never had syphilis at all. Let me impress upon you to diagnose your skin cases and then get your clinical history for verification.

We are told by the text books that the place of first appearance of psoriasis is the elbow or the knee. I may say to you that in over thirty cases in the Cook County Hospital, only eight cases could show lesions at these points. This will indicate that this predeliction for these locations is hardly to be relied upon. A second diagnostic point, given much weight in the text books, is the bleeding point left by the forceful removal of the scales. This is hardly reliable, for if the patient has been treated with arsenic the characteristic scales may be removed with no bleeding point remaining.

We have stated that psoroasis may at times be confused with syphilis, and it may be added that pityriasis rubra might also be considered, were it not for the characteristic white scales of psoriasis. Psoriasis shows none of the moisture characteristic of eczema.

Treatment of Psoriasis.-The treatment of this condition includes practically the entire pharmacopeia, and I shall not attempt to review the subject at this time. The condition is one of psoriasis universalis, and the treatment that I shall give you is the treatment not for that condition, but for this individual case of that condition. You will use three preparations: (1) An ointment of chrysarobin, made by the mixture of a drachm of chrysarobin to one ounce of vaseline. (2) An ointment of the white precipitate of mercury made by the mixture of twenty grains of the white precipitate with an ounce of vaseline. (3) Fowler's solution.

As to the administration or the use of the preparations, let me say that the chrysarobin ointment must never be used on the face or the scalp, as on the former it will produce a dermititis very similar to erysipelas, while on the latter it will turn the hair a veritable "red, white and blue." On the body it will be used in small areas only, as some patients are very susceptible to its influence, and it is better, if an irritating dermititis is to be set up, to have it show on a limited area rather than over the body. In the latter case it may result in an almost intolerable state of suffering for the patient. It will also be impressed upon the patient that any garments with which chrysarobin comes in contact will be colored and stained with an absolutely indelible purple color. Have the patient get a cheap suit of underwear that may be thrown away after using. To be sure, chrysarobin may be used without this staining, but to do this we will have to employ a mixture of one drachm of chrysarobin to an ounce of alcohol, to be painted on the individual lesions with a

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camel's hair brush and then covered with flexible collodion. It is obvious that in a general case like this such a procedure would be impracticable.

The ointment of the white precipitate is best used on the scalp and face, where it acts quite effectively. It may be stated that, since the white precipitate seemed to have a curative effect, and since the French found the iodide of potash beneficial, psoriasis was long regarded as a syphilitic condition. Others have regarded it in times past, as leprosy.

As to the administration of the Fowler's solution, let me say

ABDOMEN OF PATIENT SHOWING PSORIASIS.

Pen and ink drawing. By Geo. Thos. Palmer.

that the dose should begin with five drops after meals, increasing until the full physiological effect (puffiness under the eyes, headache and pain in the eyes) is reached, and then, instead of becoming panicstricken and stopping it (thereby losing the benefits you have already obtained) reduce the administration in about the same ratio as you have increased it, always, however, having your patient under your close observation, as every careful physician will do when administering arsenic. The degree of reduction may be lessened and the

tolerance may be increased by advising the ingestion of large amounts of water and the administration of a saline laxative water, like the Pluto water of French Lick Springs.

The method I have adopted of increasing the doses of Fowler's solution is indicated in the following table:

It is quite essential in this condition that the patient and the physician fully understand each other, and I would urge that the doctor impress upon the patient that, (1) he has psoriasis; (2) that it is no way related to syphilis; (3) that the doctor can not assure a cure, and that while at times of the year the body will be free from lesions, there will be times when the lesions will appear; (4) that a lesion as small as a pinhead is as important as one the size of the hand, as the lesions grow rapidly unless treated; (5) that two-thirds of the results depend upon the patient himself; (6) that bathing is as important as any medication and that he should take two or three hot baths a week.

As to these baths, great benefit is to be obtained by adding to each bath about a pound of common washing soda.

As to diet, I am compelled to differ from the recognized authorities. If the patient is drinking to excess I urge him to reduce the amount, or if he be an excessive tobacco user, I urge moderation, but as to curtailing meats, or sea foods, or shell fish, or oat meal or what not, I have never been able to see the value of the procedure. One writer has gone so far as to hold that oat meal will produce psoriasis, but when we consider that the disease is most common in Germany, where oat meal is almost unknown, we must feel that the assertion is hardly well founded. We must urge, however, that the patient exercise ordinary sense concerning his diet, as we would any man not similarly affected but not in the most robust condition of health.

I would say further as to the administration of Fowler's solution, that if you find the patient has been taking it previous to his coming under your care, and has about lost faith in it, it is well to give him arsenious acid, arsenate of soda, or even iodide of potassium for a

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time. After he has gotten so that he can take nine drops of Fowler's solution three times a day, you will find the so-called "Asiatic pill," composed of arsenious acid, black pepper and powdered licorice, most excellent, and this may be taken indefinitely. This pill is put up by Fraser, and is also supplied by Parke, Davis & Co.

I will merely add, in conclusion, that psoriasis often comes on after a sudden shock, although this is not found to be the case here. It is also often a family trait, passing from generation to generation, and at times skipping a generation. In this case neither the father nor the mother had the disease.

SYPHILITIC EXOSTOSIS OF THE SHIN.

This case I am especially glad to show you, as it will doubtless prevent your making a common error in diagnosis and treatment. You will find on the anterior surface of the tibia a swelling which is about the size of a section of a hen's egg, and which is to be seen even by those in the rear of the room. The swelling is apparently of bone, being hard and resistant, and it is also painful and tender to the touch, though not nearly so tender as when the case came to us some days ago. There is an area of inflammation about this swelling and the whole picture is one which might lead to a diagnosis (and often does) of tuberculous periostitis. However, this woman came to us some days ago and was given a vigorous anti-syphilitic treatment at once, six tablets of iodo-nuclein being given each day. In these few days the swelling has been reduced fifty per cent, and I can assure you that at the end of ten days no one will be able to discover where the lump has been. It is a syphilitic periostitis and one of those cases which have at times been operated upon as tuberculous, in which bone chips have been used, and in which the result has been a failure.

Never operate a case of this kind under the impression that it is tuberculous without first putting your patient on an anti-syphilitic treatment for ten days to prove your diagnosis. Make the test treatment vigorous, with iodides, hypodermic injections of bichloride of mercury and mercurial plasters. It will prevent unfortunate mistakes.

HEREDITARY SYPHILIS.

This infant, gentlemen, came to us two weeks ago covered with scabs and crusts and in a most pitiable condition. Tonight you will all notice, if the room is quiet, the peculiar breathing known as "snuffles," and characteristic of hereditary syphilis. This is characteristic, but by no means pathognomonic. It will not do for you to diagnose

every case of snuffling infant as hereditary syphilis.

It is simply, in this case, as in the non-syphilitic cases, that breathing is impeded by a tenacious mucous exudate due to a catarrhal or inflammatory condition.

In this case, after the two weeks' treatment, the child is almost well, and the "snuffles" may be easily stopped this evening with a simple alkaline antiseptic such as a solution of glyco-thymoline.

Some writers are inclined to question cases of hereditary syphilis unless they have watched the child from birth and are acquainted with the parents. In this case I have been able to watch the child since birth, and I am certain that the father has syphilis. I am not so certain as to the mother. The child is only fairly nourished, and is in need of maternal feeding, and on this point arises a very grave question. If the mother is not syphilitic she will doubtless acquire syphilis from the child, but without maternal nursing, which might prevent this condition, the chances of the child are greatly diminished. It is a matter for the mother to decide, and in this case the mother insists upon nursing the baby. A wet nurse is obviously out of the question.

The prognosis in this case is excellent. The child will in all probability grow up perfectly healthy, for the case has been seen and treated early. She will never, in all probability, have syphilis again.

Some writers suggest in the treatment of these cases small doses of the protiodid of mercury, calomel or the vapors of mercury, but, since the internal use of mercury almost invariably disturbs the digestive organs of adults, and since the disturbance of the digestion of the infant is very serious, we have regarded the use of inunctions of mercurial ointment far the best procedure. The results have been most gratifying.

As to the chances for the children of syphilitic parents, I may be permitted to say that of forty-four children, of whose parents at least one has been syphilitic, and at times both, all are in the best of physical condition at the present time. The early recognition and early treatment of hereditary syphilis makes it a comparatively simple proposition.

Within the last few weeks the University of Chicago has expended upwards of a million dollars in the purchase of land on the south side of the Midway, on which to erect the hospitals and buildings necessary for the medical department of the University (formerly Rush Medical College).