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As syphilitic tubercles are accompanied by a process of inflammation, under the increase of which they soften and ulcerate, a local treatment, whilst they are in a state of induration, is of vast service in assisting the internal treatment in their resolution. For this purpose, cooling lotions may be employed, or fomentations of poppy, henbane, or aqueous solutions of opium. Blisters are also very useful.

In the ulcerated forms of tubercles, all that has been said on the treatment of primary venereal sores may be referred to with advantage, since these secondary ulcerations require nearly the same local treatment, the use of the nitrate of silver, the aromatic wine, with astringents, sedatives, narcotics, or digestive ointments, or a local antiphlogistic treatment, according to the aspect of the sore. When caustics are indicated, the surface of the ulcers may be touched with the acid nitrate of mercury; the ulcers cicatrize rapidly under its application; the separation of the crusts or eschars may be facilitated by the warm or mercurial vapour bath.

The iodides of potassium, sodium, and iron, with decoctions of the woods, are excellent remedies during the ulcerating stages of tubercle; mercurials also may be used in certain states; the iodide, the biniodide, or the mercurial vapour bath, with sarsaparilla and cinchona, are the best remedies.

OF SYPHILITIC STAINS OF THE SKIN.1

The various forms of syphilitic diseases of the skin which I have just described are frequently followed or accompanied by alterations of its colour, without any other pathological change. These stains are generally circular in form, and either distinct, single and round, or placed in groups or clusters; or, again, consisting of a mere mottled appearance. They vary in colour, from a deep brown to a bright or a dirty yellow, and in places the skin appears as though it had not been washed clean. These spots sometimes appear on the site of previously existing diseases of the skin, or on parts which have never been affected.

1 Synonyms.-Macula syphilitica-Taches.

They do not disappear under pressure with the finger, they give rise to no irritation, and never ulcerate, or terminate in vesicle, papule, or pustule; they consist simply in an alteration of the colour of the pigment. They commonly last for years, or through the whole of life. I have succeeded in curing some forms by the mercurial vapour bath, but I have seen others which have resisted all modes of treatment. The general health is rarely disturbed in the majority of cases.

ON CONSTITUTIONAL OR SECONDARY VENEREAL ULCERS
OF THE SKIN.

Secondary venereal ulcers are most commonly a consequence of other diseases of the skin, which have immediately preceded them; thus, the ruptured vesicle, or pustule, or the softened tubercle, naturally produces an ulcer; there are, however, some rare forms of secondary ulceration which are not preceded by any of the diseases I have mentioned, or, in fact, by any apparent disease. The sites of primary sores not unfrequently become the seat of secondary ulcers, which appear long after the healing of the primary sores, and which are doubtless due to a constitutional taint. M. Cazenave mentions some very curious examples of this nature, where an accident, a wound, the application of a blister, or a relay of leeches, has been succeeded by constitutional syphilitic ulcers, and where no other evidence of a constitutional taint could be discovered. Mr Paget (Lectures on Surgical Pathology,' vol. i, p. 492,) mentions a case where a gentleman who, for not less than five years after a syphilitic affection of the testicle, had no sign of syphilis, except that of general feeble health; but he accidentally struck his nose severely, and at once a well-marked syphilitic disease of its bones ensued. In another case, syphilitic disease of the skull followed an injury of the head.

CASE XXXII.

A collier was admitted into the Queen's Hospital, whose nose had been injured by the fall of some coals upon it; he had suffered from syphilis eight years before. Caries and exfoliation of

the nasal bones, which ended in their total destruction, succeeded to the blow, and this was followed by secondary phagedena of the fauces. To these ulcers an ointment of bismuth and lard is a good application: an ounce of prepared lard, and as much of the trisnitrate of bismuth as can be incorporated with the lard.

I have already alluded to the operation of this law of proximate causes in the development of secondary syphilis, when speaking of the sylphilida generally.

CHAPTER XIX.

OF SYPHILITIC TUMOURS OF THE SKIN AND THE SUBCUTANEOUS CELLULAR TISSUE,1

ISOLATED, hard swellings, varying in size from a horse-bean to a swan's egg, form on different parts of the skin in the advanced stages of many forms of constitutional syphilis. These swellings are at first moveable, and the skin covering them not altered in appearance. In the advanced stages the tumour becomes adherent to the integument covering it, which inflames and ulcerates in one or more places, giving vent to the contents of the tumour, which softens and suppurates, discharges an offensive sanies, or quantities of brown or black sloughs the ulceration spreads till the whole skin covering the tumour is destroyed; we have then a deep, foul ulcer, filled with a black slough, and sometimes an inch or two deep, the skin surrounding which is of a livid red colour, and the edges ragged, everted, and hard.

These tumours, unlike the ordinary syphilitic tubercle, which in many respects they very much resemble, appear rather to spring from the subcutaneous cellular tissue than from the skin itself, for it is not till the more advanced periods of the disease that the skin is involved: they generally appear on the extremities. I have seen these tumours on the fore-arm, the external condyle of the humerus, on the inner part of the leg, on the external ham-string, and other parts of the upper and lower limbs; they are rarely placed on the face or the trunk, though occasionally met with in these situations. They may be confounded with the ordinary syphilitic tubercle, or when occurring as an isolated symptom, (which they rarely do,) with tumours arising from other causes, or even with common phlegmon, or chronic abscesses, particularly those of a stru

1 Tumeurs gommeuses-Gummata.

mous character; the diagnosis in such cases is important, as the syphilitic tumour, when softening, or in that stage which resembles a common abscess, should never be opened or punctured.

The syphilitic tumour occurs late in the history of a syphilitic taint, and generally many years after its primary cause; it has generally been preceded, at no long period, by other symptoms which render its nature certain. It is also frequently associated with pains, or diseases of the bones, pustules, tubercles, or secondary venereal ulcers which have succeeded to the detachment of the crusts of ruptured pustules or ulcerated tubercles. In its earlier stages, the resolution of this tumour should always be attempted; and this may generally be accomplished by appropriate treatment, if the process of softening have not proceeded too far. If the tumour be seen in its earlier stages, before the skin has become implicated, local treatment is of essential service: the most efficient remedies are blisters, frequently repeated, and dressed with mercurial ointment, or the compound iodine ointment; next in efficiency is pressure by means of discutient plasters, composed of belladonna, iodine, or mercury. The emplast. de Vigo, with mercury, also answers very well. Some writers have recommended extirpation with the knife, an absurdity too great to require a serious refutation. The internal treatment should consist of the administration of the iodides of mercury, potass, or iron, either alone or in a state of combination. The mercurial vapour bath also assists powerfully in the resolution of the tumour ; it should be used twice or three times in the week.

If the skin covering the tumour has become thin, and is of a deep red or livid colour, we shall hardly succeed in dispersing the tumour; in this diseased integument one or two small spots of ulceration soon appear, which spread rapidly till the whole covering of the tumour is destroyed. When this is the case, we have to deal with a secondary syphilitic ulcer, frequently of very formidable character, which has penetrated sometimes to a very great depth in the soft parts, having destroyed the fascia, and laid bare the muscles if situated on the soft parts of the

1 See Vidal de Cassis, p. 446.

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