magnify the parts at the fundus, the lens is now used." (p. 660.) The "An examination should not be uselessly or unreasonably long. It would be unpleasant to any one, to say the least of it, to have a concentrated light on his retina for the greater part of an hour, and this persons seem to forget when they are learning to use the ophthalmoscope. We know that it is not very uncommon for the fundus of the eye to become preternaturally red during an ordinary inspection-a fact always to be remembered, and to be guarded against by avoiding a lengthened sitting, or by resting the eye for a few seconds when the process is necessarily prolonged. No surgeon with any common sense would employ the ophthalmoscope when it would give pain or cause any uneasiness. It is just in such cases that the internal examination of the eye is not needed; there is enough indication to direct our treatment. The intolerance to light is a significant symptom; and, if it be associated with any surface-redness, there is evidence of inflammation of the eyeball. "On occasions when there is slight sensitiveness to light-so slight as to warrant a careful and brief examination,-I reduce the lamp-flame, and illuminate less toleration will then embolden us to employ more light, should it be required. "The examiner is likely to fatigue his own eye by the consecutive inspection T of several subjects. I have known indistinctness of vision to be produced, and to last for days. The prevention is, to avoid continuous work, or to use the eyes alternately." (p. 663.) Mr. Walton proceeds to describe the appearances presented in the normal state by the optic disc, the central artery, the retina, the macula lutea, the choroïd, the cornea, the crystalline, and the vitreous humour. He then directs attention to the morbid appearances. He notices anæmia, hyperæmia, apoplexy, extravasations, and pigmental changes in the disc; its cupped appearance in atrophy of the optic nerve and in glaucoma, with the seeming break in the vessels as they bend out from the cup upon the retina. The signs of hyperæmia and of inflammation of the retina are next enumerated, and of ecchymosis, hæmorrhagy, and exudation affecting that membrane; also of fatty degeneration, pigmental deposits, atrophy, and detachment from the choroid. The alterations of the choroïd are next described, originating, as they do, chiefly in inflammation; alterations affecting the pigment, which is sometimes abnormally accumulated, sometimes absorbed, or variously changed; colloïd degeneration of the elastic lamina of the choroïd; hyperemia of the capillary layer; plastic exudation; rupture of the choroïdal vessels, with and without perforation of the retina by blood; atrophy of the choroïdal vessels; detachment of the choroïd from the sclerotica. Lastly, posterior staphyloma is noticed-a diseased state in which the sclerotica bulges out behind, so as to elongate the antero-posterior axis of the eyeball, and become the cause of a peculiar variety of myopia. Some remarks on the morbid appearances of the cornea, crystalline, and vitreous body, had previously been introduced, along with the description of the normal eye. The whole account of the opthalmoscopic appearances of the eye, healthy and diseased, is executed with so much care and perspicuity, as highly to commend itself to the attention of the reader. We should willingly have extracted the remarks on the ophthalmoscopic signs of cataract (p. 668), had our limits allowed. Happy to congratulate Mr. Walton on his work having reached a second edition, we have only to repeat what we said of the first, that, on the whole, we know of no treatise on the same subject better deserving a place in the library of the surgeon. REVIEW III. A Practical Treatise on Diseases of the Skin in Children. From the French of CAILLAULT. With Notes, by R. H. BLAKE, M.R.C.S. Lond.-London, 1861. pp. 277. It must be acknowledged, that an English book on the Skin Diseases of Children is addressed to a real and not a merely imaginary want. There are no branches of medical knowledge in which the English student is so deficient as in the diseases of the skin, and the diseases of childhood; none in which he would so much suffer on comparison with a student educated in the hospitals of Paris. This cannot be attributed to any lack either of industry or of ability. The cause must be sought in the much greater facilities offered in Paris than in London for the study of these diseases. The magnificent hospitals of St. Louis and the Enfants Malades, each with many hundreds of beds, present to the industrious student ample and accessible fields for clinical observation. In London we have nothing to set against them but the small establishments in Great Ormond-street and in Blackfriars. Both of these are quite inadequate for the instruction of the large numbers of students educated in London. The former has indeed been lately somewhat increased in size; and by the praiseworthy efforts of Drs. West and Jenner, courses of lectures have been established, the previous want of which is evinced by the crowded audience that avails itself of them. The hospital is, however, still too small for the purposes of education, containing, even now that it is enlarged, only fifty beds. The case is still worse with the hospital for diseases of the skin. Here there are no beds at all for male, and six only for female patients. Students are indeed admitted within its walls, but they find there no lectures nor systematic instruction of any kind. Of the therapeutic skill of its medical officers we have that best of evidence, the ever-increasing number of out-patients that flock to them for relief. But this very multitude of out-patients is a hindrance to the proper instruction of the student. In a small and ill-lighted room, he sees on each occasion some two or three hundred patients pass by in rapid succession. The medical officer can, of course, only give to each of them that minute portion of time which enables his experienced glance to detect the nature of the affection. This is quite insufficient for the unpractised eye of the student, whose difficulties are still further increased by the use of a special and complicated pharmacopoeia. Under these circumstances, we can hardly be astonished when a gentleman who has much experience of medical students informs us, that they constantly come to the end of their hospital life without being able to name or recognise with certainty the most common diseases of the skin.* The knowledge which has been entirely neglected during the period of studentship is seldom acquired in the busy years of later life; so that we believe we are correct in stating, that there are no branches of medical knowledge so neglected and so little understood by English practitioners, as the diagnosis and treatment of skin diseases. The very books we use are almost entirely of foreign origin. For one by an English author, there are on our shelves four or five of French or German production. From time to time one of these appears in an English form; and it is to these translations that the student owes such little knowledge as he possesses of cutaneous pathology. The book before us is a fresh addition to this class. Its author, M. Caillault, was for some years "interne" in the hospital for sick children in Paris, and there it was that he gathered materials for his treatise. To say that M. Caillault is a Frenchman, is almost to say that he is not a follower of Willan. Nationality shows itself even in the classification of diseases. The English dermatologists, almost without Dr. Jenner: Medical Times, 1857. exception, have adopted the method of their compatriot Willan, whose classification was based exclusively on the anatomical lesions of the skin. The French doctors, on the contrary, though at first they accepted Willan's arrangement, have in the present day universally abandoned it in favour of the more natural method, of which their countrymen Lorry and Alibert may be considered the authors. In this no one single character is selected as a sufficient basis for classification, but all the features of a disease are taken into considerationits cause, its predominant symptoms, its usual course, its treatment; and a place is assigned to it in virtue of the general analogies and resemblances presented by it. This latter method is manifestly the more philosophical one. It stands in the same relation to the system of Willan and Bateman, as does the natural botanical arrangement of De Jussieu to the artificial one invented by Linnæus. Both Linnæus aud Willan adopted a single anatomical character as the basis of their classification. The result in both cases is, that under the same head are found grouped together individuals that have no second point of resemblance; while others are widely separated, in spite of their presenting the most striking affinity to each other. The arrangement of the botanist had, however, this advantage over that of the dermatologist, the character selected by him as a ground of classification was in reality a most important one, with which other characters were often inseparably bound up, so that it served as a key to them; and thus it not infrequently happened that his artificial groups corresponded exactly to the natural ones of De Jussieu-as, for instance, the Tetradynamia to the Cruciferæ, or the Syngenesia to the Compositæ. In dermatology, on the contrary, the anatomical element is of such secondary importance, that not one single group based upon it can in any way be considered a natural one. Those who adopt it as the basis of their classification, while they acknowledge that the natural system is the better, theoretically considered, urge that such an arrangement is practically impossible, inasmuch as our knowledge of skin diseases is not precise enough for us to be able to refer any given one to its proper heading. This is in too many cases true, though not so often as is implied. But only so far as we can thus refer them is classification of any practical use whatsoever. Moreover, the same objection might be urged with still greater force against the artificial divisions of Willan. It is frequently impossible to decide with certainty what was the external character of the original eruption. Still more frequently, the anatomical elements of several distinct classes are united in the same individual, who must therefore be supposed to suffer at the same time from several different cutaneous diseases. A still greater objection to this classification of Willan is, that it is of no use therapeutically. Even if it were possible in each instance to discover what was the original lesion, and to refer the case with certainty to its class; yet when this had been done, the practitioner would have gained nothing towards its treatment, inasmuch as the artificial groups are not, like the natural ones, therapeutic unities, but are at best only convenient modes of nomenclature. Our space will not allow us to consider the various attempts which have been made, with more or less success, to form natural classifications. We must content ourselves with a brief account of the method adopted in the volume before us. M. Caillault arranges the skin diseases of childhood under nine heads: 1. Syphilis; 2. Strophulous diseases; 3. Lymphatic; 4. Scrofulous; 5. Dartrous; 6. Parasitical; 7. Hæmorrhagic; 8. Cachectic; 9. Inflammatory. The sequence in which these classes are arranged is not an accidental one. It represents the order in which they succeed each other as age advances, each period having, so to speak, its peculiar affections. Thus the first group manifests itself chiefly during the earliest period of infancy. From this we advance to the diseases which appear during the time of dentition, and so gradually on through successive periods up to puberty, until we terminate with those affections which manifest themselves indiscriminately at all ages of infancy. The first class includes acquired and congenital syphilis. Acquired syphilis is naturally of very rare occurrence in childhood, and differs in nothing from the syphilis of adults. Congenital syphilis is preeminently the skin disease of earliest infancy. The usual period at which it manifests itself is from a month to six weeks after birth. Sometimes its appearance is delayed till so late as the seventh month, and, according to M. Hardy, occasionally even till after puberty; but in the vast majority of cases it declares itself before the end of the third month. This was the case in 146 out of 158 instances collected by Diday. Perhaps the best part of M. Caillault's treatise is that devoted to this disease. Our space will only permit us briefly to point out the peculiarities in his views. The According to M. Caillault, congenital syphilis is altogether cutaneous, exclusively confined to the skin. He takes no account of the various visceral lesions described by different observers-such as the infiltration of the liver, pointed out by Gubler; or the lesions of the lungs and thymus gland, described by Dupont and Dubois. appearance of premature decrepitude, the "look of little old men," which has been so often described, and which is usually considered a characteristic sign of syphilis, is, according to M. Caillault, of no such diagnostic value, but is a result of cachexias, of whatever kind they may be. The symptoms of congenital syphilis, thus limited to the skin, are still further restricted by him to one single external manifestation -viz., the mucous patch, or, as it has been variously styled, the mucous tubercle, the flat tubercle, the syphilitic patch, the humid papular syphilide. All the other infantile eruptions usually ascribed to syphilis-as, for instance, the pemphigus neonatorum-are to be considered as mere signs of cachexia, syphilitic or other. The contrary opinion, he says, results from the constant comparison drawn by authors between the syphilis of infants and that of adults, and the desire to find in the former all the pathological phenomena presented by the latter. Now that M. Caillault is right when he says that symptoms are frequently ascribed to congenital syphilis which are in * Leçons sur les Mal. de la Peau, tom. i. p. 167. |