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attending, let secrecy be the rule ; but when theycease to attend and resist all efforts to reclaim them,let the law step in.TABLE IlL-Illustrating the Effect of sending 1, 2,

or 3 Letter Cards to recall Absentee Patients for Treat-ment or for Wassermann Test.In the early part of 1920, 219 absentee cases were

written for ; of these : oNo. of absentees written for once .... 133 -

" ..., ,, ,, twice .... 46 -

" .. " ,. ,. thrice 40 -

219 = 100No. who attended on receipt of 1st letter card 96 = 43’9,...., 0’ 2nd ....

20 = 9’1

".. .. " 3rd .. 3 = 1’4

Letter cards returned : 119 == a4’-t

(a) Wrong address given when registering 18 = 8-2(b) Removed from address given when registering 5 = 2’3No. who ignored letter cards ...... 77 = 35’1

100 = 45’6

Summary and Conclusions.1. An analysis of the attendances of 801 new cases

of syphilis admitted to the Liverpool Royal Infirmaryvenereal clinic during one year beginning July 1st,1918, demonstrated that the attendance of thesepatients was extremely unsatisfactory. Of new

cases of primarv and secondary syphilis 50 per cent.reached the end of their first course, 20 per cent. theend of their second course, and 14 per cent. the endof their third course. If this state of affairs wereallowed to continue it would be a menace to thepublic health and a waste of the public money.

2. Apart from failure to attend through ignorance,callousness, and lack of financial interest in treat-ment, the effect of three factors upon attendance hasbeen specially considered by statistical methods.(a) Fixity of abode : This has a moderate influence ;for absenteeism of seafaring men and other " wan-derers " was only about 10 per cent. to 20 per cent.greater than that of the fixtures." (b) Severity ofsymptoms on admission : This has very little in-fluence for the absenteeism of patients with primarysyphilis was only about 2-3 per cent. greater than thatof those suffering from the constitutional symptomsof secondary syphilis. (c) Positive or negativeWassermann reaction : This has a great influence uponabsenteeism ; of 203 cases of latent syphilis theattendances during the first three months were

roughly twice as good in those admitted with a posi-tive Wassermann reaction as in those admitted witha negative reaction. Obviously great stress shouldbe laid in the instruction to patients that a negativeWassermann reaction does not mean a cure.

3. The sending of letter cards is a partial butvaluable remedy for absenteeism, resulting in therecall of half the absentees. Thus 19 absentees werewritten for, 43-9 per cent. attended on receipt of thefirst card, 9-1 per cent. on receipt of the second, butonly 1-4 per cent. on receipt of the third. 8-2 percent. gave the wrong address when registering.

I am indebted to Dr. Ernest Glynn, Professor ofPathology, to whom this investigation was indirectlydue, for much helpful criticism ; and to Mr. F. P.Wilson, surgeon in charge of the Venereal Depart-ment, Royal Infirmary, for allowing me free access tothe records employed.

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HOSPITAL SUNDAY FUND.-On July 28th at the IMansion House, the Council of the Hospital Sunday Fundmet to make their awards for the year, Mr. R. HollandMartin occupying the chair. The Fund amounted to zion,920,and the Council decided to distribute .8100,170 to hospitalsand dispensaries, the chief awards being as follows :Charing Cross Hospital, 22460 ; Great Northern CentralHospital, 2545 ; Guy’s Hospital, 24655 ; King’s CollegeHospital, ii 1320 ; London Hospital, z12,300 ; Middlesex andConvalescent Home, JB4130 ; Royal Free Hospital, 22735 ;St. George’s Hospital, JE3710 ; St. Mary’s Hospital, .82715 ;St. Thomas’s Hospital, .83520 ; University College Hospital,22415 ; West London Hospital, 22200; Westminster Hos-pital, 2220. Several other institutions received sums of over1000 ; the Fund was smaller by 210,000 than last year.

BRITISH MEDICAL ASSOCIATION.ANNUAL MEETING AT NEWCASTLE-ON-TYNE.

SECTION OF MEDICINE.

WEDNESDAY. JULY 20TH.THE first session was given up to a discussion on

Yisceml Syphi1i8,with especial reference to the cardio-vascular andcentral nervous systems.

Prof. THOMAS BEATTIE (Newcastle), the President,in his introductorv remarks recalled the last discus-sion of this subject in 1893. In those days syphiliswas largely untreated, and in this town-seaport,military depot, and industrial centre-they saw alarge number of cases. In the army a man withvenereal disease was either in hospital or in theranks ; if he had syphilis he was only treated inhospital until the primary and secondary stages werepassed. When he became a reservist the strain ofphysical labour, added to the imperfect treatment ofhis syphilis, led to the frequent development ofaneurysm, general paralysis, tabes, transverse myelitis,and peripheral neuritis, and more rarely syphiliticdisease of the pleura, lung, liver, and pancreas. Atthe present time syphilis is detected by the blood testin many cases in which it was not previously recog-nised because there was no history of previous disease.Modern treatment can eradicate the disease. In thefuture the incidence of these conditions will bediminished and fewer cases of visceral syphilis willbe seen, as there is less chance of these complicationsoccurring in treated cases.

Sir T. GuFFORT) Ai/LBUTT, who opened the discus-sion, first dealt with the histology of syphilis, insistingupon the importance of the vascular changes, whichare strictly comparable in

"

primary " and " tertiary "lesions-the disease is a disseminate lympharteritis.The rapidity of generalisation of the virus via thelymphatics was emphasised-a syphilitic septicaemiais soon established, characterised by fever, rashes, andansemia : some of the rapid deaths reported in earlysyphilis after the injection of salvarsan may be duerather to syphilitic than arsenical poisoning. He saidthat the disease when it attacks the arteries beginsin the adventitia, and the change is quite differentfrom that seen in athero-sclerosis. It arises in the aortaas a periaortitic lympharteritis, which tracks throughto the intima, in which it may spread upwards ordownwards to the aortic valve and coronary orifices.If a valve cusp is affected it may be severed from itsattachment. Atheroma rarely ends in aortic regurgi-tation, syphilitic aortitis frequently does, and isoften combined with coronary disease. In 70 percent. of cases of syphilis microscopical examinationshows that the aorta is affected, and it may be at avery early stage. Angina pectoris may be an earlysymptom of this involvement. Syphilitic disease ofthe ventricles is not common ; there is no directevidence of a diffuse fibrosis save as a consequenceof coronary disease. Certain cases of pulmonaryfibrosis and bronchiectasis may be syphilitic; a

diffuse induration of the lung either at the root orat an apex may simulate pulmonary tuberculosis,and the two infections may exist together. Bronchitisin a syphilitic subject should be carefully watched ;gumma of the lung is rare. Syphilitic lesions of the

, alimentary canal below the oesophagus are seldom. met with except in the rectum. Gumma of the kidney. is rare, and it is doubtful if there is a true syphilitic: nephritis. The central nervous system may be

infected very early in the disease, long before anyclinical symptoms arise, and this especially in those cases which show little " secondary " manifestation.L Here the essential change is also a panarteritis. The; Wassermann reaction in the cerebro-spinal fluid may; be positive while that in the blood is negative, and a positive test may be found in the cerebro-spinal fluid in the absence of symptoms. Sir Clifford Allbutt urged

that lumbar puncture should be performed at everyF2

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stage of the disease, and, if necessary, treatment should ibe by intrathecal as well as intravenous injection.

In general paralysis the vessels are affected longbefore the appearance of symptoms. The nervoussystem is involved in 40 per cent. of congenitalsyphilitics, and signs usually appear before adolescence.In all diseases of the spinal cord the cerebro-spinalfluid should be tested for the Wassermann reaction.The speaker expressed the view that it is very likelysyphilised arteries recover if treatment is begun early.

Discussion.Prof. E. S. REYNOLDS (Manchester) approached

the subject from the clinical standpoint, and com-mented on the protean character of the symptomsof visceral syphilis ; in any condition which does notrun a course typical of a recognised organic diseasesyphilis should be suspected. In a doubtful case

examination of the eye and skin not infrequentlyreveals signs of old syphilitic disease. Syphiliticlesions are more often multiple than single. In thespeaker’s opinion the majority of cord diseases arenot syphilitic. Too much reliance must not beplaced on the Wassermann reaction ; a positiveresult in the cerebro-spinal fluid does not necessarilymean nerve syphilis, and not 10 per cent. of all casesof syphilis develop either tabes or G.P.I. Spasticityis always very marked when it occurs in syphiliticdisease. The chief syphilitic affections of the spinalcord are pachymeningitis, meningo-myelitis, acutemyelitis, gumma, and Erb’s spinal myelitis.Dr. JOHN COWAN (Glasgow) showed lantern slides

illustrating syphilitic disease of the heart and aorta.The diffuse myocardial fibrosis occurring in the earlystages, gumma, diffuse fibrosis resulting from coronarydisease, or the occlusion of a coronary orifice bysyphilitic aortitis and early syphilitic disease of theaortic valve, are quite characteristic, but in manychronic diseases the cause is not recognisable. Anycardiac affection may be syphilitic in origin, he said,but its recognition in a particular case often dependson finding evidence of syphilitic infection, old or

recent, in other organs. The Wassermann reactionis a good servant but a bad master, and should beused only as an aid to diagnosis. It is not a specifictest from a serological point of view ; a positiveresult is of value, but a negative is useless. Cardiacmanifestations as a rule appear late, and only about75 per cent. give a positive blood Wassermann. Acase of aortic disease without mitral involvementarising in a patient between 30 and 50 years of ageis most likely syphilitic, whereas aortic diseaseassociated with a mitral lesion in a man between20 and 40 years old is probably rheumatic. Themajority of cases of heart block, myocardial diseaseand auricular fibrillation are not syphilitic in origin.Though too much must not be expected from anti-syphilitic treatment in cardio-vascular syphiliticdisease, it is urgently required. Large doses ofsalvarsan are contra-indicated ; moderate doses com-bined with long courses of mercury and iodide givethe best results. No amount of treatment willremove thrombus from a vessel or restore dead tissue,but it is possible to improve the endarteritis.

Dr. A. G. GIBSON (Oxford) considered the diagnosisof syphilitic aortitis. Cases may be quite latent, anunsuspected patch being discovered post mortem.The " effort syndrome " may induce substernal painand tenderness on pressure due to stretching of theaorta, an X-ray examination of which shows a wideshadow with an indefinite outline. Anginal painmay be due to coronary obstruction. Paroxysmaltachycardia may be the condition to attract atten-tion. Aortic regurgitation is the best known signand the easiest to recognise. Aortitis may cause avariety of abdominal symptoms, but in each grouppain is induced when the blood pressure is raised,there is tenderness on deep pressure over the aortaand an increased width of shadow ; the atheromatousaorta shows no such enlargement. Some cases dowell on a solution of mercury and potassium iodide,

Iand small doses of salvarsan repeated over a long Iperiod ; salvarsan in ordinary doses is contra-indicated.

Dr. Ivy McKENZIE (Glasgow) stated that he hadseen two cases of syphilitic nephritis amongst 1500cases of syphilis during the last eight years. Bothoccurred during the " secondary " stage, and in eachthe albumin and blood cleared up with the disappear-ance of the rash. In the " outdoor treatment centre "vascular symptoms are rare, whilst nervous com-plications are relatively common-in the last 500cases treated 40 returned with symptoms referableto the nervous system. He related a case whichpost mortem showed gummatous infiltration of theright ventricle, death having taken place six weeksafter the onset of symptoms. He considers anginais due to aortic disease irritating the vagus andsympathetic nerve endings in the arterial wall.

Dr. ISAAC HARRis (Liverpool) showed electro-cardiograms from two cases of syphilitic myocarditis.In the case of a man aged 41, who was admitted tohospital with symptoms suggestive of gastric ulcer,the electrocardiograph revealed a want of conductionin the right branch of the bundle of His. His bloodWassermann was positive, and there was a historyof syphilis contracted 20 years previously. Potas-sium iodide removed his symptoms and restored thecardiograph to normal in three weeks. He maintainsthat syphilitic and non-syphilitic disease of theheart may give rise to the same symptoms and signs,that iodide is very effective in localised disease ofthe myocardium, but mercury is more efficacious ingeneralised arterial disease.

Dr. JOHN EASON (Edinburgh) dealt with theanaemias of syphilis. The blood picture of "perni-cious anaemia " was found in an infant 14 months ofage, whose blood Wassermann was positive ; themother’s serum also gave a positive reaction. Headvocated the Wassermann test in all cases of anaemiain infancy both on the mother and the child. Theblood picture of " pernicious anaemia " may alsooccur in the " secondary stage " of the acquireddisease. He quoted three cases seen during the war,two of which recovered completely ; in the fatal case,a man aged 36, mercury was of no benefit in treat-ment, and at the post-mortem the liver contained nofree iron and no spirochaetes were found in the spleenor bone-marrow. In the " tertiary stage " an anaemiawith enlarged spleen simulating Banti’s disease mayoccur. In one case resembling " pernicious anaemia

"

haemosiderin was found in the liver and spleen.Sir CLIFFORD ALLBUTT, in reply, briefly referred to

angina pectoris. It is a very important symptom ofaortitis, he said, whether syphilitic or not, and indi-cates disease of the tunica adventitia. The pain isoften very trifling, and may be only a sense of oppres-sion across the upper chest, with or without painreferred down the arm.

THURSDAY, JULY 21ST.

Asthma and Allied Conditions.The opening paper was read by Sir HUMPHRY

ROLLESTON, who stated that the diseases in thegroup of

" toxic idiopathies " are hay fever, asthma,urticaria, angio-neurotic oedema, Henoch’s purpura(or purpura with abdominal symptoms), eczema, andsome other forms of acute dermatitis, some cases ofacute gastro-intestinal disturbance, and some formsof croup. Doubtful examples are migraine, epilepsy,cyclic vomiting, and possibly gout. The varioustheories as to the causation of asthma were passedin review, and the evidence in favour of these diseasesbeing anaphylactic phenomena considered ; whenthis subject was discussed at the Birmingham meetingten years ago the accepted view was that asthmawas a "reflex neurosis," only the opener of thedebate, the late Dr. G. A. Gibson, suggesting that" modern theories of anaphylaxis may in the futureaid us in our understanding."Do we now attach too much importance to hyper-

sensitiveness in asthma to the neglect of a reflexside ? In discussing aetiology, the predisposing factorof heredity was emphasised ; with a strong familyhistory a sensitiveness to several different proteinsoften appears. Whether hypersensitiveness may be