Sig. A teaspoonful in water after each meal.

(c) Treatment of the Tertiary Stage.-The drug par excel lence is iodide of potassium, which has a specific action. The initial dose is from 10 to 30 grains three times a day, largely diluted in water or in milk. In certain cases the drug should be pushed to greater limits, from 3 to 4 drams being required for a single dose. This is especially the case in cerebral syphilis.

HEREDITARY SYPHILIS.

The hereditary differs from the acquired form of syphilis chiefly in the absence of the primary stage.

Etiology.--Father Syphilitic.-(a) The child may be infected directly (sperm inheritance). The nearer the procreation is to the primary lesion in the father, the greater are the chances of the child being infected. The power of transmission rarely exceeds three or four years. It is possible, however, for a syphilitic father to beget a healthy child. (b) The mother may be infected through the placental circulation, but, whether or not active syphilis appears, a syphilitic child cannot infect the mother after birth, a maternal immunity having been created. This is known as Colles' law.

Mother Syphilitic.-If the mother be in the active stages at the time of conception, the embryo is usually infected. If the disease be acquired a few months prior to labor, the child usually escapes. Infection of the child may be minimized by judicious antisyphilitic treatment of the mother during pregnancy. About one-third of mothers abort, and

gummatous placenta or degeneration of the placental follicles may be found.

Both Parents Syphilitic.-The infant mortality from paternal transmission is 28 per cent.; from maternal transmission 60 per cent.; from both mother and father, 68 per cent. Parents with tertiary syphilis are apt to beget sickly children with a tendency to neurotic affections.

Symptoms. If the child be born diseased, there is evident poor development and malnutrition. Bullæ (pemphigus neonatorum) are usually seen upon the hands and feet; the lips are fissured; the child snuffles; the liver and spleen. are enlarged; and the epiphyses are apt to be separated. Such a child is not likely to survive.

If the child be born apparently healthy, symptoms may not develop until the fourth to the eighth week. Then the child snuffles and cutaneous lesions are apt to appear, especially about the nates. There are usually brownishred patches with a well-defined border, or they may be papular. Indolent boils in a copper-colored base may develop. Fissures (rhagades) are apt to develop about the lips, the secretions from such fissures being intensely virulent. The resulting cicatrices are characteristic. There may be falling out of the hair. Syphilitic onychia may develop.

General glandular enlargements are not so common in the hereditary as in the acquired form of syphilis. There may be purpura hæmorrhagica neonatorum, associated usually with diseased arteries. The child is apt to show increasing malnutrition, looking like a wrinkled old man. The cry is shrill and piercing. Various cutaneous eruptions may appear, with mucous patches or with ulcerations of mucous membranes. The nose may fall in. Developmental lesions of bones may develop. There may be thinning of the bones of the skull (craniotabes) or irregular growth of

bone. There may be separation or suppuration of the epiphyseal ends of bones, or formation of osteophytes on the long bones. There may be gummata of internal viscera.

The teeth are apt to be deformed, constituting the "Hutchinson teeth" (Pl. 10, Fig. 2). The upper central incisors of the permanent set are usually the ones most involved. The teeth are peg-shaped, stunted, and at the cutting edge there is a notch in which the dentine is exposed.

Interstitial keratitis is apt to occur about puberty. The cornea has a ground-glass appearance which may disappear or may lead to permanent opacity. There may be iritis. Deafness from labyrinthine disease may develop. The patient has a generally stunted appearance-undersized, and apparently much younger than he really is. There may be nodosities of the long bones from gummatous periostitis, or there may be dactylitis. For a detailed account of joint- and bone-lesions the reader is referred to works on surgery.

Treatment. The mother should receive mixed treatment throughout pregnancy, and the treatment should be continued with the child. The treatment of the child is like that of adults, but proportionately smaller doses should be given.

The syrup of Giberts is recommended:

R. Hydrarg. biniodidi,

Potassii iodidi,

Syr. zingiberis,

Aq. destillat.,

gr. ss;

zij;

aå 3ij.-M.

Sig. Dose, gtt. v-x for a child six months old.

As a rule, mercurials have less effect upon the gums and more effect upon the bowels in children than in adults.

ACUTE MILIARY TUBERCULOSIS.

Definition.-Acute miliary tuberculosis is an tubercular infection characterized by an eruption of miliary tubercles in various parts of the body, with fever, symptoms of local infection, and a fatal ending.

Etiology. The etiology of tubercular disease is considered in detail under Tubercular Disease of the Lungs (p. 373). Miliary tuberculosis is a general infection following some local tubercular lesion, and is due to the escape of tubercle bacilli into the blood, where they find lodgement in various organs and develop tubercles.

The primary tubercular focus may be apparent or may be unsuspected. It may be local tubercular disease of the lung, of the lymph-glands, of the kidneys, or of the bones. Frequently the source is found to be tubercular bronchial glands, which may even rupture into a pulmonary vein and shower bacilli into the circulation. A primary tuberculosis of the thoracic duct has been demonstrated. Well-marked cases of miliary tuberculosis have followed the use of Koch's tuberculin given for the cure of a local tubercular inflammation.

Pathology. Tubercles (for the detailed structure of which see Tubercular Disease of the Lungs) are found in various organs of the body. They are usually the size of a pin's head, but they may appear larger from a number being coalesced. When recent they are translucent, grayish, and contain bacilli. In older cases they may be caseous and yellow in the centre and may contain no bacilli. Tubercles may be found in the lungs, pleura, peritoneum, liver, kidneys, lymph-glands, pia mater, in the bone-marrow, and in the choroid coat of the eye. Less frequently they are found in other parts. There is no regularity about their distribution: they may be abundant

in some organs and scanty or absent in others, or they may be more generally distributed. This lack of regularity gives rise to great variations in clinical types. With the tubercles are often found associated various forms of inflammatory products or ordinary granulation-tissue.

Symptoms are general and local.

General symptoms are due to toxines of the general infection. Fever is a marked feature and lasts throughout the disease. Its absence is rare. It may be intermittent at the onset, resembling malarial fever. At the height of the disease it is usually markedly remittent, though it may be continuous. An "inversive type" has been described in which the highest temperature occurs in the morning-a peculiarity rarely seen in other diseases.

The pulse is more rapid and feeble than can be accounted for by the fever, running between 110 and 130.

The breathing is rapid, sometimes as frequent as 40 to 60 to the minute, and it is characteristic for the patient not to complain of shortness of the breath.

There may be profuse sweats. These may occur after remissions of temperature, or irregularly as an evidence of sepsis.

The mental condition is usually cheerful, and the mind is bright even in long-continued cases; the patient complains only of "having fever and a little cold." This sign is highly characteristic, and is often a good point of diagnosis from typhoid fever.

In acute cases with meningitis there may be delirium which is either mild or severe and amounting to mania. Stupor or coma succeeds the delirium.

The spleen is usually large; the urine is that of fever, or it may contain albumin.

The close of the discase is characterized by the symptoms of the typhoid state.