which patients who presented themselves for treatment within twelve hours of the supposed inoculation had developed a chancre six weeks later.

DOCTOR CHARLES H. CHETWOOD: There seems to be a general tendency at the present time to question whether syphilis should be treated. in the primary or in the secondary stage. The reader of the paper has emphasized the point that the question is not when to treat it, but that it should be treated when the diagnosis has been made. For my part, I have always treated it when the secondary eruption appeared, and consider it a safe procedure. I would not advise commencing treatment earlier unless the presence of the disease should be positively substantiated by the spirocheta pallida or some other germ. I treat all cases according to the general exigencies of each individual condition, and the results have been most satisfactory.

DOCTOR JOSEPH H. ABRAHAM: Next to the dermatologist and the genitourinary surgeon, the nose and throat specialist sees as many cases of syphilis as any of the specialists. They rarely see any primary syphilis, but many secondary and tertiary cases come to their notice. Personally, I have seen five cases. One patient had the initial lesion on the lip and the other four on the tonsils, and in one case the upper respiratory glands showed marked symptoms of intoxication. Another marked feature is the enlargement of the leutic glands. I agree with the principles laid down by the reader of the paper for the treatment of primary syphilis. Secondary syphilis of the larynx should be treated entirely by personal rule. I rely upon one drug, carbolic acid. An application of ten per cent chromic acid to the larynx gives rise to practically no pain and accomplishes the desired result. If the patient is given a sufficient amount of mercury for a long enough period of time, he is less liable to require the iodides or to suffer from a marked tertiary form later. I have never found it necessary to give more than seventyfive or eighty grains of the iodid at one dose, and always begin with. five grains and increase one grain daily or every other day. The absorption occurs as desired and the digestive tract is not disturbed.

DOCTOR ROBERT H. M. DAWBARN: I believe the wisest course is to begin treatment of syphilis as soon as one is sure of the character of the lesion. I do not agree with the statement that the iodid of potassium has no direct bearing upon the foundation of syphilis. In my opinion, overeating and overdrinking may so change the metabolism of the human system as to render the effects of syphilis more intoxicating.

DOCTOR JOHN A. BODINE: The time to begin treatment depends greatly on the character of the patient. The primary duty of the physician is to effect a cure. If the patient is a highly intelligent one, the treatment may begin as soon as the diagnosis is positively made, as that character of patient may be depended upon to carry the treatment. through to its logical conclusion. With a more ignorant patient, it is often necessary to first convince him that he is a victim of this disease in order to impress upon him the necessity for systematic and long

continued treatment and in this case the appearance of the skin eruption following the sore convinces him that he has syphilis.

DOCTOR ROBINSON: I still think the treatment should be begun, if possible, during the first stage of the disease. If the patient presents what he considers the initial lesion, I recommend a six weeks' course of treatment with mercury, and if, at the end of that time, there remains any question as to the diagnosis, it is very easy to bring out a small lesion as convincing proof.

REPORTS OF CASES.

URETHRAL FISTULA AND PROLAPSed kidneyS. DOCTOR CHARLES H. CHETWOOD: I wish to show a patient on whom I operated two years ago for urethritis, and who at the present time has an incomplete fistula. When first examined his symptoms seemed to point toward the urethra and prostate, the latter being about the size of a small orange and very hard. The history indicated a gonorrheal infection, and, apparently, a syphilitic abscess of the prostate. The patient urinates every half hour, day and night, and the bladder contains about twelve ounces of residual urine. The appearance of the urine is indicative of kidney pus. Both kidneys are prolapsed and the right one is very palpable, enlarged and tender. The interesting feature of the case is the prolapse of both kidneys without any apparent explanation. There is no tuberculous history and none suggestive of kidney disease. My intention is to drain the prostatic abscess through a perineal incision, examine the bladder through the opening, and possibly catheterize one of the ureters.

SYRINGOMYELIA OR LEPROSY?

DOCTOR JOHN A. BODINE: I desire to present this patient. She is twenty-one years of age, and her family history is negative. About six years ago she first noticed that she was unable to distinguish the impact of the soles of her feet against the sidewalk and began to have aching pains in her feet and legs. Later, pus formed beneath callous spots on the feet and discharged, leaving sinuses leading down to the metatarsal bones. Rest in bed healed the sinuses, but on resumption of her occupation they reopened. Pain was present in her spine from the neck to the coccyx. She was operated on for contractures of the feet in 1902. Her general health is now fair. The soles of her feet are covered with multiple perforating ulcers. The discharge is thick, brownish in color, and has a peculiar sickening, penetrating odor. There is an abscess under the skin in one thigh and another over the sacrum. There are marked motor and sensory disturbances of the feet and legs. The case is presented for diagnosis, which I think lays between syringomyelia and leprosy.

DISCUSSION.

DOCTOR WILLIAM B. PRITCHARD: I consider this patient an example of syringomyelia presenting the exception in a distribution of symptoms in the lower rather than the upper extremities, though both are involved.

The trophic disturbances in the feet, with bladder symptoms, scoli

osis, and, finally, dissociation sensory phenomena, indicate with fair clearness the diagnosis. It is not a leprous neuritis, as the nerves show no bulbous enlargements and the skin is quite free from the characteristic plaques. Tabes has been suggested, but there is little in the symptom picture to sustain such a suggestion. Absence of the Argyll-Robertson pupil, the persistence of one knee-jerk, with absence of true ataxic gait and characteristic pains were collectively conclusive in negation.

ORIGINAL ABSTRACTS.

MEDICINE.

BY GEORGE DOCK, A. M., M. D., D. SC., ANN ARBOR, MICHIGAN.

PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN.

AND

DAVID MURRAY COWIE, M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN MEDICINE IN THE UNIVERSITY OF MICHIGAN.

MALTA FEVER.

CHARLES F. CRAIG ("International Clinics," Volume IV, Fifteenth Series, page 89) gives a brief but very valuable study of this interesting disease, based upon twelve cases observed by himself. One of the twelve seems to have acquired the disease in Washington, District of Columbia, the first recorded as originating in the United States. None were fatal; all but one had had one or more previous attacks; seven presented acute exacerbations, five, chronic symptoms. Craig finds the symptomatology so complex that no case can be considered as absolutely typical. The most marked symptom and the one most complained of is severe pain in the muscles and around the joints. In acute cases it was most intense in the lumbar regions and the extremities. In chronic cases it was generally localized around one or more joints, was paroxysmal, often leaving one joint and appearing in another. The temperature curve is not so characteristic as has been believed. In first attacks the undulant type occurs, with a gradual rise, gradual fall, and several days of normal temperature. But even in acute cases such temperature curves are the exception. "In the majority of cases the temperature curve, instead of being an aid to diagnosis is the reverse, and is the chief cause of mistaken diagnosis." There is an anemia, with leucocytosis, the white count ranging from 16,000 to as high as 28,000, the increase being in the polynuclears. The kidneys seem to escape injury; even albuminuria is rare. Pain and swelling of the joints do not usually occur in first attacks, but during the second, third or fourth; rarely not at all. There is moderate swelling, with some reddening of the skin. The skin is hot; there is great tenderness on pressure, but no effusion can be detected. The most valuable aid to diagnosis is the agglutination test with micrococcus melitensis, first observed by Wright, of Netley, and in high dilutions-preferably 1:75.

The reaction is marked and immediate. Craig has never found the reaction in any other disease; it failed him once in an undoubted case. Malaria, typhoid fever, tuberculosis, pneumonia, septicæmia and pyæmia, relapsing fever, and Hodgkin's disease and articular rheumatism must be differential. The author suggests a wider distribution for Malta fever, even in temperate latitudes, than is generally supposed.

SURGERY.

G. D.

BY FRANK BANGHART WALKER, PH. B., M. D., DETROIT, MICHIGAN.

PROFESSOR of SURGERY AND OPERATIVE SURGERY IN THE DETROIT POSTGRADUATE SCHOOL OF MEDICINE; ADJUNCT PROfessor of operative surgERY IN THE Detroit College of medicine.

AND

CYRENUS GARRITT DARLING, M. D., ANN ARBOR, MICHIGAN.

CLINICAL professor of surgERY IN THE UNIVERSITY OF MICHIGAN.

SCOPOLAMINE AS AN ANESTHETIC AID.

WITHOUT championing any anesthetic or mode of anesthesia, Royster sums up in Surgery, Gynecology, and Obstetrics for February, 1906, his experience with fifty cases. He believes: (1) That ether is our safest general anesthetic; (2) That ethyl chloride secures the pleasantest primary narcosis; and (3) That the preliminary use of scopolamine with morphine increases the patient's mental resisting power and lessens the quantity of ether.

From its use clinically the writer does not regard scopolamine identical with hyocine. He believes it safe in proper doses, not to exceed one one-hundredth of a grain. This dose he has sought to use with one-sixteenth grain of morphia about one hour before the time set for the operation. When the patient is brought in, primary anesthesia is induced in about one minute by ethyl chloride sprayed on several layers of gauze folded over nose and mouth. The ether cone is then used and the patient is ready in four or five minutes. This method, apparently complicated, he states is really simple and produces sleep safely, swiftly, and sweetly. He does not regard scopolamine harmless, however, two cases having caused his anesthetizer to doubt whether he should proceed.

GYNECOLOGY.

F. B. W.

BY REUBEN PETERSON, A. B., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

AND

CHRISTOPHER GREGG PARNALL, A. B., M. D., ANN Arbor, Michigan.

FIRST ASSISTANT IN GYNECOLOgy and obstetrics in the unIVERSITY OF MICHIGAN.

THE TREATMENT OF ABORTION.

BOLDT (Journal of the American Medical Association, Volume XLVI, Number II) considers at length the treatment of abortion in its various stages. He divides abortion into four classes, that is: (1) Imminent abortion, in which the symptoms may subside on treatment;

(2) Progressing abortion, when the expulsion of the ovum cannot be prevented; (3) Incomplete abortion, when the contents of the uterus. are partially expelled, some portion still being retained; (4) Complete abortion.

The treatment of imminent abortion consists in absolute rest in bed and the administration of morphine or codeine as necessary. Tampons, ergot, and ice-bags are to be avoided on account of the liability of starting up uterine contractions.

Progressing and incomplete abortion, in the absence of symptoms of sepsis, are to be treated by first giving a hot antiseptic vaginal douche and then firmly packing the vagina with gauze. After twenty-four hours the gauze is removed and usually the products of conception are found free in the vagina. In case the os is well dilated and the ovum still remains in the uterus it may be possible to introduce the finger and effect a manual removal, or the vaginal packing failing, the cervix and lower uterine segment may be tamponed and the vagina filled with gauze; the subsequent procedures being the same as after vaginal packing alone. Should the bleeding be severe when the patient is first seen, it is inadvisable to adapt the above plan. Instead, the cervical canal should be dilated sufficiently if not already patulous and the ovaum or retained decidua removed by the finger or with a placenta forceps. Ergot may then be given.

Complete abortion requires no treatment except rest in bed, vulvar irrigation, and the usual measures carried out with puerperal cases. Curetment to remove the decidua is unnecessary and hence inadvisable.

If there is bleeding several weeks after a supposed abortion the uterine cavity should be examined and, if necessary, curetted. When evidences of infection are present, the uterine cavity should be emptied as completely as possible, whether the ovum has been spontaneously expelled or not. A curet should be used to remove adherent infected membranes or decidua, and an antiseptic intrauterine douche carefully given. Great caution is always necessary in curetting the uterus after an abortion.

The general tenor of the article is in advocacy of a conservative, expectant method of treatment in all noninfected cases of abortion. The author is of the opinion that much harm has come from a tendency on the part of many practitioners to adopt really dangerous methods of interference in simple cases.

PEDIATRICS.

C. G. P.

BY ARTHUR DAVID HOLMES, M. D., C. M., DETROIT, MICHIGAN.

ORIGIN OF TUBERCULOSIS IN CHILDREN.

HYNDS (Virginia Medical Semi-Monthly, May, 1905) observes that tuberculosis in children is a more frequent occurrence than is commonly supposed. Fisher says that one-third of the deaths of childhood are due to tuberculosis in some form or another, and more frequent under