CASE XXV. Localised constitutional syphilis-simulating schirrous mamma. M. J, a married lady, mother of two healthy children, in the fifth month of her pregnancy of her third child, was sent to me for my opinion respecting the nature of a tumour near the nipple of the left breast, which had been seen by many surgeons, who had considered it cancerous, and recommended its removal. It was a hard, solid lump, covered with a livid blush, and evidently on the point of ulceration. The position and character of the patient put the idea of syphilis quite in the background. On my third visit, my patient said, "Will you look at a lump on my forehead, which at times gives me great pain, especially at night?" I examined the lump, which was a circumscribed periostitis of the frontal bone. It struck me immediately that the disease was venereal, the lump on the forehead a node, and the lump on the breast a syphilitic tubercle, or a gummy tumour. I made my suspicions known to the husband, who admitted that he had gone astray, but was assured that he was not diseased, but had only a chafing. On examination, I found a discharge from the base of the glans penis, the site of which was thickened and hard. There was now no doubt, as intercourse had continued under these circumstances; yet on the part of the lady there was no sexual irritation, no ulceration or discharge. The lady was put on a course of mercurial vapour, with sarsaparilla, &c. The symptoms of syphilis disappeared under the treatment, but she was prematurely delivered of a dead child. She has since, however, enjoyed good health, and has had a healthy living infant. CASE XXVI. Localised secondary syphilis-simulating fissure, or ulcer of the rectum. A. W had suffered under constitutional symptoms of syphilis for some time, which had all disappeared under treatment: they had consisted of condylomata around the anus, and Syphilis, chiefly as it affects Internal Organs,' which is also very important, showing that many internal diseases, hitherto not suspected of being syphilitic, are so, and the pathological changes produced are those due to the tertiary stages of syphilis. a sore throat. He consulted me for intense pain during defecation, so great as to produce faintness, and lead him to avoid evacuating the bowels, except when actually necessary. After some difficulty, I succeeded in passing my finger within the sphincter: I found an ulcer, from which all the pain doubtless proceeded. On pressing it, a similar agonising pain was experienced to that which he felt when the bowels were moved. I suspected from the history that this disease was syphilitic. I recommended the daily use of the confection of senna to keep the stools thin, and placed the patient on a course of mercurial frictions. The disease was rapidly and soundly cured. CASE XXVII. Hoarseness, with relaxed throat, and loss of voice for three years; no benefit from ordinary treatment; subsequently an attack of tubercular syphilis; cure of the former symptoms by the treatment of the latter. A. B placed himself under my care to be treated for secondary syphilis. The symptoms consisted in the presence of a large round tubercle, covered by a patch of inflammation, in the substance of the left cheek. On the nates, and on the upper and back parts of the thigh, there had been also several of these tubercles, which had ulcerated, and become deep, irregular, foul, discharging ulcers, seated on an indurated base. He had suffered from primary sores seven years previously; and, three years ago, the throat had become painful on swallowing, was relaxed but never ulcerated, and the voice hoarse and feeble. For these symptoms he had consulted several physicians in London, and had used counter-irritation, local applications, and had been submitted to internal treatment of various kinds, with little or no benefit; as he got thin and weak, he began to fear threatenings of laryngeal phthisis. Seven weeks previous to my seeing the patient, tubercles on the back and thigh appeared, which slowly increased, ulcerated, and ran into foul sores; the tubercle on the face had also recently made its appearance. For these symptoms, doubtless syphilitic, the patient placed himself under my care. He was placed on the use of the mercurial vapour bath, a milk diet, and the biniodide of mercury with the iodide of potassium. The tubercle on the face had disappeared after the sixth bath, and the ulcers, which were dressed with the ung. hyd. nit. oxyd., and unguent. elemi, looked healthy, and were healing rapidly. In six weeks all the symptoms had disappeared; but what is remarkable, the hoarseness, and uneasy feelings in the throat, were gone, and they have never returned. The symptoms in the throat and windpipe in the preceding case were doubtless syphilitic, which is evident from their disappearing under the treatment which was directed against the syphilitic tubercles; but from their occurring as isolated symptoms of secondary syphilis, in a form not common, their nature and origin were overlooked. " Whilst, on the one hand, symptoms due to secondary syphilis are constantly unsuspected as to their nature and origin; so, on the other, are diseases reputed syphilitic, which certainly have no dependence upon the latter disease. This proposition is of immense importance in its practical application: patients who have once had any syphilitic taint, are apt to attribute the whole diseases of after life, of whatever nature they may be, to a syphilitic cause; and this apprehension or conviction is carried in many cases to such an extent that it is difficult or even impossible to combat it. A gentleman, upwards of sixty years of age, called on me one day, and showed me his hands and arms, which were covered with a well-marked eruption of psoriasis guttata." I said to him, "You are come to ask me if this eruption is syphilitic, and I tell you at once, without asking a question, that it is not." He replied, "I am glad to hear you say so, and I feel persuaded that it is not, for the opinion you have expressed coincides with others that have been given me by some of the first surgeons and physicians, both in London and on the Continent;" but, continued he, "I showed it to one. person, in whom I really had no confidence, who said it possibly might be syphilitic. I must confess, that this opinion makes me uneasy, and I cannot get rid of the idea that it is just possible the disease may be venereal, for I had a sore before I was twenty, and this eruption, which I have had forty years, came on about that time after bathing, whilst I was very hot. My chief object in coming to you, is to beg that you will test the nature of the eruption by some anti-syphilitic remedy, which will set the matter at rest, till when I shall never be easy in mind on the subject." This is not an isolated case; these fears are widely spread in society, and are sources of continual mental uneasiness; in some instances, threatening the minds of the patients, and even determining to acts of suicide. Again, on the other hand, symptoms are frequently syphilitic, which are reputed not so. A gentleman, seventy years of age, called on me and showed me his tongue, which, he said, he feared was cancerous, as he had been told so by three surgeons and one physician. I asked him if he had syphilis lately, and he admitted that he had contracted a chancre within the last two years. I placed him on a course of calomel and opium, with the iodide of potassium and sarsaparilla. The cure of the disease in the tongue was perfect; the patient is now alive, and free from all malady in the tongue. In attempting to form a diagnosis in reference to the nature of a symptom supposed to be due to secondary syphilis, several points must be taken into consideration. 1. The nature and appearance of the symptom itself. 2. Its history, the date of its appearance; the character, date, and number of primary symptoms which preceded it. 3. The constitution of the patient, what diseases he may have been subject to, and whether any similar symptoms had ever been present prior to the contraction of any syphilitic taint by the patient himself. 4. If, apparently, an isolated symptom be present, other symptoms should be looked for, which may be generally found on close examination and inquiry. 5. If the patient be married, the health of his wife and children should be noted; and, lastly, we may resort to the test of treatment itself. By attention to these circumstances, I think it will generally be found, that we shall be able to make out, in most cases, a correct diagnosis of many secondary syphilitic symptoms, of whose nature we might remain in doubt, after a more cursory or careless examination. CHAPTER XVI. OF THE PROGNOSIS OF CONSTITUTIONAL SYPHILIS. THE prognosis of constitutional syphilis involves many grave questions, besides that of the effect of the disease on the health and life of the patient. The chief points to be considered in the prognosis of constitutional syphilis are the probability of cure, or, in case of marriage, the effect of the disease on the wife or children. It is true that constitutional syphilis rarely terminates fatally, considered in reference to the number who suffer from such disease; but yet where the pustular, or tubercular, or even other forms of disease occur in advanced years, the patient's life is not unfrequently shortened by the exhaustion produced by repeated outbreaks. Where constitutional syphilis terminates fatally, organic changes are not uncommonly met with in the mucous membranes, especially in those of the intestines and larynx, where ulceration is found, and the patient sinks exhausted by diarrhoea, or symptoms resembling laryngeal phthisis; cough with profuse expectoration, and night sweats. At other times the constitutional condition is one of profound cachexia, in which the changes most evident are rather in the humours than in the solid parts of the body. In addition to its direct influence, a syphilitic taint frequently becomes the means of developing latent mischief in various organs, especially in the lungs, and I have, in more than one instance, seen patients die of ordinary phthisis, whilst suffering from syphilitic diseases of the skin and bones. The ordinary forms of constitutional syphilitic taint do not, however, terminate fatally; neither do they, in a great number of instances, appear to affect the general health of the patient; but a serious question, in reference to the prognosis of constitutional syphilis, is that which relates to its curability, and whether, and at what period, we are capable of pronouncing a |