Knutsen, C.A.
Sandefjord Sulphur Bath

Del 3

Christiania, 1884 - 62. s.

So it is these same pains and the fore-mentioned twitchings, which the patient experiences when in a horizontal position, that undoubtedly deserves the full attention of medical men, and a special testing as to their possible connection with constitutional syphilis, in this our day so prolific a disease. Even for the sake of the prognosis it ought to be of the greatest importance, that ethiological connection be cleared up as soon as possible, and should the syphilitical element be proved, then, with regard to the cure of the disease, the matter is pretty nearly made plain, and by most and the highest authorities determined, as already said, that as a rule, there is required specific treatment, besides the dietetic and hygienic both during and after the cure. Such a cure must be considered most effective, when the luetic molecules, successively, as they are loosened from the various atria, be destroyed immediately, and the introduced medicament again eliminated as soon as possible, whereby the specific treatment will be borne so much the easier, and thoroughly gone through, and, in this respect, a well-appointed powerful sulphur bath, with its skin-cultivating action, the daily performed universal massage, and at the same time a suitably conducted drinking cure must be of particular importance. Mercury is not made use of in all cases during the cure, - sometimes chinine, and iron will be employed, at all events preliminarily, but it is only in exceptional cases, that mercury cannot be borne, or that it aggravates the case, or that from the mercurial scare period, by some anti-mercurialist, there has been implanted in the minds of the patients, such a decided horror of any contact with this, according to their idea, so dangerous a remedy, that we have to resort to some other means and let the matter rest a while. Thus it is that bromide and iodide of potassium may be employed alone, whilst otherwise, according to circumstances, these are used at the same time, either alternately or after the mercurial cure, or not at all, according to the form of the disease and the individuality of the patient.

From the famed sulphur baths it is stated that patients are treated for constitutional syphilis, to much greater advantage, when suffering from obdurate, diffused, and badly treated forms: it is put forth as indisputable experience, supported by the first syphilidologists of the day, but it is, of course, not thereby settled, that one ought therefore to wait until the disorder has become as completely constitutional as possible; where there is a manifest sign of the disease or where an outbreak of the same may be feared, an easy cure, which at the same time is the most effective, ought to be considered advisable and suitable, and this is no less applicable with regard to nervous symptoms.

A patient 49 years old, it was stated, had for a couple of years been suffering from „weak nerves", with pains in the right side of his head, particularly „before change in the weather", also in his limbs, especially the hips, right shoulder, and shoulder blade ; was particularly ill this Spring, having for some time been attending upon an insane brother; iodine had been employed as a remedy. There is a soreness behind the protuberance of the hip, (trochanter major) and along the outside of the fore-arms; has slept better of late, the other functions in order; appearance healthy.

After 5 days' use of the bath the pains in the arms and legs were as usual, but then were superadded pressing pains over both eyes ; 8 days later violent pains over half of the right cheek began, since which they have alternatily encreased and decreased, until after about 1 month's stay at the bath they had encreased in a very alarming degree; had deprived him of sleep for several nights together and produced a feeling of considerable weakness; the pains were described as momentary, transitory, piercing, sometimes as twitchings, at one time worst in the right wrist, at another in the feet; on inquiry it was explained, that he had caught the infection 10 years ago, without experiencing any consequence subsequently; 1 1/2 years ago he had felt twitchings in both arms, but not since. Cura inunctionis was employed at once, beside the other bath treatment, whereupon the twitchings ceased immediately, and the pains gradually vanished, so that after a mixed cure of 3 weeks and a 7 weeks' stay altogether he departed quite freed from pain, somewhat weak, but else well in every respect. Since that time he has once used the sulphur bath alone and the whole time enjoyed uninterrupted good health.

A patient, 38 years of age, from the same year, had, it was stated, for 16 years been suffering from rheumatic pains in various parts of his limbs, and the last 2 years in his right arm and both legs, worst last Winter. Slight swelling of his right ancle and left elbow. Eats well, but cannot bear fat things; is well nourished, strong and in appearance healthy and blooming.

After 4 days' bathing he felt pain in his right arm, 4 days later severe pains in the left arm, during the application of the gytje poultice on the right arm, else not; the pains in the right arm only at night, by day only when he stood in the wind. After 8 days' cure he felt constantly pains at night in both arms and lost his sleep. On inspecting the body, there was discovered on the right leg's lower part a smooth, slightly discoloured scar of the size of a threepennypiece, somewhat below the level of the skin, said to have been from an ulcer, 13 years ago, and on the right fore-arm a similar car, more brown coloured, from an ulcer last Winter, and it afterwards came out, that 19 years ago the patient had suffered from syphilis. The inunction cure was commenced immediately, after which his pains left him; they remained longest in his right shoulder, but on his departure all his pains had vanished, and the patient was well in all respects. His weight had encreased from 154 to 157 pounds.

When, already on arrival, objective, distinct signs of the disease appear, or according to the accompanying medical statement, or by any other means, certain anamnestic data are at hand, the specific treatment may begin at once, after a suitable preparation, and thereby so much more time is gained for a correct and thorough carrying out of the cure, as the stay of a patient at the bath is almost always limited to a fixed time.

A patient, 36 years old, 12 years ago, got a venereal ulcer, and mercury was employed 4 weeks afterwards; afterwards secundaria, for which iodide of potassium was made use of for a considerable time. A few years ago ulcers broke out upon his lips and gums, for which the same remedy was made use of, but has not since been quite free from these ulcers. Ceased using the remedy 4 weeks before his arrival at the bath, in 1881. He has sores about his mouth. the nether lip hard and swollen, with several deep ulcerations, with fouled bottoms and sharply defined borders, on the inner surface, as well as on the inner side of the cheeks; the gums are considerably swollen and bleeding; on the hard palate a deep scar is perceptible, the mucous membrane in pharynx red and swollen, else nothing sickly with regard to his body. Formerly had rheumatic pains, but now not for many years; has an appetite, but relaxed bowels 3 times a day, sleeps badly; the muscles relaxed, complexion sickly, pale grey. It is a matter of course, that under such circumstances special arranaements must be made, with regard to social companionship at the bath.

After 4 days' use of the sulphur bath he felt pains in the left shoulder, and the mixed cure was adopted. After 7 inunctions there occurred a rather violent salivation, the first and only time, such has happened at the bath. The inuuction was suspended, but after the lapse of 6 days he was able to resume it, since which the cure went on uninterruptedly, and there was a steady, continued improvement, the lip became softer and the sores healed up. The diarrhea ceased, night sleep became natural, and his appearance fresher, day by day, whilst his spirits rose in proportion. On his departure his lip had returned to its natural form and size, was soft and serviceable, all his sores had healed up, all the functions were in order, his appearance was healthy and blooming, his muscles were firm, and he felt himself strong and normal. His weight had encreased from 129 to 131 pounds.

A patient 32 years old had incurred a venereal ulcus in 1873, with consequent, secondary pains in the throat, for which mercury and iodine was used. I 1875, at Christmas, after a cold, he felt severe pains in the right temple, about the ear, to behind in the neck, accompanied with nausea, these pains were so violent that he was compelled to take to his bed. The pains have sometimes left him for several months and then returned; and latterly they have advanced towards the eye, and around the eye to the nose. From 1878 soreness in the right nostril commenced, which was exaggerated every time the pain in the eye began, and occasionally there were bloody secretions from the nose. At the same time that the nose became affected, a considerable abscess with fistulas appeared on the right thigh. Since 1879 there have been exacerbations with fever every Spring, and in 1880, once only, congestion to the brain with „fainting." At present he speaks about a sensation of slight rheumatic pains in his knees, eats little, his tongue is foul, bowels loose, sleep tolerable. In the left outer auditory passage there is a chronic fouled ulcer, the size of a pea, and in the muscles of the right thigh a little, moveable nodule may be felt.

After 3 days' bathing severe pains about his eye; cura inunctionis. The pains ceased very soon, his appetite became excellent, evacuations normal, the sore in the ear healed up, and the patient left the bath after 6 weeks' stay, without pain, well in every respect and heartily pleased. Weight encreased from 141 to 149 pounds.

A patient, 35 years old, from same year 1881 states that for 10 to 12 years he had rheumatic pains, and in 1879 he lay ill several months of rheumatic fever; particularly has he felt pains in the Winter, and last Winter they settled in his head and eyes; he has also been slightly affected with a rectum catarrh, and a year ago, a sore about the anus. In 1878 he became infected, but, it is said, he has never suffered from a constitutional syphilis. In 1871 was in Aachen, and went through the whole anointing cure. He states, that when he lies down to rest in the afternoon, and also at night, he feels twitchings in his legs, just when he is about to fall asleep; else well.

After 5 days' preparatory cure the same twitchings, when in a horizontal position, Cura inunctionis. After 5 days the twitchings had ceased, and when the patient left, after completed cure, all was well.

It is principally where all outward signs of the presence, of lues are wanting, that one has been tempted to place the nervous derangements to the account of rheumatism, until the occurrence of gradual organic changes in the centres of the nervous system have at last revealed the fact, that the disease must arise from some other cause than that of rheumatism.

The atheromatous degenerations of the arteries of the brain with stopping up, thrombose, and ensuing brain emollition with other organic brain disorders, have also long been placed in connection with syphilis, and it is not seldom, that we have heard brain syphilis spoken about; on the other hand spinal syphilis has been less regarded and acknowledged, and yet of late, it becomes more manifest, that there does exist an ethiological connection between syphilis and certain organic alterations in the spine, especially in the hinder cords of the same. We read in many journals, from all parts of the world, about the same „blitzähnliche schmertzen", „douleurs fulgurantes", „lightning pains", which all medical authors are now agreed upon mentioning in their introductions to the theme which is called tabes, and that this disease, at all events, in a predominant number of cases, has its source in syphilis, seems to be a settled affair. Goiwers stated in 1880, that 2 years earlier he believed that 50 % of the Tabetikers have had syphilis, but now 75 % ; Fournier states 80 %. Erb in 1881 had advanced to 88 %, and Raynaud in the lecture that was read at the London Congress in 1881. At length it appears, that many - I will not say all - of these cases (tabes) have their ground in syphilis, and though we may not be able to cure them radically, we are at least enabled to arrest them in their further developement, by specific treatment." After we have gained a better knowledge of the initial symptoms of this disease, and have more thorougly and critically weighed the history of disease, with special regard to this pending question, it is presumable with the diagnostical means of help of the present days, that the disease will very shortly come under competent treatment, and for the formerly so hopeless sufferers there may open up a brighter future.

Locomotor ataxi, as is well known, is a remarkable phenomen in tabes dorsualis, and was formerly regarded as identical with the same, whereas it is only a symptom in the 2nd stage of the disease in which the prognosis, at present, is less favorable, and may long be wanting, after the diagnosis of the disease may be considered as proved.

Before the ataxi lacking tendon reflex often may be present, but this, besides the ataxi and other symptoms in the atactic period, is already a sorrowful sign of the advanced degenerative process in the spine's hinder cords. Fortunately we may say however, that before that stadium there do go symptoms in the so-called preatactical stadium, which for the sake of the prognosis, and the early treatment is of the very greatest importance, as the disease still at this period, according to the judgement of all competent men, by a quick and energetic treatment is decidedly curable. But it is requisite to commence operations as soon as possible, and in case of the preliminary to attack the most preliminary symptoms, and of the first, the very first, should such be found. And there is often time enough to take the matter under consideration and treatment in a stadium that may last a series of years, without any sign of ataxi making its appearance, and even after it has appeared, it seldom moves rapidly, before the disease has reached a more advanced developement; many cases of inveterate and incurable ataxi have been observed these later years, that have existed in the preatactical stadium, that was curable, in 10-15, and even more than 20 years. Even after the ataxi has appeared the patients often do not care much about their unsteady struggling gait, the frequent glancing of their eyes at their feet during their walk, which are ascribed more to the effect of individuality and habit and do not suspect the presence of deeper, perilous suffering, and less idea or fear have they or do they feel of their fateful state, before the named symptoms make their appearance; these will certainly immediately awaken every competent medical man's attention, but of a more critical importance is the doctor's apprehension, and acknowledgement of the disease earliest possible in the preatactic stadium.

To this preatactic stadium therefore, as the name explains, the ataxi does not yet belong, although towards the conclusion of the same, by careful observation, we shall be able to notice in the patients a certain uneasiness and disinclination to remain in a standing position; as is known, it is physiologically more difficult to keep the body balanced when standing than to trudge about and walk; they will therefore rather be in motion, and if they stand for any time, they like to straighten themselves up with their heels against each other and their feet at right angle; but else we cannot forcibly enough portray each particular one of the various symptoms, which partly in groups and partly altogether by a deep minute examination prove to be present and distinctly enough characterise this preliminary stadium, with serious warning as to what the future may bring.

Of such symptoms may be named: lightning pains, belt sensation, more or less extended portions of the skin, with sensation af cold or heat, with sharpened, or particularly blunted sensibility of the skin particularly in planta pedis, with a sensation of walking upon something uneven, soft or damp, as upon woollen soles, sponges; anomalies of sight; sexual excitation, nightly spermatorrhoe; frequent desire to make water, bladder paresis; more frequent need to evacuate alvus, obstipations; occasionally reduced tendon reflex, often encreased; slight joint affections; variable homour, sleeplessness. During all this the general health remains excellent and incoordination of the underextremities appears, as mentioned, first towards the conclusion, as a hint and transitory.

First of all the characteristic pains must be considered. They seldom, if ever, steadily follow any certaintain nerve, but most often are variable, most frequently present in the under-, seldom in the overextremities. Compared with the pains in the later atactic stadium, which has a deeper, more lasting character, they are in the preatactic stadium excessively momentary or of a few seconds' duration, frequently on the surface pricking the skin like a needle or the point of a lancet, sometimes cutting, lacerating, at other times more burning or more lengthened, gnawing pains, which at certain times may give way for the simplest outward applications, whereas, under violent attacks of the most frightful pains, such as cannot be described, no effect can be produced by morphine injection, and even less from chloral inwardly. The pains may assail the head, eyes, face, ears, jaws and neck; furthermore, they may choose the breast, abdomen, genitals and rectum. They may easily be mistaken for ordinary neuralgic pains, when the history of sickness fails, and no other initial symptom is to be found; they may present themselves once, or several times in 24 hours and in that manner last for years, most often for periods, with pain-free intervals.

No less attention deserve the ocular disturbances, which even in certain cases may precede the pains such as ptosis, strambismus, diplopi, hemiopi, reduced sharpness of sight, apprehension of objects with coloured contours, less clear apprehension of certain colours, also small unequal pupils.

We often find extreme contraction of the pupils, lacking reaction against light, and reduced accomodation. Erb, in 84 fresh cases of tabes, has found 59 times absolute reflex immobility of the pupils and 12 times very faint action against light, thus 71 cases of lessened reaction; of these 43 belonged to the initial stadium, in other words: the patients showed no signs of ataxi, or only the faintest trace. It appears clear from this, that in the defective excitability of the pupils, we have a sign in proportion to the preatactic stadium of the very greatest diagnostic importance. Erb says, that the symptom is also found in persons, "who have not tabes," but nobody can assure, that they may not have such later or sooner, and if the described fulminant pains, or other initial symptoms are present, the diagnosis is further confirmed or probable.

In cases of unequal sized pupils, which also are not a very rare initial sign, the contracted pupil is in greater activity during the accomodation than the dilated, but both are equally unaffected by the light.

Although, as stated, the fore mentioned symptoms from the eye may be the very first sign, they are however, as a rule, said only to exist a few years in the preatactic stadium, in comparison to the fulminant pains, which have often existed more than 20 years, before any objective sign of in-coordination of the motions have made their appearance, it is also urged, with great force, that no instance of ataxi has existed, where the pains have not preceded it, and that the same pains are the first subjective symptoms, and the very first beginning of what will ensue, months, years, perhaps many years after, and the possible presence of alteration in the pupils or what other sign may be found, is but to support diagnosis still more.

With regard to tabes it is said, that the age of „ignorance" and of „despondancy" is past, but it is clear, from what I have explained, that it will be of capital importance, that time be not lost, and the disease be allowed to have its way, and reach the higher degrees of developement, that on the contrary, soonest, preferably in the preatactic stage, with probability of recovery, it should be placed under energetic and well directed treatment, and the earlier the better. A house may be saved from destruction by fire, if action be taken at the commencement, and the old saying is no longer of any use: No extinguishing before I come", and what the doctor can save is of greater value than any house with effects and furniture.

A patient 33 years old, by the advice of 2 competent doctors, was sent to the bath in 1880 under diagnosis tabes. 4 1/2 years ago he had been treated for lues and since, it was said, had been well, until about 3 months previously on a voyage he was much exposed to hardship and caught a violent cold, after which weakness settled in both legs, and he now presented himself with every sign of a typical decided tabes dorsualis. During the latter part of his stay at home, he had been subjected to a deal of anointments with mercury, after which he fancied he felt somewhat better, but at present he was quite unable to stand with open eyes, and by no means with closed; his muscles were tolerably firm, and the single muscle contractions fairly strong, but he completely lacked power to harmonise the motion of his nether extremities, and had to be carried out and in like a child. As the season was somewhat advanced, the anointment cure, in connection with the other sulphur treatment was instituted directly, and at the same time the electrical treatment was used daily. Although the cure on account of the time, was somewhat shorter than desirable, he had however so far improved at the bath, that he was able to stand upon his feet with a little support and walk with the help of a man by his side; he felt in every respect stronger, and left the bath very satisfied with the result of his trip hither. Under a continued electrical treatment on his return home, he steadily improved, so that at last he could walk, and even run, without a stick or any other assistance, and could move about in the dark, with the same certainty as in open day. He visited the bath again in 1881 as a healthy, strong, very happy man, without any derangement of the nervous system or in any other respects; he came principally for pleasure and remained 6 weeks, but went through a complete bath cure, and on his departure his health was all that could be expected.

Some time after his arrival at home, there began to break out, on both hands, psoriasis palmaris, on which account he again came to the bath in 1882, else perfectly well. The skin disease was cured by a renewal of the inunction-cure; the cure of the patient's tabes, of which there had not appeared the least sign since, may certainly be noted as a phenomenon, and that it so early, as stated, came under special treatment, undoubtedly deserves our full attention. By the rapid developement of this disease as in the present case, the prognosis possibly may also prove more favourable.

A patient 44 years old was syphilised 20 years ago for chancre. Came to the bath in 1876, where 4 times previously he had sought help for his pseudo-rheumatical pains. Since the Winter previous, he had felt pains like smarts and burning on the foremost and lowest surface of the chest on the right side, gradually extending over the abdomen, radiating to the right shoulder and leg; constant formication on the right side and weakness of the right arm and leg ; numerous scotomata before the right eye, besides which transitory momentary pains here and there over the whole body, besides a constant sensation of a tight belt round the abdomen, sluggish bowels, and poor night sleep. As the pains after 14 days' bathing in 1876 encreased to an insupportable degree, he was obliged to leave the bath, but got better after his arrival at home by the aid of strychnine, and is said to have remained well since, until at new-year's time in 1882 he had a renewal of the attack after having sat up several nights and drunk a lot of toddy, night after night. He felt violent pinching pains as af thousands of insects in his thighs, particularly the right one, and pains in the back on lying on the same, as of glowing iron, sensation of smarting in the feet; in the left foot, of late, a lack of power. On his arrival at the bath in 1882 his left leg was helpless, and he was obliged to use crutches, when he walked; he felt cold in both legs, particulary the right one, also cold in the rectum, which felt as though stuffed with wool ; the abdomen felt as though screwed up towards the back, with a smarting sensation in the same, and round the whole portion about the hips and back; he is able to stand with closed eyes, and the knee reflex was present in both legs ; the bowels stubbornly stopped, difficulty in passing urine, which comes forth at intervals. Married since 1875, has two healthy boys, 6 & 4 years of age. The sexual nisus reduced, frequent nightly erections and pollutions, but since new-year coitus non celebratus. Poor sleep. He remained at the bath 6 weeks and went through the mixed cure completely; every day medusa applications upon his back. After completed cure the sickly sensations were considerably reduced, and partly gone; he only occasionally felt a sensation of lightning before his right eye, in the morning, and of wool under his right foot, after a fatiguing walk; his crutches he had long since cast aside, and could walk briskly long trips. On his departure he expressed himself well pleased with the result, and his weight was, as on his arrival, 161 pounds.

He came to the bath again in 1883, had been perfectly well, only that lately, after exertion, slight pain in the right leg, without the pillow sensation, and a little of the belt sensation. The evacuations, during the whole time had been in order daily, urine passing and sexual functions normal; no derangement of sight. He again went through a minor anointing cure, and on departure all well.

To the active effect of the application of the sea-anemones, medusa aurita, upon various rheumatic, neuralgic eases, and especially spinal complaints must be conceded no small importance as a powerful means of assistance during the use of the formerly indicated cure treatment. Which remedy since 1837 has been introduced in Sandefjord's bathing treatment, as a highly active bathing requisite, by the discoverer, founder, and present owner of the bath, Dr. H. A. Thaulow.

Of late the principle of counter irritation has been accentuated, that the sickly state of an organ can be removed by irritation, applied to that part of the skin, which stands in the strongest sympathetical connection with the same, according to which the physical law seems to be, that, when 2 parts are sympathetically connected, by exerting a strong influence upon the nerves of one, we may reduce the nervous activity of the other. Applied to the painful part, the medusa may often momentary remove protracted pains, and there are patients, who date cessation of the pains for ever from the first medusa application ; they work also as certain inciting means upon every reduced nervous function. The use of the medusa application appears also to have become generally clear for the bath patients. The application produces smarting and burning, sometimes in a high degree; sensations, that by no means may be reckoned amongst the most agreable, but still it is rare, that on the part of the patients, we meet with any serious objection against it though used for a lengthened period, on the contrary - they often make the proposal themselves, and when there is a strike amongst the medusae, which may happen, and they will not show themselves in the Fjord for a couple of days, there is a constant murmuring amongst the patients, who are longing for their old friends.

To the fore named bathing treatment of the sickly nervous state, in question, even in other diseases, from special indication, there comes at last the general electrical treatment, to which is added the use of hydro-electrical baths, which ought not to be lacking in a modern well arranged bathing establishment, and therefore has been introduced into Sandefjord.

As we therefore in the foregoing have seen, that rheumatism, in many cases, is the signature for acquired syphilis, such is certainly often the case with scrofula, with regard to the hereditary forms, and this sphere is also often visited by spectres, much oftener than one imagines.

The analogy in form and appearance of certain manifestations of scrofula and tertiary syphilis seems to justify such an opinion. It is scarcely to be supposed, that syphilis can be transformed to scrofula by inheritance; one has only wished to concede the causal coherence between scrofula in children and syphilis amongst parents to be in force with regard to a certain lack of the power of resistance in the body as a predisposition for scrofulous disease. With ordinary light syphilis it is not yet certain to be the case; whereas it cannot be denied, that grave syphilis, which has advanced to the tertiary period, the syphilitical kakexi, may favour the origin of scrofula by inheritance, but syphilis however is then not presumed to have specifically affected the foetus, but only as being a debilitating principle, predisposing the parents to breed scrofulous children, in the same manner as unsuitable, unsound, insufficient nourishment is often ascribed as the fountain of scrofulous diseases, the same as a lengthened stay in dark, cold houses, with damp, vitiated air, or any other unfavourable hygienic circumstances to which the lower classes of the community, besides a lack of good nursing and comfort, very naturally are more exposed, than the better situated classes, amongst whom we ought more to suppose a natural diathese in the children, as the cause of their sickness. That it is such, who most generally are recommended to, and reap the benefit of medical treatment at a bath, is a consequence of reasons very easy to be understood.

Sigmund, with his great knowledge, and rich experience, has called attention to the fact, that under the common name scrophulosis, in later time, there has always been an encrease in the number of young patients, especially children, who have been sent to bromine and iodine containing sulphur baths with excellent effect, but as a certain knowledge of the earlier diseases of their parents and near relations has convinced him, many of these sufferers do belong to the category of syphilis, inherited from parents, which appears with the gummous diseases, and the specific corneal and conjunctival ailments, often much later than was formerly supposed. The late appearance, particularly of the hereditary cartilage and bone syphilis, which he demonstrated 30 years ago but was then doubted, is now pretty generally believed. Therapia, he says, has by this acknowledgement, gained in certainty, and in every course of instruction he has exhibited patients in the ages of childhood, youth and even adults, who have been cured by quicksilver alone, or its combinations with iodine or other remedies, for old stubborn, and often very disfiguring forms, and the most anemic, strongly fainted patients have perceptibly improved during the cure. He has further added, that many such patients formerly had been treated with iodine remedies to a great degree.

It is known, that children often inherit syphilis from their parents; but it is generally supposed, that the period for the breaking out of the hereditary syphilis depends upon the age and intensity of the virus in the parents - the younger and more virulent their disease, the nearer conception will be the manifestation of the same in the children. It may make its appearance in the instrauterine life, or if not immediately after birth, certainly within the first 3 months thereafter, in most cases, of course also later, in few exceptional cases in the 4th, 5th and 6th month, and even later, and the longer the time after birth before the breaking out in the children takes place, the more seems the disease in the parents to have lost its power of being inherited. The hereditary syphilis which appears in the child shortly after birth, mostly secondary, is called „innate", and is distinguished from that in a later period, with tertiary symptoms, which is called „inherited latent". Elder, modern, and most modern authors cite numerous instances of unexpected breaking out of the hereditary syphilis, which did not appear until the 5th 7th 10th, 14th, and 15th year, or even long after the age of puberty; but when the time for the latent hereditary is placed at the 30th even 40th year (Ricord) it does seem as though the parents' faults and responsibilities were stretched rather too far, as within that period the offspring generally may have made their own conquests.

Therefore when such patients as the above, are presented to us, viz: children and younger individuals about the age of puberty, in whom we find for inst. cornea darkenings, chronical catarrh (Ozoena), swollen or suppurating glands in the neck, extended, superficial or deep, serpiginous ulcerations on the breast or extremities; elapsed or existing joint inflammations, swollen epihyses, periostites, caries, rachitic symptoms, frequent boils, with consequent chronic sores, rheumatic-like pains, pains in the legs, various chronic cutaneous diseases, irregular and defective tooth developement, principally dyscrasic sometimes thriving appearance &c. - of these symptoms a few or more at the same time - there is then an inducement to examine closely the anamnestic connection, and should there be found certainty, or well founded suspicion of former lues in the parents, then to the rest of the bath remedies there will be added specific treatment, with a modified cura inunctionis. Within 2-5 days a rapid and distinct improvement will be seen, if not, and the opposite is the case, there is always the means of being able to stop.

A boy, 8 years old, was at the bath in 1880, 81 and 82. On arrival the first year he was in a considerably reduced state, with open glands in the neck, fistulous sores about the right ancle, caries in the nether extremity of the tibia, suppuration in articulus, and deviation of the foot; the extremities useless for walking, which in cases of need was performed by the aid of crutches; badly nourished. „Hutchinson" teeth.

The 2 first years he was under the general treatment, and left each time, improving; the 3rd and last year modified anointing cure was applied, and he left the bath recovered, with the full use of his legs, and with a blooming, healthy appearance.

A girl 8 years of age was at the bath in 1882. It was stated she had had „rheumatic fever" half a year ago, and afterwards inflammation in the right thigh with abcess formation. The whole os femoris is very much thickened; only trifling moveability of the hip joint, the knee swollen and the upper part of the tibia thickened; on the fore side of the thigh a large opening with caro luxurians, and uneven, bared bone at the bottom of the fistulous ducts; a similar opening innerside of the thigh ; she cannot rest upon her leg and with great difficulty walks with crutches ; she is extremely pale and emaciated. The father is said to be sickly, and scrofula is general amongst his children.

Besides the ordinary treatment she was subjected to the inunction cure. After 6 weeks' stay she had a fresh and healthy appearance, had become lively and happy; the thigh, was considerably reduced in circumferance, and the step free, without crutches or stick.

A patient 19 years old, pale and slender limbed, was sent to the bath in 1883 for gut catarrh, in his doctor's opinion of a scrofulous nature. He had been sickly from childhood, and particularly in the last years suffered from a checkless diarrhoea 6-7 times a day, with a few days of obstipation amongst. The father, lues, before marriage; the mother first 4 abortions, and then 14 living children, all of whom scrofulous and the patient, the eldest. Sat sapienti.

Cura inunctionis. Three days after cure began, the bowels normal, with one, never more than 2 even natural evacuations daily, this continued during the cure. His weight encreased 5 pounds, and he departed, strong and healthy.

The general question of the patient on leaving, after the last perceptible sign of lues has vanished, is: if and when marriage may take place.

Sigmund and many with him consider syphilis curable, as a rule; such also appears to be the case from the relatively small number of individuals, in whom the disease arrives at the tertiary stage ; but although it is curable in the majority of cases, yet no peculiar sign unveils with certainty the final healing; the clinical art only affords probabilities. The surgeon therefore must be extremely careful not to give his approval or sanction, before having long investigated and calculated the probability of or against a relapse, and what he then will arrive at, is a sum of probabilities, nearly equivalent to certainty. Every practising surgeon to whom this question is propounded, knows that the querist may be pressing, and the situation very difficult, and yet the correct answer to the question, as far as prudence and experience goes, is of the gravest importance for the contracting parties, society, and the surgeon himself. It is a sad affair when after an overhasty concession, from weakness or other reasons, 6 months, or a whole year after the honey-moon, the client comes, unfortunately not alone, with his fait acompli, and the surgeon then reaps small thanks for his complaisance, rather everything else.

Opinions as to the employment of mercury in the earliest stage of primary infection have been divided. Some persons having considered, that there was no reason to postpone the attack upon the enemy after he had made his appearance in the field, and that an early treatment would serve to mitigate the severity of the later outbreak, and in particular, diminish the possibly occuring pains in nervous individuals, whilst others imagine they have learnt that it only delays, for an indefinite time, the breaking out of the constitutional phenomena, without lessening their violence, the consequence of which may be, that the patient will spend the rest of his days in painful uncertainty, as to whether he has had syphilis or not, and this may be the case where the disease never has existed, and has frequently been the sad cause of despair and misfortune. All, however, are agreed, as to the established fact, that mercury, whether employed early or late, is never able to cut off the disease, or prevent the secondary manifestations, which assuredly will follow, where real infection has taken place. It is well known, that constitutional syphilis generally makes its appearance within 3 months, certainly within 6, at all events, where mercury has not been employed, so long therefore must the patient wait, even should there have been a supposition, or hope, that the primary damage has not been of a specific nature - the term most cautiously calculated from the healing up of the wound, and on the supposition of minute investigation and competent control.

A distinction is made between the 2 main types, benign and grave syphilis, and after the constitutional symptoms have revealed themselves, the duration of the benign forms are stated as being, in general, 15 -18 months; but it is not seldom that the secondary forms, although slight, and each time fainter, are repeated by several renewals, for a much longer time, without the disease assuming the tertiary form; this is most often observed after the dry papulous or papulo-squamous syphilides. Syphilis of moist, suppurative form: ecthyma, impetigo &c are always signs of grave syphilis, in which there come a series of numerous recidives, and separated at short intervals; but in slight syphilis there come a less considerable number of attacks, separated by long intervals - a momentous point for prognostics.

Diday has found, that in grave syphilis the longest time between the attacks has been 139 days; in weak syphilis 302, and Langlebert, who chiefly refers to his learned colleague, remarks, that it is possible, they may not be the last words science may throw out on this point, and that a higher maximum may be found, but even he has only found, recidives in very few exeptional cases after the lapse of a whole year since the discontinuation of the last symptom of the disease; most of the recidives came during the first 6 months, after cessation of treatment, and he therefore believes, that an individual, who has had benign or middle strong syphilis, duly treated for 15-18 months, after which a year has elapsed without being stricken by any fresh occurrence, may be regarded as cured, and such a person may immediately marry; but for greater security, he requires one year more, as a probation time, and when the marriage is decided upon, he still requires of his client, that 2-3 months ante nuptias he shall subject himself to a new specific treatment. Of women he thinks a longer probationary period ought to be insisted upon. That benign syphilis, which for a long time has been regarded as cured, may, after many years, return under grave forms, is certainly true, but such cases are rare, and belong to the exceptions, so that to forbid marriage on that account is as great an excess of caution, as it would be to forbid railway travelling because a train may occasionally run off the rails; whereas, in cases of grave syphilis, with more frequent and deeper-going recidives, broken-down constitution, and nervous attacks, which may be regarded as forerunners for tabes, and in all cases of tertiary syphilis it would be unadvisable to counsel marriage, possibly it might be allowed later after strict hygiene, rigorous medical treatment and a few years of good health.

Besides the benignity of the disease, the patient's power of resistance and general constitution must be taken into account. The weak may contract slight syphilis, and the strong grave or vice versa, according to the quality
of the poison; but, with equal intensity of the material that causes the disease, the strong, robust and otherwise healthy person is better situated than the weak and sickly, who has already gone through various illnesses, and consequently had his health damaged beforehand. It is the main thing for every syphilitic person who meditates matrimony, to subject himself to a thorough specific treatment, sufficient to remove the disease, and therewith the manifold and various dangers which syphilis introduces into married life. It is true that there is no certain criterion to prove the complete absence of the disease, and no medical man at the present moment, dare swear in court, that the anxiety of the patient is for ever ended, and groundless; but, at least, he can say, that under similar circumstances numbers are quite well, and have become fathers for happy families and that the patient, with a strong constitution, and who takes due care about himself, at the expiration of a couple of years subsequent to the conclusion of the treatment, for the disease, without any sign of the appearance of the recidives, may depend upon it, that the prospects of recidives, for the future, at all events, are very small.

Vigilance, attention and the control of a competent medical man, also in this case, is necessary, and that the patient, even later, at certain intervals, goes through a light bathing cure with suitable disinfection, cannot be urged too strongly, as a further security for all the parties concerned.

Grave syphilis excepted, which with its tendency to everlasting recidives, erotions upon the mucous membranes, diffused ulcerations, or tendency to visceral localisation, must certainly be considered as absolute grounds agains, marriage, says Diday ,an absolute veto against all those who have been infected with syphilis during the excesses of the present civilisation would, in good faith, be working for the depopulation of the earth", and with him Fournie nearly agrees with regard to the conditions under which marriage is permitable after having been syphilitically affected.

With these considerations in mind, patients according to their various individualities will take the matter mor or less lightly. After having caught the infection, some individuals first begin to be busy about entering into the holy bonds of matrimony, who previously were in no great hurry on that score; whilst others, completely disheartened, at all events make up their minds to remain unmarried to the end of their lives. In both these cases there is exaggeration.

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