origin must influence the treatment to a great extent. If the disease of the skin be due to some alteration within the body it is manifest that we cannot place our sole or even our principal dependence upon external methods of treatment. It is well to get rid of the scales, because they are unsightly and a source of annoyance, but it is far better to seek control of the disease by judicious internal management. For, although we may, indeed, clear the surface of the scales by mechanical or chemical agents, they will inevitably reappear. It must be confessed that psoriasis is difficult to subdue. It demands extreme patience on the part both of the physician and the afflicted. individual. It is of decided importance to promote a healthy activity of the skin by means of exercise, massage, and baths.

Diaphoretic drugs, such as antimony and pilocarpine, act in the same direction. It is furthermore essential that the functions of the digestive tract should be properly performed. Such patients, when interrogated, will often confess to various manifestations of gastric or intestinal indigestion. The bowels and kidneys, if sluggish, must be stimulated into activity. cathartics or mineral waters, Epsom or Rochelle salt, a mercurial purgative, podophyllin, senna, rhubarb, cascara, potassium acetate, lithium carbonate, or digitalis are remedies which should be given as occasion demands. Such measures are particularly useful in beginning the course of treat

ment.

Saline

In cases which seem to be dependent upon, and are, at least, associated with, lithæmia it is well to prescribe such articles as salicin, salicylic acid.-of which that obtained from the oil of wintergreen is preferable, or we may administer the oil under its own form,—and iodide of potassium. Salicin and a compound of pure, natural salicylic acid are, in fact, not infrequently of service in cases not seemingly dependent upon the uric-acid diathesis.

When the eruption seems to be caused by disturbance of the nervous system, we

employ such remedies as silver nitrate, a zine salt, valerian, sumbul, the bromides, or resort to the use of galvanic electricity. Tobacco, coffee, and dissipation or excitement must be strictly avoided.

Potassium iodide is, in a certain proportion of cases, an efficient remedy. By some writers it has been administered in extremely large doses, and it has been claimed that these have been well borne as well as effective. Its virtue depends, in all probability, upon the existence of gout or rheumatism as a factor in the production of the skin diseases. It is particularly in this class of cases that I have witnessed improvement under the use of potassium iodide. Sulphur also is in such cases of avail. I have witnessed good results from the administration of small doses, as 5 to 10 grains, of sulphur sublimatum long continued.

I have

The remedy which has, above all others, generally been employed in chronic cases is arsenic. It is given in different forms and generally by the mouth, although in stubborn cases it may very profitably be administered by hypodermic injection. usually preferred arsenous acid, which I have prescribed in doses ranging from 1/24 or less to 1/10 grain. For injection beneath the skin sodium arsenate has been my choice. I have begun with 1/10 grain once daily, and have gradually and cautiously increased the amount until signs appeared that the limits of tolerance had been reached. Hypodermic injections of corrosive sublimate will also do good in some instances. Antimony likewise will render good service in many cases.

It cannot be claimed, however, that any of these drugs, singly or in combination, have a specific influence over the disease. We must strive to keep the assimilative and eliminative organs in healthy activity and repair whatever detriment exists in the constitutional condition, in the hope that by regulating the functions of the internal organs the outer envelope of the body will participate in the gain.

Many means have been resorted to for the

removal of the scales. Although it is, indeed, highly desirable to be rid of these incumbrances, especially when they are abundant, yet we must remember that removal of the scales is not equivalent to cure of the disease. In order to be effective local applications must be conjoined with internal treatment. Warm baths and the external use of oil will loosen and remove the scales.

These measures can be used in conjunction. Olive-oil answers a very good purpose. Some authorities recommend rubbing green soap into the patches, while friction with. sand has also been advised. Poultices have likewise been successfully used with the same intent.

After the exfoliation has been cleared away we are confronted with the rough, papulated, and infiltrated surface. The next objects of local treatment will be to stimulate the absorbent vessels to remove this infiltration, and to influence the local circulation in such a manner as to permit subsidence of the papillæ to their normal. dimensions. For these purposes the agents which have been employed most widely and most successfully are carbolic acid, creosote, naphtol, turpentine, salts of mercury, and some of the preparations which contain iodine. There are many other agents which have been employed, but those which I have named are among the most efficient. Certain authorities have championed the use of chrysarobin and pyrogallol, but these have conspicuous disadvantages which are not counterbalanced or compensated by peculiar virtues. They stain the skin and clothing; they may irritate and inflame the integument, thus aggravating instead of alleviating the disease; and, what is still worse, pyrogallo at least is capable of causing toxic manifestations. For these reasons I have abandoned their use.

To return to the patients who have furnished the occasion for these remarks. Both present unmistakable indications of the uric-acid diathesis, and this fact shall be utilized as suggestive of the treatment. For the man I shall order:—

B Salolis,

Sulphuris sublimati, of each, gr. iij.
Olei gaultheriæ, miij.

M. et ft. capsul. No. j.

Sig. Two such capsules to be taken every three hours.

This combination will combat the constitutional vice, and act upon the glandular apparatus of the skin and upon the kidney. Locally he shall make use of the following ointment:

R Acidi salicylici, 5j.

Resorcin, 5ss.

Unguent. hydrargyri nitratis, 3ss. Unguent. aquæ rosæ, 3ss.

M. et ft. ungt.

This ointment will stimulate the glands of the integument and tend to promote absorption.

For the woman, the first patient whom we examined, I shall prescribe:

R Olei gaultheriæ, miij.

Sulphuris sublimati, gr. iij.

M et ft. capsul. No. j.

Sig. Two or three such capsules four times a day.

CASE III.

ICHTHYOSIS.

This young man, 24 years of age, exhibits an oval patch of brownish color upon the left knee. The disease is said to have been in existence since his fifth year. The affected surface is dry, rough, wrinkled, and scaly. There is evidently, as in the two preceding cases, an excessive production-i.e., hypertrophy-of the epidermic layer. The natural lines and furrows of the true skin stand out more prominently than in the normal condition; so that the seat of disease appears as if marked out or mapped into segments or areas. In other words, the scales look as if seated on islands of skin, apart from the surrounding surface. Hearing of a dry, scaly surface, you may ask if we have here a third case of psoriasis, but I will call your attention to facts which plainly separate this affection from psoriasis. There are, upon this young man's

body, no isolated and scattered papules. The scales are thinner than those of psoriasis, and, though closely adherent at the center, many are loose or free around the borders. They are, moreover, of a darker hue. I am bound to inform you, however, that, though thin in the case before you, they may become immensely thick and hard. In some cases, also, the color may not differ very greatly from that seen in some cases of psoriasis. These features, therefore, are not pathognomonic; but, taken in connection with the notable dryness and harshness of the surface, the thickening both of the skin and the epiderm and the characteristic segmentation leave no doubt as regards the diagnosis. The scales are more permanent: i.e., they do not exfoliate as rapidly as those of psoriasis. Remaining long attached to their base, they become very hard and discolored by the dust of the atmosphere.

This disease, which finds its place among the hypertrophies of the skin, is denominated ichthyosis: that is to say, fish-skin disease, because in pronounced examples the overlapping scales resemble those of the fish.

Ichthyosis arises from some peculiar perversion of nutrition of the skin. It is generally inherited, sometimes congenital, and usually makes its appearance in the earlier years of life. It may differ very conspicuously in different specimens as regards severity and extent. The case before us is one of the milder manifestations. The area involved is comparatively small, and the scales are furfuraceous. It illustrates that form of the disease known as ichthyosis simplex. It is the variety most commonly observed. A more severe form is called ichthyosis hystrix. The word hystrix is Greek for porcupine. This subtitle has been bestowed because, in some instances, the hard and pointed outgrowths bear a close resemblance to the quills of the "fretful porcupine." Examples of this form of the disease are sometimes exhibited in dime museums. The scales are thick, of a greenish or blackish color, and constitute a hide

In

ous disfigurement. Fortunately these extreme cases are rare. Like psoriasis, ichthyosis preferably attacks extensor surfaces where the skin is naturally thick. The scalp is rough, dry, and scaly; the hair is lusterless; such a condition is found upon the head of this young man. The face is usually spared. The skin of ichthyosis is very susceptible to the vicissitudes of weather. It is apt to crack in winter. summer the disease may improve. It is essentially chronic, however; and, once established, endures throughout life, although strange to say, without affecting the general health. I regret that I am obliged to confess that we have no means of curing the disease. You must be prepared to recognize it, however, for parents and patients would much rather know the truth than be tantalized by repeated disappointments. Something may be done to relieve the harshness of the skin by the persistent use of arsenic, antimony, nutrient oils, and small doses of pilocarpine. Baths soften the integument and wash away an accumulation of scales. Sometimes it is necessary to scrape away the rough scales. Inunctions also relieve the situation to some extent.

For the present patient I shall order wine of antimony, to be taken in doses of 10, increasing to 20, minims three times a day. He shall be directed to keep the affected surface well anointed with codliver-oil with which a little oil of cade has been mixed.

ONE THOUSAND OPHTHALMIC

OPERATIONS. (Continued.)

BY L. WEBSTER FOX, A.M., M.D., Professor of Ophthalmology, Medico Cl irurgical College, Philadelphia, Pa. PTERYGIUM.

THE pterygium should always be transplanted; where this is not done the operation must be repeated from time to time. My method of transplantation is the following: An incision is made in the conjunctiva

with curved scissors, separating the tissues from the cellular tissues around the orbit, thus giving me a large pouch into which the globe can be inserted. I have discarded glass and silver balls and use gold balls 11, 12, 13, and 14 millimeters in diameter (Fig. 16).

It can be readily understood now that the gold ball cannot break through the center of the conjunctiva, and, as the opening is out of line of pressure, it soon closes up. If the operation is to be performed on the

this metal, rotate the ball into place. The circular opening in the conformer allows the gold ball to fit the space which will be subsequently covered by the cornea of the artificial eye. This conformer is kept over the buried ball and held under the closed eyelids for twenty-four to thirty-six hours. It does no harm to keep it in place forty-eight hours; longer than this I have never found necessary.

The conformers are made of metal, gold plated. The results obtained by this

This is a very

left orbit the incision is made up and out above the external rectus muscle, and the dissection carried out as described above.

The gold or glass ball is inserted through the opening and retained in place by a shell which I have modeled after an artificial eye and which I call a "conformer" (Fig. 17).

I have three sizes for various-sized orbits. I close up the incision with two stitches (Fig. 15), then place the conformer over the buried ball, and, by gentle manipulation on

method are perfect; no secondary troubles follow, all healing up by first intention, and the two stitches are taken out on the third day.

INJURIES OF THE EYELIDS.

By the introduction of flap-grafting by the older surgeons and skin-grafting by modern surgeons (Thiersch) we are able to repair injuries of the eyelids of almost every variety and of most serious character.