beneficial. Be sure to keep the affected area thoroughly clean and evacuate each furuncle as soon as pus forms. Touch the cavity with a broom straw or toothpick dipped in pure carbolic acid, neutralize with alcohol, and then apply a little carbenzol ointment or resin ointment. Watch the child's diet carefully. It might be well also to examine his urine. He may be diabetic.

QUERY 5747.-"Milium." C. L. J., Tennessee, has a lady patient who suffers with what he diagnosis as milium and has a muddy complexion. He desires to know what remedies are advisable.

Iridin and alnuin are both indicated in the case you so briefly describe. We should also be inclined to give calomel with podophyllin and bilein at 8 and 10 p. m. every other night for a week, and a laxative saline draught the next morning. Instruct the patient to take an epsom-salt spongebath two or three times a week (one ounce of the salt to two quarts of water). Diet carefully.

Milium, or strophulus albidus, presents small, pin-head to split-pea sized whitish or yellowish elevated papules, usually spherical in shape and slowly increasing in size up to a certain point. Diagnosis can be confirmed by incising a papula and making pressure, when, if you have to deal with milium, a small, white, round, oval or lobulated mass will be expressed. The lesions are commonly found below the eyes and on the border of the lips; they are also found on the genitals. Occasionally the mass undergoes calcarious degeneration, and cutaneous calculi are formed. Milia occur, as a rule, in infants or young adults. Sometimes they are congenital. Milia must be differentiated from xanthoma and molluscum.

Local treatment consists in incising the top of the papulæ and pressing out the contents; swab the cavity with pure carbolic acid, neutralize with alcohol in 30 seconds, then dress with a resin ointment. Electrolysis is recommended by many dermatologists as the speediest and best treatment. If for any reason these procedures are inadmissible, salicylic acid may

be applied until the skin exfoliates. The milia will then be destroyed.

QUERY 5748.-"Pityriasis Rosæ or Syphilitic Lichen?" I. D. R., Texas, requests suggestions as to diagnosis and treatment. of a troublesome dermatosis. J. E. B., farmer, married, age 46, height 5 feet 6 inches, weight 140 pounds. Had scarletfever at three years of age and malarial fever at sixteen; gonorrhea at about twenty years of age. No other serious sickness until he contracted syphilis about two years ago, and for which he took “606” in February, 1911. However, neither the syphilis nor the injections had any effect. on the present trouble. All symptoms of syphilis seemingly disappeared Urine test shows: specific gravity, 1024; reaction, acid; albumin, none; sugar, none.

Present trouble: Ten years ago the skin on lobe of left ear thickened, turned red and began to itch. There was no moisture about it, but dry scales appeared from time to time. During the following winter it vanished, only to return the next spring, when it appeared on the cheek in front of the ear. This same thing has occurred every year since. Last winter, during the cold weather, it disappeared entirely, the skin becoming smooth and soft, with normal sensation.

At present there are a number of irregular spots on his face from the size of a five-cent piece to that of a silver dollar, one on the nose, where the skin is of a dark-red color, and which, when pinched, feels as thick as sole leather. No moisture appears at any time, but dry scales form over the thickened places. When the patient stays in the house or out of the sun and wind he does not notice it much, but when he is out during daytime he has to cover his face with cloths or else it burns and itches unbearably. If he is out more than usual through the day the burning and itching frequently keep him awake that night. The patient is not inclined to nervousness, but when his face is worse than usual or bothers him at night it makes him nervous and unfit for work. It seems worse when the weather is especially dry. Ointments and salves seem to have little if any effect.

Fowler's solution given to limit of tolerance has had no appreciable effect. Cloths wrung out of water, either hot or cold, alone give any noticeable relief.

We should like to have a blood-smear from this patient and scrapings from the affected area. The man may suffer from dermatitis psoriasiformis nodularis, parapsoriasis en plaques, or pityriasis rosa. Lesions in the latter disease, however, rarely appear on the face. Itching is commonly an inconspicuous symptom. There is undoubtedly some underlying systemic disorder, and we should like to examine, not only the blood and scrapings, but also the urine. You do not say anything about the presence of indican and skatol, amount of urea excreted, etc. What is the character of the feces? It is just possible, of course, that you have to deal with a syphilitic lichen.

We should feel inclined to try a course of mercury alternated with calx iodata; iridin and rumicin would be useful adjuvants. Locally-after thoroughly cleaning the affected areas with tincture of green soapapply thuja, 1 part; carbenzol, 2 parts; lanum, 2 parts; vaseline, 4 parts.

QUERY 5749.-"Uncertain Diagnosis in Shoulder Injury." F. J. S., Oregon, was called to attend an unusually muscular and well-fed German laborer who fell and struck against an obstruction with his shoulder-tip. On stripping, it was seen that the elbow was held abducted three or four inches; the arm seemed long and the acromial end of the clavicle was humped up. On pressing the elbow up and the clavicle down, things would sort of grate and "click" together. There was no dislocation nor was the glenoid fractured downwards. Arm would drop and clavicle "hump up" on release of pressure. The end of the clavicle was free and torn from attachment. Two one-inch adhesive plasters were passed over the clavicle-tip and up and down upper arm, over the flexed elbow. These held thirgs. An axillary pad felt good, and support was given, as in clavicle fracture.

The doctor's query is, "What did I have?" He would like to know what could be done with a torn and dislocated clavicle. "The

man needs his arm; but he's got something worse than a fractured clavicle."

We fear, Doctor, that you did have a dislocation of the humerus, the blow involving the acromion, tearing the coracohumeral ligament, and dislocating the head of the humerus. Under the circumstances we believe it would be impossible for you to obtain fixation of the acromion, and if the fragment is much depressed and has become at all fixed, as it probably has by this time, it would be impossible satisfactorily to reduce the dislocation. The neck of the scapula may have been fractured.

An open operation seems to us essential, and the plastic work to be done is extremely delicate. Under the circumstances, we should suggest that you send this man to a hospital, or should you be in a position to perform the operation yourself, be sure to secure counsel. It is well to take such precautions and thus prevent a possible suit for damages. In these days the physician is never sure which of his patients is going to turn against him.

QUERY 5750.-"Supportive Splints." W. B. A., Texas, finds it necessary to construct a splint, or rather a support, for the body of a child, and is "up the tree" as to what to use for the purpose. He has tried plaster-paris but it proved too heavy.

We suggest that you use a starch cast or procure from some of the large surgical supply houses several sheets of plastic splint material. These sheets consist of a specially prepared fiber backed with felt. They are moistened and applied, while wet, to the portion of the body it is desired they should fit. They dry very rapidly, and, once dry, retain their form indefinitely.

We are not familiar enough with the conditions you have to contend with, to advise very intelligently, but a cuirass of this plastic material, reinforced with three or four turns of starch bandage would, we think, meet your requirements. Binder's felt also makes a satisfactory splint. This material can be obtained in sheets of different thicknesses. In molding a splint, roughly cut to desired shape and size, dip in boiling water, and allow to cool. Apply

to the part, cover with a layer of cotton batting and hold in place with a roll of bandage. In a few hours the splint will be hard and dry.

QUERY 5751.-"Chronic Gonorrhea." A. O. S., Iowa, "would like some information on the treatment of chronic gonorrhea. The acute stage subsided in about four weeks and the patient improved. The discharge has lessened, but remains about the same.

The patient complains of slight pain, during urination, about one-half inch from the meatus. There is no chordee, nor pain at any time. No cystitis. Health good. The amount of mucus is just enough to cover the glans, under the foreskin, every three or four hours. A microscopical examination reveals no gonococci.

Bear in mind always the necessity for instituting local and internal treatment conjointly; also vary the treatment to suit the conditions present in the individual. There can be no fixed treatment which will prove positively curative in any stages of all cases of gonorrhea. If the lacuna magna is infected or if the sinus pocularis or Cowper's glands have been invaded by the gonococcus, careful and prolonged medication is required. Sometimes eroded areas exist in the deep urethra and it is necessary to expose and treat them directly.

As you are aware, in "chronic gonorrhea" gonococci are not constantly present in the urethral discharge. The passage of sounds or the injection of a solution of silver nitrate or other irritant will, however, cause the Neisser bacillus to reappear.

You do not tell us just how long this patient has been infected; neither do you give us a clear enough idea of local conditions to enable us to prescribe positively. You might, however, irrigate the urethra with a solution of the sulphocarbolates, 5 grains to the ounce at first (gradually increasing to 10), following with injections of euarol into the deep urethra through a long-nozzled, hard-rubber uterine syringe or you may apply to the deep urethra, with a Williams or similar applicator, an ointment consisting of: methylene-blue, grs. 8; mercury bichloride, gr. 1; lanolin, oz. 1; petrolatum, ozs. 4.

Internally give hydrastin and some good antiblenorrhagic combination, keeping the bowels freely open with a saline laxative.

It might be well to have the prostatic discharge examined. Secure a specimen by massaging the gland through the rectal wall. If you have a urethral speculum, try to locate the lacuna magna; if infected, with a blunt hypodermic needle inject a few drops of hydrogen dioxide, wash out with boricacid solution, and then pass a broom straw, which has been dipped in pure carbolic acid, into the lacuna. Neutralize with alcohol in one minute.

QUERY 5752.-"Cardiac Epilepsy." W. T. H., Indiana, wishes to know how to make a differential diagnosis of cardiac epilepsy from petit-mal. He inquires what the "heart troubles are from which produce cardiac epilepsy," and what are the symptoms usually found in cardiac epilepsy.

It is incorrect to speak of "cardiac epilepsy." Idiopathic epilepsy is that form of the disease which cannot be accounted for either by organic disease, reflex irritation or morbid states of the blood. True epilepsy is never a sequence of cardiac disease, though naturally enough a serious cardiac lesion may exist in an epileptic individual, and heart complications are rather common.

Spratling, in commenting upon the undue proportion of functional and organic heart lesions encountered in 1070 cases of epilepsy, says: "We must not for a moment assume, however, that the epilepsy in these cases was due to the condition of the heart. On the contrary, in my opinion [in which the writer concurs] we may lay the cause of many of the heart troubles to the epileptic conditions, while in other instances they were present merely as coincidences. I believe that epileptics are unusually prone to diseases of the heart and lungs, and whoever has the opportunity of witnessing large numbers of epileptic seizures of a severe type-especially during the tonic stage the stage of the single long contraction when respiration is suspended and the heart under enormous strain-will find himself wondering why more epileptics do not die during the seizure from the

forceful damming back of the blood upon the heart with consequent injury to that organ."

There are cases in which the heart lesion precedes and perhaps tends to cause epilepsy, but such cases are rare. Such instances occur late in life and are associated with atheromatous changes.

Of the 1070 patients observed by Spratling, 238 presented evidences of some form of heart disease or irregularity. Mitral regurgitation existed in 77; cardiac hypertrophy in 50; systolic murmur at apex in 10; mitral stenosis in 2; aortic regurgitation in 13. It will be readily seen that almost any heart trouble may be observed in the epileptic, but it would be practically impossible to prove that any cardiac lesion was in itself the cause of epilepsy, and we certainly cannot rationally speak of a "cardiac epilepsy."

If the theory advanced by Candler is correct (and extended experience and the results secured by treatment would prove it to be), any circulatory disorder would tend to produce systemic conditions rendering epileptic seizures possible, and a cardiac lesion might prove the irritative focus precipitating the explosion. Some writers. (among them Balfour) state that diseases of the heart may cause pseudo-epileptiform attacks or spasms. English clinicians are inclined to associate the slow pulse and epi-lepsy, but here, again, the better-informed men regard the cardiac condition as an effect, and not the cause.

QUERY 5753.-"Mercurial Rheumatism." 'W., Georgia, is treating a lady patient, sixty years of age, who suffers from "mercurial rheumatism." She states that taking large doses of calomel for an extended period has left her a rheumatic. She is not "bed-ridden", but up and about. The left shoulder-joint and adjacent muscles appear to be affected. Cramps in the leg-muscles often prove troublesome. The doctor has treated her for rheumatism, without the slightest improvement. He desires to know if mercury ever really causes "rheumatism."

There is no such disease as "mercurial rheumatism." It is true that some physicians claim that mercury in any form causes

"pain in the joints," and any or all pains in the joints are, of course, "rheumatism" to them. The symptoms and treatment of mercurialism are undoubtedly known to you.

We question very much, however, whether the large doses of calomel have anything to do with the conditions present in the case under observation. The woman is probably autotoxemic. You are, of course, thoroughly familiar with the acidemic theory and the modern method of treating the underlying pathological conditions which almost always exist in "rheumatic" subjects. In order to treat this woman scientifically and secure definite results, you must have a clear conception of the underlying disorders. Make a careful examination of the woman and her excretions. With the light so gained it will be possible to institute a rational treatment.

QUERY 5754.-"Calomel Incompatible with Ammonium Chloride." S., Arkansas, desires to know whether a poisonous compound is formed when calomel is given with ammonium chloride. Sometimes he wants to give the two drugs together in pneumonia, neuralgia or "biliousness."

According to some writers, calomel is incompatible with the chlorides of potassium and of sodium (see U. S. Disp.). It is soluble in most ammonia solutions, metallic mercury being precipitated in greater or less quantity, according to conditions. Left in contact with a solution of ammonium chloride, calomel is gradually converted into the corrosive mercuric chloride, which dissolves in the water. The decomposition occurs more rapidly with a concentrated solution and at an elevated temperature. The presence of peptic juices is said to favor the reaction. Hence in view of the uncertainty of the reaction, it hardly seems wise to give calomel and ammonium chloride conjointly, at least for more than a day or two.

The mild mercury chloride should be exhibited alone (or in conjunction with emetin, podophyllin, leptandrin, euonymin or other hepatic stimulants), and in small divided doses. It is best given in the evening The other drugs should be exhibited for two or three hours.

Vol. 18

No. 12

M

Fresh

ADAME laments plaintively that she rises from bed as tired as she lay down; limbs aching, eyes bunged, face swollen with sleep. Ask her whether her room is ventilated, and she takes offense, quite as if you had suggested that she wash her face. But don't take it for granted that she knows what ventilation means-ten to one she doesn't. Inquire, and she will tell you she airs the room thoroughly, opening up the bedding, throwing windows wide and shutting the door, leaving things thus a whole hour. You suggest leaving the windows open at night, and at once you note on her face the transition from that "observance of hygiene that is a matter of course to intelligent people," and "one of that eccentric doctor's fads." She may be persuaded to leave the sash raised a half inch if the weather is not too cold, but women love warmth, and as winter nears they have the doors and windows weatherstripped and shut out every possible trickle of the life-giving oxygen; and shut in every particle of the emanations from the body, the deadliest poison existant, to be inhaled over and over again, until they rise, drugged, oppressed, entoxined,

Air

to begin the new day unrefreshed and deadly tired, as on all the days gone before.

Goes camping; sleeps in a tent where fresh air can't be entirely excluded. This same woman rises in the morning, to remark how perfectly delightful and invigorating is this air! Same old air she had in Chicago-not quite so pure, perhaps, 'cause there's decaying vegetation and camprefuse round about.

The skin exhales so much poison that when, on one occasion, it was sealed by applying gold-leaf over the whole body, the child in question died, smothered. Nature provided for to-be-expected bumps and rubs by a continuous growth of epithelium to replace wear. We prevent the wear by the use of clothes, but the epithelial cover keeps forming, so that we must remove this by daily baths and vigorous rubbing with coarse towels. Neglect this, and the excretion cutaneous is impeded and self-poisoning results. The freshness and buoyancy following a morning bath is not all merely reactive.

The great body-sewer is the colon.

Here comes old Groucho-look out, fellows! Old curmudgeon scowling, face blotchy, mouth drawn down, eyes muddy,