ence or attack of low forms of microzoic life. An interesting pamphlet relating to the treatment of diseases of this character may be had upon application to the manufacturers of listerine: Lambert Pharmacal Company, Saint Louis, Mo.

History of Coca," page 224). Thus the combination of wine with coca, such as in the well-known vin Mariani, is not only purely scientific, but a commendable preparation that presents an agreeable means of exhibiting the positive merits of properlypreserved coca.

WHY COCA IS A PANACEA. How many of our readers appreciate the true value of coca as an all-around remedy? Not cocoa, from which chocolate is made, but coca, from which that potent substance, cocaine, is produced. It requires one ounce of coca-leaves to make one grain of pure cocaine, and that alkaloid is but one of many contained in these marvelous leaves. It is because of the modified action of all the constituents that the whole drug is possessed of different therapeutic properties, and is specifically greater than any one of its parts. Coca is a nervous stimulant, acting primarily on the cerebral cells, but in this action having an elective affinity for the respiratory center and a chemico-physiological depurative influence on the blood. It is from this latter cause that coca has such a wide-spread usefulness, which seemingly classes it as a panacea for all ills. With a purified blood-stream, the organs of assimilation and the muscular and nervous systems are not only repaired, but maintained in equilibrium.

Unlike any other nervous stimulant, coca is not followed by depression, though in full doses a brief period of depression may precede its physiological action. This indicates the employment with coca of a diffusible stimulant which after an evanescent period speedily gives place to the influence of the drug. The difference between the action of alcohol and coca is well illustrated in the anecdote of the Andean Indian, who, given a first taste of whisky and asked his idea of its effects compared with coca, replied: "Coca helps a man to live, but whisky makes him row a boat" (Mortimer's "Peru:

DYSENTERY AND FLATULENCE.

The griping pain and flatulence which accompany bowel and stomach complaints, particularly during the heated term, are so readily overcome and controlled by the timely administration of 1 or 2 antikamniaand-salol tablets, repeated every two or three hours, that it behooves us to call our readers' attention to the grand efficacy of this well-known remedy in these conditions. The above doses are, of course, those for adults. Children should be given / tablet for each five years of their age. When the attack is very severe, or when the disturbance is evidenced at or near the time of the menstrual period, we find it preferable to give 2 antikamnia-and-codeine tablets, alternately with the antikamnia-and-salol tablets. The latter tablets promptly arrest excessive fermentation, and have a pronounced sedative effect on the mucous membranes of the bowels and stomach, and will check the various diarrhoeas without any untoward effect.

SANMETTO IN URINARY TROUBLES IN OLD MEN AND CHILDREN.

So far as my experience has been with sanmetto in urinary troubles it is one of the very best remedies we have at present. I recommend sanmetto in urinary troubles in old men, and also for children when subjects of that troublesome complaint, wetting the bed. I have practiced medicine over forty-five years.-A. D. H. Kemper, M.D., Sedgwick, Kansas.

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Clinical Lecture.

LUPUS VULGARIS AND LUPUS
ERYTHEMATOSUS.1

BY JOHN V. SHOEMAKER, M.D., LL.D.,

Professer of Skin and Venereal Diseases in the Medico-Chirurgical College and Hospital of Philadelphia.

CASE I. LUPUS VULGARIS. GENTLEMEN: The woman whom we have before us is 45 years of age. She comes to this clinic on account of an eruption which has been in existence upon her face for eight years. She states that the disease made its first appearance soon after an attack of erysipelas. The lesions consist of tubercles and are situated at the tip of the nose and near the canthus of the left eye. Between the tubercles are some injected capillary vessels and the orifices of the sebaceous ducts are open. Otherwise the adjacent surface is perfectly healthy, and there is no other disease upon the body. The tubercles are massed rather closely together in a circular arrangement, and are of a reddish hue. During its prolonged presence the malady has given rise to but little itching or pain. The individual tubercles are of moderate consistence.

When confronted with a disease of the skin our first object is to make a diagnosis. We must determine the nature of the affection before we can enter upon our treatment

No. 8.

with any hope of producing a cure. We have already learned three facts which will assist us in our quest. The disease is exceedingly chronic; the predominant lesions are tubercular and are not of inflammatory foundation. They must, consequently, be of neoplastic origin, and we must seek for the disease among the neoplasms of the integument. When we have established this much we have excluded syphilis. No man ever saw a case of syphilis with lesions always of the same type, persisting and recurring for eight years. There is, indeed, a tubercular syphilide, but it is of rapid development, has been preceded or is accompanied by other forms of eruption, and is not confined exclusively to the face for such a long period with so little change. We should find the tell-tale scars of syphilis in other regions. The tubercles of the present case are softer than those of syphilis, they are of another shade and not suggestive of copper or lean ham. They are flatter than those of syphilis, and upon a close examination some thin scales are seen upon their surface. The tubercles of syphilis are larger and harder than those now beneath my eye.

Syphilis being excluded, it is proper to ask if we are dealing with a case of epithelioma. The age of the patient, although not a positive prohibition against such an opinion, is, nevertheless, presumptive evidence against its truth. The woman was only 37 years of age when this disease began, and, although epithelioma may occasionally

commence at that age, or even earlier, yet such instances are rare and exceptional. Hardness is a characteristic feature of cancer. The neoplasm itself is hard and dense, and after the occurrence of ulceration the base preserves the same typical hardness. The lesions of the case before us are soft. Pain is a prominent element of an epitheliomatous growth, but this case is distinguished by the absence of pain. Finally, an epithelioma usually progresses more rapidly than the case now in the arena.

By such a process, excluding both malignant and specific disease, we are led to conclude that the case before us corresponds in its lesions and course to lupus vulgaris, which is a new-cell growth of the skin marked by reddish or brownish papules, tubercles, and infiltrations, which may be removed by absorption or may proceed to ulceration.

The first objective sign of lupus vulgaris occurs as spots from the size of a pin's head to that of a pea or bean. These, in the course of some months, become evident to touch and sight as papules and tubercles. Not infrequently the lesions coalesce into flat or raised infiltrated masses of a rounded outline. Eventually, the papules, tubercles, or infiltrations either undergo absorption or pass on to ulceration. In the former case the affected areas are the seat of some desquamation and atrophy. The ulcers of this variety of lupus are round or irregular in contour, their margins being well marked, but soft. There may be a moderate purulent exudation, which dries into crusts upon the surface of the ulcer. The granulations are red and easily bleed. Very commonly different stages of the disease coexist. At different points we may detect papules, tubercles, ulcers, and cicatrices. The affection may involve any part of the body, but usually prefers the face. Mucous membranes may also be invaded, generally as an extension from the skin, but sometimes they are primarily attacked.

The lesions consist pathologically of an infiltration of small cells which, when not

absorbed, undergo retrograde metamorphosis. The disease begins most frequently in childhood, although we meet in this clinic-and the present case is an example -with individuals who have not been afflicted until adult life. It occurs about equally in both sexes, and is much more common in continental Europe than in the United States.

In the treatment of lupus vulgaris it is necessary to employ both constitutional and local measures. Every case must be managed in accordance with the principles of general medicine and the condition of the patient. The sufferer should be placed under the best hygienic influences possible. The diet should be carefully arranged in order to promote the processes of nutrition, which are often defective. If anæmia or evidences of scrofula are present, appropriate remedies should be ordered. We should seek to restore the appetite if that is impaired, and should keep the bowels in proper activity. In a large proportion of cases benefit is derived from the administration of an alterative: i.e., a remedy which has the power, when given in small doses for a continued period, of improving the quality of the blood, increasing the number of its red corpuscles, and promoting the general vigor of the body. Among agents of this class which are serviceable in lupus are arsenic, iodine, potassium chlorate, and codliver-oil. The preparations of iron are frequently excellent synergists. Creosote is of value in tuberculous subjects and phosphorus when the nervous system is disturbed. A host of other drugs have been proposed and have been employed in this disease, but those which I have mentioned are among the most reliable. Similarly, of local remedies and procedures I may say that their name is legion. External means alone will not cure, or, at least, the case will not stay cured.

Local treatment varies according to the stage of the disease. Our objects, briefly stated, are to promote absorption, prevent ulceration, and encourage cicatrization. In

the early stage depletion by means of a needle knife is of service. After the parts have bled freely they are dressed with a mild mercurial ointment. Subsequent to ulceration we may apply ointments containing 10 per cent. of aristol, or europhen, carbolic acid, salicylic acid, or other stimulating substances may be applied. The balsam of Peru, either in full strength or made into an ointment, has likewise been recommended. In obstinate cases the most satisfactory results are achieved by more radical and heroic measures, such as erasion or cauterization. For these purposes we have our choice of a number of substances, among which are sodium ethylate, caustic potash, arsenic, zinc chloride, etc. The actual cautery and the galvanocautery have likewise been used with beneficial effect. Finally, the raw surface may be curetted or it may be removed en masse by the knife. Among more recent methods of stimulating the affected parts and securing repair are exposure to the x-rays and Finsen's phototherapy. Whatever the plan of topical treatment adopted and at whatever stage of the malady, the systemic remedies to which I have alluded must be conjoined. In applying to the case now before us the principles which I have thus outlined I shall order internally a combination of codliveroil and arsenic, as follows:

Liquoris acidi arsenici, mx.
Olei morrhuæ, 3ij.

M. For one dose. Three doses to be taken daily.

This is a nutritive and alterative combination which will improve the activity of the glands of the mucous membrane, enrich the blood, and increase the nutrition of the integument.

Locally the seat of disease shall be touched twice weekly by pure and undiluted carbolic acid.

CASE II. LUPUS ERYTHEMATOSUS. I have next, by a fortunate coincidence, a patient whom it is of rather unusual in

terest to be able to present for purposes of comparison and in order to illustrate a differential diagnosis. A young woman, 25 years of age, is afflicted with a circumscribed erythematous patch upon the left side of the nose and similar, smaller patches below the lower eyelid of the same side and upon the forehead. These all exhibit the same appearance, and are undoubtedly of the same character. The disease has been in existence for more than year. It first came upon the nose. The patch below the eyelid extends horizontally, parallel with the margin of the lid, and is about half an inch in width. Upon the surface of the chief patch can be seen the patulous orifices of the hair-follicles and sebaceous ducts, the latter being distended and plugged with sebaceous matter. Thin, yellowish scales are also present.

This is another exceedingly chronic and inveterate case, and the question naturally arises: Have we here another case of lupus vulgaris? This query, however, must be answered in the negative for several reasons. It is not characterized by the papules, tubercles, and nodules to which I called your attention in the preceding case. When I look narrowly at the seat of disease I find that, although the margin of the patch is raised above the general level, yet the center is depressed and evidently atrophied. The process is more superficial than in lupus vulgaris and there are no cicatrices such as are observed in the latter disease. Syphilis can be excluded from consideration for the same reasons given when discussing the first case and which, consequently, need not be repeated. Eczema may, indeed, be stubborn, but we do not have here the papules, vesicles, crusts, and scales of eczema, and, again, we miss the atrocious itching which accompanies eczema. In the elevated border, the pale center, and the thin scales. we witness some points of resemblance to tinea trichophytina, or ringworm, but, on the contrary, papules and vesicles attend the progress of ringworm, and the crucial test is a failure, for the trichophyton fungus