and common-sense manner most of the questions that may properly be included under the heading. The language is simple and direct and might easily be just what it pretends to be, a letter from a well-informed physician to his son. It is just the sort of pamphlet that might be given to a young man in high school or in college. Our readers are advised to send for a copy and to obtain quotations of prices in quantities.

"PAPERS FROM THE MAYO CLINIC"

Collected papers by the staff of St. Mary's Hospital Mayo Clinic, Rochester, Minnesota. 1911. Philadelphia: W. B. Saunders Company. 1912. Price $5.50 net.

This latest volume of contributions to current medical-or, better, surgical-literature from the staff of the brothers Mayo contains the papers that were published during the year 1911. It forms a splendid volume of 603 printed pages and contains a wealth of information. The reader is referred to the review in the February number of CLINICAL MEDICINE.

BOOKS RECEIVED

The Blood: A guide to its examination and to the diagnosis and treatment of its diseases. By G. Lovell Gulland, B. Sc., M. D., and Alexander Goodall, M. D. With 16 text illustrations and 16 colored plates. New York: E. B. Treat & Co. 1912. Price $5.00.

Blood Pressure: Technic Simplified. By W. H. Cowing, M. D.: Rochester, N. Y.: The Taylor Instrument Companies, 1912. Price $1.00.

Golden Rules of Diagnosis and Treatment of Diseases. (Medical Guide and Monograph Series.) Aphorisms, observations, and precepts on the method of examination and diagnosis of diseases, with practical rules for proper remedial procedures. By Henry A. Cables, B. S., M. D. St. Louis: The C. V. Mosby Company, 1911. Price $2.50.

Landmarks and Surface Markings of the Human Body. By L. Bathe Rawling, M. B., B. C. With 31 illustrations. Fifth edition. New York: Paul B. Hoeber. 1912. Price $2.00.

The Practice of Medicine, With Especial Reference to the Use of Active Principles and Other Definite Methods. By W. F. Waugh, M. D., and W. C. Abbott, M. D. Second edition, revised and greatly enlarged. Chicago: The Abbott Press. 1912. Price $5.00.

The Principles and Practice of Medicine. Designed for the use of practitioners and students of medicine. By Sir William Osler, Bart., M. D., F. R. S. Eighth edition, largely rewritten and thoroughly revised with the assistance of Thomas McCrae, M. D. New York and London: D. Appleton & Co. 1912. Price $5.50.

Practice of Medicine. (The Epitome Series.) A manual for students and practitioners. By Hughes Dayton, M. D. Second edition, revised and enlarged. New York: Lea & Febiger. 1912. Price $1.00.

A Textbook of Practical Therapeutics, with especial reference to the application of remedial measures to disease and their employment upon a rational basis. By Hobart Amory Hare, M. D., B. Sc. Fourteenth edition, enlarged, thoroughly revised, and largely rewritten. Illustrated with 131 engravings and 8 plates. Philadelphia and New York: Lea & Febiger. 1912. Price $4.00.

Manual of the Practice of Medicine; prepared especially for students. By A. A. Stevens, A. M., M. D. Ninth edition, revised. Illustrated. Philadelphia: The W. B. Saunders Company. 1911. Price $2.50.

Duodenal Ulcer. By B. G. A. Moynihan, M. S. (Lond.), F. R. C. S. Second edition, enlarged. Illustrated. Philadelphia: The W.B. Saunders Company. 1912. Price $5.00.

Emergencies of General Practice. (Oxford Medical Publications.) By Percy Sargent, M. B., B. C., and Alfred E. Russell, M. D., B. S. London: Oxford University Press. 1910. Price $5.50.

Clinical Symptomatology; with special reference to life-threatening symptoms and their treatment. By Alois Pick and Adolph Hecht. Authorized translation under the editorial supervision of Karl Konrad Koessler, M. D. New York: D. Appleton & Co. 1911. Price $6.00.

Scientific Features of Modern Medicine. (Columbia University Lectures.) By Frederic S. Lee, Ph. D. New York: The Columbia University Press. 1911. Price $1.50. Manual of Fevers. By Claude Buchanan Ker, M. D., F. R. C. P. London: Oxford University Press. 1911. Price $2.50.

Principles of Clinical Pathology. A textbook for students and physicians. By Dr. Ludolf Krehl. Authorized translation from the fourth German edition by Albion Walter Hewlett, M. D., with an introduction by William Osler, M. D. Second edition. Philadelphia: The J. B. Lippincott Company. 1907. Price $5.00.

(To be continued.)

QUERY 5855.-"Removal of Warts and Tattoo Marks." J. R. S., Indiana, wishes to know how to remove warts and tattoo marks. Warts will yield to the following procedure:

Soak the wart with a concentrated solution of magnesium sulphate several times a day (1 or 2 grains should also be taken internally four times a day). An excellent application is: chloral hydrate, ozs. 1 1-2; acetic acid, ozs. 1 1-2; salicylic acid, dr. 1; ether, dr. 1; collodion, ozs. 4. Apply with brush once daily.

Tattoo marks and powder stains can be removed, if the operator takes pains. Success often depends upon the depth of the marking, age of tattooing, and the pigments used. Some of the blue and scarlet marks frequently found upon sailors (tattoing done abroad) cannot be removed without too free removal of cuticle.

Variot, of Paris, removes tattoos as fol lows: "Apply to the skin, under antiseptic precautions, a concentrated solution of tannin, and work it in as in the tattooing operation. Then rub the skin with a pencil (or solution) of silver nitrate until the tattoo marks stand out as black points on the silver tannate. Excess of fluid should be removed. The surface turns black and moderate inflammation follows. In fourteen days, the eschar drops off, leaving a red superficial cicatrix, which fades in seven or eight weeks. This plan is safe and surebut painful and tedious."

Ordinary slight tattoo marks (powder marks, etc.) often may be removed by pricking in hydrogen-dioxide solution. Under ethyl-chloride anesthesia (local), go over the area affected with a bunch of fine cambrickneedles tied with silk and dipped in glycerole of papoid. To make the latter, take of papoid, gr. 1; water, dr. 1; glycerin, drs. 3; dilute hydrochloric acid, gtt. 3. This is also successful. After thoroughly puncturing the tattooed area, wipe off the blood and

apply the fluid on gauze and bandage. Repeat the process if necessary. Do a part of the marked area at a time. Or, also: Tattoo well over the mark with a needle dipped in a solution of zinc chloride, 30 parts, in distilled water, 40 parts. The eschar drops off in two weeks; then dress the area with simple cerate.

The fact that the insoluble substances which are used in tattooing become encapsulated explains the difficulty experienced in their removal. Under the microscope, excised portions of tattooed tissue show large particles of pigment situated in part in the corium, but more generally in the subcutaneous connective tissue itself. Carbon (charcoal, India ink, lampblack, etc.) in some form is used for the black markings, and cinnabar, carmine, indigo or prussian-blue for the other colors. If infections occur at the time of tattooing, the staining may become positively indelible without an extensive plastic operation.

The use of the punch (for small marks just as may be caused by explosions of powder, etc.), sharp-pointed knife or needle will be known to you, of course; so, also, will be the electric needles. Here the needle is attached to the negative pole of a battery, with a current of from 2 to 10 milliamperes, and inserted at various points about the periphery of the stained area, till reaction is marked enough to insure destruction of the involved tissue. The dry superficial eschar falls in a few days. Then the process may be again employed over the adjacent skin.

In all cases strict cleanliness during and after the operation is essential to success. Perhaps the best methods are those described first-the tannin and silver-nitrate process (Variot's) and Ohmann-Dumesnil's glycerole of tannin solution. Let us know how you succeed.

QUERY 5856.-"Permanence of Alkaloids in Solution." J. H. W., Illinois, propounds

this question: "If an alkaloid is dissolved in water, alcohol or other medium, under careful aseptic conditions, and kept airtight and free from contamination, how long will it keep its strength without any disintegration? For example: 1-4 grain of morphine sulphate in solution, placed in a container hermetically sealed; for how many months. or years will that solution represent therapeutically 1-4 grain of morphine sulphate?"

It is impossible to estimate accurately the length of time an alkaloidal solution will remain permanent. It is a known fact that solutions of morphine sulphate hydrolize and deposit a brown precipitate within two years. Quite lately we read an account of a sterile solution, enclosed in an ampule, decomposing within six months from the time it was made.

There is no doubt in our mind that alkaloids in solution will decompose sooner or later, the time-limit varying according to the nature of the alkaloid and character of solvent.

As the alkaloids themselves are practically unchangeable, it is rarely desirable to prepare such solutions which are to be kept for any length of time. A very much larger quantity of the alkaloid can be carried in the space required for the solution and freshly prepared solutions are always preferable to old ones.

QUERY 5857.-"Stricture of Esophagus From Drinking Lye." M. J. M., Kansas, writes: "What would be your line of treatment and when should treatment be begun for stricture of esophagus, in a child fifteen months old, caused by drinking lye? Does the fact that stricture shows early make the prognosis more grave than where it appears later say, three months after swallowing the lye?"

As you are aware, cicatricial strictures caused by corrosives make their appearance usually at a comparatively early date, especially in children. The extent and location of stricture in the case are unknown to us and procedures to a certain extent will, of course, depend thereon. The pathology doubtless is thoroughly understood by you: initial injury, subsequent inflammatory reaction, healing by granulation, and the production of a firm fibrous cicatrix, the breadth and extent of which depend upon the original lesion.

The symptoms vary with the progress of the disease. As the lumen of the gullet contracts, difficulty in swallowing is experienced. This may increase until liquids fail to pass; but the tube distends above

the stricture and sacculation ensues. The caliber of the tube increases gradually until quantities of food find lodgment. These are from time to time expelled by the patient.

The first step in the treatment is to ascertain the extent of the stricture. Olivetipped probangs are used for this purpose, but great care must be taken in making the exploration. One is continually hearing of operators passing instruments through the wall of the esophagus into the trachea, the mediastinum, and even into the aorta. If the stricture permits passage of a probang, flexible bougies may be used as dilators. In this way, most strictures may be materially enlarged and the esophageal lumen maintained comfortably open. The occasional passage of the bougie is, of course, necessary, as the stricture is liable to recur unless watched and treated occasionally.

Very narrow strictures may be treated by Dunham's method, in which the stricture is sawed through with a thread: a guidebougie is passed, an olive-tip, especially constructed, follows and engages in the stricture. Over the olive a stout thread stays. This is pulled back and forth until it cuts a way for the instrument itself, which is pushed on into the stomach. In very tight strictures, which will not permit the passage of a guide, a preliminary gastrostomy must be done and the artificial opening kept open until the secondary operation is performed.

As you will readily grasp from the above, the treatment of stricture of the esophagus in most instances is distinctly surgical, and even in cases where minor interference is necessary, a skill, gained only by experience, is requisite on the part of the operator.

We suggest, doctor, that you send your little one to a hospital. Thiosinamin (or fibrolysin) have proven of very little service in these cases. They may be tried, however, in cases where the demand for relief is not imperative.

You will find a very excellent article on stricture of the esophagus in Mumford's "Practice of Surgery."

QUERY 5858.-"A Tenacious Tenia." J. M. J., Florida, reports the case of a little girl who has received full doses of extract of male fern and chloroform with castor oil at three different times, the medication, on each occasion, resulting in the expulsion of a foot or so of tænia saginata. The child now vomits at the very sight of the mixture and the doctor is anxious to learn of some

other unobjectionable but effective preparation sure to dislodge this squatter.

We should go after this tapeworm with the old-fashioned pumpkin-seed paste, which, of course, you know how to prepare. To this you may add advantageously 1-2 grain of koussein. Two hours after giving the last dose of pumpkin-seed, exhibit castor oil in hot milk. If the worm is not voided entire within two hours, order a copious enema of salt water, throwing into the bowel first 4 ounces of olive oil with 10 drops of oil of turpentine well mixed in. This is floated up upon the salt water. The bowels should be gently massaged while the fluid is in the intestine. Very rarely indeed does this procedure fail to give the desired results.

Frankly, we do not understand how the teniacide failed to evict the parasite. The mixture you used is, as you know, successful in ninety-eight cases out of a hundred. In fact, most of the "failures" reported prove upon investigation to be due to the absence of the worm or improper technic.

J. W. S.,

QUERY 5859.-"Anal Fissures.' Texas, has a patient of 42, afflicted with a fissure of the anus. He was operated upon thirteen months ago for "piles" and during the operation the doctor found there was a fissure, but thought it would disappear. It did not, and so he operated again three months later, "cutting the fissure out altogether." The patient thought he was getting all right, but the trouble has returned as bad as ever. A prescription that might benefit or cure is requested.

We find it a little difficult, with our limited knowledge of local conditions generally, to make any positive suggestions. A simple fissure will disappear in most cases if the sphincter ani is dilated and the floor of the fissure painted with a solution of nitrate of silver every second or third day. In some cases, it is desirable to incise the floor with a sharp bistoury. In every instance, constriction of the sphincter must be corrected.

Pain may be relieved by the application of iodoform in a good antiseptic oil or by suppositories of cacao-butter, extract of belladonna, extract of hyoscyamus, and orthoform. An ointment containing hydrastin, orthoform, bismuth, and thuja, applied freely, usually proves effective.

But palliative treatment is not desirable, if the patient can be prevailed upon to submit to thorough dilatation. Gradual dilatation pay. of course, be tried with hard-rubber dilators (sets of which can be procured from

1153

any druggist), but we prefer forcible dilatation, using the thumbs in place of an instrument. The patient is first given a copious enema, to empty the lower bowel. Then he is placed on the table and, after the firststage anesthesia is produced with chloroform, ether or ethyl chloride, the operator's lubricated thumbs are introduced carefully and the sphincter is dilated, the muscles being first stretched anteroposterially, and subsequently toward the ischia. Dilatation should be done slowly and continued until resistance ceases. If subsequently the fissure is cleansed thoroughly, dried, then painted a few times with silver-nitrate solution of 20 percent, it will probably disappear.

As pointed out, however, in old-standing cases, incision of the floor is desirable. In some cases, the fissure will be found to lead to an ulcer just beyond the internal sphincter. Such ulcer should be curetted and treated with a silver-nitrate solution. The parts must be cleansed thoroughly and diligently kept clean. In some cases carbenzol works beautifully. It may be applied pure to the fissure once daily and a carbenzol suppository inserted upon retiring and after stool. Cure may be expected in from one to two weeks in a large proportion of cases.

We are quite sure that forcible divulsion and the application of silver-nitrate solution, pain being temporarily relieved by the use of orthoform and suppositories, will give satisfactory results in this case, provided that ulcers of the rectum do not coexist.

Treatment in such cases depends upon the character of the trouble. Ulcers may be somatic, syphilitic, dysenteric, tuberculous, catarrhal or rodent. Naturally, in syphilitic and tuberculous individuals, systemic treatment is essential. Somatic, or catarrhal, ulcers usually cause little trouble, if intelligently treated.

Instruct the patient to flush out the rectum with decinormal salt solution, then throw into the bowel a mixture of 1 part of fluid hydrastis and 2 parts of water, or of equal parts of aqueous extract or calendula and fluid hydrastis and 3 parts of water.

The patient should come to the office once or twice a week at first, and later once, for an application of silver-nitrate solution.

The writer has had some excellent results in stubborn cases from curetting and applying pure carbolic acid, and neutralizing in one minute with alcohol, then painting with medicinal oil of turpentine. A carbenzol suppository or one dram of an oily solution of thymol iodide should be inserted.

We need not call your attention to the necessity of keeping the bowels freely open.

QUERY 5860.-"Facial Neuralgia." H. Y. N., Pennsylvania, desires information as to the successful treatment of neuralgia on one side of the face, affecting the fifth nerve. Also for pleurodynia and intercostal neuralgia, in a case of which latter he has been unable to relieve the patient.

In very many instances, facial neuralgia is due to an underlying acidemia and in order to relieve the condition it is essential to correct this derangement of the body-chemistry. This writer is in the habit of using, locally, methyl salicylate and guaiacol after the application of compresses wrung out of a very hot solution of epsom salt. Any oral, nasal or aural disorders found must receive attention. Quite frequently a sinusitis may be at the bottom of the trouble. As, of course, you are aware, some tics are extremely rebellious; also, a predisposition exists in certain individuals, especially those of a neurotic or cachectic type. Mental and physical depression is capable of bringing on paroxysms, and, if one nerve of the face is affected, sooner or later neighboring nerves or those of the opposite side will be affected. Unquestionably, however, the majority of neuralgias will be found to be dependent upon autotoxemia; still, it must not be forgotten that a degeneration of the posterior roots of the involved nerve is apt to exist.

Thus it will readily be seen that it is impossible to lay down any specific treatment that will apply in all cases-the individual must be studied.

First and foremost, secure thorough elimination. Give calomel, 1-6 grain; or blue mass and soda, 1-2 grain; podophyllin, 1-6 grain; irisoid, 1-6 grain; half-hourly for four to six doses a night. Follow with a copious laxative saline draught the next morning upon rising. Every two or three hours give sodium sulphocarbolate, 2 grains; or, if intestinal conditions warrant the use of the larger dose, give 10 grains or the three sulphocarbolates, dissolved in water. Regulate the diet carefully. Before each meal exhibit juglandoid, gr. 1-6; boldine, gr. 3-67; . and, after food, papayotin, with pancreatin and bilein, if intestinal indigestion is a feature.

Directly to influence the pain, give gelseminine, gr. 1-250, every hour or two to effect -remedial or physiological—and, every three hours, zinc phosphide, gr. 1-6. In some cases, quinine hydroferrocyanide may advantageously be exhibited with the zinc phosphide.

In anemic, run-down individuals, the nucleinated phosphates may be given three times daily between attacks.

Maintain dermal activity with epsom-salt or plain salt sponge-baths. The modified hyoscine-morphine-cactin formula has been extensively used, recently, and proved almost a specific.

Intercostal neuralgia and pleurodynia are symptoms bespeaking a disturbed bodychemistry, and here again we must familiarize ourselves with the basal disorders. In pleurodynia, bryonin and macrotin often prove of value. Colchicine may be given as an alternant. In practically every case, a causative acidemia must be controlled in the regular manner.

D.,

QUERY 5861. "Adenitis." J. W. Ohio, asks us to outline treatment for enlarged glands upon the neck.

Calx iodata, phytolaccoid, and irisoid, or the antiscorbutic formula are indicated in adenitis. Carbenzol, ointment of potassium iodide, or iodine in glycerin, should be applied locally. The nucleinated phosphates and triple arsenates may be alternated, week and week about, for tonic effect. The urine should be carefully examined. The intestinal tract must be kept therapeutically clean. In acute cases, unguentum Crédé (colloidalsilver ointment) may be rubbed in over the affected area morning and night.

Tuberculous and syphilitic adenitis must, of course, be recognized and treatment for the basal disorder instituted. In tuberculous patients, guaiacol is of benefit, locally as well as internally; nuguaiacal meets the indications perfectly. Always examine the tonsils, and maintain perfect cleanliness of the nares, pharynx, and buccal cavity.

A peculiar and wide-spread epidemic of adenitis existed earlier in the year. The writer personally treated at least a dozen cases in his immediate vicinity, and knows that several hundred people within a tenmile radius have been affected; moreover, physicians from all parts of the country have written to this effect: "What is causing the enlargement of the cervical glands in so many children? It is not parotitis and many of the patients present none of the symptoms of tonsillar involvement. They merely feel sick, complain of pain in the neck, and present sometimes a subnormal, sometimes a comparatively high, temperature-100° to 102° F. In many instances, a coryza precedes the adenitis. Adults suffer more than children, as a rule."