allowable, especially when the integrity of some vital organ is at stake, when in pushing the use of this drug to as great an extent as the patient will bear, any possible harm caused by its use is more than atoned for in the usual rapid recovery of the patient from difficulties which would otherwise result in permanent disability or death. Dr. Klotz was of opinion that aggravated syphilis did not always depend on one of the three causes mentioned by Dr. Fox; it may occur in individuals of healthy and strong constitution, free from vicious habits and not dependent on faulty treatment without any apparent cause. On the other hand, syphilis may run a very mild course in strumous patients. The most important point in the management of syphilitic patients is to see that their general health is kept in the best possible condition, and that the functions of the important organs of the body be working in perfect order; mercury and iodide support only the natural tendency to the final elimination of the syphilitic poison. Lesions of the tongue and mouth sometimes do not heal until all specific medication is suspended.

If Dr. Otis had objected to the treatment by subcutaneous injections because the drug could not be controlled after administration, he should like to hear how Dr. Otis is able to control the mercury introduced by internal medication, and particularly by inunctions, in the face of the fact often adduced in favor of these modes of treatment, that mercury undoubtedly remains in the organs of the body for a considerable time after its administration, and continues to be found in the secretions for weeks after application has been stopped.

Dr. R. W. Taylor disagreed with almost every statement made by Dr. Fox. He thought a mistake was made in writing the paper.

Dr. Vaughan found great difficulty in getting his patients to continue treatment regularly. Those who have not been regular have apparently done about as well as the others. Although he always advised a continuous course of treatment for two years, he believed that when the chancre is distinct and diagnosis is certain, early treatment should be adopted. If anæmia is present, it should be treated the same as in any other subject. He had had under observation hundreds of strong workingmen who, although they have only had treatment for a few months, have had no further symptoms.

In closing the discussion Dr. Fox said that he had only cited a few of the mistakes made in

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the treatment of syphilis. He would like to be able to prove or disprove this question as to the effect of treatment on the occurrence of late manifestations. At one time he made it a point to observe many patients who did not desire to be treated systematically with mercury, and although he had followed many of them for years, he found himself still unable to settle this matter. He was able to say that the worst cases that he had seen had been those which have received from him the most active and prolonged murcurial treatment. Mercury, potassium iodide, and time, may be considered the three great factors in the cure of syphilis. In brain tumor, if the physician can extract from the patient the semblance of a syphilitic history, he at once assumes that the tumor is syphilitic. He had time and again seen leprosy and other conditions markedly benefited by syphilitic treatment, but this did not prove that they are themselves syphilitic in nature. Those physicians who believe most sincerely in vigorous and heroic treatment of syphilis seem to see the greatest number of the severe complications of syphilis. At the time when murcury was always given to the point of extreme salivation, syphilis was considered to be a very severe disease. The bad cases of that day resulted largely from maltreatment. He was a firm believer in the benignity of syphilis in most cases, and certain that an injudicious treatment often did as much harm to the patient as the disease.

THE MEDICINAL TREATMENT OF TYPHLITIS. Grasset states that ("The University Med. Mag.") the indications vary according as the attack is acute and inflammatory, or one of recurrent typhlitis between the attacks, or typhlitis with persistent fecal engorgement. In the last variety medicinal treatment is rarely available, and recourse must be had to operative interference. In recent typhlitis with acute exacerbations Grasset advises: A warm bath is to be given lasting from half an hour to an hour. Every hour the patient is to receive a teaspoonful of a mixture consisting of one part each of castor oil and almond oil, and two parts of syrup lemon, until the bowels move freely. unctions of an ointment of mercury and belladonna are to be made over the right iliac region, and are to be followed by the application of a large, thin, hot, flaxseed poultice. In obstinate cases a drop of croton oil may be added to the purgative mixture.

In

idiosyncrasy, which is to be regarded as the expression of differences in the tissue construction. It is, for instance, known that under ordinary circumstances insoluble medicines as oxide of iron, zinc, hermes mineral, etc., excite baneful untoward effects at times. The cause of this is to be found in excessive acidity of the stomach, through which larger quantities of the drugs named are dissolved. This difference in fluids, which may be regarded as the expression of local disturbances, is intrinsically distinct from inherent pathological diatheses, in that it is only quite temporary, and may be obviated by the employment of chemical and dietetic means.

Lewin, in his work on untoward effects of drugs, speaks of this subject in a similar manner. He states that, "There exists, however, a disposition which is but temporary; this may have its foundation either in a greater abundance in the system of chemical substances which cause an unusually prompt solution of the medicines introduced, or it may be conditional on pre-existing pathological changes in the organs; i. e., diseases of the inhibitory apparatus of the system. There is still another condition which must attract attention, that is that the inhibitory action upon the nerve centers, which are frequently the results of chemical combinations of drugs. For instance, it is known that in the food of every living organism there are found, during the process of digestion, compounds which, if allowed to enter the general circulation, would result fatally. They are taken up in part by the portal vein to the liver-that organ which stands guard over the nutrition of the economy. If the portal vein of a dog is ligated he dies of intoxication from the very products which ordinarily would be separated in the liver. Now, if a drug is given which inhibits the activity of the liver, it will be seen how these untoward effects, cerebral congestion, somnolence, etc., can be produced again if the exciting functions of the kidneys are interfered with or altered; the patient may exhibit symptoms of uræmia, albuminuria, or any of the skin lesions, such as urticaria, erythema, multiforma, etc.

CATARRHAL URETHRITIS IN Boys.-Dr. S. Rona of Budapest points out ("Med. Bull.") that under the title catarrhal urethritis is described as an acute, typical inflammation of the urethra occurring in boys. It is attributed to various mechanical and chemical irritants, as

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anæmia, introduction of foreign bodies, the action of uric-acid crystals, kidney-sand, and larger concretions passing from the bladder through the urethra, an excessive amount of uric acid dissolved in the urine, purulent balanitis, itching of the skin in the neighborhood of the pubes, etc. Dr. Rona reports sixteen cases which he had observed, and concludes that the inflammation, at least in the majority of cases, is of gonorrhoeal origin, and should be regarded as genuine gonorrhoea. This opinion had already been advanced by Cséri, who had found gonococci in the discharge. The whole course of the affection, which often lasts for months, closely resembles that of the gonorrhoea of adults. The same is true of the complications, such as balano-posthitis, lymphadenitis, lymphangitis of the penis, cystitis, and epididymitis, although these are less frequent in boys than in

men.

Dr. Rona saw developed, in a 15-monthold babe, a typical double-sided orchitis, which required several weeks for its cure. Once he met with gonorrhoea in two girls and two boys of the same family. In all cases gonococci were recognized in the discharge. From these researches it follows that the urethritis of children should not be lightly regarded, and that its prognosis is much more grave than is generally supposed. As complications, gonorrhoeal conjunctivitis was twice observed, and in one case had a favorable termination. The course of the affection was very slow, being prolonged, on an average, for two or three months, and some cases continued for a half or three-fourths of a year. The six cases of nor-gonorrhoeal origin exhibited no peculiarity. In some the discharge was tenacious, grayish-white, and scanty; in others a grayish-yellow thin pus was observed. Two cases were relics of a gonorrhoea of the previous year. Others resulted from the propagation of suppuration from surrounding parts to the vulva. Finally, a form was seen in new-born babes attributable to severe catarrh of the desquamative genital mucous membrane.

URINE TOXINS IN CONSTIPATION.-Spallaci ("Mercredi Med.") has found that inoculation of animals with the acid urine of chronically constipated individuals causes stupor, asthenia, tremor, tetanoid symptoms, hypothermia followed hyperthermia. These do not occur with the urine passed after constipation is removed.

Haig thinks that under certain conditions biurates do exist in human blood. He has found minute quantities of uric acid normally present. There are, according to him, quadurates whose only proper solvent is healthy urine. In acid urine they dissolve with aid of heat, but are redeposited on cooling; in hot alkaline urine the solution is permanent. Dr. Roberts claims that the neutral urates are not known, while biurates are known but as gouty concretions and found only after ammoniacal fermentation. Quadurates are physiological combinations of uric acid which constitute the excretions of birds and serpents. The differences between these two theories seem to indicate that large amounts of uric acid constitute only one group of urinary phenomena. In my cases indican was not present. In my opinion indicanuria is but an expression of part of the general disturbance. Most cases of neurasthenia present slight albuminuria and glycosuria, excess of uric acid, occasionally hyaline casts, while urea is in seemingly normal quantity; in other words, abnormal amounts of nitrogenous and hydrocarbonaceous metabolism are found in the urine. Many other functional neuroses are also accompanied with albuminuria, glycosuria, excessive uric acid, calcium oxalate, and occasionally indican and hyaline casts, which are the results rather than the cause. Most cases are not nephritic.

In treatment I have found no advantage from special diet. In cases where melancholia, hypochondria, epilepsy, vertigo, or neuralgia existed diet did not affect the nervous symptoms, hence I do not believe these urinary products are due to errors in diet alone. I have seen the nervous symptoms improve, and then the urinary vanish.

These cases can be divided for therapeutic purposes into three classes: Those without neurotic, or psychical, or intestinal symptoms; those without neurotic or psychical symptoms but with intestinal disturbance; finally, those with marked neurotic and psychical symptoms.

The first class is best treated with nitromuriatic acid and sodium salicylate. Large doses of the salicylate are injurious. Calomel is indicated at times, but Rochelle salts are my main reliance among laxatives. In the second class pepsin is of little value. Bismuth sub*Continued from June MEDICAL STAND RD.

gallate, salol, and codeine act well, particularly bismuth subgallate. Gastralgia during digestion is best relieved by codeine in small doses, the bowels being kept open. I have had no results of value from naphthol or guiacol. In the third class, laxatives often aggravate, and this is especially true of calomel. I have seen its use in melancholia followed by a violent outbreak. Rest treatment is of value, but absolutely applied is not imperative in neurasthenia. Massage, in my opinion, often prolongs neuras→ thenia and aggravates melancholia, hence I have relinquished it. Next to enforced rest comes ingestion of large quantities of food. In melancholia hypnotics are unavoidable. In neurasthnia strychnine is a necessity.

In the discussion Dr. A. L. Loomis remarked that it was evident slight albuminuria was present in the functional neuroses. He was of opinion that persistent albuminuria, however slight, indicated an abnormality. This abnormality may not be found in the kidneys, but it will be found in the blood, in blood pressure variations, or in the faulty using up and elimination of materials taken into the body. If Dr. Gray followed his patients through the whole twentyfour hours he would probably be astonished to find even in sleeping hours high arterial pressure. It is not necessary that these blood pressure variations should be present; in the neurasthenic blood pressure is diminished. Every epileptic has albumin in his urine, and without any other change excepting a very great variation in the blood pressure. Most clinicians have been accustomed to regard lithæmia as a condition associated with a certain train of nervous phenomena. If there be faulty metabolism which admits of excessive secretion, there will be nervous phenomena. Albuminuria is very common in so-called lithæmia. Continued circulation of irritating substances in the blood result in arterial and general fibrosis. If such persons be followed closely, albumin will be found from time to time as a result of blood pressure change. If physicians went beyond the cold nitric acid test in determination of albumin in urine, they would be in a sphere of unnecessary refinement. He had yet to examine the urine of a man past sixty years of age without finding hyaline casts, yet such a discovery need not cause any special

uneasiness because it is associated with this time of life.

Dr. A. H. Smith had been consulted recently by two gentlemen engaged in large financial interests who had nervous exhaustion. Their urine contained larger or smaller traces of albumin, determinable only by Tanred's or Millard's test, with excess of uric acid and phosphates, and an increase of the indican. All discussions regarding albuminuria are obscured by the fact that the different kinds of albumin are easily confounded. The chemist can analyze and give exact formulæ for many of the substances found in the body, but he cannot tell just what albumin is, as no two specimens will exactly correspond. There are a great many different substances which respond to tests for albumin. Albumin is not a definite step in a chemical process; the formation of albumin is a continuous process. If a normal specimen of urine be agitated thoroughly in a test-tube with some sulphuric ether a gelatinous substance will be separated. This substance will not respond to the tests which have been arbitrarily assumed to indicate albumin, yet it is an albuminoid and would probably go on to albumin if for some reason it had not been at this particular stage eliminated by the kidneys. In some cases continued presence of albumin may be due to persistent irritation of crystals in the urine. He had known slight albuminuria to disappear when oxalate crystals were no longer present. He protested against the present tendency to refer everything in the human body to fixed "chemical" laws. It could not be said that mental worry is a chemical agent, and yet it does profoundly alter chemical processes of the body. The presence of sugar in the urine might be explained by assuming that excessive mental activity, so often present in neurasthenia, acts upon the cerebral vessels in such a way as to produce an irritation of the diabetic center, which is situated very close to the vasomotor center. A product of a transient cause does not go on to fully developed diabetes, but ceases when this cause no longer persists.

Dr. C. A. Herter could not agree with Dr. Gray. He had instituted careful chemical examinations of urine. The total number which have been examined with regard to uric acid, urea, aloumin, sugar, phosphates, indican, etc., had been over 1,000; and the urine has come from about 200 persons, most of them suffering from some form of gastro-intestinal or func

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tional nervous disease. Among functional nervous diseases there have been forty of epilepy, nine of melancholia, two of mania, eight of chorea, and a large number of neurasthenics. He had never found albumin in the urine of any of these patients, with two exceptions. He had found sugar in only one case. It is important to settle on what is albumin and what is not. He was inclined to think that Dr. Gray included substances as serum albumin which should not be so included. By albuminuria was meant the presence of serum albumin in the urine, and although the exact chemical constitution of albumin is not quite clear, variations in the composition are not enough to warrant the assumption that there is a long series of allied albumins in the blood. When serum albumin is not found in the urine by the cold nitric acid test, or the heat and nitric acid, or by the picric acid test, there is no right to feel positive about presence of albumin. He had found uric acid considerably increased in the great majority of neurasthenics. Temporary increase of uric acid in a man in robust health may have no significance whatever, but when there is 15 or 30 per cent more of uric acid present in the urine for a long time, it certainly indicates a marked disturbance of nutrition. Dr. Gray failed to speak of the work by Horbaczewski, who found that nuclein, which is present in all the cells of the body, breaks down readily into substances intermediate between it and uric acid, and that uric acid is readily derived from it. The ingestion of nuclein or its injection into the blood gives rise to uric acid. His theory is that the excess of uric acid in the urine is to be regarded as the result of an excessive metabolism of a peculiar kind—an excessive breaking down of the nuclein from the nuclei of the cells. This explains in a broad way, on biological grounds, the character of this uric acid excess. Indican is not to be regarded as dependent upon disordered metabolism. It is due only to putrefaction of proteid substances, as has been abundantly shown by experiments on animals, and by clinical observations on the human subject. It is almost always due to putrefaction of albuminoid material in the intestine. The arterio-fibrosis which is found in these cases depends upon the accumulation of waste proteid material in the blood, and those cases to which Dr. Gray referred in which the arterial tension is high, are cases, if watched, would be observed to develop arterio-fibrosis, and very likely in time disease of the kidney.