The Skin.

—The late syphilides of syphilis belong to the gummatous or tuberculous types (i. e., tuberculous in the anatomical sense, or nodular). The latter may occupy the entire thickness of the skin or lie even deeper. Such lesions may begin as papules and develop into distinct and circumscribed nodules, while these may coalesce into considerable masses. These tend to break down and leave scars after they have disappeared. There is little difference, microscopically, between the nodule and the gumma. Clinically, the tuberculous lesions spread usually in a serpiginous manner, producing a more or less curvilinear outline. (See Figs. 24 to 27.) These ulcerations undermine the tissues to a greater or less extent, and pus and debris will be formed in consequence. In this way they imitate considerably the lesions of lupus, and it may require a careful study of the case and of its history to make a diagnosis. Some of these lesions are extremely slow in their course and long in duration. When scars form they are usually white and smooth, with irregular borders, but sometimes are surrounded by pigment that makes them characteristic. The extent of the scar is no criterion as to the size of the originating lesion, the former being always smaller than the latter.

The Gumma of Syphilis.

—This is as characteristic of late syphilis as is the condyloma of the earlier stage. By this term is meant a new formation which may vary in size from a millet-seed to a large mass. Sometimes it is diffuse, or it may be circumscribed. It seems to originate from connective tissue, and may be met in all parts of the body. Microscopically it consists of a delicate stroma filled with small, round cells, the mass being furnished usually with bloodvessels, also of new formation. Such a gumma may pass through various stages of integration and disintegration. The cells sometimes undergo fatty changes by which the entire mass is softened, and its interior contains a puruloid material resembling pus. The gumma, as it increases, will replace other tissues and cause them to disappear, and thus it happens that when it disappears the region previously occupied by it seems to have diminished in size. Sometimes, however, cicatricial tissue takes its place and not only distorts an organ or part but impairs its function. Thus softening and melting may occur at one time and a dense scar or mass at another.

The degree of infectiousness of gummatous and other late syphilitic ulcerations is uncertain. The later they occur, the less infectious. It would be safe, however, to assume that they are all dangerous.

The Gummatous Syphilide.

—This begins, as a rule, as a subcutaneous gumma which quickly proceeds to and involves the skin. At first it appears as an induration, developing into a distinct tumor, becoming more indurated and firmly implanted as it grows, the overlying skin becoming reddened and swollen. After a time there occurs softening in the interior of the mass, and upon incision there will escape not pus but viscid, puruloid fluid, yellowish gray in color, which may contain corpuscles resembling those of pus. It is the content of such a tumor as this which has given it its peculiar name, gumma. Should proper treatment be rapidly pushed, it is possible for a softened gumma to disappear by absorption, but if ulceration or evacuation has taken place, there remains usually a permanent disfigurement at the site of the mass; like tuberculous gummas these growths may undergo caseous or even calcareous degeneration.

A gumma of the skin will open at one or several points, and, becoming thus secondarily infected, may give exit to sloughing tissue and foul discharge. If the skin directly overlies the bone, then the tumor may involve the latter as well; and when it ulcerates, the bone will be exposed. In the healing process, however brought about, deformity from cicatricial contraction may cause much disfigurement. When a gumma appears beneath the true skin and then disappears it may leave areas of depression, with more or less adherent, bleached-out scars, perhaps with a pigmented margin. The appearance of such scars is suggestive of the disease even without a definite history.

The gummas form the most important features of syphilis, at least from a surgical standpoint, since they frequently appear in the depths as well as on the surface of the body, without any other symptoms, and they often cause no little perplexity in diagnosis. Syphilomas, tuberculous gummas, phlegmons, innocent and benign tumors, as occurring especially in and upon the bone, in the muscles, tongue, the breast, the testicle, and elsewhere, may be difficult of diagnosis. Of course, a history of syphilis is a great help. Doubt frequently arises when such a history cannot be obtained. Scarcely any other disease will produce multiple lesions such as are seen in syphilis, and when multiple they are usually distributed, with some appearance of symmetry. Ulcers formed by their breaking down are often extremely sensitive, but do not bleed easily, nor show a tendency to exuberant granulation. In cases of doubt the most successful test is perhaps the therapeutic, and consists in giving mercurial or mixed treatment to the point of toleration and noting its effect.

In many patients, especially of the hospital class, scars, which are strongly suggestive, will be visible upon the legs. It does not follow, however, that an old scar upon the legs, even if surrounded by a pigmented area, is necessarily of syphilitic origin. Old ulcers of the limbs are frequently seen in connection with varicose veins, and may show exceedingly chronic tendencies; moreover, it is possible for chronic and non-specific ulcers to occur in old syphilitic subjects when the course of the local lesions may be influenced by the old affection, although they are not specific ulcers. Benefit, however, will in such cases accrue by the reasonable administration of antispecific treatment, but it should be combined with suitable local measures.

The Vascular System.

—The lesions which are encountered in the bloodvessel walls in chancre and early syphilis have been described. The heart and vessels are liable to suffer, as they contain connective tissue. Gummas have been noted in the heart, while the poison also may produce thickening of the valves, and disease of the coronary arteries, the endocardium and the myocardial structure.

The arteries often suffer from arteriosclerosis, which is either diffuse or nodular. Endarteritis is a common manifestation of syphilis and leads frequently to the formation of aneurysm. Sometimes this appears as a single and large lesion; at other times hundreds of small aneurysms will form in the arterial system of the brain, so that the arteries are studded with them. The explanation of aneurysm under these circumstances is that the arterial walls, being weakened, dilate under the influence of blood pressure. Thus the arteries, from the largest to the smallest, also may suffer. The veins likewise are subject to syphilitic phlebitis, which is frequent in the superficial veins of the extremities.

Bones and Joints.

—Syphilitic manifestations in bones are frequent, but are not so common in the joints. While early syphilitic periostitis is not infrequent the actual lesions of the bone are mostly expressions of late syphilis. Nearly all of them are painful. The pain is worse at night, and is called the osteocopic pain of syphilis. At first these bone lesions are hyperplastic, because of the connective tissue in the bone. Periostitis is a common manifestation, and here, again, the neoplastic tendency of the disease is manifested, in that the periosteum is thickened as well as the bone beneath, and swellings called nodes are thus formed. Nodes are met with more often on the tibia and the sternum than elsewhere, but are frequent upon the skull and clavicles. No bone is exempt from these lesions. They often form at points where there has been previous injury. These swellings are ill-defined, and usually quite tender, while the skin over them is easily movable unless secondary infection has occurred and suppuration is present. The nocturnal pains in these lesions, of which patients often complain, are sometimes excruciating. Should suppuration occur, with subsequent formation of ulcer, there may be necrosis of the exposed bone. Another bone lesion of syphilis assumes the type of ostitis. Physiologically this consists essentially of gummatous involvement of the connective tissue, which may be either localized or diffuse. When this undergoes retrocession there occurs a rarefaction of the bone, by which it is weakened and easily broken, so easily in fact that we have to deal sometimes with what is referred to as spontaneous fracture. There is frequently a thickening and condensation of the entire bone, with some distortion, so that the actual weight of the bone may be nearly doubled. Dactylitis is the name given to syphilitic ostitis of the phalanges, which increase in size and become tender and useless, while the skin becomes glazed. Occasionally the disturbance appears to involve the extra-osseous tissues rather than the bones themselves. Bones which are spongy are liable to this disease. Some of the bones in the face are peculiarly susceptible; hence the loss of the bridge of the nose, or of a portion of the hard palate, by the ulcerative processes so common in this disease.

The joints are subject to changes somewhat similar to those occurring in tuberculous disease. There may be either a gummatous synovitis or an arthritis, or else destruction of articular surfaces. These joint lesions of syphilis are all slow in their course, and sometimes difficult of distinction from tuberculous and other lesions. They have so much in common with the joint expressions of tabes that some writers believe that tabes is necessarily an expression of syphilis of the cord.

As long as no active destruction has occurred within a bone or joint these cases are usually amenable to treatment, but for the actual destructions caused here or elsewhere by syphilis there is no repair possible, and the harm once done cannot be undone. Plastic operations and injections of paraffin may have to be practised for cosmetic purposes and relief of disfigurement.

Muscles and Tendons.

—It is the connective tissue of muscles which suffers most in the luetic affection of these structures. It may be met with as a diffuse process or as a gumma. In the former cases the muscle becomes irregular in shape and size, and in the latter distinct tumors are formed. As such growths advance and contract adhesions to surrounding structures, there is interference with muscle play.

Syphilitic myositis causes little pain, and patients with gummas in muscles are often not seen until ulceration has begun.

The dense fibrous structure of tendons and aponeuroses is frequently involved in late syphilis, causing pain and disability. Little is discovered on physical examination, but considerable loss of function may result. Points of tenderness sometimes are noted along junctions with the adjoining periosteum. Such a tendoperiostitis may be painful, and even crippling.

Bursæ.

—Bursæ are prone to be involved in syphilis, especially those in front of the patella. A gumma frequently develops at this point, where it constitutes a painless, somewhat tender enlargement, which may be dense or elastic. After it has become adherent to the skin it is usually infected, and a chronic ulcer results at this point, which may often manifest gangrenous tendencies. This constitutes one form of so-called housemaid’s knee.

The Eye.

—Of the manifestations of syphilis in particular organs the eye sometimes suffers severely. Iritis is the most common and serious manifestations of constitutional syphilis. It has been estimated that nearly 60 per cent. of all cases of iritis are due to this cause. It may occur in two months after the primary sore; it is usually acute, and rarely begins in both eyes at the same time, but may involve one after the other. The ciliary body is frequently associated in the lesion, and iridocyclitis occurs. It commences with congestion of the conjunctiva, photophobia, and lacrymation. The pain is not always severe. Inspection of the iris will show beads of lymph, a small pupil, with loss of contractility, or the dull iris may appear infiltrated and inflexible. The pain in some cases is extreme. Where treatment has been only partially effective relapses are common. The greatest danger to be feared is formation of adhesions between the anterior surface of the lens and the margin of the pupil, i. e., anterior synechiæ. These are detrimental, and serve as the cause of many irritations.

The treatment of these affections is constitutional; locally solutions of atropine of sufficient strength to ensure dilatation of the pupil should be used, not only to relieve the pain, but to carry the margin of the pupil from the central portion of the lens and prevent adhesions. The patients should be kept in the dark because of their photophobia. Atropine may be substituted by duboisine if the former tends to produce congestion. Leeches applied to the temples will also give relief from pain.

The cornea is often affected by a deposit on its posterior surface of particles of debris, which give it a punctate appearance known as keratitis punctata. It also becomes the seat of opacities which materially interfere with vision, and prove only partially amenable to treatment. Lesions of the cornea are frequent in hereditary syphilis.

Retinitis and choroiditis, of either acute or chronic type, are the most common syphilitic lesions of the fundus. They are usually associated and involve both eyes. They come on so insidiously that they are often far advanced when first discovered. The lesions consist of patches of exudation and areas of atrophy, accompanied by some haziness in the vitreous. Vision is affected in proportion to the area involved.

The movements of the eyes are interfered with by lesions which pertain, however, rather to the brain and the ocular nerves than to the eye itself. The sixth nerve, lying on the floor of the skull, is affected by syphilitic disease at the base of the bone. As a result of these nerve lesions paralysis is often seen, or at least disturbances of motility from which diplopia results. Ptosis occurs from affection of the third nerve. In lesions situated below the aqueduct of Sylvius, the paralytic condition which Hutchinson has spoken of as ophthalmoplegia is likely to appear. Optic neuritis is also a late manifestation of syphilis, and may be either chronic and mild, with a small disturbance of vision, or acute, with rapid loss of eyesight.

The Ear.

—The ear may suffer in various ways. The external ear may participate in affections of the adjoining skin. The middle ear may be affected as a result of extension of trouble from the nasopharynx, while in the late stages of the disease patients may suffer from labyrinthine disease, with partial or almost total deafness.

The Nose.

—The lesions of syphilis in the nose are numerous and offensive. Ulceration is frequent and followed by perforation through the septum or into the mouth. When the vomer is involved the bridge of the nose falls in. In neglected cases the whole substance of the nose may be involved and subsequently lost. The bone is often exfoliated. These ulcerations of the mucous membrane and periosteum give rise to a characteristic condition known as ozena, with its characteristic discharge.

The Oropharynx.

—The tongue may be the site of intermediate and late syphilitic lesions. Men suffer more than women, apparently because of their use of tobacco. Mucous patches, deep ulcers, and even gummas, single or multiple, are seen here. Gummas in the tongue are inclined to undergo superficial ulcerative infection and become abscesses. In these lesions there will be notable involvement of the adjoining lymphatics. The appearance of smooth, bluish-gray patches upon the mucous membrane of the tongue and cheeks is known as leukoplakia or leukokeratosis. These lesions do not respond readily to treatment; they give rise to little or no complaint, and are often followed by malignant disease.

It is difficult to distinguish between gumma of the tongue and epithelioma. Usually the latter is a single lesion; the former often multiple. In epithelioma the ulcer is superficially painful, with more elevated and indurated edges, while the pain is sometimes intense and radiates toward the ears.

Interstitial glossitis is a late manifestation of a sclerosis beginning in the connective tissue and involving the muscle fibers, leading to enlargement of the tongue and later to atrophy and inflexibility.

The Larynx.

—Syphilis of the larynx appears either as one or more ulcers, as gumma, or as chondritis or perichondritis, often with necrosis of cartilage. When ulcers form they are deep and destructive, involving even the intrinsic muscles of the larynx, and causing harshness or loss of voice, with dyspnea. Subsequently they lead to cicatrization, often leaving a stricture which may call for tracheotomy. The epiglottis is also liable to ulceration and gummatous lesions.

In these cases, aside from the general treatment, there is need also for local applications of combined antiseptic and anodyne character. Cocaine or one of its less toxic substitutes may be used in spray or by insufflation, in connection with an antiseptic powder, morphine or heroine. Edema of the glottis may be subdued by the local use of adrenalin.

The Alimentary Tract.

—Between the mouth and the rectum the intestinal canal is rarely involved in syphilitic disease. In the rectum, however, ulcers, as well as gummatous infiltrations, are frequently encountered. If the ulcers are low, within two inches of the anus, they will cause great pain. Higher up the rectum is not so well supplied with sensory nerves. Ulceration may involve the entire circumference of the anus.

In the rectum chronic ulcers are liable to be followed by stricture, which will call for surgical relief. (See chapter on the Rectum.)

In the colon chronic ulcers have been so serious as to lead to dysentery, followed by stricture formation. It has been suggested to make an artificial anus at the cecum and allow the large intestine to rest, treating it at the same time with irrigation through the opening.

The Viscera.

—Of the solid viscera the liver is more commonly affected than the spleen or kidneys. Chronic interstitial hepatitis may lead to cirrhosis, the new tissue being less distinctly distributed than when due to alcohol, the liver consequently becoming irregular, with a deep separation between its lobes. The pain is sometimes intense.

On the other hand isolated gummas, or confluent masses of smaller gummas, may be found beneath the capsule or in the substance of the liver. From one or both of these cases combined this viscus may attain an enormous size, with acute pain. Under these conditions there may occur albuminuria and evidences of amyloid disease.

Likewise in the spleen there may be diffuse or localized trouble. Here the lesions cause but slight distress.

The mercurials are of greater importance than the iodides in treatment of these lesions. The kidneys suffer less often than the spleen. Syphilitic patients do not lose their liability to renal disorders, but there seems to be but small, direct connection between syphilis and the common changes in these organs.

The Genitalia.

—In both sexes the genitalia are subject to gummatous involvement during the later stages; in the male more frequently in the corpora cavernosa and testicle. In the latter a chronic induration, with some enlargement of the epididymis, is one of the manifestations of constitutional disease. Most of the enlargements of the testicle are slow and painless, and occasionally some fluid will collect. The prostate and the seminal vesicles are rarely involved in syphilis, but frequently in a tuberculous process. This is an important diagnostic point.

In the ovaries there may occur a diffuse cirrhotic process.

The Nervous System.

—Here the manifestations of syphilis are often serious and widespread. They are produced by the same new tissue to which we have so often alluded, with its tendency at first to degeneration and later to sclerosis. They are always insidious. Gummatous thickening may occur at any point, springing often from the pia of the brain and cord. The arterial walls are frequently so affected, and at many points, that multiple minute aneurysms are produced, any one of which may give way and produce the fatal results of a cerebral hemorrhage. In diffuse gumma of the membranes or cortex the process is slow, and likely to involve areas which may be recognized by cerebral localization. Many cases presenting the features of brain tumor will yield to antisyphilitic treatment, and thus show themselves to be syphilomas.

In the spinal canal implication of the membranes is more likely to occur than in the vessels. In the cord these sclerotic changes are also quite common and produce symptoms strongly suggestive of tabes; in fact, there are those who hold that tabes is of specific origin.

In the motor and sensory nerves much connective tissue is present, and consequently these nerves are not exempt from sclerotic changes with pressure symptoms, which will give the clinical picture of a neuritis.

SYPHILIS IN CHILDREN.

Syphilis appears in young children under the following circumstances:

A. The disease may have been transmitted from the father to the ovum, at the time of conception, by infected spermatozoa.

B. From the mother, who may have acquired it before impregnation or during the early part of her pregnancy. In the latter case the infecting influence is transmitted through the placental circulation.

C. From the mother at the time of its birth, from a recently infected puerperal tract.

D. From some possible extrinsic source, a short time after its birth, as, e. g., through the umbilicus.

The later the mother acquires the disease after conception, the less likelihood that the child will be infected. If infection takes place from the placenta, then it also will be found to be diseased.

Profeta’s “Law.”

—Profeta first made the statement that the child of an infected mother who acquired the disease late in her pregnancy may not only be born healthy, but may be immune to subsequent infection, as are other healthy children of syphilitic parents. But, on the other hand, such a child may be anemic, puny, with small resisting power, or it may develop a late hereditary syphilis. When the ovum is infected by the father the healthy mother may escape, or she may acquire the disease through the placenta in her own uterus, or she may suffer from a mitigated form of syphilis whose principal features will appear as late manifestations of the disease.

Colles’ “Law.”

—Colles, in 1837, made the statement that such a mother may remain healthy with an acquired immunity to subsequent infection. The statements above made have often been alluded to as Profeta’s and Colles’ “laws.” These should, however, be regarded simply as statements of what usually occurs, and too much dependence should not be placed upon them. In fact, the immunity which the mother or the child may enjoy under conditions mentioned above is not likely to be permanent, though it may last for a varying period of time. There is no limit to the time when a parent may transmit syphilis to the child. The five-year limit given for the father is often overstepped, and the longer the man waits before marrying after acquiring the disease, and the more thoroughly he submits to judicious treatment, the less likely he is to convey it to offspring. This is the strongest kind of argument that can be used to delay marriage of syphilitics.

The indication of syphilis on the part of the mother is, in addition to those already given above, a tendency to miscarriage or abortion. The earlier she acquires the disease the earlier will the mishap occur. Should she escape the child may go on to full term, or it may die and be expelled as a dead fetus two or three months before the expiration of term. Should a child be born alive with hereditary syphilis, the evidences may appear at birth or within three months. Should a child apparently escape for six months it may grow up to be puny or develop some form of late hereditary disease, or it may possibly remain well. These children usually show developmental defect in some direction, and manifest a much weakened resisting power to other diseases; moreover, the spleen will usually be found enlarged.

Among the changes which may occur are the following: The skin becomes loose and resembles that of an old person. This is partly because it grows even faster than the tissues beneath it, so pronounced is the emaciation. Snuffles, or nasal catarrh, is one of the earliest features. This is due to specific swelling of portions of the Schneiderian membrane. Snuffles may occur in children without syphilis, but syphilis will nearly always produce snuffles, which may last for some time, and cause a widening at the root of the nose which will persist through life. Following the snuffles there usually appears a rash over the trunk and thighs and about the anus, accompanied by mucous patches. This will have the same bright, coppery tint as roseola syphilitica, already mentioned, which it much resembles. Sometimes it assumes the mixed type of eruption, while upon the palms and soles appears the so-called pemphigus syphiliticus. Should the child live nodular or gummatous syphilides may develop.

In the bone and cartilage characteristic changes are met at the lower end of the femur and at the costochondral junctions. This consists of an osteochondritis syphilitica. At the affected points enlargements take place, which may disappear under treatment or may go on to ulceration and necrosis. In the fingers and toes there are manifestations already described as syphilitic dactylitis.

The bones of the skull are likely to be involved in thickenings, especially about the anterior fontanelle, where they form the so-called Parrot’s nodes. These may disappear, with or without treatment, and the affected bone may undergo atrophy or may entirely disappear.

Among the viscera the spleen generally becomes affected first and then the liver. Syphilitic iritis may occur early, but is rather rare; ocular changes occur more often in the choroid. In the brain distinctive lesions may occur to such an extent as to lead to considerable thickening of the dura, with or without hydrocephalus, and subsequent imbecility or idiocy.

Deafness is not infrequent in hereditary syphilis. It may begin suddenly and at any age, even during infancy. It is produced by deep lesions which do not yield readily to treatment, and sometimes leads to deaf-mutism, especially when it occurs before the child has learned to talk.

Among the later manifestations of hereditary syphilis are opacities of the cornea from interstitial keratitis. This may occur in children who are apparently in good health and free from other signs of hereditary disease. The condition is rather obstinate, but it can be made to disappear under suitable treatment. Retinitis occurs frequently in young women, and is likely to lead to atrophy or detachment.

The Teeth.

—The permanent teeth often show peculiar changes that are distinctive, especially in those who have shown signs of corneal involvement, which, having been first described by Hutchinson, are frequently alluded to as Hutchinson’s teeth. When they first appear they are smaller than natural and irregular. Later they become notched. The crescentic notches show best upon the incisor teeth. Sometimes the canines are also affected, being narrow, rounded, and peg-like, with jagged edges. These teeth are usually so formed that they do not meet properly, and so small that they scarcely touch each other. The most characteristic changes are met with in the upper incisors, which may be affected when all the others are fairly normal. In such cases they will be found narrow and short, with a single broad notch at the edge, with perhaps a furrow passing from it upward and on both anterior and posterior aspects. Notching is usually symmetrical. No conclusions can be drawn from the teeth if they are normal, as they may be, but when they present the above-described features they prove a very important indication.

The relations between syphilis and rickets have attracted much attention, and there is little doubt but that rachitic changes are prone to occur in subjects with inherited syphilis. The two conditions are sometimes blended in various degrees and ways, and yet it is not safe to say that rickets is always an expression of inherited syphilis.

TREATMENT OF SYPHILIS.

There is no question but that some of the above-described lesions constitute as disgusting and repelling diseased conditions as the physician or surgeon is ever called upon to treat. In spite of these circumstances, however, it is generally believed that syphilis is a most satisfactory disease to treat. This is because of the almost mathematical certainty with which results can be predicted and estimated. There is nothing more satisfactory in therapeutics than the rapidity with which many pronounced and serious manifestations of syphilis will disappear under the influence of proper treatment. These statements, however, should be modified to make room for exceptional cases, where the disease assumes a malignant type, owing probably to some defect in the patient’s constitution, or where patients show peculiar idiosyncrasies and susceptibilities to the influence of mercury and iodine. Such cases happen occasionally and prove difficult of solution, while they sorely try the surgeon’s ingenuity and resources.

In the majority of instances syphilis is a curable disease. A patient should be first impressed with the necessity of faithfully following the directions of his physician, and continuing under treatment for a period of at least three years after the disappearance of the last manifestation of the disease. The disease is curable, but only by the judicious combination of two principal remedies, i. e., mercury and iodine. Those rare instances in which cure seems to have followed lines of treatment which do not include the use of these two drugs are so exceptional and misleading that they should not be considered criteria. Mercury and iodine are powerful remedies, needing to be administered with caution and judgment. Unfortunately there is no arbitrary limit of time for any given case. The time stated above is that usually considered requisite. While syphilis may be curable in some cases in less than the stated time, it is better to give it longer treatment than is absolutely required rather than the reverse. The treatment entails no unpleasant consequences. Warnings as to the approach of toxic symptoms from the drugs can be easily recognized.

Of the two drugs the preparations of mercury are the more important. The surgeon may adopt as his motto, mercury, more mercury, and again mercury, and if he begins with this measure early in the disease he may be able to conduct it to a successful termination with but little resort to iodine. Iodine is effective rather in those cases where treatment has been begun relatively late, and where it seems necessary to make a double impression upon the disease.

When the nature of the primary lesion is positive treatment should begin with the first visit of the patient to the surgeon. When there is uncertainty regarding the character of the venereal sore, treatment may be postponed until the appearance of the first eruption. As soon as this has appeared the treatment should be hastened. It is necessary to begin with mercury. The patient’s mouth should be examined by a dentist and all tartar removed from the teeth, especially from the gingival borders, at which lines the gums are likely to become sore when mercury is too freely used. All diseased teeth should be extracted or filled, and the mouth and its contents should be put in normal condition. The dentist should be informed as to the reason for the visit. Smoking should be discontinued, especially when there are mucous patches, since it is apt to irritate and make subsequent lesions of the mucous membrane more likely to occur. The habits of the patient should be regulated as to alcohol and other indulgences, and he should be warned as to the infectious nature of the disease, in order that others may be protected. In many instances tonic, even roborant treatment may be advantageously combined with the antispecific. It will be found that the anemia so characteristic of well-marked secondary syphilis will improve materially under the influence of mercury alone.

Should the disease occur in a married person, or develop after marriage, caution should be given as to the danger to offspring, and to the other associate in the marriage relation, which might follow the occurrence of pregnancy.

Mercury may be given by the mouth, by inunction, by hypodermic injection, or by fumigation. The intent should be to get the patient under its influence as rapidly as is consistent with safety. The most effective of these methods to which patients will ordinarily submit is that by inunction. This consists essentially in the use of mercurial ointment (blue ointment), of which 15 Gm. may be used daily or nightly, which should be thoroughly rubbed into some area of the body; the areas selected being changed at perhaps three-day intervals, in order that irritation, which its prolonged use produces, may be avoided. It takes considerable effort to so completely rub this in as to make most of it disappear, and it can be done more easily upon those parts of the body which are free from hair. It can be best done by employing someone for the purpose, but patients can be easily taught to use it themselves. There are upon the market, ointments containing mercury made with other excipients than lard, which are less uncomfortable to the skin and seem to be absorbed better; among these is a preparation made with a petroleum compound called vasogen, which may be procured in different strengths; that containing 33 per cent. or 50 per cent. is the best.

Inunction should be practised at least once every twenty-four hours, until either the gums become tender or swollen, with an offensive odor of the breath, or until the skin is irritated. The mouth should be protected by use of an astringent antiseptic mouth-wash, such as the following: Carbolic acid 10 parts, oil of wintergreen 1 part, tincture of myrrh 50 parts. A little of this solution in a tablespoonful or more of water makes a serviceable wash, which should be used several times a day. There are sanitaria and springs, or health resorts, in this country where a specialty is made of this manner of treatment. At these resorts inunction is practised freely and thoroughly, but the benefit which is obtained comes rather from the attention which patients give to the treatment, and their abstention from business or dissipation, than from any inherent medicinal features either in the mineral water or climate.

Under the influence of mercurial ointment alone, if a patient is willing to persist in its use, many cases of syphilis may be conducted to a successful termination; but its use is disagreeable to some people, and it may be impossible to resort to it for any great length of time. It has its inconveniences and disadvantages, but it should be applied in at least the first stages of the disease.

When mercurial ointment is seen to have made a distinctive impression upon the constitution of the patient it may be discarded and the treatment changed to the internal administration of the drug.

Mercurials may be given internally in any one of several different preparations. Hutchinson has recommended gray powder, in doses of ¹⁄₄ to ¹⁄₃ Gm. three or four times a day. Corrosive sublimate is a reliable form in which to administer mercury in doses which can be tolerated, from 1 to 2 Mg., three or four times a day. The red iodide may be given in similar doses, or the green iodide may be administered in doses of 0.15 to 2 Cg. These preparations sometimes irritate the intestinal tract and produce a certain amount of colic or looseness of the bowel. For the latter some astringent may be combined with the mercury, while intestinal pain may be checked by the use of extract of conium.

The hypodermic use of mercury can be made effective, but there are but few preparations which can be used that do not cause pain and subsequent irritation. Perhaps that which gives least pain is the sozoiodolate of mercury. This is sparingly soluble in water, dissolving in about 500 parts by weight. As the dose is 9 or 10 Cg., the amount of water necessary for this solution is so bulky that the dose should be injected into the gluteal region. Corrosive sublimate is also used in 1 per cent. solution, made up in common salt solution of the usual strength of 9 to 1000. Of this 10 minims represent a suitable dose to commence with, which may be increased to 30 or 40 minims when necessary. This should be given in the same region, the needle being driven in its full length perpendicularly to the surface. When this is done an injection is made into the muscle, where it seems to be more effective than in the subcutaneous fat. When the dose is increased to more than 20 minims a 2 per cent. solution may be used and the amount of fluid correspondingly reduced.

Fumigation is a method now not often adopted, calomel being used for the purpose, an ordinary cabinet hot-air bath confining the vapor about the patient. One treatment a day by either of these methods is usually sufficient.

About the initial sore dry calomel, pure or reduced with bismuth subnitrate, may be used. The condylomas met with about the perineum will often shrink and disappear under the influence of this application. Mucous patches should be treated with absolute cleanliness; in the mouth a wash of diluted hydrogen dioxide may be used, and the patches touched with a strong nitrate of silver solution, pure carbolic acid, or camphophenol. This will not prevent contagion from such a source, but will reduce it to a minimum beneficial in every respect.

The various eruptions of syphilis will disappear gradually under the influence of a local application of one of the mercurial preparations, either the ordinary mercurial ointment or ammoniated mercury.

In cases of inherited syphilis, especially in young children, a reduced mercurial ointment, or the use of gray powder (mercury with chalk) will give the best results. The dose should be regulated by the age of the patient; for instance, of the latter 1 to 2 Cg. for an infant. The iodides have also proved successful.

Iodine and its preparations have by many authorities been held to be useful in the later and especially in the gummatous lesions of syphilis. There are patients who cannot take iodine to any extent without suffering from such disturbance of mucous membranes, especially in the nose and intestines, as to make it an exceedingly unpleasant remedy.

The iodides have not proved as successful as the mercurials; nevertheless, the combination is a popular one and sometimes of peculiar value. The potassium salt is the one generally used, as it is cheaper than the sodium compound. The latter, however, is less irritating and often more available. The lithium compound is ideal in some respects, but very expensive. The iodides may be given in large doses, to the extent of 30 Gm. or more (an ounce or more) in twenty-four hours. Large doses are sometimes necessary in the treatment of late syphilis of the nervous system. When it is necessary to put the patient rapidly under the influence of antispecific medication the combined use of these two drugs, as for example by mercurial inunction and the use of one of the iodides internally, will most speedily bring about the desired result. This result may be overreached, and sore mouth or other toxic manifestations may appear suddenly and unexpectedly.

The mercuric salts are soluble in solutions of the iodides, and what is known as mixed treatment is often employed. The salts may be combined in any desired preparation. Donovan’s solution is exceedingly valuable, the arsenic which it contains seeming to reinforce both the mercury and the iodine.

The iodides produce eruptions or rashes which strongly simulate both syphilitic and non-syphilitic skin diseases, and confusion may arise from their use. In those who are sensitive to the iodides, and in whom catarrh of the mucous membranes is easily produced, it is best to begin with small doses, increasing them as circumstances may warrant. Some patients cannot take iodine in any form. When iodides irritate the stomach they should be given in essence of pepsin.

Of the various vegetable remedies some are unreliable and of little value. Certain combinations can, however, be effected in some cases by which the value of the effective agents may be enhanced. Zittmann’s decoction or McDade’s formula will occasionally prove of service. In aggravated cases the former is believed to be the most effective of all methods of administering mercury. Tonics or any other medicines which may be called for in particular cases should be given judiciously. There is nothing in antisyphilitic treatment which precludes other treatment when needed.