referable to other reasons in this case. At any rate, a series of other experiences illustrate the fact that depressions of skull bones are not necessarily followed by disturbances, while in certain other cases the existing disturbances were not referable to the re-implantation of the bones, but to focal destructions of the brain. It certainly resulted from the findings at the time of discharge, and from the subsequent examinations, that injuries of the skull-capsule alone as well as injuries with involvement of the cranial contents, in which the cranial gap was covered at once, may heal completely without any remaining disturbances.

Secondary closure of traumatic cranial gaps was performed in four cases, three times on account of the danger involved by a merely membranous covering of the brain for a man of the laboring classes, and in one instance on account of posttraumatic epileptic seizures.

In 30 patients the gap was not closed during the first management of the skull wound, and healing was aimed at by granulation. Among these 30 patients eight succumbed to the severity of the injury; the remaining 22 left the hospital cured, some with a gap in the bone. Among the cases discharged with a large gap, one patient was especially interesting in so far as he developed typical epileptic convulsions, in spite of the absent bone covering. Altogether, three among the six patients discharged from treatment with an open gap were found subsequently free from disturbances.

The author's opinion, upon the basis of his observations and of a comparison with

analogous publications from other clinics, is to the effect that it is advisable to close recently-acquired gaps in the bony roof of the skull in complicated fractures immediately if possible, since the cases treated in this manner present better results, in regard to the permanency of the cure, than those healed without covering of the cranial gap. The author hereby opposes the view of Kocher, who advocates that the skull be left open. He quotes a few cases against the validity of this view, including a recent case of Korte's, in which precisely the covering of the bony gap served to remove the preceding disturbances from vertigo up to epileptiform seizures. F. R.

In syphilis of the central nervous system the writer tested 16 cases (Endarteritis, tabes), and found 13 positive reactions, or 81 per cent. In the examination of a much greater material Plaut obtained nearly 100 per cent. of positive reactions. In cases of paralysis Raviart, Breton and Petit obtained positive results in 93 per cent. of the cases.

Interesting figures showing the results of testing latent cases, e. g., cases without manifest symptoms, are as follows:

Positive results in percentages:
Early Late

Manifest latent latent

Author Fleischmann Citron-Blaschko

Müller
Bruck-Stern

The result shows a decidedly higher percentage in cases showing symptoms of the disease. In the latent stages the number of positive reactions is decidedly smaller, and between the early and late stages a difference in favor of the first is apparent.

With regard to the influence of treatment, the following conclusions are. drawn by Citron, who was the first to experiment in this direction: Citron states that the longer the syphilitic virus has acted upon the body and the more

frequent the relapses, the more regularly and intensively does the syphilitic serum contain anti-bodies (e. g., gives a positive reaction).

Further, Citron concludes that the quicker the treatment with mercury is instituted, the longer it is continued; the more frequent the courses of treatment are repeated, the more suitable the method of treatment, and the shorter the period since the last course of treatment, just so much more often will the result of the test be negative.

In a number of cases a negative test before treatment becomes positive, after treatment of varying duration. In 18 out of 48 cases Müller saw after treatment a positive test changed to a negative one, or, at least, became less positive. Citron observes that early secondary symptoms and early relapses, by treatment of similar duration and vigor, show a greater tendency to become negative than late relapsing and tertiary cases. On account of lack of knowledge of the bodies contained in the syphilitic sera, it is not at the present time possible to say whether their disappearance means that the disease is cured. Why in a series of cases treated vigorously, some react positive and others negative, we cannot now say. We do not know how quickly a positive reaction can change to a negative

reaction, from the influence of treatment. We do know, however, that a negative writer describes a case, at first negative, reaction can later become positive. The that later became positive, when new manifestations of the disease appeared.

As we do not know fully the nature of substances found in the syphilitic sera, the meaning of a positive and negative reaction remains uncertain. One thing is certain, that a positive reaction means syphilis. It is also practically sure that the bodies for which we test do not rep

resent substances that are either protective or healing, as the test is most often positive when the disease is active, and often negative during or after a course of treatment. It is possible that we do not have to do with anti-bodies against the poison of syphilis, but with certain anti-bodies, possibly autocyto precipitins, excited under the influence of the infection.

From a diagnostic standpoint, the Wassermann test promises to give many practical results.

In many doubtful cases of disease it is of great importance to know whether at any previous time an infection with syph ilis has occurred. In the case of a primary lesion a positive reaction is conclusive of its specific nature, and probably shows that the virus has already become generalized. In these cases the serum test can rival examination for the spirochaeta pallida.

The reaction will surely be of importance in aiding in the choice of wet nurses and in the examination of prostitutes.

The reaction will also play a part in medico-legal cases where a former syphilitic infection is given as a ground for divorce.

The value of a negative test is of much less importance than a positive one. Where there are no manifest symptoms, a negative test proves nothing. Where there are suspicious symptoms of syphilis,

a negative test must be considered of more value.

No conclusions whatever can be drawn from the Wassermann test regarding the degree of infectiousness of a case of syphilis. Regarding the question of permission to marry, some weight may be given to the test. A positive test does

not necessarily mean that marriage should be forbidden. Blaschko has described cases where the father of a family, happily wedded, free from lesions, who had contracted the disease perhaps 20 years previously, yet gave a positive reaction. In other cases, where the infection is more recent, no harm will certainly be done by advising an energetic course of treatment before giving consent to marriage. A negative test, in a candidate for marriage, must be considered as favorable, and a thing to be desired. From a negative test, however, no guarantee can be given that the patient will remain free of the results of his infection.

A complete cure of the disease cannot be guaranteed from a negative test. The reaction, as stated before, can change, and a negative test change to a positive one, with the outbreak of fresh manifestations.

A most important question to consider concerns the indications given by the test for beginning or ending treatment. Citron proposes that, instead of the usual chronic intermittent method of treatment, there should be a chronic intermittent examination of the blood, and that only when the test is positive should treatment be instituted. Such a method seems to the writer dangerous, as we know that in certain cases shortly after a negative finding that lesions appear, and the test becomes positive.

In old cases in which no manifestations have occurred for a long time, a positive reaction should be an indication for again instituting treatment. On the other hand, a negative test should not prevent treating a case where clinical experience has always shown treatment to be advisable.

and Functional Neuroses.

one much discussed of recent years, but

so important to every practitioner that reiteration of its truths may be pardoned. H. E. Smith (Medical Record) summarizes as follows:

The ocular conditions which give rise to eyestrain may be refractional, accommodative, or muscular. The result is loss of neuricity. The effects are remote and reflex, and may be expended on any organ, group of organs, the nervous system as a whole, or its separate divisions. It is the little refractional errors which give rise to the greatest trouble; poor vision and eyestrain are not concomitant conditions, but exactly the reverse. It is imperative to have the eyes of all children of school age examined under atropin; not only may health and comfort be conserved, but their whole future may rest on this simple thing. Refractional errors of high degree should be corrected, not because of any reflex disturbances, but to save the eyes from disease and to give their possessor better vision. The investigation of all obscure nervous phenomena should begin with the eyes; often it will be necessary to go no further. Typical sick headache is pathognomonic of eyestrain; if it is not cured, in 99 per cent. of the cases it is the fault of the refractionist. Finally, the disease cannot be cured unless the remedy is applied. Nearly right glasses will surely aggravate the symptoms, and relief can be obtained only by mathematically correct lenses in mechanically perfect settings.

The X-ray Treatment G. E. Pfahler (New of Exophthalmic Goitre York Medical Journal, October 24) says there have been recorded in the literature at least 51 cases treated by the Röntgen rays. Of this number 42 cases were followed by good results. In nine patients there was little or no improvement. In other words, good results were obtained in over 75 per cent. of cases, with no risk to the patient and no great inconvenience. This is surely in marked contrast to the results obtained by other methods.

The treatment should be localized upon the goitre, and may be carried to the point of producing a mild dermatitis, but not The first dose should not be ex

more.

cessive.

The permanency of the results is still a question, yet all the patients in which good results had been obtained had improved or remained well up to the time of the reports, which varied from a few months to three years.

The earliest and most noticeable improvement is the increase in weight. This is followed by improvement in all the symptoms. The two symptoms that remain longest are usually the enlargement of the thyreoid and the exophthalmos.

CONCLUSIONS.

Decided improvement may be expected in about 75 per cent. of cases.

This improvement consists of an increase in weight and strength, and gradual disappearance of the Basedow symptoms.

3. Some improvement should be no