ON THE RETROSPECTIVE SEMEIOLOGICAL CHARACTERISTICS PRESENTED BY THE NAILS. By J. BEAU, M.D. It is familiarly known that, after certain diseases, as severe fevers, the nails are sometimes cast, as well as the hair. They are reproduced when the unguinal matrix resumes its secretory functions, and, after a certain time, the new nails have acquired the same form and consistence as the old ones. But less severe diseases, which do not lead to the actual shedding of the nail, may yet interfere with the secretory function sufficiently as to leave marks of their existence by certain traces on the nails. These are found in the form of furrows or depressions placed transversely on the back of the nail. They vary from the slightest depression to one which nearly occupies the whole substance of the nail. They are found larger upon the thumb than upon the finger nails, and sometimes it is upon these alone that their traces are to be discovered. They are of varying length and breadth. They will be found at different points of the nail according to the space of time which has elapsed since the occurrence of the malady. To ascertain this with exactitude, the rate of growth of the nail must be observed, which may be done by imprinting upon it an indelible mark, and observing how much this advances towards the free edge of the nail in a given time. Experiments of this kind show that the nails of all the fingers increase a millimetre ( of a line) per week; while the nails of the toes only grow thus much in four weeks. From this we may see that the thumb-nail, which, in an adult male is about 20 millimetres long, inclusive of the portion concealed in the matrix, requires 20 weeks, or 5 months, to perform its entire evolution, while that of the great toe, which averages about 24 millimetres, requires 96 weeks, or two years, for the same purpose. This law of increase is the same in health and disease, and growth differs only in the latter in the less abundance of the materials which are deposited. The furrows may be solitary, or, if there have been other illnesses, two or three are found upon the same nail, separated by more or less considerable spaces. As typhoid fever is a disease which may lead to a complete shedding of the nails, so also it is the chief of those in which these furrows are found. To this we may add the various pyrexia and phlegmasiæ; and all affections in which the reparative and assimilatory powers are suspended or notably diminished-especially when in such febrile affections are present. They are observed, also, after the operation of various moral causes which have markedly influenced the digestive functions. The few days' abstinence after parturition frequently suffice to leave traces on the nails. Of course the grooves are deep only in proportion to the gravity of the affection, and unless a slight attack appear very suddenly, the edges of the depression will be scarcely perceptible. As we have already noticed, it is upon the thumb and great toe nails we must search for these furrows; as, when existing, they are always found on these, and No. 107 17 often upon them alone. To estimate the time which has elapsed since the occurrence of the disease giving rise to the furrow, we must count as many weeks as there are millimetres between the furrow and the posterior margin of the nail, bearing in mind that this is hidden to the extent of 3 millimetres by the epidermic fold which bounds the nail behind. These furrows of the thumb-nail, however, can never furnish the indications of a disease having existed for a longer period than 5 months prior to the examination, but those of the great toe will furnish such as far back as two years each millimetre there representing a month -its posterior border being, however, hidden by the epidermis to the extent of 5 millimetres. The breadth of the furrow indicates the duration of the disease, a millimetre expressing a week or a month, according as a thumb or a great toenail is examined. If the disease has continued for less than a fortnight, and has only been slight, it leaves scarcely any traces on the toe-nail. Even the mode of the invasion and termination of the disease may be established; for, if we find the edges of the furrow of the thumb-nail are sharp and decided, we know it has appeared and terminated suddenly, while, when this is not the case, the transition from health to disease has been gradual--always remembering that the anterior edge of the furrow is that which indicates the commencement of the disease, and the posterior one its termination. It is not pretended that every acute disease must infallibly furnish these furrows. Exceptions do occur, but in spite of such, we believe these researches are sufficiently interesting to call for publication. In verifying them, practitioners will often observe with what extraordinary precision they can recognise the existence and circumstances of a past disease, to the utter astonishment of the patient. The study is therefore useful in a semeiological point of view, as it may also be in those cases of legal medicine in which it is the interest of an accused person to deny the former existence of disease. Riel, in his Memorabilium Clinicorum, notices the occasional formation of a white semicircular line after severe fever.-Archives Generales, T. xi, pp. 447–458. BLISTERS IN CONFLUENT SMALL-POX. M. Piorry has for some time past derived great assistance from the use of blisters as a means of preventing the scarring of the face by the cicatrices of confluent small-pox. The pus, retained so long in contact with the tissues, and altered in character through the agency of the air which passes through the pustules by endosmosis, operates extensive local destruction, and proves very injurious to the system when re-absorbed. Various practitioners have proposed measures for obviating this inconvenience, as by cauterisation of each pustule (impossible in the confluent disease), the opening them by scissors, needles, &c. Experience, however, shows that over such means the blister has the advantage of-1, opening at one time the whole of the pustules over which it is applied: 2, evacuating their entire contents, and preventing the consequences of the sojourn or resorption of pus: 3, counteracting the attendant erysipelas, by diminishing the swelling; and 4, causing the scabs to fall much sooner from the face than from other parts of the body. It has an advantage over mercurial plaisters in not risking the excitement of salivation, the extent of evil which results from its use being a slight ischuria. The various plaisters applied as abortives in this disease have too been reproached with exerting a repellant action, and directing the morbid action upon the brain and its membranes. A blister, on the contrary, rather acts as a derivative.--Gazette des Hôpitaux, No. 101. [Our neighbours have shown a laudable anxiety for the discovery of the means for the prevention of the hideous mark of the small-pox, once so common, now so 1847] rare. The very rarity of the occurrence has, however, led too little attention to be paid amongst ourselves for its prevention. We think M. Piorry's practice well worth a trial.—Rev.] HARDEN ON ISOPATHIA. Dr. Harden of Liberty County, Georgia, has resumed (in the July Number of the American Journal of Medical Sciences) his observations upon Isopathia (that is upon diseases of identical nature, although presenting different external appearances), which we gave an account of in a former number (July 1845). He prefaces them with some strictures upon the existing systems of Nosology, as being too exclusive. The etiological method of Boerhaave and Hoffman is only applicable to such diseases whose causes are known-while identical diseases may be brought on by very different general causes acting upon a system with a certain predisposition which is not understood. So, in regard to the sympto matological system of Cullen, Sauvages, &c. many diseases distinct in their nature, when seated in the same organ, will manifest symptoms so identical as to mislead the wisest. "The same objection applies with still greater force to the functional or physiological plan of Dr. Good," and the tissual, organic or topographic system of Bichat, more or less embraced by Broussais, Bouillaud, &c. The localisation of all essential disease, in referring it entirely to an altered vital action, without regard to the mechanical or chemical actions of the system is necessarily defective. "As the same morbid action may attack different tissues or parts of the body, so it is equally true that different morbid actions may attack the same tissue or part of the system; and, although pathological formations or types are slightly different in various parts of the body, as is the case with animals or plants in different climates or soils, yet the species is invariably and always to be recognised." Pathological Anatomy originating with Bonetus, Valsalva and Morgagni, and advanced by modern labours, such as those of Laennec, Cruveilhier, Hope, Carswell, &c., has better claims than the preceding systems, but still is defective. "Pathological anatomy is not pathology, the lesions left after death are not disease, but simply the effects of the morbid action which had been going on in the system during life, and should be considered as nothing more than a kind of special symptomatology." The revival of the Humoral Pathology under the auspices of Andral, Liebig, Dumas, Prout, Müller, &c. gives rise to the hope that disease will ere long be brought within the range of physical laws, and be treated upon physiological principles. "The question now comes up, by what method are we to distinguish and classify diseases? Our answer emphatically is, by a rightful combination and use of all the methods that have been passed in review, so far as they may be applicable to the case before us; by an investigation of the causes, so far as they may be known to us, whether predisposing or exciting; by a careful observation and comparison of symptoms, as they present themselves in connection with their seats or organs, whose functions may be disturbed during the progress of the disease; by a critical inspection of the lesions which may be presented after death; by an examination of the state of the blood or other fluids; and, lastly, by all those collateral aids which may be afforded by the history of the disease, and other circumstances alluded to in my former paper.' In the paper referred to Dr. Harden had, with the object of tracing the isopathic connection of various diseases, divided these into certain generic types; viz. Febrile, Inflammatory, Purulent, Tuberculous or Strumous, Scorbutic or Hæmorrhagic, Exanthematous, Hydropic, and Gouty or Podagric Types. In the present paper, of these, the Inflammatory and Purulent Types are treated of a considerable extent, with great lucidity and comprehensive power. The limited space we have at command quite prevents our doing justice to so elaborate a communication; and we prefer, therefore, deferring any notice of it until another opportunity, or until the completion and re-publication of the series of papers. We feel obliged by Dr. Harden's frequent and complimentary allusion to the Medico-Chirurgical Review. No exertions on our part will be wanting to furnish him and our other readers with an accurate and complete view of the progress of medical science. M. MALGAIGNE ON SIMPLE INFLAMMATION OR PSEUDO-STRANGULATION The According to Boyer, strangulation consists in a more or less complete intercep error. In the cases in which the large intestine is implicated in a hernia, such accumulation would seem natural enough, and yet M. M. sought, during two years, among all the published cases, as well as in many of those occurring in his own private or hospital practice, with the result of discovering only one example of this. Rejecting, then, this doctrine as ill-founded and dangerous, M. M. states that, in the question of strangulation three occurrences should be borne in mind. 1. There may be simple strangulation, which is very rare, occurring without inflammation, and inducing gangrene in some hours. 2. Simple inflammation, which is very common, and almost always confined to the serous membrane of the hernia. 3. Inflammation of the mass of the contents of the hernia of the omentum, adipose tissue, and all the tunics of the intestine. This scarcely ever occurs but as a consequence of the former conditions, whether from the effect of the strangulation itself when this is not sufficiently severe to induce immediate gangrene, or from the injudicious employment of the taxis in instances of simple herniary peritonitis. It is the herniary peritonitis which constitutes what M. M. terms pseudo-strangulation. Herniary Peritonitis may give rise to either the adhesive or the suppurative form of inflammation. The former is frequently slight and transient, revealing itself by more or less severe colics, which are relieved by rest, cataplasms, and hot drinks. It especially affects those in whom the hernia is badly supported, in damp, changeable weather, and after excess at table or drinking, although this last circumstance is not so important as some think, inasmuch as subjects having the large hernias frequently commit every kind of debauchery with impunity, 1 1847] or, Pseudo-strangulation of Hernias. 261 The partaking of cabbages or beans often gives rise to an accumulation of gas and the production of great suffering in the subjects of hernia. Among the most common symptoms are dull colicky pains, meteorism, and a physical or mental uneasiness, especially after any but the most moderate meals. For a long period M. Malgaigne attributed this malaise to mere change in the position of the viscera, but he now considers it a symptom of peritonitis. In some cases the local and general uneasiness is very slight, but a difficulty is found in the reduction of the tumour. If we are called at the commencement of the case, we must at once reduce the hernia; but if we see it later, we must first relieve the irritation in order to facilitate the taxis, which however must not be too long delayed. In a yet farther advanced stage, there are pains in the abdomen and the tumour, constipation and vomiting. In his memoir, M. Malgaigne has cited several facts, in which intense pains and a seeming irreducibility have yielded to a long-continued pressure. "The slightness and fugacity of the herniary colics, which I consider as the first stage of a peritonitis, have been objected to me,” M. Malgaigne observes, "but it is to be noted that many pleural adhesions are met with in persons who have never suffered other than slight stitches in the side, and adhesions of the omentum to the hernial sac are observed in those who have never suffered any durable uneasiness in the hernia." The following are the practical conclusions which M. Malgaigne draws from his experience. 1. In all old intestinal hernias, which have never been supported by a bandage, or for which the bandage has been long abandoned, there is no true strangulation-the ring or rings being much larger than is required for the pedicle of the hernia. This is the result of all the examinations I have made, whether upon the living or the dead; for I have never yet met with an exception. 2. In pure epiploceles, whatever may be their size, it is generally an adhesive or suppurative peritonitis which exists; and, although the reality of a strangulation in such cases cannot be absolutely denied, its demonstration remains to be made. I cannot avoid, however, remarking upon the inconsistency of those surgeons who, operating to remove a pretended strangulation of the omentum, and finding it changed in texture, apply a ligature to it, thereby submitting to a strangulation ten times more severe than that for which the operation was conducted. 3. Consequently, in these two specified cases, an operation is always irrational, and should in future be abandoned by surgeons. "If we adopt these conclusions, which then are the indications to be fulfilled? First of all it is essential to ascertain if the hernia could in part or entirely be returned before the accident, if the patient could return it himself, and retain it without uneasiness in the abdomen. For in this latter case we must refrain from the taxis, as we risk by succeeding in its use the production of an unexpected death. When the circumstances are favourable, and we are called in good time, before the skin of the scrotum participates in the inflammation, the taxis is the first of all means. If it does not succeed at first we may cover the tumour with a cataplasm, place the patient in a bath, give a tobacco injection, and then recur to it. This procedure is founded upon the fact that, frequently the inflammation appears to result from a simple displacement of the viscera, when their reduction suffices to dissipate it. But I cannot too strongly recommend the most gentle manners of proceeding, and that the surgeon should always bear in mind that he has to do, not with choked up organs, but with inflamed tissues; and, if he finds resistance, he must know when to abstain. In such case he must confine himself to cataplasms, leeches if necessary, and the diminution of drinks in order to check the vomiting, assuaging thirst by pieces of ice, &c. When, however, the inflammation has declined, as indicated by the diminution of the tumour and the flaccidity of the skin over it, he must again have recourse to the taxis. In enterocele the taxis has the double object of preventing the establishment of adhesions, and giving the liberated intestine power to resume its functions, which it will do better in the abdomen than elsewhere. For it is a remarkable thing |