growth of the horny layer of the epidermis. There were a great number of mast cells present, but careful search, in many sections, revealed no plasma cells. The cause of this very rare disorder is undetermined, and treatment is of little avail, the disease lasting many years with little or no change. In the two cases reported, the itching was confined to the tumors, while in Hardaway's case, it was general and the pigmented, thickened plaques, above mentioned, existed.

The

Pityriasis Rosea.-Montgomery (Jour. Cut. Dis., April, 1906) combats the common hypothesis that this disease is a cutaneous manifestation of a constitutional disturbance. The chief point against a constitutional cause is the "primitive patch." This appears a considerable time before the generalized eruption, and exactly as if it were the seat of first inoculation from which the virus afterwards spread. The primitive patch is better marked than the lesions of the subsequent rash, like the lesion of inoculation in many undoubtedly infectious diseases. Peripheral extension with central clearing of the lesions is also strongly suggestive of parasitism, but this alone is not conclusive. The results of local treatment also favor the parasitic view, for, while the disease is generally of somewhat long duration, its course can be materially shortened by appropriate external measures. It is very rare, however, to get an evidence even hinting at the transmission of the disease from person to person. Constitutional disturbance previous to or during the attack, on the other hand, is the exception. differential diagnosis from seborrhea annulata is made with difficulty: There are the same light red rings with buff wrinkled centers in both affections. Usually, however, the rapid distribution of the rosy rash is sufficient to differentiate the affections. It is differentiated from measles by the severe constitutional symptoms, the rash on the face (an unusual situation for pityriasis rosea), the catarrhal affection of the nose, throat and bronchi, and the absence of the rings with the buff colored, wrinkled center in the latter disease. In German measles, also, there is an absence of the peculiar rings. The greatest liability of error lies in its differentiation from the roseola of syphilis, and especially if the patient has at the time a venereal sore. "The first search should be for the "primitive patch," and, if that cannot be found, then a careful examination should be made for the small, red rings with the skin, in the center, buff colored, and wrinkled. The wrinkling, otherwise unobservable in the early stages, can sometimes be demonstrated by placing the thumb and finger on opposite

sides of a patch, and then opening them so as to put the skin on the stretch." Sometimes, in syphilis, a red, ringed eruption with a desquamating center occurs, but it is a rare manifestation, and occurs much later than the roseola. Of course, as in several cases quoted, syphilis and pityriasis rosea may coexist. As to treatment, he recommends: The patient should be soaked daily, for half an hour, in a bath to which two or three teaspoonsful of Condy's fluid have been added, after which

ALBERT F. KOETTER, M. D.

The After-Treatment of the Radical Operation.-(Compilation of Dr. A. Sontag in Internationales Centralblatt fuer Ohren heilkunde).-That the after-treatment of the radical operation is fully as important, and in many cases more difficult than the operation itself is a well known fact. To the physician, who, without technical training and large experience takes care of the after-treatment the results will not be flattering. The time for healing, depends on the position and the kind of case, varies from four weeks to several years. In order to have epidermization of the wound cavity take place as rapidly as possible different forms of plastic operation and transplantation are executed, these have been discussed in a former compilation by Hoelscher. Since this publication several new methods of plastic and transplantation have been published and these I will now discuss.

Alt reports a modified Koerner's plastic after formation of Koerner's flap, he places, from the upper posterior portion, a broad pedunculated flap into the wound cavity to cover the whole antrum and part of the cupola of the cochlea. The loss of substance is sewed up after making an incision to relieve tension. In order that no sinus or pocket may occur between the anterior wound margin and the pedunculated flap, a strip 1 mm. wide excised from the cutis of the pedunculated flap corresponding to the anterior wound margin and to this place the anterior margin is sewed. The complete epidermization should occur in from seven to eight weeks. The same plastic was described by Berens before the New York Otological Society.

Delsaux resects the posterior membranous wall of the canal after a horizontal incision in the median line he separates each flap by

two new incisions which unite at the extreme end of the first incision and diverge to the interior. The whole superior and posterior wall of the membranous canal, including the adjoining part of the concha are removed by Caboche, meaning thereby to simplify the operation and produce a large opening, also avoiding the curling up of the flap in the powder treatment which follows.

Luc modifies Siebermann's Y plastic, by which the crus of the Y in the concha are placed in a posterior superior and posterior inferior position in such a way that he executes one incision directly to the back and the other to the lower portion. Moreover he Moreover he does not incise the posterior wall, but the posterior superior wall of the external canal. He has never observed perichondritis following and the wide opening does not disfigure.

According to Botey none of the prevailing methods can with certainty prevent a narrowing of the canal, Siebermann's plastic which is the safest is unsatisfactory from a cosmetic standpoint. He incises from above over the whole length of the membranous canal to the upper border of the tragus and the root of the helix in the concha. As the tragus completely covers the large opening, large enough to allow the thumb to enter, the cosmetic results is a good one.

A combined plastic has been used by Bruehl in fifty cases with good results. After executing a Pance T incision in the membranous canal wall a short Koerner flap is formed by two parallel incisions in the cavum concha at the upper and lower end of the vertical transverse incision. This flap can, if desired, be enlarged to the cavum concha. Thus there are three flaps which can be made thinner by removal of epidermis from their posterior wall, so that they fit snugly to the walls of the cavity. In the almost constantly used primary suture, the short Koerner flap is seized with a thread and drawn to the back until its free margin hugs closely to the bony wall. A disfigurement of the auricle is out of question.

Passow forms a short Korener flap, as descrbied above, this he fixes posteriorly by two sutures. Then instead of a T incision he splits the external auditory canal posterior inferior entirely, but on the upper margin makes only a short incision. In this way he gets a very movable flap which fits smoothly above.

A diametrically opposite view is taken by Chevalier Jackson. This author on account of an occasionally occurring perichondritis and an ofttime remaining deformity of the external canal opening does not touch either he external canal or the concha. He makes he first incision one centimeter wide and

sometimes more posterior from the insertion of the auricle. From this skin between the incision and the line of insertion he forms, after the operation, by an incision in the line of insertion of the auricle, one or two thick flaps which are tamponed tightly to the bone and through their bulkiness fill out the cavity. The retro-auricular opening is allowed to close when the entire cavity of the antrum is filled with a thick cushion of solid fibrinous tissue that every cavity with exception of the exposed tympanic cavity is obliterated.

For epidermis transplantation after the radical operation Politzer has for some time been using glass tubes which terminate at one end in a perforated bullet. For the transplantation which should be done in six to twenty days after the operation only such cases are applicable where plastic flaps have healed and the retro-auricular wound has. been closed. There must be only slight secretion and the walls must be covered with granulation. Several hours before the transplantation the cavity is cleansed with sterile water and 6% H2O2, and then filled with sterile gauze. The Thiersch flaps are then placed on the glass bullet with the epidermis surface to the glass and by means of a bulb and rubber tube are blown on the intended surface. The flaps are held in place by small cotton sterile pads. After four days, when the bandage is removed, the flaps will be found healed in situ.

The primary closure of the retro-auricular operators if no complications exist. Heine wound by means of a suture is done by most treats the wound cavity for two or three weeks through the retro-auricular opening and then allows it to gradually close. time for the first change of bandage varies. according to the after treatment and the plastic. Heath leaves the first dressing one day, then changes daily.

The

Riechel removes first bandage after three days, and then tries tranpslantation with small flaps.

Eeman, Moure, Delsaux, Lermoyez and Caboche allow first bandage to remain four days, most authors remove it in from five to eight days. Eschweiler after fourteen days. Mahu favors chloroform narcosis for the first dressing. How often the dressing is changed afterwards depends on condition and the amount of secretion from the wound. Often times it is necessary to change every day. The too frequent change of dressing is deprecated by Krebs as the bandages after a radical operation do not show the ideal of a protective treatment of a wound, and the principle unanimously advocated by surgeons that

a wound should be disturbed as little as possible should be followed.

The

General unanimity exists in after treatment as to practice of careful asepsis to the last dressing and the avoidance of unnecessary probing and handling of and in the wound. Also the danger of too tight a tampon for as formerly this was done to avoid luxuriant granulations it has since been demonstrated that this caused prolific granulations. strip of gauze is introduced loosely without pressure. Mahu introduces gauze strips in shape of barillet and changes the position daily so that pressure is not always at the same place. Žur Muehlen stops use of tampon after eighth day and syringes the ear daily with warm water; if fetid secretion he uses 10% naphthalin solution, as soon as he notices a tendency to stenosis he returns to the use of the tampon.

Botey after the operation and plastic lays a light flattened perforated metal tube 15-22 mm. broad and 16-22 mm. long into the cavity, and allowed to remain for five to six weeks, until the epidermization of the canal is completed. In this tube a gauze strip is placed which can be changed as required without causing patient any pain. For the first dressing iodoform gauze is used, and later on sterile gauze.

Eschweiler, Werner, Siebermann and Schiebe have had excellent results with vio

form gauze for dressing. The vioform gauze

is odorless and in the after treatment it

shows deodorizing qualities and a tendency to limit granulations. Its advantages over iodoform gauze is that it can be easily sterilized, and the dressings need not be changed so often. Splendid results are reported by Heine in the use of iodoform gauze (paraiodoanisol) its action limits secretion and granulations.. The latter is so strong that if isoform gauze is used at the first dressing, granulations will be entirely absent. It is therefore necessary that the first few dressings be made with iodoform gauze until a thin cushion of granulation cover all the parts equally, then use isoform gauze for tampon. The secretion remains scant and is never fetid where this gauze used. The gauze should never be used stronger than a 3%, otherwise it may act as a caustic.

Eeman discards the tampon after the fifth day and fills wound cavity with powdered boric acid, the quantity of which he diminishes as the secretion decreases, so that finally he only dusts those places which have not epidermized. The change of dressing is painless and the duration of healing is shortened. Lesmoyez, Delsaux, Caboche and Boenninghaus also speak very highly of this method. Lafite-Dupont dusts with boric acid

after the surface of the wound cavity has become covered with granulations as the dusting of the powder directly on the exposed bone surface is very painful.

Warnecke and Lautenschläger use warm air as a remedy to control the granulation and accelerate the epidermization. In cases where local conditions prevent or retard epiderminization Bondy used picric acid in a concentrated ethereal solution (1.0:10.0), and recommends it on account of the good results he obtained. After careful cleansing and drying of the wound surfaces he touches the whole surface as well as the margin of the epidermis with picric ether. The pain caused by the ether is at first very intense, but disappears after the ether has evaporated. The evaporation is accelerated by inflation of air. This treatment was repeated every second day on the intervening days the wound cavity was cleansed and dusted with boric acid. Tampons were not used. The first and most striking action of the picrio treatment is the decrease in the secretion, then the formation of the granulations and the rapid pushing forward of the epidermis. The time in which this process takes place is often very short, in one case it was six days.

A short time ago Mahu, who had followed the treatment of Eeman, insufflation of boric acid, described a new and much more simple method which consisted in doing nothing during the after treatment, either by tampon

A

or insufflation. The motive for another form of treatment was the ofttimes unbearable pain which the patients complained of in the early part of the treatment ceased by boric acid insufflation. Although he reports only for When changing the dressing every second cases he is very enthusiastic over the results. day if abundant discharge he simply wipes out wound cavity and dries it only occasionally has it been necessary to curette some granulations at the end of the auditory canal. gauze drain only reaches to the end of the membranous canal (Maher resects the posterior portion of the membranous canal in the operation, in the cavity itself every contact of the gauze with the wound surface should be avoided. Later on when the epidermis covers the greater part of the cavity, insufflation of boric acid may be done, at this stage dermization. The above described method is it is not painful, and often hastens the epionly used in caries in cholesteatoma it is the endeavor to maintain the condition of the

cavity, as it was established at the operation.

As a remedy to limit the secretion and granulations Heath uses absolute alcohol in form of instillations; Heine introduces gauze strip saturated in alcohol. The gran

ulations usually shrink under this process, but the procedure is very painful.

Of the caustics recommended are: Silver nitrate, lactic acid, chromic acid, galvanocautery and as a last resort the curette. Grunert and Heine prefer the lactic acid, twenty to thirty per cent solution rubbed in thoroughly at the spot, silver nitrate in 50% solution and in substance fused to a probe. Through rough and incorrect use of caustics the nourishing soft parts are often destroyed, especially with chromic acid which is deliquescent and causes deep-seated corrosion, often bone caries, most often at the median wall of tympanic cavity.

Ferren in a patient in whom after a radical operation the discharge would not cease introduced into the ostium tympanale of the tube a platinum wire heated to red glow. The discharge ceased and has not returned at the present time.

The fresh newly formed epidermis is guarded from maceration by applying a zinc paste on the marign of the epidermis. Dermatitis and desquamation of the epiderneal layer of the bone cavity may be treated by pencilling with a 2% argent solution.

The duration of the after treatment to the time of healing depends on the nature of the case; it varies from four to five weeks to years. The average duration is given by most authors as from eight to twelve weeks.

M. Sig: A teaspoonful to a quart of lukewarm water, as a vaginal douche, twice daily.

NASAL POLYPI.-They nearly always start from the region of the middle turbinate, and are favored by hydrorrhea and septal deflections. The patient complains of attacks of

THE "New Lexington," Boston, will be found a pleasant stopping place for delegates to the American Medical Association in June. Make reservation early. See announcement in this issue.

AT ATLANTIC CITY, the "Chalfonte" is easily the most popular hotel on the beach. If you want to secure special rates after the Boston meeting, write the editor of the FORTNIGHTLY.

THE enterprise and courage of the members of the San Francisco drug trade were clearly exemplified during the recent disaster. Before the fire was extinguished they placed large orders with the manufacturing chemists. One house ordered 30,000 pounds of antiphlogistine, and altogether over 100,000 pounds were shipped to the coast upon order within a week. On a steamer from New York, running up the California coast at the time of the earthquake, were 35,000 pounds of antiphlogistine, and upon orders from the home office, the emergency hospitals were liberally supplied free of charge.

much with changes in the weather; also a sense of fullness in the upper portion of the nasal cavity, discomfort being most marked at night. There is a constant, profuse, watery or mucous discharge. The voice is dead and peculiar, with a faint nasal tone. The ridge of the nose is thickened, as in chronic stenosis generally. Inspection under cocaine with a good light shows glistening, bluish-gray moile growths, resilient to the probe, in the middle or upper cavity. Polypi may simu.

late empyema of the antrum in the electric transillumination test. To remove these growths Coakley employs the cold wire snare, after spraying with cocaine and dilating nostril widely. He makes the loop vertical and but little larger than the polyp, pressing the loop well up to attachment of growth before cutting it off. If the hemorrhage is sharp, place a small pledget of cotton against site of stump. Spray nose night and morning subsequently with Seiler's or normal saline solution. When polypi return, if recurrence is not due to disease of accessory sinuses, curette the region of origin quite thoroughly under cocaine or general anesthesia.-Denver Med. Times.

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MEDICAL MISCELLANY

Two UNUSUAL EPILEPTIC HISTORIES.Smith Ely Jelliffe's first patient was a girl ten years of age, who until she was eighteen months old was perfectly well and normal. At this time otitis media developed, a moderate purulent discharge from the ear beginning on the second day. In a few days, the pain and local symptoms subsiding, the child was taken out of bed. It was found at this time that she was paralyzed on the left side and epileptic phenomena developed. The general condition of this child has greatly improved, including a gain in weight of twenty-five pounds. She is mentally changed, being as bright as the average child of her age. About a year and a half ago examination by the writer showed a small cicatrix on the right drum membrane. He thinks it not improbable that the otitis was followed by the development of an abscess, the paralysis and epileptic phenomena being due to pressure or partial destruction. He believes also that the recovery, if such it proves to be, may be attributed to the rupture of a secondary cyst and the relief of pressure. The second patient had always had fair general health until an attack of santonin

poisoning. This accident offers a plausible explanation of the convulsive seizures, the amblyopia, and the nephritis which followed. The author states that the relation of santonin to naphthalene suggests the type of pathological change that occurred in this child's nervous tissues. He has little doubt that the

seizures from which this child suffered were distinctly epileptic. Med. Rec., March 31, 1906.

COLOMBIA'S INDUSTRIAL OPPORTUNITIES. -Colombia's present attitude toward Americans is dignified an commendatory. Though scarcely meriting favorable treatment, they are preferred to other foreigners in the republic, and they obtain nearly all the concessions grante to aliens. They are as welcome in Colombia as they were before the secession of Panama, and it is chiefly they who have charge of constructive work throughout the country. Two railroads of importance are being constructed by Americans. One of these, from Buenaventura, on the Pacific, to Bogota, by way of Cali, will no doubt result in a thorough develop-travel between the capital and the ocean from twelve days to forty-eight hours; the other, from the Gulf of Darien to Medellin, the second city in the republic, will place rich region in touch with commerce. The country to be traversed by the roads is elevated, and suitable for an industrial population, insuring colonization, which must start from the head waters of rivers. Employment is thereby given to twenty thousand men. As a result of all this constructive work, gold fields will be developed. Once made accessible, the Choco region will be filled with prospectors. With the enactment of laws, similar to those prevailing in the Western American States, a great increase in the mining population will soon be brought about, and even a mining boom, "on the American plan," must occur. Important discoveries of gold will certainly be made. The purpose of President Reyes is to develop the country, and he realizes that mines are the best agents for the introduction of immigration on a large scale. The mining laws of Colombia, already the most liberal in South America, will be still further improved. Very probably the coinage tax will be abolished. The export tax on bar gold has been abolished, and before long mining will be made an untaxed industry. For "The New Era in Colombia," by Francis P. Savinien, in the American Monthly Review of Reviews for May.

GIVE growing children plenty of the most nutritious food at regular intervals and allow them plenty of time for eating, teaching them swallowing. to chew each mouthful thoroughly before

THESE are the days when the skin needs especial care and attention. The high winds, together with the dust and dirt raised by them, are more severe on the skin than the coldest atmosphere.