with black wash; when painful and not healing well, iodorm is very useful. The constitutional treatment by mercury should be begun as soon as the primary sore is recognised, as by this means the secondaries may be neutralised (Hutchinson).

The secondaries are treated by mercury. For condylomata, there is nothing equal to calomel.

Mercury may be given internally in three ways—(1) by the mouth, (2) by inunction, (3) by the calomel bath.

By the mouth we give the metal in the familiar blue pill or as hydrarg. c. creta. The perchloride is given as of a grain in pill.

The red iodide is also good; it is more active when freshly prepared from the perchloride as follows.

Take about twenty

For inunction, blue ointment is employed. grains of the ointment and rub it into the skin for about ten minutes. The inunction should be made methodically on different parts of the body in rotation-arms one day, chest and abdomen the next, the back the following day, and so on (v. Sigismund). This method is best where we wish to have the action of mercury speedily-as when important organs are becoming affected, or when the digestive system is disturbed (Bäumler).

The calomel bath is recommended by Lee* and is given as follows. Strip the patient, place her on a stool with a blanket over the whole person and overhanging the stool; place under the stool a tin plate with about eight grains of calomel on it; there is a trough, surrounding the calomel on the plate, containing water which is made to evaporate slowly by means of a spirit lamp; the steam from the water carries the fumes of the calomel upwards with it. The fumigation lasts twenty minutes and the patient goes at once to bed afterwards.

The mercurial treatment may be discontinued after three or four months, if the secondaries have not developed; after a year, if they are present. Fournier continues it for two years and lays great stress on his method of successive or intermittent treatment': mercury and

Lee-Syphilis Holme's System of Surgery, London, 1870.

:

iodide of potassium after a time lose their effect, a tolerance being produced; every two or three months, their use must be discontinued for a month or more so as to ensure their action.

The patient must be warmly clad, wearing flannel next the skin, and be confined to the house and even to bed if the eruptions are severe or the weather cold; for wealthier patients, a winter's residence in the south of France is beneficial. While mercury is being taken, the mouth must be rinsed thrice daily with warm water containing an aromatic and the teeth carefully brushed night and morning; this diminishes the liability to stomatitis.

During the tertiary period, iodide of potassium is given in doses of five grains, increased to ten, thrice daily.

SYPHILIS AND MARRIAGE.

It is fortunately a very rare occurrence in this country for the gynecologist to be consulted as to marriage by women who have syphilis, but the interests of his patients come under his notice indirectly when advice is sought by a man who has had syphilis but is intending to marry. Under what circumstances is marriage justifiable? This question can only be answered after a thoughtful recognition of all the interests which will be involved, and a thorough examination of the patient who asks advice. We have to consider the interests of a wife, of children, of the father of a household. We must remember that a wife may become infected indirectly through the fœtus, as well as directly through contact with the manifestations of the secondary period; that syphilitic children are the blight of married life; that the changes of the tertiary period sometimes, though rarely, produce permanent incapacity for work and even fatal results. For a full description of these dangers, we refer the student to Fournier's work on Syphilis and Marriage. The examination of the patient should determine the following points: the date of his contracting the disease; the severity, duration, and recurrence of the local eruptions; the treatment adopted; the present existence of abrasions on the penis, the lips, or other parts, as possible foci of contagion.

Fournier lays down the following conditions of admissibility to marriage (1) Absence of actual specific symptoms at the time of marriage these symptoms being both a possible source of infection and a key to the progress of the disease; (2) Advanced age of diathesis, the more recent the syphilis the more numerous and greater are the dangers imported into marriage; (3) Period of immunity sufficiently long since last manifestations—three or four years a minimum; (4)

Non-menacing character of the diathesis, as shown by the absence of tendency to relapses and the avoidance of important organs; (5) Sufficient specific treatment.

Of these 2 and 5 are the most important; or as Fournier graphically expresses it-Time, on the one part, and the treatment on the other; here you see the two great major conditions to exact of all syphilitic patients before opening to them the marriage-gates.'

SYPHILIS AND PREGNANCY.

This subject is important, not only because syphilis takes on a more rapid development in the patient herself during this period but also because we have to consider the effects on the fœtus. three ways in which syphilis complicates pregnancy.

:

There are

1. Conception occurs in a patient already syphilitic the ovum is syphilitic, the spermatozoa may or may not be so.

2. Conception occurs in a healthy patient who becomes directly infected at the act of insemination or at some subsequent period during pregnancy.

3. Conception occurs in a healthy patient: syphilitic spermatozoa impregnate a healthy ovum; the mother is not infected

directly with the poison but through the syphilitic fœtus. With regard to the first condition, we note that the syphilitic poison wears itself out after a series of pregnancies especially when proper treatment has been adopted; thus a syphilitic patient may have first a series of abortions, then a premature still-born child, and finally give birth to a living child at full time. With regard to the second, when the mother is infected at the same time as the ovum is impregnated, the usual symptoms of syphilis develope at the tenth week of gestation; the fœtus is, of course, syphilitic. In the third form the spermatozoa are the carriers of the infection, the fœtus is the primary sore-the depot in which the poison is generated, and from which it is served out through the system of the mother; syphilis thus developes without any local source of contagion in the husband or primary sore in the wife. This form is therefore known as 'syphilis by conception' (Fournier), or 'syphilis by foetal-blood-contamination' (Hutchinson). When syphilis is acquired in this way, the mother rarely has the full course of secondary phenomena. Usually these are obscure and develope gradually, loss of hair and general weakness being the only manifestations. Sometimes there is no evidence of syphilis at allHutchinson mentions a case in which the mother gave birth to eleven

syphilitic children, and yet showed no manifestation of syphilis. Just as in vaccination the child really passes through an attack of smallpox, the only manifestation being the local pustule; so the mother has passed through an attack of syphilis, the only manifestation being the syphilitic child.

Thus Hutchinson explains the fact, first recorded by Colles, that a healthy woman may nurse her syphilitic child without being infected by it; while the same child, given to a healthy nurse, would produce a chancre on her breast and all the phenomena of an attack of syphilis. A woman who has just given birth to a syphilitic child acquires therefore the same immunity as regards a second attack as one who has had an attack of syphilis.

The clue to the existence of syphilis is often given by pregnancy. Thus a series of abortions (without any other cause to explain them) creates a suspicion of syphilis. Repeated occurrence of death of the fœtus in utero, at the seventh or eighth month, is probably due to this cause; this is confirmed by our finding, on splitting up the ends of the long bones, the 'speckled discolouration and softening of the spongy tissue of the bone in the neighbourhood of the epiphyses' described by Wegner as pathognomonic of syphilis.* If the infant has "snuffles" (due to catarrh of the nasal mucous membrane), skin eruptions and condylomata, the diagnosis of syphilis in the parent is certain.

We should always examine the grown-up children for traces of hereditary syphilis. These are usually found in the eye and teeth. In the eye there occurs at the second dentition, and at puberty in girls, an interstitial keratitis; the opacity, beginning at the circumference, extends to the centre and disappears in the same order, lasting for a period of from five to twelve months. The changes in the teeth have been fully described by Hutchinson. The teeth stand apart with interspaces between, and are rounded or peggy in form instead of flat; they usually exhibit in their border a broad shallow notch, or two or three serrations; owing to their softness they rapidly wear away, and from the deficiency of enamel have a dirty greyish colour. The teeth thus affected are the incisors and canines of the permanent set, especially the upper incisors (fig. 398). The change in form is due to syphilitic stomatitis during the first weeks of life which affects the * Virchow's Archiv., B. 50, S. 304.

+ Hutchinson, Jon. -Memoir of certain diseases of the eye, &c., London, 1863. Trans. Path. Soc. London, Vol. IX. p. 449 : Report on the effects of Infantile Syphilis in marring the Development of the Teeth. Ibid., Vol. X., p. 287: Report on Malformations of the Teeth as indicative of Diathesis; illustrated by coloured plates.

development; if a syphilitic patient escapes stomatitis, the teeth will not be affected.

Teeth from a case of hereditary syphilis, the upper central incisors are dwarfed and have a broad vertical notch in their edge (Hutchinson).

The benefits of a mercurial treatment are distinctly brought out in syphilis and pregnancy. Under efficient treatment the duration of pregnancy becomes longer, and finally a full-time healthy child is born. Mercury seems to neutralise the syphilitic virus in the blood, even though the syphilis be not cured; Fournier mentions a case where a patient gave birth to syphilitic children, then under the influence of mercury had healthy children, and discontinuing it had again a syphilitic child.

LITERATURE.

CHLOROSIS.

Balfour, G. W.-Clinical Lectures on Diseases of the Heart: Churchill, 1882. Fothergill, T. M.-Practitioner's Handbook of Treatment: Macmillan & Co. Gibson-The Cephalic Murmur of Anæmia: Brit. Med. Journ., Jan. 1882. Immerman -Articles on Chlorosis and Anæmia: Ziemssen's Cyclopædia. Niemeyer-Text-Book of Practical Medicine (Humphrey's & Hackley's Tr.): H. K. Lewis, Lond. 1880. Immerman's articles are very exhaustive and give the literature fully. Niemeyer is also good.

Chlorosis in a mild form is an exceedingly common affection among young women; although belonging properly to the province of the physician, it comes more frequently before the gynecologist owing to the menstrual irregularities which frequently accompany it.

NATURE AND PATHOLOGY.

Chlorosis is a blood-disease characterized by deficiency in the red blood-corpuscles, and occurring in young women who have primarily a hypoplasia of the arterial system. Virchow holds that in cases of severe chlorosis we have an abnormally small lumen of the aorta, which may be so narrow as barely to admit the little finger instead of the thumb as it should do; and that, associated with this, we have abnormal arterial branches and some changes in the arterial coats. It would