were doubtless made upon mistaken diagnosis, the cases being those of cerebro spinal syphilis simulating a parasyphilitic affection. But it has been recently conclusively demonstrated that a syphilitic meningitis can and often does exist contemporaneously with a pure degenerative tabes or paresis. This finding agrees with the conception of the Paris clinicians as to the cause of tabes which they attribute to a syphilitic meningitis of the posterior columns.

The fatal case of Westphals quoted illustrates the morbid anatomy of this association.

Where a syphilitic meningitis exists in tabes one can expect brilliant results from salvarsan as far as the symptoms due to the meningitis are concerned and in early cases of tabes we can hopes for a remission in the progressive course of the disease. A case of my own would illustrate this point. A man, 45 years of age, with history of syphilis seventeen years previously, had complained of pains in arms and limbs for some three months, more pronounced in the upper extremities. Reflex immobility of the pipils, vesical atony and girdle sensation were present, together with paraesthesias and moderate anaglesia and loss of deep pressure pain sense in the lower extremities. Ataxia was absent, and the tendon reflexes were exaggerated. He had been impotent for some years. In this case the salvarsan cleared up the pains entirely, the exaggerated reflexes subsided and the patient gained some twenty-five pounds in weight in the course of six months. The pupillary findings, analgesias, loss of deep pain sense, a loss of the left achilles reflex and a slowing of urination remain. The patient feels well and is engaged in business life.

Foerster of Breslau, states that he used to turn his diabetics away untreated, now he treats them with salvarsan and injections of calomel and claims good results in many cases. It is generally conceded that salvarsan very frequently relieves the lightening pains and gastric crises of tabes and a number of cases have been quoted wherein the ataxia has been greatly improved. All authors are agreed upon the general tonic and reconstructive action of the arsenic. The objective findings, the anaesthesia, loss of reflexes, the atrophies, and ocular palsies are uninfluenced.

Syphilitic headaches of an obstinate type, probably based upon a chronic meningitis, which have long resisted mercury and iodide, often clear up promptly with salvarsan. I have had

two of such cases, one of which lasted five years and had taken inunctions and baths ad libitum. His headaches ceased the second day after the intravenous infusion of 5 decigrams of 606.

As to paresis, the outlook is not favorable and evidence is present showing that salvarsan may aggravate the condition. Hufler, however, believes that early cases of acute efflorescent tabes can be checked by salvarsan and quotes two cases of re

covery.

Summarizing it would seem that the consideration as to the use of salvarsan in the syphilitic affections of the nervous system are, in the main, the same considerations that weigh with regard to its use in general syphilis; to wit, the condition of the heart, the kidneys, the vascular system, and the strength of the patient. Added to this we have possible danger from an oedematous reaction in the site of the disease process with danger to life if the vital centers of the medulla are affected. Its use in tabes and paresis should be carefully considered as in advanced cases it probably is harmful to the patient. There is no question but that in salvarsan the neourologist has a remedial agent whose rapidity and directness of action may be of the greatest value. Further observation only can define its true position.

Dr. H. B. Lemere, Omaha.

DISCUSSION.

It would be impossible to cover all the ground in a discussion of this symposium. There is however, one phase on which I wish to talk. It has been my fortune in the last two months to have four cases of ocular syphilis under salvarsan treatment. In three of these cases there was inflammation of the optic nerve and retina and in the othe rthere was probable involvement of these structures, though they could not be seen owing to interstitial keratitis. The sight was rapidly diminishing and something had to be done promptly or vision would be permanently lost. I consulted with the physicians who had referred the cases to me, and, while they agreed that salvarsan was indicated, there was a general uneasiness and a feeling that salvarsan should not be used where there was any inflammation in the eye. The result of the use of salvarsan was extremely happy, the acute inflammation being brought to an abrupt termination. It seems to me that the use of salvarsan is especially suited to these eye cases where a prompt action is absolutely necessary.

The statistics of the cases of optic atrophy following the administration of salvarsan show that this sequence is very rare, so that in those active inflammations of the retina where the process is acting very rapidly the chance of producing a toxic atrophy of the nerve is very remote. In prescribing salvarsan the oculist will be greatly handicapped in securing the consent of the patient if he does not receive the unqualified support of his consulting general practitioner.

In the case of keratitis mentioned by Dr. Bryant, we all know that often these cases of interstitial keratitis in spite of saturation with mercury will progress almost without interruption and involve the second eye. In

these cases, owing to the condition of the cornea, it is impossible to see the condition of the nerve and retina.

I wish to report a case which came under my observation about six weeks ago. I saw a boy six years of age with all the stigma of heredity syphilis, had both eyes involved from severe interstitial keratitis. His home doctor had had him thoroughly saturated with mercury, without improving the condition of the eyes. The first dose of salvarsan produced a clearing of the cornea which was marvelous. The next morning he was able to face the light of a window, which before had produced intense photophobia. blepharospasm of the day previous gave way to freely opened eyes.

Dr. A. Schalek, Omaha:

The

I would like to answer some of these suggestions, but the points were not made definite enough. The objection is not to salvarsan in syphilitic eye diseases; the objection is to use it in the eye-diseases that are not syphilitic. We know that arsenic and salvarsan have an affinity for the nerves and especially the optic nerve, and if the nerve is already diseased it is much more liable to injury from the use of salvarsan. Ehrlich advises against the use of salvarsan in any except the syphilitic eye diseases, in which, of course, the results are very good. Now, if there is a suspicion of syphilis and the clinical evidence and the Wasserman test show that the disease is present, salvarsan ought to be used, otherwise not. I am reminded of a case that Dr. Gifford sent me, a young man who had a perfect history of infection, that is of a primary lesion, of skin eruptions which finally resulted in loss of vision. Dr. Gifford sent him to me for salvarsan. I had a Wasserman test made but the result was negative; it did not mean that the man had not syphilis nor that I should not give salvarsan, but it did mean that if anything happened to the man I might be held liable. When men of large experience advise against its use except in cases of syphilis, it behooves us to be absolutely positive about the specific diagnosis before using it.

Dr. H. B. Lemere, Omaha:

I would like to answer Dr. Schalek. I wish to state in regard to the objection the doctor made to taking the risk in advising salvarsan in the treatment of eye diseases, that that is the very point I wanted to make. If a man is not willing to take the risk in advising this he is going to lose a good many eyes. The cases in which the salvarsan would be used in the eye diseases that I named would be retinitis, choroiditis and neuritis of the optic nerve. Now, with reasonable care in the exclusion of other disease, the patient known to have syphilis at the time, there is absolutely no excuse for a man to state that these ocular inflammations are due to anything else except syphilis provided they know he has syphilis. Then you have to take the responsibility and you have to advise him even though he may possible have an involvement of the optic nerve. I had, in one of my cases, a man blind in one eye, the optic nerve involved in the other eye, with the retina and choroid involved; the Wasserman negative, the vision diminished to half vision in four days, the man still under heavy doses of mercury. What was to be done? The man denied syphilis. I advised most strongly in favor of salvarsan, as other disease was excluded. The man received the dose of salvarsan and his eyesight returned to what it was, which was not normal, before this deterioration, and I have no doubt whatever in stating that the man's eyesight was saved.

Dr. F. E. Coulter, Omaha·

In regard to syphilis, I think we are learning, and the subject is becoming more and more broad every day. We are coming to have a view of the entire subject of syphilis. We used to look at one side of it and consequently our treatment was at fault in viewing it from that standpoint, so that the question that Dr. Bryant raises is very pertinent, "Can syphilis

be cured?" Another question is it self-limited, and I think we are getting far away from the idea that syphilis is a self limitation disease because we are coming to find out it is a disease of a great cycle. We must take the entire cycle and not the section of a cycle into consideration, if we would arrive at just conclusions about the treatment.

And another thing regarding salvarsan, it is like any other new remedy; it has to find its level and it is finding it and I was very glad to hear Dr. Young's resume regarding the use of salvarsan in nervous diseases. It has been proven of not much use in the parasyphilitic conditions, but in the acute diseases it has been proven that it is one of great assistance, but we should not limit our treatment to that. I have had a case under observation in which salvarsan was used, but with no appreciable effect. After a time the patient was put under the old line of treatment and made a very nice recovery. That he had a basic syphilitic meningitis there was no question, and salvarsan had been used repeatedly with no effect. One case proves nothing in any treatment, but we are glad to find out where we stand and salvarsan is a useful remedy, but it should be used, I think, as an adjunct to what we already have. Let us not destroy the bridges that have carried us over safely.

Dr. G. A. Young, Omaha:

In closing this discussion there are two points I wish to touch upon. First, with regard to the use of salvarsan in syphilitic involvement of the optic nerve and retina. Questions as to the safety of Salvarsan refer to the possible neurotropic action of the drug. Ehrlich and his followers state that the neural relapses following the use of Salvarsan and effecting the cranial nerves are no more frequent than those following treatment by mercury; that they are not due to a neurotropic action of the arsenic, but are due rather to insufficient treatment. Therefore, we should not be afraid to use Salvarsan in specific disease of the eye, but should use it promptly and fearlessly.

Secondly, we should keep in mind that destruction of tissue in the central nervous system is irreparable. Consequently, we want prompt action in our therapy of syphilis of the delicate nerve structures. Once granted that Salvarsan given properly is not neurotropic, then we have an agent which in its quickness of action is especially suited to the therapy of nerve syphilis.

Ectopic Pregnancy.

*By HARRY A. TAYLOR, M. D., University Place, Neb.

The term ectopic gestation is applied when a pregnancy develops outside of the uterus. It may occur in a tube or an ovary, or, secondary to a rupture of either of the above, may later continue to develop in the broad ligament or the abdominal cavity. The occurrence of an ovarian pregnancy is so exceedingly rare that only in very recent years has its existence been definitely proven. Possible fertilization of the ovum may occur in the abdominal cavity but the product of conception is at once destroyed and absorbed by the peritoneum. As practically all ectopic pregnancies are tubal in origin, this paper will be confined to that variety alone.

*Read before the Nebraska State Medical Association, Lincoln, May 7-9, 1912.

TUBAL PREGNANCIES-CAUSES

Tubal gestations are comparatively common, perhaps one in every one hundred pregnancies. While found more frequently after a long period of sterility, it may occur a short time after confinement. It is observed in multipara and primipara and may coexist with a normal pregnancy. Cases are on record where both tubes were involved at the same time. A number of instances of repeated tubal pregnancies have been reported. The phenomenon is probably due to some obstruction inside the tube or without, which diminishes its lumen so the fertilized ovum cannot easily pass. Usually the trouble is within the tube.

Of the intratubal causes the most frequent is chronic salpingitis. The long continued inflammation provokes a hypertrophy of the mucous membrane, and with the adhesions resulting, brings about a condition where the fertilized ovum is so long arrested in its descent that it becomes permanently attached. Certain natural peristaltic movements of the fallopian tube, aiding the passage of the fertilized ovum to its normal uterine position, are hindered by the hypertrophy and the constriction of its lumen. Much the same condition pertains to neoplasms, congenital malformations and displacements of the tube.

Pelvic adhesions and tumors are the usual extratubal causes of ectopic pregnancy.

CLASSIFICATION

The gestation may take place in any part of the tube, being most frequent in the ampullar end, less so in the isthmic part, and very rare in the interstitial portion. A tubo-ovarian pregnancy is really a subdivision of the ampullar type in which the fimbriated end becomes adherent to the ovary and the latter forms a part of the gestation sac.

COURSE

Immediately upon conception the tube begins to hypertrophy and to enlarge, while the blood supply is much increased. By the eighth week the abdominal opening is entirely closed. As development goes on the wall becomes thin and greatly weakened at the attachment of the chorionic villi.

There are four ways of tubal gestation terminating:

1. Tubal abortion.

2. Rupture of the tube.

3. Death of the embryo before tubal rupture.