An artery that has once been permanently closed by a syphilitic thrombosis will remain so in spite of all the mercury or iodides in the world, just the same as if the condition was caused by some other disease. The same holds true of the other vascular lesions. A gumma may be absorbed or become stationary, but a cicatrix of a more or less irritative character remains. The second point well to remember is, that it is the very nature of this disease to have remissions and relapses; patients are "up and down," and these hopes are often an ignis fatus following which a repu tation may perish and a valuable life be lost.

Turner makes the statement that 30 to 35 per cent of cerebral syphilis recover, that about 12 per cent are fatal and soon die, while the remainder, 53 to 58 per cent, over half you will note, are more or less permanently maimed. No doubt these cases embrace the most unfavorable of all cases and have most probably been taken from hospital practice, where those who are most likely to be past help will appear, for a hospital is not usually sought unless something serious has transpired. In the early manifestation of the condition, and we mean by this when the patient commences to manifest some of the premonitory signs, already referred to, then if recognized a more hopeful prognosis may be ventured, other things being satisfactory. As to the cord troubles it would seem that the figures mentioned are to optimistic. In summing up the prognosis one can say, if reognized early and appropriate treatment instituted, much benefit may be expected and often an apparent cure result; hence the very great importance of an early, careful and accurate diagnosis. If later manifestations are encountered less improvement is probable, but considerable benefit may be derived. If the very late manifestations are found the improvement will be but little, and if the progress of the disease is stayed it is perhaps about all that can be expected in many cases. Above all remember that each case demands individual and careful study and that a prognosis must depend upon the intelligent interpretation of the facts thus obtained, based upon the conditions present.

Treatment.-Just a few words on the very important question of treatment. When the evidence is all collected it will be found that many cases of syphilis, of the nervous system, and of other organs as well, have been allowed to perish and have been taking mercury or the iodides much of the time. The fault does not reside in the remedies, but in the method of administration. Many patients are drugged to death by these remedies who would have been saved by an intelligent exhibition of the very same remedies. As to the remedies themselves, the two just mentioned are the only ones worthy of consideration in the treatment of syphilis. How should they be given and when? are most pertinent questions.

Unfortunately the leaders in neurological work of today differ as to the size of the dose and the length of the time treatment should be continued, however, personally, the method of Gowers would seem most satisfactory. Perhaps that is because we are the more familiar with it. So far as inflammations are concerned, he rather believes that they are best controlled by mercury, while gummata are possibly better controlled by iodides.

or at least as readily controlled by them as by any remedy. In the Lettsomian lectures, he makes this statement: "I am inclined to think that when a lesion is distinctly influenced by either drug (referring to mercury and the iodides), if this is given freely the effect of one is as great as the other." In his hospital practice, in many instances, it is his custom to first give mercury until the physiological effects are established; then follow with the iodide. He does not sanction, but discourages, the large dose and long continued use of the latter drug as given in this country, and fortifies his position by pathological findings, that would seem conclusive and incontrovertible. The theory advocated is that the tissues become accustomed eventually to the remedy in large doses, and that in certain cases syphilitic lesions are not controlled as they are when the remedy is first administered; hence a moderate dose, ten to fifteen grains of the iodides, three or four times daily, and continued for from six to ten weeks only, then an interval is allowed and the treatment is resumed later. The two remedies are not usually given at the same time, unless a very rapid action is desired, the reason given being that the iodides eliminates the mercury before its full effects are obtained. Many methods of administering mercury have been used, but inunctions, and by the mouth have proven the best for all around work. In certain cases other methods may be tried perhaps with advantage; such as the hyperdermic, fumigations, etc. Baths are not to be forgotten in the treatment of this condition, and waters of a sulphurous nature are especially advantageous in assisting in the elimination.

We purposely because of time limitation, have not discussed the question, "Can syphilis be cured, and is it a self-limited disease?" Much can be said pro and con upon this subject, and it is sufficiently broad of itself to furnish material for a paper more voluminous than the present one, hence we crave your indulgence because of our inability to call your attention to but a very few of the important points in connection with this most interesting subject.

Oppenheim.

Brain. Autumn number, 1902.

Allchin, Manual of Medicine, Vol. III.

REFERENCES.

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DIAGNOSIS AND MANAGEMENT OF SYPHILIS.

M. E. Silver, M. D., Sioux City, Iowa.

HE FEW remarks I am going to make are addressed to the general practitioner-especially of the rural districts, who, owing to the sporadic nature of this disorder, or on account of its being extragenital, or because it occurs in some member of a family whose moral integrity he can vouch for, is often tripped up in the early diagnosis, when it is very important that he should recognize the disease before it spreads to others, often in a most innocent manner.

Syphilis should no longer be classified as a purely venereal disease, with the stigma that is always attached to it by the laity and by some of the profession, but should be considered as one of the great pests which infect society, and for which very little so far has been done in the way of controlling its wide-spread course; although not nearly so fatal as tuberculosis, it is almost as wide-spread. and a vast amount of ill-health and misery, to say the least, results therefrom. For a diagnosis any and all stages of the disease may present themselves, and sometimes some of the most obscure forms, so that it is only by accident that the physician is enabled to make the diagnosis. However this may be, the general practitioner should always be on the lookout for syphilis; yet he should never venture a positive diagnosis, especially with reference to beginning the treatment with mercury, until secondary symptoms appear (be they ever so mild or faint,) although he should constantly be on the watch.

I trust it will be permissible to report a few cases to illustrate my point:

(1)-Miss. J., age 22, school teacher by occupation, a daughter of a refined family in a near-by villiage, consulted me on January 23, 1901, with the following history: had always been in the best of health until a month previous, when a small ulcer appeared on the tip of the tongue on the left side. The origin of same was unknown to her, and after using some home remedies, such as listerine, etc., she consulted their family physician, who assured her that it was due to a slight derangement of her stomach, and later it was due to menstrual troubles, etc. For three weeks he was constantly treating her, internally and locally, for various disorders, but the ulcer did not heal even after being cauterized with carbolic acid and nitrate of silver. When I saw her the left margin of the tongue exhibited a hard nodule about as large as a bean, partly imbedded in the substance of the tongue and partly above its level. In the center was a flat oval ulcer, the floor of which was covered with a grayish-white secretion. The sub-maxilliary glands were somewhat enlarged, and tender on pressure. The cervical and axillary glands were but very slightly enlarged. A few scattered maculae were found on the trunk; slight headache and fever at night; the genitalia were normal. I did not venture a positive diagnosis for another week, when I convinced her and myself of her trouble, which was traced to a young man in the same town.

(2) C. H., young man 22 years of age, best of habits and health, consulted me on the 18th of November, 1901, for treatment of a primary attack of gonorrhea, for which a homeopathic physician had prescribed the use of injections in the hands of the patient. Not being able to use the injection properly himself, he came to my office and placed himself in my charge. The gonorrhea in question ran its regular course for ten days, when I noticed a slight abrasion, not larger than a pin-point, about an inch back of the corona penis, to which I jokingly referred, remarking that it looked suspicious. He, however, assured me that he had had similar abrasions before, and would not consider it very serious. As time passed, the abrasion became larger and larger, finally ulcerating, which I had hoped to be a case of soft chancre. The gonorrhea, meantime, was progressing

nicely, while the ulcer under powders also healed. I would not venture a positive diagnosis until secondary symptoms made their appearance. On December 14th the secondary eruptions appeared in an extraordinary crop all over the trunk and body, and my diagnosis was firmly established. I am convinced that had this young man been treating himself for the gonorrhea the abrasion undoubtedly would not have been noticed, or else would have been attributed to the infection of the gonorrhea, and treatment would not have been instituted perhaps after the secondary eruption.

Management. Once trained to search for syphilis everywhere, among all classes of society, we must use all our "Sherlock Holmes powers" to detect the disease for a certainty before the diagnosis is established in our own minds, and especially before we inform our patients of it, thus, in many cases, preventing the executioner's ax from falling on the innocent. victim whose whole future career might be blighted by the stigma. The concensus of opinion amongst the best syphilographers of today is that the physician should wait until he is positive (and that is only after the secondary eruptions have appeared) before attempting to treat the patient at all by specific drugs. Nor need one ever fear of doing the patient any harm by waiting; on the contrary, experience teaches that when a patient is fully informed of the gravity of his disease, which he has always supposed to be syphilis, he will never question the diagnosis or honesty of his phy sician while waiting for the secondary symptoms, but he may question both if the treatment is instituted at once and the sceondary manifestations are delayed. When fully convinced, then, that you have a case of syphilis to treat, a heart to heart talk, especially with the more intelligent class of patients, is the duty of every attending physician. First and foremost, never allow any of your patients to think that during their course of treatment they are anything but a grave source of danger to society at large, and especially to their own immediate family. As to their own welfare, assure them that by the use of your drugs you can control the disease, although you may not cure it, provided they will agree to follow your directions implicitly for the next year and a half to three years, during which time they will need your fullest moral support.

As to drugs, whilst more satisfactory in a measure than those employed in the treatment of gonorrhea, for which we have no specific, yet so they are far from being satisfactory; in fact there is hardly any one disease which is so common, of whose etiology, bacteriology and pathology we know so little, and of whose treatment we know so little more than has been known for ages. It is here that the scientific mind will in the near future, I hope. bestow a boon on humanity by clearing away the cobwebs of the past ages and proving to the world the cause of this disease, which undoubtedly must be a living micro-organism either of protozoon or bacterial origin, and if possible present for our use an antitoxine which will at once arrest the further progress of such germs before they do great damage to the finer tissues of the body. Until that time, mercury in the beginning stages and iodides in the later stages are our sheet anchors, and to these we must make our patients stick for a period of from eighteen

months to three years or over, always being careful not to produce salivation. During said treatment we must not forget that the patients will be able to fight away the disease even much better if all the accessories are brought into use, such as tonics, frequent baths, cold sponging daily, massage, plenty of fresh air and exercise. with very little tobacco or alcohol, and total abstinence from sexual intercourse.

In conclusion, the following points may be emphasized: First, that not every case is so clear for a diagnosis, especially in the primary stage, that "he who runs may read," but on the contrary, many points must be taken into consideration to make a diagnosis certain. Ever keep fresh in your memory that no one is really above acquiring this disease, as it is not always of a venereal origin; (2) the importance of never treating a case of syphilis with mercury until sufficient evidence of the disease is found by the physician; (3) the length of treatment should never be less than eighteen months, and in many cases it should be over three years.

CONGENITAL SYPHILIS IN THE NEW-BORN AND YOUNG INFANTS.

Mary Strong, M. D., Omaha.

HEN the novelist, Sarah Grand, in one of her rather remarkable books, describes a newly-born scion of nobility as "a little old man. with a cold in his head," while we may doubt the propriety of such description in a novel, yet to many of us come sad recollections of just such infants.

The county hospitals, rescue homes, the various institutions where foundlings are received, all show many such cases, and here we call it by the proper name of one of the greatest curses to humanity-congenital syphilis.

But unfortunately these places are not the only ones where we find it. When Moses wrote that the iniquities of the fathers are visited on the children," he stated a fact which is manifest in many dwellings of the wealthy-only here we may kindly call the disease marasmus.

In one respect Nature is kind; she cuts short the existence of a very large number of syphilitics before birth. But prenatal manifestations were ably discussed in Dr. Moore's paper, and I confine myself to what we find after birth.

The clinical manifestations of syphilis in little babies are of all grades of severity. If at birth the child shows pustular or pemphygoid eruptions. it is likely to die very promptly, and treatment is hardly to be considered, while the diagnosis is easy.

But in the more common forms in this country and at the present time, where there may be little or nothing about the infant to show the disease at birth, or for a varying period of time, the diagnosis, highly important as it is if we hope to save the life of the baby and enable it to attain to a fair measure of health, is not always easy, often must be deferred.