by hygiene, until the lesion has disappeared; then to commence a course of mixed treatment, and continue it mildly for a year or more, watching for relapse; finally, to terminate with a mild, pure mercurial course, extending over some months. This seems to be the most beneficial course, but in old, obstinate cases it will not always prevent subsequent outbreaks. In such cases the main reliance is in tonics, hygiene, and the symptomatic treatment of the outbreaks. It must be remembered that mercury has power, more or less marked, over all shades and dates of syphilis. It is useful in the tertiary stage, although undoubtedly not so useful as in the secondary.

CHAPTER VI.

SYPHILIS OF SKIN AND MUCOUS MEMBRANES.

Syphilides, Secondary and Tertiary.-The Secondary Syphilides.-Concomitant Symptoms on Mucous Membranes.

THE SYPHILIDES are those manifestations of general syphilis found upon the cutaneous envelope. There are two groups, the secondary and the tertiary.

Those occurring in secondary syphilis are:

1. Roseola.

2. Papular syphilide.

3. General pustular syphilide.
4. Pigmentary syphilide.

With these occur on the mucous
1. Erythematous patches.
2. Ulcers.

5. Bullous syphilide.

6. Vesicular syphilide.

7. Squamous syphilide.
8. Tubercular syphilide.
membranes:

3. Mucous patches.
4. Scaly patches.

These are all general eruptions, except the pigmentary and scaly syphilides, and they belong to the group called secondary, about in the order in which they are given. Thus the roseola and papular syphilide always appear early; the tubercular and scaly syphilide always late. The former require mercury alone for their removal; the latter demand a mixed treatment, a combination of the iodide of potassium with mercury, to insure the most prompt and effective action.

The syphilides which belong to the tertiary stage of the disease are : 4. Tertiary ulcerations.

1. Ecthyma.

2. Rupia.

3. Groups of pustules.

5. Gummy tumor.

With these occur on the mucous membranes :

1. Mucous patches.

2. Scaly patches.

3. Deep chronic ulcers.

4. Destructive gummy ulcerations.

These (tertiary) affections, it will be noticed, are none of them generalized. They all occur in patches. They will be considered later. The concomitant symptoms of the group are affections of the bones, of the larynx, of the internal organs, and nervous syphilis.

SECONDARY SYPHILIDES.

1. ROSEOLA. This is an erythema, or simple redness, occurring in small, flat patches or blotches of irregularly crescentic or circular form and slightly indented margins, each blotch varying from the size of a split pea to that of a copper penny. Occasionally the blotches become confluent. Instead of being flat, the patches of eruptions may be raised above the level of the surrounding skin by the presence of minute papillæ upon the reddened area. The patches of roseola resemble exactly what would be an exaggeration of the mottling (marbling) of the integument, which any fair-skinned individual may observe faintly upon his own person by exposing the abdomen to cold air for a few moments. This erythema is the lesion proper, but, following the rule of polymorphism in syphilitic eruptions, it is customary to find other lesions besides the erythema, such as pustules leaving scabs in the hair, and pustules and papules elsewhere, scattered through the eruption, especially about the head and face. The patches of erythema at first disappear entirely upon pressure; but, where the eruption has been intense or of long duration, a faint, tawny, yellowish-brown stain is left after pressure (pigmentation), which indeed outlasts the eruption and is removed only by time. A small amount of fine desquamation attends the disappearance of the eruption in well-marked cases.

This exanthem is usually the first to appear after chancre, generally at about six weeks, sometimes three weeks, occasionally after several months, but rarely after the fourth. Its advent usually coincides with the secondary engorgement of the lymphatic glands. It often comes on slowly, and may never be observed by the patient until his attention. is attracted to it by his physician, or it may be called out rapidly by the heat of a bath, by a cold, or other exciting cause. If the patient have had no syphilitic fever, he is less likely to have noticed the eruption. When it comes on slowly the chest and flanks are first invaded, and an inspection of these surfaces with the light shining obliquely across them will reveal sometimes the beginnings of a roseola, as yet invisible to casual inspection. In rapid cases twenty-four hours are sufficient to cover the whole body with the eruption, including even a few blotches on the palms and soles. In perhaps the majority of cases the eruption is confined to those portions of the skin covered by clothing, the hands and face escaping, or being so faintly marked as not to attract attention.

When roseola comes on early, it lasts from one to six weeks; when,

however, it first appears some months after chancre, it usually lasts several months. Treatment greatly influences its duration. Relapse occasionally occurs.

Diagnosis.-Patients with syphilophobia are apt to mistake the natural marbling of the skin produced by cold for syphilitic roseola. Heat causes this marbling to disappear. Non-specific roseola is attended by some positive febrile symptoms, often by nausea, disappearing when the eruption comes out. The latter runs a rapid course. It is more frankly inflammatory than the syphilitic roseola, and occurs chiefly in children. Copaibal roseola is frankly inflammatory, usually itches, sometimes excessively. The history shows the ingestion of copaiba (of which the urine smells), and abstinence from the balsam effects a speedy cure. Urticaria occurs in raised patches, and itches greatly. The concomitant symptoms distinguish measles. The noninflammatory character of syphilitic roseola, its lack of itching, and the accompanying indolent engorgement of the lymphatic glands, render its diagnosis easy. When itching is complained of with syphilitic roseola, pediculi, urticaria, or some accidental eruptions are to be suspected.

2. PAPULAR SYPHILIDE.-This eruption may follow a roseola, or a roseola may be transformed into a papular eruption, or the latter may be the first eruptive outbreak observed after chancre. The papules constituting the initial lesion may be miliary in form (like those seen on the spots of roseola), in which case they are often early surmounted by a minute vesicle. The papule is often larger, but acuminated, or it may be broad and flattened (this is a common form), about the size and shape of a split pea (lenticular); or, finally, this last form of papule is sometimes greatly exaggerated, reaching the size of a penny. The type varieties, then, of papule in the earlier general papular syphilide are two, the acuminated and the flat. The general characteristics of the eruption are the same in each. The papular syphilide is superficial and precocious.

The color at first is rosy, but soon darkens to the purplish hue of syphilis. Pressure removes the color at first, but later some pigmentation occurs, and then pressure is no longer effective. This final tawny coloration often outlasts all prominence of the papule. Desquamation sets in early. Fine scales become detached, especially around the base of each papule, forming a sort of little ruffled border of white. Biett considered this circular desquamation of the base of the papule of great diagnostic value. It occurs, however, occasionally in the case of large non-syphilitic papules. Sometimes the desquamation is so considerable over closely-grouped broad papules that a diagnosis with squamous syphilide becomes difficult. One form of papular syphilide is peculiar Broad, flat papules appear, scattered irregularly, especially seen about the face, forehead, and neck, and on the scalp. Each pap

ule is covered by a thin, yellowish, superficial scale, like a scab, raised at the borders, and distinctly depressed centrally. The raised edge is sometimes distended by a slight amount of serum, the whole looking like a flattened, partly desiccated bulla. Sometimes each lesion is surrounded by a reddened (livid) areola. Shortly the large superficial scale becomes detached, the papule pales, flattens, disappears, and leaves no scar.

The papular syphilide, though general, is usually most marked at the back of the neck, on the forehead, back, and flanks. There is no pain or itching with this eruption. Scabs in the hair are likely to coincide with it, and the indolent, engorged post-cervical and epitrochlear ganglions are rarely absent. The eruption may come before the third week from chancre, or after the fourth month. Its duration is from three to eight weeks; it may be prolonged for months by the recurrence of successive crops of papules.

Diagnosis.-A papular syphilide is liable to be confounded with two eruptions only. (1) When the acuminated papules are few, and scattered about the temples and over the forehead, they greatly resemble a form of acne seen in middle age upon rheumatic subjects. The syphilitic eruption may be usually distinguished by a certain amount of pigmentation around the older papules, a feature not observed in acne. (2) The flat papules, few in number, livid in color, and attended by no itching, situated over the backs of the hands, wrists, forearms, and sometimes extensively over the body, and constituting one of the forms of lichen planus seen on rheumatic subjects, are very liable to be mistaken for syphilitic lesions. The patches, however, are more irregular in shape and size, and often present a slight umbilication (without desquamation) at some period of their course, which, together with the history and lack of concomitant phenomena, serves to distinguish this affection from a syphilide. With the papular syphilide are apt to coexist scabs in the hair, engorged ganglia, perhaps patches of erythema and pustules occasionally, and pretty certainly mucous patches, erythema or ulceration of some mucous membrane, especially that of the fauces. Small, circular reddened spots on the palms and soles are also a very constant accompaniment of a generalized papular syphilide. These are attempts at papulation aborted by the thickened epithelium. They appear as circular depressions, reddened centrally and partly deprived of epithelium, which latter is undermined at the edge of each depression as a whitened, fringed circle. Several of them may usually be found on each palm. An exactly similar condition is sometimes seen on the palm after an attack of lichen urticatus of the extremities. The severe itching attending the latter eruption insures against error of diagnosis. This affection of the palms is sometimes described as syphilitic psoriasis. It is more justly an aborted papular syphilide, or results from

previous small patches of erythema. It may be found when there is no other syphilitic eruption upon the surface. Its appearance is characteristic, almost pathognomonic of syphilis. Iritis sometimes accompanies a severe outbreak of syphilitic papules.

3. GENERAL PUSTULAR SYPHILIDE.-There are three varieties of generalized pustular syphilide belonging to secondary syphilis : (a) Superficial pustules complicating other lesions.

(b) General syphilitic acne.

(c) Superficial ecthyma.

(a) Superficial Pustular Syphilide.-With a roseola, or papular syphilide, or occurring alone, there may be some superficial pustules scattered on the scalp, or along the forehead, or about the upper lip, at the base of the nose, at the labial commissures, or, indifferently, over any part of the body, more or less thickly. The pustules are small, superficial, ephemeral, without any hardened or elevated base; they often run together and dry up, forming scabs-brown, rough, uneven-like those seen in impetigo. The patches always tend toward a circular arrangement. Instead of drying up under the scabs, slight ulceration may take place, with, not infrequently, vegetation of the surface by the excessive growth of granular tissue. This feature is especially noticeable at the angles of the lips, or around the base of the alæ of the nose. Indeed, any moist, ulcerated surface may granulate, the feature being an epi-phenomenon, and not essentially a characteristic of syphilis. Occasionally, in syphilis about the labio-nasal furrows, the lips, and chin, minute, dry, irregular, papular prominences occur in rows and segments of circles where there has been no previous moist surface. These warty excrescences rarely get larger than the head of a pin; they are of a dead-gray color, sometimes pigmented. They last several weeks, then dry up and disappear without leaving any cicatrix. Hardy has described the eruption as "syphilide granuleuse."

There is nothing about the slight pustular eruption above described characteristic of syphilis, except the pigmentation of the skin in the brown areola which forms about the scabs, and the tawny, vinous-red color of the skin left after the fall of the latter. A very faint, central depression marks the spot of the pustule, and from this central depression the clearing up of the pigmentation begins, progressing centrifugally. The eruption may relapse, several crops appearing successively, especially on the scalp.

(b) General Syphilitic Acne.-This eruption occurs scattered over the scalp, face, and the extremities, the lower rather than the upper, or it may cover the whole body. Each pustule is distinct, and out of most of them grows a hair. They are not prominent, usually small, often but little larger than a grain of millet, occasionally quite large. Each separate pustule rests on a reddened base, which itself never sup