ANSWER TO QUERY 5853. -"Goiter." Regarding Query 5853, on goiter (H. P. H., Montana), I offer my own treatment, which has never failed me in the treatment of these

cases:

Locally: Fl. ext. echinacea, 2 ounces; Churchill's tincture of iodine, 4 drams; glycerin, 1 ounce; phenol, 75 percent, 40 minims. Directions: Apply night and morning with camelshair brush, but be careful not to apply to the opposite side.

Internal medication: Fl. ext. echinacea, 1 dram; water 2 (or 2 1-2) ounces; sugar, to sweeten. Label: One teaspoonful every hour. Chromium sulphate, 4-grain tablets, given 1 tablet two or three times a day. Calcidin, given 1 tablet every four hours, with a cup of hot water.

Swanscott, Mass.

E. E. HOSMER.

ANSWER TO QUERY 5852. - "Icterus Neonatorum." This case interests me greatly, since I have had some experience with similar ones. Six weeks ago I delivered a woman of a boy baby, apparently healthy, weighing seven pounds. The mother had been troubled a good deal with gastric hyperchlorhydria and nervousness.

The child remained well for four days, then inside of two hours it turned yellow. The mother had lost two children with jaundice, both apparently healthy at birth. One of these was my case. At the time the mother was in as good health as she is now, and nursed the child. On the fourth day after delivery the child turned yellow. I gave calomel and castor oil, without avail. Nursing was stopped and modified cow's milk given because the infant apparently was suffering from a severe gastroenteritis. This child died on its tenth day.

The last child was put on modified cow's milk with about 1.75 percent cream, but on the fourth day, when the baby turned yellow, we noticed that the diet did not agree with it. I gave fennel tea as a drink. For food, I told the woman to get lean beef, chop it up, stew it in a glass container till the red color was somewhat faded, then squeeze the juice out of the meat, and give of this juice 15 to 20 drops every four hours. I also gave 1-10 grain calomel three times a day for three days. This course of procedure agreed with the child, and it is growing round and rosycheeked. To the tea we added some eggalbumen. The jaundice disappeared in week.

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I am inclined to think that in the first case the calomel irritated the stomach and bowels. Judging from the symptoms, there was a severe catarrhal inflammation of stomach and bowels and affecting the bile-passages. The two cases were similar to start with. Both children turned as yellow as yellow can be. At the beginning the stools had golden color, showing that there was plenty of bile. In the last case I stopped feeding milk promptly and gave very little medicine, but fed the child on egg-albumen in fennel tea, and gave beef juice.

Sheldon, N. D.

PETER J. WEYRENS.

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[It must be remembered that a very considerable proportion of all newborn infants are icteric at birth or become so within the first three or four days. Icterus neonatotum has frequently been designated a "physiological condition," most frequently appearing on the third day after birth and continuing from seven to thirty days. This condition must not be confounded with the more severe type of jaundice, which occurs in the newborn and is dependent upon various pathological condition, i. e., syphilitic diseases of the liver, congenital stricture or absence of duct; duodenal catarrh or septicemia, resulting from infection through the umbilical vessels (omphalitis). In this variety the skin and conjunctivæ are extensively icteric, the feces acholic (pipe-clay variety), and the urine loaded with bile-pigment.

It has been pointed out that the secretion of bile begins some time before birth, and bile-acids and bile-pigment have been discovered in the intestine of a three-months' fetus. It is not difficult, therefore, to understand how children may be born deeply jaundiced.

Icterus neonatorum of the socalled "nonpathological" variety may be due to the presence of a patulous ductus venosus which allows some of the portal blood containing bile to flow into the systemic circulation; (2) the resorption of bile caused by the diminished pressure in the portal vessels and increased tension in the hepatic capillaries, from ligature of the unbilical vein; (3) the destruction of an enormous amount of red blood-corpuscles followed by an increased amount of bilepigment in the liver. This, the hematogenetic theory, has been practically disproved by Racchi, of Naples, who says:

"We can scarcely believe that the red bloodcorpuscles go to pieces in the blood and the products of such disintegration, floating freely

about and temporarily lodged in the tissues, give rise to the yellow color. It is far more in accordance with the working of the living organism that disintegration takes place in some organ, e. g., the liver, and, if the products thereof are floating about, it is apt to pass through such organ on the way to final elimination."

The fact that icterus neonatorum appears frequently in children delivered under chloroform anesthesia is worth noting; the fetal liver being extensively affected by the drug passing through the placenta.

We do not think that calomel can in any way be charged with causing the icterus in the case described by our correspondent; in fact, small doses of calomel almost invariably prove beneficial, although, as has already been stated, ordinary hygienic measures alone essential, the jaundice disappearing

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spontaneously in the course of a few days.

Simple icterus neonatorum differs from the pathological variety in that the conjunctivæ are about the natural color, urine free from bile-pigment, jaundice gradually fades from the skin, and the child throughout is comparatively well, its bowels acting normally and the stools natural colored.

The prognosis in all these cases is good. It is, of course, desirable to watch such infants carefully, and, if milk disagrees, give barley water, albumen water or, as in this case, mild raw-beef extract for a few days.-ED.]

QUERY 5866.- "Erythema Vesiculosum." J. A. J., Illinois, asks help in the case of a woman patient, 29 years of age, weighing 172 pounds, married several years, and having no children. "This woman had measles and bronchitis when a child; also, every summer when a girl, "stomach trouble" which did not yield to treatment but would not trouble her during the winter. She had her appendix removed in 1911, and two or three weeks after returning from the hospital an eruption appeared, which has prevailed to the present time, in spite of treatment.

"These skin lesions present an irregular center which looks like the epidermis remaining after a blister has been emptied. These areas are very irregular and vary in size, but most of them are as large as a dime or a cent-piece. This lifeless-looking crater is surrounded by a zone of acute and marked redness, which also

is irregular and varies in width from 1-16 to 1-2 inch, and the outer edge of the red zone is not the same distance from the outer edge of the center all the way around.

"Fresh eruptions appear from a few days to several weeks apart. For twelve to twentyfour hours before the eruption she trembles, all of her muscles being affected; is very restless, and the skin, when the eruption is about to appear, burns severely. She says this center does not fill with fluid unless she gets water on the eruption. The vesicles are very tender and pain if touched. The inflammation, after lasting for a few days to a week, or longer, gradually subsides, leaving a dry scab, which she always pulls off, showing the under tissues very red. There is continual burning during the acute stage, but no itching till after the scab forms. After the crusts come off, there is a dirty dark-brown pigmentation, which lasts for weeks. In the bend of the elbows open ulcers appeared, but healed readily.

"At no time has she been laid up, but does her own housework and helps in the field with the general farm work. The last time seen her temperature was 99° F., and pulse was 100 at 5 p. m. An acute eruption had just appeared, consisting of probably six or eight macules over the upper left arm. Both arms and a good part of her body and legs are now covered with the pigmented spots of various degrees of pigmentation. What is it?" Your patient, doctor, does not suffer from urticaria pigmentosa, but from erythema vesiculosum. As you will note, in the case of the herpetic type (sometimes it is difficult to distinguish between erythema vesiculosum and herpes iris) the eruption is most commonly found about the hands and wrists and lower parts of the legs.

Stelwagon states that in some cases various types of erythema occur; in extensive cases, the erythematopapular, for instance, the eruption may partake of the nature both of this disease and of urticaria. If of the vesical type, the patches often are painful, but the subjective symptoms rarely are troublesome; slight burning and itching alone being complained of. Constitutional disturbance is slight, though there is some slight elevation of temperature, and occasionally the lymphatic glands are affected. The causes are still obscure, but we agree with Stelwagon that the development of intestinal toxins is an all-important factor. Suppose you have this woman's urine examined.

We should clean out the intestines every second or third night, with repeated small doses of calomel, podophyllin and bilein, and give a saline laxative the next morning; then push the sulphocarbolates to effect; giving 10 grains in solution every three hours. Give two granules of the triple arsenates (preferably with nuclein) after meals, alternating, week and week about, with arsenic iodide. Wash the skin thoroughly with carbenzol soap, then sponge with a carbolized epsom-salt solution. Dust the affected areas with a mild antiseptic powder. Carbolized epsomsalt solution may be applied on compresses during the inflammatory stage, with good results. We surmise the urine of this patient will be highly acid and loaded with indican and skatol, while the urea output probably is about one-half the normal.

QUERY 5867.- "Literature on Infant Feeding." G. N. V., Kansas, asks for literature on

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infant feeding. In answer, we would refer to the chapter on this subject in Candler's "Everyday Diseases of Children." Spach's "Handbook" also is extremely practical. Numerous other books on this subject are obtainable.

As you will readily understand, it is out of the question to outline any fixed scheme for feeding, one child demanding richer milk at three months than another will tolerate at nine, hence the necessity of the physician's being able to recognize and meet individual requirements. Modified milk is perhaps the safest food. There are any number of formulas for modified milk, but in the majority of cases the simplest way is the best. Secure 24-hour milk and stir well, then, to a child of 3 months or under, give one-third milk and two-thirds water, adding milk-sugar in required quantity. A child of 6 months will require from one-half to two-thirds milk and the rest barley water. At 9 months, take practically pure milk; occasionally, however, a 9-month-old child will call for the dilution used at 6 months.

Cane-sugar should never be used, and condensed milks are to be avoided. Evaporated milk, however, is an entirely different substance, the good brands, being sterile, offer an ideal food for sick children. The writer would rather feed his babies on good evaporated milk than on most of the milk sold by city dairies.

The amount of modified milk to be given at each feeding and in twenty-four hours depends upon the age and condition of the infant. An excellent table appears in Dr. Candler's book, "Everyday Diseases of Children" already alluded to.

QUERY 5868.- "High Blood Pressure." J. M. F., Oklahoma, wants to know: "what is the best agent to lower the blood pressure where the manometer shows it to be too high."

Veratrine in small doses promptly reduces blood pressure; as also do glonoin and the nitrites. However, the cause of the condition should be sought for and, if possible, corrected.

It is to be remembered that glonoin acts very quickly and is more effective when taken by the mouth than when administered hypodermically. Within five minutes after the exhibition of 1-250 grain there is a profound fall in the vascular pressure, due to dilatation of the arterioles and veins of the surface of the body. The pulse is quickened and increased, rapidity being due to depression of the inhibitory center in the medulla.

Veratrine is a more powerful depressant to the circulation than aconitine. Small doses, while not materially affecting the pulse-rate, greatly reduce its force; large doses render the pulse almost indistinguishable. This drug does not, as does aconite, affect the sensory nerves. Small doses accelerate the respiratory movements.

Aconitine causes a marked slowing of the heart's action, due to stimulation of the vagus center in the medulla. It also has a direct action on the heart-muscle, increasing its irritability. The arterioles are contracted, owing to stimulation of the vasomotor center; but because of this action, occasioning a slowing of the heart, there is a decrease of blood pressure; moreover, the contractive action is to a certain extent counteracted by its primary stimulation of the cutaneous nerves, resulting in dilatation of the peripheral vessels.

You will readily grasp from the above that glonoin is the best available agent for reducing blood pressure. Sodium and potassium nitrite have to be given in full doses. They usually retard respiration.

Veratrine may be given with safety; preferably the small dose is adhered to.

Pilocarpine may also be regarded as a depressant. It is frequently of service in congested conditions, and may be given in alternation with veratrine.

QUERY 5869.- "Treatment of Tic." R. M., New Jersey, is treating a patient fifty-eight years old, a professional gentleman, who has been suffering intensely with tic douloureux. He has tried a number of the most "reliable remedies" of the old school without results. He now would like to try the "indicated alkalloids" and asks us to outline our favorite procedure in such cases.

Before we can make intelligent suggestions, we must have a clearer idea of conditions present in this particular case. Alcoholic and osmic-acid injections sometimes prove effective, but as often fail. In obstinate neuralgias, all medicinal treatment sometimes proves inefficacious, and surgical procedures-section of the nerve or extirpation of gasserean ganglion-may be the only resort.

Tic is to be sharply distinguished from other neuralgias. For instance, it begins almost always in middle or later life, and is characterized by pain, frequently starting in the upper lip or side of the nose, at times flashing upward along the nerve or radiating outward from a central point. The pain is of extreme severity, lasting usually a minute

or two and disappearing as abruptly as it

came.

During an attack the affected side of the patient's face is flushed, twitching of the muscles occurs, and there may be lacrimation, salivation, and discharge of serum from the nose. If, as we believe, tic is due to degenerative changes in the gasserean ganglion, the latter should be extirpated; in which case the peripheral operation may be tried first.

Aconitine and gelseminine pushed to physiologic effect have given the best results in our hands. Neuro-lecithin and calx iodata should be taken for several weeks, a morning dose of saline laxative should also be ordered. During this treatment the galvanic current may be applied with advantage. If such procedures do not avail, operation should be urged, though a great deal depends upon the age and systemic condition of the affected individual.

We cannot in any way endorse alcohol injections and do not believe that experienced physicians anywhere recommend the procedure.

QUERY 5870.- "Palmar Abscess." L. P. E., Nebraska, wishes to know how a palmar abscess can be aborted. He says that a neighbor frequently recommends "fat pork," which is applied for twenty-four hours; another will advise "salt and sugar," and with this twenty-four hours more are wasted. When the patient finally comes to the doctor his whole hand is hot and swollen and the pain severe. The doctor wishes to know if there must be a free incision (which most patients object to) before pus has formed? "Is there any kind of application which, used early, will abort the trouble?" the doctor asks.

All acute abscesses should be incised, incision being deep enough to expose the cavity freely. It makes no difference whether the abscess is in the palmar region or elsewhere, it is necessary to evacuate the pus at once. There is no use in making an incision unless infection of the deeper tissues has occurred.

A felon, as you are aware, often leads to the formation of a palmar abscess, the latter condition being practically an extension of the digital infection. The primary infection may be superficial or deep, or deep and superficial. For instance, a patient has pricked her finger with a carpet-tack or a splinter, and the little wound apparently heals up, but bacteria have entered, and after a few days the end of the finger becomes red, the skin tense, and throbbing is complained of.

There is not at this time any great collection of pus, and we tie a rubber band about the base of the finger and inject a few drops of cocaine solution over each lateral nerve; then, with scissors, trim off the little blistered area over the site of puncture. We shall have before us a red-mottled surface, looking like a granulating area. Superficial seropus has been evacuated, but, if the finger is squeezed gently, a minute drop of pus will be observed to exude slowly from some point in the granulation. We now know that this little track communicates with a deep cavity, and that we have to deal with a combined condition; that is, two pus-producing areas, one above the other. Occasionally there are two or more communication channels. In order to cure, we must clean out the upper chamber. Usually at the base is the periosteum, and from here, as you are aware, infection rapidly extends until we may have extensive palmar abscesses, but things are materially simplified when the initial lesion is the palm, and this area alone, is involved.

The skin on the palm of the hand is calloused and these callosities often continuously press upon the soft underlying structures and irritate them. Finally a break in the continuity of the skin occurs and infection of the underlying tissues is set up. Unfortunately, by the time redness and swelling have occurred even the most potent antiseptics applied locally will be unable to act upon the affected tissues; therefore, it is essential to get through the occluding skin, permitting the escape of the discharge.

It is well to remember that extensive suppuration of the hand may occur, therefore early incision is necessary, and, since few other regions of the body contain so many and such diverse structures, we must proceed cautiously. Crippling will inevitably follow a wrongly placed incision, and, yet, to reach the burrowing pus, we must open up freely. The old plan was to make short multiple incisions parallel to the bones, in this way avoiding the delicate structures of the hand. Such incisions often serve, but almost as frequently miss some of the pus pockets, while they are apt to heal too quickly, thus necessitating a second operation. Not infrequently, moreover, the resultant scars seriously limit motion.

Dr. W. A. Brooks recently devised a semicircular incision, the point of the knife beingentered over the second metacarpophalangeal joint, sweeping around the palm and coming out at the base of the thenar eminence; the flap thus formed should be dissected and then turned

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back on the thumb. Pus will be observed oozing through the palmar fascia at various points. Enlarge the openings with blunt scissors and clean out all the cavities. By this procedure all important arteries, nerves and tendons have been avoided and burrowing pus located and removed positively.

As a final procedure, the entire hand is disinfected. Wicks of gauze are placed in all the pockets and a thin layer of borated or bismuth-thymol-iodide gauze spread over the surface. Twenty-four hours later the skin flap may be turned aside and the depths of the wound explored. In forty-eight hours, as a rule, the wicks can be removed, and by the end of the week the under-surface and flap will be covered with healthy granulations. Skin should then be stitched back into place, when rapid healing may be looked for.

This sounds like an extensive and serious operation, but when one remembers the fearful deformity and crippling which may follow palmar abscess a thoroughgoing and effective operation of this kind is infinitery preferable to multitudinous and uncertain incisions.

Nothing, perhaps, proves more beneficial than moist creolin dressings and a splint. A surgeon should be able to arrest the process. It may be necessary only to disinfect the hand thoroughly. The usual procedures are to open up the wound, being quite sure that it is opened up its entire extent and that no pusburrows are left undiscovered, and to apply pure carbolic acid or oil of turpentine freely. If carbolic acid is used, it should be neutralized in one minute with pure alcohol. Copious antiseptic-oil dressings should then be applied. The fingers should be extended and the hand kept open by the application of a splint.

Briefly, then, infection may be prevented by prompt and thorough use of antiseptics on a mildly occlusive dressing; but once suppuration of the deeper structures is involved, radical measures are necessary, and in the majority of cases the operation just described in detail proves most satisfactory.

QUERY 5871.-"Convulsive Tic." F. M., Kansas, desires the best remedies for twitching of the muscle of left side of face, the eye and mouth almost continually moving.

Convulsive tic (habit-spasm) frequently proves rebellious to treatment; other times it readily yields to a course of zinc phosphate, solanine, and neuro-lecithin.

Of course, it is impossible to select the "best remedies" until one is thoroughly familiar with conditions, generally. As a rule