urge in season and out of season all practical measures for preventing infection by tuberculosis. The public benefits from such a general movement on the part of all physicians would be simply incalculable. Dr. Shakespeare, in the Hygienic Gazette, sounds the battle cry, and to it we are indebted for some of the foregoing suggestions. . The Sort of Athletics for the Building of Strong Men.-Athletics have gained a strong hold upon college men (American Lancet). In fact, one hears more in the newspapers about Harvard's and Yale's athletic clubs than about their bright scholars. Many other colleges have won a certain notoriety by the success of their athletic clubs. A few years ago the writer knew a boy bright in scholarship, true in his manly instincts, noble in all his conduct. He was fond of athletics, and won distinction in Yale both as a scholar and as an athlete. But shortly after his gradu ation he was attacked with a fatal disease of the lungs. For his athletic work large lungs were needed, but when he dropped such work the lungs in their degeneration fell an easy prey to disease, and the world lost the service of one of the noblest of spirits. Not long since, on a visit to a college whose students indulge in football, the writer observed that many had effusion into the knee-joint. He was told this was the "foot-ball knee." At least one example was observed in which this disease finally necessitated the amputation of the leg. "Base ball fingers" have become quite a common de. formity-one which cripples in many ways in most pursuits of life. No sort of athletics compensates for bodily deformities. Every physician is familiar with cases in which over-development of muscles in the training for certain games has resulted disastrously. Excessively developed muscles may be good for show, but they are not good for healthy life, especially in brain workers. Athletics for competitive feats of strength and endurance are per nicious, illogical, and dangerous (Lydston). It were far better for the average boy or man to be content with perfect control and excellent nutrition of muscles of moderate development. Strong men are not best constructed by the socalled perfect training. Brain-workers and those who lead sedentary lives are unwise in attempting to become general athletes. That sort of athletics is best which (1) is free from serious danger to life or limb; (2) is natural and pleasing to the individual taking it; (3) promotes a healthful flow of blood through every portion of the body, the more equably the better; (4) is regular as is the hour for meals and sleep; (5) permits cheerful companionship; (6) does not seriously disturb the ordinary duties of life. In short, those athletics are best for the student which are subordinated to his work as a student and the part he expects to take in after-life. Base-ball, foot ball, lawn tennis, as friendly games for simple exercise, are well enough, but when entered into "to beat" they sadly lack the features needful to commend them to the thoughtful physician. Salo-Sedatus the Best.-Dr. B. F. Thorpe, of WestfieldMass., says: I am sure it is not extravagant to say that Salo, Sedatus is the finest remedy of the kind ever brought to the notice of the profession. When I say this I speak from experience, as I have used it with the most satisfactory effect; and I have also used all of the most popular and extolled fever and pain remedies in the market besides. It is not a depressant to the heart and circulation, and its antiseptic properties, with its power to influence the secretions, puts it beyond any of them in therapeutic efficiency. Regular Weekly Issue, 10,000 Average Monthly 43,333 VOL. XXVIII. A WEEKLY JOURNAL OF MEDICINE AND SURGERY. ST. LOUIS, DECEMBER 9, 1893 ORIGINAL ARTICLES NO. 24 tion, and skin covering the part was both healthy and mobile. The patient claimed to have noticed its presence for about ten days, but was certain that it was at no time attended by external evidences of inflammation, and thought that its growth was most rapid at the onset. The localized pain, which dated from its beginning was A Case of Malignant Syphilis Resulting in extremely lancinating, but paroxysmal in character and Death. BY A. E. ROUSSEL, M.D., PHILADELPHIA, greatly increased by the slightest movement. The fever at this time was rather quotidian in character, the morning temperature averaging 99 5°, and rising in the evening to about 103°, unaccompanied by Lecturer on Physical Diagnosis and Clinical Medicine, Medico-chill but by an intense cephalgia which continued for J. P., born in France, aged forty years; chef. Good family history and excellent health (never having been sick since childhood) until the appearance of a chancre twenty-two days after exposure, which soon took upon itself a phagedenic character, and was shortly followed by induration of the inguinal glands. Nine days after he first noticed the initial lesion the patient was suddenly confined to his bed with all the symptoms of an acute attack of rheumatic fever, and was, indeed, so treated by his physician for a period of four weeks. At the expiration of this time, the disease being apparently no better, the doctor was discharged and I was called in to the case. a period of three or four hours each evening, after which a profuse perspiration took place. Under the mixed treatment the case rapidly improved and the patient was able to resume his occupation in two weeks time. The growth in question slowly dimi. nished in volume and had practically disappeared in about one month with the exception, however, of slight permanent thickening at the crest of the tibia, which remained the seat of occasional intermittent pains. Three weeks later (about ten weeks after the appear. ance of the chancre), during office treatment my atten tion was called to the sensation of pain referred to the roof of the mouth during the act of eating. An examination of the part showed a considerable amount of brawny swelling, together with a deep, irreg. After a careful examination I discovered a suspic-ular, yellowish ulcer near the median line, about 24 ious eruption on the body (roseola), and obtaining the centimetres in size, and surrounded by a line of inabove history verified the presence of the chancre which had not yet thoroughly cicatrized and bore evidence of its destructive ravages. The pains complained of were not solely localized to the joints, which were, however, hot and slightly swollen, but were also particularly severe in the long bones of the leg and characterized by their nocturnal exacerbation. Examination of the internal anterior surfaces of the right tibia in its upper third revealed the presence of a small tumor, intimately connected with the bone. It measured 5 centimetres in its transvere diameter by 44 centimetres in length, and projected to the extent of about 1 centimetre at its most salient part, but the edges were insensibly lost in the surrounding tissue. To the touch it was almost as hard as the bone itself, and was surrounded neither by edema nor peripheral inflamma flammatory redness. A few days afterward the ulceration in question was noticed to have spread considerably and had apparently invaded the deeper structures. Notwithstanding all local treatment directed to the part in conjunction with internal medication, the destruction of tissue continued until the bone itself be came affected. About this time the patient was seen by Dr. William G. Porter in consultation, but in spite of our united efforts necrosis of the hard palate, as well as of the alveolar processes of the superior maxillary bone and of the nasal bones occurred in turn, and the ulceration only assumed a latent condition during the last half of the malady when a perforation the size of 6 or 7 centimetres had taken place. This was attended by the loss of several teeth and imparted to the voice the nasal sound characteristic of this affection. Shortly after the beginning of the necrosis the pa tient commer.ced to rapidly lose in weight and strength and a marked cachexia became an important feature of the case. Early in the case the exhibition of either mercury or of iodide of potassium seemed to aggravate the gastric crises, and, besides, to be followed by an irritative diarA pustular eruption of the face and scalp was now rhea. Inunctions were tried in turn, but with similar noticed. The bone pains returned and the debility was results. Fumigations were likewise discontinued for so great that the patient was confined to the house. the same reason, and even the recently vaunted hypoCurious to state, the appetite was greatly increased; dermatic method was certainly open to the same objecindeed, the condition of syphilitic boulimia, so well tion. Inunctions were continued for the longest period described by Fournier, soon became manifest, as on of time. General tonic treatment, although better several occasions during the absence of the wife, the borne, was of little apparent use. patient invaded the pantry and partook, according to his own estimate, of enough food to satisfy three or four men. It may be apropos to mention here that the patient had become, to a certain extent, accustomed to the trouble occasioned by the passage of food and could now swallow fairly well. This condition was attended by little digestive disturbance beyond on rare occasions, slight attacks of diarrhea; but, on the other hand, gastric crises became an important feature and seemed especially to be aggra vated by any form of mercurial treatment. These pain ful attacks continued throughout the progress of the case, and were equally noticeable during a course of restricted diet. In the eighth month the anemic condition was extremely marked, and the patient, from a weight of one hundred and ninety pounds was reduced to one hundred and forty pounds. In despair he entered the Pennsylvania Hospital but remained only for two weeks, his chief grievance being the restricted diet to which he was subjected, and which ill accorded with his continued enormous appetite. During this, as well as on previous occasions, careful and repeated examinations revealed no disease of the special organs. An examination of the blood showed three millions of red corpuscles per cubic millimetre and a diminutian of the hemoglobin to 40 per cent. An anemic basic murmer as well as venous souffle were also to be de tected. Added to this, prostration, the sallow complexion, pallid face, pinched features, and sunken eyes, made a picture long to be remembered. In the tenth month esophageal obstruction was complained of and an examination by bougie made by Prof. Laplace, showed some constriction which, however, did not become extreme, At this time localized pains in the lumbar region began and soon became excruciating in their severity. This was attended by occasional loss of control of the sphincter of the bowel and remained present until the close of the disease. Some three weeks before his death he was removed from under my care to the Medico-Chirurgical Hospital but the prostration became more marked and he died a little over one year after the beginning of the disease. Unfortunately, notwithstanding strenuous efforts, a post-mortem was refused. As may be imagined in a case of the above character, our treatment was as varied as it was unsuccessfull. On investigating the literature of this subject I find a rather growing tendency among the more recent syphilographers to appreciate that our accepted laws regarding the three fixed and precise stages of the dis ease must be amendable to some modification. For example, Keys, in his last edition, writes as fol lows: "The line between secondary and tertiary syph ilis is not always well marked, and although in typical cases the lesions become progressively deeper, commencing as mere efflorescences in the secondary stage, and gradually increasing in severity to the most extensive ulcerations and destruction of bone and cartilage in the tertiary; yet some of the symytoms naturally be longing to the secondary group, as the mucous patch and scaly eruption, frequently crop out in the tertiary stage, while more rarely nodes come on with early syphilis, and occasionally most extensive ulcerative or other tertiary (gummy) lesions appear within the first few months after chancre, perhaps all the lighter sec ondary eruptions having been omitted. This latter form is called malignant syphilis." Osler tells us ("Practice of Medicine," 1892) that "in exceptional cases, manifestations which usually appear late (such as gummatous growths) may set in even be fore the primary sore has properly healed." C. Mauriac, one of the most eminent of the French authorities, in his very interesting work ("Memoire sur les Affections Syphilitiques precoces du Systeme 03seux," Paris, 1872), details the history of a number of cases, of which the following is a short resume: OBS. I.-Case beginning with indolent enlargement of both inguinal glands. Eight days afterward appear. ance of chancre. On the twentieth day of the initial lesions attacks of cephalgia with appearance of frontal tumors. Than secondary symptoms, cutaneous and mucous, etc. Mixed treatment. Cure. OBS. II.-Period of incubation of two months' duration. Short duration of secondary symptoms. Parietal tumor with neuralgic pains. OBS. III.-Omitted. Dates uncertain. OBS. IV.—Chancre of lip; swelling of cervical glands. One month afterward slight secondary symptom followed by tumor on parietal bone. OBS. V.-Syphilis of five months' duration without treatment, tumor in fronto-temporal region, etc. Mauriac claims that these nodes are the result of periosteal inflammation, and tend to spontaneous recov ery without suppuration, etc. But he quotes an accouut of a case reported by Dr. Henri Roger, which results in a different manner: He "A young man, aged twenty one years-too young, let me note, for it to be likely that he ever had syphilis A girl, age two years, acquired syphilis (kissing an before—was admitted into the London Hospital. infected mother), presented the following lesions at the had still the remain of a chancre on him which was 1. Indurated chancre on the superior lip ulcerating in places. The date assigned to the begin not yet entirely healed. 2. Copper colored spots of roseola on thighs, on forehead, nose, and cheeks, and mucous patches on the vulva and anus. 3. Multiple exostoses; gummy tumors of the frontal bone the size of a filbert, skin covering healthy; semi-soft consistency; the right one reddish and shining at apex, imparting the sensation of fluctuation, and did in time suppurate. Mauriac details the occurence of the other cases presenting similar lesions in the bones of the leg, sternum, and other parts of the body. In these thirteen cases the shortest period of incubation after the appearance of the chancre was fifteen days, and the longest one hundred and twenty days. Curiously, the shortest of the series presented a history which resembles in part the one forming the subject of this paper. Briefly stated it is as follow: OBS. VII-Urethral chancre in a man age nineteen years of habitually good health, which showed itself one month after his first connection. On the forty fifth day acute pains in the tibia, followed in from twenty-six to forty-eight hours by the spontaneous appearance of a bony tumor. Alteration of general health. On the sixty ninth day well-characterized roseola. On the sixtieth day diminution of tibial tumor and final disappear Four and a half months later mucous patches on lips and prepuce. Papular syphilis, etc. ance. Vidal de Cassis ("Traite des Maladies Veneriennes," 2d. edition, pp. 479, 480) reports a case of a tumor of the right clavicle occurring one month after chancre. The skin covering is perfectly healthy, the tumor twice the thickness of the bone. Extreme localized pains Cure in two months time. Dr Guyot (Societe Medico Chiurgicale de Paris, July 9, 1868) reports a case of syphilitic periostitis of the first metatarsal bone, fity-six days after infecting exposure. According to M. Daga ("Documents pour servir a l' Histoire de la Syphilis chez les Arabes," Archives de Medecine, 1864, t. ii. p. 314), syphilis is so severe among the Arabs that it is not rare to witness in the same subject the presence of syphilides, of gumma, and of multiple exostoses. Tertiary symptoms themslves may be observed at the very beginning of the disease. According to the researches of M. Maltegazza syphilis pursues its course with great rapidity in South America, and manifests itself from the beginning not only by superficial cutaneous and mucous lesions, but by osseous lesions and the destruction of the bones of the nose al most immediately after the appearance of the chancre, and always before its cicatrization. (Quoted by Mau riac). As eminent an authority as Prof. Hutchinson, of London ("Some of the Moot Points in the Natural History of Syphilis," British Medical Journal, January 24, 1886), reports the following interesting case: ning of the affection was only four months previous. He died suddenly and unexpectedly. The necropsy showed gummata in both testicles, in the spleen, and in the heart, death having been caused by the softening ulceration of the latter." He adde, in conclusion: "I have urged that many of the phenomena of syphilis usually counted as tertiary really occurs, as a rule, in the early periods, and there is no structure of the body which may not be attacked in the secondary stage. As an instance of this fact, I have mentioned rupia, periostitis, and disease of the viscera and nervous system." Dr. R. W. Taylor, of New York, in an article entitled "Precocious Gummata" (American Journal of the Medical Sciences, July, 1887), describes several interesting cases of that form of the skin affection. He says, in conclusion, that these lesions may appear as early as the second, third or fourth month after the initial lesion, and may terminate in ulceration. Records of early syphilis of the nervous system are also attainable. Taylor reports a case of hemiplegia in the fifth month. Bassereau and Vidal de Cassis one of facial paralysis a few weeks after appearance of chancer. Van Buren and Keys and Fournier respectively give instances of several cases of different forms of paralysis occurring before the fifth month. Fortunately these cases are very rare. For example, Mauriac mentioned that the thirteen cases reported by him represented an experience of over four thousand cases. Whether they represent an unusual amount of the virus absorbed, or an undue susceptibility on the part of the individual is an open question. The generality of opinion would seem to indicate the possibility of a severe syphilis following a case of phag edenic chancer, as in this report. For example, Batington tells us (Ricord and Hunter, "Venereal Diseases," 2d edition, p. 271) that "symptoms which follow the phagedenic sore are peculiarly severe and intractable. They commonly consist of rupia, sloughing of the throat, ulceration of the nose, severe and obstinate muscular pains, and similar inflammation of the periosteum and bones. Similar complaints will follow the ordinary chancer; but when they follow a phagedenic sore they are very difficult to be cured; and it is not uncommon that the consitution of the patient should at least give way under them, and that the case should terminate fatally," Bassereau ("Histoire Naturelle de la Syphilis, p. 84), as well as Diday, agree in the main regarding the above statment. Bumstead and Taylor ("Venereal Disease, 5, edition, |