stimulated to increased secretion by thermic influences. These stimulations of the excretory elements of the integument increases the excretory products purifying the blood and rids the system of its obnoxious elements. Ingestion of cold water will enhance the thermic influence of the sweat glands. The removal of a considerable quantity of fluid and the dilatation of the peripheral blood capillaries draws the blood away from the central to the peripheral vessels depleting the deeply seated vessels and produces the revulsive. effect removing the congestion from the affected area which influences favorably the inflammatory process.

Diaphoresis arouses the dormant nutritive changes, improves tissue metabolism by enhancing oxidation. The consumption of nitrogenous material is more pronounced as a result of the thermic influence which eliminates albuminous matter through the pores of the skin. As a result of its stimulating effect upon tissue changes enhancing metabolism we find in this agent an important alterative which can be of value. in the treatment of ocular diseases. As a result of its eliminative powers it eliminates the various toxins of the body and in consequence of its action upon the vascular system it hastens the absorption of inflammatory products, it thus acts as an absorbent and is indicated wherever absorption is essential to bring about a cure. only does diaphoresis act upon the vascular system but it also stimulates the nervous system central and peripheral and it therefore has a favorable effect upon the local inflammatory process.

Not

Indications for the use of diaphoresis. From our analytical study of the effect of diaphoresis upon the organism and indirectly upon the ocular tissues we may

well conclude that some ocular conditions of an inflammatory nature will be greatly benefited by this therapeutic measure. The ocular conditions are of course influenced through the effect upon the entire system. Those conditions of the eye that may be attributed to faulty metabolism or systemic disturbances will often yield wonderfully to this process when combined with the local and general internal medication. Scrofulous patients are greatly benefited by diaphoretic measures. Diseases of the eye attributable to scrofulous conditions such as eczema of the lids, phlyctenular conjunctivitis and the recurrent types of keratitis will often yield to a systematic course of sweating. In turpid conditions of the cornea in the so-called serpiginous form of keratitis where the cornea is ill nourished because of a general debility, steam baths will very often aid the ophthamologist to combat the disease. In scrofulous conditions where the face shows signs of ulcerations the steam bath will often clear the face as well as the ocular condition. Diseases of the eye attributable to rheumatic causes very often yield to the therapeutic effect of active diaphoresis, especially is this the case in inflammatory conditions of the iritis. In many cases the inflammatory process in iritis is much shortened by the combined treatment of local and internal measures and the sweat bath. It has undoubtedly an influence in preventing posterior synechia, by its stimulating effect to the parts, giving rise to a more vigorous activity in absorbing the inflammatory product. Notably is this method of treatment indicated when there is tendency for the inflammation to recur. The sweating treatment should, according to some clinicians, not be employed during the progressive period of the disease but rather

after the acme of the disease has been reached as well as during the period of decline and continued after the inflammatory process has subsided in which case the physiologic action and its therapeutic effect will prevent a recurrence of the disease. My experience teaches me however and it is my practice whenever there is no contraindication to its use to begin active diaphoresis by means of a Turkish bath in the very early stage of the disease and continue it during the entire course of the disease at intervals of from three to six days. This practice while it rarely aborts the iritic inflammation always tends to shorten its course and prevent complications. I always advise two Turkish baths weekly at intervals of three days in the early stages of iritis. Not only is the bath indicated in acute stage of the inflammation but also in chronic iritis and I fully believe that every ophthalmic hospital should have facilities for sweating baths which must be preferred for inducing diaphoresis to such cardiac depressants as pilocarpine.

The toxic amblyopias constitute a vast field for the employment of this method of treatment. It certainly hastens recovery by aiding in the elimination of the toxic material, especially is this true of tobacco amblyopia. Removal of the offending substance and a systematic course of sweating baths is really all that is essential from a rational point of view. In various affections of the eyes caused by the so-called uric acid diathesis sweating becomes an important adjunct in the treatment; to this class of cases belongs scleritis and episcleritis. I recall well one case of episcleritis that resisted treatment and which promptly yields to a steam bath. I order every patient with scleritis and episcleritis a Russian

bath and invariably I am thanked for it. Luetic ocular conditions are much benefited by the sweating treatment. Of course mercury is the drug par excellence but induced diaphoresis by the Turkish bath is an indispensable adjunct. The effect of the bath is manifold. The integument becomes more pliable, the skin becomes more porous, the glands, being stimulated by the sweat bath, more readily absorb the drug. Mercury is more readily tolerated because of the alterative effect of the bath enhancing metabolic changes so that a larger amount amount of mercury can be administered. with less ill effect upon the system. Moreover the eliminative processes having been stimulated by the baths the possible ill effects of the drug, such as stomatitis, ptyalism, and gastro-intestinal disorders are greatly minimized. It is further well to remember that some skins are of a peculiar rough texture and very often under such circumstances the mercurial inunctions are not yielding the proper effect; sweat baths in such cases will often remedy the evil and should be tried in preference to the use of the drug by the hypodermic method. Luetic conditions giving rise to iritis irido-cyclitis paralysis of the external and internal muscles, choroiditis, optic neuritis and opacities of the vitreous are all indications for the diaphoretic treatment by means of the vapor bath. In cases of vitreous opacities the Turkish bath should always be employed as an important adjunct to the medical treatment. In In interstitial keratitis the Russian steam bath is of great value in shortening the course of the disease and in preventing a recurrence. It should be employed with regularity once or twice weekly depending upon the age of the patient

and it may often, when only one eye is affected, prevent its appearance in the other eye.

In sympathetic inflammations of the eye. I believe it should be tried. I have had no opportunity to employ it in sympathetic inflammations; the theory however upon which the value of this diaphoretic therapeutic agent rests indicates its use in these

cases.

In cases of acute exudation into the choroid and retina, the sweat bath, either the moist Russian or the dry Turkish bath, is strongly indicated. It certainly hastens the absorption of the exudation by drawing. fluids from the circulation and by stimulating the lymphatic glands; for the same reason it is also of benefit in hemorrhages into the retina or vitreous. I have. employed the Russian bath in retinal hemorrhages with good results. In vitreous opacities and hemorrhages unless there is a contraindication because of some cardiovascular condition, the diaphoretic treatment should be employed. In diseases of the uveal tract where there exists some haziness of the media and where the absorption process is slow it should be accelerated by means of the sweat bath. The best result is obtained when the treatment is begun, early, during the acute process. From the careful study of the subject we may reach the following conclusion: That sweating either in the moist form or in

dry form is a very valuable therapeutic agent in the treatment of ocular diseases in

both the acute and the chronic conditions.

That the beneficial influence upon the ocular processes is accomplished: (a) By enhancing and readjusting metabolic

changes and its influence in removing metabolic end products and the elimination. of deleterious toxic substances from the organism. (b) By the reestablishment of the

equilibrium in the general circulation, removing all possible venous stasis and the purification of the blood itself by the elimination of circulating toxins, following the stimulation of the sweat glands and the direct effect upon the vascular system. (c) By invigoration of the peripheral and central nervous system thus increasing the nutrition of the ocular tissues affected. (d) By its action upon the lymphatics, stimulating absorption and thus carrying off the inflammatory products of the diseased parts of the eye. (e) By the local stimulative effect of moist heat so important to the tissues and so essentiial in the various inflammatory processes of the eye. 917 Spruce Street.

THE DERMATOLOGIST AS SEEN BY THE GENERAL PRACTITIONER.1

BY

ADOLPH ROSTENBERG, M. D.,

New York City.

Specialism in medicine goes back as far as the old Egyptian times, but only modern medicine has developed specialism as we find it now, until today we really live in an era of over-specialism. Not only do we have specialists for every branch of medicine, but we even have specialists in special branches. Thus in internal medicine we have heart, lung, stomach, metabolism, etc., specialists almost for every internal organ; in surgery we have brain, kidney, rectal, hernia, etc., surgeons. No doubt the highest technical skill is acquired by repeating the same kind of labor indefinitely,

but does not this lead to onesidedness? Does not this make the physician forget that his patient has some other organs besides the one he is specially interested in? Now as to the dermatologist: His branch

1 Read before the Med. Society of the Borough of the Bronx.

of medicine exists as a specialty, particularly since Hebra, if we disregard a few men before him, who reached prominence. He developed a classification of skin diseases, and practically originated its nomenclature. To my mind the dermatologist of today can be divided into three groups:

(1) The true dermatologist. A man who has successfully practised general medicine for a number of years, and thereby acquired an inclination toward dermatology; who has become associated with a good hospital or clinic, and who has studied a large amount of clinical material under a good and competent teacher; who has given up general practice entirely, and devotes his whole time and energy to dermatology.

(2) The half-baked or self-styled dermatologist: He is a man, who usually is not successful in general medicine, and thinks there is more money in a specialty. He takes a few post-graduate courses here, or goes abroad, if possible on his wedding trip, combining "utile cum dulci," studying from 3-6 months, and coming back as the great I Am, professing to strictly adhere to his specialty, but not hesitating to take a confinement, if it so happens, "of course only for his old families."

(3) The advertising dermatologist, or as he is generally known, the beauty doctor, who extends his specialty principally to cosmetic effects and enriches himself on his stupid clients, to whom he promises to correct any deformities while they wait, and to make them as beautiful as Apollo or Venus.

Now as to the true dermatologists as we general practitioners see them: What are their short-comings? Principally, in my opinion, the tendency to adhere too closely

in diagnosis and therapy to the skin lesion only, forgetting or purposely omitting its probable connection with the patient's alimentary or urinary system, or overlooking the fact that perhaps some blood changes may be the underlying cause of their skin trouble. A little occurrence which happened to me recently illustrates this: A lady brought to me her baby ten months old, which was covered with a generalized eczematous eruption. This child had been treated by a skin specialist, but as it did not seem to get any better, the mother brought it to me, and asked me if I could not recommend a better specialist. I asked her if the dermatologist had regulated the child's diet, and she answered "no." As I knew that the child ate almost anything on the table, I told the mother that she did not need another specialist if she was willing to do as I directed her, namely, to modify the child's diet and to correct its constipation. The mother consented to do so, and the child is now well. A common practice amongst dermatologists is to diagnose the case just from the appearance without asking any history. Should the history contravene the diagnosis, so much the "worse for the history," for I heard a prominent dermatologist say "Damn the history." If a lesion has some resemblance to syphilis, it will be diagnosed as such, even if the patient, who always observes himself closely and would readily confess an infection, emphatically denies it. Some of our dermatologists have developed what one might call a syphilomania. Everything which does not fit in the frame of an ordinary skin lesion is labelled syphilis. Cases are on record where the patient underwent a strict anti-syphilitic treatment for years, without ever having had syphilis, just because his physician was a

, 1910

, Vol. V., No.

Dr. A. is asked for his opinion first, he thinks the lesion is tubercular, Dr. B., who follows, is for syphilis, Dr. C. is for lupus erythematosus, Dr. F. is for eczema psoriaforme, and so on down the line; almost every one has a different diagnosis, and those who do not know, coincide with some of the previous speakers. And those are the cases we general practitioners send to the dermatologist, to get his wise opinion! A common controversy is the differential diagnosis between psoriasis and syphilis, or pityriasis rosea and syphilis. If they cannot come to an exact conclusion, they advise us to make our diagnosis "exjuvantibus,” that is, give the patient a number of injections of mercury, so that he remembers you every time he sits down, and give him K. I. until he cannot see out of his eyes, and his nose does not stop running. If the lesions are just the same after this fair trial, then you can assure your patient that he has no syphilis. Is it not fortunate that, as a rule, our patients do not die from a skin disease, so that they can stand such vivisection without much harm? Another bone of contention are the leg-ulcers. Is the ulcer specific, or caused by an ordinary parenchymatous dermatitis? I have seen the same ulcer diagnosed one week as a specific, and the next week as a parenchymatous ulcer, and that by the same

dermatologist. And again at a subsequent visit the same learned doctor diagnosed this same ulcer as a mixed infection, which was the easiest way out of a quandary. The same controversy takes place when an ulcer on the genitals is presented. One calls it a hard, another a soft chancre, and the wise man calls it a chancre mixed and does not take any chances. Wait for the roseola before you start treatment, the dermatologists tells you, but supposing the patient insists upon a diagnosis immediately and is not intelligent enough to understand your explanation why he should wait, you can be sure he will go to a less scrupulous medicus who will make a positive diagnosis immediately even though he is not sure of

being correct.

being correct. It is not embarrassing when a prominent X-ray man, who is capable of curing almost every skin lesion. with the mysterious ray-presents at a meeting a cured case of favus, and the other men jump on him, showing him. some favus scutula, which apparently must have escaped the powerful rays. An ugly large swelling on the cheek was presented as a primary syphilitic lesion (not such a common occurrence,) but what an embarrassment for the demonstrator, when a somewhat curious colleague started to squeeze the chancre a little harder, and caused its rupture with an abundant discharge of pus, showing that the suspected chancre was only a simple every-day abscess. And so I could go on, quoting similar examples, where the dermatologist has made more or less grave mistakes, and where we general practitioners could have done equally as well, or perhaps better. But we and nobody else are to blame for this state of affairs; we have taught the public to run to the specialist for every ailment which is a little out of the ordinary