ESSENCE OF PEPSINE ingredient of the GASTRIC JUICE, Extracted (FAIRCHILD). from the Peptic Glands Solution of the Essential Organic Stomach. Please compare this with any similar preparation in Minute Division--Perfect Emulsionizing of the Oil- THE CHAS. H. PHILLIPS CHEMICAL CO., 77 Pine St., New York. THE CINCINNATI Lancet-Clinic A Weekly Journal of Medicine and Surgery. NEW SERIES Terms, 83.50 per Annum. Entered at the Post Office at Cincinnati, Ohio, as second-class matter. Vol. XXVIII.-No. 14.} Cincinnati, April 2, 1892. ORIGINAL ARTICLES. WHOLE VOLUME LXVII. CONTENTS. SOCIETY REPORTS. ACADEMY OF MEDICINE. 423 REPORT OF A CASE OF LUPUS TREATED BY TUBERCULIN. CORRESPONDENCE. 430 432 See Advertisement 66 VIN MARIANI” on Insert page xii. A VALUABLE AGENT. APOLLINARIS, "The Queen of Table Waters." “Light, sparkling, and easy of digestion," FORDYCE BARKER, M.D., Professor of Clinical Midwifery and Diseases of Women in Bellevue Hospital Medical College; Surgeon of the New York State Woman's Hospital, New York, etc. 'Healthful as well as agreeable." "Well suited for Dyspeptics." AUSTIN FLINT, M.D., Professor of the Principles and Practice of Medicine and Clinical Medicine in Bellevue Hospital Medical College; Visiting Physician to Bellevue Hospital, New York, etc. "Can recommend it in the strongest terms." Professor of Orthopedic Surgery in Bellevue Hospital Medical "Every case of TYPHOID FEVER is a case of WATER POISONING. This is a useful item for the public to keep in mind." N. Y. MEDICAL RECORD., January 9th, 1892. "THE PURITY OF APOLLINARIS OFFERS THE BEST SECURITY AGAINST THE DANGERS WHICH ARE COMMON TO MOST of the orDINARY DRINKING WATERS." LONDON MEDICAL RECORD., See Advertisement BATTLE CO. last cover page." In As an "Arm of Precision." n a Recent Note we described, as follows, the characteristics of a perfect pill, adding some remarks as to the absolute necessity of using pure medicaments: PURITY of medicaments and excipients. PERFECT UNIFORMITY as to activity and identity. PALATABILITY; and ELEGANCE of appearance. We Will now Consider the second requisite-PRECISION. We The Weapons With Which Disease is Fought must be Accurately Prepared or they will give uncertain, unlooked-for, or otherwise undesirable results. From a therapeutic point of view, the exactitude of a preparation is essential to its precise effect. Disease is not overcome by giving uncertain quantities of indifferent medicaments in the hope that enough active substance will finally have been ingested to effect a cure. The condition must be "treated," that is followed up step by step until the desired result is obtained. This desideratum can be realized only with medicaments mathematically mixed and divided, and in all respects thoroughly prepared. These conditions are fully supplied in 'he W. H. S. & Co. Pill. We append the formulæ of a few of these preparations, which are presented as being seasonable, as well as of the best quality. On a future occasion we will say a few words as to uniformity. The PIL. CREASOTI " W. H. S. & Co." (From Pure Beech Tar.) Prescribed for Pulmonary Tuberculosis, Pulmonary Phthisis, and Diseases of the Bronchia. It increases Appetite, Weight and Strength. (Pills of 1⁄2 and 1 grain each.) PIL. PHENACETtine et Salol, 5 grs., “W. H. S. & Co." Valuable in Influenza (“la grippe"); in all forms of Rheumatism; in Neuralgia Migraine and Pertussis; and in all painful febrile conditions. grains each of Phenacetine-Bayer and Salol. Half strength also prepared.) (Pills containing 2}| PIL. HYDRARGYri Tannici OxyDULAT., (Mercury Tannate), "W. H. S. & Co." Available for all the Forms and Stages of Syphilis, and in all cases in whic Mercury is indicated. It does not irritate or salivate. (Pills of grain each.) PIL. TONICA LAXATIVE, (or "Tonic Laxative Pill-Skene") "W. H. S. & Co.' Adapted to the treatment of Obstinate Constipation in Weak or Broken Dow Constitutions. (Quiniæ Sulph., 1 gr.; Ext. Belladonnæ, 1-10 gr.; Ext. Colocynth Co., 1⁄2 gr.) PIL. TERPIN HYDRAT., “ W. H. S. & Co.” Employed in Coughs, Colds, Catarrh, Bronchitis, Asthma, and all Respirator Maladies. Unlike terebinthina and some of its derivatives, no unpleasant symptom follow its use. (Pills of 2 and 5 grains each.) IN PRESCRIBING BE PARTICULAR TO SPECIFY "W. H. S. & Co." W. H. Schieffelin & Co., New York THE CINCINNATI LANCET-CLINIC: New Series Vol. XXVIII. A WEEKLY JOURNAL OF MEDICINE AND SURGERY. CINCINNATI, April 2, 1892. Original Articlés. REPORT OF A CASE OF LUPUS A Paper read before the Academy of Medi- BY LINCOLN MUSSEY, M.D., CINCINNATI. I take pleasure in presenting to you to-night a case showing markedly the effect of nine months' treatment of lupus of the face with Koch's tuberculin. To Dr. S. P. Kramer is due many thanks for the tuberculin which he most generously placed at my disposal, as well as for the interest he showed and encouragement he offered in the treatment of the disease. Prof. J. G. Hyndman has likewise been most kind in the help given in investigating the laryngeal symptoms, which formed an interesting feature of the case. A. B., aged twenty-four, unmarried, German-American; father dead, cause "brain fever; mother living and well; one brother died two years ago of consumption; one sister died in infancy. Former diseases: Ordinary diseases of childhood; has had erysipelas; denies venereal diseases. Whole Volume LXVII. ing rapidly. Much alarmed, he had consulted several physicians, most of whom had pronounced the case one of lupus. In addition to this disease of the skin, the patient had noticed some cough-with, however, scanty expectoration-night-sweats, and a progressive loss of weight and strength, so marked that he was obliged to cease work. Description.-Extending from the right ala of the nose out on the right cheek was an irregular patch of diseased skin about one and one-half inches in diameter. The edges of the patch were irregular, of a dull red color, and showed distinctly small, yellowish-red, elevations in the skin, while in addition the skin showed a peculiar roughness distinct from that caused by the elevation of these nodules. The centre of the patch was covered by closely adherent scales, of a dirty-white color, which when removed showed a bleeding surface. On the nose the yellow nodules were more marked and the scales firmer and less easily detached. In the right nasal cavity only thick scabs could be seen, and some discomfort was complained of by the patient from the complete blocking of the cavity. Lungs: At apex of left lung there was slight dulness above the second rib anteriorly, with slightly prolonged expiration and a roughened respiratory murmur, but no marked râles. Diagnosis. Lupus vulgaris (nonexcedens). Koch's treatment with tuberculin was requested by the patient. The patient came under observation April 25, 1891, presenting a disease of the skin of nine months' duration. This disease manifested itself as a dull red nodulated patch on the skin of the right side of the nose and cheek, surmounted by firmly adherent dirty white scales. This, as the patient stated, had begun nine months before as a single small pimple or nodule near the angle of the nose; other nodules had appeared and the disease had spread and was spread-temperature was 98.80 F., with no April 27, 10 a.m. After the customary aseptic precautions an injection of .001 g. of the tuberculin was given in the skin of the back. Temperature at time of injection was 98° F. At 2 p.m. marked discomfort and no local reaction. | that in point of size the lupous patch is At 5 p.m., however, the temperature now larger than at the commencement reached 99.2° F.; patient's face was of treatment. flushed, slight headache, pain in joints, while the lupous patch was perceptibly reddened and swollen, a fact remarked upon by both patient and mother. At 8 p.m. temperature had reached 100.2° F., but the patient was not seen. At 9 a.m. temperature was 98°, at 9 p.m. it was 99°. a.m. April 30. Injection of one mg. at 10 A reaction more remarkable than the first occurred. At 2 p.m. temperature was 99.2°, while headache, nausea, pain in the joints, ringing in the ears, etc., compelled the patient to go to bed. Similar reddening and puffing up of lupous patches was noticed. At 5 p.m. temperature was 100.2°, at 8 p.m. 101.60. The following morning the temperature was 98°, but at 8 p.m. fever of 100.40. Thereafter the temperature was normal until May 3 to 9, when .002 g. were given. Just as prompt a reaction followed, temperature rising to 100.8°. In addition to other signs previously recorded, the dull area at apex of left lung became more prominent, and moist crackling râles were heard without difficulty. Expectoration became freer, and, the sputum being examined, tubercle bacilli were found. These three reactions have been given somewhat in detail in order to show how peculiarly characteristic has been the response of this disease to the treatment. It is not necessary to consider in detail each injection and its effect. I have, however, inserted a few notes recorded during the course of the treatment. May 29. Last dose May 27, .004 g. Temperature reached 100.2°. Lupous tissue continues to swell and redden after each injection. General reaction not so extreme, i.c., previous headaches, bone pains and general discomfort not so marked, and some tolerance to the drug seems established. Serous transudation of lupous tissue causes in its drying thickening of scales surrounding the diseased skin. The small reddishyellow nodules at the periphery of the lupous tissue apparently extending, so June 10. Ceased injections owing to slight attack of diarrhoea, which leaves the patient weak and dispirited. Scabbing increasing, scabs, however, becoming looser, and serous transudation is taking place beneath them, the discharge subsequently drying and adding to their size. Zone of redness about periphery of the area of scabbing increasing somewhat in size. June 15. Resumed injections with .007 g. Reaction, with temperature of IOI. No further extension of tubercular invasion apparent. July 20. Steady use of tuberculin— three times-usually with slowly increasing doses. Patient's general condition much improved; still coughing, and expectoration is quite free, showing presence of tubercle bacilli. Scales and scabs have been cast off about periphery of the patch, showing a smooth surface underneath, with no signs of tubercles, but the underlying skin is of a dark red color, and is somewhat glazed in appearance. Patient's weight is now 116 pounds. August 1. Marked local improvement during the last ten days; scabs now being rapidly cast off, but one central patch, gray and dirty, about one-third of an inch square, remaining. The skin over which previously scabs had formed now smooth and glistening, but of a dull-red color, which becomes more vividly red in the reaction after an injection of tuberculin. Dosage now .015 g. General reaction no longer extreme in its effects, and local reaction similarly less pronounced. Dulness at left apex remains, and moist râles apparent, but general health continues fair. August 15. Dosage now Dosage now .030 g. Fever reaction only 99.6°. Scab on cheek lessening in size day by day, and exudation process below it rapidly ceasing. Nasal cavity clear and mucous membrane clean. On the 1st of September, after tak ing 556 g. in fifty injections, the last scab had been cast off, and the patient's face was smooth and clean, the first time in eighteen months. The site of the previous disease had, however, the scarred appearance that resembles healing after deep burns, without the cicatricial contraction of the latter. This scar tissue, as it may properly be called, has retained, to a more or less degree, its dull red, glazed appearance. It is, however, becoming daily softer and smoother. No recurrence of the disease has manifested itself, due probably in part to the fact that subsequent in jections have been given. These were continued until September 28, when the patient left the city upon a visit. November 1. He again appeared for treatment, not on account of his original ailment, but because of "throat trouble.” This "trouble," characterized by dryness, dysphagia, expectoration, etc., and hoarseness almost to complete aphonia, was found upon careful examination by Dr. Hyndman to be due to a further tubercular localization in the larynx, a small tubercular ulcer being discovered on the posterior extremity of the right vocal cord near the arytenoid cartilage. Tuberculin treatment has been resumed with apparently marked success. Beginning with small doses-.01 g.– they have been continued without increase twice weekly. His general condition is now better than at any time in the past fifteen months; weight, 115 pounds. Eats and sleeps well, and has resumed work (barkeeper.) His cough is still troublesome; expectoration shows still the tubercle bacilli. In presenting this case before the Society, we are apt to find ourselves open to a few criticisms. 1. Diagnosis.-This may be dismissed without discusion, as at a previous meeting the patient was before the Academy while under treatment, and the diagnosis was almost unanimously concurred in. However, the prompt and characteristic reaction to Koch's remedy, the family history, the presence of tuberculous lesions elsewhere, the absence of any syphilitic history, and the fact that the lesions have cleared up without any anti-syphilitic treatment whatever, would serve to exclude such a possibility. A proposition was made to the patient to exsect a small piece of diseased skin to be examined microscopically, but this being objected to, the matter was not pressed. As to examining the discharge or the exfoliating scales, such examinations being so uniformly barren of results, they were likewise passed. to any 2. The Contra-indication Use of the Remedy in the Case.-The presence of apical tuberculosis may seem to have contra-indicated any such depressing agency. The presence of laryngeal phthisis, afterwards apparent, may seem to support such a criticism to those who see nothing in tuberculin, and believe in the general infection. following its injection, from the, at first, local affection. But to others the incipient tuberculosis of the lungs indicated immediate trial of the remedy, and the laryngeal complication, occuring as it did during a month's interval in the injections, can be reasonably regarded only as an unfortunate complication. Notwithstanding even this complication, the patient's general condition has been much improved during the nine months' treatment. 3. Dosage.-Most of the later observers recommend much smaller doses of tuberculin given, if necessary, with shorter intervals. Von Bergmann('), however, in a reported case, began with a dose of .01 g., and in one case, in twenty-three injections, gave one gramme. Max Schede (2), in reporting seventeen cases, began in five cases with a similar dose, .o1 g., all of which were improved by treatment; in four others, with .005 g., all much improved; while on the contrary, in death following the use of tuberculin, in Jarisch's (3) case, death followed an injection of only .002 g., while that of Koenig(1), a fatal result occurred after a dose of .005 g. Possibly no accurate, infallible rule as to dosage can at present be given, but general sentiment is undoubtedly inclined. toward small doses. It may be well to notice one or two interesting features in this case: 1. The diarrhoea of June 10 may be regarded by some as a manifestation of |