pulse was quick, and temperature somewhat
high, he was in good spirits, and we had difficulty in per-
suading him that he ought to keep his bed. He insisted
that he did not ail much, and thought that we w^ere
exaggerating.

I felt bound to say to his friends that I thought the
disease beyond the reach of treatment, and that the patient
would not live many months. This led to their subsequently
desiring to have the advice of a younger and more energetic

surgeon. About ten days after my visit C R w^as,

under the advice of a very able man, brought up to Liondon
in order to have a serum-injection treatment tried. His
temperatures continued high, usually ranging about 103®,
and he sank a few days after his journey to town. Through
the courtesy of the surgeon concerned, I have been informed
that a post-mortem was made, and that no deposits were
found in the internal organs. The left axilla and pectoral
region were at the time of death occupied by a large, brawny
swelling, hard in places and soft in others. The adjacent
muscles were infiltrated. There were also enlarged glands
in the other armpit. Microscopic examination pronounced
the tumour to be a round-celled sarcoma.

A very noteworthy feature in the above case was the
presence of the ordinary phenomena of local inflammation.
The swelling on the side of the chest below the armpit
which rapidly followed the enlargement of glands was
probably over lymphatic trunks. It was attended by acute
oedema, vivid redness, and all the indications of impending
suppuration. After a week or two, however, these condi-
tions passed away, and only a solid cake-like induration
remained. In the case which I have next to relate an
abscess, attended by suppuration which required an incision
for its relief, preceded the formation of sarcomatous growths.

All cases illustrating the connection between inflammatoiy
processes and those of maligant new growth are of great
value. They tend to destroy the artificial distinctions
which theoretic pathologists have sought to estaUiah

ACUTE LTMPHO-SABCOMA. t529

between the two. The following are the notes which I took
on June 1, 1898, the date of the only occasion on which I
saw the patient.

Case III.

Case XXXII. — Milk Abscess — Rapid development of Sar-
comatous Growths in both Breasts, both Tamils, and
the Lymphatics of Armpits and Neck.

Mrs. M is only 27 years of age. She is the mother

of three, and was in her normal health at the time of her
last confinement, on November 23, 1897. She tried for a
fortnight to nnrse her baby, and had a very large supply of
milk. An abscess formed in the right breast, and her
doctor made her give up nursing. She used the breast
pump, and had great difficulty in getting rid of her milk.
Three weeks after her confinement her surgeon opened the
abscess and let out a moderate quantity of matter. The
incision had healed in the course of a week, the drainage
tube having been removed. Very soon after this she noticed
a movable lump in the right breast.

Such was the history which Mrs. M and her sister

detailed to me on June 1, 1898. It will be seen that little
more than six months had elapsed since her confinement.
During that interval an enormous sarcomatous growth had
developed in the right breast, gland-masses had formed
in both armpits and in both sides of the neck, and both
tonsils had been excised for growths of a lympho-
sarcomatous nature. Although this rapid formation of
malignant growths might have been supposed, in one so
young, to imply a strong hereditary tendency, yet the only
fact which I could obtain in that direction was that the late
Dr. Braxton Hicks had many years ago operated on her
mother f
been "hi
living.

Thebi
and both
isfection

330 ON INFECTIVE DISEASES OF LYMPHATIC QIiANDS.

had spread through Ijnnphatics. In all probability the law
of elective proclivity of similar organs had come into play,
and cell elements, shed into the blood by the breast in which
the abscess had occurred, had contaminated first the other
breast and then the tonsils. That these separate foci of
growth had all developed independently seems incredible.
Having suggested this view as explanatory of the facts, I
will now proceed to describe the latter in more detail.

The left breast (the one in which the abscess had occurred)
was at the time of her visit to me of small size, and painless.
As the patient had lost all her fat the gland itself was
easily felt, and there could be no doubt that its lower half
was peculiarly hardened. It had, however, shown no
tendency to grow, and had it not been that a large gland-
mass was present in the axilla, doubts might have been felt
as to whether the induration was really malignant. It was
quite quiet. The other breast was as big as a child's head,
very heavy, pendulous, and quite loose from the chest wall.
It was inflamed and reddened, and presented several separate
places which looked exactly like acute abscesses jnst about
to break. Doubts had indeed been expressed as to whether
it were an instance of suppuration or of growth, and my own
opinion at first sight was that a case of milk abscesses had
been previously neglected. On finding, however, that there
was no real fluctuation anywhere, and that there was a
mass of hard glands in the armpit, I soon felt sure that it
was an inflamed sarcomatous growth. Numerous large
veins coursed over the margins of the mass, more especially
towards the clavicle, and in the root of the neck there were
many hard and large glands. The patient had much
difficulty in speaking, and I was told that within the last
month both her tonsils had been cut out by a specialist
surgeon who had declined to have anything to do with her
breast. I found the tonsils exactly alike, very large, so that
they almost met across the throat, and presenting each a
huge excavated ulcer covered with greyish secretion. These
ulcers probably occupied the line of the incision which had
passed through the growth. The tonsils could be easily felt
externally, and on the left side there was a mass of enlarged

ACUTE LYMPHO-SARCOMA. 331

glands close to it. The glands in the right neck were low
down, and had probably been infected from those in the
armpit, but those in left were from the tonsil. All the
enlarged glands in the fom: different positions in which they
were fomid presented similar features. They were firm, but
not of stony hardness, and showed but little tendency to
adhere to each other or to the surrounding structures.

The case was obviously beyond the reach of treatment,
and it did not appear likely that the patient would survive
many weeks.

Death took place about ten days after her visit to me.
Unfortunately there was no autopsy.

As regards the withering up of what I cannot but regard as
the primary growth which was attended by abscess in the
left breast, it may be remarked that shrinking of one
tumour is not unfrequently observed when others are
rapidly growing. This I have repeatedly seen when tumours
in the lumbar glands have followed primary sarcoma of the
testis. Under such circumstances the testis may shrink
until the patient may forget that it was ever enlarged,
and consult his surgeon for the abdominal tumour only.

It is of interest to note that in Case I., as in this, both
tonsils were infected.

NOTES ON SYMPTOMS.

(Continued from page 260.)

The interpretation of subjective symptoms is often a
matter of great difficulty and makes large demands on our
patience. It must, however, be attempted if we v^sh to
fill up the details of our clinical pictures.

Mr. E is liable to attacks which he calls ** bilious,"

which leave him with deep transverse furrows across his
nails. There is, therefore, no question as to their physical
severity. The problem is, what is their real nature ?

It is now about six weeks since his last, and the furrow
which was the result has travelled forward on all his finger
nails until it is only a quarter of an inch from their free
edges. It is a very conspicuous one; single, accurately
transverse, and the nail which has grown behind it is quite
sound. It is the fifth or sixth time that he has experienced
the attacks which leave this condition. I asked him to
describe carefully the nature of the " attacks.** This he did
as well as he could. He said that his finger tips became
numb and tingly, as if frostbitten, but were neither bine
nor pale. They usually felt hot rather than cold. The
condition would vary much during the day, coming and
going, and was, when at its worst, attended by a great sense
of muscular weakness so that he could not use his arms nor
walk. Always there was great weakness if he made exertion.
Thus on one occasion during his last attack he had tried to
take a walk, thinking it might do him good, but after half a
mile had been obliged to ask for a friend* s arm. On another
occasion a man on each side had been necessary. The feel-
ing was that of stiffness in the muscles and inability to use
them. Sometimes this loss of power and numbness had

CRAMP AFTER SLEEP. 333

come on him when playing at cards, and he had become
unable to take up a card without assisting one hand with
the other. The fingers became, he assured me, stiff as well
as numb. He never experienced the sensation of ** pins and
needles ** further than a slight tinghng.

It is a defect in this narrative that no trained observer
has ever noted the state of the pulse and the appearance of
the digits during an attack. The explanation which would
best fit the description is that of spasmodic arterial ischsemia.
But then we have the patient's allegation that his fingers
are neither blue nor pale. It is, however, scarcely possible
to imagine any other condition capable of producing such
definite arrest in the growth of the nails. It is to be
observed that the condition must be one of considerable
duration, the attacks usually lasting a whole day. The
larger arteries must also be imphcated, since the limb-
muscles become weak. All the larger limb-vessels must
also be simultaneously affected. Nothing in the least
approaching the gangrene of Eajmaud's malady has ever
been observed, nor, as has been stated, are there any obvious
indications of asphyxia.

No. XL. — The liability to Cramp after sleep.

ERRATUM.

By a printer's error, Case XL. {Liability to Cravip after Sleep) has been
printed here in duplicate, having appeared previously as Case XXIX. on p. 132.

it by the pain caused. Those liable to cramp in the calf
must be very careful as to movements of their legs just after
waking. When once the sleep state has passed off and the
muscles are, so to speak, thoroughly awake, there is com-
paratively little risk of its coming on.

I was explaining the above to a patient who had suffered
much from cramp, when he replied : ** Yes, I have found
that out for myself, and I am so determined to avoid bending

334 NOTES ON 87UPT0MS.

my legs soon after waking, that I always take care th.at the
bed clothes are not tucked in, bo that I can slide out of bed
feet first to keep them straight."

No. XLI. — Bug-Htes mistaken for Syphilis.

Patient. I had syphiliB eight years ago, and I wajit to
know if I may marry.

Consultant. How long have you been free from symptoms?

P. I still have some symptoms.

C. How were you treated ?

P. I had two years' continuous treat
taking medicines on and off ever since.

C. Jnet tell me what you remember o:
What did you have ?

P. Oh, I was covered with blotcheS;
it was syphilis.

C. That is enough ; hut had you nc
— a chancre ?

P. I do not remember having had
an eruption, bat my penis is often a
have been.

C. You say that you had two years' C(

P. Yes, I took mercury regularly for

G. Were you quite free from sympt
off?

P. To tell the truth, I have never be
eruption. It comes ajid goes, and I ha

C. Show me what you have.

He exhibits a group of florid dusk
irregularly (constellation-wise) on the i
In the centre of each is a minute punc

C. Why, those are nothing but bug-1

P. You don't say so ! I am living ai
but I admit I have caught a bug occasi

At this stage I make him undress, e
on limbs and tnmk vrith blotches and
in various stages, all clearly of the i
are many on his legs and ankles, and

THREATENED PABAPIiEGIA. 335

been scratched and made sore. The whole might easily
have been mistaken for a syphilitic eruption, but in the
middle of all the more recent spots a little puncture is
visible.

C, Tell me, now, how. does your eruption come out ?

P. Oh, I find a new set of spots, now here, now there,
when I get up in the mornings. They are red bumps, or
sometimes little blisters, and they burn and itch.

C How long does the burning last ?

P. Two or three days, and then it goes away, but the
spots persist for weeks and leave stains.

C. And is this eruption all that you have had? Have
you really never had a chancre ?

P. No. I have never had anything but what you have
seen.

C. And you have been taking mercury for two years ?

P. Yes, on and off ; not quite regularly.

C. It has done your health good ?

P. Yes, I think so, but it has never got rid of the eruption
for long together.

No. XLII. — Loss of ability to walk — Threatened
Paraplegia^ supposed to be syphilitic ^ but more
probably sexual.

In the case of Mr. B , the symptom which had

caused alarm had been temporary inability to walk. He
was a man of 52, of heavy frame, who had suffered from
syphilis (a mild and perhaps doubtful attack) just twenty
years before he came to me. Eight years after the syphilis
he had had inflammation of one eye, which was then
attributed to it, and for which he had specific treatment.
This attack had resulted in detachment of retina, sparkling
synchesis, and loss of perception of light. The other eye
had remained perfect, and with this exception nothing had
occurred to him to remind him of the old taint. Five
years before I saw him he had (at the age of 47) married.
His wife was near his own age. Previous to marriage he

336 NOTES ON SYMPTOMS.

had been excessively indulgent with women, but since then
much more moderate. He had always been a heavy
smoker, and free in the use of stimulants.

The failure of power to walk had occurred on several
different occasions recently. His wife had noticed that in
sitting he would lean forwards, and that he always seemed
to rise with difficulty. He had also complained of sense
of weakness across his hips. One day (three months ago)
after a drive he sat down in a chair at his club, and on
attempting, after a short rest, to rise found that he could
not walk. As he described it, he could move his legs freely,
and could stand up if he remained still, but felt that he
should certainly fall if he attempted to step forwards. He
had at the same time a dull sense of weakness across his
sacrum, but no sharp pain. On the occasion referred to
he sat down again, moved his legs about, and after a while
regained power sufficient, with assistance, to walk to a cab
and to get home. For some days afterwards he walked
badly ; but gradually he recovered, until, a few weeks before
I saw him, another very similar attack occurred. From this
also he was recovering when he was brought to me. He
still, however, walked slowly and awkwardly, and had some
difficulty in rising from his chair and starting. I may here
remind the reader that he was a big, strong-looking man,
though pale. He had not had any bladder symptoms, and
his knee reflexes were good — ^possibly a little excessive for
his age.

On inquiry I learnt that he had had, some ten or fifteen
years ago, an attack not wholly dissimilar from his recent
ones, and had found himself unable for a time to use his
lower limbs. He very readily accepted my suggestion that
he had been very excessive in sexual intercourse, but denied
that this had occurred of late. He had never had any
severe pain in his back, but a disagreeable aching and sense
of weakness.

Mr. B had been brought to me in the suspicion that

his attacks; which seemed to threaten motor paraplegia,
were in connection with his old syphilis. I did not incline
to support this view. He had no other syphilitic lesions.

PAIN FEOM ARTERIAL OCCLUSION. 337

The attacks had been transitory and wholly without sensory
complication. I was inclined rather to attribute them to
sexual causes and loss of tone in the spinal cord. In minor
degree, many persons after sexual exertion experience an
aching weakness across the hips, with some sense of

insecurity in walking. What had happened to Mr. B

seemed only an exaggeration of such feelings. The transi-
tory nature of the muscular failure seemed to favour the
view that it depended upon loss of tone, and not on struc-
tural change. As regards sexual excesses, these were fully
confessed to at former periods of life, and although denied
of late they might still have been too much for the spinal
cord of a man past middle life and which had previously
suffered. As regards treatment, I had much confidence in
advising that iodides should be avoided and tonics given.
He was at the same time enjoined to give his spine rest.

No. XLIII. — Pain in the tread, of the foot incapaci-
tating for walking — Arterial Occlusion probable.

The s3anptom of which Mr. K complained was pain

under the tread of his left foot, aggravated by walking. It
had persisted for some months and had almost disabled him
from his occupation. He was employed as an inspector in
the Health Department of the City of London, and was,
he said, often quite unable to walk or even to stand. The
pain disappeared almost wholly in the recumbent posture.
Several consultations had been had before I saw him, and
neurotomy had been strongly advised.

At first Mr. K was inclined to locate his pain in one

spot between the base of the great toe and the next, but on
careful examination it appeared that there was no single
tender spot, and that the aching extended across the whole
foot at the level of metatarso-phalangeal joints. It in-
volved also the toes themselves, to some extent. When
both feet were uncovered and placed side by side, it was
obvious that the toes of the affected foot were more dusky
and redder than those of the other. This the patient had
noticed, and he also said that they were colder. He had

VOL. IX. 22

338 NOTES ON SYMPTOMS.

varicose veins on both sides, but they were larger on the
affected one. When he was in the recumbent position the
difference in the dusky congestion of the affected foot was
obvious. We now found that whilst the anterior and pos-
terior tibials could be found very easily in the sound limb,
they could not on the affected one. The femorals beat
with equal force on the two sides. There was no very
definite history of any sudden attack of arterial occlusion,

but Mr. K remembered, when asked, that he had

suffered from pain in his calf. There could be little doubt
that the disabling pain complained of was arterial and not
nervous in origin.
The patient was a man of about 46.

No. XLIV. — Arcus Senilis as a Symptom.

The premature formation of the arcus senilis does not
appear, any more than the premature blanching of the hair,
to be indicative of premature seniUty. " Grey early grey
long" is a proverb which amounts at least to a negative
assertion of this fact as the result of popular observation. I
have just seen a gentleman, aged 64, in whom the arcus v^as
in both eyes very conspicuous. He was in good health, and
was not liable to headaches or other ailments. He told me
that a surgeon had remarked upon his eyes when he was
little more than thirty years of age. It was a family matter.

I have known two families in which several of the males
acquired the arcus very early in life. Yet those who did so
enjoyed good health and Uved to fair ages.

No. XLV.— On Gold Feet.

Digestion always increases the liability, and attacks may
come on during a meal or soon afterwa>rds. If a meal
causes cold feet, headache will usually follow. In many
patients any little mental worry or excitement brings on an
attack. Patients liable to frequently recurring coldness of
the feet and hands sometimes say that nausea or even
vomiting may be caused if the feet become very cold. I

EXTBEME FEEBLENESS OF PULSE. 339

think that the feet have more influence in this respect over
the stomach than have the hands. The mere fact of the
feet being cold (say from tight boots) will often cause head-
ache. On the other hand, severe headaches, however caused,
are usually attended by cold feet. ^

No. XL VI. — Description of a Fall in Fainting.

A man fell in a faint whilst standing in my room. He
fell backwards softly on to his buttocks and then on to his
back, and lastly his head went back. He did not strike his
occiput at all hard. He looked lividly pale, but by no means
absolutely blanched. Consciousness was entirely lost for
only a minute or so.

No. XXiVII. — Extreme feebleness of the Badial pulse.

Extreme feebleness of pulsation at the wrist, which in
minor degress we often encounter in patients who are yet in

tolerable health, was illustrated in the case of Miss M .

On two occasions, with an interval of several weeks, I was
quite unable at first to detect any pulsation at all.

I examined the wrists very carefully in order to discover
whether there were any abnormal distribution, but could
not find any. Her hands were rather thin, and a very
diminutive superficialis voles could sometimes be detected.
Even when this were felt I could not perceive the pulsation
of the radial, which was of course more deeply placed. At
length, by carefully flexing the wrist and placing the hand
at rest on the table, I succeeded in feeling a very soft and
feeble pulsation in both radials, better in the left than in the
right.

This extreme feebleness of the peripheral circulation
occurred in a young lady who was much out of tone, and
consequently complained of cold extremities. On the second
occasion of my examination of her, however, she had very
much regained her health, and the hands were quite warm.

If any one should feel surprised that so small a vessel as

340 NOTES ON SYMPTOMS.

the superficialis voIsb could be felt when the radial could
not, it may be well to remind him that just after it is given
off this httle vessel becomes, as its name implies, very
superficial. In elderly persons with enlarged arteries, its
pulsations may easily be counted by the eye, whilst tliose of
the radial itself are quite hidden.

CANCEE AND THE CANCEEOUS PEOCESS.

Serpiginous Ulceration of the Palate in an Elderly Man —
Cancer or Tuberculosis — Microscopic evidence of Epi-
thelial Cancer — Repeated cauterisations and favourable
progress during seven years,

Mr. P is a thin, rather delicate looking man. The

following notes describe the condition in 1889, at which
time he was 58 years of age.

*^ He has a patch over the right side of soft palate, extending from
foot of uvula to pillar of fauces, and forwards to border of hard palate.
It presents a level granulating surface and a slightly jagged edge with
red margin — much like lupus. The border of the velum is notched by
ulceration, but the peculiarities are that there is no deep ulceration nor
any great thickening. It has a firm evenly thickened base.

" The question is between scrofula and cancer, The sore is perfectly
clean, and looks more like lupus than cancer. I fear, however, that
some glands in the neck are enlarged, and the age of the patient and the
short duration points towards malignant disease.

*' He thinks that it has not been there more than six weeks. He
discovered it by accident when he had some tickling in his throat. He
first showed it to Dr. England two weeks ago. Three years ago Dr.
E. cut his uvula. There is no family history of cancer."

The above are the notes which I wrote at the date of my
first consultation. On a second occasion, after a month's
treatment with iodides and mercury, which had done no
good, I excised some portions for microscopic examination,
and the verdict was ** epithelial cancer." Feeling, however,
still some doubt, and not liking hastily to undertake an
excision which would have to be very extensive, I advised
him to allow me to use the actual cautery. On two
occasions under chloroform I used Pacquelin's cautery as

342 CANCEB AND THE CANCEROUS PBOCESS.

freely as possible to the whole diseased surface. The resnlt
was a complete healing. The two cauterisations ^v^ere
done in February, 1890, with an interval of three weeks.

In August, 1893, Dr. England wrote to me that the parts

had remained quite sound until May, 1892, when Mr. P

contracted a sore throat, following on which was a return of
the ^ulceration 'at one spot on the border of the scar. Dr.
England again used the actual cautery, and with the resnlt
that the resulting scar remained well until the spring of
1893, when there was another recurrence, with tendency
to spread on the left anterior pillar of the fauces. The
cautery was used for the fourth time, and the sore again
healed. At the date of Dr. England's letter, hoTvever,

Mr. P was ill in bed with symptoms of disease in the

stomach (sub-acute gastritis).

In September, 1896, Dr. England was again good enough,
at my request, to report on our patient's condition. He
wrote to me as follows : —

" I have looked up Mr. P . He is a very busy man, and hard to

find at home. He tells me that he has been very well for the most part,
but he looks thmner. We must remember, however, that he is five
years older that when you first saw him. He is now sixty-three. He
suffers occasionally in winter from the cold and damp, when his throat
becomes dry and painful, and he is hoarse. EUs disease, you will
remember, was on his hard palate, extending on the right side to pillar
of fauces, soft palate, and uvula. There is now a dark red patch, almost
round, about a quarter of an inch in diameter, on right side of hard
palate, about half an inch in front of velum. It feels to me to be
quite smooth, and like a cicatrix, but he says it spreads occasionally
when he is not very well, and feels to his tongue as though it were
about the thickness of writing-paper above the surrounding mucous
membrane."

In spite of the positive evidence given by the microscope,
I am obliged to doubt whether the disease in this instance is
really cancerous. My diagnosis in the first instance inclined
rather to lupus than to cancer, and the progress of the case
during nine years seems to favour that opinion. The use of
the actual cautery on the soft palate is not very easy, and
although I did it resolutely I could scarcely hope that it

SAECOMA IN MUSCLES. 343

would be efficient for the cure of epithelial cancer. The
diagnosis must remain in some doubt. Meanwhile, however,
whether tubercular or not, we may regard the success
obtained by cauterisation with satisfaction. There has
never been any aggressive gland disease, although in the
first instance we thought that some enlargement could be
detected.

TWO EXAMPLES OF SABCOMATOUS GEOWTHS IN CONNECTION

WITH THE VASTI MUSCLES.

Case I. — Sarcomatous growth in connection with the Vastus
externus — Excision — Early recurrence and death.

Mr. P , aged 60, a saddler from Cawood, Yorkshire,

consulted me in December, 1892. He was a thin, grey
man, and was the subject of a large, smooth tumour in the
outer part of the right thigh, which had been present for a
year. It. did not adhere to the bone, but appeared to be
developed in the vastus externus. I advised excision, but
did not urge the operation.

I subsequently learnt that he had the growth excised a
week after I saw him, and that it very quickly recurred and
grew to an enormous size, causing death six months later.

I am indebted to Dr. Hamilton, of Cawood, for this
information.

Case II. — Sarcomatous growth in Vastus inter^ius — Expansile

pulsation in the later stage,

I mention the above case at the present time because I
have recently seen another somewhat similar one. In this
also the patient is a man past middle age. The tumour was
in the first instance clearly in the muscle, and could be moved
with it. The diagnosis seemed to rest between gumma and
sarcoma. Iodide of potassium was liberally tried, without
any good result. The tumour has grown and become more
fixed, and has also acquired a slight but definitely expansive
pulsation.

344 CANCEB ANp TEE CANCEROUS PROCESS.

Primary Melanotic Sarcoma of Skin.
I excised a little nodule of melanosis from the cheek of 3
girl of 17, on April 13, 1898. It had been growing for about
five months, and had appeared in perfectly sound skin as a
little, pin-head, black spot. It had increased rather rapidly,
and was as big as a pea. Its section was homogeneous, and
coal black, and measured a quarter of an inch across. It
was well circmnscribed, and there were no other nodales
near it. No history of cancer in the family, but much gont.

Slow-growing Sarcoma of Glands.
The portrait here given is that of a woman now aged 50,
for whom, sixteen years ago, I excised a fungating tumour on

the skin of the thigh, which had been of slow growth. The
diagnosis by the microscope was that it was a spindle-celled

SABCOMA OF GLANDS. 345

sarcoma, and we constantly anticipated that it would recur.
A large elliptical portion of skin was taken. The scar has
since remained quite sound, and the patient has enjoyed on
the whole good health. At the time that I did the operation
there were some enlarged glands in the right side of her
neck. They were of inconsiderable size, and showed no
tendency to inflame. No special treatment was, I believe,
adopted. I did not see my patient again for many years.
Recently, however, she has again consulted me, and has
allowed me to have the photograph taken from which the
woodcut has been executed. The gland mass has been
slowly increasing in size during the whole intervening
period, but without causing any material inconvenience.
It now presents a smooth, rounded exterior without any
indication of separate glands. And as there has been no
infection of the other side or of the axillary glands, it may
be assumed that it has grown either from a single gland or
from a very small number. An interesting fact in its present
condition is that it has lifted the large vessels upon its sur-
face, and that the pulsations of the carotid artery are now
easily visible immediately beneath the skin. A shallow
furrow in which the vessel rests may indeed be traced in
the photograph. At no time has there been any evidence
of obstruction either of vein or artery.

Note on the position taken by the Carotid Artery in different
tumours of the Neck — Sarcomatous growth in Glands,

The position finally assumed by the carotid artery when
displaced by tumours in the neck is often of much help in
diagnosis. If a lobe of the thyroid gland has caused the
displacement, the artery will have been carried to the back
of the neck, and may be found behind the posterior edge
of the stemo-cleido muscle. If, on the other hand, the dis-
placing growth has begun in the cervical glands, the artery
will, if not embedded, probably.be lifted forwards, and have
become superficial in front. I had recourse to this condition
as an aid to diagnosis in the case of a lady whom I saw with
Mr. Butler at Guildford. In this instance the patient was

346 CAKCBB AND THE CANCEBODS PROCESS.

seventy-two years of age, and a swelling had been first
observed in the right side of her neck towards the end of
March, 1897. It was at first thought to be a, thyroid
tumour ; by the '-»-■'■>

Tangerine orau
tassium ointm£
tumour much
quently the gro
pushed the lar
that the patien
in this conditic
carotid artery n
not grown from
Death occun
a sarcoma whii
involve the thj
the growth wer
tion.

SYPHILIS A FOEM OF YAWS.

Chancres assuming the type of Frambcesia.

One of the chief arguments urged by those who have
hitherto held that Yaws and SyphiUs are distinct diseases is
that the primary sores and the secondary eruption of the former
are peculiar. Their peculiarity consists in their presenting
the Framboesial type, that is, in being attended by the pro-
duction of a granulation-mass, in form and general appearance
resembUng a fruit, such as a raspberry. In reply to this
I have urged over and over again that in England the
eruption of syphilis not unfrequently takes this form, and
have adduced the fact that cases described in Scotland as
^* Frambcesia " and in Dublin as ** Morula" were without
any reasonable doubt nothing but syphilis. Eemarkable and
very definite examples of the Framboesial type of syphilis have
been cited, not only from my own practice, but from that of
Professor Petrini, in each instance published with a por-
trait (see Archives, Vol. IX., p. 199). By a remarkable
coincidence I am enabled this week to oflfer an illustration of
the Framboesial type of the primary sore. The other cases all
illustrated the secondary eruption. The appended woodcut
has been executed from a photograph sent to me a fortnight
ago by Dr. Crossley Wright, of Halifax. It exhibits three
Framboesial chancres on the arm of a young man who had
been tatooed by a man who was no doubt the subject of
syphiUs. Nothing has been ascertained as to the operator's
condition, but there is no doubt that the sores here shown
were true chancres, for they have been followed by a specific
wh. There were enlarged glands above the elbow and in the
nnpitfl. It is believed that another youth who was tattoed
: the same time has suffered in a similar manner, having no
wer than six chancres. I feel sure that the formation of

348 SYPHILIS A FORM OF TAWS.

framboesial granulatioii-masses in connection with primary
sores is not very uncommon in English practice where the
chancre is erratic. The typical induration is seen for the
most part on the penis only. We sometimes encounter it on
other parts, as the finger, the lip, but on these latter parte
the appearances presented by the chancres may vary -within
very wide limits. From this proneness to vary, very
numerous errors in diagnosis result. The portraits of

vaccination-chancres, which I published many years ago,
well exemplified this variety in local conditions in different
persons from the same virus. In one at least the whole
sore was covered and concealed by a granulation mass. It is
time that these facts were fully and freely admitted, and
when they are so there will remain but little upon which
to base any argument against the identity of yaws with
syphilis.

The Absence of Sore Throat in Yaws.

The asserted fact that the subjects of yaws seldom or never
show any sores in the tonsils has been strongly lurged as
implying that yaws is distinct from syphilis. In the first
place it may be doubted whether the rarity is so great as
is alleged, and next it is an unquestionable fact that the
English climate renders the throat much more Uable to
suffer than does that of the tropics. There may also — ^but on
this point I have no information — be a

SYPHILIS A FOEM OF YAWS. 349

to tonsil affections in different races. As regards difference
in climate, I have obtained many items of evidence. A lady,
the wife of an Indian officer, described to me a severe attack
of "blood poisoning*' which she had passed through some
years ago in India. Wishing to know whether she had
syphilis, I asked as to eruption. ** Oh, yes, I was covered
with sores.'* "Had you a sore throat?" "I do not
remember one, but then you know we never have sore
throats in India. Before I went there I suffered much from
them, and I have done so again since I returned, but during
my ten years in India I never remember a sore throat."

Syphilis a form of Yaws.

In my last number I ventured to express, without any
reserve whatever, my belief that in yaws we have the
parent-form of syphilis. This amounts to saying that
syphilis, as we know it in Europe, is tropical yaws modified
by race and climate. If we accept the proposition that
yaws has been long indigenous amongst native inhabitants
of South America, it becomes not at all improbable that
it was really imported into Europe in the sixteenth cen-
tury. Three centuries of prevalence in European popula-
tions may easily have sufficed to give the disease such
minor peculiarities as now seem to distinguish syphilis from
yaws. Nor indeed is it by any means improbable that some
of these supposed peculiarities may be due solely to difference
in race. No good narratives of the course and symptoms of
yaws when occurring to Europeans have as yet been recorded.
It is much to be hoped that those who have opportunities
will carefully avail themselves of them, and record their
observations in full detail.

The hypothesis which I have suggested would well explain
the occasional occurrence of framboesial S3rphilis in Europe
which has been recorded, not only in isolated instances such
as those recently published by Petrini, of Galatz, and myself
(Archives, Vol. VII., p. 357), but in minor epidemics such
as those of sibbens, button scurvy, and morula. These are
but instances of syphilis reverting to its original type.

A MYXCEDEMA NAKRATIVE.

I HATE just bad a long coDversation with an intelligent
lady who has been for six years the subject of myxoedema.
The disease was, she tells me, first reco^sed by Sir John
"Williams in 1892. There are, however, some facts as to her
former history which it is of interest to record. She has
through life had a dry skin. Not even dancing would ever
cause the slightest tendency to perspiration. She has always
been a chilly subject, loving the fire and the summer weather.
She was always hable to have her lips easily become bine.
Althoagh a good walker, she could seldom get her feet w&rm
even by walking, and her experience of a Turkish bath on
several occasions was that it made her head hot and very
uncomfortable, whilst the feet remained cold. On one
occasion the bath made her faint, and after that she never
tried them again.

Her own description of her myxcedemic symptoms ie that
she became yellow or creamy looking with habitually bluish
lips. Next her features changed, and she got bags under
the eyes and thick lips. She was unable to exert herself,
and spoke thickly and slowly. It is possible that the thyroid

A CASE OF MYXCEDEMA. 351

As regards, the use of the thyroid extract, although Miss

S admits that it has done her good, and although she

still has recourse to it occasionally if she has any tendency
to relapse, she is not enthusiastic. She says that it often
makes her feel weak and feverish, and, as she thinks, makes
the psoriasis worse. It never produces the least moisture on
the skin. She has of late suffered much from pain at the
pit of the stomach.

Miss S is at present at the age of fifty-two, and seven

or eight years since the myxoedema conunenced ; a comely
lady, but with somewhat full and expressionless features.
Her complexion is, as she says, " creamy " with patches of
congestion on the cheeks. She says that she can walk
well and long distances, and she enjoys her life. Her pulse
is extremely soft and feeble, and she still, as she has done
through life, suffers much from constipation.

I have thought the above narrative worth writing out
because it carries the history of the case over a considerable
period, and also because it records facts which may possibly
prove useful as helping us to a full conception of the malady.
The habitual constipation, the very feeble circulation, and
the inability to perspire, with finally the addition of common
psoriasis, are features which may have their bearing. Al-
though myxoedema has been definitely associated with
thyroid atrophy, it would be unwise to assume that in
that fact its whole pathogeny is included. We must also
keep our eyes open to discover, if we can, the meaning of
the complications which may be associated with it. As

regards treatment, although Miss S does not speak

quite so gratefully of it as might have been expected, yet
in spite of its drawbacks I have no doubt that it has been
the means of restoring and preserving her health.

I

EHEUMATISM AND GOUT.

No. LXVII. — Anchylosis of the Wrist.

Mr. S. has his left wrist anchylosed, the hand in a

dropped position. In this forearm he retains good pronation,
&e. In the opposite limb, however, he has lost pronation,
and the limb is almost fixed at right angles, the amount of
flexion and extension being very limited.

These conditions are attributed to a three months' attack
of gonorrhoeal rhemnatism. He was three months in bed,
the elbow and wrist were the only joints afl^ected. He had
got wet through whilst suffering from gonorrhoea.

He has had gonorrhoea several times (five or six) since the
one which caused the rheumatism, and no rheumatism has
complicated them. An uncle suffered much from gout.
His father died young. He has himself been threatened in
his great toe joint and thumb.

No. LXVIII. — Spondylitis Deformans in a Cat.

At page 350 of Vol. VIII. I recorded a remarkable case,
with woodcut illustrations, of multiple arthritis deformans
in a cat. Not only were many of the large joints severely
affected, and the characteristic conditions produced, but the
joints of the spinal column were also extensively involved.
Since the publication of my case I have found almost its
exact counterpart, so far as the spinal column is concerned,
recorded long ago mLe Progris Midical.

Dr. Brison, who records the case, speaks of it as an
example of multiple exostoses, hyper-ostoses and synostoses
of the vertebral column, and distinctly states that the bones
of the limbs were almost wholly free. It would therefore

SPONDYLITIS DEFORMANS IN A CAT. 353

appear to have been a close analogue of what we know as
spondylitis deformans in the human subject. In the latter
affection, although it is unquestionably a form of rheumatic
gout, it is not uncommon for the joints of the limbs to
escape. In the cat in question the only osteophy tic growths
on the limbs were two small ones near to the trochanters.
The ribs, on the contrary, as is usual in osteitis deformans,
presented many osteophytes. The author speaks as if the
malady were well known in France, and says that it leads to
death by marasmus after the duration of several months, or
it may be of several years. He describes it as reducing the
poor animal to a state of rigidity, in which, taken up by the
head, it could be lifted without bending, and says that it
merits the name of " chat barre de fer.** He did not know
the exact age of his patient ; thought that it was at least in
its fourth year.

In my own case, although the osteophytes were numerous
and large, and must have been sufficient to greatly diminish
the flexibility of the spine, there was no true anchylosis. In
Dr. Brison's case the synostosis was, however, quite com-
plete in a great many of the joints, more especially in the
cervical region. From the fourth to the tenth vertebrae
inclusive no distinction whatever could be observed between
the bodies of the vertebrae as seen from before. Dr. Brison
inclines to attribute it to a form of periostitis of indeter-
minate nature, " a chronic and special form of inflammatory
action.*'

It may be well to remark that this affection, so closely
similar to spondylitis deformans in man, would appear
to be quite distinct from the ossification of the anterior
common ligament of the spine, which is not uncommon in
horses and asses. In the latter affection, specimens of which
are to be found in all our museums, a riband of dense bone
passes down in front of the vertebral bodies and unites
them. But there are no true 83mostoses, nor any develop-
ment of osteophytes.

VOL. IX. 23

DISEASES OF THE EYE.

No. XXXIII. — Flesliy Cyclitis in connection with

Gout.

A very marked example of chronic cyclitis was brought

under my notice in the case of Miss B , aged 23, who

was sent to me by Dr. Hewer. There was a dusky, fleshy
thickening of the whole sclero-comeal region. It was
especially conspicuous upon the upper parts, and although
it had begun on the right eye it was now nearly symmetrical.
Quite recently it had extended somewhat upon the cornea.
The present attack had commenced about six months ago,
after an attack of mumps. The history of the patient and
her family very definitely connected it, as usual, with in-
herited gout and its frequent concomitant, feeble circulation.

Miss B 's mother was rheumatic, and one of her

uncles had suffered from gout. She herself had in child-
hood suffered severely from chilblains, but the liability
had decreased since she grew up. She had once had an
attack of very severe pain in one hip-joint. The pain sud-
denly moved from the hip to the neck, and she was kept in
bed by the attack for some days. She had frequently had
fljring pains in her ankles and other joints, and had some-
times had her eyes inflamed, ** as if pins were pricking into
them." One of her brothers was liable to what was called
" neuralgia in the eyes." '

Many of the facts above mentioned may, I think, be taken
as evidences of inherited gout, and the condition of cyclitis
was exactly similar to what I have seen in other cases with
parallel history and like concomitants. I strongly recom-
mended a prolonged change of climate.

The date at which the above notes were taken was Sep-
tember 23, 1885.

CHOROIDITIS DISSEMINATA. 355

No. XXXIV. — Optic Neuritis in one eye only —

Question as to Syphilis,

A case which I have just seen raises an important
question as to the symptomatic significance of neuritis of the
optic disc in one eye only. I did not myself see the patient
during the neuritis stage, but the diagnosis had been made
by a very competent ophthalmic surgeon. When I saw the
case the disc of the affected eye was rather paler than that
of the other, and at its lower border the choroidal rim was
very definitely notched. Beyond these there were no
changes. The disc was bright and clear and free from ^11
trace of effusion, and its vessels were almost of normal size.
The patient was a young man of twenty-six, apparently in
excellent health, who had had gonorrhoea, but in whom
there was no proof of syphilis. At the time of the optic
neuritis he had no head symptom, excepting a little head-
ache, and he had had none since. The recovery had taken
place under specifics. Optic neuritis, affecting one eye
only, and resulting in complete recovery, is, in my experi-
ence, very rare. It is difficult to imaginfe, under the cir-
cumstances described, any cause other than syphilis which
could have caused it.

No. XXXV. — An instance of very extensive Choroi-
ditis Disseminata in Inherited Syphilis.

On Friday, June 3rd, a very interesting example of
extensive disseminata choroiditis in connection with
inherited syphilis was brought to me. The patient, a lady
of 27, could just manage to read one word at a time with
her remaining eye. Her choroid in this eye was dis-
organised all round the yellow spot, but the latter still
remained sound. There were very large irregular areas of
denudation in the central parts of the fundus, and at the
circumference deposits of pigment after the retinitis pig-
mentosa pattern. This was her only available eye; with
the other she had barely perception of light, and it was
not possible, owing to the state of the cornea and media,
to inspect the fundus.

356 DISEASES OF THE BYE.

This was the most extensive example of choroidal
denudation which I have ever seen in connection with
inherited syphilis. I have seen its paralle] in the acquired
syphilie more than once. In one of these latter the patient,
who was a schoolmaster, retained for many years the nse ol
his yellow spot region, all around being denuded.

In the present instance there could be no reasonaWe
doubt that the patient was hereditarily syphilitic. Apart
from the state of her comese her physiognomy was charac-
teristic, and there was a history of severe keratitis in early
life. Her teeth were not marked. It appeared that sbe
had had relapses of choroidal symptoms several times dnring
the last ten years. Quite recently opacities in the vitreous
and posterior pola>r cataract had made their appearance.
Thus there was reason to fear that the conditions may prove |
slowly aggressive, and that she may in the end lose all useful
sight. This event is, in my experience, very rare in con-
nection with inherited taint. She had good health in other
respects.

No. XXXVI. — Choroiditis simulating Retinitis Pig-
mentosa with central denudation and divergence
of Globe in connection zoith Inherited Syphilis.
Another instance of the loss of an eye for all practical

purposes in coimection with inherited syphilis has recentlj

been under my observation in the person of a youth n&me'^

(

DISEASES OF THE NEKVOUS SYSTEM.

No. Oil. — Paralysis Agitans in a man who had had
Syphilis J hut probably hereditary.

Captain H (seagoing) was under my treatment

twenty-six years ago for tertiary syphilis, and I have seen
hivi occasionally since. He is now 65 years of age and in
splendid health. He still follows his vocation as sea-
captain, and might be taken for 50. The ailment which
brings him to me to-day (July 16, 1898) is paralysis agitans
in his right arm. He thinks it is quite recent, but I con-
vince him, by reference to my notes, that he came for
precisely the same symptom four years ago. He still writes
a good hand. His mother had the same affection, and it
became aggravated in her later years. I do not think that
there is any reason to attribute the affection in the son to
his long past syphilis. No doubt it is inherited. He has
had no indications of syphihs for more than twenty years,
and has a healthy, grown-up family.

Captain H is the subject of rheumatic gout in his

terminal joints, and also of Dupuytren's induration of the
palmar fascia. He tells me that many seagoing men have
their fingers contracted into the palm. He had thought
that it was an affection peculiar to seamen.

No. cm. — Hcemorrhagic Apoplexy — Absolute right
Hemiplegia taitJiout any impairment of conscious-
ness or memory — Diaphragmatic Respiration —
No bladder symptoms. ,

The case of Mrs. F interested me much, possibly

a.use I do not often see patients suffering from apoplexy.

s lady was absolutely hemiplegic in her left limbs,

1 neither move them nor feel in them, yet she retained

ct consciousness, good memory, and could converse

358 DISEASES OF THE NERVOUS SYSTEM.

well. I certainly never saw any approach to sach a
condition after injury to the head, nor anything so well
marked after either haemorrhagic apoplexy or embolism.
There seemed good reason to think that the case was one
of haemorrhage, and it no doubt involved central parts.

Mrs. F was a stout lady, aged 52, a total abstainer

who had enjoyed good health until her present illness. She
had had two " seizures '* during the five weeks just before
I saw her. She was of course confined to her bed. She
told me, as regards her first attack, that it occurred soon after
her return from the seaside, at a time when she was feeling
unusually well. She was in her kitchen talking to a friend,
when she suddenly felt " pins and needles '* in her left foot.
She mentioned it to those with her, and it soon involved her
arm and she sank down on her knees and buttocks. Con-
sciousness was not in the least impaired. She was assisted
to bed, and the hemiplegia soon became complete as regards
both right limbs and partial in the right side of face also.
Her buttocks showed much bruising from her fall. At the
end of a month she was much better, could move the limbs,
and had regained clearness of enunciation, when, without
any fresh attack having been noticed, her symptoms were
found to be greatly aggravated and the paralysis of the
limbs was again complete.

It was about the fifth day after this relapse that I saw
her. She lay on her back in bed perfectly conscious, and,
as I have said, able to converse though speaking indistinctly.
Her face was sHghtly drawn to the right side. Her breath-
ing was almost wholly diaphragmatic and very shallow.
Her left upper and lower extremities were quite helpless.
She could not move them in the least, nor could she feel the
touch of the finger. When hairs were pulled on her leg she
thought sometimes that she could feel a little, but it seemed
uncertain. There had been, I was assured, no trouble with
the bowels or bladder. She knew when she wanted to pass
water, and there had been no dribbling, nor had the catheter
been needed.

Death took place about a week after my visit, but xmfor-
tunately there was no autopsy. It is as an example of

NEKVE SYMPTOMS EARLY IN SYPHILIS. 359

complete double function (motion and sensation) hemiplegia
with retention of perfect consciousness, that I think the
case worthy of mention.

No. CIV. — Insidious symptoms of general Nerve
Disorder in the beginning of tJie second year
of Syphilis.

A young gentleman (Mr. M , aet. 23) was brought on

account of a rather peculiar form of sj^philitic psoriasis
which affected his elbows. It was a year and a month since
his chancre, and he had been treated all the time with
mercury, but with many interruptions and never efficiently.
He was not considered to be ill, and one question was
whether he might suitably leave England for India and en-
gage in tea-planting. I found, however, on making a routine
examination that he had some very ominous symptoms.
He could see perfectly, but both discs were unquestionably
swollen and their margins blurred. He was somewhat deaf,
more especially in the right ear, and had during the last
week, when exposed to noise, several times complained that
he could not hear conversation. His right pupil was dilated
and he had had squint and diplopia. His shins were still
bruised by football kicks. He had no knee jerk on either
side. Although he looked well and reported himself as
perfectly so, yet it came out on inquiry that complaint had
of late been made as to his temper. He had just been
rejected at an examination, a result which he attributed to
the fact that he had of late not been able to read long with-
out feeling his head uncomfortable. I thought his manner
hesitating and slow, but was assured that it was cjistomary
to him. He denied any headache, and said he ate and slept
well. It came out, however, that a few weeks ago he had
experienced a sudden attack of numbness in the right limbs.
It began in his right foot and then passed upwards to his
trunk, arm, and face. It lasted, he thought, twenty minutes
and then wholly disappeared.

In the left eye, the pupil of which was moderately dilated,
there was no loss of accommodation and no defect, so far

360 DISEASES OF THE NEBYOUS SYSTEM.

as I could ascertain, of any muscle. There was not, and
had not been, any ptosis, and I was assured that the squint
(now quite gone) had been convergent. Thus there waa no
reason to think that the third nerve was affected. Th
eruption on the elbows, which was the only extant
evidence of the recent syphilis, was very peculiar. It was
exactly in the positions which non-specific psoriasis usually
affects, and it showed white scale-crusts like the latter. It
was, however, serpiginous, and was speading in irregular
crescents like a lupus. There was a single spot on the front
of one knee. With these exceptions all traces of syphiUs
had disappeared from the skin and mucous membranes.

I was obliged to give an opinion that Mr, M was in

danger of a very serious attack on his nervous system, and
he ought at once to be put under the full influence of
mercury and should on no account go from home.

No. CV. — Diplopia^ Deafness^ Facial Paralysis^ and
oilier nerve symptoms in the secondary stage of
Syphilis — Recovery — Periostitis of Sternum seven
years later.

I treated Captain P eight or nine years ago for a

very ominous attack of nerve symptoms in an early stage
of syphilis, and have, I believe, published his case. He had
diplopia, deafness, facial paralysis, and other symptoms. I
ordered him into a Home, kept him in bed, and pushed
mercury rapidly to salivation. He recovered completely,
but with absolute and permanent deafness in the left ear.
He has since served in India and other places, and has
enjoyed good health.

After an interval of seven years I have just seen him
again. He is now in good health, but has during the last
month suffered much from pain in his sternum. There is
no definite node, but the pain has been worse at night and
with decided tenderness, so that no doubt periostitis is
present.

P.S. — Eapid and complete relief by the iodide of potassium
subsequently confirmed the diagnosis.

SYPHILIS.

No. LXXXIV. — Yaws in Benin.

A gentleman who had lived in Benin, and who knew
yaws, told me that the native children take the disease,
and that their parents wish them to have it and get it over
yomig. This is precisely parallel to the statement from the
the Fiji Islands. In Benin the native name for yaws is
" effier."

No. LXXXV. — Three infections of Syphilis at inter-
vals of thirteen and seven years — Lupoid eruption
after tJie second.

In the following there appears to be good evidence of
three infections of S3rphilis. The only doubt attaches to
the third, in which the indurated chancre has not as yet been
followed by secondary symptoms. This, however, may
probably be due to the fact that he has had mercury in
anticipation. After the first and second, definite secondaries
followed. His recovery from each of these would appear to
have been complete, for he had entire .immunity from
symptoms until the next infection. The lupoid eruption
which occurred in the second year of the second attack was
a very ' peculiar one (see memorandum below). * It is, I
think, not unusual for the manifestations resulting from a

second infectioD to receive Bome modificatioDS from tht
fonner one.

52 , 1890 /

53 I 1891

54 : 1692

55 I 1899

A second infection of ayphilis. I preBcribed mercury.
After a, short course he left ofi treatmeat.
Came to mo for syphilitic lupus Oct. 18, and again Dec 12.
Second visit ; all the spota gone (Sept. 12).

PBIMAEY SYPHILIS WITHOUT MERCURY. 363

contracted them in Africa from a native woman, and the
first of them had made its appearance exactly one month
after the date of intercourse. The first was in the roll of
the reflected prepuce, close to the corona. It preceded the
others only but two or three days, and the remaining six
came almost simultaneously. At first, on account of the
multiplicity of the sores, he hoped that it was only herpes^
but as they persisted, became indurated and ulcerated
more freely, he touched them all with nitric acid. When
the effects of the acid had passed off he applied iodoform,
but still took no medicine. Finally he had fever and an
abundant eruption came out.

Dr. Z came to me a few days after the appearance of

his eruption, two months after the contagion and one after
the recognition of the sores. He was freely covered on
chest and abdomen by a characteristic erythematous and
papular eruption. He had had much aching in his bones,
and he thought some sore throat. I could, however, find
no trace of sores in his tonsils, His seven chancres had all
healed under the influence of iodoform, and were all in the
well-known parchment condition. Any one of them might
have been recognised without risk of error as an indurated
chancre, although none were of large size or much thickness.

No. LXXXVII. — A healthy family after Vaccination-
Syphilis.

Mr. W , jun., was one of those whose cases are narrated

in my first Report on Syphilis from Vaccination, 1874. He
suffered rather severely, and his arm-chancre recurred several
years later. He married in 1878, seven years after his
syphihs. In 1885 he brought his eldest child, who looked
quite healthy. He then had three living and healthy
children, and had lost none. He was himself in good
health.
I mention this case because some authors hold that erratic

>r non-venereal chancres are productive of more severe

yphihs than others.

364 SYPHILIS.

No. LXXXVIII. — Reputed transmission of Sypliiln
seven years after tJie primary disease in the
father — Fallacies.

I have so often expressed the opinion that syphilis is very
rarely transmitted to offspring when several years have been
allowed to elapse before marriage, that it becomes a duty to
record any facts which may seem to be an exception. One
such is the following. I treated a gentleman from Cornwall
on account of periostitis affecting his os calcis, and at the
same time excised one of his eyes which had been lost. I
sent him to the seaside, and he took specifics for several
mo&ths, with the result that he entirely regained his health.
This was in 1881 ; and in 1888, with my full permission, he
married. The attack of sjrphilis to which we referred his
periostitis was twelve years back from the date of his
marriage, but he had had another sore, without constitutional
symptoms, seven years later.

It was in June, 1876, that I first saw him for the node on
the OS calcis, and in October, 1881, he was under the treat-
ment of another surgeon on account of another chancre.
This second chancre led to nothing, and at the time of his
marriage he appeared to be in excellent health. He married
in April of 1888, and in December of the same year his wife
was delivered of a seven months* child, which subsequently
suffered, as I was assured by a very competent man, from
symptoms of sjrphilis which were unmistakable. His wife
also after her confinement had an eruption of an erythe-
matous character on her chest and body which was beUeved
to be specific. I did not myself see either the child or its
mother.

If the above facts can be trusted, it will be seen that a
man who had himself had no symptoms of a secondary or
tertiary class for thirteen years, and in whom seven years
had elapsed since a primary sore of doubtful character, was
the father of a sj^hilitic child which caused contaminatioo
to its mother. But we must glance at the fallacies.
Although my patient assured me most positively that he

THE RECURRENT CHANCRE. 365

had had no primary symptoms since the date mentioned, he
yet admitted having been exposed to risk, and we well know
that infection sometimes takes place without the primary
sjnnptoms being observed. The case is in my experience so
entirely exceptional, that I feel much more inclined to
suspect that fresh syphilis had in some way been contracted
shortly before marriage than to take the view which the
patient wished me to entertain. The credibility or other-
wise of such evidence depends much upon the frequency
with which it is offered to us, and I may repeat that my
experience has afforded extremely few narratives in the least
parallel to the above.

This case is of further interest as an example of the per-
manent cure of a very troublesome node. The os calcis

was very much thickened when Mr. P first came under

my care, and his treatment gave us a great deal of trouble.
It was of two years' standing, and he had already taken
specifics for a considerable time. It entirely prevented his
walking or wearing a boot. The treatment which succeeded
was a long course of large doses of iodide of potassium
during residence at the seaside. What is somewhat
remarkable in connection with bone syphilis, after it once
got well there was never any tendency to relapse.

No. LXXXIX. — Recurred Chancre or New Infection

— A question of Diagnosis.

Captain A 's case is, in reference to the theory of

recurred chancres, a very peculiar one.

In 1888 he had a soft sore, which he treated himself by
local applications only, which healed in a fortnight and was
not followed by secondaries. It left, however, a definite
scar.

In January, 1896, he had gonorrhoea, or more probably
a urethral chancre, and at the same time a large sore on one
finger which was no doubt a chancre. Six months after
the beginning of these (in July) , he was sent to me covered
with psoriasis-lupoid eruption of a very severe character.
Under mercury this quite disappeared, and in six months

366 SYPHILIS.

he was well but covered with deeply pigmented stains. He
now left oflf specifics,* and he remained quite free from
symptoms and in good health until December 1, 1897.

On December 1, 1897, he came to me again with a very
definite induration of considerable size, with rounded
elevated borders and a depressed centre. It was in the
corona, and, as he positively assured me, exactly in the site of
the '*soft sore" which had occurred nine years ago. The
scar of the more recent sore on his finger remained quite

sound and quiet. Captain A admitted having exposed

himself to risk just about a month previous tp this con-
sultation, and said that the "sore had followed about two
weeks after this occurrence.

I feel almost certain that this new chancre ought not to
considered as a gumma, but rather as the result of a new
contagion modified by the fact that he had recently been
under treatment for syphilis. If it were independent of the
recent exposure to risk and of spontaneous formation (i.^.,
an indurated gumma), then it seems more probable that the
process would have affected the site of the sore on the
finger or that near the meatus, both of which were true
chancres, whilst the scar in the corona was left by a sore of
short duration which was not followed by secondaries. Its
relation to the scar is probably simply that the latter was
a vulnerable part and thus favoured the absorption of virus.

No. XC — BemarJcable persistence of Secondary

Symptoms.

In the case of Mr. A , the secondary phenomena of

syphilis were somewhat peculiar and remarkable for their per-
sistence. This gentleman was 39 years of age when he for
the first time contracted chancres. They were, as is but too
common, diagnosed as being " soft," and no treatment was
resorted to xmtil he was covered with eruption. When he
came to me, in probably the third month from date of con-
tagion, he was literally covered with erythematous blotches,
which in some parts threatened to become papular, and the
roll of the reflected prepuce, from the froenum on one side to

SYPHILITIC MASTITIS. 367

the same point in the other, was involved in induration. He
had no sore throat. Mercury was, of course, at once pre-
scribed. A sHght ptyalism occurred at the end of a
fortnight, and at the end of a month the induration had
gone, and to a large extent the eruption also. Two months
later, however, although he had not wholly left ofif mercury,
the eruption showed a tendency to return. The mercury
vsras increased and regularity in taking it was insisted upon.
In spite of this, however, the eruption persisted, and a
month later still his back was still covered with large
erythematous patches and rings, and there were many also
on his limbs. The eruption was at this stage very peculiar.
It consisted of erythematous patches, some oval, some
round, and some irregular, all of which enclosed a pale,
almost white centre. Most of them were from the size of
a shilling to that of a halfpenny, and none showed the
slightest tendency to become pustular or even papular, and
from all the congestive redness was discharged completely
by pressure. There was no eruption on the face and but
little on the front of the body, but the back was covered.
It will be seen that the patient had now taken mercury for
four months. He was well in health, and from first to last
had had no sore throat. His chancres had quite gone, and
showed no tendency to relapse. It should be added that he
had formerly suffered from malaria.

It would seem certain that the mercury had kept the
disease in a condition of three-parts cure. Probably we had
not given quite enough.

When I last saw this patient (Oct. 29) he was returning
to his home abroad, and was almost, but not quite, free
from eruption.

No. XCI. — Gumma of one Mammary Gland in a
man after Syphilis and during treatment — Com-
plete but very gradual disappearance — A family
history.

It was ten years after the first syphilis, whilst under
mercurial treatment for a second chancre, and when the

368

SYPHILIS.

latter was disappearing satisfactorily, that the mammary
gland enlarged. It became of considerable size and very
hard. It was evenly rounded, and the nipple was fixed. It
caused no pain. This enlargement persisted, with but little
change, for six weeks. Meanwhile the chancre had become
parchment-like, but no secondary sjnnptoms had shown
themselves. After this, under the steady continuance of
mercury, the induration of the gland slowly diminished, and
in the following June no trace of it remained. Not long
after this he married (against my advice). Two years later
I saw him again for sore throat of a specific nature, and
ascertained that he had had no relapse in the breast, and
nothing further of the nature of tertiary symptoms. His
wife had remained well and had borne him two children, one
of whom had died of inanition, aged one month, whilst the
other, aged two, was in good health. Early in 1893 he had
a fresh sore, but no secondaries followed.

From this date till his marriage, twenty months later, he
continued the use of mercury. He married against my
advice. His wife remained quite well, but their first child
died, set. one month, of "inanition.'* He himself remained
quite well until 1898, when he had sore throat. Ulceration
above soft palate in right side. It is now better under
mercury and quinine. A smoker.

1884

25

1886

26

1886

27

1887

28

1888

29

1889

30

1890

31

1891

32

1892

33

1893

34

1894

35

1896

36

1896

37

1897

38

1898

39

Treated for syphilis, by Mr. Lee, by mercurial baths.
Mercurial baths. Sore throats troublesome.
I saw him for first time for his throat.
Mercurial treatment.

1

Quite well.

A new and very hard chancre in March. Breast enlarged.

Married in October.

First child died, set. one month, " inanition."
[Excellent health, but liable to herpes in penis and herpetic
j* sore throats. Second child, bom in 1896, healthy.

Comes to me with sore throat. In good general health.

DISEASES OF THE SKIN.

No. GIL — An exceptional form of Pruriginous
Eruption in a young child — (Varicella-prurigo ?).

On June 14, 1898, Dr. Fortescue Fox brought me a
patient in whose case the diagnosis was very difficult.
Those who are fond of names whicih have no real meaning
might have insisted that it was a form of " prurigo,'* whilst
those who desire that their name should imply some know-
ledge either of cause or natural alliance, might have wavered
amongst a number. It might be the result of flea-bites ; a
variety of psoriasis ; a lupus vulgaris multiplex in an early
stage; a sequel of varicella, i.e., a varicella prurigo, or a
hybrid between any two of these.

The patient was a well-grown girl of four years of age, of
gouty family. Her eruption was confined to the limbs and
face. The trunk was absolutely free. Thus the buttocks,
as well as the upper parts of thighs, were covered with
spots, but there were none on the loins and upper sacral
region, the favourite site of pruriginous lichen caused by
fleas. The absolute exemption of the trunk seemed indeed
to be conclusive against the idea of any insect causation.
The character of the eruption varied much in different parts.
Both cheeks were covered with spots, papules, and discs,
some of them more or less abraded, and all congested and
looking not unlike the very earliest stage of lupus. On the
arms and fore-arms the spots were more sparingly located,
but much of the same character. Many were slightly scaly,
like psoriasis guttata, and in a few glossy indurations had
formed like keloid. On the buttocks and thighs the features
of the eruption were much the same as on the arms, but the

VOL. IX. 24

370 DISEASES OF THE SKIN.

spots were more abundant and less indurated. On the legs
the spots were plentiful and more inflamed. Irregular in-
durations had been formed by their coalescence, and the
subcutaneous cellular tissue was involved. Some thin crusts
were present, but ulceration, although threatened, had not
actually occurred.

The history of the case gave us but little help. The
eruption in the first instance came out when the child was
on a visit in August, 1897. It was at first considered to be
chicken-pox, but it then affected the limbs only, and was
not severe. After a duration of three months it vanished,
and during the four winter months the child was quite free.
The next attack occurred in the following April, and again
when the child was visiting, but not at the same place. She
had been observed for some days to be out of temper and
tone, and then the eruption developed in successive crops,
and the cheeks were for the first time attacked. The erup-
tion on this second occasion was far more severe than on
the first, but it was not attended by any failure of health.
After it had been out a month, however, albumen was
discovered in the urine. The child was kept to bed, and
purgatives used, and this disappeared in the course of a
week. The irritation of the eruption had not been more
than moderate, and the child had kept her health, and slept
fairly well throughout. There was a history that in infancy
she had some vesicular eruption on the wrists and ankles,
but it had soon passed away. Vaccination had been per-
formed at the usual age, and without any ill consequences.
When I saw the child there was nowhere any indication of
vesication, nor any spots which showed much erythema as
if of recent formation. I was told, however, that fresh spots
did appear from time to time, and that sometimes there
were distinct vesicles. The eruption had never before
assumed such proportions as at the date of my consultation.

I presented this patient at one of my Demonstrations at
Park Crescent, and directed attention to the fact that the
eruption was almost exactly symmetrical and confined to
the limbs and cheeks. This, I remarked, was conclusive as
evidence against its being due to bites of any insect. A

DERMATOLYSIS EXFOLIATIVUS. 371

number of portraits illustrating cases of prurigo after
varicella and vaccination were placed by the side of our
naked patient, and the similarity was acknowledged to be
obvious. Taking into account the fact that in its first
outbreak the eruption was thought to be chicken-pox, I
ventured to say that I thought the diagnosis of varicella-
prurigo more probable than any other.

No. cm. — Tebb's Eruption (Keratolysis Exfolia-

tivus of Saiigster).

Dr. Sangster has published in the Journal of Dermatology
an interesting example of congenital exfoliation of the
epidermis, and accompanied it with an engraving from a
photograph. My chief concern with it at present is to ask
whether it has any relation on the one hand to congenital
pemphigus, or on the other to the eruption of which the
Tebb family were the subjects. Dr. Sangster's patient was
a man of twenty-four, and was one of ten children, of whom
four others were living and free from disease. His affection
was noticed in the third week after his birth, and began on
the forehead. By the end of the third year it had become,
as it remained ever afterwards, almost universal, the palms
and soles being the only parts exempt. The epidermis could
in some parts be peeled off in large flakes, the surface
becoming afterwards of a brilliant red, but without exuda-
tion. No bullae had ever appeared. Perspiration was
usually free, more especially in the palms and soles. The
case might have been considered one of aggravated ichthyosis
of the exfoliative tjrpe ; there was, however, no family pre-
valence. As showing some alliance to the Tebb cases. Dr.
Sangster records that the patient was liable to attacks three
or four times a year, in which the exfoliation became much
aggravated. There was, as in the Tebb cases, great irritation,
and, as in them, the appendages of the skin were not affected.
I cannot but think that the case is very closely parallel to
that of the Tebbs, and if so, further support is afforded to
Dr. Sangster' s conclusion that the disease was in the main

372 DISEASES OP THE SKIN.

non-inflammatory, and due to a congenital imperfection in
the development of the skin. In the Tebb family a brother
and sister were alike its subjects. Dr. Sangster names the
condition keratolysis exfoliativus. In the Tebb cases the
congenital peculiarity appeared to be a liability to urticarioas
irritation in association with keratolysis. Urticaria as a rule
is not followed by exfoliation. I have referred to this subject
at page 363 of Vol. VIII.

No. CIV. — On Common Warts.

A wart may be defined as an overgrown papilla which hs
protruded through the level surface of the epidermis, takir
with it only a very thin investment from the homy laye
In many instances two or more adjacent papillae are i
volved, and coalesce to form the wart. In what is call
the foliated wart the papilla has budded out in vario
directions more or less dichotomously, and a branch^
cockscomb-like growth is the result. When there is mu
foliation there is almost always a constricted base,
dilated arteriole always enters the stem of a wart. Althou
warts often, or indeed usually, occur in crops, they ne
become diffuse — that is, the papillae adjacent to them rem
quite quiet, and are not involved in the process. In spe
lating as to the cause of warts, we have therefore to :
what it is which gives to certain individual papillae a t
dency to grow beyond their due relations to the struct
of which they form a part. In reply to this question
may say that it seems certain that youthfulness of tisa
favours their occurrence, but not extreme youth, for t'
are seen frequently in children, but hardly ever in infants

GY .^—Eruptions following Varicella.

The following letter from the mother of a patient
explain itself: —

" Two and a half years ago Charlie had chicken-pox, which seemc
afifect his skin to an unusual degree, and it was quickly follo^we^

LOSS OF HAIR WITH AN ERUPTION. 373

jpernphigua^ which he suffered from in an acute degree for some months

in spite of Dr. C 's treatment, and it is only since early last simimer

that he has ceased to have any spots or gatherings. For a long time the
least blow or scratch would always cause a kind of gathering with a
great deal of discharge, and all the time he has off and on had this kind
of eczema. He has almost constantly taken the tonic with a small dose
of arsenic in it, and it has done him much good, but not cured him.

The subject of the above narrative was brought to me in
February, 1888. He was five years old, and was the subject
of a most troublesome pruriginous eczema. I prescribed a
tar wash and it suited admirably. In a few months he was
well.

]]-

\-r No. CVI. — Falling of the Hair after Influenza (?)

„iiv and in association with a Lichenoid Eruption

^^ on the Body.

Ill 1-'

A young woman, aged 27, who had formerly had an

unusually good head of hair, was sent to me because she

was losing it. Her hair had unquestionably become very

thin, and in parts, vertex and sides of temples, almost bald.

The hairs which remained were gathered into tufts of two,

three, or four together. There was a certain amount of

adherent dirty and sticky scurf in some parts and here and

there in little patches, and the skin of the scalp looked

coarse. Her hairs were strong and very long. I inquired

ate

tieK"-
:eJte
irt,t
s, tte-
itteiii-

P^P as to her nails, and she told me that she had had (in October)
*\* an illness, during which the nails and finger-ends became
'^l blue. It was called influenza ; she felt very weak and was
lessot- ^^ j^gj ^ week. During this illness she had '* red patches of
utv^^ the arms, neck, &c., which kept moving about.*' They did
rin# uqI; [iq]^^ }y^^ burned. The falling of her hair occurred

chiefly after this illness, and sometimes she would lose an
,, ounce and a half or even two ounces a day. These weights

are explained in part by the great length of her hair. Asked
^ patient as to whether she had any skin disease now, she said she had

a patch between her shoulders, and showed me one the size
.^^ of the palm of the hand, over which were rough lichen spots
^^[^0 and numerous tufts of dilated capillaries (like a neevus).

374 DISEASES OF THE SKIN.

She is a tall, rather thin yonng woman, of rather fair
complexion and feeble circulation ; often pale, with dnsky
lips.

I polled out many hairs. Their bnlhs looked thin. None
broaght away the root sheath.

No. CVII. — Disease of the Nails and Fingers be-
ginning in Childlwod — Family history of Skin
Disease — A modified form of Psoriasis.

Miss M , aged 16, a florid girl in excellent health,

was brought to me by her mother, March 17, 1898. I was
told that some years ago I had treated one of her aants
(maternal) for similar disease.

The condition was that of dry and cracked finger-ends, with
pin-pricked finger-nails and dry cracks across the flexures
of her finger-joints. The nails were also somewhat under-
mined. They were much disfigured. The fold between
thumb and forefinger was dry and cracked, and she had
formerly had some ill-defined dry scaly patches extending
from this fold towards the pahn. The paku itself was soft
and healthy. There was no xerodermic condition of the
skin generally, and she was accnstomed to perspire readily.
On the tips of both elbows and on the fronts of both knees
were dry scaly patches, but they were ill-defined and by no
means presented the conditions of characteristic psoriasis.
Of the nails the thnmbs were the worst, and the Httle and
ring fingers were almost wholly exempt. Toe-nails reported
free. She h^ had sebaceous tumours of the scalp since the
age of six.
had been t;
phanic aci
time her m
of dry dusl
It was bel
that time
defir'*" '™'
el'
hi

ECZEMA AND XERODERMA. 375

The family history was of much interest, and well illus-
trates the doctrines of transmutation in transmission. A
brother of the patient had from infancy suffered for a long
time and very severely from eczema. Of this he was now
well, but with a dry skin and such liability to asthma that
he was obUged to live at the seaside. A sister had a *' dry
skin,'* but no definite disease. On her father's side there
vsras a history of eczema. The following are notes of the
state of skin in a maternal, aunt, who, as already stated, had
been formerly under my care : —

No. CVIII. — Notes of case of Pruriginous Eczema
on a Xerodermic Skin (Patient, the Aunt of
the preceding one).

May 24, 1895. Mrs. A , aged 45, consulted me on

account of a pruriginous eczema on a xerodermic skin.
She stated that she had troublesome eczema as an infant,
and did not get well of it until, at the age of ten, she was
sent to the Askem baths (sulphur). She was liable, on
taking exercise, to burning heat in the skin, without per-
spiration. She had taken much arsenic and had become
liable to numbness of her fingers, which often caused her to
drop things. She believed that her family was gouty, and
one of her grandmothers had, she knew, suffered from an
eruption. I advised the disuse of arsenic, and prescribed
local measures only. I heard subsequently that she was
much better.

No. CIX. — Symmetrical Pigmented Areas on sides
of cheeks, temples, and Jiands — A form of
Morphoea (?).

Jn the following case an eruption of brown or blackish
vithout perceptible induration or thickening, seemed
substituted for the more ordinary conditions of
ea. The type of morphoea was that in which there
herpetiform bands, but in which symmetrical ill-
areas are affected (Mr. Denner's tjrpe).

376 DISEASES OF THE SKIN.

Mrs. C dated all her ailments from a shock from a

gas explosion in June, 1895. In Jmie of the following year
she had a miscarriage, after which "an irritable eruption"
appeared on her hands and face. She had previously
suffered from urticaria on her legs. The eruption soon
assumed the condition of brown stains, and for these she
was sent to me on January 10th, 1898.

The parts affected were the cheeks near to the ears and
the temples. The nose and whole front of face were normal.
Mainly the changes were those of pigmentation only, but I
thought that the affected area was slightly thinned and some-
what rigid. She had often been told that her face needed
washing. On the backs of her hands were numerous brown
spots which looked like lichen, but were quite imperceptible
to the touch. The regions involved were quite symmetrical.
Opinions might have differed as to whether or not they were

slightly indurated. I thought that they were. Mrs. C

said that the spots on the backs of her hands had been
usually red rather than brown.

Mrs. C was liable to a sensation of violent throbbing

in her head with noises in her ears. She had also much
pain in the small of the back and a bearing down in the
iliac fossae. She was also subject once or twice a month to
violent headaches, attended sometimes by slight epileptoid
attacks, followed by collapse. After these she would regain
consciousness but slowly. She had also very cold feet, and
according to her own expression, ** everything went to her
head." She did not consider that she was losing flesh or
strength. Her eyes were white and watery. She told me
that she could not take either quinine or arsenic.

MISCELLANEOUS.

No. CCCXXI. — Is Cystinuria a '^family disease "

or an '' heritable disease " ?

A distinguished writer on the urine states that **a curious
circumstance in the history of cystinuria is its tendency to
run in families.*' He then proceeds to cite as evidence that
Dr. Marcet observed it in two brothers, that both Lenoir
and Civiale had operated on two brothers, and that Peel
relates the case of two sisters who voided cystinous urine.
But clearly not one of these four cases illustrates more than
** family prevalence'* in the technical sense. To **run in
families " should mean to descend from parent to oifspring,
but here we have nothing of the kind proved. Nor am I
aware that inheritance has ever been observed in the case of
cystinuria.

No. CCCXXII. — Family Prevalence in relation to

Inheritance.

Family prevalence, as distinguished from inheritance, is
certainly a remarkable phenomenon. It would imply that
conditions so produced are due to some peculiarity resulting
from that particular couple, and not from either parent
singly. The close similarity often observed in twins, both
as regards features and morbid tendencies, is an example of
the same kind of influence. In animals which bring forth
many at a brood we find no difficulty in conceiving that one
litter may differ from others bred of the same parents. An
instance in which of a litter of rabbits nearly all had con-
genital cataract once occurred under my own observation.

378 MISCELLANEOUS.

Probably it will be found on careful investigation that this
diflference between inherited and family prevalence, upon
which Adams insisted so strongly, is not, after all, of univer-
sal prevalence. Some degree of inherited tendency may
probably be found in most instances of family prevalence.
In the case of retinitis pigmentosa and deaf-mutism this is
not infrequent. Still, however, the main fact remains un-
questioned that it is quite possible for several brothers and
sisters to show some very pecuUar form of proclivity which
cannot be traced in any progenitor.

No. CCCXXIII. — On Vibrissce (Nasal and Aural)
as indications of race and family descent.

Amongst personal peculiarities which may go to the
recognition of family inheritance are the development of
hairs in the nostrils and in the external ear. In the nostrils
these hairs have been named Vibrissae, but I am not aware
that those occurring in the ears have received any special
name. Some persons have the orifices of the nostrils com-
pletely protected from the entrance of dust by the develop-
ment of these hairs. They grow, I think, more usually
from the projecting fold of skin on the inner side which
covers the columna, but some may often be found just
within the outer margin as well. In the ear, the large tuft
of hair often springs from the inner side of the tragus, and
crossing the orifice, they completely protect it from intruding
objects and to some extent from cold air. Those who have
abundant vibrissse very commonly, I believe, have these
tragal tufts of hair also. A Scotchman of my acquaintance,
a thin, spare man, has both his nostrils and his ears quite
occluded by these growths of hair.*

Perhaps we might suitably speak of the hairs in the ear
as aural vibrissse. Careful observation might perhaps

• Quain, describing the vibrisssB, says, " Within the margin of the nostrils
there are several short, stiff, and slightly curved hairs which grow from the
inner surface of the alse and septum, nasi, up to the point at which the skin
is continuous with the mucous membrane lining the cavity of the nose."
Respecting the ear, he says simply that the tragus is frequently covered
with hairs.

U

PERSISTING PELLICULAR CONJUNCTIVITIS. 379

enable us to make some use of the presence or absence
of these hairs as indicative of race. In all probability they
belong chiefly to those races and to those individuals in
whom the growth of the beard, whiskers, and moustache is
also abundant. They occur chiefly, if not exclusively, in
men. Whether they are in any relation to the general
tendency to hirsute development in the individual I am
unable to say, but should think it probable that they are
rather local peculiarities incident to certain families belong-
ing to hirsute races. As indications of family relationship
no doubt they have their value and are worthy of study.
Sometimes the regions affected by them become the seats of
sycosis, and the removal of the hairs is then necessary.
Under all other circumstances their presence is rather to be
regarded as an advantage to their possessor.

No. CCCXXIV. — Persistent Pellicular Conjunctivitis
with lupus-liJce thickening of Mucous Membrane
— Death from Croup.

The patient to whom the following note refers was a
little girl of six years old. I saw her only once. She had
the mucous membrane of her upper eyehd much thickened
and partially everted. The thickened surface was covered
by a thick coherent membrane, and bled when the mem-
brane was detached. The condition, I was told, had been
present several years, and had resisted all treatment. She
was the niece of a physician who brought her to me, and
who had previously obtained much highly skilled advice.
I thought that the disease was a combination of lupus of
mucous membrane with pellicular formation, and advised
the free use of the actual cautery. The appended letter
gives all the further details with which I am acquainted.
It would appear that the child had a remarkable proclivity
topeUicular (diphtheritic) formations.

*'Dear Mb. HuTCHnfsoN, — On the 8th of July last, you were good
enough to look at my niece, who had been sufifering for the last five years
ammnre from an extraordinary affection of the eyelid. This you were

380 MISCELLANEOUS.

inclined to think was a form of lupus, but said that you had never seen a
similar case.

'* As to the result of treatment, no kind of cauterisation, Paquelin or
other, had the slightest result, the false membrane forming again alxaost
immediately.

** I regret to say that the child died after two days* illness — the cause,
* Croup and Bronchitis.' The remarkable fact about this is that less
than a year ago she had been subjected to a six- weeks course of injec-
tion with Diphtheria Antitoxin in St. Thomas' Hospital, into which she
had been admitted in order that that treatment might be thoroughly
carried out. You may perhaps remember that she was an exceptionally
well-developed child for her age.

" I promised to let you know the further progress of the case, so tell you
all I know ; but I have not seen her myself since the day you examined
her. Believe me very faithfully yours,

" P. B. M."

No. CCCXXV. — hifluence of Race and Diet in
Leprosy and Tuberculosis in Japan.

The following extract is from the pen of a Japanese
physician and contains some important facts. I take it
from one of the reprints, &c., which Dr. Albert Ashmead
sends us from time to time across the Atlantic :

** Among the classes backward in development, leprosy
still preserves its sway. In Japan, the population may be
divided into three classes. In the rich, noble class, almost
pure Indonesian blood, inbreeding of four families for 1200
years, leprosy is very rare. In the great middle class it is
more frequent. Among the outcasts, the Eta, the negroid
element, it is rampant.

*' In the first class tuberculosis makes numerous victims,
more than in either of the other classes ; in the second class
sjrphilis is the prevailing scourge, and has been so for 1300
years ; the third, as before said, is a prey to leprosy.

** These three different bacilli seem to have picked out
their ground during 1300 years in which the closely-hemmed-
in and isolated empire has been preyed upon by them.

** By changing the environment congenial to the microbe
one can change his characteristics. A change in the con-
ditions of the lower class of Japan to the hi|^H^plaqewonld
probably produce a corresponding changs.i

FISH AND LEPROSY. 381

** Two factors are necessary for the prevention of leprosy :
obstacles to inoculation, that is isolation, and improvement
of the human class preferred by the bacillus.

** The Ainos of Japan, who have been always isolated
from the Japanese, have never contracted leprosy (yet they
are the greatest salt eaters in the world). This might be
considered as an isolation of the healthy. It is our desire
to have the whole human race isolated in the Aino manner.
'*We do not know, of course, whether the Ainos have
ever been inoculated. One individual would have acted as a
nucleus for the disease. It is very probable that in the
course of twenty centuries one or more Ainos were inocu-
lated. However well isolated they were, although shunned
by the Japanese as dogs because of their hairiness, as the
country was after all a leper centre, some individuals were
contaminated. Some poor Aino must have at some time
joined the company of some outcasts in the Eta villages.
The inoculation is certainly very probable ; and the absence
of the disease among the Ainos is certain. We assume,
therefore, that the Aino has immunity, or that the bacillus
does not prosper in Aino flesh. Now, here is a curious
remark : ' There has always been a suspicion that fish diet
has something to do with leprosy. Now the leprous Japanese
eats a great deal of fish, and no meat ; while the Aino feeds
on bear meat, and is not very fond of fish ; he is, in fact,
a nomad, consequently a hunter.' *'

No. GGGXXYl.—Salt^fish in Iceland..

** Of Iceland to wryte is little nede
Save of stock fische."

These were the opening lines of a chapter in a geographical
work of the sixteenth century.

No. CCGXXYU.—aeneral Pruritus from Fish.

"I become 'quite itchy if I eat salmon." This was an
expression used by a patient, and supports an opinion which

382 MISCELLANEOUS.

was long ago forced on my mind that fish is often a cause of
general pruritus, even in persons who do not develope actual
urticaria.

No. CCCXXVIII.— -N^imm Diligentia.

It is an interesting illustration of the fact that to cease to
do evil is often the first step in medical improvement, that
one of the chief claims to the gratitude of posterity which
the biographers of Petit put forward is that he succeeded in
persuading surgeons th^t it was not necessary to cut the
frcenum lingu© of infants.

No. CCCXXIX. — Consultation Practice in the last

Century.

It is recorded quaintly of Dr. Thomas Wilhs, when in
practice at Oxford, that ** He pursued his profession and
kept Abingdon Market** (Hutchinson, Vol. II., p. 481).

No. CCCXXX. — Distinction between a Stroke and

a Fit.

The' popular distinction between a stroke and a fit was
well illustrated by a hemiplegic patient who asserted, *'I
never had a fit; I never lost my senses; I only had a stroke."

No. CCGXXXI.— Doctor and Patient.

Consultant : "\i\Tio are you under ?

Patient : Well, you see I go once a week to Dr. Brown,
but whether I am under him or he is under me, I never can
quite tell. I believe he would admit that I have had more
experience of my complaint than he has.

No. CCCXXXII. — Death of Van der Linden from

Pneumonia.

Dr. Van der Linden, of Leyden, 1604-1664, died after a
short illness in March, 1664. Guy Paton, of Paris, who

CAUSES OF DEATH OF DISTINGUISHED PERSONS. 383

T?vas his friend and correspondent, thus mentions his death
in one of his letters: **Van der Linden died at Leyden,
aged 53 years, of a fever and defluxion on the lungs, after
having taken antimony and without being blooded. What
a pity it is that a man who wrote so many books, and was so
well skilled in Latin and Greek, should die of a fever and
suffocating catarrh without being blooded.'* The illness
was probably catarrhal pneumonia.

No. CCCXXXIII.— D^a^/^ of Sir Thomas Browne

from Abdominal Obstruction.

Sir Thomas Browne (Beligio Medici) died after a week's
illness from ** colic, with much suffering.*' He may have
had an impacted gall-stone, or possibly a stricture and
blocked bowel. He was aged seventy-seven.

No. CGGXXXIY.— Cause of Napoleon's Death.

Napoleon Bonaparte died at the age of 52 of cancer of the
stomach, May, 1821. His father had died at the age of 38
of the same. Napoleon was the son of a very young
mother. His mother was possibly not sixteen when he was
bom, and certainly not twenty.

Cancer is, I believe, more common in the children of aged
parents than of young ones. We must, however, here
bear in mind the inheritance, and also the depressing and
annoying conditions under which Napoleon's last years were
passed. There can be little doubt that mental depression
disposes the tissues to cancerous changes.

No. CCCXXXV. — Coleridge at the London Hospital.

Guy's Hospital has long made its boast of Keats, but it is
perhaps not so well known that Coleridge was at times an
amateur dresser at the London. The following is from his
autobiographical memoranda : ** About this time my brother
Luke, or " the Doctor," so called from his infancy because,

3t» MISCELIiAMEOUS. I

being the seventh son, he had from his infancy been devi:-
cated to the medical profession, came to town to walk ir-
London Hospital nnder the care of Sir William Blizari
Mr. Samnarez, brother of the Admiral Lord Sanmarez. ^ca?
his intimate friend. Every Saturday I could make or obtain
leave, to the London Hospital trudged I. O the bliss if I
was permitted to hold the plasters, or to attend the dressing-
Thirty yeare afterwards Mr. Samnarez retained the liveliesj
recollections of the extraordinary, enthusiastic blae-coa;
boy, and was exceedingly affected in identifying me wilfc
that boy. I' became wild to be apprenticed to a sorgeon.
English, Latin, yea, Greek books of medicine read I
incessantly. Blanchard's Latin Medical Dictionary I h3<5
nearly learnt by heart. Briefly, it was a wild dream, which
gradually blending with, gradually gave way to a rage for
metaphysics" (p. 22).

INDEX TO VOL. IX.

A

Abortive herpes ,

Absence of digits ,

of limbs ,

of odour in urine after eating asparagus

of pectoral muscle ,

of testicles ,

Aconite, effects of doses ,

Albinism as a family peculiarity ,

Albuminuria , ,

Alcohol as a hypnotic ,

Acromegaly ,

Anchylosis of elbow, usefulness of hand ,

of patella

— of wrist

Antimony for lichen planus ,

Aphorisms respecting inheritance ,

Apoplexy, hasmorrhagic ,

Arcus senilis as a symptom

Arsenic cancer ,

keratosis ,

cancer of cBsophagus after

causing ascites

effects of large doses

herpes whilst using ,

causing herpes ,

zosteriform pigmentation after

Arteries, occlusion by coagulation

Ascites caused by arsenic

Asparagus, absence of odour in urine after ....
Atrophy, white, of optic discs

kuditory nerve epilepsy ,

B

less in the two sexes

ntyne. Dr. J. W., letter from

I's malady

notes on, in connection with sex ,

■al herpes ,

ikins in syphilis ,

cancer of

)s mistaken for syphilis ,

VOL. IX.

211

163

167

185

171

169

186

285

26

85

293

91

92

352

275

283

357

388

63, 223, Plate 20

223, Plate 20

52

184

185

212, 220

83, 117, 221

86

100

184

185

68

43

89

166

230

267

219

246

145, 150

334

11

INDEX.

Cancer and the cancerous process

arsenical

fractures of bones in cases

in both breasts

of the breast

of GBsophagus after arsenic

of tongue

Carbolic acid for lupus erythematosus

Carotid artery, position of, in tumours of neck

Cartilaginous tumours of digits

Chfuicres assuming type of frambcasia

progress when mercury not given . .

Chancre of finger

recurrent

Choroiditis disseminata

with inherited syphilis

Circulation in paralysed limbs

Coagulation, occlusion of arteries by

Cold feet

CoUes* fracture, splint-treatment

Coloboma, intra-uterine repair in

Congenital absence of pectoral muscle

defect in femur

defects in lower extremities

ichthyosis

Conjunctivis, pellicular

Contraction, painful, after injury

Cramp after sleep

Cyclitis in connection with gout

relapsing

Cystinuria, is it a family disease ?

D

Dactylitis

Deafness, with herpetic teethache ....

Dermatitis, urticarious

Dermatolysis exfoliativus

Detachment of epiphysis of humerus . .
of retina, complete

of retina from sea-sickness

Diary, extracts from my

Dichotomy, posterior

Dickinson, Dr., cases by

Diet and therapeutics.

Digits, absence of

cartilaginous timiours of

Double monsters

Dwarfdom •

Dwarfing in inherited syphilis

E

Ears, lobules affected by xanthoma . .
Eczema and xeroderma

scrof ulosorum

Elbow-joints, symmetrical deformity . .

Encephalocele, occipital

Epilepsy after syphilis

VOL, IX-

237, 341

63, 223, Plate 20

148

150

145

52

289

84

345

299

247

362

79

78,366

355

356

93

100

338

276

169

171

169

161

55

379

69

132

354

180

376

144

136

75

371

90

178

180

289

171

101

82, 184, 273

163

299

171

170

3

201
375
291
296

164, 167
68, 126

INDEX.

Ill

Epilepsy, auditory nerve .
retinal, so-called.

Epileptic hemiopia

Epiphysis of humerus, detachment of

Eruption after vaccination

Eruptions following varicella

in connection with gout . . ,

43

33

43

90

190

872

316

Erythema induratum 234

multiforme, neuro>catarrhal nature of j 301

Extracts from my diary ' 289

Eye, results from blow 178

VOL. IX.

P

Facial paralysis after herpes

paralysis in syphiUs

Fainting, fall in

Fatty tumour on finger

Feet, psoriasis-eczema of

Femur, congenital defect in

Finger-chancre

Finger, fatty tumour on

Fingers, vascular tumour of

Fish, general pruritus from

" Fish is Leprosy "

Fish-eating and leprosy in Persia . . . .

Foreign bodies in rectum

Fractures, multiple, in young children
of bones in cancer cases . . . .

Fragmentary notes

Framboesia, chancres assuming type of

in an Englishman

Futility of microscopic diagnosis

219

360

339

189

52

169

79

189

255

381

188

86

278

295

148

284

247

Plate 160

271

G

Greneral paralysis of the insane

George II. , death of

Glans penis, pigmented stains on

Gout, cyclitis in connection with

diseases of skin in

eruptions in connection with 315

inherited, ophthalmitis of ' ^^77 yjg

Gumma of one mammary gland ; 357'

Gummata, nature of hq

of testes '. . 248

152
94

75, 136
354
285

G

Hsemorrhage into vitreous 181

Hsemorrhagic apoplexy 357

sarcoma 60

Hair, falling off, after influenza ' 373

Hands, psoriasis-eczema of 52

Hematuria with Beynaud's phenomena 88

Hemiopia I 202

epileptic '43

Hemiplegia in syphilis 250

Herpes, abortive 211

after arsenic , 83, 117, 221

IV

INDEX.

Herpes after injury ,

bilateral ,

double and multiple

facial paralysis after ,

of buttock, recurring

of pharynx, recurring

of pharynx, severe

ophthabnicus

painless

recurring ,

whilst using arsenic

Herpetic stomatitis

teethache and deafness

Horripilatio

Humerus, detachment of epiphysis

Hyalitis, recurring

Hydrocele of neck

Hydrocephalus

Hydrocystoma

Hypospadias, with absence of testicles

Iceland, salt-fish in

Ichthyosis, congenital

Indian hemp, use of

Induration, peculiar form

Infantile pemphigus

Inheritance, aphorisms respecting

Inherited syphilis, selected dases

choroiditis in connection with

osteitis from

retinal epilepsy in

Intra-uterine repair of defects ,

Ischsamia, retinal

Japan, leprosy and tuberculosis in

K

Keloid

Keratolysis exfoliativus

Leprosy and fish-eating

and fish-eating in Persia

^ and tuberculosis in Japan

Lichen scrofulosorum

planus, antimony in its treatment

planus of palms

spinous form

Life insurance and syphilis

Lobules of ears affected by xanthoma. .
Lorenzo the Magnificent, last illness . .

LunulsB, note as to

Lupus erythematosus

carbolic acid for

Lupus of pharynx

VOIi IX.

215

219

212

219

127

125

217

209

130

125, 127, a06, 220

212, 220

114

186

132

90

175

170

192

159, Plato 144

168

381

55

82

78

18

283

1,139

356

187

39

169

37

380

237
371

188

86

380

243

275

258

72

289

201

94

284

290, Plate 142

84

191

INDEX.

Lupus resembling psoriasis

sebaceus ,

— vulgaris multiplex .

Liyxnph-adenoma

malignant

Lyinphatic glands, diseases of . .

Lympho-sarcoma, acute

after syphilis

M

Mabey group

Malignant lymph-adenoma

Mammary gland, gumma of

Meagre statistics, danger of

Melanotic sarcoma of skin

Mercury causing deformities of teeth

progress of chancres, when not given

Microcephalus

Microscopic diagnosis, futility of

Milk abscess

Morbus C0X8Q senilis, double

Morphoea, case of (?)

Mortimer's malady

Multiple fractures in young children

lupus vulgaris

Myxoedema, case of.

N

Nsevus, obliteration of large

Nails, disease of

psoriasis of

Nervous system, diseases of

Neuro-catarrhal nature of erythema multiforme.

Nomenclature, remarks on

Numbness, subjective

O

Occipital encephalocele

Occlusion of arteries by coagulation
GBsophagus, cancer of, after arsenic

01ecra^on, prolongation of

Ophthalmitis of inherited gout

Ophthalmoplegia, sequel of case . . . ,

Opium in Raynaud's disease ,

Osteitis deformans ,

from inherited syphilis . . . ,

^ain in shin-bones

unfol contraction after injury

«|imalady

^H||hen planus of

^^^^ ~oles, dry eczema of
various forms of
circulation in..

VOL. IX.

92
71
77, 307 ; Phites 67,

68, 76, 77 \
819
50

44, 270, 822
381
828

180

50

867

286

844

288

862

148

271

829

259

875

807, Pis. 152, 163

295

77, Pis. 67, 68, 76,

77
850

256

874

72

65,857

801

27

65

164, 167

100

52

191

177, 179

107

88

288

187

187

69

240

258

57

260

98

VI

INDEX.

Paralysis agitans ,

facial, after herpes.

in syphilis

general, of the insane

Paraplegia, recovery from
threatened

Patella, anchylosis of

Pectoral muscle, congenital ahsence

Pellicular conjunctivitis

Pemphigus and its variants

syphilitic

vegetans

Persistence of secondary symptoms

Pharynx, lupus of

recurring herpes of ....

severe herpes of

Pigmented areas, a form of morphcea (?)

patches on glans penis

stains on abdomen ,

Plugging of veins

Posterior dichotomy

Proctalgia, urethral pain with ....

Pruritus, general, from fish

Psoriasis-eczema of hands and feet ,

Psoriasis of the nails

Ptosis in a boy. ,

Pulse, radial, extreme feebleness

B

Ilaynaud's disease, opium in ,

phenomena with hematuria.

Bectum, foreign bodies in ,

Becurred chancre ,

urticaria

Becurring herpes.

hyalitis

of buttock ,
of pharynx.

Belapsing cycUtis

Betina, detachment from sea-sickness

complete detachment

Betinal epilepsy, so-called

ischsemia ,

Betinitis pigmentosa

Bheumatic gout

Bodent ulcer in brother and sister

S

Salt-fish in Iceland ,

Sarcoma hsBmorrhagic

in muscles ,

melanodes

of skin, melanotic

Scarlet fever after measles

Scirrhus resembling keloid ,

Sclerosis of tongue ,

Scrofula, ulceration of skin with

Sea-sickness causing detachment of retina

•*

vox., rx.

357

219

360

152

67

335

92

171

379

17

12, Plate 97

Plate 156

366

191

125

217

375

75,136

73

151

171

135

381

52

72

137

339

83

88

278

78,365

190

206,220

127

125

175

180

180

178

33

37

182

184

237

381

60

343

317

344

190

U7

INDEX.

Vll

Secondary symptoms, remarkable persistence

Senile papillomatosis

Sex, notes on bees and on

Shin-bones, pain in

Skin, diseases of

in conneotion with gout . . .-.

melanotic sarcoma of
ulceration of, with scrofula.

Spina bifida in two brothers

Splint-treatment in GoUes* fracture

Spondylitis deformans in a cat

Spontaneous obliteration of nsevus

Statistics, danger of meagre

Sterne, Laurence, death of

Stomatitis, herpetic

Symbiosis, in reference to human pathology

S3rmmetrical deformity of elbow-joints

Syphilis a form of yaws

bone-pains in

bug-bites mistaken for

choroiditis in connection with . . .

epilepsy after

facial paralysis in

hemiplegia in

inherited

dwarfing in

osteitis from

in Hindoos

in sixteenth century

in two brothers, course of.

life insurance and

lympho-sarcoma after . . .

mastitis ,

tertiary stage

three infections of

vaccination

Syphilitic pemphigus

VOL. IX.

36G

265

267

137

71, 369

285

344

233

168

276

352

256

286

94

114

97

296

349

246

334

356

126

360

250

1,139

3

187

79

96

78

289

323

367

246

361

363

12, Plate 97

Tabetic pains induced by cold

Tebb's eruption

Teeth-ache as distinct from " toothache
Teeth, deformities caused by mercury

Teratology

Tertiary stage of syphilis

Testes, gummata of

Testicles, absence of

Therapeutics and diet

Three infections of syphilis

Thyne, Dr., case by

Tongue, cancer of

sclerosis of

**

Tuberculosis and leprosy in Japan

Tumours of neck, position of carotid artery in

282

371

257

288

161

246

248

169

184.273

361

69

289

92

380

345

U I

Ulceration of skin, with scrofula ' 233

Urethral pain, with proctalgia 135

Urticaria pigxnentosa mistaken for syphilis ' 80

VIU

INDBX.

Urtioarift, reonrrent .
Urticarious dermatitis

Vaccination, eruption after . .

syijnilis

Varicella, erujptions following

Varioella-pningo

Vascular tumours of fingers ..

Veins, plugging of

Vesicating fire-stains

Vibrissa, nasal and aural . . . .
Vitreous, hnmorrhage into . .

W

Warts, common

corns, &c

White atrophy of optic discs.

Xanthelasma

Xanthoma as a symptom

in exceptional positions.

Xeroderma and eczema

Yaws

in Benin

— Englishmen, two cases
syphilis a form of

Z

Zoster, arsenical

whilst taking arsenic

Zosteriform pigmentation after arsenic

VOL IX.

190
76

189
863

872
869
255
151

279
876
181

872
260
68

35,92
200
201
376

Pis. 146, 147, 160

361

193, Plate 160

349

88,117
212, 220
86