ANSWER TO QUERY 5734.-"Electricity in Goitre." In your answer you recommend solution of potassium iodide locally by cataphoresis. In regard to this, allow me to repeat what years ago I read somewhere and which I have faithfully observed since then, in treating goiter by the galvanic current. It is this: "Before attempting to treat a goiter by galvanism, no matter

if there is exophthalmos or not, examine the heart carefully, and if even the slightest indication of a lesion exists, never use the negative pole."

It is this precaution I wish to mention, although I do not exactly know what might be the consequences of not heeding it. BROTHER COSMAS, O. S. B. Conception, Mo.

QUERY 5755.-"Corneal Ulcers." A. F., Illinois, has under treatment a case of "corneal ulcer" in a patient forty years of age and who has been under observation and treatment for now seven years. The ulcers appear first on one eye then the other, at various times, probably six or seven times during the year; in summer or winter, whether the patient has a bad cold or when he is, apparently, perfectly well. They are sometimes deep and at time superficial, but always incapacitate the eye for several days, being accompanied by much pain, lacrimation, photophobia, and so on. man has, on several occasions, been sent to oculists, for correction of errors of refraction. He has been on "special courses of treatment" for long periods of time, i. e. he has taken potassium iodide, mercury, and sodium cacodylate. There is absolutely no history or manifestation of a luetic taint. His vision, corrected by lenses, is all right. He has had but one sickness besides measles; that was typhoid fever at the age of twelve years. His

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general physical condition is practically perfect. He is naturally very much discouraged at the outlook, since there seems to be no let-up to the appearance of the ulcers.

The doctor asks whether we or any of the "family" can suggest measures to prevent the recurrence or to eliminate the cause of this distressing condition.

You do not describe the local conditions very fully. Neither do you state whether the invading bacteria have been recognized. Among the commoner causes of corneal ulcer may be mentioned purulent conjunctivitis, blennorrhea of the lacrimal glands (you may be dealing with a constant infection here), a lowered state of the general system, autoinfection (from the alimentary canal especially), and disturbances in the nerve supply of the cornea. Photophobia, lacrimation, and blepharospasm are observed in practically every case. The pain may be severe and affect not only the eye but the brow, temple and side of the head. In unfavorable cases pus or fibrin collects

in the lower part of the anterior chamber (hypopyon).

There is a very great difference in the behavior and tractability of corneal ulcers. In some instances they are uncontrollable and tend to go from bad to worse in spite of the best efforts of the physician. Then, again, they respond promptly to treatment. The usual classification of "infected" and "simple" ulcers can not be considered rational, for even the mildest ulcer is infected in the sense that some bacteria are present and play an important part in the production of the lesion.

The extent and malignancy of the ulcer depends to a great extent upon the nature of the bacteria, and to some degree upon the character of the biologic opposition feeble or pronounced-which they encounter in their invasion. A patient whose general vitality is lowered offers less resistance than a robust individual to even the less virulent bacteria, such as staphylococcus pyogenes aureus, and when such an individual suffers from a streptococcus, pneumococcus or Klebs-Loeffler bacillus infection, the ulcers are apt to exhibit great malignancy and to tax one's therapeutic capacity.

You will readily see that in this case it is essential to increase resistance, to correct any disorder of the body-chemistry, and to familiarize yourself with the nature of the bacteria invading the cornea. Send a smear of discharge from the ulcer and also a blood smear, together with a specimen of urine (4 ounces from the total 24-hour output, stating that amount), to our pathologist for examination. The patient is most likely acidemic. Is there any discharge from the lacrimal duct, or does a nasal catarrh coexist?

We should be inclined to give this patient, once a week, a calomel-podophyllin purge, i. e., calomel gr. 1-6, podophyllin gr. 1-6, bilein gr. 1-12, every half hour for four doses at night, and a saline draught the next morning. By thus emptying the alimentary canal, you will do much toward ridding the system of intestinal putrefactive bacteria and their toxins. Give the sulphocarbolates or calcium sulphocarbolate every three hours; the arsenates (preferably with nuclein) after meals, and echinacea, 1 grain

three times a day. Keep the skin thoroughly active and the nasal and buccal cavities clean; and should an ulcer appear, push quinine (preferably in the form of the hydroferrocyanide), and give, hypodermically, 30 minims of nuclein solution daily for ten days.

Locally, atropine, or boric acid, solution, or the yellow oxide of mercury ointment, will prove beneficial. Or you may use a solution containing 1 grain of atropine. and 10 grains of boric acid to the ounce. Follow with the application of yellow oxide of mercury ointment, 1 grain to 1 dram of vaseline. If pain, photophobia, and lacrimation are complained of (and are excessive), employ a strong solution of atropine (4 grains to the ounce). Occasionally atropine does not act favorably, and here holocain, 2 grains to the ounce, proves the better preparation, markedly relieving pain and promoting healing of the ulcer.

Foul ulcers which refuse to heal may be controlled by an application of pure carbolic acid. First cocainize the eye; then, with a finely pointed wooden toothpick about the tip of which a few fibers of absorbent cotton have been wound, apply, with a rubbing motion, the phenol to the affected area. Be quite sure that an excess of the acid is not taken up. After the phenol has been in contact with the ulcer for a few moments, apply pure alcohol in precisely the same way, after which wash the eye with normal salt solution or a saturated solution of boric acid. Should the ulcer present a foul appearance after twenty-four hours, repeat the application. The lids must, of course, be held open during this procedure, and each step must be taken with extreme care. We trust you will report your further experience.

QUERY 5756.-"Varicose Veins of the Leg. Phleboliths." F. B. W., California, requests information regarding the operation for varicose veins. His patient is a young lady about twenty years of age; somewhat neurotic; inclined to faint and to emotional spells. She has slight lateral spinal curvature. Claims not to be constipated. The trouble affects the veins running from the buttocks to the knee, one

being the vein from the great saphenous. Our correspondent inquires whether there. is any better operation than Phelp's ligation and severing the vein a number of times. Also what is the best treatment for phleboliths. The patient is very susceptible to iodine.

We regret that you present such limited clinical data. Varices are rarely seen in the locality you mention, and we cannot quite understand what should cause such a condition in so young a single woman. Were we more familiar with the nature of the spinal deformity and had we some knowledge of circulatory conditions, we might be able to explain the phenomenon. We suggest that you have the blood pressure tested.

As you are well aware, a number of etiologic factors contribute to the development of varicosities, but, unless an inflammatory condition has existed or a congenital thinness of the walls of the veins and insufficiency of the valves obtains, we should hardly expect to find varicosities about the buttocks and thighs of an individual of this age. You do not mention any history of trauma. Before any operation is done, we should advise that you familiarize yourself as fully as possible with the internal abdominal and pelvic conditions. The urine should be examined and heart-sounds carefully noted. If the varicose condition is not very pronounced and the veins assume a normal appearance when the patient lies down, we should hesitate to operate. You must also ascertain whether the deep veins are involved, or the superficial only. Is there any edema whatever, or does the patient complain of muscular contractions and neuralgic pains? If the varicosities have appeared lately, search for a tumor.

In varicose veins of the extremities a thorough resection of the diseased veins or ligation and resection of the long saphenous vein at the saphenous opening is recommended. Mayo has devised an instrument, called a "vein-stripper," which permits of the subcutaneous removal of the greater part of the varicosed vessel. The vein is exposed through a transverse incision, cut, ligated, and threaded upon the instrument.

It is then separated from the tissues and the collaterals are broken by forcing the stripper along the vein. Another incision is made over the end of the instrument, the distal portion of the vein ligated and the separated part removed. Such an operation should be performed only by a thoroughly competent surgeon, while the patient. demands careful nursing and constant attention for at least two weeks thereafter.

Phleboliths rarely form in the vessels of individuals under fifty years of age. If they are small and do not cause annoyance or disturbance of the blood stream, they may be left alone. As a true phlebolith is a calcified thrombus, it is practically impossible, of course, to influence it by medication or local treatment. The concretion must be removed together with a small portion of the varicosed vein. Should you desire to study the subject further, see any of the larger modern works upon surgery. If, however, we can answer any specific question, do not hesitate to write again.

QUERY 5757.-An Extraordinary Case of Typhoid Carrier. H. M. M., Kansas, recently forwarded to our pathologist a specimen of bile which he thought promised to show a very interesting condition. The specimen, he informs us, "was secured from a lady operated upon for gallstones about eight years ago, but the wound never healed, and about two months after the operation she had typhoid fever. Since that time she has been in good health. One day this past summer she entertained some twenty or twenty-two ladies, and every one of them had typhoid fever, caused, as I believe, by eating pressed chicken at her table. We have a reason for believing that the chicken was infected from the bile coming from this patient. It is also thought this woman is throwing off typhoid bacilli in almost pure culture. It is such an important case that verification by you is desired."

The report of our pathologist has fully verified our correspondent's suspicion. The bacillus typhosus was found in enormous numbers, being practically a "pure culture" (one-fourth of the bile-material). This is unquestionably one of the most remark

Do we understand that the twenty-two guests contracted typhoid fever subsequent to partaking of a chicken dinner at the patient's home at the same time? Under any circumstances it would seem that several chickens would have to be infected, and we should like to learn just how they gained access to the bacteria-carrying. agent. At the present time your patient is about as dangerous in the community as a bunch of healthy rattlesnakes. It would be interesting to investigate other cases of typhoid fever that may have occurred in the neighborhood during the past five years, and we await with much interest your further report.

QUERY 5758.-"Arteriosclerosis. Atheroma." W. H. L., Ontario, believes that by giving the symptoms and characteristics of arteriosclerosis, and differentiating it from atheroma, we should aid many of our subscribers.

As a matter of fact, the majority of writers have used the terms "atheroma" and "arteriosclerosis" interchangeably, and most medical men speak of an atheromatous or arteriosclerotic condition as if they were the same. This, however, is a mistake.

Atheroma is differently defined in the various dictionaries. Perhaps the best definition appears in the Century Dictionary, which describes this condition as "the formation of thickening patches on the inner coat of an artery (more rarely of a vein), constituting cavities which contain a pasty mass exhibiting fat globules, fattyacid crystals, cholesterin, more or less calcareous matter, etc., the endothelial film separating this from the blood and the atheromatous ulcer formed."

The derivation of the term "atheroma" is from a Greek word meaning "gruel." It is evident that the term as commonly used, to designate a hardening of the arteries, is employed in quite a different sense from the original.

It has grown to be the custom in recent years to designate by the word "atheroma" most of the changes in the lining of arteries which can be distinguished with the unaided

eye, including abscesses, ulcers, thickened patches, and calcareous deposits. In short, practically every disorder of the lining of the blood-vessels which can be detected without the microscope.

Dieulafoy, in his recently published "Textbook of Medicine," under the head of "Toxic Arteritis, Atheroma, Arteriosclerosis," groups all arterial lesions consecutive to pathogenic agents, to their toxins, and to vegetable or mineral poisons. He says that when an artery is affected by endoperiarteritis which diminishes its caliber and changes it into a fibrous tube, arteriosclerosis is present. If the tunica intima is affected, but only in the layers subjacent to the endothelium, with the formation of yellowish, cuplike patches filled with a fat pulp, we have atheroma to deal with. If the fluid and fatty matters are reabsorbed, then the lime salts alone remain, and the patch assumes a rigid consistency, while such atheromatous centers existing in great numbers in the same vessel finally fuse and give to the artery, or a large portion thereof, a cartilaginous or ossiform rigidity. This condition has been spoken of as "ossification of the arteries," though the term is not a correct one.

When the whole arterial system is invaded, atheroma chiefly affects the large arteries, while arteriosclerosis develops by preference in the visceral arterioles. Two changes in the vessel are produced by arteriosclerosis: (1) periarterial inflammation, which proceeds by foci in the centers of which a diseased artery is found (inflammatory sclerosis); (2) a lesion of degeneration in which sclerotic foci are formed at a long distance from the diseased vessel. Sometimes these changes are found side by side. (Mixed sclerosis.)

Of the symptoms of atheroma and arteriosclerosis, some are due to the arterial lesions themselves, others to the visceral changes which they produce. Among the former may be cited the rigid character of the arteries, the increase of arterial tension, the tortuous course of the arteries, the second heart sound, which is accentuated and which has a ringing character, and the frequency of purpura and gangrene of the extremities. Among the troubles

due to visceral changes are vertigo, hemiplegia, aphasia, loss of memory, failing intelligence or complete dementia. In some patients the heart is chiefly affected, and we shall note palpitation, cardiac hypertrophy, angina pectoris, and paroxysmal dyspnea. Again, patients will complain of loss of appetite and of indigestion. In not a few cases renal changes call attention to conditions, insufficiency of urinary depuration and the various symptoms of Brightism indicating frequently the existence of a sclerosis.

The treatment of atheroma and of arteriosclerosis is practically identical. Remedies lowering the arterial tension should be exhibited, together with the iodides or iodine in some form. It is frequently desirable to place the patient upon a milk diet.

For further information upon this subject, upon which volumes and volumes have been written, we refer to Meig's "Human Blood-Vessels." or any modern work upon diseases of the circulatory system.

QUERY 5759.-"Compatibility of Calx Iodata." B. M. W., Pennsylvania, wishes to know whether calcidin is "as compatible as potassium iodide? Can it be combined with tincture of lobelia, compound syrup of sarsaparilla, or with ammonium carbonate or chloride?"

Calcidin, like potassium iodide, is compatible with syrup of sarsaparilla and also with ammonium chloride. The addition of ammonium carbonate would cause a precipitation of calcium carbonate. It would not be advisable to combine tincture of lobelia with calcidin. The alkaloid lobeline would unquestionably be precipitated.

QUERY 5760.-"Pyelitis and Chyluria." W. C., Texas., has, as he writes, a case of pyelitis or chyluria. The patient's urine is milky. The patient has been treated. by several doctors. He asks whether we can suggest anything to put him on the right track.

There is a vast difference between pyelitis and chyluria. The treatment which would prove effective in one disease would be

detrimental in the other. We, therefore, suggest, Doctor, that you send a 4-ounce specimen of urine to our pathologist. It might be well, also, to send a blood smear. Examine the patient (who perhaps harbors the filaria sanguinis hominis) carefully and report conditions fully.

It must be remembered that chyluria is intermittent in appearance, especially in the parasitic varieties. Pyuria is also sometimes intermittent, the urine usually being acid, unless a cystitis also obtains, when the presence of pus-corpuscles is readily revealed by the microscope. In chyluria we do not find pus, but sometimes albumin, fibrin, and fat.

QUERY 5761.-"Aconitine." S., Iowa, wishes to be informed in regard to aconitine. He asks: "Can it be given safely as long as a patient has fever, say 102° F., and over? I am using the granules, in connection with other treatment, every three hours, as one dose of aconitine is entirely eliminated within that time. The patient is a man suffering with pneumonia, and I am unable to bring the temperature down to anywhere near normal. Can aconitine be used for an adult according to Shaller's rule, using enough granules dissolved in 24 teaspoonfuls of water so that each teaspoonful would contain a single dose?

We have taken pleasure in mailing our correspondent a pamphlet descriptive of aconitine, which will, we think, give him the information he desires.

It is not advisable to give aconitine at three-hour intervals. The digestive tract should be cleansed, obvious symptoms met with indicated remedies, and aconitine exhibited every thirty to sixty minutes to effect, remedial or physiological; i. e., until the fever falls and the skin becomes moist or evidences of aconitine-sufficiency (numbness of tongue and pharynx, etc.) are noticeable. It is useless to give aconitine and leave the intestinal canal full of toxin-producing material. In every case it is essential to clean out and keep clean; the skin should be kept active by the use of warm epsom-salt sponge-baths, and the toilet of the mouth and nose must receive attention.