BY LOUIS A. DUHRING, M.D., Clinical Lecturer on Dermatology in the University of Pennsylvania, Physician to the Dispensary for Skin Diseases, Philadelphia. CERTAINLY but few diseases are more distressing in their nature, development, course, and symptoms than syphilis; and taking into consideration the many phases that it is wont to assume in one part of the economy or another, and its wide- spread presence in the community, it should demand the atten- tion and careful study of every practitioner. The diagnosis of this insidious disease is often attended with difficulty, more particularly at times when we are left without a clue in the his- tory, or where we are forced to depend upon objective symptoms alone. It is for the purpose of touching on one or two points in connection with the differential diagnosis that the following case is presented. The patient, William Toland, was admitted to the Philadelphia Hospital in May, 1867, while I was Resident Physician, and came under the care of Dr. F. F. Maury, one of the surgeons of the hospital, at which time he gave the sub- joined account of himself. He was twelve years of age; was born in Erie, Pennsylvania, and had always enjoyed good health until he was six years old, when he had sore eyes, attended by some discharge; but this lasted only a month, and passed off, leaving him in sound condition. When he was about ten years old, and in apparently excellent health, he was accidentally kicked violently on the nose by a man. This bruise did not heal, but some weeks after the nose became swollen and red, when it began discharging an offensive matter. About three months after this accident he noticed obstruction in the nasal passages; and one night, with an effort, he discharged from the anterior nares several pieces of bone. For some time after this event fragments of bone came away. From this date the de- struction of the surrounding tissues began, attacking first the septum, then the end of the nose, and extending to the lips, cheeks, forehead, eyelids, etc. At this period there was also swelling of the knee-joints, pains in the bones, and his health failed rapidly. Such is a brief summary of the history as the patient himself gave it. Let us now refer to some statements which his mother presented in reply to some questions for- warded by letter. The mother had always been healthy, and, as far as she knew, had never had any signs of venereal disease. She had had four children; one died at fifteen months of brain trouble, the other three were living and healthy, except William, The mother never had any miscarriages, and her children were all born sound. As far as she knew, the father of William never had any signs of venereal disease, and was healthy with the exception of some heart trouble. Nor, after close question- ing, could any clue be obtained from the mother that there was any ground for suspecting syphilis in either parent. When he was admitted to the hospital in 1867, the accom- panying photograph was taken, which shows accurately the extent of the disease at that time. The boy was in a miserable condition, and the disease was still spreading rapidly over the face. The ulcers were deep, excavated, with sharply-defined edges, and in some cases extending down to the bone, which was bare. There was no pain, itching, or burning connected with the ulcerations except when the parts were dressed, the removal of the rags causing some pain. To the ulcers, applica- tions of various kinds were from time to time made, to favor cicatrization. Inwardly the patient took tonics and iodide of potassium for two or three months, after which time he passed from my notice. At the present time, May, 1871, the patient is still an inmate of the Philadelphia Hospital, and his condi- tion is very much as follows: He is now sixteen years of age, is thin and emaciated, with a poor appetite. appetite. He is subject to pains in the legs, and can predict a change in the weather by the fact of the pains coming on. The ulcerations which existed four years ago, already described and as seen in the photograph, have cicatrized to a great extent, but the ulcers about the eye- lids and around the nose are still open, with but little tendency to heal. His skin over the whole body is soft, flabby, and lax, particularly so about the face. He has no control over the saliva, which flows continuously from him. He suffers no pain. Both eyes are covered with a thick, opaque deposit, and his sight in consequence is nearly gone. His condition and the