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In the first case to which my attention was drawn, various forms of treatment had been already pursued. Local treatment had been tried; the nails had been washed with lotions of zinc and lead; they had been encased from the air; and they had been painted with iodine. Internally, mercury had been administered ; after that quinine; and again mercury. Believing at first that the disease was of syphilitic character, I suggested iodide of potassium internally in five grain doses three times a day; and my friend who brought the patient to me carried out this treatment fairly for many weeks. It had no effect for good. The patient got tired, and consulted a new practitioner altogether: I have been unable to learn with what effect.

In the case of the woman, the treatment adopted previously to my attendance had again been both local and general. Locally, zinc lotions, zinc ointment, glycerine, and iodine had been applied. Internally, mercury had been administered, and iodide of potassium, but with no avail. The presence of the skin-eruption turned me to another indication. Instead of pursuing local treatment, I commenced with Fowler's arsenical solution as a general medicine, in doses, first of three minims, and afterwards of four minims, three times daily. The good effect of this treatment was quickly shown. The first dose of medicine was taken on the 6th of April. On the 26th of May the eruption of the skin was greatly


better, and the disease in the nails was entirely arrested. On the 26th of July all the nails had nearly regained their normal character, except the nail of the right forefinger. At this visit the patient complained of catarrh; the arsenical mixture was therefore replaced by a saline, which she continued to take until August the 9th without consulting me. At her return on that day, I found the squamous symptoms the same. I once more ordered the arsenical solution; and, as she bore it without any unpleasant sign, it was continued steadily until August 23rd. The nails might now be considered as well. All were restored to perfect smoothness, except the first and second of the left hand. These retained the faintest signs of indentation, and the first one was rather thicker than the others; but an observer, who saw them without previous knowledge, would certainly not conceive that they had been extensively disorganized. The eruption on the skin was yet not altogether removed. There was an irritable patch around the nipple of the right mamma, and a second one in the groin. The medicine was continued until the 1st of September, when the skin eruption had also disappeared. After ceasing the arsenic for a month, there was a reappearance of cutaneous scales about the nipple; but the nails continued unaffected. The arsenical solution was reordered, again with removal of the squamous patch. This patient still remains under treatment.

The third case had been treated merely locally; iodine had been particularly tried, but without any

good result. When the case was in my hands, the first thing I did was to prohibit the “nightcap,” and otherwise to reduce the hydrocarbon supplies. Medicinally, Fowler's solution was prescribed, in three minim doses three times a day. After one month, during which the medicine was well tolerated, the nail underwent rapid progress towards renovation; and three weeks later it, together with the finger, had recovered the natural appearances.

The evidence in respect to the treatment of this disease of the nails is thus strongly in favour of arsenic as the remedy. This view in some measure removes the hypothesis of the invariably syphilitic origin of the disorder, and shows, at all events, that there may, as in lepra, be two sources, one of which is not directly of venereal growth.

In any doubtful case, where arsenic alone did not cure, it would be good practice to move from Fowler's to Donovan's solution (the compound of hydriodate of arsenic and mercury), a solution which, notwithstanding Hebra's opinion upon it, is admirable in obstinate cases of mixed syphilitic and squamous disease.




THERE is perhaps no phenomenon more curious to the practising physician, when he first meets it, than that known as reduplication of the sounds of the heart. It is so rare that its novelty strikes forcibly; it is so well marked as a peculiarity when it does occur, that its existence can admit of no dispute.

Those who have not heard what is called reduplication, may learn it by hearing what it is. In lieu of two heart-sounds to each action, there are three; in lieu of the familiar “lūb-dŭp” and pause, there is distinctly caught “lūb-dŭp-dŭp”; that is to say, a third and unexpected short sound takes in great part or altogether the place of the pause. Therefore, in strict definition, reduplication applies to but one of the sounds of the heart.

OBSERVED FACTS AND ANALYSES. In the beginning of this year (1860), a young man, 23 years of age, came before me at the Royal Infirmary for Diseases of the Chest, with the following complainings. He was subject, and had been subject for



three weeks past, to almost constant palpitation of the heart. He believed that his first symptoms were due to a “cold on his lungs”. The palpitation kept him sleepless, and in subdued suffering; he could feel a tilt of his heart against the chest-wall, not in the anterior point, where the beat is ordinarily felt, but laterally—towards the left side. At times this palpitation became unusually violent; there was a sensation of choking in the throat, a struggle for breath, and afterwards great exhaustion. In addition to these signs, there were flatulency and anæmia: but the tongue was clean, the bowels acted daily, and the skin was cool. There was desire for food, but a dread of taking it, inasmuch as anything like a meal oppressed the chest; but the urgent symptoms of which the man complained, and of which he came to be relieved, were the palpitation and oppression. “ If I could lie down and sleep”, he said, “ I should be well; but, as I try to sleep, this terrible weight and palpitation come on increasingly, and I start up at last as if I were being strangled, or crushed between two heavy doors."

The symptoms described by the man might have passed current in the run of practice for those of hysteria and anæmia. Fortunately—if that is fortunate which becomes a habit-I examined the chest of this man. I could find in the lungs no trace of tubercle, bronchial dilatation, nor other organic lesion : yet this was peculiar, and I pointed it out at the moment to Mr. Louis Parnell, who was attending my clinique, that there was everywhere a deficient

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