and by the characters this eruption shares with all syphilitic rashes. Syphilitic Eczema.-Small groups of vesicles spread over a red areola, which soon become small papules of a coppery hue. Syphilitic Herpes.-In one variety, vesicles as large as a pea form a group pretty closely together; as the vesicles form, the skin beneath is converted into a group of coppery papules, or if the vesicles unite, into one broad one. In the other variety, the vesicles group in rings and serpentine lines, leaving the skin inside the lines unaffected. According to Hutchinson, the vesicles sometimes assume an arrangement like herpes zoster, but it has a bi-lateral symmetry which simple herpes zoster hardly ever possesses. Pustular forms.-Syphilitic acne occurs only at an early period of the disease. A vesicle with puriform fluid is developed on an elevated base, with halo. The eruption is found all over the body except the palms and soles. Syphilitic Ecthyma is an exaggerated variety of the acne and is met with in very debilitated patients. The slow development and coppery areola distinguishes it from ordinary ecthyma. It occurs on the lower limbs chiefly. Syphilitic Rupia.-A form rarely seen till some years have elapsed after infection, unless the general progress of the disease is very rapid. Large bullæ form, and an areola spreads round the bulla. The vesicle shrinks, the contents dry into a crust, the skin ulcerates under the crust, the fresh secretion dries also, and the ulcer extends beneath, until a thick scab is formed of a brownish-green hue. Crops of bullæ succeed each other till several months have elapsed. Rheumatic and periosteal pains and bodily debility ordinarily accompany this eruption. Pemphigus is of exceeding rarity in adults. It developes on the palms and soles, and extends up the arms and legs; it is accompanied by mucous tubercles of the anus, and by other syphilitic affections. Tubercular Syphilides.-Solid, rounded elevations of the skin and subcutaneous cellular tissue. They are late affections, and appear usually in persons infected three or four years at least. There are two kinds, superficial and deep. The superficial are prominent nodules, the size of a pea, coppery or purple-brown in colour, collected commonly into groups, most frequent on the face, but occurring on any part of the body; this eruption is never widely spread. The tubercles are very liable to ulcerate and then leave indelible white scars. The course is slow, for fresh tubercles appear as the old ones subside, and the eruption recurs again and again. The deep tubercles are known as subcutaneous gummy tumours, much rarer than the last; they are met with only in cases of long standing syphilis. Solid nodules form beneath the skin, presently the skin becomes absorbed over them, and bluish-red in colour, and they reach the surface by slow ulceration. The contents then escape, and a round swelling with a ragged ulcerated interior is left, ending in depressed white scars. Sometimes they are reabsorbed before ulceration is reached, when they leave no trace. They are found oftenest on the neck, but occur on any part of the surface; they are identical with the gummy tumours of internal organs. The Serpiginous Tubercular Syphilides.-A tubercle forms above the surface of the skin of purple or brownish tint; at its margins little tubercles develope and merge into each other. The earliest tubercle soon ulcerates, a scab is formed, under which an ulcer creeps, that heals where it first began while spreading by the destruction of the tubercles at its margin. The course of the affection is indefinite unless controlled by treatment. These syphilitic lupoid ulcers are characterised by the solid tubercles in the skin which pre cede ulceration; by the age of the patient (they are rarely seen before middle age); and usually by the presence of the syphilitic pallor of the complexion, and previous syphilitic disease. Pigmentary Syphilide.—A rare eruption appearing about six months after infection, consists of brownish-grey spots the size of a sixpence, in groups on the neck and bosom, also on the flanks and thighs. There is no elevation. or desquamation, and the discoloration, unlike that of chloasma, is beneath the surface. It disappears in time completely. Alopecia. The hair becomes dry and withered at the outset, or during the course of the cutaneous eruptions. It often falls partially from the scalp; but the eyebrows, lashes, and down of the body occasionally fall too, and complete baldness is reached. In a few weeks new woolly hairs grow among the old, and in the course of a few months the hair is completely restored. The pustular eruptions which beset the scalp sometimes loosen the hair; it then comes away in patches and produces bald spots, which ultimately regain their covering. Onychia. The nails are attacked in three ways. 1st. The matrix, while a scaling rash is present elsewhere, is beset with papules; these ulcerate and destroy the nutrition of the nail, which acting like a foreign body, causes obstinate ulcers. 2nd. The nutrition of the nail is altered, it becomes brittle, and its edge notched and ragged. 3rd. The superficial layers of the nail split or peel off, so that the nail becomes spotted and opaque at places where the nail is breaking away. SYPHILIS. CHAPTER V. THE ALIMENTARY CANAL. The Tongue: Excoriations, Fissures, Papulo-sealy Eruptions, Gummy Nodules, Distinctions between deep Syphilitic Ulcers and Cancer-Mouth and Pharynx Erythema, Deep Ulcers, Scars, Necrosis of Hard PalateGullet: Ulcer, Stricture-Stomach and Small Intestine-Rectum: Socalled Syphilitic Stricture-Spleen-Thyroid and Pituitary Bodies-Pancreas-Liver: Cirrhosis, Gummy Nodules, Amyloid Degeneration, Symp. toms of Hepatic Disease-Summary. ON the Tongue, the most common affection is the superficial ulcers along the border, sometimes rounded, sometimes forming vertical fissures. They usually appear during the first year after infection, and are particularly obstinate, being repeated for several months by continual relapses. They are excessively sore, especially if they expose the muscular fibres, when every movement of the tongue causes pain. Less common than these are sinuous fissures of the dorsum of the tongue, which by penetrating to the muscular tissue are extremely painful. They are very characteristic of syphilis, and are frequent during the third and fourth years after infection; but may continue harassing the patient for many years, if not subjected to proper treatment. Coppery papules form on the dorsum of the tongue at the time of the papular eruptions on the skin, with which they are identical in structure and appearance. Unless they ulcerate, which they seldom do, they produce no inconve nience to the patient. The papules subside after remaining on the tongue for an uncertain period, between a few weeks and as many months, and leave no trace of their presence. Except that they do not desquamate, and are a much more frequent affection of the tongue, they resemble the next affection. Plaques Muqueuses of the Tongue.-This is a common name for a peculiar hypertrophy of the epithelium of the tongue, usually confined to that part, but sometimes it is seen on the interior of the cheeks and fauces. It presents itself as small dead white patches of epithelium scales, closely adherent to the mucous membrane, but a little raised from the surface. It is an obstinate affection, requiring a long continued course of treatment for its removal. Between the patches, white shining cicatrices of former ulcers are often seen. Usually, no pain or tenderness accompanies these patches. Now and then, excoriations form on the mucous membrane, that smart exceedingly when hot or acid food is taken. Nodules in the muscular tissue are not uncommon : they form most frequently at the base of the tongue, but are also found at the fore-part, among the muscular fibres. Those placed near the surface sometimes ulcerate into deep ragged cavities. Usually, after lasting several months, they subside and disappear without any further ill-consequences, and others form again from time to time. When the gummy tumour liquifies and escapes by ulcerating through its coverings, the irregular cavity which is left extends beyond the area of the ulcerated surface; but it slowly shrinks, and when closed leaves a very small scar. Diagnosis of syphilitic affections from non-syphilitic affections of the Tongue.-The scaling eruption is liable to be confounded with non-syphilitic psoriasis, but the latter |