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it, or by a few turns of a narrow bandage. Sublimed sulphur frequently rubbed into the sore is recommended by C. H. Mills. If the sores spread in spite of this, they should be painted with cocaine and then cauterised. When the glands in the groin are infected, the patient must be confined to bed, and a dressing impregnated with ichthyol and glycerin (10 per cent.) applied; the repeated use of a suction bell is of great service. Harrison recommends aspiration of a bubonic abscess, followed by injection of 1 in 20 solution of tincture of iodine into the cavity; this is in turn aspirated, and then 1 or 2 c.c. of the solution injected and left in. This is repeated as often as the cavity refills. It is sometimes necessary to let the pus out by one or more small incisions and continue the use of the suction bell.

Diagnosis of Primary Syphilis.—In cases in which there is a history of an incubation period of from three to five weeks, when the sore is indurated, persistent, and indolent, and attended with bullet-buboes in the groin, the diagnosis of primary syphilis is not difficult. Owing, however, to the great importance of instituting treatment at the earliest possible stage of the infection, an effort should be made to establish the diagnosis without delay by demonstrating the spirochæte. Before any antiseptic is applied, the margin of the suspected sore is rubbed with gauze, and the serum that exudes on pressure is collected in a capillary tube and sent to a pathologist for microscopical examination. A better specimen can sometimes be obtained by puncturing an enlarged lymph gland with a hypodermic needle, injecting a few minims of sterile saline solution and then aspirating the blood-stained fluid.

The Wassermann test must not be relied upon for diagnosis in the early stage, as it does not appear until the disease has become generalised and the secondary manifestations are about to begin. The practice of waiting in doubtful cases before making a diagnosis until secondary manifestations appear is to be condemned.

Extra-genital chancres, e.g. sores on the fingers of doctors or nurses, are specially liable to be overlooked, if the possibility of syphilis is not kept in mind.

It is important to bear in mind the possibility of a patient having acquired a mixed infection with the virus of soft chancre, which will manifest itself a few days after infection, and the virus of syphilis, which shows itself after an interval of several weeks. This occurrence was formerly the source of much confusion in diagnosis, and it was believed at one time that syphilis might result from soft sores, but it is now established that syphilis does not follow upon soft sores unless the virus of syphilis has been introduced at the same time. The practitioner must be on his guard, therefore, when a patient asks his advice concerning a venereal sore which has appeared within a few days of exposure to infection. Such a patient is naturally anxious to know whether he has contracted syphilis or not, but neither a positive nor a negative answer can be given—unless the spirochæte can be identified.

Syphilis is also to be diagnosed from epithelioma, the common form of cancer of the penis. It is especially in elderly patients with a tight prepuce that the induration of syphilis is liable to be mistaken for that associated with epithelioma. In difficult cases the prepuce must be slit open.

Difficulty may occur in the diagnosis of primary syphilis from herpes, as this may appear as late as ten days after connection; it commences as a group of vesicles which soon burst and leave shallow ulcers with a yellow floor; these disappear quickly on the use of an antiseptic dusting powder.

Apprehensive patients who have committed sexual indiscretions are apt to regard as syphilitic any lesion which happens to be located on the penis—for example, acne pustules, eczema, psoriasis papules, boils, balanitis, or venereal warts.

The local treatment of the primary sore consists in attempting to destroy the organisms in situ. An ointment made up of calomel 33 parts, lanoline 67 parts, and vaseline 10 parts (Metchnikoff's cream) is rubbed into the sore several times a day. If the surface is unbroken, it may be dusted lightly with a powder composed of equal parts of calomel and carbonate of zinc. A gauze dressing is applied, and the penis and scrotum should be supported against the abdominal wall by a triangular handkerchief or bathing-drawers; if there is inflammatory œdema the patient should be confined to bed.

In concealed chancres with phimosis, the sac of the prepuce should be slit up along the dorsum to admit of the ointment being applied. If phagedæna occurs, the prepuce must be slit open along the dorsum, or if sloughing, cut away, and the patient should have frequent sitz baths of weak sublimate lotion. When the chancre is within the meatus, iodoform bougies are inserted into the urethra, and the urine should be rendered bland by drinking large quantities of fluid.

General treatment is considered on p. 149.

Secondary Syphilis.—The following description of secondary syphilis is based on the average course of the disease in untreated cases. The onset of constitutional symptoms occurs from six to twelve weeks after infection, and the manifestations are the result of the entrance of the virus into the general circulation, and its being carried to all parts of the body. The period during which the patient is liable to suffer from secondary symptoms ranges from six months to two years.

In some cases the general health is not disturbed; in others the patient is feverish and out of sorts, losing appetite, becoming pale and anæmic, complaining of lassitude, incapacity for exertion, headache, and pains of a rheumatic type referred to the bones. There is a moderate degree of leucocytosis, but the increase is due not to the polymorpho-nuclear leucocytes but to lymphocytes. In isolated cases the temperature rises to 101° or 102° F. and the patient loses flesh. The lymph glands, particularly those along the posterior border of the sterno-mastoid, become enlarged and slightly tender. The hair comes out, eruptions appear on the skin and mucous membranes, and the patient may suffer from sore throat and affections of the eyes. The local lesions are to be regarded as being of the nature of reactions against accumulations of the parasite, lymphocytes and plasma cells being the elements chiefly concerned in the reactive process.

Affections of the Skin are among the most constant manifestations. An evanescent macular rash, not unlike that of measles—roseola—is the first to appear, usually in from six to eight weeks from the date of infection; it is widely diffused over the trunk, and the original dull rose-colour soon fades, leaving brownish stains, which in time disappear. It is usually followed by a papular eruption, the individual papules being raised above the surface of the skin, smooth or scaly, and as they are due to infiltration of the skin they are more persistent than the roseoles. They vary in size and distribution, being sometimes small, hard, polished, and closely aggregated like lichen, sometimes as large as a shilling-piece, with an accumulation of scales on the surface like that seen in psoriasis. The co-existence of scaly papules and faded roseoles is very suggestive of syphilis.

Other types of eruption are less common, and are met with from the third month onwards. A pustular eruption, not unlike that of acne, is sometimes a prominent feature, but is not characteristic of syphilis unless it affects the scalp and forehead and is associated with the remains of the papular eruption. The term ecthyma is applied when the pustules are of large size, and, after breaking on the surface, give rise to superficial ulcers; the discharge from the ulcer often dries up and forms a scab or crust which is continually added to from below as the ulcer extends in area and depth. The term rupia is applied when the crusts are prominent, dark in colour, and conical in shape, roughly resembling the shell of a limpet. If the crust is detached, a sharply defined ulcer is exposed, and when this heals it leaves a scar which is usually circular, thin, white, shining like satin, and the surrounding skin is darkly pigmented; in the case of deep ulcers, the scar is depressed and adherent (Fig. 39).

Fig. 39.—Syphilitic Rupia, showing the limpet-shaped crusts or scabs.

Fig. 39.—Syphilitic Rupia, showing the limpet-shaped crusts or scabs.

In the later stages there may occur a form of creeping or spreading ulceration of the skin of the face, groin, or scrotum, healing at one edge and spreading at another like tuberculous lupus, but distinguished from this by its more rapid progress and by the pigmentation of the scar.

Condylomata are more characteristic of syphilis than any other type of skin lesion. They are papules occurring on those parts of the body where the skin is habitually moist, and especially where two skin surfaces are in contact. They are chiefly met with on the external genitals, especially in women, around the anus, beneath large pendulous mammæ, between the toes, and at the angles of the mouth, and in these situations their development is greatly favoured by neglect of cleanliness. They present the appearance of well-defined circular or ovoid areas in which the skin is thickened and raised above the surface; they are covered with a white sodden epidermis, and furnish a scanty but very infective discharge. Under the influence of irritation and want of rest, as at the anus or at the angle of the mouth, they are apt to become fissured and superficially ulcerated, and the discharge then becomes abundant and may crust on the surface, forming yellow scabs. At the angle of the mouth the condylomatous patches may spread to the cheek, and when they ulcerate may leave fissure-like scars radiating from the mouth—an appearance best seen in inherited syphilis (Fig. 44).

The Appendages of the Skin.—The hair loses its gloss, becomes dry and brittle, and readily falls out, either as an exaggeration of the normal shedding of the hair, or in scattered areas over the scalp (syphilitic alopœcia). The hair is not re-formed in the scars which result from ulcerated lesions of the scalp. The nail-folds occasionally present a pustular eruption and superficial ulceration, to which the name syphilitic onychia has been applied; more commonly the nails become brittle and ragged, and they may even be shed.

The Mucous Membranes, and especially those of the mouth and throat, suffer from lesions similar to those met with on the skin. On a mucous surface the papular eruption assumes the form of mucous patches, which are areas with a congested base covered with a thin white film of sodden epithelium like wet tissue-paper. They are best seen on the inner aspect of the cheeks, the soft palate, uvula, pillars of the fauces, and tonsils. In addition to mucous patches, there may be a number of small, superficial, kidney-shaped ulcers, especially along the margins of the tongue and on the tonsils. In the absence of mucous patches and ulcers, the sore throat may be characterised by a bluish tinge of the inflamed mucous membrane and a thin film of shed epithelium on the surface. Sometimes there is an elongated sinuous film which has been likened to the track of a snail. In the larynx the presence of congestion, œdema, and mucous patches may be the cause of persistent hoarseness. The tongue often presents a combination of lesions, including ulcers, patches where the papillæ are absent, fissures, and raised white papules resembling warts, especially towards the centre of the dorsum. These lesions are specially apt to occur in those who smoke, drink undiluted alcohol or spirits, or eat hot condiments to excess, or who have irregular, sharp-cornered teeth. At a later period, and in those who are broken down in health from intemperance or

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