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Warty growths are a not infrequent accompaniment of gonorrheal infection, especially in patients who have an insufficient appreciation of the advantages of personal cleanliness. The vegetations may vary in size from a pin point to a cauliflower mass. They adopt the physical characteristics of the tissue from which they spring, whether mucous membrane or skin, but they all have essentially the same histological structure. The sites most favored by these growths are, in the male, the inner surface of the prepuce, the coronal sulcus, the meatus urinarius, and the surface of the glans. A considerable growth within the sac of a tight prepuce may give rise to sloughing and sinus formation, or a strawberry mass may project from the preputial. orifice. In women the areas most prone to be affected are the inner and outer surfaces of the labia, the base of the clitoris, the vaginal walls, the cervix, and also around the anal orifice. Pregnancy favors the formation of large masses, owing probably to the increased vascularity of the parts.

Condylomata acuminata occur more frequently in women than in men, and in the female they attain much greater dimensions. Large cauliflower masses

may cover the vulva and perineum, while numbers of small warts occupy the adjacent skin and mucous surfaces. So long as they remain untreated they are kept moist by an offensive secretion containing the detritus of macerated epithelial and pus cells and numerous microorganisms. Histologically, they are composed of elongated branching papillæ, covered with an enormously thickened epithelium. The papillæ are supplied with capillary loops, surrounding which are frequent patches of small roundcelled infiltration. Special nerve endings found in the epithelial layer are connected with a fine network of nerve fibres in the base of the papillæ. The main bulk of the hypertrophy is due to the rapid proliferation of the swollen cells of the Malpighian layer, which is therefore greatly increased in thickness. Between these epithelial cells numerous mononuclear and polynuclear wandering cells are found. The surface cells which form the thin, horny layer tend to undergo maceration and desquamation, and minute areas of necrosis allow of serous and sometimes hemorrhagic oozing.

The customary association of condylomata acuminata with gonorrhea naturally suggests that the formation of these

growths is induced by the irritation of the gonorrheal discharge. The gonococcus has not been demonstrated in sections, but other organisms such as streptococci, staphylococci, and more recently spirilla have, of course, been found. Whether these papillary hypertrophies are the product merely of a mechanical irritation, or whether they owe their existence to the action of some specific organism, acting on a suitably prepared soil, is a problem still awaiting. solution.

Treatment-The treatment which conspicuously suggests itself for all condylomata acuminata is excision with suture of the wound under local anesthesia Ligature of each portion separately of destruction by the use of caustics and cauteries are only mentioned to be dismissed as barbarous both in use and effect.

But even excision has disadvantages which prevent it from being of universal application. When large masses, such as are not infrequently found in females, have to be dealt with, a general anesthetic is required, and from one to two hours may be employed in removing several separate cauliflower excrescences as well as numbers of smaller growths. The time is mostly occupied in controlling hemorrhage from the very numerous bleeding points. When the most thorough removal possible has been effected and the remaining skin and mucous surfaces examined, these are found to be seeded with minute papillary vegetations, which one is tempted to treat with the thermo-cautery while the patient is still under the anesthetic. The latter procedure is worse than useless, as it destroys only a fraction of the minute growths, healing is painful and slow, and the results of the cicatricial deformity may be deplorable, involving perhaps loss of the sexual function or control of the bladder. But even when the temptation to use any cauterizing procedure is resisted the result will be disappointing.

Recurrence, not of large masses, but of numerous smaller vegetations, is certain; all of the wounds will not heal by primary union as the maintenance of a clean field is impossible, and one can not foresee what will be the ultimate results of the cicatricial contraction. If, then, there are other methods of treatment which have any prospect of success they demand careful consideration. Several procedures have been advocated; formaline applied to small areas at a time is effective, but slow and very painful, for which reason I have had to discard it; carbolic acid and chromic acid are useful in the case of small growths, and are most effective when used alternately, but both of these poisons must be used with caution; resorcin and starch in equal proportions make a useful paste, but it is difficult sufficiently to localize its action, and inflammatory irritation may be produced; salicylic acid 1 per cent in precipitated chalk is recommended by Taylor as a dusting powder; chloral hydrate solution (1 in 8) has been suggested as a paint; tincture of iodine is another application which has its advocates. In my experience, however, the treatment which has been found to be most simple, effective, and free from objection is the application of lactic acid,

The mode of employment will depend upon the condition present. In the male circumcision is performed when necessary, pedunculated warts may be removed with scissors, and pure lactic acid applied to the base after the bleeding has been controlled. Other growths are treated with a continuous 1 per cent wet dressing or the occasional application of a strong solution. In the female, when there are several large masses, each portion is isolated and kept surrounded by strips of lint wet with a 1⁄2 to 1 per cent solution. The base of these growths may in addition be touched at intervals of a few days with the pure acid. Smaller growths are painted with the undiluted acid or a strong solution, and

when there is a large field of minute growths the wet dressing is employed. The dressings are changed as frequently as the amount of discharge necessitates, and at each change the parts are thoroughly bathed with an antiseptic, in the case of females a sitz bath being used. The largest masses wither and drop off, small growths are inhibited, and cure results without the formation of any cicatrices and without pain. The only disadvantage I have encountered in the use of lactic acid is the occasional occurrence of a general erythema when the treatment is pushed too energetically. This erythema is of trifling significance and quickly subsides on the temporary withdrawal of the acid and the substitution of a zinc and calomel dusting powder or ointment. On this account, however, it may be necessary when large areas are involved to intermit the treatment for two days in each week, and to protect the surrounding healthy tissues. with vaseline in order to discourage excessive absorption of the acid. As soon as the seats of gonorrheal infectionurethra, cervix, rectum, etc. can be reached, appropriate treatment is initiated, and this, combined with strict cleanliness, has an important influence in preventing the appearance of fresh growths.

The histories of a few cases kindly furnished me by Sister Frisby, of the Glasgow Lock Hospital, will illustrate

the method and its results.

Case 1-The patient, aged thirteen, was admitted on September 1, 1910, suffering from gonorrhea and mediumsized warty growths in the anal region. The warts were treated by cyllin sitz baths three times daily and application of pure lactic acid once daily. In four days the warts began to improve, and they had completely disappeared in twelve days. Patient was dismissed on September 16th.

Case 2 The patient, aged twenty-one, five months pregnant, was admitted on August 22, 1910, with gonorrhea and numerous warty vegetations on the skin

and mucous surfaces of the labia majora. Continuous wet dressing of 1 per cent lactic acid was employed. Improvement was manifest on August 27th, and completed on September 8th. Patient was dismissed on September 10th.

Case 3 The patient, aged nineteen, was admitted on September 5, 1910, suffering from gonorrhea and condylomata acuminata. Large masses covered the vulva and perineum and extended beyond the anus. The whole growth was as large as a medium-sized cauliflower. The patient at first had to be isolated on account of the very offensive odor. She had been previously treated for a short time in another hospital. The growth. had prepared and grown with great rapidity three months before admission. After being cleaned up with a 1⁄2 per cent lactic acid solution the masses were separately surrounded with strips of lint soaked in 1 to 100 lactic acid. In two days portions began to drop off and in seven weeks all traces had disappeared without the formation of any cicatrices whatever.

These cases sufficiently indicate the lines of treatment and the results to be expected in most instances, but certain varieties, especially where complicated with syphilis, are more resistant. The only claim I make for this treatment is that it is the most generally satisfactory of the many systems with which I have experimented.

MYOPIA OF STUDENTS IN CALI-
FORNIA.

Investigations made at the University of California show that the number of cases of myopia is exceptionally low. As the students come mainly from public schools of the State, the chances would seem to be in favor of a large portion of myopes. As this has not been found to be true, it must be due, the experts think, to the fact that in California the climate permits an abundance of fresh air in the schools because of the open windows during practically the entire school year.

condition in the tenseness of Poupart's ligament, and instead of stitching the conjoined tendon to Poupart's, I dissected down into the femoral region so as to expose the pectineal fascia and the femoral ring and stitched the conjoined muscle to Cooper's ligament with the object to avoid a secondary femoral hernia.

I would recommend this procedure in every case in which there is a lax muscular condition and a deficiency in the tenseness of Poupart's ligament in order to avoid secondary involvement.

EARLY DIAGNOSIS OF POLIOMYE-
LITIS.

R. Foster Kennedy, in a paper read before the Medical Society of the State of New York, stated that this disease was a primary general infection with local meningeal symptoms due to vascular changes and general symptoms produced by the specific virus. It was often difficult to diagnose early. As an example he cited the case of a boy who was to go on a sea trip who began to complain of headache, and while on the companionway of the steamer fell, and when he was picked up a paralysis from the neck down was noted. He developed incontinence of urine and hyperesthesia, but finally made a practically complete recovery. The speaker said the onset of this disease was usually sudden, with febrile manifestations, the temperature ranging between 101° and 102°. This might be accompanied by headache and vomiting. The pulse as a rule was not accelerated. The symptoms might not be severe enough to cause the patient to take to bed for the first two or three days. Coma and stupor might be indicative of cerebral involvement, although that diagnosis could only be made later, when the cerebral symptoms became marked. Hyperesthesia, pain in the neck and legs, Kernig's sign, and rigidity of the neck. were symptoms also present.

Influenza was said to differ from this disease in that catarrhal symptoms were present, the specific organism could be obtained from the discharges, and it occurred in a different time of the year,. namely, during the spring and winter. Summer diarrhea differed in the occurrence of diarrhea, high fever and sweating. In rheumatic fever the typical swellings were found. In tuberculous meningitis there always was a long prodromal course. The various meningitides, as tuberculous and cerebrospinal could be distinguished by lumbar puncture. In tuberculous meningitis the fluid obtained appeared clear or slightly turbid, with a fibrinous flocculus on standing for a short time. The globulin reaction was positive and Fehling's solution was not reduced.

In

To be noted was an increase in lymphocytes, and in 80% to 85% the presence of the tubercle bacillus was to be shown by testing the clot and appropriate staining on a slide. In epidemic spinal meningitis the fluid was turbid, and only in the early stages could a reduction of Fehling's be obtained. A polynucleosis of from 94% to 65% and the presence of Gram negative extra- and intracellular diplococci could be demonstrated. poliomyelitis the fluid poliomyelitis the fluid was clear or slightly opalescent, with a less marked clot formation. Early the globulin content was slightly raised, to disappear in three weeks. Fehling's solution was reduced. During the first one or two days the cytology was mainly polynuclear cells, and then changed to a marked lymphocytosis. No organism could be demonstrated by ordinary bacteriological means. He remarked that by serological tests the presence of abortive cases had been proven. The reflexes should be taken many times during the day, as a change, especially if unilateral, might be indicative of this disease. Differentiati. n from post-diphtheritic polyneuritis was also mentioned.