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The osseous changes common to hereditary syphilis are most frequently manifested in the form of a diaphyso-epiphyseal lesion, that is, an osteochondritis of the femur, humerus, tibia, radius or ulna. This manifestation, when associated with other signs of congenital lues admits, as a rule, of a ready diagnosis, but when present as an initial symptom, so to say, it renders a diagnosis not only very difficult, but at times impossible, for some period. The following is a case in point:

Case.-Helen Z., aged three weeks, bottle-fed since birth, was brought to my dispensary service at Lebanon Hospital on December 1, 1904, with a history that for the past four days the child does not seem able to move its left arm. The child was apparently well until four days ago, when some friends who were visiting the house played with it and pulled the arm, as the guardian thought. The patient was the first-born. The labor was normal and in-so-far as the guardian knew, the parents were healthy. At the first visit both my associate and myself paid particular attention to the examination of the left upper extremity, examining carefully the clavicle, shoulder, elbow, wrist and hand; we found no subluxation, no fracture, no dislocation, no swelling of any kind. There was, however, a drop-wrist with its characteristic deformity and disability. Tickling of the palm caused slight movement of the fingers. No callus pressing on the musculospinal nerve could be detected, nor was there pain on pressure over any of the joints. In addition to the drop-wrist there was a slight inward rotation of the arm suggesting the upper arm type

1905.

1

Presented at the Pediatric Section, Academy of Medicine, Feb. 16,

of birth paralysis, but the fact that the condition had appeared during the third week of life, and that there was no atrophy, ruled out Erb's paralysis.

A physical examination of the patient at this time was absolutely negative, not even a palpable liver or spleen. A tentative diagnosis of traumatic neuritis was then made, and gentle massage with cocoa butter and rest were ordered. The guardian returned on two subsequent visits, two or three days apart, to report some improvement; on both of the latter visits, examination of the extremity and especially of the wrist-joint revealed nothing except some slight pain. On passive movement. All other joints were free and painless and the gums were normal. There were no evidences of rickets. On December 10 there was detected a distinct crepitation of the lower end of the radius and ulna, at the junction of the epiphysis and diaphysis-an epiphyseal separation; the case was then transferred to the surgical service. One week later the face was partially covered with a papulopustular eruption, with adherent crusts here and there, especially around the mouth; the crusts resembled those of impetigo contagiosa but were easily differentiated by their sitution upon a copper-hued base; the body showed a maculopapular ham-colored eruption and the skin of the soles and palms was desquamating and thickened; there were decided coryza, snuffles, mouth breathing, fissured lips, in a word, the clinical picture of congenital lues. The spleen and liver at this time were distinctly palpable. Then the diagnosis of the original condition became clear of course and the cause for the pseudoparalysis became very evident. Subsequently distinct anal condylomata made their appearance. The forearm was immobilized with lateral splints by Dr. Reiss, the surgeon in charge, and the lues was treated in the dermatological service of Dr. Gottheil, by the administration of calomel gr. 1/20 to 1/10 three times daily and by the twice daily application to the umbilical region of a pea-sized piece of white precipate ointment covered with a flannel abdominal band.

In three and a half weeks no false point of motion or crepitation was detected and in four and a half weeks the surgical aspect of the case was closed. Under the aforementioned anti-specific treatment rapid improvement was made.

It seems to me that the sequence of events in this case-pseudoparalysis (epiphysitis), epiphyseal separation, and lastly the

A CASE OF SYPHILITIC PSEUDOPARALYSIS

403

cutaneous outbreak, is interesting and instructive and warns us to be on our guard in diagnosticating mono-articular involvements in young children. When brought face to face with a similar case in the future, after excluding trauma, fracture, sepsis, perhaps infantile scurvy, it may be well to turn our thoughts to the possibility of osteochondritis epiphysaria luetica neonatorum.

WITH A PLEA FOR RATIONAL DOSAGE IN TREATMENT AND IN IMMUNIZING

BY B. FRANKLIN ROYER, M.D.

OF PHILADELPHIA.

CHIEF RESIDENT PHYSICIAN, MUNICIPAL HOSPITAL, PHILADELPHIA

(Continued from June No., page 358)

All the preceding tables seem to show that antitoxin has reduced the mortality very greatly in all hospitals.

Let us now take up the question of dosage.

From a paper recently read by Dr. Louis Fisher, of New York City (some of you will remember that Dr. Fisher was the first man in the United States to publish a clinical report of the use of antitoxin), I find that the dose he teaches the house officers of the Willard Parker Hospital is very much like that dose in use at the present time in our Municipal Hospital. He feels as we feel, that the proper dose of antitoxin must be somewhat empirical, that it must not be less than will "limit the pseudomembrane, subdue the fever, and check the progress of the disease."

In an abstract from this paper, read before the New York Academy of Medicine, November 10, 1904, published in Archives of Pediatrics for December, 1904, I culled the following mortality statistics from the Willard Parker Hospital:

RÉSUMÉ OF CASES REPORTED FROM THE WILLARD PARKER HOSPITAL DURING JULY, AUGUST AND SEPTEMBER, 1903.

RÉSUMÉ OF CASES REPORTED FROM THE WILLARD PARKER HOSPITAL DURING JULY, AUGUST, SEPTEMBER AND OCTOBER, 1904.

"The average dose of antitoxin administered during 1903 was for July 1,500, for August 1,700, and for September 2,500 units; the average dose of antitoxin administered during 1904 was for July 2,500, for August, 5,000, and for September, between 5,000 and 10,000 units. As a result, it has shown about 21 per cent. mortality where the dose was small, against a mortality of 14 per cent. where the larger doses were used."