^ ARCHIBALD CHURCH LIBRARY NORIHWESTCRN UNWERSHY MEDICAL SCHOOL THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID ON THE PSOEIASIS OH LEPEA ON THE PSORIASIS OR LEPRA BY GEORGE GASKOIN SOCIKTT OF LONDON, BTC. TC. LONDON J. & A. CHUECHILL, NEW BUELINGTON STEEET 1875 TO THE SKILFUL PHYSICIAN CHARLES JAMES BLASIUS WILLIAMS PBESIDENT OF THE ROYAL MEDICAL AND CHIRURGICAL SOCIETY &c. &c. &c. IN TESTIMONY OF HIGH AND COEDIAL ESTEEM COMMENCING FBOM THE EAELY DAYS OF STUDENT LIFE AND MAINTAINED UNDEVIATINGLY THBOUGH A LONG TEEM OF YEARS THIS WORK IS RESPECTFULLY DEDICATED BY THE AUTHOR TABLE OF CONTENTS CHAPTER I DESCRIPTION Name, 1 Scale or Crust, 3 Configuration of Patches, 9 Ringed Forms, 11 Colour, Seat, 18 Sex, 22 Stature, 23 Nation, 24 Condition, Season, and Locality, 24 Contagion, 26. CHAPTER II COURSE AND CHARACTER OP THE DISEASE Contrasts seen, 29 Independence of Texture in the Skin, 29 Duration, 31 Attendant Symptoms, 32 Pulmonary Tract much affected, 33 Acute and Chronic, 34 Illustrative Cases, 36. CHAPTER III CAUSES OF THE COMPLAINT Occasional Causes, 48 Antecedents of Psoriasis, 49 Internal Causes, 51 Catching Complaints, 52 Rheumatic Fever, 52 Asthma, 53 Phthisis, 56 Gout, 57 Direct Descent, 59 Insanity, 60 Cases, 61. CHAPTER IV AFFINITIES AND DIAGNOSIS Elephantiasis, 71 The Food Question, 74 Morphaea,74 Alopecia, 75 Lues, 76 Ichthyosis, 77 Lichen, 77 Acne Rosacea, 78 Lupus, 79 Erythema and Pernio, 79 Pemphigus, 80 Sycosis, 80 Eczema, 80 Cases, 81. Vlll TABLE OF CONTENTS CHAPTER V PSORIASIS PALMARIA ET PLANTARIA Frequently but not always Specific, 88 Seen in Young People, 90 Psoriasis and Eczema Manuum, 91 Rhagades or Cracks, 92 Commeneement of the Complaint, 93 Gyrate Forms, 94 Chalky Appearance, 95 Cases, 96. CHAPTER VI PSORIASIS OF OTHER REGIONS Lues, 105 Confusion of Diseases, 107 Psoriasis linguae, 108 Psoriasis genitalium, 114 Psoriasis infantilis, 115 Psoriasis pre- putialis, 119 Psoriasis palpebrarum, 119 Psoriasis labialis, 120 Psoriasis unguium, 122. CHAPTER YII PATHOLOGY OF THE DISEASE Defluxions and Catarrhs, 125 Humoral Pathology, 126 Neural Pathology, 127 Degeneration, Nerves, and Brain, 129 Haemo- ptysis, ] 29 Sterility, 130 Gastro -intestinal Tract, 130. CHAPTER VIII TREATMENT Bloodletting, General and Local, 131 Baths, 132 Warm Water Vapour Bath, 133 Sulphur Fume Bath, 133 Warm Bath, 133 Cold Water Cure, 134 Soap, 135 Diet, 136 Watering-places, 137. CHAPTER IX INTERNAL TREATMENT Arsenic, 139 Iron, 154 Cinchona and Tonics, 155 Antimony, 155 Pitch, Carbolic Acid, and Turpentine, 157 Acids, 157 Alkalies, 158 Purgatives, 158 Colchicum, 158 Cantharides, 158 Iodine, 159 Mercury, 159 Donovan's Solution, 160 Sulphur and Phosphorus, 161 Dulcamara, Rumex, Elm Bark, 161. TABLE OF CONTENTS IX CHAPTER X LOCAL TREATMENT Resembles that for Scabies, 163 Soap, 164 Brassage, 164 Caustic Applications, 165 Tar and Carbolic Acid, 165 Sulphuretted Water, 165 Alcoholic Washes, 165 Special Forms, their Treatment, 167. APPENDIX Impetigo excoriativa, 171 Serpentine Disease, 171 Sequelae of Smallpox and Vaccine, 171 Psoriasis, its dependence on Dyscrasia, 172 On Consumption, 172 On Cancer, 172 Confusion of Diseases, 173 Diseases and Extirpation of the Tongue, 178 Pearson's Solu- tion, 175 Girdlestone, 175 Biett, 177 De Yalangin's Mineral Solvent, 177 Robertson on Cantharides, 177 Attree, 178. PHARMACOPCEIA Mixtures and Drops, 179 Powders, 183 Lotions, 185 Ointments, 187 Baths, 192. CORRIGENDA Page 75, line 25; for "that is," read "that it is." 152, 20 ; for " one immediate," read " one of immediate." INTRODUCTION IN the prelude to this treatise it may not be amiss to say what it is that leads me to write on a subject so detached, or, let us say, so fragmentary as that which lies here before us. In the first place, I could not but feel, as well from what I chanced to see in print as from what I learnt by conversation, that the views I had of this complaint did not, in many respects, correspond with those which are commonly entertained. I was sometimes checked by assertions that were quite on a level with the age, but which I felt had a narrow ground in truth ; on the other hand, what I wished to impart had scarcely the same kind of privilege, and might even discredit me with the hearer. In this way I came to believe that the subject had lost a good deal by not being dealt with in extenso and made the special subject of a treatise. For in that branch of medical science which, if broken off from the rest, must pass under the name of dermatology, there is much, when it is dealt with systematically, beyond what may serve for present use ; much where experience gives little aid ; a good deal must be sacrificed to method and a certain forced equality in the species, regardless of number and proportion as found in our country or clime ; some space will be reserved for cases of purely exceptional interest, selected from a vast domain, as well as for original reflections ; anatomical data will also claim their share, as more than ever with avidity sought for ; so that, in fine, there remains far less room than is required to supply a familiar want, which is no other than to be able to Xll INTRODUCTION know the disease in all various shades and divergences. Instead of which, what we generally meet with is some sketch by a master hand, where a few bold strokes do duty for more lengthened exposition and more laboured treatment. The rest we must fill up for ourselves ; and we are also fortu- nate if some error is not entangled in the mesh, and the space is not further entrenched upon by some ideas the writer has about the growth of the complaint, which are wont to be of partial application, so that, after all, when a case presents itself, we have not learnt to know it by description. And this way we find not amiss the assertion of one of our contemporaries, a most experienced dermatologist, that espe- cially with these squainous affections it is necessary to pass over a good many cases before you alight upon one which answers with tolerable accuracy to the account that is given of them in books, and, in fact, many a writer has complained of the little attention that is paid to the mixed and interme- diate forms. In short, to serve the purposes of teaching, definition and the art of diagnosis are strained to such a pitch as to do extreme injustice to nature. And although nothing can be further from our aim than to detract from the merit of those to whom we lie most in debt for descrip- tions of this complaint, yet it must be allowed of these authors that they are not always in agreement among them- selves, and sometimes they do not spare to shock our com- mon sense and what we most rely on in experience. One cannot, indeed, admire too much the diligence and fidelity of these writers, inconceivable to those not princi- pally interested in such subjects, but neither are they wholly of one stamp, nor are they without those partial views and conceits, those prejudices too unduly entertained that are so much a reproach to our art and also to our art's professors. In paler copies of these which from time to time issue from the press, there is found at once a caution and a rashness that tells of inexperience in the writer. He is affirmative where most he had reason to be in doubt, he extenuates where there is room for authority, so that with all but the tyro and the crowd his laches are easily seen ; and, indeed, INTRODUCTION Xlll there is no room for trust, nor for any kind of confidence in these studies, but only in observing nature, for in a mass ot particulars the seed of error is so easily wrapped, that untruth might endure for everlasting were not nature there to set us straight; but some are so in love with foreign things that to grasp them they would traverse seas and mountains, and always by the side of homely truths there are others meretricious and unsound. But if we have nature for our instructress we have little need of these excursions, being so abundantly furnished with examples of this com- plaint, that there is no occasion to go far from home for many opportunities of observing it. Nor does the foregoing comprise all that needs be said to justify our choice of a subject : for every one, in his first acquaintance with dermatology, has learnt to use some frame- work or plan on which is seen inscribed the ultimatum of science and the most definite conclusions of experience. But whether in our ingenuous years, when the charm of knowledge most besets us, this is not rather calculated to repel than to attract, to quench rather than to gratify the intellectual desire, may be fairly a subject of doubt. Some may turn from it as a barrier raised to keep the inqui- sitive from intruding, to fence around and guard the hallowed precincts kept sacred for the congregation only. But if to the learner it is a stumbling-block, how much more is it deterring to the writer, who is never wholly satisfied about a plan ? For to such a one as is tolerably steeped in dermatological science, such schemes do not only offend, they may be said to lame and incapacitate, making it more difficult for him to tell what he has seen in the same way and measure that he has seen it. For we are not yet arrived at a certain order or marshalling of ideas agreeable to the disposition, if we had not better say the prodigality of nature. If we look to natural history and the sciences we find nothing settled as yet. No long time since Linnseus came, and borrowing a hint from social life, he gave to plants their surname and Christian name, and classed them into families and nations. XIV INTRODUCTION The daring and success here displayed was not without their influence upon the days succeeding. In a condition of science little removed from confusion, where reflection was overwhelmed by mere bulk, to divide was so greatly a necessity that the means or instruments of division were seized upon in hot haste, and with very little delicacy of choice. Not synthesis but analysis was the genius of the hour. To split the immense mass into sections was so much the predominant idea, some violence must be done to resemblances ; refinement and adjustment might follow after, if only the scheme could hold. So with Willan, our great institutor, he subdivided to excess, and gave that coherence to his species that we got to take ideas for things, abstractions for realities, and fell into the errors of the schoolmen and pre-scientific times. And if briskness in an educational course is to be the final aim of all our studies, or at least of our published books, all of system may be promised a long life, observation being of a second class of merit, disturbing all our preconceptions. But none of these systems hitherto have satisfied the requirements of science or grown with its expansion and growth; no one wholly adopts these schemes, and no one discards them wholly. Improvement is realised from hour to hour, our knowledge has outgrown the ancient bounds, but no arrangement of the kind has proved satisfactory as yet. Even that of Jussieu, which may boast to have eclipsed Linnaeus, the so-called natural system has not silenced all discontents ; and that of Alibert with equal aim, who, though he did not overthrow the edifice of Willan, yet left it totter- ing and weak, did neither conciliate his age or that imme- diately succeeding. More systems have been propounded ; they have been coupled, spliced, dove-tailed, and reformed the result is generally but a hotchpotch. The most modern idea seems to be but this : to take a strong prevailing type, such as in botany we esteem the rose, and round it to cluster all of that likeness and all that bears relation to it. In this way a block may be struck from out of the primal mass, and you may learn to know it tolerably INTRODUCTION XV well, and so by repeating the process you may get to know a portion of the kosmos. There is nothing ingenious in this ; it is but going back upon the past, a return to instinctive methods, and a more natural course of ideas. The same art or want of art may also serve our turn in medicine ; it has never yet fallen into disuse, and we are subject to meet with it every day, as, for instance, in some treatise on consumption which is, indeed, a group of morbid conditions, not identical but allied. In the same way Erasmus Wilson has given us a work on eczema, as it seems to me well inspired and not without advantage to science ; and the same I would attempt with psoriasis, a disease which has something of the picturesque, which is also extremely various, intricate in its causation, and important in its affinities. Little doubt there are others than myself who could undertake the same with confidence upheld by a superior ability, yet my experience and opportunities have been of no common kind, extending over a long course of years. I shall now address myself to my task, requesting the reader's good will. 7, WESTBOTTRNE PARK, LONDON. ON THE PSORIASIS OE LEPEA CHAPTER I DESCRIPTION PSORIASIS is a disease of the skin which is chiefly charac- terised by an alteration and abundant growth of epidermis separating for the most part in the form of dry scales. Their accumulation is conspicuous, and they are seated on a red or swollen cutis. The portion of skin affected is slightly raised above the general level. It is multiple in its distri- bution, but never involves the entire superficies. It does not run into an ulcer, nor is it followed by a scar. The nails and the adjoining mucous membranes are liable to this disease. The definition is approximate, containing indications of some utility in practice. To these may be added others of a more general and descriptive character such as those which characterise psoriasis as a disease with abundant dry scale ; the " scaly leprosy/' the " dry or branny tetter/' the dartre squammeuse seche, as opposed to eczema, the dartre squam- meuse humide, or " moist tetter." The complaint has been variously and quite of late called lepra, psoriasis, alphos. These form, in fact, but one disease. Name. In the present hour it is mostly spoken of as psoriasis. This word, in the early history of medicine, seems to have been devoted to merely local conditions ; it was far 1 ON THE PSORIASIS OR LEPRA from possessing a generic signification. But Willan withdrew it from obscurity, and put it in the place of psora a term employed by the ancients to express a medium degree of scaliness as between lepra and alphos. But in Willan's day psora by inveterate use among physicians was unfortunately appropriated to express the common itch or scabies. He replaced it then quite arbitrarily by the term psoriasis, and this is how it came into use, for the Greeks employed three words to express this scaly disease lepra, psora, and alphos. This triple division with them was dictated by pathological considerations which have no kind of cogency with us, but were primarily regulated by an idea of subordination in intensity which the ancients referred to the quality of the humours. Lepra with the Greeks signified especially a squam- ous affection, such indeed as displayed the highest degree of scaliness, the minor effects of which were seen in psora and alphos. They constitute but one disease, a fact which Willan did not sufficiently apprehend or which, at least, he did not in- culcate. Willan reduced the genera to two, lepra and psoriasis; he made alphos a subspecies or species of lepra, calling it Lepra alpho'ides, in all he did exhibiting much caution, and always loth to break with antiquity. But now the word lepra seems passing out of use, or at least there is danger of its doing so, though not long since universally employed. Convenience, or fleeting fashion, has led to a preference for psoriasis. To me it seems that lepra is the better term, the more significant and comprehensive, not Lepra grtecorum, the lepra of the Greek writers, but Lepra vulgaris, for it affects the whole human race. But since fashion irrespec- tive of antiquity, or let us say custom, inclines the other way, I must fain yield to its decision, for there is no resisting such forces in small circles or in great. I see better things and approve them, but this time I follow the bad. Let us, then, call the disease psoriasis. On the other hand, by the vulgar it is always spoken of as the scurvy, and sometimes among them it is called the scorbutic, and this perhaps, from the bluntness of their sense, i not distinguishing between the words scurvy and DESCRIPTION 3 scurfy. From the scorbutus or scurvy it differs toto ccelo ; there is no hsemorrhagic tendency, and the gums are scarce concerned in this complaint. But to reason with the vulgar on the subject would be a mere wasting of the breath ; they will not have it to be otherwise, and when they describe it in one of their family or relations they do so commonly with a sweep of the hand as if they were brushing dust or feathers off the legs or other parts of the body, and they also speak of leaving like feathers in the bed or about the chamber ; so that indeed the disease may be tolerably well known in their description. Another idea which is inveterate in the crowd, and in which they will bear no kind of contradicting, is, that the disease has its seat in the blood, for where is there an Englishman so untutored and ignorant that he will not talk to you and reason with you about the blood, and ask you to cleanse it as if it were linen for the wash ? There is not a quack advertisement that does not appeal to this foible of Englishmen. A good blood-purifier is a mine of gold to the inventor. This persuasion of its being seated in the blood may be fostered in some degree by its being a family complaint. But even great physicians have been found who humour this disposition of the vulgar by promising a remedy that shall touch the blood, and it has led to some extravagances in practice ; and some are strengthened in this opinion not only by the condition of the blood itself as drawn in this disease, but also from a certain degree of symmetry which occasionally appears, affecting both sides of the body alike a conclusion of a hasty character, which need not anticipate what we may have to say on the subject. But with the vulgar the disease is always the scurvy, and all their thought is about the blood ; they will also talk of a scro- fula of the blood. Far wiser not to contradict them ; the propaganda of science must work by other means. The scale or crust. We shall first speak of the scale, for that is the most conspicuous feature in the complaint. We might say that it is always conspicuous, for with slight exception it is so. Psoriasis is a dry scaly disease, and the scale is little absent. Sometimes in its place we find 4 ON THE PSORIASIS OR LEPRA exfoliation of skin, but only in small and ragged bits, and not in one large piece as seen in Eczema exfoliativa, and it extends no deeper than the cuticle. As a general rule of some practical utility, we may say, no scale, no psoriasis ; for instance, with localised erythema, if it lasts any time it is wont to cast and also to heap up some scale, and then it is ill distinguished from psoriasis; they are parted by no hard and fast line, but an erythema devoid of scale we may hesitate to call psoriasis ; this could only be excused and justified by certain attendant conditions. Just so with lupus in its early stage ; many times with great difficulty it will be divided from psoriasis ; true that lupus with a dry white scale will mostly lie in part beneath the superficies, and nearly always it betrays itself in a scar. The complaint called Ichthyosis, the fish-skin disease, was originally con- founded with psoriasis, and this latter, or rather lepra, was always described as exhibiting scales like those of a fish. The diseases, in fact, are very different, though having some points of analogy, especially in their causation. The scale in both is nacreous and opaque, but in neither of the two does it show little diversity ; and the popular idea in the way of comparison connects the exuviae of psoriasis rather with plumage of birds than with the scale of fish or reptile. But using the word scale as a general term, including in its meaning all of scurf, fluff, lamina, or crust, one may say it is indeed the true epidermic scale diseased, that is to say, altered or perverted in its formation or nutrition, and in such sense it differs wholly from the scale of eczema, which is scarce other than the dry residuum of serous exudation ; and especially these scales come early in psoriasis, and, as one may say, at the very first, whereas in eczema they come after and succeed to a serous discharge. Besides being free from moisture compared with eczema, the scale of psoriasis is more thick and opaque and smaller in size ; in this way it is well distinguished from the thin, flat, large semitrans- parent scale of the latter disease. Than the scale or scurf of pityriasis and lichen it is also more thick and gross. In these distinctions we must use discretion rather than DESCRIPTION 5 preciseness, for there is many a softening shade ; there are intermediate conditions, and these kinds of scales are to be found not seldom mixed. Willan has been blamed by his successors,, and more especially by the pathologists, for insisting too much upon the scale, and for putting the effect before the cause, which was said to be no other than inflammation of the derma, and the scale its unavoidable result ; but now our ideas of inflammation are modified and we have acquired new views of its processes. And yet to the observing eye it will be plain enough that here two elements obtrude themselves, that is to say, the altered epidermic scale and the hypersemic underlying cutis ; and so to speak as to external appearance, these two counterbalance and compensate one another, and thus you may have a case where the cutis is very red and raised, with a very little accumulation of scale, and that on a part of its surface, or perchance with a very thin transparent lamina protecting it ; on the other hand there may be a mass of scale which hides a pallid and exsanguine cutis, and between these every gra- dation. And as to its physical qualities, this scale will vary much. It may be loose and branlike, easily detached or quite otherwise, so firmly adherent as to be with much difficulty removed, strongly imbricated and very much dis- posed to form a crust. It may be flocculent or to all appear- ance granular. It may be evenly or sparsely spread or gathered up into quite a little heap. It may be coarse, thick, and dirty, greenish-brown and opaque, or thin, clear, and transparent like. a plate of mica. In truth it is generally white and opaque ; one may say of it very commonly in colour, a dead white, and it has been much likened to mortar and meal; if acquiring a tinge of yellow or brown in its mass this will mostly be from contracted dirt. A pearl- grey or a yellowish-white might often describe the colour exactly. These scales may display a silvery glistening aspect, with something of lustre like mother-of-pearl, and at times a transparency or semi-transparency which has been attri- buted, I believe, by microscopists to air entangled in their structure. This silvery appearance is seen to perfection on the 6 ON THE PSORIASIS OR LEPRA tongue, and occasionally though with less of frequency on the body, where it may agree with the description in Leviticus of a bright and glistening spot. The conformity to this descrip- tion is so striking that it cannot but recal it to memory, and I have met several times with this appearance, more than elsewhere, I think, on the legs, either in front or on the calf, the size of a shilling and oblong. Once only I have raised and detached it from beneath the level of the skin. The underlying cutis to which it was closely applied lay in three deep wrinkles, shrivelled and drawn in. The scale was all of a piece, highly micaceous and transparent ; and I was enabled to remove it entire. At other times the scurf is altogether scattered and divided, or there is a large rough dry exfoliation. Occasionally the deposit is heavy ; I have raised it like piecrust from the knee with an apparent hollow underneath, the accumulation of two or three years ; but even in a few short weeks it will gather to the same extent. It is far more often thin and evenly distributed over large patches of the disease, especially where subject to the friction of the clothes, as on the trunk and exterior aspect of the limbs. At the knees and elbows it is ever wont to be coarse and thick, and generally so in the neigh- bourhood of the joints. Upon the face it is in truth mostly thin, but plentiful upon the head, where I have seen it show like a rock. The legs and forearms display it abundantly. It prefers the hands to the feet, and perhaps also, though in less degree, the forearm to the leg, which last is a chosen seat of eczema. There are some deviations from the common type, which are well worthy of attention, especially as seen upon the hands, and they are mentioned here as in part descriptive of Psoriasis palmaria. In the forearm there may be found discrete patches of pso- riasis (Lepra alpho'ides) ; these as they approach the back of the hand become diminished in size, covered with less scale, a little raised, unequal and perhaps rather livid. As the side and ends of the fingers are attained, the disposition changes to small white spots not raised above the surface, and widely scattered. These look like a pock or small piece DESCRIPTION 7 of dead white skin, not much bigger than the head of a pin ; when removed by the nail as result of irritation or other- wise, there is left rather a deep pit or hole. These spots may be seen in the pulp of the fingers, or scattered over the palm of the hand with something of coarseness in the neighbour- ing skin, and a great disposition to raggedness and fissure. With this in the palm there are other irregular portions of perished skin, some containing a mealy or, as one might think, a calcareous element. These are dug away by the nail in small irregular pieces, or they are seen to have come away of themselves. The same occurs in the sole of the foot, with this addition, that between the toes some loose skin is always to be found. In psoriasis, as previously declared, there is no large exfoliation of skin, yet here we have a connection with the Eczema exfoliativcij which it is well to bear in mind, for occasionally there are intermediate forms. There is thus imparted to the sole of the foot, or to the palm, a ragged worm-eaten appearance, which would seem to depend on local anatomical conditions, but speaking under correction I do not think it is altogether so ; for sometimes in the rings of lepra elsewhere when very much devoid of scale there may be tension at one spot, and irritation, which is relieved by the appearance of a similar pock, and this is sometimes followed, precisely as in the palm, by a more general exfoliation of cuticle. In the centre of the palm of the hand the scale of psoriasis is apt to be very firm and thick, and to assume some- thing of the form which is elsewhere called the inveterate. This last condition is fortunately not very common, for the complaint may last many years without earning that title, or answering to the description which is given to Psoriasis in- veterata. This is distinguished by a great coarseness, strength, and thickness in the scale, by deep fissures sometimes emit- ting a sanious discharge, and occasionally even by small ulcers in the neighbouring skin. This last, meanwhile, loses its delicacy and pliancy, becoming thickened and rugose, with a surface in character like shagreen. The scale will sometimes form an unbroken casing or envelope, for the ex- tremities and even for the joints ; in the patches it is split 8 ON THE PSORIASIS OR LEPRA either transversely or longitudinally, generally in correspon- dence with natural creases of the skin. The scale is immo- derately thick, and the tough, crisp, squamous laminae are loosened at their edges and angles. This condition is more frequent in the lower limbs, most seen, as I think, about the ankle-joint. It has been compared to the bark of a tree or mailed coat of a warrior, but I confess I see these conditions seldom realised, though often approached; nothing, indeed, that justifies such comparison in anything like the same sense and degree as may be found in the Elephantiasis Arabum. I confess as I have seen, and daily see it, psoriasis is not a loathsome disease, though occasionally highly afflictive, and especially when it attacks the face, but this is not very frequent, nor does it display there its coarsest forms. It is possible that the most extreme of these cases do not come under my experience ; they may be found in workhouses among the aged, and in broken-down and ruined constitu- tions, for so they are described in books, but I am inclined to suspect exaggeration as applied to a large class of cases. The same may be said of the expression which is found in our Scripture version, "a leper as white as snow;" it is realised in our country, but with the greatest rarity. It will here be not amiss to dwell on the breadth of differ- ence that parts the scab of impetigo from the crust of psori- asis or lepra; they stand very much in opposition; for this reason I could never relish the arrangement of Celsus, which gathers them into one genus or group, that is to say, the im- petigo of Willan and our psoriasis, though in Celsus perhaps one should see the doctrines of the Alexandrian school. For us the scab of impetigo and the crust of lepra are generally in strong contrast. If, as is very much the case, a scab is found on the rings of psoriasis with some attendant discharge, this will be the result of irritation, probably of friction from the clothes, and if a patch of psoriasis as on the tibia receives a violent blow, it is apt to run into a profuse purulent dis- charge, which may last a considerable time, and it is only then that the similitude of lepra to impetigo becomes apparent ; the surface appears honeycombed and of no ordinary aspect. DESCRIPTION I cannot challenge any likeness to the crust of lepra in any product from wound or discharging surface that repeats it with tolerable exactness. True I have not applied my mind especially to the research, but so far as my memory serves me I have seen something like it in the exudation from old scars, especially after compound fractures of the leg, and this is where I should be inclined to look for it. There is, how- ever, something very remarkable in the distinctness of this pathological formation. If we allow ourselves to speak of cancer cell, of tubercle, and such like formations, we may surely indulge a little in dwelling on the scale of psoriasis. Configuration. As a rule the portions of skin affected are pretty exactly denned, sometimes by a roughly raised border, as best seen on the elbow or knee, and generally the patches have a clear margin with something of figure or shape, and though we may call it diffused, Psoriasis diffusa, a better name were confluent, for this diffused psoriasis is no more than a circumscribed uniform patch if only of a pretty fair size. At the very least the eruption has a limited distribution; however it may appear disseminated, and however scattered in a part, something of locality may be generally affirmed of it. In what is specially called lepra, the ringed psoriasis, the margin may be slightly raised, but often when the confines of the patch are of the very boldest, the contour is liable to be broken in upon to a considerable extent, and there may be found scarce a general indication. To understand this aright it will be well to remount to the very commencement of the complaint, though in this begin- ning often so obscure that attention has to be drawn to it as a study. Psoriasis, then, will be found to begin in a small red elevated spot, and this has been compared to a leech-bite. It is solid and very much of that size, with a tendency to be flat. Of varying tint, which is generally of a deep red, it sometimes inclines to be cold, that is, exsanguine, but seldom to the same degree as in the palest tubercles of lupus. It is so much larger than the papules of lichen, and so much less acuminated than these, as not generally liable to be mistaken 10 ON THE PSORIASIS OR LEPRA for it, nor is the neighbouring skin exasperated ; and though there may be numerous spots with very unequal distribution, these do not form groups like those of lichen, but stand some- what distant and apart, and when they approach they coalesce, and so the patch is formed and grows by their confluence or coalescence. Now, when the spots remain distinct with an early arrest in their development, which is not very fre- quently the case, that is to say, at a point before they become confluent, and especially when preserving this cha- racter, they are so multiplied as to extend over a large portion of the body ; we name it then Psoriasis punctata. Of this it may be said that it is a recognised form which has scarce attained a classical position, and when, as some- times occurs, this form is much spread over the trunk, the eruption is very apt to acquire on the legs and also on the forearms a more expanded development. In the commence- ment of the complaint, that is to say, even in the first day or two of its appearing, and some time after in its simpler forms, this little solid papular elevation is often covered by a single pearly scale, of much transparency and beauty ; but not always so, for many times it is broken and dull, and sometimes it is scanty, and the papular eminence may be little apparent, ill-defined, glossy, with a silken or silvery sheen, at one time liable to be confounded with lichen, while at another the white scale is so plentiful as to obscure the papular body, and thus by letter a patient may inform you that the disease begins with a white spot because there is nothing obvious but the scale. These papules or papular eminences, as I have said, are flattish, and the more so as they extend by their circum- ference, but sometimes before this begins there may be found in their centre a depression, a softening and falling in of the little mass, and a marked umbilication. This is seen even with some inequality of size in the spots, and where there is a general tendency to arrest, that is to say, no tendency to spread at the circumference. Though this rarely happens, when seen it shows sufficiently the approxi- mation of psoriasis to Lichen planus, and, indeed, till quite DESCRIPTION 11 of late the two complaints were not sufficiently distinguished. This umbilication is no necessary part of the progress of the disease, as it goes on to form the irregular patches of psoriasis. Just as the spots chance to be distributed, through their coalescence the patches are formed, assuming various shapes and sizes, with a surface squamous and irregular, in which some traces of its early formation in the spots are occasionally discernible both during their growth and their decline. There is a greater inclination on the limbs for the patches to be confluent than is generally seen upon the trunk. Sometimes the toes and fingers, with the greater part of the hand or foot, will be included in a single patch ; one such may involve the scrotum and inner aspect of the thighs ; and equally in the limbs and trunk it may invade any part. On the latter, where there is most room for development, the quadrilateral, pentagonal, lozenge-shaped, rounded, jagged forms, may appear; they attain a vast size, and in variety of shape and figure they defy all exactness of description. Psoriasis, if we may use the term in its limited sense, viz. the psoriasis of Willan, seems to be emancipated from a general law or principle, which is common enough among skin diseases, and which is no other than a tendency they display to rounded forms and circular development. "With none is this so apparent as with lepra, for to these rounded shapes by a sort of consent the term lepra is generally allowed, while psoriasis rather denotes the patches which have been just described as more or less irregular. One would be very mistaken, however, to limit the tendency here indicated of spreading in a circular figure to the disease which is here our subject. For these round, horseshoe, serpentine shapes are they not seen in erythema, lichen, eczema, lupus, and other complaints ? They form, indeed, the most curious feature in this our psoriasis, but do not include the largest moiety of it, which is rather expressed by an irregularity of outline in the patches. None of these last, however, are equally puzzling, equally interesting to the dermatologist with those skin complaints 12 ON THE PSORIASIS OR LEPRA that are ringed. Here, indeed, is room for great nicety in diagnosis, and not unimportant distinctions. But to describe these we must once more retrace our steps and proceed through the different gradations. We shall take then our pattern red raised spot, the solid papular-looking eminence, and we find it increase by its outer edge, and at the same time it may grow a little in height so as to project to the thickness of half-a-crown or even more, and present a surface which is neither smooth nor regular. This extension in either direction may be done with little regularity and progress may be arrested very soon, let us say, at the size of a horsebean or Windsor bean. The body may be covered with such spots with the same proviso as with P. punctata, that on legs and forearm there is commonly a wider develop- ment. This form of the complaint when somewhat raised above the skin, and when of moderate dimensions we call Lepra alpho'ides, more especially if covered with a coarse white scale ; if more on a level with the surface we name it Psoriasis guttata ; the terms are convertible or nearly so, being, indeed, but the discrete forms of psoriasis. These likewise do not always come from a single spot, but may grow from a limited number of spots or puncta. But if the outside of the spot extends with much regularity, and on every side alike, there is soon attained a shape which is not unlike a piece of money, Psoriasis nummularis , and it will be arrested at various stages of its growth, which is seldom less than that of a sixpenny piece and often much larger. There is little tendency to project ; on the contrary, a softening such as we describe is very apt to occur in the centre a depression, and after this, a return to normal character in the skin of the central part, with some little tint, perchance, of dis- coloration left. And thus are formed, that is to say, by a spreading of the outer edge and a progressive healing of the centre, those rings which are so distinctive and so inte- resting a feature of lepra ; showing, in fact, like fairy rings in a meadow field ; and, of course, when they are in this stage they are very apt to be called ringworm by the multitude, and the explanation that is given of these fairy rings, as they DESCRIPTION 13 occur iii a meadow field and as they occur in contagious ringworm, is not very discordant, both of them depending, it is said, on fungi, which, as they grow, exhaust the pabulum in the soil, and have to seek for further nutrition beyond ; and some such is the explanation given by Actuarius, as quoted in the text of Bateman, about this creeping com- plaint or herpes, namely, that like fire it exhausts the material on which it feeds, and then travels on to seek for more. But since this our lepra does not depend for its progress on any such fungi or parasitic growths, the expla- nation is not apposite, so far, at least, as the pabulum is concerned. The rationale would seem to lie in an anato- mical condition of the part which has been conjectured to be in the distribution of the vessels. Very marvellous is it, and almost past belief, to see large red rings of little breadth which have sprung from a tiny spot, and yet one must believe it to be thus, so many patients explaining it that way ; and often one of the spots increases so tardily in size as to remain for months, nay, for more than a year, quite small, that is to say, no bigger than a silver threepence, and then all at once it will take upon it to extend and grow rapidly by its outer edge, and so become a ring or a patch according as it heals in the centre or not. Such rings are called Psoriasis annularis P. orbicularis ; very frequently they are oblong or ovoid. The same are described in the papula of Celsus and herpes of old medicine ; and Alibert adopted the word herpes in this sense to express not only this but all forms of psoriasis ; and to this hour, when the French dermatologists express such action, that is, such centrifugal growth, they describe it as herpetiform, the herpes which they intend being essentially a creeping complaint, not sudden and inflammatory like that of Willan's adoption. The same disposition to a circular form is found in the palm of the hand and also in the flat of the foot ; in the former it fixed the attention of the admi- rable Rayer, and constitutes his Psoriasis palmaria centrifuga. And that the rings of lepra are thus formed I am the last to deny, and what further confirms this view is that when a 14 ON THE PSORIASIS OR LEPRA limb or edging of lepra encircles more or less a portion, however extensive, of skin, you may generally learn that the skin so enclosed is not old but of recent formation ; how- ever, it may wear a normal appearance, it has been in- volved in the disease. And yet I would not hold it for impossible that the rings of lepra can be formed in some other way than this ; for I cannot but remark that the spots of which I have spoken are sometimes arranged after the fashion or disposition of a ring, pretty widely apart, equi- distant, and over a pretty large circumference ; this even in the palm of the hand. And, again, I have seen them approximate, forming integral parts of a smaller ring or circle ; and when I have questioned patients about the forma- tion of some one of these rings, of whatever size, they do not invariably describe it as proceeding from a spot in the centre, but rather a spot is formed and the limb of a circle is thrown out from it in such and such a direction, and so the circle sweeps on. Moreover, sometimes an excessive amount of irritation exists in one of these circles, and this is relieved by the skin giving way at a single point with a little crack or dry bleb, as in Psoriasis palmaris, which shows that there is something underneath which, we may say, is equivalent to one of these papules, at least, in the irritation produced. Without affirming anything on this head I would bring the reader to the same point as myself, leaving the inquiry open. These rings may spread to an immense size, and often they enclose in their centre others of like character, but of smaller dimensions, intersecting one another; and even with those lesser rings or ovoid shapes which on the legs or elsewhere are so commonly found with abundant scale, Lepra alpho'ides, it is no rare thing to see a large circlet or a portion of a large circlet, though it be but an edge stretched round and embracing these minor developments. And often indeed the circlet of lepra is nothing more than a thin edge covered more or less with scale, and perchance solitary. But curves of every kind oblong, ovoid, horseshoe shapes, half rings or segments of rings occur in this complaint, and DESCRIPTION 15 with the disposition there is in the skin to give or assume roundness to all these shapes, when the curves meet by their extremities they combine, and so you have gyrate forms, Psoriasis gyrata, vermiform or serpiginous figures. The elegant twist of shells and of the ram's horns are featured here. These, so far as I have seen them in atlases, are no bit exaggerated, nor are they of the utmost rarity. It will be strange if in a tolerable experience something of the kind is not met with ; as, for instance, you may see an ovoid figure which is broken on one side of its longer diameter, and the ends curved sharply in and twisted in more than once ; and these half circles meeting back to back or with any accidental disposition, so they be scattered and yet approximate, by the disposition that is found in them to join at their ends, and always with a tendency to roundness in their extremities, make figures strange, complicated, and bizarre, and, as it were, patterns for a scroll. On the arms these rings may so join as to form bands which straighten after their junction, and encircle the forearms diagonally from above downwards ; crossing each other like thongs, and when irritated exerting some such pressure. Such we have seen in a case which occurred some two years since; the man had a sister under treatment for psoriasis, and he had suffered several times from the incidence of this disease. In the last year a case of psoriasis round the mouth came under treatment, presenting little or no scale, the surface generally raised and giving a strong suspicion of lupus. It was seated chiefly above and around the upper lip, and during treatment either extremity so modified itself as to become twisted round the angles of the mouth, with a bold and multiplied curve on either side, which I could only liken to the Assyrian ram's horn. The case yielded to treatment, general and local, and left behind it nothing of a scar. Whoever has seen a case of true ophiasis, with the same narrow ribbon-like band and there are few, I believe, who have seen it will scarce doubt of psoriasis being akin to alopecia. There are other ribbon-like forms meandering, irregular or more or less straight, which appear to follow as 16 ON THE PSORIASIS OR LEPRA part of the process we have indicated above, such as where a small quantity of gummy fluid would seem to have been spilt upon the skin, and here has run pursuing a meandering course obedient to the laws of gravity, such we have seen not long since from the nape of the neck, extending downwards, leaving a narrow brown track, some half a foot in length or more. The word serpigo applied equally to these forms, and to those of lupus and syphilide, includes varieties of highest interest which present great difficulties in diagnosis; and they all afford a degree of support to the view of Alibert, in the use he made of the word herpes, and in the opposition he gave to the limited and arbitrary employment of the same term by Willan. These two men of tremendous personality, distinguished alike by originality and learning, have im- printed in medical language, each in their respective country, a peculiarity which will not be lightly effaced. Colour. It may be well to say something more of the colour which is so strong and variable a feature in this com- plaint. Of the scale we have said that it is generally white, and it might be often represented by flake- white; it has also been compared to mortar or to meal. The word alphas seems derived from the barleymeal which, in certain religious ceremonies of the Greeks, was projected by hand of the ministrants and scattered on the bodies and faces of the worshippers. The word was coined expressly to denote this white and scaly leprosy. But Willan has described a Lepra nigricans, and when one considers his intense application to clinical study as well as to literary research it is scarcely likely that he would be mistaken, however that some der- matologists have supposed it to be so. It may seem possi- ble, indeed, with the strong bent he had towards learning, that he would not be slow to discern a representation in nature of the Impetigo nigra of Celsus. But first I observe that he simply terms this lepra blackish, or inclined to be dark, using the word nigricans, which is found in Pliny, and cer- tainly there are cases to which such description would apply. I have scarce myself distinguished such a Lepra nigricans, as is described in the words of Bateman, unless as a cachectic DESCRIPTION 17 impetigo, but if I look at the painted record I believe I have seen it many a time without making much account of it. In 'palmar psoriasis of adults the scale is often rather dark, crisp, lozenge shaped, violet coloured or livid, and once in a young girl aged seven, I have seen a condition of the palm of the hand that could not be called anything else than Lepra nigra or nigricans. There was a large dark stain, longest in the transverse diameter ; the scale was thin, the patch inter- sected by the lines of the palm and occupying a considerable portion of its surface. It partook of the moisture of the hand common at that age, and the skin was pliable and soft. This patch had existed about two year:., and the history agreed with that of psoriasis. There was no other complication or point of interest, nor was the skin elsewhere affected. I had the case under view for some weeks, and she left me, I believe, quite cured. As to the brown and black stains which are left by patches of psoriasis, especially on the legs, they may come pretty early in the complaint, and even with light- haired people. This depth of colour has been attributed to arsenic taken in the course of treatment, but I cannot think it is so, nor do these stains, which are generally less deep and persistent than those of syphilis, very strongly characterise the complaint, for the same, to a certain extent, will follow after the lichen of children, and especially after the Lichen urticatus ; they accompany and succeed prurigo in old people, ulcers of the legs in certain subjects, and also varicose veins. The laws of pigment seem beyond measure incompre- hensible, yet observation helps to persuade us that irritation of the sentient nerves are not foreign to these deposits, and often they seem connected with the phthisical and arthritic diathesis, and with certain visceral infarctions. So much may be said about these stains as an apropos of Lepra nigri- cans, which would seem to me as generally recognised to be little else than a patch with scale, and something of deep stain appearing from underneath. The deposit of dark pigment must in any case be regarded rather as an accident and non- essential of the disease. If now we consider the colour of the patch as modified by the cutis which, at least as to its 2 18 ON THE PSORIASIS OR, LEPRA superficial layers and the rete, we have described as hypertro- phied or swollen, where not hidden by the scale, as is fre- quently the case it will appear with any shade of red, but very commonly of a strong red colour, the Impetigo rubra of Celsus. An exception to this will be found in a few chloro- tic and phlegmatic cases, where the parts may appear mam- millated and coarse, especially on the elbow, and otherwise pallid and exsanguine. In instances of a more florid charac- ter, where all the scale has been removed by the recent bath, the larger patches show strongly red, and such patients have even been likened to fresh-boiled lobsters. But besides this dull red colour, which is the common type, there are varia- tions from the palest pink to crimson ; from the most bril- liant scarlet to violet ; from the shade of purpura to that of normal skin. With the first named the scale is often scanty, partially distributed, and adherent. I have sometimes con- nected it with a scrofulous type of constitution. The high tint of scarlet colour is often seen through a thin mica- ceous lamina. It is met with frequently over the tibia, where the bone lies nearest the surface. The appearance is very striking, and not by any means uncommon. In liveli- ness of hue it is not surpassed by Lichen planus or other erup- tions. Psoriasis as it fades may pass into shades of yellow and grey, and especially in the discrete forms (lepra alpJw'ides) may wear a sickly aspect, but this will be afterwards referred to. Seat. There is no part of the surface of the body that is not liable to the invasion of this disease, no part in which I have not verified its presence. It is nevertheless true of skin complaints, that they have each their preferential seats, and this holds good of those that are parasitic, however strange the fact; and to a certain extent it may be said of these diseases that they respect their neighbours' domains, but this is only partly true of psoriasis, it is of a character highly intrusive. In the chosen seats of eczema, lichen, ichthyosis, you do not very often find psoriasis, and yet occasionally you do, notwithstanding that it has the strongest preferences of its own, and when they are declared most we call it typical, or Lepra vulgaris. I suppose no one sees a DESCRIPTION 19 case of psoriasis without looking at the elbows and knees, for these are its strongholds, these are its chosen seats ; very rarely, when it begins there, does it quit them early to travel to some other part, and when we have a very bad fatiguing case we are sometimes driven to a compromise, and are con- tent to allow its continuance in such place, if only it will respect all beside. It generally affects the elbow, by a circle round the point of the olecranon, and extends down the ridge of the ulna, in which direction it is not generally so well defined ; it does not travel up the arm like erythema, the condition in scrofulous subjects called "red elbows/' but generally it is limited in this direction by a border or ridge. At the knee the patch is situated rather above than below the tuberosity of the tibia, more over the lig amentum patellae, where there is often a thick incrustation. This disease has also the character given to it of affecting, by preference, the joints, the extensor surfaces of the limbs, and those portions of the skin where the bone is not covered by flesh, but merely by an aponeurotic expansion ; of this the ulna and tibia are familiar examples. Whether it is in virtue of such disposi- tion or not that we find it on the back of the hand and sometimes in near neighbourhood of the spinal column it is difficult to say, but here also it is occasionally seen as well as on the hairy scalp. It affects with a peculiar fre- quency the legs and forearms, and also the palms of the hands, and after this one may doubt whether it would be well to pass to further instances and not be rather content to tell where least often psoriasis is seen than to say where most it is plentiful. It has little aversion to the fleshy parts ; on the arm and thigh it is not very frequent, yet, by a singular caprice, it will sometimes begin there. I think I have less frequently seen it in the axilla than elsewhere; this we know is a preferential seat of eczema, though less so than the fold of the arm and the ham. In this latter, psoriasis will occasionally appear, but generally it rather trifles about the inner hamstring than enters frankly into the hollow. In the fold of the arm it will be occasionally found, with a fre- quency infinitely less than occurs with eczema. Of the 20 ON THE PSORIASIS OR LEPRA latter, as is well known, these last two are the typical seats. But if it does not respect these, there are other regions where it successfully contends with eczema for possession. Such are the outlets of the body, the eye, and the palms of the hands. In these situations both complaints are occa- sionally declared. In rare instances they defy diagnosis, they glide into one another by an insensible gradation. Psoriasis is seen on the forehead, more often where nearest to the hair, very often descending by half an inch or so and terminating with a distinct margin ; at the nape of the neck the same, and the same with the region of the whiskers. On the eyebrow, the eye, the canthi, chiefly the external, and the lids, the nose at the root or tip, the apple of the cheek, the circumference of the mouth, the lower jaw, any part of the countenance or ear, you will find the disease ; behind the ear, not often, it is a chosen seat of eczema; the bosom with a comparative infrequency, it is the ordinary situation of Lichen circumscriptus. The shoulders are very liable to it, the back, and the waist and belly ; the navel is more often affected with eczema than by it, so also the folds of the groin. The fundament is much liable to be affected, and here it is often mistaken for Prurigo podicis. The pudenda in girls, occasionally in women, but far less often than by eczema; on the scrotum it disputes the field with the latter, very often by its accompaniments on other parts of the body proved to be a true psoriasis, as well as by what is figured on the part ; it may be said of the scrotum more than elsewhere that it blends these two complaints in one. On the penis it affects the prepuce, but not frequently ; this complaint is comparatively rare, but I may instance that I have seen on the glans a true patch of Lepra alphoides the size of a bean, with plenteous white scale. It remains to be said that the sole of the foot is not very unfrequently affected, far less so, however, than the palm of the hand. The nails suffer by a sort of scale underneath them, and more rarely they perish in their substance. The tongue is obnoxions to this complaint, and all the mucous membranes of the mouth and throat, as well as the lips and their commissures. DESCRIPTION 21 Age. Little or nothing is said by authors as to the occurrence of psoriasis in the first period of infancy, and when it happens in our day it is at once set down to syphilis ; those who allow that it exists as a distinct affection have written of it as mixed with impetigo and eczema. I allow that this is sometimes the case, but 1 am well assured however it may be rare that psoriasis may exist uncom- plicated in the infant and distinct. I have, indeed, ob- served it several times, and always in the constitution of the parents or in the history there was something that strengthened the opinion I had acquired from the external manifestation. True, that in a mother with psoriasis the infant is more likely to have eczema, a disease far more common in infant life, but sometimes the other will ap- pear. I would therefore have more hesitation shown iii deciding on syphilis in the infant on such narrow ground as the presence of a dry eruption. The appearance of idiopathic psoriasis, as I have seen it in infants, is not very different, so far as the skin is concerned, from what is seen in inherited syphilis, that is to say the skin is glazed, shining, somewhat silvery. It may be found accompanied with intense irritation, and at least in slight degree somewhat liable to be accompanied with eczema. In adults I have had two or three cases who date back their psoriasis to vaccination in the first months of existence. But in the field of practice it must be confessed that psori- asis is very unfrequeut until the first four years or so are past ; at this age it is commonly replaced by the strophulus or Lichen urticatus, at an earlier period by Eczema infantum. It even continues rare till about seven years are reached, when discrete psoriasis, Lepra alpho'ides, begins to show itself with more frequency, increasing up to the time of puberty. In some instances it shows itself just before this period, in girls about the age of thirteen, but more frequently about sixteen. In early life the incidence of " catching complaints," and especially their close succession, favour its occurrence. It is more amenable to treatment at this age, and also slighter, than in adults. The patches, as seen on the knees 22 ON THE PSORIASIS OR LEPRA and elbows are superficial, arid of no great range and extent. As years increase, the amount of scale is commonly more abundant. I have already mentioned a case of Psoriasis palmaris in a girl seven years of age who had been affected by it for two years previously. I have had other cases of p. pal- maris in young people of either sex before or near the age of puberty, when their innocence forbade the supposition of acquired syphilis, and that of an inherited taint was wholly unwarranted. In a very few instances it was seen in parent and child. In some cases of psoriasis at an early age it is subject to be so wide spread as to appear all but universal. On the face, from its scattered character and whiteness of its scale, it has once or twice appeared to me, at a distance, like varioloid. From the age of thirteen to sixteen, in girls, the cases exhibit a considerable frequency, and a few of these cases with scanty catamenia exhibit a hebetude of intellect which has appeared to me out of the usual course. In boys, though the change at puberty in them is supposed to take place with more disturbance than in girls, I have not seen the effect so marked; notwithstanding, they are equally represented in my clinique. I have sometimes ques- tioned whether psoriasis is not relieved by the occurrence of Acne simplex, which is so common a thing among lads. All through adult existence the complaint is frequent enough. About the age of fifty to fifty-five years of age I believe myself to have observed a marked increase in liability to its incidence that is to say, when the vital powers begin to fail. This liability is said to grow with advancing years, but I am unable to substantiate this fact. Sex. Nor can I say that it is more frequent in one or the other sex. The difference, I opine, cannot be very great, though strange assertions have been made on the subject. If I see more women with it than men, more dark- than light- haired people, this has not led me to any hasty conclusion on the subject. There are sufficient numbers of each. It is found in the florid and in red-haired people, and in those of deeply melancholy temperament, as well in the sanguin- eous as in the phlegmatic; indeed, I do not lay so much DESCRIPTION 23 stress on these temperaments as is done in Paris and else- where. It is all very well in a rapid survey and hasty clinique, but to inquire into the history of each individual case is what I approve. The temperaments belong to ancient medi- cine, arid we may borrow more advantage than through them. The same may be said of diathesis if we place this on a fanciful ground; but when it is founded on the patient's history, and that of the family in which he is begotten, it is then the diathesis rises into importance, I may say into the first rank of importance ; and understood thus, the scrofu- lous, arthritic, arid phthisical diatheses are severally not without a bearing on psoriasis. Stature. In respect of stature and bodily habit there is really something to be said. A few of my patients have been persons of dwarfed growth and imperfection in the senses, but more of them, both men and women, above the usual standard in height, and some of them extremely tall. I have seemed to remark that in a family it falls upon the tallest, who is also sometimes the eldest. Out of seven or eight in a family it generally affects but one. Here is food for further observation. Stoutness of limb has been insisted on as commonly found in psoriasis, and there is room for such a remark. Now and then I have seen a large develop- ment of the osseous system, with much unsoundness of constitution and a bad family history ; but to say the truth, the number of cases is not inconsiderable where there is muscular tenuity. This tenuity I believe to be a common cause of rejection in army recruits, under the belief that it is an inheritance from consumptive parents. On the other hand, I have observed that many of my patients, the children of the consumptive, exhibit a great muscular de- velopment this especially in young women the subjects of psoriasis. Nation. In my clinique there is a fair sprinkling of Jewish patients ; a considerable proportion of these have pso- riasis. I lean strongly to the opinion that they are, at least in slight degree, more subject to it than other people. This observation reaches all and not the very poorest of the Jews, 24 ON THE PSORIASIS OR LEPRA who, under pinch of poverty, like the rest of the world, are very apt to fall into eczema. Condition. As to condition of life it seems to me with no strong bearing on this disease. Every class is subject to it. The advantage of wearing clothes is enjoyed in quite a dif- ferent degree by different members of the community. The amount of hidden disease is sometimes quite astounding, and sometimes it is quite uncared for. Truly it would not be a bad law, nor one unprofitable to the doctor, that women should show, if not their shoulders, at least their elbows naked. In the heathen world such a complaint would have far more notoriety. But, as said above, all classes are subject to psoriasis. The Adonis of the age, the greater and lesser divinities, even the Graces, are not exempt. Great Jove himself, and Momus too, that. mocks at all the gods these have it just as much as common folk. Cleanliness does not heal it, nor do I know that starvation and dirt have very much to do with it, except by the worry they maintain. Psoriasis, at least, seems not so immediately connected as eczema with the nutritive process, nor does it stand in the same category with elephantiasis and lupus as to dependence on quality and even quantity of food. I am not prepared to deny a certain connection with scrofula, and that poor living may sometimes bring it on ; and in such degree as scro- fula is the result of innutrition, psoriasis will be not indepen- dent of the same. This truth we may affirm psoriasis equally with phthisis, equally with rheumatism, equally with asthma and gout, appears among the higher classes. Season and locality. As to season I admire the reticence of the ancients, who said "it comes and goes at certain times/' for in one it comes in summer, in another in winter, or it is aggravated in those seasons. I think I have heard most of suffering in winter. The getting into cold holland sheets when ill with this complaint has been described to me in lively language ; in summer time the sense of itching is often aggravated. Seasons of change, spring and autumn, are also critical, more especially the latter. Damp weather influences it, but not so noticeably as eczema. Altogether DESCRIPTION 25 we may rest on the assertion that it comes and goes at certain times, for nothing more can be affirmed. The geography of disease has been so ill attended to as yet that little can be said as to the distribution of psoriasis. Strange assertions have been made as to its inequality, but they need further corroboration. What I give as my own may not weigh for much, but in course of time I hope to make it more assured. I will say, then, that from the low-lying banks of the Thames, towards its mouth, I have had what I presume to be more than an average of patients aguish districts about Plaistow, Erith, and such localities. I have a fair number from the country, and often from places where there is a good deal of water about. I saw one case recently in an infant, where there was a decided psoriasis, but with a slight eczematous complication, in which, by repeated experi- ments of removal from home to the coast, it was shown to be kept up by the dampness of soil in valleys, among hills, and inland waters. I saw a woman, brought up in Cambridge, who spent all her early life in suffering from asthma and head oppression ; she married and settled in London, enjoy- ing life afterwards with a perfect freedom from these disor- ders ; but subsequently, after a lapse of some years, she had an eczematous psoriasis. If she visits Cambridge, but for a day or two, her old symptoms return, and she has to remain indoors. I have a patient, a girl with asthma and psoriasis, who comes every year to town from a cold district in York- shire to pass the winter here in London. Her parents are poor people, but are driven to this expense by the extreme aggravation both disorders receive if she remains all winter at home. I have had a few cases where bad hereditary psoriasis has been, to all appearance, cured by residence in hot climates Australia, South America, &c. For these reasons I am inclined to give some weight to the opinion expressed by Willan, that the disease is in some degree dependent on cold and dampness in climate and soil. Many have it on arriving in England from abroad. Many show it who come to the metropolis from the country. London gives us many cases. It lies, we know, in a valley of clay, and 26 ON THE PSORIASIS OR LET II A has a bad name for phthisis ; but this latter, by repeated proofs, is shown to be not independent of condition of soil and drainage ; it is highly probable that the same may hold good of psoriasis. Contagion* In an age when everything is discussed, even the infection of phthisis, one can scarce pass over the pos- sibility of contagion in this disease. The question is very often put, and I have always met it by a negative, but patients will have notions of their own. I have never thought of recording such impressions, but they might have a revived interest if we go into the question of some of these being inserted diseases, resulting from some foreign matter inoculated or insinuated into the organism. By way of showing how connected some of these stories are about con- tagion I will refer to a case now under my care. A girl, about twenty years of age, returns for treatment; her sister also has been under my care with the same. My patient tells me she first caught it when at service by sleeping with a little girl who brought it home from boarding school, and the little girl also gave it to two other persons who were my patients, and whom, she tells me, I " ought to recollect/' The patient left her service in consequence of this disease, and went home and gave it to her sister. She seems perfectly persuaded that it is all true, but to me it is a mere cog a I'ane, a foolish idle tale; and as to its being an inserted complaint we must reserve that for after-discussion. Willan seems to have had the idea of its proceeding from certain dry sordes on the skin. Beyond the effects of me- chanical irritation as an occasional course I do not know any ground for any such persuasion. But as something which borders on the subject, I hope the following may not be out of place. Graves, in his lectures, ' Prac. Med./ vol. ii, p. 353, ed. 1847, mentions the case of Psoriasis palmaris in a gentleman who communicated the scaly eruption to his butler, and also to his housemaid, through gloves, linen, or some such material. I had entered in the margin of the volume long since that on this occasion Graves had shown himself at fault as an observer. Subsequently I had occasion, at DESCRIPTION 27 least in some degree, to correct this judgment. A powerful stout man, of fifty years of age or nearly so, was my patient, with psoriasis both in the palms and soles of the feet. As is not uncommon in the latter case, the ankles were swollen, and his calling being laborious this last feature was important. Only internal mercurial medicines reduced the swelling, and I regarded the case as syphilitic in its origin. One morning his wife called upon me and said she had caught his com- plaint. This, however, turned out to be nothing more than a rather bad eczema of the hand, the result, no doubt, of irritation from contact with the dressings or discharges. Had she been disposed constitutionally to psoriasis it might have been adequate to its production, as occasional cause without the imputation of a contagious principle, for any irritant to one so disposed is competent to the production of psoriasis, and thus I would explain those cases which have led Graves, and also Elliotson, to believe that it is sometimes contagious. I have ever leaned to doctrines of contagion, and feel deeply the criminality of those who, in face of evidence, maintain the little vitality and potency of infec- tious elements. While resenting the disservice they have done to mankind, I am not yet arrived at the point of believing psoriasis to be contagious. 28 ON THE PSORIASIS OR LEPRA CHAPTER II COURSE AND CHARACTER OF THE DISEASE ALREADY we are so advanced in our description as very much to need the relief of bringing these details into an ensemble, and the same opportunity may serve to gather up some things that have been dropped in a disconnected survey. But how treat satisfactorily of a complaint that limits itself so feebly and shows such variety of types as might stand for many diseases, nay, even which have passed current as such ? And yet the task of analysis has not been spent in vain which has marked out these contrasting shades. Such types we must hold greatly in esteem, though but seldom found perfect in cast, for what we meet with in the everyday world are mostly intermediate forms. And also the work of synthesis is not to be foregone, and it will be with advantage that we contemplate as one the entire group of dry squamous diseases pityriasis, psoriasis, and ichthyosis. The first lies very near to psoriasis, and leaves a wide border land ; the same constitution produces them ; and of ichthyosis the same may be affirmed a, disease of far deeper intensity, but having with psoriasis the strongest etiological relations. All three are distinguished by dry scale, and form, indeed, a natural group; but not alone with the dry squamous diseases psoriasis betrays affinity, with the moist as well as with the papular it has a very close connection ; we cannot but acknowledge an eczematous psoriasis. Fortunate, too, will it be if in a hurried clinique lichen and psoriasis are not some- times confounded, though some have held it to be impossible ; a pruritus which has been dealt with as urticaria may turn out eventually to be a psoriasis, or a patient may display COURSE AND CHARACTER OF THE DISEASE 29 every year a psoriasis, but for once, as in reproof of anticipa- tion, there shall occur either one of the last mentioned. And yet of psoriasis it may be said that it has a good firm corpo- rate constitution, and it is so multitudinous in its incidence as to stand second in the list of skin diseases. It is familiar through repetition, and has all the essentials of a genus into which the lesser differences merge. You have, indeed, appearances so contrasting that at first sight they seem essentially different. What, indeed, can be more opposite than the superficial friable crust of alphas and the crimson or scarlet stain of the erythematous varieties, the rings of lepra from the Psoriasis diffusa ; the Lepra vul- garis, with its bold beefy looking patches, and the silvery P. yuttatttj or that which we find upon palms, face, and tongue ? For this reason we must hold something in reserve to be said about the species, if we had not better name them varieties, and also make much account of our cases. In all this disease of psoriasis there is one thing on which we may in- sist, which is that it seems no original defect or quality in the skin which brings it on. True, there is in it a modifying power, and thus we have differences that depend wholly on locality and seat which will occupy us in good time. In a woman you may contrast the roughness of the elbow under influence of the disease with the character it displays in the fold and front of the arm, where it is silken, glossy, and silvery, as in an infant's skin. The same difference may be seen in the face and sole of the foot, but these influences are not over-mastering, and the disease asserts itself occa- sionally through every local impediment. Worthy of remark is the fact that all kinds and characters of skin appear to be subject to it. There are families that pride themselves on this structure as on other ground of vantage, and it may be found that equally with all the rest the purest, cleanest, and most beautiful skins are subject to this disease. It has also the character attaching to it, that beyond the limits of the part affected the surface remains as before, quite calm, without inflammation, without exasperation. It may be said to be distinctive of the patches of psoriasis that they are not girt 30 ON THE PSORIASIS OR LEPRA round with inflammation in the neighbouring part. If ex- ception can be taken to this, it is in the very thin pink edge which environs the well-marked patches of Lepra vulgaris, just outside the sharp ridge or hedge that sometimes closes in these patches, with the slightest puckering yet beyond ; again, it may be said that in P. palmaris, and especially in P. plantaris, the neighbouring skin becomes in character occasionally very coarse. But all and every variety of psoriasis, all these species or sub-species, may be referred in their commencement to the papillary eminence or spot ; they have this at least in com- mon, although it is often faintly declared and with much difficulty discerned ; and when there is an accumulation of scale, if this be roughly removed, you may' possibly see the papillae of the skin enlarged and projecting, and they even bleed somewhat freely from their tip wherever a slight laceration has occurred on removal of the scale. The pro- duction of this last is due in great part to the papillae, in part to the rete and cutis underneath. It might be hoped at this point that aid might be lent us from anatomy and microscopy; but it has not happened so, we reach no further by their intervention than to a seemingly motiveless produc- tion of epithelial scale. There is a fulness in the vessels of the cutis, with some amount of enlargement, and the central vessel of the papilla, besides giving off its prolongations in the stroma, forms at the apex a glomerulus. Bound the vessel as a centre the epithelial scales arrange themselves, and they follow everywhere the course of the vessels in rete and cutis, notwithstanding that elsewhere in parts there are some separate growths and extensions. The superficial part of the cutis seems chiefly affected, and this agrees with my clinical experience that seldom is there redema arising from this complaint, though not unfrequent with eczema. Stripped of verbiage, the detail of the microscopist teaches us next to nothing in this disease. The researches hitherto made have relieved us from conjecture and uncertainty, and they are in that degree valuable as supplementing our ordinary experience. The most recent observations by a very excel- COURSE AND CHARACTER OF THE DISEASE 31 lent microscopist have seemed to establish the occasional but frequent existence of cryptogams in the crust of psori- asis no way different from those which are held to charac- terise ringworm, and what are called phytiform diseases ; this curious fact might be invoked to explain the fact of con- tagion in a few recorded cases, such as that instanced by Devergie, where a psoriasis of very long standing turned to ringworm in the period of its decline, with the most unmis- takable development in it of fungiform growths. Duration. It is a fact that you meet with some who are persuaded the disease is incurable, that they have to endure it as they may, and this opinion is generally imbibed early in life, when it can be founded on no experience of their own, but is commonly taken up from some one of their acquaintance or some relation that has had the complaint many years. Under such a view it would be rather of the nature of a diathesis than a disease, arid there is some amount of truth in this. Psoriasis is not much of artificial produc- tion. The study of it is very much the study of a diathesis, and in some people this diathesis is uncommonly strong, even past all rectification that is, all replacement, reconstruc- tion towards an ideal standard of health. There are patients who have repeated attacks, more than a dozen or score in their lifetime ; there are also a very few who are martyrs to the complaint. A life of vexation is spent in struggling with its annoyance. The patient goes from doctor to doctor, from climate to climate, from bath to bath, often capricious and too unsettled to reap much benefit from any kind of advice or any method of treatment. But how many are there of these ? It must be acknowledged they are very few ; and how exceedingly numerous are they that are wholly relieved by treatment, and removed from all fear of it, at least for a season ; how many where it remains quiescent for years, and even fades out of thought, with a full capacity left for enjoy- ment in every department of life. How many are there of bad cases so efficiently controlled as to be kept within limited bounds, though it appears but slumbering in its embers. Such is the alleviation derived from treatment that we have 32 ON THE PSORIASIS OR LEPRA always some old cases returning ; they come back as sheep to the fold. The inveteracy of the disease is so varied that it is difficult to estimate its duration. Some patients will be relieved in a month, but commonly it goes on to three quarters of a year. Generally we may give two months as the time in which some great progress is realised, and occa- sionally it will be much shorter than that. The relief from internal treatment is uncertain as to the hour of its event, though far less so as to its ultimate result. There also appears on the part of the disease a certain tendency to limit itself, but this is very little to be trusted to. In psoriasis, as in other cutaneous complaints, the skin is wont to enter- tain a habit which the longer it lasts unbroken the more difficult is the return to healthiness ; for this reason no patients should delay to put themselves under treatment ; and a further reason may be given, which is that a chronic pso- riasis may at any time blaze out as acute ; indeed, all acute attacks seem to have a foundation in the existence of the chronic. It must be remembered that many cases begin only late in life. Those in early youth are most tractable to treatment ; in the greater number of cases psoriasis comes on as a surprise with no kind of warning or anticipation ; in a great many it is allied to other complaints, for which the patient seeks advice, and this will be better understood as we proceed. Attendant symptoms. Let us now consider what are the attendant symptoms on this mere affection of the skin. Beyond what we have already stated, what is the amount of annoyance to which a patient is subject who suffers from this complaint ? We will not take extreme cases or invete- rate psoriasis, but an ordinary type of the disease. It will be well to treat of this at once, from the extreme exaggeration that has been here displayed. A patient has psoriasis on the skin ; and in which of his organs does he suffer besides ? In his kidneys, liver, heart, stomach, is there anything wrong? Nothing that we can perceive ; he perspires perfectly, his appetite is good, his intellect is unclouded. I say in the majority of cases it is so ; you will find nothing amiss. Does COURSE AND CHARACTER OF THE DISEASE 33 he suffer from irritation? Very often not ; perhaps he tells you that since he has had the eruption he feels ever so much lighter in spirits, better in health. You hear it said that this disease depends upon lithic acid, and some say that it is shot through the skin, and sears it as it goes through. And in how many cases do you find the renal function deranged ? Very seldom ; far less, indeed, than with eczema. You find it taught that psoriasis depends on inflammation in the gastro-intestinal tract, and this is laid down as a basis of treatment by men most experienced in dermatology. Now, granted that in this there is a valuable hint, in how many cases do you find the fact betrayed ? In very few indeed ; in the bowels there is seldom pain, occasionally there is diarrhoea ; once or twice I have seen jelly-like evacuations, never with much distress. Slight evidence of such inflammatory condition may occa- sionally appear, but less often in the intestinal tract than in the pulmonary. The liver is seldom deranged ; the heart not primarily concerned. The skin, not seldom, is habitually dry, but concerning this there has been much exaggera- tion ; dryness of the skin has scarce the constancy of a symptom; in some few patients the amount of perspiration is distressing. What, then, are the symptoms that are most constant in their attendance on psoriasis ? for we can scarce speak of any that are symptoms of psoriasis. The most marked symptom and the most constant is found in the female sex ; the catamenia are frequently, nay, they are generally scanty. I have seen cases of psoriasis where there is total absence of catamenia ; one of these in a woman aged twenty-five. She was tall, straight-limbed, and of advan- tageous appearance, the bosom flat. I treated her long for a copious psoriasis. A uterine or ovarian malformation may be very well suspected. She was a woman of lively manners, and has recently subjected herself to the experiment of marriage, with what result I know not as yet. In a lady of about thirty years of age the psoriasis affected the circumference of the mouth ; in this case also a malformation was conjectured, and she had been advised not to marry, from the total absence of catamenia. In other less marked cases of 3 34 ON THE PSORIASIS OR LEPRA amenorrhcea the suspension was clearly functional. Scanty catamenia, then, I regard as pretty constant; not less so, perhaps, than the pruritus. This last is sometimes wholly absent ; more rarely it rises to a great pitch, so that patients will tell you that they could tear their flesh from off their bones. The irritation is generally worse at night, worse from heat, and it is not always confined to the spots. I cannot make, with regard to it, the same distinction that others have done, as between lepra and psoriasis, or between these and pityriasis. The next most constant symptom is in the mouth of a morning, commonly a great thirst and sense of dry ness, a foul tongue, sometimes a bad taste, or disagreeble, sticky, and copious mucus in the throat and nostrils, very rarely foul breath. The patient is also oppressed with sleepiness at odd times, but the same occurs with eczema; sometimes there is headache. It seems out of date to speak of fulness of the head, but I may say that with pruritus of the scalp in this and other allied complaints I have seen symptoms, such as giddiness and headache, which persuade me that there is at times a local fulness. Malaise, nervousness, debility, are not very frequent in their occurrence. Occasionally the patient complains of " heat in the blood/' As to its alternating with the condition of the digestive organs, this is not much seen; at least I have not been able to appreciate it, and I find little else worthy of remark in the attendant symptoms. In treating of this disease one must speak of it as chronic or acute. It is acute when it is rapidly increasing and sometimes for a while when it is at a stand ; but the extent of surface involved does not constitute it as acute, nor yet the amount of scale, and though when you first meet with it in a florid subject it may be accompanied with a full and bounding pulse, it scarce ever begins as acute, that is to say, with rigors and shivering, pyrexia, burning heat, and violent thirst, much distress, and checked secretions. The complaint generally comes on unexpectedly under the influence of an occasional cause, but in truth the patient may long have borne about him some promise of it in previous years, either in roughness of knees or elbows, a little speck in the centre of the palm, COURSE AND CHARACTER OF THE DISEASE 35 or a rent in the cuticle at the pulpy extremity of the finger, as is common enough in gouty people. The acute form is an aggravation of the chronic, in which it commonly begins, and this may light up suddenly into flame with those symp- toms we have already described, among which occur a more painful tingling and pruritus and a sensation which is men- tioned as heat in the blood. Very often this happens in a gouty or rheumatic subject, or in one who labours under some organic defect. In course of time this acute condition is diminished, very much to the relief of the patient, but it may recur once and again before his recovery is made good, that is to say, before the chronic condition itself has given way, and he settles down into his usual standard of health. Agreeably to an ordinary licence of speech, the patient's blood is then said to be cleansed. But usually there is no acute stage; it is chronic all along, the other condition may be called somewhat rare. Very various and capricious is it as to where it begins, and as to the order and succession of parts attacked. This I have found so irregular that I propose to say little or nothing about it, only one may affirm that the elbows and knees enjoy a strong preference, but these also not seldom escape. The scalp, which some say is very rarely affected, especially in bad cases, I have found to be pretty commonly so. The axilla and bosom seem to me to suffer least. As the disease declines, the red parts shrink in their proportions, they become paler here and there, and so in a degree variegated or mottled, and this paleness ex- tends till it overcomes the red by gradually encroaching on it. Once again the elementary spot appears in its original loneliness, unsupported and unconcealed by a surrounding redness; these become daily fewer, and there is little pro- duction of scale, less pruritus, less sensibility to irritating applications ; indeed, in the season of its decline anaesthesia is often very marked. No scar follows, as in lupus, but sometimes very deep brown stains ; and occasionally, where there is a patch, the swelling and redness do not wholly sub- side for years, but remain shedding very little scale, with something of a disposition to get bad again on any inter- 36 ON THE PSORIASIS OR LEPRA mission of local remedy. This is very common on the anterior part of the leg, which is often occupied by a long red patch, but perseverance may do much with it by rendering it paler and less tense. It will not be amiss to introduce here a few cases which may serve to show the variety we are accustomed to meet with in this disorder, and also display those points to which we are inclined to attribute consequence. Since to write a methodical treatise is not our aim, but rather to establish principles, we have not thought it worth while to refer to old case-books for that which is most uncommon and astonishing. Our daily clinique furnishes us with abundance of cases, and we have given nothing but what is recent and quite within the grasp of the memory. The following are but sketches in which those points are insisted on which have seemed of most interest at the time. Acute psoriasis. A. II , set. 55, a tall, strong-built man, of pale complexion. This patient is of the middle class of life, and has been active in business, but a very fast liver. He has had three separate attacks of rheumatic fever, the first at eighteen years of age, and these have left some damage in the heart, as evidenced by blue lips and an habitual catch in his breathing. Nine years ago he was at Matlock and Buxton for a short time ; in the former place he bathed more than once, staying too long in the cold bath. On his return home he had a stoppage of the bowels, followed by diarrhrea, and after that, for the first time, a most violent attack of gout. Last January he first began to suffer from psoriasis, which commenced in the hand a small crack in the centre of the palm ; this was treated with carbolic glycerine, and then spots followed, and spread and increased up his arms, and it occurred in other parts. After remaining for four months chronic it turned to be acute, and he has had two acute attacks, lasting each about six weeks. "While these last, so long as the temperature of the room is a little cold he suffers horribly from shivering, but when it is warm he is burning hot. This heat is most dreadful, but on the whole it is more endurable than the chills. Damp weather, he thinks, disagrees with him. When this patient was at the worst the arms were affected with deep redness all the whole way up, and the same involved the axillae and parts immediately adjoining. The scrotum and inner aspect of the thighs were in an extraordinary degree affected, the anterior part of the trunk, the hams, back of the thighs, and nates. Defecation was COURSE AND CHARACTER OF THE DISEASE 37 extremely painful, and he lost a little blood by stool. The head suffered in only a less degree, and it came a little way down the forehead. The parts exempt were the shoulders, the face, and bosom ; the knees in front were little touched. In no part has there been so much and constant suffering as in the hands ; he is also plagued with burning feet, which are less affected. In one of his febrile attacks the kidneys did not secrete for nearly three days ; the weather being extremely hot, the perspiration at the time was copious, and relief seemed to be afforded by purging. I had this patient' under view for many months. On decline of the disease the chronic condition might be described as follows : The scrotum and inside of the thighs displayed a deep red stain; the hands were raw to above the wrists ; there was a large red patch about each elbow ; on the belly and near the waist there were red blotches of psoriasis, with several of its minor effects. The hands and nails are curved in- wards, the latter long and loose. He speaks of the disease as growing through the red spots ; where- ever one of these appeared there were sure to follow two more, at a distance of about half an inch, lying at first, like stars, apart ; these coalesced, and so it spread and .grew. The eruption has been generally very red, and the scale abundant and thick. There has been little headache, the tongue generally clean, except in his acute attacks, and the appetite seldom fails. His improvement has been marked under chalybeate medicines, aided by warm baths. In treating his hands, stimulating applications have seemed rather to increase the subcutaneous thickening, which serves to keep the parts contracted. In other regions he has benefited by tarry prepa- rations. This patient has an uncle on his mother's side who has suffered much from rheumatic gout. He has an only child living, a daughter, and has lost two sons from phthisis, which he attributes to the mother's constitution. Lepra vulgaris, acute. H. M , set. 68, a man of low class, presents himself to my clinique. He is desperate with pain, and all but weeping. His face is all one abnormal tint of brownish -red, with a coarse dry exfoliation of scale. He has also the eyelids partially everted ; the scalp has some amount of scale. He says his feet burn under him, so that he walks with much difficulty. He is wholly helpless in his hands, which are covered with the same dry eruption. He tells me he has it all over him, and, besides this, rheumatism everywhere, but especially now in the shoulders. He suffers from some amount of fever. He complains of broken sleep from the banging in his ears and pain in his forehead and eyes, with excru- ciating heat. On stripping him I find it, underneath his clothes, hardly so bad as stated. There are abundant coarse spots and 38 ON THE PSORIASIS OR LEPRA tubercles almost everywhere, and on the elbows especially a broad red patch. The force of the disease has expended itself on parts that are exposed to view ; it began on the back of the hand. His illness set in with acute rheumatic fever. He thinks the doctor's physic drove out this eruption, which he has had now for seven weeks. This case is rather an uncommon one, both from the face being to that extent attacked, and from the psoriasis occurring as an imme- diate incident of acute rheumatic fever. The man was evidently too ill to be out of bed. Cured speedily of psoriasis, but later of his rheumatism. Lepra alpho'ides. Miss D , photographer's assistant, genteel in address, slight figure, pale, with dark eyes, intelligent, but not carrying appearance of strong health, set. 29, spinster. She applies to me for a spot of psoriasis, the size of a shilling, on the left temple, which she fears may spread to the face; also some spots at the back of the hands, produced, she says, by the hyposulphite. She has a condition of the palms which is what some have called pityriasis palmaria, but which is, in fact, a superficial psoriasis ; there is also an amount of crust in the hair. When I push inquiry I find she has psoriasis all over her, or nearly so, with abundant light powdery and silvery scale. Large patches occupy the leg ; there are some over the spine, and she has it on arms and shoulders rather bad. The initial spot is exceedingly superficial and scurfy. According to her account, beyond what I am allowed to see, she has got it more or less everywhere. Her father has it, and his mother had it before him. She has known it as long as she can remember. She has never once applied for relief, thinking it was no good. She says it is accompa- nied with a good deal of irritation, and she breaks out into distress- ing heats. The use of soap aggravates this dryness painfully. In summer time the perspiration irritates her beyond bearing. Both her parents suffer from rheumatic gout in the hands, her father also in the feet. Out of eight children she alone has this psoriasis. This patient took the chlorides of steel and arsenic in very moderate doses, using ointments of sulphur, kali, and red precipitate, of light degree of preparation. In five weeks' time she declared herself free from all eruption, but I persuaded her to continue the medicine till the close of the second month. Psoriasis diffusa. A baker, set. 67. This is a tall, strong-built man. He has large patches on the wrists and forearms, chiefly on the external aspect, and other patches which are developed to a large size on the abdomen. Over the spine in the dorsal and lumbar regions there is one immense patch, equally distributed on each side of the spine, the shape of the diamond on playing cards, the apex prolonged upwards. COURSE AND CHARACTER OF THE DISEASE 39 The surface of these patches are rough, but as uniform as a nut- meg grater, consisting of lichenous elevations, on which lie small scales. They are intersected by regular lines and furrows, but per- fectly dry. It is the sauie eruption on a large scale as frequently seen in masons and bakers on the back of the wrist. This man took the arsenical solution for some months, but the eruption did not appear to yield until the dose was raised to seven minims instead of five. The lichenous spots then became more and more distinct. A white plot formed in the centre, and the patch became varied at the edges with healthy portions of skin. After a peculiarly obstinate illness he arrived at length at his cure. Lepra alpho'ides. Boy, set, 8, from Teddington, rather a slim lad. It could not be much fuller on him than it is. It seems peppered all over him, the size of peas, more or less, but with a good deal of white scale, and the eruption very much raised, and set very close in little irregular masses of all sorts of shapes ; the head and back are covered. On arms and legs they are more flat, some circular, some like little trails of worms. On the body the masses arrange them- selves circular-wise. Scattered patches on the face of alphos, milk- white heavy scales, unlike the usual superficial desquamation there. Besides the small masses, there are large puncta. The mother has had four children, and has lost one with congestion of the brain. Her father has gout badly. Patient's father has average health, but his mother (grandmother of patient) had asthma, and his sister suffered dreadfully from rheumatic fever, and patient's cousins, grandchildren of the asthmatic grandmother, died several of them by consumption. L&pra vulgaris. Girl, set. 14, Jewish parentage. On legs, knees, and elbows, typical. Stout frame, for her age a most extraordinary large development, more in bone than flesh or fat. There is a slight degree of lateral curvature. The eruption has lasted six years. Was made much worse by purging under a late physician highly skilled in these complaints. She has at times some phlegm on the chest. Catamenia very scanty, skin dry. The patient has eleven brothers and sisters living. A sister, aged 19, died recently of rapid consump- tion. Her father died of consumption, and his mother of asthma. The father of patient had also diabetes, which equally with phthisis is hereditary in the family. As regards phthisis the medical sheet is even more extraordinary than the physical development of the patient. The family is altogether removed from the pressure of hard circumstances. She is better at the seaside. Psoriasis. Widow, set, 34, Eurasian, born in India. Patches of the bright scarlet. She has it on knees, face, and elbows. It came 40 ON THE PSORIASIS OR LEPRA on at eighteen years of age and lasted a year ; it was cured by pills. This last time she has had it two years. She is in good flesh. An aunt on her father's side has asthma. Psoriasis. Woman, set. 58, married, no children. Erythematous patches on face, with some scale, but very trifling. She looks as if she had been fighting. On the plump part of the cheek a round patch, a small one on the centre of the forehead, another at the inner corner of the left eye ; she has had it a month and it varies from day to day. Spectacles aggravate it. She thinks it proceeds from the steam of washing. She has had three bad attacks of rheu- matic fever, the last time three years ago, when she kept her bed for five weeks. Psoriasis diffusa. Man, eat. 25. This case, without being acute, was so extensive as to be almost general. He had large patches on the trunk with a vast amount of scale. Treated with Turkish bath and warm baths with black sulphuret of antimony, which seemed to do him good, but not getting well so quickly as I wished I changed it for Fowler's solution. After the bath he looked as if he had scarlet fever. He got well in a four months' course. The terrible itching was much allayed by the Liquor Carbonis detergens. Psoriasis. Female, set. 25, since parturition, now six months ago. Has had it off and on for years. Is weak from nursing and nervous, with cold perspirations and fainting. After her confinement she suffered from rheumatic fever. In youth she has hacl scarlatina, and measles, and hooping-cough ; St. Vitus's dance once at seven years of age, and again at nine, after which came this eruption. Her intellect was low at the time. Psoriasis. Man, a3t. 28. In this case is seen a combination not exceedingly rare of psoriasis, acne rosacea, and haemoptysis. He has had psoriasis on knees and elbows, and pretty nearly all over him lepra alphoides ; the acne rosacea for seven years. I consider him to have tubercle, but he has rallied a good deal since the last spitting of blood, which was to the extent of two wineglassfuls. The psoriasis may be considered cured, at least for the present, by my treatment. The acne rosacea presents a very tumid feature in the nose ; as to his chest the condition is more favorable than could be expected. His brother had much the same psoriasis. The patient is not strong looking, and has rather a full upper lip. He lost his father in middle term of life. His mother long had an asthma cough. Psoriasis palmaris. "Woman, set. 39. Has this dry eruption of the palms of the hands. Has alopecia in the scalp, and in the ham a moist eczema. No history of gout, rheumatism, or chest complaint. COURSE AND CHARACTER OF THE DISEASE 41 She has had granular ophthalmia and purple spots. Dartrous or scrofulous condition. Psoriasis or lepra, ringed. Spinster, set. 26. On inside of the thigh superficial red rings ; at one part they appear twisted on themselves, red and level with the skin, the size of half-a-crown. Smaller size on bosom, sometimes in face. A dreadful burning heat at night. Has had rheumatic fever, and her mother is rheumatic. Psoriasis. Man, set. 67. Has two brothers who have it. Has three sisters who are free from it. Patient has four daughters, all of whom had eczema capitis. Psoriasis. Woman, set. 39, after diphtheria. Her father died at eighty, he had had asthma for forty years. Psoriasis nigricans palmaris. Girl, set. 7. She is of a delicate make and figure. The psoriasis is well defined, occupying a large part of the centre of the palm ; the stain deep, moist with the ordi- nary amount of perspiration, pliable, little scale. The father of the patient and her paternal grandmother have asthma. The children her brothers and sisters, have all a tendency to cough. Psoriasis. Female, set. 24. Father has bronchitis and eruption of the leg (eczema), his sister died of bronchitis. The patient has had rheumatic fever twice. She has a sister in a consumption, who attends the Brompton Hospital. Psoriasis. Nurse, set. 60. Has asthma and rheumatic gout in hands, both complaints hereditary. She has had psoriasis off and on for years. Her mother had asthma. She is now troubled with a long deep red stain from knee to ankle in front of the leg. It has re- mained for years. She keeps it under with creosote ointment. Iodine makes it crack and bleed ; as for tar ointment, " it ruins everything." Psoriasis inveterata. A Jewish lady, set. 50. Has it on the ankle, very hard, like a cuirass. She has constitutional bronchitis. Her mother had asthma. Psoriasis. Servant girl, spinster, set. 23. On both forearms, head, and legs, a large rough exfoliation of scale. It broke out at this time at Eastbourne six months ago, but was not quite clean of it when she went there. Was four months at the sea-side. Her mother died of consumption. Her father died of rheumatics. He had suffered from asthma as a boy, but grew out of it. His mother died of asthma. Psoriasis. Girl, set. 6. Her father had rheumatic fever twice. 42 ON THE PSORIASIS OR LEPRA Her mother is weakly, and her mother's father for this year past has had rheumatic gout. Psoriasis diffusa. Spinster, set. 18, thick lip. She had scarlet fever some time since, and thinks she may have had diphtheria. Her mother's family had asthmathat is to say, her mother's mother, aunt, and grandmother. Psoriasis. Spinster, set. 19. Her mother died of bronchitis and asthma, aged 52, this year. Patient has a weak chest and cough. Father has rheumatism. Mother had rheumatic fever some years since. Patient's sister supposed to be in a consumption. Psoriasis annulata. Valet, set. 28. On back and chest small rings. He has had them off and on all his life. Father had scurvy, and his sister something of the kind. Has been in Central America without any cure. Psoriasis diffusa. Man, set. 29 ; full on the arms and on inside of the thighs, none on the trunk ; slight tendency to be eczematous. If he scratches it little drops of water come. It makes him feel faint, and he has no appetite. He easily faints away. He has awful cough, and his breathing audibly bad. He is never free in breath. His sister and mother have asthma. His mother very bad, is supposed to be consumptive. His father was subject to scurvy. It came on soon after smallpox, three years since ; has a large nsevus, which after smallpox got a firm hardened base. Lepra alpho'ides. A boy, set. 5, came out suddenly after playing in the snow. Pretty full on the body. A good deal on the legs. His paternal grandfather has rheumatic gout. His maternal grand- mother has chalky gout, and his maternal great grandmother (his mother's father's mother) had rheumatic gout. Lepra alplioides. Married female, set. 24, very bad. Has two sisters with the like. It comes about two months after her confine- ments, and always ceases about the second month of pregnancy. It shows badly on elbows and knees, scale silvery. The mother has eczema, badly. Her father died young of diseased heart. Psoriasis. A young man, set. 21, both legs affected, one in front, one in calf, also the left elbow. He has a very dry skin. It has lasted seven years. Father died of cancer of the bowels, and father's sister of cancer in the breast. Patient's sister died of consumption. A maternal aunt with gout. A maternal uncle with erysipelas. Psoriasis. Female, set. 13. The leprous patches in this case are very definite and limited, the size of a half-crown, one below the COURSE AND CHARACTER OF THE DISEASE 43 right knee, one in the middle of the left tibia. Has had scarlatina and all catching complaints, father asthmatic. Father's mother died rapidly, it is supposed from consumption, maternal grandmother consumption. Psoriasis. Man, set. 41. One large patch inside the calf low down, a deep red tint, with nacreous scale. It has lasted two years. It came on when he was taking warm baths. It began with pimple and scale. He was given up for consumption at seventeen years of age. He has varicose veins and his father before him. His brother has had rheumatic fever and he suffers from it all along. His mother a lunatic. He lives in Radnorshire, a dry air. Psoriasis diffusa. Man, set. 52. The eruption is red and very extensively diffused, a very bad case of psoriasis with an amazing amount of scale. He has the gout rather bad; occasionally his sister has the same eruption. His father a, little. His child a little on forehead. He lives in Essex, on rather low ground. It came first at twenty-five years of age, from fretting about a girl. Psoriasis. Lad, aet. 18. He stands five feet ten inches. The patient has a large patch with the edge on one side ill-defined. On each leg over the outer margin of the gastrocnemius. His mother had the same at much about his age and had an arm withered at the fold qy. keloid ? His father died of asthma at forty years of age, got by working young at carpentering, and he suffered from rheu- matism and gout. Psoriasis. A red-haired lad, set. 19. On belly, back, and chest, a little on head, none on elbows and knees. Of a morning there is a yellow discharge from his mouth and nose, with thirst. The erup- tion came a month ago after a violent cold; they put him on a mustard poultice, which brought out this psoriasis. Lepra vulgaris. Clerk, set. 28. Has had it on knees and elsewhere off and on for years. Surrounding the olecranon is a red band, and all the enclosure white ; it is as if a loop to let the olecranon through, and seems to be made up of three circular patches. The part just inside the red is white, like urticaria. This case helps to show how the rings of lepra are formed. Psoriasis. Female, set. 28, married. It might be called diffusa, but with a tendency in parts to gyrate forms. It is pretty general, and came first before marriage, now some years since, immediately after scarlet fever, which she had in the winter time, and psoriasis came in the spring close upon the desquamation of the cuticle. This attack lasted for two years, and she then got cured of it, and was free from it for six years after. 44 ON THE PSORIASIS OR LEPRA The present eruption is only of a month's duration. Her baby is thirteen months old and still at the breast. Evidently, then, it is from nursing. She has two other children, with clear skins. Psoriasis nummularis. Woman, set. 48, married, has abscess in right arm and armpit. Has had the eruption four months. It came after the abscess, but began far away from it on the back of the hand. Her family have suffered frightfully from decline ; there is gout and rheumatism in family, but mostly decline and stoppage. During the last twelve months she has lost twelve relations, and nearly all by decline. The case is apparently scrofulous. Psoriasis or lepra vulgaris. Female, set. 50. On the forearms it shows rather a lichenous character. She has had dry scurf about the kneepans ever since she was a child, but nothing more than irri- tation attaches to it. The psoriasis is generally in patches, with loose scale ; in the ham eczematous ; on knees and elbows the dis- tinctive dry patches. She has had it off and on since seven years of age. A sister and brother were decided asthmatics. The one lived to thirty, the other to twenty -four years of age. By consumption she has lost three sisters and two brothers, besides the asthmatics as above, out of fourteen. Only one of them reached forty years. Slight rheumatism in family, no cancer or gout. Psoriasis. Female, set. 28, girl-looking. She has had it only a year. It came suddenly all over the body and then below the knee, with no great amount of scale. Her chest always weak, and she always had a bad cough till the age of twenty-one. She is a London girl. Her mother suffers much from rheumatism in the arms ; her mother's father had rheumatic fever badly. This patient afterwards brought her little boy, four years of age, with psoriasis round the mouth and nates, patchy and shiny ; he had had it three months. Psoriasis annulaia. Female, set. 28. Patches on face about nose, on concha of one ear, and behind the other. Small rings, and in other parts it looks like acne rosacea. As a girl she had bone removed from her leg in a country hospital. Her father had asthma, her mother phthisis. Psoriasis guttata.'Boy, set. 8. The eruption superficial in parts and diffused, in others with border sharply defined. Under the left clavicle he has a circumscribed patch with scale, the size of a walnut, extended in the length of the clavicle close under it. This cannot fail to bring to mind the artificial vesication used in phthisis. He has a hacking cough, and in his brothers and sisters there is the COURSE AND CHARACTER OF THE DISEASE 45 same tendency to chest complaint. The character of this spot is so striking as to interest me in the highest degree. Psoriasis. Female, set. 37. Scarlet on hands, arms, and legs. In small and large patches. Scale cohering. Desquamation slight, cough, loose bowels, frequent headache. Her mother died of rapid consumption. Her father had rheumatism, sciatica, and cancer on the tongue, and his sister had cancer in the womb. Psoriasis. Female, set. 29. Has been a nurse. Is of a consump- tive family, and has had cough. She was vaccinated, and before the places were well smallpox came out, and immediately after the smallpox that is to say,within a month of her being attacked by it psoriasis appeared. Psoriasis annulata. Male, adult. There is a trail or sort of edging of psoriasis, and within immense circle others of lesser dimension. It came in a little spot at first. No scurf or moisture. Itching at times, no pain. Fifteen months ago he had rheumatic fever, and for three months was very bad. Psoriasis. Widow, set. 50, has had it all her life long. Has had rheumatism a good deal, and indigestion in chest. Many a time has she been salivated and bled. In a large hospital used to be bled every week, but never once since twenty years. Psoriasis. Female, set. 53, married, not hereditary. No asthma. Father died of cancer of the lip, and her only brother living has gout in the foot. Psoriasis papuliformis. Male, set. 35. Asthma, phthisis, gout, in family. Went to Erith as a boy, and got abscess from malaria. He had it three years under his chin, was then at the Bluecoat School ; afterwards he had the ague at Plumstead, and at age of fourteen there began this psoriasis. Psoriasis. Female, set. 53. Worse every spring and autumn. Yery widespread. She is enormously stout. Her father had rheumatic gout, and from an early age alopecia. She has had this eruption nine years. Of seven brothers and sisters none show a sign of gout, though her father was a cripple from it. Psoriasis. Girl, set. 17. She wore a "porous plaister" on her throat, and there came out this eruption, which gradually extended. Psoriasis. Man, set. 40. Is engaged in the fish trade, and has been in the army. He has broad scars on inside of the left thigh. The surrounding parts are the seat of psoriasis, and the scar also secretes a pretty abundant scale. 40 ON THE PSORIASIS OR LEPRA Psoriasis. A sea captain, set. 48, paralysed on one side from effect of a stab supposed to be between the atlas and dentator vertebrae. On both sides some loss of sensibility. The eruption in pink ery- thematous patches, very abundant and shedding little scale. The distribution does not seem modified by the paralysis. Psoriasis. Man, set. 24. No history in family to account for it. He left the navy in 1869 from something in the heart, which came after scarlet fever at that period. It is to the same cause, no doubt, that he owes the psoriasis. Psoriasis. Widow, set. 58. On the face erythematous patches, with a granular hard crust, like mustard flour, sticking close to the patches, but not hiding them. Very refractory to treatment. Has existed two years. She has lived till late in India. L&pra vulgaris. A middle-aged gentleman, of refined pursuits and pure morals, is constitutionally affected with asthma. By the imprudent use of the tub (the cold sponge bath) he acquired a squamous eruption. As it proved somewhat obstinate, an opinion was passed that it might be syphilitic, a thing which, as he says, he well knew to be impossible. Nevertheless, he was twice subjected to a mercurial course to give him the " chance of mercury." Psoriasis. Male, set. 79. Was cabin boy of the Vestal after battle of Corunna. Has only had this five months. A hale man. Has been in Hudson's Bay Company's service. His mother died in infancy ; his sister at forty or so, and she had scurvy in the face. The psoriasis is in the arms and thick part of the thighs pretty full. It has never occurred till now. No chest complaint or gout or rheu- matism. Psoriasis. Male, set. 21, boasts of great health. His mother has had rheumatism lately. His eldest sister, through catching cold, has heart disease from rheumatism affecting the heart. Psoriasis. Man, set. 25, big, strong, but scrofulous looking. He suffers from rheumatism, and his father from the same. Mother died of bronchitis. Psoriasis diffusa. Female, set. 42. She has been treated in this hospital before for psoriasis palmaris, and got relief. After twelve years of marriage had one child extracted by craniotomy ; no other conception. Her husband healthy. Her mother is asthmatic and weakly. Out of five brothers and sisters two of the latter are dead by consumption. The patient carries a robust appearance. Psoriasis. Adult male. His mother died of decline. Patient is one of two that have it out of ten. In early days was at Margate Infirmary with scrofula. COURSE AND CHARACTER OF THE DISEASE 47 Psoriasis. Boy, set. 13. Has lost a brother and sister, the sister of cancer. Psoriasis annulata.-lfi.axi, set. 30. Hereditary. Has it also in nails of hands and feet. Two of his sisters have it, one of whom attends here. In the sisters also it is ringed. Psoriasis. Girl, set. 18. Her father has asthma, her sister psoriasis. Psoriasis. Man, set. 30. Gout on both sides of the family. Patient had rheumatic fever at ten years of age. Psoriasis guttaia. Female, set. 12, a short, well-built little girl. Has had typhoid fever and scarlet fever in succession not long since, and preceding the psoriasis. Psoriasis. Female, set. 18. A great muscular, strong, girl. Her father and maternal grandfather have asthma. Of nine brothers and sisters she has lost one by consumption, one by diseased hip, one early by convulsions. No gout or rheumatism in family. It came out first in her face after vaccination at three years of age. Psoriasis. Widow, aet. 52. Her mother had asthma, a brother and sister died of consumption, and another sister of cancer in the womb. Psoriasis gyrata. Man, set. 20. Eruption of strong type, all over him, more or less. His father has it much the same, and his father's mother died of cancer. He had scarlatina when young and lost his speech, which leaves him with an impediment now. He has discharge from his ear and slight deafness as consequence of scarlet fever. He has no brother, but ten sisters without eruption. Psoriasis. Male, set. 46. To a considerable extent. He is now suffering from rheumatism. It came first with rheumatic fever eighteen years ago. Phthisis in his mother's family. Psoriasis nigricans. Scotchman, set. 61. This patient has over the left knee-pan a brown spot bigger than a shilling, such as is commonly called ephelis ; he says he believes it always to have been there. He has also in that leg varicose veins, and four or five patches of nummular psoriasis rather raised; only one of these has a little heaped-up scale like white mortar. Their size is that of a shilling ; they have existed rather more than a year. All have the same dark brown hue as the ephelis. There are smaller, but otherwise similar, patches near the ankle on either side. The man's hair is now grey, but naturally red or auburn. His mother and his daughter have had phthisis. 48 ON THE PSORIASIS OR LEPRA CHAPTER III CAUSES OF THE COMPLAINT THE causes which are really of importance are the predis- ponent, those which lie nearest to the complaint ; but it is the occasional, or those that more immediately provoke it, that chiefly have engaged attention. These are commonly evident enough, but far too trivial in character to satisfy the earnest inquirer, though, indeed, as to the first named or proximate, writers have for the most part preferred to be silent concerning them. Nor can we hope to resolve all satisfactorily, but nevertheless the fruits of laborious investi- gation need hardly be thrown away. So, then, as to those that are occasional, external and extrinsic, it is here as with many other disorders, whatever be the organs concerned, these causes may be mostly included under the one head disturbance. Thus, where the whole system is surfeited with a materieSj or primed with a disposition to the disease, or charged with a capacity for it, it needs but little indeed to throw it into act, to make that manifest which before was scarcely dreamt of. Just as with the concentrated solution of a salt, the mere contact of a glass rod will set it into crystals just as in water brought slowly to the boiling-point, it may need a little shake before it bursts forth into steam - so where the disposition is strong, as under pressure of a mainspring, it needs but a slight touch to set it going. And thus, indeed, with psoriasis, not otherwise than with eczema, we have seen it come after trifling occasions, as trundling a hoop, or getting wet through in rain, or bathing when hot, CAUSES OF THE COMPLAINT 49 or drinking a glass of cold water, or may be after eating spiced food, or playing at snowball and such like one can scarce enumerate them all; and as to fright from thunder- storm or fire, if we have not such striking instances as are on record, of mental and bodily excitement we have not a few ; while as to others we suspend our belief, such as walking into a village where there is smallpox, and, indeed, as to bad smells generally. Others are less doubtful, as where a woman lays it to washing her baby's linen after diarrhosa, or her own after her confinement. Experience will lead to our hearing a variety of such tales, and some little judgment is required in dealing with them ; only this may be said, that the character of these things as mere irritants, and even as excitants, would rather lead to eczema as a simpler inflamma- tory act than to the production of psoriasis, except with the preformed disposition, on which we are careful to insist. And, indeed, the occasional cause is scarcely of first conse- quence, except it be in itself all complete, as happens with scarlatina, and even here it should not preclude inquiry, for, after all, in a particular case it will be but an occasional cause, comparable with varicella, which often precedes pso- riasis. And here, as apposite to the period, let us not forget what Bateman calls the " unseasonable use of the cold bath." The practice of " tubbing," which is now in daily use, has sent us a good many cases, and even during a course of warm baths it is liable to occur, and where the disposition is intense too frequent washing is a disadvantage. I have elsewhere (see Appendix) written of psoriasis which comes on soon after vaccination, and especially after revaccination too few, indeed, to justify a relaxation in legislative enact- ment, but well calculated to arrest the attention of the medi- cal philosopher. Here the doubt may well occur if the cause be external or internal ; analogy will suggest the latter, but the psoriasis began at the point of insertion in these cases, and during the healing of the sore, following immedi- ately on the lesion, as occurs, indeed, with scarlatina. But as to the synthesis, or artificial production of this disease, I know not if it has been accomplished yet. True, one has 4 50 ON THE PSORIASIS OR LEPRA read of podophyllin that it brings an eruption on the feet and hands, of the nature of which I am ignorant. What we find in Bateman as to salts of copper producing psoriasis is scarcely proved by the cases quoted (see { Edinburgh Medical Facts and Observations/ vol. iii, p. 61), and no second instance is recorded. Nor am I thoroughly convinced that psoriasis can be brought on by bad effluvia, though the opinion is so current as that it needs must have had some foundation. The only instances of late were seen in a lamp- lighter at a railway station, who works in a close and confined room, and one case from a horse reeking with glanders. But ceasing from such disquisition, to confine ourselves to simple irritants, such as flour, garden mould, brick-dust, linseed poultices, and the like, such as will take effect in a nurse who rubs in an embrocation in jewellers, engravers, photographers, and others who use chemicals bakers, masons, gardeners, bricklayers, carpenters, boatmen, all liable to be affected in their trades the result is hardly found to be conformable to the nature of the irritant, otherwise than mechanical, but to the quality of the individual it is accor- dant, agreeably to the everlasting rule, whatever is received is according to the recipient, and generally we may say that though at first the eruption may be limited it is subject to extend itself very generally, and this is even true of bakers' itch, which is generally described as occurring on the back of the hand and wrist, but sometimes it gains the waist and shoulders; and in that of washerwomen, which affects the hands and face, but afterwards the body may be affected; and accordingly as the predisposition is weak so the eruption is local or eczematous. And here we must observe that it is liable to change in outward aspect, according to the shape or pres- sure of the instrument employed, as occurs with the trowel, or plane, or spade, in the hand ; on the breast-bone from the stock and bit or other tool ; the chafing of the braces on the shoulder, the garter on the knee, the clothes about the waist, are not wholly inoperative in modifying the distribution of the eruption. And then, again, the slushing of water by a groom, an accidental blow, a chafing, an oedema, may all pro- CAUSES OF THE COMPLAINT 51 voke psoriasis, which before was non-existent, or perchance lurking in the skin. But in that which follows ague, abscess, dead bone, blenorrhagia, uterinefiux, and catching complaints, such as hooping-cough, may we not rather refer it to weak- ness, in much the same category with that which follows low spirits, original debility, scrofula, starvation, neuralgia, and insanity ; against all which there arises a doubt in the mind, for either debility may breed something wrong or a flux may leave something behind. How, indeed, explain the following ? A woman is in hospital with a large discharg- ing abscess, from which she is cured and leaves the hospital quite apparently sound; in a few weeks she comes to me with a bad urticaria, and in such sort we sometimes have psoriasis following these discharges. We come now, then, to another set of causes, those that are internal, and to deal with the subject in the simplest kind of way we allow at once that the internal organs have their reflex action on the skin; thus, urticaria has been known to occur from hydatids in the liver, or quite appa- rently so, and in angular curvature of the spine we have seen the psoriasis so arrange itself as to leave scarce a doubt that it was not indifferent to the seat of irritation within, so too the disposition of psoriasis over the throat and under the clavicle have indicated a sympathy with pulmonary condi- tions, which has also been seen with regard to other organs than those of the chest. We notice itching of the scalp as accompanying or preceding head oppression, drowsiness and sometimes vertigo at the coming on of psoriasis, but this is no less seen with eczema and other skin affections, and so we scarce with Elliotson dare speak of the head as whence the whole mischief proceeds, neither with Watson who refers all to the state of the alimentary canal, with which this skin disease is said so to vary and to alternate as to leave no doubt at all of its dependence upon some morbid condition present in that part, being seldom or never " not connected with it," notwithstanding that Dr A. T. Thompson, a physi- cian with some skill in dermatology, has pronounced the same opinion with even greater explicitness, making psoriasis 5 ON THE PSORIASIS OR LEPRA wholly to depend on a sub-inflammatory condition of the intestinal mucous membrane. This appears to us a legacy from the school of Broussais, ill sustained by a wide experi- ence. The alternation of skin complaint with internal con- ditions is not a mere dream, and yet it is of great unfre- quency. We have refused, then, to see in psoriasis a mere reflection of internal malady inscribed upon the skin ; in all such there will be a predisponent cause, the external and internal irritant will stand on a footing, perhaps not unequal. Here we may have leave to speak of certain articles of food, as vinegar and spices; but how shall we class worry, and fretting, and hard living, and trying circumstances, such as shipwreck, or a military campaign, and fevers, long-continued discharges, abscesses, fistula, haemorrhoids, and that ever recurring cause, the nursing of infants, and sometimes gesta- tion ? These, indeed, appear to have an influence which is proportionate to the debility they inflict, and the same is apparent when catching complaints, so frequent among the poor, and especially among the children of the poor, follow quickly on each other, to the vast impairment of bodily health, both future and present; but any further than that as they conduce to scrofula and to sheer debility of constitution we cannot discover in them the predisponent cause. In every hundred cases of psoriasis or so we shall find two or three that seem attributable to smallpox, the same number to typhoid fever and typhus, but fewer than such as come after scarlet fever and diphtheria, and in very far less pro- portion than after rheumatic fever, which is, indeed, a com- mon antecedent. With the first three the debility we have already spoken as favorable to the invasion of psoriasis might serve sufficiently to explain it ; with scarlatina and diphtheria it is somewhat more remarkable, not only on account of the frequency with which the cases occur, but also through what these two have in common, which is that they are both of them liable to be followed by rheumatism, albuminuria, and paralysis. When psoriasis follows scarlatina it will not seldom succeed immediately upon the usual desquamation, so that the cause is quite evident, though not conclusive, and CAUSES OF THE COMPLAINT 53 when this has happened years before it is by no means so evident as cause. Psoriasis also follows closely on erysipelas. As to septic influence, we must regard it as proven, at least in one instance, which is that of syphilis, a complaint which has evident but undefinable relations of affinity with scrofula, even, perchance, with phthisis. This singular and mysterious complaint of syphilis furnishes us with an experi- ment made by nature on the boldest and widest plan in the synthesis of disease. It needs be said that we regard as overweening the pretension of those who affirm that they can distinguish syphilis from psoriasis in all and every manifesta- tion; in certain regions this is perfectly impossible. It would even seem that the forces which produce psoriasis, or the defects that let it come, have something in common with this inoculated complaint, or with its mode of working in the frame, which seems to leave the formative or constructive processes in default as far as parts of the skin and the nails are concerned. There is equally seen in respect of pigment a want of control which is common to the phthisical, gouty, cancerous, scrofulous, and syphilitic constitutions. A disease with which we find psoriasis in frequent com- bination is asthma. The fact, indeed, is so apparent, that it is impossible to have a moderate acquaintance with this latter complaint without having met the two together; in cases of asthma it is not unfrequent to find skin disease on the legs and even on other parts. I do not say there may not be found asthmatic families where nothing is observed of skin disease, but the truth remains that they are exceedingly subject to it, and to no one kind of cutaneous complaint so much as to psoriasis (see Appendix) ; but this combination with asthma is also very marked in ichthyosis and pityriasis, and the dry squamous affections generally ; very much more so, indeed, than in the moist, as for example, in eczema. The cases where the last is found with asthma are chiefly of general eczema in children, where possibly the bronchial glands are enlarged and where the eruption may be con- jectured to extend along the mucous membrane as far as the bronchi, and this has been called eczematoud asthma, but in 54 ON THE PSORIASIS OR LEPRA the history of families the connection of asthma with eczema will be found to be less close than with psoriasis, and, so far as I can judge from my own practice and experience, the cases of asthma with eczema are numerically inferior to those with psoriasis, notwithstanding that eczema is a far more frequent complaint. But the two skin affections may be modified, mixed, or conjoined ; thus, we have seen an asthmatic with eczema of the forehead and bend of the arm, and in the palms of the hands, quite a dry psoriasis ; so, again, with psoriasis in certain asthmatic subjects, you may have acne rosacea, and even where both parents are asthmatics we have seen in many cases, not always psoriasis in the children, but acne or some other skin affection ; and what Hebra says is indeed true, that skin complaints other than psoriasis are found with the arthritic and phthisical dyscrasia, but these, as a result of inquiry, I have found to be chiefly the dry squamous diseases, and the others in less proportion ; for eczema in great part does not depend on such causes, but is frequently acquired through innutrition and nervous ex- haustion, and so far I must blame Hebra that he did not carry inquiry further. But if I be asked what kind of asthma is here intended for diagnosis is now carried to an extreme I would say that I am tolerably content with the popular notion of asthma, for that of physicians in the present day is to this end too refined ; but cardiac asthma is not what I mean, but chiefiy the asthma that comes by hereditary tendency or descent, and this whether it be spasmodic or whether it be bronchitic, and it is seldom but that the latter follows the former. But as for other conditions of the lung, such as pneumonia or pleurisy and their effects, I am not confident of these as I am of bronchitis and asthma, and as to whether psoriasis may depend or not on imperfection of the respiratory or circulatory processes, mechanical or otherwise, I dare not venture an opinion. With cardiac disease and dropsy it is certainly sometimes connected, just as these are with rheumatism, but what I pretend to affirm is that psoriasis occurs with asthma and very particularly in so-called asthmatic families, and that CAUSES OF THE COMPLAINT 55 the disposition which is found in them is that very bodily disposition which is favorable to the development of this complaint, and if there be a difference as regards such diathesis that difference has yet to be declared. And though there has been but little progress made as yet in the study of hereditary disease, it will be allowed at least of these two complaints that both are hereditary affections, at least in a certain number of instances, and observation will lead us to the point that both occur with much frequency in the same families ; but from the imperfect way in which the hereditary principle is understood, or followed out, in the study of dis- ease, these facts are altogether overlooked or nearly so. For instance, I have seen it recently observed that not above one case in a dozen of asthma is hereditary ; but if all the children of an asthmatic were necessarily asthmatics the world would indeed be thickly strewn with them, but such children will probably have some kindred disease ; and, moreover, it might be possible in examining these children attentively or study- ing the accidents of their history to find perchance in each one some trace of their antecedents, nay, probably, some faint touch of asthma ; if they open a musty old book or a drawer that has been long closed, or shake a pillow or a feather bed, if they meet the dust in the road or the raw morning air, or go where there is ipecacuanha or perchance some fresh mown hay, they experience a difficulty in breathing. It is precisely in such subjects that you will meet with dry squamous disease, and also with other affections of arthritic and phthisical complication, which an able physician will distinguish in their nexus, but which are undiscerned by the crowd. Now, such persons as I have described as so far subject to asthma constitute a vast mass in this country ; they are numerically important, and, indeed, asthma itself is an exceedingly prevalent complaint ; as to its connection on the one hand with gout and rheumatism, on the other with phthisis and every shade of bronchitis and winter cough, with certain conditions of the mouth, throat, and kidney, these have been treated of by able physicians who .are, w of admiration and respect. _ . 56 ON THE PSORIASIS OR LEPRA And here one may notice the accusation that has been made against dermatology, that it has contributed so little to general medicine ; but how little, on the other hand, has this contributed to dermatology ! When one opens a monograph on gout or phthisis, how little do we learn about skin disease. It would appear that there is nothing known of the effects of these disorders on the skin (see Appendix) nothing, I mean, with nicety, exactness, or certainty, and yet without such knowledge the history of these disorders is, to say the very least, most incomplete. We shall, therefore, enter boldly into this question and ask at once, To what is due the vast amount of skin disease in the community ? We answer without hesitation that it is deeply connected with phthisis, so extensively and univer- sally distributed. The children of the phthisical have eczema capitis in infancy, and when a little older they have some form of eczema or lichen urticatus] older still they have psoriasis, perchance eczema or lichen simplex, acne, or some other cutaneous affection. If insurance offices were aware of this they would give a little more weight to disease that has happened at some time on the skin. But this is not at. all the ordinary idea, that psoriasis and lepra is much depen- dent on the phthisical constitution, although it is confirmed by the celebrated dermatologist Erasmus Wilson, whose experience in this fact, at least, runs parallel with my own. But it will be said how, then, will psoriasis be so much a disease of hot countries, for there is no consumption there ? This is a fallacy which is very much on the wane. Since the day when Lombard showed an almost equal prevalence of phthisis in all the capitals of Europe, it has been more widely inquired for, and found in all lands, even in those bordering on the equator. As an apropos I may quote here a letter just received from a physician in excellent practice among the wealthier of the dark races in Bombay, Dr da Cuuha. " As to the word agrom" he says, " you are not wrong in your surmise that it is a word used here to specify psoriasis a 'of-t7Ji > e : t^ngiie, a complaint I have frequently met with j your *ixiea i 6f l the,ljqhnectiQn existing between asthma and psoriasis CAUSES OF THE COMPLAINT 57 is perfectly correct. I see them much together in elderly people." Modern medicine has few better reasons to con- gratulate itself than such as are founded on having traced the connection of asthma and gout with phthisis, which has been done in our days by men of great industry and talent, among whom may be mentioned Drs lames Pollock and Alfred de Mussy. It is so common to connect psoriasis with gout that we need dwell the less upon it ; it is a fact which is quite unmistakable. I have never been able to make up my mind whether this or phthisis plays the greater share in preparing the way for psoriasis, though I am rather inclined to name the latter. These diseases to the dermatologist form quite a natural group, but it is difficult for the physician, whose attention is divided over a variety of diseases, to place himself on the same point of view. To such a one the connection of phthisis with gout and rheumatism may seem doubtful or weak, he needs the intermediate link, while to the dermatologist it is assured and constant, and of everyday application. I say with gout and rheumatism, and indeed I am not able to divide them and their congeners in the same trenchant style that has been used in some modern writings. If you study them in the way of descent they will be found in close alliance. Quite recently I recollect to have seen in some respectable print that psoriasis, however it may be allied to gout, has no kind of connection with rheumatism. This is truly an audacious assertion, that shows a great want of attention in the writer, for every day in dealing with psoriasis you find it with rheumatism and sciatica; every day in its history you find rheumatic fever and rheumatic gout. Rheumatism, as we are told, was first distinguished from gout a long time since by Themison, of the school of Alexandria ; some physicians of a later period, and notably Chomel,of Paris, have been of opinion that they should not have been divided, and M. Bazin, a living dermatologist, has, I believe, embraced the same idea in attributing very much of skin disease to arthritic complication. I have no acquaintance with the work of M- Bazin, which contains this exposition, 58 ON THE PSORIASIS OR LEPRA having purposely neglected its perusal, as I wished to follow my investigations without bias. I may truly say, then, that I know nothing of his doctrine but from a sarcasm cast upon it here and there. I must express, however, my own con- viction that the rheumatic element has very much to do with skin disease, and especially with psoriasis ; it has also appeared to me that the children of the phthisical are more subject than others to rheumatism and its consequences. And in families notoriously phthisical, I have seen in single instances rheumatic gout or some divergences of pigment, just as in gouty families occasionally a single member will have asthma, and exhibit no other trace of gout. It would be well, indeed, if we looked after rheumatism in the history of disease with more attention than we do, as well as for other antecedents. There are many cases which die in our hospitals which would cause less wonder if their antecedents and family history were exactly known ; even erysipelas to a certain extent runs in families, and in the subjection of patients to pysemia there may be something of the kind. As regards elephantiasis, rheumatism should be particularly inquired after in its history, especially in moist climates, and its extreme prevalence among the poor makes it not unlikely that scanty or imperfect sustenance has sometimes to do with its production. And so again with gout, its frequency among the poorer classes in this country is exceed- ingly great ; one finds it in a social stratum where port and burgundy can never have reached, and the vast sale of quack medicines under the name of gout-pills declares sufficiently the extent of its prevalence in the land. So, then, if we question our cases with psoriasis in respect to their antecedents, we shall find three chief categories under which they may be ranged, notwithstanding that for the most part they are mixed. These categories are those of direct hereditary descent, chest complaints, and arthritic affections ; to which may be added cancer and scrofula, and under a more doubtful aspect we may rank septic infection. We must here, then, say something of the hereditary descent. This is very striking in particular instances, and CAUSES OF THE COMPLAINT 59 has been greatly exaggerated by certain dermatologists, among whom we may note some early notabilities of the French school. It would, indeed, have been better had they con- fined themselves to the modest phrase of Willan or of his expounder Bateman, that "there is obviously an hereditary disposition to it in certain individuals," for this contains the whole of the matter. But Hebra, of Vienna, considers it shown to be more or less hereditary in the greater number of cases, and Erasmus Wilson believes that about a third of them may be hereditary, but I have never been able to find this proportion higher than one eighth or perhaps one twelfth, and the cases are very few indeed in which psoriasis or lepra comes by direct descent without any other connec^ tion to which it may be in part or dubiously assigned ; for in nearly all cases where it is clearly inherited there also you find phthisis in the family, or gout, or asthma, or cancer, or some of those predisponent agencies to which we have directed attention as contributing to cause psoriasis. But in a very few cases, as I have said, there is nothing of the kind, nothing but the hereditary descent from parent to child, and possibly found in two or more children of the same. family, or some blood relation may have it, and thus we have seen it come on at the same age in a son as in the father, and in the same region in parent and child, and especially we may instance cases where we have found psoriasis palmaris and p. plantaris to be hereditary ; but sometimes the children of those with psoriasis will have eczema, which is not wonderful, and sometimes they will have gout or inherit another dia- thesis, or the same in some other form. But in looking for signs of a diathesis we must not be unmindful that the psoriasis itself may be the first betrayal of it, and that others may follow late in life. In the case of a woman with psoriasis we were entirely defeated in our endeavours to discover anything amiss in her family history, but while she was under our treatment she came forward to inform us that just then, for the first time, her father was seized with gout, and, indeed, gout comes very often late in life. In what I have written elsewhere (see Appendix) I have 60 ON THE PSORIASIS OR LEPRA fully declared my opinion that psoriasis is not wholly alien to the cancerous diathesis. This is well shown in the daughters of men afflicted with epithelioma, a form of cancer which is mostly found in male subjects ; but their daughters display psoriasis. And beyond this we have the fact sufficiently patent of psoriasis in the tongue turning into this form of cancer. As regards scrofula, without being a very prominent feature in the natural history of psoriasis, we must allow of its existence in certain cases where swollen glands in the neck, mammary abscess, pal- pebral ophthalmia, white swelling, split lip, &c., give some proof of it ; the connection is fairly recognisable, but its extent is not easily defined. A mass of cases, it is true, show nothing of the sort, but, especially among the lower orders of the community, we are accustomed to see debility in the general type, and scrofula in not a few. And here we cannot avoid mention of a disease whose effects seem inextricably mixed up with psoriasis, and which we have said to have relations of affinity, or at least of analogy, with scrofula, and even with phthisis. This, which is well known as syphilis for want of a better name, we must range under the head of septic poisoning, we know not how first be- gotten or whence proceeding, but probably due like ele- phantiasis to the joint operation in the first place of climate and of defective nutrition. Already we have spoken of its results as counterfeiting those of psoriasis. Have we to blame in this our individual discernment, or is the body, per- chance, as a musical instrument with only a limited j range of expression, and subject, as it is, to a million of injuries from without, and not a few internal griefs, provided with a barren vocabulary by which to announce its resentment ? Cases of psoriasis occur in the insane and in the children of the insane, but with no marked degree of frequency. I have seen it far less often than eczema, even than acne, in epileptic subjects ; and though it is not seldom attended with symptoms of extreme nervous depression, these are con- nected with others of general debility and apparently dependent on them, At least I cannot perceive any near CAUSES OF THE COMPLAINT 61 connection of psoriasis with these neuroses, more than attaches to other forms of skin disease ; and, indeed, sheer nervous debility, as resulting from discharges or strain, is according to my experience more likely to result in alopecia than in it. A good deal of uncertainty, however, still clings to the subject. So far as I have seen, the presence of paralysis has not appeared to modify the distribution of psoriasis. We shall continue in our plan of giving cases to illustrate the foregoing and general facts connected with the disorder. Seldom do we meet with a case which we cannot gather into one of the great categories before mentioned, and when we fail we do not the more on that account consider it a trivial disorder. The self-love of families may, however, occasion- ally prove an impediment to inquiry after the truth, and a little skill is required in drawing it from them. Lepra vulgaris in a boy, set. 11. This eruption has a strong type that is to say, there are a limited number of large patches, dark in colour, and contrasting with the skin, each limited by a little raised ledge or raised border, with a thin, almost linear, pink margin, as seen figured in atlases for L. vulgaris. These are mostly in large, rather elongated, circular, or nummular forms. The crust is dark, rather soft and plastic, like fused india rubber ; thick in the middle, thin at the edge. Of these patches one bigger than an egg is situated over the left crista ilii, another below the right olecranon, a third on the external aspect of the right leg. On the left calf there is also a very large patch $ there is no symmetry in their arrangement. Others the size of a walnut are distributed, one over the symphysis pubis, some three or four elsewhere. Two as big as a shilling behind the left trochanter, just over the sciatic nerve, and besides these some scattered tubercles and puncta. The fold of the thigh at its junction with the trunk is marked by a narrow line of redness. The scale flakes off irregularly. In two of these patches the crust has split across in its centre, and there is a slight oozing of black, grumous sanies; the general character as to colour is black, and some of them a little yellowish. There are three patches on the head, and a boil on the forearm. The patient inclines slightly to the lymphatic temperament, well grown, with blue eyes. He was nearly dying from brain fever (typhoid ?) some three years since. He has had this complaint fourteen months ; it came in red spots, which, when he bathed, turned white. His father's father had spasmodic asthma, but died with dropsy in the 62 ON THE PSORIASIS OR LEPRA legs. His maternal grandmother also had spasmodic asthma, a weakly woman with a large short-lived family. Lepra vulgaris. Young lady, set. 20, married, The eruption is extremely diffused. Her younger sister was a patient of mine with the same; her mother's brother had it, and her maternal grand- mother. The patient's father suffers much from gout ; the mother as well as herself had rheumatic fever. Her mother's family are highly consumptive, and the patient has lost a brother from phthisis ; her uncle and aunt on the mother's side died through the same. Besides the rheumatic fever, like her sister above mentioned she is constitutionally subject to headaches. The patient is now covered with eruption, and is subject to continual faintings. She has a child at the breast a twelvemonth old, and another child about a year older. The eruption came out while she was nursing. The patient's appearance is delicate and feminine, but betrays nothing of her unhappy family history, either in build or feature. Psoriasis. Married woman, set. 23. Pretty well all over her, and on her face small patches. She married at eighteen, and this came out within the month after. At the date of her marriage she was stout, weighing twelve stone, but now only eight ; she has wasted three stone since Christmas. This eruption goes away a month or so before parturition, and it returns if she perspires in bed previous to her getting up ; but if not it does so during lactation. Generally, she has nursed her children only a short time, not finding herself strong enough. The last one, now nine months old, she suckled till the fourth month. After her first lying-in she had jaundice, and the eruption disappeared under baths she used for her jaundice, but early returned. It is easily brought on by putting her arms and hands into hot water. If she does any kind of work it returns, but so long as she is lazy it is moderate, Since her last confinement the patient's memory is bad for recent things. She has pain in her heart at times and cannot breathe, but it goes off with palpitation. Her mother has asthma or at least bronchitis. She has a touch of asthma herself. Her mother's sister has asthma. Psoriasis. Man, set. 31. He has had this complaint eleven years, and with it he has acne rosacea. The scale is light and powdery, very scanty compared to extent of the patches, which are red and swollen. It is as if powdered on, and strongly adherent. The acne has existed three years. Formerly he was patient at Gerard Street Dispensary with lepra vulgaris. His mother has a sort of asthma. His father died of phthisis and effusion into the pleura ; long before that he had abscesses in the neck, besides which a cutaneous CAUSES OF THE COMPLAINT 63 eruption, not like this, but moist and mattery. A sister of the patient had an abscess under her arm when about twenty. His aunt too had abscesses as an infant, and her son has touches of the same eruption as that which is here seen. This case seems con- nected with scrofula. Psoriasis. Male, eot. 44, chair-maker. He may be said to have inveterate psoriasis. He was told by a deceased dermatologist not to mind so long as it confined itself to the knees and elbows. But now he complains of acne simplex, which is causing some worry on his shoulders. He has also an eczematous discharge from the head. So long as he can remember he has suffered from an ulcer on the leg. Of the many children he has had, eleven have died, five are left. This man is a dark, ferocious, hairy looking individual, carrying a general appearance of strength. He has a bad chest and spits of a morning. A daughter has rheumatic fever. His mother had asthma that turned to dropsy. A brother had diseased hip and ulcerated kidneys. Psoriasis diffusa. Spinster, set. 40. Has had it twenty years, and something when a child. She is deaf in both ears, with discharge off and on ever since the scarlet fever when young ; when the dis- charge is on she is quite deaf; she has also sometimes lumps in her neck. No marked family complaint. It is curious that with psoriasis from scarlatina you often get this habit of the ear, dis- charging off and on for a long term of years. But what I notice with scarlatina is that some cases of psoriasis which precede it are not sensibly aggravated by its occurrence so as to be perceptibly worse afterwards. Psoriasis. Married woman, eet. 45. The eruption is very red, with sprung veins in the leg. She has rheumatism on the right side, which is that where she is most " disabled " by the spots. Her brother had asthma from his earliest age and died at 37. She has lost a great number of her family by consumption, and so she is left with few relations. Psoriasis gyrata. A man, set. 26. Of superior education. Twelve years ago had measles, followed by varicella, and then on the head appeared this psoriasis. Confined to the head one year, afterwards it extended to the body. Not until last year did it reach the legs, but as it improved on the body began there. In large patches on the body, which, as they get better, leave tortuous lines of immense ex- tent. This case was very refractory to treatment. I do not know that it got well. 64 ON THE PSORIASIS OR LEPRA Psoriasis. Boy, set. 12. Of two months' duration. He has had hooping-cough and measles, and suffered from inflammation of the lungs when a child about two years old. His mother gives the history of the family complaints. Inflammation of the lungs has removed two of her children, and would seem to be almost here- ditary in the family. Of eleven she has had, five are living, six dead. Her father as well as her brother and sister died of consumption, and her maternal grandmother was a decided asthmatic. Her husband, the father of the patient, has gout, and his father before him ; he has also a rough place on his leg as big as a crown piece. Psoriasis guttata. Spinster, set. 25. It came at time of vaccina- tion, has had it off and on ever since. A brother and his child have it worse. Her mother has asthma (winter cough) and is always ailing. A sister has asthma. It is worse in summer, and last summer worse than before. The spots very level, but red, and more at the joints and forearm. It does not instate at all, only sore after washing at the tub. The patient has such a nasty taste in her mouth and such a smell in her nose she scarce can bear it ; her breath smells bad, the secretion from tjie nose filthy, especially in the morning. Catamenia scarcely any at all ; what there is is very dark, and she is very giddy ; she thinks it proceeds from that. Psoriasis. Widow, set. 55. An asthmatic, and her mother before her, and two of her sisters are asthmatical. Has had rheumatic fever three times. Has lost a son by phthisis. Her brother died in the Cancer Hospital. Her asthma gets worse every year, and she has been attending at a special hospital for chest complaints. The psoriasis on the arms, forearms, and elbows, lies in patches, also on the hip. On her face the nose is involved in a rough asymmetric blotch, more on the left side, with a broad silvery patch very superficial spreading over the left cheek. On the right cheek a smaller patch with a heavy crust like a scab. The psoriasis has existed seven years. The joints of her fingers sometimes swell. She had no skin complaint when young, and none of her family have cutaneous affections. She has six children ; she suffers from indigestion and haemorrhoids, and a little from varicose veins ; catamenia regular. The patient is of stout make. While she was under treatment the appearance of the face much reminded me of acne rosacea, and also of lupus. The patches were raised and very soft at first, and with- out scale, but afterwards producing it in form somewhat like a scab. Psoriasis. Shoemaker, set. 23. He has only two spots left. He has been at various institutions, and complains he cannot get cured. No history of asthma, gout, or rheumatism, in family. Has lost both his parents, his mother of dropsy, the father of fever. Has had CAUSES OF THE COMPLAINT 65 scarlet fever as a boy and smallpox ten years ago, but only slightly. He can't stand beer, but sometimes takes a little. This is one of the few cases you come across occasionally where you are at a loss to find a cause ; probably in this case it lies in the nervous system. Lepra vulgaris. Female, set. 31. Has been at various hospitals and institutions. The eruption came six years ago at fourth month of gestation. Narrow jaw, sharp features, cough. She never had any illness till her chest took to be bad. Her father died of cancer of the face (epitlieliomd). Lepra vulgaris. Married woman, set. 51. Has nodular disease in the joints, and suffers now from rheumatism in the left arm. She cannot dress herself or move a chair without much pain. The knuckles of the hand are oblong. When she closes her hand the ring finger becomes dislocated. The eruption is of typical cha- racter. Her mother had asthma, but lived to nearly eighty years of age. Psoriasis. Married woman, set. 42. Confined to the face ; none in the hair ; an erythematous psoriasis more on right cheek and in the centre of the forehead near the hair and eyebrows, seen in small patches. The father died of phthisis ; out of eight brothers and sisters four died of the same. She is deaf and has no family. Yery scanty catamenia. A bad taste in her mouth in the morning. The nose is involved from tip to bridge, where there is a narrow band of healthy skin dividing it from the redness of the forehead. The patient has been for a year in a large hospital without relief. It has existed two years. Psoriasis. Clerk, set. 27, healthy. Has five healthy children by his wife ; no miscarriages. Has stains, with faint desquamation at the roots of the hair. On the legs a few large patches of a very strong red or crimson, with a dry, thin, transparent lamina. They come out in pimples that look as if they had matter in them, but squeezed they have rather blood than matter. This patient is indignant that he has been so often accused of syphilis. Some patches near the hair are not very unlike it ; on the leg wholly different- His mother had rheumatic fever badly, and he has had inflammation of the lungs, which he attributes to accident. Psoriasis. Spinster, set. 25, girlish. First came out four years ago in spring, on the outside of the thigh, not near the patella. She has cough and is delicate. None of her five sisters have skin com- plaint, but one of them has rheumatism ; she has no brother. Her mother died of consumption. She has lost two brothers and three sisters from phthisis, besides aunts and uncles. Her father has chronic bronchitis, and scurvy on the arm and leg. 5 66 ON THE PSORIASIS OR LEPRA Psoriasis. Girl, set. 18. She had scarlet fever in 1867 and this soon followed ; it came on then in a red spot on the forehead ; but almost immediately she caught diphtheria of her brother and nearly died. This came on soon after, but not worse than she has it now. removed from the patella some thick incrustations, which she thinks must have been there some two years, or even three. Her father and his brother have rheumatism. Psoriasis nummularis et gyrata. Girl, set. 19, very 'tall; has fissure of the palate. Father gout, the mother rheumatic fever, and her father, maternal grandfather of patient, phthisis ; all his family in that way. From the inner canthus of the right eye extends a patch in the form of a sac or fig shape, with narrow neck, which extends over the cheek below the eye. It is well worthy of note that I have had other cases of psoriasis with fissured palate. Psoriasis. Man, set. 35. Yery tall ; he stands six feet two inches. He is the eldest son and the tallest. His eldest sister has something on the skin, but not like this. His father has had varix and some eruption on the legs. No gout in family. Psoriasis. Sea officer, set. 28. On the calf a large patch of psoriasis. He carries a great appearance of health, with full-rounded limbs. Of four in family, two brothers are dead of phthisis. Psoriasis. Male, set. 28. With a disposition to annulate and gyrate forms. It came out in Canada on the Bed E-iver survey. They had no subsistence for three days except in the way of spirits. He calls it a surfeit. His father had the same eruption for eight years. Psoriasis. Spinster, set. 21. It began in the face and arms in red spots or rather streaks, which, after a considerable time, became covered with fine white scale ; then it appeared on the elbows. On the inner border of the hand a small spot of lupus, which she has had for years. % Psoriasis. Unmarried, set. 71, with acne rosacea. The hands on both sides show small guttse ; they have a ragged or tattered look. On the arms high coloured and burning, with micaceous scale. Cracks on the fingers. She is of a full habit and light haired, digestion good. Subject to headaches as a girl, not to humours. The more the hands are in water the worse the eruption. Her sister had the same complaint. Lepra vulgaris.M.SLJi, set. 26. Of sparse character, nummular, with little or no scale. OS and on for several years. It came from CAUSES OF THE COMPLAINT 67 fright and anxiety. His little brother was missing, and they found him in the water-butt. This followed soon after. Of nine in family none have it ; all healthy. Lepra vulgaris. Spinster, set. 25. Girlish appearance. Bather stunted form ; suffers from rheumatism. She has a large patch on the left knee. She complains of numbness and want of feeling in the site of this patch. The anaesthesia is marked. It is seldom, indeed, that attention is drawn to this point, though, as tested by local applications, sensibility varies immensely. Lepra alpho'ides. Spinster, set. 22, blonde. Has only two circular patches with scale the size of a shilling, with much itching. One on outer hamstring of right leg, the other on sole of foot of the same leg. Phthisis, rheumatism, ulcer, and skin eruptions, eczema and acne, in family. Psoriasis. Married female, set. 23. Superficial, little scale ; it has very much the appearance of a syphilitic eruption, especially like soft tubercle on the face. In some portions it is ringed, on the lower limbs more coarse. She has had this eruption eight years, and it comes every spring and fall. Has good health. Thinks it came from taking cold after chicken-pox. Although there is so little scurf, she gets more good from soap than ointments. Psoriasis. Female, set. 25. The appearance of the psoriasis is like a sloughed skin which has loosened and readhered. It comes on the knees. Her father and brother had psoriasis. The latter was a patient of mine. The father died of asthma, which he had for ten years, and his mother before him. Psoriasis. Man, set. 38. Hereditary. Very general, with much itching. His mother and eldest sister have it. His sister has rheumatics, but her joints have recovered. The patient has been bad with rheumatism, his joints stiff, and his fingers useless, for more than six months. No gout or consumption in family. Psoriasis gyrata. Man, set. 35. Bed and scaly on scalp and chest. It portrays the elegant curve of sea- shells. The eruption goes away in winter time. He is very hot blooded, and when he puts oil on his head it is all dried up the next morning. His son attends with eczema. Psoriasis annulata. Man, set. 29. This patient has a skin white rather than delicate; whiskers red; complexion not otherwise remarkable. On the shoulders he has half rings the size of half an egg in its long diameter.' There are several of these which touch by their extremities, but do not form serpentine tracks. The colour is a fresh lively pink, or rather rose tint on the whitest possible 68 ON THE PSORIASIS OR LEPRA ground. He is in a porter brewery, superintendent, and drinks a great deal of porter without looking gross. He gets well off and on ; has been under various doctors, and has taken everything without cure. Psoriasis. Girl, set. 13. On left forearm a broad vermiform track, curled abruptly on itself. She has had it three years. No other lesion or patch. Catamenia scanty. Her mother in weak health. Psoriasis. Woman, set. 49. It came out at the seaside, which is far from uncommon with psoriasis. She never had an eruption before. Behind her ears a little eczema. Twelve years ago had erysipelas in the leg. Psoriasis. Man, set. 41. His mother was for some years before her death asthmatic. His father died of phthisis, as also a brother and sister. Has had rheumatic fever, scarlatina, and smallpox. Psoriasis. Man, set. 47. Mother very decidedly asthmatic. Brother died of asthma. Patient suffers from lumbago. Psoriasis. Female, set. 28. The patient and her father suffer from rheumatism; a sister died of consumption; cousins on the father's side have psoriasis, On the mother's side asthma. Psoriasis. Jewish female, set. 55. A bad asthmatic, Her father had asthma; she is wretchedly ill every winter. Psoriasis. Female, set. 25, single. Her father was asthmatic a year before his death, and died of disease of the bowels ; her brother has gout. This patient has never menstruated ; she is a tall well- shaped woman, but with bosom flat. The psoriasis came after re- vaccination. Lepra alphoides. Lad, Set. 17, superficial scale. He has it nearly all over him, much where the braces play over the shoulder, very bad on the ears. The skin of the penis dark, shows white super- ficial patches, with little scale, in marked contrast of colour with the surrounding skin; frightful itching. His mother had a skin eruption. Lepra vulgaris. Girl, set. 5. Srofulous type ; the scab sticks like a limpet to a rock ; in removing one a little thin pus is sometimes seen. It came after chicken-pox. She has had it since two years of age. In cool weather it is removed, but returns with the warmth of May. Lepra vulgaris. Female, set. 18. On knees, legs, and arms, there are coarse red patches, which itch much ; only a little on head CAUSES OP THE COMPLAINT 69 and face ; she has had it three months, In this case the initial spots come out quite pale, as much so as I have seen in lupus. Psoriasis guttata.~-Girl, set. 6. Two years ago she had a fall, and a bruise on the leg, which some time after was painted with iodine, and then followed this psoriasis. Psoriasis. Woman, aet. 56. Has also acne rosacea ; the psoriasis affects the hands and groins : she has boils ; a hard-working weakly woman. The mother died of decline. Psoriasis. Man, set. 47. Has it in the elbows, and eczema in the ham. Mother asthma ; father diseased stomach. Psoriasis. Girl, set. 7. Was in attendance before the measles, which have entirely cleared off the skin, though getting well before. Only now the silvery scale slips along the hair, threaded by it at different distances of its length. The hair looks strewn with silver. Psoriasis. Widow, set. 52. Her mother has asthma, a brother and sister have consumption, and another sister has cancer uteri. Psoriasis in deaf middle-aged man with asthma. He is grey and worn. On back of the knuckles of the hand torn skin ; eruption on the elbows and in the line of the nates, towards perinseum. Psoriasis. Man, set. 23. Mother asthmatical. The eruption followed scarlatina, rheumatism intervening. Psoriasis. Female, set. 44. Has also asthma. Two brothers died with consumption. Psoriasis. Man, set. 39. Father asthmatical. Patient has rheu- matism. Brother asthma and consumption. Psoriasis. Female set. 39. Recurrent. Father and two brothers died with asthma. Her nephew, a brother's son, has psoriasis, Has lost two children with consumption. Psoriasis. JEt. 25, single. Mother's sister the same. Mother's brother consumption. Mother's father asthma. Psoriasis. Female, set. 18. Mother died this year with asthma. Brother and father rheumatism. Her mother had rheumatic fever. The patient has a weak chest and cough. Psoriasis. Female, set. 25. With left hemiplegia from teething. Asthma in a brother. Psoriasis. Man, set. 25. Has had it a twelvemonth. Eighteen years ago had smallpox and lost an eye, and subsequently abscess in the hip, from which he walks lame. 70 ON THE PSORIASIS OR LEPRA Psoriasis. Female, &k. 28. Has rheumatism, and her father too. First cousins on the father's side have psoriasis. Psoriasis. Man, set. 28. Fancy box maker. On his leg a large patch of strong crimson psoriasis. Has had scarlet fever. Father scurvy on legs. Cousins phthisis. Psoriasis. Butcher, set. 22. On face and back of hands. On the former with no scale. On the hands rather takes after eczema. Lepra vulgaris. In an Irish milk-woman, set. 23. Looks healthy. She has twelve shillings a week wages, and seldom gets meat. The eruption is very refractory. The sustenance is insufficient propor- tionately to the work done. Psoriasis. Spinster, set. 46. On the forehead. Bight side of the nose scarce more than a raw surface with slight peeling of cuticle. A little erythema of the right cheek ; it might be easily mistaken for a specific eruption, j. The patient has had asthma^between the age of twenty and thirty. Only recently she has this eruption. Psoriasis inveterata. Man, set. 33, of superior ~ education. Here- ditary. His father had the same for years up to the date of his death. The patient is excessively rheumatic, and has had rheumatic iritis, which gave way to sudorifics. Mercurials affect him injuriously. He derives no benefit from colchicum. The disease is most refractory, constantly returning after temporary amelioration from treatment. Psoriasis guttata. Boy, set. 10. Chiefly on legs, but also in front of neck and throat. The boy has a bad cough. Psoriasis. Girl, set. 8. Four years ago or thereabouts had scarla- tina, whooping-cough, and varicella in rapid succession, and now this psoriasis. Has been wonderfully weak all along. Out of seven she is the weakest. Psoriasis. Female, set. 30, married," The patient broke a blood- vessel in the lung, and lost full half a pint of blood soon after her confinement with the only child she has. She has a dreadful taste in her mouth of a morning. A sister of her's had asthma, and was a patient at the Brompton Hospital. She is recommended to try America, and is much benefited by residence in Niagara County, New York State. Psoriasis. Spinster, set. 39. A brother has it, and a nephew whose father got rid of it by going to Australia. Of five brothers and sisters living three have psoriasis. Her mother's father had skin complaint, It did not come on her till 29 years of age, ON AFFINITIES AND DIAGNOSIS 71 CHAPTER IV ON AFFINITIES AND DIAGNOSIS IT can be scarcely thought strange that this disease should have been occasionally confounded with elephantiasis when one reflects on the small amount of attention which until lately has been applied to such matters, for it is even within my recollection to have met with physicians, even distinguished among us, who had but a poor idea of what was meant by the word leprosy, and scarce knew of the existence of elephantiasis. And though the Greek and Roman writers described the twp as distinct, yet they appear to have entertained the notion that one could pass or glide into the other, and, indeed, Willan seems not to have been free from this prepossession. What seems to have favoured it is the fact of psoriasis in all its forms being found not very unfrequently to accom- pany the elephantiasis. But with difficulty can it be believed that in the middle ages they were not distinguished fairly well, for the lazar houses, numerous as they were, and no doubt liable to be abused as receptacles for many sorts of skin disease, could scarce have been so ample as to include all and every case of psoriasis. Unless, then, we may sup- pose a great relaxation of duty, or a more than ordinary ignorance, the two would hardly be liable then to be con- founded, for we know that in the hands of physicians of that day some very sure tests were applied. But the fact of their meeting often in the same subject would favour the idea of their affinity ; moreover, both alike were attributed to black choler and the melancholy humour, just as cancer 72 ON THE PSORIASIS OR LEPRA and the worst kind of diseases, and so much was this idea in the ascendant that the Arabians called it the black baras, looking only to the pathological elements, while we, regarding it objectively, have been rather disposed to call it the white leprosy, for this people, mere borrowers from antiquity, were wholly submitted to such a view of its pathological consti- tution. And Celsus, with whom lepra was an impetigo, has quite unnecessarily a form, in which this black element is supposed to betray itself, which he calls the impetigo nigra, as led by the same ideas ; and Willan seems to have drank of the same fountain, for he gives some prominence to his lepra nigricans, more, perhaps, than numerically the subjects of it should claim. We cannot, however, but consider these to be as much distinct as most diseases of the skin, an expression of opinion which need not rob of interest any mixed form, but might rather serve to heighten that interest. The circumstance is well worthy of note that psoriasis is more found with elephantiasis than eczema and other forms. Psoriasis is distinguished by its scale, elephanti- asis of one kind by its tubercle and tubercular infiltration, of the other kind, or drop evil, by paralysis of sensation, and a gradual impoverishment of structure or maiming of limb. To correspond with this we can only adduce in psoriasis an occasional bluntness of sensibility, which if unmistakable in certain cases is not a very prominent feature in the com- plaint, being also found in other conditions of the skin, and notably in alopecia ; there is, indeed, in this respect, as tested by local remedies, a considerable scale of variation. Beyond this there is liable to happen such an instance as we find quoted in the ' Journal of Cutaneous Medicine/ vol. ii. p. 427, 1869, where in a case of psoriasis a certain atrophy of the fingers is found from shrinking of the bony structures, just as occurs in elephantiasis. See also Wilson's ' Diseases of the Skin/ p. 365, under head of " Atrophic Affections/ 7 Without embracing the opinion to its full extent that psoriasis was the leprosy of the Jews, we cannot but believe that it constituted some share of it, and, in fact, so much is, ON AFFINITIES AND DIAGNOSIS 73 allowed of the leprosy of Naaman and Gehazi. Indeed, there is no need to conceive of the Jewish leprosy that it was of a highly afflictive character otherwise than through the social disabilities entailed by the ceremonial law, a law which, however it may have been formed in some sort of conformity to reigning custom and prejudice, can scarcely at this hour be justified on the ground of natural precaution, its aim being far other than public health. It may be even conjectured that the botch of Egypt with which the Israelites were threatened as an extraordinary proof of God's anger was no other than the elephantiasis the same Lucretius has described as being endemic there and what gives support to this idea is not only the fact that, as regards their physical and individual well-being, this people were especially the object of God's tender care and provi- dence ; they appear besides to have been very abundantly provided with the means of sustenance, their land exception- ally healthy and productive, and the character of their religion such as to prescribe a free and generous mode of living, without those sullen and painful abstentions from food which under the name of fasts have so much disgraced Christianity, and even now do partially disgrace it. These ascetic impositions, by their mass, must have told most perniciously upon the public health in Europe, no less through their immediate effects than by the false standard of appeal created; so that scholars, ecclesiastics, and silly women have been allowed to prejudge questions which should have been dictated to them as resolved by keen observation and the broadest experience. We may at least dwell with complacency on the fact that improved nutrition and clothing have put away elephantiasis from among us, or at least brought it down to its lowest point. The same may probably have been effective in dealing with other dis- eases, such as ague and scurvy. While many more which are world-wide, such as goitre, and we might be bold to mention cholera, are fated to yield perchance to the same class of cure, being maintained and promoted for the most part by defective nutrition and a beggarly supply of food. 74 ON THE PSORIASIS OR LEPRA For the calculation of what is necessary or advantageous to human sustenance has been ever struck too low, so as to include the worst diseases in its plan. In the future of governments it will, no doubt, be recog- nised as the most imperious duty to care for the sustenance of the governed, whether by exceptional or, if need be, by penal enactment ; but hitherto, absorbed by the mental vagaries of the rich or the crude conceits of the half-informed, they have too much neglected the main purpose of government, which is scarce other than the physical well-being of the people, being that in which a large moiety of the com- munity are least able to help themselves. Now, however, that the doctrine comes to be preached that nothing can come out of a man in the shape of work but what is put into him in the way of food, we look for better ideas and more firm and lasting conclusions. But ceasing now from an apropos which does not principally concern our subject, or at least the matter in hand, we will say that there seems to be an essential difference between the two diseases, and although by attention to the physical comfort of classes we may hope to lighten the incidence of psoriasis, yet we cannot expect to get rid of it in the same way and by the same means that we have exterminated elephantiasis, as we may get rid of lupus, but that it stands very much on the same footing as scrofula, phthisis, rheumatism, and other such disorders. To morphcea alba, or hence to alopecia, it is beyond a I doubt that psoriasis has certain relations or affinities, as proved, not only by their occurring, however it be rarely, yet sometimes together, occasionally in succession, or found per- chance in the same family. This has not only been proved by myself, but mentioned by other writers. I have even noticed transitional forms between morphoea and alphos which sus- tain the assertion of Celsus that there is similarity between them. As to the leuce of Herodotus, one can but conjecture what it was. There is, however, a passage in Hippocrates with regard to leuce which has been much the subject of comment, namely, that it is only found in connection with ON AFFINITIES AND DIAGNOSIS 75 the most fatal or phthisical disease ; the word employed is so uncertain that Galen, by an interpretation which seems rather forced, has concluded it to mean the Phenician disease, or elephantiasis. But if, indeed, Hippocrates is subjected to a more simple interpretation, his experience will not be discordant from what we meet with, not alone with morphcea and also with psoriasis, viz. that they follow in the wake of the most fatal diseases; and even the simple leucoderma, though generally unattended with disturbing symptoms, we hold to be no indifferent thing, but truly a bad prognostic in health. Alopecia by some has been recently attributed to parasites on an equal footing with herpes tonsurans, the true ringworm ; by others it has been regarded as an inheritance we derive from the elephantiasis now all but extinct in its grosser forms. With us alopecia partakes greatly of the character of a neurosis. It is very much a disease of exhaustion and of shock, and much connected with psoriasis, as our cases show. One of thfese remains in our memory, being that of a young woman who attended our clinique. At eight years of age she had smallpox, alopecia a year later ; she menstruated when ten years old, and soon afterwards had psoriasis, which after a short interval of subsidence was followed by lichen in her sixteenth year. There are not a few cases, indeed, where psoriasis shows itself akin to alopecia. Already we have said something of its affinity to cancer ; the children of cancerous parents are particularly subject to skin complaints ; this occurs in various forms, and if we except moles, acne is the form we have most frequently found, but there is great variability; we can scarce be wrong, however, in what we have observed as to the daughters of cancerous fathers, especially those afflicted with epithelioma. These seem much subject to psoriasis, though it is certainly to be desired that more observations were made. The relations of cancer to psoriasis in the tongue will be the subject of after-remark when we treat of the latter complaint. Convenience will next lead us to consider its relations 76 ON THE PSORIASIS OR LEPRA with syphilis, which in a practical point of view are worthy of nicest attention, as offering an everyday difficulty, and here it is not sufficient to say that errors are frequently made. There occur cases so mixed or complicated as to defy all discrimination; the tendency, however, which I have found of late in the profession has been rather to see syphilis where it is not than to overlook the possibility of its existence. The parts where diagnosis is more obscure are generally the hands, the soles of the feet, the nails, the scrotum, and the tongue, and these regions will be dealt with separately. The inclination of syphilis to destroy the soft parts is so marked a feature that this constantly betrays it, for psoriasis does not leave a scar, and most rarely is it accompanied with any sore or breach of surface, and this tendency in syphilis is one of the best signs we have ; and often the eruption seems to take a deeper hold in the skin than psoriasis, and looks as if it threatened a breach of surface and erosion, and thus it gives grounds for suspicion that it is not a simple psoriasis ; it is also more tubercular in character, of a more fixed and livid red. Especially on the scalp, the eruption of squamous syphilide has very con- stantly a tubercular appearance, which renders the diagnosis in this part less difficult, and generally with it there is some exudation. In the rest of the skin you may say of the squamous syphilide, that is for the most part smaller in size, more greasy, glossy, or sunken on the surface, than psoriasis, and showing a scantier, finer, less numerous and more ad- herent scale ; some little weight may also be attached to the fact that in its distribution it is less symmetric than the other ; the stain is generally deeper, the colour varying less from a deep red. The ubiquitous character of syphilis may also be borne in mind ; it may be found in every part, while psoriasis evinces certain preferences ; besides this, it may be said that a more than ordinary suspicion attaches to forms that are ringed ; in all affections, as it seems to me, these ringed or annular forms speak strongly as to intensity of the affection. Those rings, which are constituted by ON AFFINITIES AND DIAGNOSIS 77 tubercular elements where the included skin remains sound, are more than the rest subject to my distrust. The dis- tinction, however, is not absolute, but may serve somewhat to assist the judgment. The poverty of these indications may easily make it suspected that I have not taken into account those that are found elsewhere. Without affirming that they are worthless, I have not myself found them in practice to be sufficient guides. In this field of uncertainty the widest experience in both disorders will be sometimes in fault, for there are cases that are irretrievably mixed, and an acquaintance with either one disease is pretty sure to lead to undue preference of it over the other. If we now compare ichthyosis with psoriasis it must be confessed that in their causation or derivation they are much alike ; both of them go much with asthma. Ichthyosis is commonly congenital, but often it is not perceived till a few weeks or longer after birth. It is not found on the palms of the hands and soles of the feet, but often very much heaped up over the instep, and is otherwise liable to spread over the whole surface of the body. In more advanced periods of life ichthyosis occurs in more partial distribution and is very capable of being confounded with psoriasis. Where there is difficulty in distinguishing them this last is best known by its more strict limitation, by the character of its scale, and by an acquaintance with the preferential seats. With pityriasis alba or fusca the scale is finer and it parts more easily. The underlying cutis is not to the same extent thickened, the complaint is more superficial and scarcely affects the same parts, there is also more irritation in proportion to the disorder. With lichen there may be more difficulty ; notwithstanding that Biett thought it impossible to confuse them, experience scarce warrants this conclusion. The papules of lichen are generally of equal size, and this equality is maintained where the arrangement is in groups ; the skin is wrinkled and thick, quite as much and even more so than in psoriasis. The lines of the skin are deep and regular, so that in old and 78 ON THE PSORIASIS OR LEPRA inveterate cases of lichen there is certainly liability to error. But the scale, though often copious, is not so thick and silvery ; it is not heaped up, and there is an appearance of regularity in a patch of lichen not to be found in psoriasis. Moreover, in the skin between the patches not only do you find here and there the acuminated papules of lichen, which differ much from the flat spots of psoriasis, as previously described, but the skin is generally exasperated, without that perfect calm that is found in psoriasis. One form of lichen recently described under the name lichen planus might be very well mistaken for a leathery psoriasis ; in this the papules have a distinct umbilication which may be commonly dis- tinguished on the edge of the cluster, or at least in those papules that are sparsely distributed wide of the patch. There is another form of lichen which occurs on the bosom chiefly, but also on the shoulders, very ill described in English works on dermatology, but occurring in London practice with a considerable degree of frequency and to the unpractised eye very liable to be mistaken for psoriasis. This complaint is well described by Devergie under the name of lichen herpetiforme. It consists in small annular or nummular circles or portions of circles, with a sharp raised margin, about the size of a silver threepenny piece, the cha- racter of the edge much heightening that resemblance. These are in incessant change, are very uncertain in their duration, the seat of a considerable itching, and they shed a fair amount of scale. No less than their seat, their size, which is pretty equal throughout, serves to distinguish them from psoriasis. In the succession of maladies lichen may precede or follow psoriasis ; we look in vain for any strong and essential mark of difference between them. Passing from lichen to acne rosacea, we see in this a com- plaint than which there is none more akin to psoriasis, and it is perfectly incomprehensible how distinguished dermato- logists have grouped it with eczema. Psoriasis and acne rosacea are often seen together, and they also mimic each other with an exceeding degree of accuracy. Thus, I have ON AFFINITIES AND DIAGNOSIS 79 known a young woman with a patcli of psoriasis on the end of the nose which had all the external character of acne \ rosacea, lasting for many years, and always treated as such until psoriasis became developed on different parts of the body, and then it was known to be psoriasis. We have even seen acne rosacea with psoriasis on the body and also on the tongue ; in like manner, psoriasis may be accompanied by other forms of acne, or be in sequence with them. Just as acne rosacea betrays itself sometimes by a sort of diffused erythematous swelling on the nose resem- bling a chilblain, in the same way psoriasis blends with erythema in circumscribed forms, so that it is often most difficult to say whether yon have before you an erythema or a psoriasis, and, indeed, there will be every now and then a case in which lupus, psoriasis, and erythema, will be affirmed by different physicians who see it separately and in succes- sion. In such cases a scrofulous element is for the most part concerned ; for that reason we deem it here best to speak of lupus in connection with psoriasis, and here the diagnosis will often be found difficult, especially among large spread- ing circles of psoriasis which extend by their edge, with crust or scab. As with syphilis so with lupus, we have to bear in mind the leading fact that psoriasis does not run into an ulcer, neither is it followed by a scar. With erythema we have to rely on other grounds ; we have erythematous patches with raised edges that heal in their centre like psoriasis, while spreading by an edge, with crust ; moreover, there is a very common form of psoriasis where the scale plays an insignificant part ; seated upon an erythematous base, this is generally somewhat raised above the surface by a gradual incline, often of a delicate pink in colour, only slightly con- cealed in one part by a little heaped-up scale. By various gradations this form passes on the one hand into the ordinary character of psoriasis, on the other into erythema and pernio; very remarkable, indeed, are these affections, particularly in the hands, which stand as inter- mediate between them. These do not always occur in winter, but pften in summer season, and are often signs of a gouty, 80 ON THE PSORIASIS OR LEPRA scrofulous, or phthisical constitution ; not only in the hands, but also in the face, such conditions are frequently seen. For this reason it seems somewhat singular to us that no distinction has been made as yet of an erythematous psoriasis. These cases are the more worthy of mention as of a pecu- liarly obstinate and lingering character, yielding very slowly to treatment. Occasionally in the course of experience it will occur that after a history of great suffering from irritation, where we look for urticaria, in due course of time we find developed a psoriasis, or these complaints may follow in succession to each other. We have seen pemphigus with psoriasis, but this has been in cachectic and debilitated subjects, occasionally as a result of over- stimulation in such. In spite of what has been said of the scab of impetigo and crust of psoriasis being con- trasted, they may be occasionally though rarely seen on the same subject ; there is a nummular or ovoid form of impetigo which has very much the fades of psoriasis, but the difference is easily discerned. The same with impetigo figurata, which is far from being common in London as compared with it. That form of sycosis which is commonly known as impetigo sycosiforme, but which may be either an eczema, impetigo, an acne, or even a psoriasis, in certain cases sends out from the region of the whisker or beard a projecting stain, which resembles that much seen with psoriasis of the scalp as descending on the forehead or nape of the neck. It is, how- ever, but rare that psoriasis is found on the body with this dry form of sycosis, nor, indeed, is it common to find palpe- bral ophthalmia and everted eyelids with psoriasis on the body, though with sycosis much the case. It does, how- ever, occur from time to time, less often, however, than with ichthyosis. All writers agree to recognise an eczematous psoriasis, whether it be a psoriasis which constantly or from time to time yields some amount of exudation, or whether the two diseases, psoriasis and eczema, retaining each one its proper character, are found in the same subject. In the latter case the dryness ON AFFINITIES AND DIAGNOSIS 81 and moisture is very apt to be determined by the regional distribution. It is quite beyond hope to suppose that writers and practitioners will come to an entire agreement on what is psoriasis and what is eczema ; the same eruption which to one is a dry eczema, to the other is an eczematous psoriasis. There are even those who extend the use of the word psoriasis a long way over the field of eczema, a source, indeed, of no little confusion ; but for us we find in dryness and moisture the best practical distinction. The diagnosis, however, is not so important as it might seem, for pretty nearly the same causes are at work in their production, and the thera- peutical indication is not very different. Whether, then, it be a dry eczema or an eczematous psoriasis that we have to deal with, the difference is scarce more than one of terms. The observations which we have just made will be considered little superfluous when it is considered how artificial is the nomenclature which is still applied to skin diseases, how large is the number of them where mixed forms predominate. To give an insight into such cases we extend our list of ex- amples, and these following will better serve to explain than, any more lengthened discussion the views we entertain about these complaints. Eczematous psoriasis. Girl, aet. 12. The patient is a genteel girl, of slim figure, tall of her age, with no appearance of ill health. She is treated by me for eczema of the legs ; all round the limb decided eczema. She is said to come of a premature birth, and her family is phthisical. Every winter she has a cough, but this year the eczema seems to have saved the cough. She suffers much from smarting and from the cold. During treatment I find she has a slight eczema on the chest, while on the arms and elbows there is a most decided psoriasis. Her mother, who accompanies her, gives me the following account of the family history. Out of eleven children that she has had there are seven living. The eldest daughter died of phthisis. The eldest daughter now living has had rheumatic fever twice, once following typhoid fever. The eldest son, who is now thirty-one years of age, has had rheumatic fever twice. The second son has decided gout, and besides this he has had rheumatic fever more than once. The father of the patient died of phthisis after ten years of chest complaint. 6 82 ON THE PSORIASIS OR LEPRA The mother of the patient displays in the knuckles a decided tendency to rheumatic gout ; her father had gout badly, and his six brothers and sisters perished by consumption. Her mother (grand- mother of patient) died of phthisis, aged thirty-one. Of her nine brothers and sisters all, or nearly all, died of consumption. Soon after hearing this the sister of the patient came to me with a doubtful sort of tumour in the breast, and then I learnt that there was an alarm from there having been cancer in the family. The mother, who volunteered this account, is a person of superior education, and the history is truly remarkable as concerns psoriasis. Psoriasis. Man, set. 31. Red haired. The eruption comes as psoriasis, but in some parts it has the facies of impetigo and eczema. Eczematous in ham, and where the collar chafes him round the neck. Had smallpox thirteen years since, and thinks it may have brought on this. Psoriasis and eczema. Married woman, ast. 50. On the forearms it shows rather a lichenous character. On elbows and knees distinctive patches of psoriasis ; has had a sort of scurf under the kneepans ever since a child, with irritation. In a few other parts patches with loose scale. In both hams eczema with a good deal of discharge, now lasting three weeks, and causing her to apply for relief. It came from a visit to the country, and living, perhaps, a little low. She has had rheumatism slightly since seven years of age. Had two sisters asthmatics, who died, one aged twenty-four, the other aged thirty. Besides these, out of fourteen brothers and sisters five died of phthisis. No gout in family. Psoriasis and eczema. Woman, set. 30. She has a bad cough, and her father has chest complaint. Her mother died of consump- tion. She has psoriasis on the arm, bounded by a distinct margin. Eczema behind the ears, and much thick, dry scurf on the head. Psoriasis (eczematous}. Female, set. 62. A sort of dry eczema, with much coarseness on the arms. A sister, who died of asthma, had the same on arms and legs. At eighteen years of age the patient had psoriasis, chiefly below the knees, peeling off in white scales. She has been married thirty-five years. Asthma and consumption have destroyed her family. "No gout or rheumatism. At forty-one years of age she had a tumour removed from the breast, before which the catamenia were most irregular, but quite normal afterwards. Psoriasis eczema et sycosis. Man, set. 45. He has psoriasis in large spots of a high red colour, with thin micaceous scale. In the groin he has eczema, and between the thighs. On the forehead he ON AFFINITIES AND DIAGNOSIS 83 has a sort of eczematous impetigo that leaves scars like sycosis capillitii, but more superficially ; this has been going on with loss of hair for eight or nine years. He had syphilis twenty-six years back. The eruption is probably due to syphilitic taint, but scarcely betrayed by the cutaneous manifestations simply. Psoriasis. Spinster, set. 30. The patient is a decided brunette, with a fine skin. On both legs, chiefly in front, there come circles about the size of a sixpence, more or less perfect, but very faintly perceived. These are always coming and going for these five years past. They are the seat of much irritation, and may be as well termed a dry eczema as a psoriasis. There is no appreciable eleva- tion, and only very fine thin scurf. No remedies have had a lasting effect ; is not apparently influenced by the catamenia. The tendency of the family is towards the rheumatic diathesis. Psoriasis. Female, set. 21. On hips and back chiefly, and in the legs. True psoriasis. She had an eruption when thirteen or fourteen years of age, but not of this kind ; it was then on arms and elbows, at first dry, and it became moist. She had typhus at twelve years of age, and rheumatic fever at seventeen. She has suffered greatly from rheumatism, and was in hospital with contracted knee. The patient is healthy looking and bright, very stout in limb. She has naked patches on her tongue, with an apparent absence of epithe- lium. The eldest of twelve children, she alone has gout and rheumatism. Her husband gave her the venereal. She lived with him for eight months, and since then they have lived separate. Her father's sister has asthma very bad. Her father died of inflammation of the lungs in two days, but inclined to asthma before. Notwith- standing the appearance on the tongue, I incline to think there is no syphilis. She gets well on steel and arsenic. Eczema of the hands. Lad, set. 21. Light haired, lymphatic constitu- tion. Worse in the country, and especially at the seaside. Has had it six years, His mother had the same eruption, only that hers was quite dry. Psoriasis. JEt. 19. Has psoriasis guttata on the legs, of well- marked character. Acne simplex on the face. Lichen with flat top on the back of his hands. His sister had phthisis. His father had gout, and died rather early. Psoriasis. Man, set. 44. A spot the size of a shilling on the right arm, which looks exactly like impetigo* possibly from his scratching it when he is warm. An inspection of the back betrays psoriasis, two patches near the spinal process of the vertebrae; on his leg the patches are more diffused. The patient's nails are affected with 84 ON THE PSORIASIS OR LEPRA psoriasis, more or less every nail. His father was scorbutic as well as asthmatic and suffered much from rheumatic fever, and two brothers, from his own account, appear to have psoriasis. On the other hand, the patient has an old syphilitic history preceding the eruption. He has marked calvities, to which none of his brothers were subject, and he had a good head of hair up to twenty-four years of age. The hair comes out as he combs it every year worse. He has had the eruption only a few years. This is one of those many cases where it is difficult to decide on the pathological element concerned. Psoriasis diffusa etpalmaria. Girl, aet. 21 ; with superficial powdery scale. She has, besides, on her face, across her nose and lip, erythe- matous patches that look like acne rosacea, but without pimples. This on her nose came at ten years of age, and after that much the same at the inner canthus of the eye, which has now disappeared. She had no eruption when younger, neither had her sisters. She has had no eruption on the knees and elbows. The patient is florid, well in flesh. Both of her parents are dead, the father of rapid consump- tion, the mother of consumption and dropsy. Her sister now attends the Brompton Hospital for disease of the chest. The patient has suffered much from fissures in the hand. They do not gather, but split, especially if she puts them into hot water. This affection of the hands first came on at the seaside. It is very aggravated ; she is obliged to give up all housework, and take to sewing for her livelihood. Psoriasis with impetigo. Spinster, set. 26. On back of calf a large high-coloured patch, orbicular ; another over the sacrum. Within the hollow of the ear it is seen, with a good deal on the head. In the inside of the thigh there is a patch of impetigo the size of a shilling, with dark black crust and matter underneath. There has been one other such on the head, which has healed and left a bald spot. A few others elsewhere. The psoriasis is very refractory to treatment. After six months not removed, but the patient's health much restored. Each spot of impetigo lasts six weeks. Her father had rheumatic fever, and her two sisters the same. She had scarlet fever at eleven years of age, measles twice, and also a low fever. Her mother paralytic. Erythematous psoriasis. Girl, set. 21. The patient is well grown and apparently of a full habit. She has a very large erythematous patch on the left cheek, with others of small size. On the back of the hand and external surface of the forearms the same, from the size of a crown piece to that of a shilling. These patches have an appearance, in the centre, of a very superficial cicatrization. They ON AFFINITIES AND DIAGNOSIS 85 are generally without scale, but where it happens it is thin, fine in grain, strongly coherent. The presence of the scale somewhat relieves the heat and irritation. She has been in hospitals and undergone treatment by arsenic and various local applications with- out marked benefit. The complaint has been classed as lupus or psoriasis. The places subside after some months, without ulcera- tion or scar, This was a case to which I gave much attention, but she benefited most by the sea air. She had always lived well, but had a sister consumptive, and her aunt was subject to abscesses. This case, which has many analogues to psoriasis, may be fairly termed a scrophulide. It has now been going on some four years. Psoriasis. Spinster, set. 25. This case looks like erythema on the back of the wrists, and the eruption of psoriasis, which is now nearly all over her, and which she has had off and on all her life, she is accustomed to refer to chilblains. On knees and elbows it is seen, but not strongly marked. She says that when she is at the worst the hands break out in vesicles (eczema) and her feet in bladders (pemphigus). Near her eyes are erythematous patches. Anything that worries her brings it on badly, during which time the itching is truly fearful ; such an attack will last a week. In winter she has cold feet. The bladders on her feet are liable to become sores. The use of water much aggravates the condition of both feet and hands. Her father has chilblains in winter, more, perhaps, in foggy weather than in cold. He has lost the use of one hand from its being lanced. Her mother's brother has gout. Psoriasis. Spinster, sat. 23. In red patches. Some so deep stained as to be very like purpura, a few of them tender to the touch. Some raised so as to resemble lichen planus, but not entirely of that character. Erythematous psoriasis. Saddler, from Surrey, set. 26. Patches of a light pink colour, with partial scanty scale ; the patches are raised above the surface. He is florid looking, not strong. Eruption dis- tributed all about him ; some in the hair, many on the back. The patches average in size from half-a-crown to an egg. He has had the eruption four months. Father died in rapid consumption. Mother also in consumption at thirty- six years of age. Psoriasis or pernio. Spinster, set. 27. Very dark red patches under the skin, pulpy. Not only on the knuckles but also on the intermediate parts of the back of the hands, and they now begin to come inside. They go away in May and return in September ; every winter worse. They gather and break, and come round the nail. On the feet little tiny places, that cause no annoyance. She has lost 86 ON THE PSORIASIS OR LEPRA no nails. She suffers a good deal with her head. Oatamenia very abundant, with much pain. It makes little difference to her hands. Psoriasis or pernio. Spinster, set. 20. This young woman, the picture of health, has small places on the back of the hands like pernio, but not in the middle of the phalanx. This she attributes to vaeciaation two years since. Each spot remains about a month. One bad place went away quite suddenly from diarrhrea. Her mother, when younger, had something of the kind on her hands. Erythematous psoriasis. JEt. 33. Has erythematous spots on the hands and forearms. On his elbows they have broken out in little bladders. His brother has psoriasis. They are very irritating. This time they have been on him two months. They never leave him entirely, but go away for a month or six weeks. Psoriasis. A man, set. 32, an under-butler. The face looked nipped ; tall and straight, but generally a poor physique. Has always lived well. Has suffered five years from this affection. On the elbow, and especially up the back of the arm, a red crimson stain ex- tremely diffused; a little along the ulna a beefy condition of the hands and inside of the wrist, but not of the extreme phalanges. On the knees the same. It sometimes forms there like a cake, but there is not so strong a red as on the elbows. It is higher up, above the knee, that psoriasis usually spreads. Some scurf peels off in washing. It is chapped and rough in the least cold wind and always worse in winter. His hands have always been worse of late years, and chaps with the least cold. He had chilblains slightly as a boy. His sister had scrofulous ophthalmia. His father's sister died of phthisis. Erythematous psoriasis. Female, a?t. 50. Has erythematous patches on the face ; on or near to the ears, eyes, and mouth. Between the index and metacarpal bone of right hand the same. Very little scale on some few of them. A few spots of lichen, which irritate her. She had the same at fifteen years of age, before she was unwell. It was then on the sole of the foot for two months, a dreadful trouble. Her legs swell much. She has difficulty of breathing, and an aching void at her chest. Erythematous psoriasis, Married woman, set. 29, with a healthy baby at breast. Inside the ear and a little behind it an erythematous patch, that goes somewhat into a circular form. She had one on the forehead and one on the hand. They come by turns. The last began eight months ago, four months before her confinement. It might be equally called scrofulous erythema or psoriasis, Pwntww with acne rosacw,MMi, eet, 31, Hyperremio patches; ON AFFINITIES AND DIAGNOSIS 87 the scale slight and powdery, covering only the central part, but strongly adherent. He has had this complaint eleven years. The patches had originally an ovoid shape. He has acne rosacea on the nose this three years past. History of scrofulous abscesses in the family ; phthisis and skin eruption. Psoriasis witJmurticaria. Married woman, set. 26. White glisten- ing scale and spots. She had it ten years ago, and again six years since, and now a third time. Her father and her brother died of galloping consumption. She always has nettlerash severely after her confinements. Erythematous psoriasis. Widow, set. 57. On the face only, with a little fine dry scale. The patches are soft and prominent on the cheeks. On the arm there have been a few similar patches. This case remained under treatment for some time without marked benefit, and was finally cured by six weeks' sojourn at the sea-side. In the preceding cases a somewhat undue prominence is given to the cases of an erythematous character which, I have observed not to be sufficiently noticed by previous writers, and which I have generally found to be of scrofulous foundation. Cases with alopecia are mentioned elsewhere in the course of the work. Of psoriasis with partial ichthyosis I have met with a few cases soon after the- change of life ; they are generally obscure, and often, I think, overlooked. A fact well worthy of notice is the moderate frequency with which boils accompany psoriasis. I have not been able to rest on this any pathological conception, but with many it might go far to convince that psoriasis proceeds from blood- poisoning or the insertion of a septic principle. Purpura and pemphigus, which sometimes depend on such contami- nation, I have not found under such immediate and palpable relations with psoriasis, though, in truth, they are sometimes seen along with it. Psoriasis often displays a condition which shows a near approach to warts ; and these, too, are controlled by the use of arsenic. The corns which are found in the palm and flat of the foot attendant on psoriasis show also a condition which is akin to it, No less can be said of projecting cornua which, seated on a papillary base, consist of epithelial ddbris. 88 ON THE PSORIASIS OR LEPRA CHAPTER V PSORIASIS PALMAEIA ET PLANTAEIA THERE are certain phases of psoriasis where it becomes modified by regional distribution or otherwise to such extent as to demand quite a separate consideration, chiefly by its complications with syphilis. We shall first treat of p. palmaria and plantaria, and proceed to the others in succession. This affection, which is called sometimes JP. palmaris and p.plantariS) is of unequal frequency, the palm being the more often affected. I know not of the former how even by dermatologists it is sometimes mentioned as an uncommon complaint, with me it is of everyday occurrence. Nor can I understand why it should be confounded with eczema, seeing that the two affections pretty much as elsewhere are distinct, and then again there is the supposition that it is always syphilitic, and this seems a worse error than the other and certainly with no novelty attaching to it. For Gr. Fallopius, quoted -by Bassereau, says, Quoties ego video rhagades in manibus indicium cerium profero morbi gallici / but who now would not recoil from such an assertion as that every one with cracks in their hands should be accused of syphilis ? And then again we have great masters of diagnosis who say that nothing is easier than to dis- tinguish true psoriasis from the squamous syphilide, and even when they occur in the hand ; and these lean each one upon some certain sign, as the copper colour, the oblique curve, the callosities, the liseret blanc or white fringe of Biett, but when put to the test there is no such resource as is promised in fact, nothing can be more difficult, nothing PSORIASIS PALMARIA ET PLANTARIA 89 more uncertain, in a vast number of instances, than the framing of a diagnosis. For in the first place a patient may have had syphilis and yet the psoriasis need not be syphilitic ; and then again, when you are pretty sure that it is syphilitic, the patient may have only had gonorrhoea or a unilateral bubo, the former of these especially being the frequent precursor of psoriasis, with other elements of uncertainty ; and if, as often occurs, you do arrive at a conclusion, this is with much difficulty and not at all framed upon the objective phenomena as seen in the part affected, but based more or less upon moral considerations. And very often the whole thing is so inextricably entangled and intermixed that no living intellect can unwind it. Only some few things more than others you may hold by. In the first place, the disposition of syphilis is so much to the destruction of the soft parts that when these are attacked by ulcera- tion, or even when there are traces of it in scars, it affords a strong presumption, though, indeed, short of absolute proof; so too when the tongue and scrotum are likewise affected the probability of its being syphilitic is greater. But what we find most perplexing is the fact as concerning this psoriasis palmaris, that it appears sometimes pretty early after an infection, that is to say, within the lapse of a very few months, but then, again, it may be delayed till after very many years are passed, as well expressed by Nicholas Massa, post sanationem a natura vel ab artefactam after the disease has wholly died out, or at least apparently so. For it is well enough known of syphilis that an infected man may have healthy children. But with women it is somewhat otherwise; they do not recover so quickly or to that extent as to bear living infants without any taint of syphilis, but a woman who has been confessedly infected may so far have recovered from the taint that she shall bear children, nay, a succession of healthy or quasi-healthy children. Yet after that she shall have her psoriasis pal- maris or plantaris developed and clinging to her for years as a true inheritance from syphilis. And although I have little faith in what is said about the 90 ON THE PSORIASIS OR LEPRA ultimate deterioration of a population from this especial cause unless it be conjointly with other causes, yet there still remains something of doubt as to whether psoriasis pal- maria may not come sometimes in this way by descent, that is, by inheritance from a syphilitic parent, a doubt which I am quite loth to entertain, but which I can not absolutely reject. Of the class affected or liable to be affected with psoriasis we know that they are a large section of the com- munity, and that they are subject to the same social risks as other people ; they acquire infection sometimes before the coming on of their psoriasis and sometimes after it, and some cases of psoriasis, where they acquire venereal, go through the entire evolution of it without the psoriasis being in the smallest degree modified ; and sometimes psoriasis will follow syphilis in such a sharp form that you can see that it is quite distinct from that disorder ; and the same with psoriasis palmaria, because it follows syphilis you cannot tell for very certain that it is the effect of syphilis. In all these things the judgment of the physician is exercised, and not seldom the thing is so entangled and so mixed that you have to travel by conjecture or in a very narrow thread of reasoning. And it is scarce necessary to say how far a good acquaintance with syphilis is in this case most desirable, and, indeed, quite a necessary accompaniment. But when we consider that a certain number of people are the subjects of psoriasis palmaria who by no kind of com- mon reasoning we can admit to have been subjects of syphilis youths, virgins, scrupulous men, and honest gentlewomen we must find established beyond all doubt the existence of a palmar psoriasis which is quite distinct from syphilis, and the question is narrowed into one of comparative frequency which it seems impossible to resolve. And our experience does not allow us to say otherwise than that psoriasis palmaria of non-specific character forms a very notable proportion of the cases that come before us, and further than this we cannot venture an opinion, but judge of every single, case as it oceurs, If now we take a case of ordinary psoriasis or lepra vulgaris, PSORIASIS PALMARIA ET PLANTARIA 91 when we examine the palms of the hands and it will be well to accustom ourselves to do this we shall very often find indicia of the disease, though it be but a little split skin, or a pock, or some little mealy specks. And this kind of study is the more advantageous and commendable, as from written accounts it is not very easy to recognise the com- plaint, and I myself, who profess to have acquired a little technical skill in diagnosing it, find a difficulty in expressing this in words, so very various are the appearances, and I am subject to all the discredit that attaches to those who cannot in plain and simple language tell what they know. Generally in studying psoriasis of the hands it is not amiss to bear in mind the common character of the com- plaint and the modifications that are likely to be impressed on it by anatomical peculiarities in the part, and in that way you may the better come to understand it ; but you must not expect to find it separated from eczema by any hard and fast line ; it is sufficient to say that the two forms of com- plaint are generally distinct, there is no want of typical cases and no lack of intermediate shades ; but since we shall be open to the cavil that we mistake one for the other, and since among writers there is little conformity on the subject, we will express ourselves here more at length. In our community there are a great number of people in whom the hand sare naturally infirm. These are frequently children of the consumptive, or of the gouty, or they inherit some taint of constitution. They will not do for rough house work, or to serve at a. refreshment bar, or to slush in water, to dig in the garden, or anything of that kind. This is found in a variety of trades, but of this our experience lies very much among servant girls in London ; over and over again we have to recommend that they should give up house work and take to sewing for a livelihood because their hands are always cracked and sore, and this one example may serve for all. But where the predisposition or diathesis is toward psoriasis, which is certainly far less frequent than toward eczema, you will get a psoriasis which is often eczematous, and both affections are accompanied by cracks, 92 ON THE PSORIASIS OR LEPRA fissures, or rhagades, which break into the lines of the skin, but often with more caprice, and such a crack is very frequently indeed the commencement or starting-point of a psoriasis. These fissures are extremely painful, sometimes large, and they will open suddenly from the skin being dry, and it is described to you as cut all at once as if by a cobbler's knife, and often the cut is so wide that you can put in a shilling by its edge, or even a half-crown. They are indeed common to either form, eczema or psoriasis, and are sometimes seen without any eruption, or with a mere dryness of the hand. In the centre of the lower lip the same is often found, and sometimes down the centre of the thumb, and such I have generally connected with a taint of scrofula in the constitution ; but any way this tetter of the hands, whether moist or dry, is very marked in certain individuals, and doubtless depending on some defect of the formative processes in distant or outlying parts. It affects a vast number of people, so much so that it has sometimes suggested to me the idea that each should have his trade allotted to him according to his medical chart and that of his family antecedents, but very often it is not till late in life that there betrays itself this constitutional defect, when the vital powers, so to speak, begin to fail. Very often in some people mere ablution, especially in hot water, betrays this weakness in the constitution, and especially with psoriasis plantaris you have to relax a little in strictness of hygiene. But eczema, of the two, more affects the dorsum of the hand and sides of the fingers, and this is so far true that one may see the whole hand involved except just the cuticle in the palm; the skin continues there intact and calm while all is sore beside, and yet very often you have eczema of the palms with vesicles larger than are elsewhere seen, nay, some- times more like pemphigus than eczema. And psoriasis too is far from unfrequent on the back of the hand, and there are intermediate cases, and in both you may have pieces of skin detached and torn away, though this is more seen with psoriasis ; and, in short, there is^nothing which better than these conditions of the hand serves to justify those who PSORIASIS PALMARIA Ef PLANTARIA 93 extend the signification of psoriasis a long way over the field of eczema, for certainly they are little short of being one affection, but, as we have said before, through the condition of extreme dryness and moisture they become sufficiently distinct. If now, on the other hand, we consider the subject of psoriasis, we shall find a great number of those who have psoriasis on the body or on the limbs of the simplest and most ordinary type, who also give us the amplest opportunity of studying it in the palms and flat of the foot, and these cases, in their intensity and also in their persistency, are little if at all behind those which are due to syphilitic cause. And when they differ from them at all it is by the most subtle shades, and they indeed form the proper school of study for those who on such a subject would be well informed. But there is also another way in which psoriasis palmaria may begin. There are many persons who, in dressing of a morning, are conscious of a little white speck in the middle of the hand, which disappears in washing, and there may be half a dozen such perchance, arranged somewhat in a circle or otherwise, and these will last for years, only subject to grow or to be lighted up all at once into a graver cast of malady or affection. At other times the disease will begin with a little crack or dry white pock, sometimes with an initial spot, such as comes on the body elsewhere, only somewhat broader than common a red flat elevation, which is the seat of much itching and heat, and is also very tender when pressed upon. But it rarely follows this classical type ; when it does so, either in foot or hand, it is subject to remain stationary the size of a silver fourpenny piece more or less, and after months, or even years, it will begin all at once to spread and increase by its outer edge, which is seen with a ragged loose fringe, and it invades nearly the whole superficies. In these conditions of the hand, when it is pressed upon by some instrument, weapon, or tool, the part diseased becomes modified in shape and also dry, swollen, and pain- ful ; where the cuticle does not separate, it is rough, but mostly it is seen that little ragged pieces of skin come away, 94 ON THE PSORIASIS OR LEPRA and this gives to the hand quite a sordid and ruined appear- ance. The starting-points are often multiple, and it may acquire a dense scale with much thickening and crispness of the surrounding cuticle, which in the foot I have resembled to shagreen, and the appearance in the palm of the hand is very much that of psoriasis inveterata, and sometimes too there are callosities quite resembling bunions or corns. And these evolutions or developments are described by various authors as if they were of the simplest character, but, in fact, they are difficult to trace and scarce ever offer themselves spontaneously to the observant eye, but require some little searching for. Our attention will be directed, with more profit, to a few characteristic appearances under which this psoriasis shows itself in everyday life. In the first place, then, we will say that it constantly shows itself in patches of renewed skin of a considerable degree of extension and of a red or violet tint, and these are bordered by an irregular fringe of somewhat ragged cuticle. In another and very frequent form small ragged pieces of cuticles have come away from the hand, giving it a sordid and somewhat elderly appearance. In another far more singular but less frequent form the cuticle is so ripped up with white ragged fringe that it would appear as if some small animal had travelled over it in every direc- tion, destroying and burrowing as he went, but not beyond a certain depth. The fourth case is rare ; it represents the psoriasis gyrata. You may have a band, some quarter of an inch broad, twisting here and there and curling round the fingers, and even you may have a ring upon the palm. It is a mistake to suppose that these all begin in the centre of the hand. One of these gyrate forms I have known commence under the nail, curling round the finger to the middle of the palm. Such are generally the features which mark the psoriasis palmaria; in the sole of the foot it is not very different, except that it mounts rather on its inner than outer margin, and the surrounding skin is more coarse. I have spoken in a former page of the white deposits in these parts of a somewhat strange-looking material, which is in PSORIASIS PALMARIA ET PLANTARIA 95 fact epithelial debris, mealy spots, either in specks or scat- tered. Occasionally, but rarely, this stuff is seen between the lines of the skin, and if you scratch it across with your nail it is like a mark with chalk upon the wall. In certain cases of ichthyosis it is much the same. Now, this disease of p. palmaris proceeds, I say, in a great many instances from a constitutional and inherited cause ; it comes with psoriasis on the body of the most ordinary and typical character, though often it occurs alone. It may come on these parts with no variety of appearance from what it displays on the trunk. I have seen it more than once in parent and child, under the clearest proof of its being inherited. It occurs sometimes at an early age, though this is not very common ; one case we have given as early as the seventh year, where it came in the fifth ; in another so late as seventy-one ; in women several cases happen at or near the change of life, and in men only a little later. Then, again, one cannot but observe that of many cases reckoned syphilitic a good many come after gonorrhoea, which is no unfrequent antecedent of general psoriasis. And if we look at this question from the point of view of social susceptibility I would be far from diminishing its importance, but in a therapeutical it is really not so important as it would seem at first. The effect of season is experienced in either form, the amount of irritation is a poor test. It may surprise that we have not said more of indications given by adepts, but, in fact, we have not experi- enced their utility ; they are to be found with some degree of industry, but they do not spring to the eye; so much may be said of the syphilide cornee of Biett and of the p. palmaire centrifuge of Eayer, they are to be seen, and yet but seldom. The cracks, the little detached pieces of skin, the denuded plots of a violet colour, surrounded by a loose fringe, the little mealy specks, these are what are more commonly met with, and a good deal of what we read in the descriptions of books raises in us the suspicion that there has been much borrowing and repetition ; they present any but lively images of these complaints, and often such as all our experience does not enable us to follow. 96 ON THE PSORIASIS on LEPRA Psoriasis palmaris.'M.au, set. 48. With dark curling hair, tall, straight, healthy build. Both hands are diseased. He acquired infection somewhere about twenty years of age ; of marked secon- daries, only iritis ; nothing seen on the skin ; took mercury under able surgeons. About six years after, he went to Australia and married. His wife made no complaint, bore no children, had no miscarriages. He continued well eleven years. After this at the diggings he found bleeding cracks in his hands, and much pain in the finger-joints. After four years' plague with this he resolved to come to England for advice, when he was cured in two months' time by a celebrated dermatologist, now deceased, with "mercury, arsenic, and red ointment. He remained in England eleven months. On his return voyage to Australia, directly he got into the tropics a raised spot or tubercle came in the palm of one hand, and after being free for some months the malady all at once returned. Arriving in the antipodes, he used long the same prescription that had served him so well in England, but it was no more use than so much water. He got disgusted with mercury and arsenic, and took to homoeopathy. He then kept a store, but suffered much and continually from his hands, in which part alone it is now of fourteen years' standing, twenty-five years since infection. He resolved once more to try Europe for its cure. Returning by Cape Horn, the ship sailed within two hundred miles of the South Pole ; and when they got into cold latitudes the complaint entirely ceased suddenly and spontaneously; his hands were wholly free from all disorder. Again as they reached the tropics the malady returned. It is now seven years since his last trip to Europe. While coming over he had salt-water baths, and in drying himself there were seen on the body faint ephemeral erythernatous patches. I observe between the brows of the patient two little indentations or scars ; they are the result of a tetter in the part some two years since. He shows me a wart on his elbow. This warty eminence is smooth, round, prominent, inclining to a point, of the colour of the skin or only a little red ; I pick off half of its mass, which I find composed of crumbling epithelial debris, and an excavation is left which bleeds from the centre; the margins apparently composed of the same debris. This raised epithelial tubercle is, he says, the exact counter- part to what came in the palm when he was returning to Australia* In studying the patient's hands, which present much confused disfigurement, I perceive by the side of the forefinger a small warty callosity, the sypliilide cornee of Biett. This becomes white in the centre, and spreads not larger than a small lentil, flat, nearly level with the surface, and with edges rather raised ; the dead white which occupies nearly the whole of the contour shows minute puncta or pin-holes. These are scattered about, but where they PSORIASIS PALMAR1A ET PLANTARIA 97 have become confused in their mass the palm is of a lively red and tender to the touch, with a very little ragged cuticle. The white places look faintly hollowed out and dry, as if a little thin parch- ment had been torn away, for so he described it. Occasionally one or two of the nails have split down the centre. Psoriasis palmaria. A man, set. 43. The patient carries an appearance of strong health. He has been steward in foreign-going ships. We find in him p. palmaria, confined to the left hand these last four years, previous to which time both hands were affected, altogether these ten years past. He acquired syphilis at the diggings in Australia shortly before that date, and the treatment all along has been simply hygienic. He had an eruption on the scalp and on hands and feet, occurring pretty early; but before three years were over they had gone clean away, and he is inclined to attribute a relapse to his change of climate. He came home and married at three years' date from his first infection ; soon afterwards only his hands became bad again, and his wife was infected, and a succession of children, four of whom are now living, have all a touch of the malady. He thinks it curious that it should remain in one hand this four years past, and all besides quite free. In the hand there are several places that begin quite small and then spread centrifugally with a ragged edge in the skin. When he picks off a bit of cuticle there is found underneath, he says, not so much a pock as a kind of bladder. The character of the eruption is wholly dry. In this case the left hand is the worst, and it is very commonly so. Psoriasis palmaris. Man, set. 39, brushmaker. He has also a faint red ring or horseshoe shape over the wrist; he acquired syphilis twenty years ago, nine years after which his hands became affected. He has had some eruption on the scrotum, and those are the only places that have been affected, except, perhaps, now and then a little sore inside the lips. "When it first came in the palms there was only peeling and new skin. Every year it has its swing for about a month. It matters not what is done for it. It comes then like two small chaps, such as happen in other people in winter, and yet it is twenty years since infection. Psoriasis palmaris. Female, set. 37. Married, acquired infection in married life some fifteen years since. For ten years was free from any symptom until revaccinated during the last epidemic, and during the last twelvemonth has had faint red, or rather livid coloured rings in different parts of the body, and cracks and blisters on the hands. There is now seen in one palm a violet coloured erythematous 7 98 ON THE PSORIASIS OR LEPRA ring, the seat of some irritation, which she says would come to blisters if she did not put it back with the ointment. Psoriasis palmaria. Navigator, set. 44. Strong looking, says he never had anything the matter with him. Yenereal twenty-five years ago and soft bubo, no sequence. Has had this eruption seven years. Psoriasis palmaria. Woman, set. 39. She became infected im- mediately after marriage, seventeen years since, and after this she bore two dead children, but her third lived and is now a hearty lad of fifteen ; subsequent to vaccination he had a tedious eruption. After this she bore three living children, of whom two survive ; both have had skin eruptions and one of them an abscess. Her seventh child also had an eruption, and the eighth is a healthy baby in arms. The patient's health is good ; it is only six years ago that she began to have psoriasis palmaria. It has something of moisture ; the skin is perished in parts to a certain depth and leaves small ragged places. It is generally painful. In cutting bread she experiences anguish. Psoriasis palmaria. Female, set. 34. Never had it till after the birth of her first child. This one lived seven years and had no skin eruption. Before the birth of the second she acquired this eruption on the palms. There have been subsequently eight births, and all these infants have had the disease out on them when born. All died ; the last lived six weeks. The father is all right now except enlargement of the bones. In the above cases the syphilitic infection is unequivocal. Psoriasis palmaria et plantaria. Man, set. 46. For three years the eruption has been palmar. He lays it all to a chill in the blood some five years since. Mother decidedly asthmatical. Had a chancre twenty years ago without result. Psoriasis palmaria. Is stoker in service of Peninsular and Oriental Steam Company, set. 38, married and has children. When it came out he was in Inftia. Pieces of cuticle detached from the foot give it the appearance of stamped leather. Declares that he has only had gonorrhoea, and believes it was that which brought it. But he has had psoriasis of the tongue, probably syphilitic. Psoriasis plantaria. Man, set. 42. On sole of the left foot and inner edge. He has also lichen of the chest, and for some months past a bad cough. The father of this patient had psoriasis palmaria. His sister rheumatic fever. Neither this nor any of the following cases have a clear history of syphiHs. Psoriasis palmaria et plantaria. Working apprentice to an engineer, PSORIASIS PALMARIA ET PLANTARIA 99 set. 18. The palm is cracked and ragged, in correspondence with the lines of the skin, more in the longitudinal than tranverse diameter. Has had it two years. Health generally not good ; had windy dropsy five years ago. His hand got well rapidly with chalybeates and carbolic lotion. Psoriasis palmaria et plantaria. Farmer's wife, set. 46. All her family asthmatic, and herself inclined to asthma. Three years ago she had inflammation of the lungs and bronchitis. She has had a lump lately in the armpit. The patient is enormously stout. She had smallpox ten years since. The eruption greatly affects the heels and that part of the palms nearest the wrist. Here it is all hard and warty. The burning and itching are dreadful. Psoriasis palmaria et plantaria. A gardener, set. 42. He had ague twenty years ago, since which time not a day's bad health. It is very ragged, both in palms and heels. History of asthma and skin eruption in family. Psoriasis palmaria et plantaria. Man, set. 36. Has had it from his youth. His mother had asthma. Both parents died with bronchitis. Psoriasis palmaria et plantaria. In a woman, middle aged. It lasts three weeks off and on when under treatment. Psoriasis palmaria et plantaria. Man, set. 42. With ragged edges, especially near clefts of fingers. The inside of the hand with tough scale split into lozenge shapes. Has had a scrofulous abscess. High shoulders. In brother and father gout and rheumatism. Has had blenorrhagia, no syphilis. Psoriasis palmaria et plantaria. An only son, set. 19. Had typhoid fever very bad, and was not well supported afterwards. Psoriasis palmaria. Man, set. 30. Grandmother asthma. Grand- father cancer. No history of syphilis. Psoriasis palmaria. Bookbinder, set. 19. First came out when he was fourteen. Yery superficial white scurf, no pimple, rhagades, costive bowels ; acne, a little tendency to cough ; weak. Father a little rheumatic. Maternal grandfather consumption. Psoriasis palmaria. Lad, set. 18. Begins in rhagades. He spits a good deal of phlegm. Psoriasis palmaria et gyrata. House painter, set. 52. It came from getting down some steps eighteen months since, from a splinter underneath the nail of the ring finger, in the right hand, on the side 100 ON THE PSORIASIS OR LEPRA nearest the thumb. It descended the ring finger, and, as it pro- ceeded downwards, at every joint there was a crack in the skin. It next travelled on to the middle finger and thence to the little finger where now the skin is renewed. The index is not invaded, neither is the thumb. It does not come in a bladder or pimple, but in a ragged edge. The eruption at present involves all the palms with a pretty even (vandyked) margin, carrying a hard, dry, tough, loose fringe ; on the included skin, which has been renewed, are small blotches recurring with the same kind of edge. No eruption on the body, none on the feet. He has had boils and a little scurvy on the head these two years past. Rheumatic fever four years ago. His father died at forty years of age in a decline. Psoriasis palmaria. Man, set. 49. Stout, florid, light haired, san- guine temperament. An exceedingly strong, tall man. The hands are squamous, yellow, crisp and hard, with crust or scale, which is adherent, except at the edges, which are sharp. It follows a longi- tudinal rather than transverse direction. The complaint began with cracks. He had had rheumatism badly, and at one time only got about with sticks. Deaf since he was a lad, which he thinks he got by bathing (probably rheumatic). Twenty years ago he had typhoid fever badly. Psoriasis plantaria. Girl, set. 14. She has lepra alpho'ides on the body ; on the sole of the left foot, below the centre, there is a ring of alphos with heavy white scale, the size of a shilling, perfectly cor- responding to what is found in the body. This is a very rare case, and an exception to what generally attends general psoriasis, the evolution on the sole of the foot having commonly a special cha- racter. Nothing else on the soles and palms, only this one patch of alphos. Psoriasis palmaria et plantaria. Woman, aet. 43, married. Had it slightly before marriage, even as a child ; is sure she had it when fifteen. Married at twenty-two. No miscarriages. Three children ; none of them have skin eruptions. Her brother, from her descrip- tion, has psoriasis badly. Her father laid up nineteen years with rheumatism settled in his limbs. Never had scale on her hands, or only trifling. They crack and bleed. She is always better after her confinements. Psoriasis palmaria et plantaria et unguiwm. A smith, set. 54. The affection is rather severe. He had it first last Christmas. At first he thought it of such kind of cracks as come in winter. He never had any kind of venereal. He has seven children, all healthy. The hands get rough and crack, and then a new skin conies. The heel, PSORIASIS PALMARIA ET PLANTARIA 101 especially, is like tough, dry leather, fissured in all directions. He has suffered so much from pain and tenderness after washing this part especially, that he is inclined to avoid it altogether, but smears the heel with tar. His nails are now very bad, but this has only come during the last three or four months. They are soft and crack up the centre. They have also transverse ridges ; in some there is a slight hollow underneath, with but little pith. Psoriasis palmaria. Widow, set. 57. Has had it twelve years. Both parents died of consumption, as well as three of her brothers and sisters and two aunts ; one sister had asthma. Her children show no signs of syphilitic taint. She has had only one miscarriage. Much debility when young, and indigestion. The eruption came first in the palms, but now sometimes on the back of the hand as well. There is chiefly dryness with fissures that bleed. She has much irritation on the body, but no eruption. They get well for a time under skilful treatment, but soon return. Pityriasis with psoriasis palmaria. Female, set. 23. She had erysipelas of the face last Christmas. Now she has pityriasis of the face and spots of acne rosacea on the nose. She complains much of constant dryness in the palms of the hands and a sort of white powder or meal that she rubs off the surface. With this a distressing headache, especially in the morning. Her mother spat blood for fourteen years and died of hsemoptysis, with swollen legs. Psoriasis palmaria or eczema. Female, set. 43. Married sixteen years ; no children. Catamenia always scanty ; her sister had the like of this at change of life. Within a month or so in the bend of the arms, on the neck, and in the ham, she has a dry eczema. Inside the thighs the same. The palms of her hands are dry and crack. In the soles of the feet the cracks are very large indeed, she could not get about till she closed them with plaster. Since the eruption she feels better in herself. Before it came she had swimming in her head and bile. Psoriasis palmaria. Female, set. 38. It came out first last autumn, when at the sea-side ; it went away in winter time and has returned this summer for two months past. She has been married eighteen years. Four children. No miscarriages. Psoriasis palmaria. Woman, set. 54. It came at change of life with cracks in the hands and eczema close behind the ears. A good deal of burning and itching in the soles of the feet. The palmar eruption has existed for six years, but before this had an eruption (psoriasis) on the body. 102 ON THE PSORIASIS OR LEPRA Psoriasis palmaria. Female, set. 25, with alopecia. Has also eczema in the legs. The palms heal and crack, and, as well as the eczema, are very irritating. Psoriasis palmaria. Engineer, set. 40. It comes spring and fall. Dust makes it worse. Highly nervous temperament. Children healthy. Psoriasis palmaria et gyrata. Female, aet. 33. It forms a narrow ribbon-like tract a quarter of an inch broad. From the upper part of the palm it has mounted to the tip of the forefinger, and in the palm it bends in form of ring with an appearance somewhat like Indian ringworm. Psoriasis plantaria. Man, set. 22. When you make a scratch on it with a nail there is left a white mark as on a wall. Psoriasis palmaria. Man, aet. 29. It spreads by a broad margin, not stayed by the edge of the hand. The portion of the skin en- closed, when he washes it, becomes of an intense red, and then there push up little white bubbles ; it becomes mottled, as if stung by nettles or something of the kind. Psoriasis palmaria. Man, set. 34. This man has strong red hair ; decided lymphatic temperament. Perhaps one may be permitted to lay the eruption to this, as nothing else is discoverable. Psoriasis palmaria et plantaria. Spinster, middle aged, a gover- ness. It has lasted seven years, with a good deal of irritation on the body. Psoriasis palmaria. Man, set. 43. Has had it twelve years. Also has some show of it on tip of elbow and in axilla. Worse in summer. It itches much and burns. Psoriasis palmaria. Carpenter, works with plane, set. 34. Has had it eight months; a patch also on the left leg. It is rather scabby than ragged, very sore and tender, and threatens ulceration. The patient is rheumatic. His mother has asthma. His father lumbago and grandfather phthisis. Psoriasis plantaria. Spinster, set. 17. A modest girl; attends with her mother, who was herself my patient with psoriasis only a short time back. Psoriasis palmaria. Young Frenchwoman, set. 24. Engaged in an English family, with healthy appearance and singularly fresh com- plexion. An unlikely subject of syphilis ; asthma in near relatives, PSORIASIS PALMARIA ET PLANTARIA 103 Psoriasis palmaria. Man servant, set. 33. In palmar aspect of fingers, in the creases of the skin, cracks somewhat of an impe- tiginous character. There are small scabby rings and one starred, with a tendency to scabbiness, on fingers. Has had it a twelvemonth. His father had the same on the hand, and also rheumatic gout. Psoriasis palmaria et plantaria. Man, set. 34. Has had it five years. Slight rheumatism, digestion bad. It comes in May and goes off in October. It began at the top of the forefinger in the right hand. It begins as a sort of inflammation underneath, and the skin dies away and always keeps peeling. Last May he had it on the heel. Psoriasis palmaria. Jeweller, set. 49. Only one patch. It takes in the palms and both sides of the fingers up to the second joint. The margin well defined just below the wrist. About four years ago it began at the tip of the index finger. Married, with no children. He has foul mouth of a morning and much thirst. He perspires exceedingly when he hurries in walking. His mother died of asthma, and the doctors considered that he had it when young. Psoriasis palmaria et plantaria. Man, set. 25. He has palpebral ophthalmia, which came first after measles. He describes the itching in the hands and feet as something awful. He is rather depressed in spirits. It begins in the hands, in what he calls moles, and then he has to scratch a bit of skin out and it leaves a sort of irregular pit, which is ill defined. The skin seems dead at the time and the itching underneath fearful. As the skin dies he picks it off. Psoriasis palmaria et plantaria. Man, set. 50. In feet and hands only. It came in the hands after using Portland cement. Has been a lamplighter and his father the same. His father and mother both have some such dry eruption. The mother scurvy in the legs. He has been to Buxton for gout, and was laid up with it a great portion of last year. Psoriasis palmaria, plantaria, et diffusa. Man, set. 51. The disease leaves a fades much like lichen planus. On palms like old scars, ragged and with holes. On the flat of the foot some amount of scale. On the arms, outside of the thigh, and in the cleft of the buttocks, superficial spreading, with irritation, and leaving deep stains. The same on the head. His hair falls with erythematous splotches on the vertex, and much itching. Psoriasis rubra might well describe this eruption. There is an approach to psoriasis near the olecranon, but none over the lig. patellse. Married twenty years, no children. No history of venereal. Has had hydrocele. No other bad health. 104 ON THE PSORIASIS OR LEPRA Has had it on hands and feet since Christmas, never before. Has always enjoyed good health. Psoriasis palmaria et plantaria. Man, set. 38. Has had psoriasis ever since he was a child, but latterly it has confined itself to the palms and soles of the feet. It disappeared under treatment in these parts and returned on the ankle. Yery dry. He had rheumatism twelve years ago. Psoriasis palmaria. Sailor. A serious sort of man. Is most positive that he has had no venereal. This began eleven months ago. It came from a splinter in his finger when trimming a ge- ranium, and it worked round and round. His mother has gout. Little bits of cuticle were detached in a great many places, differing much in character from the preceding. Psoriasis palmaria. Man, set. 30. Fresh coloured. The psoriasis has rather a moist or eczematous character. All his sisters had scald head, one of them died of consumption. His father and grand- father suffered greatly from rheumatism. Psoriasis palmaria. Man, set. 43. Has psoriasis also on the tip of the elbow and in the axilla. In the palms of the hands it itches and burns. He has had it on the palms twelve years. Psoriasis palmaria. Married woman, cook, set. 58. Since the menopause. It begins in cracks and forms a sort of serpiginous eruption, with new red skin between the arches of the various curves. She has had general psoriasis oif and on since she was a child, some- times with a little rheumatism. The eruption has always been, she says, something like ringworm. She feels giddy at times, as if she should fall into the fire, and has left her place on account of the disease. Bowels loose. No headache or indigestion. A coppery taste in the mouth of a morning. Her husband is healthy, and always was a steady man. She has had no children or miscarriages. The appearance of the hand would lead one to believe it to be syphilitic, but clearly it is not so in this case. Psoriasis palmaria. Man, set. 40, florid. Has had patches of psoriasis on the body, but for some time since only on the hands. He had gastric fever some ten years since. His father had gout, a sister died of phthisis, and a brother had swollen glands. He appears himself a model of health, but of rather a full habit. He married very early, and has always been steady. He was getting on very well with his last doctor, but left him, disgusted on being told the com- plaint was syphilitic, which he knew was an impossible thing. ON THE PSORIASIS OF SOME OTHER REGIONS 105 CHAPTER VI ON THE PSORIASIS OF SOME OTHER REGIONS IT is in the nature of human circumstance that we cannot reserve ourselves in the exercise of our art for the necessities of those alone who are shielded from all contact with vice and walk in the straight paths of virtue, for, as proved by hourly experience, that which lays the chief claim upon our knowledge is often the effect of human folly. Nor need we much marvel at this when we see how loosely and to human apprehension how indiscriminately scattered are the con- sequences of neglect and libertinism, so that they are liable to fall on such as are wholly ignorant of their nature and innocent of any kind of blame, equally with those who have guiltily incurred them ; and, indeed, for a physician to be too nice and particular is much the same thing as to be ignorant, and he is no longer a pillar of safety to those who give him their trust, but rather a delusion and a snare. And especially of one disease, that might be almost called the chief among diseases, it is necessary that we should not be ill informed, since its complications tend to introduce themselves into the entire field of pathology, and whether designed for the correction or instruction of mankind it is not easy to conjecture, but there is indeed much to favour the latter supposition. By a more searching study applied to it, not at all improbably we may attain to generalisations which otherwise would never have been reached ; so, again, we may thus be warned from conclusions . which are as utterly false as they are fondly embraced, for however rich in recorded data, the last word is very far from being yet spoken con- cerning this lues venerea. In its quality of infection it is 106 ON THE PSORIASIS OR LEPRA not, perhaps, so exceptional as by the vulgar generally appre- hended, for this it has in common with other diseases, such as typhus and impetigo, the result of ill conditions and want. The more liberal use of the lancet-point of late in the field of clinical research has served to extend our views in this respect. For more than one disease may be the subject of inoculation. So also, if we compare it with malarial poison- ing, we must confess that they have much in common. Whether or not with propriety we may call it a disease of the skin has been sometimes brought into discussion; we say it is totius substantice, but this, perhaps, is no more than may be affirmed of many other diseases, especially those that are heritable, and of psoriasis among the rest. In fine, its manifestations are what we are very liable to meet with, especially in women of the lower class who have become liable to it in the course of marriage, and one can but admire the wonderful patience and forgiveness they carry into circumstances so well calculated to provoke resentment. The opportunities of our clinique are not scanty for follow- ing out the thread of a specific principle, and yet being of a special character it may not be wholly unexpected that they should lead us to conclusions, or at least to a habit of thought, somewhat different from what is found in those who are en- gaged in other special work ; for of this disease we are rather accustomed in our clinique to see the ultimate effects, we hear its distant echo, we view its expiring edge, and our confession about it is this, that we are very far from being in accord with all of our contemporaries, who are, many of them, very apt to see syphilis where it is not, while others again miss seeing it where it is capable of demonstration, or at least of reasonable proof. And many of the indications seen in books we find, when put to the test, to be insufficient for the occasion; and altogether the subject is one which leaves much room for difficulty and suspension of judgment. We enter- tain, indeed, a strong notion of the possible duration of this complaint, which may extend over a long term of years, but the point we would insist on is chiefly to the effect that, as time goes on and according as its residence in the body is ON THE PSORIASIS OF SOME OTHER REGIONS 107 prolonged, its manifestations, though pretty strong, cease to be peculiar and distinctive; the monster is tamed into human ways and speaks with a human voice, no longer with the harsh tones of heretofore. Its manifestations are, most of them, equivocal, with none of the clear sound they had at first. So, then, in the hands, the scrotum, and the tongue, we see effects which are indeed its result, but which might happen from other causation. Nevertheless those who pursue to its ultimate consequences the thread of any one disease are conferring great services on humanity, even if they give themselves thoroughly up to following the track that lies before them. According as the data they arrive at become more confirmed, we shall find safer ground to reason on ; no longer embracing such hasty generalisations as those of a century since, when elephantiasis, yaws, scrofula, lues, were all confusedly mixed, for although, no doubt, there was an element of truth in such a view, its practical consequences were full of harm, and it served to dull the edge of inquiry, a result which was very much indeed to be deprecated. (See Appendix.) But, however, in those times it was a perfectly recognised fact that certain rashes and tetters, which are equally common and innocent, are also subject to be pro- duced by syphilis such, for instance, as impetigo, acne, inentagra, what was then called porrigo, and the lichens ; so the same was held to be the case with certain constitutional affections, among which may be mentioned asthma. Of late years we have seen removed, or apparently so, from the land of uncertainty, certain ultimate affections of the eye, ear, and teeth, which formerly went undistinguished under the general head of scrofula, but now are recognised as inherited syphilis. On the other hand, some degree of doubt still surrounds the affection which has long enjoyed the name of syphilitic psoriasis of the tongue, concerning which some affirm that it has nothing to do with psoriasis, others that it is invariably either syphilitic or cancerous in its nature, but concerning which it may be permissible to say that an unimpassioned estimate and exact knowledge of it is what remains to be desired. 108 ON THE PSORIASIS OR LEPRA It may be considered rather remarkable how, only quite of late, among a flood of medical writings so little space has been especially devoted to diseased conditions of the tongue. (See Appendix.) If we reflect on the wear and tear in daily life, we may very well think of it as an insensible, or at least as a not very irritable, organ. Apart from lues and tobacco smoking, which constitute the two great provocations to morbid change, the amount of disease is surely inconsider- able ; the result of the former of these causes, in my lifetime at least, has always been fully appreciated. We are all ac- quainted with the term syphilitic psoriasis of the tongue, and it has been taken so much as a thing of course that attention had very much relaxed upon the subject, but recently there have been discovered other conditions, or let us say rather other results, of an abraded and diseased surface in this organ, for the local conditions are not yet denned which lead to this termination in cancer, concerning which very much has been said. Among other influences which have led to more exact attention on the subject we must place on the first rank the improved mode of operating for cancer in the tongue as practised in later years. It seems, then, that chiefly in male subjects, past the middle term of life, many of whom have been the subject of anterior syphilitic manifestations, there is subject to come an epithelioma or cancer in this organ, and this fact has drawn attention to minor affections of the tongue, with the hope of distinguishing and displaying those conditions and appearances which specially indicate the termination in ephithelioma. And though we seem as far off as ever from a rapid discrimination of such a condition, it is not improbable that ultimately we may have more suc- cess. In the year 1845, or thereabouts, not long, indeed, after commeneing practice, I had for some twelvemonth or more under my care a case of this description, and, trusting to the previous history, which rather pointed to early syphilitic con- tamination, I treated the case with sarsaparilla and chloride of mercury, applying the usual local caustics, but with little benefit to the patient. There were abrasions of surface, ON THE PSORIASIS OF SOME OTHER REGIONS 109 continually renewed, which, healed with a hard, leathery, or parchmented scar; fissures especially at the sides, but very little or none of that coating and glaze which has elsewhere been observed. The case terminated in epithelioma, and with the assistance of my friend Mr Tatum I made use of ligature to remove a large portion of the tongue, with no eventual relief to the patient. No doubt such cases happened elsewhere, but since the date of a communication made by Neligan on this subject to the insurance offices, in the year 1862, an increased attention has been exercised upon it. Still, as it appears to me, we have not yet discovered what is this precise condition of the tongue which naturally termi- nates in cancer, nor have we learnt how it is distinguished from other various appearances which resemble it, nor do we know whether all or not a few of these sores and seats of irritation are subject to develop a cancer or to terminate in cancer. As somewhat apropos of this, I may be per- mitted to draw attention to the observation I have already made as to the daughters of men afflicted with epithelioma, that these are in a special measure become the subjects of psoriasis. (See Appendix.) In a clinique of diseases of the skin, and also in private practice, one meets with conditions of the tongue which vary a good deal in their character, not all of which it may be presumed tend towards the result of cancer. Some of these occur in women, some in early adult existence; one may demur at their being called frequent, it is enough to say that they are not very rare, and always to be met with in an ex- tensive clinique. There is one condition which I suppose every physician to be acquainted with. It is where the tongue is cut up into sections or squares, with longitudinal and transverse sulci, generally red and irritable, sometimes swollen, sometimes, not always covered with a partial white investment, but often rather bare of epithelium, with more or less hypertrophy of the papillae. Such we have had from a long time since occasionally under view in a patient who is troubled sometimes with a dry eruption of the legs, and belonging to a highly asthmatic and gouty family; herself 110 ON THE PSORIASIS OR LEPRA with something of asthma, but farther troubled with a granular condition of the fauces with projecting papillary eminences. This patient has always taken her wine freely and without dilution, always exhibiting a strong aversion to medicine. The character of tongue to which attention has been chiefly drawn, as leading sometimes to the worst kind of result, is distinguished by a silvery pellicle which bestows on it an appearance certainly analogous to what we occasionally find displayed on the body in psoriasis ; as an external manifesta- tion, it is not, indeed, frequent, and between the two there is a similarity of appearance so obvious and striking as involun- tarily to suggest the term of psoriasis of the tongue, which we doubt not will eventually survive in medical phraseology. This organ is, at the same time, quivering, soft, cut about, and sore. Besides this we have cases where this film is rather of a milky opalescence, or as if it had been touched with lunar caustic ; at other times there are lumps and healed surfaces of leathery or parchmented hardness. In some of these cases the history is syphilitic, in more of them it is equivocal or mixed, sometimes a rheumatic or dartrous dia- thesis is displayed. I have, indeed, quite of late heard it stoutly affirmed that this condition of tongue is never found with psoriasis. I am well aware that it is not confined to this form of skin disease, for one of my cases, not long since, which exhibited such a state of tongue had acne rosacea^ but I confess that my con- viction is quite the other way. I cannot consent to this assertion, for I believe that I have seen it in unmixed cases, though more frequently, I confess, where they were not above the suspicion of the syphilitic taint, and if it be true that it never exists with n on- syphilitic psoriasis I certainly cannot account for the notes I have on the subject; but since these notes are not taken with a special view to resolve this doubt, nor are they of that degree of precision that could set this question wholly at rest, I shall abstain from ex- pressing more than a very strong impression on the sub- ject. Had I thought of its being challenged I doubt not I should have been better prepared. I have also met with con- ON THE PSORIASIS OF SOME OTHER REGIONS 111 ditions of the gums which do not appear to be of a different character, accompanied with general scorbutic or dartrous tendency, as a result of enthetic fever, which proved to be exceedingly obstinate in its duration. When these affections are found with falling hair, eczema scroti, palmar or plantar psoriasis, and other symptoms too well known to need men- tion, they may generally be set down to venereal antecedents. Not unfrequently, after the patient has been some time under treatment, evidence will show itself in red marks on the face or elsewhere of either this or of another diathesis, consti- tutional or acquired. It is now some twelve years since that I saw a gentleman who presented in perfection the character of the tongue as above described. He had spent the greater part of his life in India and was suffering at the time from ulcerated cartilages in the knee-joint, apparently from scrofulous constitution. This gentleman informed me that such a condition of the tongue 'was in India exceedingly com- mon, and there supposed to depend on the bad quality of the drinking water, and that he had heard it called the Patna tongue, the water in Patna being exceedingly foul and bad. I confess at the time I thought this condition syphilitic, but afterwards I changed my opinion, for I heard since of its frequency in the Indian peninsula, and I also found a men- tion of it in old books under the name of agrom, showing that it had not escaped the notice of our predecessors, though I have never completed my inquiries concerning it. (See Appendix.) The following cases serve to display the uncertainties which surround this subject : Psoriasis lingua. Carpenter, set. 33. He has been in attendance off and on these three years past. This is one of the best cases of silvery psoriasis of the tongue. At this hour he is not cured, but far better than I have seen him at other times. The tongue is soft and pliable, but tremulous and tender, with no open sores. Recently he has been taking iodide of mercury, but while under its administra- tion he has had patches of red eruption not different from psoriasis, which come out on his face and arms. He begs to have the arsenic given him again, as what did him previously most good. He has now 112 ON THE PSORTASIS OR LEPRA no psoriasis on face or forearms. This eruption was never seen before he was twenty years old, now some fourteen years back, when he had primaries, but with no glandular swelling or pains in the body or limbs ; no sore throat. The primaries lasted six months. Soon afterwards, for the first time, he had this kind of eruption ; it was on the knees and elbows at first as well as on the body. A year or two after having it he was treated at the Edinburgh Infirmary, evidently it was thought to be non-syphilitic psoriasis. They gave him arsenical preparations, under which treatment he nearly got well. The complaint in his tongue has lasted some four years ; there is no hardness or loss of substance in the organ ; it is at times terribly sore, but notwithstanding the inveteracy of the disorder he will not wholly abandon the use of the pipe. He has had no second infection. On the whole I cannot but consider this case as one of non- syphi- litic psoriasis of the tongue. When the psoriasis gets worse on the body I remark that the tongue improves. Psoriasis lingua. Middle-aged man. The tongue is cut into ragged holes, with smooth shining white surfaces ; no hardness ; a quivering tongue. He has had the most undoubted psoriasis. He confesses only to blenorrhagia. Psoriasis linguce. Man, set. 40. The subject of asthma and ulcer of the leg. He has a brother asthmatic. He thinks his breath began to be bad about a year before infection, which happened some nine years since. He has been under treatment at another institu- tion for disease of the tongue, which used to be all over sore, with lumps ; now there is much less left. His asthma has been bad this three years. No history of other eruption. Psoriasis linguce. Man, set. 29. He has had typical psoriasis or lepra this twenty years past, off and on. His little girl, seren years of age, has psoriasis, but three other children have not. His mother died young, with the slightest history of scurvy ; his father had swelled bone from gout. Patient acquired lues three years since, a simple sore, no bubo, and had smallpox when in hospital, followed by abscesses in the legs, and sore throat, perhaps from smallpox ; but he has now psoriasis of the tongue ; and he displays sparse psoriasis on the trunk, which has rather a syphilitic character, but not decided. The case is one of some perplexity as to the existence of secondaries. Psoriasis lingua. Man, set. 27. Syphilitic typical case. Infection four years since, now only has the disease on his tongue, where it is dreadfully bad, but only this last two weeks. When he speaks it is wretchedly painful. A central fissure very deep. The tongue is sodden with depressions ; it is a good deal cut about and takes the ON THE PSORIASIS OF SOME OTHER REGIONS 113 marks of the teeth, with some white sloughs, and his gums the same ; the surface of the gurns white, like the tongue. He has taken no mercury lately. Describes the primaries as merely a swollen glans. The scars on his body, especially about the elbows, knees, back, and head, are extraordinarily large and deep. Has been in several hos- pitals, uncured. Two years ago the eruptions came in his face, and seemed to leave his body. A most aggravated case of syphilis, which seems now to fasten on the tongue. Psoriasis linguce. Woman, set. 38, recently married. Psoriasis general on the body. The tongue is peculiar ; it is a nice clear tongue, not cut about, but smooth ; only as regards the centre de- nuded of epithelium, with the usual V shape in the base of tongue prolonged forward and elongated. This V shape is distinctly but not sharply denned. She feels it troublesome and dry. When the rest of the tongue is foul this in the centre is still red and clean. Psoriasis linguce. Man, middle aged. Has a tongue glazed, jagged, and sore. Inside the cheek, opposite one of the ulcerations, there is a red raised ulcer, probably of the character of mucous patch. Psoriasis (eczematous). Man, middle aged. This might with more propriety be called dry eczema, as it affects' the bend of the arm. The tongue seems starred by lacerations in several places. These lacera- tions resemble that figured in a coloured drawing, p. 153, in Jeffrey's ' Cases of Surgery.' See Appendix. Psoriasis linguce. In a man, middle aged. Has on the body an eczematous psoriasis. The tongue is much cut about and sore. The gums in very bad condition. He has urticaria occasionally. Psoriasis linguce. A girl, set. 6. The following case I saw with my friend Mr. Nourse, of Brighton, who has assisted me in the following notes. The child had angular curvature of the spine and open abscess, and was placed under tonic medicines. Seized with catarrh, in the course of a month a catarrhal ophthalmia came on. In two or three days' time the lining membrane of both nostrils was attacked with a similar affection, and in a day or two more this was shared in by the tongue and throat. In the latter situation false membranes like those of diphtheria appeared, which after a couple of days came also inside both lower eyelids. The nasal affection suggested the idea of glanders. At this time the true nature of the case was not obvious, and no remedies had appeared to produce any benefit. The ophthalmia became more intense in the right eye, and in spite of remedies the cornea ulcerated and perforation was threatened. Every suitable application was used both for this and 8 114 ON THE PSORIASIS OR LEHtA tlie other eye, with but partial benefit; lotions were injected into the nares. The child was well fed and supported. Quinine with free chlorine and chlorate of potash were given. Yery slow im- provement took place. The ulcerated cornea slowly healed, leaving so much opacity that the sight was nearly lost. The diphtheritic membrane had almost disappeared, but both conjunctivas, nasal mucous membranes, and tongue, were still much inflamed with dis- charge from eyes and nose. The nasal inflammation now extended a few lines round the opening of the nares, encroaching on the skin and reminding one of the appearance in serpiginous syphilide. This led to the suspicion of inherited syphilis, but there was no other clue nor history pointing that way. The parents of the child were people in a humble condition of life. Small doses of bichloride of mercury were now given with cinchona, and in the course of a few days there was a very marked improvement. This medicine was continued for a month, after which time the ophthalmia was gone. The affection of the nares removed, all but a little soreness at the orifices. The throat was well, but the tongue still remained as it were mapped by differences in the epithelium with ragged red and white alternate patches. This condition of the tongue still remains, two months after leaving off the bichloride. See Appendix. Scorlutus. Girl, set. 20. The gums are white and silvery, showing a narrow red margin as they approach the teeth. This silvery film is not seen on the tongue, lips, or inside the cheeks, nor are the gums very spongy or bleeding. No purpura on the body, or ecchymosis. The girl shows a countenance universally red, with a little pityriasis. The eyelids threaten chronic ophthalmia, but she says she has been bad with it. She had smallpox three years ago, and has never recovered her strength since ; from that time she dates her present disorder. She has been under many physicians without improve- ment. Salt irritates her mouth exceedingly. Acne simplex. Female, blonde, set. 37. The condition of the tongue is peculiar on the surface like little round seeds, on the other parts protuberances as from agglomerated papillae, papillary growths, holes, or excavations. Her tongue has been always bad, but when she was a child, and even as an infant. More than a year ago she had an attack of acute glossitis. They put her a large poultice on, and there followed this acne, chiefly on the chin. She has no asthma. Her mother's sister had phthisis. She has in the left side a submaxil- lary lump, which she supposes to cause this condition of the tongue. Psoriasis genitalium. There is an affection which is some- thing of the character indicated in the preceding remarks, which may be called psoriasis genitalium, under which we ON THE PSORIASIS OP SOME OTHER, REGIONS 115 should include psoriasis and even eczema scroti. These affec- tions are far from being essentially connected with syphilis, yet they are not unfrequently so. Indeed, as regards the affection of the scrotum, this is so commonly the case that the circumstance may assist diagnosis where there is greatest need of such support. It is not unfrequent to find eczema scroti with psoriasis on the palms or on the tongue. It is in vain we would draw a hard and fast line between the two affections. There is, indeed, in the region something which inclines to eczema, so that, with a dry eruption on other parts,, on the scrotum or pudenda it may be moist. Of psoriasis scroti we may say that, when it is part of a more general eruption, it is the seat of much distress and painful suffering. When chronic it is occasionally the seat of rings sometimes large, sometimes minute, but generally with a tendency to moisture. The suffering attendant on this con- dition is often intense. It is the seat of pruritus with heat to such an extent as to preclude all repose. It looks raw, livid, and even glass-like. Sometimes much thickened in its substance and chapped, it carries a most pitiable appear- ance, and is indeed the cause of extreme wretchedness and distress ; but this is not always the case, occasionally there is only a little dry scale. Psoriasis is also apt to come in the crease between the scrotum and the thigh, as well as towards the, lower bowel, where it often causes inexpressible anguish, and is liable to be mistaken for prurigo podicis, and this con- dition is almost a peculiarity in those we have mentioned, as showing signs of asthmatic constitution. Of psoriasis geni- talium it is not our purpose further to speak than to say that the cases we have seen in connection with lues venerea are quite as much of the moist sort as the dry variety ; indeed, as regards their frequency, we esteem them to be mostly eczematous. Of psoriasis or eczema pudendi, as found in women, a great number of cases occur after the menopause. Sometimes it is connected with uterine discharge, more rarely with worms in the lower bowel. It is exceedingly apt to be brought on by faulty uterine conditions, and also by injec- tions of an irritative character. 116 ON THE PSORIASIS OR LEPRA Psoriasis or eczema genitalium. Footman, iet. 37, a married man. Is much distressed by the eruption. It varies much with the weather. Generally it lasts three weeks. Does not think of it when outside the house, but indoors the itching is intense. Psoriasis or eczema genitalium. Male, set. 34. Yery distressing. Eight years ago had eczematous psoriasis over the whole body. Spots like lichen come out on the forearm in cold weather. It is now con- fined to the genitals. He has had three such attacks. Psoriasis genitalium. Male, set. 32. On the glans penis a white spot, dry, with white scale, like alphos. Is a married man. Much worse at times, but on the whole does not suffer from it much. Some disposition to psoriasis on the scrotum. Has had psoriasis on the seat for two years, which disappeared when it came on the genitals. History obscure as to syphilis. His father had asthma and rheu- matism. Psoriasis pudendi. Widow, set. 60. Yery extensive and painful ; it drives her quite wild. She has only had it eight months. She accounts for it by her getting up early in the morning on the damp flagstones of the laundry, with naked feet. Her father had rheumatic gout badly, her mother jaundice. One of her daughters has had jaundice twice. Her son has changed from the Horse Artillery, crippled in his hands from rheumatic fever. Of this three times he has had dreadful attacks she says, cast for death. Her last child was born when she was forty-eight years of age. The personal history of this patient is singular. She had no catamenia till twenty- six years of age, the date of her marriage, but pains at the catamenial period, which sometimes laid her up for three days ; she was white as chalk, though she had the best of food and advice. A month after marriage she saw menses for the first time, with some degree of suffering, and had her first child some nine months and three days after marriage. She had a child every two years, a week more or less, but could never tell her time exactly, as she often had no menses between. Since her courses left her she is stout and better in health ; before that she was thin and subject to quinsies. Her only brother is stout. Her five daughters have good periods. On being closely questioned as to the amenorrhosa, she is positive that there was no show but at four- teen years of age, when there was just a little. This case may be added to other cases of menstrual irregularity from gouty constitution. Psoriasis pudendi. Girl, set. 8. Occupies both labia, and down the thigh a few small patches ; a sort of ring in the groin. Eruption five weeks. No appetite. The mother is a cadaverous-looking woman, with some internal disease, and her mother died of phthisis. This patient got well rapidly. ON THE PSORIASIS OF SOME OTHER EEGIONS 117 Psoriasis genitalium. Man, ssti. 35. Only the scrotum affected. This is one of the worst cases I have seen of this complaint. The loss of sleep was almost total. He had primaries some fifteen years since, and while taking 'mercury was exposed to a cold wind and got paralysis, which leaves him with partial weakness of that side at the present hour. The scrotum was quite raw. He had been under a great many doctors, with no kind of benefit. He has four healthy children. Psoriasis ani. .2Et. 34. Has for five months been afflicted with spots of psoriasis in the arms and the legs ; but now it is only seen on the anus, around the edge of the gut, and it extends between the nates and over part of the sacrum. The itching is frightful, and only controlled by renewed applications of dilute tar ointment, which he is obliged to carry about with him. Milder ointments aggravate the suffering, and nothing else has been found of use. Naphtha pro- duces no good. Psoriasis infantilis. We have already touched on psoriasis infantilis as not being of the greatest unfrequency when an un- complicated affection. These cases are generally attributed to inherited syphilis, but just now there has been an attempt at re- action, which, if it leads to a review of the subject, will be of no disservice to science. There is, no doubt, a good deal of inherited syphilis in the community ; but, in absence of other symptoms, the mucous patch and snuffles form the evidence on which this diagnosis is generally made, and this is sup- posed to be of a sufficiently convincing character. The latter symptom is wont to be equivocal, and I have sometimes had occasion to doubt the mucous patch ; and indeed, as before said, I doubt all of this nature as bearing proof con- clusive of syphilis. The following cases are such as I have generally diagnosed as non-syphilitic. Psoriasis infantilis Boy, set. 6 months. He had had it five weeks It came by a tiny spot outside the foreskin, rather low down. The doctor said it would spread, and so it did, over buttocks and privates and hypogastric regions, and with a pretty large patch on the neck. The skin is dry, shining, and with a gloss on the affected parts, with scarce any attempt at scale. No eczema or impetigo, no snuffles or mucous patch. The child does not look ill, is not ill-nourished, but suffers irritation and keeps them all awake at night. The other 118 ON THE PSORIASIS OR LEPRA children are clear of eruption. The husband gives no suspicion of ailment. The father's mother died of consumption. On the mother's side there is asthma in the family. The case is probably not syphilitic. Psoriasis infantilis. Roy, aat. 7 weeks. The mother is a strong- looking, florid, Dover woman. Her appearance is healthy in the last degree. Her husband, she says, is a strong, hearty man, but they cannot rear any children. All have gone off by convulsions but the last before this, and that one was tubercular all through and died at six- teen months the oldest that lived. The child before us had thrush for the first day or two ; two weeks after, the legs swelled, and shone wonderfully. Brought up by bottle ; no mucous patch. The mother says she is married thirteen years. Her own mother lost a brother and sister in consumption. The history of her husband and his family reveals nothing more than some little nervous ailment, shown in tightness of breath and spasms. They are both of them stout and hearty. Psoriasis infantilis. Girl, set. 7 weeks. About nates very well marked in definition, some on elbow ; generally very red and spread about; some on scalp. Came a fortnight after she was born. Yery doubtful mucous patch. The mother's father had phthisis; the father's mother the same. As to the father, he has had fistula since fifteen years of age, and is now thirty-six. He is steady, but rather given to drink. Three years ago he had smallpox, and this is the first child since. No rheumatism, skin disease, or miscarriages. Other children healthy. Psoriasis infantilis. .2Et. 3 months. Snuffles, and very doubtful mucous patch. It came after vaccination ; as that changed on his arm, so this came out ; first in his mouth, like thrush, and then on his arm, and spread. The father is consumptive, and has a dreadful cough. He lost his mother last year by consumption, and his sisters have died of it. No gout in family. Psoriasis infantilis. Infant, 5 weeks. Snuffles slight. No mucous patch. Other five children healthy. Over the brows a good deal of white scurf. Has had it almost from birth. Mother very delicate. Father slight eczema, rheumatism, and gout. Asthma on the mother's side. Psoriasis infantilis. Female infant. No mucous patch. Snuffles doubtful. Loins and nates dry and silvery. Eczematous in scalp. Much irritation. Her water scalds her before she makes it, and when it comes the baby screams, and it burns the mother. Phthisis in the father's brother. ON THE PSORIASIS OF SOME OTHER REGIONS 119 Psoriasis preputialis. There are two affections which might be almost called classical, mentioned in all the text- books, but not very frequent in our experience ; one of these is psoriasis preputialis, the other psoriasis palpebrarum. We believe both of them to be rare. As regards the former, there is no need to add to the brief description which Batemanhas given of it. It is characterised by some thickening of the part, with fissures, and such a degree of constriction as de- termines a phymosis. In getting back the foreskin it cracks and bleeds, with a good deal of pain. Beyond this it is not attended with much suffering, but it is tedious in getting well. I have only seen it in those of middle age. It is very rarely accompanied with any general eruption. This com- plaint is of so simple a nature that there is no necessity for giving cases ; indeed, I do not remember meeting with any such for these three years past. Psoriasis palpebrarum. It is difficult to say what authors mean by p. palpebrarum when they describe it as a frequent affection. Surely they do not intend the common scrofulous affection of the lids, for this does not go along with psoriasis, or but very rarely so. Psoriasis palpebrarum appears to me a different thing altogether, and is by no means a frequent affection. When psoriasis is seated on the face very often small patches lie close upon the canthi, and more rarely on the lids. They rarely cause irritation of the conjunctival covering, but sometimes they do so. We have never seen the conjunctivse generally affected in this complaint, as occurs in elephantiasis. The following case is the nearest approach we have seen lately to this rare affection. Psoriasis palpebrarum. "Woman, set. 26. Stout and well grown. Along the lower border of the left eye and inner canthus red patches ; another at the outer canthus. The conjunctiva of the lower lid red, but not scaly. On right side a patch over the lachrymal sac ; another at the outer canthus ; a few insignificant spots dotted here and there about the nose and face. It came first in two little pimples outside the lids, on the inner side of right eye. Has had it on lips as well ; 120 ON THE PSORIASIS OR LEPRA which arc white in the morning, with dry skin on them. A little behind the lug of the left ear ; some went away. Catamenia a bad colour; Ieucorrho3a. Has been treated by distinguished oculists, without internal medicine. Psoriasis labialis. This affection is sometimes of a strongly pronounced character. It may occur in middle life, under various forms, as modified by a diathesis hereditary or acquired. What is generally intended by p. labialis affects young people, sometimes children, at an early period ; some- times young females of any class, and in them it appears as a serious defect. There are chaps and clefts in the lips, and a circle round the mouth appears dry and rough, with lines drawn as from the circumference to the centre, giving some- thing of a, sinister expression. This occurs generally some half inch or more around the buccal orifice. The skin is dry and scaly, rugose and cracked. It rarely appears with a full psoriasis on the body, but sometimes with a partial eruption. It has a close affinity to eczema. The eruption above described is of a wholly innocent character, appearing under the same diathesis as general psoriasis. But there are, besides these, other forms of dry eruption about the mouth, many of them with something of local thickening ; and here I may avow that, although there are cases quite above suspicion, yet experience has taught me the exercise of an extreme mistrust in all partial affections of the lips and their commissures, especially with attendant thickening, as I constantly, though not invariably, find them to be the seat of what proves to be secondary or tertiary manifestations. Psoriasis labialis. Girl, set. 15. Her lips have many fissures; round the mouth a scaly condition, with peeling of the cuticle, which looks sore at times, and reaches sometimes to the nose. Her face generally rough. Her mother has had the same, and also psoriasis palmaris, and lost her nails. The brothers and sisters of the patient have nothing of the kind. Psoriasis labialis. Governess, set. 26. Tall in figure. The eruption forms a broad circle round the mouth, with small, dry, adherent scales. The part thickened and stiff. It gives a marked appearance to the countenance. Occasionally there are cracks in the lips. Has ON THE PSORIASIS OF SOME OTHER REGIONS 121 had tins eruption off and on for several years. History of rheuma- tism in family. Health generally good. Psoriasis labialis. Lad, set. 16. He went to the theatre, and drank out of a ginger-beer bottle. He thinks it came from that. He has had it ever since round the mouth. Psoriasis labialis et lingua. Woman, set. 23 ; girl-looking ; married four years. Had rheumatic fever three years since. Has three children, the last two years old. She never had an eruption before. All round the mouth has a brownish-red eruption, rather marked by lines, but also somewhat like lupus. She has had it these eight months, all through the winter. It came with a speck inside the lip. The tongue is a good deal cut about, in squares and lozenge shapes. Her skin is naturally diy. An uncle died of phthisis. The case presents a strong presumption of contagious infection. Psoriasis labialis. Married woman, set. 35. Ringed eruptions round the mouth, which is surrounded by a series of these rings, each about the size of a halfpenny, the cavity towards the orifice. The eruption is superficial. The lips have been sore on the inside. Her face clears entirely at the sea-side. She has lost some of her hair, but has had no general eruption, no sore throat. The eruption only bears very mild ointments. It is aggravated by caustic and mercu- rial applications. The husband of the patient is a bad syphilitic. She has been ill these nine years past, but has borne three children, after which her health immensely improved. She has now had no child for four years, and is falling away in health. Her symptoms have always been of light character. She imagines the children have cleared her blood. Psoriasis labialis. Widow, set. 33. A raised red eruption, that curls round the corners of the mouth, extending from the upper lip, with some thickening; extremely gyrate as it turns round at the angles or commissures. She has two children. A plain, steady looking woman. She got well without a scar, with arsenic and mercurial applications. Psoriasis unguium. We do not hesitate to include the nails in our description, although here again the diagnosis is difficult between the nails as affected through psoriasis and by other disease. In psoriasis the nails are often bent and curved with transverse fissures, but sometimes they are longitudinally creased. Besides this, if we bear in mind the general character of the complaint, we shall seldom have difficulty in identifying the scale as it collects beneath the nails ; and 122 ON THE PSORIASIS OR LEPRA generally it appears at the free extremity, where it may be cleared away as a sort of gross pith. Very commonly several of the nails are thus affected, and display a broad lunated edge halfway down their length, where the diseased portion terminates. Sometimes white spots appear on the nails, and these are gradually brought forward to the free margin by the growth of the nails. Sometimes the structure becomes thin and torn. Occasionally the skin that neighbours on the root and overlies it becomes fissured. We might extend further what we have to say on the conditions of the nails if they were fairly distinguishable from those which depend on other disorders, and notably on syphilis. It is sufficient to say that, in the disfigurement which proceeds from constitu- tional psoriasis there is generally more scale j it is less moist, broken, and thin than that which is found with eczema and impetigo. For the rest, we may refer to the cases which succeed. I cannot but here remark the much greater frequency with which this affection occurs in cases which are most distinctly hereditary in character. Psoriasis unguium. Man, set. 44. With plantar psoriasis. In the anterior part of the foot has rather a moist character ; runs into wet superficial sores. He has lost all the nails in the foot; those of the hand not affected; has had this two years, preceded by eczema scroti. Is worse in east winds and damp weather. "Wears a worn, bloated appearance, as if a hard drinker. He is a widower. All his children died. The eldest lived till five years of age. The nails are torn and ragged, and come away from a red and flabby matrix. Psoriasis unguium. Man, set. 40. The psoriasis hereditary; un- complicated otherwise than by inherited gout. The complaint is extensive, and refractory to treatment. It is curious to observe the nails. The spots begin in all parts beneath, in the form of small white spots, which completely separate that part of the nail below which they are situated, and they grow out to the end in the same detached state, when there may be removed from beneath some mica- ceous scales. All the nails are similarly affected. Psoriasis unguium. Man, set. 37. Typical psoriasis in elbows and knees, head and whiskers, also in the axillse and pubes and palms of the hands. His sister has a dry eruption. Gout and asthma in family. The nails are all affected. The quick seems to die. A speck ON THE PSORIASIS OF SOME OTHER REGIONS 123 comes in the centre or at the side, for the most part on the left side, and so spreads and forms a white blotch beneath the nail. Psoriasis unguium. ~M.a,n, set. 44. The nails are flat, weak, and thin, and a yellow powder appears on them. One of them has a transverse groove. He has had scarlet fever and syphilis. Psoriasis unguium. Girl, set. 14. For the last two years has lost the nails from the hands and feet. It began by an appearance of irregularity, and came off in small pieces at a time, until now there are no remains of a nail left, except slight stria?. At the base of each nail, or rather where it should be, a slight indication of fluid exists, just where the nail should terminate in the fold of the cuticle, appear- ing as though it were a bursa enlarged. A small blister was applied to one finger, and kept open for three weeks. Muriatic acid lotion relieves the itching. There was no accompanying affection of the skin. Psoriasis unguium. Man, oat. 27. The psoriasis is of three months' duration. The nails are bad, with dark puncta or pinholes, trans- verse streaks, and pith underneath. Psoriasis unguium. Man, set. 54. A soft crack in the centre and a hollow underneath. Psoriasis palmaris or plantaris of one year's duration. The nails bad these three or four months past. Psoriasis unguium. Man, set. 27. Has lepra alpho'ides. The nails go bad. White within a line of the free margin ; the point of limit in an even curve. Some faint history of syphilis, but the pso- riasis is typical and not syphilitic. Psoriasis unguium. Man, set. 24. Most of the nails of the hands affected, and all those of the feet. He has psoriasis on the body, with little or no scale. His brother has the same. No history of venereal. The nails have transverse streaks and dark puncta, and as if pieces dug out of them like the skin in psoriasis palmaris, at the free edge broken and as if gnawed. No pith underneath. They decay, he says, at the quick. He has suffered from rheu- matism. In closing this chapter, in which I have been so much em- barrassed by the complication of syphilis, I may say that I have not found its manifestations one bit less fugitive in character, or less under the influence of weather and exterior circumstances, than those that arise from non-syphilitic cause. Of course a good deal of patience and tact is re- 124 ON THE PSORIASIS OR LEPRA quired in coming at the truth in these cases, and one can only arrive at it by cultivating such inquiry as a habit, and making the diathesis your principal object of research. Human life I have seen somewhere compared to a thread of gold that is to say, to what passes for gold thread, which is no other than silver thread gilt, and this silver thread is nothing but silk with a coating of silver. Now, if you stretch this gold thread there are made cracks in it, and you perceive the silver, and if you go on extending you perceive the silk. So it is with your patients ; they assure you there is nothing in the family there is nothing at all in their past history. If you are at all skilful in your inquiries you first perceive one defect and then another. Sometimes it is asthma, sometimes it is rheumatism, and in very much the same class of cases sometimes it is syphilis. Behind a great show of health there often lies ambushed some disease. PATHOLOGY OF THE DISEASE 125 CHAPTER VII PATHOLOGY O* 1 THE DISEASE HAVING adventured thus far, am I not under obligation to provide a pathology for this complaint? But this is very much like leaving the shore to embark for a land of dreams. True, we need not use pathology as a creed that is to rule us in all our proceedings; it is rather something we ever strive after and work forward to, as the final result of all our perceptions and conjectures. A stiff creed is very apt to make a negligent observer, and the field of observation is so far from exhausted as yet that there are many im- portant points that have been entirely neglected many that are closed against all scrutiny. Yet here we have not to blame so much the industry of human thought as the im- maturity of physiological science. What we have gained in recent discovery divorces us from old associations, yet does not supply enough to occupy the place of that which in the lapse of centuries was so extremely elaborated as to boast the merit of completeness. And so it is. The humoral pathology still exercises much influence over the minds of men still survives in common speech, It seems to live on by an inherent strength and capability, and may promise itself many a revival. Thus, quite of late years, in derma- tology we have seen a work, by a foreign hand, which is based on the defluxions and catarrhs of an early period in science, and it has been honoured with no slight praise ; for granted that this pathology is artificial, nay, even that it is brutish and incredible, however false its foundation it is so enriched by additions and qualifications and provisoes 126 ON THE PSORIASIS OR LEPRA that it looks quite firm and entire, and is such that all the world can understand it. Thus, when a patient tells you that there is a good deal of salt rheum in the family you conjure up the idea of asthma, rheumatism, winter cough, occasional eruptions, pretty nearly all, indeed, that we have signalised as obviously connected with this complaint ; and yet not all, as we shall presently explain. Such is the compactness of the system, such its adaptability to every- day circumstances, such its incorporation into European lan- guages, that it is very far yet from extinction, and threatens a most lingering decease. Quite recently, have we not seen the liver once more installed as a blood-producing and blood-depurating organ ? a condition called lithsemia affirmed as constituting a diathesis, which, however supported by sound reasoning, looks very much like a return upon old paths ? So that, what with the longevity of the old pathology and the rawness of the new, we are very much unsettled in our conclusions. For as to the nervous system, what is known about it as yet can bear no manner of proportion to what remains as food for expectation, and every hour gives proof of the insta- bility of our prepossessions. Nor have we simply to make our choice as to which of two schools we shall follow. The neural pathology is not so entirely independent of the humoral, nor are they so entirely opposed. Sanguis mo- derator nervorum is a maxim which ever holds. So, again, many a disease, such as diabetes, supposed formerly to belong to the blood, may be shown to depend upon the brain; and oxyluria, which, if the conjecture be permitted, would seem to lie nearer to psoriasis than this lithsemia, has been affirmed to be of nervous origin. And nervous diseases are in no less degree liable to be of an hereditary character than those that reside in the blood, though this escapes the notice of the multitude, who, when they make mention of family complaints, ever speak of them as seated in the blood. And that gout is hereditary as well as phthisis, cancer, asthma, rheumatism, psoriasis, is no proof at all of their being blood diseases, for the nervous element maybe prin- PATHOLOGY or THE DISEASE 127 cipally concerned, and yet we would not give the nerves that precedence that we cannot discern a life and a purpose in creatures not yet provided with the nervous element. These are transmitted after their kind, conveying also certain de- fects and peculiarities and germs of decay. From a strong cutting or from selected seed there will arise strong plants, and vice versa; and in the animal world degenerations are transmissible, and various defects of formation, as seen in fissured palate, club foot, &c. ; and in such sort disease is conveyed, not always according to one type, or exhibiting one disease in all its foregone integrity, but with much variety of range and character displayed. Nor is it necessary to believe that the blood is a stranger to these mutations, or that it is anything more than participant in them. When taken from the arm we find it in psoriasis to be cupped and buffed, as if sympathising with the general condition ; but this cupped and buffed appearance of the blood is often accidental, and not inconsistent with a moderately sound condition of health. It occurs in pregnancy ; it is produced by night-watching. Such as it is, we may not overlook it here. We are inclined, then, to see in psoriasis a sort of degenera- tion or defect, an imperfection and irregularity of the forma- tive processes which far short in death of the individual, partakes of the nature of decay, at least in race or type. Evidently the nerves of organic life are concerned, and these, we know, are not independent of the cerebro-spinal. In the imperfection of the menstrual function, in the disordered secretion of the salivary and other glands, clear evidence is shown of this. Moreover, if we have a moderate acquaint- ance with spinal nerves in their subcutaneous distribution, we are tempted sometimes to imagine that the patches of psoriasis arrange themselves across their trunks, being in some degree modified or regulated by the anatomical arrange- ment of these nerves. I do not speak of this as substan- tiated and verified, but as open to further inquiry. It is, above all, to be regretted that we have not in psoriasis as yet anything of anatomical research into the condition of the 128 ON THE PSORIASIS OR LEPRA nerves, such as have been undertaken in elephantiasis with very remarkable results. The fact that the sensibility of the nerves is found to be impaired by the test of the sesthesio- meter gives greater reason to suppose that they may be anatomically changed ; and there is the more reason to conjecture this because of the analogy which certainly exists between the two disorders, for not only is elephantiasis frequently accompanied by psoriasis far more so than by eczema, but of late years another point of similarity has been noted in an atrophy of bone, which as to elephantiasis is an early and pretty constant symptom of the anaesthetic variety, but it only rarely occurs in the other complaint. But even if we suppose the nerves not structually changed, it is more difficult to believe there is nothing wrong in the spinal cord, for it is by no means unfrequent to see large patches, semicircles, and horseshoe-shapes, seated as if astride the spine in the lumbar and lower dorsal regions, and very commonly they are seen to follow the line of the spinal column in their distribution. It is remarkable about psoriasis that it is wont to appear on the surface whenever there is internal mischief; thus, we have noticed a patch of psoriasis over the apex of a diseased lung, over the throat in phthisical condi- tions, on the scrotum with stricture, and in a case of angular curvature in the spine we have seen psoriasis profusely distributed around and beneath the projecting parts, and truly in a remarkable manner. In one case of psoriasis we took note of a sense of constriction, as by a cord tightened round the waist, precisely as observed in spinal myelitis. In the above lies the foundation of our conjecture that the spinal cord is not indifferent. There is equal ground for believing the same to be the case with eczema. If now we turn to the conclusion that the cause of this complaint is in the brain, we shall find it suggested without doubt by the sense of fulness, occasional pain, dulness, bad dreams, inconvenient sleepiness, with itching of the scalp, which are sometimes complained of, and especially by ver- tigo. This last I have known continuing for two years before the appearance of the eruption, at times with considerable PATHOLOGY OF THE DISEASE 129 intensity, in a youthful adult, and to be on its appearing altogether relieved, but here again we have to accuse eczema of producing the same symptoms, and there is besides the reflection that they may be produced by gouty blood circulating in the organ. I am, myself, inclined to the idea that there is a certain fulness of the head in psoriasis, but what shakes me in the opinion of its depending on the brain is the fact that paralysis seems to make no kind of difference in the distribution of the eruption, whieh occurs just as much in the paralysed part as elsewhere. This we have especially remarked in our patient, who was the subject of a stab between the atlas and dentator vertebrae, where also there was impairment of sensibility on both sides of the body, a condi- tion which corresponds to what is ordinarily found in psoriasis. The tendency of modern research leads us to see in the nerves of the periphery an independence of function which was previously underestimated ; we no longer regard them so completely as receiving the behests of the central ganglions, and obedient to their direction ; they are generators as well as vehicles of force. We speak also of trophic nerves, and it is no heresy to dream that the nutrition or maintenance of a part may depend much on the nerves of its locality or territory, and its integrity be modified by their anatomical distribution. In this way we arrive at explanations which otherwise might present some difficulty. For instance, where the arms, as in a hostler, are most exposed to wet, it is there psoriasis will appear. By other observers than myself has been noticed the fact of pulmonary haemorrhage occurring with psoriasis. To any man tolerably conversant with disease such haemorrhage will always weigh much in evidence of phthisis ; the mass of such cases are phthisical; not only are patients frequently relieved by haemorrhage, and seem to gain through it a pro- longation of existence, but certain cases will be met with where haemorrhage is not followed, at least immediately, by tubercle; indeed, there has been such a thing spoken of as rheumatic haemoptysis. And this haemorrhage does now 9 130 ON THE PSORIASIS OR LEPRA and then occur with psoriasis, and the pulmonary tubercle does not follow, at least with rapidity. Although I have been little under circumstances of following out these cases, or at least many of them, the presence of psoriasis would certainly make me in a degree less alarmed about the haemoptysis, but this, too, stands much in need of confirmation, and the same may be said of the suspicion I have entertained that sterility rules somewhat above the average in marriages contracted with those who are affected with psoriasis. As regards the theory that psoriasis depends on conditions of the stomach and intestines, the gastro-intestinal mucous track, although this is a very attractive argument it does not seem borne out by experience. In cases of psoriasis geni- talium where there is most distress we have found it much influenced by articles of food, such as salt meats, beer, vinegar. It is beyond doubt that several cases have diar- rhoea, some most obstinate constipation. In a recent case of psoriasis palmaris we have noticed dejections of intestinal mucus, but this is exceedingly rare ; more common is the complication of haemorrhoids. We have thus failed in great part to find a pathology for psoriasis, happy if we can furnish some data for stronger intellects coming after us, but it may be seen that we connect it far less with exuberance than with decay, and that we incline to the neural pathology, for at least in a higher class of creatures the nerves are the regulators of existence. We are content to bide our time for an explanation of these phenomena, regarding with great interest that course of discovery which will assuredly shed great fame and lustre on those engaged in it. CHAPTER VIII TEEATMENT Bleeding, Baths, and Regimen As will be conjectured from what precedes, our treatment will be empirical, that is to say, will be the result of all that is to be gathered from others' experience and our own, with- out abandoning the use of reflection or neglecting the teach- ing of science, and this, we hope, may pass for a rational empiricism. With regard to bleeding, so much practised some fifty years since, and now not done at all except by old hands, or a little in country places, we are not inclined indeed to undertake the defence of it, though of its entire abandonment who can doubt that it is partly the effect of prejudice, partly of more enlightened views ? And just as in times past we have known wise physicians who were not dominated by the folly or rather the fury of the hour, and of such character, indeed, were our instructors, so even now one may speak with reserve of the total rejection of bleeding from the number of our means of cure. Such extremes are only too palpable to the multitude, and do little credit to our art. Their daily exaggeration, of which we hear so much, does certainly falsify or misrepresent the character and opinion of wise physicians. So we will say of bleeding in this disease, that there are circumstances in which it may be excused and may prove of vast service to the patient, partly in alleviation of present distress and how great this is in certain cases will scarce be imagined and where the patient is florid, with heightened pulse and colour, as we have sometimes seen in butchers and men of plethoric habits, who ON THE PSORIASIS OR LEPRA are accustomed to feed on meat to excess. This will not only do much to shorten the disease, but also prove a fit preliminary to treatment ; only that we must not be betrayed by the merely florid aspect of the patient, for fulness of flesh and heightened complexion are no proper tests of the appro- priateness of the remedy. These may occur with a history of scrofula or phthisis in the kindred ; and quite recently we have had a patient who was recommended to be bled, but we, on the other hand, with great subsequent benefit, treated the case with tonics and sent her to the sea-side, the complaint depending wholly upon scrofula. But it has appeared to me, so far as I can judge of the excessive and repeated bleedings which were practised in inveterate cases of a bygone age, that, however they might have appeared to do good at the time, they rather tended to lengthen out the disorder ; and although in some persons a bleeding may prove to be an indifferent thing, in others it is recovered from with difficulty, and its effects will last with some permanence. So that it is only as an exceptional means that we should advocate the drawing of blood, and this may be done in a few cases so as to spare the patient a good deal of suffering, and if put off too late we may even see our patient quite broken by distress and torment, and regret not having used the method opportunely. This, however, will happen rarely, and in a very large experience only once now and then ; and the place of it in more moderate cases may often be supplied, though less conveniently, perhaps, by anti- phlogistic drugs and purging, of which we shall hereafter speak. As to local bleeding, I do not recommend it or em- ploy it, though this method has been largely used in London practice in the preceding generation, and even in cases of lupus. The question of baths is by no means unimportant in psoriasis, though secondary, in my opinion, to that of medi- cines. In combination with these, the adjuvant effect of baths, if not always necessary, or even expedient, is at least well worthy of attention. The moist vapour bath is decidedly that we should most value in treating the disease ; it requires to TREATMENT 133 be repeated thrice, or at least twice, a week, and to be con- tinued for several weeks. Such baths are better used under direction of the prescriber and at a first-class bathing establishment ; but if only convenient to make use of them at home, a suitable apparatus will be found at Messrs. Walters & Co/s, Moorgate Street, City, or a simple con- trivance may be extemporised. The patient should generally be exposed to the watery vapour until the body is well relieved by sweat ; and used in this way, and not to excess, it rather improves the spirit and appetite, and does not lower the bodily strength. It should never be pushed to faintness, nor continued without advice where it appears to disagree. The vapour bath assists in shedding the scale, and fulfils other indications of cure. The sulphur fume bath may be also used without timidity, either by itself or alternating with the preceding. A great number of these baths may be taken without the strength of the patient being in any degree impaired. I have known so many as fifty or more to be used in succession without any debilitating effect, but, above all, their succession should not be hurried, and the advice of the physician should always be taken with regard to them. Their local use is not objectionable. They may be extem- porised by ingenious persons, but in truth it is always best to have them under such as are experienced in their application. In both these kinds of baths the head is, of course, left free. The use of iodine with sulphur in fume (iodine 1 part, sulphur 12 parts; or iod. gr. v, sulphuris 5J) is also a remedy of great resource in certain cases, and its local application is also a good remedial means, but it should be used in very moderate proportions. The Turkish bath is not inefficacious, often contributing much to the shedding of scale, but is inferior to the vapour bath in general efficacy, also not so free from accidents, and in some cases, connected with gout and com- plicated with other affections, subject to disagree; besides which it may be said that, in certain persons and constitutions, we have found, upon trial, an evident repugnance to this bath, and there is, of course, the objection of exposure which deters from it. The warm water bath is so far from being objection- 134 ON THE PSORIASIS OR LEPRA able in the greater number of instances that I am accustomed to encourage its employment at least twice a week, if it be not used too hot, and provided it does not produce debility, for it must never be forgotten that the warm bath is one of the most direct sedative agents we have, in which respect it differs much from that of water in vapour ; but used at a temperate heat it has a very soothing effect, and, especially towards the close of the disorder, assists in shedding the scale. More efficient are baths made in imitation of the Bareges and Har- rogate water, or simply of liver of sulphur, or even lotions of the same. And we may also praise the muriatic acid bath, and especially its local use. Besides these the chlorine fume bath may be ventured on, with much discretion, in extreme cases, where the sulphur fume does not succeed. Baths of creosote may also be used, and we must also be alive to the benefit derived from certain softening and gelatinous baths, with size and tragacanth or other such material. The curative agency of the cold water system has been praised by Hebra, the method employed being not very different from that which is stereotyped for other disorders. We have no practical experience on this subject, having early conceived a prejudice against this treatment from cases within our knowledge where the predisposition was certainly con- siderable being made suddenly much worse by this German system of water cure. Indeed, we have already protested against the use of the cold bath and sitzbad in certain well- pronounced diatheses as highly conducive to psoriasis, if not also to other ailments, and this no less in warm countries than in cold. We do not fear to oppose our experience to the bent of modern prejudice in this respect. If we remember right, Bruce, in his Abyssinian experience, recommends the cold plunge under the hottest sun as a safe and healthy roborant, but we have found elephantiasis occur under such circum- stances, where, indeed, there was no predisposition in the family. The shock to the system of nerves by such sudden immersion is of the nature of a blow inflicted by a sledge- hammer, the bad result of which may last through life ; and we will put it to any medical man of experience, who has TREATMENT 135 taken a regiment of soldiers to bathe, whether some casualties do not happen in the way of illness as consequence. We have also seen, since the introduction of the cold water cure, how experience has dictated a good deal of reserve and a milder method in the employment of such powerful agencies ; indeed, we may safely say that, to those of phthisical and gouty antecedents, these violent means should be spared to a very great extent. So immediate are the ill results of much wash- ing in some forms of psoriasis, and especially in the feet and hands, that it is sometimes difficult to get patients to use the proper hygienic ablutions. In such cases baths with weak muriatic or carbolic acid are a great resourse, combined with greasy applications to the fissures. The use of soap, which is now a little neglected for the "tub," is inestimable in psoriasis. The English are generally esteemed the best soap- boilers in the world ; it is true, however, that some of our cheaper soaps, as found in commerce, do not seem so good as they were some forty years since. At that time their exten- sive use in eczema and lichen agrius, and some other disorders, was very well known in London, but this knowledge was not very generally diffused. How well these rough means of dealing with eczema were known in Paris may be learned from Valleix's ' Guide du Medicin Practicien/ vol. v, p. 165, ed. 2eme, where one reads of nail-brushes worn to the stump in the course of friction for these complaints. The French school used soap very freely, but Hebra must be allowed the merit of having diffused and systematised its use, so that now it is become familiar to all. He seems to have been very particular as to quality, procuring his stock from Stuttgard, but now, probably, the Viennese makers are no way behind (see Appendix) . Our soft soap of the * Pharmacopoeia/ equally with that of some few manufacturers, is an excellent article ; and besides these, many other kinds may be used with advantage, especi- ally those of coal tar, juniper tar, carbolic acid, as found in commerce. These may be liberally employed, as not only cleansing from scale, but as having besides some curative effect ; es- 136 ON THE PSORIASIS OR LEPRA pecially is this the case with the soft soap, which may be directed to be laid directly on the part for a quarter of an hour or longer, provided it become not raw or inflamed, and the soap can then be washed off. To apply this soft soap as an ointment may, indeed, be attempted, but with much caution, and it is not what we generally approve. The patients them- selves, however, allow it to be curative, and sometimes in this respect they prefer the soap to ointment. Of soaps generally it may be said that the alkali is so powerful an ingredient as generally to kill any acid or chemical in its substance, and their application to the part being evanescent, there is not much effect produced on the disease by the common daily ablutions. The effect of the alkali on the part is generally good, whether; employed as lotion, ointment, or, as we have already stated, in the form of soft or as it is called green soap. Soap should be used always once if not twice a day to the parts affected, and sometimes even then it is ineffectual in removing the scale, which may be scraped off with the back of a steel or bone knife, taking care that no sore result. In the palm of the hand the soap with pumice-stone powder, as sold in balls by the perfumers, or the pumice-stone alone, may serve to get rid of the scale, which is often an impediment to contact of remedial agents. Nitric acid or caustic potash may be occasionally required for the same. After baths we may speak of exercise as often necessary to be maintained, especially with deficient perspiration. Its regulation will, of course, depend on the nature of the indi- vidual case. The diet should be supporting and not stimulating. I commonly recommend such a diet as is approved of in phthisis, bland and unirritating ; but in this respect there is room for divergence, or perhaps one may say that in cases of considerable inveteracy it may be excusable to venture on experiment. For instance, many years since it was not un- common to deprive a patient of meat and confine him to puddings and milk diet, or even to a diet of vegetables, and it is undeniable that this plan was sometimes followed by suc- cess, but, indeed, it should not be lightly undertaken. These TREATMENT 137 experiments with food may very much interfere with the powers of life and vital resistance. Several persons, however, of a gouty diathesis have attained to health through a simpler form of diet, and several of them through total abstinence from meat. It is common with me to recommend meat twice a day, and even a little wine for the stomach's sake ; but as for beer, I cannot but remember that many cases have been rendered refractory to treatment by using it in large quantity. For this reason I prefer that patients should abstain from beer, except in small quantities, and use wine moderately and generally of an unstimulating character, without regard to colour, but choosing of red or white as found best to agree, and those the least fitting in gout are generally to be avoided, and in some cases more than in the rest. It is only of recent years that we have heard of the treatment of psoriasis by meat diet only, making an exclusive or almost exclusive use of this. I have not witnessed any experiments of the kind. Those related seem to have been too few in number to rest upon them any conclusion. As to watering places, foreign baths, and climate, I have generally given the preference to the ataxic waters of Bath, probably equal in efficacy to those of Leuk ; but in a selec- tion of cases others may be ventured on; for iodide and bromide ingredients, as that of Woodhall ; or for sulphur, Harrogate and the Radnorshire wells ; of foreign baths, Kreuz- nach, Schinznach, Aix la Chapelle, and the Pyrenees. A warm climate will recommend itself in many cases. We have already noticed the frequency with which psoriasis reappears on a return to this country from Australia. Many cases get well at the sea-side, especially where a scrofulous basis may be suspected. But very often it is the mere venturing an experiment, for with cases of psoriasis it will often disagree, and many times psoriasis begins near the coast. 138 ON THE PSORIASIS OR LEPRA CHAPTER IX INTERNAL TREATMENT IT has been said that by arsenic and tar any case of psori- asis will be cured, and no other means of treatment need be cared for. This may serve to show the high repute of these remedies and the degree of preference they have attained. Nay, some have carried further the process of simplification, and chosen one of these to the exclusion of all beside. There is to be observed in this something of boastfulness and of the spirit of charlatanism, for why not use all resources that nature has provided for our hand ? And as to the certainty of cure in psoriasis, experience has shown that it is no such easy matter. To the use of either remedy, occasionally, an objection may arise, and the door be left open to some con- venient suggestion ; and, besides, the cases vary so much as to warrant quite a different treatment, according to the patient's constitution. Nor is the distinction of the cases or the use of either remedy at all a simple affair, but one of great nicety and experience, and each is well worthy of a chapter apart. Of schools of dermatology in Europe, until lately, those of London and Paris were held in chief esteem ; that of Paris by virtue of its endowed institutions, possessing greater expansion and of far wider effect in teaching, but also owing very much, in the first place, to experience accumulated in England during the long war which severed us from the Continent. In London teaching has been desultory and fitful, but never without a certain thread of permanency ; but now the school of Vienna seems to have attained at least a temporary pre-eminence, m many respects differing from our own, pre- INTERNAL TREATMENT 139 senting conclusions with difficulty understood and prejudices which we are ill disposed to embrace, but admirable in many respects and swelling the tide of progress in dermatology. One has to regret in this school that through its ablest re- presentative, it ignores or all but ignores the great efficacy of arsenic in the cure of psoriasis, which is one of the most cherished traditions of English medicine, relying chiefly on topical applications, which are neither cleanly nor convenient, nor wholly void of that element of danger which may be very well avoided in arsenic, for, used as we know how to use it, this last has no kind of danger attaching to it. Its medicinal doses stand a long way off from those that are poisonous, and its application in the cure of disease is extremely varied ; but what is at this hour least contested among us is its efficacy in the treatment of psoriasis. Sometimes I have been minded to refrain from its use in the treatment of skin com- plaints, but have always soon returned to it with a faster conviction of its superior utility. Sometimes I have cured psoriasis with very simple local applications, but this only once in a way; and, indeed, the efficacy of arsenic in the treatment of psoriasis is so much a matter of evidence that I am tempted to say of one who cannot see it, or is wilfully unobservant of it, that he has mistaken his calling as phy- sician. Not only to psoriasis, but to all we have named as its kindred diseases, is arsenic more or less applicable to rheumatic gout, to asthma, to chorea, to chronic rheumatism, to phthisis and winter cough. In short, to deal ably with psori- asis it is necessary in the first place to know all about arsenic, and, indeed, to make a particular study of this drug ; and since my life and fortunes have led me to consider these things more nicely than happens with many, I will here put down a few things which are not commonly found in text-books, leaving to these to supply any deficiency which may be want- ing in thread-worn detail such things, I mean, as are im- bibed in everyday teaching. Arsenic. It would appear that this substance was not only well known to the ancients, but they were acquainted with some of the most refined of its uses and its application 140 ON THE PSORIASIS OR LEPRA to a variety of affections, and it is probably in descent from them that its use remains in existing civilisations which are very much more backward than our own, e.g. for asthma in the east of Europe and for paralysis of the face in Hindoo- stan. The knowledge of it in these ancient times was confined to the sulphurets, which they called sandaracha and arseni- con, and we realgar and orpiment; but of the two the former was more employed, and, from what we learn of them, it is sure that they contained a good deal of arsenic uncombined with the sulphur that both of them were powerful drugs. The application of these was various ; thus, we read of their use in onychia and alopecia ; but as to the extent of their internal use, it is very much a matter of conjecture. The Arab writers are some of them silent about them, while others treat freely of their uses ; to the Arabians belongs the merit of having discovered and prepared the white arsenic or arsenious acid. They seem to have adopted all the recommendations found in Galen and other such writers as were accessible to them concerning the use of arsenic. They invented new formulae, and probably found for it novel applications. They employed it as a caustic to open hydrocele, and probably the receipts for cancer that have come down to us as heirlooms in great families and in the bosom of convents are but fragments of this earlier civilisation. The internal use of arsenic in the cure of skin disease among the Arabians was probably of a limited character; externally they used it for lepra, lupus, herpes, impetigo, foul sores, and pediculi. Their appreciation and employment of it is probably represented, however im- perfectly, by the practice of the Hindoos in the present day, who use arsenic externally, mixed in poultices and otherwise, but also sometimes in substance internally. All experience in modern medicine, however, serves to forbid to us the external use of arsenic, whereas its internal use grows upon us more and more ; and this internal use of the drug, although in part derived by tradition from the ancients, may be claimed as the result of modern study so far as regards the modera- tion of its doses, the precautions of its use, and the knowledge INTERNAL TREATMENT 141 of its effects. Numerous physicians, indeed, in continuity from the Arabian school, make mention of the internal use of arsenic; thus, we read of a certain king of Hungary cured of asthma and orthopncea by its use in the middle of the sixteenth century (1570-80), and the prescription still survives. But the employment of it internally seems to have gained upon the community in a somewhat unaccountable manner through its prodigious efficacy in the cure of agues and malarial fever, a monster plague in centuries preceding our own ; and in its acquired repute it seems to have owed nothing to the faculty, at least not till the beginning of the eighteenth century. At this time several physicians undertook its defence, but it is astounding to learn the enormous doses which even those its defenders ventured on when undertaking to find for it a legitimate application in medicine. These doses averaged from half a grain to a grain and a half of white arsenic given daily for a succession of days, whereas we are content to give a twelfth or twentieth part of a grain, or even far less. In the course of the eighteenth century the use of arsenic, generally disapproved by physicians, was never- theless employed, more or less avowedly, by a few of them ; thus, we read of a Prussian surgeon, in quite the early part of the century, who placed three ounces of white arsenic with one of nitre to liquefy slowly in a damp cellar, and employed the resulting compound. I find, however, in an English dispensatory of the year 1730, that all account of the prepa- rations of arsenic is withheld, on the plea that mercury will fulfil in a better way all the indications derivable from it. Such were the partial decisions of the epoch, the truth being that, in the stout contest which it underwent with cinchona as an antiperiodic and with mercury as an antiscorbutic remedy, or antilymphatic, as it was then called, arsenic re- mained, if not master of the field, at least on an equality with the other two. The preparations of arsenic sold as secret were mostly prepared with nitre and salts of tartar. Among these the well-known drops of Jacobi may be con- sidered the predecessors of Fowler's solution, but the prepa- rations were multiform that had arsenic for their basis. Here 142 ON THE PSORIASIS OR LEPRA in England they were current under the name of tasteless ague drops, Edwards 1 ague tincture, and such other denomi- nations. In the years 1746-8 the papers of Macquer, read before the Royal Academy of Sciences in Paris, led to a clearer notion of therapeutic combinations of the metal. He combined the metallic acid with potash by melting and subliming them together; the resulting compound is the well-known salt of Macquer familiar in Continental formulae. In the course of the war with the French in America we read of arsenic employed instead of bark in certain hands. In the latter half of the century it was scarce a secret among the faculty that quite equally efficacious with cinchona was arsenic in the treatment of intermittents. So when Fowler had the ague drops analysed he did no more than others had done before him, and followed but the impulsion of his age. The attention he paid to these facts and the publication of his work gave, however, a higher degree of interest and noto- riety to a subject which was already emerging from obscurity. A great publicity arose out of the circumstance, and the experience of Drs Fowler of Stafford, Arnold of Leicester, and Withering of Birmingham, was widely quoted. From the time it was found that arsenic could be given with a degree of safety and even with marked benefit in many diseases, its use began to extend over the whole field of physic ; it was proved in many ways, and fortunately by men of great credit and repu- tation, who went far beyond Fowler in experience of its use. Among these may be mentioned Willan and Pearson as chief. The former well known as the father of British derma- tology, but less appreciated than he deserves in the field of general medicine seems to have employed it in the cure of intermittents, and made public the subsequent experience that he had never found any remedy more efficacious or more safe than this, if only a proper degree of care accompanied its use. He had given, as he asserts, the Fowler's drops to persons of every age and class of temperament, i. e. from the ages of five years to seventy, and he had never met with those colics and diarrhoeas that had been urged as prohibiting its exhibition, Among cases quoted is that of a lad cured by INTERNAL TREATMENT 143 him of quartan ague, who, being otherwise very ailing, suffered much from abdominal plethora of a quasi-inflamma- tory character. Other physicians had to combat the prejudice against arsenic as producing paralysis and conducing to fulness of the head. Such published observations gave stronger confidence to treatment and dispelled an undue timidity. We are, however, far from recommending the use of arsenic where inflammation in any organ is ascertained ; nevertheless this experience is valuable, derived from days when the use of the drug was far, rougher than in our time, for the scale of doses laid down by Fowler is now considered far too high. In a short cycle of years arsenic was used over the whole field of medicine. Every physician of intelligence, of any amount of enterprise, took an interest in this so-called Herculean remedy ; thus, by Jenkinson, Bardesley, Haygarth, it was applied to the cure of chronic rheumatism and nodular disease of the joints, by Alexander to angina pectoris, by Ferriar to hooping-cough, and it was used by other physi- cians in chorea, epilepsy, scrofula, asthma, and the early stage of phthisis. Especially above his contemporaries in experience of the use of arsenic was Dr George Pearson, of St George's Hospital, skilled alike in chemistry and in pathology (see Appendix), who, by his choice of it, cured the Duke of York of a violent and obstinate intermittent, and also has left us the Pearson's solution, arrived at by very much the same process as the salt of Macquer, and which now is adopted into the 'Pharmacopoeia/ and is generally esteemed to be the mildest of the arsenical preparations. Pearson averred that he had never known any dangerous or hurtful effects from the use of the mineral, and so long as he had it he wanted, as he affirms, no other antifebrile remedy. We have seen, then, how, from its application to a variety of disorders, the use of arsenic became adopted in physic, and how confidence daily grew in its use. The subject occupied so large a share of attention in the medical annals of the early part of the century that one can only wonder at its shrunken proportions and lament that the perversity of each generation expends itself in decrying the preceding. One 144 ON THE PSORIASIS OR LEPRA feels discouraged to see how advance in any one line is infal- libly followed by the reaction of neglect. It is no manner of proof, but only conjecture, which leads us to the idea that, with all this curious research in the uses of arsenic, which lasted through more than the life of an individual, it was seldom or scarce ever applied to the cure of diseases of the skin ; literature, indeed, is silent on this sub- ject, or nearly so. Willan seems, under this aspect, to have neglected or undervalued it; and however others may have had the same idea as Girdlestone, it is on him we find bestowed the imperishable honour of having first boldly recommended the use of arsenic in the cure of lepra and other skin disease ; and as, from local acquaintance and family relations, I take a more than an ordinary interest in his fame, I shall here put down some things concerning the man which may retrieve a long cycle of neglect, and which seem, indeed, to grow out of my subject. But seeing that our intention is wholly towards truth, and not to the idolatry of an individual, we shall first consider what degree of merit is his own as making the first great step in this direction. Some foreign physicians have been willing to thrust his name aside, on the plea that to make fair mention of him is a proof of ignorance in the history of medicine ; but the instances they give apply, with but few exceptions, to the external use of the drug, and this we have allowed to have been frequent in former ages in the treatment of all sores and skin complaints. These exceptions we shall presently dis- cuss, and if he caught at its use from any hint in literature, which is a supposition we are not unwilling to share, this shall be no diminution of his fame, for these hints lie so deep concealed that they were not certainly for every one's reading. Girdlestone was simply a well-read man and one of the best informed of his day, keeping himself on a level with all that was going on and taking his share in the pro- gress of the age. Let us, then, inquire what were the antecedents of arsenic in the history of medicine, as regards its internal exhibition. It is fully allowed that the Hindoos made a use of it internally in dealing with skin disease, and INTERNAL TREATMENT 145 we find Langius quoted, a celebrated medical author, A.D. 1555, who mentions Rechfeld, a professor of Erfurt, making a perfect cure in a certain case of leprosy by an accurate exhibition of arsenic, arsenico accuratissime preparato. But there is one work with which Girdlestone was very probably acquainted, which gives a strong suggestion on this subject. It is that of Melchior Frick, De usu venenorum medicd, A.D. 1701, one of the very first written in defence of arsenic from the hand of an honorable physician, and one of the most influential in establishing its adoption by the faculty. In his chapter on this substance Frick has recom- mended it as a resource in advanced syphilis. Pilulae Plummeri, gr. iii vel iv ; Liq. Potassse Arsenitis, gtt. iv. F. pil. secundem artem, ter in die sumend. Or again the following recipe : p> Antimonii Oxysulphureti, grana qninque ; Pulveris Antimonialis, granum unum ; Liquoris Potassse Arsenitis, guttas duas ; Micse panis, q. s. F. pil. ii, sumat unam vel duas vel tres pro dosi ter in die. For children $> Antimonii Oxysulphureti, gr. i ; Magnesise Ustse, gr. iii. F. pulvis, ter in die. Such use of antimony may be considered, however, as a divergence from routine. My employment of it is excep- tional. The addition of antimony is long disused in the confection INTERNAL TREATMENT 157 of the sarsaparilla decoction as found in our Pharmacopeia, however it formed an ingredient of the Lisbon diet drink, on which this decoction was modelled. Under certain circumstances we might avail ourselves of the addition, or make use of the tisane de Feltz much esteemed on the Conti- nent. Of the practice mentioned by Devergie of producing a tolerans by tartar emetic and then extending its use over a considerable period, I have no experience. Pitch, Carbolic Acid, and Chios Turpentine. I have seen pitch pills largely exhibited in hospital practice, but am unable to express any strong conviction concerning them. They often fail to do good and constitute an awkward and cumbrous remedy. Occasionally I have heard strong assertions as to their excellence, and my prepossession is very much in their favour. One of my patients, who had psoriasis of the tongue, declared that he was perfectly cured of the first attack by taking only three pitch pills. I do not entirely discredit such tales, but it is a highly incommodious mode of treatment. The use of carbolic acid has been pretty successful in my hands, though I deem it far inferior to arsenic in efficacy. The dose is generally about five grains. I have prescribed it in the form of glycerinum acidi carbolici of the British Pharmacopoeia, and have given pretty large doses of it. Of this I find two scruples or half a drachm to be a full dose, but sometimes I have even used a drachm and continued its use with benefit for several weeks ; but this dose I consider too high. It is apt to produce a sense of fulness and pain in the head and stomach, with a general discomfort. In some old-standing cases of psoriasis, especially with rheumatism, the chios turpentine will be found a con- venient resource. Acids. In the treatment of psoriasis the only one I need make mention of is nitro-muriatic acid, and this has no par- ticular application ; there is nothing with regard to it that will not be anticipated by a skilful physician. 158 ON THE PSORIASIS OR LEPRA Alkalies. The use of alkalies has been much extolled in this complaint. Without denying their efficacy or their applicability to many cases, especially with gout and acid conditions of urine, I think they have been overpraised. It is in the form of alkaline purgatives that I have found them of most utility. Magnesia with the Epsom salts, or the E/ochelle salt with soda ; the last may be given before meals, sometimes with addition of nitre, more rarely after meals. Small doses of alkali are also sometimes joined with advantage to Fowler's or Pearson's solution, and to the iodide of potassium or sodium. Purgatives. These are sometimes expedient against obsti- nate constipation or full habit, especially in psoriasis palmaris. Colchicum. The use of colchicum is permissible and even advantageous in certain cases of psoriasis, especially when complicated with gout, and this not only where these symptoms are acute, but even in obstinate chronic cases. One must be careful, however, against abuse of this medicine, which is a strong depressant. In the majority of such instances I prefer the iodide of potassium. Cantharides or Lytta. I have frequently tested the effi- cacy of this remedy by giving it internally unassisted by any local application. It is recommended in sluggish leuco- phlegmatic temperaments, and in these I have found it of no doubtful efficacy ; but its action does not seem to be entirely confined to these. I believe it to have a great power over psoriasis, especially in conditions of debility, but I have refrained perhaps with too much scruple from the use of it, through an impression made on me a long time since by the case of a gentleman who was a victim of its employment. Nevertheless, I have given it sometimes in pretty full doses without ever having met with such a result. The dose of cantharides scrupulously given is from eight to ten minims two or three times a day, or a drop may be given for every two years of a boy's age till ten to twelve drops is attained and INTERNAL TREATMENT 159 fifteen drops I have seldom overpassed. For the cure of dropsy I have been accustomed to see much larger doses prescribed. This medicine recommended by Dr Mead was also much employed by Biett, and after him by Devergie. It is, perhaps, not so generally known in the profession that it has been highly praised in veterinary medicine for the cure of glanders and farcy. It is certainly a strong stimulant and stomachic, and wonderfully improves the appetite for food. By some the medicinal power of cantharides is wholly attributed to the stimulus it bestows on the stomach. Its use in medicine owes much to a surgeon of the name of Roberton, who published some excellent practical works on the subject in the beginning of the century. It was by him chiefly recommended for the cure of leucor- rhcea and affections of the mucous membrane of the urethra, and, moreover, for ulcers of the skin, wherein I have also prescribed it, I believe, with advantage. It would appear that all forms of complaint for which lytta has been successfully prescribed are more or less conditions of debility (see Appendix). Iodine. The iodide of potassium enjoys a certain repu- tation as curative of psoriasis, and it is a very useful pre- paration, and one for which the physician will find many indications. Above all, employed with Fowler's solution in cases complicated with rheumatic gout, or even with chronic rheumatism. Given alone, for non-syphilitic psoriasis, it has a marked inferiority to arsenical preparations, yet some- times it is seen to cure where the arsenic has seemed to fail. In doubtful syphilitic cases it is of great service, and some- times does away with the necessity of using mercury. Iodide of iron proves a useful tonic, and iodide of arsenic may be found sometimes convenient, but I generally reserve it for lupus. Mercury. Biett treated psoriasis in children by the administration of calomel purges in frequently repeated doses, that is to say, a full purging dose twice or three times 160 ON THE PSORIASIS OR LEPRA weekly ; this he thought the only kind of treatment available for children. I have not found the benefit of this practice, and do not follow it. It seems to me mistaken. I am accustomed to use mercury with a sparing hand. A few Plummer's pills may be prescribed with advantage in the course of the treatment for psoriasis or an alterative dose with purgative. The Donovan's solution, which con- sists of arsenic, iodine and mercury, has certainly approved itself to many practitioners. It is chiefly useful, as it seems to me, where there is something of an inflammatory base in the patch, and in a class of cases on which we have dwelt very largely, viz. those in which a trace of syphilis is suspected or found ; not unfrequently success is attained by combinations of mercury and arsenic, where each separately has seemed to fail. One of the most successful practitioners in this metropolis was very much in the habit of adding to his arsenical formula minute doses of corrosive sublimate, and Devergie has given us a series of cases cured by medicines not unlike the Donovan' s solution ; although scarcely of a scientific character, these prescriptions appear sometimes to succeed in cases when other remedies have proved ineffective ; but I generally hold to great simplicity in prescribing. Cod-liver oil. This will often be found useful in psoriasis. Graves relates the history of a case sent to foreign baths, and there cured by the local physician by means of this re-constituent, without any use made of the waters, and in fact many who resort to such places are healed by well- experienced doctors with the most powerful class of drugs. The cod-liver oil for this purpose should be given in large doses. Where there is a foundation in scrofula this remedy is of the greatest efficacy, and can scarcely be too highly praised. One may venture to say, the character of many of these cases is such that whoever has acquired great skill in the management of phthisical conditions will be very far advanced in the treatment of psoriasis. Sulphur, Phosphorus, and other remedies. It is not often INTERNAL TREATMENT 161 that I use sulphur in the treatment ; sometimes it may be added to the purgative salts, sometimes given with nitre, sometimes with soda. Sulphur was once considered to be equally healing to the lungs and to the skin, but it has lost very much of its repute. There is no doubt that psoriasis is cured by sulphuretted waters, as those of Harrogate, Aix-la- Chapelle, and Bareges, in long draughts, and this is also true of their imitations ; but who will submit to the disgusting potions, let alone if there were certainty as to the remedy ? Where this aversion is not unconquerable, such waters may be tried. Some years ago patients more willingly submitted to such treatment, and the same may be said of the chloride of lime or soda in solution. This has been used in London practice pretty extensively, but I cannot speak confidently of the result ; some cases, however, have seemed to show that it may be of service. We now generate chlorine by simpler means. I suppose no one would employ copaiba for the cure of psoriasis, except in corpore vili ; the punishment would be too extreme for any one of gentle nurture ; if this is attempted, however, the resin as recom- mended by Dr Wilks would be the preferable form. The experience I have with phosphorus is too immature for me to venture au opinion on the subject. Its effects as a poisonous substance have imprinted on me perhaps an undue dread of it. This may be held to be unreasonable, as the fatty degeneration of the liver, which has made me so timid with phosphorus, is found equally after poisoning with arsenic and carbolic acid. A high degree of interest attaches to the use of phosphorus in medicine, but we have scarce got beyoud the experimental stage as yet. Dulcamara, Rumex, Elm bark. When one considers the extensive use that has been made of dulcamara in hospital and also in private practice, one may be inclined to think that its loss of reputation, now almost total, can scarcely be undeserved ; no remedy, in fact, has had fairer and longer trial. Without going so far as to declare it to be worth- less, we may say that it was introduced at first with exag- gerated praise, and that this has been followed by a 11 16.2 ON THE PSORIASIS OR LEPRA general disappointment. Nevertheless, some physicians of great talent persevere in its use, and some, among whom we may reckon the late Dr Addison, of Guy's Hospital, thought very highly of dulcamara. The fact is, that in metallic principles it has had very strong competitors ; we have thus found means to do without it, and it is almost wholly superseded. The arsenic is such a handy remedy that this circum- stance alone makes competition with it impossible. I have also known physicians who were strongly convinced of the medicinal efficacy of the Rumex and employed it largely in decoction, and even some who had faith in the urtica dioica. These remedies are now relegated to herb women, who even now find a source of profit in frequenting markets and fair. As far as I can judge, they still boast of a certain measure of success. But in London these remedies have suffered an eclipse, as ill calculated to withstand the tide of favour which has set towards medicines both more efficacious and of far less costly and tedious pre- paration. What I have said of the preceding applies to sarsaparilla and the woods. The former still remains a favourite with the public, though with the profession it has fallen in favour. I still retain a prepossession in favour of elm bark, which assists, I think, in shedding the scale, especially where it is heavy, and toward the decline of the disorder. For this the simple decoction may be em- ployed or the compound decoction in Jeffrey's well-known formula, which is found in chemist handbooks. 163 CHAPTER X LOCAL TREATMENT IT is beyond a doubt that the cure of psoriasis will be accelerated by appropriate local treatment; nay, in certain cases it may be brought about by simply external medica- tion ; and, indeed, this kind of treatment was chiefly relied on before the beginning of the present century ; it is, in truth, the most ancient of all, and in the olden time one treatment did for this and scabies. Thus, in Celsus, we find formulae, with resin and nitre, and other such ingre- dients, and they are recommended for scabies and also for this complaint. And so in modern times those who do not embrace the improvements that have been made in the internal treatment are very much thrown upon the use of external applications, and these continue to be very much the same as are used in the cure of itch ; that is to say, sulphur with alkali, Helmerich's ointment, Wilkinson's ointment, Vleminck's solution and such like things. If now to these we add the use of tar which surpasses all others as an antipruriginous remedy, we arrive at what now in modern times is presented to us as the best treatment possible ; but neither is this latter remedy of novel sugges- tion. We shall not contest, however, that there is a certain improvement in formulae and also in the method intro- duced, but chiefly through the publicity and extension it has attained a certain amount of improvement in external treatment has been realised. Far better than formerly the medical world is now instructed in the use of tar arid of all this class of applications. 164 ON THE PSORIASIS OR LEPRA We shall not hesitate, however, to say what we think of this boasted treatment of psoriasis by external remedies only, which, indeed, seems better adapted to a regiment of soldiers, or to a convict establishment, than what is generally met with in civil society, for the first lesson one has to learn in skin disease is that cases differ much in sensibility or irritability of the cutaneous investment, that is to say, in the resentment the skin betrays to any kind of rough handling or treatment. The idiosyncrasies are many, the varieties are incalculable; so that a dermatologist, who does not take a sufficient account of this in his intercourse with the outer world, must always live, as the saying is, in hot water; for he will be always in some scrape or other. And this applies not only to one class of violent remedies, but to all forms of local application. As much to the biniodide of mercury, to the iodide of sulphur, as to pitch and kreosote ointment, and certainly to the Vleminck's solution, and yet there are certain skins that will bear them very well, but this is not the case with all, or even with the greater number. In English practice we may say it is quite an exception ; for this reason it is necessary in apply- ing these irritant substances to proceed tentatively and to use much caution, so that in the end you may gain their major effects. This rough way of dealing with diseases of the skin, we have said, is no way new; for frictions in certain forms, either with towel or nail brush (brassage), and a lavish use of soap, were certainly among the traditions of the Paris school and fully understood in London practice very many years ago; and this we have already hinted at (see p. 135), and if we turn to works published in this country of half a century since, we see prescribed combinations of nitrate of mercury and tar, sulphur and tar, as the commonest appli- cation, but this does not invalidate the recommendation of Rayer to use the white precipitate ointment very frequently. For this, indeed, is highly serviceable and safe to begin with, and in the psoriasis palmaris I commonly commence with Kirkland's ointment, or with one of red oxide of mercury with LOCAL TREATMENT 165 no more than some fifteen grains to the ounce of lard. But if there is much scale in psoriasis, I make use of the soft soap, ^which may be allowed to lie on the part for a little while, or an ointment with alkali, or what I find extremely useful, Helmerich's ointment, composed of eight parts of lard, two of sulphur and one of subcarbonate of potash, and the patient often finds it more efficacious than tar, at the same time that I give arsenic internally. It is well to remove the scale not only with these alkaline applications, but also with a little mechanical aid. Sometimes where this seems impracticable, the strong liquor potasses or nitric acid may be required so to clear the scale away that remedies may reach the part; and these caustics, again, are useful where the parts are horny or display a warty character. If the psoriasis is eczematous Kirkland's ointment or zinc ointment may be used, the latter perhaps with a small portion of huile de cade. As antipruriginous remedies, narcotic oint- ments, weak solutions of perchloride of mercury, with addi- tion of camphor or chloroform, may be had recourse to, but none of these in relieving the sense of itching can compete with preparations of tar and carbolic acid. Of the former the alcoholic solution diluted, the liquor carbonis deter gens is very useful as a wash. The acid may be used weak in lotions, in ointment, or with glycerine. I generally prefer to employ it with the last named (one part in five), adding four parts of water to one of the carbolic glycerine and frequently using it much stronger. When, however, the psoriasis is very extensive it will be best to refrain from carbolic washes, employing instead alkaline lotions or a weak dilution of the hydrochloric acid, which with a sponge may be freely applied ; the same is also useful as a bath for the hands;' or acetic acid may be employed very much diluted to sponge the body, or highly concen- trated as in the form of aromatic vinegar to touch the initial spots where they are few in number and slow to dis- appear; in same way we may use Harrogate or Bareges water in washing the parts two or three times daily. But if it be found that the patient is tolerant of irritant applications 166 ON THE PSORIASIS OR LEPRA the choice will probably be made between those of the French introduction, which generally are elegant and cleanly, those, viz., of iodide of sulphur and biniodide of mercury, or the tarry preparations which have recently come into increased favour, as recommended from the Vienna school. Of the former the same warning should be given as of the latter ; in certain cases they all betray by creating immense irritation ; this is rarely the case with iodide of sulphur, but is com- monly so with the biniodide of mercury, which should be prescribed at first in small dose, say ten grains to the ounce of lard. Used with discretion, in the greater number of cases it is generally capable of fulfilling the same indications we obtain from tar and kreosote. The former of these has the drawback of fouling the bed linen and underclothing to such extent that it is to be feared it will never find much favour with patients, not even those of the poorer class ; nevertheless, when it can be borne there is no doubt that it gets the patients on surprisingly, and sometimes I find them ask to have it and preferring it to the kreosote ointment. The pitch should be washed off" every day and renewed; to say the truth it requires a little artifice to remove it. The pungency of kreosote renders it disagreeable to many. It may be used in a few drops mixed with mercurial ointments or with some old cases in greater strength, equal parts or nearly so with white wax, as well as in all intermediate pro- portions. It is a very efficient remedy, and more acceptable than the tar, but its odour can scarce be overcome. With the tar, on the other hand, by mixing scents and gums you may better conceal the odour. Hebra advises tar baths of some hours' duration, but these are little in the habits of our people. The introduction of the huile de cade and oleum rusci have very much softened the disagreeableness that attaches to this class of remedy. They may be used with soft soap and alcohol equal parts, or with cod -liver oil in equal proportions, or with aether and alcohol when applied to the regions covered with the hair to make it dry rapidly. These oils may also be used in thin layers painted on by a brush. The spiritus saponis alkalinus of Hebra, which con- LOCAL TREATMENT 167 sists of soft soap dissolved in spirits of wine, is very handy for- a wash, especially to the head, in removing the scale, also washing with an egg, using the douche afterwards, is very cleansing to the scalp when affected with psoriasis. Concerning the use of these remedies I would not enter into too much detail, as directions for each as well as prescriptions are found in many other works. Particular cases require particular treatment, and there are some that warrant far stronger measures than the rest. If we miss the graver effects that result from toxic doses of tar and carbolic acid, which we must allow to be of inconsiderable frequency, so that they might be almost left out of account, there will still occur to the practitioner some occasional disagreeableness from prescribing them : such as an erythematous redness with considerable itching ; a good deal of oedema sometimes accompanied by pemphigus or followed by impetiginous or running sores. I have raised more discontents by the use of tar than ever by me experienced from the employment I have made of arsenic ; but this does not hinder my seeing in it a valuable remedy, which we should be extremely sorry to miss; no doubt the effect of tar is not a mere irritant, but it acts constitutionally, that is to say, that its effects when applied externally are not different from those that result from its internal use. (See Appendix.) Special forms. Treatment. Since I do not intend to make an exhaustive treatise on this subject, I shall pass over many minutiae and bring my work to a close, first saying a few words as to the management of the disease as it occurs in particular situations. As to psoriasis palmaris, there is little to be added to the suggestions that have been already made in this work. The practitioner should not be in a hurry to apply tar or iodine in any form, for these at the first onset often serve to aggravate the condition, however eventually they may prove of service ; nor should he be in haste to give mercury internally, for this is rarely warranted, and very often steel remedies, even in syphilitic cases, are far more advantageous. In psoriasis of the face there is often much anxiety to save appearances, and it is a great trouble to the 168 ON THE PSORIASIS OR LEPRA doctor as well as to the patient. Here the thin colourless distillations of tar are in application scarce less effectual than tar itself, but also generally of pungent odour : the carbolic glycerine more than anything is what we use ; the oleate of mercury sometimes, but we have not observed in it a superiority to older remedies. The truth is that in the face psoriasis is wont to be extremely obstinate. In such cases purging has been strongly recommended, and the bismuth ointment with white precipitate. Some of these cases under my hands have resisted all means of cure, and benefited unmistakably by change of air. The psoriasis of the eyelids I class with that of the face. To that of the lips, p. labialis, I apply drying ointment, generally calamine with wax and a little honey ; sometimes I treat it with an alkaline wash : very often there is need of tar. The psoriasis pudendi in women is very troublesome ; I am accustomed to use glycerine and borax with belladonna extract or sulphate of atropia to make a wash. In some cases it will be necessary to have recourse to the nitrate of silver in pretty strong solution. If time can be allowed, the arsenic taken internally has a great control over the symptoms. Cases of psoriasis scroll are in no degree less tormenting ; in this as in the former case it will be necessary to be very particular about food, as the least deviation in the use of salt meats, beer, &c., is apt to cause great aggravation of the symptoms. Early hours of rest must be enforced, and sleep procured, if necessary, by narcotics. Sulphur fume baths, or those of sulphur and iodine, or sulphur with cinnabar, may in extreme cases be employed. In psoriasis mfantilis tar water mixed with some emollient as thin gruel or barley water may be tried, or lotions of lime water with sulphur, or calamine with addition of glycerine ; the Fowler's solution in minute doses, sulphuret of anti- mony with magnesia or steel wine ; great attention to food and nursing; sometimes change of air. Farinaceous food must give way to milk, animal broths, cod-liver oil. In dealing with psoriasis lingua we have indeed a difficult task ; in addition to the nitrate of silver, sulphate of copper, LOCAL TREATMENT 169 borax, I would add chlorate of potash in solution or in lozenge ; the perchloride of mercury in feeble solution, with or without the addition of a small amount of nitric acid, alkaline washes, and the hand spray. It must be confessed that we are little advanced as yet in the treatment of psoriasis unguium ; in these cases I have been inclined to give carbolic acid internally, instead of the arsenic, and believe I have found some advantage in this, but as yet my experience of it is too short. Carbolic acid in solution seems to do good as a wash, but sometimes produces suppuration. I commonly use this or the muriatic acid lotion sometimes in the form of bath, with mercurial or tar ointment, expecting much from the improvement of general health, and sometimes recommending the cod-liver oil to be taken freely. APPENDIX Page 8. In the middle ages psoriasis was called impetigo excoria- tiva, as found in Avicenna, and the explanation is given in lexicons quod cutis in cortices quasi squammas que resolvitur. Something more of detail as to the nomenclature of this disease in early times will be found in a paper of mine which appeared in the ' Medical Times and Gazette,' under date Feb. 21st, 1874. Page 40. With respect to these serpentine forms, one cannot but recollect that one of the first names which syphilis received after its translation to Europe was that of the serpentine disease. They are, therefore, fairly an object of suspicion, but clinical observation bears us out in saying that they are not absolutely confined to this disorder. Page 49. In the ' Medical Press and Circular/ June llth, 1873, p. 504, there is a paper from my hand on the " Sequelae of Yariola and Vaccinia since the last Epidemic of Smallpox in the Metropolis." In this I have made mention of some half dozen cases of psoriasis which occurred after revaccination, and generally supervening imme- diately on healing of the puncture or vesicle. Without offering an explanation of these cases I am in no kind of doubt about the facts Page 53. In a paper which I communicated to the Royal Medical and Chirurgical Society of London, which was read at the meeting March 10, 1874, I have treated of the transmission of the disease in families, which, as directly transmitted, I found to be far less frequent than as stated by Hebra and by Wilson; and I have opposed myself to the statement too freely expressed by the former of these writers that psoriasis is not connected with any so-called dyscrasia. Hebra has stated that if psoriasis is found in the same families with asthma, it happens also with other forms of skin disease, and this, indeed, is perfectly true ; but he says nothing of 172 APPENDIX number and proportion. In a more minute inquiry he would have found a great preponderance on the side of dry squamous forms. In 2000 consecutive cases of non-parasifcic skin disease I inquired for asthma in the patient's family, and I found there were 141 instances where such complication was discernible. Sixty-five of these were cases of psoriasis; of eczema, 28; of acne simplex, 10; of acne rosacea, 8 cases ; of acne punctata, 2 ; of sycosis, 4 ; of lichen, 3 cases ; of lichen planus, 2 ; of strophulus, 3 ; of pityriasis, 2 ; of impetigo, 1 case ; of pemphigus, 1 ; of urticaria, 1 ; of boils and ecthyma, 1 ; of varix with eczema, 1 case ; of alopecia, 5 cases ; of leucoderma, 1 case ; of ichthyosis, 2 cases ; of lupus, 1 case. This will suffice to show that psoriasis is more frequent in its connection with asthma than eczema or any other form, though I believe if we had more cases to bring into comparison that ichthyosis would be found not less connected with asthma than is psoriasis. In respect to the gouty and the phthisical dyscrasia3, it seems to me a very strange prejudice that should deny their connection with psoriasis, and as to what Hebra says about black people being born of black and white of white, this does not touch the question, for to the eye of the physician many are the divergences of pigment, especially in these dyscrasia3. In the children of the phthisical we are accustomed to see large patches of ephelis on the forehead ; in the gouty and syphilitic we see the like divergences as well as in psoriasis, not to mention Addison's disease, where the skin is like a mulatto's ; so that we cannot understand how it is that he persists in denying any transmission of disease, but what takes place in unvarying and, as I may say, undeviating forms, and surely some idola theatri lies at the foundation of this. Nor is it easy to understand how Erasmus Wilson, who, in an analysis he has made of 500 cases of psoriasis, has distinctly pointed out the con- nection of psoriasis with phthisis, should have overlooked the relations which it has with asthma. Page 56. To this rule there are exceptions, among which I may instance the careful work of Dr J. Pollock on consumption, where l&me cases are mentioned of psoriasis in the phthisical. Page 59. See a paper of mine in the ' Medical Times and Gazette,' under date May 16th, 1874. which treats of skin disease in connection with cancer and as seen in the children of the cancerous. Page 107. Thus, only a century since, in the French ' Encyclo- pedia/ we see quoted with approval the words of Levinus Lemnius, A.D. 1574, pp. 174-5, where he declares that not only are lues venerea, elephantiasis and lepra, and what the vulgar call scrofula, nearly allied diseases, but that they are mutually convertible, and are always passing one into the other ; black jaundice, too, is said to be of the APPENDIX 173 same family. We should seem to be entirely corrected of this way of thinking, but it is not so. Some modern arguments rest on the conclusion that syphilis has no existence independent of scrofula, and that it is idle to consider otherwise. Page 108. At the very onset of my medical studies, living among a mass of sick people, my attention was directed by my instructors to the perusal of practical treatises from the hand of celebrated physicians, contained among what are now esteemed to be no better than old magazines. Such are the * Transactions of the College of Phy- sicians,' ' Bradley's Medical Facts and Observations,' &c., and among these I well remember the relation of a case where the tongue had been extirpated, if I remember right, in Algiers ; where subsequently articulation was in some degree regained by the gradual rising and carrying forward of the larynx and its appendages. This case does not lie very far off, but it has not been quoted, I believe, in what recently has been written on the tongue, either in a popular or scientific shape. It must be confessed that t}ie old medical literature tells us very little about diseases of this organ, and we are much indebted for recent contributions on the subject, which seem likely to lead to greater discrimination and a better colloca- tion of these complaints. Meanwhile we may say that a sympathy between the skin and the tongue, both physiological and patholo- gical, is plainly shown in recorded cases; indeed, we have some- where read of hair growing on the tongue, and several writers have mentioned rheumatic pains in this organ as well as glossitis in con- nection or alternation with rheumatism in the fibrous tissues. There is a case in Morgagni of repelled eruption affecting these tissues and also the tongue, though we are rather inclined to regard as coincidences than consequences many of those results which this author is at pains to quote. There is nothing much besides in Mor- gagni that is interesting in connection with this subject, except hy- pertrophy or atrophy in the lenticular papillary bodies. Of higher interest is a case quoted in ' Cooper's Surgical Dictionary,' from the ' Encyclopedic Methodique,' of a middle-aged woman with cutaneous eruption and numerous small swellings in the tongue. The interest of this case is surpassed by one in the ' Edinburgh Medical Journal/ A.D. 1811, where there is related a case much resembling carcinoma of the tongue proposed for extirpation. This subject was a middle- aged female addicted to the use of the pipe ; the woman had besides some eruption on the face. She was perfectly cured by arsenic. I need scarce draw attention to the papers of Sir Everard Home, or those of Travers and Earle, in the earlier volumes of the ' Medico- Chirurgical Transactions.' The extraordinary case mentioned in 174 APPENDIX the 8th volume of these ' Transactions,' communicated by Mr C. Lane, A.D. 1817, can scarce escape mention. The cure was here equally achieved through the use of an arsenical preparation. Bichter has described a remarkable case where the ulcer of the tongue was highly fetid, the edges swollen and hard, simulating cancer, which was effectually cured by purgatives and the topical application of astringent washes. Page 109. See reference to page 59 of the Appendix. Page 111. The word Agrom I have ascertained to be a Maharatta word. I have not found that our medical officers long resident in India are acquainted with it. In ' Parr's Medical Dictionary,' Edin- burgh, 1809, I find the following : " AGROM : a disease of the tongue not uncommon in India, in which it becomes extremely rough and chapped." They relieve it by drinking a chalybeate fluid, " or the juice of a large species of mint, or chewing the black- seeded basilica." It is not an uninteresting observation that the Rumex aquaticus, which has enjoyed a considerable reputation for the cure of psoriasis, is also extolled in herbal medicine for cure of ulcers of the mouth. Its reputation, indeed, dates from Dioscorides, who recommends it, not only for eruptions of the face, but also for diseased nails. Page 113. Jeffreys, ' Cases of Surgery,' A.D. 1820. Henry Jeffreys, surgeon to the Guards, afterwards to the St George's and James's Dispensary, and subsequently to the Lock Hospital and to St George's Hospital. It is of him that Brodie said he learned to take cases, yet Brodie could have been little, if at all, his junior. Jeffreys died in middle life, before reaping the reward of professional toil, a man of fair ability. The case referred to is in page 188 of his book, with a beautiful coloured drawing from the hand of Dr Cloves, his colleague at the Dispensary. By the same Dr Cloves are some very handsome paintings in the museum of St George's Hospital, especially two of an immense tumour removed by Sir Everard Hcme from the side of the head, which every visitor will recollect. Jeffreys advo- cated the use of the elm bark, as well as Dr Daniel Lysom, in the second volume of the ' Medical Transactions.' Page 135. In detracting from the use of the tub and cold bathing generally, what we have said applies to the undiscerning use of it. Its general utility is incontestable. A friend of mine, one of its strongest advocates, who resides in Italy, affirms that he has never known the dreaded miliaria to affect any of those whom he has persuaded to adopt it. But where there is an hereditary dis- position to skin disease, to chest complaint, to gout or rheumatism, the cold tub is far better avoided. Soap and hot water should take APPENDIX 175 its place. Some have been so unwise as to recommend the cold bath for most unsuitable conditions in a state of animal depression ; for cold spasm ; nay, even for cholera. Girdlestone's work gives some instances of this. In hysterical affections one must allow it to be wonderful, especially as shower-bath. The medicinal use of soap which, before its adoption in Germany, was certainly well appreciated in Paris, seems to have been adopted from the French by Yeiel, and yet more strongly advocated by Hebra. His countryman Auspitz has even thought it worth while to give a treatise on the subject, in which, however, there is little that was a secret to the British medical public. Page 143. Though fairly well convinced that Dr George Pearson was the introducer of the Pearson solution, or, as he called it, Aqua Natri Arseniati, I have to confess that I cannot, after paying some considerable attention to the subject, furnish proofs that might fully establish the truth of this assertion. The fact is that this renowned and most highly accomplished physician is already confused with Dr Richard Pearson, his cotemporary ; I might venture to say irre- trievably so. It is perfectly well recollected by me, when house pupil at St. George's Hospital, that the soda preparation remained in the hospital Pharmacopeia, though no longer in use in that esta- blishment ; and I find it mentioned elsewhere that this preparation was placed in the St George's Pharmacopoeia by Pearson, who was editor of the same so early as the year 1806 (see Harles, ' De Arsenici Usu,' Nuremburgh, 1811), but in foreign works he is always men- tioned as Richard Pearson, and also at home the same confusion has crept in. Even in an account given of the preparations of arsenic, by Mr Hume of Long Acre, ' Med. and Phys. Journal,' vol. xxiv, A.D. 1810, no mention is made of Pearson's solution ; and what we learn of Pearson In connection with arsenic in the writings of his cotem- poraries seems more the result of common notoriety than from any- thing that Pearson has written on the subject. But I hope that chance may some day furnish that which labour has failed as yet to unravel. Let us say, however, that Richard Pearson, first of Birmingham, and afterwards of London, was the author of the 'Thesaurus Medicaminum.' On the other hand, the Dr George Pearson of whom I have given some relation came from Doncaster, and had a long career in London. Even so late as 1820 he was the leading physician of St George's. He lectured at his own house in Leicester Square, afterwards in George Street, Hanover Square, to a crowd of pupils. In therapeutics, in morbid anatomy, and in che- mistry he was alike distinguished. Page 147. Besides the work on hepatitis already mentioned 176 APPENDIX Girdlestone published a case of diabetes with history of the disorder, Yarmouth, 1799. He interested himself in the spread of vaccina- tion, and contributed much to the medical periodicals of the day. In the year 1802 there were three contributions from his hand in the 'Medical and Physical Journal.' He seems to have taken a large share in a controversy raging at that time as to the nature and treatment of apoplexy, writing anonymously. Moreover, he trans- lated the ' Odes of Anacreon ' in English verse 1803-6, and this little work seems to have reached a third edition. He also published a short work on ' The Authorship of the Letters of Junius.' Girdle- stone died in the year 1822, and may thus be considered the cotemporary of Willan and Beddoes. His chief title, however, to distinction arises from his commendation of arsenic in skin diseases in the ' Medical and Physical Journal,' March, 1806. The gentleman he had cured of lepra long before had suffered from this malady, he says, for several years. At the above date Girdlestone declares he had used arsenic for skin disease in many hundred cases, com- prising lepra, lichen, prurigo, psoriasis, and tinea capitis. This certainly puts him far in advance of his cotemporaries, and being at this time in the height of his profession the recommendation of such a man had great weight. Besides what we have said of Rush and Edwards, p. 147, we may mention that in the year 1805 there is found in the ' Medical and Physical Journal ' a communication from J. C. Otto, of Philadelphia, mentioning three cases of skin disease cured by arsenic. It seems to me that a just measure of the extent to which the use of this substance was carried before the paper of Girdlestone may be taken from the earliest recommendation of Jenkinson, who first introduced its employment for rheumatism only a few years previous. The suggestion, he says, arose in him in this wise. The usual medication in skin disease is equally available for rheumatism ; cinchona bark, guaiac, elm bark, dulcamara, anti- mony, these are all used in skin disease, and arsenic is sometimes so employed. In the year following the communication of Girdlestone, there is another case in the same Journal, March, 1807, p. 253, where psoriasis palmaria is perfectly cured by arsenic, and the patient had even taken the sulphur- smelling bit noben, an Indian remedy of much celebrity. In the presence of such records those who, in the present day, are so bold as to assert that p. palmaria is always the result of syphilis, must allow arsenic to have a prodigious influence over this disorder. I have said that my family had some relations of friendship with that of Girdlestone. He married a widow lady of good means, who bore him an only son, whom I remember very well when I was but a APPENDIX 177 child. He died in early manhood, and the same happened to Girdle- stone's son-in-law, my father's intimate friend. Girdlestone has no descendants. Page 149. The favorable inclination that Biett displayed to all of English experience is perfectly well known, but I cannot say to what extent his friendship with my uncle may have influenced him in his adoption of arsenic as a means of cure in skin disease. It appears that Biett used the Fowler's solution in the hopital St Louis before 1817, the date of his visit to London, and he introduced the Pearson's solution soon afterwards. On the other hand, Gaskoin is quoted in Plumbe's work as having administered the Fowler's drops in very large doses at the hopital St Louis, and this must have been before the year 1817. Page 151. The solution of white arsenic in dilute hydrochloric acid, which I have mentioned as a chloride of arsenic, though it would appear that there is some doubt about its chemical composi- tion, was adopted into the London Pharmacopoeia of 1851. At the date I am treating of, so far as I was then informed, it no longer was procurable at the Hall, but Mr Brande, who was then connected with that institution, furnished the preparation required. At a subsequent date Dr. Farre has been mentioned in Pereira's work as using the chloride in choraea, but at the time I am writing of Mr Freeman, of Spring Gardens, alone in London seems to have had the secret of treating chorsea by this preparation, and this he learnt from Mr Hammond, of Whetstone, the country practitioner alluded to in the text. In a correspondence I have by me from this gentle- man he speaks of De Yalangin's solvent as the strongest tonic known. His directions are very minute and precise, especially as to purging in chorsea, which should only be allowed with the greatest amount of caution, and the diet should be liberal and moderately stimulating. Under such a system as he lays down he declares that he never met with failure, and this strong assertion of success agrees perfectly with what Begbie says of the use of arsenic in chorea. Page 159. Roberton (John). A practical treatise ' On the Use of Cantharides when Used Internally,' A.D. 1806. The author was an Edinburgh surgeon. This is the only work I have met with by this author, but I believe he published some others subsequently on much the same subject, and one as late as the year A.D. 1827. Roberton suggested the use of cantharides in veterinary practice to Bracy Clarke, but it was previously known by tradition in London stables, and especially advocated by Yines A.D. 1830. Roberton allows that he gained his first hints about this remedy from a work of rather extravagant character by a certain Dr Greenfield, of a century 12 178 APPENDIX. before, who incurred the disgrace of being sent to Newgate through the illiberality or intrigues of the faculty. I recollect Brodie curing a private case of obstinate gleet by use of a seton on the groin and cantharides taken internally, and I have seen the late Dr Seymour use the tincture very extensively in dropsy, prescribing it in half- drachm doses ; it is especially adapted to old cases of this disease. The cases to which cantharides are most applicable are those of extraordinary debility. To Biett and Devergie belong very much the credit attaching to its use in skin disease. In my early days I had two fellow- students, both of heavy leuco -phlegmatic frame, both subsequently well known in the profession. They were equally the subject of lepra, and they got perfectly well with the cantharides, using no external application. From the great similarity of their temperament these cases impressed me greatly. Some dermatologists believe cantharides to be even more useful in moist eruptions than in the dry. The considerable use that has been made of it in per- tussis proves that it may be given with impunity to children. Page 167. More than half a century since the treatment of skin disease by tar was practised with some little notoriety at Brighton by Mr William Attree, of the Sussex County Hospital, who applied it, so to speak, to all chronic ailments of the skin. This treatment consisted in covering the whole body with tar-ointment and keeping it so covered, and the patient confined to his bed for the space of three or four days and nights consecutively. At the same time was ad- ministered tar internally, continuing it in adequate doses till colic or some intestinal disturbance arose when, the drug was withheld for a while and the patient purged with castor oil. To remove the tar-ointment Mr Attree made use of warm oil. Of toxic and medicinal agents liable to produce a modification of pig- ment in the urine, tar and kreosote are perhaps the best known. This occurs after their internal and also after their external use. It is, however, but very seldom that attention is drawn to the fact. The urine in such cases is dark -coloured and even black. From observa- tion on some of these cases, Dr Odling, the experienced chemist, is inclined to identify this abnormal colouring matter with indigo blue, pointing out the close chemical aflinity which this substance has with kreosote. The fact is not of such importance as in any degree to deter from the use of these remedies. Gallic acid in a less degree has somewhat of the same effect. PHARMACOPOEIA MISTUR^E ET GUTTJE3 9> Liq. Arsenicalis, 513" ; Tinct. Aurantii, ^iij. Misce, Cochl. parvum unum tantum e cyatho aquae post cibum sumend. ter in die. 9> Liq. Arsenicalis, 5iss ; Tinct. Hyoscyami, ^iss ; Spir. Chloroform., 5\j ; Aquae Camphor., ^j. Misce. Cochl. j minimum ter in die e cyatho aquae sumendum. J> Liq. Sodse Arseniatis, 5y ; Ext. Opii liquidi, 5iss ; Syrupi Tolutani, 5iij ; Aq. Camphora3, ad ^iij. Misce. Sumat 5J ter in die ex aqua. $k Dec. Dulcamaras, ^xij ; Liq. Arsenicalis, 9ij. M. Sumat cochl. iij magna ter in die. $> Dec. Rumicis Acut., ^ vss > Liq. Arsenicalis, TT^XX ; Liq. Potassse, ^ias ; Tinct. Cinnam., ^iiss. M. Cochl. iij magna ter in die. J& Magnesiae Sulphatis, 5iij ; Tinct. Ferri Perchloridi, 5iij ; Liq. Arsenici Hydrochlorici, 9iiss ; Aq. Camphorae, ad ^xij. M. Cochl. ij magn. c. cochl. ij aquae ter in die sumenda 180 PHARMACOPOEIA p> Citratis Ferri et Quin., 5\j J Liq. Arsenicalis, ^isa ; Tinct. Aurantii, ^iiiss ; Syrupi, 5ij. Sumat 3j pro dosi ex aqua ter in die. Jjl Liq. Arsenicalis, ^ij ; Liq. Potassae, ^iss ; Ammon. Garb., 5\j ; Tinct. Calumbae, giv. Sumat cochl. ij parva e cyatho aquae ter in die. 9> Tinct. Cantharidis, ^iij ; Potass. lodidi, 3ij ; Tinct. Cinnamomi, 5ix. Sumat guttas xxx e cyatho aquae ter in die. 9> Liq. Arsenicalis, ij ; Tinct. Cantharidis, 5^ v > Potassae lodidi, 5J ; Liq. Potassae, ^j ; Tinct. Camphorae Co., 5x. M. Sumat cochl. parvum j e cyatho a'quae ter in die. Jjk Decoct. Taraxaci, Tinct. Calumbae, 5iv ; Liq. Potassae, 5iss ; Liq. Arsenicalis, TT\xxx. M. Cochl. iij magna ter in die sumenda. p> Decoct. Ulmi, gviss ; Liq. Potass., ^iss ; Pulv. Rhei, 9ij ; Tinct. Ehei co., Tinct. Cardani. co., ana 5v. Cochl. iij magn. ter in die. $> Yin. Ferri, ^iiss ; Liq. Arsenicalis, 5\j ; Syrupi Tolutani, 5ij- Cochl. j parrum tantum e cyatho aquae ter in die. For children it may be lowered to a fourth or fifth of the strength of the Liquor Arsenicalis. The above doses are for adults, five minims being a full dose. PHARMACOPEIA 181 $> Liq. Sodae Arseniatis, 5v ; Tinct. Cantharidis, 5* ; Tinct. Serpentariae. 5xv. M. Sumat guttas xxx e cyatho aquae ter in die. 9> Liq. Arsenicalis, 5iss ; Potassae lodidi, gr. xl ; Tinct. Aurantii, ^iij ; Syrupi Aurantii, j ; Aquae, ^ij. M. Cochl. ij parv. ter in die sumend. ex aqua. 9> Ferri Citratis, 5j ; Liq. Arsenicalis, 9iv; Syrupi Aurantii, j ; Aq. Cinnamomi ad ^viij. M. Sumat cochleare j magnum ter in die. > Solut. lodidi Hydrarg. et Arsenici (Donovan), ^ss ; Syr. Zingiberis, 3j ; Aquae, ^viss. M. Sumat cochleare magn. j, ter in die. $> Liq. Arsenicalis, l)|lxxx; Liq. Potassae, 5ij ; Syr. Zingiberis, 5iv ; Infus. Carophylorum, ^viiss. M. Sumat cochl. magn. j, ter in die. fy> Yin. Ferri, ^iss ; Liq. Arsenicalis, 9j ; Syrupi Tolutani, 5iij ; Aq. Anethi, ad ^iij. M. Cochl. parv. j ter in die pro infante. |fc> Tinct. Cantharidis, 5j ; Liq. Feni Perchloridi, 5ij ; Aq. Pimentae ad %vj. M. Cochl. magnum j ter in die sumend. 9> Tinct. Cantharidis, ^ij ; Sulphat. Quinae, gr. xxiv ; Acid. Sulphuric. Dil., $j ; Syrupi Aurantii, ^ss. M. Sumat guttas xv e cyatho aquae ter in die. 182 PHARMACOPOEIA > Acid. Nitric. Dil., 5j ; Acid. Hydrochlor. Dil., %j ; Sp. .2Etheris Nitrici, ss ; Extr. Sarsse, ^j ; Aquae, ^viss. M. Coclil. magnum j ter in die. $> Potass. lodidi, gr. viij ; Liq. Potass., 5vj ; Aquae, 5 X M. Cochl. ij minima ex Decoct. Ulmi ter in die sumenda > Tinct. Cinchonse co., ^ij ; Liq. Hydrarg. Perchlor., 5*ij ; Tinct. Cantharidis, ^ij ; Tinct. Lavandulae Co., 5\j ; Aq. Cinnamomi, ij- Sumat ^ss ex aqua ter in die. fy Decoct. Ulmi Co., ^xiv; Liq. Potassse, 5\j ; Tinct Rhei Co., 5iij ; Tinct. Calumb., 5iij. M Coclil. iij ter in die sumenda. fy Creosoti, Pulv. Tragacanth, Mist. Campliorse. ^v M Cochl. ij magna ter in die. , 01. Terebinth., tt|xi ; Mucilaginis Acac., Sacchari Alb., ana 5 Aq. Cinnamomi, 5 X - M Ft. haustus, ter in die sumenda. > Ol. Terebinth., 5j ; Aq. Naphthaa, ^vi Mucilaginis, 5vj ; Mannse, 5iv. M. Sumat cochlearia tria magna ter in die. PHARMACOPEIA 183 PULYERES ft Antimonii Nigri, gr. v ; Potass. Bicarbonat., gr. xv; Pulv. Cretae Aromat., gr. ij. Ft. pulv., ter in die sumend. ft Sulphuris praecip., gr. x ; Potass. Bicarb., gr. viij ; Potass. Nitratis, gr. iij. Ft. pulv., ter in die. ft Magn. Carbonat., Sodae Garb., Sulphur, praecip., ana gr. x. Ft. pulv., ter in die. ft Sodae Tartariz., ^ij ; Potass. Bicarb., 5\j ; Sulphur, praecip., 3ij. Cochl. parv. j vel ij ex aqua ter in die. ft Sodae Tart., 5J ; .Potass. Bicarb., gr. viij ; Potass. Nitratis, gr. iij. Ft. pulv., bis vel ter in die ante cibum. ft Hydr. Sulphuret. Rub., Magnesiae Ustae, ana 5ss. Etheriaca ter in die. ft Hydrarg. c. Greta, 5j ; Pulv. Antim. Tart. gr. j. M. Divide in pulv. xxx, sumat j bis die. PILULE ft Hyd. Sulphuret. Nigr., Antim. Nigri levigati, ana 5j ; Pulv. Rhei, 5ss ; Pulv. Ipecac., gr. viij ; Sodae Carbonat. exsiccatae, 5j ; Conf. Ros. Can., q. s. ut ft. pil. xxx, Sumat ij ter in die. 184 PHARMACOPCEIA 9> Acid. Arsenici, gr. ij ; Opii in pulv., gr. viij Saponis duri, gr. xxxij. M. Tere optime et divide in pil. xxxij, sumat j bis in die. 9> Sodae Arseniatis, gr. iij ; Guaiaci pulv., 5 SS ; Antimonii Sulphurati, gr. xx ; Mucilaginis, q. s. Solve Sod. Arsen. c. pauxillo aquae destillat., superaddend. alia, et divide in pil. xxiv. Sumat j semel in die. 5k Arseniatis Ammoniae, gr. v; Extr. Gentianse, q. s. ut fiant pil. m. Sumat j bis in die. Jfa Arsenici Albi, gr. ij ; Pulv. Glycyrrhizae, gr. xv; Antim. Oxysulphureti, gr. xlv ; Sapon. Duri, gr. x. Ft. pil. xxiv, sumat j bis in die. Jjk Ferri Arseniatis, gr. iij ; Exfcr. Humuli, 5ij ; Pulv. Acaciae, q. s. ; Syr., q. s. Ft. pil. xlviij, sumat j vel ij bis in die. Jpk Picis exsiccat., gr. x ; Antim. Sulphurat., gr. iv. Ft. pil. iij, bis vel ter in die sumenda. 5k Creosoti opt., gutt. xx ; Pulv. Glycyrrhizae, gr. xx Miese Panis, q. s. In pil. xx, sumat j ter in die. 9> Acid. Carbolic., gr. xv ; Pulv. Glycyrrhizss, q. s. Syrupi simplicis, q. s. Ft. pil. xx, sumat j vel ij ter in die. $k Bals. Canadensis, Magnes. Ustae, ana 5j. Ft. pil. xxiv, sumat ij ter in die. PHARMACOPOSIA 185 LOTIONES ET LINIMENTS fy> Acid. Hydrochlorici, 5iv ; Aquae, Jviij. Ft. lotio. ]}o Acidi Carbolici, ^ss ; Aquas, Oj. Ft. lotio. 9> Acid. Hydrochlorici, 5y ; Sodii Chloridi, 5j ; Aquae purae, 5^. IT;, lotio. 9> Glycer. Acid. Garb., ^iiss ; Aquae, ^ivss. Ft. lotio. Jjk Acid. Acetici, j ; Aq. Sambuci, ^xj. Ft. lotio. , Boracis, 5vj ; Acet. destillat., ^iv ; Aqusa, ^iv. Ft. lotio. 9> Boracis, 5J > Sp. Yini Rect., ^ss ; Hydrarg. Perchlor., gr. ij ; Aq. Camph., $viiss. M. Ft. lotio. $t Acid. Carbolic., 5\j ; Alcohol, Glycerin., ana %j ; Aq. destillat., ^vj. Ft. lotio. fy Acid. Hydrochlor., 5\j ; Sp. Yin. reet., ^ij ; Aquae, ^viij. Ft. lotio. fy Liq. Carbonis detergens, ss ; Aquae, xiss. Ft. lotio. 5^ Boracis, ^rj ; Acet. destillat., ^iv; Aq. purae, xij. Ft. lotio. 9> Acid. Acet. fort., ^v Aq. Flor. Aurant., ^vj. Ft. lotio, 186 PHARMACOPEIA P> Picis liquidae, 5ij ; Potass. Causticae, 5J ; Aquae, $v. M. Ft. lotio. This caustic wash mixes with water in all proportions, and leaves very little stickiness. It may be used equally with Guyst's solution of tar and the phenol of Boboeuf. 9> 01. Cadini, j ; Saponis Mollis, ^ij ; Acid. Hydrocyanici dil., 9iv ; Ol. Rosmarini, 5iss ; Aquae, ad ^v. Ft. lotio. ^ Ol. Rusci, j ; JEther. Sulph., Sp. Yin. rectif., ana 5J ; Ol. Lavandulae, Ol. Rosmarini, ana gtt. xxx. Ft. linimentum. $k Potass. Cyanidi, gr. x ; Lactis Amygdalae, ^vj. Ft. lotio. Yenenum inscript. B> Potass. Sulphuratae, ^iss ; Spir. Yini, ^ij ; Aquae, ^vj. Ft. lotio. 9> Potassae Sulphurat, 5J ; Sodae Carbonat., 5iss ; Sodii Chloridi, 5y ; Aquae, 5xij. M. Ft. lotio. $1 Potass. Sulphuret., 5j ; Potass. lodidi, 5J ; Aquae, ^xij. M. Ft. lotio (in stoppered bottles). $1 Potass. Sulphurat., 5j ; Camphorae, 9j ;. Al. Amygdalae dulc., ^j. M. Ft. linimentum. 9> Potassae Sulphuratse, 5j ; Calaminae, 5ij ; Aq. destillat., vj. Ft. lotio. For psoriasis, especially of the prepuce. PHARMACOPOEIA 187 $> Liq. Plumbi Subacet., 5j ; Extr. Belladonnas, 5ij ; Aquas, ^xij. Ft. lotio. $k Extr. Belladonnas, 5iss ; Boracis, 5iij ; Acidi Hydrocyanic! dil., 5J ; Glycerin!, ^ss ; Aquas, ad xij. Ft. lotio. Jfc> Creosoti opt., 5iss; Aquae, ^x. Ft. lotio. > Tinct. Myrrhae, ^ss ; Acet. destill., ^j ; Aqii83, ^viss. M. Ft. lotio. $> Acidi Hydrocyanic! dil., 5!]" ; Plumbi Acetat., 3j ; Acid. Acet. dil., 5iij ; Spir. Yini, $iv ; Aquae, ^vij. Ft. lotio. $k Hydrarg. Perchloridi, gr. vj ; Hydrarg. Sulphat., gr. iij ; Creosoti T7\ij ; Aquae, ^viij. M. Ft. lotio. 9> Liq. Sodaa Chloratae, gss; Sp. Yini rectif., ^j ; Aquae, ^xj. Ft. lotio. fy Sulphur. lodidi, 5ss ; Potass. lodidi, 5 g s ; Aquae, Oj. Ft. lotio. 9> Sulphur. lodidi, 5ss ; Ol. Olivae, ^iij, solve. Ft. linimentum. A solution of iodide of sulphur in almond oil may be ex- temporaneously prepared by mixing together solutions in the same oil, of each of its component substances. The solution of sulphur is effected by heating this in a glass vessel till it no longer appears in the oil, the proportion 188 PHARMACOPEIA is ten grains to the ounce. That of iodine is thirty-two grains to the ounce of almond oil, dissolved in it by tritu- ration. The mixture of the solutions is in equal propor- tions, say an ounce of each ; it leaves no free iodine, or does not irritate the skin. Iodide of sulphur may be also dis- solved in glycerine, one part in a hundred, for external use. UNGUENTA Acid. Carbolici, 3j ; Adipis, ^j ; adde propter elegantium Ol. E-osmarini, gtt. ij. Ft. ung. . Zinci, j ; Acid. Carbolici, gr. v ad x. Ft. ung. |& Acid. Carbolici, Terebinth. Canadense, ana 5J ; Cerse Albse, $v ; Adipis, 5*. Ft. ung. > Ung. Hydr. Mtratis, gss ; Acid. Carbolici, gr. viij ; Ung. Simplicis, %j. Ft. ung. P> Picis, Spiritus Methylat., Saponis Mollis p. seq. Misce. ]> Sap. Mollis, Spir. rectif., Ol. Cadini, ana ^j ; Ol Lavandulse, ^ij. Misce. To be rubbed firmly on the eruption night and morning. The remainder of all these ointments to be removed by wash- ing previous to renewed application on the part. Where this is required to be done with much nicety several ex- pedients have been proposed, among which we may notice a mixture of powdered extract of liquorice, made into a paste with oil of aniseed, the thickness of cream. This is PHARMACOPEIA 189 well rubbed into the parts stained by tar, and subsequently removed by aid of soap and flannel. , Adipis, ^ij ; Picis, 5iss ; Ol. Macis, 5J ; Gum. Ben/., 5J ; Ol. Lavandulse, 5J ; Ess. Moschi, 9j. Ft. ung. P> Ol. Cadini (Huile de Cade), 5vj ad BJ ; Sevi Bovini purif., ^vij ; Bals. Peruvian., 5\j ; Ol. Nucis Moschat., 5iss ; Ol. Lavand. et Ess. Moschi, q. s. propter elegantiam. Ft. ung. The oil of citronella or lemon grass is also excellent for removing the odour of pitch. 9> Hydr. Subchlor., ^j ; Ung. Picis liquidae, $iv ; Adipis prsepar., %ij. Ft. ung, ]$> Sulphuris, j ; Ung. Picis liq., 5yj > Adipis Benzoat., iv. Ft. ung. ^ Picis, 5ij ; Camphorse, 3ss ; Adipis, 5J. Ft. ung. 9, Picis, 5vj ; Glycerini, 5vj ; P. Amyli, 5ij. Calefac glycerinum et adde amylum subjiciendo flammam, dein calefac ad 212 cum velocitate et cola s. a., adde propter elegantiam Ol. Origani 5J vel quantum sufficiat. fy Ung. Hydr. Oxyd. Eub., j ; Ung. Picis Hq., ^j. Ft. ung. 190 PHARMACOPOEIA 9> Plumbi Acetat., 5ij ; Aq. Lauri Oerasi, 5ij ; Picis, 5iss ; Camphorse, 5J ; Adipis, 3j. Ft. ung. $c Ung. Sulphuris, Ung. Hydrarg. Nitr., Ung. Picis liq., ana 5\rj. Ft. ung. $> Hydrarg. Subchlor., 5j ; Adipis Praep., giss ; Ung. Hydr. Nitrat., Ung. Picis liq., ana, 5ij. M. Ft. unguentum. |k Ol. Cadini, 5j ; Adipis, ^j. Ft. ung. $1 Ung. Zinci, ^j ; Ol. Cadini, TIlxv. Ft. ung. 9> Picis Mineralis, 5\j Glycerini, 5iij ; Adipis, ^iss. M. Ft. unguentum. ^ Napthalinse ; Petrolei, ana 5\j ; Sapon. mollis ; Adipis, ana 5iv ; Pulv. Pumicae, q. s. . Ft. unguentum. 9> Napthalinaa, 5ss; Adipis, ^j. Ft. ung. & Sulphur. Lot., ^iv ; Hydrarg. Subchlor., 5J ; Adipis, 3J. Ft. ung. fy Potassae Sulphuratae, 5J ; Sodsa Carbonat., 5J ; Adipis, ^j. Ft. ung. PHARMACOPEIA 191 $> Creosoti, n\x ; Extr. Opii liq., 9ij ; Adipis, j. Ft. ung. B> Hydr. Oxyd. Rubr., gr. vj ; Hydr. Ammoniat., gr. vj ; Creosoti opt., Vl\\j ; Adipis, %j. Ft. ung. $> Hydrarg. Subchlor., 5ij ; Aluminis Ust., $i.v ; Plumbi Carbonat., $iv ; Terebinth. Yenet., 5vj ; Ung. Cetacei, ^j. Ft. ung. P> Calaminse opt., 5\j ; Chloroform., 5ij ; Ung. simplicis, ^iiss. Ft. ung. Jfc> Potass. Cyanid., gr. xij ; Ol. Amygdalae, 3ij ; Ung. Galeni, ^ij. Ft. ung. P> Potass. Cyanidi, gi\ xij ; Ung. Zinci, ^x ; Ung. Hydrarg. Nitr., 5vj. Ft. ung. 51 Hydrarg. Sulphocyanidi, gr. v ; Adipis, 3J. Ft. ung. 9? Hydr. Subchlor., gr. xx ; lodinaa, gr. viij ; Leni igne f usis, adjice Adipis, ^ij ; Succi Conii, 5J- Ft. ung. ^ Sulph. lodidi, 9j ad 9ij ; Adipis, ^j. Ft. ung. 9> Sulphuris Praecip., Sulphuris lodidi, ana 3ss ; Ung. simplicis, 5J ; Ol. Amygd. Amar., q. s. Ft. ung. 192 PHARMACOPOEIA $> Sulphuris lodidi, gr. xv ; Hydr. Biniod. Rub., gr. x; Adipis, 3j. Ft. ung. fy Hydr. Biniodid. Rub., gr. xv ad xxiv ; Adipis prsep., ^ij ; Ol. Limonis, gutt. xx. Ft. ung. 9> Hydrarg. Subchlor., Plumbi Acetat., ana 9ij ; Ung. Hydr. Nitratis, Ung. simplicis, ana ss. Ffc. ung. P> Ung. Hyd. Ammoniat., 5ij ; Ol. Olivse, 5yj ; Ung. simplicis, 5ij ; Tinct. Benzoini co., gutt. xxx. Ft. ung. $k Hydrarg. Sulphatis, 9j ; Extr. Opii liquid., gutt. xij ; Adipis, %j. Ft. ung. For psoriasis genitalium. 9= Hydr. Subchlor., ^ij ; Adipis, ^j. Ft. ung. $t Emplast. Hydrarg. ; Ung. Terebinthinee, p. seq. M. Ft. unguent, for psoriasis palmaris. > Hydr. Subchlor., 5iij ; Camphorse, 5J ; Solve in 01. Olivse et adde Cerat. Plumbi Acet., ^iss ; Cei-se Alb., 5ij. Ft. ung. ^ Plumbi Subcarb., 5\j ; Cretse prseparat., ^ij ; Ung. simpljcis, ^ij ; Ol. Amyg. Dulc., q. s. Ft. ung. fy Calcis Chlorinate, 5"j ; Hydrarg. Subsulphatis, *>ij ; Ol. Amygdalae Dulc., 5vj ; Adipis, ^ij. Ft. ung. PHARMACOPOEIA 193 $> Ung. Sulphuris, 5vj ; Ung. lodinii Co. P. L., 5ij. Ft. ung. 9> Sulphuris Hypochlor., 5iij ; Bismuth! Trisnitrat., ^ij ; Ung. simplicis, %iij. Ft. ung. For eczematous psoriasis. $k Sulphuris Hypochlor., 3ij ; Potassse Bicarb., gr. x ; Adipis, ^j. M. Ft. unguentum. $k Sulphuris Hypochlor., 5iij ; Adipis Prsep., ^iv. Ft. ung. Ung. Cetacei, $ ; Ol. Theobromse, ^ss. Ft. ung. BALNEA BALNEUM ACID. MURIATICI ; Acidi Hydrochlorici, ^ij ad Aquee tepid., ad cong. xxx. BALNEUM ALKALINUM Potass. Subcarbonat., ^iv ad Aq. tepid., cong. xxx. BALN. SULPHURED GELATINOSUM 9= Potass. Sulphurat., ^ij ad ^iv ; Aq. tepid., cong. xxx'; Adde Ichthyocollse, ftj vel Ibij. In aquae bullientis ftx solut. This bath may be made stronger in certain cases. BALN. EMOLLIENS To an ordinary tepid bath add a large basinful of thick gruel 01 paste, and well mixed with the water. 13 194 PHARMACOPOEIA BALN. GELATINOSUM Gelatin, prseparat., ftj. Solve in aq. fervent, octarios ij, et add aq., calidss cong. j, coque per 4tam part, horse et adjice balneo. The expense of isinglass, and even of gelatine, makes the recom- mendation of the bath for the most part ineffectual. A pound or a pound and a half of parchment-clippings may replace the gelatine by long boiling, or a neat's foot or calf's foot will- serve the same purpose. Some six pounds of patent size dissolved in the warm water may answer pretty well, and good glue may also be employed ; but for children I prefer gruel mixed in the bath, starch of rice, or potato boiled into a thin paste and added. Formula for Bareges and Harrogate water are to be had at every chemist's. It is therefore unnecessary to give them at length. They are of some utility in psoriasis, though, probably, very poor imitations of the natural waters, which generally contain free carbonic acid, a fact which seems incompatible with the existence of the ordinary sulphuret. I have found, however, much benefit from the assistance of these artificial waters employed as lotions. Something more might be said on the subject of baths, both those of chemicals and medicated with herbs, but I might be accused of over-refinement. The hot-water vapour constitutes the bath par excellence for psoriasis. In using the sulphur-fume baths a considerable desquamation of the skin may be expected in many cases. For the iodine and sulphur fume, when locally applied, a tin box or jar may be conveniently employed. INDEX Abdominal complication, 33, 51, 130, 143 Absence of surrounding inflammation, 10, 29, 30 Abscess and dead bone as cause, 51 Abstinence from meat, 137 Acetic acid, 165, 184 Acids, 52, 165, 184 Acne in asthmatic families, 54 rosacea, 40, 63, 66, 69, 75, 78, 101, 110 simplex, its substitution, 22, 63, 75 Aqua natri arsenlati, 175 Age, 21, 46 Agrom, 56, 111, 174 Agues, use of arsenic in, 141, 147, 149 Albuminuria, 52, 152 Alibert, 13, 16, 148 Alkalies, 158, 165 Alimentary canal, 51, 130 Allied diseases, 59, 172 Alopecia, 15, 61, 75, 172 Alphos, 1, 2, 16 and morphcea in transitional forms, 74 - in tbe sole of the foot, 100 Alternation of skin complaint with other disease, 52 Amenorrhcea in psoriasis, 33, 127 sometimes constant and complete, 33, 68 Arnmoniacal solution of arsenic, 148, 150 Anesthesia, 35, 67, 72 Anatomy, microscopical, 30 Angina pectoris, use of arsenic in, 143 Angular curvature of spine, 51, 128 Animal food, 137 Antecedents of psoriasis, 52, 58 specific, 111 Antilymphatic or antiscorbutic (arsenic), 141 Antimony, 155, 168 formula?, 156, 182, 183 Antiphlogistic^, 132 Antipruriginous remedies, 165 Aqua natri arseniati, or Pearson's solu- tion, 175 Arabians, their knowledge of arsenic, 140 Aromatic vinegar, 165 Arseniate of ammonia, 183 of iron, 183 Arsenic, 139, 150, 153, 162, 173, 175, 176, 177, 179 accumulative in its action, 151 antiperiodic and antiscorbutic, 141 choice of its preparations, 153 - chloride of, 150, 177 forms of, 150, 153, 179 given to children, 153, 180, 181 history of, 139, 144, 150 ill-appreciated in Vienna, 139 in ague, 141 196 INDEX Arsenic in chorea, 40, 177 in pertussis, 143 - in pill, 154 in rheumatism, 176 its preparations, 150, 153, 179 prescriptions containing, 179 used as prophylactic in phthisis, 147 as vermifuge, 147 by Girdlestone, in various forms of skin disease, 176 recommended in syphilis, 145, 147 - therapeutically employed, 145, 148, 153, 173, 176, 179 valuable in all diseases akin to pso- riasis, 137 white, its dose, 141 known to the Arabians, 140 Arseniousacid, or white arsenic, 140, 141 Arthritides (Bazin), 58 Asiatic pills, 154 Asthma, 53, 64, 171 a frequent complaint, 55 and gout connected with phthisis, 57 and orthopncea cured by arsenic, 141 and rheumatic gout with psoriasis, 41 as connected with dry squamous affections, 53 with eczema, 53 with skin disease, 53, 171 a slight tendency to, sometimes betrayed, 56 bronchitic, 54 cardiac, 54 eczematous, 53 in both parents, its result, 54 inherited, the signs of, 55 its affinities, 55 spasmodic, 54 with ichthyosis, 77, 172 with alopecia, 172 Attendant symptoms, 31 Atrophy of bone or usure in psoriasis, 72, 128 Attrce, Mr William, of Brighton, 178 Australia, 70, 96, 97, 137 Axilla not often affected, 19 Bad dreams, 127 smells productive of psoriasis, 50 family histories, 62, 81 Balance of chlorides and sulphates, 154, 179 Barley meal (alpUton), 16, 101 Bateman, his work, 148, 150 Bath as watering place, 137 Baths, 49, 132, 166, 168, 175, 190 Bazin, M., 58 Beddoes, Dr, 147, 176 Beer, indulgence in, objectionable, 68 Begbie, Dr, on chordae, 177 Biett, 148, 177, 178 his ammoniacal solution, 148 Biniodide of mercury, 164, 166 Bismuth in ointment, 168 Black baras, black choler, &c., 72 Blood affected, 3, 126 cupped and buffed, 1 27 Bloodletting, 45, 131 local, 132 Blood-purifier, 3 Bodily habit, 23 Boils, 69, 100 Bone not covered by flesh, 19 Borax, 168, 184 Boudin's work on 'Treatment of Ague,' 149 Bradley's ' Medical Facts and Observa- tions,' 173 Brande, Mr, 151, 177 Branny tetter, 1 Bright and glistening spot, 6 Brassage, 136, 164 Bromide of potassium, 155 Bronchitis, 54 Brown stains, 17, 35, 152 INDEX 197 Calomel, 159, 187, 188, 189 Camphor, 165, 189 Canada balsam, 183, 186 Cancerous diathesis, 42, 45, 47, 60, 65, 69, 75, 172 Cancer of the tongue, 60, 108, 185 Cantharides, 158, 177, 181 - in dropsy, &c., 178 in moist eruptions, 178 Carbolic acid, 156, 165, 169, 183, 184 with glycerine, 165, 168, 184 Catainenia, scanty, 33, 68 Catching complaints, 21, 47, 52,68, 70, 72 Causes of psoriasis, 48 internal, 51 occasional, 48 Caustic applications, 136, 165 168, 184 Celsus, 8, 13, 72, 163 Chalk -like mark, 95, 102 Chalybeates, 154, 179 Change of season, 24 Children of the cancerous, 41, 45, 60, 65, 69, 75 of the consumptive, 56 subject to rheumatism, 58 Chios turpentine, 157 Chloride of arsenic, 151 Chlorides and sulphates, 38, 154 of lime and soda, solutions of, 161 Chlorine, 161 Cholera described by Girdlestone, 146 Chorsea, 40, 60, 151, 177 Chronic as usually seen, 35 Cinchona and tonics, 155 Cinnabar, 168 Classes affected by psoriasis, 24 Clavicle, patch under, 45, 51 Cleansing the blood, 3, 15, 34 the head, 167 Climate and soil, 25 of Yorkshire, London, 25 Cod-liver oil, 160, 166, 169 Colchicum, 156 Cold and damp productive of psoriasis 25,49 bath, titz-lad, or tub, 36, 46, 49, 74, 175 water cure, 134 Colour, 5, 9, 16 Complexion, 22 Condition, social, of life, 24 Configuration of patches, 9 Confluent psoriasis, 9 Confusion of diseases, 107, 172 names and identity, 175 Conjunctival redness, 152 Contagion cases quoted, 26 Contrasts in psoriasis, 18, 29 ] Copaiba, 161 Copper salts productive of psoriasis, 50 Cord around the waist, sensation of, 128 Corns in the palm or elsewhere, 87, 9i, 95 Corrosive sublimate, 160, 165, 185 Creosote, 41, 134, 166 Crimson psoriasis, 18, 29, 65, 70 Crude antimony, 155, 182 Crust or scale, 3, 6, 9 Cryptogams, 31 Curvature of the spine, 51, 128 Curves, their variety in psoriasis, 14 Cutis or derm, 5, 18 exsanguine, 9, 18 superficially affected, 30 Cyanide of potassium, 185 D Da Cunha, Dr, of Bombay, 56 Damp and aguish locality, 25, 45 Damp weather, 25 Dark colour in the urine from tar and creosote, Dead bone, 44, 51 Deafness, with psoriasis, 63, 100 from scarlatina, 47, 63 Debility, 34, 51, 52, 60,61, 62 Debris, epithelial, 6, 91, 95, 96, 101 Decline of the disease, 35 198 INDEX Decoctum ulmi, 161, 174, 180, 181 Defluxions and catarrhs, 126 Deformities accompanying psoriasis, 127 Degeneration, 127 Derm or cutis, 5, 18 Description of psoriasis, 1 De Valangin, or de Valenger, 150 his mineral solvent, 150 a strong tonic, 177 Devergie, 31, 178 Diabetes, 39, 126 Diagnosis of psoriasis, 76, 89 from eczema, 4, 80, 93 erythema, 80 lichen, 9, 77 sycosis, 80 syphilis, 21, 53, 76, 89 Diarrhoea, 33 Diathesis, 23, see Dyscrasia cancerous, 42, 47 phthisical, 46 scrofulous, 46 Diet, 52, 130, 136, 168, 177 Diphtheria and scarlatina, 52 Disabilities in Jewish law to be taken in a religious sense, 73 Discharges, their operation as cause, 51 Discoloration from arsenic, 132 Diseases allied to psoriasis, 59, 139 depending on low sustenance, 73 of the tongue, 109, 173 cured by arsenic, 173 mistaken for cancer, 173, 174 Disposition, anatomical, in papilla, 30 Disturbance causes psoriasis, 48 Disturbed function not much found in psoriasis, 32 Donovan's solution, 160, 181 Drains on the constitution, 50 Dreams, bad, 127 Drops of Jacobi, 141 Dry and branny tetter, 1, 3 skin, 33 mouth, 34 squamous diseases, 28, 53, 55, 172 Dulcamara, 31, 161, 179 Duration, 31 Dyscrasia, 54, 62, 80, 124, 171, 174 E. Early hours of rest, 168 treatment of lepra, by Girdlestone, 147 Eczema, 4, 19, 24, 41 manuum described, 92, 101 Eczematous asthma, 53 psoriasis, 28, 80, 81, 190 Edge of patches, 9, 14, 19, 30 * Edinburgh Medical Journal,' 173 Edwards, his case of ps. palmaria, 147 Effects, toxic, of arsenic, 152 Effluvia productive of psoriasis, 50 Elbows and knees, typical seat, 19 Eldest born, 23 Elementary spot, 9, 12, 35, 37 Elephantiasis, 8, 24, 71 attended by psoriasis, 71 Elm bark, 161, 174, 180, 181 Emollient bath, 191 ' Encyclopaedia, 5 the French, 172 * Encyclopedic Methodique/ 173 English watering places, 137 Ephelis, 47 Epidermis, increased growth of, 1 Epidermic scale altered, 4 Epilepsy, 60 Epithelioma of the tongue, 108 Errors in diet, 130 Erysipelas, 53, 58 Erythema, 4, 76, 79, 85 Erytheinatous psoriasis, 79, 85 Exercise, 136 Excitement, bodily or mental, 49 Exfoliation of skin, 4, 7 Exsanguine cutis, 9, 18 Extensor surfaces most affected, 19 External and extrinsic causes, 48 Extirpation of the tongue, 109, 173 Eyelids, 20, 120 INDEX 199 F. Face, psoriasis of, 6, 167 Fairy rings, 12 Fallopius, G., 88 Farriery, medicines used in, 145, 155, 159, 177 Fasting pernicious to public health, 73 Fatigue and worry, 52 Fatty degeneration of the liver, 161 Feathers, flocculent scale, 3, 5, 34 Ferriar, Dr, his use of arsenic in hoop- ing-cough, 143 Fever, 34 Fine skins, 29 Fissured palate, 66 Fistula, 32, 118 Fold of the arm, 19, 29, 54 Food, its importance, 74 Foreign springs and baths, 137 Foul smell in nostrils, 64 and sticky mucus in the mouth, 34, 64, 65, 70, 103, 104 linen, the washing of, 49 Fowler, Dr, his solution of arsenic, 141, 142, 154, 155 Freeman, Mr, 177 * French Encyclopaedia,' 172 Friction of clothes, its effect, 6 Fright and excitement, 49 Fulness of the head, 34, 51, 128 Fume baths, 168 Functional derangement, 127 Fungiforin developments, 31 G Gaskoin, John Samuel, 148 quoted by Plunibe, 177 Gastro-intestinal tract, 51, 130 Gelatine bath, 191 Geography of the disease, 25 Girdlestone, 144, 146, 147, 176 his works, 175 Glanders, effluvia from, 50 Glomerulus, 30 Glue, 191 Glycerini Acidi Carbolici, 157, 165, 183, 184 Gout, 42 among the poor, 58 and phthisis, 57 and rheumatism, 57 rheumatic, 57 succeeding psoriasis, 59 Gouty diathesis, 44 Granular scale, 5 Graves, Dr, 26, 160 Green or soft soap, 136, 165 Greenfield, Dr, on cantharides, 177 Gruel, 191 Gums, 111 Gyrate forms, 15, 66, 67, 69, 94, 99, 102 Habit, maintained, of disease, 32 Hahnemann, 153 Ha3inoptysis with psoriasis, 40, 70, 120, 129 Haemorrhage, 3 Hemorrhoids with psoriasis, 130, 150 Hammond, Mr, of Whetstone, 177 Ham not often affected, 19 Headache and vertigo, 34, 51, 128 Heat in the blood, 34, 35 . Hebetude of intellect with psoriasis, 22 Hebra, 50, 53, 135, 166, 171 his opinion of the dyscrasia, 54, 55 Helmerich's ointment, 165 Heredity, limited views of, 55, 172 not necessarily direct, 59, 172 Hereditary asthma, 54, 58 disease, 55, 59, 127 diseases akin to psoriasis, 55, 59 - psoriasis, 58, 67, 95 syphilis, 107 Herpes, 13, 16 200 INDEX Hindoos, their knowledge of arsenic, 140,144 History, its importance in psoriasis, 23 Horns, cutaneous, 87 Horseshoe forms, 11, 14, 97 over the spine, 128 Hot countries, phthisis in, 56 Huile de Cade, 154, 166, 184 Humoral pathology, 126 Humours, 2, 71 Hunt, 149, 151 Hypochlorite of sulphur, 190 Hydrochloric acid, 165, 184 Hypersemic cutis, 5, 30 Ichthyosis, 4, 28, 77, 80, 95, 172 Impetigo, 8, 80 itsscah,8 Impetigo excoriativa, 171 nigra, 72 rulra, 18 figurata, 80 Infants healthy no proof of cure from syphilis, 89 Inflammation of the derma, 5 Inherited syphilis, 21, 90, 97, 98, 107 Initial spot, 9, 12, 35, 37, 93 Inland waters, 25, 45 Inoculation, 53 used experimentally, 106 Innutrition, 24, 66, 70 Insane, 61 Insurance offices, 56, 109 Internal treatment, 138 Intestinal mucus, 33, 130 Iodides, 158, 159, 164, 166, 185 Iodide of sulphur, 164, 166, 189 Iodine, 159 Iodine and sulphur fume, 133, 168, 193 Iron, 154, 179, 180 Irritability of skins uncertain, 72, 164 166, 167 Irritants, local, 43, 50, 166 Itch ointments, 163 Itching of the scalp, 51, 128 Jacobi, his drops, 141 Jeffreys, Henry, 113, 162, 174 Jelly-like mucus from the bowels, 33 Jenkinson, use of arsenic in rheuma- tism, 176 Jewish nation, 23, 39, 41, 68 Juniper tar oil, 165, 184 Kinship in hereditary diseases, 50 Kirkland's ointment, 165 Knees and elbows most affected, 19 Kreosote, 166, 183, 185, 188 Lane, Charles, case by, 174 Large doses of arsenic, 141 Lazar houses, 71 Leathery surface on tongue, 110 Length of treatment, 31 " Leper white as snow," 8 Lepra cured by Girdlestone, 147, 176 Lepra alpho'ides, 2, 6, 12, 16, 21, 42 from cold bathing, 46 generally rounded, 9, 11 grcecorum, 2 nigricans, 16, 17, 41, 47 vulgaris, 2 unguium, 84, 122, 123, 169 Leprosy of Gehazi, 73 of the Jews, 73 scaly, 1 Level of the skin, 1, 6 Leuce, 75 Leuco-phlegmatic cases, 17, 158, 178 Lichen, 77 Lichen circumscriptus, 20 herpetiforme, 77 planus, 10, 18 urticatus, 17, 21 INDEX 201 Lips involved, 20 Liquor Arsenic! Hydrochloricus, 150 Carbonis Detergens, 40, 165 Lisbon diet drink, 157 Liseret blanc, 88 Lithic acid, 33 Liver, 33, 126, 151, 161 Local distribution and contour, 9 irritation, its effect, 50, 69, 93, 120, 129, 164 treatment, 163 Loins and spine seat of psoriasis, 128 London much subject to psoriasis, 25 dermatology in, 149, 150 Lotions, 184 Low diet in rare instances, 136 Low and damp situation, 25 Lues, 105, 172 Lupus, 4, 9, 24, 66, 79 Lytta, 158, 177, 180 M Malformation frequent with psoriasis, 127 Mark as by chalk on scratching, 95, 101, 102 Massa, Nicholas, 89 Mealy specks and marks, 7, 91, 95, 101 Meat exclusively used, 137 Medical and Chirurgical Society, 171 ' Medico-Chirurgical Transactions,' 173 'Medical and Physical Journal/ 147, 176 Facts and Observations/ 50, 173 Press and Circular/ 171, 172 Times and Gazette/ 171, 172 Melancholy humour, 71 Melchior Frick, his work, 145 Menopause, 115 Mercury, 159, 167, 169 its sulphurets, 182 its sulphate, 189 Micaceous scale, 5 Microscopical appearances, 30 Mineral waters imitated, 154 Moisture on the skin, 33 Moles, 75 Morbid expression limited, 60 anatomy of psoriasis, 30 Morphaa alba, 74 Mouth and throat dry, 34 Mucous membrane subject to psoriasis, 1, 116 patch no sure proof of syphilis, 117 tract of bowels, 51, 60, 130 Mucus, foul and sticky, in mouth, 34 intestinal, 33, 130 N Name, 1 Nails, 1, 20, 47, 83, 120, 169, 174 and mucous membrane subject to psoriasis, 1 Naphtha water, 181 Naphthaline, 188 Narcotics combined with arsenic, 154 Nation, 23 Neligan, 109 Nerves blunted in their sensibility, 35, 67,72 of the periphery, 129 principally concerned, 127 Nervous depression, 34, 60 diseases hereditary, 126 Neural pathology, 128 Nicholas Massa, 86 Nitrate of silver, 168 Nitre, 157, 160, 163 Nitric acid, 136 Nitro-muriatic acid, 157 Nodular disease, or rheumatic gout, 57, 65,143 Nourse, Mr, of Brighton, 113 Nutritive processes at fault, 83 O Oblong or ovoid forms, 13 Occasional causes, 48 202 INDEX (Edema, unfrequent, 30 from use of tar, 167 Ointments, 186 Old cases, stains in, 36 Ol. Cadini, or huile de Cade, 165, 166, 184 Ol. rusci, 166, 185 Ophiasis, 15 Otto of Philadelphia, 176 Outlets of the body, 20, 111, 117 Oxyluria, 126 Palpebrai ophthalmia, 80 Papilla, anatomical disposition in, 30, 33 projecting, 30 Papula of Celsus, 13 Papular elevation, or elementary spot, 9, 12, 30, 35, 37 Paralysis with psoriasis, 52, 61, 69, 129 Pathology of psoriasis, 125 Patna, 111 Pearson, Dr. George, 143, 175 Dr. Richard, 175 Pearson's solution, 143, 175 Pemphigus, 80, 85 Pereira on arsenic, 152, 177 Peripheral nerves, 69, 129 Pernio, 79, 86 Perspiration, 32, 33, 35, 103 Pertussis, 17, 143, 178 Pharmacopoeia, 177 Phosphorus, 161 Phthisical diathesis, 46, 56 Phthisis, asthma, and gout connected, 57 much connected with skin disease, 56 connected with rheumatism, 56, 58 its treatment somewhat resembles that for psoriasis, 160 Phytoform developments, 31 Pigment, 17, 49, 53, 172 in urine, 178 its variations and divergencies, 17, 58, 172 Pitch, 156, 164, 166, 167, 178, 183, 186, 187 or tar, its removal, 166, 178 Pityriasis, 88, 101 Pneumonia, 54, 64 Pock marks in the hands, 6 Poor man's gout, 58 sustenance, disease depending on, 173 Predisposition, 48, 49, 52, 58 Production of scale, 30 Projecting papilla?, 40 Prurigo podicis, 20, 115 Pruritus, 29, 34, 80, 103, 115, 116, 165 Psora, 2 Psoriasis, 1, 34 acne rosacea and hemoptysis, 40 acute, 34, 36, 37 affected by locality, 25 after abscess, 51 blenorrhagia, 95 cold bathing, &c., 36, 46, 49 scarlatina, 43, 46, 47, 49, 52, 63 the menopause, frequent, 115 typhoid and typhus, 47, 52, 61, 62,99 vaccination, 47, 49, 68 variola, 42, 45 varicella, 49, 63, 67, 68, 70 ani, 117 annulata, 13, 47 capitis, 6, 167 chronic and acute, 34 confounded with elephantiasis, 71 connected with amenorrho3a, 33,68, 116, 127 with asthma, 54, 115 with cancer, 59, 172 with chlorosis, 116 with erysipelas, 53 with phthisis, 41, 44, 56, 101, 172 with pneumonia, 54, 64 considered as a diathesis, 31 course and character of, 28 curable, 33 INDEX 203 Psoriasis diffusa vel confluens, 9 during pregnancy, 43 eczematous, 83 erythematous, 79, 85, et seq. faciei, 6, 167, 168 - from asthma, 64, 68, 69 from lactation, 42 genitalium, 114 guttata, 12 in families, 172 infantilis, its treatment, 21, 117, 168 in the aged, 8, 46 in the insane, 60 inveterata, 7, 94 in youth less refractory to treat- ment, 21, 32 its contrasts, 29 its definition, 1 its description, 1 its diagnosis, 76 from acne rosacea, 77 from lichen, 77 its limits feeble, 28 labialis, 19, 120, 121, 168 lingua, 20, 83, 98, 107, 108, 110, 112, 121, 168, 173 its treatment, 169 multiple and limited, 1 nigricans, 17, 41, 47 not contagious, 26 not dependent on texture of skin, 29 not followed by cicatrices, 1, 35, 79 not of artificial production, 31, 49 nummularis, 12 obstinate cases, 31 orbicularis, 13 over the sciatic nerve, 61 over the throat, 51 over the spine, 128 palmaria, 6, 7, 20, 22, 36, 41, 84, 88, 96, 165, 167, 176 beginning near the nail, 99, 103 concealed, 34 centrif uga, 13, 97 cured by arsenic, 147, 176 Psoriasis palmaria, hereditary, 59, 90, 95 i n young people, 22, 98, 99, 100 its commencement, 93 its diagnosis, 89 its treatment, its varieties, 94 not always syphilitic, 89, 95 possibly inherited from syphilis, 90 sypMlitica, 95 - palpebrarum, 119, 120, 168 plantaria, 20, 88, 100, 102 - preceding gout, 59 preputialis, 20, 119 pudendi, 20, 116, 168 punctata, 10, 12, 110 - scroti, 115, 168 sequela of vaccination, &c., 21, 49, 63, 68, 171 of variola, 42, 45, 171 sudden in its attack, 32 under the clavicle, 44, 51 unguium, 84, 101, 122, 123 its treatment, 109 where it begins, 33 with acne rosacea, &c., 40, 62 with dropsy and heart disease, 54 with eczema, 54 with history of cancer, 42, 45, 47, 60, 64 with history of gout, 59 with phthisis, 41, 172 with pyrexia, 36 with rheumatism, 37, 44, 58, 67 with varix, 43 Pulmonary track often affected, 33, 54, 64 Pulp of fingers, 7, 35, 91 Pumice-atone, 136 Purgatives, 158 Purpura, 18 Pyrexia with psoriasis, 34 Q Qualities, physical, of scale, 5, 9 Quality of skin indifferent, 29 204 INDEX R Ragged bits of skin, 4, 92, 93, 94 Rayer, 13, 164 Recurrence, 31 Red elbows, 19 Redness of the conjunctiva, 152 Regimen, 131 Regional distribution, 20 psoriasis, 105 Relapse, 31 Removal of scale, 136, 165 Renal function seldom disordered, 33> 118 Result not an ulcer or scar, 1 Revaccination, 172 Rhagades or cracks, 88, 92 Rheumatic gout, 57, 65, 103 Rheumatism, medication in, 176 allied to phthisis, 58 possibly to elephantiasis and pyaemia, 58 in children of the phthisical, 58 Rigors, 34, 36 Ringed forms, 11, 12, 43, 77 psoriasis, 9, 12, 76 Ringworm, 12 Robertson on use of cantharides, 162, 172 Rumex, 161, 174, 179 Rush, of Philadelphia, 145 Salivary secretion perverted, 34, 64, 70, 103, 127 Sanitation not aimed at in Jewish law, 71 Salt of Macquer, 142 rheum, 126 food objectionable, 130 Sarsaparilla and the woods, 162 Scab of impetigo, 8 Scabies, 2, 163 Scale or crust, 3, 6, 9, 10 beneath the level of the skin, G encasing the limb, 8 granular, 5 heavy, 6 its physical qualities, 5, 9 as modified by region, 6 its removal, 136, 165 of eczema, 4 of pityriasis, 4 split and fissured, 8, 61 sunken in, 6 Scaliness, degrees of, 2 Scaly leprosy, 1 Scalp often affected, 19, 35 Scarlatina and diphtheria, 42, 52, 66 Scar not the result of psoriasis, 1, 35 Scars and ulcers signs of syphilis, 76, 79 Schools of dermatology, 138, 149 Sciatic nerve, patch over, 61 Scrofula, 23, 24, 52, 58, 60, 137, 160, 173 of the blood, 3, 58, 60 Scorbutic, 2, 114 Scrotum seat of eruption, 20 Scurvy, 2 Seaside, 41, 83, 85, 101, 132, 137, 139 Season and locality, 24 Seat of the eruption, 18 Secretions at fault, 127 Sensibility, variable, 35, 67, 72, 164, 166 Septic influence, 53 Serpentine disease, 171 Serpigo, 11, 16, 76 Serpiginous or ribbon-like forms, 11 12, 16, 76 Sex, 22 Shagreen, 7, 94 Shivering, 34, 36 Signs of asthma inherited, 55 of syphilis, 21, 89 of saturation by arsenic, 152 Silvery scale, 56, 69, 110 Size or parchment clippings, 191 Skin disease much dependent on phthisis, 56 INDEX 205 Skin disease connected with cancer, 172 Skins calm in parts unaffected, 29, 78 differ in irritability, 164 Skin not always dry, 33 Sleepy feeling, 34, 127 Sleeplessness, 117 Smells, bad, productive of psoriasis, 50 Soap, 38, 135, 165, 174, 175 Social condition, 24 Soda salts in renewed favour, 153 Soda, arseniate of, 153, 179, 181, 183 Society, Koyal Medical and Chirurgical, 172 Soda and potash, choice of, 153 Solution, mineral, of Fowler, 141, 142, 150, 155 Pearson's, 175 Solvent, mineral, of De Valangin, 150 Sordes on skin, 26 Sores, deep, and ulcers, signs of syphilis, 89 Special forms, 105, 107 treatment, 167 Spine, angular curvature of, 128 Spine and spinal column, 51, 127 Spiritus saponis alkalinus, 166 Split skin, 91 Spot, elementary, or initial, 9, 12, 35, 37 Stains, brown and black, 17, 35, 152 Starch, 191 Starved condition not an evident cause, 24 Stature, 23, 43 Sterility, 130 Steel, preparations of, 154, 167, 179 180 Sticky mucus in the mouth, 34 Stoutness of limb, 23 occasional, in families subject to phthisis, 23 Sulphates and chlorides, 179 Sulphur, 161 fume bath, 133, 168 Sulphuretted waters, 134, 161, 165, 184 Sulphuret of potash, 184, 190 Sycosis, 80, 83 Syphilide cornee,95 Tar, or pitch, 166, ] 78 an ancient remedy, 163 baths, 166 distillates from, 168 objections to, 164, 166, 167, 178 ointments, 164, 166, 189 removal of, 166, 178 Temperaments, 23 Tenuity of limb, 23 Tisane de Feltz, 157 Tongue, extirpation of, 109, 173 diseases of, 109 Toxic effects of arsenic, 152 Treatment, 22, 130 internal, 138, 139 Tub, or sitz-bad, 46, 49, 174 Turkish bath, 133 Typhoid and typhus as cause, 52, 61 62 Turpentine, 157, 182, 185 Twist of shells and horns counterfeited, 15 U Ulceration a sign of syphilis, 76, 79 Umbilication, 10 Unguents, 186 Urine dark coloured from tar and kreosote, 178 Urtica dioica, 162 Urticaria, 28, 51, 80 Use of cantharides, 178 soap, 135 Uterine flux and discharge, 51, 115 Valleix, Guide du Praticien,' 135 Vapour bath, 133, 194 Variola, varicella, vaccination, 42, 45, 47, 49, 52, 171 Veiel uses soap for psoriasis, 175 206 INDEX Vertigo, prominent symptom, 34, 64, 101, 104, 128 Veterinary medicine, 145, 155, 177 Vienna School of Dermatology, 138 Vinegar and spices, 52 Violet colour, 17, 18, 94, 97 W Warm-water bath, 135 Warty appearance, 87 Washing increases rhagades, 135 Worm-eaten or ragged appearance, 7,47 Waters, inland, 25 sulphuretted, 163 Watering places, 137 Willan, 1, 5, 8, 13, 16, 25, 71, 142, 143, 144, 148 his case, with abdominal plethora, 143 and Bateman, their feeble employ- ment of arsenic in skin disease, 144, 148 Wine, 137 FEINTED BY J. E. ADLABD, BABTHOLOMEW CLOSE. Price 5s., in handsome 8vo., THE MEDICAL WORKS OF FRANCISCO DE VILLALOBOS, COURT PHYSICIAN OF SPAIN, IN PROSE AND VERSE. TRANSLATED BY GEORGE GASKOIN, K. COMMANDEE OPJTHE E. OEDEE ISABELLA LA CATOLICA OF SPAIN, AND THE E. OEDEE OP CHEIST OP POETUGAL. WITH BIBLIOGRAPHICAL, BIOGRAPHICAL, AND HISTORICAL NOTICES, AND AMPLE COMMENTARY. The above work contains one of the very earliest descriptions of syphilis and its treatment by mercury. There may be also remarked something like an anticipation of Harvey's discovery of the systemic circulation, and many other points of curious obser- vation characteristic of the sixteenth and seventeenth centuries. Mr. Gaskoiu has done his work con amove, and his volume deserves our warm praise." Athenceum. J. & A. CHURCHILL, NEW BURLINGTON STREET. London, New Burlington Street, December, 1874. SELECTION FEOM MESSES J. & A, CHUBCHILL'S faeral COMPRISING ALL EECENT WOKKS PUBLISHED BY THEM ON THE ART AND SCIENCE OF MEDICINE INDEX Acton on the Reproductive Organs on Prostitution Adams on Clubfoot . on Rheumatic Gout Allen on Aural Catarrh . . Allingham on Diseases of Rectum Anatomical Remembrancer Anderson (McC.) on Eczema PAGE . 8 . 8 . 6 . 18 . 5 . 6 . 11 . 19 (McC.) on Parasitic Affec- tions . . . . 19 (A. F.) Photographs of Le- prosy . . . .19 Arnott on Cancer . . . .18 Aveling's English Midwives . . 13 Barclay's Medical Diagnosis . . 10 Barker's Puerperal Diseases . . 12 Barnes* Obstetric Operations . .13 Diseases of Women . . 13 Bashain on Renal Diseases . . 7 on Diseases of the Kidneys . 7 Beale on Kidney Diseases . . .7 on Disease Germs . . .23 Bellamy's Guide to Surgical Anatomy 11 Bennet's Winter and Spring on the Shores of the Mediter- ranean . . . .16 on the Treatment of Pulmo- nary Consumption . . 16 Bennett on Cancerous and other Intra- thoracic Growths . . 18 Birch on Constipated Bowels . 17 on Oxygen . . .19 Black on the Urinary Organs . 8 Brodhurst on Deformities . 6 Browne's Medical Jurisprudence of Insanity ... .20 Bryant's Practice of Surgery . 4 Buchanan's Circulation of the Blood 9 Bucknill and Tuke's Psychological Medicine 21 Buzzard on Syphilitic Nervous Affec- tions 8 Carpenter's Human Physiology . . 9 Carter on Structure of Calculi . . 7 onMycetoma . . .18 Cauty on Diseases of the Skin . . 19 Chambers on the Indigestions . . 17 Chapman on Neuralgia . . .17 Chavasse's Advice to a Mother . . 12 Counsel to a Mother . 12 Advice to a Wife . . 12 Clark's Outlines of Surgery . . 4 Surgical Diagnosis . . 5 Clarke's Autobiographical Recollec- tions . . . . . .22 Clay's Obstetric Surgery . . .13 Cobbold on Worms . . . .19 PAGE Coles' Dental Mechanics . . .23 Cooper's Surgical Dictionary . . 5 Cotton on Phthisis and the Stethoscope 14 Coulson's Treatise on Syphilis . . 8 on Stone in the Bladder . 8 Dalby on the Ear .... 5 Dale's Practical Medicine . . .11 Day on Children's Diseases . . 12 De Morgan on the Origin of Cancer 18 De Valcourt on Cannes . . .15 Dillnberger's Diseases of Women and Children 12 Dobell's Lectures on Winter Cough . 14 first stage of Consumption . 14 Domville's Manual for Hospital Nurses 1 4 Druitt's Surgeon's Vade-Mecuni . 4 Dunglison's Dictionary of Medical Science 22 Elam on Cerebria . . . .20 Ellis's Manual of Diseases of Children 12 Fayrer's Observations in India . . 4 Fergusson's Practical Surgery . . 4 Fen wick's Guide to Medical Diagnosis 10 on the Stomach, &c. . .17 Flower's Nerves of the Human Body 10 Foster's Clinical Medicine . . 11 Frey's Histology and Histo-Chem- istry of Man . . .9 Gamgee on Fractures of the Limbs 5 Gaut on the Science and Practice of Surgery .... 4 on the Irritable Bladder . . 7 Garrett on Irritative Dyspepsia . 15 Glenn on the Laws affecting Medical Men 20 Habershon on Diseases of the Liver . 16 Hamilton on Syphilitic Osteitis and Periostitis ... .9 Hancock's Surgery of Foot and Ankle 6 Harley on the Urine . . . .8 Headland on the Action of Medicines 11 Heath's Minor Surgery and Bandaging 5 Diseases and Injuries of the Jaws ... .5 Practical Anatomy . . 10 Hill on Stricture of the Urethra . 7 Holden's Human Osteology . . 9 - Dissections .... 9 Holt on Stricture of the Urethra . 7 Holthouse on Hernial and other Tumours 6 Hood on Gout, Rheumatism, &c. . 18 Hooper's Physician's Vade-Mecum . 11 Horton's Diseases of Tropical Cli- mates 16 Jones (C. H.) and Sieveking's Patho- logical Anatomy . . .10 INDEX 3 Jones (C. H.) on Functional Nervous Disorders . . . .17 (Wharton) Ophthalmic Medi- cine and Surgery . . 22 Jordan on Treatment of Surgical In- flammations . . .6 Surgical Inquiries . . 6 Kennion's Springs of Harrogate . 15 Lee (H.) Practical Pathology . . 8 Leared on Imperfect Digestion . . 17 Liebreich's Atlas of Ophthalrnoscopy 21 Liveing on Megrim, &c. . . .17 MacCormac's Notes and Recollec- . tions of an Ambulance Surgeon . 6 Mackenzie on Growths in the Larynx 1 5 on Hoarseness . . .15 Throat Hospital Pharma- copoeia . . . .15 Macnamara on Diseases of the Eye . 22 Marsden on certain Forms of Cancer 18 Maunder 's Operative Surgery . . 4 Mayne's Medical Vocabulary . . 22 Meryon's System of Nerves . . 18 Moore's Family Medicine for India . 16 Morris on Irritability . . .17 on Germinal Matter . . 23 Paton on Action and Sounds of Heart 15 Parker on Syphilitic Diseases . . 9 Parkes' Manual of Practical Hygiene 21 Parkin's Epidemiology . . .23 Pavy on Diabetes . . . .17 on Digestion . . . .17 on Food and Dietetics . .17 Peacock on Valvular Disease of the Heart . . . .15 on Malformations of the Heart . . . .15 Phillips' Materia Medica and Thera- peutics . . . . .11 Pirrie's Surgery ... .4 Power on Diseases of the Eye . . 23 Ramsbotharn's Obstetric Medicine and Surgery . . . .13 Reynolds' Uses of Electricity . . 21 Richardson's Practical Physic . . .11 Ross's Graft Theory of Disease . . 23 Royle and Headland's Manual of Materia Medica . . . .11 Sabben and Browne's Handbook of Law and Lunacy . . .20 Sanderson's Physiological Laboratory 9 Sankey on Mental Diseases . . 20 Savage on the Female Pelvic Organs 5 Savory's Domestic Medicine . . 14 Schroeder's Manual of Midwifery . 13 Shapter's Diseases of the Heart . 14 Shaw's Medical Remembrancer . 10 Sheppard on Madness . . .20 PAGE Sibson's Medical Anatomy . . . 10 Sieveking's Medical Adviser in Life Assurance . . . . .20 Smith (H.) on the Surgery of the Rectum . . 6 (E.) on Wasting Diseases of Children . . . .12 Smith's Dental Anatomy . . .23 Spender on Ulcers of Lower Limbs . 19 Squire's Temperature Observations . 18 Steiner's Diseases of Children . , 12 Stowe's Toxicological Chart . . 20 Swain on the Knee- Joint . . .6 Surgical Emergencies . . 4 Swayne's Obstetric Aphorisms . . 13 Taylor's Principles of Medical Juris- prudence . . . .20 Manual of Medical Juris- prudence . . . .20 Thompson on Stricture of Urethra . 7 on Practical Lithotomy and Lithotrity . . 7 on Diseases of the Urinary Organs . . .7 on Diseases of the Prostate 7 Thorowgood on Asthma . . .15 on Materia Medica . 12 Tibbits' Medical Electricity . . 21 Tilt's Uterine Therapeutics . . 13 Change of Life . . .13 Tomes' Dental Surgery . . .23 Tuke on the Influence of the Mind upon the Body . . . .21 Van Buren on Diseases of the Geuito- Urinary Organs . . .8 Veitch's Handbook for Nurses . . 14 Wahltuch's Materia Medica . . 11 Walker on Egypt as a Health Resort 16 Ward on Affections of the Liver . 16 Waring's Practical Therapeutics . 11 Bazaar Medicines of India . 16 Waters on Diseases of the Chest . 14 Wells (Soelberg) on Diseases of the Eye 22 Long, Short, and Weak Sight . 22 (Spencer) on Diseases of the Ovaries . . . . li West on Diseases of Women . . 14 Wife's Domain . . . .14 Wilks' Pathological Anatomy . . 10 Wilson (E.) Anatomist's Vade-Mecurn 10 on Diseases of the Skin . 19 Lectures on Ekzema . . 19 Lectures on Dermatology . 19 (G.) Handbook of Hygiene . 21 Winslow's Obscure Diseases of the Brain and Mind . . .21 Wolff on Zymotic Diseases . . 23 CATALOGUE OF RECENT WOEKS THE PRACTICE OF SURGERY: A Manual by THOMAS BRYANT, F.RC.S., Surgeon to Guy's Hospital. Crown 8vo, with 507 Engravings on wood, 21s. [W2] THE PRINCIPLES AND PRACTICE OF SURGERY by WILLIAM PIRRIE, F.RS.E., Professor of Surgery in the University of Aberdeen. Third Edition, 8vo, with 490 Engravings, 28s. [WSJ A SYSTEM OF PRACTICAL SURGERY by Sir WILLIAM FERGUSSON, Bart., F.RC.S., F.RS., Seijeant- Surgeon to the Queen. Fifth Edition, 8vo, with 463 Illustrations on Wood, 21s. [1870] OPERATIVE SURGERY by C. F. MAUNDER, F.RC.S., Surgeon to the London Hospital, for- . merly Demonstrator of Anatomy at Guy's Hospital. Second Edition, post 8vo, with 164 Wood Engravings, 6s. C 18 ? 2 ! THE SURGEON'S VADE-MECUM by ROBERT DRUITT. Tenth Edition, fcap. 8vo, with numerous En- gravings on Wood, 12s. 6d. [I87oj THE SCIENCE AND PRACTICE OF SURGERY: a complete System and Textbook by F. J. GANT, F.RC.S., Surgeon to the Royal Free Hospital. 8vo, with 470 Engravings, 24s. 0871] OUTLINES OF SURGERY and Surgical Pathology, including the Diagnosis and Treatment of Obscure and Urgent Cases, and the Surgical Anatomy of some Im- portant Structures and Regions, by F. LE GROS CLARK, F.RS., Con- sulting Surgeon to St. Thomas's Hospital. Second Edition, Revised and Expanded by the Author, assisted by W. W. WAGSTAFFE, F.RC.S., Assistant- Surgeon to, and Joint -Lecturer on Anatomy at, St. Thomas's Hospital. 8vo, 10s. 6d. 0873} CLINICAL AND PATHOLOGICAL OBSERVATIONS IN INDIA by J. FAYRER, C.S.I., M.D., F.RC.P. Lond., F.RS.E., Honorary Physician to the Queen. 8vo, with Engravings on Wood, 20s. 0873 j SURGICAL EMERGENCIES together with the Emergencies attendant on Parturition and the Treatment of Poisoning : a Manual for the use of General Practi- tioners by WILLIAM P. SWAIN, F.RC.S., Surgeon to the Royal Albert Hospital, Devonport. Fcap. 8vo, 6s. PUBLISHED BY J. AND A. CHURCHILL MINOR SURGERY AND BANDAGING (A Manual of) for the Use of House -Surgeons, Dressers, and Junior Practitioners, by CHRISTOPHER HEATH, i'.R.C.S., Surgeon to Uni- versity College Hospital. Fourth Edition, fcap 8vo, with 74 Engrav- ings, 5s. 6d. two] BY THE SAME AUTHOE, INJURIES AND DISEASES OF THE JAWS: JACKSONIAN PRIZE ESSAY. Second Edition, 8vo, with 164 Engrav- ings, 12s. [1872] DICTIONARY OF PRACTICAL SURGERY and Encyclopaedia of Surgical Science, by SAMUEL COOPER. New Edition, brought down to the present Time by SAMUEL A. LANE, Consulting Surgeon to St. Mary's and to the Lock Hospitals ; assisted by various Eminent Surgeons. 2 vols. 8vo, 50s. Cisei and 1872] THE FEMALE PELVIC ORGANS (the Surgery, Surgical Pathology, and Surgical Anatomy of), in a Series of Coloured Plates taken from Nature: with Commentaries, Notes, and Cases, by HENRY SAVAGE, M.D. Lond., F.R.C.S., Consulting Physician to the Samaritan Free Hospital. Second Edition, greatly Enlarged, 4to, 1 11s. 6d. ^870] FRACTURES OF THE LIMBS (On the Treatment of) by J. SAMPSON GAMGEE, Surgeon to the Queen's Hospital, Birmingham. 8vo, with Plates, 10s. 6d. C 18 ?!] ON DISEASES AND INJURIES OF THE EAR by W. B. DALBY, F.B.C.S., M.B., Aural Surgeon and Lecturer on Aural Surgery at St. George's Hospital. Crown 8vo, with 21 Engrav- ings, 6s. 6d. [1873] AURAL CATARRH; or, the Commonest Forms of Deafness, and their Cure, by PETER ALLEN, M.D., F.R.C.S.E., late Aural Surgeon to St. Mary's Hospital. Second Edition, with Engravings, crown 8vo, 8s. 6d. PRINCIPLES OF SURGICAL DIAGNOSIS (Lectures on the) especially in Relation to Shock and Visceral Lesions, delivered at the Royal College of Surgeons by F. LE GROS CLARK, F.B.C.S, Consulting Surgeon to St. Thomas's Hospital. 8vo, 10s. 6d. CATALOGUE OP EEOENT WOEKS CLTJBFOOT: its Causes, Pathology, and Treatment; being the Jacksonian Prize Essay by WM. ADAMS, F.R.C.S., Surgeon to the Great Northern Hos- pital. Second Edition, 8vo, with 106 "Wood Engravings and 6 Litho- graphic Plates, 15s. n 8 73] INJURIES AND DISEASES OF THE KNEE-JOINT and their Treatment by Amputation and Excision Contrasted : Jack- sonian Prize Essay by W. P. SWAIN, F.R.C.S., Surgeon to the Royal Albert Hospital, Devonport. 8vo, with 36 Engravings, 9s. t 1869 3 ON DEFORMITIES OF THE HUMAN BODY: a System of Orthopaedic Surgery, by BERNARD E. BRODHTJRST, F.R.C.S., Surgeon to the Royal Orthopaedic Hospital. 8vo, with Engravings, 10s. 6d. t 18 ^ OPERATIVE SURGERY OF THE FOOT AND ANKLE (The) by HENRY HANCOCK, F.R.C.S., Consulting Surgeon to Charing Cross Hospital. 8vo, 15s. C 18 73] THE TREATMENT OF SURGICAL INFLAMMATIONS by a New Method, which greatly shortens their Duration, by FURNE AUX JORDAN, F.R.C.S., Professor of Surgery in Queen's College, Birming- ham. 8vo, with Plates, 7s. 6d. BY THE SAME AUTHOE, SURGICAL INQUIRIES With numerous Lithographic Plates. 8vo, 5s. ON HERNIAL AND OTHER TUMOURS of the Groin and its Neighbourhood, with some Practical Remarks on the Radical Cure of Ruptures by C. HOLTHOTJSE, F.R.C.S., Surgeon to the Westminster Hospital. 8vo, 6s. 6d. L 18 ?0] NOTES AND RECOLLECTIONS of an Ambulance Surgeon, being an Account of Work done under the Red Cross during the Campaign of 1870, by WILLIAM MAcCoRMAC, F.R.C.S., M.R.I.A., Surgeon to St. Thomas's Hospital. 8vo, with 8 Plates, 7s. 6d. [1S71] THE SURGERY OF THE RECTUM: Lettsomian Lectures by HENRY SMITH, F.R.C.S., Surgeon to King's College Hospital. Third Edition, fcap 8vo, 3s. 6d. d 8 ?!] FISTULA, HAEMORRHOIDS, PAINFUL ULCER, Stricture, Prolapsus, and other Diseases of the Rectum : their Diagnosis and Treatment. By WM. ALLINGHAM, F.R.C.S., Surgeon to St. Mark's Hospital for Fistula, &c., late Surgeon to the Great Northern Hospital. Second Edition, enlarged, 8vo, 7s. PUBLISHED BY J. AND A. CHUECH1LL STRICTURE OF THE URETHRA and Urinary Fistulas ; their Pathology and Treatment : Jacksonian Prize Essay by Sir HENRY THOMPSON, F.R.C.S., Surgeon-Extraordi- nary to the King of the Belgians. Third Edition, Svo, with Plates, 10s. C1869] BY THE SAME ATJTHOE, PRACTICAL LITHOTOMY AND LITHOTRITY; or, An Inquiry into the best Modes of removing Stone from the Bladder. Second Edition, 8vo, with numerous Engravings. 10s. [1871] ALSO, DISEASES OF THE URINARY ORGANS (Clinical Lectures on). Third Edition, crown 8vo, with Engravings, 6s. [1S72] ALSO, THE DISEASES OF THE PROSTATE: their Pathology and Treatment. Fourth Edition, Svo, with numerous Plates, 10s. C 18 73] STRICTURE OF THE URETHRA (On the Immediate Treatment of), by BARNARD HOLT, F.R.C.S., Consulting Surgeon to the Westminster Hospital. Third Edition, Svo, 6s. 1868 J ORGANIC STRICTURE OF THE URETHRA (An Analysis of 140 Cases of), by JOHN D. HILL, F.R.C.S., Surgeon to the Royal Free Hospital, Svo, 3s. t 1871 ^ ON KIDNEY DISEASES, URINARY DEPOSITS and Calculous Disorders by LIONEL S. BEALE, M.B. F.B.S., F.R.C.P., Physician to King's College Hospital. Third Edition, much En- larged, Svo, with 70 Plates, 25s. t 1868 3 THE IRRITABLE BLADDER: its Causes and Treatment, by F. J. GANT, F.B.C.S., Surgeon to the Royal Free Hospital. Third Edition, crown Svo, with Engravings, 6s. 1872] RENAL DISEASES: A Clinical Guide to their Diagnosis and Treatment by W. R. BASHAM, M.D., F.R.C.P., Senior Physician to the Westminster Hospital. Post Svo, 7s. [1870] BY THE SAME AUTHOB, THE DIAGNOSIS OF DISEASES OF THE KIDNEYS (Aids to). Svo, with 10 Plates, 5s. t 1873 ! MICROSCOPIC STRUCTURE OF URINARY CALCULI (On the) by H. V. CARTER, M.D., Surgeon- Major, H.M.'s Bombay Army. Svo, with Four Plates, 5s. [1873] CATALOGUE OF RECENT WORKS THE URINE AND ITS DERANGEMENTS (Lectures on), with the Application of Physiological Chemistry to the Diagnosis and Treatment of Constitutional as well as Local Diseases by GEORGE HARLEY, M.D., F.R.S., F.R.C.P., formerly Professor in University College. Post 8vo, 9s. [1872] THE REPRODUCTIVE ORGANS in Childhood, Youth, Adult Age, and Advanced Life (The Functions and Disorders of), considered in their Physiological, Social, and Moral Relations, by WILLIAM ACTON, M.R.C.S. Fifth Edition, 8vo, 12s. [1871] BY THE SAME AUTHOB, PROSTITUTION : Considered in its Moral, Social, and Sanitary Aspects. Second Edition, enlarged, 8vo, 12s. [1869] FUNCTIONAL DISEASES of the Renal, Urinary, and Reproductive Organs (On the), by D. CAMPBELL BLACK, M.D., L.R.C.S. Edin., Member of the General Council of the University of Glasgow. 8vo, 10s. 6d. [1872] PRACTICAL PATHOLOGY: containing Lectures on Suppurative Fever, Diseases of the Veins, Hsemorrhoidal Tumours, Diseases of the Rectum, Syphilis, Gonor- rheal Ophthalmia, &c., by HENRY LEE, F.R.C.S., Surgeon to St. George's Hospital. Third Edition, in 2 rols. 8vo, 10s. each vol. [ 18 70] GENITO-URINARY ORGANS, INCLUDING SYPHILIS A Practical Treatise on their Surgical Diseases, designed as a Manual for Students and Practitioners, by W. H. YAN BUREN, M.D., Pro- fessor of the Principles of Surgery in Bellevue Hospital Medical Col- lege, New York, and E. L. KEYES, M.D., Professor of Dermatology in Bellevue Hospital Medical College, New York. With 140 Engravings, royal 8vo, 21s. CW*] SYPHILITIC NERVOUS AFFECTIONS (Clinical Aspects of) by THOMAS BUZZARD, M.D., F.R.C.P. Lond., Physician to the National Hospital for Paralysis and Epilepsy. Post 8vo, 5s. [iw-i] A TREATISE ON SYPHILIS by WALTER J. COULSON, F.R.C.S., Surgeon to the Lock Hospital 8vo, 10s. [ 18G9 J BY THE SAME AUTHOE, STONE IN THE BLADDER: Its Prevention, Early Symptoms, and Treatment by Lithotrity. 8vo, 6s. PUBLISHED BY J. AND A. CHURCHILL ON SYPHILITIC OSTEITIS AND PERIOSTITIS Lectures by JOHN HAMILTON, F.R.C.S.I., Surgeon to the Richmond Hospital and to Swift's Hospital for Lunatics, Dublin. With Plates, Svo, 6s. 6d. WW SYPHILITIC DISEASES (The Modern Treatment of), both Primary and Secondary ; comprising the Treatment of Constitutional and Confirmed Syphilis, by a safe and successful Method, by LANGSTON PARKER, F.R.C.S. Fifth Edition, Svo, 10s. 6d. . P871] PRINCIPLES OF HUMAN PHYSIOLOGY by W. B. CARPENTER, M.D., F.R.S. Seventh Edition by Mr. HENR? POWER. Svo, with nearly 300 Illustrations on Steel and Wood, 28s. [1669] PHYSIOLOGICAL LABORATORY (Handbook for the) by E. KLEIN, M.D., formerly Privat-Docent in Histology in the University of Yienna, Assistant Professor in the Pathological Laboratory of the Brown Institution, London ; J. BUR- DON-SANDERSON, M.D., F.R.S., Professor of Practical Physiology in University College, London; MICHAEL FOSTER, M.D., F.R.S. , Fellow of, and Prselector of Physiology in, Trinity College, Cambridge ; and T. LAUDER BRTJNTON, M.D., D.Sc., Lecturer on Materia Medicain the Medical College of St. Bartholomew's Hospital ; edited by J. BURDON- SANDERSON. Svo, with 123 Plates, 24s. HISTOLOGY AND HISTO-CHEMISTRY OP MAN A Treatise on the Elements of Composition and Structure of the Human Body, by HEINRICH FREY, Professor of Medicine in Zurich. Translated from the Fourth German Edition by ARTHUR E. J. BARKER, Surgeon to the City of Dublin Hospital ; Demonstrator of Anatomy, Royal College of Surgeons, Ireland. And Revised by the Author. Svo, with 608 Wood Engravings, 21s. . { I 18 ?*] THE CIRCULATION OF THE BLOOD (The Forces which carry on the) by ANDREW BUCHANAN, M.D., Professor of Physiology in the University of Glasgow. Second Edition, Svo, with Engravings, 5s. [1874] HUMAN OSTEOLOGY: with Plates, showing the Attachments of the Muscles, by LUTHER HOLDEN, F.R.C.S., Surgeon to St. Bartholomew's Hospital. Fourth Edition, Svo, 16s. ' C 1869 ] BY THE SAME AUTHOR, THE DISSECTION OF THE HUMAN BODY (A Manual of). Third Edition, Svo, with Engravings on Wood, 16s. [1806] 10 CATALOGUE OP RECENT WORKS THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS by SAMUEL FENWICK, M.D., F.R.C.P., Assistant Physician to the London Hospital. Third Edition, fcap 8vo, with 87 Engravings, 6s. 6d. A MANUAL OF MEDICAL DIAGNOSIS by A. "W. BARCLAY, M.D., F.R.C.P., Physician to, and Lecturer on Medicine at, St. George's Hospital. Third Edition, fcap 8vo, 10s. 6d. [1870] THE MEDICAL REMEMBRANCER; or, Book of Emergencies. Fifth Edition by JONATHAN HUTCHINSON, F.R.C.S., Senior Siirgeon to the London Hospital. 32mo, 2s. 6d. [1867] MEDICAL ANATOMY By FRANCIS SIBSON, M.D., F.R.C.P., F.R.S., Consulting Physician to St. Mary's Hospital. Imp. folio, with 21 coloured Plates, cloth, 42s. ; half -moroCCO, 50s. [Completed in 1869] THE ANATOMIST'S VADE-MECUM: a System of Human Anatomy by ERASMUS WILSON, F.R.C.S., F.R.S. Ninth Edition, by Dr. G. BUCHANAN, Professor of Anatomy in Anderson's University, Glasgow. Crown 8vo, with 371 Engravings on Wood, 14s. I 1 * PRACTICAL ANATOMY: a Manual of Dissections by CHRISTOPHER HEATH, F.R.C-S., Surgeon to University College Hospital. Third Edition, fcap 8vo, with 226 Engravings tl874 J PATHOLOGICAL ANATOMY (Lectures on) by SAMUEL WILKS, M.D., F.R.S., Physician to, and Lecturer on Medicine at, Guy's Hospital; and WALTER MOXON, M.D., F.R.C.P., Physician to, and late Lecturer on Pathology at, Guy's Hospital. Second Edition, 8vo. [ 18 7*] PATHOLOGICAL ANATOMY (A Manual) by C. HANDFIELD JONES, M.B., F.R.S., Physician to St. Mary's Hospital; and EDWARD H. SIEVEKING, M.D., F.R.C.P., Physician to St. Mary's Hospital. Edited by J. F. PAYNE, M.D., F.R.C.P., Assistant Physician and Demonstrator of Morbid Anatomy at St. Thomas's Hospital. Second Edition, crown 8vo, with En- gravings. 1874 J DIAGRAMS OF THE NERVES OF THE HUMAN BODY Exhibiting their Origin, Divisions, and Connexions, with their Distri- bution, by WILLIAM HENRY FLOWER, F.R.S., Conservator of the Museum of the Royal College of Surgeons. Second Edition, roy. 4to 12s. PUBLISHED BY ,7. AND A. CHURCHILL 11 STUDENT'S GUIDE TO SURGICAL ANATOMY: a Text-book for the Pass Examination, by E. BELLAMY, F.R.C.S., Senior Assistant-Surgeon and Teacher of Operative Surgery at Charing Cross Hospital. With 50 Engravings, fcap 8vo, 6s. 6d. [1873] THE ANATOMICAL REMEMBRANCER; or, Complete Pocket Anatomist. Seventh Edition, carefully Revised, 32mo, 3s. 6d. fi872] A MANUAL OF PRACTICAL THERAPEUTICS by E. J. WARING, M.D., F.R.C.P. Lond. Third Edition, fcap 8vo, 12s. 6d. HOOPER'S PHYSICIAN'S VADE-MECUM; or, Manual of the Principles and Practice of Physic, Ninth Edition by W. A. GUY, M.B., F.R.S., and JOHN HARLEY, M.D., F.R.C.P. Fcap 8vo, with Engravings, ]2s. 6d. [1874] A COMPENDIUM OF PRACTICAL MEDICINE and Morbid Anatomy by WILLIAM DALE, M.D. Lond. 12mo, with Plates, 7s. CLINICAL MEDICINE Lectures and Essays by BALTHAZAR FOSTER, M.D., F.R.C.P. Lond., Professor of Medicine in Queen's College, Birmingham. 8vo, 10s. 6d. [1874] DISCOURSES ON PRACTICAL PHYSIC by B. W. RICHARDSON, M.D., F.R.C.P., F.R.S. 8vo, 5s. d87i] ON THE ACTION OF MEDICINES in the System by F. W. HEADLAND, M.D., F.R.C.P., Professor of Medicine in Charing Cross Medical College. Fourth Edition, 8vo, 14s. t 1866 3 A MANUAL OF MATERIA MEDICA by J. F. ROYLE, M.D., F.R.S., and F. W. HEADLAND, M.D., F.R.C.P. Fifth Edition, fcap 8vo, with numerous Engravings on Wood, 12s. 6d. [1868] A DICTIONARY OF MATERIA MEDICA and Therapeutics by ADOLPHE WAHLTUCH, M.D. 8vo, 15s. C 18 ^] MATERIA MEDICA AND THERAPEUTICS: Vegetable Kingdom, by CHARLES D. F. PHILLIPS, M.D., F.R.C.S.E. 8vo, 15s. 12 CATALOGUE OF EEGENT WORKS THE STUDENT'S GUIDE TO MATERIA MEDICA by JOHN C. THOROWGOOD, M.D. Lond., Physician to tlie City of London Hospital for Diseases of the Chest. "With Engravings, fcap 8vo, 6s. 6d. [1874] MANUAL OF THE DISEASES OF CHILDREN (A Practical), with a Formulary, by EDWARD ELLIS, M.D., Physician to the Victoria Hospital for Children. Second Edition, crown 8vo, 7s. [1873] ESSAYS ON THE DISEASES OF CHILDREN by WILLIAM HENRY DAY, M.D., Physician to the Samaritan Hospital for Diseases of Women and Children. Fcap 8vo, 5s. [i 8 ? 3 ] ON THE WASTING DISEASES OF CHILDREN by EUSTACE SMITH, M.D. Lond., Physician to the King of the Belgians, Physician to the East London Hospital for Children. Second Edition, post 8vo, 7s. 6d. t 18 ? ! COMPENDIUM OF CHILDREN'S DISEASES A Handbook for Practitioners and Students, by JOHANN STEINER, M.D., Professor of the Diseases of Children in the University of Prague. Translated from the Second German Edition by LAWSON TAIT, F.E.C.S., Surgeon to the Birmingham Hospital for Women. 8vo, 12s. 6d. [1874] A TRANSLATION OF DR. DILLNBERGER'S Handy-Book of the Treatment of Women's and Children's Diseases according to the Yienna Medical School, with Prescriptions, by PATRICK NICOL, M.B. Fcap 8vo, 5s. [i 8 ? 1 ] ADVICE TO A MOTHER on the Management of her Children by PYE H. CHAVASSE, F.R.C.S. Eleventh Edition, fcap 8vo, 2s. 6d. H 87 ^ BY THE SAME ATJTHOK, COUNSEL TO A MOTHER on the Care and Rearing of her Children, being the Companion Yolume of ' Advice to a Mother.' Third Edition, fcap 8vo. 2s. 6d. [1874] AISO, ADVICE TO A WIFE on the Management of her own Health. With an Introductory Chapter especially addressed to a Young Wife. Tenth Edition, fcap 8vo, 2s. 6d. t 187 ^ PUERPERAL DISEASES Clinical Lectures by FOEDYCE BARKER, M.D., Obstetric Physician to Bellevue Hospital, New York. 8vo, 15s. PUBLISHED BY J. AND A. CHUECHILL 13 LECTURES ON OBSTETRIC OPERATIONS, including the Treatment of Heemorrjiage, and forming a Guide to the Management of Difficult Labour, by ROBERT BARNES, M.D., F.R.C.P., Obstetric Physician to, and Lecturer 011 Midwifery at, St. Thomas's Hospital. Second Edition, 8vo, with 113 Engravings, 15s. [IWH BY THE SAME ATJTIIOB, MEDICAL AND SURGICAL DISEASES OF WOMEN (a Clinical History of the). With 169 Engravings, 8vo, 28s. [1873] OBSTETRIC SURGERY A Complete Handbook, giving Short Rules of Practice in every Emer- gency, from the Simplest to the most Formidable Operations connected with the Science of Obstetricy, by CHARLES CLAY, Ext.L.R.C.P. Lond., L.R.C.S.E., late Senior Surgeon and Lecturer on Midwifery, St. Mary's Hospital, Manchester. With 91 Engravings, fcap 8vo, 6s. 6d. [1874] OBSTETRIC MEDICINE AND SURGERY (The Principles and Practice of) by F. H. RAMSBOTHAM, M.D., F.R.C.P. Fifth Edition, Svo, with 120 Plates on Steel and Wood, 22s. [1867] OBSTETRIC APHORISMS for the Use of Students commencing Midwifery Practice by J. G. S WAYNE, M.D., Physician- Accoucheur to the Bristol General Hos- pital. Fifth Edition, fcap Svo, with Engravings on Wood, 3s. 6d. [1871] SCHROEDER'S MANUAL OF MIDWIFERY, including the Pathology of Pregnancy and the Puerperal State. Translated by CHARLES H. CARTER, B.A., M.D. 8vo, with Engrav- ings, 12s. 6d. [1873] A HANDBOOK OF UTERINE THERAPEUTICS and of Diseases of Women by E. J. TILT, M.D,, M.R.C.P. Third Edition, post 8vo, 10s. [1868] BY THE SAME AUTHOB, THE CHANGE OF LIFE in Health and Disease : a Practical Treatise on the Nervous and other Affections incidental to Women at the Decline of Life. Third Edition, 8vo, 10s. 6d. t 18 7oj ENGLISH MIDWIVES: their History and Prospects, by J. H. AVELING, M.D., Physician to the Chelsea Hospital for Women, Examiner of Midwives for the Obstetrical Society of London. Crown 8vo, 5s. [1872] 14 CATALOGUE OF RECENT WORKS LECTURES ON THE DISEASES OF WOMEN by CHARLES WEST, M.D., F.R.C.P. Lond. Third Edition, 8vo, 16s. [1864] DISEASES OF THE OVARIES : their Diagnosis and Treatment, by T. SPENCER WELLS, F.R.C.S., Surgeon to the Queen's Household and to the Samaritan Hospital. 8vo, with about 150 Engravings, 21s. [ 18 73] HANDBOOK FOR NURSES FOR THE SICK by Miss YEITCH. Crown 8vo, 2s. 6d. [187Q] A MANUAL FOR HOSPITAL NURSES and others engaged in Attending on the Sick by EDWARD J. DOM- VILLE, L.R.C.P., M.R.C.S. Second Edition, crown 8vo, 2s. 6d. [1874] A COMPENDIUM OF DOMESTIC MEDICINE and Companion to the Medicine Chest ; intended as a Source of Easy Reference for Clergymen, and for Families residing at a Distance from Professional Assistance, by JOHN SAVORY, M.S. A. Eighth Edition, 12mo, 5s. [1871] THE WIFE'S DOMAIN The Young Couple The Mother The Nurse The Nursling, by Pm- LOTHALOS. Second Edition, post 8vo, 3s. 6d. [ 18 ?4] LECTURES ON WINTER COUGH (Catarrh, Bronchitis, Emphysema, Asthma) by HORACE DOBELL, M.D., Senior Physician to the Royal Hospital for Diseases of the Chest. Second Edition, with Coloured Plates, 8vo, 8s. 6d. [1872] BY THE SAME ATJTHOB, THE TRUE FIRST STAGE OF CONSUMPTION (Lectures on). Crown 8vo, 3s. 6d. [1867] DISEASES OF THE CHEST: Contributions to their Clinical History, Pathology, and Treatment by A. T. H. WATERS, M.D., F.R.C.P., Physician to the Liverpool Royal Infirmary. Second Edition, 8vo, with Plates, 15s. [ 18 ?3] PHTHISIS AND THE STETHOSCOPE; or, the Physical Signs of Consumption, by R. P. COTTON, M.D., E.R.C.P., Senior Physician to the Hospital for Consumption, Brompton. Fourth Edition, fcap 8vo, 3s. 6d. [ 1869 3 DISEASES OF THE HEART and of the Lungs in Connexion therewith Notes and Observations by THOMAS SHAPTER, M.D., F.R.C.P. Lond., Senior Physician to the Devon and Exeter Hospital. 8vo, 7s. 6d. PUBLISHED BY J. AND A. CHURCHILL 15 ON VALVULAR DISEASE OF THE HEART (some of the causes and effects of). Croonian Lectures for 1865. By THOMAS B. PEACOCK, M.D., F.R.C.P., Physician to St. Thomas's Hospital. With Engravings, Svo, 5s. [1865] BY THE SAME AUTHOR, ON MALFORMATIONS OF THE HUMAN HEART With Original Cases and Illustrations. Second Edition, with Plates, Svo, 10s. [1867] THE ACTION AND SOUNDS OF THE HEART (Researches on). By GEORGE PATON, M.D., author of numerous papers published in the British and American Medical Journals. Re-issue, with Appendix, Svo, 3s. 6d. [1874] NOTES ON ASTHMA; its Forms and Treatment, by JOHN C. THOEOWGOOD, M.D. Lond., Physician to the Hospital for Diseases of the Chest, Victoria Park. Second Edition, Revised and Enlarged, crown Svo, 4s. 6d. [1873] IRRITATIVE DYSPEPSIA and its Important Connection with Irritative Congestion of the Windpipe and with the Origin and Progress of Consumption. By C. B. GAEEETT, M.D. Crown Svo, 2s. 6d. [1868] GROWTHS IN THE LARYNX, with Reports and an Analysis of 100 consecutive Cases treated since the Invention of the Laryngoscope by MOEELL MACKENZIE, M.D. Lond., M.R.C.P., Physician to the Hospital for Diseases of the Throat. Svo, with Coloured Plates, 12s. 6d. [1871] BY THE SAME AUTHOR, HOARSENESS, LOSS OF VOICE, and Stridulous Breathing in relation to Nervo-Muscular Affections of the Larynx. Second Edition, Svo, fully Illustrated, 3s. 6d. [1868] ALSO, THROAT HOSPITAL PHARMACOPEIA, containing upwards of 150 Formulae. Second Edition, fcap Svo, 2s. 6d. [ 18 733 MINERAL SPRINGS OF HARROGATE (Dr. KENNION'S Observations on the). Ninth Edition, revised and enlarged by ADAM BEALEY, M.A., M.D. Cantab., F.R.C.P. Lond. Crown Svo, Is. [1873] SKETCH OF CANNES AND ITS CLIMATE By TH. DE VALCOTJET, M.D. Paris, Physician at Cannes. Second Edition, with Photographic View and Six Meteorological Charts, crown Svo, 2s. 6d. 16 CATALOGUE OF EEOENT WORKS WINTER AND SPRING on the Shores of the Mediterranean ; or, the Genoese Rivieras, Italy, Spain, Greece, the Archipelago, Constantinople, Corsica, Sardinia, Sicily, Corfu, Malta, Tunis, Algeria, Smyrna, Asia Minor, with Biarritz and Arcachon, as "Winter Climates. By HENRY BENNET, M.D. Fifth Edition, post 8vo, with numerous Plates, Maps, and Wood Engravings, 12s. 6d. [1874] BY THE SAME AUTHOE, TREATMENT OF PULMONARY CONSUMPTION (On the) by Hygiene, Climate, and Medicine. Second Edition, enlarged, Svo, 5s. [1871] EGYPT AS A HEALTH RESORT; with Medical and other Hints for Travellers in Syria, by A. D UNBAR WALKER, M.D. Fcap Svo, cloth, 3s. 6d. [1873] FAMILY MEDICINE FOR INDIA A Manual, by WILLIAM J. MOORE, M.D., Surgeon-Major H.M. Indian Medical Service. Published under the Authority of the Government of India. Post Svo, with 57 Engravings, 8s. 6d. VW THE DISEASES OF TROPICAL CLIMATES and their Treatment : with Hints for the Preservation of Health in the Tropics, by JAMES A. HORTON, M.D., Surgeon-Major of the Army Medical Department. Post Svo, 12s. 6d. [1847] BAZAAR MEDICINES OF INDIA and Common Medical Plants : Remarks on their Uses, with Full Index of Diseases, indicating their Treatment by these and other Agents pro- curable throughout India, &c., by EDWARD J. WARING, M.D., F.R.C.P. Lond., Retired Surgeon H.M. Indian Army. Fcap Svo, 4s. C 18 74] ON SOME AFFECTIONS OF THE LIVER and Intestinal Canal ; with Remarks on Ague and its Sequelse, Scurvy,. Purpura, &c., by STEPHEN H. WARD, M.D. Lond., F.R.C.P., Physician to the Seamen's Hospital, Greenwich. Svo, 7s. [1872] ON DISEASES OF THE LIVER: Lettsomian Lectures for 1872 by S. O. HABERSHON, M.D., F.R.C.P., Senior Physician to Guy's Hospital. Post Svo, 3s. 6d. L 18 ? 2 3 PUBLISHED BY J. AND A. CHURCHILL 17 THE STOMACH AND DUODENUM (The Morbid States of) and their Relations to the Diseases of other Organs, by SAMUEL FENWICK, M.D., F.R.C.P., Assistant-Physician to the London Hospital. 8vo, with 10 Plates, 12s. 1868] CONSTIPATED BOWELS: the Various Causes and the Different Means of Cure, by S. B. BIRCH, M.D., M.R.C.P. Third Edition, post 8vo, 3s. 6d. [1868] DIABETES: Researches on its Nature and Treatment by F. W. PAVY, M.D., F.R.S., F.R.C.P., Physician to Guy's Hospital. Second Edition, 8vo, with Engravings, 10s. [iscs] BY THE SAME AUTHOE, DIGESTION: its Disorders and their Treatment. Second Edition, 8vo, 8s. 6d. [18691 BY THE SAME AUTHOE, TOOD AND DIETETICS Physiologically and Therapeutically Considered. 8vo, 16s. QW*] THE INDIGESTIONS; or, Diseases of the Digestive Organs Functionally Treated, by T. K. CHAMBERS, M.D., F.R.C.P., Lecturer on Medicine at St. Mary's Hospital. Second Edition, 8vo, 10s. 6d. C 186 73 IMPERFECT DIGESTION: its Causes and Treatment by ARTHUR LEARED, M.D., F.R.C.P., Senior Physician to .the Great Northern Hospital. Fifth Edition, fcap 8vo, 4s. 6d. Win ON MEGRIM, SICK-HEADACHE, and some Allied Disorders : a Contribution to the Pathology of Nerve- Storms by EDWARD LIVEING, M.D. Cantab., Hon. Fellow of King's College, London. 8vo, with Coloured Plate, 15s. [1873J IRRITABILITY: Popular and Practical Sketches of Common Morbid States and Con- ditions bordering on Disease; with Hints for Management, Allevia- tion, and Cure, by JAMES MORRIS, M.D. Lond. Crown 8vo, 4s. 6d. [1868] STUDIES ON FUNCTIONAL NERVOUS DISORDERS by C. HANDFIELD JONES, M.B., F.R.C.P., F.R.S., Physician to St. Mary's Hospital. Second Edition, much enlarged, 8vo, 18s. C 18 '3 NEURALGIA AND KINDRED DISEASES of the Nervous System : their Nature, Causes, and Treatment, with a series of Cases, by JOHN CHAPMAN, M.D., M.R.C.P. 8vo, 14s. 18 CATALOGUE OF EECENT WOEKS SYMPATHETIC SYSTEM OF NERVES as a Physiological Basis for a Rational System of Therapeutics (On the Functions of the) by EDWARD MERYON, M.D., F.R.C.P., Physician to the Hospital for Diseases of the Nervous System. Svo, 3s. 6d. [ 18 ? 3 3 A TREATISE ON GOUT, RHEUMATISM and the Allied Affections, by P. HOOD, M.D. Crown Svo, 10s. 6d. [1871} A TREATISE ON RHEUMATIC GOUT, or Chronic Rheumatic Arthritis of all the Joints, by ROBERT ADAMS, M.D., M.R.I.A., Surgeon to H.M. the Queen in Ireland, Regius Pro- fessor of Surgery in the University of Dublin. Second Edition, Svo, with Atlas of Plates, 21s. [1872] TEMPERATURE OBSERVATIONS containing (1) Temperature Variations in the Diseases of Children, (2) Puerperal Temperatures, (3) Infantile Temperatures in Health and Disease, by WM. SQUIRE, M.R.C.P. Lond. Svo, 5s. C 18 ?!] MYCETOMA ; or, the Fungus Disease of India, by H. VANDYKE CARTER, M.D., Sur- geon-Major H.M. Indian Army. With 11 Coloured Plates, 4to, 42s. [1874} THE ORIGIN OF CANCER considered with Reference to the Treatment of the Disease by CAMP- BELL DE MORGAN, F.R.S., F.R.C.S., Surgeon to the Middlesex Hos- pital. Crown Svo, 3s. 6d. [1S72] CANCER: its varieties, their Histology and Diagnosis, by HENRY ARNOTT, F.R.C.S., Assistant-Surgeon to, and Lecturer on Morbid Anatomy at, St. Thomas's Hospital. Svo, with 5 Lithographic Plates and 22 Wood Engravings, 5s. 6d. C 187 ^ CANCEROUS AND OTHER INTRA-THORACIC GROWTHS: their Natural History and Diagnosis, by J. RISDON BENNETT, M.D., F.R.C.P., Member of the General Medical Council. Post Svo, with Plates, 8s. [1873] CERTAIN FORMS OF CANCER (a New and successful Mode of Treating)/" to which is prefixed a Prac- tical and Systematic Description of all the varieties of this Disease, by ALEX. MARSDEN, M.D., F.R.C.S.E., Consulting Surgeon to the Royal Free Hospital, and Senior Surgeon to the Cancer Hospital, London and Brompton. Second Edition, with Coloured Plates and Illus- trative Cases, Svo, 8s. 6d. PUBLISHED BY J. AND A. CHURCHILL 19 ON DISEASES OF THE SKIN: a System of Cutaneous Medicine by ERASMUS WILSON, F.R.C.S., F.R.S. Sixth Edition, 8vo, 18s., with Coloured Plates, 36s. [1867] BY THE SAME AUTHOB, LECTURES ON EKZEMA and Ekzematous Affections : with an Introduction on the General Pathology of the Skin, and an Appendix of Essays and Cases. 8vo, 10s. 6d. C1870] ALSO, LECTURES ON DERMATOLOGY delivered at the Royal College of Surgeons, 1870, 6s. ; 1871-3, 10s. 6d. ECZEMA by McCALL ANDERSON, M.D., Professor of Clinical Medicine in the University of Glasgow. Third Edition, 8vo, with Engravings, 7s. 6d. [1874] BY THE SAME AUTHOE, THE PARASITIC AFFECTIONS OF THE SKIN Second Edition, 8vo, with Engravings, 7s. 6d. [ 1868 1 DISEASES OF THE SKIN in Twenty-four Letters on the Principles and Practice of Cutaneous Medicine, by HENRY EVANS CATJTY, Surgeon to the Liverpool Dis- pensary for Diseases of the Skin, 8vo, 12s. 6d. liWQ ULCERS AND CUTANEOUS DISEASES of the Lower Limbs (A Manual of the Pathology and Treatment of) by J. K. SPENDER, M.D. Lond. 8vo, 4s. [ 1868 3 FOURTEEN COLOURED PHOTOGRAPHS OF LEPROSY as met with in the Straits Settlements, with Explanatory Notes by A. F. ANDERSON, M.D., Acting Colonial Surgeon, Singapore. 4to, 31s. 6d. WORMS: a Series of Lectures delivered at the Middlesex Hospital on Practical Helminthology by T. SPENCER COBBOLD, M.D., F.R.S. Post 8vo, 5s. ^ 73] OXYGEN: its Action, Use, and Yalue in the Treatment of Various Diseases otherwise Incurable or very Intractable, by S. B. BIRCH, M.D., M.R.C.P. Second Edition, post 8vo, 3s. 6d. [1868] 20 CATALOGUE OF RECENT WORKS MEDICAL JURISPRUDENCE (The Principles and Practice of) by ALFRED S. TAYLOR, M.D., F.R.C.P., F.R.S. Second Edition, 2 vols., 8vo, with 189 Wood En- gravings, 1 11s. 6d. C 18 ^ BY THE SAME AUTHOB, A MANUAL OF MEDICAL JURISPRUDENCE Ninth Edition. Crown 8vo, 14s. [ 1874] A TOXICOLOGICAL CHART, Exhibiting at one View the Symptoms, Treatment, and mode of Detecting the various Poisons Mineral, Yegetable, and Animal: with Concise Directions for the Treatment of Suspended Animation, by WILLIAM STOWE, M.R.C.S.E. Thirteenth Edition, 2s.; on roller, 5s. t 18 THE MEDICAL ADVISER IN LIFE ASSURANCE by EDWARD HENRY SIEVEKING, M.D., F.R/.C.P., Physician to St. Mary's and the Lock Hospitals; Physician-Extraordinary to the Queen; Physician-in- Ordinary to the Prince of Wales, &c. Crown 8vo, 6s. [1874] THE LAWS AFFECTING MEDICAL MEN (A Manual of) by ROBERT G. GLENN, LL.B., Barrister-at-Law ; with a Chapter on Medical Etiquette by Dr. A. CARPENTER. 8vo, 14s. [1871] XECTURES ON MADNESS in its Medical, Legal, and Social Aspects by EDGAR SHEPPARD, M.D., M.R.C.P., Professor of Psychological Medicine in King's College; one of the Medical Superintendents of the Colney Hatch Lunatic Asylum. 8vo, 6s. 6d. 0*W XECTURES ON MENTAL DISEASES by WILLIAM HENRY OCTAVIUS SANKEY, M.D. Lond., F.R.C.P., Lecturer on Mental Diseases at University College, London. Svo, 8s. [1866] THE MEDICAL JURISPRUDENCE OF INSANITY by J. H. BALFOUR BROWNE, Barrister-at-Law. Svo, 10s. 6d. t 18 ?!] HANDBOOK OF LAW AND LUNACY; or, the Medical Practitioner's Complete Guide in all Matters relating to Lunacy Practice, by J. T. SABBEN, M.D., and J. H. BALFOUR BROWNE. Svo, 5s. [1872] ON CEREBRIA and other Diseases of the Brain by CHARLES ELAM, M.D., F.R.C.P., Assistant-Physician to the National Hospital for Paralysis and Epilepsy. Svo, 6s. [1872] PUBLISHED BY J. AND A. CHURCHILL 21 PSYCHOLOGICAL MEDICINE: A Manual, containing the Lunacy Laws, the Nosology, ^Etiology, Statistics, Description, Diagnosis, Pathology (including Morbid His- tology), and Treatment of Insanity, by J. C. BUCKNILL, M.D., F.R.S., and D. H. TUKE, M.D. Third Edition, much Enlarged, with 10 Plates and 34 Wood Engravings, 8vo, 25s. [18731 THE INFLUENCE OF THE MIND UPON THE BODY in Health and Disease (Illustrations of), designed to elucidate the Action of the Imagination, by DANIEL HACK TUKE, M.D., M.R.C.P. Svo, 14s. [1872] OBSCURE DISEASES OF THE BRAIN AND MIND by FORBES WINSLOW, M.D., D.C.L. Oxon. Fourth Edition, post Svo, 10s. 6d. [1868] A MANUAL OF PRACTICAL HYGIENE by E. A. PARKES, M.D., F.R.C.P., F.R.S., Professor of Hygiene in the Army Medical School. Fourth Edition, Svo, with Plates and Woodcuts, 16s. [1873] A HANDBOOK OF HYGIENE for the Use of Sanitary Authorities and Health Officers by GEORGE WILSON, M.D. Edin., Medical Officer of Health for the Warwick Union of Sanitary Authorities. Second Edition, crown Svo, with Engravings, 8s. 6d. [1873] HANDBOOK OF MEDICAL ELECTRICITY by HERBERT TIBBITS, M.D., M.R.C.P.E., Medical Superintendent of the National Hospital for the Paralysed and Epileptic. Svo, with 64 Wood Engravings, 6s. [1873] CLINICAL USES OF ELECTRICITY (Lectures on the) delivered at University College Hospital by J. RTJSSELL REYNOLDS, M.D. Lond., F.R.C.P., F.R.S., Professor of Medicine in University College. Second Edition, post Svo, 3s. 6d. [18733 ATLAS OF OPHTHALMOSCOPY: representing the Normal and Pathological Conditions of the Fundus Oculi as seen with the Ophthalmoscope : composed of 12 Chromo- lithographic Plates (containing 59 Figures), accompanied by an Explanatory Text by R. LIEBREICH, Ophthalmic Surgeon to St. Thomas's Hospital. Translated into English by H. ROSBOROUGH SWANZY, M.B. Dub. Second Edition, Enlarged and Revised, 4to, 110s. ' 22 CATALOGUE OF RECENT WORKS AUTOBIOGRAPHICAL RECOLLECTIONS of the Medical Profession, being personal reminiscences of many distinguished Medical Men during the last forty years, by J. FER- NANDEZ CLARKE, M.R.C.S., for many years on the Editorial Staff of the ' Lancet,' Post 8vo, 10s. 6d. [1874] A DICTIONARY OF MEDICAL SCIENCE Containing a concise explanation of the various subjects and terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Medical Chemistry, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence and Dentistry ; Notices of Climate and Mineral Waters ; formulae for Officinal, Empirical, and Dietetic Preparations ; with the Accentuation and Etymology of the terms and the French and other Synonyms, by ROBLEY DUNGLISON, M.D., LL.D. New Edition, enlarged and thoroughly revised by RICHARD J. DUNGLISON, M.D. Royal 8vo, 25s. [W4] A MEDICAL VOCABULARY; or, an Explanation of all Names, Synonymes, Terms, and Phrases used in Medicine and the relative branches of Medical Science, by R. G. MAYNE, M.D., LL.D. Third Edition, fcap 8vo, 8s. 6d. C1868] A MANUAL OF OPHTHALMIC MEDICINE AND SURGERY by T. WHARTON JONES, F.R.S., Professor of Ophthalmic Medicine and Surgery in University College. Third Edition, much Enlarged and thoroughly Revised, with 9 Coloured Plates and 173 Engravings on Wood, fcap 8vo, 12s. 6d. , C1865] A MANUAL OF THE DISEASES OF THE EYE by C. MACNAMARA, Surgeon to the Calcutta Ophthalmic Hospital Second Edition, fcap 8vo, with Coloured Plates, 12s. 6d. [ 18 72] DISEASES OF THE EYE (A Treatise on the) by J. SOELBERG WELLS, F.R.C.S., Ophthalmic Surgeon to King's College Hospital and Surgeon to the Royal London Ophthalmic Hospital. Third Edition, 8vo, with Coloured Plates and Wood Engravings, 25s. C 1 ^] BY THE SAME AUTHOR, ON LONG, SHORT, AND WEAK SIGHT, and their Treatment by the Scientific use of Spectacles. Fourth Edition, Revised and Enlarged, 8vo, 6s. [1873] PUBLISHED BY J. AND A. CHUECHILL 23 DISEASES OF THE EYE (Illustrations of some of the Principal), with an Account of their Symptoms, Pathology, and Treatment, by HENRY POWER, F.R.C.S., M.B. Lond., Ophthalmic Surgeon to St. Bartholomew's Hospital. 8vo, with 12 Coloured Plates, 20s. [1867] A SYSTEM OF DENTAL SURGERY by JOHN TOMES, F.R.S., and CHARLES S. TOMES, M.A., Lecturer on Dental Anatomy and Physiology, and Assistant Dental Surgeon to the Dental Hospital of London. Second Edition, fcap 8vo, with 268 Engravings, 14s. [ 18 ?3] A MANUAL OF DENTAL MECHANICS with an Account of the Materials and Appliances used in Mechanical Dentistry, by OAKLEY COLES, L.D.S., E/.C.S., Surgeon-Dentist to the Hospital for Diseases of the Throat. Crown 8vo, with 140 Wood Engravings, 7s. 6d. . t 18 73] HANDBOOK OF DENTAL ANATOMY and Surgery for the use of Students and Practitioners by JOHN SMITH, M.D., F.R.S. Edin., Surgeon-Dentist to the Queen in Scotland. Second Edition, fcap 8vo, 4s. 6d. [1871] EPIDEMIOLOGY; or, the Remote Cause of Epidemic Diseases in the Animal and in the Vegetable Creation, by JOHN PARKIN, M.D., F.R.C.S. Part I, 8vo, 5s. C 18 73] GERMINAL MATTER AND THE CONTACT THEORY: an Essay on the Morbid Poisons by JAMES MORRIS, M.D. Lond. Second Edition, crown 8vo, 4s. 6d. C 186 ?] DISEASE GERMS; and on the Treatment of the Feverish State, by LIONEL S. BEALE, M.B., F.R.C.P., F.R.S., Physician to King's College Hospital. Second Edition, crown 8vo, with 28 Plates, 12s. 6d. [1872] THE GRAFT THEORY OF DISEASE being an Application of Mr. DARWIN'S Hypothesis of Pangenesis to the Explanation of the Phenomena of the Zymotic Diseases, by JAMES Ross, M.D., "Waterfoot, near Manchester. 8vo, 10s. [1872] ZYMOTIC DISEASES: their Correlation and Causation. By A. WOLFF, F.R.C.S. Post 8vo, 5s. The following CATALOGUES issued by Messrs CHURCHILL will be forwarded post free on application : 1. Messrs Churchill's General List of nearly 600 works on Medicine, Surgery, Midivifery, Materia Medica, Hygiene, Anatomy, Physiology, Chemistry, fyc., fyc., with a complete Index to their Titles, for easy reference. N.B. This List includes Nos. 2 and 3. 2. Selection from Messrs CliurchiWs General List, com- prising all recent Works published by them on the Art and Science of Medicine. 3. A descriptive List of Messrs Chur chill 9 s Works on Chemistry, Pharmacy, Hotany, Photography, and other branches of Science. 4. Messrs Churchiirs Red-Letter List, giving the Titles of forthcoming Neiv Works and New Editions. [Published every October.] 5. The Medical Intelligencer, an Annual List of New Worlcs and Neiv Editions published by Messrs J. fy A. Churchill, together with Particulars of the Periodicals issued from their House. [Sent in January of each year to every Medical Practitioner in the United Kingdom whose name and address can be ascertained. A large number are also sent to the United States of America, Continental Europe, India, and the Colonies.] MESSES CHUECHILL have a special arrangement with MESSES LINDSAY & BLAKISTON, OF PHILADELPHIA, in accordance with which that Finn act as their Agents for the United States of America, either keeping in Stock most of Messrs CHUECHILL'S Books, or reprint- ing them on Terms advantageous to Authors. Many of the Works in this Catalogue may therefore be easily obtained in America. PKINTED BY J. E. ADLAKD, BARTHOLOMEW CLOSE.