this woman had syphilis. She said that for some time before coming to me she had felt some soreness in her rectum and that it did not disappear until after she began treatment with me for her other symptoms. This woman evidently had an initial sore in her

rectum.

Recently I saw a man who was sent west for nervous prostration. He consulted me because of a sore throat. His throat lesion was that of mucous patches. I at once asked him when he had had his initial sore. He denied having had one. He was married but acknowledged having been exposed three months before. About thirty days after this exposure he was alarmed by an eruption appearing upon his penis, and consulted his physician at once, who pronounced the eruption herpetic and gave him a powder to dust on it. In ten days it was well. If there was any swelling of his inguinal glands he was not aware of it. He absolutely denied having ever had any other trouble with his penis. After learning this history I had him expose his chest and abdomen and found a roseola eruption, which he said he had first noticed about three or four weeks before, after taking a warm bath. His throat had been sore for a few days only. I watched him for a week, giving no treatment other than local applications of nitrate of silver to the mucous patches, which had no beneficial effect. While I felt sure that he was in the beginning of the secondary stage of syphilis I did not believe that he felt sure of it. He was going on to San Francisco and I accordingly advised him to consult there a dermatologist and a rhinologist. A letter from him informed me that the physicians consulted in San Francisco said he had syphilis, that he had placed himself under treatment with complete clearing up of all his symptoms.

I remember very well the case of a man and his wife who were under my care about nine years ago. The man consulted me for some simple ocular affection, and as his wife was with him he asked me to look at her throat, as it had been sore for a few weeks. I found she had what appeared to be mucous patches and referred her a gynecologist for a vaginal examination, who reported that she had a chancre of the vulva and a skin eruption. I then inquired of the husband if he had syphilis. He insisted that he had not. Examination of his genitals showed no evidence of his ever having had a chancre. It seemed rather remarkable that he had not acquired the disease of his wife, as she gave a history of vaginal soreness, especially during intercourse, for about two months. He finally turned out his lip and showed me an indurated sore on the mucous surface near the angle. He supposed it was only a canker sore that came about two weeks before. Examination of the glands on that side of the neck showed enlargement, with especial swelling of the submaxillary. The only way he

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could account for his wife's infection was that about three months before she had a vaginal examination made to determine if she was pregnant. The physician used a speculum. The remarkable feature of the case was that he should have acquired a chancre of the lip from kissing her, rather than a chancre in the usual situation acquired in the regular way.

The difficulties of diagnosis in tertiary lesions are much greater because of the absence of secondary symptoms which are so positive, together with the fact that the period of time which has elapsed since the primary infection renders the memory of the patient very inaccurate if his disease was not at that time diagnosticated and treated. It is many times impossible to get a history of either primary lesion or secondaries, and in such cases unless the tertiary lesion is very typical we should not place such patients upon antispyhilitic treatment until a reasonable trial of other remedies has been given. If we find that the disease only responds to antisyphilitic treatment, and the improvement is sufficiently rapid to warrant a diagnosis of syphilis, then the patient should be made acquainted with the nature of the disease and the necessity of a long course of treatment, covering a period of at least three years. It is a great mistake to dismiss these patients from treatment shortly after the disappearance of symptoms, for a recurrence is almost certain, either in the same situation or somewhere else.

The neurologist, the laryngologist and the ophthalmologist see a very large proportion of the cases of neglected syphilis. Many cases are such because of the inherent tendencies of the patient to be neglectful, and others, I am sorry to say, are neglected by the medical attendant. I am convinced that many physicians have an idea that syphilis can be cured by a six months course of treatment. If all physicians thoroughly understood that at least two and preferably three years' persistent treatment are required to eradicate the disease, I feel sure we would see fewer cases of late syphilis.

I trust I may be pardoned for touching upon the hackneyed subject of treatment. If a patient fully understands the importance of this disease, he is usually willing to carry out the treatment no matter how arduous. The long continued administration of mercury by the mouth is very liable to derange the intestinal canal, and thus undermine the vital forces so necessary to be sustained in the management of syphilis. In the early and late manifestations of this disease it is my custom to prescribe mercurial inunctions with kali iodide internally, pushing the iodide in accordance with the nature of the lesion. After the external lesions are gone the iodide is stopped and the inunctions continued in doses of one drachm daily for three weeks out of every month for the first year, two weeks out of every month for the second year, and one week out of every month for the third year. Dur

ing the interims of the use of the mercury it is well to administer kali iodide in 20 grain doses three times daily in plenty of water, or if the physical condition of the patient demands it, substitute for the iodide some form of supporting tonic treatment. I have found the emulsion of mixed fats a valuable agent for this purpose. It must be explained to the patient that the inunctions must be well rubbed in, not by brisk hard rubbing, but by slow gentle movements for at least half an hour. The best place to rub is over the small of the back. This necessitates an attendant who uses a rubber glove, or glass rod. I find an attendant does better work than the patient, being more persistent and thorough.

I believe one reason why salivation occurs so often is because of the irritation of the intestinal tract from the internal administration of mercury and from bad teeth. It is my custom to always examine the teeth and gums of syphilitic patients and if a dentist's care is needed to insist upon the patient consulting his dentist at once. I have very few cases of salivation to contend with. A few years ago I did not pay much attention to the teeth and was many times compelled to temporarily discontinue treatment because of salivation.

In conclusion, let me urge that in the early stages of syphilis the patient should not be placed upon treatment until the secondaries appear. The common practice of starting treatment with. the initial sore as the only evidence of the disease is to be condemned. It is always better to wait until the secondaries appear. When the patient as well as the physician is sure of the diagnosis there are then no lurking doubts in the mind of the patient to cause him to finally conclude that he never had syphilis and of his own accord discontinue treatment. If the patient is a married woman and has contracted the disease from her husband the latter should be made to understand that she must know the nature of her disease that she may properly appreciate the necessity of the long course of treatment required for its cure.

THE CURE OF STRABISMUS.*

By DR. EDWARD JACKSON,

Denver, Colo.

WHAT IS THE CURE OF SRABISMUS?

Within the last week I have seen a patient who came for headache and asthenopia, and gave a history of the eyes having been crossed at times when a child, but said nothing of the kind had been noticed for many years. During examination she showed intermittent strabismus 8 to 12 degrees, more than onefourth of the time. Within a month I have seen a similar case *Read before the Rocky Mountain Interstate Medical Society, Cheyenne, Wyo., Sept. 9th, 1902.

in which the deviation is sometimes almost 20 degrees. Both of these cases have been regarded by the patients themselves and their friends, as instances of spontaneous cure.

About a year ago I saw a case of "cure" by operation, in which the movement of the eyes inward was limited to half the normal convergence, was attended with the rolling upward of one eye, and the eye operated upon was displaced forward 1.5 millimetres in advance of the other.

Anything, from a very moderate diminution in the amount of turning, has been called a "cure" of strabismus. It is possible, however, in a considerable proportion of cases to cure strabismus so that every movement of the eyeballs will conform to the general normal standards, so that binocular vision will be constant, easy and complete. In view of this nothing else can be accepted as a cure, and by such a standard of cure, methods of treatment must be judged.

FACTORS OF CAUSATION.

The

Scientific methods of treatment deal first with causes. causes of strabismus are intimately connected with the requirements for normal binocular vision.

The first of these is the possession of two eyes, each of which has sufficiently good vision.

Second, each of these eyes must be able to execute the necessary movements.

Third, the centers controlling their movements must possess those intimate connections that render harmonious movements of the two eyes possible.

Fourth, the reflex circuit, by which the retinal impressions control the ocular movements, must be sufficiently good to insure accuracy of movement.

Fifth, the conditions of innervation required for accurate vision must be such as will not seriously disturb the innervation required for exact movements.

Among 250 cases of convergent squint, the notes of which were reviewed in the preparation of this paper, I found that in every one the vision of one eye was imperfect, or the refraction of the two eyes differed so much that they could not both see clearly at a given distance at the same time, or there was so much hyperopia that the necessary effort of accommodation strongly predisposed to excessive convergence. Thus in 85 per cent. vision in one eye was reduced to less than one-half the normal; in 23 per cent. the difference of refraction between the two eyes was over 1 diopter; and in 88 per cent. there was hyperopia of 1 diopter or over. Imperfection of visual apparatus in any one of these particulars will prevent perfect binocular vision and may cause strabismus.

HOW STRABISMUS ARISES.

Confining these remarks to the convergent strabismus of childhood, the factor common to all cases is the failure to develop

accurate reflex movements, and binocular vision. The child comes into the world without any developed power of using the two eyes together. Even its accuracy of vision is greatly below the normal standard for older persons; and often does not reach that standard until six years of age or older. The movements of the two eyes are roughly but not exactly co-ordinated. The ability to use the eyes together, as the ability to use them at all, is slowly developed. The failure to develop it, or the development of an abnormal relation between the movements of the two eyes, constitutes strabismus. The cure of strabismus necessarily includes the removal of all obstacles to the normal development, and the carrying forward of that development until binocular vision is established.

OPERATION CANNOT CURE STRABISMUS.

The accuracy of the normal ocular movements is such that the eyes can be properly directed only in response to a reflex impulse. The variation of one of the ocular muscles by a half of the diameter of a blood corpuscle, will cause for normal eyes, intolerable confusion and diplopia. An adjustment of such accuracy is beyond the possibilities of operative exactness. Operations may remove some essential obstacles to binocular vision. But without the reflex mechanism which secures accurate movements, and without the co-ordination that effects binocular vision, a cure of strabismus is impossible.

TIME FOR TREATMENT.

If strabismus is due to arrest in the development or co-ordination, the obstacles to such development should be removed while the patient is still young enough for the development to go on to completion. If strabismus is due to the development of an inaccurate co-ordination, the causes of that inaccurate co-ordination should be removed at the earliest possible moment, before it has become thoroughly established, and while it can be most readily corrected. In all cases the best time to treat strabismus is when it is beginning. In a great majority of cases, cure is impossible at any other time.

In the series above referred to there were 167 cases in which the time of the beginning of the strabismus could be fixed with probable certainty. In 155. that is 94 per cent., it began before the age of six years. When operation, which cannot by itself cure strabismus, was the only method of treatment, the uncertainty of its results justined delay. But now that the great majority of curable cases can be cured without operation, without taking any step that cannot be retraced, there is absolutely no justification for delay in the treatment of squint. The point which might be urged, that some cases recover without treatment, can be urged with equal or greater appropriateness in regard to typhoid fever, fracture of the humerus, or complicated labor. The

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