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litis and urethral catarrh, malpositions of the uterus, with their sequelae, and various ovarian troubles. The first should be considered in the case of every young person, and while it is a delicate subject to deal with, one can always, by the exercise of sufficient tact, impress upon the patient the fact that any unnatural irritation of the sexual apparatus is bound to show in his face. I am sure that this may be done in such a way that no offense can possibly be taken. In the event of there being malpositions of the uterus or ovarian irritation, there will almost invariably be symptoms other than acne, such as dysmenorrhoea, menorrhagia, pelvic pain, vesical or rectal tenesmus, backache, unusual amount of leucorrhoea, and all these increased by walking or standing. With such symptoms, a patient is certainly entitled to the relief of her local troubles, even aside from the acne. But the acne is bound to be helped as the exciting cause is removed.

By far the most common internal cause of acne, however, the one which I believe to be active in nine cases out of every ten which are due to things internal, is trouble in the digestive tract.

If asked to name the single combination which I consider most useful in acne, the answer would certainly be-—the aloin, strychnine and belladonna tablets. So many patients who say that their bowels are perfectly regular are helped by this pill that it seems to me good routine treatment to give it, whatever they say. As for indigestion, it seems to me more wise to try to correct improper habits of eating, to insist on rest after meals, to prescribe proper food and exercise, and bitter tonics to brace up the digestive glands to the performance of their function, rather than to indefinitely supply the deficiency by giving hydrochloric acid or pepsin, pancreatin or oxgall. The trouble with digestion, in fact, is often due to one of the causes considered aboveanaemia and chlorosis. But there are, without doubt, articles of food which cannot be taken even by many perfectly healthy people without causing a tendency to acne. Such are cheese, an excess of butter, bananas and candy. Of course it goes without saying that articles like these should be avoided by acne patients. Then even small doses of certain medicines will cause an eruption not distinguishable from ordinary acne, probably because these remedies are eliminated partly through the sebaceous glands, and are irritating enough to cause inflammation in them. Such drugs are bromine and iodine. If in such a case the admin. istration of the medicine is of more importance than the cure of the acne (e. g. when, as in a recent New Haven Dispensary case, potassium bromide had to be given for epilepsy though it was

proved to be the cause of acne), the remedy may sometimes be continued without producing the eruption by combining it with various intestinal antiseptics in small doses, or with arsenic.

Coming down to the final and more unusual causes of acne, it is only necessary to bear in mind that in otherwise unexplainable cases, rhinitis or some mental trouble may be the starting point for reflexes which end in seborrhoea.

Before closing, I would mention three drugs which are certainly useful for particular forms of lesions, without reference to the causes at work. One is ichthyol, given internally, combined with licorice powder, in capsule form. This is most useful in lesions that are large and nodular, containing pus, but deepseated. Given in one-third to one-half gramme doses after meals, it will sometimes cause absorption of the nodules, pus and all, in a highly gratifying way.

The second empirical drug is sulphide of calcium, which is most useful in superficial pustules. It is given in about fifteen milligramme doses every three or four hours. The taste and odor of this drug are, however, most abominable, and it is not reliable.

The third and last drug is glycerine, given in tablespoonful doses twice a day.

In conclusion, it has been the aim of the writer to give as clearly as possible the principles to be followed in the treatment of this annoying disease, and no attempt has been made to multiply prescriptions. As almost every medical journal contains some prescription “good for acne," it is believed that any one who understands the causes of the disease can select for himself, or can originate combinations of the appropriate drugs which will be more applicable to the case in hand than any mixture designed for another patient could possibly be.




F. B. SWEET, M.D.,

On June 26, 1895, I was consulted by Mr. P-, a farmer, thirtyfive years of age, regarding an injury to his left knee, received two week's previously. At that time he had been suddenly awakened from sleep. Jumping from his bed, he had felt a sharp stabbing pain in the knee and fallen to the floor. Next morning, as he was still suffering and noticing a hard movable body on the inner aspect of the articulation, he summoned his family physician, who diagnosed a floating cartilage. A plaster of Paris splint was at once applied which he was still wearing when he came to me.

On removing this I found a knee slightly swollen, hot to the touch and with motion limited. On its outer aspect, a hard body was palpated, which was freely movable and eluded the grasp. In fact, its mobility seemed only limited by the confines of the joint cavity. I had evidently to do with a floating body in a joint where its presence had already been the source of traumatic inflammation, the continuance of which promised to induce serious secondary conditions. For this reason and because its extreme mobility seemed to preclude the possibility of fixation by any apparatus, I advised its removal.

After a week of rest, the existing inflammation completely subsided and I operated as follows: The limb having been prepared aseptically, and the patient etherized, the floating body was pushed up as high as possible, just external to the quadriceps tendon, and grasped with thumb and finger. A longitudinal incision, an inch in length, was made directly down upon it, opening the joint cavity. A tenaculum was introduced and the body dragged through the opening. About a drachm of synovial fluid escaped. The synovial membrane was at once seized and

sutured with fine cat-gut. The cutaneous wound was fushed with 1-1000 by chloride solution and closed without drainage. A voluminous dressing of sterilized gauze and cotton was applied and the leg fixed in extension by a posterior splint.

The dressing was taken down on the fifth day for the first time. The wound had healed by first intention. On the fourteenth day the splint was removed, the leg flexed, and the patient walked from the office, unassisted. His recovery from this point was complete and uneventful. The body removed was about the size and shape of a large lima bean. It was of bony hardness, with slightly convex surfaces. Its circumference had a frayed villous appearance and evidently had been the surface of attachment. As usual in these cases, the origin of the offending body was obscure. The patient had never suffered from any disease constitutional or local that could be considered an etiological factor. I have reported this case because the result obtained adds to the evidence in favor of early operative interference in properly selected cases of this class, rather than the use of the more conservative treatment by apparatus. The latter subjects the joint to the danger of repeated traumatism which often ends in serious secondary changes.

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