perhaps into the rectum, along the sides of the scrotum from friction. between the toes, where they may become very painful, at the angles of the lips, on the tonsils.

The secretion of mucous patches is contagious, and when they are present on the lips, or anywhere within the buccal cavity, the patient can not be too urgently warned of the possibility of spreading the disease among members of his own family, by kissing or using the same spoon, cup, pipe, etc., as other members of the household. Mucous patches of the mouth are often of irregular shape, owing to the irritation of friction against the teeth. At the angles of the lips, and on the dorsum and sides of the tongue, they are often more or less fissured. The whitish pellicle on the surface is thick and adherent, sometimes covering the whole patch, sometimes having a circinate distribution. The buccal patches are usually flat, sometimes slightly depressed. Upon the tongue they may vegetate, while extensive ulceration upon the tonsils is not unusual. In connection with such ulcerations, the tonsils swell, there is a good deal of inflammatory thickening and induration around, swallowing may become painful, the submaxillary glands enlarge.

Since the use of the laryngoscope, mucous patches have been repeatedly seen within the larynx and trachea. They do not become large in these situations, or secrete much, and they disappear in a few weeks, even without treatment.

Symptoms are hoarseness, perhaps aphonia, no pain, cough, or expectoration.

Mucous patches come on with the earliest syphilides. They appear upon the skin, usually in connection with the papular syphilide, especially the broad, flat variety. They may outlast several crops of different eruptions, and they relapse (especially about the lips, tongue, and tonsils) with more pertinacity than any other symptom of syphilis. They occur late along in the secondary and even in the tertiary stage of the disease, but become gradually less and less prominent, until finally they pass over into the scaly patch of mucous membrane, so closely resembling the mucous patch in some of its features.

Nothing is of more importance in the prevention of mucous patches than thorough cleanliness, nothing more active as an exciting cause (upon a syphilitic patient) than local irritation, prominently the use of tobacco, smoked or chewed (for the mouth), or snuffed (for the nose), the retention of a naturally irritating secretion from lack of cleanliness for the anus and genitals. Mucous patches do not leave cicatrices unless they have ulcerated deeply. The tonsils may hypertrophy and look excoriated in secondary syphilis without being the seat of true mucous patch.

Diagnosis. The only maladies with which the mucous patch can be confounded are certain forms of so-called canker sore, or aphthous

sore mouth, and a sort of a ringworm-looking herpetic condition of the mouth and tongue seen in neurotic patients. The former sometimes copies the mucous patch (the exulcerated mucous patch) to perfection, and there is no point of diagnostic differentiation that I can mention. The only difference is that these spots are, as a rule, more subjectively tender than the exulcerated mucous patch, and more likely to occur singly than in groups. The second affection is often an inherited one. The scalded circular and oval patches suggest and do not closely imitate syphilis. The papillæ are prominent and red in places, pale in others, and the epithelium shed off certain rounded areas. The tongue is very tender, and the malady likely to persist, relapsing paroxysmally.

Treatment of the mucous patch, simple or ulcerated, is general and local, as already given.

4. SCALY PATCHES.-These patches, sometimes described as mucous patches, and sometimes as psoriasis, resemble mucous patches to casual inspection, but are found on closer observation to differ. They appear on the inside of the cheeks, especially near the angles of the mouth, and on the sides, tip, and dorsum of the tongue. They are rounded or irregular in shape, often gyrate on the back of the tongue. They are flat, smooth, shining, and of the bluish-white color of skimmed (city) milk. When mild, they are not at all sensitive; when severe, they become whiter in color, and the epithelium, whose thickening constitutes the lesions, cracks in places, causing pain. The scales are very firmly adherent, so much so that it is often impossible to scrape them off, and very rough handling fails to provoke bleeding. The patches may become confluent and cover the greater part of the dorsum of the tongue, making it feel stiff and uncomfortable for the patient.

These patches sometimes occur along with the true mucous patch, but usually they appear later in the course of the disease. They may be found at any time, even during tertiary syphilis, and often remain long after all other symptoms have disappeared. They are sometimes seen in inherited syphilis. Smoking is an efficient exciting cause. They are rebellious to internal measures, and are more effectively treated locally. They indicate a continuance of the syphilitic diathesis.

The diagnosis between these patches and ordinary non-specific ichthyosis of the tongue, or tylosis, is often impossible from inspection alone. In either condition the mucous membrane on the inside of the cheek may look as if it had been lightly varnished over with collodion. The tylosis, however, occurs on the gums at times, and on the soft parts beneath the tongue and in the floor of the mouth, which is not the case, so far as my experience goes, for syphilitic scaly patches. Moreover, the non-specific epithelial thickening is likely to be more pronounced and irregular than the syphilitic scaly patch. Wart-like

prominences of pure white and great hardness, and uneven patches of pearly thickening, are found in the non-specific form. Fissures more or less ulcerated occur in both, but more on the dorsum in the nonspecific malady, on the sides of the tongue in the syphilitic form. Epithelial degeneration sooner or later is to be feared in the non-specific form, which, moreover, does not yield at all to antisyphilitic treatment, and is often scarcely modified by local means. A test by treatment must be appealed to to decide the nature of some doubtful I remember one case which occurred in a young man who had no syphilis. It failed to yield to treatment. Later the youth acquired syphilis, and under the treatment of the latter the tongue became much better than it had been before, although it did not entirely

cases.

clear up.

Treatment. These scaling patches require internal mixed treatment, and locally powerful stimulants. I think the acid nitrate of mercury the best. Tobacco must be stopped. I know several old cases of syphilis in which smoking for a few days will produce the white appearance over almost the entire dorsum of the tongue. In these gentlemen (all with ancient syphilis) nothing will keep the tongue clean except the cessation of smoking. These patches, indeed, have been called smoker's patches ("plaques des fumeurs ").

CHAPTER VII.

SYPHILIS OF SKIN AND MUCOUS MEMBRANES.

The Tertiary Syphilides.-Concomitant Symptoms on Mucous Membranes.

THE results of tertiary syphilis, as seen upon the tegumentary expansions, are most advantageously considered in connection with the lesions of the same structures encountered in secondary syphilis already discussed.

Tertiary is a far graver form of syphilis than secondary. Its presiding genius is destruction, the tendency of its lesions is to softening and ulceration, and the medium through which these changes are effected is a substance known as gummy material, either diffused through the tissues or collected into circumscribed tumors. This gummy material is a specific neoplasm analogous to tubercle, cancer, lupous deposit, etc. It is a hyperplasia of cells, which have not generally the vitality to become organized. They grow at the expense of the tissue in which they are formed, and after reaching a certain stage of development undergo a retrograde metamorphosis, and either become absorbed gradually, without solution of continuity of the tissue in which

they are deposited, or break down in mass, occasioning abscess or ulceration-in either case leaving indelible cicatrices behind. Certain of the new formations due to tertiary syphilis become organized, leading to permanent thickening, sub-periosteal exostoses, pachymeningitis, chronic laryngeal thickenings, etc.

Tertiary symptoms rarely appear during the first two years after chancre. After that period they may come on at any indefinite time, having been observed as late as fifty-five years. The appearance of tertiary phenomena (unlike the secondary) is rarely marked by the occurrence of any preparatory or accompanying febrile excitement. Cachexia is apt to accompany them, but even this is often lacking, and, except for the visible lesion upon the skin, the patient may consider himself in perfect health. Tertiary lesions of the skin and mucous membranes are rarely attended by any considerable heat, burning, itching, or pain-in fact, are usually devoid of any sensitiveness whatThe course of tertiary affections is generally slow, occasionally terribly rapid. Sometimes they yield promptly to treatment, sometimes they are particularly rebellious, lasting for years. As a rule, however, skillfully-directed and long-continued treatment masters them, but it can not restore lost parts, or remove the indelible injuries sometimes left by the ravages of the disease.

ever.

Tertiary syphilitic cachexia requires a word of description. It occurs at times independently of any visible or tangible lesion; or, again, may accompany any of the recognized forms of tertiary disease. It is probably always due to some physical change (amyloid, gummy) in the blood-making organs or the viscera, or to some nerve-change, rather than to any specific poisonous effect of syphilitic virus-since at this, the tertiary period of syphilis, the virus has lost its transmissibility, and seems to have worn out its intensity by lapse of time, while none the less the changes it has instituted upon the organism continue in full force. Syphilitic cachexia is attended by loss of appetite and strength, and by general anæmia. The sufferer becomes mentally depressed. He looks thin and pinched. The skin is tawny, dry, dirtylooking, without luster. The hair thins, the epidermis exfoliates excessively, occasioning a more or less general furfuraceous desquamation. The heart and vessels of the neck exhibit the anæmic murmur, the pulse is small and rapid, and some anasarca is apt to be observed. Sleep is disturbed, and mental activity lessened. The patient may be nervous and fretful, or very despondent; occasionally he keeps cheerful.

This general condition indicates great depression of the vital force. It sometimes resists treatment effectually, so that none of the so-called specifics are of any avail. It calls for tonics and change of life and air, and, if not relieved, becomes progressively worse, either carrying off the patient or favoring his death by some intercurrent malady.

The existence of syphilitic cachexia with other syphilitic lesions always demands careful hygienic and tonic as well as (or perhaps rather than) specific treatment.

3. Deep chronic ulcers.

4. Destructive gummy ulcers.

1. Mucous patches. 2. Scaly patches. 1. ECTHYMA.-In tertiary syphilitic ecthyma there is gummy infiltration of the true skin. After a few days a pustule appears on the top of the solid elevation. This grows rapidly and breaks, or is scratched off. The matter dries up into a dark-brown scab, perhaps containing a shade of green. Underneath this pus forms, increasing the thickness and roughness of the scab, while the solid portion of the lesion increases also in size, and becomes surrounded by a livid areola. The scab growing from beneath may finally become larger than the ulcer, but the livid areola and the interstitial thickening of the skin extend usually beyond it. Often the scab is depressed, let-in, as it were, inlaid into the skin, and firmly adherent to it. If removed, an ulcer, with sharp-cut edges and pultaceous floor, is found, very closely resembling a chancroid.

This form of deep ecthyma may occur separately or in groups; in the latter case giving rise to a scabbed patch of irregular form, under which there is ulceration, which may become circumscribed and heal under the crust, or, rarely, advance as a serpiginous ulcer.

The favorite seat of this eruption is the lower extremities. It may occur anywhere upon the body. The duration is often many months, by successive crops of ecthymatous pustules. An indelible, often deeply-depressed scar results, which remains of a livid color long after the fall of the scab, and is bronzed more or less in different subjects. Blanching commences centrally, until finally the cicatrix is of a pearly white, perhaps surrounded by a faint ring of pigment, which is slower in disappearing.

Mixed treatment is the most valuable.

2. RUPIA. The lesion in rupia is a bulla, quickly becoming pustular, the pus usually mixed with blood. It may be a flat pustule. It varies from the size of a pea up to (in bad cases) a penny. It rests usually upon a flat base surrounded by a red areola. The pustule breaks in a few days or dries into a crust, under which ulceration progresses. New supplies of pus are furnished from beneath, while the