struction of the itch insect; therefore it should be used (I speak of the majority of cases) to the hands where the acari are: and as it is an irritant to inflamed parts, it should not be hazardously applied to the parts where the secondary eruption exists, for it can serve no other purpose than that of increasing the eruption; and even applied to the apparently sound through irritable skin of a scabious patient, it will induce eruption. Then much of the eruption is the result of scratching the skin to relieve the irritation, its character depending upon the state of health of the patient.

Well, these are very simple truths. But they really require to be repeated over and over again, because the practice of many is to apply sulphur ointment, in a patient affected with itch, to every part that itches; or, indeed, as in the case where the sulphur bath is used, to the whole body. This is a mode of treatment from which I entirely dissent. The specific remedy should be used to the hands as freely as possible, and there only in the vast majority of cases. There is another point of importance. As sulphur is a stimulant, and if freely used an irritant, of course it is desirable to employ it in the least possible amount, but of course such as suffices to effectually kill the acari. I am sure the ordinary sulphur ointment is much too strong. Usually it contains one part in five. I think one in sixteen (half a drachm to the ounce) is sufficient if combined with the ingredients to be presently noticed. The use of the old sulphur and hellebore ointment should be utterly rejected. Before using sulphur it is well to wash the hands with soap. Then another important consideration is the length of time during which it should be used. Very many practitioners continue the sulphur treatment long after this is at all necessary. They are misled by the continuance of the itching, which they take to mean the continuance of the disease, whereas it is sometimes the result of the action of the sulphur. If the acari are killed the itching ceases, of course, and if we carefully note the patient's condition, we shall find that after a few vigorous applications to the interdigits and the wrist only, the itching is subsiding, and the general irritation would then soon cease; but if sulphur has been and continues to be, applied to the sympathetic or secondary eruption, the itching is often only increased and though the true scabies itself (that constituted by the acari in their burrows) is in reality well, the disease is apparently worse, because the secondary eruption has been intensified. Leave off, as I have done in scores of cases that have fallen into my hands, under such circumstances, all sulphur treatment, give a bran bath, and use freely an oxide-of-zinc lotion, and the patient soon gets well. But I have said that there are a few acari scattered about in the midst of the secondary eruption over the body in some cases, especially chronic ones. To kill these it is only necessary to smear over the dark-looking papules about the body, and any eruption along the upper line of the penis, the specific remedy, taking care not to irritate any parts that are "weeping" or "oozing."

These observations relative to the unnecessary irritation of secondary eruptions, apply with special force to the case of children.

I may sum up, then, by saying that in treating scabies we should use the specific remedy in recent cases as freely as we like to the interdigits and wrists only, and apply soothing remedies to the general surface; that the sulphur should be in small quantity, and that sulphur baths should be discarded. I employ half a drachm to an ounce of lard, with three drops of creasote, and five grains of ammonio-chloride of mercury, a little olive oil, and a drop or two of essential oil. In chronic itch, however, this form of specific remedy may be applied to all eruptions of discrete character. I prefer the three days' treatment of scabies, keeping on the same linen, and then having a thorough cleansing with soap and a clean change. Less after-consequences follow this than more heroic and rapid modes of cure.

I may just say in regard to skin diseases, generally, that sulphur is only admissible in chronic cases where there is an absence of active inflammatory action. We find it said in books that it is good for eczema, psoriasis, acne, erythema, and other diseases. Well, not in the acute or active stage. It does harm. When diseases have become indolent, and the skin needs to be

stimulated, then sulphur is of use, and I think then only. I have seen on many faces and many skins a dirty, rough, and slightly reddened surface, difficult of cure, produced by the use of sulphur, very much to the annoyance of patients. Stimulation is constantly effected where soothing is required. The matter is a simple one, as I have said, but important for all that to practitioners.-Lancet, March 6, 1869, p. 322.

82.-A FEW CURIOUS FACTS RESPECTING HERPES ZOSTER. By JONATHAN HUTCHINSON, Esq.

Herpes zoster is a disease which offers to the clinical observer some very interesting and important problems. Its non-symmetry and non-contagiousness, its observance of stages and spontaneous disappearance, and its occurrence but once in the patient's life, are well established as general facts, though none of them without occasional exceptions. The first two seem to connect it with the neuroses, the others to ally it to the exanthems. Such being the puzzling position which it occupies, I think the following facts and remarks worthy of publication.

I regard it as certain that special conditions of the blood may so irritate the roots of the sensory nerve trunks as to induce those trunks to cause at the periphery herpetic inflammation. Thus we have a syphilitic herpes zoster, in which the patches are located exactly as are those of common herpes zoster, and clearly under the influence of nerve distribution. But these cases differ from the common herpes zoster in that the eruption is usually on both sides of the trunk and on other parts of the body. It may also last much longer than common herpes zoster does. These circumstances, symmetry of eruption and long persistence, are what we should expect in connexion with the blood cause. Some facts which have recently come under my notice incline me to believe that herpes zoster, in its most typical form, and following its usual course, may be produced by a blood cause. A priori, we should have thought it most improbable that a non-symmetrical eruption could occur in connexion with such a cause. The facts to which I refer are a group of cases in which herpes zoster has occurred in patients who were at the time taking arsenic. They have been so numerous that I think their occurrence must be something more than a coincidence. Should further experience confirm my present suspicion, we shall have gained a step in our knowledge of the pathology of herpes zoster, and shall, perhaps, have also furnished another fact to those modern neurologists who hold that the nervous system is less symmetrical in function than has hitherto been supposed.

Case 1.-Partially Symmetrical Herpes Zoster occurring in a Patient who was taking Arsenic.-The following notes were taken about three years ago, and describe the condition of a patient who was kindly sent to me by Dr. Hughlings-Jackson. It was of special interest both as an example of symmetrical herpes, and because it came on during an arsenic course. I have described its positions in more detail than would otherwise have been requisite because of its occurrence on both sides.

"A robust man, aged 67, is attending at the London Hospital, under Dr. Hughlings-Jackson, for sciatica, and has been taking five-minim doses of liquor arsenicalis. He is now the subject of herpes zoster, which began a few days ago. He says he had very trifling pain when the rash began to come out. It first appeared behind his right ear. It now covers the right side of his neck, his right shoulder as low down as the spine of the scapula and the right side of the front of his chest as low as the upper border of the third rib. On the front of the right arm it extends as low as about two inches below the axilla. The vesicles are quite characteristically those of herpes zoster, with some tendency to ulcerate in parts. Looking at the front of his chest, the inflammation of his skin stops abruptly at the middle line, but at a distance from this, on the left side, there are a few isolated small patches of vesicles over precisely the same area as is affected on the other side. There

are a few isolated vesicles on the left side of the neck, but they are only to be seen when looked for very carefully. There are none on the left side of his cheek nor behind the left ear; none on the left front of his neck. Thus the disease is fairly symmetrical as to the areas affected, but occurs very much more severely and copiously on one side than the other. The amount of irritation has been much less than usual."

Case 2.-Arsenic administered in a Case of Eczema-Herpes Zoster on the Trunk a fortnight later.-A man, aged 32, was admitted at the Hospital for Skin Diseases, in January, 1866, for eczema, &c. Three-minim doses of Fowler's solution were ordered. A fortnight later he had a free eruption of shingles on the right side of the chest. The arsenic was continued. The shingles went through the usual course, and soon disappeared. On November 30 he again attended for a relapse of the original eruption. On examination it was found that the shingles had not left any perceptible scars. It had been a mild attack.

Case 3.-Herpes Zoster on Lower Part of Abdomen one Week after beginning an Arsenical Course.-A man, aged 66, was admitted on September 7, 1866, with eczema rubrum of the legs, and amongst other treatment arsenic internally was ordered. On September 18 there was a free eruption of herpes zoster on the right side, in the iliac region, and side of abdomen. He had taken the medicine about a week before the herpes showed itself.

Case 4-Herpes Zoster Six Weeks after beginning an Arsenical Course.-A woman, aged 48, who attended in December, 1866, had been taking arsenic six weeks for eczema. At the end of that time herpes zoster showed itself on the right side of the chest, and went through its usual course.

Case 5.-Herpes Zoster Frontalis Three Months after commencing the Use of Arsenic.-A woman, aged 44, admitted on April 9, 1867, on account of psoriasis, had six minims of Fowler's solution ordered three times a day. On June 14 the dose was reduced to three minims. On July 12, her psoriasis being now nearly cured, she was attacked by herpes zoster frontalis in the right side. The herpes was of no great severity, and it disappeared as usual although the arsenic was continued.

Case 6.-Herpes Zoster of the Buttock after Three Months' Use of Arsenic. -A boy, aged 8, the subject of complicated and chronic skin diseases (lichen, &c.), took small doses of arsenic from November to March, when he had herpes zoster on the left buttock.

Case 7.-Herpes Zoster during the Use of Arsenic.-A girl, aged 14, admitted on January 1, 1867, with psoriasis of the scalp, took arsenic from that date to the 29th, when she had herpes zc ster on the right side of trunk.

Case 8.--An Eruption resembling Herpes in Arrangement, but not Vesicular, during treatment by Arsenic.-A man, aged 50, who was taking arsenic, had a curious unsymmetrical eruption arranged just like shingles, but which remained papular, and never showed vesicles. It disappeared, as usual with shingles, after about ten days' duration.-Medical Times and Gazette, Dec. 26, 1868, p. 722.

83.-ON THE TREATMENT OF CARBUNCLE.

By JAMES PAGET, Esq., F. R. S., Surgeon to St. Bartholomew's Hospital. Although you may not have seen much of it, you must all have heard of the ordinary manner in which carbuncles were treated formerly, and still are by some; a method which consists mainly in making large incisions through them, and giving very large quantities of food and stimulants, as well as considerable doses of quinine, bark, and other tonics. I do not at all mean to say that the things which in these cases I left undone would have done any harm; but what I hold of them is, that they would have been quite usel ss, and some would have been sources of great discomfort to the patients. And in the way in which I speak of these things you may notice that I exemplify that rule which I have always impressed upon you, of asking yourselves, when

you seem to have been successful with some medicine, "What would have happened if I had not given it?" The apparent consequence of giving a medicine may be plain enough; but you cannot too often repeat to yourselves the question-as a rule, I will not say of practice, but of the study of your own practice," What would have happened if this or that, which seems to have been successful, had not been done?"

First, with regard to the incisions made in carbuncles. The ordinary plan, still recommended by some, is, as soon as a carbuncle is seen, to make two incisions crucially from border to border. It is said that they must go even beyond the edges of the carbuncle into the adjacent healthy textures. I have not followed that method of practice very often, but I have followed it quite often enough to be sure that it does not produce the effects which are commonly assigned to it. It is commonly said that if you will thus make crucial incisions into a carbuncle, you will prevent it spreading. If you can find a carbuncle two or three days old, and cut that right across in both directions, I think it very likely that you will prevent it spreading. But even therein is a fallacy; for there is no sign by which, on looking at a commencing carbuncle, you can tell whether it will spread or not, whether it will have a diameter of an inch, or of three, six, or ten inches. The question, therefore, that I spoke of comes back, "What would have happened if I had not made these incisions?" And the answer to that question will be rather according to temper than according to knowledge. For as I watch men in their conclusions upon such cases as that, I generally find that self-satisfaction says, "I saved the man's life;" self-dissatisfaction, "I did him no good." The truer scientific temper stands midway, and says, "I will wait for further information on the matter-till I have seen more cases, and then decide whether, in the earliest stages of carbuncle, incisions are useful or not." After this time of three or four days I have seen sufficient numbers of carbuncles thus divided, and have divided enough for myself, to say that it will not hinder the spreading. I have seen carbuncles spread in as large a proportion of cases after incision as in cases that have never been incised at all. I have in my mind a striking case that occurred to me early in practice, when I followed the routine, and, in a friend of my own, divided a carbuncle most freely. I cut it after the most approved fashion in depth and length and width, and then it spread. After two or three days more all the newly-formed part was cut as freely as the first, and then it spread again, and again it was cut as freely. Then it spread again and was not cut. Then, in a natural time, it ceased to spread, and all went on well. These are only general impressions that I give you, because one cannot count the cases in which cutting has been practised, and those similar cases in which it has not; nor even then could it be said whether those in which the cutting was practised would have spread if left alone. On a very strong general impression, however, I say that carbuncles will spread after cutting in as large a proportion of cases as they will spread in without cutting.

Then it is said that carbuncles are relieved of their pain if they are thus very freely cut. Here, again, however, is only a partial truth. A carbuncle of two or three days' standing, which is hard, tense, and brawny, is very painful; and cutting it will relieve, in many cases, a considerable portion of the pain. But after this, when the carbuncle begins to soften, and when pustules begin to form upon its surface, and pus in its interior, it ceases to be painful of its own accord, and without incisions. Thus there are two distinct stages of carbuncle in reference to the pain; the early stage, when it is hard and still spreading, and is generally intensely painful, and the latter stage, in which that pain nearly ceases. A curbuncle divided in the first stage, in the first two or three days of its existence, may be relieved of some of its pain; if divided in the later stage, what little pain may exist is altogether unaffected by the cutting. And even cut as you may, you cannot always put aside the extreme pain that a carbuncle sometimes has, even to its later time. Some two or three years ago, I was called to a member of our profession with a large carbuncle in the middle of his back. His friends had been much alarmed about the state of his mind, for he had been suffering great mental

anxiety for some time, and they were in fear lest the excessive pain of the carbuncle should, in his disturbed state, do his mind permanent damage. So they persuaded me to cut it, and I cut it after the old plan, very wide across. and far into the adjacent textures, as freely as could be. It did not in the least relieve him. I never saw a carbuncle through its whole course so painful as that was, and up to the last, till the healing was nearly completed, he suffered more or less pain in it. So that the conclusion in reference to the pain must be this: if they can be divided in the first three or four days, while still hard and brawny, it may relieve some measure of the suffering; at a later period the incisions have no influence at all.

The third point is stated thus, that by the incision of carbuncles you accelerate their healing, giving facility for the exit of sloughs. But herein is the greatest fallacy of all. When the cutting of carbuncles was more customary in this hospital than it is now, when I did not cut them, and some of my colleagues did, I used to be able to compare the progress of cases cut and of cases uncut, and time after time it was evident that the cases uncut healed more readily than those cut. A man who is now in the hospital I have brought round here that I may illustrate this point to you. This is the man, Timothy C., aged fifty-five. When he came in, this carbuncle had a length of more than six inches, and a breadth of three and a half; and it formed the ordinary hard, compact, tense, and brawny mass that a carbuncle usually does. It had at that time already taken to suppurate, and little pustules were pointing on the surface. If I had followed the practice of incisions, I should have had to make a cut in one direction of about seven inches, and in the other of about five, and after that I should have had not only the wounds wide, open, and gaping, and having themselves to heal, but a great part of the substance of the carbuncle fairly exposed, and also under the necessity of healing. But you will observe that the whole of the space that now remains to heal is a series of openings in the middle of the carbuncle, through which the sloughs are to be separated, through which, indeed, nearly the whole of the sloughs have already been discharged, and which now merely remain to be healed like the cavities of small abscesses. In that way you narrow greatly the extent of wounded surface to be healed. Indeed, it by no means always follows that the whole carbuncle, or its whole base, sloughs. Carbuncles, if not divided, not unfrequently only suppurate about their centres, and slough only in their central parts, and the borders merely clear up by the softening and dispersion of the inflammatory products in them. In every case of that kind you save greatly the amount of healing which has to be gone through. Nay, in some cases carbuncles completely abort. One of these cases, of which I have the paper on the table, was that of a woman, aged 64, who came in with a carbuncle nearly as large as this, in a condition which, it might be said, required incision at once; but, with the exception of two or three small points, no suppuration or sloughing ensued. That carbuncle dispersed, aborted, cleared away. This case shows the more ordinary course of events-the sloughing of the central part, the gradual discharge of the sloughs, and the comparatively small spaces which are left in the centre of the carbuncle as the sole space in which the process of healing has to be achieved,

On these three points, which are the grounds that have been assigned as reasons for cutting carbuncles, I have now given you the evidence on which I have ceased from the practice. I fully believe that crucial incisions do not prevent extension; that it is only a limited set of cases in which the incisions diminish pain; and that with regard to the time that is occupied in healing with or without incisions, the healing without incisions is very clearly and certainly a great deal the quicker.

The kind of incisions that I have been speaking of is the old plan of crucial incisions. Another method which I have occasionally tried, but of which I can only state the same general results, is that of subcutaneous incision. This has been supposed to have the same general effect as the other; and I think that the same general conclusions may be drawn respecting it that it is a measure unnecessary in the treatment of carbuncle, and