5

back into the remoter parts of the abdomen and so for thetime being to have disappeared. That tumours, especiallyif they be moveable kidneys, sometimes do this is a matterof common knowledge, but the tumour which has vanishedunder the anæsthetic may. have been a phantom. The

diagnosis here is a matter of great importance from thepoint of view of treatment. Suppose, for .instance, that ina case of this kind whilst the surgeon’s hand is on thetumour during anaesthesia it suddenly slips away ; the evidenceof a positive tumour is sure and would not interfere withthe progress of, the operation. If, on the other hand, thetumour melts away gradually as a phantom does, the ques-tion of procedure would require consideration, and carefulsearch should be made for any possible source of irritationbefore proceeding to extreme measures. It is curious howvery slight an irritation in some subjects will produce a

phantom tumour, especially of the abdominal wall, notably inthe region of the rectus. By a little rough manipulationwith the points of the fingers a very typical phantom canoften be produced in the segment of the rectus above theumbilicus which will persist for some hours. This leads meto impress upon you a very elementary surgical detail-viz.,that in examining any part of the body the warm hand shouldalways at first be placed fiat upon the part. If by chancethe use of the finger ends are necessary in the diagnosis,they should be employed so that the fiat of the pulps of thefingers, and not the extreme tips, are in contact with thepart. The pain, muscular rigidity, and other difficultiescaused by the indiscriminate manipulation by cold handsand by,the finger tips account for many errors in diagnosis.I have called your attention to this point more than oncepreviously in these lectures, and I should have had somehesitation in dwelling so strongly on it now had it not beenthat I have seen practitioners in other respects competentand reliable, and candidates at examinations otherwise good,apparently quite oblivious to the importance of this very’elementary principle in diagnosis.

TREATMENT.On this head there is not much to be said. The obvious

’indication in the irritation phantoms is to cure or to removethe source of irritation, if it has been discovered. In the

occupation phantoms rest from the usual occupation as arule gives temporary relief only ; a change of occupation is

nearly always necessary. When these tumours are persistent’even after a change of occupation the discriminating useof electricity with massage is of much advantage. Theimitative phantom is generally of little real conseluence ;the only treatment is the removal of the patient fromassociation with the person imitated, the existence of the

spurious tumour being entirely ignored. Galvanism

vigorously applied may be a useful adjunct when theresults of the condition are sufficiently serious to makemethodical treatment necessary.Some interesting phantom tumours are prone to result from

the rather exaggerated physical exercises now in vogue ; theyhardly, however, come within the scope of the presentlecture. 1 have also intentionally omitted any reference tothe temporary tumours, which are not true phantoms, some-times resulting from erratic distension of hollow viscera, aswell as to those muscular tumours producible at will bytricksters and malingerers. On a future occasion, should theopportunity arise, I may speak of them, as they are of somepractical importance.

SEWAGE DISPOSAL AT DEVIZES.-At the meetingof the Devizes Urban District Council held on Dec. 20th, 1901,it was decided to supplement the present system of sewagedisposal (which is that of treatment of the sludge bychemicals) by adapting the existing works to Dibdin’sopen contact beds. The estimated cost was stated to be£6900.

VACCINATION EXPENDITURE.-At a meeting ofthe Cardigan Board of Guardians held on Dec. 23rd, 1901, anadjourned discussion upon the increase of the expenses inconnexion with the Vaccination Act took place It wasstated that before the present Act came into operation the’expenditure was £46 per annum, but now the amount wasZ197 per annum. This was said to be due to the abolitionof central stations and to domiciliary vaccination. Theguardians resolved to petition the Local Government Boardto initiate such statutory modification of the Act as willenable the re-establishing of vaccination stations.

A Clinical LectureON

THE GENERAL PRINCIPLES OF TREATMENTOF DISEASES OF THE SKIN.

Delivered at the Royal Free Hospital on Oct. 18th, 1901,

BY WILLMOTT EVANS, M.D., B.S.,B.SC. LOND., F.R.C.S. ENG.,SURGEON TO THE SKIN DEPARTMENT.

IN the treatment of diseases affecting the skin it is of thefirst importance to recognise that dermatology is nothingmore than a part of general medicine. It is true that as the

skin differs to some extent in its structure and in its physicalconditions from the other tissues and organs of the body,its morbid manifestations are not identical with those metwith in other parts of the organism ; therefore, in a way thediseases of the skin are peculiar to it, but they are similarto the diseases met with elsewhere. On the whole, the

pathology of cutaneous diseases is practically identical withgeneral pathology, and the treatment is a part of generaltherapeutics. Moreover, it must not be forgotten that manyso-called diseases of the skin are merely outward manifesta-tions of internal morbid conditions. In these it is obvious that

to concentrate the attention unduly on the cutaneous lesionwill result in a neglect of the underlying disease of whichit is nothing more than the outward expression.The importance of care in diet in disease of the skin is

generally recognised. It is in the first place certain thatsome skin diseases may be produced by food ; one of thebest instances of this is urticaria, which is most commonlyproduced by the ingestion of fish-especially shellfish ; butin certain cases many forms of food may give rise to it.Usually there is an idiosyncrasy on the part of the patientwhich enables articles of diet otherwise harmless to causethe urticaria, but certain conditions of the food also mayexcite the appearance of the urticaria-for instance, foodthat is not perfectly fresh is much more prone to give rise tothe wheals ; in the latter case we are justified in thinkingthat some chemical changes must have occurred in the foodand that the chemical substances produced are the cause ofthe disease. There are many other affections of the skinwhich can also be traced to the diet, though in none is theconnexion so striking as in urticaria. Thus as in healthfood may cause disease of the skin, so when the skin isdiseased the nature of the food may maintain or increase the

severity of the skin lesion. Errors as to the quantity of thefood, even though the quality be unexceptionable, are

also very liable to produce or aggravate diseases of the skin.The method of cooking, moreover, and the time at which thefood is taken, may be of great importance in the preventionor cure of cutaneous disease. All these points must be takeninto consideration in arranging a diet.A dieting for a disease of the skin does not necessarily

mean semi-starvation. The food should be so regulated botliin quality and quantity that its digestion is ensured.

Especially, however, should the patient beware of taking anyfood, whether solid or liquid, which experience has showndoes not agree either with his digestion or with his skin. Itis customary to give lists of foods which should be avoidedby those who suffer from cutaneous disorders, and there ismuch justification for the drawing up of these tables ; but itmust be distinctly understood that they cannot be ofuniversal application. Carbohydrates in excess are certainly

. injurious and it is therefore advisable that they should betaken only in moderation. Pastry especially should be

avoided, for it consists of an intimate mixture of carbo-

hydrates and fat, which experience has shown to be: especially hurtful. Fat in itself appears to have a beneficialaction on the skin, but it must be taken in a digestible form.L Probably it is most easily digested in the form of the fat of meat.L I have hitherto referred only to solid articles of food, but1 the liquids consumed are of at least equal importance.

Alcohol is harmful even. in small quantities in many skin

6

diseases. It acts both by its influence on digestion and by causing cutaneous hyperasmia. It does least harm when Itaken with food and when the percentage of alcoholpresent is small. On the whole the lighter wines are lessprejudicial in their effects than other forms of alcohol, butspirits (except when well diluted), champagne, and beershould be avoided. Tea frequently does much harm, chieflybecause it is taken in excess and apart from food ; it is alsooften infused too long. Coffee and cocoa are less injurious,but these, too, should be taken in moderation.

I may mention now the influence of tobacco. The con-nexion between disease of the skin and tobacco is not soobvious as in the case of alcohol, but I have little doubt ofthe harmful effect of tobacco, especially in excess : cautionon the part of the patient in this respect is thereforeadvisable.There are, however, other ingesta deserving notice, as

they can give rise to disease of the skin. These are drugs.Many medicines have the power of evoking skin manifesta-tions even in those who are in health, and still more likely isthe skin to be affected in disease, so that the possibility ofsome part of the lesion being the result of medication mustalways be borne in mind.The climate and air have much influence on many diseases

of the skin. On the whole, a fairly dry inland situation isbest for these cases, for sea air is very irritating in manyforms of eczema ; but for conditions in which the generalnutrition is impaired, as in lupus, sea air may have a

markedly beneficial effect. It is difficult to lay down generalrules on the subject and each case must be treated on itsmerits.The effect on cutaneous disease of soap and water is

so important as to require special mention. Even inhealth frequent washing damages the skin by deprivingit of much or all of its natural fat, so that it becomes

unnaturally dry and also probably more easily invadedby parasitic micro-organisms. The effect is still more

harmful in disease. Except in the skin diseases due to theanimal and some of the vegetable parasites washing is ofno therapeutic value, and in many morbid cutaneous con-ditions, especially in eczema, it may be exceedingly harmful.Where washing cannot be avoided the injurious effect of thewater may be to some extent mitigated by the addition to itof oatmeal or gelatin, so that a demulcent action is exertedon the skin. In cases in which washing is admissible thechoice of a soap is generally not difficult. That soap isbeneficial to the individual patient the use of which is notfollowed by redness or smarting. It is hardly necessary tosay that there is no soap that far surpasses all others. Ofrecent years superfatted soaps have been introduced, andthey are certainly less irritating to most skins ; they are not,however, so pleasant to use, and naturally their detergenteffect is less. Of medicated soaps I have little to say, as Ido not consider soap to be a convenient vehicle for the

application of drugs except in very peculiar cases.We now come to the more directly therapeutic part of the

subject. It is obvious that if the general health be impairedwe should endeavour to restore it, although we mav beunable to recognise that any causal connexion exists betweenthe general condition and the cutaneous lesion. The diges-tion should be treated if dyspepsia be present, and anyabnormal condition of the bowels, such as constipation ordiarrhoea, should be corrected. In many cases, however, thegeneral health appears to be perfect.

There is a very definite opinion prevalent amongst thepublic and held even by some medical men that there issome risk in curing a disease of the skin. The eruption and the discharge from it are imagined to be beneficial and it is

thought that if these are removed then the disease is " driveninwards " and produces very serious symptoms. These ideaswere formerly very widespread among the medical pro-fession and they are to be found in all the older works on

dermatology. Yet at the present time it cannot be said thatwe have any definite facts to support such an opinion. It isknown that in some of the specific fevers, if the rash doesnot come out well, or if it recedes, the constitutionalsymptoms tend to be more severe and a fatal result oftenfollows. This is probably the foundation or part of thefoundation for the idea that the rapid removal of a cutaneousmalady may give rise to severe internal disease. Possibly since the skin is a great excretory organ the cessation of its Isecretion may cause the retention in the body of

noxious substances, but of this we know very little. At all events,no apprehension of doing harm to the patient need deter

us from removing as speedily as possible a disease of theskin.An accurate diagnosis is the first essential for the satis-

factory treatment of skin diseases, as of disease in any otherpart of the body. Our aim in treatment should be toremove the cause of the disease, if possible ; but if thecause is unknown or if it cannot be removed we musttreat the symptoms, and even when the cause is known andthe disease is readily amenable to treatment the symptoms,or some of the symptoms, may need treatment, either becausethey are especially distressing to the patient or because it isnot possible to remove the cause immediately. For instance,it is sometimes necessary to treat the itching of psoriasis.because it may be very troublesome in itself, although we.can in a few weeks or months completely remove the disease.It must not be imagined that when we know the cause thetreatment which is the most obvious is necessarily the best.Many cutaneous diseases are now known to be microbic inorigin, yet the direct application of antiseptics will in manycases not lead to recovery. Indirect methods are thus some-times indicated.The treatment of a disease of the skin may be internal or-

external. At one time the internal treatment was consideredof very great importance in all forms of cutaneous disease,while external applications were thought to be of much lessimportance. On the whole the recent tendency has been to.exalt the efficacy of external treatment and to discreditsomewhat internal medication. It should be obvious fromeven a superficial study of the etiology of the diseases of theskin, even so far as we are acquainted with it, that in one-disease internal treatment and in another external treatmentmust be of the most value, but in nearly all diseases of the*skin both methods of treatment are desirable or even’

necessary.Here seems to be the most convenient place to speak of

the use of the natural mineral waters in dermatology. Ithink there can be no question that their value has beenoverrated. Doubtlessly in some cases the pure air, the

simple diet, and the early hours observed at a spa contributematerially to the improvement of the condition of the skin,.but it is improbable that the mineral waters themselves have-any more than a very slight beneficial effect. Yet there is a.

very general opinion that these waters are of great efficacy,but disappointment will almost certainly follow any veryexalted expectation of the benefit likely to result from theiremployment.

I have no intention of considering all the drugs which-may be administered in cutaneous disease, but I think it.well to say a few words on one of them-namely, arsenic.For many years arsenic has been looked upon as the specialdrug to be employed in many skin diseases, and, in fact,many medical men administer arsenic in almost every caseof disease of the skin with which they have to deal. Yet.,curiously, those who have most to do with the treatment ofcutaneous disease employ the drug comparatively rarely-in fact, I am inclined to think that they employ it more-’

rarely every year that goes by. Some 30 or 40 years.ago a Mr. Thomas Hunt advocated the administration.of arsenic in all skin diseases ; he gave it very sys-

tematically and for very long periods, even for many years.This very prolonged use of arsenic is not common nowa--

days, yet at the recent Dermatological Congress in Breslau,one speaker maintained that arsenic could not be said tohave failed until it had been administered for several vears.Arsenic is indeed of value, even of great value, in severalcutaneous disorders, for instance, in psoriasis, pemphigus,and lichen planus, but its action is by no means certain ; it.is often slow in manifesting itself and the drug cannot OFshould not be given if the skin is distinctly inflamed, for itincreases the inflammation and may cause the spread of thedisease which it was intended to cure. Moreover, arsenic is-capable of giving rise itself to morbid changes in the skin;not only does it increase, as I have said, any inflammationwhich is already present, but when the drug is administeredfor a prolonged period, even in small doses, the skin becomes

pigmented, and on the palms and soles great thickening ofthe epidermis occurs, and in a few cases multiple epithelio-mata have developed. Enough has been said to show thatarsenic should not be given unnecessarily or hastily ; indeed,as a rule arsenic should only be tried late in a disease, whenother modes of treatment have failed. There is no other

drug about which I think it necessary to speak in this con-nexion, for there is no other which has been so misused asarsenic.

7

With regard to the external remedies the dermatologisthas an extensive choice. Baths are in certain cases of

great value. In no other way is it possible to obtainso thorough an action on the skin, but, on the otherhand. there is the risk of the absorption by the skin ofsubstances from the bath, so that a bath should never containany substance the absorption of which might be dangerous." Permanent "baths, in which a patient is immersed for

days or even weeks, are but little used in this country andthough occasionally of great use they are troublesome andare of very limited application. The capacity of an ordinarybath is about 30 gallons, and the quantity of drug to beadded must be calculated for that amount. Many modernbaths, however, do not hold much more than 20 or 25 gallons,so that a little less medicament should be ordered.Ointments are certainly more frequently prescribed than

any other form of application, and they are very convenient,especially when inunction is required, but they are uncleanlyand may often usefully be replaced by other applications.Ointments are usually at the present day made up withhard and soft paraffin. These keep well, never becomingrancid, and therefore do not tend to irritate even thoughthey have been made long previously. This advantage doesnot appear to me to be of any great moment, forointments are better for being freshly prepared, butthe animal and vegetable fats seem to me to bemuch better suited for ointment bases than the paraffins,and I think that a drug made into an ointmentwith a basis of fat is able to exert a deeper effect on theskin. It is important for you to bear in mind that ointmentscontaining mercury and its salts must not be applied overtoo large an area as there is great risk of absorption.Ointments are not suited for any condition in which thereis a large amount of exudation, for this exudation raises theointment from the surface of the skin and to a great extentprevents it exerting its effect. When there is a profusesecretion from the skin lotions and dusting powders aresuitable. When lotions are applied it is generally advisableto keep the part continuously moist, but no oil-silk should beapplied over the dressing. Dusting powders act chiefly byabsorbing any exudation that may be present. They have eto be used freely to obtain the best effect, and are hardlysaited for patients who have to go about their work. Trau-maticin, which is a solution of gutta-percha in chloroform,forms a very convenient vehicle for many drugs. When

painted on the surface of the skin it dries quickly and formsan impermeable covering, which maintains the medicament

, in close contact with the part and at the same time effectuallyprevents any staining of the clothes. Bassorin and gelanthumare two very pleasant bases. They can be smeared on theskin, and in a short time they dry and form a closely-adherent pellicle, which is, however, readily soluble in water,so they can be removed quickly. Unna’s plaster muslinsand salve muslins are useful vehicles when it is desired to

-

obtain the prolonged action of a drug on a part.Pastes are also of value as they allow an exudation to makeits way through them and they are therefore often superior toointments. Pastes are practically composed of a combinationof an ointment with a powder.

I need say but little of surgical treatment, scraping,excision, skin-grafting-all have their place in dermatologicaltherapeutics-nor need I here describe the treatment ofdisease of the skin with light or the Roentgen rays ; they areboth of them of considerable value in suitable cases. Youwill find that as the disease varies from time to time so willit be necessary to alter the drugs employed and the mode oftheir application.Finally, I might suggest that to become well acquainted

with the therapeutics of a few substances and the best modeof employing them will be better than to make a hasty in-conclusive trial of every new preparation or treatment that isdevised.

HOSPITAL FOR EPILEPSY AND PARALYSIS, REGENT’SPARK.-In aid of the funds of this hospital there will be anamateur production of a new and original four-act play (forfirst time in London) entitled The Scarred Hand, by Val deGarno and Leopold Montague, on Monday, Jan. 13th, at St.George’s Hall, Langham-place, W. We understand that thep6c-na’ne of Val ae Garno yeils more or less closely the

identity of a member of the medical profession and that theplay itself, which has had considerable success in the pro-Ykcee. possesses a strong medical element.

A Clinical LectureON

SEVENTEEN CASES OPERATED ON FORSO-CALLED "INTERNAL DERANGE-

MENT OF THE KNEE-JOINT."Delivered at University College Hospital

BY ARTHUR E. J. BARKER, F.R.C.S. ENG.AND IREL.,

PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY ATUNIVERSITY COLLEGE AND SURGEON TO UNIVERSITY

COLLEGE HOSPITAL, LONDON.

GENTLEMEN,-It so happens that an interesting group of;ases of "internal derangement of the knee-joint "has com-)aratively recently been operated on in my wards at UniversityCollege Hospital. These are well deserving of study, helpingis as they do to understand something of the pathology,;linical history, and treatment of this affection. But for

any safe generalisation on these points we must take largerlumbers. To this end I have looked up the notes of all the;ases which have fallen to my lot for operation within the pastive years or so in hospital and added some seven on which Ilave operated in private during the same period. All these,;aken together, in which the joint has been opened are saferguides than others treated by palliative measures in whichthe structures involved have not been seen and in which theactual details of the lesions must accordingly remain,o some extent doubtful. Of the latter, of comse,me sees a much larger number ; for it must be obvious atmce to anyone who goes into the matter that all cases of"internal derangement of the knee-joint" do not requireoperation.Now, first of all, what is meant by the title just employed,

which was, I believe, first used by Mr. Hey of Leeds manyfears ago ? Although the usual name now given to the con-dition described formerly as ’’ internal derangement of theknee-joint " is "dislocation of the semilunar cartilage," itbecomes quite clear to anyone who sees many cases of thelesion in open joints that there are several varieties of dis-placement, both as to position and degree, included underthe term. It is important to bear this in mind, inasmuch ashe same treatment is not applicable to all. In order to obtain;ome clear notion on these points let us glance at what hasbeen actually seen when operating on the joints in this groupof cases alluded to. In the first place, the cartilage affectedbas been in every case the internal. And in the manyother cases which I have seen but not operated on there hasbeen clear evidence that the internal meniscus was the oneat fault in all but one doubtful case. This may be only acoincidence, but it is at least significant. The next pointobserved was that the semilunar cartilage was in all these

FIG. 1.

" Peripheral complete." The serrated line indicates ttte rfBt - .a, Internal lateral ligament. b, Head of filiula. c, Liga-menttun patellx, d, Internal nteniseus. e. Jagged lineindicates the position of rent in " complete " peripheralseparation.

casessplit in the direction of its fibres, which ran, as is wellknown, in a semicircle. In none of them was the cartilagetorn across at any point between it,, two ends. Such lesionsare said to occur, and I know of one most competent observer