sleep with warm stockings on or with his feet upon a hotwater bag. When a chilblain is only a congested spot it should be washed twice a day in cold salt water, rubbed dry with flannel, and subjected to applications of tincture of iodin and soap liniment (1 : 2), tincture of cantharides and soap liniment (1 : 6), or equal parts of turpentine and olive oil (W. H. A. Jacobson). Jacobson says itching is relieved by painting belladonna liniment upon the part and allowing it to dry. If vesicles form, paint with contractile collodion; if ulcers form, dress antiseptically. If ulcers are sluggish, use equal parts of resin cerate and spirits of turpentine. A good antiseptic and protective is the following: oxid of zinc, gr. vj; chlorid of zinc, gr. xx; gelatin, zij; distilled water, 3j.

XXXI. DISEASES OF THE SKIN AND NAILS.

Dermatitis venenata results from irritants and from garments containing arsenic, but is generally due to rhuspoisoning. Rhus-poisoning arises from the poison-oak, the poison-ash, the poison-ivy, and other species of sumach. Actual touching of the plants is not always necessary.

The symptoms are burning and itching, redness and edema of the face and hands. A vesicular eruption begins between the fingers, and the eruption and the inflammation spread widely over the body. There may be some slight fever.

The treatment, when a moderate area is involved, comprises the application of cloths wet with black wash or leadwater and laudanum. If an extensive area is involved, apply grindelia robusta (3iv to Oj of water) or moisten the surface frequently with sweet spirits of niter. For the face use borated-talc powder. Oxid-of-zinc ointment containing 10 gr. of carbolic acid to 3j gives great relief. A 1:8 solution of phénol sodique allays pain and itching.

Furuncle, or boil, is an acute and circumscribed inflammation of the deep layer of the true skin and the subcutaneous cellular tissue following on bacterial infection of a hair-follicle or a sebaceous gland. A boil is caused by infection of a hair-follicle, through a slight wound (by scratching, shaving, etc.), with the staphylococcus pyogenes aureus. Boils are very common during Bright's disease, diabetes, gout, tuberculosis, and disorders of menstruation and digestion; and crops of boils are apt to appear during convalescence from typhoid fever. Boils are commonest in the spring,

and sometimes an epidemic of furunculosis appears in a hospital, a jail, or an asylum.

The symptoms of a boil are as follows: a red elevation appears, which stings and itches; this elevation enlarges and becomes dusky in color; a pustule forms, that ruptures and gives out a very little discharge which forms a crust. Inflammatory infiltration of adjacent connective tissue advances rapidly, and the boil in about three days consists of a large, red, tender, and painful base capped by a pustule and some crusted discharge. In rare instances, at this stage, absorption occurs, but in most cases the swelling increases, the discoloration becomes dusky, the skin becomes edematous, the pain becomes fierce and pulsatile, and the center of the boil becomes raised. About the seventh day rupture occurs, pus runs out, and a "core" of necrosed tissue is found in the center of a ragged opening. This core consists of the sebaceous gland and hair-follicle, which have undergone coagulation-necrosis (Warren). In a day or two more the core will be discharged, and healing by granulation will occur. A blind boil lasts only three or four days and has no core. The constitution often shows reaction during the progress of a boil. Boils may be either single or multiple. The development of one boil after another, or the formation of several boils at once, is known as "furunculosis." Boils are commonest upon the neck and the back.

The treatment consists of crucial incision, removal of necrotic tissue, irrigation with peroxid of hydrogen and corrosive sublimate, and antiseptic dressing.

Aleppo boils (endemic boils of the tropics) are papules appearing upon the exposed parts of the body. These papules, which ulcerate and do not cicatrize for at least a year, are due to a pathogenic bacterium and leave ineradicable scars.

Carbuncle (benign anthrax) is a circumscribed infectious inflammation of the deeper layer of the true skin and of the subcutaneous tissue, with fibrinous exudation in which multiple foci of necrosis arise and the tissue adjacent to each necrotic plug becomes gangrenous. The infection takes place through a hair-follicle. It is really a boil with extensive infiltration of adjacent tissues. A boil may become a carbuncle, and pus from a carbuncle inoculated into a healthy person may cause either a boil or a carbuncle. The causative organism seems to be the staphylococcus pyogenes aureus. The local symptoms in the start resemble those of a boil, but the constitution sympathizes from

the beginning (a chill and a septic fever) and the pain is agonizing. The inflammatory area enlarges enormously, is boggy to the touch, is dusky in color, is edematous, and the skin is not freely movable over the deeper parts. In a few days many pustules appear, each pustule marking the site of a focus of necrosis. Large vesicles filled with bloody serum very frequently occur. In some cases, about the tenth day, the pustules rupture, the necrotic plugs are discharged, and the case slowly progresses toward cure; but in many cases the carbuncle spreads at the periphery while pustules are rupturing near the center of inflammation, and pus forms in the deeper tissues, reaching the surface through many small openings, each of which is partly blocked by a plug of dead tissue. A carbuncle in this stage resembles a honeycomb, discharges bloody pus, and large masses of skin and subcutaneous tissue are destroyed. The entire carbuncular mass may become gangrenous, and a sudden and almost complete cessation of pain points to this complication. An ordinary carbuncle remains acute for about three weeks, but healing requires a month more. The most dangerous situations in which to have a carbuncle are the face and neck (tends to produce septic phlebitis, septic clots in the cerebral sinuses, or infective emboli). The most usual positions for carbuncle are the neck, the back, and the buttocks. The diagnosis of carbuncle is made by noting the multiple foci of necrosis and the profound constitutional involvement.

Treatment.-Give ether, make free crucial incisions, remove dead and necrosing tissue with the scissors and forceps, curet pockets, stop hemorrhage by pressure and hot water, cauterize with pure carbolic acid, dust with iodoform, pack with iodoform gauze, and dress with hot antiseptic fomentations. Cover the gauze with a piece of some impermeable material and lay a hot-water bag upon the dressing. Every day, or several times a day, remove the dressings, wash with peroxid of hydrogen, irrigate with corrosive-sublimate solution, dust with iodoform, and reapply the iodoform gauze and antiseptic fomentation. Keep up this treatment until sloughs are separated, and then dress with dry antiseptic gauze. In some carbuncles it is wise to extirpate the entire mass. Secure sleep by morphin, give quinin, milkpunch, and nourishing diet, and attend to the bowels and kidneys.

Clavus, or Corn.-A corn is a tender, painful, and circumscribed thickening of the epidermis, and is commonest

over one of the joints of the toes. Hard corns are situated on exposed parts of the digits; soft corns appear between the digits, where the parts are kept constantly moist. Corns are caused by pressure.

Treatment.-By wearing well-fitting boots corns upon the toes will usually disappear. Soak the feet often in water containing bicarbonate of sodium, dry them, and apply a circular corn-plaster to the corn to take off the pressure of the boot. Another method is to touch the corn with iodin every night and pare away the hard tissue every morning. An old and valuable plan is to paint the corn every night with a mixture composed of salicylic acid, 3iss; extract of cannabis indica, gr. x; and collodion, 3j, and to scrape this mixture away every morning. Soft corns are treated by washing the feet often with ethereal soap, drying, gently removing the sodden epithelium, dusting with borated talc, and placing absorbent cotton between the toes. Incurable soft corns require the freshening of the adjacent sides of the two toes and suturing them together (thus converting two toes into one). In inflamed corns employ rest and lead-water and laudanum, and let out pus when it forms. Remember that in old persons the cutting of a corn may cause senile gangrene. In the inflamed and painful feet of a person who has corns nothing gives so much relief as washing the feet with ethereal soap, soaking in hot water, and wrapping the feet for half an hour in cloths wet with a mixture composed of linseed oil and lime-water, each, 3ij, and spirits of camphor, 3j.

Warts. (See page 231.)

Onychia is inflammation of the matrix of the nail. A "run-around" is suppuration of the matrix and the root of the nail, of traumatic origin. It requires incision, trimming away of the buried edge of the nail, and packing with iodoform gauze. Malignant onychia, which is inflammation and ulceration of the entire matrix, occurs only in a person of dilapidated constitution. This condition requires removal of the entire nail, cauterization of the matrix, dressing with iodoform gauze, and the internal use of stimulants, tonics, and nourishing diet. Ingrown toe-nail is due either to lateral hypertrophy of the edge of the nail or to the forcing of the soft tissues over the margin of the nail. The condition is treated by splitting the nail, removing the piece of nail, the soft tissue, and the adjacent matrix, and dressing antiseptically.

XXXII. DISEASES AND INJURIES OF THE THYROID GLAND.

Wounds cause violent hemorrhage which is difficult to arrest. Ligatures cut out and forceps will not hold. The hemorrhage is arrested by suture-ligatures, purse-string sutures, the actual cautery, or removal of the bulk of the gland. The thyroid gland may be absent at birth. Congenital atrophy or congenital hypertrophy may exist.

Acquired atrophy leads to myxedema, a condition characterized by the presence of a firm subcutaneous swelling in the face, neck, and limbs; slow speech; mental dulness; and subnormal temperature. The condition is identical with that produced by removal of the entire gland (cachexia strumapriva).

Cretinism is a form of idiocy due to atrophy of glandular elements in the thyroid, although the size of the gland is often increased. The body is dwarfed; the face, neck, and extremities resemble those parts in myxedema, and a low grade of idiocy exists. Myxedema and cretinism are treated by the internal administration of thyroid extract.

Congestion of the thyroid may be caused by violent exertion, prolonged effort, febrile maladies and venous obstruction. It is treated by removing the cause and applying heat locally. Tracheotomy may be required.

Inflammation of the thyroid (acute or inflammatory goiter) may be caused by a septic or febrile malady, rheumatism, muscular strain causing vascular rupture, a wound or contusion of the thyroid. But one lobe is affected. The ordinary symptoms of inflammation are present. In addition there are dysphagia, dyspnea, venous congestion of the face, epistaxis, nausea and vomiting, and possibly delirium. It may terminate in resolution, suppuration, or fibrous induration.

Goiter. A goiter is an enlargement of the thyroid gland not due to malignant tumor or to inflammation. Goiter may affect a portion of one lobe, both lobes, or both lobes and the isthmus, and it may occur sporadically or endemically. In Switzerland it is very common. Among the alleged causes are the playing of wind-instruments, the drinking of snow-water, and the use of water impregnated with the salts of lime. Hereditary influence is frequently noted. The forms of goiter are as follows: simple hypertrophy, a hypertrophy of the gland-tissue, usually symmetrical, in reality an adenoma; cystic goiter or bronchocele, in which cysts form in hypertro