The patches are in general quite isolated, and at first not very large, the predominating shape, if anything with such an irregular outline can be said to have a shape at all, being a ragged oval. Usually they are, as stated, of a lake colour, and this seems to betoken a milder phase; in two cases, where the hue might very fitly have been compared to carmine, the constitutional disturbance was out of all proportion to the extent of skin affected. After a time, and particularly when they are seated on the face, two or more patches gradually fuse, and take on a dark, angry hue, which gives the part the look of having been burnt with fire. Now and then they assume a papular form, and then resemble flattened, aggregated lichen spots; these appear to be overlaid by a cuticle not unlike the horny covering of lichen. On other patches the cuticle, after taking on a brown crumpled look, is cast off, as in the rising stage of eczema. In a third set of patches the scarf skin may be fairly adherent. The constitutional symptoms point to much and often grave disturbance of the health. General uneasiness, feeling of being unwell, sometimes of the system having taken the alarm, loss of appetite, nausea, headache, inability to walk straight, and prostration, are perhaps the most prominent and frequent among the many signs which arrest the attention of the practitioner. It will thus be seen that, while the affection in some features resembles acrodynia and erysipelas, it is yet distinct from both It runs a much slower course than either, and in it the constitutional symptoms come on much later. The phlyctænæ, pustules, oedema, and perspirations of the former are wanting. When it attacks the face it is accompanied by none of the swelling and closing of the eyelids which so distinctly mark erysipelas. It is sometimes attended, too, by the formation of huge bullæ at a distance from the chief site of active disease. Though, perhaps, in this complaint the skin is just as much poisoned by the air as it is by the aniline and arsenic dyes in a case of glove or sock poisoning, yet we do not find the sudden swelling, heat, tenderness, and subsequent discharge of serum seen in the latter affection. On the contrary, every one of these symptoms may be absent; indeed, redness and exfoliation are usually the sole local signs. But while I never saw much internal disturbance, and particularly internal disturbance culminating in delirium, from the aniline dye affection, I have met with both under a very pronounced form in this kind of dermatitis. And no form of poisoning of the skin which I have either read of or seen, or any variety of erysipelas known to myself, is ever followed, as dermatitis ferox sometimes is, by a raised, fused, red, papular eruption. For all such reasons the latter seems to me a distinct individual complaint. The case spoken of is as follows: Martha S., aged 24, a tall, strongly-built woman, was admitted into St John's Hospital, 17th April 1885, in a state of great prostra EDINBURGH MED. JOURN., VOL. XXXI.—NO. IX. 5 L tion and suffering. The face, from the roots of the hair to below the chin, was of a fiery red, extremely stiff, and very slightly swollen. The lips, which were covered with sordes as bad as in any case of typhus, were superficially eroded all over, and, according to the patient's account, bled so much when she attempted to eat, that she frequently turned sick from this cause. The combined effect of these symptoms on the face was to give it a most singular and revolting look. There was a slight discharge from the right ear. According to her account, which was only with great difficulty extracted from her, the woman being in a state approaching coma-she was a hawker of oil and floorcloths-and therefore of necessity much exposed to the weather, which, I may remark, had long been very inclement, bitter east winds prevailing for some time before. She was in the habit of carrying the cloth in her arms, and the first appearance of the eruption was on the flexor side of the tip of one finger. peculiarly exposed to the action of the material in question. The disease had been ascribed to this fact, the influence of which, however, is very doubtful, as it was impossible that the other fingers could have altogether escaped, and they were not affected at that time. I may remark, however, that with regard to both dates and symptoms, her narrative, not only at this period, but even long after her health had materially improved, frequently contradicted itself; not that I believe she ever had any wish to deceive us; on the contrary, she always appeared truthful and communicative enough. The difficulty was that her memory evidently failed her on some points, and that she had not observed very accurately on others. As well as we could make out, the spot on the finger just alluded to and a patch on the right cheek formed several months before her admission. The latter gradually spread till the whole face was covered, without a break in the redness. About three weeks prior to her entrance the morbid process had gained the lips, and had affected them as I have described. Rather more than three weeks before this again the flexors of the fingers began to crack, and deep keens formed in them. At the time of her admission there were several of these cracks, and the edges of some of them seemed nearly in a sloughing state, almost as if each had been the site of a bad whitlow. On the right foot and underneath the ball of the great toe, extending for some way along the sole of the foot, was a large bulla about half filled with what seemed to be pultaceous matter, though the contents could not be accurately determined on account of the skin not having broken. On its being opened the next day a most offensive semi-purulent discharge came away. There was a similar but smaller bleb on the left foot, both being of very irregular shape. The patient was very hoarse, which might, however, be due to her calling. Syphilis had been suggested as the cause of all this, but there was no history of syphilis, and there were no symptoms of it. She was put on 20 minim doses of tincture of steel every four hours, with a gentle aperient at bedtime; the day following the dose was raised to 30 minims. Light diet was ordered, with a free allowance of wine; the face to be covered with benzoated zinc ointment, and the lips to be repeatedly washed with solution of chlorate of potass, 5 grains to an ounce. For four days she seemed to go on extremely well; but on the fifth day, 21st April, an extensive crop of papules, exactly like those of lichen ruber, broke out on the backs of the hands and arms, accompanied by some failing of the appetite. The following morning I noticed that she was very depressed, and learned that she had been crying without any reason. During the ensuing night she was very restless, and passed a great deal of blood by the bowel; she had also copious bleeding from the nose, which was stopped by plugging. The night after this she turned delirious, attacked and overpowered two nurses, and was only prevented by the efforts of the bath keeper from rushing out into the street. Next day when I saw her she was much worse than at any previous visit; the lips were thickly crusted with sordes, and she rambled continually. She had torn off all the dressings laid on the lichenous spots, and had so violently scratched these that it would have been almost impossible for any one, who had not seen the case before, to make out the character of the eruption. The stools were passed involuntarily, along with an immense quantity of flatus and urine; her pulse was quick and weak, and her strength seemed failing. She was ordered 5 minims of tincture of aconite every four hours, along with 20 of spirit of chloroform and 15 of syrup of red gum; a small bottle of Guiness's best stout night and morning, as much light soup and mutton broth as she could be induced to take, and brandy if there seemed to be need for it. This change in the treatment was at first followed by beneficial results. On the morning of the 25th she was quieter, and there were fewer sordes about the mouth; the redness of the face was also declining. She had taken the stout freely, and expressed a wish for some solid food; the stools no longer passed involuntarily. With all this the eruption had spread on the neck, arms, and backs of the hands, over which were scattered an extraordinary number of lake-coloured erythema patches, looking as if she had an eruption of chilblains. A large bulla, nearly if not quite 2 square inches in area, had formed on the back part of the sole of the right foot. During the whole time her tongue had kept clean, and this continued to be the case. The day after the stools were still loose, but there was no return to involuntary passing of them. The colour of the face had abated, but the rash was extending, and crops of flattened lichen papules were continuing to break out on the patches, while more large blebs were forming on the soles of the feet. She was still very violent, and could with difficulty be kept in bed. The dose of aconite tincture was increased to 7 minims; the violence, however, continued all through the next day, and up to four o'clock the following morning, when she fell into a deep sleep, from which she awoke, comparatively speaking, quite rational. She was ordered to continue the stout and jelly, but the aconite was suspended, unless a fresh necessity for it should arise; the steel, which had been interrupted during the height of the attack, was renewed. She now went on very well for five days, when she had an attack of delirium, which lasted six hours; this was the last of the acme. On the 9th of May I noticed that the skin of the face and hands was peeling off, and on further search found that nearly every part of the arms and body was undergoing the same process; the erythema patches and the skin at first spared by them being alike involved in one general dematitis. Her appetite, however, was now excellent, and her strength returning so fast that she asked to be discharged; and she accordingly left four days after, being directed to continue her steel and attend as out-patient. On the 18th of May, however, she reappeared with every sign of a bad relapse. The colour of the eruption had deepened again, and the mingling of this fresh hue with the brown of the dying epidermis gave the face and neck the look of having been severely scorched. She was low, hysterical, and scarcely able to stand; her feet were very painful, and on the wrists were several patches of almost a carmine colour. She reported herself as having been most attentive to her case; asserting that she had remained quietly at home, had taken her medicine quite regularly, and had carried out all the instructions given her; nor did there seem any reason to doubt her statement. The weather, too, had been so very bad that she would scarcely have been tempted out of doors. There being no vacant bed at the time, she could not be re-admitted then, and later on declined to come in, having to look after her household; she was, therefore, simply directed to continue her treatment. I did not see her again till the 1st of June, when her condition had very little altered, the cuticle still looking dry, brown, and withered, and the patient herself low, weak, and hysterical. Some of the patches on the body and arms were better, and a certain, very slight, degree of eczema, which had appeared on some of them, was now gone. With all this, she soon after once more began to improve in health, and by the middle of the month reported herself as feeling quite well, one result of which was that I had to threaten, more than once, to discharge her for irregular attendance. She had kept up the use of the steel, and was directed to continue it, and to have a vapour bath once a week, a recommendation which she carried out very indifferently. At a visit paid on the 2nd of July she said she felt quite well, though she really seemed to be very ill, while the skin looked nearly as bad as ever, and on the 27th was a great deal worse again, that on the face especially having a most angry appearance, and the fronts of the arms being almost covered with lakecoloured spots. Some part of this change was perhaps due to the violent heat which had prevailed during the two foregoing days. A full dose of calomel at bedtime, to be repeated three days after, and followed up each time with a black draught, seemed to do her good, and at her visit ten days later the patches looked paler, and there was much less dying cuticle. From this time I saw no more of her. She attended very irregularly during my absence on a long holiday, neglected her vapour bath, and finally died, December 2nd, of pneumonia. This was the second instance in which the health seemed to be irretrievably shattered by the affection-a former patient, previously a strong man, having to resign his profession and go abroad. Å nurse who had known this patient, and who visited him during his illness, said "no words could convey an idea of the ravages it had made in a fortnight." With the exception of the person whose case forms the subject of this paper, all the patients were middleaged people in easy circumstances. IV.-SEX IN CONNEXION WITH PULMONARY PHTHISIS. By ALEXANDER JAMES, M.D., Assistant Physician, Royal Infirmary, Edinburgh. WHEN We look for data upon which to form an opinion as to the relative frequency of pulmonary consumption in the sexes, we find results which are decidedly conflicting. From some writers, as Williams, Bennett,2 Pollock, it might be inferred that the disease preponderated in males; others, as Louis, Laennec,5 Walshe, Hutchinson, give evidences of an increased liability to it in the female sex; whilst a third, as Niemeyer, Bristow, Ruehle,10 Andrew,11 consider that no distinction as regards relative frequency can be drawn. 6 Further, not only have such contradictory statements been made, but by many physicians of eminence theories have been put forward in explanation of a supposed greater liability to consumption in one or the other sex. Those who believed it more common in men ascribed it to occupations and greater liability to exposure, and, indeed, to all injurious influences; whilst among those who 1 Pulmonary Consumption, p. 294. 2 Reynold's System of Medicine, p. 546. 3 Elements of Prognosis in Consumption, pp. 245 and 256. 4 Researches on Phthisis (Sydenham Society translation), p. 480. 5 Diseases of the Chest (Sir John Jules' translation), p. 307. 6 Diseases of the Lungs (4th edition), p. 462. 7 The Spirometer, Stethoscope, and Scale Balance, etc. (1852), p. 46. 8 Text-Book of Practical Medicine, vol. i. p. 216. 9 Theory and Practice of Medicine (2nd edition), p. 433. 11 Brit. Med. Journal, i. 1884, p. 709. |