it is impossible, and the attempt irrational, for the two run into each other. The presence of tubercules or of thick masses of new growth, the tendency to ulcerate and to scab, and the non-symmetrical arrangement, all denote common lupus in an easily definite manner. Whatever is symmetrical, and affects at once, with separate patches, ears, cheeks, and nose, is probably of the erythematous variety.

You will have gathered from what I have said as to the absence of tendency to ulceration and to inflammatory swelling, that lupus erythematosus is not, in any marked degree, scrofulous, for these features are characteristic of struma wherever we meet with it. There can be no doubt that this form of lupus is more nearly connected with psoriasis (or the dartrous diathesis) than it is with scrofula. We may infer that from its symmetry; and the inference is, as I shall have to show in the sequel, sometimes borne out by the occurrence of a general scaly eruption in conjunction with patches of lupus on the face.

The connexion of lupus erythematosus with the same tendencies which evoke chilblains is illustrated by the fact that the parts affected are, for the most part, those which suffer most from exposure to cold-for instance, the nose, ears, and hands. Erythematous lupus is very rarely seen in those parts of the surface which are constantly protected by clothes. It is also always made worse by exposure to wind and cold, and very often there is the history of actual chilblains having occurred on the ears. The conditions are, however, although allied, not identical, and exposure to heat is as injurious to these lupus cases as is cold. Sun-burn of the nose is a common exciting cause.

Although lupus erythematosus is a somewhat rare disease, you have fortunately had, during the last year, many opportunities for examining its peculiarities. I have shown you repeatedly its symmetry, its resemblance to dry eczema, its differences as to vascularity in different cases, its proneness to attack the ears, and its long persistence. On the present occasion I propose to bring before you the notes of many cases, for it is hopeless to attempt to produce an accurate picture of the malady without constant reference to written records. Some of the more important cases I shall read to you in full detail, but of the majority I shall give only short abstracts. These cases will classify themselves in natural division somewhat as follows:-First, the more common type of the disease, in which erythema is the most conspicuous feature; secondly, those in which erythema is almost absent, and the diseased condition of the sebaceous glands is the most obvious thing (for these I shall retain the name Lupus sebaceus); thirdly, cases in which there is a close approach to common lupus; fourthly, cases in which the disease simulates nævus, and is possibly hæmorrhagic; and, fifthly, cases which show affinities with common acne, with chilblains, with psoriasis, and with eczema. This long enumeration may appear somewhat alarming, but if we get hold of the proper clue the subject is really not so complex as it looks. Be that as it may, however, we shall gain nothing by an arbitrary simplification, and it would be a very false policy were I to aim at lightening your labours by any attempt in that direction. We must follow clinical facts into all their details. It would be of no use whatever to tell you that lupus erythematosus consists essentially in the paralytic dilatation of blood vessels, for that is only one part of the process which varies in degree in different cases; nor would it do to separate it utterly from common lupus by asserting that the latter alone presents us with cell-growth, for although cell-growth is comparatively small, it is certainly present in degree; nor, lastly, can we properly fix our attention exclusively on the diseased states of the sebaceous glands, for these, although common, are not invariable, and occur only in certain regions. We must not restrict ourselves, but rather try to get a view of the whole matter and recognise the morbid process in all its various relationships.

That we may be the better able to deal justly with our facts, I will, before going further, give you a brief summary of the opinions of authors. We shall find in the different names which have been proposed for the malady good illustrations of its chief features and also of the fact that these are not always the same.

More than thirty years ago it fell to the lot of Hebra to notice that "certain patients, otherwise healthy, showed sharply defined patches of a deep red colour on the face, especially on the cheeks, nose, and chin." He observed that on these patches the ducts of the sebaceous glands were

very conspicuous, being dilated and plugged by their secretion. He made combined reference to the two chief features by naming the malady "seborrhea congestiva." The term seborrhoea was unfortunate, because there is seldom any flux of the secretion, which latter is rather too much inspissated. The name also failed to recognise the alliance of the malady with lupus. Six years later, in 1851, M. Cazenave, in Paris, described the same malady in its more definitely erythematous forms and named it Lupus erythematosus-a name which Hebra, with that candour which marks his character, at once adopted. In his "Atlas," and in his work on Skin Disease, Hebra employs this term, though he attempts to show that the disease is, after all, one in which the sebaceous glands take the almost exclusive share. This opinion was induced, I cannot but believe, by restricting attention to too few facts. I am not aware that the late Mr. Startin ever wrote upon the subject, but I well recollect being taught by him to distinguish certain forms of this disease (those, no doubt, which first attracted Hebra's attention) under the name of "lupus sebaceus."

In the "Atlas of Photographic Illustrations," published in Paris from the St. Louis Hospital, I find a portrait of very extensive lupus erythematosus of the nose, cheeks,. and forehead, with the designation "Scrofulide erythémateuse." The letterpress accompanying it, which is only meagre, appears to suggest this term for all cases in preference to that in general use, but it certainly does nothing to justify it. The malady occurs sometimes to the scrofulous, but not exclusively to them, and the name omits reference to the sebaceous glands. It would be much to be regretted that any name should be used which should imply a closer connexion with scrofula than is done by that of lupus. We all acknowledge that the latter term involves an association with scrofula in greater or less degree. I show you the portrait to which I have referred. It is a very valuable one, since it gives a life-like representation of a very well characterised and extensive example of the malady. patient is, I think, a young woman, and you will see that her cheeks, nose, chin, temples, and forehead are almost covered with abruptly margined erythematous patches, and that these are placed with almost exact symmetry.

The

I show you also the two portraits published in Hebra's "Atlas." One of these represents the face of a lad with large bat's-wing patches on cheeks and nose. The sebaceous glands are very conspicuously affected, and the surface is roughened over by their open orifices, and the little plugs of dry discoloured secretion which project from them. There is but little erythema. The other is that of a woman of middle age. It would be very difficult from this portrait to distinguish the disease from common lupus. On the lips are some discs, the edges of which are a good deal thickened by a growth which appears to be exactly like the "apple-jelly of the latter malady. Indeed, I am inclined to claim this portrait as proof that the erythematous form and the common form may occur to the same patient.

One of the two portraits given by the New Sydenham Society is that of a lad whose face shows large symmetrical patches like those in the first of Hebra's, with the difference that they are not sebaceous, but rather erythematous only, In this point it resembles the Paris portrait, but it differs from the latter in that the patch is almost single and appears to have been produced by spreading at the edge rather than by coalescence of many smaller ones. The other New Sydenham portrait shows the hands of a boy whose case I shall detail to you at the end of our lecture. It is an example of the most erythematous form of all; indeed, it is all but hæmorrhagic.

I shall conclude this lecture by referring to some of the very rarest forms of the disease, but those in which the vascular element is developed in the most severe degree.

In these for the most part all evidence of implication of sebaceous glands is absent, and the dilatation of capillaries takes place on such a large scale that it is difficult to distinguish the case from one of rapidly spreading nævus.

I may here observe also that the special type of lupus erythematosus is determined to some extent by age. The more purely erythematous type occurs in early life almost exclusively, the sebaceous and less vascular in middle life. Most of the cases in which the extremities are affected, and almost all in which any tendency to bleeding is present, occur in childhood. Two very remarkable cases were shown me a few years ago by my colleague, Mr. Macarthy. A boy

and girl, brother and sister, one about five, the other eight, were the subjects of the most vascular form of lupus erythematosus. In both, the condition affected the cheeks, arms, trunk, and legs. In the girl, the younger, it was less severe than in her brother, and in her the ears were not as yet involved. The conditions had suggested the diagnosis of cicatrising nævus, but against such an opinion is the fact, amongst others, that in neither child did it begin until the age of three. In both children the cheeks and nose were patched over with dilated vessels, looking like a slight form of port-wine nævus, but interspersed with white streaks, which had resulted from scars. The scars were exceedingly superficial, but very positive. The skin of the nose was rendered thin, tight, and glossy by scarring.

A very curious example of erythema-lupus, in which the phenomena of that disease were mixed up with those of nævus, and in which an infant was its subject, came under my notice in October, 1871. I am indebted to Mr. Higgens, who at that time acted as Mr. Streatfeild's clinical assistant at Moorfields, for showing it to me and for allowing me to make notes of it.

Mr. Higgens' patient was a little girl named Alice Waring, aged two years and a half. Both sides of her forehead were covered with large white scars, at the margins of which was a narrow vascular border looking like a partially cured nævus. On different parts of the scar there were little tufts of dilated capillaries. At first sight I felt no doubt that the child had had large superficial nævi which had been cured by cauterisation. On the back of the child's neck was a large white scar, somewhat elevated by puffy tissue underneath, exactly like what results in nævus cured by external applications. On the child's abdomen there was a small vascular stain, unscarred, and in no respect differing from a nævus.

I will now mention the facts which make me say that this case partook of the characters of erythema-lupus, as well as of those of nævus. The patches on the forehead were very large indeed, and at every part presented the vascular border which I have described. Thus, they looked like serpiginous patches healing in the centre, and the mother stated that this was the case, and that they were still steadily creeping on. Then, too, the mother asserted that when the child was born no red marks were observed, and that it was not till a week after birth that some very small red spots were first observed on each temple. These spots spread very rapidly. The diseased skin inflamed spontaneously, became covered with scab, and afterwards resulted in scar. No escharotic treatment had ever been adopted excepting to one small patch. The patches, as they inflamed and healed in the middle, had continued to spead at their edges.

The

This history of spreading edges and spontaneous ulceration does not fit with what we know of ordinary nævus. following fact is, however, yet more conclusive as to the difference. At the age of six weeks the child's upper lip and nose were attacked, and the resulting ulceration destroyed a considerable portion of the septum. At present the upper lip shows a thick vascular patch, only moderately florid and in parts seamed with scar. The nose is not sunken, but there is a large notch in the columna. At the age of four months the child's right cornea inflamed, and a large white scar has resulted. There appeared reason to believe that the child inherited a strumous diathesis from its father, who was, the mother said, a delicate man, liable to eruptions, etc. None of her children had enjoyed good health, and one of them had suffered for long from abscesses in the neck.

Our patient was a little, feeble-looking girl. I could find nothing in the history to support a suspicion of inherited syphilis.

Such cases as these show us lupus erythematosus in very close connexion with cicatrising nævus. By nævus, however, we understand a condition of dilatation of capillaries which is congenital. If the condition begins a year or two after birth, then it comes into a different category, but it is clear that the association is very close. The boy whose hands are figured in the New Sydenham Society's plate supplies us with facts which are of much interest in this association. You will see in the portrait that the hands are covered with deep purple vascular stains, looking much like the port-wine nævus, but with the difference that the disease is evidently more or less inflammatory, since it does not remain stationary like a nævus, but spreads and cicatrises. Interspersed amongst the red patches are white streaks which

result from scars. We have also the further distinction from nævus that the disease did not commence till he was seven years old.

I will read you the particulars of this case, in most respects the most severe that I have ever seen :

Arthur D. is a very fair-complexioned lad, aged fourteen. He is the subject of a very peculiar form of lupus erythematosus. It began when he was only seven years old, on his forearms. At this time he wore short sleeves, and when longer ones were supplied to him the inflammation left the forearms and passed down to the hands, where it still persists. Two years ago it attacked his face. It began on his feet about the same time as on his forearms, and it here attacked the heels, soles, and toes first. It was early spring when it began. Before that he had always been delicate and feeble, and could not eat well. He was liable to "bilious attacks." He rather dislikes fat. He is very thin, but has never had cough. There is no history of consumption in the family of either parent. The boy had not had any exanthem or other illness before the lupus appeared. He does not complain (subjectively) of cold weather-says, indeed, that it suits him quite as well as hot; but his mother informs me that in childhood his feet were always cold, and used to perspire so much that "his socks were always wet.' At the age of three so much was this the case that he had washleather socks made, to wear under others, but still with the result that both were always damp. He is very liable to "c like cold hands, and when chilled his hands become stones," and "dead cold." In childhood he had bad chilblains on the feet, but not on the hands; they never broke. · He does not dislike cold weather, if it be not damp. He was once taken to the seaside, and there got worse, his face swelling up much. In hot weather the patches show more, becoming of a deeper red. On the forearms, no scars, or only very doubtful ones, have been left.

Present Condition of the Disease.-(On Face.)-His nose, cheeks, lips, and ears are congested, and with patches of dilated capillaries, presenting a condition which in an adult might be mistaken for the effects of drinking. On minute inspection, however, his nose is seen to be roughened by sebaceous accumulations (lupus sebaceus), and on his neck beneath the ears are patches which resemble dry eczema. The patches are symmetrically placed, and nowhere is there any positive lupus deposit or scar.

(On Hands.)-Here the disease is much more positively lupus. It affects the thumb and all the fingers and the borders of the hand, but leaves both the palms and the back surfaces free. On the thumb and fingers the dorsal and palmar aspects are both involved. They are deeply congested, and the patches of congestion are well margined and with slightly raised edges. They are rough on the surface from epidermic peeling, and here and there accumulations of horny epidermis have formed, but nowhere is there actual ulceration or pus-scab. There are numerous scars left where the inflammation has ceased. The tips of the fingers are pointed, their pulps having withered. His thumbs are stiff from the contraction and atrophy of all the soft tissues; no actual anchylosis of joints.

(On the Feet.)-The disease affects chiefly the edges of the sole, the whole of the heel, and most of the toes. The epidermis is thickened and split up, and there is violent congestion at the borders of the patches. His toes resemble his fingers. The backs of the feet and the middle of their soles are free.

He has never taken much medicine, but for two years he took cod-liver oil without any perceptible benefit. During His hands are the last year the disease has got much worse.

so tender that he can scarcely use them for anything. The following note refers to his condition on September 21, 1871:

He has had an illness (fever with swollen glands) at home, and his eruption has almost disappeared from the face. It leaves a few lichen spots and numerous dilated venous capillaries in tufts. Thus, his nose and adjacent parts of cheeks are red like those of a spirit-drinker. His hair is falling, and he has some branny desquamation over the whole scalp. His hands are still tender and red. His mother tells me that tonics (quinine) given after his illness brought out His feet are the eruption and made his face red all over. still very prone to get damp and chilly. After this date I lost sight of the boy, and could obtain no further information as to his progress.

ORIGINAL COMMUNICATIONS.

PRACTICAL NOTES ON

THE ORDINARY DISEASES OF INDIA,

ESPECIALLY THOSE PREVALENT IN BENGAL.

By Dr. CHEVERS.

FIRST among the many new impressions which the mind of the observant physician receives, on landing in India, is a strong conviction that, before he can resume in his new home the practice of his profession with satisfaction to himself and advantage to his patients, he has a good deal to learn, and probably much more to unlearn. In this respect the path of him who has previously gone through the admirable course of special instruction afforded at Netley is greatly facilitated; but many go to India who have not enjoyed the advantage of a Netley training; and I have long thought that, to them, some practical hints from one who has encountered the difficulties with which they will have to contend when they enter upon Indian practice will be useful and acceptable. I also think that these notes may assist our students at the London Hospital, and at other hospitals at European ports where many persons suffering from Indian diseases are constantly under treatment.

When I joined the Indian Medical Department I had been somewhat unusually fortunate in having steadily worked in the hospitals and medical societies of London for twelve years. Still, the first thing that struck me, in practising in Bengal, was that DOUBT beset me on every side. As I advanced, I soon began to discover that my knowledge was more troublesome even than my ignorance; and that, while I had to learn how native patients ought to be dieted, when quinine can best be administered in remittents, and what are the uses of the chief drugs in the native materia medica, and to satisfy myself upon a hundred other questions of the greatest local importance, I found that I had before me the still more difficult task of divesting my mind of a host of strong opinions-such as that the medical man should never leave his house without his case of bleeding-lancets, that colchicum is "good" for rheumatism, that mercury is supreme in hepatic diseases, and that cathartics are therapeutic agents of almost Morisonian universality. In fact, I only avoided great mischief by the observance of strict moderation and the most vigilant caution.

My object is to give my readers, in the following notes, that information of which I then found myself most in need. Except for illustration, I shall avoid the discussion of points with which every well-educated young English physician may be expected to be familiar: my wish being to enable my reader to bring his home knowledge up to the Indian standard.

Nothing can be farther from my design than to attempt to write an elaborate systematic treatise upon the diseases of India, or a work of deep literary research. Except where small collections of Indian statistics are needful, and reference has to be made to local publications which are scarcely accessible to the English physician, I shall merely record with extreme brevity the leading results of my own clinical experience, corrected and amplified by the observation of others. A few remarks upon

THE GENERAL CHARACTERS AND COMPARATIVE FREQUENCY OF THE DISEASES WHICH PRESENT THEMSELVES TO THE NOTICE OF THE PHYSICIAN IN BENGAL

will not be out of place here. On my first arrival in India, I was told by a medical man of great local experience, "All the diseases of England occur in abundance here." I, however, soon began to notice that this observation was not to be freely accepted. Several of the most prevalent diseases of England are either unknown or rare in India. Neither I nor any of my professional associates ever saw a case of Scarlatina in that country, although it is to be feared that this disease is beginning to be introduced there in troop-ships. I never treated a case of Typhus, nor heard of any except a few which one of my colleagues believed occurred in his practice in Calcutta. True Enteric Fever prevails from time to time in Calcutta, and it appears to be increasing in frequency; but it is happily not common. It probably did not exist in India fifty years ago. True Scirrhus is very rare,

both in natives and Europeans. A good many cases of Medullary Cancer occur among natives of the poorer classes. A few years ago, Erysipelas, both in its idiopathic and traumatic forms, was almost absent from Calcutta. I never treated but one case of idiopathic facial Erysipelas in India. But, of late years, the traumatic form has become nearly as prevalent in all the hospitals of Calcutta as it is in those of London. The idiopathic disease appears to be upon the increase, and with it has appeared its congener, Puerperal Fever, previously a rare disease. Those conditions of the glands and joints which are commonly known as "Strumous " occasionally present themselves in poor natives, but they are by no means prevalent. I should have known very little of this class of diseases had I depended solely upon what I saw of it in Bengal.

The physician will not have practised long in India before he meets with a case of Phthisis; but the disease is comparatively rare in that country. Thus, unless a European takes latent tubercles with him, he can scarcely become the subject of tuberculosis in India, except under very exceptional circumstances. Natives suffer from Phthisis-but in this manner. In England a city hospital usually refuses to admit cases of Phthisis, or the whole of its beds would become filled with the consumptive, and yet every form of tubercular disease is constantly to be seen in the postmortem room. In Calcutta, during the cold season, my native wards were generally nearly filled with cases of Phthisis; but, the disease being one of my specialities, I never refused a case; and I believe that the other physicians' wards and mine contained nearly all the phthisical poor in a city of 400,000 inhabitants. It has been said that, at home, the Englishman generally dies at the lungs; it is equally true of the native of India that his natural death is by some form of intestinal flux. The Anglo-Indian is not at all peculiarly liable to either pulmonary or intestinal disease; and, in retirement to his native land, he has, I think, a decided advantage over his contemporaries who have remained at home, in the fact that, while he is not remarkably subject to bronchitis, his bronchial tubes have been far seldomer visited by catarrh than theirs have, and have therefore a fair chance of retaining their integrity longer. Among the ill-fed and badly clothed poor of India, Chest Inflammations occur during the cold season and rains, which try them very severely; but cases of Pneumonia and Pleurisy are far less frequent in Bengal than in England. Among the poorest natives Pneumonia of the apex is rather common. Apart from Hepatic Abscess and Kirrhosis, Diseases of the Liver are not prevalent in India. Sallow complexions and jaundiced eyes are much more frequently seen in London than they are in Calcutta. Those forms of Dyspepsia which so frequently render life almost unendurable in England are nearly unknown in India. There, if food disagrees it may cause diarrhoea; but heartburn, gastric distress after meals, and dyspeptic hypochondriasis, very rarely occur. This is, I believe, due to the fact that, in England, the skin generally acts imperfectly for nine months in the year, and the con-sequence is chronic portal and hepatic and gastric congestion. India, too, has its portal congestions, but they are not generally chronic, the skin for nine months in the year doing its duty fully.

I believe that Hydatid Disease never originates in any part of India. Tape-worm is not uncommon among the lower class of Europeans. I think that all of my many patients acknowledged that they were eaters of raw meat. European ladies and children occasionally suffer from Lumbrici. Native children are very liable, and native women of the poorer class are so almost invariably the victims of these parasites that my house-physician was instructed to order infusion of quassia as the vehicle of every fluid medicine prescribed in the female ward.

True Acute Rheumatism occurs distinctly, but very rarely, in Bengal. I seldom met with more than one or two cases every year in Calcutta. In these, cardiac complication was liable to occur. Two of the cardiac cases proved fatal within my observation, one in a native lad in my own ward, the other in a European gentleman whom I visited with a friend. Chronic Cardiac Disease, of rheumatic origin, is very rarely produced in Bengal. I once attended an English civilian suffering from moderate symptoms of Gout. Subacute arthritic and muscular rheumatism is not uncommon, but is usually mild and transient. The so-called Chronic "Rheumatic" affections of natives will generally be found to be

of malarious origin, and may therefore be more properly termed "neuralgic," and be treated as such.

True Morbus Brightii is certainly far less common in Bengal than it is in London, still cases frequently occur in natives, especially the intemperate; and I can recall several fatal cases in officers who have lived carefully. As frequent attacks of intermittent fever induce Kirrhosis of the liver, malarious influence-and probably also excessive sweatingappears to be capable of setting up organic renal mischief. I have seen a good deal of simple albuminuria, both in young and old Indian officers, apparently unassociated with permanent disease of the kidneys. Such cases, well sifted,

would probably range themselves under the head of Intermittent Albuminuria dependent upon spanæmia and serous hæmorrhage.

Croup is said to occur in the hills of India, but I think that this statement requires confirmation. I never saw or heard of it in Bengal, where, however, Diphtheria is not infrequent, and Spurious Croup is very prevalent during the rains. (a)

It will thus be seen that, although the popular idea at home is that Bengal is a very deadly climate, and although a military surgeon has recently (not without reason) called India "the worst country in the world," those Europeans who seek fortune in the East may fairly reckon upon a very singular immunity from some of the gravest diseases of Europe; while, as regards the deadliest maladies of the East, well-to-do Europeans are very little liable to Cholera, the premonitory diarrhoea of which may generally be checked. Whereas attacks of Fever, Dysentery, and Hepatic Abscess are almost always avertible when quinine and ipecacuanha are promptly and judiciously employed. Parturition is, doubtless, more generally easy (except among immature native girls) in India than in Europe; but the tendency to post-partum hæmorrhage, owing to spanæmia and deficient muscular tone, is certainly greater. (b)

Except the nobility and landed gentry of England, no class in the world are more "well-to-do" than European officers and gentlemen in India, or generally lead more temperate, regular, and moral lives. In old times, India gained most of its reputation as a deadly climate from the writings of ships' doctors, who observed disease as it occurred in sailors, debilitated by sea-scurvy, on the loose in Indian ports, at a time when mercury and bleeding were the leading therapeutic indications. Now mercury, leeches, and bleedinglancets are almost unknown in India; and the consequence is, that although occasionally attacked with Malarious Fever and Dysentery, a large proportion of educated English gentlemen and ladies and well-conducted soldiers live very healthy lives in India, and retire with fairly preserved constitutions, which, with due care, bear the change to England not only with impunity, but with singular advantage.

Still, almost universal as temperance is among welleducated Europeans in India, it was probably the exception in all classes until of late; and even now, European roughs, and men who cannot devote their leisure either to books or to field sports, are generally drunkards. Now, as of old, many an English mother exclaims, "India killed my poor boy!" where, could she only know the truth, she would perceive that his mode of living was so intemperate and so grossly imprudent as to be incompatible with longevity in any climate.

On the darker side of the picture we have to observe the fact strongly defined by one of my professional friends in the axiom, "We, in India, work remarkably well, but we are nearly all a parcel of screws." That is to say, the European constitution deteriorates in India, as it does everywhere else, as life advances, but probably by different modes of decay and mal-nutrition. Thus the old Indian is generally either thinner or much fatter (both externally and internally) than he ought to be; and there must be something very wrong, constitutionally, with those multitudes of Europeans in India who cannot swallow a dose of

(a) It appears from the recent report of the Committee of the Royal Medico-Chirurgical Society on Membranous Croup and Diphtheria (Lancet, October 26, 1878) that we are not at present able to draw a clear line of distinction between these two (if they be two, and not one) morbid conditions. I have seen several cases of membranous laryngitis and a great deal of laryngeal diphtheria, but have never met with a case of true membranous croup. None of the above cases, except the many sufferers from false croup, which is a mere neurosis, had the characteristic brassy cough. Indeed, I do not see how such a cough can be produced where the upper air-passage is generally inflamed and lined with a tube of exudation matter. (b) As I may not recur to this subject, I may mention that I usually gave ergot as soon as I was convinced that the head was about to pass.

Epsom salts or of Seidlitz-powder without imminent danger of Asiatic cholera, (c) or stand for five minutes in a draught without shivering and falling into a paroxysm of intermittent fever. It is not so much by violent attacks of disease that the constitutions of prudent Europeans in India become impaired, as by the insensible but constant operation of mischievous climatic influences, such as the marsh-poison and the violent transitions of temperature, producing undue cutaneous action alternating with portal and other venous congestion, from which no one can entirely escape. True, we drain our cities and cantonments, spend a large proportion of our income in obtaining healthy residences, and clothe ourselves all the year round in outer garments of flannel, knowing that our predecessors often got their death by dressing in linen. Still, these morbific influences are constantly at work, producing fatty, fibrotic, and amyloid changes in the viscera, and deteriorating the blood and loading it with waste material which the degenerating liver, kidneys, and other organs can no longer adequately eliminate. We, the Indian doctors of the old school, have, I think, done our part in investigating and contending with the outward maladies-fevers and fluxes-which abound in India; but our successors, who have learnt from us to regard pathology as physiology gone astray, may hope to effect very much more than we have achieved in the prevention and treatment of the constitutional diseases of India.

(To be continued.)

AN ANOMALOUS CASE OF PEMPHIGUS TERMINATING FATALLY.

By ALFRED SANGSTER, M.B., Physician for Diseases of the Skin to Charing-cross Hospital. THE following notes were extracted from a report of the case made by Dr. Robert Smith, Medical Registrar:

G. H., a tailor by occupation, was admitted into Charingcross Hospital on May 1, 1878. He was sixty-eight years of age, and had had good health up to the time of the onset of the malady for which he was admitted. According to his wife's statement, he had been a heavy drinker, having "been on the drink for days together." Apparently in connexion with these drinking bouts, he had recently had two epileptiform seizures.

His wife further supplied the following statements regarding his present illness. About six months ago he began to complain of red raised spots on the skin. They were at first "solid," and no larger than shirt-buttons, but soon became "watery," and attained the size of shillings. They itched intensely, and the patient gained relief by pricking them and evacuating their contents. Although each spot ran its course in from eight to ten days, fresh spots continued to make their appearance until the skin became covered with crusts, and the patient "looked like a leopard." Latterly the spots had coalesced. After the skin became affected a troublesome cough had been present, and for the last six weeks the legs had been swollen and red.

Various kinds of treatment had been pursued, but without relief; on the contrary, "salves had made the skin worse." It was ascertained that at one time the patient took iodide of potassium. On May 8 (when Dr. Pollock, under whom the case was admitted, kindly transferred it to me) the patient's expression was anxious, and there was some degree of wandering. Pulse hard and full; respirations 40. Urine pale, specific gravity 1018, acid; albumen one-twentieth; oxalate of lime crystals detected by the microscope. Appetite good. The condition of the skin was as follows:A few blood-crusts, and papules surmounted by bloodcrusts, were to be seen on the face and scalp. The skin over the sides of the neck was coarse-grained and infiltrated like prurigo-skin. Almost the entire surface of the trunk, excepting the upper part of the thorax-back and front-was red, and towards the lower part of the abdomen and in the loins, oedematous. The erythematous surface was covered with patches of coarse vesiculation, the pattern of which caused an appearance resembling Herpes. The vesicles, or rather the small bullæ, became confluent in many

(c) I never gave a dose of either of these medicines in India, and I never gave more than half the ordinary dose of any purgative at a time to a European, recommending the patient to repeat the dose if needful. The second dose was scarcely ever required.

places, and gave rise to large map-like, flattened, flaccid bullæ, filled with milky serum or more purulent contents. Here and there, bullæ had collapsed, leaving a thin dry incrustation. Where the bullæ had been ruptured, especially on the back, whole regions were excoriated, the surface being moist with exudation or covered with shreds of sodden epidermis as if the part had been scalded. Towards the shoulders the erythema was festooned in outline and devoid of vesicles or bullæ. On the buttocks, thighs, and arms the appearances corresponded with those just described-flattened, map-like bullæ, and excoriated surfaces. On the legs, forearms, and dorsal surfaces of the hands and feet there was more sound skin to be seen, with occasional flattened and isolated bullæ. There were also round and oval-shaped patches of yellowish skin, not raised, and differing but slightly in appearance from the surrounding normal surface. On sliding the finger over them, the epidermis, which had lost organic continuity with the structures below, readily became detached, disclosing the moist rete. The palms and soles presented none of these abnormal appearances. Ordered-R. Liq. sod. arseniat., mvij.; tinct. cinch. flav., 3j.; syrup. aurant. mxx.; aquæ, ad 3j.-M., t. d. s.; after food. R. Liq. pbi. diacet. dil., 3iv.; glycerin., 3ss.; aq. chlorof., ad 3x.-M.; ft. lotio; the surface to be wrapped in linen moistened with the lotion.

May 9.-A few moist sounds to be heard towards the bases of the lungs. No evidence of fluid in any of the cavities. The fluid from the interior of the blebs found to be very albuminous, showing under the microscope numerous white cells and moving point-like bodies (bacteria).

11th. To be fed every four hours night and day: champagne, milk, beef-tea, etc. R. Zinci oxid., pulv. amyli, āā æquales partes; to be used instead of the lotion.

12th.-Fresh bullæ seen on legs and thighs; tremor, muttering.

15th.-Patient gradually sinking. An erysipelatous blush round right eye.

Blebs continued to come out. The older patches of disease showed flake-like crusts in many places, and the erysipelatous blush spread over the side of face, but no bullæ appeared on it.

The patient died on the 18th. The temperature ranged irregularly between 98.4° and 102° during the time he was under observation.

Necropsy, thirty-six hours after Death.-The body showed signs of decomposition, green discoloration of abdominal walls, and dusky lines mapping out the veins over upper part of thorax. The trunk and extremities were covered more or less with yellowish-brown incrustations, in appearance not unlike flaky pie-crust. The legs were oedematous. There was a depressed cicatrix to be seen on the anterior and upper part of the glans penis. No scars in groins. About a pint of serous fluid was found in the peritoneal cavity, but no inflammatory appearances were present. Both pleural cavities contained some fluid of a bright-red colour-the right cavity about twelve ounces, the left about nine ounces. The left lung showed old pleural adhesions; both lungs were emphysematous, and very oedematous on section. The heart weighed eleven ounces; the right ventricle was dilated, and the ventricular wall thin. Much fat was deposited on the heart externally, and the muscular substance itself showed fatty degeneration. There were patches of atheroma in the aorta, and the coronary arteries were also atheromatous. The endocardium and inner surface of the aorta showed postmortem staining. The liver weighed three pounds eleven ounces and a half; it was pale, and the cut surface greasy. The kidneys weighed-left seven ounces, right six ounces. Both capsules were adherent. Microscopical examination of the kidneys showed the only marked change to be in the capsules, which were thickened. The spleen was small, weighing two ounces and a half. The capsule was thickened, but no other unusual appearance was seen. It is to be regretted that the stomach and intestines were not examined, the omission being due to the fact that this necropsy was performed rather hurriedly with several others the same afternoon.

Remarks. Of late we have increased our knowledge materially with regard to the nature of bullous eruptions, so that, instead of being at once dismissed and treated as Pemphigus, they are now scrutinised with the view of determining whether they may not occur as accidents in other forms of acute inflammations of the skin, where the "type"

more generally stops short of exudation between the Rete and the Stratum Corneum. Again, we have been shown lately that drug-poisoning may give rise to bullous eruptions. True, the eruption described by Mr. Hutchinson as due to iodide of potassium is made up of small bullæ, and more closely resembles the so-called Hydroa; but, if small-sized bullæ may be produced by iodide of potassium, may not larger bullæ be produced by other substances? The frequency of urticaria as produced by drugs is interesting in connexion with this point, especially as urticaria sometimes becomes bullous. The Acarus Scabiei has been known to cause a bullous eruption such as has been mistaken for Pemphigus, not only in children, in whom the mistake occurs tolerably often, but also in adults. Lastly, there are to be found in medical literature, reports of bullous eruptions, which appear to be due to bloodpoisoning, such as the case reported by Sir G. Burrows, of the eruption produced in a butcher after a poisoned wound (Medical Times and Gazette, June 14, 1856). A few lines of his general description may be quoted:- The external appearance of this eruption generally resembles that of acute Pemphigus, but not altogether, for we observe that in some parts, this vesicular eruption resembles the aggravated form of Herpes, the vesicles being small and congregated together with inflamed margins. In other parts the vesicles are larger and isolated, the eruption more closely resembling pemphigus. In other parts the surface appears blistered as by the action of boiling water." In connexion with this simultaneous appearance of herpetic-looking vesicles and bullæ on the skin, Cazenave says (Gazette des Hopitaux, October, 1850), in describing a general herpetic eruption which occurred in a girl-" The vesicles, instead of as heretofore enjoying a separate existence, became opaque and ran together, forming bullæ, giving the eruption the appearance of chronic pemphigus. It often happens, indeed, that by an insensible transition one of these eruptions is converted into the other. We have remarked this more than once in old men." Mr. Hutchinson ("Lectures on Clinical Surgery," vol. i., part i., page 61) gives a case combining some of the features of Herpes and Erythema multiforme with Pemphigus. Now, with regard to the case above reported, it certainly did not look like pemphigus, for the pseud-herpetic eruption formed its chief characteristic, and most of the bullæ were obviously formed by the confluence of the vesicles on the herpetic-looking patches. The flaky crusts and the abortive isolated bulle on the legs suggested Pemphigus Foliaceus, but the appearances did not correspond to those described in that disease (whether, later on, if the patient had lived, they would have done so, may be open to question); still, if the history, imperfectly as it could be ascertained, be accepted, the case clearly commenced as a case of pemphigus. The continuous outbreak of small itching bullæ, extending over a long period of time, is a common history in pemphigus attacking old people with broken constitutions; and in fact is always the precursory condition in the almost uniformly fatal variety, Pemphigus Foliaceus. The pseud-herpetic eruption only simulated Herpes in the clustered arrangement of the vesicles and small bulla: the latter were flaccid, their bases were irregular and zigzag in outline, and they rose from the surface in an inclined plane-conditions precisely opposite to what is seen in Herpes. The course of the eruption, so long as the patient was under observation, was not that of Herpes. No pain was ever complained of. In endeavouring to account for the pseud-herpetic eruption in this, and probably in some other cases that have been described, I would venture to suggest that it is an Erysipelas induced by the absorption of pus from the pemphigus bullæ. In support of this it may be mentioned that erysipelas often accompanies diseases of the skin, such as acute eczema, variola, lupus, where pus is pent up beneath crusts. The patient's general condition was such as frequently accompanies erysipelas, and he actually had a patch of erysipelas on the side of the face, although there were no vesicles or bullæ on the affected surface. The disease, then, might be summed up as pemphigus complicated secondarily with vesicular and bullous erysipelas. As regards the postmortem appearances it may be stated, in connexion with the fatty liver, that the same condition is described as being almost constant in Pemphigus Foliaceus. Microscopical examination of the affected skin showed, besides the usual appearance of inflammation (cell infiltration, etc.), a plugged condition of the small vessels exactly similar to that seen in pyæmic viscera, and said to be due to the presence of