OBSERVATIONS ON THREE CASES 
OF 
SYMMETRICAL HAND AND FOOT DISEASE. 
BY 
JAMES NEVINS HYDE, A.M., M.D., 
PROFESSOR OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, CHICAGO 
FROM 
THE MEDICAL NEWS, 
October 8, 1887. [From The Medical News, October 8, 1887.] 
OBSERVATIONS ON THREE CASES OF 
SYMMETRICAL HAND AND FOOT DISEASE. 
By JAMES NEVINS HYDE, A.M., M.D., 
PROFESSOR OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, 
CHICAGO 
The cases reported below are given in brief but 
essential detail, with a view to illustration, of one 
phase merely of the pathological condition which 
they are believed to represent, and which is described 
later. 
Case I.—C. S., aged nineteen years, a resident 
of Indiana, applied for advice on the 23d of May, 
1887. He was an intelligent, bright-looking lad, 
then attending school. He used no tobacco in any 
form and denied all history of venereal disease. His 
father was living and in good health, fifty-four years 
of age ; his mother the same, aged forty-nine. Four 
sisters were living and in good health. One brother 
died in infancy. One sister was married and had 
five healthy children. There was no history of cuta- 
neous trouble in any member of the family. He 
gave no history of disease prior to the occurrence 
of the present ailment. All the bodily functions 
were propeily performed. He stated that three years 
before the present date he noticed the first signs of 
his present disorder on the tips of the fingers. Some- 
what later the toes were affected, and soon after that 
the palms of the hands and the soles of the feet. 
Since the beginning of his trouble the local affection 
had very slowly and gradually increased until the 
present condition has been reached. His complaint 
now is chiefly of stiffness and inflexibility of the 
hands and some soreness of the feet. 
The state of the patient when examined was as 2 
HYDE, 
follows: weight, 135 pounds, and gaining at the 
rate to be expected at his years. Vision, as tested 
by Snellen’s types, in both eyes, normal. There 
was no sensori-motor evidence of disease of the ner- 
vous system. The hands and feet were symmetri- 
cally involved. The palms of the hands and the 
palmar faces of all the digits were the seat of a dense, 
inelastic, epidermal thickening, which had proceeded 
to such an extent as to render the complete exten- 
sion of the digits slightly uncomfortable. The tylo- 
sis of the palmar surface of hands and fingers alike, 
was defined with tolerable clearness at the margins 
between the palmar and dorsal surfaces, to such a 
degree that the latter were, with only the exceptions 
noted below, exempt from involvement. Within 
the limits described, the sclerosis of the tissue was 
uniform and unbroken. The color of the palmar 
surfaces of the hands was markedly different from 
that of the plantar surfaces of the feet, having a 
reddish-yellow tint, somewhat suggestive of the 
diffuse eczema of the palms observed in certain 
mechanics, whose occupation has induced such dis- 
order. He gave no history of other subjective sen- 
sations in connection with the local ailment than 
pain and a sensation of stiffness. A few linear fis- 
sures near the thumb were productive of slight dis- 
comfort. There was no history of itching, nor of 
any pathological discharge from the surface. 
All the nails of the fingers of both hands were 
similarly involved and apparently to the same de- 
gree. The free border of each, which had evidently 
been carefully trimmed short, was tilted away from 
the axis of the phalanx; and in the angle thus 
formed, in consequence of a species of onychauxis, 
appeared a yellowish-white and irregular stratum of 
horny material. The body of the nail was manifestly 
thickened and its transverse diameter apparently in- 
creased. The nail-substance itself was dry, friable, HAND AND FOOT DISEASE. 
3 
rugous, and destitute of the normal polish. When 
closely questioned upon this point he stated that his 
nails were thicker and dryer than before, that they 
fractured with unusual readiness, and were on that 
account particularly tender. He had within a short 
time noticed some sweating of the hands, a circum- 
stance which until lately had not attracted his atten- 
tion. 
Both feet were cold and damp, and were the seat 
of a slight bromidrosis. The sole of each, with the 
exception of a narrow portion contiguous to the in- 
step, was the seat of a uniform, smooth, firm, ine- 
lastic tylosis, which spread irregularly upward around 
the point of the heel, and involved to a less degree, 
the plantar faces of the distal phalanges of the toes. 
The color of this indurated and thickened epidermis 
was a whitish-yellow, strongly suggestive of the hue 
of wet wash-leather. The coldness and dampness of 
the organs were not limited to the regions affected by 
the tylosis, but were not noticeable over the entire 
surface. 
All the nails of the toes of both feet were involved 
in an onychauxis, precisely similar in character to 
that described in connection with the fingers. The 
nails were tilted up at the free border from the nail- 
beds, and between the two lay a substratum of scle- 
rosed epidermis. The nails were lustreless, rugous, 
transversely enlarged, and cut short on account of 
their undue friability. The soles were the seat of a 
moderate anaesthesia. 
The pulse was registered at 84 per minute. There 
was no history of headache or backache, no cardiac 
murmur, and no marked deviation from the normal 
standard in the tendon-reflexes. 
Case II.—N. B., female, unmarried, aged twenty- 
four years, lymphatic temperament, a servant by 
occupation, was first brought to my clinic from the 
County Hospital, where she had been a patient for 4 
HYDE, 
several previous weeks in the spring of 1884. She 
stated that her parents, two sisters, and one brother 
living in Scotland, were healthy and free from symp- 
toms of her disease. She had been admitted to the 
hospital for relief of a symmetrical, recurrent tylo- 
sis of the feet, and failing to secure relief there ap- 
plied elsewhere. Some months later, she was admit- 
ted to the Presbyterian Hospital and was under my 
observation in that institution till the spring of 1887. 
During all this time her physical symptoms were 
practically repeated in a recurring cycle of changes. 
About one year previous to her original admission to 
hospital, she first began to suffer from her disorder, 
though insignificant symptoms of it had been noticed 
some time before the date referred to above. 
When carefully examined in hospital, her condi- 
tion was as follows: Her intelligence was above the 
standard to be expected in one of her position. Her 
nutrition was fair, menstruation and functions of the 
alimentary canal properly performed. In the sitting 
posture, the cardiac pulsations averaged between 
fifty and sixty per minute, and were often counted 
at fifty. No organic disease of the heart could be 
recognized. The hands were constantly cold and 
bathed in a profuse sweat. This perspiration was 
poured out to such excess as to be a constant source 
of annoyance to her. All the nails of the hands 
were slightly discolored, somewhat rugous, their 
free borders slightly separated from that part of the 
nail-bed adjoining the tip of the finger. In the 
angle thus formed was a grayish, irregular mass of 
tissue, proliferated from the bed of the nail. This 
condition was very much less marked than the simi- 
lar onychauxis to be noticed in the toes. There 
was no tylosis of the palms or symptoms of anaes- 
thesia in those organs; the skin of the hands was 
soft and supple, though clammy and macerated with 
sweat. HAND AND FOOT DISEASE. 
5 
The soles of the feet, including the plantar faces 
of the distal phalanges of the first and fifth toes, 
were symmetrically involved and displayed a uni- 
form, grayish-yellow, thick, firm, and closely adher- 
ent callosity, whose surface was exceedingly rough 
and irregular. It was absent over but a small area 
of the sole, next the instep and plantar faces of the 
second, third, and fourth toes. On account of the 
habitual shedding and recurrence of this plantar 
shell, the feet had been at times exceedingly tender, 
and the inability of the patient to pursue her usual 
vocation on foot, resulting from this cause, had first 
induced her to seek hospital relief. While she was 
under observation, the truth of her statements rela- 
tive to the periodical sloughing of these horny casts 
of the feet was abundantly substantiated. She was, 
while under treatment, subjected to repeated mace- 
rations of the soles of the feet for weeks at a lime in 
water of various temperatures and medicated in vari- 
ous ways; in oil; with shampooings by the aid of 
green soap and alcohol; and treated also by external 
applications of caustic potash, mercury, tar, pyro- 
gallol, and other substances, in the face of all which 
every six or eight weeks there was a reformation of 
the thick plantar callosity on each foot. When it 
was removed, either spontaneously or as a result of 
the soapings and scrapings practised by the patient 
herself, a sound tissue was never recognized beneath, 
but always an irregularly roughened, yellowish-gray 
and softish, macerated, horny layer of the epider- 
mis. As a result, whether the cast were forming, 
formed, or recently shed, the soles of the feet were 
tender and locomotion correspondingly impeded. 
The feet were habitually cold and wet, and there 
was some anaesthesia as far as the ankle. Two pea- 
sized callosities on the dorsal surfaces of the fourth 
and fifth toes of one foot, participated in all these 
changes. 6 
HYDE, 
The nail of each toe was so deformed as to make 
the wearing of the usual coverings of the feet pain- 
ful. Each nail was enlarged, irregularly thick- 
ened, unusually friable, deprived of its polish, and 
tilted up, often at an angle of thirty degrees from 
its bed. In the groove thus formed had accumu- 
lated an irregular mass of tissue, which resembled to 
a certain extent the uneven surface of the sole of the 
foot when the callous plate which covered it had 
been partially scraped off. The dorsum of the foot, 
though cold and macerated with constantly effused 
sweat, was apparently otherwise unaltered. Through- 
out the time during which this patient was under 
observation, no tendency whatever to ulceration be- 
neath the plantar encrustation could be recognized : 
nor did the patient appear to be in the slightest de- 
gree permanently affected by either the internal or 
external medication which had been pursued, the 
former including the administration of arsenic, cod- 
liver oil, and the ferruginous tonics. 
Case III.—In July of 1886, M. D., male, pattern- 
maker, a Scandinavian, twenty-eight years of age, 
with an excellent family history, no tobacco habits, 
and no record of venereal disease, presented himself, 
complaining of loss of hair on the lower extremities. 
He was wtll-nourished and weighed 175 pounds. He 
had for two years noticed the alopecia for which he 
sought relief. His lower extremities were numb at 
times; this sensation annoying him often at night 
when wakeful in bed. In the daytime he had felt 
occasionally as though the lower limbs were yielding 
under the weight of the body. Questioned more 
closely he gave no history of prior disease; but re- 
membered that fifteen years before, in his thirteenth 
year, he had been struck on the vertex of the head 
with a brick. This had not produced insensibility, 
but somewhat later a degree of cephalic pain in the 
vertex, for which a surgical operation was performed HAND AND FOOT DISEASE. 
7 
in the site of his former scalp wound, that gave him 
relief. He was uncertain as to the precise nature of 
the operation, but believed that a piece or pieces of 
bone had been removed from the skull. Lately he had 
again suffered from a peculiar pumping pain in the 
head, which prevented steady attention to his work. 
When examined, a linear cicatrix, two inches in 
length and slightly attached to the bone was discov- 
ered to the left of the anterior terminus of the sagit- 
tal suture. The hands and feet were habitually cold. 
Broad areas of the skin, vertically disposed, extended 
from the middle of each leg downward, chiefly on 
the outer aspect of each, where no single filament of 
hair could be found. Anaesthesia was marked in both 
lower extremities; more so on the right side where 
also the alopecia was most distinct. Each nail of 
those on the hands exhibited a distinctly outlined, 
and unusually large and pale lunula. The nails of 
the index and fourth fingers of each hand were sin- 
gularly flecked with shining, white, stellate, and 
irregularly outlined, translucent maculations. Care- 
ful investigation disclosed no removal of the free 
border of the nails from the nail beds. Vision, tested 
by Snellen’s types was normal; tendon reflexes un- 
altered. 
Says Mr. Charles Atkin, in commenting on a dis- 
order, which I take to be identical with that repre- 
sented in the three cases described above: “As the 
pathology is as imperfectly understood as the treat- 
ment is unsatisfactory, I think every one who meets 
with a case is in duty bound to give a faithful account 
of its coincident symptoms and progress, so that in 
time a more definite idea of the disease may be 
formed.” These pages are written with a view to 
making some response to that plea, and with a full 
conviction as to the unsatisfactory state of our knowl- 
edge on the general subject. 8 
HYDE, 
Of the several names for the group of disorders 
which in this connection we have reason to believe 
should be designated by a common title for identifi- 
cation, some are confusing, some indefinite, some 
imperfect, others positively misleading. The name 
mal perforant dupied, Latinized as “ malum perforans 
pedis,” the ” perforating ulcer of the foot” of Eng- 
lish and American authors, was first employed by 
Vesigne. It seems to be a permanent survivor of 
other names used in this connection, though defec- 
tive in that we now well know the disease it desig- 
nates may affect the hands as well as the feet, and 
may not be productive at any time of a perforating 
ulcer. The title of the present paper has been se- 
lected, not merely with a view to indicating the gen- 
eral character of the affection under discussion, but 
to permit of a brief glimpse over the wide field of 
which it is believed but a very small part is covered 
by cases of the kind represented in the clinical 
sketches just given. 
Two chief reasons may be assigned for the uncer- 
tainty and confusion that seem to have attended the 
discussion of this subject. First, may be named the 
very wide multiformity of the symptoms presented 
in each case, as well as the differences exhibited by 
any two cases in the same general category. Second, 
as a result of the fact last stated, the circumstance 
that a number of English and French surgeons have 
named, described, and treated the prominent surg- 
ical complications of these singular hand and foot 
disorders, leaving to neurologists chief consider- 
ation of the nervous phenomena evident in another 
group ; and to dermatologists the symptoms dis- 
played for the most part in the skin. 
Glancing over the entire field, it seems to me that 
we can establish tolerably distinct relations between 
four classes of symptoms displayed in these cases. 
They are not, strictly speaking, either stages or HAND AND FOOT DISEASE. 
9 
varieties of a single disease, though they may be 
indicative, in occasional instances, of periods of 
evolution of a single affection. 
In the first class, relatively limited as to the 
number of symptoms displayed, we can recognize 
merely functional or transitory disturbances in the 
affected organs. Here, as in other classes, we find 
involved either the hands alone, or the feet alone, 
or both hands and feet. In this event a preponder- 
ance of symptoms may be noted either in the former 
or the latter. Among these symptoms may be 
named symmetrical hyperidrosis, limited to the 
organs affected, accompanied by a sense of both 
subjective and objective coldness. To this class be- 
long the cases described by Mr. Hutchinson and 
other English authors, as “ symmetrical asphyxia” 
of the extremities; and aho those popularly named 
in Great Britain “dying of the hands and feet,” a 
phenomenon occasionally noted as following the 
immersion of these organs in cold water. Bromi- 
drosis is another symptom noted by Atkin and others, 
both in hands and feet. Tiie bond of union between 
these disturbances and those mentioned later is to be 
sought in the nervous and vascular systems. With 
the local phenomena are often associated a pulse 
ranging, with rapid variations in adults, from fifty 
to one hundred and twenty-five to the minute ; local 
anaesthesia, claimed by Schwimmer as a constant 
symptom ; suddenly occurring giddy and dizzy sen- 
sations ; unusual spells, supposed to be of faintness ; 
and vague pains, popularly believed to be rheumatic 
in character. No distinct line of demarcation sep- 
arates the first from the second class of symptoms, 
many cases exhibiting the combined features of the 
two. 
In a second and relatively large group may be 
collected the cases where, with or without, usually 
with, the functional disturbance named above, occur 10 
HYDE, 
symmetrical structural changes in the skin and its 
appendages without ulceration or other destructive 
degeneration in the skin and subcutaneous tissue. 
This group includes many of the cases reported and 
described by dermatologists, and excludes many of 
those recorded by surgeons and neurologists. The 
first and most common of the symptoms here noted, 
in addition to the habitual blueness, coldness, and 
wetness of the hands or feet, or hands and feet, is a 
djstrophia unguim. This may involve all of the 
nails of the twenty digits, whether the two hands 
only or the two feet only are the seat of the hyperi- 
drosis. Here the changes vary from slight roughness 
to extreme gryphosis. In some of Hutchinson’s 
cases there was hyperidrosis with changes in every 
nail. Here should be included the same author’s 
“true psoriasis of the nails contrasted with chronic 
onychitis;” his “ chronic inflammatory disease of 
many finger-nails,” and his “symmetrical slight 
disease of the nails in a young boy.” In Elliott’s 
case, lately discussed before the New York Derma- 
tological Society, and reported under the title of 
“trophoneurotic affection of the nails,” the nails of 
the ring-finger of each hand were first changed, and 
later all save that of the right index. In this con- 
nection the nail-change is described as a dystrophy, 
waiving for the present purpose any discussion of its 
pathological character; though I may add that the 
term onychauxis, employed in the description of my 
two cases, expresses my belief in the fact that there 
is at first certainly hypertrophy, and not atrophy, of 
the nail-substance. 
As strictly cutaneous symptoms in this group of 
cases, may be named tender, painful, or insensitive 
maculations of the hands or feet, or both ; pigmented 
patches, both palmar, plantar, and dorsal in situa- 
tion ; livid, dull crimson, or lurid blotches; per- 
sistent “erythemas,” vesiculation, “ ichthyoses,” HAND AND FOOT DISEASE. 
11 
and “eczemas.” The latter terms may, in this 
connection, be misused, since they may have been 
employed by a writer unfamiliar with dermatological 
distinctions, in order to point merely to the dry, 
slightly reddish condition of the palms seen in the 
first of my cases, resembling certain forms of eczema 
squamosum. Another symptom less frequently ob- 
served is a local alopecia or hypertrichosis, the 
hairs either entirely absent or multiplying or grow- 
ing to an unusual and conspicuous length over the 
organs affected. The symmetrical tylosis, or cal- 
losity, which may involve the palms or soles, either 
or both, is well illustrated by two of the cases 
here reported. It may be partial or general, and 
persistently of one type or characterized by a spon- 
taneous exfoliation and recurrence of a horny cast 
of a part or the whole of a palm or sole. With 
it, as appears from what has preceded, there may be 
symmetrical involvement of all the nails; it is 
reasonable to believe, from the gross appearance of 
such nails, that their beds are the seat of precisely 
the same pathological process as that resulting in the 
tylosis. An unusual multiplication and cornification 
of the cells constituting the nail-bed would, particu- 
larly if that change were limited strictly to the nail- 
bed and did not affect the matrix of the nail proper, 
tilt up and distort the nail-substance so as to explain 
in part the clinical deformity described above. The 
free border of the nail would thus be carried further 
from the nail-bed than the proximal border, which, 
being next the matrix, would be least involved, and 
therefore far less dislocated. 
With these phenomena may be observed the com- 
mon anaesthesia, the loss of tendon-reflexes, the 
wetness of the hands and feet ; and pains sirhulating 
those occurring in rheumatism. Kirmisson reports 
seven cases with symptoms of glycosuria; and 
Heusner confirms this with his observations. 12 
HYDE, 
In a third division may be grouped the symptoms 
exhibiting ulcerative or other degenerative sequelae. 
Here may be catalogued most of the surgical cases 
first described by Nelaton, to which Vesign£ gave 
his name, “perforating disease of the foot,” includ- 
ing the well-known phenomena first completely 
described by Messrs. Savory and Butlin. Even in 
this group we find the name defective from a descrip- 
tive point of view. Hancock, Nelaton, Terillon, 
Treves, Trelat, and others, report symmetrical ulcers 
of the hands as well as ulcers of the feet, which 
conditions are also represented in a number of 
faithful wood-cuts. Here we find the surgeons 
dilating upon the difference between suppurating 
ulcers beneath a corn (Callender, Erichsen), a tuber- 
culous ulcer of the sole, and the lesion of malum 
perforans pedis. Here we find them also figuring 
and describing the shortening of the digits, and 
even of the entire foot (Jones), resulting from the 
same process. Some report spontaneous healing; 
some, a healing only after operative interference ; 
some, a recovery if only the hands and feet are 
disused—one reports a case with resulting bony 
ankylosis. 
In the same group may be placed the reported 
cases of symmetrical ulceration and dry gangrene 
of the extremities. Here may be named Atkinson’s 
“case of multiple cutaneous ulceration,” ending in 
recovery, where the lesions of hands, arms, feet, and 
legs began with pruritus, anaesthesia, papulation, and 
vesiculation, and terminated in ulceration and loss 
of phalanges. In this case there were also buccal 
and labial ulcerations. Here, also, should be in- 
cluded Simon’s cases of “ multiple cachectic gan- 
grene,” beginning with vesiculation and ascribed by 
the author to the occurrence of thrombosis, even 
though congenital syphilis was present in the two 
children. The cases reported by Eichhoff and Csesar HAND AND FOOT DISEASE. 
13 
Boeck, cited by Dr. Atkinson as closely related to his, 
seem to me to have no such connection. Weiss accu- 
rately describes these conditions in discussing Ray- 
naud’s disease, referring them to a central neurosis, 
“ involving symmetrical (for the most part) portions 
of the handsand feet (phalanges), more rarely other 
regions of the body, in gangrene of a peculiar char- 
acter.” One French author does not hesitate to set 
in the same category the symmetrical gangrenous 
affections of the feet occurring in the senile condi- 
tion. 
In a fourth and last group, may be collected the 
fatal cases, those fatal by reason of a gravity of the 
general pathological condition, aside from any septi- 
caemia or other cause originating in local disease of 
the extremities. Here may be cited Hutchinson’s 
“ form of inflammation of the lips and mouth, which 
sometimes ends fatally, and is usually attended by 
some disease of the skin.” Here we find reported, 
as in other of the grave cases, the same changes in 
the nails and symmetrical involvement of the hands 
and feet. In this group also the cases observed 
by neurologists may be included, which embrace 
Charcot’s disease (pied tabetique); and a series of 
grave disorders, such as progressive posterior spinal 
sclerosis betrayed in hand and foot ulcerations. 
Surveying this rather formidable category of symp- 
toms, we find the widest divergence among authors 
as to their etiology and mutual dependence. One 
discovers an absence of the axis-cylinder in a nerve; 
another, thickening of the neurilemma; another de- 
scribes evidences of arterial disease; yet another, 
explains an increase of endoneurium, by the results 
of pressure upon the hands and feet. 
Kaposi, in the latest edition of his work, explains 
some of these cases by paralysis of the vaso-con- 
strictors ; some, by the occurrence of thrombosis. 
Others find the motor nerves intact and the sensory 14 
HYDE, 
nerves only diseased. Hereditary influences, tuber- 
culosis, and spinal injury, have been held to explain 
some cases. Duplay and Moret account for another 
case by discovering a hydatid cyst compressing the 
scrotum. Some have observed the disease only in 
women; and Ogston and Baker are inclined to this 
view. Treves and Fox, of New York, are on record 
as pronouncing some of them “ purely local ” mani- 
festations. No more striking illustration of the 
purely neurotic origin of some of these cases can be 
cited than the interesting symptoms observed by 
Tilden, after injury to the median nerve of one side. 
If we can agree that these phenomena are, from 
first to last, in some way related, we have taken at 
least one step forward. On this point it seems to 
me that most can agree. Bromidrosis, vesiculation, 
papulation, ulceration, hypertrichosis, alopecia, hy- 
peridrosis, tylosis, onychauxis, or (if the name be 
preferred) distrophia unguium—these are certainly 
multiform symptoms, but they are, several of them, 
displayed in the immense majority of all cases grouped 
in the four classes described above. The most con- 
spicuous likeness between them all is that, with few 
and usually grave exceptions, they are limited to the 
hands and feet, and the regions nearest those organs, 
such as the wrists, ankles, forearms, and legs. 
Now there are few strictly regional affections of 
the body characterized by marked multiformity of 
symptoms. In syphilis, for example, the multiform- 
ity is remarkable, but never limited to one organ or 
set of organs. 
In view of these considerations, the suspicion arises 
that, whether always of strictly trophoneurotic or 
vaso motor origin, the key to these resemblances and 
the link which connects them, is their distinctly re- 
gional limitation. They are all hand and foot dis- 
eases. These organs are farthest removed from the 
great centres of nervous and vascular force. They HAND AND FOOT DISEASE. 
15 
are also to a far greater extent than any portions of 
the body, subject to the important influences of the 
force of gravity and the effects of friction. Further, 
in any attempt at explaining some of this long series 
of symptoms, we cannot forget anatomical peculi- 
arities of those organs possessing a striking signifi- 
cance. For example, Hoyer has shown that capil- 
laries springing from the arteries, empty directly into 
lacuna like veins in the nad-bed. This is a provision 
undoubtedly intended to furnish a safety-valve for 
occasions of temporarily increased vascular pressure, 
as for example, when the hand is constricted in toil; 
and its working even in severe paroxysmal asthma is 
visible to the naked eye. 
In brief, admitting all that Atkin says, in the sen- 
tence quoted at the outset of this discussion, relative 
to the imperfect knowledge of the pathology of this 
disorder, or this group of many symptoms, I have 
striven to call attention to the fact that regional limi- 
tations may explain some of the obscurity which has 
hitherto invested the subject. We shall, for exam- 
ple, search in vain for the name of any disease whose 
pathology will explain the chain of symptoms that 
has resulted in a given scar on a man’s leg. But 
the mind so readily replaces the links that satisfy 
our conception of the case, that we follow its con- 
nections no farther. First came a venous enlarge- 
ment, whether from traumatism, from pressure effects, 
or from causes unknown to us, operating on one leg 
and not another. Then followed an eczema e venis 
varicosis; then an ulcer; then cicatrization; and 
lastly, deep pigmentation in the periphery. We may 
not demand for these diseases of the hand and of the 
foot the same links of the self-same chain. We may, 
however, look to see some of their phenomena ex- 
plained by as simple a process of reasoning. 16 
HYDE, HAND AND FOOT DISEASE. 
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