colored stain. No part of the body is exempt from liability to it, but it predominates on flexor aspects, on the face, and especially on the forehead at the margin of the hair, also around the mouth and nose.

Large papular syphilid is one of the common early eruptions, often following closely upon and mixed up with the erythematous lesions, or it may be one of the relapsing forms at a later period. The papules may be widely spread and numerous, but do not often group. most common position being on the forehead, lower part of the face, nape and trunk, especially the back.

The

Follicular syphilide appears in a large or small form, in which the hair follicles are the seat of the lesion, sometimes called the syphilitic lichen. It generally occurs in the first six months of the disease and its distinctive character, if any, is its occurrence in irregular groups of three or four up to twenty. The most common positions of this form are the extensor aspect of the limbs and the back, but not usually found on the neck and breast. The papules are about as large as a pin head or millet seed, bright red at first, but soon changing to brownish-red and crowned with scales.

The vesicular and pustular syphilides tend to pass from one to the other in their course and are often present simultaneously. The foundation of nearly all of these eruptions is a papule of varying size and grouping, hence presenting some similarities to eczema, herpes, varicella or variola, pemphigus, ecthema and impetigo in the pustular form. Upon these papules small pustules develop. Each lesion is of short duration, then ruptures and dries up into a scale or crust; the scale soon falls off and leaves a deep, flat, red papule which dies down, and a pigment spot is left.

The varioliform syphilid may in some instances need the greatest care in order to avoid an error in diagnosis. Liveing relates a case of this kind which was refused admittance to several hospitals on the supposition that it was small-pox. The absence of the premonitory symptoms of small-pox, its slow development and course, and other evidences of syphilis are the principal points to consider.

The above review of a few of the early forms of syphilides will serve to illustrate their protean character even in the primary period. Within the scope of a single paper the many manifestations in the secondary and tertiary stages, as well as the congenital forms, cannot even be mentioned. The difficulties of diagnosis are manifold and tax the discriminating power of the physician in many cases, coming, as such cases do, sometimes from sources unsuspected and in which the benefit of every doubt must be given the patient. Then it is that the protean character of these manifestations is fully appreciated.

A couple of cases from my private practice will serve to illustrate the heavy responsibility attending a diagnosis in some instances.

Mr. A., a young man high in business and social circles, came under my observation some weeks after having what he called an insignificant abrasion on the glans penis, but about which some doubt arose as to its character. Symptoms indicative of syphilis had also been very slight and would not have been considered only on account of the suspicion. A few mucous patches and a slight sore throat had entirely disappeared. Upon examination the only lesions found were two small papules in the palm of his left hand. The history and these two papules were the basis upon which a diagnosis was founded, which was confirmed

by Dr. Geo. Henry Fox, of New York. Six weeks after I saw him small nodes developed on the olecranon process, internal tuberosity of the tibia and on the great trochanter of the femur. The above conditions yielded to Kali iodide, and he is still taking the drug. The father of the young man, who had been taken into his confidence, came to my residence one morning much distressed and said he thought the family in great trouble, as his wife had an eruption like. that which appeared in the palms of the son's hands. He wished me to go immediately to see her and tell him the exact truth in regard to it, and above all things, not to let the son know if it proved to be specific.

1

From the reputation of the lady there seemed to be no source of contagion other than from her son through the patches on his lips. Not suspecting, therefore, it possible that any specific disease existed I unthinkingly went to see the patient. To my astonishment I found mucous patches in the buccal cavity and on the lips also, a mixed eruption of the macular and papular varieties, located in the palms of the hands, forehead and inner side of the thighs. The palmar eruption was the most suspicious, because of the location and the scaly character.

An immediate answer being demanded, I explained the striking resemblance syphilis had to other eruptions, therefore could not positively determine until after a little time had elapsed. I ventured to treat the case as specific and in consequence of which the eruption soon disappeared, at least so I thought, yet by the natural course of syphilis the skin manifestations might have disappeared without medication. The sore

throat still continued and has been observed by specialists, who have referred

the case back to me for an opinion as to whether specific or not, as they were undecided as to whether it would be benefited by local treatment. All seemed indisposed to be positive in their diag nosis owing, no doubt, to the masked appearance, as well as the character and environments of the patient.

The above cases illustrate not only the protean character, but also the difficulties of diagnosis, as well as the embarrassment to the physician.

Treatment. For many years the large experience of the profession in the medication of syphilis has proven the undoubted efficacy of Mercury and Potas. Iod. in its treatment, and much depends upon the mode of administration as well as the proper time and indications for their use. The general rule observed is to use Mercury in the primary stages and Potas. Iod. in the second, or more especially, when the disease affects the tissues, namely, glands, bones, etc., and in congenital syphilis.

I am convinced that many times the disease is aggravated by giving Mercury in the early stages and in too large quantities, and that better results are obtained in many cases if the administration of the drug is postponed until the initial lesions have disappeared. When the mucous membrane lesions are inclined to slough and more or less saneous discharge is present, Mercury aggravates, and Nitric Acid will serve the case much better, also when the throat is sensitive to hot drinks and has an angry, red look.

There comes a time, often, when the disease seems to stop progress towards recovery, then a new start is made by giving Kali iod. alone or in combination with Mercury. When the deeper structures of the body are involved, as the bones, glands, etc., no remedies have

Hg. Ammonii Tinct. Sulph.

grs. XV-XX grs. XI Adapis Bor qs. to make thick cream. M. Sig. Apply at night and wear kid. gloves.

When the patient is so situated as to make it possible to give Mercury by inunction I have found results are reached sooner than in almost any other mode of administration. The usual method is to use a piece of Ung. hydrarg. about as large as a hazelnut thoroughly rubbed in daily where the skin is thin, such as the inside of the thighs, the arms, the flanks, etc., changing the site of inunction often so as to avoid local irritation. Frequent baths are necessary in order to fit the skin for absorption. One great advantage is that damage to the digestive organs is avoided.

After long treatments patients often become anæmic and need building up. The best preparation I have ever used is Pepto-Mangan (Gude), and no substitute should be accepted, as there are many preparations manufactured for which are claimed equal value, but after long. use I am convinced are not so efficacious

DIPHTHERIA AND ITS TREATMENTWITH SOME CASES.

By G. J. Damon, M. D., Medina, Ohio.

The diagnosis of diphtheria is not al

ways easy. It is more apt to be confounded with follicular tonsillitis than any other disease.

The membrane is at first a thin, white pellicle on fauces and tonsils; increasing rapidly in thickness and spreading very fast in area. It adheres firmly to underlying structures, and forcible removal causes bleeding.

In follicular tonsillitis the membrane is not so thick, does not adhere so firmly, and can be separated from tonsils without bleeding. The cases about half way between and presenting some features of each, are those which give us the most trouble in making a diagnosis.

Other diagnostic symptoms are, enlarged glands of neck, and the patellar tendon reflex is lost early in the disease. The temperature is not a reliable guide, as we sometimes get very little fever till septic conditions set in.

Treatment: Antitoxine 500 to 4000 units, according to age of patient and severity of attack, repeated in 12 to 24 hours if necessary. If given early it nearly always cures; and improvement. begins within a few hours.

Patients who have refused to take the treatment for a day or two after calling the physician, and where the disease was progressing rapidly in spite of remedies, have shown immediate improvement on taking the antitoxine. Before using, cleanse parts thoroughly with soap and water, then wash with alcohol or some other, antiseptic.

The antitoxine now sent out has a separate syringe for each patient, a saving in time in making instruments sterile. The latest is a glass syringe put up by the Mulford Co., perfectly sterile and easier to use than the rubber bulbs.

The remedies most generally indicated are Mercurious Cyan. 6x for malignant type.

Iodide of Mercury 3x for those having a great deal of glandular enlargement.

Kali Bich. 2x in laryngeal form, and Arum Triph. 3x in nasal form, with corroding discharge, excoriating lips. But none of the remedies take the place of antitoxine.

Keep the patient well nourished with milk, malted milk, and egg beaten up in milk, with a small quantity of whiskey added.

If patient is a child, hire him to take nourishment if necessary, but if he refuses to take the egg, whiskey and milk mixed, just alternate a little whiskey sling with milk, which proved to be a success in my own child's case; but be sure to have him nourished with liquid food by some means.

Local applications are dilute alcohol, perman. of potash, and crude sulphur.

Keep patient quiet on account of heart failure, and if necessary give whiskey or strychnine if heart shows symptoms of failing.

The physician should disinfect hands, face, and hair with a 10 per cent. solution of Formaldehyde, i. e., 1 part Formaldehyde to 3 parts water; change clothing, i. e., outside clothing, or spray with 20 per cent. Formaldehyde solution on leaving sick room.

When pa

tient recovers, if living outside of large cities where sanitary work is not good, have health officer use 10 oz. of Formaldehyde for each 1,000 cubic feet of air space in sick rooms, or in whole house, if necessary, and use in a large generator, leaving rooms or house shut up for six hours afterwards.

It is well to insist on this, as the ordinary health officer does not know how to disinfect with anything but sulphur, and the Formaldehyde is so much more effective.

Following are some cases treated by myself since May, 1903.

Case 1. Baby S., six months old, diphtheria three days, laryngeal form. Getting croupy, and hard to breathe. Used 1500 units of antitoxine at 4 P. M. Next morning breathing much easier, and made a rapid recovery after this.

Case 2. Virgil D., age 8 years. Mild sore throat, with a little membrane for a week. Began to get hoarse, and membrane appeared in nose. Called Dr. Quay, who prescribed antitoxine 2000 units that night. Next day slightly better, gave 2000 units more. In one week membrane had left throat and nose, although the nose-bleed continued for a few days more. The two points in this case were first, that statistics show that before antitoxine was known 95 per cent. of cases of nasal diphtheria died. while this case recovered although antitoxine was not used till the disease had been in throat for nearly a week; when after using it he made a rapid recovery. The second point is the folly of a physician attempting to treat his own family for any serious illness without counsel. If this case had been in any other family than my own, should have used antitoxine at once. But with my own child was afraid there might be some bad effects from the antitoxine, so postponed doing what should have been done several days sooner. Many thanks to Dr. Quay for using it when I did.

Eulaila D., age 10 years, my daughter, who contracted the diphtheria from her brother. Used antitoxine a few hours after discovering the membrane in her throat; it was on both tonsils and on the pharynx. In four days after using antitoxine the membrane had entirely disappeared.

Case 4. Baby H., age 2 years. Had diphtheria one week when I was called.

Nasal form, glands of neck badly swollen. Used antitoxine 1500 units, but patient died in three days after first call.

Case 5. Homer B., age 8 years. Diphtheria five days before being called. Used 2000 units antitoxine. Membrane had disappeared in four days after using.

Case 6. Mrs. B., age 40 years. Severe attack of diphtheria. Saw the case

about fifth day, advised antitoxine, but she was afraid of it. Next day much worse and consented to have it used. Gave 2000 units and she has improved steadily since, although she had a sharp attack of asthma, which hindered her progress to some extent.

Three other cases which I am now treating where I used antitoxine about second day of disease are improving rapidly.

ONE TREATMENT FOR GASTRIC ULCER. Dr. Walho advises the internal use of olive oil in peptic ulcer. In the acute form of the disease he would begin with a teaspoonful and gradually increase the dose until an ounce and a half, or even more, are taken three times a day. The mouth may then be rinsed out with any mouth wash. If the olive oil be repugnant one may give 100-200 c.cms. through a stomach tube. This treatment is continued as long as the most severe symptoms persist-three to five days when no other food is administered. Then other foods are given simultaneously for fourteen days. It may also be tried in the chronic variety of the disease. Hospitalstidende, No. 29, 1903. -Pritchard, in Hah. Monthly.

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PISCIDIA IN WHOOPING-COUGH. Dr. Frank V. Horne, of Detroit, reports unusual success with this remedy in the treatment of pertussis. He prescribes from five drops to one drachm of the fluid extract, at intervals of from three to five hours. He has the records of seventeen children and five adults treated with this remedy. The adult cases had reached the stage of distinct

whooping and had very severe paroxysms of coughing. Nevertheless, this remedy quickly stopped the whooping and terminated the cases within a fortnight. night. If administered early in the course of the disease, the doctor believes the spasmodic features and the whooping may be held in abeyance or altogether prevented in the majority of instances. The average dosage in children varied from five to eight drops.-Hah. Monthly.

WHAT HAS BECOME OF THE LOCKJAW BACILLUS?

"The common opinion is that tetany is a functional disease, but the author's clinical observations convince him that it is a disease due to lesions of the roots of the nerves that control the muscles concerned. All the symptoms may be explained by such lesions. The lower cervical and the upper lumbar roots are those most frequently affected, but there are exceptions to this rule. The probable seat of the lesion is in the points of exit from the spinal canal, where the nerve roots are united into distinct functional units."-New York Medical Journal.