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commissure. At an early stage of the development of the glottis the vocal cords are continuous anteriorly in the form of a web or a sickleshaped band, which normally undergoes suppression, but, in some instances, persists even to adult life. Should the modelling of this commissural web be imperfect, tags of tissue may be left, which might eventually constitute pendulous growths, especially should the subjects become mouth-breathers.

"In the case of pure papillomata, or warts, irritation is an accepted factor in their pathogeny, and no situation is more favorable to that influence than the larynx, especially in habitual mouth-breathers, for laryngeal papillomata have been reported not only as coexisting with adenoids, but also as having spontaneously disappeared after the removal of the postnasal obstruction."

PRIMARY ACTINOMYCOSIS OF THE NECK, WITH RAPID

EXTENSION INTO THE TRACHEA AND BRONCHI.

CASTENEDA (Revue Hebdomadaire de Laryngologie, d'Otologie et de Rhinologie, May 19, 1906) gives an interesting review of a rare case, which occurred in a healthy man, aged fifty-nine. The etiology was not ascertained. The first symptom noticed was three tumefactions on the neck: the first about the size of a small orange, situated in the right lateral region, between the posterior border of the sternomastoid and the trapezius above the clavicle; the second situated just below the hyoid, about the size of an egg; and the third, a little smaller, on the left side of the neck. There was some stenosis of the trachea due to pressure, which produced dyspnea. Temperature normal; pulse 80. A vertical incision was made over the central tumor, and the tissues were all found infiltrated and the trachea involved. Microscopic examination confirmed the diagnosis. A tracheal canula was introduced, but it did not relieve the dyspnea. While actinomycosis may involve different organs, this case seems unique, and the growth might have been taken for various solid or polycystic tumors.

PROCTOLOGY.

LOUIS JACOB HIRSCHMAN, M. D.
CLINICAL PROFESSOR OP PROCTOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

NOTES ON TREATMENT OF PRURITUS ANI. The Medical World for April, 1906, contains the following practical hints on the very troublesome affection, pruritus ani:

A saturated solution of boric acid, employed as a wash in pruritus ani, is both a cleansing agent of value, and in many cases a curative An ointment prepared by thoroughly blending one ounce of lard and one dram of calomel is a good application in cases of pruritus ani (Hare).

power as well.

The internal use of calcium chlorid should not be forgotten in cases of pruritus ani. It should be given in doses of twenty grains three times a day, and may be prescribed as follows:

R Calcium chlorid, 2 drams.

Tincture orange flowers, 6 drams.

Chloroform water, enough to make 6 ounces.
Mix, and direct one or two tablespoonfuls, three times a day.

Smaller doses may have to be ordered if the stomach proves irritable. These doses often cause an increased thirst. It is best given one hour after meals.

Cocain, incorporated in ointments, often fails utterly in pruritus ani, as the fats prevent its exerting its power.

Sodium thiosulphate, one-half dram to the ounce of water, is of service in certain cases of pruritus ani.

Ringer commends the use of the following ointment in cases of pruritus ani:

R Acid salicyl, 2 drams.

Ol. theobrom, 5 drams.
Cetaceæ, 3 drams.
Ol. myristica, 12 drams.

DERMATOLOGY.

WILLIAM FLEMING BREAKEY, M. D.
CLINICAL PROFESSOR OP DERMATOLOGY AND SYPHILOLOGY IN THE UNIVERSITY OF MICHIGAN.

AND
JAMES FLEMING BREAKEY, M. D.
ASSISTANT IN DERMATOLOGY IN THE UNIVERSITY OF MICHIGAN,

A STUDY OF SYPHILIS. THE April number of the American Journal of Dermatology is devoted to a study of syphilis, and each of its eight articles is worth reading in its entirity.

*

THE SPIROCHÆTA PALLIDA OR TREPONEMA PALLIDA. The opening article by Doctor Edgar G. Ballenger is a fairly exhaustive résumé of the recent bibliography on this subject, with reports and findings similar to those of Shennan in the March The Lancet and reviewed in the May the physician and Surgeon

The author prefers as staining agents azur one, azur two and Giesmas eosin, and gets better and darker results by staining three or four days instead of sixteen to twenty-four hours. Increasing the strength of solutions did not improve results.

Regarding the spirochæta, Schaudinn says that the pallida is the only one having a flagellum at one or both ends.

Robert W. Taylor thinks that the finding of the spirochæta pallida in inherited syphilis is the most convincing evidence as to its connection with syphilitic processes.

Treponema, and no other microbes have been found by Levaditi and others in the interior of the liver and spleen of stillborn children.

Castellani demonstrated a spiral microorganism in the early lesions of yaws similar to the treponema pallida, for which he proposes the name spirochæta pertenuis or pallidula. The great similarity of this disease and syphilis makes the observation of peculiar significance.

The deeper layers of the syphilitic lesions show the parasite in larger numbers than does the secretion of the surface. Control tests have almost always failed to reveal treponema.

Although not established beyond a doubt, nearly all the evidence, direct and circumstantial, points strongly towards the treponema pallida as the cause of syphilis.

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THE DIAGNOSTIC VALUE OF THE SPIROCHÆTA PALLIDA IN SYPHILIS.

Doctor George M. Mackee concludes this article with the following propositions:

(1) The spirochæta pallida has definite morphological characteristics.

(2) It is constantly found in primary and secondary syphilis.

(3) There is no corroborative evidence of this organism having been found in any but syphilitic lesions.

(4) The number of organisms found in a lesion is in direct proportion to its degree of infectiousness.

(5) The relation of this organism to syphilis is in perfect accord with our clinical knowledge of the disease. For instance, there is no confirmatory evidence of its having been found in tertiary lesions. It has been found in the blood in very few instances, while it has frequently been demonstrated in the lymphatic glands, surrounding, and even in the lumen of the lymph channels.

(6) The spirochæta pallida has been demonstrated in congenital syphilis by several investigators, both in smears and in sections of the disseased tissue.

(7) The organism has been followed from man through the apes.

(8) It has also been followed from the primary to the secondary period of the disease.

(9) In cases of supposed chancres, when the pallida could not be demonstrated, the patient has subsequently failed to develop secondary syphilis.

Doctor Mackee uses Goldhorn's stain, which has the advantage of requiring but a few seconds exposure.

THE STAGES OF SYPHILIS. Doctor A. H. Ohmann-Dumesnil objects to the classification of syphilitic processes as primary, secondary and tertiary.

The chancre or primary helcosis is the first symptom of luetic infection. The terming of this primary syphilis is but a matter of taste.

Secondary syphilis is a misnomer from the fact that it is not invariably secondary, as confirmed by the presence of iridial gummata in patients before the appearance of any secondary manifestations.

For this reason the author proposes another and more exact classification, based upon the pathologic developement of the disease.

Attention is called to the fact that the so-called secondary lesions are chiefly confined to the cutaneous envelope and are superficial in character. The one exception being iritis and iridochoroiditis.

In the so-called tertiary manifestations we find that it is the deeper tissues that are involved, as the periosteum, bones, secretory glands, and elements of the nervous system and the cerebrospinal axis.

In view of these facts the author proposes the following classification: First, the chancre or primary helcosis; second, the stage of involvement of the superficial epithelial tissues; and third, the involvement of the per and the connective tissue.

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INFANTILE SYPHILIS. . Doctor Edward F. Cushing says that statistics of the number of cases of congenital syphilis among the little patients in the various Children's hospitals, show that these cases vary in number from onehalf to one per cent. These findings, together with the records of our Maternity Hospital and Foundlings' asylums emphasize how great is the early mortality of the disease and how few, comparatively, survive to an age to come under the observation of the pediatrist or dermatologist.

In infantile syphilis proper, as distinguished from fetal and neonatal syphilis, no definite signs of the disease are apparent at birth. Such manifestations usually appear in the second month of life, sometimes in the first month, rarely after the third month.

The various and many manifestations of infantile syphilis are enumerated. That the bullous rash should be characteristic of syphilis in childhood is doubtless due to the loose attachment of the epidermis and its easy separation from the underlying true skin at this early life. Syphilitic pemphigus is distinguished from nonsyphilitic pemphigus by its predilection for the palms and soles, by the serosanguineous or purulent contents of the bullæ and the resulting irregular ulcers upon rupture, and perhaps we shall find by the constant presence of the spirochæta pallida in the lesions. Syphilitic coryza and simple acute coryza (with or without adenoids) must be differentiated, as must also simple dermatoses and the various syphilodermata. It is here that the finding of the

spirochæta pallida will be of much value. The physiognomy, the hair, nails and blood vessels may all show changes of varying degree. Of the visceral lesions, those of the liver, spleen and kidneys are of the greatest importance for diagnosis. Orchitis is not rare, the swollen testicle showing but little, if any, tenderness. The Roentgen rays may assist in demonstrating epiphyseal changes in both long and short bones, or other osseous or periosteal changes.

Feebleness in the newborn or the presence of the "syphilitic wig' should arouse suspicion enough to lead to search for confirmatory signs of visceral disease; or, the problem of an infantile anemia or marasmus may be solved by looking for an orchitis or splenic tumor.

Thus in all instances of possible or suspected infantile syphilis, the nostrils should be investigated, the abdomen examined for enlarged spleen, the testicles palpated, the fingernails inspected, the blood and urine studied, and perhaps even the Roentgen rays resorted to for aid, whether or not seemingly characteristic skin eruptions are present.

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Doctor Henry Illoway opens this article as follows:

"Though as susceptible to disease as any other part of the human economy, still, insofar as the specific infection under consideration is concerned, the digestive tract forms a marked exception. Just as frequent as are the manifestations of this infection in the nervous system, so rare, indeed, are they in the organs especially concerned with the function of digestion. In fact, cases of syphilitic disease of this part of the organism, indubitably demonstrated as such, are few and far between.”

He reports cases of syphilis, both acquired and inherited, showing gummata and ulcers of the esophagus, recovering under specific treatment. The stomach is most resistant to the specific pathologic processes, succumbing only after such vital tissue changes of the liver, spleen or other organs as to profoundly impair the nutrition of the whole organism. For the stomach alone to become the seat of specific disease is of the rarest occurrence. Syphilitic gastroenteritis with recovery under appropriate treatment is reported. The intestines, like the stomach, are infrequently invaded by syphilis. The forms of manifestation are the same in each: (a) Diffuse interstitial inflammation; (b) gumma (tumor); (c) ulceration with consequent cicatrization; (d) stricture. Hemmeter divides the diffuse interstitial inflammations of the intestine into: (1) Acute specific enteritis; and (2) chronic specific enteritis; both of which conditions, however, are more or less assumptive. Ulcers, of syphilitic origin, are rarely seen in the stomach or bowels, and those of the large intestine (the rectum excepted) are more infrequent than those of the small bowel. The rectum may present any of the forms or manifestations of syphilis.

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