successfully held to act merely in a mechanic way, while the iodid of potassium is claimed to be generally effective only by liberating accumulations of metallic mercury that have settled in the tissues of the body, and doing this by converting the metal into a soluble salt, which again allows it to be carried about by the circulating blood, and be eliminated, and the remainder again decomposed, so that the released metallic mercury may again do its work. But the efficiency of the But the efficiency of the iodid of potassium is not limited to the release of mercury, to its acting merely as a means of re-administering this metal to the patient from deposits of it in his own tissues, for the iodid of potassium has produced its characteristic effects in advanced syphilis in individuals who have never taken any mercury.

Mercury, however taken, is, as I have said, supposed to act mechanically. Its finely-divided globules, in the metallic state, are supposed to penetrate the minute vessels, carrying before them obstructing cell accumulations. They are all the better able to do this by the flexibility of the metal, which readily takes upon itself any form necessary to get through a narrow passage. Metallic mercury taken in bulk is useless in syphilis because it is not self-divisible. The most finely-divided preparation of metallic mercury is to be found in mercurial ointment, and it is for this reason that inunctions with this ointment are so markedly effective in syphilis. It is also very finely divided in the oleate of inercury, but this preparation is not so reliable, because the heavy metal tends to precipitate and become united after standing for some time. The mercury pill is the most finely-divided preparation next to the ointment. The bichlorid and the proto-iodid are salts of mercury which, it is claimed, are decomposed in the system, after which the free metallic mercury does its work as when the ointment is used upon the skin. According to this idea, it is effective in syphilis by clearing all the vascular tubules of obstructing cell accumulations in the same way as leaden shot cleanse small, irregularlyshaped tubes, through which they are run

continuously, if lined with irregular accumulations, say of rust. This mechanic theory of the action of mercury is ingenious, attractive, and plausible. It is based upon actual experiment and microscopic observation of its action in the capillaries of the web of a live frog's foot.

I am very much inclined to believe this view of the mechanic action of mercury to be correct. Mercury can be given more freely in warm weather than in cold because then elimination is more active. It is said to promote the development and higher activity of the red cells of the blood by opening all the channels of circulation, thus permitting free glandular activity, and an ample supply of nourishment and oxygen to all the tissues of the body.

The Mercurial Preparations.

My preference of the mercurial preparations has always been for the bichlorid, of which I give one-twenty-fourth grain three times a day, well diluted, after meals. In the later forms, I use a saturated solution of the iodid of potassium, and begin by giving 10 drops, well diluted, after each meal, adding one drop to each dose every day until there is either a recession of symptoms or commencing evidence of iodism, of which the first marked sign is coryza. If there is a concurrent amelioration of symptoms. with this physiologic manifestation of the drug, I reduce the dose slightly and continue it at that point. Should there be no recession of symptoms, although the drug is producing its characteristic unpleasant effects, I rapidly increase it by five or ten drops a day, or even per dose, if the patient's stomach will stand it, until the point of susceptibility is passed, and tolerance beyond this established. After this, the drug may be increased almost indefinitely, and the point be reached in due time when the symptoms of the disease will recede. In the intermediate period, when one is somewhat uncertain as to whether to use the mercury or the iodid, I use both, giving one-twentyfourth grain of the bichlorid, and ten or fifteen of the iodid at each dose. Should the mercury disagree, it is often very helpful to give one-eighth grain of either

the extract of hyoscyamus or belladonna with each dose. In lieu of this, or with it, may also be given ten grains of the subnitrate of bismuth for several days. In giving bismuth, however, it is always well to make sure that it is a chemically pure product, because, when impure, it contains arsenic, the presence of which would only serve to aggravate the irritating effect of the mercury, which one is trying to overcome. It is also well to remember that, when the stomach rebels against mercury, the more effective, but less convenient, method of inunction is left us. For this purpose, I prefer the mercurial ointment because it is both

cheaper and more readily attainable. The oleate is more elegant, but also more expensive, and apt to be unstable. Whichever one is used, it should be rubbed gently into the skin at any place where it is thin, say the axilla, belly, groins, or joint flexures. It may be used in one place a number of times until this becomes a little tender from irritation, when recourse should be had to one or the other of the several regions designated.

The Hypodermic Use of Mercury. I have had no experience with the hypodermic injection of mercury. It is It is apt to produce more or less soreness, and is objected to by many patients, though the treatment is only given about once a week, which is a very convenient point in its favor, under certain conditions. An eighth of a grain is given at a time by this method. Six grains of the biSix grains of the bichlorid of mercury are added to one ounce of distilled water, of which twenty drops would constitute the initial dose. Inject ing oftener than once a week is apt to cause salivation. There are other methods of carrying out this treatment, but this is the simplest. In using mercury, it is proper to increase it gradually until there is a recession of the symptoms, or until the gums become tender and the teeth sore when sharply brought together. When this occurs, it is well to stop the drug until the soreness disappears. If it has a tendency to remain, it is best to switch off to the iodid of potassium. The iodid of potassium and the mercury are apt to be followed by a disagreeable and

metallic taste, the iodid much sooner than the mercury. In the case of the iodid, this is usually preventable by taking the drug in milk, or following each dose with it. Ptyalism.

This condition may be developed in any patient, despite the utmost care in the use of mercury. It may stick to him tenaciously for a long time, even growing worse after the mercury has been withdrawn. The general indication, then, is, besides the withdrawal of the mercury, to continue with the iodid which helps the elimination of the drug, and the use of slightly astringent antiseptic mouthwashes, in connection with which the patient should be given a good nervous brace, and I know of none as good as nux vomica in half-grain doses before each meal. As an astringent, I would suggest any of the vegetable products; and as an antiseptic, I know of nothing so unobjectionable, and yet efficient, as a saturated solution of boracic acid.

Extreme Susceptibility.

There are some people who are unable to take mercury in even very minute doses. I had such a case several years ago; a very intelligent young man, in active business, under very high pressure, and compelled to spend much of his time upon the road between the larger cities in the eastern part of the country. He had been to several specialists in some of the large eastern cities, and always with about the same result, being placed either upon mercury or the iodid of potassium in minimum doses, with the uniform effect of causing nausea, occasional vomiting, abdominal pain, and an exhausting diarrhea, all this after only one or two doses. I made a solution of the red iodid of mercury in 87% per cent. alcohol, which is used by homeopaths for moistening their sugar pellets, and is of this percentage because found to insure the highest degree of penetration of the sugar mass by it and the drug it carries, without dissolving the mass. The red iodid is very insoluble in alcohol, more so in water, and only very slightly so in alcohol of homeopathic strength. I filled an

ordinary two-drachm vial with No. 50 homeopathic sugar pellets, and then added not more than twenty-five or thirty drops of the solution, only part of which was absorbed by the pellets. I should roughly estimate that each pellet contained less rather than more than one-five-thousandth of a grain of the drug. He took one of these after each meal, chewing it, and allowing it to dissolve in his mouth. He was to add one a day until he either had a recession of symptoms, or his usual manifestation of poisoning with mercury. He took three of these the first day, four upon the second, and four upon the third, when recession of symptoms began, and he continued taking four a day without any bad effects, though there was a total recession of all his symptoms, and he finally appeared to get entirely well upon a well-known gold preparation. This was an instance of extraordinary susceptibility to the drug, and I was right in supposing that a remedy which would in ordinary doses have such a profound effect upon his organism, would in much minuter doses have a curative effect upon the disease without causing him any inconvenience. His case simply shows the necessity for individualizing your patients and treating each one according to personal peculiarities.

Potassium vs. Sodium Salts.

I have sometimes used the sodium iodid in place of the potassium salt, and think it much the better of the two. should advise its use in preference to the other, and must frankly admit that my failure to use it entirely is due to the habit of having used the potassium salt for many years with satisfactory effects. I may add that the sodium salts are preferable to the potassium salts because less irritating and more soluble.

As I have already stated, the iodids are the most effective of the remedies used in the tertiary stage of syphilis, and they are more especially effective in the treatment of gummata. They should also be the main reliance for the removal of secondary lesions that persist, despite a liberal use of mercury. The mixed treatment, so called, which means a combination of mercury and the iodid, will succeed in

many cases in which neither drug alone is effective.

Need of Tonics.

Inasmuch as both mercury and the iodid tend to pull down the patient, particularly in large doses, it is well to increase the dosage gradually, and to simultaneously employ tonic treatment.

This would include the bitter tonics for those who do not object to them, and the more assimilable forms of iron. Quinine is often a very good nerve-stimulant and tonic when given in five grain doses night and morning. This may be taken in gelatine-coated pills or in capsules.

Dosage of the Iodid.

The dosage of iodid of potassium varies enormously with different people. Thus, while some are incapable of taking more than a few grains without marked symptoms of iodism, there are others who take enormous doses of the drug for quite lengthy periods without signs of iodism, or deterioration of any kind. I have often given large doses of this drug, the largest

to a man about 48, affected with a transverse myelitis. He took one-half ounce (240 grains) three times a day for several months, with two intervals of a week each, during which he took none. I took the precaution of examining his urine twice a week in the fear that there might be renal irritation because of the elimination of so large a quantity of this irritant, but such examinations were always negative. I want to emphasize the desirability of making frequent examinations of the urine of patients taking more than, say, forty grains of the iodid of potassium thrice daily. The drug should be stopped as soon as there is any evidence of kidney irritation. Water should be taken in the largest possible quantities during a course of the iodids, for the double purpose of securing free elimination and diluting the drug to as extreme a point as possible. It will thus be seen that a syphilitic individual having kidney disease is very seriously handicapped in his effort to get well, particularly if his syphilis requires large doses of the iodid. When the iodide of potassium proves irritating, either to the stomach or kidneys, I should always advise using the sodium salt.

The Use of Gold.

In the more advanced syphilitic conditions and by this I mean those that present new connective-tissue formations with their inevitable contraction and entailed atrophy of the essential cells involved-there is no remedy so effective or so promising as the assimilable gold preparations now upon the market under a well-known name. The value of these preparations is not alone in their removal of excessive connective tissue, but in their

general tonic or stimulating effect upon the body.

General Management.

In the treatment of syphilis, next to the two specific remedies that are almost always able to cure the disease, is the general management of the case. In this, the aim should be to place the individual under the best possible conditions favorable to the highest degree of health. Thus, he should have fresh air, sunlight, moderate exercise, and an ample supply of nourishing food properly prepared. He should be adequately clad to protect him from cold in winter and to guard against overheat in summer. He should be bathed often to promote the free activity of the skin, and to rid himself of the minute accumulations of mercury found upon the skin during a course of treatment with this remedy. The mouth and teeth should receive the utmost care. They should be frequently cleaned with a proper antiseptic, and the teeth placed in a first-class condition, and so maintained; nor should a patient neglect, under such circumstances, to inform his dentist of the nature of his trouble, both for his protection and that of his patients.

Tobacco Objectionable.

It seems hardly necessary to say that the use of tobacco in any form is objectionable because of its more or less irritating effect, thus encouraging, and often inducing, the formation of sores, like mucous patches, of an infectious nature. The importance of this advice is readily appreciated when one considers the ease with which syphilis may be communicated to others by kissing, and it should hardly be necessary to call attention to

the extreme desirability of having these patients refrain from the use of alcohol, particularly its abuse.

Get Confidence of Patient.

Finally, if undertaking to treat a patient for syphilis, it is very desirable to get his absolute confidence. To this end, it is necessary to impress upon his mind the nature of his disease, the necessity for prolonged treatment, even despite the absence of symptoms, the danger of infecting others for a certain period, and the probability of transmitting it to offspring, even for some time after there is no danger of communicating it to others by contact. He must be impressed with the fact that it is impossible, by any known means, to cure syphilis in a short time, say in a few months or one or two years. His prejudice, if he has any, against the use of mercury must be overcome, and, if he has none, it is still advisable to show the necessity for, and the harmlessness of, mercurial treatment if properly undertaken by a competent physician. This safeguards him against later suggestions of the danger of using mercury, and having it get in his bones.

Encourage Elimination.

Everything that stimulates elimination is good during a course of treatment for syphilis, and it is better that elimination should be a little overactive than that it On this account, should be deficient. hot baths are very useful, as is also active out-of-door exercise, especially in hot weather. Let your patient know that syphilis is one of the most curable of all the serious diseases, but that this requires. at least three years of continuous effort.

Be Sure of Diagnosis.

No case of syphilis should be treated as such until the diagnosis can be made with absolute certainty. In this, I refer to the disease at its beginning. A supposed chancre should not be destroyed, nor should it be arrested. You should explain to him the necessity for observing the sore, and watching for secondary symptoms, so that a positive diagnosis may be made, and he be satisfied that a course of treatment, covering a period of

at least three years, is not needlessly entered into. Later syphilis, that may have been acquired without the knowledge of the patient, which has long passed the primary stage, may often have to be diagnosed by the application and effects of specific treatment.

Never forget that the sequelæ of syphilis are its after-effects, not the disease itself, and that they should be treated independently for what they are, though in some cases they are benefited by the iodids. Last of all, and yet one of the most important things to remember, is that it is not safe for any syphilitic to marry within less than three years from the inception of the primary lesion, and even then he should have been entirely free from all symptoms of the disease for at least a year and a half. Should he have had symptoms of syphilis for two or two and a half years, marriage cannot be conscientiously advised or permitted until after three and a half or four years from the beginning of the disease.

Communications.

Some Cases of Eruptive Fevers.

TO THE MEDICAL COUNCIL :

etc.

I was called to see a young lady, age 20, in a family of six, consisting of the father; Miss S., the patient; a boy 14; girl, 12; boy, 9; girl, 4; none of the children having had any of the eruptive fevers, i. e., scarlet fever, measles, rötheln, The patient was very restless; respiration very hurried, with deep sighing every 7 to 10 respirations. She could not speak above a whisper; complained of very sore throat; considerable swelling involving the glands of the throat and neck; complained of muscular soreness, with stiff neck; post-cervical glands enlarged; neck swollen until almost thickness of face; throat and tongue a deep scarlet, and no coating; heart's action 180, with failure of the valve to hold on contraction; she said that her hands and feet were asleep; subcutaneous tissue markedly livid; extremities cold; tingling in hands so unbearable that she would have them rubbed by some one or rub them against the bedrail or anything for relief; very alert, sitting propped up in bed, as she could not lay down, nor be still; absolutely sleepless, and nervous to an alarming extent, the least noise causing her to start or jump. It was an absolute punishment even to listen to music, and a false note was like a shock from a galvanic battery. Mental faculties very acute, and has a mind away above the average. It was keyed up to at least double pitch.

Suspecting scarlet fever, but finding no history of exposure, and the family being practically isolated, and fearing to add the anxiety of that in her overwrought nervous condition, I put her on appropriate treatment, and waited for develop

ments.

The next day she began showing a pronounced scarlatinous rash, but it did not spare the usual area around the mouth. By the second or third day it covered the body, partaking in places of a scarlatin