from the disease. In very rare cases this febrile re-action acquires a periodic character. Among Zambaco's1 cases is one in which the fever was particularly well marked: it was that of a woman, 26, who was attacked with pain in the limbs and slight fever. A fortnight later the fever became severe. Every day, at 5 p.m., she had a shiver lasting fifteen minutes, then followed by heat and sweat. This ague-fit was repeated during a week, after which a papular eruption over the whole body, and other unmistakeable signs of syphilis appeared. The fever continued unabated during seven weeks, in spite of aj of quinine per diem and other febrifuge medicines. When mercury was given, the fever subsided in four days, and in six had entirely left her; her recovery of strength and appetite was so rapid that the patient left the hospital in a short time, relieved of all her symptoms. Yvaren recites a case, and Zambaco inserts another case reported by Lasègue, where this intermittent character was well marked. Lancereaux, too, has collected similar examples from the works of Boyer and others. intense as that of the foregoing cases is exceedingly rare, but a short period of general malaise and loss of appetite is usually present. MacCarthy (quoted by Lancereaux) states that he found premonitory febrile reaction in forty out of sixty cases of early eruption. A curious feature of these constitutional derangements is, that they all, from the lightest to the severest, subside at once under the influence of mercury.

3

Reaction so

This preliminary febrile stage of a few days' duration, is continued by an exanthematous eruption, which runs its course, and is followed by, or transformed into, other erup

Zambaco: Maladies Nerveuses Syphilitiques, Case 74, extracted from the Archives de la Société Méd. d'Observation.

2 Yvaren: Metamorphoses de la Syphilis, p. 173.

3 Lancereaux, loc. cit., pp. 121 and 123.

tions with tolerable regularity. The eruption first assumes the macular form; as such it subsides, or, while fading, is replaced by varieties of the papular eruption. In many cases, the disease terminates with the subsidence of the papular eruption, at the end of the exanthematous period, and about six months after contagion.

If mercurial treatment is employed before the appearance of the eruptions, the preliminary fever is completely prevented, and the rashes are postponed, or assume a slower course, and are limited in extent; but mercury seldom wholly prevents the general symptoms. Another character of the rash is, that the first eruption often appears suddenly, or greatly increases its extent, after bodily excitement, such as a night's dancing, or supper-party, or sexual enjoyment. Besides this one, there are doubtless other ill-understood reasons affecting the time at which the eruption appears. The excitement of the system produced by vaccination pro. bably arouses latent syphilis into activity in children inheriting the disease from their parents. But neither season, nor age, nor sex, has power to occasion its appearance or prevent its absence.

ERUPTIONS ON THE SKIN, OR SYPHILIDES.

General Remarks.-Syphilitic eruptions resemble many of the ordinary cutaneous eruptions; hence, the various forms have been named accordingly. They are distinguished from the latter, however, by characters they have in common, and by some peculiar to each: thus their diagnosis is rarely a matter of much difficulty.

Characters possessed in Common by the early Forms.— 1. The papular is the commonest eruption. All the other, even the macular, eruptions are mingled more or less with papules, and for this reason the papule becomes the type or basis of all syphilitic eruptions. With this tendency to

produce papules, the different rashes do not develope into typical examples of the kind among which they are classed. The vesicles are abortive, and the scaling patches desquamate but scantily.-2. Symmetry of the rash. In the early stages both sides of the body, both arms, both legs, are beset with spots, because the virus producing them pervades all parts of the body.-3. The colour of the eruptions. At first, this is often bright red, but it changes quickly to the hue of raw ham, or assumes a coppery tint. As the eruption fades, the brown colour becomes more distinct, and ultimately turns to brownish-grey before disappearing altogether. In vascular or dependent situations, like the face or lower limbs, a purplish tinge sometimes pervades the brown, but this is less common than the coppery-red hue. The rapid change of the bright redness to the peculiar coppery-red or raw hamlike colour, is very characteristic.-4. Rarity of irritation. Syphilitic rashes are almost always entirely free from heat, itching, or smarting, symptoms of which one or other is a common character of most non-syphilitic affections of the skin, and is often their prominent symptom. This peculiarity in syphilis is in part owing to the usually slow progress of the eruption, for a little transitory itching does accompany a syphilitic rash when that is very rapid in development.-5. Favourite localities. Most frequently the trunk, the forehead, especially along the border of the scalp, the margins of the nostrils, and the nape of the neck are chosen by the eruption. The outer aspects of the extremities more often escape, and the backs of the hands and feet are rarely marked. On the contrary, the palms and soles are frequently attacked by syphilis-situations commonly avoided by non-syphilitic rashes. Again, the favourite localities of the non-syphilitic eruptions are not those of the corresponding syphilitic rashes. For instance, simple macular eruptions prefer the extremities, syphilitic maculæ select the

trunk of the body. Non-syphilitic psoriasis, when it is scattered in patches over the surface, always prefers the outer and rough aspect of the limbs. In syphilitic scaly eruptions, the desquamating patches are often widely spread over the body, without attacking the special sites of simple psoriasis, and show a preference for the inner over the outer aspects of the limbs.-6. The form and arrangement of the spots and patches in syphilis are often arches or circles, or segments of circles; a disposition less frequent in nonsyphilitic skin-diseases.-7. Multifarious character of the eruption. A character seldom failing to the syphilitic eruptions is their association together; the papules appear among the maculæ, the scaling patches co-exist with mucous patches, or with pustules and vesicles of the scalp. This intermingling of different eruptions is very unusual except in syphilis, where they have a common exciting cause. In 153 patients with maculæ, Bassereau1 found only 28 free from some other eruption.-8. Transformation of one form into another is often observed when there is opportunity for watching the progress of the disease. It is not unfrequent to perceive smooth papules become rough with desquamation, or, if kept moist, develope into mucous tubercles.-9. A most important diagnostic sign is the presence of other syphilitic affections in other organs, for instance, in the lymphatic glands, the throat, &c. These peculiarities more or less accompany all the early syphilitic eruptions.

The later eruptions, which appear when the disease is losing its activity, have not so goodly a collection of special characters. They are seldom spread widely over the body, but more often limited to a very small part of its surface. The brownish tinge is well marked from their chronic course. They often cause considerable destruction of tissue by slow

1 Affections de la Peau Symptomatiques de la Syphilis, p. 58. Paris, 1852.

ulceration or suppuration, and therefore their sites are marked by scars. They are often the sole evidence of active syphilitic disease. Under proper treatment they commonly heal rapidly. They have an exceedingly slow course, and are apt to recur again and again.

Relative Frequency with which the various Eruptions occur. -The table of admissions into the Royal Naval Hospital afford some means of estimating this point. In 931 cases of general syphilis, there were

These tables do not tell us how often each eruption occurred, but only the number of patients admitted, with each particular affection. The course previous or subsequent to admission is not given, and obviously those affections which more readily attract attention will stand highest in the order of frequency.

After this sketch of the general characters of syphilitic eruptions, the description of their individual forms may be more minutely given, beginning with—

Macular Syphilide; Syphilitic Roseola.-Roseola being the earliest general eruption, is usually preceded or accompanied by the constitutional disturbance described as syphilitic fever. Its appearance is often sudden, sometimes immediately after violent exercise, or occasion of debauchery, and then developes to its full extent in twentyfour hours; or, if much slower, it does not reach its acme in less than a week or ten days. According to Hardy, it is

1 Hardy: Maladies de la Peau, p. 156.