beaten and patted into shape. The white spread, that should have been removed at bedtime the night before and neatly folded, is now fresh and smooth. The bed is not all that needs close care in the sleeping-room. The dusting is far more important than many people suspect. Accumulations of fluff and dust form a favorite resting-place for disease germs and unsavory smells. On this ac count many ornaments are not to be commended in a bedchamber. The bits of drapery, the brackets, the gay Japanese fans, the photographs and the pieces of bric-a-brac that are admirable in other parts of the house are out of place here. Whatever furniture there is should be carefully wiped off each day with a soft cloth, and this shaken out of the window afterward.-Health. -MATERIA MEDICA AND THERAPEUTICS. ALFRED C. PRENTICE, A.M., M.D., Assistant in Surgery. College of Physicians and Surgeons; Attending Physician, New York Home for Destitute and Crippled Children. The Preparation of In an article which Surgical Catgut. appeared recently in the Lancet and British Medical Journal Lord Lister discusses the conditions required of surgical catgut, and its mode of preparation. Catgut used for ligatures or sutures in surgery should, after soaking in water of blood-serum, be strong enough to bear any strain, and should hold perfectly when tied in a reefknot. It must not be too rigid, or it may work its way out by mechanical irritation, and it should not be too quickly absorbed. It should also be perfectly aseptic when applied. The best substance for the preparation of catgut is chromium sulphate. As this chemical is liable to vary considerably in quality according to the process of manufacture, a process is given for the preparation of a suitable solution. Chromic acid, 4 grains, is dissolved in distilled water, 240 grains, and sulphurous acid solution added till a green color is produced. If too much of the latter be used the color becomes blue, and a small quantity of chromic acid solution must be added to restore the green color, after which the liquid is made up to 480 grains with distilled water, and, lastly, a solution of corrosive sublimate, 2 grains, in distilled water, 320 grains, is added. The preparing liquid must be 20 times the weight of the catgut used. The catgut is kept for 24 hours in the liquid, after which it is dried on the stretch. Prepared in this way catgut remains aseptic for an indefinite period. The Prescriber. The Treatment of Du- Koch (Aerztliche puytren's Contracture Rundschau, No. 40, with Injections of Fibrolysin. 1907). A complete and permanent cure was obtained by the author by means of subcutaneous injections of fibrolysin in a typical case of aponeurosis-contracture of three years' standing. Commenting upon this case, Richartz (Ctrlbltt. f. Inn. Med., No. 6, 1908) says that the powerful effect of the remedy in suitable cases is well illustrated by this cure of an old Dupuytren's contracture, which otherwise, and by no means always, yields only to operative interference. A number of negative results of the thiosinamin treatment in critical strictures of internal organs have recently been reported, and there is some danger of this valuable and well-nigh harmless remedy's being relegated to unmerited oblivion. Apparently it cannot exert its action upon all kinds of scars alike. Richartz recently succeeded by its employment in the cure of a case of esophageal stricture subsequent to lye cauterization, which had proved rebellious to all other forms of treatment. F. R. Bismuth Treatment of E. G. Beck, Chicago Sinuses, etc. (Journal A. M. A., March 14), describes the method of treating and diagnosing fistulous tracts, tuberculous sinuses and abscess cavities by bismuth paste injections and radiography, which he has used since March, 1906. He gives the formulas for the material used, as follows: Formula for diagnosis and early treatment: R. Bismuth subnitrate, 30 grams; vaselin, 60 grams. Mix while boiling. Formula for late treatment: R. Bismuth subnitrate, 30 grams; white wax and soft paraffin, of each 5 grams; vaselin, 6o grams. Mix while boiling. The soft paraffin, unlike hard paraffin, is absorbed in the tissues, and the bismuth, being opaque to the X-ray, gives a shadow that shows the shape and ramifications of the cavities. In making the injections he first dries out the cavity, if possible, by packing with plain gauze, which is removed just before the injection. The emulsion is sterilized before using, and is injected hot and liquid from a sterilized syringe. The first case injected for diagnostic purposes suggested the value of the method for curative purposes also; after one injection of the bismuth paste the psoas abscess fistula of nearly two years' standing closed up entirely and remained closed. Subsequent experience confirmed its value. Beck thinks it probable that the bismuth, which becomes radioactive on exposure to the X-rays, promotes the I. formation of granulations where it comes in contact with the walls of the cavities, and to increase this effect, in some cases, he has added strontium salicylate. Eleven cases are reported, and the author's conclusions are summed up as follows: A successful surgical operation on fistulous tracts depends principally on the exact knowledge of the extent and direction of the sinuses before the operation is undertaken. 2. Radiographs taken after the fistulas have been injected with bismuth paste show the extent and direction of the fistulous tract. 3. Skiagraphs of all fistulous tracts should be taken before an operation is decided on. 4. Fistulous tracts, tuberculous sinuses or abscess cavities, including empyema, can be cured by injection of bismuth paste. 5. Cavities or fistulas should be as clean and as dry as possible before the injection of bismuth paste. 6. The bismuth paste, when mixed with wax or soft paraffin, and injected in a liquid state, solidifies in the fistula and serves as a framework for new connective tissue. The paste is absorbed and the fistula obliterated. 7. Bismuth paste injection will not heal out sinuses where sequestra are present; these must be removed before injection. 8. The bismuth paste injections are painless and produce no unpleasant or dangerous symptom." The article is illustrated. tions, such as respiratory difficulty, coma, great weakness, anæmia and extreme old age of the patient. If used after the operation it should only be after all the reflexes have reappeared. It is useful both with chloroform and æther, but is safer with æther because of the stimulating effect of æther on the respiration. The possibility of an idiosyncrasy to opium and its derivatives must, of course, be kept in mind. The following general rules as to the administration of morphine with anæsthetics are given: I. Whenever morphine is used it should be before the operation instead of after, in order to obtain the benefit of the drug in the induction and maintenance of anesthesia. 2. All athletes and alcoholics should have this preliminary dose of morphine. 3. In extremes of life, the very old and the very young, morphine should be administered with very great caution. Whenever morphine is used a lighter grade of narcosis should be maintained than when it is not used. There is no question that all or the majority of the fatalities that have occurred, especially with scopolamin and morphine, have been due to neglect of this rule. Complete surgical anesthesia from scopolamin and morphine or any other tablet is unscientific, and will never become a routine practice. If ethyl chlorid is used to induce anæsthesia it is safe to follow it with æther, but very unsafe to follow it with chloroform, as both are depressants and kill in the same way, suddenly and without warning. It is, however, he says, legitimate to start with ethyl chlorid, then switch to æther, and if the reflexes are only slightly in abeyance, to follow with chloroform. In giving æther or chloroform alone, most of the reflexes must be 4. abolished to keep up the proper degree of anesthesia, but if morphine is administered these reflexes may be allowed to remain, and yet the patient will be perfectly quiet. From this fact Gwathmey devised the plan of giving morphine and relying on its nerve-blocking properties and merely putting the patient to sleep with the safest pulmonary anæsthetic known, warmed nitrous oxid and oxygen, in the majority of cases, stopping short of the stertor. If the reflexes cannot be sufficiently abolished, he would add a few whiffs of æther in preference to pushing the gas and oxygen to the limit. It is impossible in most cases to maintain surgical anæthesia with gas alone for any great length of time without marked cyanosis, but by giving from 1-16 to 4 grain of morphine from one-half to threequarters of an hour before the operation (perhaps best in two doses) the best effect is obtained. He has followed this plan in a great number of cases, of which he promises a detailed report in the near future. He pleads for a more careful inquiry into the subject of mixed narcosis. ORIGINAL COMMUNICATIONS. FEIGNED DISEASES OF THE SKIN. By F. C. CURTIS, M.D., of Albany, Consulting Dermatologist, New York State Department of Health. Self-inflicted eruptions upon the skin are well calculated to deceive those not especially familiar with the affections of this external cover of the body, and, indeed, to puzzle even those who are conversant with the varying manifestations of dermatological pathology as it finds expression in cutaneous lesions. They may readily simulate other forms of dermatitis, and unless the surroundings of the subject are such as to awaken suspicion, which often is not the case, the nature of their production is very likely to be overlooked. Indeed, it is quite probable that they not infrequently occur and escape recognition as to their character throughout. They are, in fact, infrequently reported, and they receive no lengthy reference in most textbooks. A crafty and well-informed individual could easily produce them so as to render a diagnosis very difficult. Such persons are not likely to produce, however, these factitious lesions, or else they would probably have some certain cause for doing so which would be apparent, and this might be sufficiently conspicuous to turn attention. to the nature of the disturbance. Such would be the case with suspicious malingerers, who might have a rational motive for producing these lesions, or in those of mental unbalance of a hysterical sort. But, occurring in persons, as they may easily be found to do, who have no conspicuous motive and no apparent mental aberration, they usually deceive the general practitioner, or sometimes a wellversed specialist in diseases of the skin. The agencies employed to set up these feigned affections of the skin are as various as the ingenuities of the individual affected. The most common are those which are irritants, with a resulting trauma characteristic of the medium used, that is some sort of a dermatitis. The lesions consequently vary according to the resources or humor of the subject. Sandpaper, for example, produces superficial excoriations of the cuticle, which are usually in patches of superficial area. It is frequently employed, and the scratch marks, such as would be anticipated from abrasions, thereby made are often suggestive. The skin may be torn with the finger nails, and as these are very likely to be infected, an eruption simulating scabies may result, the chief lesions of which are produced in this fashion. Persistent scratching with the nails may produce a well-defined eczematous patch, and I have often seen this done innocently, a person inadvertently scratching a spot of healthy skin, as for instance about the ankle, and establishing a habit unconsciously with resultant development of a patch of eczema. The circumscribed erythema produced by mustard, or the blebs of cantharides, or the pustules of croton oil are illustrations of the lesions of agents sometimes employed by the subjects of feigned and factitious diseases of the skin. There is a wide va riety of traumatic agencies that have been found to be used. Acids, strong alkalies, carbolic acid and the like have been used; anything, indeed, from a pin to whatever in the way of an escharotic may come to hand and appeal to the individual of a mechanical or chemical irritant nature has been found producing the trauma or der matitis with which the subject is affected. Consequently the lesions of what may be denominated dermatitis factitia vary greatly in character, severity and distribution, when of traumatic origin especially. This artificial dermatitis can be of any degree from slight excoriation to a sloughing ulcer, caused by repeatedly applying some sort of irritant at one spot. The lesions may be erythematous, vesicular, bullous or ulcerative. They may be transient or may recur for a considerable period of time. They are rarely numerous Gottheil (Journal of Cutaneous Discases, January, 1904), however, reports a case in which at least 100 lesions at one time of bullous character were distributed over the entire anterior surface save the palms, soles and face, and there was recurrence over a period of six months. This was produced, as he conjectured, by carbolic acid, but my observation is that this agent will not cause blister. The intentional reproduction of any certain disease, such as scabies, or eczema, is seldom to be looked for with the uninitiated subjects that we commonly meet. In European countries this appears to be more often resorted to by soldiers or conscripts, prisoners or mendicants. Men are more rational than women when becoming the subjects of this condition, usually resorting to it for a purpose, and have been found to attempt the imitation of such defined diseases as scabies or eczema, sycosis, impetigo, favus, and also other diseases not of an inflammatory na ture. A very considerable catalogue of these "Maladies Simulées" is given in an article by Laugier and quoted in some of the textbooks. Besides the self-inflicted dermatitis set up by these various irritants of the skin, other forms of dermatosis are set up. Ringworm of the scalp has been ingeniously set up by the use of the depilatories, as they are called, which, indeed, simply destroy the fabric of the hair over the surface to which the paste is applied, so that, thus becoming friable, the area is made bald in fair imitation of ringworm. Alopecia areata can be imitated readily by pulling out the hairs over a circumscribed area. Bromidrosis has been effectively reproduced by applying to the feet or axillæ grease impregnated with some fœtid substance. Axillary chromidrosis or red sweat is a legitimate disease. of parasitic origin which could be easily. simulated, as is apparent. The so-called black chromidrosis, if it occurs at all as an idiopathic disease, is found in hysterical subjects. It consists of bluish or black discoloration of the skin in limited areas, and is readily imitated by rubbing into the skin plumbago or some dark substance mixed with talcum powder, which may be so applied with skill as to be very deceptive. Not long since a middle-aged woman came to me with diffused brown spots or patches on the sides of the neck extending to the upper trunk, which she gave a history of having lasted for a considerable time with recurrences; they were superficial and only involved the scarf skin and were removable by vigorous friction with green soap. I believe it was a discoloration of external application, accidental or very likely intentional, as it lacked the characteristics of true chromidrosis. It is apparent that in many ways, and |