R Ferri carbonatis, gr. xxiv. Strychninæ sulphatis, gr. j. Acidi arseniosi, gr. j. teristic of lupus erythematosus. Not infre- | strychnine, and arsenic, as constitutional quently, for instance, there will be found a tonics. We may order, for example, a compatch upon each side of the nose united by bination as follows:a narrow line across the bridge of that organ, forming a considerable resemblance to the figure of a butterfly with extended wings. Yet I am unable to attribute much diagnostic value to this figure, inasmuch as I have found it quite as well marked in a number of cases of undoubted lupus vulgaris which have appeared in this clinic and which you probably remember. In the treatment of lupus vulgaris both constitutional and local measures are indicated. Whatever is amiss with the general health must, as far as possible, be corrected. The hygienic and dietetic management is of much importance. If the patient be anæmic or scrofulous we should make use of remedies and methods suitable to those conditions. Codliver-oil is of decided benefit to many weakly patients. If there be a tuberculous tendency we must employ the systemic agents which are of most promise in that affection. Gastro-intestinal disturbances call for intelligent regulation or restriction of the diet, together with such drugs as strengthen the digestive power and promote nutrition. As regards local therapy, our objects must be to cause absorption or destruction of lupous tissue and the cicatrization of lupous ulcers. I am not a partisan of certain rude mechanical procedures, such as curettage, etc. An equal result may be obtained with much less disturbance by applying pure carbolic acid to the diseased surface twice a week, in the intervals dressing the parts with an ointment containing some mildly stimulant and antiseptic substances. The carbolic acid is destructive and at the same time acts as a local anesthetic. It may be very well applied upon a roll of absorbent cotton held by the dressing forceps or attached to a match-stick. This plan shall be followed in the present case, conjoined with the use of a 5-per-cent. oinment of oleate of mercury. Internally this patient, who is of advancing years, shall be placed upon iron, M. et ft. pil. No. xxiv. CASE II. TERTIARY SYPHILIS. A colored woman, 28 years of age, comes here on account of an eruption upon the neck, breast, palms, and other parts of the body. These evidences of disease are said to have been in existence for only three or four weeks. As I scan the affected areas, one fact stands out prominently: the lesions. are not all of the same variety. They differ among themselves in character and appearance. In other words, to use a descriptive term, they are polymorphous. In some regions I perceive pigmented spots, in other places there are papules, in still others pustules or tubercles are present. Upon the hands macules are symmetrically arranged. The lesions upon the neck consist principally of tubercles aggregated to form annular outlines. These also are symmetrically displayed. Upon the breast are pigmented spots due to absorption of tubercles. Some of the spots are covered with small, dirty scales. Now, whenever you meet with a case in which the eruption is polymorphous, you should ask yourselves: Is this a case of syphilis? For a variety of co-existent lesions is very suggestive of syphilis. If the lesions, though differing in aspect, possess in common a certain coppery color, if the scales are thin and scanty, the crusts brownish, greenish, or blackish in color, and if they are free from itching we may conclude that we are dealing with syphilis. features of this case are in accordance with those which I have just enumerated, and I therefore assert confidently that the patient suffers from syphilis. As regards the The color of an eruption, we are not, indeed, | necessary to prescribe any special local treat able to judge so easily in negroes. The cop- ment. No clear or reliable history can be obtained. The objective characters which I have indicated stamp the disease as syphilis. It is evident, however, that it is of no recent origin. Large pustules and tubercles belong to the later cutaneous manifestations. The small flat pustular syphilide does not, as a rule, make its appearance before the end of the second year after infection, and its advent may be much longer postponed. The large flat pustular syphilide does not genrally develop until the third year of the disease. The tubercular is apt to be still later in the course of the malady. We may reasonably infer from these facts that this patient has been infected not less than two and probably as long as four years. She has manifestly received little, if any, antisyphilitic treatment. CASE III. PUSTULAR ECZEMA. Our third patient is a little boy, 8 years of age, whose mother states that he has been afflicted for about five years with an eruption upon the scalp and other parts of the body. There has been pustulation upon the scalp, which is now covered with crusts and spots of infiltration. The disease began with papules. At times the disease causes intense itching. The extent of the disorder, its actively inflammatory character, the occurrence of papules, pustules, infiltration, and crusts, together with the age of the patient at the commencement of the trouble, point to the conclusion that this is a case of eczema. You are already aware that this is a very prevalent affection, that it attacks all ages, and that it assumes a great variety of phases. Formerly it was believed that eczema was invariably attended by vesiculation and moisture, but it is now recognized that the progress of the disease may be dry from first to last, although it is true that in most cases weeping occurs at some period or in certain situations. In infancy and childhood eczema presents characters which distinguish it as a Cases which have progressed to the ter- subvariety from the same disease as extiary stage require the most favorable hy-hibited in adult life. These differences are gienic conditions. Our chief medicinal due to the greater delicacy of the integureliance is potassium iodide. In the case ment in children. Infantile eczema occurs now before us, however, on account of the from birth to the fifth year of age, the time coated condition of the tongue, I shall be- at which it began in the present patient. gin the treatment by the use of hydrargy- It is usually due to improper food either as rum cum cretâ: mercury with chalk. This regards quantity or quality. A common preparation acts upon the glands of the fault with parents is to allow or even enmucous membrane of the alimentary tract, courage babes to partake of hearty food belessens irritability and acidity, and places fore their digestive functions are suffithe patient in a position to receive with ciently developed. External causes also are more benefit the usual mixed treatment of naturally more operative upon the sensitive mercury and iodide. We will order for this texture of the child's skin. woman 3 grains of mercury with chalk to be taken four times a day. In a case like this where there are no ulcerated lesions it is not Like the same disease in the adult, infantile eczema may begin in any one of the chief forms, but generally exhibits simul taneously or in succession several or all of the manifestations characteristic of the disease. The head and face are favorite localities invaded. There is a decided tendency in the disease to become chronic. There is usually intense itching, and the constant scratching aggravates the case. The skin becomes torn by the nails; vesicles form; serum escapes, dries upon the surface, and forms crusts. In many instances, as in the present, pustules arise, and their rupture discharges pus upon the scalp. This pus also dries into thick, yellow or yellowish brown crusts. If the crusts are raised or detached the exposed parts are seen to be moist and raw or perhaps bleeding. An old name for this condition is "crusta lactea," or "milk-crust." The tendency to suppuration is especially noticeable in scrofulous children. In extreme cases the itching banishes sleep and the child loses flesh and strength. In such cases the cervical glands may become swollen. From the scalp infantile eczema may spread to the face. In fact, the disease may attack other and more distant parts of the body, as exemplified by this case. In The treatment of infantile eczema must be largely dependent upon the cause. babes we must look to the quality and quantity of the mother's milk if the child be breast-fed. If reared upon the bottle we must see that the milk supplied is of good quality, and if the child is old enough starchy food may advantageously be added. in proper proportion. Whatever the little patient's age, the digestive capacity must be narrowly watched. I need delay no longer to speak of infant-feeding, as the case now under discussion concerns a child of older years, in whom under favorable circumstances the diet may approach that of adults or at least that of adolescents. This boy has, however, undoubtedly a certain degree of habitual indigestion, as is shown by a furred tongue, sluggishness of the bowels, and occasional attacks of sick stomach. For this reason I shall order for him a stomachic tonic: When the tongue has become clean, this mixture will be replaced by syrup of ferrous iodide given in doses of 10, increasing to 20, drops three times a day. In the local management of such a case as that before us the first thing to be done is to clear the surface of crusts. This obtices, oils, or alkalinized baths. After these ject can be accomplished by means of poulproducts of disease have been removed it is necessary to supply some bland or slightly erate stimulation is permissible and benestimulating lotion or ointment. Only modficial in chronic cases. The texture of the skin in children is too tender to allow the what is not beneficial is generally injurious. use of strong remedies, and in such cases Among the milder agents which can be emcarbonate of lead or zinc, bismuth subployed in infantile eczema are arrowroot, nitrate, and zinc oxide. In old cases, where some measure of stimulation seems advis able, we may make use of calomel, sulphur, naphthol, or camphor. As the patient now later childhood, it will be of advantage for in our presence has reached the time of us to select one or more of the latter class of agents, especially in view of the fact that the disease is of five years' duration. A combination such as the following will prove of service in such a case: R Sulphuris sublimati, gr. xx. Camphoræ, gr. x. M. et ft. ungt. Tenth Congress of Alienists and Neurologists.-The tenth meeting of the above body is announced to take place at Marseilles, France, on April 4th, under the presidency of Dr. Doutrebende, Chief Physician and Director of the Asile de Blois. proposition, he was only allowed to have the Original Communications. exudation upon the tonsils examined in the pathological laboratory of the school of A CASE OF DIPHTHERIA FAUCIUM medicine in Cairo. The microscopical an CURED BY SERUM. BY RUDOLF MEYER, M.D. (ZURICH), A PRACTITIONER acquires his conviction of the efficacy of a new therapeutic method by the close study of correctly-diagnosticated cases in his own practice, where experience had formerly taught him to form an unfavorable prognosis, but which, nevertheless, were cured by the use of the new remedy. I recently saw such a case of diphtheria faucium cured by serum in Cairo, Egypt, and esteem it worth reporting, though I presume that most of my colleagues in the United States are already completely convinced of the eminent value of serotherapy in diphtheria. Cairo, the Arabian Paris, the metropolis of Egypt, is, in general, a healthy place. In the old quarters, in the narrow sideways of the Muski, the commercial centre, fevers of malarial type, and in the prisons, of recurrent and bilious character, are not rare. But the "Sharia Abdul-Aziz," a very large street with electric tramway, flanked by handsome and modern buildings, was the last region where I expected to meet diphtheria. However, I was called in consultation by Dr. N. to a child of 3 years, the daughter of an Italian merchant, dwelling on the second floor of one of the best houses of that street. Clelia L., such was her name, had shown symptoms of slight indisposition of indefinite character from the eighteenth of October, but Dr. N. did not see the child until the twenty-second of that month. He diagnosed diphtheria tonsillaris and proposed injections of serum (Roux), but the mother and grandmother of the child objected. On the following day, Sunday, was the baptism of the youngest sister of the patient, and though Dr. N. persisted in his alysis performed on the twenty-fourth of October, found no bacilli of Loeffler. In this indecisive situation I saw the case with Dr. N. on the twenty-fourth of the month. The Inspection of the fauces was difficult. The left tonsil seemed to be ulcerated, and its surface covered with sanguinolent fluid and white exudation. The mucous membrane on the left side of the uvula was overlaid with a thin white membrane. right tonsil was covered by a thick and adherent membrane. Depression of the tongue caused vomiting movements, with ejection of fragments of exudation and bloody mucus. The upper surface of the epiglottis appeared swollen and hyperæmic. The submaxillary glands, though painless, were swollen, more on the left than on the right side. The voice was clear; there was no stridor of respiration. The pulse was 108 in the morning and rectal temperature 37.2° C. (99° F.); pulse 132 and temperature 37.8° C. (100° F.) at 5 o'clock in the evening. Undoubtedly there was tonsillar diphtheria. Twenty centimetres of serum (Roux) were injected in the left hypochondriac region. In the evening of the following day we found a slight, but visible, progress of the disease in general. The morning temperature was 38.3° C. (101° F.); pulse, 148. The urine contained albumin, and, what seemed most ominous, the voice had become hoarse, and the breathing sounded slightly stridulous. The membranaceous inflammation had doubtless begun in the glottic or subglottic mucous membranes, and there was also a general effect of the diphtheritic local infection on the kidneys (albuminuria) and nervous centres (fever). Injection of 20 cubic centimetres of serum (Roux) was again performed. On the third day, at 8 o'clock in the morning, Dr. N. and I found a positive amelioration in the local as well as the gen The voice was clearer; in weeping loose laryngeal rhonchi were heard, but there was no stridor. The left tonsil was free from exudation. The mucous membrane on the left side of the uvula was clean, and not bleeding. On the right tonsil the pseudomembrane was much reduced, being scarcely a third as extensive as on the preceding day. The urine was secreted in very small quantity, and there was still a trace of albumin. The rectal temperature was 38° C. (100.4° F.), and the pulse was 128. No injection of serum was made. eral state of our little and delicate patient. | plication of serum. At the second day of my observation, the fourth day of medical attendance, the local and general state of the child led me to expect an unfavorable termination. There was exudation, not only on both tonsils, but also on the uvula; the epiglottis was inflamed, the voice hoarse, breathing stridulous, the lymphatic glands infected, albuminuria pronounced, and increasing fever with frequent pulse; at this period the injection of the second dose of serum (Roux) caused a sudden cessation of the local and general symptoms. The membranous exudations decreased and the laryngeal-or, rather, glottic and subglottic-inflammation became catarrhal, while the albuminuria and fever disappeared in fortyeight hours. At 2 o'clock of the same day the respiration seemed quite normal; inspiration was through the nose; in expiration there were abundant loose laryngeal rhonchi. There was no cough; the voice was weak, but almost clear; stridor was absent. The urine contained no albumin. The temperature was 38.1° C. (100.5° F.), and the pulse 132. Both tonsils were clean; there were 24 respirations in a minute. At 7 o'clock there was occasionally slight stridulous breathing; the voice was weak; speech was somewhat difficult, but clear. We accordingly resolved to promote the resolution of the local inflammation by a third dose of 20 grammes of serum (Roux). Rectal temperature, 38.0° C. (100.5° F.); pulse, 112. In the morning of the twenty-seventh of October, the fourth day of our observation, convalescence was manifest. The night had passed well; there was no albuminuria; breathing was quite free; the voice was clear, and there were no rhonchi in the throat; both tonsils were clear, but sore; there was no hyperæmia nor swelling of the pharyngeal mucous membrane. Thirst had disappeared; the appetite had improved. The submaxillary glands were much smaller. Rectal temperature, 37.8° C. (100° F.); pulse, 108, softer and smaller than in the preceding days. My experience assures me that the best treatment in such a case of pronounced tonsillar diphtheria would not have had so quick and excellent result without the ap The serum was injected during three days, each time 20 grammes. It had been prepared by Roux in the beginning of last September. The injections were made into the abdominal integument without pains or any consequent irritation. No other local treatment was employed except inhalations with aqua calcis and placing vessels with hot water and some eucalyptus leaves under the bed of the patient. We were thus enabled to control the local process without the influence of caustics. Twenty-five years of laryngoscopic special practice have convinced me that in the treatment of syphilis faucium the effect of internal remedies is best shown by the changes of the local processes without topical applications, and that, if no important destruction demands the employment of all our resources simultaneously, we possess in the local troubles and its change a most valuable guide as to the effect of our constitutional measures. Now, I applied the same principle in the treatment of diphtheria faucium, where the serum has to perform the same action as and more than mercury and iodides in syphilis. As long as no severe and threatening symptoms compel us to local measures, I think we do better to avoid caustics. The disappearance of the false membranes, the loose catarrhal rhonchi |