tertiary syphilis, Wilhelm Perls comes to thing is certain, the association of lupus the following conclusions: I. In the clinic (Breslau) and in private practice from January 1, 1901, to January 1, 1907, there were 6203 syphilitic patients who applied for treatment. Six hundred and five of these were suffering from tertiary syphilis, and of this number 60.3 per cent. had never received any antisyphilitic treatment, 17.3 per cent. had received one course of treatment, 21.4 per cent. had been treated symptomatically, and .66 per cent. had been treated by the chronic intermittent method. The statistics showed that the main cause of the appearance of tertiary manifestations consisted in insufficient treatment or entire lack of treatment during the primary and secondary stages of the disease. Two objections to the chronic intermittent method of treatment have been erythematosus and lupus vulgaris is extremely rare, only two cases, those of Besnier and of Lacavalérie having been reported. In neither of these cases were histological examinations made which would have rendered the double diagnosis positive. Jarisch, indeed, considers that in these cases a mistake in diagnosis must have been made. He considers that masses of elastic fibers in a condition of colloid degeneration have been mistaken. for lupus tubercles. In the writer's case histological examinations were made which showed positively the associated lesions of lupus erythematosus and lupus vulgaris. In some of the sections tubercle bacilli were found. A Case of Activomy- Kulbs (Wiener Klin. cosis of the Big Toe. Ichschrfts. No. 2, 1907). The author calls attention to the resemblance of the pathological and mi raised. In the first place, it is claimed croscopical picture observed in this case that as the tissues become accustomed to mercury the potency of the latter decreases. In the second place, it is claimed that the continued employment of mercury produces injurious effects on the tissues that counterbalance its well-known good effects. These objections have not proven valid, in the writer's opinion. Certainly no injurious effects have been noted in the chronic intermittent form of treatment, the method advocated by the writer. Association of Lupus Ludwig Spitzer Spitzer Erythematosus and Lu- (Annal. de dermapus Vulgaris. tol. et de syph., March, 1907). With regard to the question as to whether lupus erythematosus is a form of tuberculosis or not dermatologists are divided in their opinions. One with the peculiar condition known as Madura-foot. The patient underwent an inflammation of the big toe, with suppuration of the matrix of the nail, followed some months after its complete subsidence by another thickening of the toe, but without any pain or other disturbance. Two years after the shedding of the nail the toe rapidly increased to the triple circumference of the opposite toe, vesicles appearing on the skin and undergoing suppuration. The toe was amputated, and the examination showed the presence of actinomycosis. of actinomycosis. The author assumes that the infection with actinomyces occurred during the first inflammation of the matrix, perhaps through the use of straw soles. No definite anamuestic data were obtainable, and the prolonged latent period appears noteworthy. F. R. The Treatment of Gonorrhoea. IN CHARGE OF WALTER C. KLOTZ, M.D., Genito-Urinary Surgeon, Roosevelt Hospital, O. P. D. . The Scottish Medical and Surgical Journal contains a useful paper on the treatment of gonorrhoea by irrigation, from the pen of Dr. J. S. Purdy, who has made some interesting experiments in order to demonstrate that ordinary urethral injections do not penetrate beyond the membranous urethra. With a fourdrachm glass syringe he injected into the urethra of a cadaver a solution of methylene blue. He found that staining occurred as far as the termination of the membranous portion, but no further. On using the douche tin an elevation of two and one-half feet was sufficient to stain the prostatic urethra, and of three feet for intravesical irrigation. On the living subject an elevation of not less than five and one-half feet was necessary to reach the bladder without a catheter. For intravesical irrigation it is better to use a catheter. Although the resistance may be overcome by using a column of water sufficiently high, it is not always advisable to do so, especially in nervous patients. Dr. Purdy has previously published his experience in the treatment of gonorrhoea with the new organic compound of silver, protargol, at the London Lock Hospital. This body has the advantage of being non-irritating even in strong solutions. After first washing out the urethra he injects four times daily a 5 per cent. solution, which the patient holds. in the urethra for at least five minutes. In from four to ten days all obvious discharge ceases. On the cessation of the discharge he uses a weak astringent injection, a solution of sulphate of zinc, one grain to the ounce, which is held in the urethra for half a minute. In some cases cure is completed within 14 days. In posterior urethritis Dr. Purdy has obtained good results from deep instillations of silver nitrate, and in some obstinate cases finds this method necessary, but he considers that no method gives such uniformly satisfactory results as urethral and intravesical irrigation. He uses a doublechannel nozzle made of celluloid or metal, consisting of two tubes concentrically arranged so as to allow the fluid to flow through the inner and to return by the outer. An ordinary burette clip serves to control the stream. Dr. Purdy's experience of the urethroscope is not fortunate. In some cases the disease was even aggravated by its use. Much practice and skilful manipulation are required in order to use this instrument with benefit.-The Lancet. Cystocele. C. P. Noble, Philadelphia (Journal A. M. A., December 14), says that cystocele must be understood as a part of a complicated process, is usually secondary to injury of the pelvic floor, and is generally associated with hernia of the pelvic contents, commonly spoken of as procidentia uteri. The exceptions are in cases of marked muscular relaxation of the pelvic tissues, of absorption of perivaginal fat, of exaggerated intra-abdominal pressure, or combination of two or three of these factors. Its cure involves, therefore, not only the restoration of the anterior vaginal wall to the normal, together with as much detachment of the bladder as will permit it to rise to its normal position in the pelvis, but in addition the various ments. 2. Besides these mixed embryonic tumors there occur in children certain socalled malignant kidney tumors, which originate, as a rule, however, from the surroundings (suprarenals, perirenal tissues, retroperitoneal glands), secondarily involving the kidney. These tumors do not grow as rapidly as the first-mentioned group; they often extend to the surroundings, and they have a marked tendency to the formation of metastases. other pelvic lesions must be corrected. striped muscle tissue and glandular eleThe bladder is supported not only by its own proper ligaments, but, like the other pelvic contents, by the sacral segment of the pelvic floor. Another important factor is the position of the uterus. Normally it is anteflexed, and increase of intra-abdominal pressure serves to increase the anteflexion. With retroversion the pressure forces the uterus down and out the vaginal canal, and the bladder with it. The chief credit of demonstrating the correct principle of the operation for cystocele is due to Hadra of Texas, who showed that the proper method is to incise the anterior vaginal wall, detach the bladder from the anterior face of the uterus and laterally from the vagina so as to permit it to rise in the pelvis, then to resect the anterior vaginal wall to get rid of excess of tissue, and follow this by suturing the anterior vaginal wall to the anterior face of the cervix so that it may become attached and prevent the descent of the bladder. All the various new operations proposed are more or less dependent on this principle for their value. Noble describes his technique of the operation in detail. Malignant Tumors of Wiener Klin. (Wih I. Embryonic adenosarcomata, or tumors sharply outlined from the renal tissue by a connective tissue layer. This form is clinically characterized by its excessively rapid growth, its slight tendency to involve neighboring organs and the formation of metastases. HistologHistologically, these tumors are especially characterized by the constant occurrence of The author describes three cases concerning children aged 24, 134 and 21⁄2 years, respectively. The first case belonged to the former, the second and third to the latter group. All three cases presented the common clinical feature that all symptoms pointing to the existence of a renal tumor were absent, except the demonstration of a reteoperitoneal swelling. The urine was invariably found to be normal. The absence of hæmaturia, etc., seems to be by far the most common in the renal tumors of early childhood (about 75 per cent. of the cases). The extirpation of the neoplasm can enter into consideration only in the embryonic adenosarcomata, which are not associated with the formation of metastases. However, the results are as yet unfavorable even in these cases, because the patient, as a rule, is placed too late under the care of the physician. F. R. megaly, hyperplaria, duplication of the bladder and the formation of diverticula. Small diverticula, which do not give rise to disturbances, do not require treatment. As regards vesicular exstrophy, the author considers Treudelenburg's method as the most rational. In a general way, the only therapeutic measures indicated in congenital malformations of the bladder consist in surgical interventions, such as incision, exclusion or extirpation. F. R. Eye-Strain. OPHTHALMOLOGY. UNDER THE CHARGE OF W. M. CARHART, A.B., M.D., Assistant Surgeon, Manhattan Eye and Ear Hospital, New York City. In an interesting article (The Medical Standard, December and January), entitled "The Seven Deadly Sins of Civilization," George M. Gould names eyestrain as the greatest of these, and gives the following reasons: 1. Because of its almost universal existence, the majority of people in our life being subject to it in varying degrees. 2. Because it is almost impossible for nature to make the human eyeball without little or much imperfection of shape (astigmatism, hyperopia, myopia), so its functioning becomes necessarily malfunction or pathogenic. 3. Because civilization compels nearwork of the eyes (reading, writing, sewing, handicrafts, machinery, etc.), by so large a majority, for so many hours a day; for this the mechanism of the "accommodation" was not created, nor much used prior to very modern times. Continuous innervation of a muscle or its too constant contraction is impossible, and produces disease; when, as in the case of complicating astigmatism, etc., the too long and too severe contraction becomes otherwise obnormal and unequal, then the pathogenic action becomes extreme. 4. Because, as no other sense organ, the eye is the conditio sine qua non of motility and development of all the higher organisms. The essential structure of the eye, the retina, is embryologically brain substance. The brain comes out to see. And every activity of the body depends upon precedent and governing vision. Intellect itself is fundamentally and initially visual. Morbid vision is therefore the great cause of the exclusion of the unfit in evolutional history, and the natural selection or survival of the fit has consisted in large part of the survival of the ocularly fit. And eyestrain, therefore, while not suddenly or directly killing, produces more widespread and varying morbid functions. of the organism, more suffering, than any other cause enumerated. Toxic Amblyopia. Eugene M. Blake (Yale Medical Journal, January) describes nicely toxic amblyopia in its chronic form of retrobulbar neuritis as follows: The man says that there is a cloud or film before his eyes. In the objective examination of the eye we discern nothing abnormal until we search the eye-ground in the region of the optic nerve entrance with the ophthalmoscope. Here we find usually an area on the temporal half of the discs much paler than the rest of the nerve-head and roughly triangular in shape, with its apex at the center of the disc and base at the margin. The situation of this triangular area corresponds to the location of the papillo-macular bundle which supplies the macula lutea. The degree of pallor varies; in the early cases it may even be replaced by a slight congestion, while in older cases it is a glistening white sector. Uthoff found this white area in 14 per cent. of 1000 inebriates. The visual acuity varies from nearly normal to the ability to count fingers at but a few feet distant. Both eyes are almost invariably affected, although Dayne saw a case where one only was involved. ner. An examination of the field of vision shows it to be of normal extent for form and color, but as we approach the fixation point we discover a negative scotoma for color-a region in which colors are indistinctly seen and easily confused. Thus, red and green are not accurately identified as separate colors, but merely possessing different intensities of one color. Other colors may be confused in a similar manA bit of absorbent cotton seen in the periphery of the visual field seems to be a purer white than one upon which the patient fixes his gaze. The central scotoma for color extends from the fixation point to the temporal side for about 15 degrees, and corresponds to the area of the fundus included between the optic nerve entrance and the macula lutea. The scotoma is roughly oval with its long axis horizontal. The fact that the perception of red and green is most disturbed points to a lesion of the transmitting fibers, while the inability to distinguish blue and yellow would indicate a lesion of the recipient elements. The presence of a central color scotoma is the most important symptom of toxic amblyopia (Fuchs). The prognosis of this type of amblyopia depends upon the stage in which the patient is seen and upon his ability to discontinue the use of the causative factors. If seen before the pallor of the disc sets in (which is at first due to an anæmia of the nerve and later to atrophy), the physician may expect a restoration of sight practically to the normal. If, however, the nerve is atrophic, the prognosis is not so good, but better vision may be looked for upon the withdrawal of the poisons. Absolute blindness never results. The first step in treatment is the complete withdrawal of tobacco and alcohol, and this in mild cases suffices for a cure. The next indication is to aid the elimination of toxins by the use of potassium iodid, Turkish baths and careful regulation of the diet to secure of its being easily digested. Potassium iodid may be given as an alterative when improvement. ceases. Strychnine is used with great advantage and in ascending doses. Some observers have claimed an added effect by injecting the sulphate into the temples. The use of the eyes for close work should be prohibited. Treatment usually extends over several weeks to months. The Conjunctival Re- An editorial in the action in Tuberculosis. Yale Medical Journal (January) says: The conjunctival test, or, as some call it, the ophthalmo-reaction, if positive, results in a conjunctivitis of varying intensity, most marked in the region of the caruncle, at times quite severe, but usually nearly painless. The conjunctival reaction has the great advantage over the subcutaneous reaction that it does not cause. general symptoms, and for this reason it may be used in febrile patients. It is contraindicated only in inflammatory diseases. of the eye itself. If the later figures continue to indicate the same degree of reliability as the earlier ones, we have in the conjunctival test an easily-applied and valuable aid in the early diagnosis of pulmonary tuberculosis. There is not yet |