an ounce of brandy again introduced into stomach. September 4th. Doing fairly. Cough still troublesome. Took some broth in night, and an egg-nog this morning. Slough pretty well off wound, but skin on its edges is red and irritable looking. This is probably in part due to escape of liquids that are swallowed. Pulse 88. Bowels regular. September 6th. No food injected into stomach yesterday. Does not seem quite so well. Wound looks more sloughy. A large piece of dead tissue removed from deeper part of wound. September 7th. Gave two meals by tube yesterday. Seems rather stronger to-day. No food, except brandy and water, to be swallowed till none comes out through wound. This assented to reluctantly by patient, who dislikes very much the introduction of tube. Discharge is copious this morning, and some more sloughy tissue removed. September 8th. Wound less open and not so inflamed. A smaller tube used to-day, No. catheter. No. 12 causes some bleeding. Has had two meals a day of milk and brandy for last few days. Seems a little nauseated by a pint; to have less than that amount, and it is to be given the day instead of twice. September 10th. Cough continues troublesome. Mustard poultices relieve it somewhat. Simple enemata used to procure motion of bowels when required. September 15th. Wound healing. Cough so troublesome that Dr. Coburn gave an enema of chloral to produce sleep. September 22d. For last few days Dr. Coburn gave a bromide of potash and tinct. lupulin mixture, with good effect on cough. Wound nearly healed. No fluid passes out of wound on swallowing. May therefore omit use of tube, and take soft solids and liquids ad libitum. September 29th. Swallows well. October 2d. Wound entirely healed. Able to go out-of-doors. three times in Remarks. At the time of writing, February 13, 1879, the patient swallows without difficulty, and with the exception of her old asthmatic cough is quite well. I would state also that I am much indebted to Dr. Coburn, who in my absence conducted the patient safely through her sickness after September 10th. In another case I should not allow nourishment to be taken so soon by the mouth, for I cannot help thinking that the wound was made unhealthy by its contact as it escaped externally. RECENT PROGRESS IN DERMATOLOGY. BY JAMES C. WHITE, M. D. Classification of Skin Diseases. The system of classification and nomenclature adopted by the American Dermatological Association at its last annual meeting, and published without comment in the JOURNAL for December 12, 1878, is presented to the profession by the committee1 not as a perfect scheme, but as the result of long-continued study and effort on their part to simplify systems now in use. As it was modeled upon that of Hebra, a brief notice of some of the modifications adopted will be of importance, as there can be no doubt that it will commend itself in time to the medical profession of our own country at least. In the first place, Hebra's twelve classes are reduced to nine by dropping the first two, hyperemiæ and anæmiæ, as artificial and unnecessary, and by placing his two groups of benign and malignant new growths under one class. The classification as thus amended is as follows: I. Disorders of the glands. II. Inflammations. III. Hæmorrhages. IV. Hypertrophies. V. Atrophies. VI. New growths. VII. Ulcers. VIII. Neuroses. IX. Parasitic affections. The first class is the same as the third of Hebra's, excepting 1 Transactions of the American Dermatological Association. D. Appleton & Co. 1879. the introduction of that fugitive affection of the sweat glands, miliaria crystallina. The second class comprises the first, second, and fourth of Hebra, and substitutes for his term, exudations, the more comprehensive title, inflammations. His separation of the erythemata, for instance, into hyperæmic and exudative forms is forced and unnecessary; no such distinction can be drawn between the two processes excepting in degree. This class, inflammations, is of course a large one, and comprises a great part of the most common diseases of the skin, over twenty distinct affections. No attempt has been made to group them, as Hebra has done, because his arrangement is incongruous, useless, and not even correct, as such attempts must be. The affections are arranged mainly in the order of the pathological processes they represent and according to their natural relations as far as possible. Some changes have been made in membership of the class. As many of the affections it contains may pathologically be called dermatitis, the meaning of this term, as employed to represent a distinct disease, has been specifically defined to indicate acute conditions not included under other titles of this class (the forms traumatica, venenata, and calorica being recognized); for some forms of artificial eczema are nothing but a dermatitis venenata, for instance. Pellagra has been excluded as of doubtful existence as a distinct disease; roseola, also, for the same reason. Phlegmona diffusa has been introduced, and glanders omitted. Lichen planus and ruber are recognized, but the ordinary simple forms, so called, are included under eczema, and lichen scrofulosorum is excluded. Hebra's three forms of acne, disseminata, sycosis, and rosacea, are included, so far as they exist, under the simple term acne. Non-parasitic sycosis is merely acne in the beard, and rosacea has been transferred to Class IV., hypertrophies of connective tissue. Seven stages or clinical varieties of eczema are recognized by subtitle. Under the fourth class, the same anatomical groups are retained, but several changes in nomenclature are made. Under the pigment group, lentigo is recognized, but all other forms of melanoderma are included under the single term chloasma. In the hypertrophies of the papillary and epidermal layers keratosis pilaris and senilis (lichen pilaris and senile epidermal accumulations) are introduced, and so is the title xerosis, to indicate the xeroderma (dry skin) of the English writers, and to avoid the confusion which has arisen from the use of this word with another meaning by German authors. Morphoea has been placed here, under hypertrophies of connective tissue, at least until we understand its nature better. Here, too, the title rosacea has been placed, to signify the excessive growth of the integument of the face, both in its erythemmatous and hypertrophic stages. In Class V., atrophies, the disease called by Hebra and Kaposi xeroderma has been stricken out. The name is wholly an improper one for it, and, moreover was in use for a well-known and simple affection, which is to be called xerosis, as just stated. For the former grave and complex disease the title angioma pigmentosum et atrophicum is proposed to express its pathological relations, and it has been transferred to its proper place among the new growths in Class VI. Among the latter class, which includes the eighth and ninth of Hebra, neuroma has been introduced, and the term fibroma substituted for molluscum fibrosum. The word angioma has also been substituted for the various terms employed to denote new growths of vessels. Under new growths of granulation tissue have been placed with lupus the "malignant" new growths of Hebra, but to these have been added scrofuloderma and syphiloderma. The various forms of cancer have all been included under the one term carcinoma. Class VII., ulcers, was admitted into the system by clinical compulsion, it may be said, but under scientific protest. The eighth class, neuroses, is small, but it includes all the affections which properly belong there. The only change in the last, the ninth class, is the introduction of the generic term tinea, to be applied to all the vegetable parasitic affections in place of the old names, as follows: tinea favosa, tinea trichophytina, and tinea versicolor. As will readily be seen, the changes above indicated have been made for the purposes of removing confusion where identical names have been applied to different diseases, of abbreviating where divisions and titles have been unnecessarily multiplied, of substituting appropriate names and positions for those incorrectly registered, and of introducing affections which properly belong to dermatology. As published in list form the scheme thus presented occupies fifty lines less than that of Hebra. No attempt of course was made to base the classification upon any uniform or consistent plan; that is an impossibility. It is therefore partly anatomical, pathological, clinical, and ætiological. But short as it necessarily is of perfection, it seems to us worthy of general adoption by teachers, writers, and students of dermatology. Contagiousness of Molluscum Sebaceum. Data upon this disputed point have been collected from recent periodical literature by Dr. Campbell, and presented in the following order. Dr. Barnes reports five cases occurring in one family. The disease manifested itself first upon the hands and face of a girl aged seven, then upon the baby eight months old, then upon the mother's breast, then under the father's eye, and lastly upon another child. Dr. Lieving gives nine cases occurring in a school at the same time. It appeared in November upon one child, and after several weeks successively upon the others, affecting chiefly the face and neck. Smith, in a report upon the cases observed in a Dublin hospital, cites instances to prove the contagiousness of the affection. Finally, Vidal gives two cases of successful inoculation, in one of which the characteristic tumor appeared in three months, and in the other six months after inoculation. Molluscum Sebaceum. - Bollinger described, in 1873, a contagious affection in fowls, in which the pock-like efflorescence contained bodies resembling the peculiar corpuscles of molluscum. Recent investigation of the same disease in hens and doves has convinced 2 him that it is analogous to molluscum sebaceum in man, and that the peculiar corpuscles in both affections are really gregarinæ, one of the lowest forms of animal parasites, consisting of cells or sacs with a nucleus, which reproduce themselves by self-division. The affection with birds is a fatal and highly contagious one, and Bollinger believes that the parasite is identical with that of molluscum sebaceum of man, although attempts to transfer the disease from one host to the other have hitherto been unsuccessful. 1 Archives of Dermatology, April, 1879. 2 Viertelj. für Derm. und Syph., vi. Jahrg. 1 Heft, from Versaml. deutsch. Naturforscher, 1878. Excretion of Iodine. - Adamkiewicz states that he has demonstrated the presence of iodine in the pus taken from the eruption produced by the administration of iodide of potassium by the starch and nitric acid test. The quantity was of course exceedingly minute. He infers from this that iodide of potassium is excreted by the sebaceous glands, and, being decomposed in them by the products of cell disintegration, the free iodine causes the inflammation of the gland. Inasmuch as the iodine efflorescence spares those portions of the general surface which are provided with sweat glands alone, the palms and soles, he concludes that it is not these but the sebaceous glands which are the cause and seat of the eruption. Excretion of Bromine. Guttmann 2 has also demonstrated the presence of bromine in the pus of the acne pustules of a patient who had been taking bromide of potassium for a long time. Exfoliative Dermatitis of Nursing Children. Ritter von Rittershain describes, under this title, an affection which has been observed in two hundred and ninety-seven cases, during the past ten years, in the infant asylum at Prag, with a mortality of fifty per cent. The prodromal stage, consisting of a dryness of the skin, is followed by an erythema, beginning generally upon the lower half of the face, and spreading with more or less turgescence over the whole surface. At the same time fissures are formed about the mouth, and the mucous membrane within is covered with an exudation. The child remains generally without fever, and nurses well. In a few days the epidermis becomes separated by the effusion beneath it of fluid exudation, and is cast off in large and small masses, leaving red excoriations which soon dry, or crusts. The cuticle upon the hands and feet comes off in glove-form. Occasionally the eruption resembles a fine vesicular eczema, or pemphigus-like bullæ are observed. The brownish-red excoriated patches assume rapidly a brighter color, and are followed by a fine desquamation. The whole process generally lasts but a week or ten days. Occasionally it is followed by prolonged furunculosis and phlegmonous and gangrenous inflammation. Postmortem examination fails to reveal the cause of the cutaneous manifestations. Histology of Dysidrosis. Dr. Tilbury Fox and Dr. Crocker, of London, publish in a separate form their latest contribution to the literature of this much-mentioned affection. As stated in former reports, we differ from Dr. Fox in regarding it as essentially a disease of the sweat glands, and consider it to be a dermatitis, the vesicles of which do not differ materially from those in palmar eczema, especially those which occur in cases of artificial origin. In their article the authors adhere to their original opinion, and give seven figures illustrative of the minute anatomy of the disease. From this study they conclude that it is an "affection of the sweat apparatus, in which the ducts in the Malpighian layer probably become choked, but certainly distended, which is followed by the escape of fluid from them into the tissue around, giving rise to the formation of characteristic vesiculations, which are at first imbedded in 1 Medicinisch-chirurgische Rundschau, January, 1879. 2 Medicinische-chirurgische Rundschau, February, 1879. 8 Centralbl. für med. Wissensch., from Central-Zeit. für Kinderheilk., 1878, No. 1. • Transactions of the Pathological Society of London, 1878. the skin, but afterwards, in consequence of the increase of the effusion, enlarge so as to cause uplifting of the cuticle and the formation of loculated bullæ." The question to be determined is the nature of the fluid of the vesicles. If Dr. Fox can demonstrate that it is perspiration and not serous, such as is found in all other forms of dermatitis, his sections and deductions from them would be unnecessary; until he does this we must decline to regard them as settling the question, especially as they conflict with the results of similar anatomical investigations made by other observers. (See notice of Dr. Robinson's paper in JOURNAL of December 13, 1877.) Treatment of Psoriasis by Immersion. Dr. Balmanno Squire reports a case of extensive psoriasis treated for six weeks by immersion for several hours a day in a warm bath. At the end of this time the disease had greatly abated, and the cure was finished by chrysophanic acid ointment. The action of prolonged bathing upon psoriasis has been fully tested in the baths of Leuk and by Hebra's continual bath. Acne in Flax Mills. Dr. Purdon, of Belfast, Ireland, reports the occurrence of a peculiar form of acne upon the fore-arms of operatives in the linen mills of that district, the great centre of this industry. It affects principally the young girls who remove the bobbins from the machines and oil the same, and the spinners. The skin of the arms is harsh, dry, and covered with a papulo-pustular efflorescence, having a "shotty" feel in its early stage, and is accompanied by numerous comedones. The eruption is frequently observed upon the face, and is accounted for by wiping the face while it is perspiring with oily hands. The disease is attributed to the oil used for the machinery, and to the oil, also, contained in the flax. A certain description of Russian flax is supposed to produce a pustular eruption closely resembling that in variola. A chemist of Belfast is stated to have obtained from flax fibre a volatile oil. Treatment in the affection seems to be of little service as long as the patient remains in the mill. (To be concluded.) PROCEEDINGS OF THE BOSTON SOCIETY FOR MEDICAL OBSERVATION. A. M. SUMNER, M. D., SECRETARY. OCTOBER 7, 1878. Involution of Uterus. DR. E. H. STEVENS, of Cambridge, read the regular paper, on A Case of Involution of the Uterus, which was published in the JOURNAL for February 20, 1879. — DR. H. I. BOWDITCH asked if it was not customary to keep patients in bed for a longer time than stated by the reader. He also inquired what was the cause of the pain spoken of after the first attempt at reduction. DR. STEVENS replied that the patient was so hard to manage that she could not be kept in bed longer than the time mentioned. The pain spoken of was caused by the deep wire sutures which had been passed through the cervix. — DR. C. P. PUTNAM inquired if it had 1 The Clinical Society's Transactions, vol. xi. 2 Archives of Dermatology, January, 1879. |