to the meatus for frequent inspection. Such unnecessary handling will often force the infection into the small follicles of the canal, and it always increases and continues the local inflammation. This practice should be absolutely proscribed, just as you would forbid rubbing of an eye affected with conjunctivitis.

I think we are all agreed with Dr. Littlejohn that the criterion of a cure is the absence of gonococci (and they must be diligently searched for and eliminated from all the secretions which flow into the urethra, at several successive intervals of time). And so I would add as a conclusion to the other instructions, and in heavy type: Don't stop treatment until you are completely cured.

I thank Dr. Littlejohn sincerely for his very instructive paper.

DR. GEORGE BLUMER (New Haven): I just want to call attention to one point. It has not much to do with the treatment of gonorrhœa, however. That is, the distinction between red and white meats. It is now known that the white meats have rather more extractives, if anything, than the red. If meat is stopped, it should be meat of all kinds.

DR. RALPH A. MCDONNELL (New Haven): I had not the pleasure of hearing the entire paper, but I enjoyed very much the part of it that I did hear. There were two points that I want to speak of, one being the influence of diet on gonorrhoea. I have been unable to satisfy myself that it has any influence after the acute part of the affection is over. In the beginning, I advise a milk diet. The patients almost never follow this advice; but when they do, they get control over the acute symptoms more quickly than in any other way. After this, I tell them to eat as usual, but not to overeat.

In regard to drinking large quantities of water, I think that this is very valuable; but it ought to be controlled toward the latter part of the evening, because one of the bad effects of a full bladder is priapism at night, which is manifestly unfavorable to the disease. I direct my patients to stop drinking water at seven o'clock, and not to drink any after that time.

DR. P. DUNCAN LITTLEJOHN (New Haven): I was well aware that white meats may have more extractives than the red; but most of the people of this class eat less poultry than others, especially the workingmen. Therefore, that was my idea in warning them against red meat. I knew that if they did not eat red meat, they would eat very little meat of any kind.

Dr. McDonnell's point about the diet is well taken. My idea was that people who come to the physician with a new complaint or a recent infection, never having had any previous experience with trouble of this kind, should be told what to avoid in the way of eating. In chronic cases, the diet is not as important.

Gentlemen, I thank you for your kind attention.

The Management of Syphilis.

ALFRED G. NADLER, M.D., NEW HAVEN, CONN.

It is a moot question whether syphilis is or is not increasing. Possibly, owing to better methods for accurate diagnosis, or perhaps because the physician of to-day is better qualified to recognize the disease, the number of syphilitics is apparently greater. Some men with large dispensary and hospital services declare that as many cases do not appear as formerly. It is true, symptoms of the disease in newly inoculated patients are not so severe as, say, ten or fifteen years ago. On the other hand, the neurologist and the internist will show us more cases of tertiary lesions, of organic syphilis. Personally I do not believe there are more such patients to-day than ten years ago. With improved methods of studying a case and advanced laboratory facilities, with the knowledge that practically 100 per cent of paresis, 90 per cent. of tabes, and a large proportion of aortic disease is due to lues, the specialist is more apt to consider syphilis and when present, to confirm his diagnosis. The large number of patients with the late lesions must be due to insufficient treatment. Some of this can be attributed to the patients themselves, but a large, a very large share of the blame must be laid on the shoulders of the members of our profession. Either the diagnosis was not made (it is surprising how often this occurs), or else the treatment was not insisted upon for a sufficiently long period. Since the discovery of the spirocheta and the Wasserman reaction, no excuse remains for the practitioner either to fail in a diagnosis or to be remiss in his treatment.

Of course we all know that a certain percentage of patients cannot be convinced of the seriousness of their disease and the liability of future sequelæ. Putting those on one side,

M*

there still remains those whom physicians, by their failure to prolong treatment, doom to future misery.

Not only is the treatment not persisted in, but, strange to say, although it should be well known that mercury is the cure for lues, many times mercury is not even prescribed, or if it is, in some such fashion as will make it convenient for the patient and assist him in hiding his disease. Ofttimes, too, potassium iodide is prescribed and depended upon as the remedy. Potassium iodide is not and never was a cure for syphilis. True, it helps to improve certain symptoms, especially the late manifestations, but it never can permanently influence the disease.

In this contribution I shall only consider the management of the usual everyday forms of syphilis.

In the management of syphilis there are three questions to be answered:

When to begin treatment?

How to treat?

When to stop treatment?

When to begin treatment? Answer-As soon as the diagnosis is made. When can we make a diagnosis? In practically every case, at the first visit or very soon thereafter.

In 1905 Shaudin and Hoffman declared the spirochaeta to be the cause of syphilis. There is no need for me to relate the history of previous attempts to find the luetic germ and their failures. Since Shaudin's discovery, much work has been devoted to disprove his claim, but now, although all the conditions of Koch's law have not been fulfilled, nevertheless the best investigators universally acknowledge the treponema pallida.

When a patient with a suspicious sore first presents himself, a smear should at once be examined for the spirochæta. The technique is very simple and the latest improved methods for staining make the task a light one and the time required comparatively short. Should the spirochata not be found at the first examination, a mild cleansing lotion is prescribed

and the patient instructed to return within two days, when a second smear is examined. Sometimes, very seldom, it is necessary to wait for secondary symptoms to appear. But for anyone with a little experience and with some care in the technique, the microscope will almost invariably make or confirm the diagnosis. An undoubted chancre with its attendant symptoms is readily recognized. Even in such cases it is well to confirm the diagnosis. Everyone has seen such initial lesions as baffle the most expert diagnostician. In these cases the microscopical examination clears up the diagnosis and saves much valuable time.

The treatment:

Excision of the chancre.

My own experience is limited to one case and that so recent that the effect on the future progress of the disease cannot be stated.

Excision of the chancre was done in the sixteenth century. One hundred years ago Hunter used the method. Later Ricord advocated it. Thirty years ago it became again the fashion, only to be abandoned. Recently the Vienna School revived the practice.

The chancre should always be removed when convenient, but the patient should be treated just as if the operation were not attempted. The presence or absence of enlarged glands does not influence our action. When glands are not perceptible, we may in some cases remove the entire focus of the disease, freeing the patient from further manifestations. On the other hand, when the glands are present, the excision of the chancre removes a host of active infecting agents from the system. Always bear in mind, however, that the treatment must be conducted in the same manner as if the procedure were omitted.

The syphilitic chancre should never be cauterized. The destruction is often extensive and the result frequently undesirable.

The methods for internal administration are the weakest, should never be used except when conditions prevent the use of inunctions or injections.

Treatment by suppository is also inefficient, owing to the small absorption.

The old method of inhalation, viz., with the cabinet and vapor bath, is entirely abandoned, owing to the severity and danger of the method. At present we use, very often with good results, the Welander sack or the Mercolint apron or the Kromayer mask, all intermediate cures.

Administration by inunction is one of the main and best methods. It is really an inhalation of the drug. The contraindications are idiosyncracy against mercury, eczema, ichthyosis, hypertrichosis, and other skin diseases.

From three to five grammes of the unguentum hydrargyri diluti, U. S. P., freshly prepared, should be gently rubbed in daily, the body to be divided into five areas-calves, thighs, belly, arms, back-one area being used each day. Five days' treatment is one tour. The next day a hot bath is taken, the seventh day a rest, then the tour is repeated. Six tours constitute one main course. The rubbings should be made at night in a hot room. The method is ideal in hospital and institutional practice, but it is difficult to use with private patients for obvious reasons.

I am not qualified to discuss intravenous injections, having had no experience with the method.