and air from the chamber of the sick. But in doing this the opposite extreme must be avoided; for it is well known that warmth and moisture (for you can scarcely exclude the air without increasing warmth and moisture) increase suppuration, and materially influence the development of all eruptions: even a poultice applied to a vaccine vesicle, from its warmth and moisture, will so alter the action of its secretory vessels, as in twenty-four hours to convert it into a pustule. Destroying the pores and the transparency of the skin by the application of nitrate of silver, successfully practised by Dr. Serres in this disease, amounts, in my opinion, only to the exclusion of light and gases.

"Mr. Le Grand's plan of smearing the surface with gummucilage, and covering with gold beater's skin, also lessens the action of light and excludes air; but it advances a step farther, by exerting another powerful curative agency, viz. an uniform pressure. Which reminds me of a method I have pursued for years, that of curing pustules, vesicles and sloughing ulcers on the face, &c., by a stiff coating of hot yellow wax and oil, after they had resisted all common treatment.

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"Mr. George's plan of caking over the surface with calamine, acts not only by excluding light, but by absorbing moisture, and through its astringent qualities causing contraction of the living pustule. I have long since so applied the white oxide of zinc, and found it to act in a similar way upon vesicles, causing them to break, part with their contents, and heal. A coating of pure liquor plumbi acts in almost the same man. ner; and many eruptions about the face, hands, and neck, that have been obstinate, cease to come out, and speedily heal, if light and air be excluded, and motion restrained by uniform pressure; though effected if only by adhesive plaster and a roller.* Thus we approach by degrees, and in effect, almost to the method recommended by Dr. Olliffe; viz. the applica tion of emplastruni ammoniaci cum hydrargyro, which in itself seems to possess the curative qualities of most of the other methods, with the valuable addition of power to promote absorption of the serum and lymph, when applied early in the disease, or even of the raised edges of the cup-like bases, which give rise to pits, scars and seams in a later stage. the serum and lymph be thus caused to be absorbed, the ve sicles are not completed, and therefore the pustules do not

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* I have not noticed the early puncturing of each pustule, which is useful to prevent pits, and but anticipate Nature's plan.

occur. And this power over the disease we may fairly consider the remedy to possess, knowing, as we do, that the absorption of new-formed parts can be so much more easily promoted than that of originally formed structure. Any other specific action from the mercury and ammoniacum appears very unlikely; and as to animalcula causing the pits, Dr. Olliffe may certainly dismiss that idea from his consideration, notwithstanding that animalcules exist in all long-retained secretions in the human body.

After numerous dissections and microscopic examination, I may affirm that this eruption does not commence by enlarged papillæ, but by simple zones of minute vessels projecting from the cutis, throwing out serum, and raising the vesicle: and that although the red depositions protrude beneath the cuticle, so as to be felt on the surface, it is merely from distension; and enlarged papillæ are not to be found until after the maturating stage, and not then, except in the base of the pustule, and only when ulceration has penetrated the surface of the cutis. In many cases, even where lasting pits and deformity ensue, sloughing and ulceration will not generally be found to have penetrated through the corium to the cellular membrane beneath. I explain these points merely to set right some mistaken theory in the lately published paper.

"The application of the mask, or plaster, in the very early part of the eruption, is well insisted on. It should be applied as soon as the nature of the eruption is ascertained, and the red projections can be distinctly felt as early as the third day, and be continued without intermission or removal until the maturating stage has been completed in other parts of the body, a period of about five days. That this mode of treatment possesses vast power to arrest the full development of the eruption is undoubted; and I conceive so innocent a preventive merits trial by all medical practitioners desirous of preserving the appearance of their patients, and of advancing science."-Am. Jour. Med. Sci.

Permanent Contraction of the Fingers. By Prof. VELpeau. -Permanent flexion or contraction of the fingers depends on a great number of causes; it may arise from wounds, paralysis of the extensor muscles, anchylosis of the joints, tumors, shortening of the tendons, irregular cicatrices, &c. On the present occasion, however, I wish to direct your notice to that form which depends on contraction of the palmar fascia, or on

the formation of fibrous bands extending from the palm of the hand to the fingers, and binding down the latter in their irreg ular position.

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Before the remarks published in 1831, by Dupuytren, followed up by those of MM. Lemoine, Mandet, Vidal, Goyraud, &c. permanent contraction of the fingers had not been much noticed by surgeons. Boyer alludes to the affection under the name of crispatura tendinum; Sir Astley Cooper, also, speaks of permanent retraction of the fingers and toes, which he attributes to contraction of the sheaths of the tendons of the palmar and plantar aponeuroses. Dupuytren has clearly shown that the tendons are seldom engaged in this affection, but he has not so evidently demonstrated that it depends on induration, or shortening of one or more bands of the palmar fascia. The disease now under consideration, is characterised by the formation of certain bands or chords, which are elevated beneath the skin, and extend along a considerable portion of the palmar surface of the finger; these bands generally occupy the median line, and are attached usually to the first phalanx, but sometimes prolonged to the second or third. According to Dupuytren this disease generally begins on the ring finger, and thence extends to the little finger; it increases gradually, without occasioning pain; the patient, at first, experiences a feeling of stiffness in the palm of the hand, and is unable to extend one or more fingers; the latter soon become contracted, and, in extreme cases, the tip of the finger rests on the palm of the hand. On examination, the first thing which we notice is a chord extending along the palm and finger; if you attempt to straighten the finger, this chord becomes more tense, and it disappears when you flex the finger completely; it is rounded off in shape, and forms a kind of bridge or prominence at the metacarpo phalangeol joint. The skin is wrinkled into arched folds, extending from the middle of the palm of the hand to the base of the finger. The disease, thus progressing, may attain its maximum degree of severity without causing any pain, or appearance of anchylosis; the joints are easily flexed, but cannot be extended by the most powerful efforts; Dupuytren has seen 150 pounds weight suspended on the bent finger without producing any effect on it.

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This retraction of the fingers is a very disagreeable affection; it prevents the patient from seizing any large body, and, when he closes the fingers strongly, severe pain is felt. Persons laboring under permanent contraction of the fingers, are usually those who have made violent efforts with the palm of the hand, or been employed in occupations during which the

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palm and fingers are frequently pressed against hard bodies. Thus, it is met with amongst masons, ploughmen, watermen, coachmen, &c. Dupuytren mentions the case of a literary personage who was attacked in consequence of frequently using a round-handled office-seal for his letters.

What is the anatomical lesion which characterises permanent contraction of the fingers? Upon this point there exists a variety of opinions. Some attribute it to thickening and contraction of the skin; others, to spasm of the muscles; disease of the flexor tendons; inflammation and contraction of the sheaths of the tendons; some change in the joints and their lateral ligaments; finally, contraction of the palmar fascia. This latter idea was chiefly supported by Dupuytren and Sir Astley Cooper; the following case was the one which influenced Dupuytren's opinion:-An old man, who had been af fected for many years with retraction of the fingers, died in the Hôtel-Dieu; Dupuytren examined the parts with great care; on removing the skin from the palm of the hand, it was found that the folds of integument completely disappeared, the palmar fascia was contracted and shortened, and several bands passed from its lower part to the sides of the deformed finger. On endeavoring to extend the fingers, Dupuytren perceived that the fascia and these bands were rendered more tense; he divided the bands, and effected, at once, complete extension. of the contracted fingers; the tendons and their sheaths had not been touched; the joints likewise and bones were completely free from any appearance of alteration. From this case Dupuytren naturally concluded that the disease originated in the abnormal tension of the palmár fascia, a tension depending on contraction excited by the pressure of some hard substance on the palm of the hand. The case certainly shows that contraction of the fingers may sometimes depend on a change in the palmar fascia, but it does not prove that this is always the cause. The bands or hard chords, which, as I have already mentioned to you, are seen projecting under the skin. extend to the palmar surface of the first phalanx, and sometimes to the second or third phalanx. Now we know that the palmar fascia terminates at the root of the finger, by becoming attached to the sheaths of the tendons and ligaments; besides, the fascia does not cover the ball of the thumb or extend to its root, yet we have permanent contraction of the thumb. with the sub-cutaneous chords already noticed. Having determined, by dissection, that the palmar fascia remained sometimes intact, after the removal of these chords, I announced, in 1833, that the prolongations mentioned by Dupuytren were

not always formed by the palmar fascia; but that they seemed to me to depend on the transformation of the subcutaneous cellular tissue into fibrous bands. M. Goyraud, surgeon to the Hôtel-Dieu of Aix has proved the correctness of this opinion by his researches on permanent contraction of the finger, published in the third volume of the Memoirs of the Royal Academy of Medicine. In addition to a carefully performed dissection, M. Goyraud relates the following case, which confirms my view of the nature of this disease.

"M. Chaine, steward of the hospital, presents a remarkable example of the permanent contraction of the fingers. The three last fingers of the right hand are flexed; of the left, the four last are in the same condition. The left ring-finger is more flexed than the others; on the right side, the little finger is the one most contracted; the middle fingers are only semiflexed. The contraction came on gradually, and without any pain. M. Chaine is now 58 years of age; when at the age of 42, he first perceived that he was unable to extend the left ring-finger completely. The latter became gradually contracted, and the affection soon extended to the two neighbor. ing fingers. Shortly afterwards, the right little finger began to contract, and then the ring and middle fingers of the same hand. The first phalanges are now flexed at a right angle on the metacarpal bones, and the second phalanges at various angles on the first. On attempting to extend the fingers, it is evident that they are retained in the flexed position by a number of bands running from the palmar fascia to the middle part of the fingers."

In this case, the disease consists in flexion of the first phalanx on the metacarpal bone, and of the second phalanx on the first; the joints of the third phalanges are completely free.

Hence, since contraction of the palmar fascia and its digital prolongations could only influence the first phalanx, it is evident that the contraction of the second phalanx must depend on some other cause. Even in the lectures of Dupuytren we may find a proof of this. Mr. L. had contraction of the ring and little fingers of the left hand, which were completely flexed on the palm; the second phalanx was bent on the first, and the tip of the third applied to the ulnar edge of the palm; the little finger was constantly flexed on the palm of the hand also. M. Dupuytren operated in the following manner:-He commenced by making a transverse incision, ten lines in length, opposite the metacarpo-phalangeal joint of the ring-finger,

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