tribution of the eruption aids the diagno- LUPUS VULGARIS. The patient is a young man of 22, a cabinet-maker by trade, born in Pennsylvania, of foreign (English and Irish) parentage. There is no family history of disease, excepting that his mother's sister died of consumption. His own health has always been and continues to be, in general, good. of 1-2 millimetres, the surface irregular and higher about the border than in the centre. On closer inspection the lesion is seen to be made up of a number of papules and papulo-tubercles of various size, which have coalesced at their edges, and, to a considerable degree, merged into one another. These papules are of a dusky brownish-red color, scantily covered with minute grayish scales easily detached and showing when removed a dry surface beneath. In the centre of the lesion some of the diseased skin has been removed, in part probably by absorption, in part by the action of remedies, leaving small, irregularly radiating scars here and there. The surface in the centre of the patch is thus lower than that about the periphery; where, also, the disease process appears at present most active, giving a somewhat circinate effect to the lesion viewed as a whole. The second lesion, situated over the angle of the jaw on the left side, is oblong and rather squarish in outline; it is about three centimetres long by one centimetre wide, and is composed of papular lesions fused together. It is only slightly raised above the surface at any point, and in most parts is, in truth, sunken below it, owing to absorption of the new growth. In general color it resembles closely the lesion upon the right cheek. There is little or no itching or burning in the lesions, even when the patient becomes heated. Lupus vulgaris is a rare disease in our country, and does not often occur in this The eruption for which he seeks relief is composed of two patches of disease, sit-clinic. In the present instance the charuated on either side of the face. These were first noticed when the patient was not more than two years of age; at that time they were no larger than pea-size, but they gradually and steadily increased in area until in his tenth year, at which time he remembers first to have noticed them. The larger one was then the size of a cent (1.5 cm. in diameter). From that time the patches increased under the patient's observation until he was seventeen or eighteen years of age. Since then they have remained unchanged. The eruption has made no progress in the last five years. Examination shows two patches of disease unequal in size and shape. One of these is situated on the middle of the right cheek, of a roundish oval shape, about the size of a half-dollar, papular and tubercular in character, rising somewhat abruptly from the surrounding skin to the height acters of the disease are so well marked that they should be attentively noted, with a view to distinguishing this affection from the two others which most resemble it,— namely, epithelioma and the tubercular syphiloderm. The differential diagnosis between these diseases is sometimes a matter of no little difficulty, but there are certain characteristics of each which should be kept in mind. Thus, in epithelioma the affection is usually localized in a single spot; it is painful; the lesion is often made up of smooth, pearly nodules. When ulceration takes place, more tissue is usually destroyed than in lupus, the ulceration going deeper. It starts, usually, from one point and spreads upon the periphery, while the ulceration of lupus begins at several points within the patch. Finally, the history of lupus almost always points to its beginning in early life, while epithelioma originates in adult life, and usually beyond middle age. In the tubercular syphiloderm, aside from the history of infection, the papules and tubercles are larger and firmer, the general tint of the eruption is a dusky ham-color, while that of lupus vulgaris is rather of a yellowishbrown shade. When the lesions ulcerate, the syphilitic ulcer is apt to be single, deep, excavated, suppurating freely, while that of lupus, as has been said before, is multiple, often shallow, and scantily secreting. The course of lupus vulgaris is exceedingly chronic, and in the more stubborn forms, as frequently met with abroad, cases may frequently be seen which have for years been under the best treatment in hospitals. On the other hand, in the milder forms of the disease, such as are usually encountered in this country, proper treatment is often successful. In some cases internal treatment, as cod-liver oil and iodide of potassium, acts most beneficially. In other instances, as in the present case, where the disease is circumscribed, local treatment-cauterization, etc. is preferable. The treatment which shall be adopted with this patient is erasion, by means of the curette or sharp spoon, a procedure first adopted by Volkmann, a German surgeon. I here show the instrument to be employed, a small round steel spoon about a quarter of an inch in diameter, and attached to a handle. In order to prevent undue pain from the operation, local anesthesia shall be employed, with the aid of rhigolene spray, projected against the part to be operated on, with a hand-ball atomizer. The larger patch having been frozen, and being kept insensible by the rhigolene spray during the operation, I now scrape all the diseased tissue thoroughly away, going down as deeply as possible in order to include every part of the lupus infiltration. The operation is quite painless. The wound shall be dressed with a simple water dressing; later, with a bland ointment. syphilis, and several years ago he had gonorrhoea, which left him with a urethral stricture of a very troublesome character. He had suffered from dysuria for the previous three years. Lately the stricture had been so tight that he had had the greatest difficulty and pain in micturition. The stricture was situated far back in the membranous portion of the urethra. Forty-eight hours before his admission to the hospital, while attempting to urinate, and while making violent straining efforts, he suddenly felt something give way in his perineum, at once followed by very severe burning pain, which involved not only the perineum, but also the hypogastric, inguinal, and scrotal regions, and extended along the under surface of the penis. The scrotum now swelled enormously, and the pain continued, increasing rather than diminishing. Since this time he had passed no urine externally. Upon admission, the patient was exhausted by pain and sleeplessness; the bladder was rather distended, and the scrotum was swollen to the dimensions of a small cocoa-nut, and was firm, glistening, dusky red, painful, and hot. In the perineum, to the left of the raphé and immediately behind the scrotum, was a firm swelling about the size of a walnut: this was also red and painful, as was the entire perineum, but no fluctuation could be detected. All of the adjacent tissues were much infiltrated; the testicles could not be felt, and an attempt to pass a catheter into the urethra failed on account of the infiltration of the tissues of the penis, blocking the urethra. Upon the left, lower, outer part of the scrotum was a round dark patch of integument which was about to slough. A deep incision was made into the perineum upon either side of the raphé, near the scrotum, from which flowed much dark blood having a highly urinous odor; but no pus was seen. Warmwater dressing applied. It being found impossible to reach the bladder with the catheter, the attempt was abandoned. Very little relief was experienced from incisions in the perineum. Upon the following day he was much prostrated; the patch of integument had sloughed away from the scrotum, and the urine was escaping from it in drops, no urine having flowed by urethra since its rupture. The patient was carefully etherized, and a deep incision. was made low Ex down upon either side of the median line of the scrotum anteriorly, from which flowed very freely blood, urine, and pus of a very offensive character. The patient experienced immediate relief, and the bulk of the swelling was much reduced. ploration with the finger failed to discover the testicles. The wounds were packed with tents of carbolized lint, and the scrotum was elevated. Ordered whisky, f3iv, quinia, gr. viii, daily. Upon the 6th of May-ten days after admission-it was noted that about one-half of the urine flowed from the openings, the remainder in the natural manner through the penis. By the 20th the deep incisions in the perineum had healed, those of the scrotum granulating rapidly. No urine then flowed from the wound in the right side of the scrotum, but that of the left side was a urinary fistula, through which about one-fourth of the urine flowed. In about ten days more all the wounds had cicatrized, with the exception of a small puckered orifice in the left side of the scrotum, through which escaped a little urine in drops during each act of urination. This showing no disposition to close under ordinary stimulating applications, a soft catheter was passed into the bladder without much difficulty, tied in, and allowed to remain for four days. A stick of nitrate of silver was passed into this fistula to a depth of three inches, and the external opening was dressed with compound resin cerate. Upon the fourth day the catheter was withdrawn, and subsequently no urine passed from this tract. It healed rapidly. The patient remained after this for several weeks in the hospital, when he was discharged cured, no opening of this fistula occurring. He still had a stricture, with considerable thick dense cicatricial tissue at the point of rupture in the membranous portion of the urethra; but he was much pleased to discover that his misfortune had not involved the integrity of the testicles. I have had but three cases of urinary infiltration under my charge, but they showed well the effects upon the system of poisoning by urea, notably that of reduction of the temperature of the body notwithstanding a coexistent amount of local inflammation and suppuration sufficient to justify a considerable amount of irritative fever. A glance at the accompanying chart of tem Forty-eight hours after escape of urine into connective tissue the temperature was 100°; a chill occurred, and, the blood by this time carrying urea, the temperature fell, instead of rising, to a point far below the normal. His worst symptom was a low temperature, which seemed to bid defiance to the most active efforts to warm and stimulate him; and this condition continued in the face of an amount of local irritation which involved the genital organs and the entire perineum and a discharge of pus which amounted to many ounces daily. After the establishment of a free drain for all effete and poisonous matters, and after the system had found time to throw off the effects of the absorbed poison, the temperature gradually rose to the normal point, and even exceeded this for a few days, but quickly returned to the neighborhood of 98.5°, and the patient slowly convalesced. 1237 ARCH STREET. FOR orthopnoea due to defective heartaction, free purgation, with the hourly administration of digitalis and nux vomica, is recommended by Dr. H. Cook.—Practitioner. TRANSLATIONS. THE INDELIBLE VESTIGE OF CHANCRE. -In a notice of a brochure on this subject by Dr. Leon Montaz (Le Progrès Médical, 1881, p. 548), Dr. Malherbe says that the interest attaching to the retrospective diag. nosis of chancre is so great that his conclusions are worthy of notice. Montaz asserts that every chancre leaves an indelible scar, while chancroid does not necessarily do so. This is curiously opposed to the doctrine 'formerly in vogue, which was precisely the reverse. To state Dr. Montaz's case more exactly, he asserts that chancre leaves behind it sometimes a cicatrix, when the ulceration has been excavated, and particularly when it has been phagedænic, sometimes a slight depression, when the ulceration has been merely at the expense of the erosive papule, that tissue designated by the rather bad but convenient term "syphiloma." Montaz quotes Horand, Guibout, Langlebert, and Jullien as partaking more or less of his view, while Ricord, Rollet, Clerc, Fournier, and others are disposed to admit the total disappearance of the chancre. Montaz considers Fournier to lean to the latter view because most of his experience has been with women, where the trace of former chancre is particularly difficult to make out. Fournier, however, must have met with many chancres on men in his large private practice: so that the reason given will not altogether account for his point of view. The classic doctrine of the complete disappearance of all trace of chancre in every case is, however, in the opinion of Le Progrès Médical, too absolute. Chancroid is doubtless destined before very long to disappear from ordinary observation: it becomes rarer every day. As to chancre, it must not be forgotten that this is infinitely variable in area, depth, and even in aspect, and the vestige which it may leave behind may vary greatly as the ulceration may have been shallow or deep. Dr. Montaz gives notes of more than one hundred cases of recent or old syphilis where the vestige of the chancre was to be found. The critic, however (Dr. Malherbe), thinks that the observation was in many of these cases made too early, even before the induration had entirely disappeared. Others were cases of working-people, when the sore might have been irritated by neglect. Montaz concludes by a chapter on the medico-legal aspect of the vestige of chancre; but he is, in the opinion of his critic, too sanguine here. TREMORS CURED BY THE GALVANIC BATH.-At a recent meeting of the Société de Thérapeutique (Bull. de la Soc. de Thérap., 1881, p. 123) Dr. M. C. Paul read a paper on this subject, in which he alluded to fourteen cases previously reported by himself, and added several others of a confirmatory character. These included cases of mercurial trembling, chorea, paralytic ataxia, scrivener's palsy, and trembling of the hands caused by sclerosis in patches. All were greatly benefited. Speaking of the characteristics of mercurial tremor, Dr. Paul says that its onset is sudden and unexpected. The patient perceives that his arm has failed him, and from this moment the tremor invades successively the left arm, and then first one leg and then the other. It preserves during its whole course, and until cured, three characters. 1. The onset is sudden. The tremor is continuous; once having appeared, it does not cease. 3. It is progressive, the interval between its extension from one limb to another being very brief, though it is longer between the upper and the lower members. In one case the attack first involved the masseter; but this is rare. 2. In alcoholic tremor the course of the affection is quite different. It is slow, progressive, and proceeds by successive attacks. Thus, the day after a debauch the patient observes that his hands tremble and fail, but after the effect of the debauch has passed off the tremor disappears. At a subsequent debauch the tremor again appears, lasting this time a little longer. At each new attack the tremor lasts a little longer, until at last the drunkard cannot work. Although slight alcoholic tremor is not rare, yet tremor to such a degree as to prevent work or locomotion or eating is rare. Both mercurial and alcoholic trembling are amenable to treatment by the galvanic bath. But, while twenty-five baths are required to cure mercurial tremor, six to eight are sufficient to cause alcoholic tremor to disappear. Dr. Paul thought it worth while to remark thus regarding these two affections because they are so comparatively little known. TREATMENT OF CHANCROID BY APPLICATIONS OF PYROGALLIC ACID.-MM. Ler moyer and Hitier in an article on this subject (Bull. Gen. de Thér., vol. c., 1881, p. 403) allude to the experiments of Terrillon, who found pyrogallic acid to take a place between nitrate of silver, which rarely does good and often aggravates the sore, and iodoform, which is efficacious but slow in its action, and the powerful and disgusting odor of which renders its employment extremely repulsive. During three months all the chancroids coming under Dr. Terrillon's care were treated with pyrogallic acid, and with such good effect that this topical application has entirely superseded nitrate of silver and iodoform. Lermoyer and Hitier, working under Terrillon, have abandoned the formula introduced by Vidal (vaseline, 4 parts; pyrogallic acid, 1 part), as liquefying too rapidly in contact with the body; they make a firmer ointment, as follows: R Pulv. amyli, 3ijss; Acidi pyrogallici, 3ijss. M. This pasty mixture applies itself thoroughly to the diseased parts without becoming liquefied. The admixture of starch does not in any way affect the activity of the pyrogallic acid. In order to be of benefit, this ointment should be freshly made, and it should be kept in a tightly-stopped bottle, for it absorbs oxygen from the air very readily and becomes brown. When thus discolored it acts less satisfactorily and also at times excites pain. A single application daily is sufficient. If more than one is required, it is not because of the malignity of the chancroid, but because of its position. Thus, in women a chancroid of the fourchette is much more rapidly curable than a chancroid of the anus. On this account one application per diem is sufficient for the former, while the chancroid of the anus requires two at the least. In cases of virulent buboes much pain is caused by the pyrogallic acid ointment; nevertheless the sores heal very rapidly. In fact, the rapidity of cure in all chancroids treated by means of pyrogallic acid is something remark able. METHOD OF PRESCRIBING RESORCIN, SCLEROTINIC ACID, AND PICRONITRATE OF QUINIA.-Resorcin may be given in mild cases, or when prescribed for the first time, to the amount daily of fifteen to thirty grains; in severe cases, or after trial of the smaller dose, in doses of forty-five to seventy-five grains in three ounces of water. It is best to give this in divided doses, so as to guard against toxic effect. It is only when the medicine has been taken for some time in moderate doses without toxic symptoms, and when the amount of septic material is quite considerable, that larger doses are to be given. When given in a fluid form, the best vehicles are alcohol, glycerin, and syrup of oranges. When possible, the disagreeable taste of resorcin is best masked by giving it in powder, either in wafers or gelatin. capsules. The following formulæ will be found convenient: 1. R Resorcin. puriss., gr. xv ad xxx; aquæ destillat., f3iij; syrupi aurantii corticis ad f3iv. M. Sig.-A tablespoonful every second hour. Emulsion: 2. R Emuls. amygdal. dulcis, f3v ad f3iij; resorcin. puriss., gr. xv ad xxx; syr. aurantii flor., f3j. M. Sig.-Tablespoonful every second hour. For dressings: One and a half per cent. resorcin gauze. Every kilogramme of the gauze contains fifteen grammes of resorcin previously dissolved in four hundred and fifty grammes of alcohol and one hundred and fifty grammes of glycerin. One kilogramme equals thirty metres of gauze it is put up in five packages. Three per cent. cotton is made of one kilogramme of cotton batting, containing thirty grammes of resorcin previously dissolved in one hundred grammes of alcohol and seventy grammes of glycerin. Each kilogramme is divided into four packages, every one containing two hundred and fifty grammes of cotton. Resorcin spray: R Resorcin. puriss., Div; aq. destillat., Oij. M. It may be remarked, in passing, that resorcin is peculiarly fitted for use in disinfecting surgical instruments, as it has no effect upon steel, as salicylic acid has. Sclerotinic Acid: 1. R Acid. sclerotinic., gr. xv; aquæ destillat., 3iiss ad 3iv. M. For subcutaneous injection. 2. R Ácid. sclerotinic., gr. xv; aquæ des |