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made an excellent working preparation, and though the repeated variations rendered the dosage inaccurate in point of tolerance and stability, it was a marked improvement over the original formula.

There was another feature of the treatment which hung over me like the sword of Damocles, and that was the danger of embolism. Notwithstanding the fact that I had administered between 2,000 and 3,000 injections and have never noted the slightest symptom of such a complication, I was aware that many reliable cases had been properly observed and carefully reported to impress me that this character of danger was always present. The full realization of the danger came over me when one of my patients, who had just received twelve injections, suddenly developed a facial paralysis. Coincidently another patient who had received injections at the hands of one of my colleagues, Dr Gilbert Bailey, developed a paraplegia of the lower extremities. Fortunately, neither of these conditions were attributable to the injections, for the facial paralysis was a Bell's as confirmed not only by subsequent course, but also by careful examination by Dr D. I. Wolfstein. The paraplegia, of course, could not have been of an embolic nature. These instances, however, induced me to endeavor to minimize the danger. The first impulse was to remove the albolene which, by reason of its liquid nature and mineral character, not only strongly predisposed embolism, but once lodged as a foreign body could not be assimilated and removed. For this reason injections were attempted with the following formula:

Hydrarg. metal bidistil.
Lanolin, (Liebreich.)

aa 25.0

Conteratur usque ad perfect extinctionem hydrargeri.

Sig. Inject 1 to 3 minims every 3 or 4 days.

It was found necessary to heat the preparation to about 100° F (38° C) in an oven, or over an ordinary radiator, to render it sufficiently fluid to allow it to be readily drawn into the barrel of an hypodermic syringe, and to be maintained at that temperature, if an ordinary syringe (Fig. 1) is used

A....

MAX WOCHER & SON.

for injection purposes. If however an extra strong syringe (an ordinary obtunding dental syringe will readily answer), armed with a 20 gauge needle is employed, the contents can be readily expressed at ordinary temperature and in such semisolid form that danger from embolism is minimized to an extreme degree. I have employed this formula exclusively during the past three or four months with the greatest degree of satisfaction and success. One to three minims can be readily measured by means of the retaining screw (Fig. 1, A) and injected with the greatest degree of tolerance to the patient. Each grain of lanolin by volume (which forms the bulk of the preparation) contains a grain of metallic mercury, so that the dosage is correspondingly heavy. Control is perfect, induration and painful reaction are practically nil. The preparation is exceedingly and almost indefinitely stable at all ordinary temperatures, and can be prepared with the greatest ease. The simplicity and ease of its preparation and administration, the extreme tolerance as evidenced by the absence of pain, induration and other forms of complication, its uniform and indefinite stability under all ordinary conditions, the control exercised over the patient, greater cleanliness and privacy, larger and more accurate dosage, the lack of insult and distress to other organs and the unfailing character and promptness of the results is sufficient proof, I believe, to stamp this method of mercurial treatment of syphilis the most successful and practical of all methods.

Fig. 1.

Dentists exercise great care in the selection of a purè bidistilled mercury for the preparations of their amalgams. The commercial metallic mercury obtainable from common sources will not form a satisfactory amalgam.

REFERENCES

1. Alex. Wood. Zienssen-Hand-buch d. Algemeinen Therapie, 1880. 2. Chas. Hunter and Barclay Hill-Lancet, 1856.

8. Hebra Zeissl-Lehr-buch d. Constitut. Syphilis, Erlanger, 1864.

4. Scarenzio—Annali Universali, 602, 1865.

5. Lewin-Annal. d. Charite, XIV, 1868.

6. Welander-Archiv. f. Dermatologie u. Syph., 46.

7. Blaschko—Berlin, Klin. Woch., 46, Nov.

8 Lewin-Ibid.

9. Sigmund-Wien. Med, Woch., 1870.

10. Zeissl-1870, Lehr-buch d. Syph., 1875, p. 376. 11. Lewin- Berlin Klin. Woch., 1876.

12. Lang-Lehr-buch d. Syphilis, 1896.

18. Ullmann-Wien. Med. Blaetter, 1889.

14. Lang-Wien. Med. Wochenschr., 1889.

15. Düring--Monatsheft f. Prak. Derm., IX, p 490.

16. R. W. Taylor-Med. News, Dec., 1889.

17. Watrazewski-Arch. f. Dermat. u. Syph., 46, 21.

18. Lesser-Deut. Med. Woch., 1894, 39.

19. Bayet-Jour. des Malad, Cutan. et Syph., 1895.

20. White-The present status of hypodermic therapy of Syphilis, 1894.

DISCUSSION

Dr J. H. McCassy, Dayton: While I am an eye, ear, nose and throat man, one might think that I, with my fellow specialists, did not come into contact with many syphilitic cases, yet the contrary is the case. When you consider that about 75% of the cases of iritis are due to syphilis, and that the manifestations of syphilis in the nose and throat are exceedingly common you can see how we specialists come to see and do with a great many cases of syphilis.

I wish to add my testimony to the fact that I have known of a number of cases of syphilis which led on to certain conditions because the injection method of treatment was not employed. We have been taught to inject as near as possible to the seat of the disease, and that is something which I wish to bring out. While we are called upon to treat syphilitic manifestations about the eye, nose and throat, those of you who have not used injections about the throat very much would be surprised to see how simple it is to make such injections. As a rule mercurial injections under the skin give rise to great pain, but even so I think we would do well to try the injection method in these cases as far as we can, of course feeling our way with the patient, yielding to his inclination as much as you can, and as the case progresses you will be able to have your way and thereby cure your patient. If you do not use the injection treatment on your cases you will find that quite a number of your patients will drift away from you and go to the physician that will use the up-to-date treatment-the injection method.

Dr M. L. Heidingsfeld, closing: In closing I have only to add that in presenting this paper I have endeavored to detail my personal experience with a preparation which has served me by far the best in the method of syphilitic treatment, and which appeals to me to be the most rational, scientific and effective. The features which impress me the strongest are the simplicity and ease of preparation, relative large dosage, marked tolerance, and stability of the preparation. The ease with which it is tolerated has been kindly pointed out in Dr McCassey's remarks by the faci that clinical patients have shown no disposition to withdraw from treatment, but persist until the full course has been administered, an occurrence that is unusual, no matter what form of treatment is administered.

I trust that the preparation will receive a thorough trial at the hands of the profession, and hope that its use, with the proper regard for the above mentioned instructions, will be attended with the same gratifying results.

I only wish to say further that it is desirable to begin the treatment with the minimum dose, 1⁄4 to 1⁄2 grain, and to increase slowly within the bounds of tolerance. Do not attribute every bad result to the method until you are satisfied your technic is perfect. A case of this character recently came to my notice where the injection was made in the calf of the leg.

Diphtheria

Its Symptomatology and Clinical Diagnosis

By F. D. CASE, M. D., Ashtabula

There are two forms of pseudomembranous sore throat of bacterial origin-diphtheria caused by the presence and development of the Klebs-Loefler bacillus, and pseudodiphtheria caused by streptococci and other pus-forming cocci. Diphtheria is an acute infectious disease primarily local, characterized by a fibrinous exudate upon the surface attacked, and by constitutional symptoms of varying intensity. The constitutional symptoms are due to a soluble poison, elaborated at the seat of the lesion by the bacillus, and

absorbed from thence into the general system. Diphtheria always results either directly or indirectly from a previous case, the presence of the bacillus in quantity and activity sufficient to overcome the individual's power of resistance constituting the condition necessary for the production of the disease.

Diphtheria differs much in general character in individual cases. Sometimes both the general and local symptoms are trifling, attended with little fever, slight soreness of the throat, little disturbance of the nervous system, and perhaps a trace of albumin in the urine.

Sometimes again the disease is terribly severe from the first; the mucous membrane of the throat may be dark red or livid, the dysphagia extreme, the fever high, but of low adynamic type, with great muscular weakness, the urine loaded with albumin and casts. The period of incubation is generally shorter than that of other infectious diseases, being usually two or three days, but may be prolonged to eight or ten days.

A typical case of diphtheria is ushered in with a chill or chilly sensation, attended with malaise, fever, and "during the same day-sore throat." (Northrup.) It is characteristic of diphtheria to show objective signs in the throat early in the disease, but the nares, larynx, and occasionally other localities may be the primary seat of the lesion. Along with complaints of dryness, burning and dysphagia, there may be at first merely a hyperemia of the tonsils, palatine arches, or pharynx, then white or grayish-white patches from deposit of lymph are seen. Sometimes two or three centers of deposit are seen from the very first; these are filmy and easily detachable. The submaxillary and adjacent lymphatics become swollen and tender. A viscid mucus forms in the throat, which keeps the patient hawking, spitting, or swallowing. The pulse is increased in frequency in proportion to the severity of the disease. In malignant attacks it is weak with cold extremities, and the usual indication of a feeble capillary circulation.

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