I do not believe that women in the early settlement of this country were so liable to laceration of the perineum as they are to-day, because they were so much more robust and healthy, with broad, expansive pelves; while, upon the other hand, we find women of this generation with narrow, contracted pelves, which, as we all know, increase the danger of bearing children. This, no doubt, is due to the manner in which women of this latter age dress and live. As this is well understood by you, I shall not enter into details.

Therefore, gentlemen, I would recommend that each and every one of you go to your cases of labor well equipped with needles, thread, and silver wire, so that if the emergency presents itself you will be prepared to combat it without delay.

My after-treatment in these cases is an iodoform dressing, keeping the parts perfectly clean and keeping the knees bound together with a bandage to prevent separation of the parts.

The sutures should be removed on the eighth day, as this is generally quite sufficient time for union to take place.

It has not been my purpose in writing this paper to take in the scope of this subject, nor to offer any thing of a new and startling nature, but simply to call your attention to some very important facts that have been heretofore overlooked by the generality of the profession.

BOWLING GREEN, KY.

ARSENIC IN SKIN DISEASES.*

BY JOHN EDWIN HAYS, A. M., M. D.

Professor of Anatomy and Clinical Lecturer on Diseases of the Skin, Hospital College of Medicine.

It can not be denied that arsenic has long enjoyed a high and honorable place in cutaneous therapeutics. If we take a survey of dermatological literature we find wonderful accounts of the success said to be attained by the use of this drug. Many practitioners are inclined to regard arsenic as the most serviceable agent we possess in many of the more obstinate forms of skin trouble. So almost universal is the belief in its virtues it has become in fact a widely prevailing custom among many physicians to rely chiefly upon its use in a large range of skin affections.

It is nevertheless true that the use of a remedy is not in itself proof of its value; and therefore it is that the claim of arsenic as a specific is

*Read before the Medico-Chirurgical Society, February 8, 1895. For discussion see page 227.

an occasionally contested one. I think that it can be truthfully affirmed that a healthy and growing skepticism is the present attitude among not a few members of the profession, especially in this country, as to what arsenic is capable of accomplishing in skin affections. As a consequence of this we are now in better position to estimate the true merits of the remedy. It has become a well-established fact that the claims have been greatly exaggerated, and that in many cases the remedy has been very injudiciously used. This has resulted in largely restricting its use. I have little personal experience to offer as regards the use of arsenic in diseases of the skin. While not desiring to speak too disparagingly of the remedy or question the good faith of those who are such enthusiastic believers in its virtues, I feel bound to say that my own experience has led me to conclusions not favorable as to its efficacy. Indeed, I am strongly disposed to believe that the control exerted by arsenic, even in the so-called properly selected cases of skin troubles, is very limited and uncertain.

I have more often employed the remedy in psoriasis than in any other form of skin disease. The drug is by many observers regarded as of great value in the removal of this often most obstinate affection. From what we know of the action of arsenic upon the epithelial structures of the skin, this disease would more likely than any other yield to its influence. I can only remember of two cases of psoriasis of long standing, where the remedy was used to the limit of tolerance by the patient, in which satisfactory results were obtained. As both cases, however, were also using approved local remedies in conjunction with the arsenic, it would be impossible to accurately calculate the amount of good effected by the drug. It is worthy of mention that in both these cases there was a recurrence of the trouble in as nearly bad form as before. In one case the disease returned after an interval of nearly two years; in the other after an interval of a few months. The treatment of psoriasis is oftentimes so unsatisfactory that almost any remedy that promises to remove the difficulty, even in a measure, is worthy of consideration. I do not remember to have seen any record of cases in which the internal administration of arsenic was the sole treatment in psoriasis so as to be able to accurately gauge its value. It is the only internal remedy which seems to exert any real influence over the disease, and that is by no means uniform. It is only after the disease has existed for a considerable length of time, and the patches have almost if not entirely ceased to spread, that arsenic should be resorted to. If

given earlier it has a tendency to aggravate the trouble. It is to be regretted that we do not know the precise way in which arsenic acts in these cases. As psoriasis is essentially a disease characterized by an inflammatory overgrowth of epithelial cells, a prominent authority suggests that arsenic does good by stimulating the cells of the epidermis to exhaustion, and that destruction overruns construction. Hebra and Kaposi give arsenic in psoriasis in combination with black pepper, each pill containing one twelfth grain of arsenious acid, and is known as “Asiatic Pill." They recommend that one pill be given three times daily, and the number gradually increased until ten or twelve, if tolerated, are taken daily. If no improvement results after five hundred pills have been taken the remedy is abandoned as a failure.

It has been my usual custom when prescribing arsenic in psoriasis to use the iodide, beginning with a very small dose and increasing slowly until the physiological limit is reached as evidenced by the usual injection of the conjunctiva and itching of the lids.

The use of arsenic has been advised in certain forms of eczema, especially in the dry and scaly form, which have persisted for months or years. My first experience with this drug in eczema was obtained during my terms of service as resident physician in the Louisville City Hospital in 1880. I had then several cases of eczema that puzzled me greatly by their persistency. Fowler's solution was used in all without exerting any control. In fact it seemed at times to do harm by intensifying the process. Having early received an unfavorable opinion as to the influence of arsenic upon eczema, I have used it very little since that time in the affection, but occasionally have had patients upon whom it had been thoroughly tried in this variety of eczema without benefit. It is my opinion that when we examine the proofs upon which its reputation is based in this exceedingly common form of skin trouble we shall find little to encourage us in the belief that it possesses any power of removing the affection superior or even equal to many other remedies. There are several other affections of the skin, among which may be mentioned acne, lupus, lichen ruber, and pemphigus, in which arsenic is supposed to exert a curative influence. I have no experience with the drug in any of these affections. As prominent an authority as Jonathan Hutchinson claims that arsenic possesses almost specific power over pemphigus, and also that it accomplishes great good in dermatitis herpetiformis.

There is a feature about the internal administration of arsenic that deserves attention, and that is the liability of the drug itself to produce

certain affections of the skin. A case was recently reported in the British Journal of Dermatology in which three minims of liquid arseniatis produced a violent and almost universal erythema, the eruption being most marked on the chest, abdomen, thighs, and upper part of the arms. Upon the fingers were numerous little papules. The conjunctivæ were slightly injected and there was also some diarrhea. Upon discontinuing the drug the eruption gradually left, being followed by light furfuraceous desquamation. The whole amount of the arsenic taken by this patient was fifteen minims of the solution. Moreover, it is a well-known fact that the drug sometimes causes an attack of herpes zoster by inducing a peripheral neuritis. A patient of mine, a large, fleshy lady, about fifty years of age, developed an attack of herpes while taking arsenic for the relief of malaria. The outbreak was confined to the upper and back part of the thigh on one side to the area of skin, in all probability supplied by the small sciatic nerve.

It is also worthy of notice that the long-continued use of arsenic occasionally causes pigmentation to occur in the skin, on the face or other parts of the body, which are very difficult to remove. As arsenic is sometimes taken with the view of improving the complexion it would be well to bear in mind that the remedy may aggravate the very condition it is expected to remove.

In conclusion I may venture to say that, in view of its disadvantages, its limitations and uncertainties, arsenic is rarely called for in the management of skin affections.

LOUISVILLE.

NOTES ON THE PRACTICE OF ORTHOPEDIC SURGERY AT THE CLINIC OF PROF. LORENZ, IN VIENNA, MARCH, 1892.

BY JAMES B. BULLITT, M. D.

[Continued from page 169.]

Osteoclast. The Lorenz osteoclast consists in two stout plates about eight inches high and six inches wide, the apposed surfaces being slightly convex and padded with inch-thick rubber plates, slightly larger than the iron plates. These plates are fixed in and moved by thumb-screws so that they can be made to grasp, as in a vice, the limb that is to be osteoclasized. The heavy rubber pads prevent any damage to the tissues, such a thing as an abrasion of the skin even being

an uncommon occurrence. We will say it is desired to produce a fracture at the lower third of the femur: the femur is grasped firmly in the vice-like device described above, the point selected for the fracture being brought just even with the edge of the iron plate. A heavy leathern sling is now thrown over the lower end of the femur; the two ends of this sling are provided with holes and are caught on two pins. which project from the end of a threaded rod. This rod runs through an iron holder, on the other side of which plays a bar three to four feet in length, perforated in the center with a threaded hole into which the

threaded rod runs. The length of this bar gives a tremendous leverage, and it is possible to exercise by means of it a breaking force with the little finger of one hand. The angle made between the limb to be broken and this bar and sling arrangement is somewhat less than a right angle, the idea being that, by the time the bone fractures, the 'give" due to the elasticity of the bone will have rendered this angle about a right angle. This osteoclast has decided advantages over any yet devised. In the first place it is possible to fracture a bone absolutely and certainly at the point elected, and without doing damage to adjacent and surrounding structures. The force can be so nicely gauged that not more than enough is ever employed to effect the fracture, and the fracturing itself removes and relieves the force employed