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had afterwards been rubbed with a black substance. Beneath the nails thickening now began, so that some were raised an eighth of an inch. The edges also crumbled, but not with the same degree of irregularity as was noticed in the first named case.
At the time when the patient came under my observation, every nail on the hands was affected, except that of the left forefinger; the nails of the great toes were also diseased in a similar way. The nails were firmly fixed, to my sensation, when trying to move them ; but the patient said that they felt loose to her sensation, and that after soaking them in water they really were loose. Some of them were deeply cupped in the centre. I sent this patient to Mr. Orrin Smith for illustration. He has sketched four of the fingers with great care, together with a patch of the scaly eruption from the arm. The different drawings, given in the accompanying plate, show the nail-disease in various phases, and supply a description which could not be fully expressed in words.
I have only to add, that this patient, though a tall, delicate looking woman, had suffered little illness, and throughout life had been comfortably provided for.
A third example of this form of disease calls for the annexed observations. The patient was thirtyeight years old; a man actively engaged in business, and of genial disposition. He had become stout these last years, much too stout for his time of life, and very dyspeptic. His hair was grey, but firm. He had lived well at all times; and, without being intemperate, had habitually taken ante horam somni a “ nightcap,” in the form of one tumbler of whiskey toddy. Twenty years ago he had a slight attack of illness, which taught him that Venus not unfrequently transfers her devotees from the sphere of her own charms to the gentle guardianship of Mercury. There was, however, nothing very severe in this attack, and recovery was believed to be complete. In the latter end of 1859, the forefinger of the left hand gave to the patient a disagreeable sensation ; the sensation was that of numbness and tingling. The skin then, for about an inch from the tip of the finger, assumed à dry, scaly appearance, with what seemed also to be absolute shrinking of the extremity. The nail became of dirty brown, and slightly pitted ; it also wore away at the edges, but not irregularly. The finger was unpresentable, and gave its owner so much annoyance, that he assured me he would rather have it removed by amputation than that it should remain in its existing condition.
The analysis of the cases above cited leave the nature of the disease in obscurity. In the first and last cases, there was a pre-existent syphilitic taint; in the second case, while there were symptoms which are compatible with syphilis, such as lepra and falling off of the hair, all other evidence was against the pre-existence of that disorder. In the first case there was no eruption of the skin; in the last two the skin was affected more or less with scaly disease. The patients were all about the middle age; but in constitutional character the first and last were strongly
opposed to the second. One patient had worked in lead as a painter; the woman had all her life been at domestic duties; and the third was engaged in a mercantile pursuit, in which the pen was more employed than aught else manually. *
CAUSE AND CAUSATION OF THE DISEASE. The disease allies itself to squamous disorders of the skin, but whether it is identical either with lepra or psoriasis I am not prepared to say; for, while it may exist with these disorders, it may also, as we have seen, exist independently. I think there is no doubt that it commences in the matrix, and that all the conditions of nail are due to a partial or complete death of the structures attacked ; in other words, there are interposed between the secreting membrane and the under surface of the nail, epithelial layers, which separate the two structures, and prevent that osmotic change by which the nail is repaired in proportion to its mechanical or natural destruction.
Is the disease purely of syphilitic or of mercurial origin? An affirmative answer has been assumed to this question. Mr. Gay, who spoke at the meeting of the Medical Society, at which some of the cases narrated here were discussed, assumed this affirmative in its entirety, and brought forward, it must be
* In addition to these, I once incidentally saw another case at that period of the disease when pitting with dirty glazed surface are the external symptoms. The history of this case is not known to me accurately; but I may say that the patient was engaged in a profession in which manual labour is excluded.
admitted, considerable evidence in favour of such affirmative. However, I am not prepared to admit the point as proven. I shall show, indeed, evidence further on, which will prove that in some cases treatment negatives the argument of a syphilitic origin. Indeed, in the two examples which I have given, where there had really been an attack of syphilis, I doubt whether that disease was still at work. It seemed to me in both these cases that a free mode of living, and dyspepsia, had more to do with the affection than the specific and long removed enemy.
There is clearly nothing in occupation which leads to the disorder; the first named patient had worked in lead; but I have made inquiries amongst leadpainters, and find that no special affection of this kind is known amongst them; further, we had before us other occupations, all different, and one not manual, so that the evidence points to a constitutional, as opposed to a local, origin for the disease.
DIAGNOSIS. The disease of the nails under review has three stages. The first stage is marked by a sensation of numbness and tingling beneath the surface of the nail. In the second stage there is an appearance of dirty glazed discoloration of the nail, with pitting of the surface. In the third stage there is a crumbling down of the nail-structure from the edges and the free margin, with more or less of irregularity, thickening from the under part, cupped surface depression, and looseness.