colored material, about the color of maple sugar in the cake, and the size of a hemp seed. The color of the lesion does not fade upon pressure, but really stands out more distinctly upon increased pressure. When this material is examined microscopically, it is found to be a collection of many plasma cells, fewer epithelioid cells, and few giant cells containing one or more bacilli. From the point of inoculation the bacilli advance into healthy tissue, and cause the development of fresh "apple jelly " nodules, which are usually more thickly set along the advancing line of the affected area. They may be discrete, or may coalesce and form irregular areas. A few scattered nodules are usually found on the older affected part. The nodules are softer than the surrounding healthy tissue, and this can be demonstrated by palpating the nodules and the healthy skin with the rounded end of a small probe. As the disease spreads, the affected area becomes hyperemic, the epidermis continues intact, and the surface remains smooth, and in a cleanly patient will continue this way for a year or longer, constituting lupus simplex. If the skin becomes infected with pus cocci, an ulcerative type - lupus exulcerans — is developed. The grade of inflammation is more intense, and the diagnosis is made more difficult on account of the pus, crusts, and intense redness. This type resembles syphilis more than the other types. do. The surface may not ulcerate at any time, but an abundance of fibrous tissue may be developed, and scars may be formed without an open wound. This is the fibroid type, and corresponds to fibroid tuberculosis in the lungs. Lupus is usually met with in one of the three types here mentioned, simple, ulcerative, or fibroid, but there are other rare clinical types named on account of a peculiar form of ulceration, hypertrophy, or swelling, or from the development of some other peculiar feature. The diagnosis of the simple type with the "apple jelly' nodules presents no difficulty. One would observe a red, smooth area, showing along the margin upon pressure with a glass slide the "apple jelly" nodules. The ulcerative type must be differentiated from syphilis, and the ulcerative type with hypertrophied edges can be differentiated from rodent ulcer. Some of the rare non-ulcerative types are differentiated from syphilis with great difficulty. In a case of difficult diagnosis the history will be very helpful Lupus more often begins in youth, while the other two rather belong to middle age and later. Lupus and rodent ulcer are slow in development; syphilis is rapid. A careful examination will usually reveal the "apple jelly" nodule in lupus. There is nothing positively characteristic in the appearance of a syphilitic ulcer, while rodent ulcer usually presents a pearly, rolled margin. The discharge from a syphilitic ulcer is usually more profuse and more purulent than that from the other two. Rodent ulcer usually occurs singly, the others may or may not be single. Lupus patients sometimes show a tuberculous nature, and syphilitics will more often present other signs of syphilis, while rodent ulcer will show none. There is one point in suspected lupus of the face which should not be overlooked, and that is the examination of the mucous membrane of the nose and gums. In Finsen's clinic, seventy-five per cent. show mucous membrane affection. The nodules on the mucous surface are slightly elevated, and give but little inconvenience to the patient. In the event there is much doubt as to the diagnosis, a thorough test with potassium iodide should be made, and in this country, where lupus is very rare, the physician is safer in treating the doubtful case as syphilis. Differentiation of lupus from rosacea, eczema, and blastomycosis is rarely necessary, and they will not be presented here. The treatment of lupus is chiefly local, and consists of curetting and scarification, the local application of caustics, and radiotherapy. Radio-therapy- that is, X-ray, Finsen light, and violet rays is at present considered the most acceptable method of treatment, and should always be used if the patient is in reach of it, so I shall not discuss treatment by curetting, etc. The X-rays and Finsen light are both satisfactory, but the ideal treatment, as stated last summer before the British Medical Association by Dr. Sequeira of the London Hospital, is the combined use of X-rays and Finsen light. He would use the X-rays to clear up a large surface of shallow nodules, and then apply the Finsen light on the remaining deeper nodules, as he believes the Finsen light is more penetrating than the X-rays, which, however, is a mooted question. Dr. Norman Walker states, in the 1905 edition of his text on dermatology, that the X-rays will accomplish in the treatment of lupus all that the Finsen light will accomplish. X-rays have been satisfactory in this country. Tonics should be used as needed, and cod-liver oil in some form is the best. The patient should have fresh air, sunlight, and hygienic surroundings. Scrofuloderma is not, strictly speaking, a disease of the skin, like lupus. It is an ulceration following the caseation and suppuration of a lymphatic gland or nodule located in the subcutaneous tissue, or may proceed from a bone lesion. It usually occurs in those individuals whose general make-up is tubercular. Their flesh is flabby, complexion pasty, resistance low, fingers probably clubbed, and manner dull and apathetic. In diagnosis one should remember the origin and the peculiar character of ulceration. The ulcer is usually not deep, with the edges thin, dull red, undermined, and irregularly outlined, with an uneven base covered with pale, sluggish granulations scantily bathed in pus. It increases in size very slowly, and sometimes remains nearly stationary two or three years. The syphilitic ulcer and epithelioma should be differentiated by the above signs in conjunction with the general tubercular tendency of the patient, which is usually more evident in scrofuloderma than in lupus. The treatment of scrofuloderma is general and local. Properly the best general treatment is cod-liver oil and iron iodide, with hygienic surroundings, fresh air, and sunlight. The best local measures in cases originating from the deeper glands are to enucleate the gland or thoroughly currette the cavity and cauterize with lactic acid, or treat with tincture iodine and keep dressed with an antiseptic wet dressing. Balsam of Peru and iodoform may be used from time to time as a local stimulant. The superficial ulcer should be well curetted, going a little beyond the margin, and should be followed with the application of pyrogallol ointment, one half to one dram to one ounce, for a few days, and then dress with mild ointment. Tuberculosis verrucosa should be discussed under two heads. as verruca necrogenica, or post-mortem wart, and tuberculosis verrucosa cutis. The former, as its name indicates, is caused by infection in post-mortem work on tuberculous cadavers, and on tuberculous meats, and is met with on the hands of pathologists, medical students, and butchers. The latter is more often a result of inoculation from other sources than those above named, such as auto-inoculation of a patient by wiping the mouth and mustache with the back of the hand. It is also found frequently among coal miners, and is there caused by the many abrasions on the hands becoming inoculated with the bacilli. Both lesions are met with most frequently on the hands, although they do occur in other places, as on the face and lower extremities, and practically they are one and the same with slight variation. The most striking feature of the lesion is its warty appearance, consequently it is chiefly epithelial growth. The surface is elevated and rough, the center higher than the sides, and varies in size from that of a dime to a half dollar. The lesion begins as a small red papule, and grows peripherally into the larger warty type. Sometimes pus may be pressed out from between the papillary projections, but there is but slight tendency to ulceration. Starting from the point of inoculation in the skin, the small lesion develops into one presenting this clinical picture when attention is called to it: on the back of the hand, probably about the knuckles, will be observed a warty elevation of slow growth, round or oval, with sloping edges, dark red color, infiltrated, and surrounded by a dark red border fading into the normal skin. Sometimes pus may be pressed out from the cracks of the lesion. There are no subjective symptoms. One case under my care presented three lesions, one on the outer aspect of the middle third of the left leg, one on the back of the left hand, and one on the left side of the face. All three lesions presented the typical clinical signs, the one on the face consisting of abundant and extremely prominent papillomatous vegetations, corresponding in that respect to a case reported by Morrow. When the lesions are well developed, the diagnosis is not difficult. Syphilis, other forms of tuberculosis cutis, and blastomycosis might have to be differentiated. When blastomycosis resembles it very closely and there are no other signs of tuberculosis, conclusive differentiation can be made only by a microscopic examination. Local treatment alone is needed. Curette the lesions with a sharp spoon, apply strong carbolic acid, and dress with a mild. ointment, is the best plan. Milder treatment can be successfully used by applying a salicylic acid plaster or paste to remove the horny covering, and then destroy the remaining part with acid nitrate of mercury, which should be applied to small areas at a time, as it is painful for some hours after application. Bibliography "Diseases of the Skin," by Stellwagon. Sequeira, of the London Hospital. - TREATMENT OF TAPEWORM.-The author slights the preliminary preparation of the patient, and uses a much smaller dose of the vermifuge than some consider necessary. He gives from 5 to 8 grams of extract of male fern in the morning, fasting. Six hours later not before he gives the purgative, preferring a "bitter water" for the purpose. Oil is liable to promote the absorption of the fern extract, and calomel is unreliable in these cases. Several instances are related to show the success of this simple technique after the failure of ten or more previous "tapeworm treatments." When the patient vomits easily, he pours the extract into the stomach in the form of a thin gum arabic emulsion. In one instance morphine was injected at the same time.-I. Boas, Therapeutische Monatshefte, vol xviii, No. 12; Journal of the American Medical Association, April 22, 1905. |