The importance of thorough dilatation of the sphincter ani has already been pointed out.

QUERY 5714.-"Brachial Neuritis." W. H. C., Tennessee, has a patient suffering from brachial neuritis since last August. She is forty-seven years old, married, and has a family. The affection was variously diagnosed in her home town, but she did not improve and came under our correspondent's care in April. At that time her condition was as follows:

She suffered with pain at night in her right shoulder and arm, and felt pain on any start or sudden movement; there were tender spots at various places along the course of the nerves, hand being swelled and burning, fingers semiflexed and helpless; they were painful on any attempt at passive motion beyond a limited range; knuckles were enlarged and reddened. Although she was generally cheerful, there was a drawn look on the face from constant pain.

Treatment, at first, was eliminative and antirheumatic, then tonic. Galvanic current (positive pole) to tender points, negative to the hand; vibratory treatment to muscles of arm and shoulder.

At present her general health is excellent and she has no pain at night; tender spots are gradually disappearing; hand is more nearly normal in appearance, but the fingers, although somewhat more flexible than at first, are not regaining their usefulness as rapidly as could be wished, and she is still sensitive to changes in the weather, having what she calls "rain-pains" in the affected arm. Motion in the shoulderjoint is lessened, so that she cannot raise the arm, but the elbow has good action."

Brachial neuritis, we all know, proves rebellious to treatment in a great many cases. The question is just what caused it in this case. If a neuroma exists, it should be recognized, and an operation may be essential. When the circumflex nerve is affected, there is inability to raise the arm, considerable wasting of the muscles, and there may be localized anesthesia. The musculospiral is more often paralyzed than any other nerve, its position rendering

If the

it particularly liable to pressure. nerve is affected, we get wrist-drop, fingerdrop (inability to extend the hand on the forearm). The first phalanges of the fingers and thumb are also involved. Sensory symptoms vary. There may be slight impairment or a tingling, burning sensation.

You do not give any history of the arm being injured. Neither do you say that a tumor or aneurism exists. Look into the case thoroughly, doctor. As we are aware, exposure to cold occasionally produces neuritis. Neuralgic pains in the neck and shoulder usually precede more definite symptoms of nerve involvement. Primary brachial neuritis usually occurs after middle life, especially in individuals with a gouty history (uric acidemia). In such cases we have paroxysmal or continuous pain, increased by any movement of the arm, tenderness on pressure over the affected

nerves.

Faradization, or, better, the use of the sinusoidal current, proves useful, and we have secured some remarkable results from the application of guaiacol and methyl salicylate, rubbed in well after sponging the affected arm with a hot solution of epsom salt. Internal treatment depends. to a great extent upon the conditions present. Nucleinated phosphates, neuro-lecithin and macrotin are always indicated. Elimination must be maintained. What are the pelvic conditions here? Is the menopause over? Upon receipt of further data, we shall be pleased to make further and more definite therapeutic suggestions.

QUERY 5715.-"Obstinate Nasal Hemorrhage." A. V. P., Pennsylvania, asks: "Is there any cure for a girl 25 years old who has obstinate nose bleeding? Nothing seems to aid her. She has had repeated attacks of late and nearly bleeds to death. before the flow stops."

In all cases of nasal bleeding, locate, if possible, the hemorrhagic area. It may be necessary to cauterize a small ulcer or erosion. Are any other members of the family "bleeders"? What conditions are revealed by the nasal speculum and reflected light? Is the girl full-blooded or anemic? Is the hemorrhage always from

the same nostril? Does the bleeding occur at definite intervals?

Atropine in small doses and the application of adrenalin chloride on gauze or cotton should be tried. Iron-alum may be insufflated or applied in strong solution. It is not a difficult matter to stop the bleeding, once the source is discovered. It may be necessary to plug the posterior nares. Calcium lactate and calcium chloride may be given if examination reveals any blood abnormality.

QUERY 5716.-"Another Attack on Calomel." W. H. Y., Arkansas, propounds the query, "Is calomel harmless?" and to prove its toxic character, he recites the case of one of his town's best citizens. This man was being chilled with malarial shakes, but nothing else, apparently, ailed him. Calomel was taken and salivation produced, with resulting sloughing of the gums and loosening of the teeth on the fourth day. Within twelve hours thereafter, he complained of difficulty in breathing. This continued for about twenty-four hours, and ended fatally in acute edema of the lungs with suffocation.

One more victim of the king cure-all! Sighs the doctor: "Pass it up; but the calomel M. D. will never 'pass it up' long. Inconsiderate therapeutist! It is the inevitable tendency of the human mind, when it is always exercised on the same problem, to become automatic in its operation. Hence, many doctors prescribe it in a routine manner, which supplies a remedy for every bodily ill, in exchange for a penny in the slot."

Like most attacks upon calomel, this is a "blow in the dark." You ask whether calomel is harmless, and then answer the question in the negative, by quoting the results following the administration of unknown quantities of this drug in a case of malaria. You simply say: "G. G. [age and general physical condition not mentioned], chilling with malarial shakes; calomel was taken; salivation produced, with sloughing of the gums and loosening of the teeth, on the fourth day."

How much of the calomel was given? Why calomel alone? Upon what ground,

doctor, do you base your conclusion that the edema of the lungs was due to the calomel? Is it not possible that the chills and "malarial shakes" evidenced the oncoming of pulmonary congestion?

Calomel given intelligently is one of the most useful remedial agents we have; so, for that matter, are aconitine, strychnine, gelseminine, and many other toxic drugs. We should not think of giving a whole grain of strychnine or half a grain of aconitine. Neither should we give calomel in large doses without flushing the intestinal tract immediately afterward with a saline. The large dose of calomel is not used by the modern practician. We know now that 1-6 grain, given at half-hourly or hourly intervals until six doses have been taken, will produce all the desirable results of the drug without the possibility of salivating or in any way injuring the patient.

Because calomel unwisely exhibited affects the system inimically, it does not follow that the small dose given at intervals, to effect, where indicated, should not be employed. We have for many years fought the large dose of mercurials, and urge the doctor, in season and out of season, to give small quantities of calomel or blue mass at short intervals, the usual maximum dosage being 1 grain of calomel, or 2 grains of blue mass and soda. In every case we advise the subsequent administration of a laxative saline. We have yet to see salivation or any sign of mercurialism follow such medication.

The routine prescriber is an undesirable member of the profession, and, as you know, the positive therapeutist's success is due to the fact that he ignores the names of diseases, but treats the pathologic conditions presented by the individual, giving small doses of the indicated remedy until effect, remedial or physiological.

Use calomel-as you should any potent remedy-in the right way, and you will find it not only harmless but extremely beneficial in a host of pathologic conditions.

QUERY 5717.-"Keloid." E. E. F., Oklahoma, asks for the best method of removing keloid on the ball of the indexfinger. One growth has been cut off

several times, but always recurs. This condition was caused from a slight burn about one year ago.

We should be inclined to try injections of thiosinamin in this case, giving at the same time fairly full doses of a solution of the drug internally. (That is, if the patient has no laparotomy scar that might yield.) The injection should be made every third day. In some cases better results follow the injection of the solution into and around the growth.

QUERY 5718.-"Chronic Urethritis." L. B. C., Ohio, is treating a case of chronic urethritis which so far has refused to yield. Along the canal for several inches are mucous patches, and the urine is full of mucous shreds. It clears up part of the time, and then will get very bad again. There has been a good deal of pain part of the time, mostly in the prostatic urethra and in the testicles, but that is now considerably better. The mucous patches have been touched up with silver nitrate several times through the urethroscope, but the procedure does not seem to do much good.

In order to cure a case of this kind, it is absolutely essential to be familiar with the basal pathologic conditions. A specimen of urine taken the first thing upon rising in the morning (by the "three-glass" method) and a urethral swabbing should be sent to our pathologist. Just how long has this man been affected? What age is he? Is there any possibility of a mixed infection here? Any strictures? Does he drink alcohol or use tobacco excessively?

An ointment containing methylene-blue and thuja proves efficacious in a great many

Silver iodide has also given the writer excellent service. In simple erosions of the urethra, however, euarol is perhaps the very best remedy. There may be an infection of the lacuna magna or sinus pocularis. If so, you will never get rid of the urethritis until the infected area is treated.

How are you equipped for making posturethral applications? Have you a urethroscope? Give us all the light you can, doctor, and we will serve you to the best of our ability.

QUERY 5719.-"Thrombosis of Veins of Extremity.” Extremity." W. H. S., Michigan, has under observation a case of thrombosis of the veins of a patient's leg following operation. In June, 1910, Mrs. S. was operated on for cystic ovary and adherent uterus. The abdominal wound suppurated, due to a piece of unsterilized gut. About eight weeks after operation, the left leg began to swell around the ankle, this gradually working upward until the entire leg was involved. The skin was not stretched tight and shiny, but varying from onehalf inch to one and one-half inches larger than its fellow. The doctor asks why this thrombosis should come so late, and what would be the treatment.

Thrombosis of the veins of an extremity may follow operation any time within. three months. A great deal depends upon the condition of the blood and vascular tone. The condition in this case resembles that occurring in parturition (phlegmasia alba dolens). It is a little difficult to determine just where the occlusion occurred in this case, and whether the thrombi are red or white. As you are aware, the red thrombi form in the blood by coagulation when the circulation through the vessel has ceased, e. g., after ligature or embolism. A portion of such a thrombus may have been carried into the vessels of the extremity and set up the pathologic conditions described.

White thrombi are found in the circulating blood and may be deposited about a damaged vessel or fibrinous blood, which form a surface of attraction for the sticky leukocyte and mikrocyte. These adhere and form a ferment, which causes a further deposition of fibrin from the blood. Obliterating thrombi, those completely filling a vessel, are generally red. Those adhering to a portion of the wall often are colorless.

with the subsequent thrombosis, unless the deeper structures were involved. As we are not thoroughly familiar with local and general conditions, we can not express an intelligent opinion as to the ultimate

cause.

The treatment, at this late date, will have to be based, to a considerable extent, upon a clear understanding of the bodychemistry. Have specimens of this woman's urine and blood examined. Arsenic iodide may be given in small divided doses, and nuclein pushed. Bathe the leg with a hot carbolized solution of epsom salt (epsom salt, 2 ounces; water, 3 pints; carbolic acid, 10 minims). Then apply gentle pressure with a woven elastic bandage. The bathing should be repeated twice daily. We should also be inclined to massage the limb thoroughly but gently with antiseptic oil. Hamamelis has been advocated, but we have never been able to get any appreciable results from its use.

Upon receipt of clearer data, doctor, it will give us pleasure to make further suggestions. State especially whether the patient is a prima- or multipara; also prior conditions of the extremities. Has she varicose veins? Is there any renal or cardiac lesion?

QUERY 5720.-"Treatment of Infected Wounds." G. L. J., Minnesota, desires an outline for the most effective plan to treat what is, by the laity, called "blood poison," resulting from a scratch or wound produced by a rusty nail and the like. He further asks about the time it takes for the symptoms to manifest themselves, the course and duration.

Punctured wounds, if deep, should be laid open wide and then irrigated with a 1:2000 bichloride solution and then covered with a sterilized or bichloride dressing, without suture or adhesive strapping. If a foreign body remains in the wound or the presence of poisonous substances or of bacteria is suspected, open up the tissue freely and irrigate with an antiseptic, then dress as described. Infected wounds should be carefully washed out with a germicidal solution (creolin, bichloride of mercury 1:2000, etc.), then dress with a moist

antiseptic dressing. Alcohol dressings are gaining in favor. If, despite such dressing or for the lack of it, the wound, in a few hours, becomes inflamed and painful, and evidences of lymphatic involvement show themselves, the wound should be thoroughly cleansed, opened up if necessary, and the surface sponged with a 2-percent solution of formalin, 1 : 2000 bichloride, or 30-grain solution of chloride of zinc; then covered with antiseptic gauze.

The bowels should be kept open, and intestinal and systemic antiseptics (the sulphocarbolates, calcium sulphide, nuclein, echinacea) freely administered. An antiseptic oil may be applied advantageously to incised or infected wounds. The parts should first, however, be cleansed thoroughly with a bichloride, alcohol or formalin solution.

When on examination it is found that suppuration exists, the pus is evacuated, the parts are irrigated with hydrogen dioxide until froth ceases, then cleansed with boric-acid solution, and finally pure carbolic acid is applied-one minute-and this neutralized with alcohol. Or pure oil of turpentine (Merck) may be swabbed over the surface and into the cavities. A dressing of gauze, saturated with antiseptic oil should then be applied.

Thorough drainage is the most important part in the treatment of infected wounds. The skin surrounding the lesion should be wiped with oil of turpentine and scrubbed with antiseptic soap, then washed with a bichloride solution. Any dirt or sloughing should be removed with forceps and scissors. sors. Then into the depths of the wound introduce a few strips of iodoform or bismuth formic-iodide gauze, to secure drainage.

Do not attempt to bring together the edges of an infected wound. If there is much discharge, dry dressings may be applied; but if the discharge is ropy or viscid, moist antiseptic dressings prove preferable. By this method it is possible to convert a septic wound into an aseptic one, and the treatment of aseptic wounds is too well known to need description. For further information, see Wharton's "Minor Surgery," or any similar book.

I

N his address, in Philadelphia, President Taft enumerated some of the triumphs won of late years by the American doctor. He referred to the discovery of the mosquito transmission of yellow-fever, and the results of the application of this in the eradication of this pest from Cuba.

The tropical anemia of Porto Rico was traced by Dr. Ashford to the hookworm. Half a million people there have been treated for it, and the campaign now planned is expected to rid the island of the disease.

"In the Philippines, we found, in glorious exuberance, cholera, bubonic plague, beriberi, malaria, smallpox, amebic dysentery, and leprosy, a bill of fare for the enterprising physician and knight of investigation and research calculated to make his mouth water, and a list of scourges which the civil administrator views with alarm and despair."

Cholera has been combated by bringing to Manila pure mountain water, by artesian wells in many towns, and by inoculation with cholera lymph, effecting a great reduction in the number of victims. Vaccination has put an end to smallpox. The crusade against rats and the destruction of the disease-foci have taken the terrors

No. 8

of mosquitoes has greatly moderated malaria. Amebic dysentery persists, but has been found amenable to treatment if taken in time. The lepers have been segregated, and collected in the Island of Culion, where they have been made so happy that no difficulty is now found in inducing them to go and remain there. This has reduced the new cases to 16 percent of their former number. Beriberi has been traced to the use of polished rice, and the change to unpolished grain has practically stamped out the disease.

"Investigations into the character of the intestines of the Filipinos indicate that these intestines are a veritable zoological garden of germs, microbes and bacilli, that greatly enfeeble the race; and that by proper treatment might be eliminated."

Possibly in time we may similarly investigate our home conditions, with similar results.

With this experience before them, our army doctors tackled the Panama problems, where malignant malaria and yellowfever had more than any other one cause contributed to the failure of the French. It has been said that in the building of the Panama railroad every tie laid represented. a human life lost there. In our own hands,