ment of the spleen had long been recognized in heredi- married people, and in the last place, where in the case tary syphilis, that it was just as common and just as of pregnant women, where we owe our highest duty to constant in early acquired syphilis, although it had not the child. Now, in such cases, you ask, does not the before that been pointed out. According to him, how objection which you have already urged remain? They ever, the course of enlargement of the spleen prior to do remain, but they are superceded by a more important the occurrence of the roseola is the earliest syphilitic consideration, so that we take the chances. I believe symptom-the earliest secondary symptom. But this then that this is not a matter to be decided upon theo enlargement of the spleen differs from the enlargement retical grounds, but on practical grounds; if we begin of the spleen characteristic of malaria, in the fact that the treatment too early we cloud the patient's future, we the extension of the spleen is not downward and forward obscure the diagnosis; we will never be certain in our but upward and backward-progressing backward, that own minds as to the diagnosis, and in the last place, the is, beginning with the post margin below and progress- patient, as Dr. Ohmann Dumesnil said, is in a condition ing upward. I have found more than three and a half in which he suspects his physician of having defrauded finger breadths of dullness extending upward in the him and neglects treatment afterwards, and it is apt to axillary line with the corresponding dullness backward. become the subject of tertiary acident later. I have I know of no reason why the enlargement should extend had patients say to me, speaking of some of our most in that particular direction. I have looked for that in reputable physicians, Oh, that fellew tried to play me my clinical and private practice, and I must say that I for a sucker; that is the conclusion they come to, even have found it as a constant feature, and I regard it as where they have been treated for syphilis by reputable a symptom of the highest importance, but I would not physicians. base a diagnosis on it. I am inclined not to make up my mind until I see the roseola, although it may before that amount to an eminent probability.

DR. JELKS.-I am very glad to have heard the paper of Dr. Phillips. I did not expect to go into the physi ological pathology of syphilis as has been done, hence But now as to the second question: When shall we I shall say but little as to that. Dr. Phillips is in good commence the treatment of syphilis? shall we commence company,as one gentleman said, in the minority company it as soon as we are sure of our diagnosis? As both the that he keeps; and while that is true, I do not believe gentlemen who have spoken before me have said, there with that minority. David Crocket has well said: "Be is much good authority on both sides, some of the names sure you are right and then go ahead." Some one else have been mentioned of those who believe it best to has said that the only evidence that a sore is an infected defer treatment, as well as those who think it best to sore is the fact that it is infected—the demonstration of treat as early as possible. Now, what is the advantage the infection; and the only evidence that is obtained, to of waiting? Well, as Jonathan Hutchinson says, by our eyes, is the eruption or the lymphatic enlargement; beginning the use of mercury at the commencement-there is nothing else. If we commence the treatment as soon as the chancre appears, we abort the secondary prior to this time, we do as some one else has said, cast stage or entirely suppress it. They, however, lose sight of what I think is the chief disadvantage, which is this, that we, as the last speaker stated, deny to our patient that most important thing, a demonstation that he has the disease. What is the treatment of syphilis is the most important question? The acquiring of the pa tient's co-operation, and the best way of doing that is to allow the cutaneous efflurescence to take place. There is plenty of authority to the effect that the occurrence of such manifestations do not in any way increase the liability of the patient to relapse later, nor does it les sen his amenability to treatment, and some even go so far as to say that it actually exerts a valuable influence on the later development of the malady.

a doubt over the whole future of the man's life, and there may be nothing to be doubtful about. It has been my fortune, or misfortune, to see a good many patients at Hot Springs, who have been treated for syphilis, and who had not the slightest vestage of the disease, yet those patients are more unhappy, are harder to control, pathose than if they had syphilis. They come to us afflicted with what might be called syphilophobia, and it is impossible to make them believe that they have no syphi lis; he goes out of the office sure that he has syphilis. Now, it is undoubtedly true, Hutchinson and the princi ple syphilographers agree that we can not demonstrate the certainty of any infecting sore with the manifestations of the infection. If this is true, and it is also true that if we treat these cases prior to the demonstration of the disease we make the case doubtful, then there is abundant reason why we should wait until the diagnosis is made before we treat it. If these eminent men can not determine the diagnosis, how can the gen. eral practitioner do so? Eissel, in order to settle this matter of the effect of mercury in absorbing the disease, divided some of his hospital patients into three classes as near as he could make it all alike. To one of the classes he gave nothing, only placebo; to the second class the iodides, and to the third class mercury. What

Now, as to the exceptions mentioned by Taylor, which have been referred to, I have nothing special to say, except that it seems to me there are five of the nine most important exceptions that I would insist upon des pite the objections of the last speaker, and they are: where the chancre is upon the face, so that it disfigures the patient or reveals the trouble; secondly, where it is situated about the mucous cutaneous junctions that the resulting cicatrix may be a serious matter-about the anus; thirdly, where it is upon the finger of a physician, accoucheur or midwife; then, again, where it occurs in

DR. PREWITT.—I did not expect to say anything on this subject, but it is certainly very important, and we have had a very intelligent paper read, advocating a practice which I think is wrong. There is no question in my mind but what the treatment of syphilis should DR PHILLIPS.-I will say that the various speakers be commenced as soon as the disease is diagnosed. But have lost sight of the title of the paper entirely. The when can we be sure of the diagnosis? That is the title of the paper is not the differential diagnosis of

ABSTRACTS

MEDICINE.

chanore from chancroid, or a consideration of points necessary to make up one's mind as to what constitutes syphilis, not at all; and the discussion of the paper does not give a fair estimate of the situation. With very few exceptions, everything offered upon the subject has been along a line not included in the title of the paper or in the paper itself. As Dr. Ohmann-Dumesnil, the first speaker said "no one can say when a chancre begins," and this he said is a way to lead one to The Treatment of Apoplexy.-There are few think that was one of the premises laid down in the conditins met by the practioner of medicine in which paper; which is not correct. I say no one can say the possibilities of treatment are so limited as they are where primary syphilis begins. Then again he speaks in that condition which we generally term apoplexy,

of the use of tonics. I said nothing about the use of for although this term has been applied to a general tonics. The proposition I laid down was "How soon is train of symptoms, these symptoms may arise from mercury of service in the treatment of syphilis. Mer several different causes, and unfortunately each and cury in my hands has not prevented secondry manifes all of these causes have heretofore at least been tations. I claim there is no such a thing as primary largely beyond medical or surgical treatment syphilis, or tertiary syphilis, etc.; I take the position (Therapeutic Gazette.) Within the last year there has that these attempts to divide syphilis by periods of been published in the shape of a small volume an time is ineffectual. Dr. Ohmann-Dumesnil referred to exceedingly valuable experimental research by Leonard those rare case where we have tertiary syphilis before Hill of London, upon the physiology and pathology of the secondary stage. Of course that is the exception the cerebral circulation; and in its pages, in addition but it is not an extremely rare thing.

Dr. Grindon speaks about the practical advantage, etc., in the use of this drug delayed in the manner in which he puts its. That is proper and all right in un certain cases, but the title of the paper is "How soon should we begin the treatment of syphilis.". It deals only with cases of syphilis, and the only part of Dr. Grindon's remarks which so far as all can see,based upon the premises, is when he alludes to Taylor's exceptions, and I believe that he does give mercury in those so called primary conditions in which there is urgency for the return of the parts.

to finding much of great interest, certain thoughts are advanced which may be of value to the physician in the treatment of the conditions of which we are speak. ing. He points out that Falkenheim and Naunyn recommend that the blood pressure should be kept up by every means in conditions of cerebral compression; while on the other hand Bergmann, with whom Hill is in accord, clings to the traditional treatment of lowering blood pressure by depletion. After pointing out certain facts which support the opinion of himself and Bergmann, Hill goes on to empsize the fact that depletion is only indicated when the arterial tension is Dr. Jelks in his usual happy mood cautions us, in a high, and he reiterates the statement already made by very nice way, about the folly of using the drug until Gowers that before depletion is attempted the diagnosis we are possitively sure of the diagnosis. No one will of hemorrhage should be reasonably certain, because in take issue with him in the premises. Of course, we are thrombosis, embolism, and acute cerebral anemia a loss all apt to make mistakes, but I am slow to think any of blood will only do harm by weakening the cerebral physician intenionally misrepresents the condition to circulation. The question as to the differential diagno the patient, nor does he for a mercenary purpose. Then sis between the paralysis produced by hemorrhage, by again the experiment he referred to where a certain thrombosis, and ebolism gains an additional importance number of patients were given no treatment, or a from a therapeutic standpoint over and above its diagos. placebo, a second number given iodide and a third tic interest, and while we have not as yet outlined any number mercury, is an argument against his position as definite series of systoms which will separate positively they show that mercury did not abort the secondary these conditions from one another, it will be rememmanifestations. Dr. Prewitt too pleads that we wait bered that there are at least a few manifestations which until we are sure of our diagnosis, and that we are apt may point to the exact cause of the paralysis. to do a wrong to the patient by making a mistake in In the first place apoplexy, which is due to hemor our diagnosis, all of which is right. But if we are rhage into the brain, is usually met with only in that dealing with syphilis we have made no mistake in our class of patients who have attained such an age that diagnosis, and it is with syphilis that the paper deals. their arterial walls are undergoing atheromatous Dr. Fry has advaced something which I neglected to changes, although of course, the presence of a syphili put in my paper. I have a great deal of respect for tic history or other causes which tend to produce such Dr. Dana and am glad that his investigations bear out changes in the arteries, may result in hemorrhagic my views in regard to the treatment of the disease, apoplexy during the earlier years of life. Again in that at least mercury does not do harm, I am very hemorrhage into the brain consciousness is generally lost thankful to the speakers for having evaded the question because they they have said nothing which militates and the compression of the lower centres in the brain against the views expressed by me. which is produced by hemorrhage is apt to result into

the development of vomiting and contracted pupils, 120° F. it is unbearable. What seems to be the imand again, it is usually the case that in hemorrhage portant element of the treatment-namely, heat of into the brain the systemic shock is more manifest and from 200° to 300°-cannot be applied, or at any rate the febrile movement is apt to be greater than when not for a sufficient length of time, except as dry heat. the paralysis results from thrombosis or embolism. It The dry hot air method about to be described was is true, on the other hand, that thrombosis of the cere first brought under his notice in August 1894. He has bral blood-vessels is rather a condition of advanced age tried the treatment in a great variety of cases during than of youth, and it is noteworthy fact that thrombosis the last two years. He believes that the value of the frequently comes on during sleep, whereas hemorrhage treatment is not merely temporary. The "Tallermanusually follows some exertion and frequently takes place after the ingestion of circulatory stimulants. The history of syphilitic infection producing an endarteritis would of course point to thrombosis quite as much as to hemorrhage.

The differential diagnosis of paralysis due to embolism from that due to hemorrhage is still more difficult, but should the physician find evidence of chronic or ulcerative endocarditis or their results, or other causes for the formation of emboli, the diagnosis would be rather in favor of such a cause than of hemorrhage It is also a noteworthy fact that paralysis from embolus is more commonly met with on the right side of the body owing to the fact that it is more easy for the embolus to pass into the left middle cerebral artery than into the right. Having endeavored to the best of our ability, therefore, to make differential diagnosis be tween these three causes of cerebral paralysis according to Hill, we have certain therapeutic procedures to undertake. If it is embolism or thrombosis it will as a general rule be a mistake to bleed the patient; while if the cause of the paralysis be hemorrhage, venesection is usually indicated.

Sheffield localized hot air apparatus" consists of a cop. per chamber, generally cylindrical, made in various shapes and sizes, so that the hand, the elbow, the arm, in whole or in part, and in the lower extremity the foot, knee, thigh, or even the pelvis, can be inserted and treated locally. The contained air is maintained in a dry condition during the whole time the treatment is being administered. The temperature is varied at will, and is indicated by a thermometer, the bulb of which is passed into the chamber to the level of the part under treatment, and the scale red on the outside. It is pos. sible to admit medicated vapor, and to detect any increase of atmospheric pressure in the chamber. The heating agency used is gas or oil, as is convenient. The difficulty of suspending or resting the part during the treatment has been met by an arrangement of asbestos, which in no way interfers with the free circulation in the limb or of the superheated dry air. The patient, suitably clad in flannel to encourage free perspiration and prevent too much radiation of heat from the body, whether seated on a chair or lying in bed, suffers no inconvenience or discomfort from the high temperature. The treatment lasts usully from fifty minutes to an hour, and it is to this prolonged application that the therapeutic effect is due. When the part is first put into the chamber the temperature is usually about 150°, and this 18 gradually raised to 220°, and thence upwards, in some cases to as high as 300°. When the treatment is required to act quickly as an anodyne the temperature is rapidly raised to 270° or 280°. But under ordinary circumstances it is gradually raised and a general free perspiration breaks out over the whole body; at the same time the body temperature is tem porarily raised from one half to three degrees; the pulse increases in frequency and, to a less marked extent, the respiration. A few minutes after the operation is completed the pulse, respiration and temperature return to the normal previous condition; about an hour after the pulse is usually found to be slower and stronger than it was before treatment; this was especially noticed in some cases of weak hearts. In cases with much pain this is almost at once relieved, and under the influence of the heat the parts soon become more lax and supple. When the limb is first removed there is often a trasient erythematous blush. After the bath the whole body is briskly and lightly rubbed Local Hot-Air Treatment in Rheumatism down with a dry towel and the limb sometimes gently and Allied Affections.-W. Knowsley Sibley massaged with olive or other oil. The patients then (Lancet; Medicine) says it is impossible to obtain a waits until quite cool before going out of the room in high temperature with moist heat, as at from 115° to order to avoid the risk of a chill.

Hill goes even further than this, and asserts his be lief that in cases of paralysis due to hemorrhage it would be a justifiable experiment to open the skull cap in order to relieve the pressure which is being exerted upon the brain substance through the leeking blood vessels; and at the same time the depletion results in a fall of general blood pressure sc that hemorrhage ceases by the more rapid coagulation of the blood and the plugging of the artery, and death is put aside be cause the opening in the skull prevents the compression of the medulla, which Hill's experiments have proved to be so fatal.

In other words, intracranial hemorrhage may be reasonably treated on the same surgical lines as intracranial abscess whenever death is imminent from compression. Hill also emphasizes a fact which has been familiar to physicians for may years but which has not heretofore rested upon such scientific evidence, that . free purgation depletes the brain and causes a determination of blood to the abdomen; and, on the other hand, that the application of cold to the head fails to cause constriction of the cerebral or any other vessels.

It will be seen that this method differs materially in to five drachams of oil, were given; from the 16th of the following points from a Turkish bath: (1) The March to the 20th of April the quantity of creosote was temperature is higher; (2) the application of this tem' increased to fifteen minims, and from the 20th of April perature is continuous for nearly or quite an hour; (3) to the 27th of May to twenty two minims. At this the patient breathes the air of the room and not that time an attack of diarrhea necessitated an interruption of the heated chamber; (4) the application of the heat of the treatment for several days, but up to this period is only local, the part most affected being treated; and the abdomen had diminished in volume, the hard reit may here be remarked that this local treatment has a sisting masses seemed to have been reabsorbed so that general effect, and is evidenced by the result that, al- the resistance was not so marked to palpation, and by though the particular part treated receives the greatest the 25th of June the infant left for the country in a benefit, other parts of the body affected, but not ac much improved condition, with normal lungs and good tually immersed in the chamber, also improve greatly appetite; it had gained in weight and become free of both with regard to pain and to increase of movement; pain. It is stated by the 12th of April following the (5) the treatment does not tend to produce cardia de- child was still in good health, had been subjected to the pression even in the very feeble, or those conditions of use of sea baths in the south of France, and was con exhaustion which are in some cases apt to occur when sidered absolutely cured. heat is applied to the whole surface of the body and is at the same time inspired,-a Turkish bath is less stimulating in its effects, and this local treatment may be confidently recommended in cases in which the former would be quite out of the question; (6) the por table character of the apparatus enables it to be taken to the sick room and used by the bedside in cases where it would be impossible to move the patient; (7) the local bath gives far more successful results as a method of treatment.

The author describes thirteen cases of arthritis deformans, articular rheumatism, lumbago, sciatica, and neuralgia following herpes.

The Treatment of Peritoneal Tuberculosis. The Journal des Practiciens points out that peritoneal tuberculosis can be treated in several ways, says the Therapeutic Gazette. In a certain number of cases surgical intervention is absolutely justifiable; and if there is ascites, opening the abdominal cavity often gives excellent results. On the other hand, it is not to be forgotten that in many young subjects peritoneal tuberculosis often disappears if the patient is put under good hygienic circumstances, receives proper tonics, has counter-irritation applied to the abdomeu, and per haps wears over the abdomen, in place of counter-irrita. tion, an application of iodoform maintained in place by collodion. Simple puncture of the abdominal cavity, with drawing off of the liquid, also gives good results in some cases. In other instances it has been found that rectal injections of creosote were of value.

Thus, one case is quoted of a child of eleven years, whose sister and mother died of tuberculosis, and who was herself attacked in 1894 with enlargement of the bronchial glands, and early in 1895 with abdominal pain, loss of appetite, signs of pleurisy at the left base, and other evidences of tubercular infection; there was no vomiting, but the abdomen was large, painful, and markedly resisted to palpation. The treatment consisted in the regulation of the diet, which was largely liquid, and the application of ichthyol to the abdomen. Later on, from the 7th to the 16th of March, enemas of creosote in an emulsion of cod-liver oil, seven drops

Another child, seven years of age, without bad here. ditary antecedents, but who had been attacked with influenza and a severe bronchitis in 1890, was presented for treatment, with signs of right pleuro pneumonia and general bronchitis, abundant expectoration, febrile involvement, but no abdominal symptoms. A month later, however, anemia was marked, there were signs of dry pleurisy at the right base, the breathing was bronchial, the left side of the abdomen swollen, the belly puffy, and the intestinal coils seemed to be agglutinated. Inunctions of ichthyol were used, and creosote injec tions in the dose of fifteen minims were resorted to. Under this treatment the symptoms of pulmonary and abdominal disease gradually disappeared, so that two months after the treatment was begun the abdominal condition was much ameliorated, although physical signs of trouble still existed at the right base. The child, however, which had weighed only 17 kilogrammes on the 10th of May, weighed 21 kilogrammes on the 9th of September; its digestion was also greatly im proved, and later on it was subjected to the sea baths.

The third case was that of a young man of eighteen years, who was treated in the same way and rapidly im. proved.

SURGERY.

Erythema Multiforme-Report of Case Following Circumcision.-This form of ery. thema is rare, on that account easily overlooked, and sometimes mistaken for more serious trouble. In my own practice only two case can now be recalled, and these have occurred since I have begun to interest myself in the study of dermatology. The first of these was associated with an attack of acute gonorrhea, and the last followed an operation for circumcision in a young boy. It appeared singular that these two cases should have had a somewhat similar origin, yet, by reference to the literature of this subject such cases are not unusual.

Operations upon the urethral tract, such as the intro